Discussion 6

See attached for instructions. Use attached book.

Discussion 6
Refer to Ch. 9 and 10

Please apply the cognitive behavioral model to this case example: A client presents with panic attacks
and fear of being out on public spaces and crowded places where a quick “exit” or escape might be
difficult. The client has been avoiding any situations that might involve crowds including stores, malls,
and restaurants. This avoidance has begun to limit her life. She is terrified she will have a panic attack
if she enters any of these situations and fears that she may even die or go “crazy” if she experiences
another panic attack. Please apply the CBT approach to this case. Be sure to include how exposure
therapy would fit.

California State University, Fullerton
Diplomate in Counseling Psychology
American Board of Professional Psychology
Theory and Practice
of Counseling
and Psychotherapy
G E R A L D C O R E Y
ninth edition
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About the Author
GERALD COREY is a Professor Emeritus of Human Serv-
ices at California State University at Fullerton and a licensed
psychologist. He received his doctorate in counseling from
the University of Southern California. He is a Diplomate
in Counseling Psychology, American Board of Professional
Psychology; a National Certified Counselor; a Fellow of the
American Psychological Association (Counseling Psychol-
ogy); a Fellow of the American Counseling Association; and
a Fellow of the Association for Specialists in Group Work.
He also holds memberships in the American Group Psycho-
therapy Association; the American Mental Health Counselors Association; the As-
sociation for Spiritual, Ethical, and Religious Values in Counseling; the Associa-
tion for Counselor Education and Supervision; and the Western Association for
Coun selor Education and Supervision.
Along with Marianne Schneider Corey, Jerry received the Lifetime Achieve-
ment Award from the American Mental Health Counselors Association in 2011
and the Eminent Career Award from the Association for Specialists in Group
Work in 2001. Jerry was the recipient of the Outstanding Professor of the Year
Award from California State University at Fullerton in 1991. He teaches both
undergraduate and graduate courses in group counseling, as well as courses
in experiential groups, the theory and practice of counseling, theories of coun-
seling, and professional ethics. He is the author or coauthor of 16 textbooks
in counseling currently in print, 5 student videos/DVDs with workbooks, and
more than 60 articles in professional publications. Theory and Practice of Coun-
seling and Psychotherapy has been translated into the Arabic, Indonesian, Por-
tuguese, Korean, Chinese, and Turkish languages. Theory and Practice of Group
Counseling has been translated into Chinese, Korean, Russian, and Spanish.
Issues and Ethics in the Helping Professions has been translated into Korean, Japa-
nese, and Chinese.
Jerry and Marianne Corey often presents workshop in group counseling. In
the past 35 years the Coreys have conducted group counseling training workshops
for mental health professionals at many universities in the United States as well as
in Korea, Ireland, Germany, Belgium, Scotland, Mexico, China, Hong Kong, and
Canada. The Coreys also frequently give presentations and workshops at state and
national professional conferences. In his leisure time, Jerry likes to travel, hike and
bicycle in the mountains, and drive his 1931 Model A Ford.
A
ss
oc
ia
te
d
Pr
es
s
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Recent publications by Jerry Corey, all with Brooks/Cole, Cengage Learning,
include:
Case Approach to Counseling and Psychotherapy, Eighth Edition (2013)
The Art of Integrative Counseling, Third Edition (2013)
Theory and Practice of Group Counseling (and Student Manual, Eighth Edition,
2012)
Becoming a Helper, Sixth Edition (2011, with Marianne Schneider Corey)
Issues in Ethics in the Helping Professions, Eighth Edition (2011, with Marianne
Schneider Corey and Patrick Callanan)
Groups: Process and Practice, Eighth Edition (2010, with Marianne Schneider
Corey and Cindy Corey)
I Never Knew I Had a Choice, Ninth Edition (2010, with Marianne Schneider
Corey)
Group Techniques, Third Edition (2004, with Marianne Schneider Corey,
Patrick Callanan, and J. Michael Russell)
Jerry is coauthor (with Barbara Herlihy) of Boundary Issues in Counseling: Multiple
Roles and Responsibilities, Second Edition (2006) and ACA Ethical Standards Case-
book, Sixth Edition (2006); he is coauthor (with Robert Haynes, Patrice Moulton,
and Michelle Muratori) of Clinical Supervision in the Helping Professions: A Practi-
cal Guide, Second Edition (2010); he is the author of Creating Your Professional
Path: Lessons From My Journey (2010). All four of these books are published by the
American Counseling Association.
He also has made several educational DVD and video programs on various as-
pects of counseling practice: DVD for Theory and Practice of Counseling and Psycho-
therapy: The Case of Stan and Lecturettes (2013); DVD for Integrative Counseling: The
Case of Ruth and Lecturettes (2013, with Robert Haynes); DVD—Theory and Practice
of Group Counseling (2012); Groups in Action: Evolution and Challenges—DVD and
Workbook (2006, with Marianne Schneider Corey and Robert Haynes); and Ethics
in Action: CD-ROM (2003, with Marianne Schneider Corey and Robert Haynes).
All of these programs are available through Brooks/Cole, Cengage Learning.
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
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This is an electronic version of the print textbook. Due to electronic rights restrictions,
some third party content may be suppressed. Editorial review has deemed that any suppressed
content does not materially affect the overall learning experience. The publisher reserves the right
to remove content from this title at any time if subsequent rights restrictions require it. For
valuable information on pricing, previous editions, changes to current editions, and alternate
formats, please visit www.cengage.com/highered to search by ISBN#, author, title, or keyword for
materials in your areas of interest.

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

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To Terry Hendrix and in memory of Claire Verduin,
our first editors at Brooks/Cole; they had faith
in the potential of this book and encouraged us to
write early in our careers.
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P R E FA C E X I I
PA R T 1
Basic Issues in Counseling Practice�3
1 Introduction and Overview�4
Introduction 5
Where I Stand 6
Suggestions for Using the Book 8
Overview of the Theory Chapters 9
Introduction to the Case of Stan 13
2 The Counselor: Person and Professional�17
Introduction 18
The Counselor as a Therapeutic Person 18
Personal Therapy for the Counselor 20
The Counselor’s Values and the Therapeutic Process 22
Becoming an Effective Multicultural Counselor 24
Issues Faced by Beginning Therapists 28
Summary 34
3 Ethical Issues in Counseling Practice�36
Introduction 37
Putting Clients’ Needs Before Your Own 37
Ethical Decision Making 38
The Right of Informed Consent 40
Dimensions of Confidentiality 41
Ethical Issues in a Multicultural Perspective 42
Ethical Issues in the Assessment Process 44
Ethical Aspects of Evidence-Based Practice 46
Contents
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Managing Multiple Relationships in Counseling Practice 48
Becoming an Ethical Counselor 51
Summary 52
Where to Go From Here 52
Recommended Supplementary Readings for Part 1 53
References and Suggested Readings for Part 1 55
PA R T 2
Theories and Techniques of Counseling 61
4 Psychoanalytic Therapy 62
Introduction 63
Key Concepts 64
The Therapeutic Process 72
Application: Therapeutic Techniques and Procedures 78
Jung’s Perspective on the Development of Personality 83
Contemporary Trends: Object-Relations Theory,
Self Psychology, and Relational Psychoanalysis 85
Psychoanalytic Therapy From a Multicultural Perspective 91
Psychoanalytic Therapy Applied to the Case of Stan 92
Summary and Evaluation 94
Where to Go From Here 97
Recommended Supplementary Readings 98
References and Suggested Readings 99
5 Adlerian Therapy 101
Introduction 102
Key Concepts 103
The Therapeutic Process 109
Application: Therapeutic Techniques and Procedures 113
Adlerian Therapy From a Multicultural Perspective 123
Adlerian Therapy Applied to the Case of Stan 125
Summary and Evaluation 127
Where to Go From Here 129
Recommended Supplementary Readings 131
References and Suggested Readings 132
6 Existential Therapy 136
Introduction 139
Key Concepts 145
The Therapeutic Process 154
Application: Therapeutic Techniques and Procedures 157
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Existential Therapy From a Multicultural Perspective 160
Existential Therapy Applied to the Case of Stan 162
Summary and Evaluation 163
Where to Go From Here 166
Recommended Supplementary Readings 168
References and Suggested Readings 169
7 Person-Centered Therapy 172
Introduction 173
Key Concepts 178
The Therapeutic Process 179
Application: Therapeutic Techniques and Procedures 184
Person-Centered Expressive Arts Therapy 189
Motivational Interviewing 191
Person-Centered Therapy From a Multicultural Perspective 194
Person-Centered Therapy Applied to the Case of Stan 196
Summary and Evaluation 197
Where to Go From Here 203
Recommended Supplementary Readings 205
References and Suggested Readings 206
8 Gestalt Therapy 210
Introduction 212
Key Concepts 213
The Therapeutic Process 219
Application: Therapeutic Techniques and Procedures 224
Gestalt Therapy From a Multicultural Perspective 233
Gestalt Therapy Applied to the Case of Stan 234
Summary and Evaluation 236
Where to Go From Here 239
Recommended Supplementary Readings 241
References and Suggested Readings 241
9 Behavior Therapy 244
Introduction 247
Key Concepts 250
The Therapeutic Process 252
Application: Therapeutic Techniques and Procedures 255
Behavior Therapy From a Multicultural Perspective 274
Behavior Therapy Applied to the Case of Stan 276
Summary and Evaluation 277
Where to Go From Here 281
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Recommended Supplementary Readings 282
References and Suggested Readings 282
10 Cognitive Behavior Therapy 287
Introduction 290
Albert Ellis’s Rational Emotive Behavior Therapy 291
Key Concepts 292
The Therapeutic Process 295
Application: Therapeutic Techniques and Procedures 297
Aaron Beck’s Cognitive Therapy 302
Donald Meichenbaum’s Cognitive Behavior Modification 310
Cognitive Behavior Therapy From a Multicultural Perspective 315
Cognitive Behavior Therapy Applied to the Case of Stan 318
Summary and Evaluation 320
Where to Go From Here 324
Recommended Supplementary Readings 327
References and Suggested Readings 327
11 Reality Therapy 333
Introduction 335
Key Concepts 336
The Therapeutic Process 340
Application: Therapeutic Techniques and Procedures 342
Reality Therapy From a Multicultural Perspective 349
Reality Therapy Applied to the Case of Stan 352
Summary and Evaluation 354
Where to Go From Here 356
Recommended Supplementary Readings 357
References and Suggested Readings 358
12 Feminist Therapy 360
Introduction 362
Key Concepts 367
The Therapeutic Process 370
Application: Therapeutic Techniques and Procedures 373
Feminist Therapy From a Multicultural and Social
Justice Perspective 380
Feminist Therapy Applied to the Case of Stan 382
Summary and Evaluation 384
Where to Go From Here 388
Recommended Supplementary Readings 390
References and Suggested Readings 391
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13 Postmodern Approaches 395
Introduction to Social Constructionism 397
Solution-Focused Brief Therapy 400
Narrative Therapy 410
Postmodern Approaches From a Multicultural Perspective 419
Postmodern Approaches Applied to the Case of Stan 421
Summary and Evaluation 423
Where to Go From Here 426
Recommended Supplementary Readings 429
References and Suggested Readings 429
14 Family Systems Therapy 432
Introduction 434
Development of Family Systems Therapy and Personal
Development of the Family Therapist 437
A Multilayered Process of Family Therapy 445
Family Systems Therapy From a Multicultural Perspective 451
Family Systems Therapy Applied to the Case of Stan 452
Summary and Evaluation 456
Where to Go From Here 458
Recommended Supplementary Readings 458
References and Suggested Readings 459
PA R T 3
Integration and Application�463
15 An Integrative Perspective�464
Introduction 465
The Movement Toward Psychotherapy Integration 465
Issues Related to the Therapeutic Process 477
The Place of Techniques and Evaluation in Counseling 483
Summary 497
Where to Go From Here 498
Recommended Supplementary Readings 499
References and Suggested Readings 499
16 Case Illustration: An Integrative Approach
in Working With Stan 503
Counseling Stan: Integration of Therapies 504
Concluding Comments 521
A U T H O R I N D E X 523
S U B J E C T I N D E X 528
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

xii
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This book is intended for counseling courses for undergraduate and graduate stu-
dents in psychology, counselor education, human services, and the mental health
professions. It surveys the major concepts and practices of the contemporary ther-
apeutic systems and addresses some ethical and professional issues in counseling
practice. The book aims to teach students to select wisely from various theories and
techniques and to begin to develop a personal style of counseling.
I have found that students appreciate an overview of the divergent contem-
porary approaches to counseling and psychotherapy. They also consistently say
that the first course in counseling means more to them when it deals with them
personally. Therefore, I stress the practical application of the material and encour-
age reflection. Using this book can be both a personal and an academic learning
experience.
In this ninth edition, every effort has been made to retain the major qualities
that students and professors have found helpful in the previous editions: the suc-
cinct overview of the key concepts of each theory and their implications for prac-
tice, the straightforward and personal style, and the book’s comprehensive scope.
Care has been taken to present the theories in an accurate and fair way. I have at-
tempted to be simple, clear, and concise. Because many students want suggestions
for supplementary reading as they study each therapy approach, I have included an
updated reading list at the end of each chapter.
This edition updates the material and refines existing discussions. Part 1 deals
with issues that are basic to the practice of counseling and psychotherapy. Chapter 1
puts the book into perspective, then students are introduced to the counselor—
as a person and a professional—in Chapter 2. This chapter addresses a number
of topics pertaining to the role of the counselor as a person and the therapeutic
relationship. Chapter 3 introduces students to some key ethical issues in coun-
seling practice, and several of the topics in this chapter have been updated and
expanded.
Part 2 is devoted to a consideration of 11 theories of counseling. Each of the
theory chapters follows a common organizational pattern, and students can easily
compare and contrast the various models. This pattern includes core topics such
as key concepts, the therapeutic process, therapeutic techniques and procedures,
multicultural perspectives, theory applied to the case of Stan, and summary and
evaluation. In this ninth edition, all of the chapters in Part 2 have been revised,
updated, and expanded to reflect recent trends. Revisions were based on the rec-
ommendations of experts in each theory, all of whom are listed in the Acknowledg-
ments section. Both expert and general reviewers provided suggestions for adding,
replacing, and expanding material for this edition. Attention was given to current
Preface
n of 11 theo
zational patt
This pattern
erapeutic t
to the ca
he chapte
trends. R
, all of wh
eviewers
is edition.
f the
nts can easily
ludes core topics such
echniques and procedures,
e of Stan, and summary and
s in Part 2 ha
evisions w
m are li
rovide
Atten
ave been revised,
ere based on the rec-
sted in the Acknowledg-
suggestions for adding,
rental for t
uggestions for addin
on was given to curr
y p
mpare and cont
oncepts, the t
ral perspectiv
n this ninth
expanded to r
s of experts in
Both expert a
expanding m
key c
lticultu
uation.
ated, and
mendatio
ents sectio
replacing, an
up
om
m
g
onship. Chapter 3 in
eling practice, and several
expanded.
Part 2 is devoted to a consid
theory chapters follows a common
st the various m
rapeutic proce
theory applie
ion, all o
c
a
m
e
tion update
with issues that are bas
puts the book into pe
as a person and a pro
of topics p
rela
Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

xiii
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trends and recent developments in the practice of each theoretical approach. For
each chapter in Part 2, the citations have been updated.
Each of the 11 theory chapters summarizes key points and evaluates the con-
tributions, strengths, limitations, and applications of these theories. Special
attention is given to evaluating each theory from a multicultural perspective as
well, with a commentary on the strengths and shortcomings of the theory in
working with diverse client populations. The consistent organization of the sum-
mary and evaluation sections makes comparing theories easier. Students are
given recommendations regarding where to look for further training for all of the
approaches. Updated annotated lists of reading suggestions and extensive refer-
ences at the end of these chapters are offered to stimulate students to expand on
the material and broaden their learning through further reading. In addition, a
list of DVD resources has been added to the ninth edition for each of the theory
chapters.
w h at ’s n e w i n t h i s e d i t i o n
Significant changes for the ninth edition for each of the theory chapters are out-
lined below:
c h a p t e r 4 Psychoanalytic Therapy
Increased emphasis on the role of the relationship in analytic therapy
Increased coverage on contemporary psychodynamic therapy
Broadened discussion of relational psychoanalysis
A new perspective on therapist neutrality and anonymity
More emphasis on the role of termination in analytic therapy
New material on countertransference, its role in psychoanalytic therapy, and
guidelines for effectively dealing with countertransference
Expanded discussion of resistance and how to work with it effectively
Revised and expanded section on brief psychodynamic therapy
c h a p t e r 5 Adlerian Therapy
Revised material on the concept of lifestyle
Expanded discussion of social interest
New material on early recollections
Streamlined discussion of some key concepts
c h a p t e r 6 Existential Therapy
Revised material on existential themes
New and expanded coverage of the contributions of Irvin Yalom and James
Bugental to existential therapy
More attention on international developments of existential therapy
New material on main aims of existential therapy
Revised section on the client–therapist relationship
Revised discussion of strengths of the approach from a diversity perspective
New discussion of integration of existential concepts in other therapies
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xiv
c h a p t e r 7 Person-Centered Therapy
Expanded coverage on the contributions and influence of Carl Rogers on the
counseling profession
New section on the Abraham Maslow’s contributions to humanistic philosophy
and psychology
New material on Maslow’s concept of self-actualization and relation to person-
centered philosophy
Broadened discussion of clients as active self-healers
Updated coverage of the core conditions of congruence, unconditional positive
regard, and empathy
Recent research on contextual factors as the main predictors of effective therapy
New material on the limitations and criticisms of the approach
New material on the diversity of styles of practicing person-centered therapy
More emphasis on how the basic philosophy of the person-centered approach
can be applied to other therapeutic modalities
Inclusion of emotion-focused therapy, stressing the role of emotions as a route
to change
Revised coverage on person-centered expressive arts
New section on motivational interviewing (person-centered approach with a twist)
Additional coverage of the stages of change as applied to motivational inter-
viewing
c h a p t e r 8 Gestalt Therapy
Revised discussion of the role of experiments in Gestalt therapy
More emphasis on therapist presence
Added description of emotion-focused therapy and its relationship to Gestalt
therapy
More attention to the relational approach to Gestalt practice
c h a p t e r 9 Behavior Therapy
Increased attention to the trends in contemporary behavior therapy
Broadened discussion of the role of the therapeutic relationship in behavior
therapy
Expanded and updated discussion of social skills training
Revision of multimodal therapy section
Revised discussion of systematic desensitization and exposure procedures
Revision of section on EMDR
More attention to the role of mindfulness and acceptance strategies in contem-
porary behavior therapy
New material on mindfulness-based cognitive therapy and stress reduction
Expanded and revised treatment of dialectical behavior therapy
c h a p t e r 1 0 Cognitive Behavior Therapy
Revised and expanded coverage of Aaron Beck’s cognitive therapy
Increased coverage of Judith Beck’s role in the development of cognitive therapy
P
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xv
Increased attention on Donald Meichenbaum’s influence in the development
of CBT
New material on Meichenbaum’s stress inoculation training
Revised section on Meichenbaum’s constructivist approach to CBT
Increased coverage of relapse prevention
Increased discussion of CBT from a multicultural perspective
New material on the potential limitations of the multicultural applications of CBT
c h a p t e r 1 1 Reality Therapy
Revised discussion of the relationship of choice theory to reality therapy
Expanded discussion of the role of questions in reality therapy
Revision of section on the role of planning in reality therapy
More emphasis on the value of reality therapy with reluctant clients
Additional material on reality therapy from a diversity perspective
c h a p t e r 1 2 Feminist Therapy
Updated treatment of the principles of feminist therapy
Updated discussion of the role of assessment and diagnosis in feminist therapy
Increased attention given to empowerment
New example of applying feminist therapy interventions with the case of Alma
Revised and expanded discussion on therapeutic techniques and strategies
c h a p t e r 1 3 Postmodern Approaches
Additional material on parallels between solution-focused brief therapy and
positive psychology
Broadened discussion of the key concepts of solution-focused brief therapy
(SFBT)
More emphasis on the client-as-expert in the therapy relationship in postmod-
ern approaches
Revision of material on techniques in the postmodern approaches
New material on listening with an open mind in narrative therapy
More emphasis on the collaborative nature of narrative therapy and SFBT
c h a p t e r 1 4 Family Systems Therapy
A reconceptualization and streamlining of the chapter
New section describing the multilayered process of family therapy
More emphasis on the personal development of the family therapist
Addition of reflection questions to assist in the personal application of family
theory
New material on genogram work for understanding the self of the therapist
and clients
Expanded section on recent developments in family therapy
New material on the postmodern perspective on family therapy
More attention given to feminism, multiculturalism, and postmodern constru-
ctionism as applied to family therapy
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xvi
In Part 3 readers are helped to put the concepts together in a meaningful
way through a discussion of the integrative perspective and consideration of a
case study. Chapter 15 (“An Integrative Perspective”) pulls together themes from
all 11 theoretical orientations. This chapter has been revised to expand discus-
sion of the psychotherapy integration movement; revise treatment of the various
integrative approaches; update and expand the section on integration of multi-
cultural issues in counseling; revise the section on integration of spirituality in
counseling; add material on research demonstrating the importance of the thera-
peutic relationship; more discussion on the central role of the client in determin-
ing therapy outcomes; and update coverage of the conclusions from the research
literature on the effectiveness of psychotherapy. Chapter 15 develops the notion
that an integrative approach to counseling practice is in keeping with meeting
the needs of diverse client populations in many different settings. Numerous
tables and other integrating material help students compare and contrast the 11
approaches.
The “Case of Stan” has been retained in Chapter 16 to help readers see the
application of a variety of techniques at various stages in the counseling process
with the same client. This chapter illustrates an integrative approach that draws
from all the therapies and applies a thinking, feeling, and behaving model in
counseling Stan. Applying the various theories to a single case example allows
for a comparison among the approaches. The video program (DVD for Theory
and Practice of Counseling and Psychotherapy: The Case of Stan and Lecturettes) can
be used as an ideal supplement to this chapter. For each of the 13 sessions in the
DVD program in my counseling with Stan, I apply just a few selected techniques
designed to illustrate each theory in action. New to accompany this ninth edition
is a series of lecturettes that I present for each chapter in this textbook. This ex-
panded DVD program now includes both demonstrations of my counseling with
Stan and brief lectures that highlight my perspective on the practical applications
of each theory.
This text can be used in a flexible way. Some instructors will follow my se-
quencing of chapters. Others will prefer to begin with the theory chapters (Part 2)
and then deal later with the student’s personal characteristics and ethical issues.
The topics can be covered in whatever order makes the most sense. Readers are
offered some suggestions for using this book in Chapter 1.
In this edition I have made every effort to incorporate those aspects that have
worked best in the courses on counseling theory and practice that I regularly teach.
To help readers apply theory to practice, I have also revised the Student Manual,
which is designed for experiential work. The Student Manual for Theory and Prac-
tice of Counseling and Psychotherapy still contains open-ended questions, many new
cases for exploration and discussion, structured exercises, self-inventories, and a
variety of activities that can be done both in class and out of class. The ninth edition
features a structured overview, as well as a glossary, for each of the theories, and
chapter quizzes for assessing the level of student mastery of basic concepts.
CourseMate, a new online resource, is available to accompany this textbook. It
contains the video program for Theory and Practice of Counseling and Psychotherapy:
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xvii
The Case of Stan and Lecturettes, as well as a glossary of key terms, interviews with ex-
perts (questions and answers by experts in the various theories), and case examples
for each of the theories illustrating ways of applying these concepts and techniques
to a counseling case.
The newly revised and enlarged Case Approach to Counseling and Psychotherapy
(Eighth Edition) features experts working with the case of Ruth from the vari-
ous therapeutic approaches. The casebook can either supplement this book or
stand alone. An additional chapter covering transactional analysis is available on
WebTutor.® This material is provided in the same format as the 11 theory chapters
in this book and includes experiential exercises that can be completed individually
or in small groups.
Accompanying this ninth edition of the text and Student Manual is a DVD for
Integrative Counseling: The Case of Ruth and Lecturettes, in which I demonstrate an
integrative approach in counseling Ruth (the central character in the casebook).
It contains lecturettes on how I draw from key concepts and techniques from the
various theories presented in the book. This DVD program has been developed for
student purchase and use as a self-study program, and it makes an ideal learning
package that can be used in conjunction with this text and the Student Manual.
The Art of Integrative Counseling (Third Edition), which expands on the material in
Chapter 15 of the textbook, also complements this book.
Some professors have found the textbook and the Student Manual or the online
program (CourseMate) to be ideal companions and realistic resources for a single
course. Others like to use the textbook and the casebook as companions. With
this revision it is now possible to have a unique learning package of several books,
along with the DVD for Integrative Counseling: The Case of Ruth and Lecturettes. The
Case Approach to Counseling and Psychotherapy and the Art of Integrative Counseling
can also be used in a various classes, a few of which include case-management
practicum, fieldwork courses, or counseling techniques courses.
Also available is a revised and updated Instructor’s Resource Manual, which
includes suggestions for teaching the course, class activities to stimulate inter-
est, PowerPoint presentations for all chapters, and a variety of test questions
and final examinations. This instructor’s manual is now geared for the following
learning package: Theory and Practice of Counseling and Psychotherapy, Student
Manual for Theory and Practice of Counseling and Psychotherapy, Case Approach
to Counseling and Psychotherapy, The Art of Integrative Counseling, and two video
programs: DVD for Integrative Counseling: The Case of Ruth and Lecturettes, and
DVD for Theory and Practice of Counseling and Psychotherapy: The Case of Stan and
Lecturettes.
Acknowledgments
The suggestions I received from the many readers of prior editions who took the
time to complete the survey at the end of the book have been most helpful. Many
other people have contributed ideas that have found their way into this ninth
edition. I especially appreciate the time and efforts of the manuscript reviewers,
who offered constructive criticism and supportive commentaries, as well as those
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professors who have used this book and provided me with feedback that has been
most useful in these revisions. Those who reviewed the complete manuscript of
the ninth edition are:
Sylinda Banks, Norfolk State University
Jayne Barnes, Nashua Community College
Eric Bruns, Campbellsville University
Joya Crear, George Mason University
Samantha Daniel, Fayetteville State University
Melodie Frick, West Texas A&M University
Amanda Healey, Sam Houston State University
Paula Nelson, Saint Leo University
Terence Patterson, University of San Francisco
Holly Seirup, Hofstra University
Special thanks are extended to the chapter reviewers, who provided consulta-
tion and detailed critiques. Their insightful and valuable comments have generally
been incorporated into this edition:
Chapter 4 (Psychoanalytic Therapy): William Blau, Copper Mountain College,
Joshua Tree, California; and J. Michael Russell of California State University,
Fullerton
Chapter 5 (Adlerian Therapy): James Robert Bitter, East Tennessee State
University, and I coauthored Chapter 5
Chapter 6 (Existential Therapy): Emmy van Deurzen, New School of Psy-
chotherapy and Counselling, London, England, and University of Sheffield;
J. Michael Russell of California State University, Fullerton; David N. Elkins,
Graduate School of Education and Psychology, Pepperdine University; Bryan
Farha, Oklahoma City College; Jamie Bludworth, private practice, Phoeniz,
Arizona; Kirk Schneider, the Existential-Humanistic Institute; and Victor
Yalom, president, Psychotherapy.Net
Chapter 7 (Person-Centered Therapy): Natalie Rogers, Person-Centered Ex-
pressive Arts Associates, Cotati, California; David N. Elkins, Graduate School
of Education and Psychology, Pepperdine University; and David Cain, Cali-
fornia School of Professional Psychology at Alliant International University,
San Diego
Chapter 8 (Gestalt Therapy): Jon Frew, Private Practice, Vancouver, Washington,
and Pacific University, Oregon; Ansel Woldt, Kent State University
Chapter 9 (Behavior Therapy): Sherry Cormier, West Virginia University;
Frank M. Dattilio, Harvard Medical School, and the University of Pennsylvania
School of Medicine; and Arnold A. Lazarus, Rutgers University, and the Lazarus
Institute
Chapter 10 (Cognitive Behavior Therapy): Sherry Cormier, West Virginia
University; Frank M. Dattilio, Harvard Medical School, and the University of
Pennsylvania School of Medicine; Windy Dryden, Professor of Psychothera-
peutic Studies at Goldsmiths College, London; and Donald Meichenbaum,
Research Director of the Melissa Institute for Violence Prevention
xviii
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Chapter 11 (Reality Therapy): Robert Wubbolding, Center for Reality Therapy,
Cincinnati, Ohio
Chapter 12 (Feminist Therapy): Carolyn Zerbe Enns, Cornell College; Barbara
Herlihy, University of New Orleans, and I coauthored Chapter 12
Chapter 13 (Postmodern Approaches): John Winslade, California State Uni-
versity, San Bernardino; Linda Metcalf, Texas Women’s University, and the
Solution Focused Institute for Education and Training; and John Murphy, Uni-
versity of Central Arkansas
Chapter 14 (Family Systems Therapy): Jon Carlson, Governors State Univer-
sity; James Robert Bitter, East Tennessee State University, and I coauthored
Chapter 14
I want to acknowledge those on the Brooks/Cole, Cengage Learning team who are
involved with our projects. These people include Seth Dobrin, editor of counseling,
social work, and human services; Julie Martinez, consulting editor, who monitored
the review process; Caryl Gorska, for her work on the interior design and cover of
this book; Elizabeth Momb, media editor; Naomi Dreyers, supplemental materials
for the book; Michelle Muratori, Johns Hopkins University, for her work on up-
dating the Instructor’s Resource Manual and assisting in developing the other sup-
plements; and Rita Jaramillo, project manager. We thank Ben Kolstad of Cenveo
Publisher Services, who coordinated the production of this book. Special recogni-
tion goes to Kay Mikel, the manuscript editor of this edition, whose exceptional
editorial talents continue to keep this book reader friendly. We appreciate Susan
Cunningham’s work in preparing the index. The efforts and dedication of all of
these people certainly contribute to the high quality of this edition.
– Gerald Corey
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3
p a r t 1
Basic Issues in
Counseling Practice
1 I n t r o d u c t i o n a n d O v e r v i e w 4
2 Th e Co u n s e lo r : P e r s o n a n d P r o f e s s i o n a l 17
3 E t h i c a l I s s u e s i n Co u n s e l i n g P r a c t i c e 36
R e c o m m e n d e d S u p p l e m e n ta ry R e a d i n g s
f o r Pa r t 1 53
R e f e r e n c e s a n d S u g g e s t e d R e a d i n g s
f o r Pa r t 1 55
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i n t r o d u ct i o n
w h e r e i sta n d
s u g g est i o n s f o r u s i n g t h e b o o k
ov e rv i e w o f t h e t h eo ry c h a p t e r s
i n t r o d u ct i o n to t h e c a s e o f sta n
• Intake Interview and Stan’s Autobiography
• Overview of Some Key Themes in Stan’s Life
c h a p t e r 1
Introduction and Overview
4
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i n t r o d u c t i o n
Counseling students can begin to acquire a counseling style tailored to their own
personality by familiarizing themselves with the major approaches to therapeutic
practice. This book surveys 11 approaches to counseling and psychotherapy, pre-
senting the key concepts of each approach and discussing features such as the
therapeutic process (including goals), the client–therapist relationship, and spe-
cifi c procedures used in the practice of counseling. This information will help you
develop a balanced view of the major ideas of each of the theories and acquaint
you with the practical techniques commonly employed by counselors who adhere
to each approach. I encourage you to keep an open mind and to seriously consider
both the unique contributions and the particular limitations of each therapeutic
system presented in Part 2.
You do not gain the knowledge and experience needed to synthesize various
approaches by merely completing an introductory course in counseling theory.
This process will take many years of study, training, and practical counseling ex-
perience. Nevertheless, I recommend a personal integration as a framework for
the professional education of counselors. The danger in presenting one model to
which all students are expected to subscribe is that it can limit their effectiveness
in working with a diverse range of future clients.
An undisciplined mixture of approaches, however, can be an excuse for
failing to develop a sound rationale for systematically adhering to certain con-
cepts and to the techniques that are extensions of them. It is easy to pick and
choose fragments from the various therapies because they support our biases
and preconceptions. By studying the models presented in this book, you will
have a better sense of how to integrate concepts and techniques from differ-
ent approaches when defi ning your own personal synthesis and framework for
counseling.
Each therapeutic approach has useful dimensions. It is not a matter of a theory
being “right” or “wrong,” as every theory offers a unique contribution to under-
standing human behavior and has unique implications for counseling practice.
Accepting the validity of one model does not necessarily imply rejecting other
models. There is a clear place for theoretical pluralism, especially in a society that
is becoming increasingly diverse.
Although I suggest that you remain open to incorporating diverse approaches
into your own personal synthesis—or integrative approach to counseling—let
me caution that you can become overwhelmed and confused if you attempt to
learn everything at once, especially if this is your introductory course in coun-
seling theories. A case can be made for initially getting an overview of the major
theoretical orientations, and then learning a particular approach by becoming
steeped in that approach for some time, rather than superfi cially grasping many
theoretical approaches. An integrative perspective is not developed in a random
fashion; rather, it is an ongoing process that is well thought out. Successfully
integrating concepts and techniques from diverse models requires years of refl ec-
tive practice and a great deal of reading about the various theories. In Chapter 15
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I discuss in more depth some ways to begin designing your integrative approach
to counseling practice.
See the video program for Chapter 1, DVD for Theory and Practice of
Counseling and Psychotherapy: The Case of Stan and Lecturettes. I suggest
that you view the brief lecturette for each chapter in this book prior to
reading the chapter.
w h e r e i s ta n d
My philosophical orientation is strongly infl uenced by the existential approach.
Because this approach does not prescribe a set of techniques and procedures, I
draw techniques from the other models of therapy that are presented in this book.
I particularly like to use role-playing techniques. When people reenact scenes from
their lives, they tend to become more psychologically engaged than when they
merely report anecdotes about themselves. I also incorporate many techniques
derived from cognitive behavior therapy.
The psychoanalytic emphasis on early psychosexual and psychosocial develop-
ment is useful. Our past plays a crucial role in shaping our current personality and
behavior. I challenge the deterministic notion that humans are the product of their
early conditioning and, thus, are victims of their past. But I believe that an explora-
tion of the past is often useful, particularly to the degree that the past continues to
infl uence present-day emotional or behavioral diffi culties.
I value the cognitive behavioral focus on how our thinking affects the way we
feel and behave. These therapies also emphasize current behavior. Thinking and
feeling are important dimensions, but it can be a mistake to overemphasize them
and not explore how clients are behaving. What people are doing often gives us a
good clue to what they really want. I also like the emphasis on specifi c goals and
on encouraging clients to formulate concrete aims for their own therapy sessions
and in life. Contracts between clients and therapists can be very useful. I frequently
suggest either specifi c homework assignments or ask my clients to devise their own
assignments, or together we develop goals and tasks that guide the therapy process.
More approaches have been developing methods that involve collaboration be-
tween therapist and client, making the therapeutic venture a shared responsibility.
This collaborative relationship, coupled with teaching clients ways to use what they
learn in therapy in their everyday lives, empowers clients to take an active stance
in their world. It is imperative that clients be active, not only in their counseling
sessions but in daily life as well. Homework can be a vehicle for assisting clients in
putting into action what they are learning in therapy.
A related assumption of mine is that we can exercise increasing freedom to cre-
ate our future. The acceptance of personal responsibility does not imply that we can
be anything that we want. Social, environmental, cultural, and biological realities
oftentimes limit our freedom of choice. Being able to choose must be considered
in the sociopolitical contexts that exert pressure or create constraints; oppression
is a reality that can restrict our ability to choose our future. We are also infl uenced
by our social environment, and much of our behavior is a product of learning and
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conditioning. That being said, I believe an increased awareness of these contextual
forces enables us to address these realities. It is crucial to learn how to cope with
the external and internal forces that limit our decisions and behavior.
Feminist therapy has contributed an awareness of how environmental and
social conditions contribute to the problems of women and men and how gender-
role socialization leads to a lack of gender equality. Family therapy teaches us that
it is not possible to understand the individual apart from the context of the system.
Both family therapy and feminist therapy are based on the premise that to un-
derstand the individual it is essential to take into consideration the interpersonal
dimensions and the sociocultural context rather than focusing primarily on the
intrapsychic domain. Thus a comprehensive approach to counseling goes beyond
focusing on our internal dynamics and addresses those environmental and sys-
temic realities that infl uence us.
My philosophy of counseling does not include the assumption that therapy is
exclusively for the “sick” and is aimed at “curing” psychological “ailments.” Such
a focus on the medical model restricts therapeutic practice because it stresses
defi cits rather than strengths. Instead, I agree with the postmodern approaches
(see Chapter 13), which are grounded on the assumption that people have both
internal and external resources to draw upon when constructing solutions to their
problems. Therapists will view these individuals quite differently if they acknowl-
edge that their clients possess competencies rather than pathologies. I view each
individual as having resources and competencies that can be discovered and built
upon in therapy.
Psychotherapy is a process of engagement between two people, both of whom
are bound to change through the therapeutic venture. At its best, this is a collabora-
tive process that involves both the therapist and the client in co-constructing
solutions to concerns. Most of the theories described in this book emphasize the
collaborative nature of the practice of psychotherapy.
Therapists are not in business to change clients, to give them quick advice, or
to solve their problems for them. Instead, counselors facilitate healing through
a process of genuine dialogue with their clients. The kind of person a therapist
is remains the most critical factor affecting the client and promoting change. If
practitioners possess wide knowledge, both theoretical and practical, yet lack
human qualities of compassion, caring, good faith, honesty, presence, realness,
and sensitivity, they are more like technicians. In my judgment those who func-
tion exclusively as technicians do not make a signifi cant difference in the lives of
their clients. It is essential that counselors explore their own values, attitudes, and
beliefs in depth and work to increase their own awareness. Throughout the book,
I encourage you to fi nd ways to personally relate to each of the therapies. Applying
this material to yourself personally takes you beyond a mere academic understand-
ing of theories.
With respect to mastering the techniques of counseling and applying them
appropriately and effectively, it is my belief that you are your own very best tech-
nique. Your reactions to your clients, including sharing how you are affected in
the relationship with them, are useful in moving the therapeutic process along.
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It is impossible to separate the techniques you use from your personality and the
relationship you have with your clients.
Administering techniques to clients without regard for the relationship var-
iables is ineffective. Techniques cannot substitute for the hard work it takes to
develop a constructive client–therapist relationship. Although you can learn atti-
tudes and skills and acquire certain knowledge about personality dynamics and
the therapeutic process, much of effective therapy is the product of artistry. Coun-
seling entails far more than becoming a skilled technician. It implies that you are
able to establish and maintain a good working relationship with your clients, that
you can draw on your own experiences and reactions, and that you can identify
techniques suited to the needs of your clients.
As a counselor, you need to remain open to your own personal development
and to address your personal problems. The most powerful ways for you to teach
your clients is by the behavior you model and by the ways you connect with
them. I suggest you experience a wide variety of techniques yourself as a client.
Reading about a technique in a book is one thing; actually experiencing it from
the vantage point of a client is quite another. If you have practiced mindfulness
exercises, for example, you will have a much better sense for guiding clients in
the practice of becoming increasingly mindful in daily life. If you have carried
out real-life homework assignments as part of your own self-change program,
you can increase your empathy for clients and their potential problems. Your
own anxiety over self-disclosing and addressing personal concerns can be a most
useful anchoring point as you work with the anxieties of your clients. The cour-
age you display in your therapy will help you appreciate how essential courage is
for your clients.
Your personal characteristics are of primary importance in becoming a coun-
selor, but it is not suffi cient to be merely a good person with good intentions. To
be effective, you also must have supervised experiences in counseling and sound
knowledge of counseling theory and techniques. Further, it is essential to be well
grounded in the various theories of personality and to learn how they are related to
theories of counseling. Your conception of the person and the individual characteris-
tics of your client affect the interventions you will make. Differences between you
and your client may require modifi cation of certain aspects of the theories. Some
practitioners make the mistake of relying on one type of intervention (supportive,
confrontational, information giving) for most clients with whom they work. In
reality, different clients may respond better to one type of intervention than to
another. Even during the course of an individual’s therapy, different interventions
may be needed at different times. Practitioners should acquire a broad base of
counseling techniques that are suitable for individual clients rather than forcing
clients to fi t one approach to counseling.
s u g g e s t i o n s f o r u s i n g t h e b o o k
Here are some specifi c recommendations on how to get the fullest value from this
book. The personal tone of the book invites you to relate what you are reading to your
own experiences. As you read Chapter 2, “The Counselor: Person and Professional,”
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begin the process of refl ecting on your needs, motivations, values, and life expe-
riences. Consider how you are likely to bring the person you are becoming into
your professional work. You will assimilate much more knowledge about the vari-
ous therapies if you make a conscious attempt to apply their key concepts and
techniques to your own personal life. Chapter 2 helps you think about how to use
yourself as your single most important therapeutic instrument, and it addresses a
number of signifi cant ethical issues in counseling practice.
Before you study each therapy in depth in Part 2, I suggest that you at least
briefl y read Chapter 15, which provides a comprehensive review of the key concepts
from all 11 theories presented in this textbook. I try to show how an integration of
these perspectives can form the basis for creating your own personal synthesis to
counseling. In developing an integrative perspective, it is essential to think holisti-
cally. To understand human functioning, it is imperative to account for the physi-
cal, emotional, mental, social, cultural, political, and spiritual dimensions. If any
of these facets of human experience is neglected, a theory is limited in explaining
how we think, feel, and act.
To provide you with a consistent framework for comparing and contrasting
the various therapies, the 11 theory chapters share a common format. This format
includes a few notes on the personal history of the founder or another key fi gure;
a brief historical sketch showing how and why each theory developed at the time
it did; a discussion of the approach’s key concepts; an overview of the therapeutic
process, including the therapist’s role and client’s work; therapeutic techniques
and procedures; applications of the theory from a multicultural perspective;
application of the theory to the case of Stan; a summary and evaluation; sugges-
tions of how to continue your learning about each approach; and suggestions for
further reading.
Refer to the preface for a complete description of other resources that fi t as a
package and complement this textbook, including Student Manual for Theory and
Practice of Counseling and Psychotherapy and DVD for Integrative Counseling: The
Case of Ruth and Lecturettes. In addition, in DVD for Theory and Practice of Coun-
seling and Psychotherapy: The Case of Stan and Lecturettes, I demonstrate my way of
counseling Stan from the various theoretical approaches in 13 sessions and present
my perspective on the key concepts of each theory in a brief lecture, with emphasis
on the practical application of the theory.
o v e r v i e w o f t h e t h e o ry c h a p t e r s
I have selected 11 therapeutic approaches for this book. Table 1.1 presents an over-
view of these approaches, which are explored in depth in Chapters 4 through 14. I
have grouped these approaches into four general categories.
First are the psychodynamic approaches. Psychoanalytic therapy is based largely
on insight, unconscious motivation, and reconstruction of the personality. The
psychoanalytic model appears fi rst because it has had a major infl uence on all of
the other formal systems of psychotherapy. Some of the therapeutic models are ba-
sically extensions of psychoanalysis, others are modifi cations of analytic concepts
and procedures, and still others are positions that emerged as a reaction against
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TA B L E 1 .1 Overview of Contemporary Counseling Models
Psychodynamic Approaches
Psychoanalytic therapy Founder: Sigmund Freud. A theory of personality
development, a philosophy of human nature, and a method
of psychotherapy that focuses on unconscious factors that
motivate behavior. Attention is given to the events of the fi rst
6 years of life as determinants of the later development of
personality.
Adlerian therapy Founder: Alfred Adler. Key Figure: Following Adler, Rudolf
Dreikurs is credited with popularizing this approach in the
United States. This is a growth model that stresses assuming
responsibility, creating one’s own destiny, and fi nding meaning
and goals to create a purposeful life. Key concepts are used in
most other current therapies.
Experiential and Relationship-Oriented Therapies
Existential therapy Key fi gures: Viktor Frankl, Rollo May, and Irvin Yalom.
Reacting against the tendency to view therapy as a system of
well-defi ned techniques, this model stresses building therapy
on the basic conditions of human existence, such as choice,
the freedom and responsibility to shape one’s life, and self-
determination. It focuses on the quality of the person-to-person
therapeutic relationship.
Person-centered therapy Founder: Carl Rogers. Key fi gure: Natalie Rogers. This approach
was developed during the 1940s as a nondirective reaction
against psychoanalysis. Based on a subjective view of human
experiencing, it places faith in and gives responsibility to the
client in dealing with problems and concerns.
Gestalt therapy Founders: Fritz and Laura Perls. Key fi gures: Miriam and
Erving Polster. An experiential therapy stressing awareness and
integration; it grew as a reaction against analytic therapy.
It integrates the functioning of body and mind.
Cognitive Behavioral Approaches
Behavior therapy Key fi gures: B. F. Skinner, Arnold Lazarus, and Albert Bandura.
This approach applies the principles of learning to the
resolution of specifi c behavioral problems. Results are subject
to continual experimentation. The methods of this approach are
always in the process of refi nement.
Cognitive behavior therapy Key fi gure: A. T. Beck founded cognitive therapy, which gives
a primary role to thinking as it infl uences behavior; Judith
Beck continues to develop CBT. Donald Meichenbaum is
a prominent contributor to the development of cognitive
behavior therapy.
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psychoanalysis. Many theories of counseling and psychotherapy have borrowed
and integrated principles and techniques from psychoanalytic approaches.
Adlerian therapy differs from psychoanalytic theory in many respects, but it can
broadly be considered an analytic perspective. Adlerians focus on meaning, goals,
purposeful behavior, conscious action, belonging, and social interest. Although
Adlerian theory accounts for present behavior by studying childhood experiences,
it does not focus on unconscious dynamics.
The second category comprises the experiential and relationship-oriented thera-
pies: the existential approach, the person-centered approach, and Gestalt therapy.
The existential approach stresses a concern for what it means to be fully human.
Rational emotive
behavior therapy
Key fi gure: Albert Ellis founded rational emotive behavior
therapy, a highly didactic, cognitive, action-oriented model of
therapy that stresses the role of thinking and belief systems as
the root of personal problems.
Reality therapy Founder: William Glasser. Key fi gure: Robert Wubbolding. This
short-term approach is based on choice theory and focuses on
the client assuming responsibility in the present. Through the
therapeutic process, the client is able to learn more effective
ways of meeting her or his needs.
Systems and Postmodern Approaches
Feminist therapy This approach grew out of the efforts of many women, a few
of whom are Jean Baker Miller, Carolyn Zerbe Enns, Oliva
Espin, and Laura Brown. A central concept is the concern
for the psychological oppression of women. Focusing on
the constraints imposed by the sociopolitical status to which
women have been relegated, this approach explores women’s
identity development, self-concept, goals and aspirations, and
emotional well-being.
Postmodern approaches A number of key fi gures are associated with the development of
these various approaches to therapy. Steve de Shazer and Insoo
Kim Berg are the co-founders of solution-focused brief therapy.
Michael White and David Epston are the major fi gures associated
with narrative therapy. Social constructionism, solution-focused
brief therapy, and narrative therapy all assume that there is
no single truth; rather, it is believed that reality is socially
constructed through human interaction. These approaches
maintain that the client is an expert in his or her own life.
Family systems therapy A number of signifi cant fi gures have been pioneers of the
family systems approach, including Alfred Adler, Murray
Bowen, Virginia Satir, Carl Whitaker, Salvador Minuchin, Jay
Haley, and Cloé Madanes. This systemic approach is based
on the assumption that the key to changing the individual is
understanding and working with the family.
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It suggests certain themes that are part of the human condition, such as freedom
and responsibility, anxiety, guilt, awareness of being fi nite, creating meaning in
the world, and shaping one’s future by making active choices. This approach is not
a unifi ed school of therapy with a clear theory and a systematic set of techniques.
Rather, it is a philosophy of counseling that stresses the divergent methods of
understanding the subjective world of the person. The person-centered approach,
which is rooted in a humanistic philosophy, places emphasis on the basic attitudes
of the therapist. It maintains that the quality of the client–therapist relationship
is the prime determinant of the outcomes of the therapeutic process. Philosophi-
cally, this approach assumes that clients have the capacity for self-direction without
active intervention and direction on the therapist’s part. Another experiential ap-
proach is Gestalt therapy, which offers a range of experiments to help clients gain
awareness of what they are experiencing in the here and now—that is, the present.
In contrast to person-centered therapists, Gestalt therapists tend to take an active
role, yet they follow the leads provided by their clients. These approaches tend to
emphasize emotion as a route to bringing about change, and in a sense, they can
be considered emotion-focused therapies.
Third are the cognitive behavioral approaches, sometimes known as the action-
oriented therapies, because they all emphasize translating insights into behav-
ioral action. These approaches include reality therapy, behavior therapy, rational
emotive behavior therapy, and cognitive therapy. Reality therapy focuses on cli-
ents’ current behavior and stresses developing clear plans for new behaviors.
Like reality therapy, behavior therapy puts a premium on doing and on taking
steps to make concrete changes. A current trend in behavior therapy is toward
paying increased attention to cognitive factors as an important determinant of
behavior. Rational emotive behavior therapy and cognitive therapy highlight the
necessity of learning how to challenge inaccurate beliefs and automatic thoughts
that lead to behavioral problems. These cognitive behavioral approaches are used
to help people modify their inaccurate and self-defeating assumptions and to
develop new patterns of acting.
The fourth general approach encompasses the systems and postmodern perspec-
tives. Feminist therapy and family therapy are systems approaches, but they also
share postmodern notions. The systems orientation stresses the importance of
understanding individuals in the context of the surroundings that infl uence their
development. To bring about individual change, it is essential to pay attention to
how the individual’s personality has been affected by his or her gender-role sociali-
zation, culture, family, and other systems.
The postmodern approaches include social constructionism, solution-focused
brief therapy, and narrative therapy. These newer approaches challenge the basic
assumptions of most of the traditional approaches by assuming that there is no sin-
gle truth and that reality is socially constructed through human interaction. Both
the postmodern and the systemic theories focus on how people produce their own
lives in the context of systems, interactions, social conditioning, and discourse.
In my view, practitioners need to pay attention to what their clients are think-
ing, feeling, and doing, and a complete therapy system must address all three of
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these facets. Some of the therapies included here highlight the role that cognitive
factors play in counseling. Others place emphasis on the experiential aspects of
counseling and the role of feelings. Still others emphasize putting plans into action
and learning by doing. Combining all of these dimensions provides the basis
for a comprehensive therapy. If any of these dimensions is excluded, the therapy
approach is incomplete.
i n t r o d u c t i o n to t h e c a s e o f s ta n
You will learn a great deal by seeing a theory in action, preferably in a live
demonstration or as part of experiential activities in which you function in the
alternating roles of client and counselor. An online program (available in DVD
format as well) demonstrates one or two techniques from each of the theories.
As Stan’s counselor, I show how I would apply some of the principles of each
of the theories you are studying to Stan. Many of my students fi nd this case
history of the hypothetical client (Stan) helpful in understanding how various
techniques are applied to the same person. Stan’s case, which describes his life
and struggles, is presented here to give you signifi cant background material to
draw from as you study the applications of the theories. Each of the 11 theory
chapters in Part 2 includes a discussion of how a therapist with the orientation
under discussion is likely to proceed with Stan. We examine the answers to
questions such as these:
• What themes in Stan’s life merit special attention in therapy?
• What concepts would be useful to you in working with Stan on his problems?
• What are the general goals of Stan’s therapy?
• What possible techniques and methods would best meet these goals?
• What are some characteristics of the relationship between Stan and his therapist?
• How might the therapist proceed?
• How might the therapist evaluate the process and treatment outcomes of therapy?
In Chapter 16 (which I recommend you read early) I present how I would work
with Stan, suggesting concepts and techniques I would draw on from many of the
models (forming an integrative approach).
A single case illustrates both contrasts and parallels among the approaches.
It also will help you understand the practical applications of the 11 models and
provide a basis for integrating them. A summary of the intake interview with Stan,
his autobiography, and some key themes in his life are presented next to provide
a context for making sense of the way therapists with various theoretical orienta-
tions might work with Stan. Try to fi nd attributes of each approach that you can
incorporate into a personalized style of counseling.
Intake Interview and Stan’s Autobiography
The setting is a community mental health agency where both individual and group
counseling are available. Stan comes to counseling because of his drinking. He
was convicted of driving under the infl uence, and the judge determined that he
needed professional help. Stan recognizes that he does have problems, but he is
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not convinced that he is addicted to alcohol. Stan arrives for an intake interview
and provides the counselor with this information:
At the present time I work in construction. I like building houses, but probably won’t stay
in construction for the rest of my life. When it comes to my personal life, I’ve always had
diffi culty in getting along with people. I could be called a “loner.” I like people in my life,
but I don’t seem to know how to stay close to people. It probably has a lot to do with why I
drink. I’m not very good at making friends or getting close to people. Probably the reason I
sometimes drink a bit too much is because I’m so scared when it comes to socializing. Even
though I hate to admit it, when I drink, things are not quite so overwhelming. When I look
at others, they seem to know the right things to say. Next to them I feel dumb. I’m afraid
that people don’t fi nd me very interesting. I’d like to turn my life around, but I just don’t
know where to begin. That’s why I went back to school. I’m a part-time college student ma-
joring in psychology. I want to better myself. In one of my classes, Psychology of Personal
Adjustment, we talked about ourselves and how people change. We also had to write an
autobiographical paper.
That is the essence of Stan’s introduction. The counselor says that she would
like to read his autobiography. Stan hopes it will give her a better understanding
of where he has been and where he would like to go. He brings her the autobiog-
raphy, which reads as follows:
Where am I currently in my life? At 35 I feel that I’ve wasted most of my life. I should be
fi nished with college and into a career by now, but instead I’m only a junior. I can’t afford
to really commit myself to pursuing college full time because I need to work to support
myself. Even though construction work is hard, I like the satisfaction I get when I look at
what I have done.
I want to get into a profession where I could work with people. Someday, I’m hoping to get
a master’s degree in counseling or in social work and eventually work as a counselor with
kids who are in trouble. I know I was helped by someone who cared about me, and I would
like to do the same for someone else.
I have few friends and feel scared around most people. I feel good with kids. But I wonder
if I’m smart enough to get through all the classes I’ll need to become a counselor. One of
my problems is that I frequently get drunk. This happens when I feel alone and when I’m
scared of the intensity of my feelings. At fi rst drinking seemed to help, but later on I felt
awful. I have abused drugs in the past also.
I feel overwhelmed and intimidated when I’m around attractive women. I feel cold, sweaty,
and terribly nervous. I think they may be judging me and see me as not much of a man.
I’m afraid I just don’t measure up to being a real man. When I am sexually intimate with a
woman, I am anxious and preoccupied with what she is thinking about me.
I feel anxiety much of the time. I often feel as if I’m dying inside. I think about committing
suicide, and I wonder who would care. I can see my family coming to my funeral feeling
sorry for me. I feel guilty that I haven’t worked up to my potential, that I’ve been a failure,
that I’ve wasted much of my time, and that I let people down a lot. I get down on myself and
wallow in guilt and feel very depressed. At times like this I feel hopeless and that I’d be better
off dead. For all these reasons, I fi nd it diffi cult to get close to anyone.
There are a few bright spots. I did put a lot of my shady past behind me, and did get into
college. I like this determination in me—I want to change. I’m tired of feeling the way I do.
I know that nobody is going to change my life for me. It’s up to me to get what I want. Even
though I feel scared at times, I like that I’m willing to take risks.
What was my past like? A major turning point for me was the confi dence my supervisor
had in me at the youth camp where I worked the past few summers. He helped me get my
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job, and he also encouraged me to go to college. He said he saw a lot of potential in me for
being able to work well with young people. That was hard for me to believe, but his faith
inspired me to begin to believe in myself. Another turning point was my marriage and
divorce. This marriage didn’t last long. It made me wonder about what kind of man I was!
Joyce was a strong and dominant woman who kept repeating how worthless I was and how
she did not want to be around me. We had sex only a few times, and most of the time I was
not very good at it. That was hard to take. It made me afraid to get close to a woman. My
parents should have divorced. They fought most of the time. My mother (Angie) constantly
criticized my father (Frank Sr.). I saw him as weak and passive. He would never stand up
to her. There were four of us kids. My parents compared me unfavorably with my older
sister (Judy) and older brother (Frank Jr.). They were “perfect” children, successful honors
students. My younger brother (Karl) and I fought a lot. They spoiled him. It was all very
hard for me.
In high school I started using drugs. I was thrown into a youth rehabilitation facility for
stealing. Later I was expelled from regular school for fi ghting, and I landed in a continua-
tion high school, where I went to school in the mornings and had afternoons for on-the-job
training. I got into auto mechanics, was fairly successful, and even managed to keep myself
employed for 3 years as a mechanic.
I can still remember my father asking me: “Why can’t you be like your sister and brother?
Why can’t you do anything right?” And my mother treated me much the way she treated my
father. She would say: “Why do you do so many things to hurt me? Why can’t you grow up
and be a man? Things are so much better around here when you’re gone.” I recall crying
myself to sleep many nights, feeling terribly alone. There was no talk of religion in my house,
nor was there any talk of sex. In fact, I fi nd it hard to imagine my folks ever having sex.
Where would I like to be 5 years from now? What kind of person do I want to become? Most
of all, I would like to start feeling better about myself. I would like to be able to stop drink-
ing altogether and still feel good. I want to like myself much more than I do now. I hope
I can learn to love at least a few other people, most of all, a woman. I want to lose my fear
of women. I would like to feel equal with others and not always have to feel apologetic for
my existence. I want to let go of my anxiety and guilt. I want to become a good counselor
for kids. I’m not certain how I’ll change or even what all the changes are I hope for. I do
know that I want to be free of my self-destructive tendencies and learn how to trust people
more. Perhaps when I begin to like myself more, I’ll be able to trust that others will fi nd
something about me to like.
Effective therapists, regardless of their theoretical orientation, would pay atten-
tion to suicidal thoughts. In his autobiography Stan says, “I think about commit-
ting suicide.” At times he doubts that he will ever change and wonders if he’d be
“better off dead.” Before embarking on the therapeutic journey, the therapist would
need to make an assessment of Stan’s current ego strength (or his ability to manage
life realistically), which would include a discussion of his suicidal thoughts.
Overview of Some Key Themes in Stan’s Life
A number of themes appear to represent core struggles in Stan’s life. Here are
some of the statements we can assume that he may make at various points in his
therapy and themes that will be addressed from the theoretical perspectives in
Chapters 4 through 14:
• Although I’d like to have people in my life, I just don’t seem to know how to go
about making friends or getting close to people.
• I’d like to turn my life around, but I have no sense of direction.
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• I want to make a difference.
• I am afraid of failure.
• I know that when I feel alone, scared, and overwhelmed, I drink heavily to feel
better.
• I am afraid of women.
• Sometimes at night I feel a terrible anxiety and feel as if I’m dying.
• I often feel guilty that I’ve wasted my life, that I’ve failed, and that I’ve let people
down. At times like this, I get depressed.
• I like it that I have determination and that I really want to change.
• I’ve never really felt loved or wanted by my parents.
• I’d like to get rid of my self-destructive tendencies and learn to trust people more.
• I put myself down a lot, but I’d like to feel better about myself.
In Chapters 4 through 14, I write about how I would apply selected concepts
and techniques of the particular theory in counseling Stan. In addition, in these
chapters you are asked to think about how you would continue counseling Stan
from each of these different perspectives. In doing so, refer to the introductory
material given here and to Stan’s autobiography as well. To make the case of Stan
come alive for each theory, I highly recommend that you view and study the video
program, DVD for Theory and Practice of Counseling and Psychotherapy: The Case of
Stan and Lecturettes. In this video program I counsel Stan from each of the various
theories and provide brief lectures that highlight each theory.
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i n t r o d u ct i o n
t h e co u n s e lo r a s
a t h e r a p e u t i c p e r s o n
p e r s o n a l t h e r a p y
f o r t h e co u n s e lo r
t h e co u n s e lo r ’s va l u es
a n d t h e t h e r a p e u t i c p r o c es s
b eco m i n g a n e f f ect i v e
m u lt i c u lt u r a l co u n s e lo r
issues faced by beginning
therapists
s u m m a ry
c h a p t e r 2
The Counselor: Person
and Professional
b eco m i n g a n
m u lt i c u lt u r
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One of the most important instruments you have to work with as a counselor is
yourself as a person. In preparing for counseling, you will acquire knowledge about
the theories of personality and psychotherapy, learn assessment and intervention
techniques, and discover the dynamics of human behavior. Such knowledge and
skills are essential, but by themselves they are not suffi cient for establishing and
maintaining effective therapeutic relationships. To every therapy session we bring
our human qualities and the experiences that have infl uenced us. In my judg-
ment, this human dimension is one of the most powerful infl uences on the thera-
peutic process.
A good way to begin your study of contemporary counseling theories is by
refl ecting on the personal issues raised in this chapter. By remaining open to self-
evaluation, you not only expand your awareness of self but also build the founda-
tion for developing your abilities and skills as a professional. The theme of this
chapter is that the person and the professional are intertwined facets that cannot be
separated in reality. We know, clinically and scientifi cally, that the person of the
therapist and the therapeutic relationship contribute to therapy outcome at least
as much as the particular treatment method used (Duncan, Miller, Wampold, &
Hubble, 2010; Norcross, 2011; Norcross & Guy, 2007).
See the DVD program for Chapter 2, DVD for Theory and Practice of Counseling
and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you view
the brief lecture for each chapter prior to reading the chapter.
t h e c o u n s e lo r a s a
t h e r a p e u t i c p e r s o n
Because counseling is an intimate form of learning, it demands a practitioner who
is willing to be an authentic person in the therapeutic relationship. It is within the
context of such a person-to-person connection that the client experiences growth.
If we hide behind the safety of our professional role, our clients will likely keep
themselves hidden from us. If we strive for technical expertise alone, and leave our
own reactions and self out of our work, the result is likely to be ineffective coun-
seling. Our own genuineness can have a signifi cant effect on our relationship with
our clients. If we are willing to look at our lives and make the changes we want, we
can model that process by the way we reveal ourselves and respond to our clients.
If we are inauthentic, our clients will probably pick that up and be discouraged
by it. Our clients can be encouraged by our way of being with them. If we model
authenticity by engaging in appropriate self-disclosure, our clients will tend to be
honest with us as well.
I believe that who the psychotherapist is directly relates to his or her ability
to establish and maintain effective therapy relationships with clients. But what
does the research reveal about the role of the counselor as a person and the thera-
peutic relationship on psychotherapy outcome? Abundant research indicates the
centrality of the person of the therapist as a primary factor in successful therapy
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(Norcross & Lambert, 2011; Norcross & Wampold, 2011). Clients place more value
on the personality of the therapist than on the specifi c techniques used (Lambert,
2011). Norcross and Lambert (2011) cite considerable evidence indicating that the
person of the psychotherapist is inextricably intertwined with the outcome of psy-
chotherapy. Indeed, evidence-based psychotherapy relationships are critical to the
psychotherapy endeavor.
Techniques themselves have limited importance in the therapeutic process.
Wampold (2001) conducted a meta-analysis of many research studies on therapeu-
tic effectiveness and found that the personal and interpersonal components are es-
sential to effective psychotherapy, whereas techniques have relatively little effect on
therapeutic outcome. The contextual factors—the alliance, the relationship, the per-
sonal and interpersonal skills of the therapist, client agency, and extra-therapeutic
factors—are the primary determinants of therapeutic outcome. This research sup-
ports what humanistic psychologists have maintained for years: “It is not theories
and techniques that heal the suffering client but the human dimension of therapy
and the ‘meetings’ that occur between therapist and client as they work together”
(Elkins, 2009, p. 82). In short, both the therapy relationship and the therapy methods
used infl uence the outcomes of treatment, but it is essential that the methods used
support the therapeutic relationship being formed with the client.
Personal Characteristics of Effective Counselors
Particular personal qualities and characteristics of counselors are signifi cant in
creating a therapeutic alliance with clients. My views regarding these personal
characteristics are supported by research on this topic (Norcross, 2011; Skovholt &
Jennings, 2004). I do not expect any therapist to fully exemplify all the traits de-
scribed in the list that follows. Rather, the willingness to struggle to become a
more therapeutic person is the crucial variable. This list is intended to stimulate
you to examine your own ideas about what kind of person can make a signifi cant
difference in the lives of others.
• Effective therapists have an identity. They know who they are, what they are capa-
ble of becoming, what they want out of life, and what is essential.
• Effective therapists respect and appreciate themselves. They can give and receive
help and love out of their own sense of self-worth and strength. They feel ad-
equate with others and allow others to feel powerful with them.
• Effective therapists are open to change. They exhibit a willingness and courage to
leave the security of the known if they are not satisfi ed with the way they are.
They make decisions about how they would like to change, and they work
toward becoming the person they want to become.
• Effective therapists make choices that are life oriented. They are aware of early
decisions they made about themselves, others, and the world. They are not the
victims of these early decisions, and they are willing to revise them if necessary.
They are committed to living fully rather than settling for mere existence.
• Effective therapists are authentic, sincere, and honest. They do not hide behind rigid
roles or facades. Who they are in their personal life and in their professional
work is congruent.
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• Effective therapists have a sense of humor. They are able to put the events of life
in perspective. They have not forgotten how to laugh, especially at their own
foibles and contradictions.
• Effective therapists make mistakes and are willing to admit them. They do not dis-
miss their errors lightly, yet they do not choose to dwell on them, either.
• Effective therapists generally live in the present. They are not riveted to the past, nor
are they fi xated on the future. They are able to experience and be present with
others in the “now.”
• Effective therapists appreciate the infl uence of culture. They are aware of the ways
in which their own culture affects them, and they respect the diversity of values
espoused by other cultures. They are sensitive to the unique differences arising
out of social class, race, sexual orientation, and gender.
• Effective therapists have a sincere interest in the welfare of others. This concern is
based on respect, care, trust, and a real valuing of others.
• Effective therapists possess effective interpersonal skills. They are capable of entering
the world of others without getting lost in this world, and they strive to create
collaborative relationships with others. They readily entertain another person’s
perspective and can work together toward consensual goals.
• Effective therapists become deeply involved in their work and derive meaning from it.
They can accept the rewards fl owing from their work, yet they are not slaves to
their work.
• Effective therapists are passionate. They have the courage to pursue their dreams
and passions, and they radiate a sense of energy.
• Effective therapists are able to maintain healthy boundaries. Although they strive to
be fully present for their clients, they don’t carry the problems of their clients
around with them during leisure hours. They know how to say no, which ena-
bles them to maintain balance in their lives.
This picture of the characteristics of effective therapists might appear unreal-
istic. Who could be all those things? Certainly I do not fi t this bill! Do not think of
these personal characteristics from an all-or-nothing perspective; rather, consider
them on a continuum. A given trait may be highly characteristic of you, at one
extreme, or it may be very uncharacteristic of you, at the other extreme. I have pre-
sented this picture of the therapeutic person with the hope that you will examine
it and develop your own concept of what personality traits you think are essential
to strive for to promote your own personal growth. For a more detailed discussion
of the person of the counselor and the role of the therapeutic relationship in out-
comes of treatments, see Psychotherapy Relationships That Work (Norcross, 2011)
and Master Therapists: Exploring Expertise in Therapy and Counseling (Skovholt &
Jennings, 2004).
p e r s o n a l t h e r a p y f o r t h e co u n s e lo r
Discussion of the counselor as a therapeutic person raises another issue debated
in counselor education: Should people be required to participate in counseling or
therapy before they become practitioners? My view is that counselors can benefi t
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greatly from the experience of being clients at some time, a view that is supported
by research. Some type of self-exploration can increase your level of self-aware-
ness. This experience can be obtained before your training, during it, or both, but I
strongly support some form of personal exploration as vital preparation in learning
to counsel others.
The vast majority of mental health professionals have experienced personal
therapy, typically on several occasions (Geller, Norcross, & Orlinsky, 2005b). A
review of research studies on the outcomes and impacts of the psychotherapist’s
own psychotherapy revealed that more than 90% of mental health professionals
report satisfaction and positive outcomes from their own counseling experiences
(Orlinsky, Norcross, Ronnestad, & Wiseman, 2005). Orlinsky and colleagues sug-
gest that personal therapy contributes to the therapist’s professional work in the
following three ways: (1) as part of the therapist’s training, personal therapy offers
a model of therapeutic practice in which the trainee experiences the work of a more
experienced therapist and learns experientially what is helpful or not helpful; (2) a
benefi cial experience in personal therapy can further enhance a therapist’s inter-
personal skills that are essential to skillfully practicing therapy; and (3) successful
personal therapy can contribute to a therapist’s ability to deal with the ongoing
stresses associated with clinical work.
In his research on personal therapy for mental health professionals, Norcross
(2005) states that lasting lessons practitioners learn from their personal therapy
experiences pertain to interpersonal relationships and the dynamics of psycho-
therapy. Some of these lessons learned are the centrality of warmth, empathy, and
the personal relationship; having a sense of what it is like to be a therapy client;
valuing patience and tolerance; and appreciating the importance of learning how
to deal with transference and countertransference. By participating in personal
therapy, counselors can prevent their potential future countertransference from
harming clients.
Through our work as therapists, we can expect to confront our own unexplored
personal blocks such as loneliness, power, death, and intimate relationships. This
does not mean that we need to be free of confl icts before we can counsel others, but
we should be aware of what these confl icts are and how they are likely to affect us
as persons and as counselors. For example, if we have great diffi culty dealing with
anger or confl ict, we may not be able to assist clients who are dealing with anger or
with relationships in confl ict.
When I began counseling others, old wounds were opened, and feelings I had
not explored in depth came to the surface. It was diffi cult for me to encounter a cli-
ent’s depression because I had failed to come to terms with the way I had escaped
from my own depression. I did my best to cheer up depressed clients by talking
them out of what they were feeling, mainly because of my own inability to deal
with such feelings. In the years I worked as a counselor in a university counseling
center, I frequently wondered what I could do for my clients. I often had no idea
what, if anything, my clients were getting from our sessions. I couldn’t tell if they
were getting better, staying the same, or getting worse. It was very important to me
to note progress and see change in my clients. Because I did not see immediate
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results, I had many doubts about whether I could become an effective counselor.
What I did not understand at the time was that my clients needed to struggle to
fi nd their own answers. To see my clients feel better quickly was my need, not
theirs, for then I would know that I was helping them. It never occurred to me
that clients often feel worse for a time as they give up their defenses and open
themselves to their pain. My early experiences as a counselor showed me that I
could benefi t by participating in further personal therapy to better understand how
my personal issues were affecting my professional work. I realized that periodic
therapy, especially early in one’s career, can be most useful.
Personal therapy can be instrumental in healing the healer. If student coun-
selors are not actively involved in the pursuit of healing their psychological wounds,
they will probably have considerable diffi culty entering the world of a client. As
counselors, can we take our clients any further than we have gone ourselves? If we
are not committed personally to the value of examining our own life, how can we
inspire clients to examine their lives? By becoming clients ourselves, we gain an
experiential frame of reference with which to view ourselves. This provides a basis
for understanding and compassion for our clients, for we can draw on our own
memories of reaching impasses in our therapy, of both wanting to go farther and
at the same time resisting change. Our own therapy can help us develop patience
with our patients! We learn what it feels like to deal with anxieties that are aroused
by self-disclosure and self-exploration and how to creatively facilitate deeper levels
of self-exploration in clients. Through our own therapy, we can gain increased
appreciation for the courage our clients display in their therapeutic journey. Being
willing to participate in a process of self-exploration can reduce the chances of
assuming an attitude of arrogance or of being convinced that we are totally healed.
Our own therapy helps us avoid assuming a stance of superiority over others and
makes it less likely that we would treat people as objects to be pitied or disre-
spected. Indeed, experiencing counseling as a client is very different from merely
reading about the counseling process.
For a comprehensive discussion of personal therapy for counselors, see
The Psychotherapist’s Own Psychotherapy: Patient and Clinician Perspectives (Geller,
Norcross, & Orlinsky, 2005a).
t h e c o u n s e lo r ’s va l u e s
a n d t h e t h e r a p e u t i c p r o c e s s
As alluded to in the previous section, the importance of self-exploration for coun-
selors carries over to the values and beliefs they hold. My experience in teaching
and supervising students of counseling shows me how crucial it is that students
be aware of their values, of where and how they acquired them, and of how their
values can infl uence their interventions with clients.
The Role of Values in Counseling
Our values are core beliefs that infl uence how we act, both in our personal and
our professional lives. Personal values infl uence how we view counseling and
the manner in which we interact with clients, including the way we conduct client
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assessments, our views of the goals of counseling, the interventions we choose, the
topics we select for discussion in a counseling session, how we evaluate progress,
and how we interpret clients’ life situations.
Although total objectivity cannot be achieved, we can strive to avoid being en-
capsulated by our own worldview. As counselors we need to guard against the
tendency to use our power to infl uence the client to accept our values because it is
not our function to persuade clients to accept or adopt our value system From my
perspective, the counselor’s role is to create a climate in which clients can examine
their thoughts, feelings, and actions and to empower them to arrive at their own
solutions to problems they face. The counseling task is to assist individuals in fi nd-
ing answers that are most congruent with their own values. It is not benefi cial to
provide advice or to give clients your answers to their questions.
You may not agree with certain of your clients’ values, but you need to respect
their right to hold divergent values from yours. This is especially true when coun-
seling clients who have a different cultural background and perhaps do not share
your own core cultural values. Your role is to provide a safe and inviting context in
which clients can explore the congruence between their values and their behavior.
If clients acknowledge that what they are doing is not getting them what they want,
it is appropriate to assist them in developing new ways of thinking and behaving to
help them move closer to their goals. This is done with full respect for their right
to decide which values they will use as a framework for living. Individuals seeking
counseling need to clarify their own values and goals, make informed decisions,
choose a course of action, and assume responsibility and accountability for the
decisions they make.
There is a difference between exposing our values and imposing our values
on clients. Value imposition refers to counselors directly attempting to defi ne a
client’s values, attitudes, beliefs, and behaviors. It is possible for counselors to
impose their values either actively or passively. Counselors are cautioned about
not imposing their values on their clients. On this topic, the American Counseling
Association’s Code of Ethics (ACA, 2005) has this standard:
Personal Values. Counselors are aware of their own values, attitudes, beliefs, and behaviors
and avoid imposing values that are inconsistent with counseling goals and respect for the
diversity of clients, trainees, and research participants. (A.4.b.)
Even though therapists should not directly teach the client or impose spe-
cifi c values, therapists do implement a philosophy of counseling, which is, in
effect, a philosophy of life. Counselors communicate their values by the thera-
peutic goals to which they subscribe and by the procedures they employ to reach
these goals.
The Role of Values in Developing Therapeutic Goals
Who should establish the goals of counseling? Almost all theories are in agree-
ment that it is largely the client’s responsibility to decide upon goals, collaborating
with the therapist as therapy proceeds. Counselors have general goals, which are
refl ected in their behavior during the therapy session, in their observations of the
client’s behavior, and in the interventions they make. The general goals of coun-
selors must be congruent with the personal goals of the client.
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Setting goals is inextricably related to values. The client and the counselor need
to explore what they hope to obtain from the counseling relationship, whether
they can work with each other, and whether their goals are compatible. Even more
important, it is essential that the counselor be able to understand, respect, and
work within the framework of the client’s world rather than forcing the client to fi t
into the therapist’s scheme of values.
In my view, therapy ought to begin with an exploration of the client’s expecta-
tions and goals. Clients initially tend to have vague ideas of what they expect from
therapy. They may be seeking solutions to problems, they may want to stop hurt-
ing, they may want to change others so they can live with less anxiety, or they may
seek to be different so that some signifi cant persons in their lives will be more
accepting of them. In some cases clients have no goals; they are in the therapist’s
offi ce simply because they were sent for counseling by their parents, probation
offi cer, or teacher.
So where can a counselor begin? The initial interview can be used most pro-
ductively to focus on the client’s goals or lack of them. The therapist may begin
by asking any of these questions: “What do you expect from counseling? Why are
you here? What do you want? What do you hope to leave with? How is what you
are currently doing working for you? What aspects of yourself or your life situation
would you most like to change?”
When a person seeks a counseling relationship with you, it is important to
cooperatively discover what this person is expecting from the relationship. If you
try to fi gure out in advance how to proceed with a client, you may be depriving the
client of the opportunity to become an active partner in her or his own therapy.
Why is this person coming in for counseling? It is the client’s place to decide on
the goals of therapy. It is important to keep this focus in mind so that the client’s
agenda is addressed rather than an agenda of your own.
b e c o m i n g a n e f f e c t i v e
m u lt i c u lt u r a l c o u n s e lo r
Part of the process of becoming an effective counselor involves learning how to
recognize diversity issues and shaping one’s counseling practice to fi t the client’s
worldview. It is an ethical obligation for counselors to develop sensitivity to cultural
differences if they hope to make interventions that are consistent with the values
of their clients. The therapist’s role is to assist clients in making decisions that are
congruent with their worldview, not to live by the therapist’s values.
Diversity in the therapeutic relationship is a two-way street. As a counselor,
you bring your own heritage with you to your work, so you need to recognize the
ways in which cultural conditioning has infl uenced the directions you take with
your clients. Unless the social and cultural context of clients and counselors
are taken into consideration, it is diffi cult to appreciate the nature of clients’
struggles. Counseling students often hold values—such as making their own
choices, expressing what they are feeling, being open and self-revealing, and
striving for independence—that differ from the values of clients from different
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cultural backgrounds. Some clients may be very slow to disclose and have dif-
ferent expectations about counseling than the therapist has. Counselors need
to become aware of how clients from diverse cultures may perceive them as
therapists, as well as how clients may perceive the value of formal helping. It is
the task of counselors to determine whether the assumptions they have made
about the nature and functioning of therapy are appropriate for culturally di-
verse clients.
Clearly, effective counseling must take into account the impact of culture on
the client’s functioning, including the client’s degree of acculturation. Culture is,
quite simply, the values and behaviors shared by a group of individuals. It is im-
portant to realize that culture refers to more than ethnic or racial heritage; culture
also includes factors such as age, gender, religion, sexual orientation, physical and
mental ability, and socioeconomic status.
Acquiring Competencies in Multicultural Counseling
Effective counselors understand their own cultural conditioning, the condition-
ing of their clients, and the sociopolitical system of which they are a part. Acquir-
ing this understanding begins with counselors’ awareness of the cultural origins
of any values, biases, and attitudes they may hold. Counselors from all cultural
groups must examine their expectations, attitudes, biases, and assumptions about
the counseling process and about persons from diverse groups. Recognizing our
biases and prejudices takes courage because most of us do not want to acknowl-
edge that we have cultural biases. Everyone has biases, but being unaware of the
biased attitudes we hold is an obstacle to client care. It takes a concerted effort and
vigilance to monitor our biases, attitudes, and values so that they do not interfere
with establishing and maintaining successful counseling relationships.
A major part of becoming a diversity-competent counselor involves challeng-
ing the idea that the values we hold are automatically true for others. We also need
to understand how our values are likely to infl uence our practice with diverse cli-
ents who embrace different values. Furthermore, becoming a diversity-competent
practitioner is not something that we arrive at once and for all; rather, it is an
ongoing process.
Sue, Arredondo, and McDavis (1992) and Arredondo and her colleagues
(1996) have developed a conceptual framework for competencies and standards
in multicultural counseling. Their dimensions of competency involve three areas:
(1) beliefs and attitudes, (2) knowledge, and (3) skills. For an in-depth treatment of
multicultural counseling and therapy competence, refer to Counseling the Cultur-
ally Diverse: Theory and Practice (D. W. Sue & Sue, 2008).
b e l i e f s a n d at t i t u d e s First, effective counselors have moved from being
culturally unaware to ensuring that their personal biases, values, or problems will
not interfere with their ability to work with clients who are culturally different from
them. They believe cultural self-awareness and sensitivity to one’s own cultural her-
itage are essential for any form of helping. Counselors are aware of their positive and
negative emotional reactions toward persons from other racial and ethnic groups
that may prove detrimental to establishing collaborative helping relationships.
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They seek to examine and understand the world from the vantage point of their
clients. They respect clients’ religious and spiritual beliefs and values. They are
comfortable with differences between themselves and others in terms of race, eth-
nicity, culture, and beliefs. Rather than maintaining that their cultural heritage
is superior, they are able to accept and value cultural diversity. They realize that
traditional theories and techniques may not be appropriate for all clients or for all
problems. Culturally skilled counselors monitor their functioning through consul-
tation, supervision, and further training or education.
k n o w l e d g e Second, culturally effective practitioners possess certain knowl-
edge. They know specifi cally about their own racial and cultural heritage and
how it affects them personally and professionally. Because they understand the
dynamics of oppression, racism, discrimination, and stereotyping, they are in a
position to detect their own racist attitudes, beliefs, and feelings. They understand
the worldview of their clients, and they learn about their clients’ cultural back-
grounds. They do not impose their values and expectations on their clients from
differing cultural backgrounds and avoid stereotyping clients. Culturally skilled
counselors understand that external sociopolitical forces infl uence all groups, and
they know how these forces operate with respect to the treatment of minorities.
These practitioners are aware of the institutional barriers that prevent minorities
from utilizing the mental health services available in their communities. They pos-
sess knowledge about the historical background, traditions, and values of the client
populations with whom they work. They know about minority family structures,
hierarchies, values, and beliefs. Furthermore, they are knowledgeable about com-
munity characteristics and resources. Those who are culturally skilled know how
to help clients make use of indigenous support systems. In areas where they are
lacking in knowledge, they seek resources to assist them. The greater their depth
and breadth of knowledge of culturally diverse groups, the more likely they are to
be effective practitioners.
s k i l l s a n d i n t e r v e n t i o n s t r at e g i e s Third, effective counselors
have acquired certain skills in working with culturally diverse populations. Coun-
selors take responsibility for educating their clients about the therapeutic process,
including matters such as setting goals, appropriate expectations, legal rights, and
the counselor’s orientation. Multicultural counseling is enhanced when practition-
ers use methods and strategies and defi ne goals consistent with the life experiences
and cultural values of their clients. Such practitioners modify and adapt their in-
terventions to accommodate cultural differences. They do not force their clients
to fi t within one counseling approach, and they recognize that counseling tech-
niques may be culture-bound. They are able to send and receive both verbal and
nonverbal messages accurately and appropriately. They become actively involved
with minority individuals outside the offi ce (community events, celebrations, and
neighborhood groups). They are willing to seek out educational, consultative, and
training experiences to enhance their ability to work with culturally diverse client
populations. They consult regularly with other multiculturally sensitive profession-
als regarding issues of culture to determine whether referral may be necessary.
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Incorporating Culture in Counseling Practice
It is unrealistic to expect a counselor to know everything about the cultural back-
ground of a client, but some understanding of the client’s cultural and ethnic
background is essential. There is much to be said for letting clients teach coun-
selors about relevant aspects of their culture. It is a good idea for counselors to
ask clients to provide them with the information they will need to work effectively.
Incorporating culture into the therapeutic process is not limited to working with
clients from a certain ethnic or cultural background. It is critical that therapists
take into account the worldview and background of every client. Failing to do this
seriously restricts the potential impact of the therapeutic endeavor.
In the case of individuals who have lived in more than one culture, it is useful
to assess the degree of acculturation and identity development that has taken place.
Clients often have allegiance to their culture of origin, and yet they may fi nd cer-
tain characteristics of their new culture attractive. They may experience confl icts
in integrating the two cultures in which they live. Different rates of acculturation
among family members is a common complaint of clients who are experiencing
family problems. These core struggles can be explored productively in the thera-
peutic context if the counselor understands and respects this cultural confl ict.
w e lc o m i n g d i v e r s i t y Counseling is by its very nature diverse in a multi-
cultural society, so it is easy to see that there are no ideal therapeutic approaches.
Instead, different theories have distinct features that have appeal for different cul-
tural groups. Some theoretical approaches have limitations when applied to certain
populations. Effective multicultural practice demands an open stance on the part
of the practitioner, fl exibility, and a willingness to modify strategies to fi t the needs
and the situation of the individual client. Practitioners who truly respect their cli-
ents will be aware of clients’ hesitations and will not be too quick to misinterpret
this behavior. Instead, they will patiently attempt to enter the world of their clients
as much as they can. Although practitioners may not have had the same experi-
ences as their clients, the empathy shown by counselors for the feelings and strug-
gles of their clients is essential to good therapeutic outcomes. We are more often
challenged by our differences than by our similarities to look at what we are doing.
p r a c t i c a l g u i d e l i n e s i n a d d r e s s i n g c u lt u r e If the counseling
process is to be effective, it is essential that cultural concerns be addressed with all
clients. Here are some guidelines that may increase your effectiveness when work-
ing with clients from diverse backgrounds:
• Learn more about how your own cultural background has infl uenced your think-
ing and behaving. Take steps to increase your understanding of other cultures.
• Identify your basic assumptions, especially as they apply to diversity in culture,
ethnicity, race, gender, class, spirituality, religion, and sexual orientation. Think
about how your assumptions are likely to affect your professional practice.
• Examine where you obtained your knowledge about culture.
• Remain open to ongoing learning of how the various dimensions of culture
may affect therapeutic work. Realize that this skill does not develop quickly or
without effort.
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• Be willing to identify and examine your own personal worldview and any preju-
dices you may hold about other racial/ethnic groups.
• Learn to pay attention to the common ground that exists among people of diverse
backgrounds.
• Be fl exible in applying the methods you use with clients. Don’t be wedded to a
specifi c technique if it is not appropriate for a given client.
• Remember that practicing from a multicultural perspective can make your job
easier and can be rewarding for both you and your clients.
It takes time, study, and experience to become an effective multicultural coun-
selor. Multicultural competence cannot be reduced simply to cultural awareness
and sensitivity, to a body of knowledge, or to a specifi c set of skills. Instead, it re-
quires a combination of all of these factors.
i s s u e s fa c e d by b e g i n n i n g
t h e r a p i s t s
In this section I identify some of the major issues that most of us typically face,
particularly during the beginning stages of learning how to be therapists. When
you complete formal course work and begin facing clients, you will be challenged
to integrate and to apply what you have learned. At that point some real concerns
are likely to arise about your adequacy as a person and as a professional. Here are
some useful guidelines for your refl ection on becoming an effective counselor.
Dealing With Your Anxieties
Most beginning counselors have ambivalent feelings when meeting their fi rst cli-
ents. A certain level of anxiety demonstrates that you are aware of the uncertainties
of the future with your clients and of your abilities to really be there for them. A
willingness to recognize and deal with these anxieties, as opposed to denying them,
is a positive sign. That we have self-doubts is normal; it is how we deal with them
that matters. One way is to openly discuss our self-doubts with a supervisor and
peers. The possibilities are rich for meaningful exchanges and for gaining support
from fellow interns who probably have many of the same concerns and anxieties.
Being Yourself and Self-Disclosure
Because you may be self-conscious and anxious when you begin counseling, you
may have a tendency to be overly concerned with what the books say and with the
mechanics of how to proceed. Inexperienced therapists too often fail to appreciate
the values inherent in simply being themselves. If we are able to be ourselves in
our therapeutic work and appropriately disclose our reactions in counseling ses-
sions, we increase the chances of being authentic. It is this level of genuineness
and presence that enables us to connect with our clients and to establish an effec-
tive therapeutic relationship with them.
It is possible to err by going to extremes in two different directions. At one end
are counselors who lose themselves in their fi xed role and hide behind a profes-
sional facade. These counselors are so caught up in maintaining stereotyped role
expectations that little of their personal selves shows through. Counselors who
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adopt this behavior will likely remain anonymous to clients, and clients may per-
ceive them as hiding behind a professional role.
At the other end of the spectrum is engaging in too much self-disclosure. Some
counselors make the mistake of inappropriately burdening their clients with their
spontaneous impressions about their clients. Judging the appropriate amount of
self-disclosure can be a problem even for seasoned counselors, and it is often espe-
cially worrisome for new counselors. In determining the appropriateness of self-
disclosure, consider what to reveal, when to reveal, and how much to reveal. It may
be useful to mention something about ourselves from time to time, but we must
be aware of our motivations for making ourselves known in this way. Assess the
readiness of a client to hear these disclosures as well as the impact doing so might
have on the client. Remain observant during any self-disclosure to get a sense of
how the client is being affected by it.
The most productive form of self-disclosure is related to what is going on
between the counselor and the client within the counseling session. The skill of
immediacy involves revealing what we are thinking or feeling in the here and now
with the client, but be careful to avoid pronouncing judgments about the client.
When done in a timely way, sharing persistent reactions can facilitate therapeutic
progress and improve the quality of our relationship with the client. Even when
we are talking about reactions based on the therapeutic relationship, caution is
necessary, and discretion and sensitivity are required in deciding what reactions
we might share.
Avoiding Perfectionism
Perhaps one of the most common self-defeating beliefs with which we burden
ourselves is that we must never make a mistake. Although we may well know inte-
llectually that humans are not perfect, emotionally we often feel that there is little
room for error. To be sure, you will make mistakes, whether you are a beginning or
a seasoned therapist. If our energies are tied up presenting an image of perfection,
this will affect our ability to be present for our clients. I tell students to question
the notion that they should know everything and be perfectly skilled. I encourage
them to share their mistakes or what they perceive as errors during their supervi-
sion meetings. Students willing to risk making mistakes in supervised learning
situations and willing to reveal their self-doubts will fi nd a direction that leads
to growth.
Being Honest About Your Limitations
You cannot realistically expect to succeed with every client. It takes honesty to
admit that you cannot work successfully with every client. It is important to learn
when and how to make a referral for clients when your limitations prevent you
from helping them. However, there is a delicate balance between learning your
realistic limits and challenging what you sometimes think of as being “limits.”
Before deciding that you do not have the life experiences or the personal qualities
to work with a given population, try working in a setting with a population you do
not intend to specialize in. This can be done through diversifi ed fi eld placements
or visits to agencies.
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Understanding Silence
Silent moments during a therapeutic session may seem like silent hours to a
beginning therapist, yet this silence can have many meanings. The client may be
quietly thinking about some things that were discussed earlier or evaluating some
insight just acquired. The client may be waiting for the therapist to take the lead
and decide what to say next, or the therapist may be waiting for the client to do
this. Either the client or the therapist may be distracted or preoccupied, or neither
may have anything to say for the moment. The client and the therapist may be
communicating without words. The silence may be refreshing, or the silence may
be overwhelming. Perhaps the interaction has been on a surface level, and both
persons have some fear or hesitancy about getting to a deeper level. When silence
occurs, acknowledge and explore with your client the meaning of the silence.
Dealing With Demands From Clients
A major issue that puzzles many beginning counselors is how to deal with clients
who seem to make constant demands. Because therapists feel they should extend
themselves in being helpful, they often burden themselves with the unrealistic
idea that they should give unselfi shly, regardless of how great clients’ demands
may be. These demands may manifest themselves in a variety of ways. Clients
may want to see you more often or for a longer period than you can provide.
They may want to see you socially. Some clients may expect you to continually
demonstrate how much you care or demand that you tell them what to do and
how to solve a problem. One way of heading off these demands is to make your
expectations and boundaries clear during the initial counseling sessions or in the
disclosure statement.
Dealing With Clients Who Lack Commitment
Involuntary clients may be required by a court order to obtain therapy, and you
may be challenged in your attempt to establish a working relationship with them.
It is possible to do effective work with mandated clients, but practitioners must
begin by openly discussing the nature of the relationship. Counselors who omit
preparation and do not address clients’ thoughts and feelings about coming to
counseling are likely to encounter resistance. It is critical that therapists not prom-
ise what they cannot or will not deliver. It is good practice to make clear the limits
of confi dentiality as well as any other factors that may affect the course of therapy.
In working with involuntary clients, it is especially important to prepare them for
the process; doing so can go a long way toward lessening resistance.
Tolerating Ambiguity
Many beginning therapists experience the anxiety of not seeing immediate results.
They ask themselves: “Am I really doing my client any good? Is the client perhaps
getting worse?” I hope you will learn to tolerate the ambiguity of not knowing for
sure whether your client is improving, at least during the initial sessions. Realize
that oftentimes clients may seemingly “get worse” before they show therapeutic
gains. Also, realize that the fruitful effects of the joint efforts of the therapist and
the client may manifest themselves after the conclusion of therapy.
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Becoming Aware of Your Countertransference
Working with clients can affect you in personal ways, and your own vulnerabili-
ties and countertransference are bound to surface. If you are unaware of your
personal dynamics, you are in danger of being overwhelmed by a client’s emo-
tional experiences. Beginning counselors need to learn how to “let clients go”
and not carry around their problems until we see them again. The most thera-
peutic thing is to be as fully present as we are able to be during the therapy hour,
but to let clients assume the responsibility of their living and choosing outside of
the session. If we become lost in clients’ struggles and confusion, we cease being
effective agents in helping them fi nd solutions to their problems. If we accept
responsibility for our clients’ decisions, we are blocking rather than fostering
their growth.
Countertransference, defi ned broadly, includes any of our projections that in-
fl uence the way we perceive and react to a client. This phenomenon occurs when
we are triggered into emotional reactivity, when we respond defensively, or when
we lose our ability to be present in a relationship because our own issues become
involved. Recognizing the manifestations of our countertransference reactions is
an essential step in becoming competent counselors. Unless we are aware of our
own confl icts, needs, assets, and liabilities, we can use the therapy hour more for
our own purposes than for being available for our clients. Because it is not appro-
priate for us to use clients’ time to work through our reactions to them, it is all the
more important that we be willing to work on ourselves in our own sessions with
another therapist, supervisor, or colleague. If we do not engage in this kind of self-
exploration, we increase the danger of losing ourselves in our clients and using
them to meet our unfulfi lled needs.
The emotionally intense relationships we develop with clients can be expected
to tap into our own unresolved problem areas. Our clients’ stories and pain are
bound to affect us; we will be touched by their stories and can express compassion
and empathy. However, we have to realize that it is their pain and not carry it for
them lest we become overwhelmed by their life stories and thus render ourselves
ineffective in working with them. Although we cannot completely free ourselves
from any traces of countertransference or ever fully resolve all personal confl icts
from the past, we can become aware of ways these realities infl uence our profes-
sional work. Our personal therapy can be instrumental in enabling us to recognize
and manage our countertransference reactions.
Developing a Sense of Humor
Therapy is a responsible endeavor, but it need not be deadly serious. Both clients
and counselors can enrich a relationship through humor. What a welcome relief
when we can admit that pain is not our exclusive domain. It is important to recog-
nize that laughter or humor does not mean that clients are not respected or work
is not being accomplished. There are times, of course, when laughter is used to
cover up anxiety or to escape from the experience of facing threatening material.
The therapist needs to distinguish between humor that distracts and humor that
enhances the situation.
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Sharing Responsibility With the Client
You might struggle with fi nding the optimum balance in sharing responsibility
with your clients. One mistake is to assume full responsibility for the direction
and outcomes of therapy. This will lead to taking from your clients their rightful
responsibility of making their own decisions. It could also increase the likelihood
of your early burnout. Another mistake is for you to refuse to accept the responsi-
bility for making accurate assessments and designing appropriate treatment plans
for your clients. How responsibility will be shared should be addressed early in
the course of counseling. It is your responsibility to discuss specifi c matters such
as length and overall duration of the sessions, confi dentiality, general goals, and
methods used to achieve goals. (Informed consent is discussed in Chapter 3.)
It is important to be alert to your clients’ efforts to get you to assume respon-
sibility for directing their lives. Many clients seek a “magic answer” as a way of
escaping the anxiety of making their own decisions. It is not your role to assume
responsibility for directing your clients’ lives. Collaboratively designing contracts
and homework assignments with your clients can be instrumental in your clients’
increasingly fi nding direction within themselves. Perhaps the best measure of our
effectiveness as counselors is the degree to which clients are able to say to us,
“I appreciate what you have been to me, and because of your faith in me, and what
you have taught me, I am confi dent that I can go it alone.” Eventually, if we are
effective, we will be out of business!
Declining to Give Advice
Quite often clients who are suffering come to a therapy session seeking and even
demanding advice. They want more than direction; they want a wise counselor to
make a decision or resolve a problem for them. However, counseling should not be
confused with dispensing information. Therapists help clients discover their own
solutions and recognize their own freedom to act. Even if we, as therapists, were
able to resolve clients’ struggles for them, we would be fostering their dependence
on us. They would continually need to seek our counsel for every new twist in their
diffi culties. Our task is to help clients make independent choices and accept the
consequences of their choices. The habitual practice of giving advice does not work
toward this end.
Defining Your Role as a Counselor
One of your challenges as a counselor will be to defi ne and clarify your professional
role. As you read about the various theoretical orientations in Part 2, you will discover
the many different roles of counselors that are related to these diverse theories. As a
counselor, you will likely be expected to function with a diverse range of roles.
From my perspective, the central function of counseling is to help clients rec-
ognize their own strengths, discover what is preventing them from using their
resources, and clarify what kind of life they want to live. Counseling is a process by
which clients are invited to look honestly at their behavior and make certain deci-
sions about how they want to modify the quality of their life. In this framework
counselors provide support and warmth yet care enough to challenge clients so that
they will be able to take the actions necessary to bring about signifi cant change.
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Keep in mind that the professional roles you assume are likely to be dependent
on factors such as the client populations with whom you are working, the specifi c
therapeutic services you are providing, the particular stage of counseling, and the
setting in which you work. Your role will not be defi ned once and for all. You will
have to reassess the nature of your professional commitments and redefi ne your
role at various times.
Learning to Use Techniques Appropriately
When you are at an impasse with a client, you may have a tendency to look for a
technique to get the sessions moving. As discussed in Chapter 1, relying on tech-
niques too much can lead to mechanical counseling. Ideally, therapeutic tech-
niques should evolve from the therapeutic relationship and the material presented,
and they should enhance the client’s awareness or suggest possibilities for experi-
menting with new behavior. Know the theoretical rationale for each technique you
use, and be sure the techniques are appropriate for the goals of therapy. This does
not mean that you need to restrict yourself to drawing on procedures within a sin-
gle model; quite the contrary. However, it is important to avoid using techniques
in a hit-or-miss fashion, to fi ll time, to meet your own needs, or to get things mov-
ing. Your methods need to be thoughtfully chosen as a way to help clients make
therapeutic progress.
Developing Your Own Counseling Style
Be aware of the tendency to copy the style of a supervisor, therapist, or some other
model. There is no one way to conduct therapy, and wide variations in approach
can be effective. You will inhibit your potential effectiveness in reaching others if
you attempt to imitate another therapist’s style or if you fi t most of your behavior
during the session into the procrustean bed of some expert’s theory. Your coun-
seling style will be infl uenced by your teachers, therapists, and supervisors, but
don’t blur your potential uniqueness by trying to imitate them. I advocate borrow-
ing from others, yet at the same time, doing it in a way that is distinctive to you.
Maintaining Your Vitality as a Person and as a Professional
Ultimately, your single most important instrument is the person you are, and your
most powerful technique is your ability to model aliveness and realness. It is of
paramount importance that we take care of ourselves, for how can we take care of
others if we are not taking care of ourselves? We need to work at dealing with those
factors that threaten to drain life from us and render us helpless. I encourage you
to consider how you can apply the theories you will be studying to enhance your
life from both a personal and a professional standpoint.
Learn to look within yourself to determine what choices you are making (and not
making) to keep yourself vital. If you are aware of the factors that sap your vitality
as a person, you are in a better position to prevent the condition known as profes-
sional burnout. You have considerable control over whether you become burned out
or not. You cannot always control stressful events, but you do have a great deal of
control over how you interpret and react to these events. It is important to realize
that you cannot continue to give and give while getting little in return. There is a
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price to pay for always being available and for assuming responsibility over the
lives and destinies of others. Become attuned to the subtle signs of burnout rather
than waiting for a full-blown condition of emotional and physical exhaustion to
set in. You would be wise to develop your own strategy for keeping yourself alive
personally and professionally.
Self-monitoring is a crucial fi rst step in self-care. If you make an honest
inventory of how well you are taking care of yourself in specifi c domains, you will
have a framework for deciding what you may want to change. By making periodic
assessments of the direction of your own life, you can determine whether you are
living the way you want to live. If not, decide what you are willing to actually do to
make changes occur. By being in tune with yourself, by having the experience of
centeredness and solidness, and by feeling a sense of personal power, you have
the foundation for integrating your life experiences with your professional experi-
ences. Such an awareness can provide the basis for retaining your physical and
psychological vitality and for being an effective professional.
Counseling professionals tend to be caring people who are good at taking care
of others, but often we do not treat ourselves with the same level of care. Self-care
is not a luxury but an ethical mandate. If we neglect to care for ourselves, our cli-
ents will not be getting the best of us. If we are physically drained and psychologi-
cally depleted, we will not have much to give to those with whom we work. It is not
possible to provide nourishment to our clients if we are not nourishing ourselves.
Mental health professionals often comment that they do not have time to take
care of themselves. My question to them is, “Can you afford not to take care of
yourself?” To successfully meet the demands of our professional work, we must
take care of ourselves physically, psychologically, intellectually, socially, and spir-
itually. Ideally, our self-care should mirror the care we provide for others. If we
hope to have the vitality and stamina required to stay focused on our professional
goals, we need to incorporate a wellness perspective into our daily living. Wellness
is the result of our conscious commitment to a way of life that leads to zest, peace,
vitality, and happiness.
Wellness and self-care are being given increased attention in professional jour-
nals (see Counseling Today, January 2011) and at professional conferences. When
reading about self-care and wellness, refl ect on what you can do to put what you
know into action. If you are interested in learning more about therapist self-care,
I highly recommend Leaving It at the Offi ce: A Guide to Psychotherapist Self-Care
(Norcross & Guy, 2007) and Empathy Fatigue: Healing the Mind, Body, and Spirit
of Professional Counselors (Stebnicki, 2008). For more on the topic of the counselor
as a person and as a professional, see Creating Your Professional Path: Lessons From
My Journey (Corey, 2010).
s u m m a ry
One of the basic issues in the counseling profession concerns the signifi cance
of the counselor as a person in the therapeutic relationship. In your professional
work, you are asking people to take an honest look at their lives and to make choices
concerning how they want to change, so it is critical that you do this in your own
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life. Ask yourself questions such as “What do I personally have to offer others who
are struggling to fi nd their way?” and “Am I doing in my own life what I may be
urging others to do?”
You can acquire an extensive theoretical and practical knowledge and can make
that knowledge available to your clients. But to every therapeutic session you also
bring yourself as a person. If you are to promote change in your clients, you need
to be open to change in your own life. This willingness to attempt to live in accord-
ance with what you teach and thus to be a positive model for your clients is what
makes you a “therapeutic person.”
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i n t r o d u ct i o n
p u t t i n g c l i e n t s ’ n e e ds
b e f o r e yo u r o w n
e t h i c a l d ec i s i o n m a k i n g
• The Role of Ethics Codes as a Catalyst for
Improving Practice
• Some Steps in Making Ethical Decisions
t h e r i g h t o f i n f o r m e d co n s e n t
d i m e n s i o n s o f co n f i d e n t i a l i t y
e t h i c a l i s s u es i n a m u lt i c u lt u r a l
p e r s p ect i v e
• Are Current Theories Adequate in Working
With Culturally Diverse Populations?
• Is Counseling Culture Bound?
• Focusing on Both Individual and
Environmental Factors
e t h i c a l i s s u es i n t h e
a s s es s m e n t p r o c es s
• The Role of Assessment and Diagnosis in
Counseling
e t h i c a l a s p ect s o f e v i d e n c e –
b a s e d p r act i c e
m a n ag i n g m u lt i p l e r e l at i o n s h i p s
i n co u n s e l i n g p r act i c e
• Perspectives on Multiple Relationships
b eco m i n g a n e t h i c a l co u n s e lo r
s u m m a ry
w h e r e to g o f r o m h e r e
c h a p t e r 3
Ethical Issues in
Counseling Practice
36
oth Individu
mental Factors
Are Current Theories Adeq
With Culturally Diverse Pop
• Is Counseling Culture Bou
• Focusing on
Enviro
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i n t r o d u c t i o n
This chapter introduces some of the ethical principles and issues that will be a ba-
sic part of your professional practice. Its purpose is to stimulate you to think about
ethical practice so that you can form a sound basis for making ethical decisions.
To help you make these decisions, you can consult with colleagues, keep yourself
informed about laws affecting your practice, keep up to date in your specialty fi eld,
stay abreast of developments in ethical practice, refl ect on the impact your values
have on your practice, and be willing to engage in honest self-examination. Top-
ics addressed include balancing clients’ needs against your own needs, ways of
making good ethical decisions, educating clients about their rights, parameters
of confi dentiality, ethical concerns in counseling diverse client populations, ethi-
cal issues involving diagnosis, evidence-based practice, and dealing with multiple
relationships.
At times students think of ethics in a negative way, merely as a list of rules
and prohibitions that result in sanctions and malpractice actions if practitioners
do not follow them. Mandatory ethics is the view of ethical practice that deals with
the minimum level of professional practice, whereas aspirational ethics is a higher
level of ethical practice that addresses doing what is in the best interests of clients.
Ethics is more than a list of things to avoid for fear of punishment. Ethics is a way
of thinking about becoming the best practitioner possible. Positive ethics is an ap-
proach taken by practitioners who want to do their best for clients rather than sim-
ply meet minimum standards to stay out of trouble (Knapp & VandeCreek, 2006).
See the video program for Chapter 3, DVD for Theory and Practice of
Counseling and Psychotherapy: The Case of Stan and Lecturettes. I suggest that
you view the brief lecture for each chapter prior to reading the chapter.
p u t t i n g c l i e n t s ’ n e e d s
b e f o r e yo u r o w n
As counselors we cannot always keep our personal needs completely separate from
our relationships with clients. Ethically, it is essential that we become aware of
our own needs, areas of unfi nished business, potential personal problems, and
especially our sources of countertransference. We need to realize how such factors
could interfere with effectively and ethically serving our clients.
Our professional relationships with our clients exist for their benefi t. A useful
question to frequently ask yourself is this: “Whose needs are being met in this
relationship, my client’s or my own?” It takes considerable professional maturity
to make an honest appraisal of how your behavior affects your clients. It is not
unethical for us to meet our personal needs through our professional work, but it
is essential that these needs be kept in perspective. An ethical problem exists when
we meet our needs, in either obvious or subtle ways, at the expense of our clients’
needs. It is crucial that we avoid exploiting or harming clients.
We all have certain blind spots and distortions of reality. As helping profes-
sionals, we have responsibilities to work actively toward expanding our own
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self-awareness and to learn to recognize areas of prejudice and vulnerability. If
we are aware of our personal problems and are willing to work through them,
there is less chance that we will project them onto clients. If certain problem
areas surface and old confl icts become reactivated, we have an ethical obligation
to do whatever it takes to avoid harming our clients.
We must also examine other, less obviously harmful personal needs that can
get in the way of creating growth-producing relationships, such as the need for
control and power; the need to be nurturing and helpful; the need to change others
in the direction of our own values; the need for feeling adequate, particularly when
it becomes overly important that the client confi rm our competence; and the need
to be respected and appreciated. It is crucial that we do not meet our needs at the
expense of our clients. For an expanded discussion of this topic, see M. Corey and
Corey (2011, chap. 1).
e t h i c a l d e c i s i o n m a k i n g
The ready-made answers to ethical dilemmas provided by professional organiza-
tions typically contain only broad guidelines for responsible practice. As a practi-
tioner, ultimately you will have to apply the ethics codes of your profession to the
many practical problems you face. Professionals are expected to exercise prudent
judgment when it comes to interpreting and applying ethical principles to specifi c
situations. Although you are responsible for making ethical decisions, you do not
have to do so alone. Part of the process of making ethical decisions involves learn-
ing about the resources from which you can draw when you are dealing with an
ethical question. You should also be aware of the consequences of practicing in
ways that are not sanctioned by organizations of which you are a member or the
state in which you are licensed to practice.
The Role of Ethics Codes as a Catalyst
for Improving Practice
Professional codes of ethics serve a number of purposes. They educate counseling
practitioners and the general public about the responsibilities of the profession.
They provide a basis for accountability, and through their enforcement, clients
are protected from unethical practices. Perhaps most important, ethics codes can
provide a basis for refl ecting on and improving your professional practice. Self-
monitoring is a better route for professionals to take than being policed by an
outside agency (Herlihy & Corey, 2006a).
From my perspective, one of the unfortunate trends is for ethics codes to in-
creasingly take on legalistic dimensions. Many practitioners are so anxious to
avoid becoming embroiled in a lawsuit that they gear their practices mainly toward
fulfi lling legal minimums rather than thinking of what is right for their clients. If
we are too concerned with being sued, it is unlikely that we will be very creative
or effective in our work. In this era of litigation, it makes sense to be aware of the
legal aspects of practice and to do what is possible to reduce a malpractice suit, but
it is a mistake to equate behaving legally with being ethical. Although following
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the law is part of ethical behavior, being an ethical practitioner involves far more.
One of the best ways to prevent being sued for malpractice rests in demonstrating
respect for clients, having their welfare as a central concern, and practicing within
the framework of professional codes.
No code of ethics can delineate what would be the appropriate or best course
of action in each problematic situation a professional will face. In my view, ethics
codes are best used as guidelines to formulate sound reasoning and serve practi-
tioners in making the best judgments possible. A number of professional organi-
zations and their websites are listed at the end of this chapter; each has its own
code of ethics, which you can access through its website. Compare your profes-
sional organization’s code of ethics to several others to understand their similari-
ties and differences.
Some Steps in Making Ethical Decisions
There are a number of different models for ethical decision making; most tend to
focus on the application of principles to ethical dilemmas. After reviewing a few
of these models, my colleagues and I have identifi ed a series of procedural steps
to help you think through ethical problems (see Corey, Corey, & Callanan, 2011):
• Identify the problem or dilemma. Gather information that will shed light on the
nature of the problem. This will help you decide whether the problem is mainly
ethical, legal, professional, clinical, or moral.
• Identify the potential issues. Evaluate the rights, responsibilities, and welfare of
all those who are involved in the situation.
• Look at the relevant ethics codes for general guidance on the matter. Consider
whether your own values and ethics are consistent with or in confl ict with the
relevant guidelines.
• Consider the applicable laws and regulations, and determine how they may have
a bearing on an ethical dilemma.
• Seek consultation from more than one source to obtain various perspectives on
the dilemma, and document in the client’s record what suggestions you received
from this consultation.
• Brainstorm various possible courses of action. Continue discussing options
with other professionals. Include the client in this process of considering
options for action. Again, document the nature of this discussion with your
client.
• Enumerate the consequences of various decisions, and refl ect on the implica-
tions of each course of action for your client.
• Decide on what appears to be the best possible course of action. Once the course
of action has been implemented, follow up to evaluate the outcomes and to
determine whether further action is necessary. Document the reasons for the
actions you took as well as your evaluation measures.
In reasoning through any ethical dilemma, there is rarely just one course of
action to follow, and practitioners may make different decisions. The more sub-
tle the ethical dilemma, the more complex and demanding the decision-making
process.
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Professional maturity implies that you are open to questioning and discussing
your quandaries with colleagues. In seeking consultation, it is generally possible to
protect the identity of your client and still get useful input that is critical to making
sound ethical decisions. Because ethics codes do not make decisions for you, it is a
good practice to demonstrate a willingness to explore various aspects of a problem,
raise questions, discuss ethical concerns with others, and continually clarify your
values and examine your motivations. To the degree that it is possible, include the
client in all phases of the ethical decision-making process. Again, it is essential
to document how you included your client as well as the steps you took to ensure
ethical practice.
t h e r i g h t o f i n f o r m e d c o n s e n t
Regardless of your theoretical framework, informed consent is an ethical and legal
requirement that is an integral part of the therapeutic process. It also establishes
a basic foundation for creating a working alliance and a collaborative partnership
between the client and the therapist. Informed consent involves the right of clients
to be informed about their therapy and to make autonomous decisions pertaining to
it. Providing clients with information they need to make informed choices tends to
promote the active cooperation of clients in their counseling plan. By educating
your clients about their rights and responsibilities, you are both empowering them
and building a trusting relationship with them. Seen in this light, informed con-
sent is something far broader than simply making sure clients sign the appropriate
forms. It is a positive approach that helps clients become active partners and true
collaborators in their therapy. Some aspects of the informed consent process in-
clude the general goals of counseling, the responsibilities of the counselor toward
the client, the responsibilities of clients, limitations of and exceptions to confi den-
tiality, legal and ethical parameters that could defi ne the relationship, the qualifi ca-
tions and background of the practitioner, the fees involved, the services the client
can expect, and the approximate length of the therapeutic process. Further areas
might include the benefi ts of counseling, the risks involved, and the possibility
that the client’s case will be discussed with the therapist’s colleagues or supervi-
sors. This process of educating the client begins with the initial counseling session
and continues for the duration of counseling.
The challenge of fulfi lling the spirit of informed consent is to strike a balance
between giving clients too much information and giving them too little. For exam-
ple, it is too late to tell minors that you intend to consult with their parents after
they have disclosed that they are considering an abortion. In such a case the young
people involved have a right to know about the limitations of confi dentiality before
they make such highly personal disclosures. Clients can be overwhelmed, how-
ever, if counselors go into too much detail initially about the interventions they are
likely to make. It takes both intuition and skill for practitioners to strike a balance.
Informed consent in counseling can be provided in written form, orally, or
some combination of both. If it is done orally, therapists must make an entry in
the client’s clinical record documenting the nature and extent of informed consent
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(Nagy, 2011). I think it is a good idea to have basic information about the therapy
process in writing, as well as to discuss with clients topics that will enable them to
get the maximum benefi t from their counseling experience. Written information
protects both clients and therapists and enables clients to think about the informa-
tion and bring up questions at the following session. For a more complete discus-
sion of informed consent and client rights, see Issues and Ethics in the Helping
Professions (Corey, Corey, & Callanan, 2011, chap. 5), Ethical, Legal, and Professional
Issues in Counseling (Remley & Herlihy, 2010), and Essential Ethics for Psychologists
(Nagy, 2011, chap. 5).
d i m e n s i o n s o f c o n f i d e n t i a l i t y
Confi dentiality and privileged communication are two related but somewhat dif-
ferent concepts. Both of these concepts are rooted in a client’s right to privacy.
Confi dentiality is an ethical concept, and in most states it is the legal duty of thera-
pists not to disclose information about a client. Privileged communication is a
legal concept that generally bars the disclosure of confi dential communications
in a legal proceeding (Committee on Professional Practice and Standards, 2003).
All states have enacted into law some form of psychotherapist–client privilege, but
the specifi cs of this privilege vary from state to state. These laws ensure that disclo-
sures clients make in therapy will be protected from exposure by therapists in legal
proceedings. Generally speaking, the legal concept of privileged communication
does not apply to group counseling, couples counseling, family therapy, or child
and adolescent therapy. However, the therapist is still bound by confi dentiality
with respect to circumstances not involving a court proceeding.
Confi dentiality is central to developing a trusting and productive client–therapist
relationship. Because no genuine therapy can occur unless clients trust in the privacy
of their revelations to their therapists, professionals have the responsibility to defi ne
the degree of confi dentiality that can be promised. Counselors have an ethical and
legal responsibility to discuss the nature and purpose of confi dentiality with their
clients early in the counseling process. In addition, clients have a right to know that
their therapist may be discussing certain details of the relationship with a supervisor
or a colleague.
Although most counselors agree on the essential value of confi dentiality, they
realize that it cannot be considered an absolute. There are times when confi dential
information must be divulged, and there are many instances in which keeping or
breaking confi dentiality becomes a cloudy issue. In determining when to breach
confi dentiality, therapists must consider the requirements of the law, the institu-
tion in which they work, and the clientele they serve. Because these circumstances
are frequently not clearly defi ned by accepted ethics codes, counselors must exer-
cise professional judgment.
There is a legal requirement to break confi dentiality in cases involving child
abuse, abuse of the elderly, abuse of dependent adults, and danger to self or oth-
ers. All mental health practitioners and interns need to be aware of their duty
to report in these situations and to know the limitations of confi dentiality. Here
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are some other circumstances in which information must legally be reported by
counselors:
• When the therapist believes a client under the age of 16 is the victim of incest,
rape, child abuse, or some other crime
• When the therapist determines that the client needs hospitalization
• When information is made an issue in a court action
• When clients request that their records be released to them or to a third party
In general, the counselor’s primary obligation is to protect client disclosures
as a vital part of the therapeutic relationship. Informing clients about the limits of
confi dentiality does not necessarily inhibit successful counseling.
For a more complete discussion of confi dentiality, see Issues and Ethics in the
Helping Professions (Corey, Corey, & Callanan, 2011, chap. 6), The Ethical and Pro-
fessional Practice of Counseling and Psychotherapy (Sperry, 2007, chap. 6), and Es-
sential Ethics for Psychologists (Nagy, 2011, chap. 6).
e t h i c a l i s s u e s i n a
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Ethical practice requires that we take the client’s cultural context into account in
counseling practice. In this section we look at how it is possible for practitioners to
practice unethically if they do not address cultural differences in counseling practice.
Are Current Theories Adequate in Working
With Culturally Diverse Populations?
I believe current theories need to be, and can be, expanded to include a multicul-
tural perspective. With respect to many of the traditional theories, assumptions
made about mental health, optimum human development, the nature of psycho-
pathology, and the nature of effective treatment may have little relevance for some
clients. For traditional theories to be relevant in a multicultural and diverse soci-
ety, they must incorporate an interactive person-in-the-environment focus. That is,
individuals are best understood by taking into consideration salient cultural and
environmental variables. It is essential for therapists to create therapeutic strate-
gies that are congruent with the range of values and behaviors that are characteris-
tic of a pluralistic society.
Is Counseling Culture Bound?
Historically, therapists have relied on Western therapeutic models to guide their
practice and to conceptualize problems that clients present in mental health set-
tings. Value assumptions made by culturally different counselors and clients have
resulted in culturally biased counseling and have led to underuse of mental health
services by diverse populations (Pedersen, 2000; D. W. Sue & Sue, 2008). Mul-
ticultural specialists have asserted that theories of counseling and psychotherapy
represent different worldviews, each with its own values, biases, and assump-
tions about human behavior. Some of these approaches may not be applicable to
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clients from different racial, ethnic, and cultural backgrounds. Western models
of counseling have some limitations when applied to special populations and
cultural groups such as Asian and Pacifi c Islanders, Latinos, Native Americans,
and African Americans. A therapist’s methods often need to be modifi ed when
working with clients from diverse cultural backgrounds.
Contemporary therapy approaches are grounded on a core set of values,
which are neither value-neutral nor applicable to all cultures. For example, the
values implicit in most traditional counseling theories include an emphasis on
individualism, the separate existence of the self, individuation as the foundation
for maturity, and decision making and responsibility resting with the individual
rather than the group. These values of individual choice and autonomy do not
have universal applicability. In some cultures the key values are collectivist, and
primary consideration is given to what is good for the group. Regardless of the
therapist’s orientation, it is crucial to listen to clients and determine why they
are seeking help and how best to deliver the help that is appropriate for them.
Unskilled clinicians may inappropriately apply certain techniques that are not
relevant to particular clients. Competent therapists understand themselves as
social and cultural beings and possess at least a minimum level of knowledge
and skill that they can bring to bear on any counseling situation. These prac-
titioners understand what their clients need and avoid forcing clients into a
preconceived mold.
The attitudes, values, and behaviors counselors and clients bring to the therapy
relationship can vary widely. Denying the importance of these cultural variables
or overemphasizing cultural differences both can result in counselors losing their
spontaneity and failing to be present for their clients. Counselors need to under-
stand and accept clients who have a different set of assumptions about life, and
they need to be alert to the possibility of imposing their own worldview. In working
with clients from different cultural backgrounds and life experiences, it is impor-
tant that counselors resist making value judgments for them.
Focusing on Both Individual and Environmental Factors
A theoretical orientation provides practitioners with a map to guide them in a
productive direction with their clients. It is hoped that the theory orients them
but does not control what they attend to in the therapeutic venture. Counselors
who operate from a multicultural framework also have certain assumptions and a
focus that guides their practice. They view individuals in the context of the family
and the culture, and their aim is to facilitate social action that will lead to change
within the client’s community rather than merely increasing the individual’s
insight. Both multicultural practitioners and feminist therapists maintain that
therapeutic practice will be effective only to the extent that interventions are tai-
lored toward social action aimed at changing those factors that are creating the
client’s problem rather than blaming the client for his or her condition. These
topics are developed in more detail in later chapters.
An adequate theory of counseling does deal with the social and cultural factors
of an individual’s problems. However, there is something to be said for helping
clients deal with their response to environmental realities. Counselors may well be
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at a loss in trying to bring about social change when they are sitting with a client
who is in pain because of social injustice. By using techniques from many of the
traditional therapies, counselors can help clients increase their awareness of their
options in dealing with barriers and struggles. However, it is essential to focus on
both individual and social factors if change is to occur, as the feminist, postmod-
ern, and family systems approaches to therapy teach us. Indeed, the person-in-the-
environment perspective acknowledges this interactive reality. For a more detailed
treatment of the ethical issues in multicultural counseling, see Corey, Corey, and
Callanan (2011, chap. 4).
e t h i c a l i s s u e s i n t h e
a s s e s s m e n t p r o c e s s
Both clinical and ethical issues are associated with the use of assessment and
diagnostic procedures. As you will see when you study the various theories of
counseling, some approaches place heavy emphasis on the role of assessment as
a prelude to the treatment process; other approaches fi nd assessment less useful
in this regard.
The Role of Assessment and Diagnosis in Counseling
Assessment and diagnosis are integrally related to the practice of counseling
and psychotherapy, and both are often viewed as essential for planning treat-
ment. For some approaches, a comprehensive assessment of the client is the
initial step in the therapeutic process. The rationale is that specifi c counseling
goals cannot be formulated and appropriate treatment strategies cannot be
designed until a client’s past and present functioning is understood. Regardless
of their theoretical orientation, therapists need to engage in assessment, which
is generally an ongoing part of the therapeutic process. This assessment may be
subject to revision as the clinician gathers further data during therapy sessions.
Some practitioners consider assessment as a part of the process that leads to a
formal diagnosis.
Assessment consists of evaluating the relevant factors in a client’s life to iden-
tify themes for further exploration in the counseling process. Diagnosis, which is
sometimes part of the assessment process, consists of identifying a specifi c mental
disorder based on a pattern of symptoms. Both assessment and diagnosis can be
understood as providing direction for the treatment process.
Diagnosis may include an explanation of the causes of the client’s diffi cul-
ties, an account of how these problems developed over time, a classifi cation of
any disorders, a specifi cation of preferred treatment procedure, and an estimate
of the chances for a successful resolution. The purpose of diagnosis in coun-
seling and psychotherapy is to identify disruptions in a client’s present behavior
and lifestyle. Once problem areas are clearly identifi ed, the counselor and client
are able to establish the goals of the therapy process, and then a treatment plan
can be tailored to the unique needs of the client. A diagnosis provides a working
hypothesis that guides the practitioner in understanding the client. The therapy
sessions provide useful clues about the nature of the client’s problems. Thus
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diagnosis begins with the intake interview and continues throughout the dura-
tion of therapy.
The classic book for guiding practitioners in making diagnostic assessments is
the fourth edition of the American Psychiatric Association’s (2000) Diagnostic and
Statistical Manual of Mental Disorders, Text Revision (also known as the DSM-IV-TR),
which is presently being revised. The DSM-5 is scheduled to be published in 2013.
Clinicians who work in community mental health agencies, private practice, and
other human service settings are generally expected to assess client problems
within this framework. This manual advises practitioners that it represents only
an initial step in a comprehensive evaluation and that it is necessary to gain infor-
mation about the person being evaluated beyond that required for a DSM-IV-TR
diagnosis.
Although some clinicians view diagnosis as central to the counseling process,
others view it as unnecessary, as a detriment, or as discriminatory against ethnic
minorities and women. As you will see when you study the therapeutic models in
this book, some approaches do not use diagnosis as a precursor to treatment.
c o n s i d e r i n g e t h n i c a n d c u lt u r a l fa c t o r s i n a s s e s s m e n t
a n d d i a g n o s i s A danger of the diagnostic approach is the possible failure
of counselors to consider ethnic and cultural factors in certain patterns of behav-
ior. The DSM-IV-TR emphasizes the importance of being aware of unintentional
bias and keeping an open mind to the presence of distinctive ethnic and cultural
patterns that could infl uence the diagnostic process. Unless cultural variables are
considered, some clients may be subjected to erroneous diagnoses. Certain be-
haviors and personality styles may be labeled neurotic or deviant simply because
they are not characteristic of the dominant culture. Counselors who work with
diverse client populations may erroneously conclude that a client is repressed,
inhibited, passive, and unmotivated, all of which are seen as undesirable by West-
ern standards.
a s s e s s m e n t a n d d i a g n o s i s f r o m va r i o u s t h e o r e t i c a l
p e r s p e c t i v e s The theory from which you operate infl uences your thinking
about the use of a diagnostic framework in your therapeutic practice. Many practi-
tioners who use the cognitive behavioral approaches and the medical model place
heavy emphasis on the role of assessment as a prelude to the treatment process.
The rationale is that specifi c therapy goals cannot be designed until a clear picture
emerges of the client’s past and present functioning. Counselors who base their prac-
tices on the relationship-oriented approaches tend to view the process of assessment
and diagnosis as external to the immediacy of the client– counselor relationship,
impeding their understanding of the subjective world of the client. As you will see
in Chapter 12, feminist therapists contend that traditional diagnostic practices are
often oppressive and that such practices are based on a White, male-centered, West-
ern notion of mental health and mental illness. Both the feminist perspective and
the postmodern approaches (Chapter 13) charge that these diagnoses ignore societal
contexts. Therapists with a feminist, social constructionist, solution-focused, or nar-
rative therapy orientation challenge many DSM-IV-TR diagnoses. However, these
practitioners do make assessments and draw conclusions about client problems and
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strengths. Regardless of the particular theory espoused by a therapist, both clinical
and ethical issues are associated with the use of assessment procedures and possibly
a diagnosis as part of a treatment plan.
a c o m m e n ta ry o n a s s e s s m e n t a n d d i a g n o s i s Most practition-
ers and many writers in the fi eld consider assessment and diagnosis to be a contin-
uing process that focuses on understanding the client. The collaborative perspec-
tive that involves the client as an active participant in the therapy process implies
that both the therapist and the client are engaged in a search-and-discovery process
from the fi rst session to the last. Even though some practitioners may avoid formal
diagnostic procedures and terminology, making tentative hypotheses and sharing
them with clients throughout the process is a form of ongoing diagnosis. This per-
spective on assessment and diagnosis is consistent with the principles of feminist
therapy, an approach that is critical of traditional diagnostic procedures.
Ethical dilemmas may be created when diagnosis is done strictly for insur-
ance purposes, which often entails arbitrarily assigning a client to a diagnostic
classifi cation. However, it is a clinical, legal, and ethical obligation of therapists to
screen clients for life-threatening problems such as organic disorders, schizophre-
nia, bipolar disorder, and suicidal types of depression. Students need to learn the
clinical skills necessary to do this type of screening, which is a form of diagnostic
thinking.
It is essential to assess the whole person, which includes assessing dimensions
of mind, body, and spirit. Therapists need to take into account the biological proc-
esses as possible underlying factors of psychological symptoms and work closely
with physicians. Clients’ values can be instrumental resources in the search for
solutions to their problems, and spiritual and religious values often illuminate cli-
ent concerns.
For a more detailed discussion of assessment and diagnosis in counseling
practice as it is applied to a single case, consult Case Approach to Counseling and
Psychotherapy (Corey, 2013b), in which theorists from 12 different theoretical ori-
entations share their diagnostic perspectives on the case of Ruth.
e t h i c a l a s p e c t s o f
e v i d e n c e – b a s e d p r a c t i c e
Mental health practitioners are faced with the task of choosing the best interven-
tions with a particular client. For many practitioners this choice is based on their
theoretical orientation. In recent years, however, a shift has occurred toward pro-
moting the use of specifi c interventions for specifi c problems or diagnoses based
on empirically supported treatments (APA Presidential Task Force on Evidence-
based Practice, 2006; Cukrowicz et al., 2005; Deegear & Lawson, 2003; Edwards,
Dattilio, & Bromley, 2004).
This trend toward specifi c, empirically supported treatment is referred to as
evidence-based practice (EBP): “the integration of the best available research with
clinical expertise in the context of patient characteristics, culture, and prefer-
ences” (APA Presidential Task Force on Evidence-based Practice, 2006, p. 273).
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Increasingly, those practitioners who work in a behavioral health care system
must cope with the challenges associated with evidence-based practice. Norcross,
Hogan, and Koocher (2008) advocate for inclusive evidence-based practices that
incorporate the three pillars of EBP: looking for the best available research, rely-
ing on clinical expertise, and taking into consideration the client’s characteristics,
culture, and preferences. The central aim of evidence-based practice is to require
psychotherapists to base their practice on techniques that have empirical evidence
to support their effi cacy. Research studies empirically analyze the most effective
and effi cient treatments, which then can be widely implemented in clinical prac-
tice (Norcross, Beutler, & Levant, 2006).
Evidence-based practice is a potent force in psychotherapeutic practice today,
and it may mandate the types of treatments therapists can offer in the future
(Wampold & Bhati, 2004). In many mental health settings, clinicians are pres-
sured to use interventions that are both brief and standardized. In such settings,
treatments are operationalized by reliance on a treatment manual that identifi es
what is to be done in each therapy session and how many sessions will be required
(Edwards et al., 2004). Edwards and his colleagues point out that psychological
assessment and treatment is a business involving fi nancial gain and reputation.
In seeking to specify the treatment for a specifi c diagnosis as precisely as possi-
ble, health insurance companies are concerned with determining the minimum
amount of treatment that can be expected to be effective. This raises ethical ques-
tions about whether the insurance company’s need to save money is being placed
above the needs of clients.
Many practitioners believe this approach is mechanistic and does not take into
full consideration the relational dimensions of the psychotherapy process and indi-
vidual variability. Indeed, relying exclusively on standardized treatments for specifi c
problems may raise another set of ethical concerns because the reliability and valid-
ity of these empirically based techniques is questionable. Human change is com-
plex and diffi cult to measure beyond such a simplistic level that the change may be
meaningless. Furthermore, not all clients come to therapy with clearly defi ned psy-
chological disorders. Many clients have existential concerns that do not fi t with any
diagnostic category and do not lend themselves to clearly specifi ed symptom-based
outcomes. EBP may have something to offer mental health professionals who work
with individuals with specifi c emotional, cognitive, and behavioral disorders, but it
does not have a great deal to offer practitioners working with individuals who want
to pursue more meaning and fulfi llment in their lives.
Counseling is not merely a technique that needs to be empirically validated.
Many aspects of treatment—the therapy relationship, the therapist’s personality
and therapeutic style, the client, and environmental factors—are vital contribu-
tors to the success of psychotherapy. Evidence-based practices tend to emphasize
only one of these aspects—interventions based on the best available research.
Norcross and his colleagues (2006) argue for the centrality of the therapeutic rela-
tionship as a determinant of therapy outcomes. They add, however, that the client
actually accounts for more of the treatment outcome than either the relationship
or the method employed.
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Norcross and his colleagues (2006) believe the call for accountability in mental
health care is here to stay and that all mental health professionals are challenged
by the mandate to demonstrate the effi ciency, effi cacy, and safety of the services
they provide. They emphasize that the overarching goal of EBP is to enhance the
effectiveness of client services and to improve public health and warn that mental
health professionals need to take a proactive stance to make sure this goal is kept
in focus. They realize there is potential for misuse and abuse by third-party payers
who could selectively use research fi ndings as cost-containment measures rather
than ways of improving the quality of services delivered.
Miller, Duncan, and Hubble (2004) are critical of the EBP movement and
argue that “signifi cant improvements in client retention and outcome have been
shown where therapists have feedback on the client’s experience of the alliance
and progress in treatment. Rather than evidence-based practice, therapists tailor
their work through practice-based evidence” (p. 2). Practice-based evidence involves
using data generated during treatment to inform the process and outcome of treat-
ment. This topic is discussed in more detail in Chapter 15.
For further reading on the topic of evidence-based practice, I recommend
Clinician’s Guide to Evidence-based Practice (Norcross, Hogan, & Koocher, 2008).
m a n a g i n g m u lt i p l e r e l at i o n s h i p s
i n c o u n s e l i n g p r a c t i c e
Dual or multiple relationships, either sexual or nonsexual, occur when coun-
selors assume two (or more) roles simultaneously or sequentially with a client.
This may involve assuming more than one professional role or combining pro-
fessional and nonprofessional roles. The term multiple relationship is more often
used than the term dual relationship because of the complexities involved in these
relationships. The terms dual relationships and multiple relationships are used
interchangeably in various professional codes of ethics, and the ACA (2005) uses
the term nonprofessional relationships. In this section I use the broader term of
multiple relationships to encompass both dual relationships and nonprofessional
relationships.
When clinicians blend their professional relationship with another kind of
relationship with a client, ethical concerns must be considered. Many forms of
nonprofessional interactions or nonsexual multiple relationships pose a challenge
to practitioners. Some examples of nonsexual dual or multiple relationships are
combining the roles of teacher and therapist or of supervisor and therapist; barter-
ing for goods or therapeutic services; borrowing money from a client; providing
therapy to a friend, an employee, or a relative; engaging in a social relationship with
a client; accepting an expensive gift from a client; or going into a business venture
with a client. Some multiple relationships are clearly exploitative and do serious
harm both to the client and to the professional. For example, becoming emotionally
or sexually involved with a current client is clearly unethical, unprofessional, and
illegal. Sexual involvement with a former client is unwise, can be exploitative, and is
generally considered unethical.
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Because nonsexual multiple relationships are necessarily complex and multi-
dimensional, there are few simple and absolute answers to resolve them. It is not
always possible to play a single role in your work as a counselor, nor is it always
desirable. You may have to deal with managing multiple roles, regardless of the
setting in which you work or the client population you serve. It is a wise practice to
give careful thought to the complexities of multiple roles and relationships before
embroiling yourself in ethically questionable situations.
Ethical reasoning and judgment come into play when ethics codes are applied
to specifi c situations. The ACA Code of Ethics (ACA, 2005) stresses that counseling
professionals must learn how to manage multiple roles and responsibilities in
an ethical way. This entails dealing effectively with the power differential that is
inherent in counseling rela tionships and training relationships, balancing bound-
ary issues, addressing nonprofessional relationships, and striving to avoid using
power in ways that might cause harm to clients, students, or super visees (Herlihy &
Corey, 2006b).
Although multiple relationships do carry inherent risks, it is a mistake to con-
clude that these relationships are always unethical and necessarily lead to harm
and exploitation. Some of these relationships can be benefi cial to clients if they are
implemented thoughtfully and with integrity (Zur, 2007). An excellent resource
on the ethical and clinical dimensions of multiple relationships is Boundaries in
Psychotherapy: Ethical and Clinical Explorations (Zur, 2007).
Perspectives on Multiple Relationships
What makes multiple relationships so problematic? Herlihy and Corey (2006b)
contend that some of the problematic aspects of engaging in multiple relation-
ships are that they are pervasive; they can be diffi cult to recognize; they are una-
voidable at times; they are potentially harmful, but not necessarily always harmful;
they can be benefi cial; and they are the subject of confl icting advice from various
experts. A review of the literature reveals that dual and multiple relationships are
hotly debated. Except for sexual intimacy with current clients, which is unequivo-
cally unethical, there is not much consensus regarding the appropriate way to deal
with multiple relationships.
Some of the codes of the professional organizations advise against forming
multiple relationships, mainly because of the potential for misusing power, ex-
ploiting the client, and impairing objectivity. When multiple relationships exploit
clients, or have signifi cant potential to harm clients, they are unethical. The eth-
ics codes do not mandate avoidance of all such relationships, however; nor do
the codes imply that nonsexual multiple relationships are unethical. The current
focus of ethics codes is to remain alert to the possibilities of harm to clients and
to develop safeguard to protect clients. Although codes can provide some gener-
al guidelines, good judgment, the willingness to refl ect on one’s practices, and
being aware of one’s motivations are critical dimensions of an ethical practitioner.
It bears repeating that multiple relationship issues cannot be resolved with ethics
codes alone; counselors must think through all of the ethical and clinical dimen-
sions involved in a wide range of boundary concerns.
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A consensus of many writers is that multiple relationships are inevitable and
unavoidable in some situations and that a global prohibition is not a realistic
answer. Because interpersonal boundaries are not static but undergo redefi nition
over time, the challenge for practitioners is to learn how to manage boundary fl uc-
tuations and to deal effectively with overlapping roles (Herlihy & Corey, 2006b).
One key to learning how to manage multiple relationships is to think of ways to
minimize the risks involved.
ways o f m i n i m i z i n g r i s k In determining whether to proceed with a
multiple relationship, it is critical to consider whether the potential benefi t to the
client of such a relationship outweighs its potential harm. Some relationships may
have more potential benefi ts to clients than potential risks. It is your responsibility
to develop safeguards aimed at reducing the potential for negative consequences.
Herlihy and Corey (2006b) identify the following guidelines:
• Set healthy boundaries early in the therapeutic relationship. Informed consent
is essential from the beginning and throughout the therapy process.
• Involve clients in ongoing discussions and in the decision-making process, and
document your discussions. Discuss with your clients what you expect of them
and what they can expect of you.
• Consult with fellow professionals as a way to maintain objectivity and identify
unanticipated diffi culties. Realize that you don’t need to make a decision alone.
• When multiple relationships are potentially problematic, or when the risk for
harm is high, it is always wise to work under supervision. Document the nature
of this supervision and any actions you take in your records.
• Self-monitoring is critical throughout the process. Ask yourself whose needs are
being met and examine your motivations for considering becoming involved in
a dual or multiple relationship.
In working through a multiple relationship concern, it is best to begin by ascertain-
ing whether such a relationship can be avoided. Nagy (2011) points out that multi-
ple relationships cannot always be avoided, especially in small towns. Nor should
every multiple relationship be considered unethical. However, when a therapist’s
objectivity and competence are compromised, the therapist may fi nd that personal
needs surface and diminish the quality of the therapist’s professional work. Some-
times nonprofessional interactions are avoidable and your involvement would put
the client needlessly at risk. In other cases multiple relationships are unavoidable.
One way of dealing with any potential problems is to adopt a policy of completely
avoiding any kind of nonprofessional interaction. As a general guideline, Nagy
(2011) recommends avoiding multiple relationships to the extent this is possi-
ble. Therapists should document precautions taken to protect clients when such
relationships are unavoidable. Another alternative is to deal with each dilemma
as it develops, making full use of informed consent and at the same time seeking
consultation and supervision in dealing with the situation. This second alternative
includes a professional requirement for self-monitoring. It is one of the hallmarks
of professionalism to be willing to grapple with these ethical complexities of day-
to-day practice.
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establishing personal and professional boundaries Establish-
ing and maintaining consistent yet fl exible boundaries is necessary if you are to
effectively counsel clients. If you have diffi culty establishing and maintaining
boundaries in your personal life, you are likely to fi nd that you will have diffi –
culty when it comes to managing boundaries in your professional life. Developing
appropriate and effective boundaries in your counseling practice is the fi rst step
to learning how to manage multiple relationships. There is a relationship between
developing appropriate boundaries in the personal and professional realms. If you
are successful in establishing boundaries in various aspects of your personal life,
you have a good foundation for creating sound boundaries with clients.
One important aspect of maintaining appropriate professional boundaries is to
recognize boundary crossings and prevent them from becoming boundary viola-
tions. A boundary crossing is a departure from a commonly accepted practice that
could potentially benefi t a client. For example, attending the wedding of a client
may be extending a boundary, but it could be benefi cial for the client. In contrast,
a boundary violation is a serious breach that harms the client and is therefore
unethical. A boundary violation is a boundary crossing that takes the practitioner
out of the professional role, which generally involves exploitation and results in
harm to a client (Gutheil & Brodsky, 2008). Flexible boundaries can be useful in the
counseling process when applied ethically. Some boundary crossings pose no ethi-
cal problems and may enhance the counseling relationship. Other boundary cross-
ings may lead to a pattern of blurred professional roles and become problematic.
b e c o m i n g a n e t h i c a l c o u n s e lo r
Knowing and following your profession’s code of ethics is part of being an ethi-
cal practitioner, but these codes do not make decisions for you. As you become
involved in counseling, you will fi nd that interpreting the ethical guidelines of your
professional organization and applying them to particular situations demand the
utmost ethical sensitivity. Even responsible practitioners differ over how to apply
established ethical principles to specifi c situations. In your professional work you
will deal with questions that do not always have obvious answers. You will have
to assume responsibility for deciding how to act in ways that will further the best
interests of your clients.
Throughout your professional life you will need to reexamine the ethical ques-
tions raised in this chapter. You can benefi t from both formal and informal op-
portunities to discuss ethical dilemmas during your training program. Even if you
resolve some ethical matters while completing a graduate program, there is no guar-
antee that these matters have been settled once and for all. These topics are bound
to take on new dimensions as you gain more experience. Oftentimes students bur-
den themselves unnecessarily with the expectation that they should resolve all poten-
tial ethical problem areas before they begin to practice. Throughout your profession-
al life, seek consultation from trusted colleagues and supervisors whenever you face
an ethical dilemma. Ethical decision-making is an evolutionary process that requires
you to be continually open and self-refl ective. Becoming an ethical practitioner is not
a fi nal destination but a journey that will continue throughout your career.
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s u m m a ry
It is essential that you learn a process for thinking about and dealing with ethical
dilemmas, keeping in mind that most ethical issues are complex and defy simple
solutions. A sign of good faith is your willingness to share your struggles with
colleagues. Such consultation can be helpful in clarifying issues by giving you an-
other perspective on a situation. The task of developing a sense of professional
and ethical responsibility is never really fi nished, and new issues are constantly
surfacing. Positive ethics demands periodic refl ection and an openness to change.
If there is one fundamental question that can serve to tie together all the issues
discussed in this chapter, it is this: “Who has the right to counsel another person?”
This question can be the focal point of your refl ection on ethical and professional
issues. It also can be the basis of your self-examination each day that you meet with
clients. Continue to ask yourself: “What makes me think I have a right to counsel oth-
ers?” “What do I have to offer the people I’m counseling?” “Am I doing in my own life
what I’m encouraging my clients to do?” At times you may feel that you have no ethi-
cal right to counsel others, perhaps because your own life isn’t always the model you
would like it to be for your clients. More important than resolving all of life’s issues is
knowing what kinds of questions to ask and remaining open to refl ection.
This chapter has introduced you to a number of ethical issues that you are
bound to face at some point in your counseling practice. I hope your interest has
been piqued and that you will want to learn more. For further reading on this
important topic, choose some of the books listed in the Recommended Supplemen-
tary Readings section for further study.
w h e r e to g o f r o m h e r e
The following professional organizations provide helpful information about what
each group has to offer, including the code of ethics for the organization.
American Association for Marriage and www.aamft.org
Family Therapy (AAMFT)
American Counseling Association (ACA) www.counseling.org
American Mental Health Counselors www.amhca.org
Association (AMHCA)
American Music Therapy Association www.musictherapy.org
American Psychological Association (APA) www.apa.org
American School Counselor www.schoolcounselor.org
Association (ASCA)
Commission on Rehabilitation Counselor www.crccertifi cation.com
Certifi cation (CRCC)
National Association of Alcohol and www.naadac.org
Drug Abuse Counselors (NAADAC)
National Association of Social Workers www.socialworkers.org
(NASW)
National Organization for Human www.nationalhumanservices.org
Services (NOHS)
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Free Podcasts for ACA Members
You can download ACA Podcasts (prerecorded interviews) relevant to topics
discussed in Chapter 3 by going to www.counseling.org, clicking on the Resource
button, and selecting the Podcast Series:
Multicultural and Diversity (Dr. Courtland Lee)
The Counselor and the Law: A Guide to Legal and Ethical Practice
(Drs. Nancy Wheeler and Burt Bertram)
The Ethics of Confi dentiality, Who Needs to Know What?
(Larry Freeman)
The Death of Dual Relationships, or Relationships with Clients, Benefi cial
Versus Harmful (Dr. Rocco Cottone)
Clinical Supervision in the Helping Professions (Drs. Gerald Corey, Robert
Haynes, Patrice Moulton, and Michelle Muratori)
For interviews on topics introduced in subsequent chapters, see the following
podcasts:
Chapter 5: Adlerian Theory and Practice (Dr. Jon Carlson)
Chapter 6: Existential Therapy (Dr. Gerald Corey)
Chapter 7: Carl Rogers and the Person-Centered Approach (Dr. Howard
Kirschenbaum)
Chapter 11: Reality Therapy, Choice Theory: What’s the Difference?
(Dr. Robert Wubbolding)
Chapter 13: Solution-Focused Counseling in Schools (Dr. John Murphy)
Chapter 13: Narrative Therapy: Remembering Lives, Conversations With
the Dying and Bereaved (Lorraine Hedtke, MSW, LCSW, and Dr. John
Winslade)
Recommended Supplementary
Readings for Part 1
Leaving It at the Offi ce: A Guide to Psychotherapist Self-Care (Norcross & Guy,
2007) addresses 12 self-care strategies that are supported by empirical evidence.
The authors develop the position that self-care is personally essential and profes-
sionally ethical. This is one of the most useful books on therapist self-care and on
prevention of burnout.
Psychotherapy Relationships That Work: Evidence-based Responsiveness (Norcross,
2011) is a comprehensive treatment of the effective elements of the therapy
relationship. Many different contributors address ways of tailoring the therapy
relationship to individual clients. Implications from research for effective clinical
practice are presented.
Ethics Desk Reference for Counselors (Barnett & Johnson, 2010) is a practical guide
to understanding and applying the ACA Code of Ethics. It is a reference that is
easy to read, interesting, and has appeal for both students and practitioners.
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The Gift of Therapy: An Open Letter to a New Generation of Therapists and Their
Patients (Yalom, 2003) is a highly readable, insightful, and useful resource. It
includes 85 short chapters on a wide variety of topics that pertain to the counselor
as a person and as a professional.
ACA Ethical Standards Casebook (Herlihy & Corey, 2006a) contains a variety of
useful cases that are geared to the ACA Code of Ethics. The examples illustrate and
clarify the meaning and intent of the standards.
Boundary Issues in Counseling: Multiple Roles and Responsibilities (Herlihy & Corey,
2006b) puts the multiple-relationship controversy into perspective. The book
focuses on dual relationships in a variety of work settings.
Boundaries in Psychotherapy: Ethical and Clinical Explorations (Zur, 2007) ex-
amines the complex nature of boundaries in professional practice by offering a
decision-making process to help practitioners deal with a range of topics such as
gifts, nonsexual touch, home visits, bartering, and therapist self-disclosure.
Issues and Ethics in the Helping Professions (Corey, Corey, & Callanan, 2011) is devoted
entirely to the issues that were introduced briefl y in Chapter 3. The book is designed
to involve readers in a personal and active way, and many open-ended cases are pre-
sented to help readers formulate their thoughts on a wide range of ethical issues.
Becoming a Helper (M. Corey & Corey, 2011) has separate chapters that expand
on issues dealing with the personal and professional lives of helpers and ethical
issues in counseling practice.
Ethics in Action: CD-ROM (Corey, Corey, & Haynes, 2003) is a self-instructional
program divided into three parts: (1) ethical decision making, (2) values and the
helping relationship, and (3) boundary issues and multiple relationships. The
program includes video clips of vignettes demonstrating ethical situations aimed
at stimulating discussion.
Student Manual for Theory and Practice of Counseling and Psychotherapy (Corey,
2013c) is designed to help you integrate theory with practice and to make the
concepts covered in this book come alive. It consists of self-inventories, overview
summaries of the theories, a glossary of key concepts, study questions, issues
and questions for personal application, activities and exercises, comprehension
checks and quizzes, and case examples. The manual is fully coordinated with the
textbook to make it a personal study guide.
Case Approach to Counseling and Psychotherapy (Corey, 2013b) provides case ap-
plications of how each of the theories presented in this book works in action.
A hypothetical client, Ruth, experiences counseling from all of the therapeutic
vantage points.
The Art of Integrative Counseling (Corey, 2013a) is a presentation of concepts and
techniques from the various theories of counseling. The book provides guidelines
for readers in developing their own approaches to counseling practice.
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DVD for Theory and Practice of Counseling and Psychotherapy: The Case of Stan
and Lecturettes (Corey, 2013) is an interactive self-study tool that consists of two
programs. Part 1 includes 13 sessions in which Gerald Corey counsels Stan us-
ing a few selected techniques from each theory. Part 2 consists of brief lectures
by the author for each chapter in Theory and Practice of Counseling and Psycho-
therapy. Both programs emphasize the practical applications of the various
theories.
DVD for Integrative Counseling: The Case of Ruth and Lecturettes (Corey & Haynes,
2013) is an interactive self-study tool that contains video segments and interac-
tive questions designed to teach students ways of working with a client (Ruth)
by drawing concepts and techniques from diverse theoretical approaches. The
topics in this video program parallel the topics in the book The Art of Integrative
Counseling.
Creating Your Professional Path: Lessons From My Journey (Corey, 2010) is a per-
sonal book that deals with a range of topics pertaining to the counselor as a person
and as a professional. In addition to the author’s discussion of his personal and
professional journey, 18 contributors share their personal stories regarding turn-
ing points in their lives and lessons they learned.
The Counselor as Person and Professional (DVD) elaborates on the themes in Chap-
ter 2 and is available from the American Counseling Association. This program is
a keynote address that was given by Gerald Corey at the ACA conference in 2010
in Pittsburgh.
References and Suggested Readings
for Part 1
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*Books and articles marked with an asterisk are suggested for further study.
American Counseling Association.
(2005). ACA code of ethics. Alexandria,
VA: Author.
American Psychiatric Association. (2000).
Diagnostic and statistical manual of mental
disorders, text revision (4th ed.). Washington,
DC: Author.
American Psychological Association. (2002).
Ethical principles of psychologists and code
of conduct. American Psychologist, 57(12),
1060–1073.
American Psychological Association. (2003).
Guidelines on multicultural education, training,
research, practice, and organizational change
for psychologists. American Psychologist, 58(5),
377–402.
*American Psychological Association
Presidential Task Force on Evidence-Based
Practice. (2006). Evidence-based practice in
psychology. American Psychologist, 61, 271–285.
Arredondo, P., Toporek, R., Brown, S., Jones,
J., Locke, D., Sanchez, J., & Stadler, H. (1996).
Operationalization of multicultural counseling
competencies. Journal of Multicultural Coun-
seling and Development, 24(1), 42–78.
*Baker, E. K. (2003). Caring for ourselves: A
therapist’s guide to personal and professional
well-being. Washington, DC: American
Psychological Association.
*Barnett, J. E., & Johnson, W. B. (2008). Ethics
desk reference for psychologists. Washington, DC:
American Psychological Association.
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*Barnett, J. E., & Johnson, W. B. (2010). Ethics
desk reference for counselors. Alexandria, VA:
American Counseling Association.
Cardemil, E. V., & Battle, C. L. (2003). Guess
who’s coming to therapy? Getting comfortable
with conversations about race and ethnic-
ity in psychotherapy. Professional Psychology:
Research and Practice, 34(3), 278–286.
Codes of Ethics for the Helping Professions
(4Th Ed.). (2011). Belmont, CA: Brooks/Cole,
Cengage Learning.
Comas-Diaz, L. (2011). Multicultural ap-
proaches to psychotherapy. In J. C. Norcross,
G. R. Vandenbos, & D. K. Freedheim (Eds.),
History of psychotherapy (2nd ed., pp. 243–
268). Washington, DC: American
Psychological Association.
Committee on Professional Practice and
Standards. (2003). Legal issues in the profes-
sional practice of psychology. Professional Psy-
chology: Research and Practice, 34(6), 595–600.
*Corey, G. (2010). Creating your professional
path: Lessons from my journey. Alexandria,
Va: American Counseling Association.
*Corey, G. (2013a). The art of integrative coun-
seling (3rd ed.). Belmont, CA: Brooks/Cole,
Cengage Learning.
*Corey, G. (2013b). Case approach to counseling
and psychotherapy (8th ed.). Belmont, CA:
Brooks/Cole, Cengage Learning.
*Corey, G. (2013c). Student manual for theory
and practice of counseling and psychotherapy
(9th ed.). Belmont, CA: Brooks/Cole,
Cengage Learning.
*Corey, G., & Corey, M. (2010). I never knew
I had a choice (9th ed.). Belmont, CA: Brooks/
Cole, Cengage Learning.
*Corey, G., Corey, M., & Callanan, P. (2011).
Issues and ethics in the helping professions (8th ed.).
Belmont, CA: Brooks/Cole, Cengage Learning.
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p a r t 2
Theories and Techniques
of Counseling
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61
p a r t 2
Theories and Techniques
of Counseling
4 P s yc h oa n a ly t i c Th e r a p y 62
5 A d l e r i a n Th e r a p y 101
6 E x i s t e n t i a l Th e r a p y 136
7 P e r s o n – C e n t e r e d Th e r a p y 172
8 G e s ta lt Th e r a p y 210
9 B e h av i o r Th e r a p y 244
1 0 Co g n i t i v e B e h av i o r Th e r a p y 287
1 1 R e a l i t y Th e r a p y 333
1 2 Fe m i n i s t Th e r a p y 360
1 3 Po s t m o d e r n A p p r oa c h e s 395
1 4 Fa m i ly Sy s t e m s Th e r a p y 432
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62
i n t r o d u ct i o n
k e y co n c e p t s
t h e t h e r a p e u t i c p r o c es s
a p p l i c at i o n : t h e r a p e u t i c
t ec h n i q u es a n d p r o c e d u r es
j u n g ’s p e r s p ect i v e o n t h e
d e v e lo p m e n t o f p e r s o n a l i t y
co n t e m p o r a ry t r e n d s : o b j ect-
r e l at i o n s t h eo ry, s e l f
p syc h o lo gy, a n d r e l at i o n a l
p syc h oa n a lys i s
p syc h oa n a ly t i c t h e r a p y f r o m
a m u lt i c u lt u r a l p e r s p ect i v e
p syc h oa n a ly t i c t h e r a p y
a p p l i e d to t h e c a s e o f sta n
s u m m a ry a n d e va l u at i o n
w h e r e to g o f r o m h e r e
c h a p t e r 4
Psychoanalytic Therapy
w h e r r e
ect i v e o n
o f p e r s o n
p e r s p
m e n t
62
e
t y
j u n g ’
d e v e l
a p p l i c at i o n : t h e r a p e
t ec h n i q u es a n d p r o c
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Sigmund Freud
S I G M U N D F R E U D (1856–
1939) was the firstborn in
a Viennese family of three
boys and five girls. His father,
like many others of his time
and place, was very authori-
tarian. Freud’s family back-
ground is a factor to consider
in understanding the devel-
opment of his theory.
Even though Freud’s family had limited financ-
es and was forced to live in a crowded apartment,
his parents made every effort to foster his obvious
intellectual capacities. Freud had many interests,
but his career choices were restricted because of
his Jewish heritage. He finally settled on medicine.
Only 4 years after earning his medical degree from
the University of Vienna at the age of 26, he at-
tained a prestigious position there as a lecturer.
Freud devoted most of his life to formulat-
ing and extending his theory of psychoanalysis.
Interestingly, the most creative phase of his life
corresponded to a period when he was experienc-
ing severe emotional problems of his own. During
his early 40s, Freud had numerous psychosomatic
disorders, as well as exaggerated fears of dying and
other phobias, and was involved in the difficult task
of self-analysis. By exploring the meaning of his
own dreams, he gained insights into the dynamics
of personality development. He first examined his
childhood memories and came to realize the intense
hostility he had felt for his father. He also recalled his
childhood sexual feelings for his mother, who was
attractive, loving, and protective. He then clinically
formulated his theory as he observed his patients
work through their own problems in analysis.
Freud had very little tolerance for colleagues
who diverged from his psychoanalytic doctrines.
He attempted to keep control over the movement
by expelling those who dared to disagree. Carl
Jung and Alfred Adler, for example, worked closely
with Freud, but each founded his own therapeutic
school after repeated disagreements with Freud on
theoretical and clinical issues.
Freud was highly creative and productive,
frequently putting in 18-hour days. His col-
lected works fill 24 volumes. Freud’s productivity
remained at this prolific level until late in his life
when he contracted cancer of the jaw. During his
last two decades, he underwent 33 operations and
was in almost constant pain. He died in London
in 1939.
As the originator of psychoanalysis, Freud
distinguished himself as an intellectual giant. He
pioneered new techniques for understanding
human behavior, and his efforts resulted in the
most comprehensive theory of personality and
psychotherapy ever developed.
i n t r o d u c t i o n
In
de
x
St
oc
k
Im
ag
er
y/
Ph
ot
oL
ib
ra
ry
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the
See the DVD program for Chapter 4, DVD for Theory and Practice of Counseling
and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you view
the brief lecture for each chapter prior to reading the chapter.
k e y c o n c e p t s
View of Human Nature
libido
life instincts
death instincts,
Structure of Personality
id
ego
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superego,
t h e i d id
pleasure principle,
t h e e g o ego
reality principle,
t h e s u p e r e g o superego
Consciousness and the Unconscious
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F
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unconscious
Anxiety
Anxiety
Reality anxiety
Neurotic anxiety
Moral anxiety
Ego-Defense Mechanisms
Ego-defense mechanisms
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TA B L E 4 .1 Ego-Defense Mechanisms
D E F E N S E U S E S F O R B E H A V I O R
Repression
Denial
Reaction
formation
Projection
Displacement
Rationalization
(continues)
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Sublimation
Regression
Introjection
Identification
Compensation
Development of Personality
i m p o r ta n c e o f e a r ly d e v e lo p m e n t
psychosexual stages
TA B L E 4 .1 Ego-Defense Mechanisms (continued)
D E F E N S E U S E S F O R B E H A V I O R
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oral stage,
anal stage,
phallic stage,
e r i k s o n ’s p s yc h o s o c i a l p e r s p e c t i v e
psychosocial stages
crisis
Classical psychoanalysis id psychol-
ogy,
Contemporary
psychoanalysis ego psychology,
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N
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T
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T
H
E
R
A
P
Y
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TA B L E 4 . 2 Comparison of Freud’s Psychosexual Stages and Erikson’s
Psychosocial Stages
P E R I O D
O F L I F E

F R E U D

E R I K S O N
First year of life Oral stage Infancy: Trust versus mistrust
Ages 1–3 Anal stage Early childhood: Autonomy versus
shame and doubt
Ages 3–6 Phallic stage
Oedipus complex,
Electra complex,
Preschool age: Initiative versus guilt
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Ages 6–12 Latency stage School age: Industry versus inferiority
Ages 12–18 Genital stage Adolescence: Identity versus role confusion
Ages 18–35 Genital stage continues Young adulthood: Intimacy versus
isolation.
Ages 35–60 Genital stage continues Middle age: Generativity versus
stagnation.
Ages 60+ Genital stage continues Later life: Integrity versus despair
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c o u n s e l i n g i m p l i c at i o n s
t h e t h e r a p e u t i c p r o c e s s
Therapeutic Goals
Therapist’s Function and Role
“blank-screen” approach
transference relationship,
projections
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Client’s Experience in Therapy
free
association;
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not
classical psychoanalysis
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Relationship Between Therapist and Client
Transference
working-through
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countertransference
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lose their objectivity in a relationship because their own conflicts are triggered.
Wolitzky (2011b) states that over the years this traditional view of countertrans-
ference has broadened to include all of the therapist’s reactions, not only to the
client’s transference but to all aspects of the client’s personality and behavior.
In this broader perspective, countertransference involves the therapist’s total
emotional response to a client. In today’s psychoanalytic practice, countertrans-
ference is manifested in the form of subtle nonverbal, tonal, and attitudinal
actions that inevitably affect clients, either consciously or unconsciously (Curtis &
Hirsch, 2011).
It is critical that therapists become aware of their countertransference so that
their reactions toward clients do not interfere with their objectivity. For example,
a male client may become excessively dependent on his female therapist. The cli-
ent may look to her to direct him and tell him how to live, and he may look to her
for the love and acceptance that he felt he was unable to secure from his mother.
The therapist herself may have unresolved needs to nurture, to foster a dependent
relationship, and to be told that she is significant, and she may be meeting her
own needs by in some way keeping her client dependent. Unless she is aware of
her own needs as well as her own dynamics, it is very likely that her dynamics will
interfere with the progress of therapy.
Not all countertransference reactions are detrimental to therapeutic progress.
Indeed, countertransference reactions are often the strongest source of data for
understanding the world of the client and for self-understanding on the therapist’s
part. The therapist’s countertransference reactions are inevitable because all ther-
apists have unresolved conflicts, personal vulnerabilities, and unconscious “soft
spots” that are activated through their professional work (Curtis & Hirsch, 2011;
Hayes, Gelso, & Hummel, 2011; Wolitkzy, 2011a). Hayes (2004) reports that most
research on countertransference has dealt with its deleterious effects and how to
manage these reactions. Hayes adds that it would be useful to undertake system-
atic study of the potential therapeutic benefits of countertransference.
Although countertransference can greatly benefit the therapeutic work, this
is true only if therapists study their internal reactions and use them to under-
stand their clients (Ainslie, 2007; Gelso & Hayes, 2002; Wolitzky, 2011a, 2011b).
It is critical that therapists monitor their own feelings during therapy sessions and
use their responses as a source for increased self-awareness and understanding of
their clients.
A therapist who pays attention to his or her countertransference reactions and
observations to a particular client may use this as a part of the therapy. The thera-
pist who notes a countertransference mood of irritability, for instance, may learn
something about a client’s pattern of being demanding, which can be explored in
therapy. Viewed in this more positive way, countertransference can become a key
avenue for helping the client gain self-understanding.
Psychoanalytic therapists vary in the manner in which they use their observa-
tions of countertransference. In some instances the feelings may be shared with
the client, but traditional analytic therapists strive to minimize their expression of
countertransference while silently learning from its inevitable occurrence. Hayes,
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a p p l i c at i o n : t h e r a p e u t i c
t e c h n i q u e s a n d p r o c e d u r e s
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Case Approach to Counseling and Psychotherapy
Maintaining the Analytic Framework
Maintaining the analytic frame-
work
Free Association
free association,
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Interpretation
Interpretation
Dream Analysis
Dream analysis
Latent
content
manifest content,
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dream work
Analysis and Interpretation of Resistance
Resistance,
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Analysis and Interpretation of Transference
Application to Group Counseling
think
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Theory and Practice of Group
Counseling
Psychodynamic Group Psychotherapy
j u n g ’s p e r s p e c t i v e o n t h e
d e v e lo p m e n t o f p e r s o n a l i t y
analytical psychology
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Memories, Dreams, Reflections
individuation
collective unconscious
archetypes
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persona
animus anima
shadow
Memories, Dreams,
Reflections Living With Paradox: An Introduction to Jungian Psy-
chology
c o n t e m p o r a ry t r e n d s : o b j e c t-
r e l at i o n s t h e o ry, s e l f p s yc h o lo gy,
a n d r e l at i o n a l p s yc h oa n a lys i s
Ego psychology
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Object-relations theory
object
other
Self-psychology,
relational model
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s u m m a ry o f s ta g e s o f d e v e lo p m e n t
normal infantile autism
symbiosis,
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separation–individuation
narcissistic
narcissistic personality
borderline personality disorder
separation–individuation
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t r e at i n g b o r d e r l i n e a n d n a r c i s s i s t i c d i s o r d e r s
Psychotherapy for Borderline Personality
some directions of contemporary psychodynamic therapy
the trend toward brief, time-limited psychodynamic therapy
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brief psychodynamic therapy (BPT)
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Brief Dynamic Therapy
p s yc h oa n a ly t i c t h e r a p y f r o m a
m u lt i c u lt u r a l p e r s p e c t i v e
Strengths From a Diversity Perspective
Shortcomings From a Diversity Perspective
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after
In each of the chapters in Part 2, the
case of Stan is used to demonstrate
the practical applications of the theory
in question. To give you a focus on Stan’s central
concerns, refer to the end of Chapter 1, where
his biography is given. I also recommend that
you at least skim Chapter 16, which deals with
an integrative approach as applied to Stan.
The psychoanalytic approach focuses on the
unconscious psychodynamics of Stan’s behavior.
Considerable attention is given to material that
he has repressed. At the extreme Stan demon-
strated a self-destructive tendency, which is a
way of inflicting punishment on himself. Instead
of directing his hostility toward his parents and
siblings, he turned it inward toward himself.
Stan’s preoccupation with drinking could be
hypothesized as evidence of an oral fixation.
Because he never received love and acceptance
during his early childhood, he is still suffering
from this deprivation and continues to desper-
ately search for approval and acceptance from
others. Stan’s gender-role identification was
fraught with difficulties. He learned the basis
of female–male relationships through his early
experiences with his parents. What he saw was
fighting, bickering, and discounting. His father
was the weak one who always lost, and his
mother was the strong, domineering force who
could and did hurt men. Stan generalized his fear
of his mother to all women. It could be further
hypothesized that the woman he married was
similar to his mother, both of whom reinforced
his feelings of impotence.
The opportunity to develop a transference
relationship and work through it is the core of
the therapy process. Stan will eventually relate to
me, as his therapist, as he did to his father, and
this process will be a valuable means of gaining
insight into the origin of Stan’s difficulties in
relating to others. The analytic process stresses
an intensive exploration of Stan’s past. Stan
devotes much therapy time to reliving and
exploring his early past. As he talks, he gains
increased understanding of the dynamics of his
behavior. He begins to see connections between
his present problems and early experiences in his
childhood. Stan explores memories of relation-
ships with his siblings and with his mother and
father and also explores how he has generalized
his view of women and men from his view of
these family members. It is expected that he will
reexperience old feelings and uncover buried
feelings related to traumatic events. From anoth-
er perspective, apart from whatever conscious
insight Stan may acquire, the goal is for him to
Psychoanalytic Therapy Applied to the Case of Stan
92
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have a more integrated self, where feelings split
off as foreign (the id) become more a part of what
he is comfortable with (the ego). In Stan’s relation-
ship with me, his old feelings can have different
outcomes from his past experiences with significant
others and can result in deep personality growth.
I am likely to explore some of these ques-
tions with Stan: “What did you do when you felt
unloved?” “As a child, what did you do with your
negative feelings?” “As a child, could you express
your anger, hurt, and fears?” “What effects did your
relationship with your mother and father have on
you?” “What did this teach you about women and
about men?” Brought into the here and now of the
transference relationship, I might ask, “When have
you felt anything like you felt with your parents?”
The analytic process focuses on key influ-
ences in Stan’s developmental years, some-
times explicitly, sometimes in terms of how those
earlier events are being relived in the present
analytic relationship. As he comes to understand
how he has been shaped by these past experi-
ences, he is increasingly able to exert control
over his present functioning. Many of Stan’s fears
become conscious, and then his energy does not
have to remain fixed on defending himself from
unconscious feelings. Instead, he can make new
decisions about his current life. He can do this
only if he works through the transference rela-
tionship, however, for the depth of his endeav-
ors in therapy largely determine the depth and
extent of his personality changes.
If I am operating from a contemporary
object-relations psychoanalytic orientation,
my focus may well be on Stan’s developmental
sequences. Particular attention is paid to un-
derstanding his current behavior in the world as
largely a repetition of one of his earlier develop-
mental phases. Because of his dependency, it is
useful in understanding his behavior to see that
he is now repeating patterns that he formed
with his mother during his infancy. Viewed from
this perspective, Stan has not accomplished the
task of separation and individuation. He is still
“stuck” in the symbiotic phase on some levels.
He is unable to obtain his confirmation of worth
from himself, and he has not resolved the
dependence–independence struggle. Looking
at his behavior from the viewpoint of self
psychology can shed light on his difficulties in
forming intimate relationships.
Follow-Up: You Continue as
Stan’s Psychoanalytic Therapist
With each of the 11 theoretical orientations, you
will be encouraged to try your hand at applying
the principles and techniques you have just stud-
ied in the chapter to working with Stan from that
particular perspective. The information presented
about Stan from each of these theory chapters will
provide you with some ideas of how you might
continue working with him if he were referred to
you. Do your best to stay within the general spirit
of each theory by identifying specific concepts
you would draw from and techniques that you
might use in helping him explore the struggles he
identifies. Here are a series of questions to provide
some structure in your thinking about his case:
How much interest would you have in Stan’s
early childhood? What are some ways you’d
help him see patterns between his childhood
issues and his current problems?
Consider the transference relationship that is
likely to be established between you and Stan.
How might you react to his making you into a
significant person in his life?
In working with Stan, what countertransfer-
ence issues might arise for you?
What resistances and defenses might you
predict in your work with Stan? From a psy-
choanalytic perspective, how would you inter-
pret and work with this resistance?
Which of the various forms of psychoanalytic
therapy—classical, relational, or object relations—
would you be most inclined to apply in work-
ing with Stan?
See DVD for Theory and Practice of
Counseling and Psychotherapy: The Case
of Stan and Lecturettes (Session 1, an initial
session with Stan, and Session 2, on psycho-
analytic therapy) for a demonstration of my
approach to counseling Stan from this perspec-
tive. The first session consists of the intake
and assessment process. The second session
focuses on Stan’s resistance and dealing with
transference.
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s u m m a ry a n d e va l u at i o n
Summary

Contributions of the Psychoanalytic Approach
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Contributions of Modern Psychoanalytic Approaches
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Limitations and Criticisms of the Psychoanalytic Approach
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w h e r e to g o f r o m h e r e
DVD for Integrative Counseling: The Case of Ruth and
Lecturettes,
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Psychoanalytic Therapy Relational
Psychotherapy Psychoanalytic Therapy Over Time
Integrative Relational Psychotherapy Brief Dynamic Therapy
Over Time
Otto Kernberg: Live Case Consultation Psychoanalytic Psychotherapy for Personal-
ity Disorders: An Interview with Otto Kernberg, MD
American Psychoanalytic Association
309 East 49th Street, New York, NY 10017-1601
Telephone: (212) 752-0450
Fax: (212) 593–0571
Website: www.apsa.org
Recommended Supplementary Readings
Psychoanalytic Theory: An Introduction
Brief Dynamic Therapy
Psychodynamic Psychiatry in Clinical Practice
Object Relations and Self Psychology: An Introduction
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psychotherapies: Theory and practice (3rd ed.,
pp. 33–71). New York: Guilford Press.
Wolitzsky, D. L. (2011b). Psychoanalytic
theories in psychotherapy. In J. C. Norcross,
G. R. Vandenbos, & D. K. Freedheim (Eds.),
History of psychotherapy (2nd ed., pp. 65–100).
Washington, DC: American Psychological
Association.
Yalom, I. D. (2003). The gift of therapy: An
open letter to a new generation of therapists and
their patients. New York: HarperCollins
(Perennial).
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101
i n t r o d u ct i o n
k e y co n c e p t s
t h e t h e r a p e u t i c p r o c es s
a p p l i c at i o n : t h e r a p e u t i c
t ec h n i q u es a n d p r o c e d u r es
a l d e r i a n t h e r a p y f r o m a
m u lt i c u lt u r a l p e r s p ect i v e
a d l e r i a n t h e r a p y a p p l i e d
to t h e c a s e o f sta n
s u m m a ry a n d e va l u at i o n
w h e r e to g o f r o m h e r e
c h a p t e r 5
Adlerian Therapy
Coauthored by Gerald Corey and James Robert Bitter
a p p l i c at i o n :
t ec h n i q u es
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A L F R E D A D L E R (1870–
1937) grew up in a Vienna
family of six boys and two
girls. His younger brother
died at a very young age
in the bed next to Alfred.
Adler’s early childhood was
not a happy time. He was
sickly and very much aware
of death. At age 4 he almost died of pneumonia.
He heard the doctor tell his father that “Alfred is
lost.” Adler associated this time with his decision
to become a physician. Because he was ill so much
during the first few years of his life, Adler was
pampered by his mother. He developed a trusting
relationship with his father, but did not feel very
close to his mother. He was extremely jealous of
his older brother, Sigmund, which led to a strained
relationship between the two during childhood and
adolescence. When we consider Adler’s strained
relationship with Sigmund Freud, one cannot help
but suspect that patterns from his early family
constellation were repeated in this relationship
with Freud.
Adler’s early childhood experiences had an
impact on the formation of his theory. Adler is an
example of a person who shaped his own life as
opposed to having it determined by fate. Adler
was a poor student. His teacher advised his father
to prepare Adler to be a shoemaker, but not much
else. With determined effort Adler eventually rose
to the top of his class. He went on to study medi-
cine at the University of Vienna, entering private
practice as an ophthalmologist, and then shifting to
general medicine. He eventually specialized in neu-
rology and psychiatry, and he had a keen interest in
incurable childhood diseases.
Adler had a passionate concern for the com-
mon person and was outspoken about child-rearing
practices, school reforms, and prejudices that
resulted in conflict. He spoke and wrote in simple,
nontechnical language so that the general popula-
tion could understand and apply the principles
of his approach in a practical way, which helped
people meet the challenges of daily life. Adler’s
(1927/1959) Understanding Human Nature was
the first major psychology book to sell hundreds
of thousands of copies in the United States. After
serving in World War I as a medical officer, Adler
created 32 child guidance clinics in the Vienna
public schools and began training teachers, social
workers, physicians, and other professionals. He
pioneered the practice of teaching profession-
als through live demonstrations with parents and
children before large audiences, now called “open-
forum” family counseling. The clinics he founded
grew in number and in popularity, and he was inde-
fatigable in lecturing and demonstrating his work.
Although Adler had an overcrowded work
schedule most of his professional life, he still
took some time to sing, enjoy music, and be with
friends. In the mid-1920s he began lecturing in the
United States, and he later made frequent visits
and tours. He ignored the warning of his friends
to slow down, and on May 28, 1937, while taking
a walk before a scheduled lecture in Aberdeen,
Scotland, Adler collapsed and died of heart failure.
If you have an interest in learning more about
Adler’s life, see Edward Hoffman’s (1996) excellent
biography, The Drive for Self.
Alfred Adler
i n t r o d u c t i o n
Along with Freud and Jung, Alfred Adler was a major contributor to the initial
development of the psychodynamic approach to therapy. After 8 to 10 years of col-
laboration, Freud and Adler parted company, with Freud taking the position that
Adler was a heretic who had deserted him. Adler resigned as president of the Vien-
na Psychoanalytic Society in 1911 and founded the Society for Individual Psychology
in 1912. Freud then asserted that it was not possible to support Adlerian concepts
and still remain in good standing as a psychoanalyst.
H
ul
to
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et
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Later, a number of other psychoanalysts deviated from Freud’s orthodox
position (see Chapter 4). These Freudian revisionists—including Karen Horney,
Erich Fromm, and Harry Stack Sullivan—agreed that relational, social, and cul-
tural factors were of great signifi cance in shaping personality. Even though these
three therapists are typically called neo-Freudians, it would be more appropri-
ate, as Heinz Ansbacher (1979) has suggested, to refer to them as neo-Adlerians
because they moved away from Freud’s biological and deterministic point of view
and toward Adler’s social-psychological and teleological (or goal-oriented) view of
human nature.
Adler stresses the unity of personality, contending that people can only be
understood as integrated and complete beings. This view also espouses the pur-
poseful nature of behavior, emphasizing that where we have come from is not as
important as where we are striving to go. Adler saw humans as both the creators
and the creations of their own lives; that is, people develop a unique style of liv-
ing that is both a movement toward and an expression of their selected goals. In
this sense, we create ourselves rather than merely being shaped by our childhood
experiences.
After Adler’s death in 1937, Rudolf Dreikurs was the most signifi cant fi gure
in bringing Adlerian psychology to the United States, especially as its principles
applied to education, individual and group therapy, and family counseling.
Dreikurs is credited with giving impetus to the idea of child guidance centers and
to training professionals to work with a wide range of clients.
See the DVD program for Chapter 5, DVD for Theory and Practice of Coun-
seling and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you
view the brief lecture for each chapter prior to reading the chapter.
k e y c o n c e p t s
View of Human Nature
Adler abandoned Freud’s basic theories because he believed Freud was exces-
sively narrow in his emphasis on biological and instinctual determination. Adler
believed that the individual begins to form an approach to life somewhere in the
fi rst 6 years of living. He focused on the person’s past as perceived in the present
and how an individual’s interpretation of early events continued to infl uence that
person’s present behavior. According to Adler, humans are motivated primarily
by social relatedness rather than by sexual urges; behavior is purposeful and goal-
directed; and consciousness, more than unconsciousness, is the focus of therapy.
Adler stressed choice and responsibility, meaning in life, and the striving for suc-
cess, completion, and perfection. Adler and Freud created very different theories,
even though both men grew up in the same city in the same era and were educated
as physicians at the same university. Their individual and distinct childhood
experiences, their personal struggles, and the populations with whom they worked
were key factors in the development of their particular views of human nature
(Schultz & Schultz, 2009).
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Adler’s theory starts with a consideration of inferiority feelings, which he saw
as a normal condition of all people and as a source of all human striving. Rather
than being considered a sign of weakness or abnormality, inferiority feelings can
be the wellspring of creativity. They motivate us to strive for mastery, success
(superiority), and completion. We are driven to overcome our sense of inferiority
and to strive for increasingly higher levels of development (Ansbacher & Ansbacher,
1956/1964). Indeed, at around 6 years of age our fi ctional vision of ourselves as
perfect or complete begins to form into a life goal. The life goal unifi es the person-
ality and becomes the source of human motivation; every striving and every effort
to overcome inferiority is now in line with this goal.
From the Adlerian perspective, human behavior is not determined solely by
heredity and environment. Instead, we have the capacity to interpret, infl uence,
and create events. Adler asserted that genetics and heredity are not as important
as what we choose to do with the abilities and limitations we possess. Although
Adlerians reject a deterministic stance, they do not go to the other extreme and
maintain that individuals can become whatever they want to be. Adlerians recog-
nize that biological and environmental conditions limit our capacity to choose and
to create.
Adlerians put the focus on reeducating individuals and reshaping society.
Adler was the forerunner of a subjective approach to psychology that focuses on
internal determinants of behavior such as values, beliefs, attitudes, goals, interests,
and the individual perception of reality. He was a pioneer of an approach that is
holistic, social, goal oriented, systemic, and humanistic. Adler also was the fi rst
systemic therapist: he maintained that it is essential to understand people within
the systems in which they live.
Subjective Perception of Reality
Adlerians attempt to view the world from the client’s subjective frame of reference,
an orientation described as phenomenological. Paying attention to the individual
way in which people perceive their world, referred to as “subjective reality,” includes
the individual’s perceptions, thoughts, feelings, values, beliefs, convictions, and
conclusions. Behavior is understood from the vantage point of this subjective per-
spective. From the Adlerian perspective, objective reality is less important than how
we interpret reality and the meanings we attach to what we experience.
As you will see in subsequent chapters, many contemporary theories have
incorporated this notion of the client’s subjective worldview as a basic factor ex-
plaining behavior, including existential therapy, person-centered therapy, Gestalt
therapy, the cognitive behavioral therapies, reality therapy, feminist therapy, and
the postmodern approaches.
Unity and Patterns of Human Personality
Adler chose the name Individual Psychology (from the Latin individuum, meaning
indivisible) for his theoretical approach because he wanted to avoid reductionism.
Adler emphasized the unity and indivisibility of the person and stressed under-
standing the whole person in the context of his or her life—how all dimensions
of a person are interconnected components, and how all of these components
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are unifi ed by the individual’s movement toward a life goal. This holistic concept
implies that we cannot be understood in parts; rather, all aspects of ourselves must
be understood in relationship (Carlson & Englar-Carlson, 2008). The focus is on
understanding whole persons within their socially embedded contexts of family,
culture, school, and work. We are social, creative, decision-making beings who act
with purpose and cannot be fully known outside the contexts that have meaning in
our lives (Sherman & Dinkmeyer, 1987).
The human personality becomes unifi ed through development of a life goal.
An individual’s thoughts, feelings, beliefs, convictions, attitudes, character, and
actions are expressions of his or her uniqueness, and all refl ect a plan of life that
allows for movement toward a self-selected life goal. An implication of this holistic
view of personality is that the client is an integral part of a social system. There is
more emphasis on interpersonal relationships than on the individual’s internal
psychodynamics.
b e h av i o r a s p u r p o s e f u l a n d g oa l o r i e n t e d Individual Psychol-
ogy assumes that all human behavior has a purpose. The concept of the purposeful
nature of behavior is perhaps the cornerstone of Adler’s theory. Adler replaced
deterministic explanations with teleological (purposive, goal-oriented) ones. A basic
assumption of Individual Psychology is that we can only think, feel, and act in rela-
tion to our goal; we can be fully understood only in light of knowing the purposes
and goals toward which we are striving. Although Adlerians are interested in the
future, they do not minimize the importance of past infl uences. They assume that
most decisions are based on the person’s experiences, on the present situation, and
on the direction in which the person is moving—with the latter being the most
important. They look for continuity by paying attention to themes running through
a person’s life.
Adler was infl uenced by the philosopher Hans Vaihinger (1965), who noted
that people often live by fi ctions (or views of how the world should be). Many Adle-
rians use the term fi ctional fi nalism to refer to an imagined life goal that guides a
person’s behavior. It should be noted, however, that Adler ceased using this term
and replaced it with “guiding self-ideal” and “goal of perfection” to account for our
striving toward superiority or perfection (Watts & Holden, 1994). Very early in life,
we begin to envision what we might be like if we were successful, complete, whole,
or perfect. Applied to human motivation, a guiding self-ideal might be expressed
in this way: “Only when I am perfect can I be secure” or “Only when I am impor-
tant can I be accepted.” The guiding self-ideal represents an individual’s image of
a goal of perfection, for which he or she strives in any given situation. Because of
our subjective fi nal goal, we have the creative power to choose what we will accept
as truth, how we will behave, and how we will interpret events.
s t r i v i n g f o r s i g n i f i c a n c e a n d s u p e r i o r i t y Adler stressed that
the recognition of inferiority feelings and the consequent striving for perfection
or mastery are innate (Ansbacher & Ansbacher, 1979)—they are two sides of the
same coin. To understand human behavior, it is essential to grasp the ideas of
basic inferiority and compensation. From our earliest years, we recognize that
we are helpless in many ways, which is characterized by feelings of inferiority.
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This inferiority is not a negative factor in life. According to Adler, the moment we
experience inferiority we are pulled by the striving for superiority. He maintained
that the goal of success pulls people forward toward mastery and enables them to
overcome obstacles. The goal of superiority contributes to the development of hu-
man community. However, it is important to note that “superiority,” as used by
Adler, does not necessarily mean superiority over others. Rather, it means moving
from a perceived lower (or minus) position to a perceived better (or plus) position.
People cope with feelings of helplessness by striving for competence, mastery,
and perfection. They can seek to change a weakness into a strength, for example,
or strive to excel in one area to compensate for defects in other areas. The unique
ways in which people develop a style of striving for competence is what constitutes
individuality or lifestyle. The manner in which Adler reacted to his childhood and
adolescent experiences is a living example of this aspect of his theory.
l i f e s t y l e The movement from a felt minus to a desired plus results in the devel-
opment of a life goal, which in turn unifi es the personality and the individual’s core
beliefs and assumptions. These core beliefs and assumptions guide each person’s
movement through life and organize his or her reality, giving meaning to life events.
Adler called this life movement the individual’s “lifestyle.” Synonyms for this term
include “plan of life,” “style of life,” “strategy for living,” and “road map of life.” Life-
style includes the connecting themes and rules of interaction that give meaning to
our actions. Lifestyle is often described as our perceptions regarding self, others, and
the world. It includes an individual’s characteristic way of thinking, acting, feeling,
living, and striving toward long-term goals (Mosak & Maniacci, 2011).
Adler saw us as actors, creators, and artists. Understanding one’s lifestyle is
somewhat like understanding the style of a composer: “We can begin wherever
we choose: every expression will lead us in the same direction—toward the one
motive, the one melody, around which the personality is built” (Adler, as cited in
Ansbacher & Ansbacher, 1956/1964, p. 332).
People are viewed as adopting a proactive, rather than a reactive, approach
to their social environment. Although events in the environment infl uence the
development of personality, such events are not the causes of what people become;
rather, it is our interpretation of these events that shape personality. Faulty in-
terpretations may lead to mistaken notions in our private logic, which will sig-
nifi cantly infl uence present behavior. Once we become aware of the patterns and
continuity of our lives, we are in a position to modify those faulty assumptions and
make basic changes. We can reframe childhood experiences and consciously create
a new style of living.
Social Interest and Community Feeling
Social interest and community feeling (Gemeinschaftsgefühl) are probably Adler’s
most signifi cant and distinctive concepts (Ansbacher, 1992). These terms refer to
individuals’ awareness of being part of the human community and to individuals’
attitudes in dealing with the social world.
Social interest is the action line of one’s community feeling, and it involves
being as concerned about others as one is about onself. This concept involves the
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capacity to cooperate and contribute (Milliren & Clemmer, 2006). Social interest
requires that we have enough contact with the present to make a move toward a
meaningful future, that we are willing to give and to take, and that we develop our
capacity for contributing to the welfare of others and striving for the betterment of
humanity. The socialization process associated with social interest begins in child-
hood and involves helping children to fi nd a place in society and acquire a sense of
belonging, as well as the ability to make a contribution (Kefi r, 1981). While Adler
considered social interest to be innate, he also believed that it must be learned,
developed, and used.
Adler equated social interest with a sense of identifi cation and empathy
with others: “to see with the eyes of another, to hear with the ears of another, to feel
with the heart of another” (as cited in Ansbacher & Ansbacher, 1979, p. 42). Social
interest is the central indicator of mental health. Those with social interest tend to
direct the striving toward the healthy and socially useful side of life. From the Adle-
rian perspective, as social interest develops, feelings of inferiority and alienation
diminish. People express social interest through shared activity and mutual respect.
Individual Psychology rests on a central belief that our happiness and success
are largely related to this social connectedness. Because we are embedded in a
society, and indeed in the whole of humanity, we cannot be understood in isola-
tion from that social context. We are primarily motivated by a desire to belong.
Community feeling embodies the feeling of being connected to all of humanity—
past, present, and future—and to being involved in making the world a better place.
Those who lack this community feeling become discouraged and end up on the
useless side of life. We seek a place in the family and in society to fulfi ll basic needs
for security, acceptance, and worthiness. Many of the problems we experience are
related to the fear of not being accepted by the groups we value. If our sense of
belonging is not fulfi lled, anxiety is the result. Only when we feel united with oth-
ers are we able to act with courage in facing and dealing with our problems (Adler,
1938/1964).
Adler taught that we must successfully master three universal life tasks: build-
ing friendships (social task), establishing intimacy (love–marriage task), and con-
tributing to society (occupational task). All people need to address these tasks,
regardless of age, gender, time in history, culture, or nationality. Each of these
tasks requires the development of psychological capacities for friendship and be-
longing, for contribution and self-worth, and for cooperation (Bitter, 2006). These
basic life tasks are so fundamental to human living that impairment in any one of
them is often an indicator of a psychological disorder (American Psychiatric As-
sociation, 2000). More often than not, when people seek therapy, it is because they
are struggling unsuccessfully to meet one or more of these life tasks. The aim of
therapy is to assist clients in modifying their lifestyle so they can more effectively
navigate each of these tasks (Carlson & Englar-Carlson, 2008).
Birth Order and Sibling Relationships
The Adlerian approach is unique in giving special attention to the relationships
between siblings and the psychological birth position in one’s family. Adler
identifi ed fi ve psychological positions, or vantage points, from which children
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tend to view life: oldest, second of only two, middle, youngest, and only. Birth
order is not a deterministic concept but does increase an individual’s probability
of having a certain set of experiences. Actual birth order is less important than
the individual’s interpretation of his or her place in the family. Because Adle-
rians view most human problems as social in nature, they emphasize relation-
ships within the family as our earliest and, perhaps, our most infl uential social
system.
Adler (1931/1958) observed that many people wonder why children in the
same family often differ so widely, and he pointed out that it is a fallacy to assume
that children of the same family are formed in the same environment. Although
siblings share aspects in common in the family constellation, the psychological
situation of each child is different from that of the others due to birth order. The
following description of the infl uence of birth order is based on Ansbacher and
Ansbacher (1964), Dreikurs (1953), and Adler (1931/1958).
1. The oldest child generally receives a good deal of attention, and during the time
she is the only child, she is typically somewhat spoiled as the center of attention.
She tends to be dependable and hard working and strives to keep ahead. When a
new brother or sister arrives on the scene, however, she fi nds herself ousted from
her favored position. She is no longer unique or special. She may readily believe
that the newcomer (or intruder) will rob her of the love to which she is accustomed.
Most often, she reasserts her position by becoming a model child, bossing younger
children, and exhibiting a high achievement drive.
2. The second child of only two is in a different position. From the time she is born,
she shares the attention with another child. The typical second child behaves as
if she were in a race and is generally under full steam at all times. It is as though
this second child were in training to surpass the older brother or sister. This com-
petitive struggle between the fi rst two children infl uences the later course of their
lives. The younger child develops a knack for fi nding out the elder child’s weak
spots and proceeds to win praise from both parents and teachers by achieving
successes where the older sibling has failed. If one is talented in a given area, the
other strives for recognition by developing other abilities. The second-born is often
opposite to the fi rstborn.
3. The middle child often feels squeezed out. This child may become convinced
of the unfairness of life and feel cheated. This person may assume a “poor me”
attitude and can become a problem child. However, especially in families charac-
terized by confl ict, the middle child may become the switchboard and the peace-
maker, the person who holds things together. If there are four children in a family,
the second child will often feel like a middle child and the third will be more easy-
going, more social, and may align with the fi rstborn.
4. The youngest child is always the baby of the family and tends to be the most
pampered one. Because of being pampered or spoiled, he may develop helpless-
ness into an art form and become expert at putting others in his service. Youngest
children tend to go their own way, often developing in ways no others in the family
have attempted and may outshine everyone.
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5. The only child has a problem of her own. Although she shares some of the char-
acteristics of the oldest child (for example, a high achievement drive), she may not
learn to share or cooperate with other children. She will learn to deal with adults
well, as they make up her original familial world. Often, the only child is pampered
by her parents and may become dependently tied to one or both of them. She may
want to have center stage all of the time, and if her position is challenged, she will
feel it is unfair.
Birth order and the interpretation of one’s position in the family have a great
deal to do with how adults interact in the world. Individuals acquire a certain style
of relating to others in childhood and form a defi nite picture of themselves that
they carry into their adult interactions. In Adlerian therapy, working with family
dynamics, especially relationships among siblings, assumes a key role. Although
it is important to avoid stereotyping individuals, it does help to see how certain
personality trends that began in childhood as a result of sibling rivalry infl uence
individuals throughout life.
t h e t h e r a p e u t i c p r o c e s s
Therapeutic Goals
Adlerian counseling rests on a collaborative arrangement between the client and
the counselor. In general, the therapeutic process includes forming a relationship
based on mutual respect; a holistic psychological investigation or lifestyle assess-
ment; and disclosing mistaken goals and faulty assumptions within the person’s style
of living. This is followed by a reeducation or reorientation of the client toward
the useful side of life. The main aim of therapy is to develop the client’s sense
of belonging and to assist in the adoption of behaviors and processes character-
ized by community feeling and social interest. This is accomplished by increasing
the client’s self-awareness and challenging and modifying his or her fundamental
premises, life goals, and basic concepts (Dreikurs, 1967, 1997). Milliren, Evans,
and Newbauer (2007), identify this goal of Adlerian therapy: “to assist clients to
understand their unique lifestyles . . . and to act in such a way as to meet the tasks
of life with courage and social interest” (p. 145).
Adlerians do not view clients as being “sick” and in need of being “cured.”
They favor the growth model of personality rather than the medical model. As
Mosak and Maniacci (2011) put it: “The Adlerian is interested not in curing sick
individuals or a sick society but in reeducating individuals and in reshaping soci-
ety” (p. 78). Rather than being stuck in some kind of pathology, Adlerians contend
that clients are often discouraged. The counseling process focuses on providing
information, teaching, guiding, and offering encouragement to discouraged cli-
ents. Encouragement is the most powerful method available for changing a per-
son’s beliefs, for it helps clients build self-confi dence and stimulates courage.
Courage is the willingness to act even when fearful in ways that are consistent with
social interest. Fear and courage go hand in hand; without fear, there would be no
need for courage. The loss of courage, or discouragement, results in mistaken and
dysfunctional behavior. Discouraged people do not act in line with social interest.
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Adlerian counselors provide clients with an opportunity to view things from
a different perspective, yet it is up to the clients to decide whether to accept an
alternative perspective. Adlerians work collaboratively with clients to help them
reach their self-defi ned goals. Adlerians educate clients in new ways of looking at
themselves, others, and life. Through the process of providing clients with a new
“cognitive map,” a fundamental understanding of the purpose of their behavior,
counselors assist them in changing their perceptions. Mosak and Maniacci (2011)
lists these goals for the educational process of therapy:
• Fostering social interest
• Helping clients overcome feelings of discouragement and inferiority
• Modifying clients’ views and goals—that is, changing their lifestyle
• Changing faulty motivation
• Encouraging the individual to recognize equality among people
• Helping people to become contributing members of society
Therapist’s Function and Role
Adlerian counselors realize that clients can become discouraged and function
ineffectively because of mistaken beliefs, faulty values, and useless or self-absorbed
goals. These therapists operate on the assumption that clients will feel and behave
better once they discover and correct their basic mistakes. Therapists tend to look
for major mistakes in thinking and valuing such as mistrust, selfi shness, unrealis-
tic ambitions, and lack of confi dence.
Adlerians assume a nonpathological perspective and thus do not label clients
with pathological diagnoses. One way of looking at the role of Adlerian therapists
is that they assist clients in better understanding, challenging, and changing their
life story. “When individuals develop a life story that they fi nd limiting and prob-
lem saturated, the goal is to free them from that story in favor of a preferred and
equally viable alternative story” (Disque & Bitter, 1998, p. 434).
A major function of the therapist is to make a comprehensive assessment of
the client’s functioning. Therapists often gather information about the individual’s
style of living by means of a questionnaire on the client’s family constellation,
which includes parents, siblings, and others living in the home, life tasks, and
early recollections. When summarized and interpreted, this questionnaire gives a
picture of the individual’s early social world. From this information on the family
constellation, the therapist is able to get a perspective on the client’s major areas
of success and failure and on the critical infl uences that have had a bearing on the
role the client has assumed in the world.
The counselor also uses early recollections as an assessment procedure. Early
recollections (ERs) are defi ned as “stories of events that a person says occurred
[one time] before he or she was 10 years of age” (Mosak & Di Pietro, 2006, p. 1).
ERs are specifi c incidents that clients recall, along with the feelings and thoughts
that accompanied these childhood incidents. These recollections are quite useful
in getting a better understanding of the client (Clark, 2002). After these early rec-
ollections are summarized and interpreted, the therapist identifi es some of the
major successes and mistakes in the client’s life. The aim is to provide a point of
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departure for the therapeutic venture. ERs are particularly useful as a functional
assessment device because they indicate what clients do and how they think in
both adaptive and maladaptive ways (Mosak & Di Pietro, 2006). The process of
gathering early memories is part of what is called a lifestyle assessment, which
involves learning to understand the goals and motivations of the client. When this
process is completed, the therapist and the client have targets for therapy.
Mosak and Maniacci (2011) consider dreams to be a useful part of the assess-
ment process. Freud assumed that dreams were wish fulfi llment, or, in some
instances, an attempt at solving an old problem; Adler, on the other hand, viewed
dreams as a rehearsal for possible future actions. Just as early recollections refl ect
a client’s long-range goals, dreams suggest possible answers to a client’s present
problems. In interpreting dreams, the therapist considers their purposive func-
tion. Mosak and Maniacci (2011) assert that “dreams serve as weather vanes for
treatment, bringing problems to the surface and pointing to the patient’s move-
ment” (p. 88).
Client’s Experience in Therapy
How do clients maintain their lifestyle, and why do they resist changing it? A per-
son’s style of living serves the individual by staying stable and constant. In other
words, it is predictable. It is, however, also resistant to change throughout most of
one’s life. Generally, people fail to change because they do not recognize the errors
in their thinking or the purposes of their behaviors, do not know what to do differ-
ently, and are fearful of leaving old patterns for new and unpredictable outcomes.
Thus, even though their ways of thinking and behaving are not successful, they
tend to cling to familiar patterns (Sweeney, 2009). Clients in Adlerian counseling
focus their work on desired outcomes and a resilient lifestyle that can provide a
new blueprint for their actions.
In therapy, clients explore what Adlerians call private logic, the concepts about
self, others, and life that constitute the philosophy on which an individual’s life-
style is based. Private logic involves our convictions and beliefs that get in the way
of social interest and that do not facilitate useful, constructive belonging (Carlson,
Watts, & Maniacci, 2006). Clients’ problems arise because the conclusions based
on their private logic often do not conform to the requirements of social living. The
heart of therapy is helping clients to discover the purposes of behaviors or symp-
toms and the basic mistakes associated with their personal coping. Learning how
to correct faulty assumptions and conclusions is central to therapy.
To provide a concrete example, think of a chronically depressed middle-aged
man who begins therapy. After a lifestyle assessment is completed, these basic
mistakes are identifi ed:
• He has convinced himself that nobody could really care about him.
• He rejects people before they have a chance to reject him.
• He is harshly critical of himself, expecting perfection.
• He has expectations that things will rarely work out well.
• He burdens himself with guilt because he is convinced he is letting everyone
down.
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Even though this man may have developed these mistaken ideas about himself and
life when he was young, he is still clinging to them as rules for living. His expecta-
tions, most of which are pessimistic, tend to be fulfi lled because on some level he
is seeking to validate his beliefs. Indeed, his depression will eventually serve the
purpose of helping him avoid contact with others, a life task at which he expects
to fail. In therapy, this man will learn how to challenge the structure of his private
logic. In his case the syllogism goes as follows:
• “I am basically unlovable.”
• “The world is fi lled with people who are likely to be rejecting.”
• “Therefore, I must keep to myself so I won’t be hurt.”
This person holds onto several basic mistakes, and his private logic offers a psy-
chological focus for treatment. A central theme or convictions in this client’s life
might be: “I must control everything in my life.” “I must be perfect in everything
I do.”
It is easy to see how depression might follow from this thinking, but Adlerians
also know that the depression serves as an excuse for this man’s retreat from life.
It is important for the therapist to listen for the underlying purposes of this cli-
ent’s behavior. Adlerians see feelings as being aligned with thinking and as the
fuel for behaving. First we think, then we feel, and then we act. Because emotions
and cognitions serve a purpose, a good deal of therapy time is spent in discover-
ing and understanding this purpose and in reorienting the client toward effective
ways of being. Because the client is not perceived by the therapist to be mentally
ill or emotionally disturbed, but as mainly discouraged, the therapist will offer the
client encouragement so that change is possible. Through the therapeutic proc-
ess, the client will discover that he or she has resources and options to draw on in
dealing with signifi cant life issues and life tasks.
Relationship Between Therapist and Client
Adlerians consider a good client–therapist relationship to be one between equals
that is based on cooperation, mutual trust, respect, confi dence, collaboration, and
alignment of goals. They place special value on the counselor’s modeling of com-
munication and acting in good faith. From the beginning of therapy, the relation-
ship is a collaborative one, characterized by two persons working equally toward
specifi c, agreed-upon goals. Adlerian therapists strive to establish and maintain
an egalitarian therapeutic alliance and a person-to-person relationship with their
clients. Developing a strong therapeutic relationship is essential to successful out-
comes (Carlson et al., 2006). Dinkmeyer and Sperry (2000) maintain that at the
outset of counseling clients should begin to formulate a plan, or contract, detailing
what they want, how they plan to get where they are heading, what is preventing
them from successfully attaining their goals, how they can change nonproductive
behavior into constructive behavior, and how they can make full use of their assets
in achieving their purposes. This therapeutic contract sets forth the goals of the
counseling process and specifi es the responsibilities of both therapist and client.
Developing a contract is not a requirement of Adlerian therapy, but a contract can
bring a tight focus to therapy.
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a p p l i c at i o n : t h e r a p e u t i c
t e c h n i q u e s a n d p r o c e d u r e s
Adlerian counseling is structured around four central objectives that correspond to
the four phases of the therapeutic process (Dreikurs, 1967). These phases are not
linear and do not progress in rigid steps; rather, they can best be understood as a
weaving that leads to a tapestry. These phases are as follows:
1. Establish the proper therapeutic relationship.
2. Explore the psychological dynamics operating in the client (an assessment).
3. Encourage the development of self-understanding (insight into purpose).
4. Help the client make new choices (reorientation and reeducation).
Dreikurs (1997) incorporated these phases into what he called minor psycho-
therapy in the context and service of holistic medicine. His approach to therapy
has been elaborated in what is now called Adlerian brief therapy, or ABT (Bitter,
Christensen, Hawes, & Nicoll, 1998). This way of working is discussed in the fol-
lowing sections.
Phase 1: Establish the Relationship
The Adlerian practitioner works in a collaborative way with clients, and this rela-
tionship is based on a sense of interest that grows into caring, involvement, and
friendship. Therapeutic progress is possible only when there is an alignment of
clearly defi ned goals between therapist and client. The counseling process, to be
effective, must deal with the personal issues the client recognizes as signifi cant
and is willing to explore and change. The therapeutic effi cacy in the later phases of
Adlerian therapy is predicated upon the development and continuation of a solid
therapeutic relationship during this fi rst phase of therapy (Watts, 2000; Watts &
Pietrzak, 2000).
Adlerian therapists focus on making person-to-person contact with clients
rather than starting with “the problem.” Clients’ concerns surface rather quickly
in therapy, but the initial focus should be on the person, not the problem. One way
to create effective contact is for counselors to help clients become aware of their
assets and strengths rather than dealing continually with their defi cits and lia-
bilities. During the initial phase, a positive relationship is created by listening;
responding; demonstrating respect for clients’ capacity to understand purpose and
seek change; and exhibiting faith, hope, and caring. When clients enter therapy,
they typically have a diminished sense of self-worth and self-respect. They lack faith
in their ability to cope with the tasks of life. Therapists provide support, which is
an antidote to despair and discouragement. For some people, therapy may be one
of the few times in which they have truly experienced a caring human relationship.
Adlerians pay more attention to the subjective experiences of the client than
they do to using techniques. They fi t their techniques to the needs of each client.
During the initial phase of counseling, the main techniques are attending and
listening with empathy, following the subjective experience of the client as closely
as possible, identifying and clarifying goals, and suggesting initial hunches about
purpose in client’s symptoms, actions, and interactions. Adlerian counselors are
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generally active, especially during the initial sessions. They provide structure and
assist clients to defi ne personal goals, they conduct psychological assessments,
and they offer interpretations (Carlson et al., 2006). Adlerians attempt to grasp
both the verbal and nonverbal messages of the client; they want to access the core
patterns in the client’s life. If the client feels deeply understood and accepted, the
client is likely to focus on what he or she wants from therapy and thus establish
goals. At this stage the counselor’s function is to provide a wide-angle perspective
that will eventually help the client view his or her world differently.
Phase 2: Explore the Individual’s Psychological Dynamics
The aim of the second phase of Adlerian counseling is to get a deeper understand-
ing of an individual’s lifestyle. During this assessment phase, the focus is on the
individual’s social and cultural context. Rather than attempting to fi t clients into a
preconceived model, Adlerian practitioners allow salient cultural identity concepts
to emerge in the therapy process, and these issues are then addressed (Carlson &
Englar-Carlson, 2008). This assessment phase proceeds from two interview forms:
the subjective interview and the objective interview (Dreikurs, 1997). In the subjective
interview, the counselor helps the client to tell his or her life story as completely as
possible. This process is facilitated by a generous use of empathic listening and
responding. Active listening, however, is not enough. The subjective interview
must follow from a sense of wonder, fascination, and interest. What the client
says will spark an interest in the counselor and lead, naturally, to the next most
signifi cant question or inquiry about the client and his or her life story. Indeed,
the best subjective interviews treat clients as experts in their own lives, allowing
clients to feel completely heard. Throughout the subjective interview, the Adlerian
counselor is listening for clues to the purposive aspects of the client’s coping and
approaches to life. “The subjective interview should extract patterns in the person’s
life, develop hypotheses about what works for the person, and determine what
accounts for the various concerns in the client’s life” (Bitter et al., 1998, p. 98).
Toward the end of this part of the interview, Adlerian brief therapists ask, “Is there
anything else you think I should know to understand you and your concerns?”
An initial assessment of the purpose that symptoms, actions, or diffi culties
serve in a person’s life can be gained from what Dreikurs (1997) calls “The Ques-
tion.” Adlerians often end a subjective interview with this question: “How would
your life be different, and what would you be doing differently, if you did not have
this symptom or problem?” Adlerians use this question to help with differential
diagnosis. More often, the symptoms or problems experienced by the client help
the client avoid something that is perceived as necessary but from which the per-
son wishes to retreat, usually a life task: “If it weren’t for my depression, I would
get out more and see my friends.” Such a statement betrays the client’s concern
about the possibility of being a good friend or being welcomed by his or her friends.
“I need to get married, but how can I with these panic attacks?” indicates the per-
son’s worry about being a partner in a marriage. Depression can serve as the cli-
ent’s solution when faced with problems in relationships. If a client reports that
nothing would be different, especially with physical symptoms, Adlerians suspect
that the problem may be organic and require medical intervention.
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The objective interview seeks to discover information about (a) how problems
in the client’s life began; (b) any precipitating events; (c) a medical history, includ-
ing current and past medications; (d) a social history; (e) the reasons the client
chose therapy at this time; (f) the person’s coping with life tasks; and (g) a lifestyle
assessment. Mozdzierz and his colleagues (1986) describe the counselor as a “life-
style investigator” during this phase of therapy. Based on interview approaches
developed by Adler and Dreikurs, the lifestyle assessment starts with an investiga-
tion of the person’s family constellation and early childhood history (Powers &
Griffi th, 1987; Shulman & Mosak, 1988). Counselors also interpret the person’s
early memories, seeking to understand the meaning that she or he has attached
to life experiences. They operate on the assumption that it is the interpretations
people develop about themselves, others, the world, and life that govern what they
do. Lifestyle assessment seeks to develop a holistic narrative of the person’s life, to
make sense of the way the person copes with life tasks, and to uncover the private
interpretations and logic involved in that coping. For example, if Jenny has lived
most of her life in a critical environment, and now she believes she must be perfect
to avoid even the appearance of failure, the assessment process will highlight the
restricted living that fl ows from this perspective.
t h e fa m i ly c o n s t e l l at i o n Adler considered the family of origin as having
a central impact on an individual’s personality. Adler suggested that it was through
the family constellation that each person forms his or her unique view of self, others,
and life. Factors such as cultural and familial values, gender-role expectations, and
the nature of interpersonal relationships are all infl uenced by a child’s observation
of the interactional patterns within the family. Adlerian assessment relies heavily on
an exploration of the client’s family constellation, including the client’s evaluation
of conditions that prevailed in the family when the person was a young child (family
atmosphere), birth order, parental relationship and family values, and extended fam-
ily and culture. Some of these questions are almost always explored:
• Who was the favorite child?
• What was your father’s relationship with the children? Your mother’s?
• Which child was most like your father? Your mother? In what respects?
• Who among the siblings was most different from you? In what ways?
• Who among the siblings was most like you? In what ways?
• What were you like as a child?
• How did your parents get along? In what did they both agree? How did they
handle disagreements? How did they discipline the children?
An investigation of family constellation is far more comprehensive than these few
questions, but these questions give an idea of the type of information the counselor
is seeking. The questions are always tailored to the individual client with the goal
of eliciting the client’s perceptions of self and others, of development, and of the
experiences that have affected that development.
e a r ly r e c o l l e c t i o n s As you will recall, another assessment procedure used
by Adlerians is to ask the client to provide his or her earliest memories, including the
age of the person at the time of the remembered events and the feelings or reactions
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associated with the recollections. Early recollections are one-time occurrences, usu-
ally before the age of 9, pictured by the client in clear detail. Adler reasoned that out
of the millions of early memories we might have we select those special memories
that project the essential convictions and even the basic mistakes of our lives. Early
recollections are a series of small mysteries that can be woven together into a tapes-
try that leads to an understanding of how we view ourselves, how we see the world,
what our life goals are, what motivates us, what we value and believe in, and what we
anticipate for our future (Clark, 2002; Mosak & Di Pietro, 2006).
Early memories cast light on the “story of our life” because they represent met-
aphors for our current views. From the thousands of experiences we have before
the age of 9, we tend to remember only 6 to 12 memories. By understanding why
we retain these memories and what they tell us about how we see ourselves, others,
and life in the present, it is possible to get a clear sense of our mistaken notions,
present attitudes, social interests, and possible future behavior. Early recollections
are specifi c instances that clients tell therapists, and they are very useful in under-
standing those who are sharing a story (Mosak & Di Pietro, 2006). Exploring early
recollections involves discovering how mistaken notions based on faulty goals and
values continue to create problems in a client’s life.
To tap such recollections, the counselor might proceed as follows: “I would like
to hear about your early memories. Think back to when you were very young, as
early as you can remember (before the age of 10), and tell me something that hap-
pened one time.” After receiving each memory, the counselor might also ask: “What
part stands out to you? What was the most vivid part of your early memory? If
you played the whole memory like a movie and stopped it at one frame, what would
be happening? Putting yourself in that moment, what are you feeling? What’s your
reaction?” Three memories are usually considered a minimum to assess a pattern,
and some counselors ask for as many as a dozen memories.
Adlerian therapists use early recollections as a projective technique (Clark, 2002;
Hood & Johnson, 2007) and to (a) assess the client’s convictions about self, others,
life, and ethics; (b) assess the client’s stance in relation to the counseling session
and the counseling relationship; (c) verify the client’s coping patterns; and (d) assess
individual strengths, assets, and interfering ideas (Bitter et al., 1998, p. 99).
In interpreting these early recollections, Adlerians may consider questions
such as these:
• What part does the client take in the memory? Is the client an observer or a
participant?
• Who else is in the memory? What position do others take in relation to the client?
• What are the dominant themes and overall patterns of the memories?
• What feelings are expressed in the memories?
• Why does the client choose to remember this event? What is the client trying to
convey?
i n t e g r at i o n a n d s u m m a ry Once material has been gathered from both
subjective and objective interviews with the client, integrated summaries of the
data are developed. Different summaries are prepared for different clients, but
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common ones are a narrative summary of the person’s subjective experience and
life story; a summary of family constellation and developmental data; a summa-
ry of early recollections, personal strengths or assets, and interfering ideas; and
a summary of coping strategies. The summaries are presented to the client and
discussed in the session, with the client and the counselor together refi ning
specifi c points. This information provides the client with the chance to discuss
specifi c topics and to raise questions.
Mosak and Maniacci (2011) believe lifestyle can be conceived of as a personal
mythology. People behave as if the myths were true because, for them, they are
true. Mosak and Maniacci list fi ve basic mistakes in what is essentially an integra-
tion of Adlerian psychology and cognitive behavioral theory: overgeneralizations,
false or impossible goals of security, misperceptions of life and life’s demands,
minimization or denial of one’s basic worth, and faulty values.
In addition to the concept of basic mistakes, Adlerian theory is useful in as-
sisting clients to identify and examine some of their common fears. These fears
include being imperfect, being vulnerable, being disapproved of, and suffering
from past regrets (Carlson & Englar-Carlson, 2008).
The Student Manual that accompanies this textbook includes a concrete
example of the lifestyle assessment as it is applied to the case of Stan. In Case
Approach to Counseling and Psychotherapy (Corey, 2013, chap. 3), Drs. Jim Bitter
and Bill Nicoll present a lifestyle assessment of another hypothetical client, Ruth.
Phase 3: Encourage Self-Understanding and Insight
During this third phase, Adlerian therapists interpret the fi ndings of the assess-
ment as an avenue for promoting self-understanding and insight. Mosak and
Maniacci (2011) defi ne insight as “understanding translated into constructive action”
(p. 89). When Adlerians speak of insight, they are referring to an understanding of
the motivations that operate in a client’s life. Self-understanding is only possible
when hidden purposes and goals of behavior are made conscious. Adlerians con-
sider insight as a special form of awareness that facilitates a meaningful understand-
ing within the therapeutic relationship and acts as a foundation for change. Insight
is a means to an end, and not an end in itself. People can make rapid and signifi cant
changes without much insight.
Disclosure and well-timed interpretations are techniques that facilitate the proc-
ess of gaining insight. Interpretation deals with clients’ underlying motives for
behaving the way they do in the here and now. Adlerian disclosures and interpreta-
tions are concerned with creating awareness of one’s direction in life, one’s goals
and purposes, one’s private logic and how it works, and one’s current behavior.
Adlerian interpretations are suggestions presented tentatively in the form of
open-ended questions that can be explored in the sessions. They are hunches or
guesses, and they often begin with phrases such as “I could be wrong, but I am
wondering if . . . ,” “Could it be that . . . ,” or “Is it possible that . . .” Because inter-
pretations are presented in this manner, clients are not led to defend themselves,
and they feel free to discuss and even argue with the counselor’s hunches and
impressions. Through this process, both counselor and client eventually come to
understand the client’s motivations, the ways in which these motivations are now
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contributing to the maintenance of the problem, and what the client can do to
correct the situation. During this phase of therapy, the counselor helps the client
understand the limitations of the style of life the client has chosen.
Phase 4: Reorientation and Reeducation
The fi nal stage of the therapeutic process is the action-oriented phase known as
reorientation and reeducation: putting insights into practice. This phase focuses
on helping clients discover a new and more functional perspective. Clients are
both encouraged and challenged to develop the courage to take risks and make
changes in their life. During this phase, clients can choose to adopt a new style of
life based on the insights they gained in the earlier phases of therapy.
Adlerians are interested in more than changes in behavior. Reorientation
involves shifting rules of interaction, process, and motivation. These shifts are
facilitated through changes in awareness, which often occur during the therapy ses-
sion and which are transformed into action outside of the therapy offi ce (Bitter &
Nicoll, 2004). In addition, especially at this phase of therapy, Adlerians focus on
reeducation (see the section on therapeutic goals).
In some cases, signifi cant changes are needed if clients are to overcome discour-
agement and fi nd a place for themselves in this life. More often, however, clients
merely need to be reoriented toward the useful side of life. The useful side involves a
sense of belonging and being valued, having an interest in others and their welfare,
courage, the acceptance of imperfection, confi dence, a sense of humor, a willing-
ness to contribute, and an outgoing friendliness. The useless side of life is charac-
terized by self-absorption, withdrawal from life tasks, self-protection, or acts against
one’s fellow human beings. People acting on the useless side of life become less
functional and are more susceptible to psychopathology. Adlerian therapy stands
in opposition to self-depreciation, isolation, and retreat, and it seeks to help clients
gain courage and to connect to strengths within themselves, to others, and to life.
Throughout this phase, no intervention is more important than encouragement.
t h e e n c o u r a g e m e n t p r o c e s s Encouragement is the most distinctive
Adlerian procedure, and it is central to all phases of counseling and therapy. It
is especially important as people consider change in their lives. Encouragement
literally means “to build courage.” Courage develops when people become aware
of their strengths, when they feel they belong and are not alone, and when they
have a sense of hope and can see new possibilities for themselves and their daily
living. Encouragement entails showing faith in people, expecting them to assume
responsibility for their lives, and valuing them for who they are (Carlson et al.,
2006). Carlson and Englar-Carlson (2008) note that encouragement involves
acknowledging that life can be diffi cult, yet it is critical to instill a sense of faith in
clients that they can make changes in life. Milliren, Evans, and Newbauer (2007)
consider encouragement key in promoting and activating social interest. They add
that encouragement is the universal therapeutic intervention for Adlerian coun-
selors, that it is a fundamental attitude rather than a technique. Because clients
often do not recognize or accept their positive qualities, strengths, or internal
resources, one of the counselor’s main tasks is to help them do so.
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Adlerians believe discouragement is the basic condition that prevents people
from functioning, and they see encouragement as the antidote. As a part of the
encouragement process, Adlerians use a variety of relational, cognitive, behavioral,
emotional, and experiential techniques to help clients identify and challenge self-
defeating cognitions, generate perceptional alternatives, and make use of assets,
strengths, and resources (Ansbacher & Ansbacher, 1964; Dinkmeyer & Sperry,
2000; Watts & Pietrzak, 2000; Watts & Shulman, 2003).
Encouragement takes many forms, depending on the phase of the coun-
seling process. In the relationship phase, encouragement results from the mutual
respect the counselor seeks to engender. In the assessment phase, which is partially
designed to illuminate personal strengths, clients are encouraged to recognize that
they are in charge of their own lives and can make different choices based on new
understandings. During reorientation, encouragement comes when new possibili-
ties are generated and when clients are acknowledged and affi rmed for taking posi-
tive steps to change their lives for the better.
c h a n g e a n d t h e s e a r c h f o r n e w p o s s i b i l i t i e s During the reo-
rientation phase of counseling, clients make decisions and modify their goals. They
are encouraged to act as if they were the people they want to be, which can serve
to challenge self-limiting assumptions. Clients are asked to catch themselves in the
process of repeating old patterns that have led to ineffective behavior. Commitment
is an essential part of reorientation. If clients hope to change, they must be willing
to set tasks for themselves in everyday life and do something specifi c about their
problems. In this way, clients translate their new insights into concrete actions. Bit-
ter and Nicoll (2004) emphasize that real change happens between sessions, and
not in therapy itself. They state that arriving at a strategy for change is an important
fi rst step, and stress that it takes courage and encouragement for clients to apply
what they have learned in therapy to daily living.
This action-oriented phase is a time for solving problems and making deci-
sions. The counselor and the client consider possible alternatives and their con-
sequences, evaluate how these alternatives will meet the client’s goals, and decide
on a specifi c course of action. The best alternatives and new possibilities are those
generated by the client, and the counselor must offer the client a great deal of sup-
port and encouragement during this stage of the process.
m a k i n g a d i f f e r e n c e Adlerian counselors seek to make a difference in the
lives of their clients. That difference may be manifested by a change in behavior or
attitude or perception. Adlerians use many different techniques to promote change,
some of which have become common interventions in other therapeutic models.
Techniques that go by the names of immediacy, advice, humor, silence, paradoxi-
cal intention, acting as if, spitting in the client’s soup, catching oneself, the push-
button technique, externalization, reauthoring, avoiding the traps, confrontation, use
of stories and fables, early recollection analysis, lifestyle assessment, encouraging,
task setting and commitment, giving homework, and terminating and summariz-
ing have all been used (Carlson & Slavik, 1997; Carlson et al., 2006; Dinkmeyer &
Sperry, 2000; Disque & Bitter, 1998; Mosak & Maniacci, 2011; Mozdzierz, Peluso, &
Lisiecki, 2009). Adlerian practitioners can creatively employ a wide range of other
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techniques, as long as these methods are philosophically consistent with the basic
theoretical premises of Adlerian psychology (Milliren et al., 2007). Adlerians are prag-
matic when it comes to using techniques that are appropriate for a given client. In
general, however, Adlerian practitioners focus on motivation modifi cation more than
behavior change and encourage clients to make holistic changes on the useful side of
living. All counseling is a cooperative effort, and making a difference depends on the
counselor’s ability to win the client’s cooperation.
Areas of Application
Adler anticipated the future direction of the helping professions by calling upon
therapists to become social activists and by addressing the prevention and reme-
diation of social conditions that were contrary to social interest and resulted in
human problems. Adler’s pioneering efforts on prevention services in mental health
led him to increasingly advocate for the role of Individual Psychology in schools and
families. Because Individual Psychology is based on a growth model, not a medical
model, it is applicable to such varied spheres of life as child guidance; parent–child
counseling; couples counseling; family counseling and therapy; group counseling
and therapy; individual counseling with children, adolescents, and adults; cultural
confl icts; correctional and rehabilitation counseling; and mental health institutions.
Adler’s basic ideas have been incorporated into the practices of school psychology,
school counseling, the community mental health movement, and parent education.
Adlerian principles have been widely applied to substance abuse programs, social
problems to combat poverty and crime, problems of the aged, school systems, reli-
gion, and business.
a p p l i c at i o n t o e d u c at i o n Adler (1930/1978) advocated training both
teachers and parents in effective practices that foster the child’s social interests and
result in a sense of competence and self-worth. Adler had a keen interest in apply-
ing his ideas to education, especially in fi nding ways to remedy faulty lifestyles of
schoolchildren. He initiated a process to work with students in groups and to edu-
cate parents and teachers. By providing teachers with ways to prevent and correct
basic mistakes of children, he sought to promote social interest and mental health.
Adler was ahead of his time in advocating for schools to take an active role in de-
veloping social skills and character education as well as teaching the basics. Many
of the major teacher education models are based on principles of Adlerian psychol-
ogy (see Albert, 1996). Besides Adler, the main proponent of Individual Psychol-
ogy as a foundation for the teaching–learning process was Dreikurs (1968, 1971).
a p p l i c at i o n t o pa r e n t e d u c at i o n Parent education seeks to im-
prove the relationship between parent and child by promoting greater understand-
ing and acceptance. Parents are taught how to recognize the mistaken goals of chil-
dren and to use logical and natural consequences to guide children toward more
productive behavior. Adlerian parent education also stresses listening to children,
helping children accept the consequences of their behavior, applying emotion
coaching, holding family meetings, and using encouragement. Two of the leading
parent education programs in the United States—STEP (Dinkmeyer & McKay,
1997) and Active Parenting (Popkin, 1993)—are based on Adlerian principles.
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a p p l i c at i o n t o c o u p l e s c o u n s e l i n g Adlerian therapy with couples
is designed to assess a couple’s beliefs and behaviors while educating them in
more effective ways of meeting their relational goals. Clair Hawes has developed
an approach to couples counseling within the Adlerian brief therapy model. In addi-
tion to addressing the compatibility of lifestyles, Hawes looks at the early recollections
of the marriage and each partner’s relationship to a broad set of life tasks, including
occupation, social relationships, intimate relationships, spirituality, self-care, and
self-worth (Bitter et al., 1998; Hawes, 1993; Hawes & Blanchard, 1993). Carlson,
Watts, and Maniacci (2006) describe how Adlerians achieve the goals of brief
couples therapy: they foster social interest, assist couples in decreasing feelings
of inferiority and overcoming discouragement, help couples modify their views
and goals, help couples to feel a sense of quality in their relationships, and pro-
vide skill-building opportunities. Therapists aim to create solutions for problems,
increase choices of couples, and help clients discover and use their individual and
collective resources.
The full range of techniques applicable to other forms of counseling can be used
when working with couples. In couples counseling, couples are taught specifi c
techniques that enhance communication and cooperation. Some of these tech-
niques are listening, paraphrasing, giving feedback, having marriage conferences,
listing expectations, doing homework, and enacting problem solving. Adlerians
use psychoeducational methods and skills training in counseling couples. For use-
ful books on this topic, see Carlson and Dinkmeyer (2003) and Sperry, Carlson,
and Peluso (2006).
Adlerians will sometimes see clients as a couple, sometimes individually, and
then alternately as a couple and as individuals. Rather than looking for who is at fault
in the relationship, the therapist considers the lifestyles of the partners and the inter-
action of the two lifestyles. Emphasis is given to helping them decide if they want to
maintain their relationship, and, if so, what changes they are willing to make.
a p p l i c at i o n t o fa m i ly c o u n s e l i n g With its emphasis on the fam-
ily constellation, holism, and the freedom of the therapist to improvise, Adler’s
approach contributed to the foundation of the family therapy perspective. Adleri-
ans working with families focus on the family atmosphere, the family constellation,
and the interactive goals of each member (Bitter, 2009). The family atmosphere is
the climate characterizing the relationship between the parents and their attitudes
toward life, gender roles, decision making, competition, cooperation, dealing with
confl ict, responsibility, and so forth. This atmosphere, including the role models
the parents provide, infl uences the children as they grow up. The therapeutic proc-
ess seeks to increase awareness of the interaction of the individuals within the
family system. Those who practice Adlerian family therapy strive to understand
the goals, beliefs, and behaviors of each family member and the family as an entity
in its own right. Adler’s and Dreikurs’s infl uence on family therapy is covered in
more depth in Chapter 14.
a p p l i c at i o n t o g r o u p c o u n s e l i n g Adler and his coworkers used
a group approach in their child guidance centers in Vienna as early as 1921
(Dreikurs, 1969). Dreikurs extended and popularized Adler’s work with groups
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and used group psychotherapy in his private practice for more than 40 years.
Although Dreikurs introduced group therapy into his psychiatric practice as a way
to save time, he quickly discovered some unique characteristics of groups that
made them an effective way of helping people change. Inferiority feelings can be
challenged and counteracted effectively in groups, and the mistaken concepts and
values that are at the root of social and emotional problems can be deeply infl u-
enced because the group is a value-forming agent (Sonstegard & Bitter, 2004).
The rationale for Adlerian group counseling is based on the premise that our
problems are mainly of a social nature. The group provides the social context in
which members can develop a sense of belonging, social connectedness, and com-
munity. Sonstegard and Bitter (2004) write that group participants come to see
that many of their problems are interpersonal in nature, that their behavior has
social meaning, and that their goals can best be understood in the framework
of social purposes.
The use of early recollections is a unique feature of Adlerian group counseling.
As mentioned earlier, from a series of early memories, individuals can get a clear
sense of their mistaken notions, current attitudes, social interests, and possible fu-
ture behavior. Through the mutual sharing of these early recollections, members
develop a sense of connection with one another, and group cohesion is increased.
The group becomes an agent of change because of the improved interpersonal
relationships among members and the emergence of hope.
We particularly value the way Adlerian group counselors implement action
strategies at each of the group sessions and especially during the reorientation
stage when new decisions are made and goals are modifi ed. To challenge self-
limiting assumptions, members are encouraged to act as if they were the persons
they want to be. They are asked to “catch themselves” in the process of repeating
old patterns that have led to ineffective or self-defeating behavior. The mem-
bers come to appreciate that if they hope to change, they need to set tasks for
themselves, apply group lessons to daily life, and take steps in fi nding solutions
to their problems. This fi nal stage is characterized by group leaders and mem-
bers working together to challenge erroneous beliefs about self, life, and others.
During this stage, members are considering alternative beliefs, behaviors, and
attitudes.
Adlerian group counseling can be considered a brief approach to treatment.
The core characteristics associated with brief group therapy include rapid estab-
lishment of a strong therapeutic alliance, clear problem focus and goal alignment,
rapid assessment, emphasis on active and directive therapeutic interventions, a
focus on strengths and abilities of clients, an optimistic view of change, a focus
on both the present and the future, and an emphasis on tailoring treatment to
the unique needs of clients in the most time-effi cient manner possible (Carlson
et al., 2006).
Adlerian brief group therapy is addressed by Sonstegard, Bitter, Pelonis-
Peneros, and Nicoll (2001). For more on the Adlerian approach to group coun-
seling, refer to Theory and Practice of Group Counseling (Corey, 2012, chap. 7) and
Sonstegard and Bitter (2004).
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a d l e r i a n t h e r a p y f r o m
a m u lt i c u lt u r a l p e r s p e c t i v e
Strengths From a Diversity Perspective
Adlerian theory addressed social equality issues and social embeddedness of
humans long before multiculturalism assumed central importance in the profes-
sion (Watts & Pietrzak, 2000). Adler introduced notions with implications toward
multiculturalism that have as much or more relevance today as they did during
Adler’s time (Pedersen, as cited in Nystul, 1999b). Some of these ideas include
(1) the importance of the cultural context, (2) the emphasis on health as opposed
to pathology, (3) a holistic perspective on life, (4) the value of understanding indi-
viduals in terms of their core goals and purposes, (5) the ability to exercise freedom
within the context of societal constraints, and (6) the focus on prevention and the
development of a proactive approach in dealing with problems. Adler’s holistic per-
spective is an articulate expression of what Pedersen calls a “culture-centered” or
multicultural approach to counseling. Carlson and Englar-Carlson (2008) maintain
that Adlerian theory is well suited to counseling diverse populations and doing so-
cial justice work. They assert: “Perhaps Adler’s greatest contribution is that he de-
veloped a theory that recognizes and stresses the effects of social class, racism, sex,
and gender on the behavior of individuals. His ideas, therefore, are well received by
those living in today’s global society” (p. 134).
Although the Adlerian approach is called Individual Psychology, its focus is on
the person in a social context. Thus clients are encouraged to defi ne themselves
within their social environments. Adlerians allow broad concepts of age, ethnicity,
lifestyle, sexual/affectional orientations, and gender differences to emerge in ther-
apy. The therapeutic process is grounded within a client’s culture and worldview
rather than attempting to fi t clients into preconceived models.
In their analysis of the various theoretical approaches to counseling, Arciniega
and Newlon (2003) state that Adlerian theory holds a great deal of promise for
addressing diversity issues. They note a number of characteristics of Adlerian the-
ory that are congruent with the values of many racial, cultural, and ethnic groups,
including the emphasis on understanding the individual in a familial and socio-
cultural context; the role of social interest and contributing to others; and the focus
on belonging and the collective spirit. Cultures that stress the welfare of the social
group and emphasize the role of the family will fi nd the basic assumptions of Adle-
rian psychology to be consistent with their values.
Adlerian therapists tend to focus on cooperation and socially oriented values
as opposed to competitive and individualistic values (Carlson & Carlson, 2000).
Native American clients, for example, tend to value cooperation over competition.
One such client told a story about a group of boys who were in a race. When one
boy got ahead of the others, he would slow down and allow the others to catch up,
and they all made it to the fi nish line at the same time. Although the coach tried
to explain that the point of the race was for an individual to fi nish fi rst, these boys
were socialized to work together cooperatively as a group. Adlerian therapy is easily
adaptable to cultural values that emphasize community.
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Not only is Adlerian theory congruent with the values of people from diverse
cultural groups, but the approach offers fl exibility in applying a range of cognitive
and action-oriented techniques to helping clients explore their practical problems
in a cultural context. Adlerian practitioners are not wedded to any particular set
of procedures. Instead, they are conscious of the value of fi tting their techniques
to each client’s situation. Although they utilize a diverse range of methods, most
of them do conduct a lifestyle assessment. This assessment is heavily focused on
the structure and dynamics within the client’s family. Because of their cultural
background, many clients have been conditioned to respect their family heritage
and to appreciate the impact of their family on their own personal development. It
is essential that counselors be sensitive to the confl icting feelings and struggles of
their clients. If counselors demonstrate an understanding of these cultural values,
it is likely that these clients will be receptive to an exploration of their lifestyle.
Such an exploration will involve a detailed discussion of their own place within
their family.
It should be noted that Adlerians investigate culture in much the same way
that they approach birth order and family atmosphere. Culture is a vantage point
from which life is experienced and interpreted; it is also a background of values,
history, convictions, beliefs, customs, and expectations that must be addressed by
the individual. Culture provides a way of grasping the subjective and experien-
tial perspective of an individual. Although culture infl uences each person, it is
expressed within each individual differently, according to the perception, evalua-
tion, and interpretation of culture that the person holds. Contemporary Adlerians
appreciate the role of spirituality and religion in the lives of clients because these
factors are manifestations of social interest and responsibility to others (Carlson &
Englar-Carlson, 2008).
Adler was one of the fi rst psychologists at the turn of the century to advocate
equality for women. He recognized that men and women were different in many
ways, but he felt that the two genders were deserving of equal value and respect.
This respect and appreciation for difference extends to culture as well as gender.
Adlerians fi nd in different cultures opportunities for viewing the self, others, and
the world in multidimensional ways.
Shortcomings From a Diversity Perspective
As is true of most Western models, the Adlerian approach tends to focus on the
self as the locus of change and responsibility. Because other cultures have differ-
ent conceptions, this primary emphasis on changing the autonomous self may be
problematic for many clients. Assumptions about the Western nuclear family are
built into the Adlerian concepts of birth order and family constellation. For people
brought up in extended family contexts, some of these ideas may be less relevant
or at least may need to be reconfi gured.
Adlerian theory has some potential drawbacks for clients from those cultures
who are not interested in exploring past childhood experiences, early memories,
family experiences, and dreams. This approach also has limited effectiveness with
clients who do not understand the purpose of exploring the details of a lifestyle
analysis when dealing with life’s current problems (Arciniega & Newlon, 2003).
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In addition, the culture of some clients may contribute to their viewing the coun-
selor as the “expert” and expecting that the counselor will provide them with solu-
tions to their problems. For these clients, the role of the Adlerian therapist may
pose problems because Adlerian therapists are not experts in solving other people’s
problems. Instead, they view it as their function to collaboratively teach people
alternative methods of coping with life concerns.
Many clients who have pressing problems are likely to be hesitant to discuss
areas of their lives that they may not see as connected to the struggles that bring
them into therapy. Individuals may believe that it is inappropriate to reveal family
information. On this point Carlson and Carlson (2000) suggest that a therapist’s
sensitivity and understanding of a client’s culturally constructed beliefs about dis-
closing family information are critical. If the therapist is able to demonstrate an
understanding of a client’s cultural values, it is likely that this person will be more
open to the assessment and treatment process.
The basic aims of an Adlerian thera-
pist working with Stan are fourfold
and correspond to the four stages
of counseling: (1) establishing and maintain-
ing a good working relationship with Stan,
(2) exploring Stan’s dynamics, (3) encouraging
Stan to develop insight and understanding, and
(4) helping Stan see new alternatives and make
new choices.
To develop mutual trust and respect, I pay
close attention to Stan’s subjective experience
and attempt to get a sense of how he has
reacted to the turning points in his life. During
the initial session, Stan reacts to me as the
expert who has the answers. He is convinced
that when he makes decisions he generally ends
up regretting the results. Stan approaches me
out of desperation. Because I view counseling
as a relationship between equals, I initially focus
on his feeling of being unequal to most other
people. A good place to begin is exploring his
feelings of inferiority, which he says he feels in
most situations. The goals of counseling are
developed mutually, and I avoid deciding for
Stan what his goals should be. I also resist
giving Stan the simple formula he is
requesting.
I prepare a lifestyle assessment based on a
questionnaire that taps information about Stan’s
early years, especially his experiences in his
family. (See the Student Manual for Theory and
Practice of Counseling and Psychotherapy for a
complete description of this lifestyle assessment
form as it is applied to Stan.) This assessment
includes a determination of whether he poses
a danger to himself because Stan did mention
suicidal ideation. During the assessment phase,
which might take a few sessions, I explore with
Stan his social relationships, his relationships
with members of his family, his work responsi-
bilities, his role as a man, and his feelings about
himself. I place considerable emphasis on Stan’s
goals in life and his priorities. I do not pay a great
deal of attention to his past, except to show him
the consistency between his past and present as
he moves toward the future.
As an Adlerian counselor, I place value on
exploring early recollections as a source of
understanding his goals, motivations, and
values. I ask Stan to report his earliest
memories. He replies as follows:
I was about 6. I went to school, and I was
scared of the other kids and the teacher. When I
came home, I cried and told my mother I didn’t
want to go back to school. She yelled at me and
called me a baby. After that I felt horrible and
even more scared.
Adlerian Therapy Applied to the Case of Stan
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Another of Stan’s early recollections was at
age 8:
My family was visiting my grandparents. I was
playing outside, and some neighborhood kid
hit me for no reason. We started fighting, and
my mother came out and scolded me for being
such a rough kid. She wouldn’t believe me when
I told her he started the fight. I felt angry and
hurt that she didn’t believe me.
Based on these early recollections, I suggest
that Stan sees life as frightening and unpredict-
ably hostile and that he feels he cannot count on
women; they are likely to be harsh, unbelieving,
and uncaring.
Having gathered the data based on the lifestyle
assessment about his family constellation and his
early recollections, I assist Stan in the process of
summarizing and interpreting this information. I
give particular attention to identifying basic mis-
takes, which are faulty conclusions about life and
self-defeating perceptions. Here are some of the
mistaken conclusions Stan has reached:
• “I must not get close to people, because they
will surely hurt me.”
• “Because my own parents didn’t want me and
didn’t love me, I’ll never be desired or loved by
anybody.”
• “If only I could become perfect, maybe people
would acknowledge and accept me.”
• “Being a man means not showing emotions.”
The information I summarize and interpret
leads to insight and increased self-understanding
on Stan’s part. He gains increased awareness of
his need to control his world so that he can keep
painful feelings in check. He sees more clearly
some of the ways he tries to gain control over
his pain: through the use of alcohol, avoiding
interpersonal situations that are threatening, and
being unwilling to count on others for psycholog-
ical support. Through continued emphasis on his
beliefs, goals, and intentions, Stan comes to see
how his private logic is inaccurate. In his case, a
syllogism for his style of life can be explained in
this way: (1) “I am unloved, insignificant, and do
not count”; (2) “The world is a threatening place
to be, and life is unfair”; (3) “Therefore, I must
find ways to protect myself and be safe.” During
this phase of the process, I make interpretations
centering on his lifestyle, his current direction,
his goals and purposes, and how his private logic
works. Of course, Stan is expected to carry out
homework assignments that assist him in trans-
lating his insights into new behavior. In this way
he is an active participant in his therapy.
In the reorientation phase of therapy, Stan
and I work together to consider alternative atti-
tudes, beliefs, and actions. By now Stan sees that
he does not have to be locked into past patterns,
feels encouraged, and realizes that he has the
power to change his life. He accepts that he will
not change merely by gaining insights and knows
that he will have to make use of these insights by
carrying out an action-oriented plan. Stan begins
to feel that he can create a new life for himself
and not remain the victim of circumstances.
Follow-Up: You Continue as
Stan’s Adlerian Therapist
Use these questions to help you think about how
you would counsel Stan using an Adlerian approach:
• What are some ways you would attempt to
establish a relationship with Stan based on trust
and mutual respect? Can you imagine any diffi-
culties in developing this relationship with him?
• What aspects of Stan’s lifestyle particularly
interest you? In counseling him, how would
these be explored?
• The Adlerian therapist identified four of Stan’s
mistaken conclusions. Can you identify with
any of these basic mistakes? If so, do you think
this would help or hinder your therapeutic
effectiveness with him?
• How might you assist Stan in discovering his
social interest and going beyond a preoccupa-
tion with his own problems?
• What strengths and resources in Stan might
you draw on to support his determination and
commitment to change?
See the DVD for Theory and Practice
of Counseling and Psychotherapy: The
Case of Stan and Lecturettes (Session 3 on
Adlerian therapy) for a demonstration of my
approach to counseling Stan by focusing on his
early recollections.
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s u m m a ry a n d e va l u at i o n
Summary
Adler was far ahead of his time, and most contemporary therapies have incorpo-
rated at least some of his ideas. Individual Psychology assumes that people are
motivated by social factors; are responsible for their own thoughts, feelings, and
actions; are the creators of their own lives, as opposed to being helpless victims;
and are impelled by purposes and goals, looking more toward the future than back
to the past.
The basic goal of the Adlerian approach is to help clients identify and change
their mistaken beliefs about, self, others, and life and thus to participate more
fully in a social world. Clients are not viewed as psychologically sick but as dis-
couraged. The therapeutic process helps individuals become aware of their pat-
terns and make some basic changes in their style of living, which lead to changes
in the way they feel and behave. The role of the family in the development of the
individual is emphasized. Therapy is a cooperative venture that challenges clients
to translate their insights into action in the real world. Contemporary Adlerian
theory is an integrative approach, combining cognitive, constructivist, existential,
psychodynamic, and systems perspectives. Some of these common characteristics
include an emphasis on establishing a respectful client–therapist relationship,
an emphasis on clients’ strengths and resources, and an optimistic and future
orientation.
The Adlerian approach gives practitioners a great deal of freedom in work-
ing with clients. Major Adlerian contributions have been made in the following
areas: elementary education, consultation groups with teachers, parent education
groups, couples and family therapy, and group counseling.
Contributions of the Adlerian Approach
A strength of the Adlerian approach is its fl exibility and its integrative nature.
Adlerian therapists can be both theoretically integrative and technically eclectic
(Watts & Shulman, 2003). This therapeutic approach allows for the use of a variety
of relational, cognitive, behavioral, emotive, and experiential techniques. Adlerian
therapists are resourceful and fl exible in drawing on many methods, which can be
applied to a diverse range of clients in a variety of settings and formats. Therapists
are mainly concerned with doing what is in the best interests of clients rather than
squeezing clients into one theoretical framework (Watts, 1999, 2000; Watts &
Pietrzak, 2000; Watts & Shulman, 2003).
Another contribution of the Adlerian approach is that it is suited to brief, time-
limited therapy. Adler was a proponent of time-limited therapy, and the techniques
used by many contemporary brief therapeutic approaches are very similar to
interventions created by or commonly used by Adlerian practitioners (Carlson et
al., 2006). Adlerian therapy and contemporary brief therapy have in common a
number of characteristics, including quickly establishing a strong therapeutic alli-
ance, a clear problem focus and goal alignment, rapid assessment and application
to treatment, an emphasis on active and directive intervention, a psychoeducational
focus, a present and future orientation, a focus on clients’ strengths and abilities
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and an optimistic expectation of change, and a time sensitivity that tailors treatment
to the unique needs of the client (Carlson et al., 2006). According to Mosak and
Di Pietro (2006), early recollections are a signifi cant assessment intervention in
brief therapy. They claim that early recollections are often useful in minimizing
the number of therapy sessions. This procedure takes little time to administer and
interpret and provides a direction for therapists to pursue.
Bitter and Nicoll (2000) identify fi ve characteristics that form the basis for an
integrative framework in brief therapy: time limitation, focus, counselor directive-
ness, symptoms as solutions, and the assignment of behavioral tasks. Bringing a
time-limitation process to therapy conveys to clients the expectation that change
will occur in a short period of time. When the number of sessions is specifi ed,
both client and therapist are motivated to stay focused on desired outcomes and
to work as effi ciently as possible. Because there is no assurance that a future ses-
sion will occur, brief therapists tend to ask themselves this question: “If I had only
one session to be useful in this person’s life, what would I want to accomplish?”
(p. 38).
The Adlerian concepts I (Jerry Corey) draw on most in my professional work are
(1) the importance of looking to one’s life goals, including assessing how these goals
infl uence an individual; (2) the focus on the individual’s interpretation of early expe-
riences in the family, with special emphasis on their current impact; (3) the clinical
use of early recollections in both assessment and treatment; (4) the use of dreams as
rehearsals for future action; (5) the need to understand and confront basic mistakes;
(6) the cognitive emphasis, which holds that emotions and behaviors are largely
infl uenced by one’s beliefs and thinking processes; (7) the idea of working out an
action plan designed to help clients make changes; (8) the collaborative relation-
ship, whereby the client and therapist work toward mutually agreed-upon goals;
and (9) the emphasis given to encouragement during the entire counseling proc-
ess. Several Adlerian concepts have implications for personal development. One
of these notions that has helped me to understand the direction of my life is the
assumption that feelings of inferiority are linked to a striving for superiority
(Corey, 2010).
It is diffi cult to overestimate the contributions of Adler to contemporary thera-
peutic practice. Many of his ideas were revolutionary and far ahead of his time. His
infl uence went beyond counseling individuals, extending into the community men-
tal health movement (Ansbacher, 1974). Abraham Maslow, Viktor Frankl, Rollo
May, Paul Watzlawick, Karen Horney, Erich Fromm, Aaron T. Beck, and Albert Ellis
have all acknowledged their debt to Adler. Both Frankl and May see him as a fore-
runner of the existential movement because of his position that human beings
are free to choose and are entirely responsible for what they make of themselves.
This view also makes him a forerunner of the subjective approach to psychology,
which focuses on the internal determinants of behavior: values, beliefs, attitudes,
goals, interests, personal meanings, subjective perceptions of reality, and strivings
toward self-realization. Bitter (2008) and his colleagues (Bitter, Robertson, Healey, &
Cole, 2009) have drawn attention to the link between Adlerian thinking and femi-
nist therapy approaches.
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One of Adler’s most important contributions was his infl uence on other therapy
systems. Many of his basic ideas have found their way into most of the other psy-
chological schools, a few of which include existential therapy, cognitive behavior
therapy, rational emotive behavior therapy, reality therapy, solution-focused ther-
apy, and family therapy. In many respects, Adler seems to have paved the way for
current developments in both the cognitive and constructivist therapies (Watts,
2003). Adlerians’ basic premise is that if clients can change their thinking then
they can change their feelings and behavior. A study of contemporary counseling
theories reveals that many of Adler’s notions have reappeared in these modern
approaches with different nomenclature, and often without giving Adler the credit
that is due to him (Watts, 1999; Watts & Pietrzak, 2000; Watts & Shulman, 2003).
It is clear that there are signifi cant linkages between Adlerian theory and most of
the present-day theories, especially those that view the person as purposive, self-
determining, and striving for growth. Carlson and Englar-Carlson (2008) assert
that Adlerians face the challenge of continuing to develop their approach so that it
meets the needs of contemporary global society: “Whereas Adlerian ideas are alive
in other theoretical approaches, there is a question about whether Adlerian theory
as a stand-alone approach is viable in the long term” (p. 133). These authors believe
that for the Adlerian model to survive and thrive it will be necessary to fi nd ways
to strive for signifi cance.
Limitations and Criticisms of the
Adlerian Approach
Adler had to choose between devoting his time to formalizing his theory and teach-
ing others the basic concepts of Individual Psychology. He placed practicing and
teaching before organizing and presenting a well-defi ned and systematic theory.
As a result, his written presentations are often diffi cult to follow, and many of
them are transcripts of lectures he gave. Initially, many people considered his ide-
as somewhat loose and too simplistic.
Research supporting the effectiveness of Adlerian theory is limited but has
improved over the last 25 years (Watts & Shulman, 2003). However, a large part of
the theory still requires empirical testing and comparative analysis. This is especial-
ly true in the conceptual areas that Adlerians accept as axiomatic: for example, the
development of lifestyle; the unity of the personality and an acceptance of a sin-
gular view of self; the rejection of the prominence of heredity in determining
behavior, especially pathological behavior; and the usefulness of the multiple inter-
ventions used by various Adlerians.
w h e r e to g o f r o m h e r e
Refer to the DVD for Integrative Counseling: The Case of Ruth and Lecturettes, Ses-
sion 6 (“Cognitive Focus in Counseling”), which illustrates Ruth’s striving to live
up to expectations and measure up to perfectionist standards. In this particular
therapy session with Ruth, you will see how I draw upon cognitive concepts and
apply them in practice.
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Free Podcasts for ACA Members
You can download ACA Podcasts (prerecorded interviews) by going to www.
counseling.org and then clicking on the Resource button, and then the Podcast
Series. For Chapter 5, look for Podcast 11, Adlerian Therapy, by Dr. Jon Carlson.
Other Resources
Videos from Psychotherapy.net demonstrate Adlerian therapy with adults, fami-
lies, and children, and are available to students and professionals at their website,
www.Psychotherapy.net. New articles, interviews, blogs, therapy cartoons, and vid-
eos are published monthly. For this chapter, see the following:
Carlson, J. (1997). Adlerian Therapy (Psychotherapy with the Experts Series)
Carlson, J. (2001). Adlerian Parent Consultation (Child Therapy with the Experts
Series)
Kottman, T. (2001). Adlerian Play Therapy (Child Therapy with the Experts Series)
If your thinking is allied with the Adlerian approach, you might consider seeking
training in Individual Psychology or becoming a member of the North American
Society of Adlerian Psychology (NASAP). To obtain information on NASAP and a
list of Adlerian organizations and institutes, contact:
North American Society of Adlerian Psychology (NASAP)
614 Old West Chocolate Avenue
Hershey, PA 17033
Telephone: (717) 579-8795
Fax: (717) 533-8616
E-mail: nasap@msn.com
Website: www.alfredadler.org
The society publishes a newsletter and a quarterly journal and maintains a list of
institutes, training programs, and workshops in Adlerian psychology. The Jour-
nal of Individual Psychology presents current scholarly and professional research.
Columns on counseling, education, and parent and family education are regular
features. Information about subscriptions is available by contacting the society.
If you are interested in pursuing training, postgraduate study, continuing edu-
cation, or a degree, contact NASAP for a list of Adlerian organizations and institutes.
A few training institutes are listed here:
Adler School of Professional Psychology
65 East Wacker Place, Suite 2100
Chicago, IL 60601-7298
Telephone: (312) 201-5900
Fax: (312) 201-5917
E-mail: admissions@adler.edu
Website: www.adler.edu
Adler Graduate School
1550 East 78th Street
Richfield, MN 55423
Telephone: 612-861-7554
Fax: 612-861-7559
E-mail:info@alfredadler.edu
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Adler School of Professional Psychology, Vancouver Campus
595 Burrard Street, Suite 753
P.O. Box 49104
Vancouver, BC, Canada V7X 1G4
Telephone: (604) 482-5510
Fax: (604) 874-4634
Adlerian Training Institute, Inc.
Dr. Bill Nicoll, Coordinator
P.O. Box 881581
Port St. Lucie, FL 34988
Telephone/Fax: (772) 807-4141
Cell Phone: (954) 650-0637
E-mail: adleriantraining@aol.com
Website: www.adleriantraining.com
The Alfred Adler Institute of Northwestern Washington
2565 Mayflower Lane
Bellingham, WA 98226
Telephone: (360) 647-5670
E-mail: HTStein@att.net
Website: http://ourworld.compuserv.com/homepages/hstein/
Alfred Adler Institute of San Francisco
266 Bemis Street
San Francisco, CA 94131
Telephone: (415) 584-3833
E-mail: DPienkow@msn.com
The International Committee of Adlerian
Summer Schools and Institutes
Michael Balla, ICASSI Administrator
257 Billings Avenue
Ottawa, Ontario, Canada K1H 5L1
Fax: (613) 733-0289
E-mail: mjballa@sympatico.ca
Website: www.icassi.net
Recommended Supplementary Readings
Adlerian Therapy: Theory and Practice (Carlson, Watts, & Maniacci, 2006) clearly
presents a comprehensive overview of Adlerian therapy in contemporary practice.
There are chapters on the therapeutic relationship, brief individual therapy, brief
couples therapy, group therapy, play therapy, and consultation. This book lists
Adlerian intervention videos that are available.
Adlerian Counseling and Psychotherapy: A Practitioner’s Approach (Sweeney, 2009)
is one of the most comprehensive books written on the wide range of Adlerian
applications to therapy and wellness.
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Adlerian Psychotherapy: An Advanced Approach to Individual Psychology (Oberst &
Stewart, 2003) is an up-to-date and in-depth presentation of Adlerian psychother-
apeutic process, including chapters on family therapy and the relevance of this
model to postmodern approaches.
Early Recollections: Interpretative Method and Application (Mosak & Di Pietro,
2006) is an extensive review of the use of early recollections as a way to under-
stand an individual’s dynamics and behavioral style. This book addresses the
theory, research, and clinical applications of early recollections.
Understanding Life-Style: The Psycho-Clarity Process (Powers & Griffi th, 1987) is a
useful source of information for doing a lifestyle assessment. Separate chapters
deal with interview techniques, lifestyle assessment, early recollections, the fam-
ily constellation, and methods of summarizing and interpreting information.
References and Suggested Readings
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Adler, A. (1964). Social interest. A challenge to
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*Ansbacher, H. L., & Ansbacher, R. R. (Eds.).
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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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i n t r o d u ct i o n
• Historical Background in Philosophy
and Existentialism
• Key Figures in Contemporary Existential
Psychotherapy
k e y co n c e p t s
• View of Human Nature
• Proposition 1: The Capacity for Self-Awareness
• Proposition 2: Freedom and Responsibility
• Proposition 3: Striving for Identity and
Relationship to Others
• Proposition 4: The Search for Meaning
• Proposition 5: Anxiety as a Condition
of Living
• Proposition 6: Awareness of Death and
Nonbeing
t h e t h e r a p e u t i c p r o c es s
• Therapeutic Goals
• Therapist’s Function and Role
• Client’s Experience in Therapy
• Relationship Between Therapist and Client
a p p l i c at i o n : t h e r a p e u t i c
t ec h n i q u es a n d p r o c e d u r es
• Phases of Existential Counseling
• Clients Appropriate for Existential Counseling
• Application to Brief Therapy
• Application to Group Counseling
e x i st e n t i a l t h e r a p y f r o m a
m u lt i c u lt u r a l p e r s p ect i v e
• Strengths From a Diversity Perspective
• Shortcoming From a Diversity Perspective
e x i st e n t i a l t h e r a p y a p p l i e d to
t h e c a s e o f sta n
s u m m a ry a n d e va l u at i o n
• Summary
• Contributions of the Existential Approach
• Limitations and Criticisms of the Existential
Approach
w h e r e to g o f r o m h e r e
• Recommended Supplementary Readings
• References and Suggested Readings
c h a p t e r 6
Existential Therapy
•
• Refer
y Read
ed Readings
136
t i c p r o
eutic Goals
rapist’s Function and Role
ent’s Experience in Therapy
lationship Between Therapist and Cl
a C
Living
• Proposition 6: Awareness o
Nonbeing
t h e t h e r a
• Thera
• Th
• C
• Re
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Viktor Frankl / Rollo May / Irvin Yalom
V I K TO R F R A N K L (1905–
1997) was born and educat-
ed in Vienna. He founded the
Youth Advisement Centers
there in 1928 and directed
them until 1938. From 1942
to 1945 Frankl was a pris-
oner in the Nazi concentra-
tion camps at Auschwitz
and Dachau, where his parents, brother, wife, and
children died. He vividly remembered his horrible
experiences in these camps, yet he was able to
use them in a constructive way and did not allow
them to dampen his love and enthusiasm for life.
He traveled all around the world, giving lectures
in Europe, Latin America, Southeast Asia, and the
United States.
Frankl received his MD in 1930 and his PhD
in philosophy in 1949, both from the University of
Vienna. He became an associate professor at the
University of Vienna and later was a distinguished
speaker at the United States International University
in San Diego. He was a visiting professor at Har-
vard, Stanford, and Southern Methodist universi-
ties. Frankl’s works have been translated into more
than 20 languages, and his ideas continue to have
a major impact on the development of existential
therapy. His compelling book Man’s Search for Mean-
ing (1963) has been a best-seller around the world.
Although Frankl had begun to develop an exis-
tential approach to clinical practice before his grim
years in the Nazi death camps, his experiences
there confirmed his views. Frankl (1963) observed
and personally experienced the truths expressed
by existential philosophers and writers who hold
that we have choices in every situation. Even in
terrible circumstances, he believed, we could
preserve a vestige of spiritual freedom and inde-
pendence of mind. He learned experientially that
everything could be taken from a person except
one thing: “the last of human freedoms—to choose
one’s attitude in any given set of circumstances, to
choose one’s own way” (p. 104). ). Frankl believed
that the essence of being human lies in searching
for meaning and purpose. He believed that love
is the highest goal to which humans can aspire and
that our salvation is through love. We can discover
this meaning through our actions and deeds, by
experiencing a value (such as love or achievements
through work), and by suffering.
Frankl knew and read Freud and attended
some of the meetings of Freud’s psychoanalytic
group. Frankl acknowledged his indebtedness
to Freud, although he disagreed with the rigidity
of Freud’s psychoanalytic system. Frankl often
remarked that Freud was a depth psychologist and
that he is a height psychologist who built
on Freud’s foundations. Reacting against most of
Freud’s deterministic notions, Frankl developed
his own theory and practice of psychotherapy,
which emphasized the concepts of freedom,
responsibility, meaning, and the search for values.
He established his international reputation as the
founder of what has been called “The Third School
of Viennese Psychoanalysis,” the other two being
Sigmund Freud’s psychoanalysis and Alfred Adler’s
Individual Psychology.
I have selected Frankl as one of the key figures
of the existential approach because of the dramatic
way in which his theories were tested by the trag-
edies of his life. His life was an illustration of his
theory, for he lived what his theory espouses.
IM
A
G
N
O
/V
ik
to
rF
ra
nk
lA
rc
hi
v
R O L LO M AY (1909–1994)
first lived in Ohio and then
moved to Michigan as a
young child along with his
five brothers and a sister.
He remembered his home
life as being unhappy, a
situation that contributed
to his interest in psychol-
ogy and counseling. In his personal life May
struggled with his own existential concerns and the
failure of two marriages.
Despite his unhappy life experiences, he gradu-
ated from Oberlin College in 1930 and then went
to Greece as a teacher. During his summers in
Greece he traveled to Vienna to study with Alfred
Adler. After receiving a degree in theology from
Union Theological Seminary, May decided that the Hu
lto
n
A
rc
hi
ve
/G
et
ty
Im
ag
es
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best way to reach out and help people was through
psychology instead of theology. He completed his
doctorate in clinical psychology at Columbia Uni-
versity and started a private practice in New York;
he also became a supervisory training analyst for
the William Alanson Institute.
While May was pursuing his doctoral program,
he came down with tuberculosis, which resulted in
a 2-year stay in a sanitarium. During his recovery
period, May spent much time learning firsthand
about the nature of anxiety. He also spent time
reading, and he studied the works of Søren Kierke-
gaard, which was the catalyst for his recognizing
the existential dimensions of anxiety. This study
resulted in his book The Meaning of Anxiety (1950).
His popular book Love and Will (1969) reflects his
own personal struggles with love and intimate rela-
tionships and mirrors Western society’s question-
ing of its values pertaining to sex and marriage.
The greatest personal influence on Rollo May
was the existential theologian Paul Tillich (author
of The Courage to Be, 1952), who became his men-
tor and a personal friend. The two spent much
time together discussing philosophical, religious,
and psychological topics. Most of May’s
writings reflect a concern with the nature of
human experience, such as recognizing and deal-
ing with power, accepting freedom and respon-
sibility, and discovering one’s identity. He draws
from his rich knowledge based on the classics and
his existential perspective.
Rollo May was one of the main proponents
of humanistic approaches to psychotherapy, and
he was the principal American spokesperson of
European existential thinking as it is applied to
psychotherapy. He believed psychotherapy should
be aimed at helping people discover the mean-
ing of their lives and should be concerned with
the problems of being rather than with problem
solving. Questions of being include learning to
deal with issues such as sex and intimacy, growing
old, facing death, and taking action in the world.
According to May, the real challenge is for people
to be able to live in a world where they are alone
and where they will eventually have to face death.
He contends that our individualism should be
balanced by what Adler refers to as social inter-
est. It is the task of therapists to help individuals
find ways to contribute to the betterment of the
society in which they live.
I RV I N YA LO M (b. 1931- )
was born of parents who
immigrated from Russia
shortly after World War I.
During his early childhood,
Yalom lived in the inner city
of Washington, D.C., in a
poor neighborhood. Life on
the streets was perilous,
and Yalom took refuge indoors reading novels and
other works. Twice a week he made the hazardous
bicycle trek to the library to stock up on reading
supplies. He found an alternative and satisfying
world in reading fiction, which was a source of
inspiration and wisdom to him. Early in his life he
decided that writing a novel was the very finest
thing a person could do, and subsequently he has
written several teaching novels.
Irvin Yalom is professor emeritus of psychia-
try at the Stanford University School of Medicine.
A psychiatrist and author, Yalom has been a
major figure in the field of group psychotherapy
since publication in 1970 of his influential book
The Theory and Practice of Group Psychotherapy
(1970/2005), which has been translated into 12
languages and is currently in its fifth edition. His
pioneering work, Existential Psychotherapy, written
in 1980, is a classic and authoritative textbook on
existential therapy. Drawing on his clinical experi-
ence and on empirical research, philosophy, and
literature, Yalom developed an existential approach
to psychotherapy that addresses four “givens of
existence” or ultimate human concerns: freedom
and responsibility, existential isolation, meaning-
lessness, and death. These existential themes deal
with the client’s existence, or being-in-the-world.
Yalom urges all therapists, regardless of theoretical
orientation, to develop a sensibility to existential
issues because generally these issues emerge in all
courses of therapy.
Psychotherapy has been endlessly intriguing
for Yalom, who has approached all of his patients
with a sense of wonderment at the stories they
reveal. He believes that a different therapy must be
Ph
ot
o
co
ur
te
sy
of
Jo
se
ph
Si
ro
ke
r.
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designed for each client because each has a unique
story. He advocates using the here and now of
the therapeutic relationship to explore the client’s
interpersonal world, and he believes the therapist
must be transparent, especially regarding his or
her experience of the client. His basic philosophy
is existential and interpersonal, which he applies to
both individual and group therapy.
Irvin Yalom has authored many stories and
novels related to psychotherapy, including Love’s
Executioner (1987), When Nietzsche Wept (1992),
Lying on the Couch (1997), Momma and the Meaning
of Life (2000), and The Schopenhauer Cure (2005a).
His 2008 nonfiction book, Staring at the Sun:
Overcoming the Terror of Death, is a treatise on the
role of death anxiety in psychotherapy, illustrating
how death and the meaning of life are foundational
themes associated with in-depth therapeutic
work. Yalom’s works, translated into more than 20
languages, have been widely read by therapists and
laypeople alike.
Yalom’s wife, Marilyn, has a PhD in compara-
tive literature and has had a successful career as
a university professor and writer. His four children
have chosen a variety of careers—medicine, pho-
tography, creative writing, theater directing, and
clinical psychology. He has five grandchildren and
is still counting.
i n t r o d u c t i o n
Existential therapy is more a way of thinking, or an attitude about psychotherapy,
than a particular style of practicing psychotherapy. It is neither an independent
nor separate school of therapy, nor is it a clearly defi ned model with specifi c tech-
niques. Existential therapy can best be described as a philosophical approach that
infl uences a counselor’s therapeutic practice. Yalom and Josselson (2011) capture
the essence of this approach:
Existential psychotherapy is an attitude toward human suffering [that] has no manual. It
asks deep questions about the nature of the human being and the nature of anxiety, despair,
grief, loneliness, isolation, and anomie. It also deals centrally with the questions of mean-
ing, creativity, and love. (p. 310)
Existential therapy focuses on exploring themes such as mortality, meaning, free-
dom, responsibility, anxiety, and aloneness as these relate to a person’s current
struggle. The goal of existential therapy is to assist clients in their exploration of
the existential “givens of life,” how these are sometimes ignored or denied, and
how addressing them can ultimately lead to a deeper, more refl ective and mean-
ingful existence. Clients are invited to refl ect on life, to recognize their range of
alternatives, and to decide among them.
The existential approach rejects the deterministic view of human nature es-
poused by traditional psychoanalysis and radical behaviorism. Psychoanalysis sees
the individual as primarily determined by unconscious forces, irrational drives,
and past events; behaviorists see the individual as primarily determined by socio-
cultural conditioning. Although deterministic forces affect us and we sometimes
cannot control external events thrust upon us, existential therapists believe we
retain the freedom to choose how we respond to such events. Existential therapy
is grounded on the assumption that we are free and therefore responsible for our
choices and actions. We are the authors of our lives, and we design the pathways
we follow. This chapter addresses some of the existential concepts and themes that
have signifi cant implications for the existentially oriented practitioner.
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A basic existential premise is that we are not victims of circumstance because,
to a large extent, we are what we choose to be. Once clients begin the process of
recognizing the ways in which they have passively accepted circumstances and
surrendered control, they can start down a path of consciously shaping their own
lives. The fi rst step in the therapeutic journey is for clients to accept responsibility.
As Yalom (2003) puts it, “Once individuals recognize their role in creating their
own life predicament, they also realize that they, and only they, have the power to
change that situation” (p. 141). One of the aims of existential therapy is to challenge
people to stop deceiving themselves regarding their lack of responsibility for what
is happening to them and their excessive demands on life (van Deurzen, 2002b).
Emmy van Deurzen (2002a), a key contributor to British existential psychol-
ogy, writes that existential counseling is not designed to “cure” people of illness in
the tradition of the medical model. She does not view clients as being sick, but as
“sick of life or clumsy at living” (p. 18) and unable to live a productive life.
See the DVD program for Chapter 6, DVD for Theory and Practice of Counseling
and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you view
the brief lecture for each chapter prior to reading the chapter.
Historical Background in Philosophy and Existentialism
The existential therapy movement was not founded by any particular person or
group; many streams of thought contributed to it. Drawing from a major orienta-
tion in philosophy, existential therapy arose spontaneously in different parts of Eu-
rope and among different schools of psychology and psychiatry in the 1940s and
1950s. Many Europeans found that their lives had been devastated by World War
II, and they struggled with existential issues including feelings of isolation, aliena-
tion, and meaninglessness. Early writers focused on the individual’s experience
of being alone in the world and facing the anxiety of this situation. The European
existential perspective focused on human limitations and the tragic dimensions of
life (Sharp & Bugental, 2001).
The thinking of existential psychologists and psychiatrists was infl uenced by a
number of philosophers and writers during the 19th century. To understand the
philosophical underpinnings of modern existential psychotherapy, one must have
some awareness of such fi gures as Søren Kierkegaard, Friedrich Nietzsche, Martin
Heidegger, Jean-Paul Sartre, and Martin Buber. These major fi gures of existential-
ism and existential phenomenology and their cultural, philosophical, and religious
writings provided the basis for the formation of existential therapy. Ludwig Bin-
swanger and Medard Boss are also included in this section because both were early
existential psychoanalysts who contributed key ideas to existential psychotherapy.
s ø r e n k i e r k e g a a r d ( 1 8 1 3 – 1 8 5 5 ) A Danish philosopher and Chris-
tian theologian, Kierkegaard was particularly concerned with angst—a Danish and
German word whose meaning lies between the English words dread and anxiety—
and he addressed the role of anxiety and uncertainty in life. Existential anxiety
is associated with making basic decisions about how we want to live, and it is
not pathological. Kierkegaard believed that anxiety is the school in which we are
educated to be a self. Without the experience of angst, we may go through life as
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sleepwalkers. But many of us, especially in adolescence, are awakened into real life
by a terrible uneasiness. Life is one contingency after another, with no guarantees
beyond the certainty of death. This is by no means a comfortable state, but it is
necessary to our becoming human. Kierkegaard believed that “the sickness unto
death” arises when we are not true to ourselves. What is needed is the willingness
to risk a leap of faith in making choices. Becoming human is a project, and our task
is not so much to discover who we are as to create ourselves.
f r i e d r i c h n i e t z s c h e ( 1 8 4 4 – 1 9 0 0 ) The German philosopher Nietzsche
is the iconoclastic counterpart to Kierkegaard, expressing a revolutionary approach to
the self, to ethics, and to society. Like Kierkegaard, he emphasized the importance
of subjectivity. Nietzsche set out to prove that the ancient defi nition of humans
as rational was entirely misleading. We are far more creatures of will than we are
impersonal intellects. But where Kierkegaard emphasized the “subjective truth” of
an intense concern with God, Nietzsche located values within the individual’s “will to
power.” We give up an honest acknowledgment of this source of value when society
invites us to rationalize powerlessness by advocating other worldly concerns. If, like
sheep, we acquiesce in “herd morality,” we will be nothing but mediocrities. But if
we release ourselves by giving free rein to our will to power, we will tap our poten-
tiality for creativity and originality. Kierkegaard and Nietzsche, with their pioneer-
ing analyses of anxiety, depression, subjectivity, and the authentic self, together are
generally considered to be the originators of the existential perspective (Sharp &
Bugental, 2001).
m a r t i n h e i d e g g e r ( 1 8 8 9 – 1 9 7 6 ) Heidegger’s phenomenological exis-
tentialism reminds us that we exist “in the world” and should not try to think of
ourselves as beings apart from the world into which we are thrown. The way we
fi ll our everyday life with superfi cial conversation and routine shows that we often
assume we are going to live forever and can afford to waste day after day. Our
moods and feelings (including anxiety about death) are a way of understanding
whether we are living authentically or whether we are inauthentically constructing
our lives around the expectations of others. When we translate this wisdom from
vague feeling to explicit awareness, we may develop a more positive resolve about
how we want to be. Phenomenological existentialism, as presented by Heidegger,
provides a view of human history that does not focus on past events but motivates
individuals to look forward to “authentic experiences” that are yet to come.
m a r t i n b u b e r ( 1 8 7 8 – 1 9 6 5 ) Leaving Germany to live in the new state of
Israel, Buber took a less individualistic stand than most of the other existentialists.
He said that we humans live in a kind of betweenness; that is, there is never just an
I, but always an other. The I, the person who is the agent, changes depending on
whether the other is an it or a Thou. But sometimes we make the serious mistake
of reducing another person to the status of a mere object, in which case the rela-
tionship becomes I/it. Although Buber recognizes that of necessity we must have
many I/it interactions (in everyday life), we are seriously limited if we live only in
the world of the I/it. Buber stresses the importance of presence, which has three
functions: (1) it enables true I/Thou relationships; (2) it allows for meaning to exist
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in a situation; and (3) it enables an individual to be responsible in the here and now
(Gould, 1993). In a famous dialogue with Carl Rogers, Buber argued that the thera-
pist and client could never be on the same footing because the latter comes to the
former for help. When the relationship is fully mutual, we have become “dialogic,”
a fully human condition.
l u d w i g b i n s wa n g e r ( 1 8 8 1 – 1 9 6 6 ) An existential analyst, Binswanger
proposed a holistic model of self that addresses the relationship between the per-
son and his or her environment. He used a phenomenological approach to explore
signifi cant features of the self, including choice, freedom, and caring. He based his
existential approach largely on the ideas of Heidegger and accepted Heidegger’s
notion that we are “thrown into the world.” However, this “thrown-ness” does not
release us from the responsibility of our choices and for planning for the future
(Gould, 1993). Existential analysis (dasein analyse) emphasizes the subjective and
spiritual dimensions of human existence. Binswanger (1975) contended that crises
in therapy were typically major choice points for the client. Although he originally
looked to psychoanalytic theory to shed light on psychosis, he moved toward an exis-
tential view of his patients. This perspective enabled him to understand the worldview
and immediate experience of his patients, as well as the meaning of their behavior, as
opposed to superimposing his view as a therapist on their experience and behavior.
m e da r d b o s s ( 1 9 0 3 – 1 9 9 1 ) Both Binswanger and Boss were early existen-
tial psychoanalysts and signifi cant fi gures in the development of existential psycho-
therapy. They made reference to dasein or being-in-the-world, which pertains to our
ability to refl ect on life events and attribute meaning to these events. They believed
that the therapist must enter the client’s subjective world without presuppositions
that would get in the way of this experiential understanding. Both Binswanger
and Boss were signifi cantly infl uenced by Heidegger’s seminal work, Being and
Time (1962), which provided a broad basis for understanding the individual (May,
1958). Boss was deeply infl uenced by Freudian psychoanalysis, but even more so
by Heidegger. Boss’s major professional interest was applying Heidegger’s phil-
osophical notions to therapeutic practice, and he was especially concerned with
integrating Freud’s methods with Heidegger’s concepts, as described in his book
Daseinanalysis and Psychoanalysis (1963).
j e a n – pa u l s a r t r e ( 1 9 0 5 – 1 9 8 0 ) A philosopher and novelist, Sartre was
convinced, in part by his years in the French Resistance in World War II, that
humans are even more free than earlier existentialists had believed. The existence
of a space—nothingness—between the whole of our past and the now frees us to
choose what we will. Our values are what we choose. The failure to acknowledge
our freedom and choices results in emotional problems. This freedom is hard to
face, so we tend to invent an excuse by saying, “I can’t change now because of
my past conditioning.” Sartre called excuses “bad faith.” No matter what we have
been, we can make choices now and become something quite different. We are
condemned to be free. To choose is to become committed; this is the responsibility
that is the other side of freedom. Sartre’s view was that at every moment, by our
actions, we are choosing who we are being. Our existence is never fi xed or fi nished.
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Every one of our actions represents a fresh choice. When we attempt to pin down
who we are, we engage in self-deception (Russell, 2007).
Key Figures in Contemporary Existential Psychotherapy
Viktor Frankl, Rollo May, Irvin Yalom, and James Bugental all developed their
existential approaches to psychotherapy from strong backgrounds in both existen-
tial and humanistic psychology. Some of their contributions to psychotherapy are
illustrated in the brief sketches that follow.
v i k t o r f r a n k l ( 1 9 0 5 – 1 9 9 7 ) Viktor Frankl was a central fi gure in de-
veloping existential therapy in Europe and also in bringing it to the United States.
As a youth, Frankl was deeply infl uenced by Freud, but he became a student of
Adler. Later, he was infl uenced by the writings of existential philosophers, and he
began developing his own existential philosophy and psychotherapy. He was fond
of quoting Nietzsche: “He who has a why to live for can bear with almost any how”
(as cited in Frankl, 1963, pp. 121, 164). Frankl contended that those words could
be the motto for all psychotherapeutic practice. Another quotation from Nietzsche
seems to capture the essence of his own experience and his writings: “That which
does not kill me, makes me stronger” (as cited in Frankl, 1963, p. 130).
Frankl developed logotherapy, which means “therapy through meaning.”
Frankl’s philosophical model sheds light on what it means to be fully alive. The
central themes running through his works are life has meaning, under all circum-
stances; the central motivation for living is the will to meaning; we have the freedom
to fi nd meaning in all that we think; and we must integrate body, mind, and spirit to be
fully alive. Frankl said that Freud viewed humans as motivated by the “will to pleas-
ure” and that Adler focused on the “will to power.” For Frankl, the most powerful
motivation for humans is the “will to meaning.” Frankl’s writings refl ect the theme
that the modern person has the means to live, but often has no meaning to live for.
The therapeutic process is aimed at challenging individuals to fi nd meaning and
purpose through, among other things, suffering, work, and love (Frankl, 1965).
(For more background information on Viktor Frankl, see his biography at the
beginning of this chapter).
r o l lo m ay ( 1 9 0 9 – 1 9 9 4 ) Along with Frankl, psychologist Rollo May was
deeply infl uenced by the existential philosophers, by the concepts of Freudian psy-
chology, and by many aspects of Alfred Adler’s Individual Psychology. May was
one of the key fi gures responsible for bringing existentialism from Europe to the
United States and for translating key concepts into psychotherapeutic practice. His
writings have had a signifi cant impact on existentially oriented practitioners. Of
primary importance in introducing existential therapy to the United States was
the book Existence: A New Dimension in Psychiatry and Psychology (May, Angel, &
Ellenberger, 1958). According to May, it takes courage to “be,” and our choices
determine the kind of person we become. There is a constant struggle within us.
Although we want to grow toward maturity and independence, we realize that
expansion is often a painful process. Hence, the struggle is between the security of
dependence and the joys and pains of growth. (For more background information
on Rollo May, see his biography at the beginning of this chapter).
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i r v i n ya lo m ( 1 9 3 1 – ) Irvin Yalom is a signifi cant contemporary existential
therapist in the United States. He acknowledges the contributions of both Euro-
pean and American psychologists and psychiatrists who have infl uenced the devel-
opment of existential thinking and practice (Yalom, 1980). Yalom has developed
his approach to individual and group psychotherapy based on the notion that
existentialism deals with basic “givens of existence”: isolation and relationship with
others; death and living fully; and meaninglessness and meaning. Yalom believes
the vast majority of experienced therapists, regardless of their theoretical orienta-
tion, employ many of the core existential themes. He also contends that how we
address these existential themes has a good deal to do with the design and quality
of our lives. Yalom recognizes Frankl as an eminently pragmatic thinker who has
had an impact on his writing and practice. He also acknowledges the infl uence on
his writings of several novelists and philosophers. More specifi cally, he draws on
the following themes from those philosophers discussed earlier:
• From Kierkegaard: creative anxiety, despair, fear and dread, guilt, and nothingness
• From Nietzsche: death, suicide, and will
• From Heidegger: authentic being, caring, death, guilt, individual responsibility,
and isolation
• From Sartre: meaninglessness, responsibility, and choice
• From Buber: interpersonal relationships, I/Thou perspective in therapy, and
self-transcendence
(For more background information on Irvin Yalom, see his biography at the
beginning of this chapter.)
ja m e s b u g e n ta l ( 1 9 1 5 – 2 0 0 8 ) James Bugental coined the term “existen-
tial-humanistic” psychotherapy, and he was a leading spokesman for this approach.
His philosophical and therapeutic approach included a curiosity and focus that
moved him away from the traditional therapeutic milieu of labeling and diagnos-
ing clients. His work emphasized the cultivation of both client and therapist pres-
ence. He developed techniques to assist the client in deepening inner exploration,
or searching. The therapist’s primary task involved helping clients to make new dis-
coveries about themselves in the living moment, as opposed to merely talking about
themselves.
Central to Bugental’s approach is his view of resistance, which from an existential-
humanistic perspective is not resistance to therapy per se but rather to being fully
present both during the therapy hour and in life. Resistance is seen as part of
the self-and-world construct —how a person understands his or her being and rela-
tionship to the world at large. Forms of resistance include intellectualizing, being
argumentative, always seeking to please, and any other life-limiting pattern. As re-
sistance emerges in the therapy sessions, the therapist repeatedly notes, or “tags,”
the resistance so the client increases his or her awareness and ultimately has an
increased range of choices.
Bugental’s theory and practice emphasized the distinction between therapeutic
process and content. He became known for being a masterful teacher and psycho-
therapist, primarily because he lived his work. He was an existentialist at heart,
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which made him a great model and mentor, not only for clients but also for stu-
dents and professionals. In his workshops, he developed many exercises to help
therapists refi ne and practice their skills. He frequently brought his techniques
to life with live demonstrations, which emphasized therapeutic work taking place
in the moment, impromptu here-and-now dialogue, and exploring in the context
of self as client or therapist. Bugental’s (1987) classic text, The Art of the Psycho-
therapist, is widely recognized for deconstructing the therapy process and moving
beyond theory and generalizations to show what actually occurs moment-to-
moment in the therapeutic encounter. Psychotherapy Isn’t What You Think (Bugental,
1999) is the last book he wrote before he died in 2008, at the age of 93.
ot h e r c o n t r i b u t o r s t o e x i s t e n t i a l t h e r a p y A more recent in-
fl uential fi gure in contemporary existential psychology is Kirk Schneider, who with
colleagues Orah Krug, David Elkins, and Ken Bradford are helping to extend exis-
tential principles to a new generation of practitioners. Schneider and his colleagues
developed an existential-integrative therapy (see Schneider, 2008, 2011; Schneider &
Krug, 2010) mainly because of the need to address today’s ethnically and diagnosti-
cally diverse clinical populations. The existential-integrative approach emphasizes
such areas as personal and interpersonal presence, the working through of resist-
ance, the rediscovery of meaning and awe, and contemplative practices. These
themes are increasingly being incorporated into the therapeutic mainstream.
Signifi cant developments in the existential approach are also occurring in
Britain, largely due to the efforts of Emmy van Deurzen, who is developing aca-
demic and training programs at the New School of Psychotherapy and Counselling
(see Other Resources at the end of the chapter for details). In the past decades the
existential approach has spread rapidly in Britain and is now an alternative to tra-
ditional methods (van Deurzen, 2002b). For a description of the historical context
and development of existential therapy in Britain, see van Deurzen (2002b) and
Cooper (2003); for an excellent overview of the theory and practice of existential
therapy, see van Deurzen (2002a) and Schneider and Krug (2010).
k e y c o n c e p t s
View of Human Nature
The crucial signifi cance of the existential movement is that it reacts against the
tendency to identify therapy with a set of techniques. Instead, it bases therapeu-
tic practice on an understanding of what it means to be human. The existential
movement stands for respect for the person, for exploring new aspects of human
behavior, and for divergent methods of understanding people. It uses numerous
approaches to therapy based on its assumptions about human nature.
The existential tradition seeks a balance between recognizing the limits and
tragic dimensions of human existence on one hand and the possibilities and
opportunities of human life on the other hand. It grew out of a desire to help people
engage the dilemmas of contemporary life, such as isolation, alienation, and mean-
inglessness. The current focus of the existential approach is on the individual’s
experience of being in the world alone and facing the anxiety of this isolation.
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“No relationship can eliminate existential isolation, but aloneness can be shared in
such a way that love compensates for its pain” (Yalom & Josselson, 2011, p. 326).
The existential view of human nature is captured, in part, by the notion that the
signifi cance of our existence is never fi xed once and for all; rather, we continually
recreate ourselves through our projects. Humans are in a constant state of transi-
tion, emerging, evolving, and becoming in response to the tensions, contradictions,
and confl icts in our lives. Being a person implies that we are discovering and mak-
ing sense of our existence. We continually question ourselves, others, and the world.
Although the specifi c questions we raise vary in accordance with our developmental
stage in life, the fundamental themes do not vary. We pose the same questions
philosophers have pondered throughout Western history: “Who am I?” “What can I
know?” “What ought I to do?” “What can I hope for?” “Where am I going?”
The basic dimensions of the human condition, according to the existential
approach, include (1) the capacity for self-awareness; (2) freedom and responsi-
bility; (3) creating one’s identity and establishing meaningful relationships with
others; (4) the search for meaning, purpose, values, and goals; (5) anxiety as a con-
dition of living; and (6) awareness of death and nonbeing. I develop these proposi-
tions in the following sections by summarizing themes that emerge in the writings
of existential philosophers and psychotherapists, and I also discuss the implica-
tions for counseling practice of each of these propositions.
Proposition 1: The Capacity for Self-Awareness
Freedom, choice, and responsibility constitute the foundation of self-awareness. The
greater our awareness, the greater our possibilities for freedom (see Proposition 2).
Schneider (2008) explains that the core existential position is that we are both free (will-
ful, creative, and expressive) and limited (by environmental and social constraints). We
increase our capacity to live fully as we expand our awareness in the following areas:
• We are fi nite and do not have unlimited time to do what we want in life.
• We have the potential to take action or not to act; inaction is a decision.
• We choose our actions, and therefore we can partially create our own destiny.
• Meaning is the product of discovering how we are “thrown” or situated in the
world and then, through commitment, living creatively.
• As we increase our awareness of the choices available to us, we also increase our
sense of responsibility for the consequences of these choices.
• We are subject to loneliness, meaninglessness, emptiness, guilt, and isolation.
• We are basically alone, yet we have an opportunity to relate to other beings.
We can choose either to expand or to restrict our consciousness. Because self-
awareness is at the root of most other human capacities, the decision to expand it is
fundamental to human growth. Here are some areas of emerging awareness that
individuals may experience in the counseling process:
• They see how they are trading the security of dependence for the anxieties that
accompany choosing for themselves.
• They begin to see that their identity is anchored in someone else’s defi nition of
them; that is, they are seeking approval and confi rmation of their being in others
instead of looking to themselves for affi rmation.
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• They learn that in many ways they are keeping themselves prisoner by some of
their past decisions, and they realize that they can make new decisions.
• They learn that although they cannot change certain events in their lives they
can change the way they view and react to these events.
• They learn that they are not condemned to a future similar to the past, for they
can learn from their past and thereby reshape their future.
• They realize that they are so preoccupied with suffering, death, and dying that
they are not appreciating living.
• They are able to accept their limitations yet still feel worthwhile, for they under-
stand that they do not need to be perfect to feel worthy.
• They come to realize that they are failing to live in the present moment because
of preoccupation with the past, planning for the future, or trying to do too many
things at once.
Increasing self-awareness—which includes awareness of alternatives, motivations,
factors infl uencing the person, and personal goals—is an aim of all counseling.
Clients need to learn that a price must be paid for increased awareness. As we
become more aware, it is more diffi cult to “go home again.” Ignorance of our
condition may have brought contentment along with a feeling of partial deadness,
but as we open the doors in our world, we can expect more turmoil as well as the
potential for more fulfi llment.
Proposition 2: Freedom and Responsibility
A characteristic existential theme is that people are free to choose among alterna-
tives and therefore play a large role in shaping their own destiny. Schneider and
Krug (2010) write that existential therapy embraces three values: (1) the freedom to
become within the context of natural and self-imposed limitations; (2) the capacity
to refl ect on the meaning of our choices; and (3) the capacity to act on the choices we
make. A central existential concept is that although we long for freedom, we often try
to escape from our freedom by defi ning ourselves as a fi xed or static entity (Russell,
2007). We have no choice about being thrust into the world, yet the manner in
which we live and what we become are the result of our choices. Because of the real-
ity of this freedom, our task is to accept responsibility for directing our lives. How-
ever, it is possible to avoid this reality by making excuses. In speaking about “bad
faith,” the existential philosopher Jean-Paul Sartre (1971) refers to the inauthenticity
of not accepting personal responsibility. Here are two statements that reveal bad
faith: “Since that’s the way I’m made, I couldn’t help what I did” or “Naturally I’m
this way, because I grew up in a dysfunctional family.” An inauthentic mode of
existence consists of lacking awareness of personal responsibility for our lives and
passively assuming that our existence is largely controlled by external forces. Sartre
claims we are constantly confronted with the choice of what kind of person we are
becoming, and to exist is never to be fi nished with this kind of choosing.
Freedom implies that we are responsible for our lives, for our actions, and
for our failures to take action. From Sartre’s perspective people are condemned
to freedom. He calls for a commitment to choosing for ourselves. Existential guilt
is being aware of having evaded a commitment, or having chosen not to choose.
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This guilt is a condition that grows out of a sense of incompleteness, or a realiza-
tion that we are not what we might have become. Guilt may be a sign that we have
failed to rise to the challenge of our anxiety and that we have tried to evade it by
not doing what we know is possible for us to do (van Deurzen, 2002a). This condi-
tion is not viewed as neurotic, nor is it seen as a symptom that needs to be cured.
Instead, the existential therapist explores it to see what clients can learn about the
ways in which they are living their life. This guilt also results from allowing others
to defi ne us or to make our choices for us. Sartre said, “We are our choices.”
Authenticity implies that we are living by being true to our own evaluation of what
is a valuable existence for ourselves; it is the courage to be who we are.
For existentialists, then, being free and being human are identical. Freedom
and responsibility go hand in hand. We are the authors of our lives in the sense
that we create our destiny, our life situation, and our problems (Russell, 1978).
Assuming responsibility is a basic condition for change. Clients who refuse to
accept responsibility by persistently blaming others for their problems are not
likely to profi t from therapy.
Frankl (1978) also links freedom with responsibility. He suggested that the
Statue of Liberty on the East Coast should be balanced with a Statue of Respon-
sibility on the West Coast. His basic premise is that freedom is bound by certain
limitations. We are not free from conditions, but we are free to take a stand against
these restrictions. Ultimately, these conditions are subject to our decisions, which
means we are responsible.
The therapist assists clients in discovering how they are avoiding freedom
and encourages them to learn to risk using it. Not to do so is to cripple clients
and make them dependent on the therapist. Therapists have the task of teaching
clients that they can explicitly accept that they have choices, even though they may
have devoted most of their life to evading them. Those who are in therapy often
have mixed feelings when it comes to choice. As Russell (2007) puts it: “We resent
it when we don’t have choices, but we get anxious when we do! Existentialism is all
about broadening the vision of our choices” (p. 111).
People often seek psychotherapy because they feel that they have lost control
of how they are living. They may look to the counselor to direct them, give them
advice, or produce magical cures. They may also need to be heard and understood.
Two central tasks of the therapist are inviting clients to recognize how they have
allowed others to decide for them and encouraging them to take steps toward
choosing for themselves. In inviting clients to explore other ways of being that are
more fulfi lling than their present restricted existence, some existential counselors
ask, “Although you have lived in a certain pattern, now that you recognize the price
of some of your ways, are you willing to consider creating new patterns?” Others
may have a vested interest in keeping the client in an old pattern, so the initiative
for changing it will have to come from the client.
Cultural factors need to be taken into account in assisting clients in the process
of examining their choices. A person who is struggling with feeling limited by her
family situation can be invited to look at her part in this process and values that
are a part of her culture. For example, Meta, a Norwegian American, is working to
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attain a professional identity as a social worker, but her family thinks she is being
selfi sh and neglecting her primary duties. The family is likely to exert pressure on
her to give up her personal interests in favor of what they feel is best for the wel-
fare of the entire family. Meta may feel trapped in the situation and see no way out
unless she rejects what her family wants. In cases such as this, it is useful to
explore the client’s underlying values and to help her determine whether her values
are working for her and for her family. Clients such as Meta have the challenge of
weighing values and balancing behaviors between two cultures. Ultimately, Meta
must decide in what ways she might change her situation, and she needs to assess
values based on her culture. The existential therapist will invite Meta to begin to
explore what she can do and to realize that she can be authentic in spite of pres-
sures on her by her situation. According to Vontress (2008), we can be authentic
in any society, whether we are a part of an individualistic or collectivistic society.
It is essential to respect the purpose that people have in mind when they initiate
therapy. If we pay careful attention to what our clients tell us about what they want,
we can operate within an existential framework. We can encourage individuals to
weigh the alternatives and to explore the consequences of what they are doing with
their lives. Although oppressive forces may be severely limiting the quality of their
lives, we can help people see that they are not solely the victims of circumstances
beyond their control. Even though we sometimes cannot control things that hap-
pen to us, we have complete control over how we choose to perceive and handle
them. Although our freedom to act is limited by external reality, our freedom to
be relates to our internal reality. At the same time that people are learning how to
change their external environment, they can be challenged to look within them-
selves to recognize their own contributions to their problems. Through the therapy
experience, clients may be able to discover new courses of action that will lead to a
change in their situation.
Proposition 3: Striving for Identity
and Relationship to Others
People are concerned about preserving their uniqueness and centeredness, yet at
the same time they have an interest in going outside of themselves to relate to other
beings and to nature. Each of us would like to discover a self or, to put it more authen-
tically, to create our personal identity. This is not an automatic process, and creating
an identity takes courage. As relational beings, we also strive for connectedness with
others. Many existential writers discuss loneliness, uprootedness, and alienation,
which can be seen as the failure to develop ties with others and with nature.
The trouble with so many of us is that we have sought directions, answers,
values, and beliefs from the important people in our world. Rather than trusting
ourselves to search within and fi nd our own answers to the confl icts in our life, we
sell out by becoming what others expect of us. Our being becomes rooted in their
expectations, and we become strangers to ourselves.
t h e c o u r a g e t o b e Paul Tillich (1886–1965), a leading Protestant theolo-
gian of the 20th century, believes awareness of our fi nite nature gives us an appre-
ciation of ultimate concerns. It takes courage to discover the true “ground of our
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being” and to use its power to transcend those aspects of nonbeing that would de-
stroy us (Tillich, 1952). Courage entails the will to move forward in spite of anxiety-
producing situations, such as facing our death (May, 1975). We struggle to discover,
to create, and to maintain the core deep within our being. One of the greatest fears
of clients is that they will discover that there is no core, no self, no substance, and
that they are merely refl ections of everyone’s expectations of them. A client may
say, “My fear is that I’ll discover I’m nobody, that there really is nothing to me.
I’ll fi nd out that I’m an empty shell, hollow inside, and nothing will exist if I shed
my masks.” If clients demonstrate the courage to confront these fears, they might
well leave therapy with an increased tolerance for the uncertainty of life. By assist-
ing clients in facing the fear that their lives or selves are empty and meaningless,
therapists can help clients to create a self that has meaning and substance that they
have chosen.
Existential therapists may begin by asking their clients to allow themselves to
intensify the feeling that they are nothing more than the sum of others’ expecta-
tions and that they are merely the introjects of parents and parent substitutes.
How do they feel now? Are they condemned to stay this way forever? Is there a way
out? Can they create a self if they fi nd that they are without one? Where can they
begin? Once clients have demonstrated the courage to recognize this fear, to put it
into words and share it, it does not seem so overwhelming. I fi nd that it is best to
begin work by inviting clients to accept the ways in which they have lived outside
themselves and to explore ways in which they are out of contact with themselves.
t h e e x p e r i e n c e o f a lo n e n e s s The existentialists postulate that part
of the human condition is the experience of aloneness. But they add that we can
derive strength from the experience of looking to ourselves and sensing our sepa-
ration. The sense of isolation comes when we recognize that we cannot depend on
anyone else for our own confi rmation; that is, we alone must give a sense of mean-
ing to life, and we alone must decide how we will live. If we are unable to tolerate
ourselves when we are alone, how can we expect anyone else to be enriched by our
company? Before we can have any solid relationship with another, we must have a
relationship with ourselves. We are challenged to learn to listen to ourselves. We
have to be able to stand alone before we can truly stand beside another.
There is a paradox in the proposition that humans are existentially both alone
and related, but this very paradox describes the human condition. To think that
we can cure the condition, or that it should be cured, is erroneous. Ultimately we
are alone, yet our aloneness is set in the context of our inevitable relatedness to
other people.
t h e e x p e r i e n c e o f r e l at e d n e s s We humans depend on relationships
with others. We want to be signifi cant in another’s world, and we want to feel that
another’s presence is important in our world. When we are able to stand alone and
tap into our own strength, our relationships with others are based on our fulfi ll-
ment, not our deprivation. If we feel personally deprived, however, we can expect
little but a clinging and symbiotic relationship with someone else.
Perhaps one of the functions of therapy is to help clients distinguish between a
neurotically dependent attachment to another and a life-affi rming relationship in
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which both persons are enhanced. The therapist can challenge clients to examine
what they get from their relationships, how they avoid intimate contact, how they
prevent themselves from having equal relationships, and how they might create
therapeutic, healthy, and mature human relationships. Existential therapists speak
of intersubjectivity, which is the fact of our interrelatedness with others and the
need for us to struggle with this in a creative way.
s t r u g g l i n g w i t h o u r i d e n t i t y Because of our fear of dealing with
our aloneness, Farha (1994) points out that some of us get caught up in ritualis-
tic behavior patterns that cement us to an image or identity we acquired in early
childhood. He writes that some of us become trapped in a doing mode to avoid the
experience of being.
Part of the therapeutic journey consists of the therapist challenging clients
to begin to examine the ways in which they have lost touch with their identity,
especially by letting others design their life for them. The therapy process itself
is often frightening for clients when they realize that they have surrendered their
freedom to others and that in the therapy relationship they will have to assume
their freedom again. By refusing to give easy solutions or answers, existential
therapists confront clients with the reality that they alone must fi nd their own
answers.
Proposition 4: The Search for Meaning
A distinctly human characteristic is the struggle for a sense of signifi cance and
purpose in life. In my experience the underlying confl icts that bring people into
counseling and therapy are centered in these existential questions: “Why am I
here?” “What do I want from life?” “What gives my life purpose?” “Where is the
source of meaning for me in life?”
Existential therapy can provide the conceptual framework for helping clients
challenge the meaning in their lives. Questions that the therapist might ask are,
“Do you like the direction of your life?” “Are you pleased with what you now are
and what you are becoming?” “If you are confused about who you are and what you
want for yourself, what are you doing to get some clarity?”
t h e p r o b l e m o f d i s c a r d i n g o l d va l u e s One of the problems in
therapy is that clients may discard traditional (and imposed) values without creat-
ing other, suitable ones to replace them. What does the therapist do when clients
no longer cling to values that they never really challenged or internalized and now
experience a vacuum? Clients may report that they feel like a boat without a rudder.
They seek new guidelines and values that are appropriate for the newly discovered
facets of themselves, and yet for a time they are without them. One of the tasks of
the therapeutic process is to help clients create a value system based on a way of
living that is consistent with their way of being.
The therapist’s job is to trust in the capacity of clients to eventually create an
internally derived value system that provides the foundation for a meaningful life.
They will no doubt fl ounder for a time and experience anxiety as a result of the
absence of clear-cut values. The therapist’s trust is important in helping clients
trust their own capacity to create a new source of values.
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m e a n i n g l e s s n e s s When the world they live in seems meaningless, clients
may wonder whether it is worth it to continue struggling or even living. Faced with
the prospect of our mortality, we might ask, “Is there any point to what I do now,
since I will eventually die? Will what I do be forgotten when I am gone? Given the
fact of mortality, why should I busy myself with anything?” A man in one of my
groups captured precisely the idea of personal signifi cance when he said, “I feel
like another page in a book that has been turned quickly, and nobody bothered to
read the page.” For Frankl (1978) such a feeling of meaninglessness is the major
existential neurosis of modern life.
Meaninglessness in life can lead to emptiness and hollowness, or a condition
that Frankl calls the existential vacuum. This condition is often experienced when
people do not busy themselves with routine or with work. Because there is no
preordained design for living, people are faced with the task of creating their own
meaning. At times people who feel trapped by the emptiness of life withdraw from
the struggle of creating a life with purpose. Experiencing meaninglessness and
establishing values that are part of a meaningful life are issues that become the
heart of counseling.
c r e at i n g n e w m e a n i n g Logotherapy is designed to help clients fi nd
meaning in life. The therapist’s function is not to tell clients what their particular
meaning in life should be but to point out that they can create meaning even in suf-
fering (Frankl, 1978). This view holds that human suffering (the tragic and negative
aspects of life) can be turned into human achievement by the stand an individual
takes when faced with it. Frankl also contends that people who confront pain, guilt,
despair, and death can effectively deal with their despair and thus triumph.
Yet meaning is not something that we can directly search for and obtain. Para-
doxically, the more rationally we seek it, the more likely we are to miss it. Frankl
(1978) and Yalom and Josselson (2011) are in basic agreement that, like pleasure,
meaning must be pursued obliquely. Finding satisfaction and meaning in life is
a by-product of engagement, which is a commitment to creating, loving, working,
and building. Meaning is created out of an individual’s engagement with what is
valued, and this commitment provides the purpose that makes life worthwhile
(van Deurzen, 2002a). I like the way Vontress (2008) captures the idea that mean-
ing in life is an ongoing process we struggle with throughout our lives: “What
provides meaning one day may not provide meaning the next, and what has been
meaningful to a person throughout life may be meaningless when a person is on
his or her deathbed” (p. 158).
Proposition 5: Anxiety as a Condition of Living
Anxiety arises from one’s personal strivings to survive and to maintain and as-
sert one’s being, and the feelings anxiety generates are an inevitable aspect of the
human condition. Existential anxiety is the unavoidable result of being confronted
with the “givens of existence”—death, freedom, choice, isolation, and meaningless-
ness (Vontress, 2008; Yalom, 1980; Yalom & Josselson, 2011). Existential anxiety
arises as we recognize the realities of our mortality, our confrontation with pain and
suffering, our need to struggle for survival, and our basic fallibility. We experience
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this anxiety as we become increasingly aware of our freedom and the consequenc-
es of accepting or rejecting that freedom. In fact, when we make a decision that
involves reconstruction of our life, the accompanying anxiety can be a signal that we
are ready for personal change and can be a stimulus for growth. If we learn to listen
to the subtle messages of anxiety, we can dare to take the steps necessary to change
the direction of our lives.
Existential therapists differentiate between normal and neurotic anxiety, and
they see anxiety as a potential source of growth. Normal anxiety is an appropriate
response to an event being faced. Further, this kind of anxiety does not have to
be repressed, and it can be used as a motivation to change. Because we could not
survive without some anxiety, it is not a therapeutic goal to eliminate normal anxi-
ety. Existential philosophers have argued that at the root of our normal (or ontic)
anxiety, which is an appropriate anxiety that relates to concrete things in the world,
is a more fundamental existential (or ontological) anxiety, which is based on our
awareness of our own temporality and is present even when we do not have to face
particularly diffi cult situations. Neurotic anxiety, in contrast, is anxiety about con-
crete things that is out of proportion to the situation. Neurotic anxiety is typically
out of awareness, and it tends to immobilize the person. Being psychologically
healthy entails living with as little neurotic anxiety as possible, while accepting and
struggling with the unavoidable existential anxiety that is a part of living.
Many people who seek counseling want solutions that will enable them to elimi-
nate anxiety. Attempts to avoid anxiety by creating the illusion that there is security
in life may help us cope with the unknown, yet we really know on some level that
we are deceiving ourselves when we think we have found fi xed security. Facing
existential anxiety involves viewing life as an adventure rather than hiding behind
imagined securities that seem to offer protection. Opening up to new life means
opening up to anxiety. We pay a steep price when we short-circuit anxiety.
People who have the courage to face themselves are, nonetheless, frightened. I
am convinced that those who are willing to live with their anxiety for a time profi t
from personal therapy. Those who fl ee too quickly into comfortable patterns might
experience temporary relief but in the long run seem to experience the frustration
of being stuck in old ways.
The existential therapist can help clients recognize that learning how to tolerate
ambiguity and uncertainty and how to live without props can be a necessary phase in
the journey from dependence to autonomy. The therapist and client can explore the
possibility that although breaking away from crippling patterns and building new
ways of living will be fraught with anxiety for a while, anxiety will diminish as the cli-
ent experiences more satisfaction with newer ways of being. When a client becomes
more self-confi dent, the anxiety that results from an expectation of catastrophe is
likely to decrease.
Proposition 6: Awareness of Death and Nonbeing
The existentialist does not view death negatively but holds that awareness of death
as a basic human condition gives signifi cance to living. A distinguishing human
characteristic is the ability to grasp the reality of the future and the inevitability of
death. It is necessary to think about death if we are to think signifi cantly about life.
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Death should not be considered a threat; death provides the motivation for us to
take advantage of appreciating the present moment. Instead of being frozen by the
fear of death, death can be viewed as a positive force that enables us to live as fully
as possible. Although the notion of death is a wake-up call, it is also something
that we strive to avoid (Russell, 2007). If we defend ourselves against the reality
of our eventual death, life becomes insipid and meaningless. But if we realize that
we are mortal, we know that we do not have an eternity to complete our projects
and that the present is crucial. Our awareness of death is the source of zest for life
and creativity. Death and life are interdependent, and though physical death de-
stroys us, the idea of death saves us (Yalom, 1980, 2003).
Yalom (2008) recommends that therapists talk directly to clients about the
reality of death. He believes the fear of death percolates beneath the surface and
haunts us throughout life. Death is a visitor in the therapeutic process, and Yalom
believes that ignoring its presence sends the message that death is too overwhelm-
ing to explore. Confronting this fear can be the factor that helps us transform an
inauthentic mode of living into a more authentic one. Accepting the reality of our
personal death can result in a massive shift in the way we live in the world (Yalom &
Josselson, 2011). We can turn our fear of death into a positive force when we accept
the reality of our mortality. In Staring at the Sun: Overcoming the Terror of Death,
Yalom (2008) develops the idea that confronting death enables us to live in a more
compassionate way.
One focus in existential therapy is on exploring the degree to which clients
are doing the things they value. Without being morbidly preoccupied by the ever-
present threat of nonbeing, clients can develop a healthy awareness of death as a
way to evaluate how well they are living and what changes they want to make in
their lives. Those who fear death also fear life. When we emotionally accept the
reality of our eventual death, we realize more clearly that our actions do count, that
we do have choices, and that we must accept the ultimate responsibility for how
well we are living (Corey & Corey, 2010).
t h e t h e r a p e u t i c p r o c e s s
Therapeutic Goals
Existential therapy is best considered as an invitation to clients to recognize the
ways in which they are not living fully authentic lives and to make choices that
will lead to their becoming what they are capable of being. An aim of therapy is to
assist clients in moving toward authenticity and learning to recognize when they
are deceiving themselves (van Deurzen, 2002a). The existential orientation holds
that there is no escape from freedom as we will always be held responsible. We can
relinquish our freedom, however, which is the ultimate inauthenticity. Existential
therapy aims at helping clients face anxiety and engage in action that is based on
the authentic purpose of creating a worthy existence.
May (1981) contends that people come to therapy with the self-serving illu-
sion that they are inwardly enslaved and that someone else (the therapist) can free
them. Existential therapists are mainly concerned about helping people to reclaim
and reown their lives. The task of existential therapy is to teach clients to listen to
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what they already know about themselves, even though they may not be attend-
ing to what they know. Schneider and Krug (2010) identify four essential aims of
existential-humanistic therapy: (1) to help clients become more present to both
themselves and others; (2) to assist clients in identifying ways they block them-
selves from fuller presence; (3) to challenge clients to assume responsibility for de-
signing their present lives; and (4) to encourage clients to choose more expanded
ways of being in their daily lives.
Increased awareness is the central goal of existential therapy, which allows
clients to discover that alternative possibilities exist where none were recognized
before. Clients come to realize that they are able to make changes in their way of
being in the world.
Therapist’s Function and Role
Existential therapists are primarily concerned with understanding the subjective
world of clients to help them come to new understandings and options. Existen-
tial therapists are especially concerned about clients avoiding responsibility; they
consistently invite clients to accept personal responsibility. When clients complain
about the predicaments they are in and blame others, the therapist is likely to ask
them how they contributed to their situation.
Therapists with an existential orientation usually deal with people who have
what could be called a restricted existence. These clients have a limited aware-
ness of themselves and are often vague about the nature of their problems. They
may see few, if any, options for dealing with life situations, and they tend to feel
trapped, helpless, and stuck. For Bugental (1997), a therapist’s function is to assist
clients in seeing the ways in which they constrict their awareness and the cost of
such constrictions. The therapist may hold up a mirror, so to speak, so that clients
can gradually engage in self-confrontation. In this way clients can see how they be-
came the way they are and how they might enlarge the way they live. Once clients
are aware of factors in their past and of stifl ing modes of their present existence,
they can begin to accept responsibility for changing their future.
Existential practitioners may make use of techniques that originate from
diverse theoretical orientations, yet no set of techniques is considered essen-
tial. The therapeutic journey is creative and uncertain and different for each cli-
ent. Russell (2007) captures this notion well when he writes: “There is no one
right way to do therapy, and certainly no rigid doctrine for existentially rooted
techniques. What is crucial is that you create your own authentic way of being
attuned to your clients” (p. 123). Existential therapists encourage experimenta-
tion not only within the therapy offi ce but also outside of the therapy setting,
based on the belief that life outside therapy is what counts. Practitioners often
ask clients to refl ect on or write about problematic events they encounter in daily
life (Schneider, 2011).
Client’s Experience in Therapy
Clients in existential therapy are clearly encouraged to assume responsibility for
how they are currently choosing to be in their world. Effective therapy does not stop
with this awareness itself, for the therapist encourages clients to take action on the
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basis of the insights they develop through the therapeutic process. Experimentation
with new ways of behaving in the outside world is necessary if clients are to change.
Further, clients must be active in the therapeutic process, for during the sessions
they must decide what fears, guilt feelings, and anxieties they will explore.
Merely deciding to enter psychotherapy is itself a frightening prospect for most
people. The experience of opening the doors to oneself can be frightening, excit-
ing, joyful, depressing, or a combination of all of these. As clients wedge open the
closed doors, they also begin to loosen the deterministic shackles that have kept
them psychologically bound. Gradually, they become aware of what they have been
and who they are now, and they are better able to decide what kind of future they
want. Through the process of their therapy, individuals can explore alternatives for
making their visions real.
When clients plead helplessness and attempt to convince themselves that they
are powerless, May (1981) reminds them that their journey toward freedom began
by putting one foot in front of the other to get to his offi ce. As narrow as their range
of freedom may be, individuals can begin building and augmenting that range by
taking small steps. The therapeutic journey that opens up new horizons is poeti-
cally described by van Deurzen (2010):
Embarking on our existential journey requires us to be prepared to be touched and shaken by
what we fi nd on the way and to not be afraid to discover our own limitations and weaknesses,
uncertainties and doubts. It is only with such an attitude of openness and wonder that we can
encounter the impenetrable everyday mysteries, which take us beyond our own preoccupa-
tions and sorrows and which by confronting us with death, make us rediscover life. (p. 5)
Another aspect of the experience of being a client in existential therapy is confront-
ing ultimate concerns rather than coping with immediate problems. Rather than
being solution-oriented, existential therapy is aimed toward removing roadblocks
to meaningful living and helping clients assume responsibility for their actions
(Yalom & Josselson, 2011). Existential therapists assist people in facing life with
courage, hope, and a willingness to fi nd meaning in life.
Relationship Between Therapist and Client
Existential therapists give central prominence to their relationship with the client.
The relationship is important in itself because the quality of this person-to-person
encounter in the therapeutic situation is the stimulus for positive change. Atten-
tion is given to the client’s immediate, ongoing experience, especially what is go-
ing on in the interaction between the therapist and the client. Therapy is viewed
as a social microcosm in the sense that the interpersonal and existential problems
of the client will become apparent in the here and now of the therapy relationship
(Yalom & Josselson, 2011).
Therapists with an existential orientation believe their basic attitudes toward the
client and their own personal characteristics of honesty, integrity, and courage are
what they have to offer. Therapy is a journey taken by therapist and client that delves
deeply into the world as perceived and experienced by the client. But this type of quest
demands that therapists also be in contact with their own phenomenological world.
Existential therapy is a voyage into self-discovery and a journey of life-discovery
for both client and therapist (van Deurzen, 2010; Yalom & Josselson, 2011).
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Buber’s (1970) conception of the I/Thou relationship has signifi cant implica-
tions here. His understanding of the self is based on two fundamental relation-
ships: the “I/it” and the “I/Thou.” The I/it is the relation to time and space, which
is a necessary starting place for the self. The I/Thou is the relationship essential
for connecting the self to the spirit and, in so doing, to achieve true dialogue. This
form of relationship is the paradigm of the fully human self, the achievement of
which is the goal of Buber’s existential philosophy. Relating in an I/Thou fashion
means that there is direct, mutual, and present interaction. Rather than prizing
therapeutic objectivity and professional distance, existential therapists strive to cre-
ate caring and intimate relationships with clients.
The core of the therapeutic relationship is respect, which implies faith in
clients’ potential to cope authentically with their troubles and in their ability to
discover alternative ways of being. Existential therapists share their reactions to
clients with genuine concern and empathy as one way of deepening the therapeu-
tic relationship. Therapists invite clients to grow by modeling authentic behavior.
If therapists keep themselves hidden during the therapeutic session or if they en-
gage in inauthentic behavior, clients will also remain guarded and persist in their
inauthentic ways.
Bugental (1987) emphasizes the crucial role the presence of the therapist plays
in the therapeutic relationship. In his view many therapists and therapeutic sys-
tems overlook its fundamental importance. He contends that therapists are too
often so concerned with the content of what is being said that they are not aware of
the distance between themselves and their clients:
The therapeutic alliance is the powerful joining of forces which energizes and supports the
long, diffi cult, and frequently painful work of life-changing psychotherapy. The conception
of the therapist here is not of a disinterested observer-technician but of a fully alive human
companion for the client. (p. 49)
Schneider (2011) believes that the therapist’s presence is both a condition and a goal
of therapeutic change. Presence serves the dual functions of reconnecting people
to their pain and to attuning them to the opportunities to transform their pain.
a p p l i c at i o n : t h e r a p e u t i c
t e c h n i q u e s a n d p r o c e d u r e s
The existential approach is unlike most other therapies in that it is not technique-
oriented. Although existentially oriented therapists may incorporate many tech-
niques from other models, these interventions are made within the context of striv-
ing to understand the subjective world of the client. The interventions existential
practitioners employ are based on philosophical views about the nature of human
existence. These practitioners prefer description, understanding, and exploration
of the client’s subjective reality, as opposed to diagnosis, treatment, and prognosis
(van Deurzen, 2002b). As Vontress (2008) puts it: “Existential therapists prefer
to be thought of as philosophical companions, not as people who repair psyches”
(p. 161). Yalom and Josselson (2011) assert that existential therapists are “fel-
low travelers” (p. 332), willing to make themselves known through appropriate
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self-disclosure. As mentioned earlier, existential therapists are free to draw from
techniques that fl ow from many other orientations. However, they do not employ an
array of unintegrated techniques; they have a set of assumptions and attitudes that
guide their interventions with clients. See Case Approach to Counseling and Psycho-
therapy (Corey, 2013, chap. 4) for an illustration of how Dr. J. Michael Russell works
in an existential way with some key themes in the case of Ruth.
Van Deurzen (2010) identifi es as a primary ground rule of existential work the
openness to the individual creativity of the therapist and the client. She maintains
that existential therapists need to adapt their interventions to their own person-
ality and style, as well as being sensitive to what each client requires. The main
guideline is that the existential practitioner’s interventions are responsive to the
uniqueness of each client.
Van Deurzen (2002a, 2002b) believes that the starting point for existential
work is for practitioners to clarify their views on life and living. She stresses the
importance of therapists reaching suffi cient depth and openness in their own lives
to venture into clients’ murky waters without getting lost. The nature of existential
work is assisting people in the process of living with greater expertise and ease.
Van Deurzen (2010) identifi es how therapists make a difference with clients: “We
help them to get better at refl ecting on their situation, deal with their dilemma,
face their predicament and think for themselves” (p. 236). Van Deurzen reminds
us that existential therapy is a collaborative adventure in which both client and
therapist will be transformed if they allow themselves to be touched by life. When
the deepest self of the therapist meets the deepest part of the client, the counseling
process is at its best. Therapy is a creative, evolving process of discovery that can be
conceptualized in three general phases.
Phases of Existential Counseling
During the initial phase of counseling, therapists assist clients in identifying
and clarifying their assumptions about the world. Clients are invited to defi ne and
question the ways in which they perceive and make sense of their existence. They
examine their values, beliefs, and assumptions to determine their validity. This is
a diffi cult task for many clients because they may initially present their problems
as resulting almost entirely from external causes. They may focus on what other
people “make them feel” or on how others are largely responsible for their actions
or inaction. The counselor teaches them how to refl ect on their own existence and
to examine their role in creating their problems in living.
During the middle phase of existential counseling, clients are assisted in more
fully examining the source and authority of their present value system. This proc-
ess of self-exploration typically leads to new insights and some restructuring of
values and attitudes. Individuals get a better idea of what kind of life they consider
worthy to live and develop a clearer sense of their internal valuing process.
The fi nal phase of existential counseling focuses on helping people take what
they are learning about themselves and put it into action. Transformation is not
limited to what takes place during the therapy hour. The therapeutic hour is a
small contribution to a person’s renewed engagement with life, or a rehearsal
for life (van Deurzen, 2002b). The aim of therapy is to enable clients to discover
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ways of implementing their examined and internalized values in a concrete way
between sessions and after therapy has terminated. Clients typically discover their
strengths and fi nd ways to put them to the service of living a purposeful existence.
Clients Appropriate for Existential Counseling
Existential practice has been applied in a variety of settings and with a diverse pop-
ulation of clients, including those with substance abuse issues, ethnic and racial
minorities, gay and lesbian clients, and psychiatric inpatients (Schneider, 2011). A
strength of the perspective is its focus on available choices and pathways toward
personal growth. For people who are coping with developmental crises, experienc-
ing grief and loss, confronting death, or facing a major life decision, existential
therapy is especially appropriate. Some examples of these critical turning points
that mark passages from one stage of life into another are the struggle for identity
in adolescence, coping with possible disappointments in middle age, adjusting to
children leaving home, coping with failures in marriage and work, and dealing
with increased physical limitations as one ages. These developmental challenges
involve both dangers and opportunities. Uncertainty, anxiety, and struggling with
decisions are all part of this process.
Van Deurzen (2002b) suggests that this form of therapy is most appropriate
for clients who are committed to dealing with their problems about living, for peo-
ple who feel alienated from the current expectations of society, or for those who
are searching for meaning in their lives. It tends to work well with people who
are at a crossroads and who question the state of affairs in the world and are will-
ing to challenge the status quo. It can be useful for people who are on the edge of
existence, such as those who are dying or contemplating suicide, who are working
through a developmental or situational crisis, who feel that they no longer belong
in their surroundings, or who are starting a new phase of life.
Application to Brief Therapy
The existential approach can focus clients on signifi cant areas such as assuming
personal responsibility, making a commitment to deciding and acting, and ex-
panding their awareness of their current situation. It is possible for a time-limited
approach to serve as a catalyst for clients to become actively and fully involved in
each of their therapy sessions. Strasser and Strasser (1997), who are connected to
the British school of existential analysis, maintain that there are clear benefi ts to
time-limited therapy, which mirrors the time-limited reality of human existence.
Sharp and Bugental (2001) maintain that short-term applications of the existential
approach require more structuring and clearly defi ned and less ambitious goals.
At the termination of short-term therapy, it is important for individuals to evaluate
what they have accomplished and what issues may need to be addressed later. It is
essential that both therapist and client determine that short-term work is appropri-
ate, and that benefi cial outcomes are likely.
Application to Group Counseling
An existential group can be described as people making a commitment to a lifelong
journey of self-exploration with these goals: (1) enabling members to become honest
with themselves, (2) widening their perspectives on themselves and the world
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around them, and (3) clarifying what gives meaning to their present and future life
(van Deurzen, 2002b). An open attitude toward life is essential, as is the willingness
to explore unknown territory. Recurring universal themes evolve in many groups
and challenge members to seriously explore existential concerns such as choice,
freedom and anxiety, awareness of death, meaning in life, and living fully.
Yalom (1980) contends that the group provides the optimal conditions for
therapeutic work on responsibility. The members are responsible for the way they
behave in the group, and this provides a mirror for how they are likely to act in
the world. A group represents a microcosm of the world in which participants live
and function. Over time the interpersonal and existential problems of the partici-
pants become evident in the here-and-now interactions within the group (Yalom &
Josselson, 2011). Through feedback, members learn to view themselves through
others’ eyes, and they learn the ways in which their behavior affects others. Build-
ing on what members learn about their interpersonal functioning in the group,
they can take increased responsibility for making changes in everyday life. The
group experience provides the opportunity to participants to relate to others in
meaningful ways, to learn to be themselves in the company of other people, and to
establish rewarding, nourishing relationships.
In existential group counseling, members come to terms with the paradoxes of
existence: that life can be undone by death, that success is precarious, that we are
determined to be free, that we are responsible for a world we did not choose, that
we must make choices in the face of doubt and uncertainty. Members experience
anxiety when they recognize the realities of the human condition, including pain
and suffering, the need to struggle for survival, and their basic fallibility. Clients
learn that there are no ultimate answers for ultimate concerns. Through the sup-
port that is within a group, participants are able to tap the strength needed to create
an internally derived value system that is consistent with their way of being.
A group provides a powerful context to look at oneself, and to consider what
choices might be more authentically one’s own. Members can openly share their
fears related to living in unfulfi lling ways and come to recognize how they have
compromised their integrity. Members can gradually discover ways in which they
have lost their direction and can begin to be more true to themselves. Members
learn that it is not in others that they fi nd the answers to questions about signifi –
cance and purpose in life. Existential group leaders help members live in authentic
ways and refrain from prescribing simple solutions. For a more detailed discus-
sion of the existential approach to group counseling, see Corey (2012, chap. 9).
e x i s t e n t i a l t h e r a p y f r o m a
m u lt i c u lt u r a l p e r s p e c t i v e
Strengths From a Diversity Perspective
Because the existential approach does not dictate a particular way of viewing or relat-
ing to reality, and because of its broad perspective, this approach is highly relevant in
working in a multicultural context (van Deurzen, 2002a). Vontress and colleagues
(1999) write about the existential foundation of cross-cultural counseling: “Existential
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counseling is probably the most useful approach to helping clients of all cultures fi nd
meaning and harmony in their lives, because it focuses on the sober issues each of us
must inevitably face: love, anxiety, suffering, and death” (p. 32). These are the human
experiences that transcend the boundaries that separate cultures.
Existential therapy is useful in working with culturally diverse clients because
of its focus on universality, or the common ground that we all share. This approach
emphasizes presence, the I/Thou relationship, and courage. As such, it can be
effectively applied with diverse client populations with a range of specifi c problems
and in a wide array of settings (Schneider, 2008, 2011; Schneider & Krug, 2010).
Schneider’s (2008) “existential-integrative” model of practice coordinates a variety
of therapeutic modes within an overarching existential or experiential framework.
Vontress (1996) points out that all people are multicultural in the sense that they
are all products of many cultures. He encourages counselors-in-training to focus
on the universal commonalities of clients fi rst and secondarily on areas of differ-
ences. In working with cultural diversity, it is essential to recognize simultaneously
the commonalities and differences of human beings: “Cross-cultural counseling,
in short, does not intend to teach specifi c interventions for each culture, but to
infuse the counselor with a cultural sensitivity and tolerant philosophical outlook
that will befi t all cultures” (p. 164).
The focus on subjective experience, or phenomenology, is a strength from a
multicultural perspective. Another strength of the existential approach is that it
enables clients to examine the degree to which their behavior is being infl uenced
by social and cultural conditioning. Clients can be challenged to look at the price
they are paying for the decisions they have made. Although it is true that some
clients may not feel a sense of freedom, their freedom can be increased if they
recognize the social limits they are facing. Their freedom can be hindered by insti-
tutions and limited by their family. In fact, it may be diffi cult to separate individual
freedom from the context of their family structure.
There is wide-ranging international interest in the existential approach. Several
Scandinavian societies, an East European society (encompassing Estonia, Latvia,
Lithuania, Russia, Ukraine, and Belarus), and Mexican and South American socie-
ties are thriving. In addition, an Internet course, SEPTIMUS, is taught in Ireland,
Iceland, Sweden, Poland, Czech Republic, Romania, Italy, Portugal, France, Belgium,
the United Kingdom, Israel, and Australia. Most recently, the First International East-
West Existential Psychology conference was held in Nanjing, China, with representa-
tives from the United States, Korea, and Japan. These international developments, as
well as the creation of the International Collaborative of Existential Counselors and
Psychotherapists, which has members from all over the world, reveal that existential
therapy has wide appeal to diverse populations in many parts of the world.
Shortcomings From a Diversity Perspective
For those who hold a systemic perspective, the existentialists can be criticized on the
grounds that they are excessively individualistic and that they ignore the social factors
that cause human problems. However, with the advent of the “existential-integrative”
model of practice (Schneider, 2008), this situation is beginning to change. According
to Schneider (2011), existential practitioners are not only concerned with facilitating
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individual change but with promoting an in-depth inquiry that has implications for
social change: “One cannot simply heal individuals to the neglect of the social con-
text within which they are thrust. To be a responsible practitioner, one must develop
a vision of responsible social change alongside and in coordination with one’s vision
of individual transformation” (p. 281).
Some individuals who seek counseling may operate on the assumption that
they have very little choice because environmental circumstances severely restrict
their ability to infl uence the direction of their lives. Even if they change internal-
ly, they see little hope that the external realities of racism, discrimination, and
oppression will change. They are likely to experience a deep sense of frustration and
feelings of powerlessness when it comes to making changes outside of themselves.
As you will see in Chapter 12, feminist therapists maintain that therapeutic practice
will be effective only to the extent that therapists intervene with some form of social
action to change those factors that are creating clients’ problems. In working with
people of color who come from the barrio or ghetto, for example, it is important to
engage their survival issues. If a counselor too quickly puts across the message to
these clients that they have a choice in making their lives better, they may feel pa-
tronized and misunderstood. These real-life concerns can provide a good focus for
counseling, assuming the therapist is willing to deal with them.
A potential problem within existential theory is that it is highly focused on the
philosophical assumption of self-determination, which may not take into account
the complex factors that many people who have been oppressed must deal with. In
many cultures it is not possible to talk about the self and self-determination apart
from the context of the social network and environmental conditions. However,
a case can be made for the existential approach being instrumental in enabling
clients to make conscious choices when it comes to the values they live by. Existen-
tial therapists do not push autonomy apart from a client’s culture. They do assist
clients in critically evaluating the source of their values and making a choice rather
than uncritically accepting the values of their culture and family.
Many clients expect a structured and problem-oriented approach to counseling
that is not found in the conventional existential approach. Although clients may
feel better if they have an opportunity to talk and to be understood, they are likely to
expect the counselor to do something to bring about a change in their life situation.
A major task for the counselor who practices from an existential perspective is to
provide enough concrete direction for these clients without taking the responsibility
away from them.
As an existentially oriented therapist, I
counsel Stan with the assumption that
he has the capacity to increase his
self-awareness and decide for himself the future
direction of his life. I want him to realize more
than anything else that he does not have to be
the victim of his past conditioning but can be the
architect in redesigning his future. He can free
himself of his deterministic shackles and
accept the responsibility that comes with
directing his own life. This approach emphasizes
the importance of my understanding of Stan’s
Existential Therapy Applied to the Case of Stan
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world, primarily by establishing an authentic
relationship as a means to a fuller degree of
self-understanding.
Stan is demonstrating what Sartre would call
“bad faith” by not accepting personal respon-
sibility. I confront Stan with the ways in which
he is attempting to escape from his freedom
through alcohol and drugs. Eventually, I chal-
lenge Stan’s passivity. I reaffirm that he is now
entirely responsible for his life, for his actions,
and for his failure to take action. I do this in a
supportive yet firm manner.
I do not see Stan’s anxiety as something
negative, but as a vital part of living with uncer-
tainty and freedom. Because there are no guar-
antees and because the individual is ultimately
alone, Stan can expect to experience some degree
of healthy anxiety, aloneness, guilt, and even
despair. These conditions are not neurotic in
themselves, but the way in which Stan orients
himself and copes with these conditions is critical.
Stan sometimes talks about his suicidal feel-
ings. Certainly, I investigate further to determine
if he poses an immediate threat to himself. In
addition to this assessment to determine lethality,
I view his thoughts of “being better off dead” as
symbolic. Could it be that Stan feels he is dying
as a person? Is Stan using his human potential?
Is he choosing a way of merely existing instead
of affirming life? Is Stan mainly trying to elicit
sympathy from his family? I invite Stan to explore
the meaning and purpose in his life. Is there any
reason for him to want to continue living? What
are some of the projects that enrich his life? What
can he do to find a sense of purpose that will
make him feel more significant and alive?
Stan needs to accept the reality that he may
at times feel alone. Choosing for oneself and
living from one’s own center accentuates the
experience of aloneness. He is not, however,
condemned to a life of isolation, alienation from
others, and loneliness. I hope to help Stan dis-
cover his own centeredness and live by the values
he chooses and creates for himself. By doing so,
Stan can become a more substantial person and
come to appreciate himself more. When he does,
the chances are lessened that he will have a need
to secure approval from others, particularly his
parents and parental substitutes. Instead of form-
ing a dependent relationship, Stan could choose
to relate to others out of his strength. Only then
would there be the possibility of overcoming his
feelings of separateness and isolation.
Follow-Up: You Continue as
Stan’s Existential Therapist
Use these questions to help you think about
how you would counsel Stan using an existential
approach:
• If Stan resisted your attempts to help him see
that he is responsible for the direction of his
life, how might you intervene?
• Stan experiences a great deal of anxiety. From
an existential perspective, how do you view his
anxiety? How might you work with his anxiety
in helpful ways?
• If Stan talks with you about suicide as a re-
sponse to despair and a life without meaning,
how would you respond?
See the DVD for Theory and Practice of
Counseling and Psychotherapy: The Case
of Stan and Lecturettes (Session 4 on existential
therapy) for a demonstration of my approach
to counseling Stan from this perspective. This
session focuses on the themes of death and the
meaning of life.
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s u m m a ry a n d e va l u at i o n
Summary
As humans, according to the existentialist view, we are capable of self-awareness,
which is the distinctive capacity that allows us to refl ect and to decide. With this
awareness we become free beings who are responsible for choosing the way we live,
and we infl uence our own destiny. This awareness of freedom and responsibility
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gives rise to existential anxiety, which is another basic human characteristic. Wheth-
er we like it or not, we are free, even though we may seek to avoid refl ecting on this
freedom. The knowledge that we must choose, even though the outcome is not cer-
tain, leads to anxiety. This anxiety is heightened when we refl ect on the reality that
we are mortal. Facing the inevitable prospect of eventual death gives the present
moment signifi cance, for we become aware that we do not have forever to accom-
plish our projects. Our task is to create a life that has meaning and purpose. As
humans we are unique in that we strive toward fashioning purposes and values that
give meaning to living. Whatever meaning our life has is developed through free-
dom and a commitment to make choices in the face of uncertainty.
Existential therapy places central prominence on the person-to-person relation-
ship. It assumes that client growth occurs through this genuine encounter. It is not
the techniques a therapist uses that make a therapeutic difference; rather, it is the
quality of the client–therapist relationship that heals. It is essential that therapists
reach suffi cient depth and openness in their own lives to allow them to venture
into their clients’ subjective world without losing their own sense of identity. Pres-
ence is both a condition for therapy to occur and a goal of therapy. Existential thera-
pists are fellow travelers, and as such they strive to be authentic and self-disclosing
in their therapy work. Because this approach focuses on the goals of therapy, ba-
sic conditions of being human, and therapy as a shared journey, practitioners are
not bound by specifi c techniques. Although existential therapists may apply tech-
niques from other orientations, their interventions are guided by a philosophical
framework about what it means to be human.
Contributions of the Existential Approach
The existential approach has helped bring the person back into central focus. It
concentrates on the central facts of human existence: self-consciousness and our
consequent freedom. To the existentialist goes the credit for providing a new view
of death as a positive force, not a morbid prospect to fear, for death gives life mean-
ing. Existentialists have contributed a new dimension to the understanding of anx-
iety, guilt, frustration, loneliness, and alienation.
I particularly appreciate the way van Deurzen (2002a) views the existential
practitioner as a mentor and fellow traveler who encourages people to refl ect upon
the problems they encounter in living. What clients need is “some assistance in
surveying the terrain and in deciding on the right route so that they can again fi nd
their way” (p. 18). According to van Deurzen, the existential approach encourages
people to live life by their own standards and values: “The aim of existential work is
to assist people in developing their talents in their own personal way, helping them
in being true to what they value” (p. 21).
One of the major contributions of the existential approach is its emphasis on
the human quality of the therapeutic relationship. This aspect lessens the chances
of dehumanizing psychotherapy by making it a mechanical process. Existential
counselors reject the notions of therapeutic objectivity and professional distance,
viewing them as being unhelpful.
I very much value the existential emphasis on freedom and responsibility
and the person’s capacity to redesign his or her life by choosing with awareness.
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This perspective provides a sound philosophical base on which to build a personal
and unique therapeutic style because it addresses itself to the core struggles of the
contemporary person.
contributions to the integration of psychotherapies
From my perspective, the key concepts of the existential approach can be inte-
grated into most therapeutic schools. Regardless of a therapist’s orientation, the
foundation for practice can be based on existential themes. Existential psychother-
apy continues to have an enduring impact on a variety of psychological practices.
“Indeed, existential psychotherapy is in the ironic position of being one of the most
widely infl uential yet least offi cially embraced orientations on the professional
scene” (Schneider, 2008, p. 1). Bruce Wampold (2008), a leading researcher in the
psychotherapy fi eld, agrees “that an understanding of the principles of existential
therapy is needed by all therapists, as it adds a perspective that might . . . form the
basis for all effective treatments” (p. 6).
A key contribution is the possibility of a creative integration of the concep-
tual propositions of existential therapy with many other therapeutic orientations
(Bugental & Bracke, 1992; Schneider, 2008, 2011; Schneider & Krug, 2010). One
example of such a creative integration is provided by Dattilio (2002), who inte-
grates cognitive behavioral techniques with the themes of an existential approach.
As a cognitive behavior therapist and author, Dattilio maintains that he directs
much of his efforts to “helping clients make a deep existential shift—to a new
understanding of the world” (p. 75). He uses techniques such as restructuring
of belief systems, relaxation methods, and a variety of cognitive and behavioral
strategies, but he does so within an existential framework that can begin the proc-
ess of real-life transformation. Many of his clients suffer from panic attacks or
depression. Dattilio often explores with these people existential themes of mean-
ing, guilt, hopelessness, anxiety—and at the same time he provides them with cog-
nitive behavioral tools to cope with the problems of daily living. In short, he grounds
symptomatic treatment in an existential approach.
Some people have argued that the new trend toward positive psychology is
similar to the existential approach, but this rests on a superfi cial comparison of
these two approaches. Existential therapists favor intensity and passionate experi-
ence, including that of happiness, but they equally value the darker side of human
nature and would encourage clients to learn to value both sides of their experience
(van Deurzen, 2009).
Limitations and Criticisms of the Existential Approach
A major criticism often aimed at this approach is that it lacks a systematic state-
ment of the principles and practices of psychotherapy. Some practitioners have
trouble with what they perceive as its mystical language and concepts. Some thera-
pists who claim adherence to an existential orientation describe their therapeutic
style in vague and global terms such as self-actualization, dialogic encounter, au-
thenticity, and being in the world. This particular use of language causes confusion
at times and makes it diffi cult to conduct research on the process or outcomes of
existential therapy.
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Both beginning and advanced practitioners who are not of a philosophical turn
of mind tend to fi nd many of the existential concepts lofty and elusive. As we have
seen, this approach places primary emphasis on a subjective understanding of the
world of clients. It is assumed that techniques follow understanding. The fact that
few techniques are generated by this approach makes it essential for practitioners
to develop their own innovative procedures or to borrow from other schools of
therapy. For counselors who believe they need a specifi c set of techniques to coun-
sel effectively, this approach has limitations (Vontress, 2008).
Practitioners who prefer a counseling practice based on research contend that
the concepts should be empirically sound, that defi nitions should be operational,
that the hypotheses should be testable, and that therapeutic practice should be
based on the results of research into both the process and outcomes of counseling.
Certainly, the notions of manualized therapy and evidence-based practice are not
part of the existential perspective because every psychotherapy experience is unique
(Walsh & McElwain, 2002). According to Cooper (2003), existential practitioners
generally reject the idea that the therapeutic process can be measured and evalu-
ated in quantitative and empirical ways. Although existential practices are gener-
ally upheld by recent research on therapeutic effectiveness (see Elkins, 2009), few
studies directly evaluate and examine the existential approach. To a large extent,
existential therapy makes use of techniques from other theories, which makes it
diffi cult to apply research to this approach to study its effectiveness (Sharf, 2012).
According to van Deurzen (2002b), the main limitation of this approach is
that of the level of maturity, life experience, and intensive training required of
practitioners. Existential therapists need to be wise and capable of profound and
wide-ranging understanding of what it means to be human. Authenticity is a
cardinal characteristic of a competent existential practitioner, which is certainly
more involved than mastering a body of knowledge and acquiring technical skills.
Russell (2007) puts this notion nicely: “Authenticity means being able to sign your
own name on your work and your life. It means you will want to take responsibility
for creating your own way of being a therapist” (p.123).
w h e r e to g o f r o m h e r e
Refer to the DVD for Integrative Counseling: The Case of Ruth and Lecturettes, Ses-
sion 11 (“Understanding How the Past Infl uences the Present and the Future”),
for a demonstration of ways I utilize existential notions in counseling Ruth. We
engage in a role play where Ruth becomes the voice of her church and I take on
a new role as Ruth—one in which I have been willing to challenge certain beliefs
from church. This segment illustrates how I assist Ruth in fi nding new values.
In Session 12 (“Working Toward Decisions and Behavioral Changes”) I challenge
Ruth to make new decisions, which is also an existential concept.
Free Podcasts for ACA Members
You can download ACA Podcasts (prerecorded interviews) at www.counseling.org;
click on the Resource button and then the Podcast Series. For Chapter 6, Existen-
tial Therapy, look for Podcast 14 by Dr. Gerald Corey.
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Other Resources
The American Psychological Association offers a DVD by K. J. Schneider (2009)
titled Existential-Humanistic Therapy in their Systems of Psychotherapy Video Series.
Psychotherapy.net is a comprehensive resource for students and profession-
als that offers videos and interviews on existential therapy featuring Irvin Yalom,
James Bugental, and Rollo May. New video and editorial content is made available
monthly. DVDs relevant to this chapter are available at www.psychotherapy.net
and include the following:
Bugental, J.F.T. (1995). Existential-Humanistic Psychotherapy in Action
Bugental, J. (1997). Existential-Humanistic Psychotherapy (Psychotherapy
with the Experts Series)
Bugental, J. (2008). James Bugental: Live Case Consultation
May, R. (2007). Rollo May on Existential Psychotherapy
Yalom, I. (2002) The Gift of Therapy: A Conversation with Irvin Yalom, M.D.
Yalom, I. (2006). Irvin Yalom: Live Case Consultation
Yalom, I. (2011) Confronting Death and Other Existential Issues in
Psychotherapy
If you are interesting in further information on Irvin Yalom, check out his website
at www.yalom.com.
The Existential-Humanistic Institute, Dr. Kirk Schneider, Orah Krug, and Nader
Shabahangi
Website:www.ehinstitute.org
The Existential-Humanistic Institute’s (EHI) primary focus is training; offering
courses, and in conjunction with Saybrook University, a new certifi cate program
in existential-humanistic therapy and theory. A secondary focus is community
building. EHI was formed as a nonprofi t organization under the auspices of the
Pacifi c Institute in 1997 and provides a home for those mental health profession-
als, scholars, and students who seek in-depth training in existential-humanistic
theory and practice. EHI’s year-long certifi cate program offers graduate and post-
graduate students an opportunity to gain a basic foundation in the theory and
practice of existential-humanistic therapy. EHI offers courses on the principles of
existential-humanistic practice and case seminars in existential-humanistic theory
and practice. Most of EHI’s instructors have studied extensively with such masters
as James Bugental, Irvin Yalom, and Rollo May, and are, like Kirk Schneider and
Orah Krug, acknowledged leaders of the existential-humanistic movement today.
Society for Existential Analysis
Website: www.existentialanalysis.co.uk/
Additional Information: www.dilemmas.org
The Society for Existential Analysis is a professional organization devoted to
exploring issues pertaining to an existential/phenomenological approach to coun-
seling and therapy. Membership is open to anyone interested in this approach
and includes students, trainees, psychotherapists, philosophers, psychiatrists,
counselors, and psychologists. Members receive a regular newsletter and an
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annual copy of the Journal of the Society for Existential Analysis. The society provides
a list of existentially oriented psychotherapists for referral purposes. The School of
Psychotherapy and Counselling at Regent’s College in London offers an advanced
diploma in existential psychotherapy as well as short courses in the fi eld.
International Society for Existential Psychotherapy and Counselling
Website: www.existentialpsychotherapy.net
The International Society for Existential Psychotherapy and Counselling was cre-
ated in London in July 2006 and was renamed International Collaborative of Exis-
tential Counselors and Psychotherapists soon after (www.icecap.org.uk). It brings
together the existing national societies as well as providing a forum for the devel-
opment and accreditation of the approach.
Psychotherapy Training on the Net: SEPTIMUS
Website: www.septimus.info
Additional Information: www.psychotherapytraining.net
SEPTIMUS is an Internet-based course taught in Ireland, Iceland, Sweden, Po-
land, Czech Republic, Romania, Italy, Portugal, Austria, Belgium, France, Israel,
Australia, and the United Kingdom.
New School of Psychotherapy and Counselling
Royal Waterloo House
51-55 Waterloo Road
London, England SE1 8TX
Telephone: +44 (0) 20 7928 43 44
E-mail: Admin@nspc.org.uk
Website: www.nspc.org.uk
The New School of Psychotherapy and Counselling (NSPC) is set up especially for
training existential therapists. It offers an MA and doctoral program in Existen-
tial Psychotherapy and Counseling together with Middlesex University, as well as
an MSC and professional doctorate in Existential Counseling Psychology and Psy-
chotherapy also jointly with Middlesex University. NSPC offers intensive courses
for distance learners (worldwide student body), including e-learning.
Recommended Supplementary Readings
Everyday Mysteries: A Handbook of Existential Psychotherapy (van Deurzen, 2010) pro-
vides a framework for practicing counseling from an existential perspective. The au-
thor puts into clear perspective topics such as anxiety, authentic living, clarifying one’s
worldview, determining values, discovering meaning, and coming to terms with life.
Existential Therapies (Cooper, 2003) provides a useful and clear introduction to
the existential therapies. There are separate chapters on logotherapy, the British
school of existential analysis, the U.S. existential-humanistic approach, dimen-
sions of existential therapeutic practice, and brief existential therapies.
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Existential Psychotherapy (Yalom, 1980) is a superb treatment of the ultimate
human concerns of death, freedom, isolation, and meaninglessness as these
issues relate to therapy. This book has depth and clarity, and it is rich with clini-
cal examples that illustrate existential themes.
Existential-Humanistic Therapy (Schneider & Krug, 2010) is a clear presentation
of the theory and practice of existential-humanistic therapy. This approach incor-
porates techniques from other contemporary therapeutic approaches.
Existential-Integrative Psychotherapy: Guideposts to the Core of Practice (Schneider,
2008) is an edited book that offers recent and future trends in existential-
integrative therapy and case illustrations of this model.
I Never Knew I Had a Choice (Corey & Corey, 2010) is a self-help book written
from an existential perspective. Topics include our struggle to achieve autonomy;
the meaning of loneliness, death, and loss; and how we choose our values and
philosophy of life.
References and Suggested Readings
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*Books and articles marked with an asterisk are suggested for further study.
Binswanger, L. (1975). Being-in-the-world:
Selected papers of Ludwig Binswanger. London:
Souvenir Press.
Boss, M. (1963). Daseinanalysis and psychoa-
nalysis. New York: Basic Books.
Buber, M. (1970). I and thou (W. Kaufmann,
Trans.). New York: Scribner’s.
Bugental, J.F.T. (1986). Existential-humanistic
psychotherapy. In I. L. Kutash & A. Wolf (Eds.),
Psychotherapist’s casebook (pp. 222–236). San
Francisco: Jossey-Bass.
*Bugental, J.F.T. (1987). The art of the psycho-
therapist. New York: Norton.
Bugental, J.F.T. (1997). There is a fundamental
division in how psychotherapy is conceived. In
J. K. Zeig (Ed.), The evolution of psychotherapy:
The third conference (pp. 185–196). New York:
Brunner/Mazel.
*Bugental, J.F.T. (1999). Psychotherapy isn’t
what you think: Bringing the psychotherapeutic
engagement into the living moment. Phoenix,
AZ: Zeig, Tucker.
Bugental, J.F.T. (2008). Preliminary sketches
for a short-term existential-humanistic
therapy. In K. J. Schneider (Ed.), Existential-
integrative psychotherapy: Guideposts to the
core of practice (pp. 165–168). New York:
Routledge.
Bugental, J.F.T., & Bracke, P. E. (1992). The fu-
ture of existential-humanistic psychotherapy.
Psychotherapy, 29(l), 28–33.
*Cooper, M. (2003). Existential therapies.
London: Sage.
Corey, G. (2012). Theory and practice of group
counseling (8th ed.). Belmont, CA: Brooks/
Cole, Cengage Learning.
*Corey, G. (2013). Case approach to counseling
and psychotherapy (8th ed.). Belmont, CA:
Brooks/Cole, Cengage Learning.
*Corey, G., & Corey, M. (2010). I never knew I
had a choice (9th ed.). Belmont, CA: Brooks/
Cole, Cengage Learning.
Dattilio, F. M. (2002, January-February).
Cognitive-behaviorism comes of age: Ground-
ing symptomatic treatment in an existential
approach. The Psychotherapy Networker, 26(1),
75–78.
*Deurzen, E., van. (2002a). Existential counsel-
ling and psychotherapy in practice (2nd ed.).
London: Sage.
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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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*Deurzen, E., van. (2002b). Existential therapy.
In W. Dryden (Ed.), Handbook of individual
therapy (4th ed., pp. 179–208). London: Sage.
Deurzen, E., van. (2009). Psychotherapy and
the quest for happiness. London: Sage.
*Deurzen, E., van. (2010). Everyday mysteries: A
handbook of existential psychotherapy (2nd ed).
London: Routledge.
*Elkins, D. N. (2009). Humanistic psychology:
A clinical manifesto. Colorado Springs, CO:
University of the Rockies Press.
Farha, B. (1994). Ontological awareness: An
existential/cosmological epistemology. The
Person-Centered Periodical, 1(1), 15–29.
*Frankl, V. (1963). Man’s search for meaning.
Boston: Beacon.
*Frankl, V. (1965). The doctor and the soul.
New York: Bantam Books.
*Frankl, V. (1978). The unheard cry for
meaning. New York: Simon & Schuster
(Touchstone).
Gould, W. B. (1993). Viktor E. Frankl: Life with
meaning. Pacific Grove, CA: Brooks/Cole.
Heidegger, M. (1962). Being and time.
New York: Harper & Row.
May, R. (1950). The meaning of anxiety.
New York: Ronald Press.
*May, R. (1953). Man’s search for himself.
New York: Dell.
May, R. (1958). The origins and significance
of the existential movement in psychology. In
R. May, E. Angel, & H. R. Ellenberger (Eds.),
Existence: A new dimension in psychiatry and
psychology. New York: Basic Books.
*May, R. (Ed.). (1961). Existential psychology.
New York: Random House.
May, R. (1969). Love and will. New York: Norton.
May, R. (1975). The courage to create.
New York: Norton.
May, R. (1981). Freedom and destiny. New York:
Norton.
*May, R. (1983). The discovery of being:
Writings in existential psychology. New York:
Norton.
May, R., Angel, E., & Ellenberger, H. F. (Eds.).
(1958). Existence: A new dimension in psychiatry
and psychology. New York: Basic Books.
Russell, J. M. (1978). Sartre, therapy, and
expanding the concept of responsibility.
American Journal of Psychoanalysis, 38, 259–269.
*Russell, J. M. (2007). Existential psychother-
apy. In A. B. Rochlen (Ed.), Applying coun-
seling theories: An online case-based approach
(pp. 107–125). Upper Saddle River, NJ: Pear-
son Prentice-Hall.
Sartre, J. P. (1971). Being and nothingness.
New York: Bantam Books.
*Schneider, K. J. (Ed.). (2008). Existential-
integrative psychotherapy: Guideposts to the core
of practice. New York: Routledge.
*Schneider, K. J. (2011). Existential-humanistic
psychotherapies. In S. B. Messer & A. S.
Gurman, (Eds.), Essential psychotherapies:
Theory and practice (3rd ed., pp. 261–294).
New York: Guilford Press.
*Schneider, K. J., & Krug, O. T. (2010). Exis-
tential-humanistic therapy. Washington, DC:
American Psychological Association.
*Schneider, K. J., & May, R. (Eds.). (1995). The
psychology of existence: An integrative, clinical
perspective. New York: McGraw-Hill.
Sharf, R. S. (2012). Theories of psychotherapy
and counseling: Concepts and cases (5th ed.).
Belmont, CA: Brooks/Cole, Cengage
Learning.
*Sharp, J. G., & Bugental, J.F.T. (2001). Existen-
tial-humanistic psychotherapy. In R. J. Corsini
(Ed.), Handbook of innovative therapies (2nd ed.,
pp. 206–217). New York: Wiley.
*Strasser, F., & Strasser, A. (1997). Existential
time-limited therapy: The wheel of existence.
Chichester: Wiley.
Tillich, P. (1952). The courage to be. New
Haven, CT: Yale University Press.
*Vontress, C. E. (1996). A personal retrospec-
tive on cross-cultural counseling. Journal
of Multicultural Counseling and Development,
24(3), 156–166.
*Vontress, C. E. (2008). Existential therapy. In
J. Frew & M. D. Spiegler (Eds.), Contemporary
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psychotherapies for a diverse world
(pp. 141–176). Boston: Lahaska Press.
*Vontress, C. E., Johnson, J. A., & Epp, L. R.
(1999). Cross-cultural counseling: A casebook.
Alexandria, VA: American Counseling
Association.
*Walsh, R. A., & McElwain, B. (2002). Existen-
tial psychotherapies. In D. J. Cain & J. Seeman
(Eds.), Humanistic psychotherapies: Handbook
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Washington, DC: American Psychological
Association.
*Watson, J. C., Goldman, R. N., & Greenberg,
L. S. (2011). Humanistic and experiential
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R. Vandenbos, & D. K. Freedheim (Eds.), History
of psychotherapy (2nd ed., pp. 141–172).
Washington, DC: American Psychological
Association.
Wampold, B. (2008, February 6). Existential-
integrative psychotherapy comes of age
[Review of Existential-integrative psycho-
therapy: Guideposts to the core of
practice]. PsycCritiques, 53, Release 6,
Article 1, p. 6.
*Yalom, I. D. (1980). Existential psychotherapy.
New York: Basic Books.
*Yalom, I. D. (1987). Love’s executioner: And
other tales of psychotherapy. New York: Harper
Perennial.
Yalom, I. D. (1992). When Nietzche wept.
New York: Basic Books.
*Yalom, I. D. (1997). Lying on the couch: A novel.
New York: Harper Perennial.
*Yalom, I. D. (2000). Momma and the meaning
of life: Tales of psychotherapy. New York: Harper
Perennial.
*Yalom, I. D. (2003). The gift of therapy: An open
letter to a new generation of therapists and their
patients. New York: HarperCollins (Perennial).
Yalom, I. D. (2005a). The Schopenhauer cure: A
novel. New York: HarperCollins.
*Yalom, I. D. (with Leszcz, M). (2005b). The
theory and practice of group psychotherapy (5th
ed.). New York: Basic Books. (Original work
published 1970)
*Yalom, I. D. (2008). Staring at the sun: Overcom-
ing the terror of death. San Francisco: Jossey-Bass.
*Yalom, I. D., & Josselson, R. (2011). Existential
psychotherapy. In R. Corsini & D. Wedding (Eds.),
Current psychotherapies (9th ed., pp. 310–341).
Belmont, CA: Brooks/Cole, Cengage Learning.
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i n t r o d u ct i o n
• Four Periods of Development of the Approach
• Existentialism and Humanism
• Abraham Maslow’s Contributions to
Humanistic Psychology
k e y co n c e p t s
• View of Human Nature
t h e t h e r a p e u t i c p r o c es s
• Therapeutic Goals
• Therapist’s Function and Role
• Client’s Experience in Therapy
• Relationship Between Therapist and Client
a p p l i c at i o n : t h e r a p e u t i c
t ec h n i q u es a n d p r o c e d u r es
• Early Emphasis on Refl ection of Feelings
• Evolution of Person-Centered Methods
• The Role of Assessment
• Application of the Philosophy of the
Person-Centered Approach
• Application to Crisis Intervention
• Application to Group Counseling
p e r s o n – c e n t e r e d e x p r es s i v e
a rt s t h e r a p y
• Principles of Expressive Arts Therapy
• Creativity and Offering Stimulating Experiences
• Contributions of Natalie Rogers
m ot i vat i o n a l i n t e rv i e w i n g
• The MI Spirit
• The Basic Principles of Motivational
Interviewing
• The Stages of Change
p e r s o n – c e n t e r e d t h e r a p y f r o m
a m u lt i c u lt u r a l p e r s p ect i v e
• Strengths From a Diversity Perspective
• Shortcomings From a Diversity
Perspective
p e r s o n – c e n t e r e d t h e r a p y a p p l i e d
to t h e c a s e o f sta n
s u m m a ry a n d e va l u at i o n
• Summary
• Contributions of the Person-Centered
Approach
• Limitations and Criticisms of the Person-
Centered Approach
w h e r e to g o f r o m h e r e
• Recommended Supplementary Readings
• References and Suggested Readings
c h a p t e r 7
Person-Centered Therapy
es
• Recom
• Referenc
mentary Read
and Suggested Readings
cation to Gro
n t e r e d e x
y
essive Arts Th
ring Stimulati
atalie Rogers
n – c
e r a p
es of Exp
y and Of
butions of
172
ati
Contr
f Assessment
cation of the Philosophy of th
son-Centered Approach
plication to Crisis Intervention
plication to Group Counseling
es s i v e p e r s o
a r t s t
• Princ
• Cre
• C
i c at i o n : t h e r a p e
t ec h n i q u es a n d p r o c
• Early Emphasis on Refl ecti
• Evolution of Pe
• The Rol
• App
Pe
• A
App
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Carl Rogers
C A R L R O G E R S (1902–1987),
a major spokesperson for
humanistic psychology, led a
life that reflected the ideas he
developed for half a century.
He showed a questioning
stance, a deep openness to
change, and the courage to
forge into unknown territory
both as a person and as a professional. In writ-
ing about his early years, Rogers (1961) recalled
his family atmosphere as characterized by close
and warm relationships but also by strict religious
standards. Play was discouraged, and the virtues
of the Protestant ethic were extolled. His boyhood
was somewhat lonely, and he pursued scholarly
interests instead of social ones. Rogers was an
introverted person, and he spent a lot of time
reading and engaging in imaginative activity and
reflection. During his college years his interests and
academic major changed from agriculture to history,
then to religion, and finally to clinical psychology.
Rogers held academic positions in various
fields, including education, social work, coun-
seling, psychotherapy, group therapy, peace, and
interpersonal relations, and he earned recognition
around the world for originating and developing
the humanistic movement in psychotherapy. His
foundational ideas, especially the central role of the
client–therapist relationship as a means to growth
and change, have been incorporated by many other
theoretical approaches. Rogers was a pioneer
whose groundbreaking discoveries continue to
have far-reaching effects on the field of psycho-
therapy (Cain, 2010).
It is difficult to overestimate the significance
of Rogers’s contributions to clinical and counseling
psychology. He was a courageous pioneer who
“was about 50 years ahead of his time and has
been waiting for us to catch up” (Elkins, 2009,
p. 20). Often called the “father of psychotherapy
research,” Rogers was the first to study the coun-
seling process in depth by analyzing the transcripts
of actual therapy sessions; he was the first clinician
to conduct major studies on psychotherapy using
quantitative methods; he was the first to formulate
a comprehensive theory of personality and psy-
chotherapy grounded in empirical research; and he
contributed to developing a theory of psychother-
apy that de-emphasized pathology and focused on
the strengths and resources of individuals. He was
not afraid to take a strong position and challenged
the status quo throughout his professional career.
During the last 15 years of his life, Rogers ap-
plied the person-centered approach to world peace
by training policymakers, leaders, and groups in
conflict. Perhaps his greatest passion was directed
toward the reduction of interracial tensions and
the effort to achieve world peace, for which he was
nominated for the Nobel Peace Prize.
For a detailed video presentation of the life and
works of Carl Rogers, see Carl Rogers: A Daughter’s
Tribute (CD ROM, 2002), which is described at the
end of this chapter. See also Carl Rogers: The Quiet
Revolutionary (Rogers & Russell, 2002) and The Life
and Work of Carl Rogers (Kirschenbaum, 2009).
©
Ro
ge
rR
es
sm
ey
er
/C
or
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s
i n t r o d u c t i o n
Of all the pioneers who have founded a therapeutic approach, for me Carl Rogers
stands out as one of the most infl uential fi gures in revolutionizing the direction of
counseling theory and practice. Rogers has become known as a “quiet revolution-
ary” who both contributed to theory development and whose infl uence continues to
shape counseling practice today (see Cain, 2010; Kirschenbaum, 2009; Rogers &
Russell, 2002).
The person-centered approach shares many concepts and values with the
existential perspective presented in Chapter 6. Rogers’s basic assumptions are
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that people are essentially trustworthy, that they have a vast potential for under-
standing themselves and resolving their own problems without direct interven-
tion on the therapist’s part, and that they are capable of self-directed growth if
they are involved in a specifi c kind of therapeutic relationship. From the begin-
ning, Rogers emphasized the attitudes and personal characteristics of the thera-
pist and the quality of the client–therapist relationship as the prime determi-
nants of the outcome of the therapeutic process. He consistently relegated to
a secondary position matters such as the therapist’s knowledge of theory and
techniques. This belief in the client’s capacity for self-healing is in contrast with
many theories that view the therapist’s techniques as the most powerful agents
that lead to change (Bohart & Tallman, 2010). Clearly, Rogers revolutionized the
fi eld of psychotherapy by proposing a theory that centered on the client as the
primary agent for constructive self-change (Bohart & Tallman, 2010; Bozarth,
Zimring, & Tausch, 2002).
Contemporary person-centered therapy is the result of an evolutionary process
that continues to remain open to change and refi nement (see Cain, 2010; Cain &
Seeman, 2002). Rogers did not present the person-centered theory as a fi xed and
completed approach to therapy. He hoped that others would view his theory as
a set of tentative principles relating to how the therapy process develops, not as
dogma. Rogers expected his model to evolve and was open and receptive to change.
See the video program for Chapter 7, DVD for Theory and Practice of Counseling
and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you view
the brief lecture for each chapter prior to reading the chapter.
Four Periods of Development of the Approach
In tracing the major turning points in Rogers’s approach, Zimring and Raskin
(1992) and Bozarth, Zimring, and Tausch (2002) have identifi ed four periods of
development. In the fi rst period, during the 1940s, Rogers developed what was
known as nondirective counseling, which provided a powerful and revolutionary
alternative to the directive and interpretive approaches to therapy then being prac-
ticed. While he was a professor at Ohio State University, Rogers (1942) published
Counseling and Psychotherapy: Newer Concepts in Practice, which described the phi-
losophy and practice of nondirective counseling. Rogers’s theory emphasized the
counselor’s creation of a permissive and nondirective climate. His theory took
power away from the therapist and honored the inherent power of the client. When
he challenged the basic assumption that “the counselor knows best,” he realized
this radical idea would affect the power dynamics and politics of the counseling
profession, and indeed it caused a great furor (Elkins, 2009).
Rogers also challenged the validity of commonly accepted therapeutic proce-
dures such as advice, suggestion, direction, persuasion, teaching, diagnosis, and
interpretation. Based on his conviction that diagnostic concepts and procedures
were inadequate, prejudicial, and often misused, Rogers omitted them from his
approach. Nondirective counselors avoided sharing a great deal about themselves
with clients and instead focused mainly on refl ecting and clarifying the clients’
verbal and nonverbal communications.
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In the second period, during the 1950s, Rogers (1951) wrote Client-Centered
Therapy and renamed his approach client-centered therapy, to refl ect its emphasis
on the client rather than on nondirective methods. In addition, he started the Coun-
seling Center at the University of Chicago. This period was characterized by a shift
from clarifi cation of feelings to a focus on the phenomenological world of the client.
Rogers assumed that the best vantage point for understanding how people behave
was from their own internal frame of reference. He focused more explicitly on the
actualizing tendency as the basic motivational force that leads to client change.
The third period, which began in the late 1950s and extended into the 1970s,
addressed the necessary and suffi cient conditions of therapy. Rogers (1957) set
forth a hypothesis that resulted in three decades of research. A signifi cant pub-
lication was On Becoming a Person (Rogers, 1961), which addressed the nature of
“becoming the self that one truly is,” an idea he borrowed from Kierkegaard. Rogers
published this work during the time that he held joint appointments in the depart-
ments of psychology and psychiatry at the University of Wisconsin. In this book he
described the process of “becoming one’s experience,” which is characterized by
an openness to experience, a trust in one’s experience, an internal locus of evalua-
tion, and the willingness to be in process. During the 1950s and 1960s, Rogers and
his associates continued to test the underlying hypotheses of the client-centered
approach by conducting extensive research on both the process and the outcomes
of psychotherapy. He was interested in how people best progress in psychotherapy,
and he studied the qualities of the client–therapist relationship as a catalyst lead-
ing to personality change. On the basis of this research the approach was further
refi ned and expanded (Rogers, 1961). For example, client-centered philosophy was
applied to education and was called student-centered teaching (Rogers & Freiberg,
1994). The approach was also applied to encounter groups (Rogers, 1970).
The fourth phase, during the 1980s and the 1990s, was marked by considerable
expansion to education, couples and families, industry, groups, confl ict resolution,
politics, and the search for world peace. Because of Rogers’s ever-widening scope
of infl uence, including his interest in how people obtain, possess, share, or surren-
der power and control over others and themselves, his theory became known as the
person-centered approach. This shift in terms refl ected the broadening application
of the approach. Although the person-centered approach has been applied mainly
to individual and group counseling, important areas of further application include
education, family life, leadership and administration, organizational development,
health care, cross-cultural and interracial activity, and international relations. It
was during the 1980s that Rogers directed his efforts toward applying the person-
centered approach to politics, especially to efforts related to the achievement of
world peace.
In a comprehensive review of the research on person-centered therapy over a
period of 60 years, Bozarth, Zimring, and Tausch (2002) concluded the following:
• In the earliest years of the approach, the client rather than the therapist deter-
mined the direction and goals of therapy and the therapist’s role was to help
the client clarify feelings. This style of nondirective therapy was associated with
increased understanding, greater self-exploration, and improved self-concepts.
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• Later a shift from clarifi cation of feelings to a focus on the client’s lived experi-
ences took place. Many of Rogers’s hypotheses were confi rmed, and there was
strong evidence for the value of the therapeutic relationship and the client’s
resources as the crux of successful therapy.
• As person-centered therapy developed further, research centered on the core
conditions assumed to be both necessary and suffi cient for successful therapy.
The attitude of the therapist—an empathic understanding of the client’s world
and the ability to communicate a nonjudgmental stance to the client—along
with the therapist’s genuineness were found to be basic to a successful therapy
outcome.
• The main source of successful psychotherapy is the client. The therapist’s atten-
tion to the client’s frame of reference fosters the client’s utilization of inner and
outer resources.
Existentialism and Humanism
In the 1960s and 1970s there was a growing interest among counselors in a “third
force” in therapy as an alternative to the psychoanalytic and behavioral approaches.
Under this heading fall existential therapy (Chapter 6), person-centered therapy
(Chapter 7), Gestalt therapy (Chapter 8), and certain other experiential and rela-
tionship-oriented approaches.
Partly because of this historical connection and partly because representatives
of existentialist thinking and humanistic thinking have not always clearly sorted
out their views, the connections between the terms existentialism and humanism
have tended to be confusing for students and theorists alike. The two viewpoints
have much in common, yet there also are signifi cant philosophical differences
between them. They share a respect for the client’s subjective experience, the
uniqueness and individuality of each client, and a trust in the capacity of the cli-
ent to make positive and constructive conscious choices. They have in common
an emphasis on concepts such as freedom, choice, values, personal responsibility,
autonomy, purpose, and meaning. Both approaches place little value on the role
of techniques in the therapeutic process and emphasize instead the importance of
genuine encounter. They differ in that existentialists take the position that we are
faced with the anxiety of choosing to create an identity in a world that lacks intrinsic
meaning. Existentialists tend to acknowledge the stark realities of human experi-
ence, and their writings often focus on death, anxiety, depression, and isolation.
The humanists, in contrast, take the somewhat less anxiety-evoking position and
more optimistic view that each of us has a natural potential that we can actualize
and through which we can fi nd meaning. Many contemporary existential therapists
refer to themselves as existential-humanistic practitioners, indicating that their roots
are in existential philosophy but that they have incorporated many aspects of North
American humanistic psychotherapies (Cain, 2002a; Schneider & Krug, 2010).
As will become evident in this chapter, the existential and person-centered
approaches have parallel concepts with regard to the client–therapist relationship at
the core of therapy. The phenomenological emphasis that is basic to the existentialist
approach is also fundamental to person-centered theory. Both approaches focus on
the client’s perceptions and call for the therapist to be fully present with the client
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so that it is possible to understand the client’s subjective world, and they both em-
phasize the client’s capacity for self-awareness and self-healing. The therapist aims
to provide the client with a safe, responsive, and caring relationship to facilitate self-
exploration, growth, and healing (Watson, Goldman, & Greenberg, 2011).
Abraham Maslow’s Contributions
to Humanistic Psychology
Abraham Maslow (1970) was a pioneer in the development of humanistic psychol-
ogy and was infl uential in furthering the understanding of self-actualizing indi-
viduals. Many of Carl Rogers’s ideas, especially on the positive aspects of being
human and the fully functioning person, are built on Maslow’s basic philosophy.
Maslow criticized Freudian psychology for what he saw as its preoccupation with
the sick and negative side of human nature. Maslow believed too much research
was being conducted on anxiety, hostility, and neuroses and too little into joy, crea-
tivity, and self-fulfi llment. Self-actualization was the central theme of the work
of Abraham Maslow (1968, 1970, 1971). The positive psychology movement that
recently has come into prominence shares many concepts on the healthy side of
human existence with the humanistic approach.
Maslow studied what he called “self-actualizing people” and found that they
differed in important ways from so-called normal individuals. The core character-
istics of self-actualizing people are self-awareness, freedom, basic honesty and car-
ing, and trust and autonomy. Other characteristics of self-actualizing individuals
include a capacity to welcome uncertainty in their lives, acceptance of themselves
and others, spontaneity and creativity, a need for privacy and solitude, autonomy,
a capacity for deep and intense interpersonal relationships, a genuine caring for
others, an inner-directedness (as opposed to the tendency to live by others’ expec-
tations), the absence of artifi cial dichotomies within themselves (such as work/
play, love/hate, and weak/strong), and a sense of humor (Maslow, 1970). All of
these personal characteristics have been identifi ed by Rogers as being central to
the person-centered philosophy.
Maslow postulated a hierarchy of needs as a source of motivation, with the most
basic needs being physiological needs. If we are hungry and thirsty, our attention
is riveted on meeting these basic needs. Next are the safety needs, which include
a sense of security and stability. Once our physical and safety needs are fulfi lled,
we become concerned with meeting our needs for belonging and love, followed by
working on our need for esteem, both from self and others. We are able to strive
toward self-actualization only after these four basic needs are met. The key factor
determining which need is dominant at a given time is the degree to which those
below it are satisfi ed. We cannot strive toward self-actualization, for example, if our
self-esteem is low.
t h e v i s i o n o f h u m a n i s t i c p h i lo s o p h y The underlying vision of
humanistic philosophy is captured by the metaphor of how an acorn, if provided
with the appropriate conditions, will “automatically” grow in positive ways, pushed
naturally toward its actualization as an oak. In contrast, for many existentialists
there is nothing that we “are,” no internal “nature” we can count on. We are faced
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at every moment with a choice about what to make of this condition. Maslow’s em-
phasis on the healthy side of being human and the emphasis on joy, creativity, and
self-fulfi llment are part of the person-centered philosophy. The humanistic phi-
losophy on which the person-centered approach rests is expressed in attitudes and
behaviors that create a growth-producing climate. According to Rogers (1986b),
when this philosophy is lived, it helps people develop their capacities and stimu-
lates constructive change in others. Individuals are empowered, and they are able
to use this power for personal and social transformation.
k e y c o n c e p t s
View of Human Nature
A common theme originating in Rogers’s early writing and continuing to permeate
all of his works is a basic sense of trust in the client’s ability to move forward in a
constructive manner if conditions fostering growth are present. His professional
experience taught him that if one is able to get to the core of an individual, one fi nds
a trustworthy, positive center (Rogers, 1987a). In keeping with the philosophy of
humanistic psychology, Rogers fi rmly maintained that people are trustworthy, re-
sourceful, capable of self-understanding and self-direction, able to make construc-
tive changes, and able to live effective and productive lives. When therapists are able
to experience and communicate their realness, support, caring, and nonjudgmental
understanding, signifi cant changes in the client are most likely to occur.
Rogers maintained that three therapist attributes create a growth-promoting
climate in which individuals can move forward and become what they are capable
of becoming: (1) congruence (genuineness, or realness), (2) unconditional positive
regard (acceptance and caring), and (3) accurate empathic understanding (an ability to
deeply grasp the subjective world of another person). According to Rogers, if thera-
pists communicate these attitudes, those being helped will become less defensive
and more open to themselves and their world, and they will behave in prosocial
and constructive ways.
Brodley (1999) writes about the actualizing tendency, a directional process of
striving toward realization, fulfi llment, autonomy, and self-determination. This nat-
ural inclination of humans is based on Maslow’s (1970) studies of self-actualizing
people. This growth force within us provides an internal source of healing, but it
does not imply a movement away from relationships, interdependence, connec-
tion, or socialization. This humanistic view of human nature has signifi cant im-
plications for the practice of therapy. Because of the belief that the individual has
an inherent capacity to move away from maladjustment and toward psychological
health and growth, the therapist places the primary responsibility on the client.
The person-centered approach rejects the role of the therapist as the authority who
knows best and of the passive client who merely follows the beliefs of the therapist.
Therapy is rooted in the client’s capacity for awareness and self-directed change in
attitudes and behavior.
In the person-centered approach the emphasis is on how clients act in their
world with others, how they can move forward in constructive directions, and how
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they can successfully deal with obstacles (both from within themselves and outside
of themselves) that are blocking their growth. By promoting self-awareness and
self-refl ection, clients learn to exercise choice. Humanistic therapists emphasize
a discovery-oriented approach in which clients are the experts on their own inner
experience (Watson, Goldman, & Greenberg, 2011), and they encourage clients to
make changes that will lead to living fully and authentically, with the realization
that this kind of existence demands a continuing struggle. Maslow taught us that
becoming self-actualizing individuals is an ongoing process rather than a fi nal
destination.
t h e t h e r a p e u t i c p r o c e s s
Therapeutic Goals
The person-centered approach aims toward the client achieving a greater degree
of independence and integration. Its focus is on the person, not on the person’s
presenting problem. Rogers did not believe the goal of therapy was merely to solve
problems. Rather, the goal is to assist clients in their growth process so clients can
better cope with problems as they identify them.
Rogers (1961) wrote that people who enter psychotherapy often ask: “How can
I discover my real self? How can I become what I deeply wish to become? How can
I get behind my facades and become myself?” The underlying aim of therapy is to
provide a climate conducive to helping the individual strive toward self-actualiza-
tion. Before clients are able to work toward that goal, they must fi rst get behind the
masks they wear, which they develop through the process of socialization. Clients
come to recognize that they have lost contact with themselves by using facades. In
a climate of safety in the therapeutic session, they also come to realize that there
are more authentic ways of being.
When the facades are put aside during the therapeutic process, what kind of
person emerges from behind the pretenses? Rogers (1961) described people who
are becoming increasingly actualized as having (1) an openness to experience,
(2) a trust in themselves, (3) an internal source of evaluation, and (4) a willingness
to continue growing. Encouraging these characteristics is the basic goal of person-
centered therapy.
These four characteristics provide a general framework for understanding the
direction of therapeutic movement. The therapist does not choose specifi c goals
for the client. The cornerstone of person-centered theory is the view that clients
in a relationship with a facilitating therapist have the capacity to defi ne and clarify
their own goals. Person-centered therapists are in agreement on the matter of not
setting goals for what clients need to change, yet they differ on the matter of how to
best help clients achieve their own goals and to fi nd their own answers (Bohart &
Watson, 2011).
Therapist’s Function and Role
The role of person-centered therapists is rooted in their ways of being and atti-
tudes, not in techniques designed to get the client to “do something.” Research on
person-centered therapy seems to indicate that the attitude of therapists, rather than
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their knowledge, theories, or techniques, facilitate personality change in the client
(Rogers, 1961). Basically, therapists use themselves as an instrument of change.
When they encounter the client on a person-to-person level, their “role” is to be
without roles. They do not get lost in a professional role. It is the therapist’s attitude
and belief in the inner resources of the client that creates the therapeutic climate for
growth (Bozarth et al., 2002).
Thorne (2002a) reinforces the importance of therapists encountering clients
in a person-to-person way, as opposed to being overly reliant on a professional con-
tract. He cautions about retreating into a stance of pseudo-professionalism charac-
terized by presenting a detailed contract to clients, rigid observation of boundaries,
and the commitment to empirically validated methods. He suggests that this over-
emphasis on professionalism is aimed at protecting therapists from overinvolve-
ment with clients, which often results in underinvolvement with them.
Person-centered theory holds that the therapist’s function is to be present and
accessible to clients and to focus on their immediate experience. First and fore-
most, the therapist must be willing to be real in the relationship with clients. By
being congruent, accepting, and empathic, the therapist is a catalyst for change. In-
stead of viewing clients in preconceived diagnostic categories, the therapist meets
them on a moment-to-moment experiential basis and enters their world. Through
the therapist’s attitude of genuine caring, respect, acceptance, support, and un-
derstanding, clients are able to loosen their defenses and rigid perceptions and
move to a higher level of personal functioning. When these therapist attitudes are
present, clients then have the necessary freedom to explore areas of their life that
were either denied to awareness or distorted.
Client’s Experience in Therapy
Therapeutic change depends on clients’ perceptions both of their own experience
in therapy and of the counselor’s basic attitudes. If the counselor creates a cli-
mate conducive to self-exploration, clients have the opportunity to explore the full
range of their experience, which includes their feelings, beliefs, behavior, and
worldview. What follows is a general sketch of clients’ experiences in therapy.
Clients come to the counselor in a state of incongruence; that is, a discrepancy
exists between their self-perception and their experience in reality. For example,
Leon, a college student, may see himself as a future physician, yet his below-aver-
age grades could exclude him from medical school. The discrepancy between how
Leon sees himself (self-concept) or how he would like to view himself (ideal self-
concept) and the reality of his poor academic performance may result in anxiety
and personal vulnerability, which can provide the necessary motivation to enter
therapy. Leon must perceive that a problem exists or, at least, that he is uncomfort-
able enough with his present psychological adjustment to want to explore possibili-
ties for change.
One reason clients seek therapy is a feeling of basic helplessness, powerless-
ness, and an inability to make decisions or effectively direct their own lives. They
may hope to fi nd “the way” through the guidance of the therapist. Within the per-
son-centered framework, however, clients soon learn that they can be responsible
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for themselves in the relationship and that they can learn to be more free by using
the relationship to gain greater self-understanding.
As counseling progresses, clients are able to explore a wider range of beliefs and
feelings. They can express their fears, anxiety, guilt, shame, hatred, anger, and other
emotions that they had deemed too negative to accept and incorporate into their
self-structure. With therapy, people distort less and move to a greater acceptance and
integration of confl icting and confusing feelings. They increasingly discover aspects
within themselves that had been kept hidden. As clients feel understood and accepted,
they become less defensive and become more open to their experience. Because they
feel safer and are less vulnerable, they become more realistic, perceive others with
greater accuracy, and become better able to understand and accept others. Individuals
in therapy come to appreciate themselves more as they are, and their behavior shows
more fl exibility and creativity. They become less concerned about meeting others’
expectations, and thus begin to behave in ways that are truer to themselves. These
individuals direct their own lives instead of looking outside of themselves for
answers. They move in the direction of being more in contact with what they are
experiencing at the present moment, less bound by the past, less determined, freer to
make decisions, and increasingly trusting in themselves to manage their own lives.
In short, their experience in therapy is like throwing off the self-imposed shackles
that had kept them in a psychological prison. With increased freedom they tend to
become more mature psychologically and move toward increased self-actualization.
Person-centered therapy is grounded on the assumption that it is clients who
heal themselves, who create their own self-growth, and who are active self-healers
(Bohart & Tallman, 1999, 2010; Bohart & Watson, 2011). The therapy relationship
provides a supportive structure within which clients’ self-healing capacities are
activated. What clients value most is being understood and accepted, which results
in creating a safe place to explore feelings, thoughts, behaviors, and experiences;
clients also value support for trying out new behaviors (Bohart & Tallman, 2010).
Relationship Between Therapist and Client
Rogers (1957) based his hypothesis of the “necessary and suffi cient conditions for
therapeutic personality change” on the quality of the relationship: “If I can provide
a certain type of relationship, the other person will discover within himself or her-
self the capacity to use that relationship for growth and change, and personal devel-
opment will occur” (Rogers, 1961, p. 33). Rogers (1967) hypothesized further that
“signifi cant positive personality change does not occur except in a relationship”
(p. 73). Rogers’s hypothesis was formulated on the basis of many years of his pro-
fessional experience, and it remains basically unchanged to this day. This hypoth-
esis (cited in Cain 2002a, p. 20) is stated thusly:
1. Two persons are in psychological contact.
2. The fi rst, whom we shall term the client, is in a state of incongruence, being
vulnerable or anxious.
3. The second person, whom we term the therapist, is congruent (real or genuine)
in the relationship.
4. The therapist experiences unconditional positive regard for the client.
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5. The therapist experiences an empathic understanding of the client’s internal
frame of reference and endeavors to communicate this experience to the client.
6. The communication to the client of the therapist’s empathic understanding and
unconditional positive regard is to a minimal degree achieved.
Rogers hypothesized that no other conditions were necessary. If the therapeutic
core conditions exist over some period of time, constructive personality change
will occur. The core conditions do not vary according to client type. Further, they
are both necessary and suffi cient for therapeutic change to occur.
From Rogers’s perspective the client–therapist relationship is characterized by
equality. Therapists do not keep their knowledge a secret or attempt to mystify the
therapeutic process. The process of change in the client depends to a large degree
on the quality of this equal relationship. As clients experience the therapist listen-
ing in an accepting way to them, they gradually learn how to listen acceptingly to
themselves. As they fi nd the therapist caring for and valuing them (even the as-
pects that have been hidden and regarded as negative), clients begin to see worth
and value in themselves. As they experience the realness of the therapist, clients
drop many of their pretenses and are real with both themselves and the therapist.
This humanistic approach is perhaps best characterized as a way of being and as
a shared journey in which therapist and client reveal their humanness and partici-
pate in a growth experience. The therapist can be a relational guide on this journey
because he or she is usually more experienced and more psychologically experienced
in this role than the client. Thorne (2002b) delivered this message: “Therapists can-
not confi dently invite their clients to travel further than they have journeyed them-
selves, but for person-centred therapists the quality, depth and continuity of their
own experiencing becomes the very cornerstone of the competence they bring to
their professional activity” (p. 144). Therapists are invested in broadening their own
life experiences and are willing to do what it takes to deepen their self-knowledge.
Rogers admitted that his theory was striking provocative and radical. His for-
mulation has generated considerable controversy, for he maintained that many
conditions other therapists commonly regard as necessary for effective psychother-
apy were nonessential. The core therapist conditions of congruence, unconditional
positive regard, and accurate empathic understanding subsequently have been em-
braced by many therapeutic schools as essential in facilitating therapeutic change.
These core qualities of therapists, along with the therapist’s presence, work holis-
tically to create a safe environment for learning (Cain, 2010). Regardless of theo-
retical orientation, most therapists strive to listen fully and empathically to clients,
especially during the initial stages of therapy. We now turn to a detailed discussion
of how these core conditions are an integral part of the therapeutic relationship.
c o n g r u e n c e , o r g e n u i n e n e s s implies that therapists are real; that is,
they are genuine, integrated, and authentic during the therapy hour. They are with-
out a false front, their inner experience and outer expression of that experience
match, and they can openly express feelings, thoughts, reactions, and attitudes that
are present in the relationship with the client. This communication is done with
careful refl ection and considered judgment on the therapist’s part (Kolden, Klein,
Wang, & Austin, 2011).
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Through authenticity the therapist serves as a model of a human being strug-
gling toward greater realness. Being congruent might necessitate expressing a
range of feelings including anger, frustration, liking, concern, and annoyance.
This does not mean that therapists should impulsively share all their reactions, for
self-disclosure must be appropriate, well timed, and have a constructive therapeu-
tic intent. Counselors can try too hard to be genuine; sharing because one thinks
it will be good for the client, without being genuinely moved to express something
regarded as personal, can be incongruent. Person-centered therapy stresses that
counseling will be inhibited if the counselor feels one way about the client but acts
in a different way. For example, if the practitioner dislikes or disapproves of the
client but feigns acceptance, therapy will be impaired. Cain (2010) stresses that
therapists need to be attuned to the emerging needs of the client and to respond in
ways that are in the best interests of the individual. If therapists keep this in mind,
they are likely to make sound clinical decisions most of the time.
Rogers’s concept of congruence does not imply that only a fully self-actualized
therapist can be effective in counseling. Because therapists are human, they can-
not be expected to be fully authentic. Congruence exists on a continuum from
highly congruent to very incongruent. This is true of all three characteristics.
u n c o n d i t i o n a l p o s i t i v e r e g a r d a n d a c c e p ta n c e The second
attitude therapists need to communicate is deep and genuine caring for the client
as a person, or a condition of unconditional positive regard, which can best be
achieved through empathic identifi cation with the client (Farber & Doolin, 2011).
The caring is nonpossessive and is not contaminated by evaluation or judgment of
the client’s feelings, thoughts, and behavior as good or bad. Therapists value and
warmly accept clients without placing stipulations on their acceptance. It is not
an attitude of “I’ll accept you when . . .”; rather, it is one of “I’ll accept you as you
are.” Therapists communicate through their behavior that they value their clients
as they are and that clients are free to have feelings and experiences. Acceptance
is the recognition of clients’ rights to have their own beliefs and feelings; it is not
the approval of all behavior. All overt behavior need not be approved of or accepted.
According to Rogers’s (1977) research, the greater the degree of caring, priz-
ing, accepting, and valuing of the client in a nonpossessive way, the greater the
chance that therapy will be successful. He also makes it clear that it is not possible
for therapists to genuinely feel acceptance and unconditional caring at all times.
However, if therapists have little respect for their clients, or an active dislike or
disgust, it is not likely that the therapeutic work will be fruitful. If therapists’ caring
stems from their own need to be liked and appreciated, constructive change in the
client is inhibited. This notion of positive regard has implications for all therapists,
regardless of their theoretical orientation (Farber & Doolin, 2011).
accurate empathic understanding One of the main tasks of the ther-
apist is to understand clients’ experience and feelings sensitively and accurately as they
are revealed in the moment-to-moment interaction during the therapy session. The
therapist strives to sense clients’ subjective experience, particularly in the here and
now. The aim is to encourage clients to get closer to themselves, to feel more deeply
and intensely, and to recognize and resolve the incongruity that exists within them.
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Empathy is a deep and subjective understanding of the client with the client.
Empathy is not sympathy, or feeling sorry for a client. Therapists are able to share the
client’s subjective world by drawing from their own experiences that may be similar
to the client’s feelings. Yet therapists must not lose their own separateness. Rogers
asserts that when therapists can grasp the client’s private world as the client sees
and feels it—without losing the separateness of their own identity—constructive
change is likely to occur. Empathy, particularly emotionally focused empathy,
helps clients (1) pay attention to and value their experiencing, (2) process their
experience both cognitively and bodily, (3) view prior experiences in new ways, and
(4) increase their confi dence in making choices and in pursuing a course of action
(Cain, 2010).
Clark (2010) describes an integral model of empathy in the counseling process
that is based on three ways of knowing: (1) subjective empathy enables practition-
ers to experience what it is like to be the client; (2) interpersonal empathy pertains
to understanding a client’s internal frame of reference and conveying a sense of
the private meanings to the person; and (3) objective empathy relies on knowledge
sources outside of a client’s frame of reference. By using a multiple-perspective
model of empathy, counselors have a broader way to understand clients.
Accurate empathy is the cornerstone of the person-centered approach, and it
is a necessary ingredient of any effective therapy (Cain, 2010). Accurate empathic
understanding implies that the therapist will sense clients’ feelings as if they were
his or her own without becoming lost in those feelings. It is a way for therapists
to hear the meanings expressed by their clients that often lie at the edge of their
awareness. A primary means of determining whether an individual experienc-
es a therapist’s empathy is to secure feedback from the client (Norcross, 2010).
According to Watson (2002), full empathy entails understanding the meaning and
feeling of a client’s experiencing. Therapists need to understand clients on both
emotional and cognitive levels. Empathy is an active ingredient of change that fa-
cilitates clients’ cognitive processes and emotional self-regulation. Watson (2002)
states that 60 years of research has consistently demonstrated that empathy is the
most powerful determinant of client progress in therapy.
Clients’ perceptions of feeling understood by their therapists relate favorably to
outcome. Empathic therapists strive to discover the meaning of the client’s experi-
ence, understand the overall goals of the client, and tailor their responses to the
particular client. Effective empathy is grounded in authentic caring for the client
(Elliott, Bohart, Watson, & Greenberg, 2011).
a p p l i c at i o n : t h e r a p e u t i c
t e c h n i q u e s a n d p r o c e d u r e s
Early Emphasis on Reflection of Feelings
Rogers’s original emphasis was on grasping the world of the client and refl ecting
this understanding. As his view of psychotherapy developed, however, his focus
shifted away from a nondirective stance and emphasized the therapist’s relation-
ship with the client. Many followers of Rogers simply imitated his refl ective style,
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and client-centered therapy has often been identifi ed primarily with the technique
of refl ection despite Rogers’s contention that the therapist’s relational attitudes
and fundamental ways of being with the client constitute the heart of the change
process. Rogers and other contributors to the development of the person-centered
approach have been critical of the stereotypic view that this approach is basically a
simple restatement of what the client just said.
Evolution of Person-Centered Methods
Contemporary person-centered therapy is the result of an evolutionary process of
more than 70 years, and it continues to remain open to change and refi nement.
One of Rogers’s main contributions to the counseling fi eld is the notion that the
quality of the therapeutic relationship, as opposed to administering techniques,
is the primary agent of growth in the client. The therapist’s ability to establish a
strong connection with clients is the critical factor determining successful coun-
seling outcomes.
No techniques are basic to the practice of person-centered therapy; “being with”
clients and entering imaginatively into their world of perceptions and feelings is
suffi cient for facilitating a process of change. Person-centered therapists are not
prohibited from suggesting techniques, but how these suggestions are presented is
crucial. Techniques may be suggested when doing so fosters the process of client
and therapist being together in an empathic way. Techniques are not attempts at
“doing anything” to a client (Bohart & Watson, 2011).
The person-centered philosophy is based on the assumption that clients have
the resourcefulness for positive movement without the counselor assuming an
active, directive, or problem-solving role. Traditional person-centered therapists
would not tend to suggest a technique (Bohart & Watson, 2011). What is essential
for clients’ progress is the therapist’s presence, being completely attentive to and
immersed in the client as well as in the client’s expressed concerns (Cain, 2010).
This way of being is far more powerful than any technique a therapist might use
to bring about change. Qualities and skills such as listening, accepting, respect-
ing, understanding, and responding must be honest expressions by the therapist.
As discussed in Chapter 2, counselors need to evolve as persons, not just acquire
a repertoire of therapeutic strategies. Therapists mainly stay within the client’s
frame of reference and strive to understand and refl ect the client’s communication
and experience.
Rogers expected person-centered therapy to continue to evolve and supported
others in breaking new ground. One of the main ways in which person-centered
therapy has evolved is the diversity, innovation, and individualization in practice.
There is no longer one way of practicing person-centered therapy (Cain, 2010), and
there has been increased latitude for therapists to share their reactions, to confront
clients in a caring way, and to participate more actively and fully in the therapeutic
process (Bozarth et al., 2002). Immediacy, or addressing what is going on between
the client and therapist, is highly valued in this approach. This development en-
courages the use of a wider variety of methods and allows for considerable diversity
in personal style among person-centered therapists. The shift toward genuineness
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enables person-centered therapists both to practice in more fl exible and integra-
tive ways that suit their personalities and to have greater fl exibility in tailoring the
counseling relationship to suit different clients (Bohart & Watson, 2011).
Cain (2008, 2010) believes it is essential for therapists to adapt their therapeu-
tic style to accommodate the unique needs of each client. Person-centered thera-
pists have the freedom to use a variety of responses and methods to assist their
clients; a guiding question therapists need to ask is, “Does it fi t?” Cain contends
that, ideally, therapists will continually monitor whether what they are doing fi ts,
especially whether their therapeutic style is compatible with their clients’ way of
viewing and understanding their problems. For an illustration of how Dr. David
Cain works with the case of Ruth in a person-centered style, see Case Approach to
Counseling and Psychotherapy (Corey, 2013, chap. 5).
Today, those who practice a person-centered approach work in diverse ways
that refl ect both advances in theory and practice and a plethora of personal styles.
This is appropriate and fortunate, for none of us can emulate the style of Carl
Rogers and still be true to ourselves. If we strive to model our style after Rogers,
and if that style does not fi t for us, we are not being ourselves and we are not being
fully congruent.
The Role of Assessment
Assessment is frequently viewed as a prerequisite to the treatment process. Many
mental health agencies use a variety of assessment procedures, including diagnos-
tic screening, identifi cation of clients’ strengths and liabilities, and various tests.
Person-centered therapists generally do not fi nd traditional assessment and diag-
nosis to be useful because these procedures encourage an external and expert per-
spective on the client (Bohart & Watson, 2011). What matters is not how the coun-
selor assesses the client but the client’s self-assessment. From a person-centered
perspective, the best source of knowledge about the client is the individual client.
In the early development of nondirective therapy, Rogers (1942) recommend-
ed caution in using psychometric measures or in taking a complete case history
at the outset of counseling. If a counseling relationship began with a battery of
psychological tests and a detailed case history, he believed clients could get the
impression that the counselor would be providing the solutions to their problems.
Assessment seems to be gaining in importance in short-term treatments in most
counseling agencies, and it is imperative that clients be involved in a collaborative
process in making decisions that are central to their therapy. Today it may not be a
question of whether to incorporate assessment into therapeutic practice but of how
to involve clients as fully as possible in their assessment and treatment process.
Application of the Philosophy of the
Person-Centered Approach
The person-centered approach has been applied to working with individuals, groups,
and families. Bozrath, Zimring, and Tausch (2002) cite studies done through the
1990s that revealed the effectiveness of person-centered therapy with a wide range
of client problems including anxiety disorders, alcoholism, psychosomatic problems,
agoraphobia, interpersonal diffi culties, depression, cancer, and personality disorders.
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Person-centered therapy has been shown to be as viable as the more goal-oriented
therapies. Furthermore, outcome research conducted in the 1990s revealed that
effective therapy is based on the client–therapist relationship in combination
with the inner and external resources of the client (Duncan, Miller, Wampold, &
Hubble, 2010).
The person-centered approach has been applied extensively in training both
professionals and paraprofessionals who work with people in a variety of settings.
This approach emphasizes staying with clients as opposed to getting ahead of
them with interpretations. People without advanced psychological education are
able to benefi t by translating the therapeutic conditions of genuineness, empathic
understanding, and unconditional positive regard into both their personal and pro-
fessional lives. Learning to listen with acceptance to oneself is a valuable life skill
that enables individuals to be their own therapists. The basic concepts are straight-
forward and easy to comprehend, and they encourage locating power in the person
rather than fostering an authoritarian structure in which control and power are
denied to the person. These core skills also provide an essential foundation for
virtually all of the other therapy systems covered in this book. If counselors are
lacking in these relationship and communication skills, they will not be effective
in carrying out a treatment program for their clients.
The person-centered approach demands a great deal of the therapist. An ef-
fective person-centered therapist must be grounded, centered, genuine, respect-
ful, caring, present, a focused and astute listener, patient, and accepting in a way
that involves maturity. Without a person-centered way of being, mere application
of skills is likely to be hollow. Natalie Rogers (2011) points out that the person-
centered approach is a way of being that is easy to understand intellectually but
is very diffi cult to put into practice. She continues to fi nd the core conditions of
genuineness, positive regard, and empathy most important in developing trust,
safety, and growth in a group.
Application to Crisis Intervention
The person-centered approach is especially applicable in crisis intervention such as
an unwanted pregnancy, an illness, a disastrous event, or the loss of a loved one. Peo-
ple in the helping professions (nursing, medicine, education, the ministry) are often
fi rst on the scene in a variety of crises, and they can do much if the basic attitudes
described in this chapter are present. When people are in crisis, one of the fi rst steps
is to give them an opportunity to fully express themselves. Sensitive listening, hear-
ing, and understanding are essential at this point. Being heard and understood helps
ground people in crises, helps to calm them in the midst of turmoil, and enables
them to think more clearly and make better decisions. Although a person’s crisis is
not likely to be resolved by one or two contacts with a helper, such contacts can pave
the way for being open to receiving help later. If the person in crisis does not feel
understood and accepted, he or she may lose hope of “returning to normal” and may
not seek help in the future. Genuine support, caring, and nonpossessive warmth can
go a long way in building bridges that can motivate people to do something to work
through and resolve a crisis. Communicating a deep sense of understanding should
always precede other more problem-solving interventions.
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In crisis situations person-centered therapists may need to provide more struc-
ture and direction than would be the case for clients who are not experiencing a
crisis. Suggestions, guidance, and even direction may be called for if clients are
not able to function effectively. For example, in certain cases it may be necessary
to take action to hospitalize a suicidal client to protect this person from self-harm.
Application to Group Counseling
The person-centered approach emphasizes the unique role of the group counselor
as a facilitator rather than a leader. The primary function of the facilitator is to cre-
ate a safe and healing climate—a place where the group members can interact in
honest and meaningful ways. In this climate members become more appreciative
and trusting of themselves as they are and are able to move toward self-direction
and empowerment. Ultimately, group members make their own choices and bring
about change for themselves. Yet with the presence of the facilitator and the sup-
port of other members, participants realize that they do not have to experience
the struggles of change alone and that groups as collective entities have their own
source of transformation. The facilitator’s way of being can create a productive
climate within a group:
Facilitators cannot make participants trust the group process. Facilitators earn trust by
being respectful, caring, and even loving. Being an effective group facilitator has much to
do with one’s “way of being.” No method or technique can evoke trust unless the facilitator
herself has a capacity to be fully present, considerate, caring, authentic, and responsive.
This includes the ability to challenge people constructively (N. Rogers, 2011, p. 57)
Rogers (1970) clearly believed that groups tend to move forward if the facilitator
exhibits a deep sense of trust in the members and refrains from using techniques
or exercises to get a group moving. The core conditions of person-centered therapy
apply to the process of a group. The role of the facilitator is to empathically under-
stand what an individual is communicating within the group. Instead of leading
the members toward specifi c goals, the group facilitator assists members in de-
veloping attitudes and behaviors of genuineness, acceptance, and empathy, which
enables the members to interact with each other in therapeutic ways to fi nd their
own sense of direction as a group.
From Rogers’s perspective, facilitators should avoid making interpretive com-
ments or group process observations because such comments are apt to make
the group self-conscious and slow the process down. Group process observations
should come from members, a view that is consistent with Rogers’s philosophy of
placing the responsibility for the direction of the group on the members. Accord-
ing to Raskin, Rogers, and Witty (2008), groups are fully capable of articulating
and pursuing their own goals. They assert, “when the therapeutic conditions are
present in a group and when the group is trusted to fi nd its own way of being,
group members tend to develop processes that are right for them and to resolve
confl icts within time constraints in the situation” (p. 143).
Regardless of a group leader’s theoretical orientation, the core conditions that
have been described here are highly applicable to any leader’s style of group facili-
tation. Only when the leader is able to create a person-centered climate will move-
ment take place within a group. All of the theories discussed in this book depend
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on the quality of the therapeutic relationship as a foundation. As you will see, the
cognitive behavioral approaches to group work place emphasis on creating a work-
ing alliance and collaborative relationships. In this way, most effective approaches
to group work share key elements of a person-centered philosophy. For a more
detailed treatment of person-centered group counseling, see Corey (2012, chap.
10). Also see Natalie Rogers’s (2011), The Creative Connection for Groups: Person-
Centered Expressive Arts for Healing and Social Change.
p e r s o n – c e n t e r e d e x p r e s s i v e
a r t s t h e r a p y *
Natalie Rogers (1993, 2011) expanded on her father, Carl Rogers’s (1961), theory
of creativity using the expressive arts to enhance personal growth for individuals
and groups. Rogers’s approach, known as expressive arts therapy, extends the per-
son-centered approach to spontaneous creative expression, which symbolizes deep
and sometimes inaccessible feelings and emotional states. Counselors trained in
person-centered expressive arts offer their clients the opportunity to create move-
ment, visual art, journal writing, sound, and music to express their feelings and
gain insight from these activities.
Principles of Expressive Arts Therapy
Expressive arts therapy uses various artistic forms—movement, drawing, painting,
sculpting, music, writing, and improvisation—toward the end of growth, healing,
and self-discovery. This is a multimodal approach integrating mind, body, emo-
tions, and inner spiritual resources. Methods of expressive arts therapy are based on
humanistic principles but giving fuller form to Carl Rogers’s notions of creativity.
These principles include the following (N. Rogers, 1993):
• All people have an innate ability to be creative.
• The creative process is transformative and healing. The healing aspects involve
activities such as meditation, movement, art, music, and journal writing.
• Personal growth and higher states of consciousness are achieved through self-
awareness, self-understanding, and insight.
• Self-awareness, understanding, and insight are achieved by delving into our
feelings of grief, anger, pain, fear, joy, and ecstasy.
• Our feelings and emotions are an energy source that can be channeled into the
expressive arts to be released and transformed.
• The expressive arts lead us into the unconscious, thereby enabling us to express
previously unknown facets of ourselves and bring to light new information and
awareness.
• One art form stimulates and nurtures the other, bringing us to an inner core or
essence that is our life energy.
*Much of the material in this section is based on key ideas that are more fully developed in two of Natalie
Rogers’s books, The Creative Connection: Expressive Arts as Healing (Rogers, 1993) and The Creative Connec-
tion for Groups: Person-Centered Expressive Arts for Healing and Social Change (Rogers, 2011). This section was
written in close collaboration with Natalie Rogers.
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• A connection exists between our life force—our inner core, or soul—and the
essence of all beings.
• As we journey inward to discover our essence or wholeness, we discover our
relatedness to the outer world, and the inner and outer become one.
The various art modes interrelate in what Natalie Rogers calls the “creative connec-
tion.” When we move, it affects how we write or paint. When we write or paint, it
affects how we feel and think.
Natalie Rogers’s approach is based on a person-centered theory of individual
and group process. The same conditions that Carl Rogers and his colleagues found
basic to fostering a facilitative client–counselor relationship also help support crea-
tivity. Personal growth takes place in a safe, supportive environment created by
counselors or facilitators who are genuine, warm, empathic, open, honest, congru-
ent, and caring—qualities that are best learned by fi rst being experienced. Taking
time to refl ect on and evaluate these experiences allows for personal integration at
many levels—intellectual, emotional, physical, and spiritual.
Creativity and Offering Stimulating Experiences
According to Natalie Rogers, this deep faith in the individual’s innate drive to
become fully oneself is basic to the work in person-centered expressive arts. Indi-
viduals have a tremendous capacity for self-healing through creativity if given the
proper environment. When one feels appreciated, trusted, and given support to
use individuality to develop a plan, create a project, write a paper, or to be authen-
tic, the challenge is exciting, stimulating, and gives a sense of personal expansion.
N. Rogers believes the tendency to actualize and become one’s full potential, in-
cluding innate creativity, is undervalued, discounted, and frequently squashed in
our society. Traditional educational institutions tend to promote conformity rather
than original thinking and the creative process.
Person-centered expressive arts therapy utilizes the arts for spontaneous cre-
ative expression that symbolizes deep and sometimes inaccessible feelings and
emotional states. The conditions that foster creativity require acceptance of the
individual, a nonjudgmental setting, empathy, psychological freedom, and availa-
bility of stimulating and challenging experiences. With this type of environment in
place, the facilitative internal conditions of the client are encouraged and inspired:
a nondefensive openness to experience and an internal locus of evaluation that
receives but is not overly concerned with the reactions of others. N. Rogers (1993)
believes that we cheat ourselves out of a fulfi lling and joyous source of creativity if
we cling to the idea that an artist is the only one who can enter the realm of creativ-
ity. Art is not only for the few who develop a talent or master a medium. We all can
use various art forms to facilitate self-expression and personal growth.
Contributions of Natalie Rogers
As is clear from this brief section, Natalie Rogers has built upon a person-centered
philosophy and incorporated expressive and creative arts as a basis for personal
growth. Cain (2010) believes “Natalie Rogers’s expressive arts therapy represents
a major innovation in practice and helped open the way for other person-centered
therapists to expand the variety and range of practice” (p. 60). Sommers-Flanagan
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(2007) notes that person-centered expressive arts therapy may be a solution for
clients who are stuck in linear and rigid ways of being. He concludes: “Using her
own love of creativity and art in combination with her father’s renowned thera-
peutic approach, Natalie Rogers developed a form of therapy that extends person-
centered counseling into a new and exciting domain” (p. 124). Rogers continues
her active professional life, conducting workshops in the United States, Europe,
Japan, Hong Kong, Latin America, and Russia. At the end of this chapter are some
resources for those interested in training in the person-centered approach to ex-
pressive arts therapy.
m ot i vat i o n a l i n t e r v i e w i n g
Motivational Interviewing (MI) is a humanistic, client-centered, psychosocial, di-
rective counseling approach that was developed by William R. Miller and Stephen
Rollnick in the early 1980s. The clinical and research applications of motivational
interviewing have received increased attention in recent years, and MI has been
shown to be effective as a relatively brief intervention (Levensky, Kersh, Cavasos, &
Brooks, 2008). MI has been defi ned as “a directive, client centered counseling
style for eliciting behavior change by helping clients to explore and resolve am-
bivalence” (Rollnick & Miller, 1995, p. 326). Motivational interviewing is based on
humanistic principles, has some basic similarities with person-centered therapy,
and expands the traditional person-centered approach.
Motivational interviewing was initially designed as a brief intervention for
problem drinking, but more recently this approach has been applied to a wide
range of clinical problems including substance abuse, compulsive gambling, eat-
ing disorders, anxiety disorders, depression, suicidality, chronic disease manage-
ment, and health behavior change practices (Arkowitz & Miller, 2008; Arkowitz &
Westra, 2009). MI stresses client self-responsibility and promotes an invitational
style for working cooperatively with clients to generate alternative solutions to
behavioral problems. MI therapists avoid arguing with clients, avoid assuming a
confrontational stance, reframe resistance as a healthy response, express empathy,
and listen refl ectively. MI therapists do not view clients as opponents to be de-
feated but as allies who play a major role in their present and future success. Both
MI and person-centered practitioners believe in the client’s abilities, strengths,
resources, and competencies. The underlying assumption is that clients want to be
healthy and desire positive change.
The MI Spirit
MI is rooted in the philosophy of person-centered therapy, but with a “twist.”
Unlike the nondirective and unstructured person-centered approach, MI is delib-
erately directive and is aimed at reducing client ambivalence about change and
increasing intrinsic motivation (Arkowitz & Miller, 2008). It is essential that thera-
pists function within the spirit of MI, rather than simply applying the strategies of
the approach (Levensky et al., 2008). The attitudes and skills in MI are based on a
person-centered philosophy and include using open-ended questions, employing
refl ective listening, affi rming and supporting the client, responding to resistance
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in a nonconfrontational manner, guiding a discussion of ambivalence, summariz-
ing and linking at the end of sessions, and eliciting and reinforcing change talk.
MI works by activating clients’ own motivation for change and adherence to treat-
ment. Practitioners assist clients in becoming their own advocates for change and
the primary agents of change in their lives.
In both person-centered therapy and MI, the counselor provides the condi-
tions for growth and change by communicating attitudes of accurate empathy
and unconditional positive regard. In MI, the therapeutic relationship is as impor-
tant in achieving successful outcomes as the specifi c theoretical model or school
of psychotherapy from which the therapist operates (Miller & Rollnick, 2002).
Both MI and person-centered therapy are based on the premise that individuals
have within themselves the capacity to generate intrinsic motivation to change.
Responsibility for change rests with clients, not with the counselor, and therapist
and client share a sense of hope and optimism that change is possible. Once cli-
ents believe that they have the capacity to change and heal, new possibilities open
up for them.
The Basic Principles of Motivational Interviewing
Miller and Rollnick (2002) formulated fi ve basic principles of MI, which are sum-
marized below:
1. Therapists practicing motivational interviewing strive to experience the world
from the client’s perspective without judgment or criticism. MI emphasizes refl ec-
tive listening, which is a way for practitioners to better understand the subjective
world of clients. Expressing empathy is foundational in creating a safe climate for
clients to explore their ambivalence for change. When clients are slow to change,
it may be assumed that they have compelling reasons to remain as they are as well
as having reasons to change.
2. MI is designed to evoke and explore both discrepancies and ambivalence. Coun-
selors using MI refl ect discrepancies between the behaviors and values of clients to
increase the motivation to change. Counselors pay particular attention to clients’
arguments for changing compared to their arguments for not changing. Thera-
pists elicit and reinforce change talk by employing specifi c strategies to strengthen
discussion about change. MI therapists assume a directive stance by steering the
conversation in the direction of considering change without persuading clients to
change. Clinicians encourage clients to determine whether change will occur, and
if so, what kinds of changes will occur and when.
3. Reluctance to change is viewed as a normal and expected part of the therapeutic
process. Although individuals may see advantages to making life changes, they
also may have many concerns and fears about changing. People who seek therapy
are often ambivalent about change, and their motivation may ebb and fl ow dur-
ing the course of therapy. A central goal of MI is to increase internal motivation
to change based on the personal goals and values of clients (Arkowitz & Miller,
2008). MI therapists assume a respectful view of resistance and work therapeuti-
cally with any reluctance or caution on the part of clients.
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4. Practitioners operating from an MI orientation support clients’ self-effi cacy,
mainly by encouraging them to use their own resources to take necessary actions
that can lead to success in changing. MI clinicians strive to enhance client agency
about change and emphasize the right and inherent ability of clients to formulate
their own personal goals and to make their own decisions. MI focuses on present
and future conditions and empowers clients to fi nd ways to achieve their goals.
5. When clients show signs of readiness to change through decreased resistance
to change and increased talk about change, a critical phase of MI begins. In this
stage, clients may express a desire and ability to change, show an interest in ques-
tions about change, experiment with making changes between sessions, and envi-
sion a future picture of how their life will be different once the desired changes
have been made. At this time therapists shift their focus toward strengthening
clients’ commitments to change and helping them implement a change plan.
The Stages of Change
The stages of change model assumes that people progress through a series of fi ve
identifi able stages in the counseling process. In the precontemplation stage, there is
no intention of changing a behavior pattern in the near future. In the contemplation
stage, people are aware of a problem and are considering overcoming it, but they
have not yet made a commitment to take action to bring about the change. In the
preparation stage, individuals intend to take action immediately and report some
small behavioral changes. In the action stage, individuals are taking steps to modify
their behavior to solve their problems. During the maintenance stage, people work
to consolidate their gains and prevent relapse.
People do not pass neatly through these fi ve stages in linear fashion, and a cli-
ent’s readiness can fl uctuate throughout the change process. If change is initially
unsuccessful, individuals may return to an earlier stage (Prochaska & Norcross,
2010). MI therapists strive to match specifi c interventions with whatever stage of
change clients are experiencing. If there is a mismatch between process and stage,
movement through the stage will be impeded and is likely to be manifested in
reluctant behavior. When clients demonstrate any form of reluctance or resistance,
this could be due to a therapist’s misjudgment of a client’s readiness to change.
Certain behaviors on a therapist’s part may lead to a client feeling invalidated or
misunderstood, which is likely to result in what appears to be a client’s resistive
behavior (Levensky et al., 2008).
Working within the framework of the stages of change model has implica-
tions for the therapist’s role at the different stages. Norcross, Krebs, and Prochaska
(2011) describe the relational stances and roles taken by therapists during the
course of therapy. With clients in the precontemplation stage, the role assumed
is that of a nurturing parent. With clients in contemplation, therapists function as
a Socratic teacher who encourages them to achieve their own insights. For clients
who are in the preparation stage, therapists take the stance of an experienced coach.
With clients who are progressing into action and maintenance, therapists function
in the role of a consultant. As termination approaches, therapists are consulted less
often as a way to foster client autonomy.
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Motivational interviewing is but one example of how therapeutic strategies
have been developed based on the foundational principles and philosophy of the
person-centered approach. Indeed, most of the therapeutic models illustrate how
the core therapeutic conditions are necessary aspects leading to client change.
Where many therapeutic approaches, including motivational interviewing, diverge
from traditional person-centered therapy is the assumption that the therapeu-
tic factors are both necessary and suffi cient in bringing about change. Many other
models employ specifi c intervention strategies to address specifi c concerns clients
bring to therapy.
p e r s o n – c e n t e r e d t h e r a p y f r o m
a m u lt i c u lt u r a l p e r s p e c t i v e
Strengths From a Diversity Perspective
One of the strengths of the person-centered approach is its impact on the fi eld of
human relations with diverse cultural groups. Person-centered philosophy and prac-
tice can now be studied in several European countries, South America, and Japan.
Here are some examples of ways in which this approach has been incorporated in
various countries and cultures:
• In several European countries person-centered concepts have had a signifi cant
impact on the practice of counseling as well as on education, cross-cultural com-
munication, and reduction of racial and political tensions. In the 1980s Rogers
(1987b) elaborated on a theory of reducing tension among antagonistic groups
that he began developing in 1948.
• In the 1970s Rogers and his associates began conducting workshops promoting
cross-cultural communication. Well into the 1980s he led large workshops in
many parts of the world. International encounter groups have provided partici-
pants with multicultural experiences.
• Japan, Australia, South America, Mexico, and the United Kingdom have all
been receptive to person-centered concepts and have adapted these practices to
fi t their cultures.
• Shortly before his death, Rogers conducted intensive workshops with profes-
sionals in the former Soviet Union.
Cain (1987c) sums up the reach of the person-centered approach to cultural diver-
sity: “Our international family consists of millions of persons worldwide whose
lives have been affected by Carl Rogers’s writings and personal efforts as well as
his many colleagues who have brought his and their own innovative thinking and
programs to many corners of the earth” (p. 149).
There is no doubt that Carl Rogers has had a global impact. His work has reached
more than 30 countries, and his writings have been translated into 12 languages.
In addition to this global impact, the emphasis on the core conditions makes the
person-centered approach useful in understanding diverse worldviews. The under-
lying philosophy of person-centered therapy is grounded on the importance of hear-
ing the deeper messages of a client. Empathy, being present, and respecting the
values of clients are essential attitudes and skills in counseling culturally diverse
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clients. Cain (2008, 2010) contends that although person-centered therapists are
aware of diversity factors, they do not make initial assumptions about individuals.
They realize that each client’s journey is unique and take steps to tailor their meth-
ods to fi t each individual.
Several writers consider person-centered therapy as being ideally suited to cli-
ents in a diverse world. Cain (2008, 2010) views this approach as being a potent
way of working with individuals representing a wide range of cultural backgrounds
because the core therapeutic conditions are qualities that are universal. Bohart and
Watson (2011) claim that the person-centered philosophy is particularly appropri-
ate for working with diverse client populations because the counselor does not
assume the role of expert who is going to impose a “right way of being” on the cli-
ent. Instead, the therapist is a “fellow explorer” who attempts to understand the cli-
ent’s phenomenological world in an interested, accepting, and open way and checks
with the client to confi rm that the therapist’s perceptions are accurate. Motivational
interviewing, which is based on the philosophy of person-centered therapy, is a cul-
turally sensitive approach that can be effective across population domains, includ-
ing gender, age, ethnicity, and sexual orientation (Levensky et al., 2008).
Shortcomings From a Diversity Perspective
Although the person-centered approach has made signifi cant contributions to
counseling people from diverse social, political, and cultural backgrounds, there
are some shortcomings to practicing exclusively within this framework. Many cli-
ents who come to community mental health clinics or who are involved in outpa-
tient treatment want more structure than this approach provides. Some clients
seek professional help to deal with a crisis, to alleviate emotional problems, or to
learn coping skills in dealing with everyday problems. Because of certain cultural
messages, when these clients do seek professional help, it may be as a last resort.
They often expect a directive counselor and can be put off by a professional who
does not provide suffi cient structure.
A second shortcoming of the person-centered approach is that it is diffi cult to
translate the core therapeutic conditions into actual practice in certain cultures.
Communication of these core conditions must be consistent with the client’s cul-
tural framework. Consider, for example, the expression of therapist congruence
and empathy. Clients accustomed to indirect communication may not be comfort-
able with direct expressions of empathy or self-disclosure on the therapist’s part.
For some clients the most appropriate way to express empathy is for the therapist
to demonstrate it indirectly through respecting their need for distance or through
suggesting task-focused interventions (Bohart & Greenberg, 1997).
A third shortcoming in applying the person-centered approach with clients
from diverse cultures pertains to the fact that this approach extols the value of
an internal locus of evaluation. The humanistic foundation of person-centered
therapy emphasizes dimensions such as self-awareness, freedom, autonomy, self-
acceptance, inner-directedness, and self-actualization. In collectivist cultures, cli-
ents are likely to be highly infl uenced by societal expectations and not simply mo-
tivated by their own personal preferences. The focus on development of individual
autonomy and personal growth may be viewed as being selfi sh in a culture that
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stresses the common good. Cain (2010) contends that “persons from collectivistic
cultures are oriented less toward self-actualization and more toward intimacy, con-
nection, and harmony with others and toward what is best for the community and
the common good” (p. 143).
Consider Lupe, a Latina client who values the interests of her family over her
self-interests. From a person-centered perspective she could be viewed as being in
danger of “losing her own identity” by being primarily concerned with her role in
taking care of others in the family. Rather than pushing her to make her personal
wants a priority, the counselor will explore Lupe’s cultural values and her level of
commitment to these values in working with her. It would be inappropriate for the
counselor to impose a vision of the kind of woman she should be. (This topic is
discussed more extensively in Chapter 12.)
Although there may be particular shortcomings in practicing exclusively with-
in a person-centered perspective, it should not be concluded that this approach is
unsuitable for working with clients from diverse cultures. There is great diversity
among any group of people, and therefore, there is room for a variety of thera-
peutic styles. According to Cain (2010), rigid insistence on a nondirective style of
counseling for all clients, regardless of their cultural background or personal pref-
erence, may be perceived as an imposition that does not fi t the client’s interper-
sonal and therapeutic needs. Counseling a culturally different client may require
more activity and structuring than is usually the case in a person-centered frame-
work, but the potential positive impact of a counselor who responds empathically
to a culturally different client cannot be overestimated.
Stan’s autobiography indicates that
he has a sense of what he wants
for his life. As a person-centered
therapist, I rely on his self-report of the way he
views himself rather than on a formal assess-
ment and diagnosis. My concern is with under-
standing him from his internal frame of refer-
ence. Stan has stated goals that are meaningful
for him. He is motivated to change and seems
to have sufficient anxiety to work toward these
desired changes. I have faith in Stan’s ability
to find his own way, and I trust that he has the
necessary resources for reaching his therapy
goals. I encourage Stan to speak freely about
the discrepancy between the person he sees
himself as being and the person he would like
to become; about his feelings of being a failure,
being inadequate; about his fears and uncer-
tainties; and about his hopelessness at
times. I attempt to create an atmosphere of
freedom and security that will encourage Stan
to explore the threatening aspects of his
self-concept.
Stan has a low evaluation of his self-worth.
Although he finds it difficult to believe that
others really like him, he wants to feel loved.
He says, “I hope I can learn to love at least a
few people, most of all, women.” He wants to
feel equal to others and not have to apologize
for his existence, yet most of the time he feels
inferior. By creating a supportive, trusting, and
encouraging atmosphere, I can help Stan learn
to be more accepting of himself, with both his
strengths and limitations. He has the opportu-
nity to openly express his fears of women, of
not being able to work with people, and of feel-
ing inadequate and stupid. He can explore how
he feels judged by his parents and by
Person-Centered Therapy Applied to the Case of Stan
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s u m m a ry a n d e va l u at i o n
Summary
Person-centered therapy is based on a philosophy of human nature that postulates
an innate striving for self-actualization. Further, Rogers’s view of human nature
is phenomenological; that is, we structure ourselves according to our perceptions
of reality. We are motivated to actualize ourselves in the reality that we perceive.
Rogers’s theory rests on the assumption that clients can understand the fac-
tors in their lives that are causing them to be unhappy. They also have the capacity
for self-direction and constructive personal change. Change will occur if a con-
gruent therapist makes psychological contact with a client in a state of anxiety or
incongruence. It is essential for the therapist to establish a relationship the cli-
ent perceives as genuine, accepting, and understanding. Therapeutic counseling
is based on an I/Thou, or person-to-person, relationship in the safety and accept-
ance of which clients drop their defenses and come to accept and integrate aspects
that they have denied or distorted. The person-centered approach emphasizes this
authorities. He has an opportunity to express
his guilt—that is, his feelings that he has not
lived up to his parents’ expectations and that
he has let them and himself down. He can
also relate his feelings of hurt over not having
ever felt loved and wanted. He can express the
loneliness and isolation that he so often feels,
as well as the need to numb these feelings with
alcohol or drugs.
Stan is no longer totally alone, for he is taking
the risk of letting me into his private world of
feelings. Stan gradually gets a sharper focus on
his experiencing and is able to clarify his own
feelings and attitudes. He sees that he has the
capacity to make his own decisions. In short, our
therapeutic relationship frees him from his self-
defeating ways. Because of the caring and faith
he experiences from me in our relationship, Stan
is able to increase his own faith and confidence
in himself.
My empathy assists Stan in hearing him-
self and accessing himself at a deeper level.
Stan gradually becomes more sensitive to his
own internal messages and less dependent on
confirmation from others around him. As a result
of the therapeutic venture, Stan discovers that
there is someone in his life whom he can depend
on—himself.
Follow-Up: You Continue as Stan’s Person-
Centered Therapist
Use these questions to help you think about how
you would counsel Stan using a person-centered
approach:
• How would you respond to Stan’s deep feelings
of self-doubt? Could you enter his frame of ref-
erence and respond in an empathic manner that
lets Stan know you hear his pain and struggle
without needing to give advice or suggestions?
• How would you describe Stan’s deeper strug-
gles? What sense do you have of his world?
• To what extent do you think that the relation-
ship you would develop with Stan would help
him move forward in a positive direction?
What, if anything, might get in your way—
either with him or in yourself—in establishing
a therapeutic relationship?
See DVD for Theory and Practice of
Counseling and Psychotherapy: The Case
of Stan and Lecturettes (Session 5 on person-
centered therapy) for a demonstration of my
approach to counseling Stan from this perspec-
tive. This session focuses on exploring the
immediacy of our relationship and assisting
Stan in finding his own way.
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personal relationship between client and therapist; the therapist’s attitudes are
more critical than are knowledge, theory, or techniques employed. In the context
of this relationship, clients unleash their growth potential and become more of the
person they are capable of becoming.
This approach places primary responsibility for the direction of therapy on the
client. In the therapeutic context, individuals have the opportunity to decide for
themselves and come to terms with their own personal power. The underlying
assumption is that no one knows the client better than the client; in short, the cli-
ent is viewed as an expert on his or her own life (Cain, 2010). The general goals
of therapy are becoming more open to experience, achieving self-trust, developing
an internal source of evaluation, and being willing to continue growing. Specifi c
goals are not suggested for clients; rather, clients choose their own values and
goals. Current applications of the theory emphasize more active participation by
the therapist than was the case earlier. Counselors are now encouraged to be fully
involved as persons in the therapeutic relationship. More latitude is allowed for
therapists to express their reactions and feelings as they are appropriate to what is
occurring in therapy. Person-centered practitioners are willing to be transparent
about persistent feelings that exist in their relationships with clients (Watson et al.,
2011). It is the therapist’s job to adapt and accommodate in a manner that works
best for each client, which means being fl exible in the application of methods in
the counseling process (Cain, 2010).
Contributions of the Person-Centered Approach
When Rogers founded nondirective counseling more than 70 years ago, there
were very few other therapeutic models. The longevity of this approach is certainly
a factor to consider in assessing its infl uence. Cain (2008) states: “An extensive
body of research has been generated and provides support for the effectiveness
of person-centered therapy with a wide range of clients and problems of all age
groups” (p. 214).
Rogers had, and his theory continues to have, a major impact on the fi eld of
counseling and psychotherapy. When he introduced his revolutionary ideas in the
1940s, he provided a powerful and radical alternative to psychoanalysis and to the
directive approaches then practiced. Rogers was a pioneer in shifting the therapeu-
tic focus from an emphasis on technique and reliance on therapist authority to that
of the power of the therapeutic relationship.
Kirschenbaum (2009) contends that the scope and infl uence of Rogers’s work
has continued well beyond his death; the person-centered approach is alive, well,
and expanding. Today there is not one version of person-centered therapy, but a
number of continuously evolving person-centered psychotherapies (Cain, 2010).
Although few psychotherapists claim to have an exclusive person-centered theo-
retical orientation, the philosophy and principles of this approach permeate the
practice of most therapists. Other schools of therapy are increasingly recogniz-
ing the centrality of the therapeutic relationship as a route to therapeutic change
(Kirschenbaum, 2009).
Person-centered therapy is strongly represented in Europe, and there is con-
tinuing interest in this approach in both South America and the Far East. The
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person-centered approach has established a fi rm foothold in British universities.
According to Natalie Rogers (2011), some of the most in-depth training of person-
centered counselors is in the United Kingdom. In addition, British scholars includ-
ing Fairhurst (1999), Keys (2003), Lago and Smith (2003), Mearns and Cooper
(2005), Mearns and Thorne (2000, 2007), Merry (1999), Natiello (2001), Thorne
(2002a, 2002b), and Watson (2003) continue to expand and refi ne this approach.
As we have seen, Natalie Rogers has made a signifi cant contribution to the
application of the person-centered approach by incorporating the expressive arts as
a medium to facilitate healing and social change, primarily in a group setting. She
has been instrumental in the evolution of the person-centered approach by using
nonverbal methods to enable individuals to heal and to develop. Many individu-
als who have diffi culty expressing themselves verbally can fi nd new possibilities
for self-expression through nonverbal channels and through the expressive arts
(N. Rogers, 2011).
e m p h a s i s o n r e s e a r c h One of Rogers’s contributions to the fi eld of psy-
chotherapy was his willingness to state his concepts as testable hypotheses and to
submit them to research. He literally opened the fi eld to research. He was truly a
pioneer in his insistence on subjecting the transcripts of therapy sessions to criti-
cal examination and applying research technology to counselor–client dialogues
(Combs, 1988). Rogers’s basic hypothesis gave rise to a great deal of research and
debate in the fi eld of psychotherapy, perhaps more than any other school of ther-
apy (Cain, 2002a). According to Cain (2010), an enormous body of research, con-
ducted over a period of 70 years, supports the effectiveness of the person-centered
approach. This research is ongoing in many parts of the world and continues to
expand and refi ne our understanding of what constitutes effective psychotherapy.
Cain (2010) concludes, “person centered therapy is as vital and effective as it has
ever been and continues to develop in ways that will make it increasingly so in the
years to come” (p. 169).
Even his critics give Rogers credit for having conducted and inspired others to
conduct extensive studies of counseling process and outcome. Rogers presented a
challenge to psychology to design new models of scientifi c investigation capable of
dealing with the inner, subjective experiences of the person. His theories of ther-
apy and personality change have had a tremendous heuristic effect, and though
much controversy surrounds this approach, his work has challenged practitioners
and theoreticians to examine their own therapeutic styles and beliefs.
t h e i m p o r ta n c e o f e m pat h y Among the major contributions of person-
centered therapy are the implications of empathy for the practice of counseling.
More than any other approach, person-centered therapy has demonstrated that
therapist empathy plays a vital role in facilitating constructive change in the client.
Watson’s (2002) comprehensive review of the research literature on therapeutic
empathy has consistently demonstrated that therapist empathy is the most potent
predictor of client progress in therapy. Indeed, empathy is an essential component
of successful therapy in every therapeutic modality.
Person-centered research has been conducted predominantly on the hypoth-
esized necessary and suffi cient conditions of therapeutic personality change (Cain,
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1986, 1987b). Most of the other counseling approaches covered in this book have
incorporated the importance of the therapist’s attitude and behavior in creating a
therapeutic relationship that is conducive to the use of their techniques. For in-
stance, the cognitive behavioral approaches have developed a wide range of strate-
gies designed to help clients deal with specifi c problems, and they recognize that
a trusting and accepting client–therapist relationship is necessary for successful
application of these procedures. In contrast to the person-centered approach, how-
ever, cognitive behavioral practitioners contend that the working relationship is
not suffi cient to produce change. They contend that active procedures, in combina-
tion with a collaborative relationship, are needed to bring about change.
i n n o vat i o n s i n p e r s o n – c e n t e r e d t h e r a p y One of the strengths
of the person-centered approach is “the development of innovative and sophisti-
cated methods to work with an increasingly diffi cult, diverse, and complex range
of individuals, couples, families, and groups” (Cain, 2002b, p. xxii). A number of
people have made signifi cant advancements that are compatible with the essential
values and concepts of person-centered therapy. Table 7.1 describes some of the
innovators who have played a role in the evolution of person-centered therapy.
Rogers consistently opposed the institutionalization of a client-centered
“school.” Likewise, he reacted negatively to the idea of founding institutes, grant-
ing certifi cates, and setting standards for membership. He feared this institution-
alization would lead to an increasingly narrow, rigid, and dogmatic perspective. If
Rogers (1987a) were to give students-in-training advice it would be: “There is one
best school of therapy. It is the school of therapy you develop for yourself based on
a continuing critical examination of the effects of your way of being in the relation-
ship” (p. 185).
e m ot i o n – f o c u s e d t h e r a p y One of the developments associated with
the person-centered approach is the emergence of emotion-focused therapy (EFT).
Leslie Greenberg (2011) is a prominent fi gure in the development of this integra-
tive approach. Emotion-focused therapy is rooted in a person-centered philosophy,
but it is integrative in that it synthesizes aspects of Gestalt therapy and existential
therapy. EFT is a therapeutic practice informed by an understanding of the role of
emotion in psychotherapeutic change. A number of strategies in EFT are aimed
at the goal of strengthening the self, regulating affect, and creating new mean-
ing. Many traditional therapies emphasize conscious understanding and cognitive
and behavioral change, yet they often neglect the foundational role of emotional
change. EFT emphasizes the importance of awareness, acceptance, and under-
standing of emotion and the visceral experience of emotion. In EFT, clients are
assisted to identify, experience, accept, explore, transform, and manage their emo-
tions. A premise of EFT is that we can change only when we accept ourselves as
we are. This approach has a good deal to offer with respect to teaching us about the
role of emotion in personal change and how emotional change can be a primary
pathway to cognitive and behavioral change.
Other therapeutic approaches are increasingly focusing on emotions. For
example, both psychoanalytic and cognitive behavioral approaches are giving more
attention to the role of emotions and are rapidly assimilating many aspects of EFT.
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TA B L E 7.1 Therapists Who Contributed to the Evolution
of Person-Centered Theory
I N N O V A T O R C O N T R I B U T I O N
Natalie Rogers (1993, 1995, 2011) Expanded the theory by developing person-centered
expressive arts therapy in groups.
Virginia Axline (1964, 1969) Made signifi cant contributions to client-centered
therapy with children and play therapy.
Eugene Gendlin (1996) Developed experiential techniques, such as focusing, as
a way to enhance client experiencing.
Laura Rice (Rice & Greenberg,
1984)
Taught therapists to be more evocative in re-creating
crucial experiences that continue to trouble the client.
Peggy Natiello (2001) Works on collaborative power and gender issues.
Art Combs (1988, 1989, 1999) Developed perceptual psychology.
Leslie Greenberg (2011); Greenberg
and colleagues (Greenberg,
Korman, & Paivio, 2002;
Greenberg, Rice, & Elliott, 1993)
Contributed to the development of emotion-focused
therapy. Focused on the importance of facilitating
emotional change in therapy and advanced person-
centered theory and methods. Demonstrated that the
emotional route can be a key to changing cognitions
and behavior.
David Rennie (1998) Provided a glimpse at the inner workings of the
therapeutic process.
Art Bohart (Bohart & Greenberg,
1997; Bohart & Tallman, 1999;
2010; Bohart & Watson, 2011)
Contributed to a deeper understanding of empathy in
therapeutic practice and the active role of the client.
Jeanne Watson (2002) Demonstrated that when empathy is operating on the
cognitive, affective, and interpersonal levels it is one of
the therapist’s most powerful tools.
Dave Mearns and Brian Thorne
(2000, 2007)
Contributed to understanding new frontiers in the
theory and practice of the person-centered approach
and have been signifi cant fi gures in teaching and
supervising in the United Kingdom.
C. H. Patterson (1995) Showed that client-centered therapy is a universal
system of psychotherapy.
Barry Duncan, Scott Miller, Bruce
Wampold, & Mark Hubble (2010)
Demonstrated that the client-centered relationship
and the core conditions are essential to all therapeutic
approaches.
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A strength of EFT is that it is an evidence-based approach, an idea that is increas-
ingly being emphasized in graduate programs (Greenberg, 2011).
Limitations and Criticisms of the Person-Centered Approach
Although I applaud person-centered therapists for their willingness to subject their
hypotheses and procedures to empirical scrutiny, some researchers have been crit-
ical of the methodological errors contained in some of these studies. Accusations
of scientifi c shortcomings involve using control subjects who are not candidates
for therapy, failing to use an untreated control group, failing to account for placebo
effects, relying on self-reports as a major way to assess the outcomes of therapy,
and using inappropriate statistical procedures.
There is a similar limitation shared by both the person-centered and existential
(experiential) approaches. Neither of these therapeutic modalities emphasizes the
role of techniques aimed at bringing about change in clients’ behavior. Proponents
of psychotherapy manuals, or manualized treatment methods for specifi c disor-
ders, fi nd serious limitations in the experiential approaches due to their lack of
attention to proven techniques and strategies. Those who call for accountability as
defi ned by evidence-based practices within the fi eld of mental health also are quite
critical of the experiential approaches.
I do not believe manualized treatment methods can be considered the gold
standard in psychotherapy, however. There is good research demonstrating that
techniques account for only 15% of client outcome (see Duncan et al., 2010), whereas
contextual factors have powerful effects on what happens in therapy (Elkins, 2009).
Research points to relational and client factors as the main predictors of effective
therapy. Furthermore, the evaluation of evidence-based practices should be broad-
ened to include best available research, the expertise of the clinician, and client char-
acteristics, culture, and preferences (see Norcross, Hogan, & Koocher, 2008).
A potential limitation of the person-centered approach is that some students-in-
training and practitioners with this orientation may have a tendency to be very support-
ive of clients without being challenging. Out of their misunderstanding of the basic
concepts of the approach, some have limited the range of their responses and coun-
seling styles mainly to refl ections and empathic listening. Although there is value in
really hearing a client and in refl ecting and communicating understanding, counseling
entails more than this. I believe that the therapeutic core conditions are necessary for
therapy to succeed, yet I do not see them as being suffi cient conditions for change for
all clients at all times. From my perspective, these basic attitudes are the foundation on
which counselors must then build the skills of therapeutic intervention. Motivational
interviewing rests on the therapeutic core conditions, for example, but MI employs a
range of strategies that enable clients to develop action plans leading to change.
A related challenge for counselors using this approach is to truly support
clients in fi nding their own way. Counselors sometimes experience diffi culty in
allowing clients to decide their own specifi c goals in therapy. It is easy to give lip
service to the concept of clients’ fi nding their own way, but it takes considerable
respect for clients and faith on the therapist’s part to encourage clients to listen to
themselves and follow their own directions, particularly when they make choices
that are not what the therapist hoped for.
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More than any other quality, the therapist’s genuineness determines the power
of the therapeutic relationship. If therapists submerge their unique identity and style
in a passive and nondirective manner, they are not likely to affect clients in powerful
ways. Therapist authenticity and congruence are so vital to this approach that those
who practice within this framework must feel natural in doing so and must fi nd a
way to express their own reactions to clients. If not, a real possibility is that person-
centered therapy will be reduced to a bland, safe, and ineffectual approach.
w h e r e to g o f r o m h e r e
In the DVD for Integrative Counseling: The Case of Ruth and Lecturettes, you will see
a concrete illustration of how I view the therapeutic relationship as the foundation
for our work together. Refer especially to Session 1 (“Beginning of Counseling”),
Session 2 (“The Therapeutic Relationship”), and Session 3 (“Establishing Thera-
peutic Goals”) for a demonstration of how I apply principles from the person-
centered approach to my work with Ruth.
Free Podcasts for ACA Members
You can download ACA Podcasts (prerecorded interviews) by going to www.coun-
seling.org; click on the Resource button and then select the Podcast Series. For
Chapter 7, Carl Rogers and the Person-Centered Approach, look for Podcast 7 by
by Dr. Howard Kirschenbaum.
Other Resources
The American Psychological Association offers the following DVDs in their Psy-
chotherapy Video Series:
Greenberg, L. S. (2010). Emotion-Focused Therapy Over Time
Cain, D. J. (2010). Person-Centered Therapy Over Time
Psychotherapy.net is a comprehensive resource for students and professionals that
offers videos and interviews featuring Natalie Rogers, Rollo May, and more. New
articles, interviews, blogs, therapy cartoons, and videos are published monthly.
DVDs relevant to this chapter are available at www.psychotherapy.net and include
the following:
Rogers, N. (1997). Person-Centered Expressive Arts Therapy
May, R. (2007). Rollo May on Existential Psychotherapy
Association for the Development of the Person-Centered Approach, Inc. (ADPCA)
P. O. Box 3876
Chicago, IL 60690-3876
E-mail: enquiries@adpca.org
Website: www.adpca.org
Journal Editor: jonmrose@aol.com
The Association for the Development of the Person-Centered Approach (ADPCA)
is an interdisciplinary and international organization that consists of a network of
individuals who support the development and application of the person-centered
approach. Membership includes a subscription to the Person-Centered Journal, the
28549_ch07_rev01.indd 203 20/09/11 3:40 PM
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association’s newsletter, a membership directory, and information about the an-
nual meeting. ADPCA also provides information about continuing education and
supervision and training in the person-centered approach. For information about
the Person-Centered Journal, contact the editor (Jon Rose).
Association for Humanistic Psychology
1516 Oak Street #320A
Alameda, CA 94501-2947
Telephone: (510) 769-6495
Fax: (510) 769-6433
E-mail: AHPOffice@aol.com
Website: www.ahpweb.org
Journal website: http://jhp.sagepub.com
The Association for Humanistic Psychology (AHP) is devoted to promoting per-
sonal integrity, creative learning, and active responsibility in embracing the chal-
lenges of being human in these times. Information about the Journal of Human-
istic Psychology is available from the Association for Humanistic Psychology or at
publisher’s website.
Society for Humanistic Psychology
Website: http://www.societyforhumanisticpsychology.com/
Division 32 of APA, Society for Humanistic Psychology, represents a constellation
of “humanistic psychologies” that includes the earlier Rogerian, transpersonal,
and existential orientations as well as the more recently developing perspectives.
Division 32 seeks to contribute to psychotherapy, education, theory, research, epis-
temological diversity, cultural diversity, organization, management, social respon-
sibility, and change. The division has been at the forefront in the development of
qualitative research methodologies. The Society for Humanistic Psychology offers
journal access to The Humanistic Psychologist. Information about membership,
conferences, and journals is available from the website of Division 32.
Carl Rogers: A Daughter’s Tribute
Website: www.nrogers.com
The Carl Rogers CD-ROM is a visually beautiful and lasting archive of the life
and works of the founder of humanistic psychology. It includes excerpts from his
16 books, over 120 photographs spanning his lifetime, and award-winning video
footage of two encounter groups and Carl’s early counseling sessions. It is an es-
sential resource for students, teachers, libraries, and universities. It is a profound
tribute to one of the most important thinkers, infl uential psychologists, and peace
activists of the 20th century. Developed for Natalie Rogers, PhD, by Mindgarden
Media, Inc.
Center for Studies of the Person
1150 Silverado, Suite #112
La Jolla, CA 92037
Telephone: (858) 459-3861
E-mail: centerfortheperson@yahoo.com
Website: www.centerfortheperson.org
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205
The Center for Studies of the Person (CSP) offers workshops, training seminars, ex-
periential small groups, residential workshops, and sharing of learning in community
meetings. The Distance Learning Project and the Carl Rogers Institute for Psychother-
apy Training and Supervision provide experiential and didactic training and supervi-
sion for professionals interested in developing their own person-centered orientation.
Saybrook Graduate School
E-mail: admissions@saybrook.edu
Website: www.nrogers.com
For training in expressive art therapy, you could join Natalie Rogers, PhD, and Shel-
lee Davis, MA, faculty of the certifi cate program at Saybrook Graduate School in
their course, “Expressive Arts for Healing and Social Change: A Person-Centered
Approach.” A 16-unit certifi cate program includes 6 separate weeks spread over 2
years at a retreat center north of San Francisco. Rogers and Davis offer expressive
arts within a person-centered counseling framework. They use counseling demon-
strations, practice counseling sessions, readings, discussions, papers, and a creative
project to teach experiential and theoretical methods.
Recommended Supplementary Readings
On Becoming a Person (Rogers, 1961) is one of the best primary sources for fur-
ther reading on person-centered therapy. This is a collection of Rogers’s articles
on the process of psychotherapy, its outcomes, the therapeutic relationship, edu-
cation, family life, communication, and the nature of the healthy person.
A Way of Being (Rogers, 1980) contains a series of writings on Rogers’s personal
experiences and perspectives, as well as chapters on the foundations and applica-
tions of the person-centered approach.
The Creative Connection: Expressive Arts as Healing (N. Rogers, 1993) is a practical,
spirited book lavishly illustrated with color and action photos and fi lled with fresh
ideas to stimulate creativity, self-expression, healing, and transformation. Natalie
Rogers combines the philosophy of her father with the expressive arts to enhance
communication between client and therapist.
The Life and Work of Carl Rogers (Kirschenbaum, 2009) is a defi nitive biography
of Carl Rogers that follows his life from his early childhood through his death.
This book illustrates the legacy of Carl Rogers and shows his enormous infl uence
on the fi eld of counseling and psychotherapy.
Person-Centered Psychotherapies (Cain, 2010) contains a clear discussion of person-
centered theory, the therapeutic process, evaluation of the approach, and future
developments.
Humanistic Psychology: A Clinical Manifesto (Elkins, 2009) offers an insightful
critique of the medical model of psychotherapy and the myth of empirically
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supported treatments. The author calls for a relationship-based approach to psy-
chotherapy that can provide both individual and social transformation.
References and Suggested Readings
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

*Rogers, N. (1995). Emerging woman: A decade
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28549_ch07_rev01.indd 209 20/09/11 3:40 PM
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210
i n t r o d u ct i o n
k e y co n c e p t s
t h e t h e r a p e u t i c p r o c es s
a p p l i c at i o n : t h e r a p e u t i c
t ec h n i q u es a n d p r o c e d u r es
g esta lt t h e r a p y f r o m a
m u lt i c u lt u r a l p e r s p ect i v e
g esta lt t h e r a p y a p p l i e d
to t h e c a s e o f sta n
s u m m a ry a n d e va l u at i o n
w h e r e to g o f r o m h e r e
c h a p t e r 8
Gestalt Therapy
210
a p p l i c at i o n : t h e r a p e
t ec h n i q u es a n d p r o c
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Fritz Perls / LAU R A PE R L S
F R E D E R I C K S . ( “ F R I TZ ” ) P E R L S , M D, P h D
(1893–1970), was the main originator and devel-
oper of Gestalt therapy. Born in Berlin, Germany,
into a lower-middle-class Jewish family, he later
identified himself as a source of much trouble for
his parents. Although he failed the seventh grade
twice and was expelled from school because of
difficulties with the authorities, his brilliance was
never quashed, and he returned—not only to
complete high school but to earn his medical
degree (MD) with a specialization in psychiatry.
In 1916 he joined the German Army and served
as a medic in World War I. His experiences with
soldiers who were gassed on the front lines led to
his interest in mental functioning, which led him to
Gestalt psychology.
After the war Perls worked with Kurt Goldstein
at the Goldstein Institute for Brain-Damaged
Soldiers in Frankfurt. It was through this associa-
tion that he came to see the importance of viewing
humans as a whole rather than as a sum of dis-
cretely functioning parts. It was also through this
association that he met his wife, Laura, who was
earning her PhD with Goldstein. Later he moved to
Vienna and began his psychoanalytic training.
Perls was in analysis with Wilhelm Reich, a
psychoanalyst who pioneered methods of self-
understanding and personality change by working
with the body.
Perls and several of his colleagues established
the New York Institute for Gestalt Therapy in 1952.
Eventually Fritz left New York and settled in Big
Sur, California, where he conducted workshops and
seminars at the Esalen Institute, carving out his
reputation as an innovator in psychotherapy. Here
he had a great impact on people, partly through his
professional writings, but mainly through personal
contact in his workshops.
Personally, Perls was both vital and perplexing.
People typically either responded to him in awe
or found him harshly confrontational and saw him
as meeting his own needs through showmanship.
Having a predilection for the theater since child-
hood, he loved being on stage and putting on a
show. He was viewed variously as insightful, witty,
bright, provocative, manipulative, hostile, demand-
ing, and inspirational. Unfortunately, some of the
people who attended his workshops went on to
mimic the less attractive side of Perls’s personality.
Even though Perls was not happy with this, he did
little to discourage it.
For a firsthand account of the life of Fritz Perls,
I recommend his autobiography, In and Out of the
Garbage Pail (1969b). For a well-researched chap-
ter on the history of Gestalt therapy, see Bowman
(2005).
L A U R A P O S N E R P E R L S , P h D (1905–1990),
was born in Pforzheim, Germany, the daughter
of well-to-do parents. She began playing the
piano at the age of 5 and played with profes-
sional skill by the time she was 18. From the
age of 8 she was involved in modern dance, and
both music and modern dance remained vital
parts of her adult life and were incorporated
into her therapy with some clients. By the time
Laura began her practice as a psychoanalyst she
had prepared for a career as a concert pianist,
had attended law school, achieved a doctoral
degree in Gestalt psychology, and made an
intensive study of existential philosophy with
Paul Tillich and Martin Buber. Clearly, Laura
already had a rich background when she met
Fritz in 1926 and they began their collaboration,
which resulted in the theoretical foundations
of Gestalt therapy. Laura and Fritz were married
in 1930 and had two children while living and
practicing in South Africa. Laura continued to
be the mainstay for the New York Institute
for Gestalt Therapy after Fritz abandoned his
family to become internationally famous as the
traveling minstrel for Gestalt therapy. Laura
also made significant contributions to the
development and maintenance of the Gestalt
therapy movement in the United States and
throughout the world (although in very different
ways) from the late 1940s until her death
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i n t r o d u c t i o n
aware-
ness
relational Gestalt therapy,
in 1990. Laura’s own words make it clear that
Fritz was a generator, not a developer or organ-
izer. At the 25th anniversary of the New York
Institute for Gestalt Therapy, Laura Perls (1990)
stated, “Without the constant support from
his friends, and from me, without the constant
encouragement and collaboration, Fritz would
never have written a line, nor founded
anything” (p. 18).
Laura paid a great deal of attention to
contact and support, which differed from Fritz’s
attention to intrapsychic phenomena and his
focus on awareness. Her emphasis on contact
underscored the role of the interpersonal and
of being responsive at a time when the popular
notion of Gestalt therapy was that it fostered
responsibility only to oneself. She corrected
some of the excesses committed in the name
of Gestalt therapy and adhered to the basic
principles of Gestalt therapy theory as
written in Gestalt Therapy: Excitement and
Growth in the Human Personality (Perls, Heffer-
line, & Goodman, 1951). She taught that every
Gestalt therapist needs to develop his or her
own therapeutic style. From her perspective,
whatever is integrated in our personality
becomes support for what we use technically
(Humphrey, 1986).
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213
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what how
field
Emotion-focused therapy
Learning Emotion-Focused Therapy: The Process-Experiential Approach to
Change Emotion-Focused Ther-
apy
See the video program for Chapter 8, DVD for Theory and Practice of Counseling
and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you view
the brief lecture for each chapter prior to reading the chapter.
k e y c o n c e p t s
View of Human Nature
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214
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paradoxical theory of change.
Some Principles of Gestalt Therapy Theory
h o l i s m Gestalt
figure
ground
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215
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f i e l d t h e o ry field theory,
t h e f i g u r e – f o r m at i o n p r o c e s s
figure-formation process
o r g a n i s m i c s e l f – r e g u l at i o n
organismic self-regulation,
The Now
Phenomenological inquiry
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talk about
now.
Unfinished Business
unfinished business,
do seek
impasse,
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217
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Y
Contact and Resistances to Contact
Con-
tact
Introjection
Projection
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218
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Retroflection
Deflection
Confluence
interruptions in contact boundary disturbance
Energy and Blocks to Energy
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219
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Y
t h e t h e r a p e u t i c p r o c e s s
Therapeutic Goals
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220
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Therapist’s Function and Role
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221
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It” talk.
“You” talk.
Questions.
Language that denies power.
Listening to clients’ metaphors.
Listening for language that uncovers a story.
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222
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Client’s Experience in Therapy
dis-
covery.
accommodation,
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223
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Y
assimilation,
Relationship Between Therapist and Client
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224
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a p p l i c at i o n : t h e r a p e u t i c
t e c h n i q u e s a n d p r o c e d u r e s
The Experiment in Gestalt Therapy
Case Approach to Counseling and Psycho-
therapy
Exercises
Experiments,

225
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Y
Preparing Clients for Gestalt Experiments
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226
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personally
way
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227
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Y
The Role of Confrontation
Confrontation
invited
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228
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Gestalt Therapy Interventions
t h e i n t e r n a l d i a lo g u e e x e r c i s e
empty-chair technique
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229
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T
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Y
m a k i n g t h e r o u n d s
t h e r e v e r s a l e x e r c i s e
t h e r e h e a r s a l e x e r c i s e
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230
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I
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t h e e x a g g e r at i o n e x e r c i s e
s tay i n g w i t h t h e f e e l i n g
t h e g e s ta lt a p p r oa c h t o d r e a m w o r k
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231
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Application to Group Counseling
talking about
talking about
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232
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E
I
G
H
T
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233
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T
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A
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g e s ta lt t h e r a p y f r o m a
m u lt i c u lt u r a l p e r s p e c t i v e
Strengths From a Diversity Perspective
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234
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Shortcomings From a Diversity Perspective
Gestalt-oriented therapy focuses on the
unfinished business Stan has with his
parents, siblings, and ex-wife. It appears
that this unfinished business consists mainly of
feelings of resentment, and Stan turns this resent-
ment on himself. His present life situation is
spotlighted, but he may also need to reexperience
past feelings that could be interfering with his
present attempts to develop intimacy with others.
Although the focus is on Stan’s present
behavior, I guide him toward becoming aware
of how he is carrying old baggage around and
how it interferes with his life today. My task is to
assist him in re-creating the context in which he
made creative adjustments during his childhood
years that no longer serving him well. One of
his cardinal introjections was, “I’m stupid, and it
would be better if I did not exist.”
Gestalt Therapy Applied to the Case of Stan
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235
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Stan has been influenced by cultural mes-
sages that he has accepted. I am interested in
exploring his cultural background, including
his values and the values characteristic of his
culture. With this focus, I assist Stan in identify-
ing some of the following cultural introjections:
“Don’t talk about your family with strangers,
and don’t hang your dirty linen in public.” “Don’t
confront your parents because they deserve re-
spect.” “Don’t be too concerned about yourself.”
“Don’t show your vulnerabilities; hide your feel-
ings and weaknesses.” I invite Stan to examine
those introjections to assess their utility in his
present circumstances. Although he can decide
to retain those aspects of his culture that he
prizes, he is in a position to modify or reject
other cultural expectations. Of course, this will
be done when these issues emerge in the fore-
ground of his work.
I ask Stan to attend to what he becomes
aware of as the session begins: “What are you
experiencing as we are getting started today?”
As I encourage Stan to tune in to his present
experience and selectively make observations, a
number of figures will emerge. The goal is to
focus on a figure of interest, one that seems to
hold the most energy or relevance for Stan. When
a figure is identified, my task is to deepen Stan’s
awareness of this thought, feeling, body sensa-
tion, or insight through related experiments.
In typical Gestalt fashion, Stan deals with
his present struggles within the context of our
relationship and through experimentation. One
possible experiment would involve Stan becom-
ing some of those individuals who told him how
to think, feel, and behave as a child. He can then
become the child that he was and respond to
them from the place where he feels the most
confusion or pain. He experiences in new ways
the feelings that accompany his beliefs about
himself, and he comes to a deeper appreciation
of how his feelings and thoughts influence what
he is doing today.
Stan has learned to hide his emotions rather
than to reveal them. Understanding this about
him, we explore his objections and concerns about
“getting into feelings.” The figure of interest now
is his hesitation to experience or express emotion.
Although I have no agenda to get Stan to experi-
ence his feelings at this point, it is important for
him to increase his awareness of his reluctance
and to explore the meaning it holds for him.
If Stan decides that he wants to experience
his emotions rather than deny them, I ask: “What
are you aware of now having said what you did?”
Stan says that he can’t get his ex-wife out of his
mind. He tells me about the pain he feels over
that relationship and how he is frightened of get-
ting involved again lest he be hurt again. I con-
tinue to ask him to focus inward and get a sense
of what stands out for him at this very moment.
Stan replies: “I’m hurt and angry over all the pain
that I’ve allowed her to inflict on me.” I ask him to
imagine himself in earlier scenes with his ex-wife,
as though the painful situation were occurring
in the here and now. He symbolically relives and
reexperiences the situation by talking “directly”
to his wife. By expressing his resentments and
hurts directly, Stan can begin to complete some
unfinished business that is interfering with his
current functioning. By participating in this
experiment, Stan is attaining more awareness of
what he is now doing and how he keeps himself
locked into his past.
Follow-Up: You Continue as Stan’s
Gestalt Therapist
Use these questions to help you think about how
to work with Stan using the Gestalt approach:
How might you begin a session with Stan?
Would you suggest a direction he should pur-
sue? Would you wait for him to initiate work?
Would you ask him to continue from where he
left off in the previous session? Would you at-
tend to whatever theme or issue becomes fig-
ural to him?
What unfinished business can you identify in
Stan’s case? Does any of his experience of be-
ing stuck remind you of yourself? How might
you work with Stan if he did bring up your own
unfinished business?
What kind of an experiment might you pro-
pose to assist Stan in learning more about his
hesitation and reluctance to access and ex-
press his feelings?
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236 s u m m a ry a n d e va l u at i o n
Summary
Contributions of Gestalt Therapy
Stan participated in an experiment to deal
with pain, resentment, and hurt over situa-
tions with his ex-wife. How might you have
worked with the material Stan brought up?
What kind of experiment might you design?
How would you decide what kind of experi-
ment to create?
How might you work with Stan’s cultural mes-
sages? Would you be able to respect his cul-
tural values and still encourage him to make
an assessment of some of the ways in which
his culture is affecting him today?
See DVD for Theory and Practice of
Counseling and Psychotherapy: The Case
of Stan and Lecturettes (Session 6 on Gestalt
therapy) for a demonstration of my approach
to counseling Stan from this perspective. This
session consists of Stan exploring one of his
dreams in Gestalt fashion.
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Handbook for Theory, Research and Practice in Gestalt Ther-
apy Becoming a Practitioner Researcher: A Gestalt Approach to
Holistic Inquiry
Limitations and Criticisms of Gestalt Therapy
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facilitating
s o m e c a u t i o n s
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w h e r e to g o f r o m h e r e
DVD for Integrative Counseling: The Case of Ruth and Lecturettes,
Other Resources
Gestalt Therapy with Children
Psychotherapy With the Unmotivated Patient
Gestalt Institute of Cleveland. Inc.
1588 Hazel Drive
Cleveland, OH 44106-1791
Telephone: (216) 421-0468
Fax: (216) 421-1729
E-mail: registrar@gestaltcleveland.org
Website: www.gestaltcleveland.org
Pacific Gestalt Institute
1626 Westwood Blvd., Suite 104
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E
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Los Angeles, CA 90024
Telephone: (310) 446-9720
Fax: (310) 475-4704
E-mail: info@gestalttherapy.org
Website: www.gestalttherapy.org
Gestalt Center for Psychotherapy and Training
220 Fifth Avenue, Suite 802
New York, NY 10001
Telephone: (212) 387-9429
E-mail: info@gestaltnyc.org
Website: www.gestaltnyc.org
Gestalt International Study Center
1035 Cemetery Road
South Wellfleet, Cape Cod, MA 02667
Telephone: (508) 349-7900
E-mail: office@gisc.org
Website: www.GISC.org
Gestalt Therapy Training Center Northwest
757 SE 34th Avenue
Portland, OR 97214
Telephone: (503) 230-0900
E-mail: gttcnw@aol.com
Website: www.gttcnw.org
Gestalt Associates Training, Los Angeles
1460 Seventh Street, Suite 300
Santa Monica, CA 90401
Telephone/Fax: (310) 395-6844
E-mail: ritaresnick@gatla.org
Website: www.gatla.org
Association for the Advancement of Gestalt Therapy (AAGT)
Website: www.AAGT.org
European Association for Gestalt Therapy (EAGT)
Website: www.EAGT.org
Gestalt Review
Website: www.gestaltreview.com
British Gestalt Journal
Website: www.britishgestaltjournal.com
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Recommended Supplementary Readings
Gestalt Therapy Verbatim (Perls, 1969a) provides a firsthand account of the way Fritz Perls
worked. It contains many verbatim transcripts of workshop demonstrations.
Gestalt Therapy: History, Theory, and Practice (Woldt & Toman, 2005) introduces the historical
underpinnings and key concepts of Gestalt therapy and features applications of those concepts
to therapeutic practice. This is a significant recent publication in the field of Gestalt therapy that
contains pedagogical learning activities and experiments, review questions, and photographs of
all contributors.
Gestalt Therapy Integrated: Contours of Theory and Practice (Polster & Polster, 1973) is a classic in
the field and an excellent source for those who want a more advanced and theoretical treatment
of this model.
References and Suggested Readings
*Barber, P. (2006). Becoming a practitioner
researcher: A Gestalt approach to holistic inquiry.
London: Middlesex University Press.
Beisser, A. R. (1970). The paradoxical theory
of change. In J. Fagan & I. L. Shepherd (Eds.),
Gestalt therapy now (pp. 77–80). New York:
Harper & Row (Colophon).
*Bowman, C. (2005). The history and develop-
ment of Gestalt therapy. In A. Woldt & S. To-
man (Eds.), Gestalt therapy: History, theory, and
practice (pp. 3–20). Thousand Oaks, CA: Sage.
Breshgold, E. (1989). Resistance in Gestalt
therapy: An historical theoretical perspective.
The Gestalt Journal, 12(2), 73–102.
*Brown, J. R. (2007). Gestalt therapy. In A. B.
Rochlen (Ed.), Applying counseling theories: An
online case-based approach (pp. 127–141).
Upper Saddle River, NJ: Pearson Prentice-Hall.
*Brownell, P. (2008). Handbook for theory,
research and practice in Gestalt therapy.
Newcastle, UK: Cambridge Scholar Publishing.
*Cain, D. J. (2002). Defining characteristics,
history, and evolution of humanistic psycho-
therapies. In D. J. Cain & J. Seeman (Eds.),
Humanistic psychotherapies: Handbook of
research and practice (pp. 3–54). Washington,
DC: American Psychological Association.
Clarkson, P., & Mackewn, J. (1993). Fritz Perls.
Newbury Park, CA: Sage.
Corey, G. (2012). Theory and practice of group
counseling (8th ed.). Belmont, CA: Brooks/
Cole, Cengage Learning.
*Corey, G. (2013). Case approach to counseling
and psychotherapy (8th ed.). Belmont, CA:
Brooks/Cole, Cengage Learning.
Elliott, R., Watson, J. C., Goldman, R. N., &
Greenberg, L. S. (2004). Learning emotion-
focused therapy: A process-experiential approach
to change. Washington, DC: American Psycho-
logical Association.
*Feder. B. (2006). Gestalt group therapy: A prac-
tical guide. New Orleans: Gestalt Institute Press.
*Feder, B., & Frew, J. (Eds.). (2008). Beyond the
hot seat revisited: Gestalt approaches to group.
New Orleans: Gestalt Institute Press.
Feder, B., & Ronall, R. (Eds.). (1996). A living
legacy of Fritz and Laura Perls: Contemporary
case studies. Montclair, NJ: Walden.
Fernbacher, S., & Plummer, D. (2005).
Cultural influences and considerations in
Gestalt therapy. In A. Woldt & S. Toman (Eds.),
Gestalt therapy: History, theory, and practice (pp.
117–132). Thousand Oaks, CA: Sage.
Frew, J. E. (1986). The functions and patterns
of occurrence of individual contact styles
during the development phase of the Gestalt
group. The Gestalt Journal, 9(l), 55–70.
Frew, J. E. (1997). A Gestalt therapy theory
application to the practice of group leadership.
Gestalt Review, 1(2), 131–149.
241
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*Frew, J. (2008). Gestalt therapy. In J. Frew &
M. D. Spiegler (Eds.), Contemporary psychother-
apies for a diverse world (pp. 228–274). Boston:
Lahaska Press.
*Greenberg, L. S. (2011). Emotion-focused
therapy. Washington, DC: American Psycho-
logical Association.
Humphrey, K. (1986). Laura Perls: A biograph-
ical sketch. The Gestalt Journal, 9(l), 5–11.
*Hycner, R., & Jacobs, L. (1995). The healing
relationship in Gestalt therapy. Highland, NY:
Gestalt Journal Press.
Jacobs, L. (1989). Dialogue in Gestalt theory
and therapy. The Gestalt Journal, 12(l), 25–67.
*Latner, J. (1986). The Gestalt therapy book.
Highland, NY: Center for Gestalt Development.
*Lee, R. G. (Ed.). (2004). The values of connec-
tion: A relational approach to ethics. Cambridge,
MA: Gestalt Press.
Levitsky, A., & Perls, F. (1970). The rules and
games of Gestalt therapy. In J. Fagan & I.
Shepherd (Eds.), Gestalt therapy now (pp. 140–
149). New York: Harper & Row (Colophon).
Maurer, R. (2005). Gestalt approaches with
organizations and large systems. In A. Woldt
& S. Toman (Eds.), Gestalt therapy: History,
theory, and practice. (pp. 237–256). Thousand
Oaks, CA: Sage.
Melnick, J., & Nevis, S. (2005). Gestalt
therapy methodology. In A. Woldt & S. Toman
(Eds.), Gestalt therapy: History, theory, and prac-
tice. (pp. 101–116). Thousand Oaks, CA: Sage.
Parlett, M. (2005). Contemporary Gestalt
therapy: Field theory. In A. Woldt & S. Toman
(Eds.), Gestalt therapy: History, theory, and prac-
tice (pp. 41–64). Thousand Oaks, CA: Sage.
Passons, W. R. (1975). Gestalt approaches in
counseling. New York: Holt, Rinehart & Winston.
*Perls, F. (1969a). Gestalt therapy verbatim.
Moab, UT: Real People Press.
Perls, F. (1969b). In and out of the garbage pail.
Moab, UT: Real People Press.
Perls, F., Hefferline, R., & Goodman, R. (1951).
Gestalt therapy: Excitement and growth in the
human personality. New York: Dell.
Perls, L. (1976). Comments on new direc-
tions. In E.W.L. Smith (Ed.), The growing edge
of Gestalt therapy (pp. 221–226). New York:
Brunner/Mazel.
Perls, L. (1990). A talk for the 25th anniver-
sary. The Gestalt Journal, 13(2), 15–22.
Polster, E. (1987a). Escape from the present:
Transition and storyline. In J. K. Zeig (Ed.), The
evolution of psychotherapy (pp. 326–340). New
York: Brunner/Mazel.
*Polster, E. (1987b). Every person’s life is worth
a novel: How to cut through emotional pain and
discover the fascinating core of life. New York:
Norton.
*Polster, E. (1995). A population of selves: A
therapeutic exploration of personality diversity.
San Francisco: Jossey-Bass.
*Polster, E., & Polster, M. (1973). Gestalt
therapy integrated: Contours of theory and prac-
tice. New York: Brunner/Mazel.
Polster, E., & Polster, M. (1976). Therapy with-
out resistance: Gestalt therapy. In A. Burton
(Ed.), What makes behavior change possible?
(pp. 259–277). New York: Brunner/Mazel.
Polster, M. (1987). Gestalt therapy: Evolution
and application. In J. K. Zeig (Ed.), The evolu-
tion of psychotherapy (pp. 312–325). New York:
Brunner/Mazel.
Polster, M., & Polster, E. (1990). Gestalt thera-
py. In J. K. Zeig & W. M. Munion (Eds.), What
is psychotherapy? Contemporary perspectives
(pp. 103–107). San Francisco: Jossey-Bass.
*Strumpfel, U., & Goldman, R. (2002). Con-
tacting Gestalt therapy. In D. J. Cain & J.
Seeman (Eds.), Humanistic psychotherapies:
Handbook of research and practice (pp. 189–
219). Washington, DC: American Psychologi-
cal Association.
Watson, J. C., Goldman, R. N., & Greenberg,
L. S. (2011). Humanistic and experiential theo-
ries in psychotherapy. In J. C. Norcross, G. R.
Vandenbos, & D. K. Freedheim (Eds.), History of
psychotherapy (2nd ed., pp. 141–172). Washing-
ton, DC: American Psychological Association.
*Woldt, A., & Toman, S. (Eds.). (2005). Gestalt
therapy: History, theory, and practice. Thousand
Oaks, CA: Sage.
242
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*Yontef, G. M. (1993). Awareness, dialogue and
process: Essays on Gestalt therapy. Highland,
NY: Gestalt Journal Press.
*Yontef, G. (1995). Gestalt therapy. In A. S.
Gurman & S. B. Messer (Eds.), Essential psy-
chotherapies: Theory and practice (pp. 261–303).
New York: Guilford Press.
Yontef, G. (1999). Awareness, dialogue and
process: Preface to the 1998 German edition.
The Gestalt Journal, 22(1), 9–20.
*Yontef, G. M. (2005). Gestalt therapy theory
of change. In A. Woldt & S. Toman (Eds.),
Gestalt therapy: History, theory, and practice
(pp. 81–100). Thousand Oaks, CA: Sage.
*Yontef, G., & Jacobs, L. (2011). Gestalt
therapy. In R. Corsini & D. Wedding (Eds.),
Current psychotherapies (9th ed., pp. 342–382).
Belmont, CA: Brooks/Cole, Cengage Learning.
Zahm, S. (1998). Therapist self-disclosure in
the practice of Gestalt therapy. The Gestalt
Journal, 21, 21–52.
*Zinker, J. (1978). Creative process in Gestalt
therapy. New York: Random House (Vintage).
243
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244
i n t r o d u ct i o n
• Historical Background
• Four Areas of Development
k e y co n c e p t s
• View of Human Nature
• Basic Characteristics and Assumptions
t h e t h e r a p e u t i c p r o c es s
• Therapeutic Goals
• Therapist’s Function and Role
• Client’s Experience in Therapy
• Relationship Between Therapist and Client
a p p l i c at i o n : t h e r a p e u t i c
t ec h n i q u es a n d p r o c e d u r es
• Applied Behavioral Analysis: Operant
Conditioning Techniques
• Progressive Muscle Relaxation
• Systematic Desensitization
• In Vivo Exposure and Flooding
• Eye Movement Desensitization and
Reprocessing
• Social Skills Training
• Self-Management Programs and Self-Directed
Behavior
• Multimodal Therapy: Clinical Behavior
Therapy
• Mindfulness and Acceptance-Based Cognitive
Behavior Therapy
• Application to Group Counseling
b e h av i o r t h e r a p y f r o m a
m u lt i c u lt u r a l p e r s p ect i v e
• Strengths From a Diversity Perspective
• Shortcomings From a Diversity Perspective
b e h av i o r t h e r a p y a p p l i e d to t h e
c a s e o f sta n
s u m m a ry a n d e va l u at i o n
• Summary
• Contributions of Behavior Therapy
• Limitations and Criticisms of Behavior
Therapy
w h e r e to g o f r o m h e r e
• Recommended Supplementary Readings
• References and Suggested Readings
c h a p t e r 9
Behavior Therapy
• Recomm
• References
ntary Readin
Suggested ReadingsSkills Training
244
Muscle Relaxati
atic Desensitization
ivo Exposure and Flooding
e Movement Desensitization and
processing
• Socia
r a p e
t ec h n i q u es a n d p r o c
• Applied Behavioral Analysi
Conditioning Techniques
• Progressive
• System
• In
• Ey
Re
28549_ch09_rev01.indd 244 20/09/11 3:52 PM
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

245
B
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Y
B. F. Skinner / Albert Bandura / Arnold Lazarus
B . F. S K I N N E R (1904–
1990) reported that he was
brought up in a warm, stable
family environment.* As he
was growing up, Skinner was
greatly interested in building
all sorts of things, an interest
that followed him through-
out his professional life. He
received his PhD in psychol-
ogy from Harvard University in 1931 and eventu-
ally returned to Harvard after teaching in several
universities. He had two daughters, one of whom is
an educational psychologist and the other an artist.
Skinner was a prominent spokesperson for
behaviorism and can be considered the father of
the behavioral approach to psychology. Skinner
championed radical behaviorism, which places
primary emphasis on the effects of environment
on behavior. Skinner was also a determinist; he
did not believe that humans had free choice. He
acknowledged that feelings and thoughts exist, but
he denied that they caused our actions. Instead,
he stressed the cause-and-effect links between
objective, observable environmental conditions
and behavior. Skinner maintained that too much
attention had been given to internal states of
mind and motives, which cannot be observed and
changed directly, and that too little focus had been
given to environmental factors that can be directly
observed and changed. He was extremely inter-
ested in the concept of reinforcement, which he
applied to his own life. For example, after working
for many hours, he would go into his constructed
cocoon (like a tent), put on headphones, and listen
to classical music (Frank Dattilio, personal commu-
nication, September 24, 2010).
Most of Skinner’s work was of an experimental
nature in the laboratory, but others have applied his
ideas to teaching, managing human problems, and
social planning. Science and Human Behavior
(Skinner, 1953) best illustrates how Skinner thought
behavioral concepts could be applied to every
domain of human behavior. In Walden II (1948)
Skinner describes a utopian community in which
his ideas, derived from the laboratory, are applied
to social issues. His 1971 book, Beyond Freedom and
Dignity, addressed the need for drastic changes if
our society was to survive. Skinner believed that
science and technology held the promise for a
better future.
*This biography is based largely on Nye’s (2000)
discussion of B. F. Skinner’s radical behaviorism.
A
P
Ph
ot
o
A L B E RT B A N D U R A
(b. 1925) was born in a
small town in northern
Alberta, Canada; he was
the youngest of six children
in a family of Eastern Eu-
ropean descent.* Bandura
spent his elementary and
high school years in the one
school in town, which was
short of teachers and resources. These meager
educational resources proved to be an asset
rather than a liability as Bandura early on learned
the skills of self-directedness, which would later
become one of his research themes. He earned his
PhD in clinical psychology from the University of
Iowa in 1952, and a year later he joined the faculty
at Stanford University. Bandura and his colleagues
did pioneering work in the area of social modeling
and demonstrated that modeling is a powerful
process that explains diverse forms of learning
(see Bandura 1971a, 1971b; Bandura & Walters,
1963). In his research programs at Stanford
University, Bandura and his colleagues explored
social learning theory and the prominent role of
observational learning and social modeling in
human motivation, thought, and action. By the
mid-1980s Bandura had renamed his theoretical
approach social cognitive theory, which shed light
on how we function as self-organizing, proactive,
self-reflective, and self-regulating beings (see
Bandura, 1986). This notion that we are not simply
reactive organisms shaped by environmental
forces or driven by inner impulses represented
a dramatic shift in the development of behavior
therapy. Bandura broadened the scope of behavior
therapy by exploring the inner cognitive-affective
forces that motivate human behavior.
Co
ur
te
sy
,D
r.
A
lb
er
tB
an
du
ra
,S
ta
nf
or
d
U
ni
ve
rs
ity
,P
al
o
A
lto
,C
A
28549_ch09_rev01.indd 245 20/09/11 3:52 PM
Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

246
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N
I
N
E
A R N O L D A . L A Z A R U S
(b. 1932) was born and
educated in Johannesburg,
South Africa. The young-
est of four children, he
grew up in a neighborhood
where there were very few
children, and he remembers
being lonely and frightened.
He learned to play the piano at an early age and
recalls, “When I was 7 I used to play like a talented
12-year-old, but when I turned 14 and still played
like a 12-year-old, I decided to quit!” His interests
then changed to bodybuilding, weight lifting, box-
ing, and wrestling. He adds, “I was a pathetically
skinny kid, often beaten up and bullied, so I started
training rather frantically” (personal communica-
tion, April 15, 2011). Through sheer determination
he ended up winning boxing and weight-lifting
competitions and planned to own and operate a
gym or health center.
Although Lazarus grew up in South Africa,
he strongly identified with the United States. At
an early age he felt that racism and discrimina-
tion were totally unacceptable. He entered col-
lege intending to major in English with a view to
journalism as a career but soon switched majors
to psychology. He obtained his master’s degree
in experimental psychology in 1957 and a PhD in
clinical psychology in 1960, and then went into full-
time private practice in Johannesburg. In 1963 he
was invited by Albert Bandura to teach at Stanford
University. Later he held teaching positions at
Temple University Medical School, Yale University,
and Rutgers University.
He has received many honors and won numer-
ous awards, including two Distinguished Profes-
sional Contributions Awards from the American
Psychological Association and the prestigious
Cummings PSYCHE AWARD. Lazarus has written
17 books and more than 300 professional articles.
He is a pioneer in clinical behavior therapy and
the developer of multimodal therapy, which is
a comprehensive, systematic, holistic approach
to behavior therapy. Although the assessment
process is multimodal, the treatment is cognitive
behavioral and draws on empirically supported
methods. In terms of clinical practice, behavior
therapy and multimodal therapy are very similar.
He is recognized as an authority on brief, efficient,
and effective psychotherapy.
In addition to his contribution to the develop-
ment of behavior therapy, Lazarus has shown a
keen interest in the subject of dual and multiple
relationships in psychotherapy. Through his writing
and lecturing on this topic, he has done a great deal
to challenge the rigidity of a rule-based approach
to practicing psychotherapy. One significant book
Co
ur
te
sy
of
th
e
La
za
ru
s
In
st
itu
te
There are some existential qualities inherent
in Bandura’s social cognitive theory. Bandura has
produced a wealth of empirical evidence that dem-
onstrates the life choices we have in all aspects
of our lives. In Self-Efficacy: The Exercise of Control
(Bandura, 1997), Bandura shows the compre-
hensive applications of his theory of self-efficacy
to areas such as human development, psychol-
ogy, psychiatry, education, medicine and health,
athletics, business, social and political change, and
international affairs.
Bandura has concentrated on four areas of
research: (1) the power of psychological modeling
in shaping thought, emotion, and action; (2) the
mechanisms of human agency, or the ways people
influence their own motivation and behavior
through choice; (3) people’s perceptions of their
efficacy to exercise influence over the events that
affect their lives; and (4) how stress reactions and
depressions are caused. Bandura has created one
of the few mega-theories that still thrive at the
beginning of the 21st century. He has shown that
people need a sense of self-efficacy and resilience
to create a successful life and to meet the inevita-
ble obstacles and adversities they encounter.
To date Bandura has written nine books, many
of which have been translated into various lan-
guages. In 2004 he received the Outstanding Life-
time Contribution to Psychology Award from the
American Psychological Association. In his early
80s, Bandura continues to teach and do research
at Stanford University and to travel throughout the
world. He still makes time for hiking, opera, being
with his family, and wine tasting in the Napa and
Sonoma valleys.
*This biography is based largely on Pajares’s
(2004) discussion of Bandura’s life and work.
28549_ch09_rev01.indd 246 20/09/11 3:52 PM
Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

247
B
E
H
A
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I
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T
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i n t r o d u c t i o n
Behavior therapy practitioners focus on directly observable behavior, current de-
terminants of behavior, learning experiences that promote change, tailoring treat-
ment strategies to individual clients, and rigorous assessment and evaluation.
Behavior therapy has been used to treat a wide range of psychological disorders
with different client populations. Anxiety disorders, depression, posttraumatic
stress disorder, substance abuse, eating and weight disorders, sexual problems,
pain management, and hypertension have all been successfully treated using this
approach (Wilson, 2011). Behavioral procedures are used in the fi elds of develop-
mental disabilities, mental illness, education and special education, community
psychology, clinical psychology, rehabilitation, business, self-management, sports
psychology, health-related behaviors, medicine, and gerontology (Miltenberger,
2012; Wilson, 2011).
Historical Background
The behavioral approach had its origin in the 1950s and early 1960s, and it was
a radical departure from the dominant psychoanalytic perspective. The behavior
therapy movement differed from other therapeutic approaches in its application of
principles of classical and operant conditioning (which will be explained shortly)
to the treatment of a variety of problem behaviors. Today, it is diffi cult to fi nd
a consensus on the defi nition of behavior therapy because the fi eld has grown,
become more complex, and is marked by a diversity of views. Contemporary
behavior therapy is no longer limited to treatments based on traditional learning
theory (Antony & Roemer, 2011b). Indeed, as behavior therapy has evolved and
developed, it has increasingly overlapped in some ways with other psychotherapeutic
approaches (Wilson, 2011). Behavior therapists now use a variety of evidence-based
techniques in their practices, including cognitive therapy, social skills training,
relaxation training, and mindfulness strategies—all of which are discussed in this
chapter. The following historical sketch of behavior therapy is largely based on
Spiegler and Guevremont (2010).
Traditional behavior therapy arose simultaneously in the United States, South
Africa, and Great Britain in the 1950s. In spite of harsh criticism and resistance
from psychoanalytic psychotherapists, the approach has survived. Its focus was on
demonstrating that behavioral conditioning techniques were effective and were a
viable alternative to psychoanalytic therapy.
In the 1960s Albert Bandura developed social learning theory, which combined
classical and operant conditioning with observational learning. Bandura made
cognition a legitimate focus for behavior therapy. During the 1960s a number of
is Dual Relationships and Psychotherapy, (Lazarus &
Zur, 2002). Arnold Lazarus is currently the presi-
dent of The Lazarus Institute in Skillman, New
Jersey, where his son (Clifford N. Lazarus, PhD)
is the executive director and his daughter-in-law
(Donna Astor-Lazarus, MSW, LCSW) is the
clinical director.
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cognitive behavioral approaches sprang up, which focus on cognitive representations
of the environment rather than on characteristics of the objective environment.
Contemporary behavior therapy emerged as a major force in psychology during
the 1970s, and it had a signifi cant impact on education, psychology, psychotherapy,
psychiatry, and social work. Behavioral techniques were expanded to provide solu-
tions for business, industry, and child-rearing problems as well. Behavior therapy
techniques were viewed as the treatment of choice for many psychological problems.
The 1980s were characterized by a search for new horizons in concepts and
methods that went beyond traditional learning theory. Behavior therapists con-
tinued to subject their methods to empirical scrutiny and to consider the impact
of the practice of therapy on both their clients and the larger society. Increased
attention was given to the role of emotions in therapeutic change, as well as to the
role of biological factors in psychological disorders. Two of the most signifi cant
developments in the fi eld were (1) the continued emergence of cognitive behavior
therapy as a major force and (2) the application of behavioral techniques to the
prevention and treatment of health-related disorders.
By the late 1990s the Association for Behavioral and Cognitive Therapies (ABCT)
(formerly known as the Association for Advancement of Behavior Therapy) claimed
a membership of about 4,500. Currently, ABCT includes approximately 6,000
mental health professionals and students who are interested in empirically based
behavior therapy or cognitive behavior therapy. This name change and description
reveals the current thinking of integrating behavioral and cognitive therapies.
By the early 2000s, the behavioral tradition had broadened considerably, which
involved enlarging the scope of research and practice. This newest development,
sometimes known as the “third wave” of behavior therapy, includes dialectical
behavior therapy (DBT), mindfulness-based stress reduction (MBSR), mindfulness-
based cognitive therapy (MBCT), and acceptance and commitment therapy (ACT).
See the video program for Chapter 9, DVD for Theory and Practice of Counseling
and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you view
the brief lecture for each chapter prior to reading the chapter.
Four Areas of Development
Contemporary behavior therapy can be understood by considering four major
areas of development: (1) classical conditioning, (2) operant conditioning, (3) social-
cognitive theory, and (4) cognitive behavior therapy.
Classical conditioning (respondent conditioning) refers to what happens prior
to learning that creates a response through pairing. A key fi gure in this area is
Ivan Pavlov who illustrated classical conditioning through experiments with dogs.
Placing food in a dog’s mouth leads to salivation, which is respondent behavior.
When food is repeatedly presented with some originally neutral stimulus (some-
thing that does not elicit a particular response), such as the sound of a bell, the dog
will eventually salivate to the sound of the bell alone. However, if a bell is sounded
repeatedly but not paired again with food, the salivation response will eventually
diminish and become extinct. An example of a procedure that is based on the clas-
sical conditioning model is Joseph Wolpe’s systematic desensitization, which is
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described later in this chapter. This technique illustrates how principles of learn-
ing derived from the experimental laboratory can be applied clinically. Desensiti-
zation can be applied to people who, through classical conditioning, developed an
intense fear of fl ying after having a frightening experience while fl ying.
Technically one can develop an intense fear of fl ying without having a frighten-
ing experience personally. For example, someone may see visual images of a plane
crashing off the coast of Brazil and develop a fear of fl ying even though that person
has never fl own anywhere. Some researchers hold a different view and believe
that fear of fl ying may be due primarily to claustrophobia (Frank Dattilio, personal
communication, September 24, 2010).
Most of the signifi cant responses we make in everyday life are examples of
operant behaviors, such as reading, writing, driving a car, and eating with uten-
sils. Operant conditioning involves a type of learning in which behaviors are infl u-
enced mainly by the consequences that follow them. If the environmental changes
brought about by the behavior are reinforcing—that is, if they provide some reward
to the organism or eliminate aversive stimuli—the chances are increased that the
behavior will occur again. If the environmental changes produce no reinforcement
or produce aversive stimuli, the chances are lessened that the behavior will recur.
Positive and negative reinforcement, punishment, and extinction techniques, de-
scribed later in this chapter, illustrate how operant conditioning in applied settings
can be instrumental in developing prosocial and adaptive behaviors. Operant tech-
niques are used by behavioral practitioners in parent education programs and with
weight management programs.
The behaviorists of both the classical and operant conditioning models excluded
any reference to mediational concepts, such as the role of thinking processes,
attitudes, and values. This focus is perhaps due to a reaction against the insight-
oriented psychodynamic approaches. The social learning approach (or the social-
cognitive approach) developed by Albert Bandura and Richard Walters (1963) is
interactional, interdisciplinary, and multimodal (Bandura, 1977, 1982). Social-
cognitive theory involves a triadic reciprocal interaction among the environment,
personal factors (beliefs, preferences, expectations, self-perceptions, and interpre-
tations), and individual behavior. In the social-cognitive approach the environmen-
tal events on behavior are mainly determined by cognitive processes governing
how environmental infl uences are perceived by an individual and how these events
are interpreted (Wilson, 2011). A basic assumption is that people are capable of self-
directed behavior change and that the person is the agent of change. For Bandura
(1982, 1997), self-effi cacy is the individual’s belief or expectation that he or she can
master a situation and bring about desired change. An example of social learning
is ways people can develop effective social skills after they are in contact with other
people who effectively model interpersonal skills.
Cognitive behavior therapy (CBT) represents the mainstream of contemporary
behavior therapy and is a popular theoretical orientation among psychologists.
Cognitive behavioral therapy operates on the assumption that what people believe
infl uences how they act and feel. Since the early 1970s, the behavioral movement
has conceded a legitimate place to thinking, even to the extent of giving cognitive
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factors a central role in understanding and treating emotional and behavioral prob-
lems. By the mid-1970s cognitive behavior therapy had replaced behavior therapy as
the accepted designation, and the fi eld began emphasizing the interaction among
affective, behavioral, and cognitive dimensions (Lazarus, 2008a; Wilson, 2011).
Today only the integrative therapies are more popular than CBT (Hollon &
DiGiuseppe, 2011). A good example of this more integrative approach of cognitive
and behavioral dimensions is multimodal therapy, which is discussed later in this
chapter. Many techniques, particularly those developed within the last three dec-
ades, emphasize cognitive processes that involve private events such as the client’s
self-talk as mediators of behavior change (see Bandura, 1969, 1986; Beck, 1976;
Beck & Weishaar, 2011).
Contemporary behavior therapy has much in common with cognitive behavior
therapy in which the mechanism of change is both cognitive (modifying thoughts
to change behaviors) and behavioral (altering external factors that lead to behav-
ior change) (Follette & Callaghan, 2011). Considered broadly, the term “behavior
therapy” refers to practices based primarily on social-cognitive theory and encom-
passes a range of cognitive principles and procedures (Wilson, 2011). This chapter
goes beyond the traditional behavioral perspective and deals mainly with applied
aspects of this model. Chapter 10 is devoted to the cognitive behavioral approaches,
which focus on changing clients’ cognitions (thoughts and beliefs) that maintain
psychological problems.
k e y c o n c e p t s
View of Human Nature
Modern behavior therapy is grounded on a scientifi c view of human behavior that
accommodates a systematic and structured approach to counseling. This view does
not rest on a deterministic assumption that humans are a mere product of their
sociocultural conditioning. Rather, the current view is that the person is the pro-
ducer and the product of his or her environment.
The current trend in behavior therapy is toward developing procedures that
give control to clients and thus increase their range of freedom. Behavior therapy
aims to increase people’s skills so that they have more options for responding. By
overcoming debilitating behaviors that restrict choices, people are freer to select
from possibilities that were not available to them earlier, which increases individ-
ual freedom. People have the capacity to choose how they will respond to external
events in their environment, which makes it possible for therapists to use behavio-
ral methods to attain humanistic ends (Kazdin, 1978, 2001).
Basic Characteristics and Assumptions
Seven key characteristics of behavior therapy are described below.
1. Behavior therapy is based on the principles and procedures of the scientifi c meth-
od. Experimentally derived principles of learning are systematically applied to help
people change their maladaptive behaviors. The distinguishing characteristic of
behavioral practitioners is their systematic adherence to precision and to empirical
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evaluation. Behavior therapists state treatment goals in concrete objective terms
to make replication of their interventions possible. Treatment goals are agreed
upon by the client and the therapist. Throughout the course of therapy, the thera-
pist assesses problem behaviors and the conditions that are maintaining them.
Evaluation methods are used to discern the effectiveness of both assessment and
treatment procedures. Therapeutic techniques employed must have demonstrated
effectiveness. In short, behavioral concepts and procedures are stated explicitly,
tested empirically within a conceptual framework, and revised continually.
2. Behavior is not limited to overt actions a person engages in that we can observe;
behavior also includes internal processes such as cognitions, images, beliefs, and
emotions. The key characteristic of a behavior is that it is something that can be
operationally defi ned.
3. Behavior therapy deals with the client’s current problems and the factors
infl uencing them, as opposed to an analysis of possible historical determinants.
Emphasis is on specifi c factors that infl uence present functioning and what fac-
tors can be used to modify performance. At times understanding of the past may
offer useful information about environmental events related to present behavior.
Behavior therapists look to the current environmental events that maintain prob-
lem behaviors and help clients produce behavior change by changing environmen-
tal events, through a process called functional assessment, or what Wolpe (1990)
referred to as a “behavioral analysis.” Behavior therapy recognizes the importance
of the individual, the individual’s environment, and the interaction between the
person and the environment in facilitating change.
4. Clients involved in behavior therapy are expected to assume an active role by en-
gaging in specifi c actions to deal with their problems. Rather than simply talking
about their condition, clients are required to do something to bring about change.
Clients monitor their behaviors both during and outside the therapy sessions,
learn and practice coping skills, and role-play new behavior. Therapeutic tasks that
clients carry out in daily life, or homework assignments, are a basic part of this ap-
proach. Behavior therapy is an action-oriented and an educational approach, and
learning is viewed as being at the core of therapy. Clients learn new and adaptive
behaviors to replace old and maladaptive behaviors.
5. This approach assumes that change can take place without insight into underly-
ing dynamics and without understanding the origins of a psychological problem.
Behavior therapists operate on the premise that changes in behavior can occur prior
to or simultaneously with understanding of oneself, and that behavioral chang-
es may well lead to an increased level of self-understanding. While it is true that
insight and understanding about the contingencies that exacerbate one’s problems
can supply motivation to change, knowing that one has a problem and knowing
how to change it are two different things (Martell, 2007).
6. Assessment is an ongoing process of observation and self-monitoring that
focuses on the current determinants of behavior, including identifying the problem
and evaluating the change; assessment informs the treatment process. Therapists
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also assess their clients’ cultures as part of their social environments, including
social support networks relating to target behaviors (Tanaka-Matsumi, Higgin-
botham, & Chang, 2002). Critical to behavioral approaches is the careful assess-
ment and evaluation of the interventions used to determine whether the behavior
change resulted from the procedure.
7. Behavioral treatment interventions are individually tailored to specifi c prob-
lems experienced by the client. Several therapy techniques may be used to treat an
individual client’s problems. An important question that serves as a guide for this
choice is, “What treatment, by whom, is the most effective for this individual with
that specifi c problem and under which set of circumstances?” (Paul, 1967, p. 111).
t h e t h e r a p e u t i c p r o c e s s
Therapeutic Goals
Goals occupy a place of central importance in behavior therapy. The general goals
of behavior therapy are to increase personal choice and to create new conditions
for learning. The client, with the help of the therapist, defi nes specifi c treatment
goals at the outset of the therapeutic process. Although assessment and treatment
occur together, a formal assessment takes place prior to treatment to determine
behaviors that are targets of change. Continual assessment throughout therapy
determines the degree to which identifi ed goals are being met. It is important to
devise a way to measure progress toward goals based on empirical validation.
Contemporary behavior therapy stresses clients’ active role in deciding about
their treatment. The therapist assists clients in formulating specifi c measurable
goals. Goals must be clear, concrete, understood, and agreed on by the client and
the counselor. The counselor and client discuss the behaviors associated with the
goals, the circumstances required for change, the nature of subgoals, and a plan of
action to work toward these goals. This process of determining therapeutic goals
entails a negotiation between client and counselor that results in a contract that
guides the course of therapy. Behavior therapists and clients alter goals throughout
the therapeutic process as needed.
Therapist’s Function and Role
Behavior therapists conduct a thorough functional assessment (or behavioral anal-
ysis) to identify the maintaining conditions by systematically gathering informa-
tion about situational antecedents (A), the dimensions of the problem behavior
(B), and the consequences (C) of the problem. This is known as the ABC model,
and the goal of a functional assessment of a client’s behavior is to understand the
ABC sequence. This model of behavior suggests that behavior (B) is infl uenced by
some particular events that precede it, called antecedents (A), and by certain events
that follow it, called consequences (C). Antecedent events cue or elicit a certain
behavior. For example, with a client who has trouble going to sleep, listening to a
relaxation tape may serve as a cue for sleep induction. Turning off the lights and
removing the television from the bedroom may elicit sleep behaviors as well. Con-
sequences are events that maintain a behavior in some way, either by increasing
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or decreasing it. For example, a client may be more likely to return to counseling
after the counselor offers verbal praise or encouragement for having come in or
for having completed some homework. A client may be less likely to return if
the counselor is consistently late to sessions. In doing a behavioral assessment
interview, the therapist’s task is to identify the particular antecedent and conse-
quent events that infl uence, or are functionally related to, an individual’s behavior
(Cormier, Nurius, & Osborn, 2013).
Behaviorally oriented practitioners tend to be active and directive and to func-
tion as consultants and problem solvers. They rely heavily on empirical evidence
about the effi cacy of the techniques they apply to particular problems. Behavio-
ral practitioners must possess intuitive skills and clinical judgment in selecting
appropriate treatment methods and in determining when to implement specifi c
techniques (Wilson, 2011). They pay close attention to the clues given by clients,
and they are willing to follow their clinical hunches. They use some techniques
common to other approaches, such as summarizing, refl ection, clarifi cation, and
open-ended questioning. However, behavioral clinicians perform other functions
as well (Miltenberger, 2012; Spiegler & Guevremont, 2010):
• The therapist strives to understand the function of client behaviors, including
how certain behaviors originated and how they are sustained. With this under-
standing, the therapist formulates initial treatment goals and designs and
implements a treatment plan to accomplish these goals.
• The behavioral clinician uses strategies that have research support for use with
a particular kind of problem. These evidence-based strategies promote generali-
zation and maintenance of behavior change. A number of these strategies are
described later in this chapter.
• The clinician evaluates the success of the change plan by measuring progress
toward the goals throughout the duration of treatment. Outcome measures are
given to the client at the beginning of treatment (called a baseline) and collected
again periodically during and after treatment to determine whether the strategy
and treatment plan are working. If not, adjustments are made in the strategies
being used.
• A key task of the therapist is to conduct follow-up assessments to see whether
the changes are durable over time. Clients learn how to identify and cope with
potential setbacks. The emphasis is on helping clients maintain changes over
time and acquire behavioral and cognitive coping skills to prevent relapses.
Let’s examine how a behavior therapist might perform these functions. A client
comes to therapy to reduce her anxiety, which is preventing her from leaving the
house. The therapist is likely to begin with a specifi c analysis of the nature of her
anxiety. The therapist will ask how she experiences the anxiety of leaving her house,
including what she actually does in these situations. Systematically, the therapist
gathers information about this anxiety. When did the problem begin? In what
situations does it arise? What does she do at these times? What are her feelings
and thoughts in these situations? Who is present when she experiences anxiety?
What does she do to reduce the anxiety? How do her present fears interfere with
living effectively? After this assessment, specifi c behavioral goals are developed,
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and strategies such as relaxation training, systematic desensitization, and exposure
therapy are designed to help the client reduce her anxiety to a manageable level.
The therapist will get a commitment from the client to work toward the specifi ed
goals, and the two of them will evaluate the client’s progress toward meeting these
goals throughout the duration of therapy.
For a description of applying a behavioral approach to the assessment and treat-
ment of an individual client, see Dr. Sherry Cormier’s behavioral interventions
with Ruth in Case Approach to Counseling and Psychotherapy (Corey, 2013a, chap. 7).
Client’s Experience in Therapy
One of the unique contributions of behavior therapy is that it provides the therapist
with a well-defi ned system of procedures to employ. Both therapist and client have
clearly defi ned roles, and the importance of client awareness and participation in
the therapeutic process is stressed. Behavior therapy is characterized by an active
role for both therapist and client. A large part of the therapist’s role is to teach
concrete skills through the provision of instructions, modeling, and performance
feedback. The client engages in behavioral rehearsal with feedback until skills are
well learned and generally receives active homework assignments (such as self-
monitoring of problem behaviors) to complete between therapy sessions. Behavior
clinicians emphasize that changes clients make in therapy need to be translated
into their daily lives. It is important for clients to be motivated to change, and they
are expected to cooperate in carrying out therapeutic activities, both during therapy
sessions and in everyday life. If clients are not involved in this way, the chances
are slim that therapy will be successful. However, if clients are not motivated, an-
other behavioral strategy that has considerable empirical support is motivational
interviewing (Miller & Rollnick, 2002). This strategy involves honoring the client’s
resistance in such a way that his or her motivation to change is increased over time
(Cormier et al., 2013).
Clients are encouraged to experiment for the purpose of enlarging their rep-
ertoire of adaptive behaviors. Counseling is not complete unless actions follow
verbalizations. Behavioral practitioners make the assumption that it is only when
the transfer of changes is made from the sessions to everyday life that the effects
of therapy can be considered successful. Clients are as aware as the therapist is
regarding when the goals have been accomplished and when it is appropriate to
terminate treatment. It is clear that clients are expected to do more than merely
gather insights; they need to be willing to make changes and to continue imple-
menting new behavior once formal treatment has ended.
Relationship Between Therapist and Client
The charge is often made that the importance of the relationship between client
and therapist is discounted in behavior therapy. Antony and Roemer (2011b) ac-
knowledge that examining the effi cacy of particular behavioral techniques has been
given more emphasis than the quality of the therapeutic relationship in behavior
therapy. However, behavioral practitioners have increasingly recognized the role
of the therapeutic relationship and therapist behavior as critical factors related to
the process and outcome of treatment. Today, most behavioral practitioners stress
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the value of establishing a collaborative working relationship with their clients. For
example, Lazarus (1993) believes a fl exible repertoire of relationship styles, plus a
wide range of techniques, enhances treatment outcomes. He emphasizes the need
for therapeutic fl exibility and versatility above all else. Lazarus contends that the
cadence of client–therapist interaction differs from individual to individual and
even from session to session. The skilled behavior therapist conceptualizes prob-
lems behaviorally and makes use of the client–therapist relationship in facilitating
change.
As you will recall, the experiential therapies (existential therapy, person-centered
therapy, and Gestalt therapy) place primary emphasis on the nature of the en-
gagement between counselor and client. In contrast, most behavioral practitioners
contend that factors such as warmth, empathy, authenticity, permissiveness, and
acceptance are necessary, but not suffi cient, for behavior change to occur. The client–
therapist relationship is a foundation on which therapeutic strategies are built to
help clients change in the direction they wish.
a p p l i c at i o n : t h e r a p e u t i c
t e c h n i q u e s a n d p r o c e d u r e s
A strength of the behavioral approaches is the development of specifi c therapeutic
procedures that must be shown to be effective through objective means. The re-
sults of behavioral interventions become clear because therapists receive continual
direct feedback from their clients. A hallmark of the behavioral approaches is that
the therapeutic techniques are empirically supported and evidence-based practice
is highly valued. To its credit, the effectiveness of behavior therapy has been re-
searched with different populations and a wide array of disorders.
According to Lazarus (1989, 1992b, 1996b, 1997a, 2005, 2008a, 2008b),
behavioral practitioners can incorporate into their treatment plans any technique
that can be demonstrated to effectively change behavior. Lazarus advocates the
use of diverse techniques, regardless of their theoretical origin. It is clear that
behavior therapists do not have to restrict themselves only to methods derived from
learning theory. Likewise, behavioral techniques can be incorporated into other
approaches. This is illustrated later in this chapter in the sections on the incorpora-
tion of mindfulness and acceptance-based approaches into the practice of behavior
therapy.
The therapeutic procedures used by behavior therapists are specifi cally designed
for a particular client rather than being randomly selected from a “bag of tech-
niques.” Therapists are often quite creative in their interventions. In the following
sections I describe a range of behavioral techniques available to the practitioner:
applied behavioral analysis, relaxation training, systematic desensitization, expo-
sure therapies, eye movement desensitization and reprocessing, social skills train-
ing, self-management programs and self-directed behavior, multimodal therapy,
and mindfulness and acceptance-based approaches. These techniques do not
encompass the full spectrum of behavioral procedures, but they do represent a
sample of the approaches used in the practice of contemporary behavior therapy.
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Applied Behavioral Analysis: Operant
Conditioning Techniques
This section describes a few key principles of operant conditioning: positive rein-
forcement, negative reinforcement, extinction, positive punishment, and negative
punishment. For a detailed treatment of the wide range of operant conditioning
methods that are part of contemporary behavior modifi cation, I recommend
Miltenberger (2012).
In applied behavior analysis, operant conditioning techniques and methods of
assessment and evaluation are applied to a wide range of problems in many differ-
ent settings (Kazdin, 2001). The most important contribution of applied behavior
analysis is that it offers a functional approach to understanding clients’ problems
and addresses these problems by changing antecedents and consequences (the
ABC model).
Behaviorists believe we respond in predictable ways because of the gains we
experience (positive reinforcement) or because of the need to escape or avoid
unpleasant consequences (negative reinforcement). Once clients’ goals have been
assessed, specifi c behaviors are targeted. The goal of reinforcement, whether posi-
tive or negative, is to increase the target behavior. Positive reinforcement involves
the addition of something of value to the individual (such as praise, attention,
money, or food) as a consequence of certain behavior. The stimulus that follows
the behavior is the positive reinforcer. For example, a child earns excellent grades
and is praised for studying by her parents. If she values this praise, it is likely that
she will have an investment in studying in the future. When the goal of a program
is to decrease or eliminate undesirable behaviors, positive reinforcement is often
used to increase the frequency of more desirable behaviors, which replace undesir-
able behaviors. In the above example, the parental praise functions as the positive
reinforcer and makes it more likely that the child will maintain or even increase
the frequency of studying and earning good grades. Note that if a child did not
value parental praise, this would not serve as a reinforcer. The reinforcer is not
defi ned by the form or substance that it takes but rather by the function it serves:
namely, to maintain or increase the frequency of a desired behavior.
Negative reinforcement involves the escape from or the avoidance of aversive
(unpleasant) stimuli. The individual is motivated to exhibit a desired behavior to
avoid the unpleasant condition. For example, a friend of mine does not appreci-
ate waking up to the shrill sound of an alarm clock. She has trained herself to
wake up a few minutes before the alarm sounds to avoid the aversive stimulus of
the alarm buzzer.
Another operant method of changing behavior is extinction, which refers to
withholding reinforcement from a previously reinforced response. In applied
settings, extinction can be used for behaviors that have been maintained by posi-
tive reinforcement or negative reinforcement. For example, in the case of chil-
dren who display temper tantrums, parents often reinforce this behavior by the
attention they give to it. An approach to dealing with problematic behavior is
to eliminate the connection between a certain behavior (tantrums) and positive
reinforcement (attention). In this example a parent uses extinction when during
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and after a child’s temper tantrum, the parent ignores the child’s tantrum-related
behaviors. Doing so can decrease or eliminate such behaviors through the ex-
tinction process. It should be noted that extinction might well have negative side
effects, such as anger and aggression. Also note that initially when using extinc-
tion that unwanted behaviors may increase temporarily. Extinction can reduce or
eliminate certain behaviors, but extinction does not replace those responses that
have been extinguished. For this reason, extinction is most often used in behav-
ior modifi cation programs in conjunction with various reinforcement strategies
(Kazdin, 2001).
Another way behavior is controlled is through punishment, sometimes re-
ferred to as aversive control, in which the consequences of a certain behavior result
in a decrease of that behavior. The goal of reinforcement is to increase target behav-
ior, but the goal of punishment is to decrease target behavior. Miltenberger (2012)
describes two kinds of punishment that may occur as a consequence of behavior:
positive punishment and negative punishment. In positive punishment an aver-
sive stimulus is added after the behavior to decrease the frequency of a behavior
(such as a time-out procedure with a child who is displaying misbehavior).
In negative punishment a reinforcing stimulus is removed following the behav-
ior to decrease the frequency of a target behavior (such as deducting money from
a worker’s salary for missing time at work, or taking television time away from a
child for misbehavior). In both kinds of punishment, the behavior is less likely to
occur in the future. These four operant procedures form the basis of behavior ther-
apy programs for parent skills training and are also used in the self-management
procedures that are discussed later in this chapter.
Some behavioral practitioners are opposed to using aversive control or punish-
ment, and recommended substituting positive reinforcement. The key principle in
the applied behavior analysis approach is to use the least aversive means possible
to change behavior, and positive reinforcement is known to be the most powerful
change agent. In everyday life, punishment often is used as a means of getting
revenge or expressing frustration. However, as Kazdin (2001) has noted, “punish-
ment in everyday life is not likely to teach lessons or suppress intolerable behavior
because of the specifi c punishments that are used and how they are applied” (p. 231).
Even in those cases when punishment suppresses undesirable responses, punish-
ment does not result in teaching desirable behaviors. Punishment should be used
only after nonaversive approaches have been implemented and found to be inef-
fective in changing problematic behavior (Kazdin, 2001; Miltenberger, 2012). It is
essential that reinforcement be used as a way to develop appropriate behaviors that
replace the behaviors that are suppressed.
Progressive Muscle Relaxation
Progressive muscle relaxation has become increasingly popular as a method of
teaching people to cope with the stresses produced by daily living. It is aimed at
achieving muscle and mental relaxation and is easily learned. After clients learn
the basics of relaxation procedures, it is essential that they practice these exercises
daily to obtain maximum results.
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Jacobson (1938) is credited with initially developing the progressive muscle
relaxation procedure. It has since been refi ned and modifi ed, and relaxation pro-
cedures are frequently used in combination with a number of other behavioral
techniques. These include systematic desensitization, assertion training, self-
management programs, audiotape recordings of guided relaxation procedures,
computer simulation programs, biofeedback-induced relaxation, hypnosis, medi-
tation, and autogenic training (teaching control of bodily and imaginal functions
through autosuggestion).
Progressive muscle relaxation involves several components. Clients are given
a set of instructions that teaches them to relax. They assume a passive and
relaxed position in a quiet environment while alternately contracting and relax-
ing muscles. This progressive muscle relaxation is explicitly taught to the client
by the therapist. Deep and regular breathing also is associated with producing
relaxation. At the same time clients learn to mentally “let go,” perhaps by focus-
ing on pleasant thoughts or images. Clients are instructed to actually feel and
experience the tension building up, to notice their muscles getting tighter and
study this tension, and to hold and fully experience the tension. It is useful for
clients to experience the difference between a tense and a relaxed state. The
client is then taught how to relax all the muscles while visualizing the various
parts of the body, with emphasis on the facial muscles. The arm muscles are
relaxed fi rst, followed by the head, the neck and shoulders, the back, abdo-
men, and thorax, and then the lower limbs. Relaxation becomes a well-learned
response, which can become a habitual pattern if practiced daily for about
25 minutes each day.
Relaxation procedures have been applied to a variety of clinical problems, ei-
ther as a separate technique or in conjunction with related methods. The most
common use has been with problems related to stress and anxiety, which are often
manifested in psychosomatic symptoms. Relaxation training has benefi ts in areas
such as preparing patients for surgery, teaching clients how to cope with chron-
ic pain, and reducing the frequency of migraine attacks (Ferguson & Sgambati,
2008). Some other ailments for which progressive muscle relaxation is helpful
include asthma, headache, hypertension, insomnia, irritable bowel syndrome, and
panic disorder (Cormier et al., 2013).
For an exercise of the phases of the progressive muscle relaxation procedure
that you can apply to yourself, see Student Manual for Theory and Practice of Coun-
seling and Psychotherapy (Corey, 2013b). For an excellent audiotape demonstration
of progressive muscle relaxation, see Dattilio (2006). For a more detailed discus-
sion of progressive muscle relaxation, see Ferguson and Sgambati (2008).
Systematic Desensitization
Systematic desensitization, which is based on the principle of classical condition-
ing, is a basic behavioral procedure developed by Joseph Wolpe, one of the pio-
neers of behavior therapy. Clients imagine successively more anxiety-arousing
situations at the same time that they engage in a behavior that competes with
anxiety. Gradually, or systematically, clients become less sensitive (desensitized) to
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the anxiety-arousing situation. This procedure can be considered a form of expo-
sure therapy because clients are required to expose themselves to anxiety-arousing
images as a way to reduce anxiety.
Systematic desensitization is an empirically researched behavior therapy pro-
cedure that is time consuming, yet it is clearly effective and effi cient in reducing
maladaptive anxiety and treating anxiety-related disorders, particularly in the area
of specifi c phobias (Cormier et al., 2013; Head & Gross, 2008; Spiegler & Guevre-
mont, 2010). Before implementing the desensitization procedure, the therapist
conducts an initial interview to identify specifi c information about the anxiety
and to gather relevant background information about the client. This interview,
which may last several sessions, gives the therapist a good understanding of who
the client is. The therapist questions the client about the particular circumstances
that elicit the conditioned fears. For instance, under what circumstances does the
client feel anxious? If the client is anxious in social situations, does the anxiety
vary with the number of people present? Is the client more anxious with women
or men? The client is asked to begin a self-monitoring process consisting of
observing and recording situations during the week that elicit anxiety responses.
Some therapists also administer a questionnaire to gather additional data about
situations leading to anxiety.
If the decision is made to use the desensitization procedure, the therapist gives
the client a rationale for the procedure and briefl y describes what is involved. Once
it has been determined that systematic desensitization is an appropriate form of
treatment, a three-step process unfolds: (1) relaxation training, (2) development
of a graduated anxiety hierarchy, and (3) systematic desensitization proper that
involves the presentation of hierarchy items while the client is in a deeply relaxed
state (Head & Gross, 2008).
The steps in progressive muscle relaxation, which were described earlier, are pre-
sented to the client. The therapist uses a very quiet, soft, and pleasant voice to teach
progressive muscular relaxation. The client is asked to create imagery of previously
relaxing situations, such as sitting by a lake or wandering through a beautiful fi eld.
It is important that the client reach a state of calm and peacefulness. The client is
instructed to practice relaxation both as a part of the desensitization procedure and
also outside the session on a daily basis.
The therapist then works with the client to develop an anxiety hierarchy for
each of the identifi ed areas. Stimuli that elicit anxiety in a particular area, such as
rejection, jealousy, criticism, disapproval, or any phobia, are analyzed. The thera-
pist constructs a ranked list of situations that elicit increasing degrees of anxiety
or avoidance. The hierarchy is arranged in order from the most anxiety-provoking
situation the client can imagine down to the situation that evokes the least anxiety.
If it has been determined that the client has anxiety related to fear of rejection, for
example, the highest anxiety-producing situation might be rejection by the spouse,
next, rejection by a close friend, and then rejection by a coworker. The least dis-
turbing situation might be a stranger’s indifference toward the client at a party.
Desensitization does not begin until several sessions after the initial interview
has been completed. Enough time is allowed for clients to learn relaxation in therapy
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sessions, to practice it at home, and to construct their anxiety hierarchy. The de-
sensitization process begins with the client reaching complete relaxation with eyes
closed. A neutral scene is presented, and the client is asked to imagine it. If the
client remains relaxed, he or she is asked to imagine the least anxiety-arousing
scene on the hierarchy of situations that has been developed. The therapist moves
progressively up the hierarchy until the client signals that he or she is experiencing
anxiety, at which time the scene is terminated. Relaxation is then induced again,
and the scene is reintroduced again until little anxiety is experienced to it. Treat-
ment ends when the client is able to remain in a relaxed state while imagining
the scene that was formerly the most disturbing and anxiety-producing. The core
of systematic desensitization is repeated exposure in the imagination to anxiety-
evoking situations without experiencing any negative consequences.
Homework and follow-up are essential components of successful desensiti-
zation. Clients are encouraged to practice selected relaxation procedures daily, at
which time they visualize scenes completed in the previous session. Gradually,
they can expose themselves to daily-life situations as a further way to manage their
anxieties. Clients tend to benefi t the most when they have a variety of ways to cope
with anxiety-arousing situations that they can continue to use once therapy has
ended (Head & Gross, 2008).
Systematic desensitization is among the most empirically supported therapy
methods available, especially for the treatment of anxiety (Head & Gross, 2008).
Not only does systematic desensitization have a good track record in dealing with
fears, it also has been used to treat a variety of conditions including anger, asth-
matic attacks, insomnia, motion sickness, nightmares, and sleepwalking (Spiegler,
2008). Systematic desensitization is often acceptable to clients because they are
gradually and symbolically exposed to anxiety-evoking situations.
For a more detailed discussion of systematic desensitization, see Head and
Gross (2008) and Cormier et al. (2013).
In Vivo Exposure and Flooding
Exposure therapies are designed to treat fears and other negative emotional
responses by introducing clients, under carefully controlled conditions, to the situ-
ations that contributed to such problems. Exposure is a key process in treating a
wide range of problems associated with fear and anxiety. Exposure therapy involves
systematic confrontation with a feared stimulus, either through imagination or in
vivo (live). Imaginal exposure can be used prior to implementing in vivo exposure
when a client’s fears are so severe that the client is unable to participate in live
exposure (Hazlett-Stevens & Craske, 2008). Whatever route is used, exposure in-
volves contact by clients with what they fi nd fearful. Desensitization is one type
of exposure therapy, but there are others. Two variations of traditional systematic
desensitization are in vivo exposure and fl ooding.
i n v i v o e x p o s u r e In vivo exposure involves client exposure to the ac-
tual anxiety-evoking events rather than simply imagining these situations. Live
exposure has been a cornerstone of behavior therapy for decades. Hazlett-
Stevens and Craske (2008) describe the key elements of the process of in vivo
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exposure. Typically, treatment begins with a functional analysis of objects or situ-
ations a person avoids or fears. Together, the therapist and the client generate a
hierarchy of situations for the client to encounter in ascending order of diffi culty.
In vivo exposure involves repeated systematic exposure to fear items, beginning
from the bottom of the hierarchy. Clients engage in a brief, graduated series
of exposures to feared events. As is the case with systematic desensitization,
clients learn responses incompatible with anxiety, such as responses involving
muscle relaxation. Clients are encouraged eventually to experience their full fear
response during exposure without engaging in avoidance. Between therapy ses-
sions, clients carry out self-directed exposure exercises. Clients’ progress with
home practice is reviewed, and the therapist provides feedback on how the client
could deal with any diffi culties encountered.
In some cases the therapist may accompany clients as they encounter feared
situations. For example, a therapist could go with clients in an elevator if they had
phobias of using elevators. Of course, when this kind of out-of-offi ce procedure is
used, matters of safety and appropriate ethical boundaries are always considered.
People who have extreme fears of certain animals could be exposed to these ani-
mals in real life in a safe setting with a therapist. Self-managed in vivo exposure—a
procedure in which clients expose themselves to anxiety-evoking events on their
own—is an alternative when it is not practical for a therapist to be with clients in
real-life situations.
f lo o d i n g Another form of exposure therapy is fl ooding, which refers to either
in vivo or imaginal exposure to anxiety-evoking stimuli for a prolonged period of
time. As is characteristic of all exposure therapies, even though the client experi-
ences anxiety during the exposure, the feared consequences do not occur.
In vivo fl ooding consists of intense and prolonged exposure to the actual anxiety-
producing stimuli. Remaining exposed to feared stimuli for a prolonged period
without engaging in any anxiety-reducing behaviors allows the anxiety to decrease
on its own. Generally, highly fearful clients tend to curb their anxiety through the
use of maladaptive behaviors. In fl ooding, clients are prevented from engaging in
their usual maladaptive responses to anxiety-arousing situations. In vivo fl ooding
tends to reduce anxiety rapidly.
Imaginal fl ooding is based on similar principles and follows the same proce-
dures except the exposure occurs in the client’s imagination instead of in daily life.
An advantage of using imaginal fl ooding over in vivo fl ooding is that there are no re-
strictions on the nature of the anxiety-arousing situations that can be treated. In vivo
exposure to actual traumatic events (airplane crash, rape, fi re, fl ood) is often not
possible nor is it appropriate for both ethical and practical reasons. Imaginal fl ood-
ing can re-create the circumstances of the trauma in a way that does not bring about
adverse consequences to the client. Survivors of an airplane crash, for example, may
suffer from a range of debilitating symptoms. They are likely to have nightmares
and fl ashbacks to the disaster; they may avoid travel by air or have anxiety about
travel by any means; and they probably have a variety of distressing symptoms such
as guilt, anxiety, and depression. In vivo and imaginal exposure, as well as fl ooding,
are frequently used in the behavioral treatment for anxiety-related disorders, specifi c
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phobia, social phobia, panic disorder, obsessive-compulsive disorder, posttraumatic
stress disorder, and agoraphobia (Hazlett-Stevens & Craske, 2008).
Because of the discomfort associated with prolonged and intense exposure,
some clients may not elect these exposure treatments. It is important for the behav-
ior therapist to work with the client to create motivation and readiness for exposure.
From an ethical perspective, clients should have adequate information about pro-
longed and intense exposure therapy before agreeing to participate. It is important
that they understand that anxiety will be induced as a way to reduce it. Clients need
to make informed decisions after considering the pros and cons of subjecting them-
selves to temporarily stressful aspects of treatment. Clients should be informed that
they can terminate exposure if they experience a high level of anxiety.
The repeated success of exposure therapy in treating various disorders has re-
sulted in exposure being used as a part of most behavioral treatments for anxiety
disorders. Spiegler and Guevremont (2010) conclude that exposure therapies are
the single most potent behavioral procedures available for anxiety-related disor-
ders, and they can have long-lasting effects. However, they add, using exposure as
a sole treatment procedure is not always suffi cient. In cases involving severe and
multifaceted disorders, more than one behavioral intervention is often required.
Increasingly, imaginal and in vivo exposure are being used in combination, which
fi ts with the trend in behavior therapy to use treatment packages as a way to en-
hance the effectiveness of therapy.
Eye Movement Desensitization and Reprocessing
Eye movement desensitization and reprocessing (EMDR) is a form of exposure
therapy that entails assessment and preparation, imaginal fl ooding, and cognitive
restructuring in the treatment of individuals with traumatic memories. The treat-
ment involves the use of rapid, rhythmic eye movements and other bilateral stimu-
lation to treat clients who have experienced traumatic stress. Developed by Francine
Shapiro (2001), this therapeutic procedure draws from a wide range of behavio-
ral interventions. Designed to assist clients in dealing with posttraumatic stress
disorders, EMDR has been applied to a variety of populations including children,
couples, sexual abuse victims, combat veterans, victims of crime, rape survivors,
accident victims, and individuals dealing with anxiety, panic, depression, grief, ad-
dictions, and phobias. The treatment consists of three basic phases involving as-
sessment and preparation, imaginal fl ooding, and cognitive restructuring.
Shapiro (2001) emphasizes the importance of the safety and welfare of the
client when using this approach. EMDR may appear simple to some, but the
ethical use of the procedure demands training and clinical supervision, as is
true of using exposure therapies in general. Because of the powerful reactions
from clients, it is essential that practitioners know how to safely and effectively
manage these occurrences. Therapists should not use this procedure unless they
receive proper training and supervision from an authorized EMDR instructor. A
more complete discussion of this behavioral procedure can be found in Shapiro
(2001, 2002a).
There is some controversy over whether the eye movements themselves create
change or the application of cognitive techniques paired with eye movements act
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as change agents. The role of lateral eye movements has yet to be clearly demon-
strated, and some evidence indicates that the eye movement component may not
be integral to the treatment (Prochaska & Norcross, 2010; Spiegler & Guevremont,
2010). In a review of controlled studies of EMDR in the treatment of trauma, Sha-
piro (2002b) reports that EMDR clearly outperforms no treatment and achieves
similar or superior results as other methods of treating trauma. When it comes
to the overall effectiveness of EMDR, Prochaska and Norcross (2010) note that
“in its 20-year history, EMDR has garnered more controlled research than any
other method used to treat trauma” (p. 236). In writing about the future of EMDR,
Prochaska and Norcross make several predictions: increasing numbers of practi-
tioners will receive training in EMDR; outcome research will shed light on EMDR’s
effectiveness compared to other current therapies for trauma; and further research
and practice will provide a sense of its effectiveness with disorders besides post-
traumatic stress disorder.
Social Skills Training
Social skills training is a broad category that deals with an individual’s ability to
interact effectively with others in various social situations; it is used to help clients
develop and achieve skills in interpersonal competence. Social skills involve being
able to communicate with others in a way that is both appropriate and effective.
Individuals who experience psychosocial problems that are partly caused by inter-
personal diffi culties are good candidates for social skills training. Typically, social
skills training involves various behavioral techniques such as psychoeducation,
modeling, behavior rehearsal, and feedback (Antony & Roemer, 2011b). Social
skills training is effective in treating psychosocial problems by increasing clients’
interpersonal skills (Segrin, 2008). Social skills involve the ability to relate to oth-
ers in appropriate and effective ways. Some of the desirable aspects of this training
are that it has a very broad base of applicability and that it can easily be tailored to
suit the particular needs of individual clients.
Segrin (2008) identifi es these key elements of social skills training, which entail
a collection of techniques: assessment, direct instruction and coaching, modeling,
role-playing, and homework assignments. Clients learn information that they can
apply to various interpersonal situations, and skills are modeled for them so they
can actually see how skills can be used. A key step involves the necessity of clients
putting into action the information they are acquiring. It is through role-playing
that individuals actively practice desired behaviors that are observed. Segrin notes
that by monitoring clients’ successes and failures therapists can fi ne-tune clients’
performances. The feedback and reinforcement clients receive assists them in con-
ceptualizing and using a new set of social skills that enables them to communicate
more effectively. A follow-up phase is critical for clients in establishing a range of
effective behaviors that can be applied to many social situations.
A few examples of evidence-based applications of social skills training include
alcohol/substance abuse, attention-defi cit/hyperactivity disorder, bullying, social
anxiety, emotional and behavioral problems in children, behavioral treatment for
couples, and depression (Antony & Roemer, 2011b; Segrin, 2008). A popular vari-
ation of social skills training is anger management training, which is designed for
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individuals who have trouble with aggressive behavior. Assertion training, which is
described next, is useful for people who lack assertive skills.
a s s e r t i o n t r a i n i n g One specialized form of social skills training consists
of teaching people how to be assertive in a variety of social situations. Many people
have diffi culty feeling that it is appropriate or right to assert themselves. People
who lack social skills frequently experience interpersonal diffi culties at home, at
work, at school, and during leisure time. Assertion training can be useful for those
(1) who have diffi culty expressing anger or irritation, (2) who have diffi culty saying
no, (3) who are overly polite and allow others to take advantage of them, (4) who
fi nd it diffi cult to express affection and other positive responses, (5) who feel they
do not have a right to express their thoughts, beliefs, and feelings, or (6) who have
social phobias.
The basic assumption underlying assertion training is that people have the
right (but not the obligation) to express themselves. One goal of assertion train-
ing is to increase people’s behavioral repertoire so that they can make the choice
of whether to behave assertively in certain situations. It is important that clients
replace maladaptive social skills with new skills. Another goal is teaching people
to express themselves in ways that refl ect sensitivity to the feelings and rights of
others. Assertion does not mean aggression; truly assertive people do not stand up
for their rights at all costs, ignoring the feelings of others.
Generally, the therapist both teaches and models desired behaviors the client
wants to acquire. These behaviors are practiced in the therapy offi ce and then en-
acted in everyday life. Most assertion training programs focus on clients’ negative
self-statements, self-defeating beliefs, and faulty thinking. People often behave in
unassertive ways because they don’t think they have a right to state a viewpoint or
ask for what they want or deserve. Thus their thinking leads to passive behavior.
Effective assertion training programs do more than give people skills and techniques
for dealing with diffi cult situations. These programs challenge people’s beliefs that
accompany their lack of assertiveness and teach them to make constructive self-state-
ments and to adopt a new set of beliefs that will result in assertive behavior.
Assertion training is often conducted in groups. When a group format is used,
the modeling and instructions are presented to the entire group, and members
rehearse behavioral skills in role-playing situations. After the rehearsal, the mem-
ber is given feedback that consists of reinforcing the correct aspects of the behavior
and instructions on how to improve the behavior. Each member engages in fur-
ther rehearsals of assertive behaviors until the skills are performed adequately in a
variety of simulated situations (Miltenberger, 2012).
Because assertion training is based on Western notions of the value of assert-
iveness, it may not be suited for clients with a cultural background that places
more emphasis on harmony than on being assertive. This approach is not a pana-
cea, but it can be an effective treatment for clients who have skill defi cits in asser-
tive behavior or for individuals who experience diffi culties in their interpersonal
relationships. Although counselors can adapt this form of social skills training
procedures to suit their own style, it is important to include behavioral rehearsal
and continual assessment as basic aspects of the program. If you are interested in
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learning more assertion training, consult Your Perfect Right: A Guide to Assertive
Behavior (Alberti & Emmons, 2008).
Self-Management Programs and Self-Directed Behavior
For some time there has been a trend toward “giving psychology away.” This involves
psychologists being willing to share their knowledge so that “consumers” can
increasingly lead self-directed lives and not be dependent on experts to deal with
their problems. Psychologists who share this perspective are primarily concerned
with teaching people the skills they will need to manage their own lives effectively.
An advantage of self-management techniques is that treatment can be extended
to the public in ways that cannot be done with traditional approaches to therapy.
Another advantage is that costs are minimal. Because clients have a direct role in
their own treatment, techniques aimed at self-change tend to increase involvement
and commitment to their treatment.
Self-management strategies include self-monitoring, self-reward, self-contract-
ing, and stimulus control. The basic idea of self-management assessments and in-
terventions is that change can be brought about by teaching people to use coping
skills in problematic situations. Generalization and maintenance of the outcomes are
enhanced by encouraging clients to accept the responsibility for carrying out these
strategies in daily life.
In self-management programs people make decisions concerning specifi c behav-
iors they want to control or change. People frequently discover that a major reason
they do not attain their goals is the lack of certain skills or unrealistic expectations of
change. Hope can be a therapeutic factor that leads to change, but unrealistic hope
can pave the way for a pattern of failures in a self-change program. A self-directed
approach can provide the guidelines for change and a plan that will lead to change.
For people to succeed in such a program, a careful analysis of the context of the
behavior pattern is essential, and people must be willing to follow some basic steps
such as those provided by Watson and Tharp (2007):
1. Selecting goals. Goals should be established one at a time, and they should be
measurable, attainable, positive, and signifi cant for you. It is essential that expecta-
tions be realistic.
2. Translating goals into target behaviors. Identify behaviors targeted for change.
Once targets for change are selected, anticipate obstacles and think of ways to
negotiate them.
3. Self-monitoring. Deliberately and systematically observe your own behavior, and
keep a behavioral diary, recording the behavior along with comments about the
relevant antecedent cues and consequences.
4. Working out a plan for change. Devise an action program to bring about actual
change. Various plans for the same goal can be designed, each of which can be
effective. Some type of self-reinforcement system is necessary in this plan because
reinforcement is the cornerstone of modern behavior therapy. Self-reinforcement
is a temporary strategy used until the new behaviors have been implemented in
everyday life. Take steps to ensure that the gains made will be maintained.
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5. Evaluating an action plan. Evaluate the plan for change to determine whether
goals are being achieved, and adjust and revise the plan as other ways to meet goals
are learned. Evaluation is an ongoing process rather than a one-time occurrence,
and self-change is a lifelong practice.
Self-management strategies have been successfully applied to many popula-
tions and problems, a few of which include coping with panic attacks, helping
children to cope with fear of the dark, increasing creative productivity, managing
anxiety in social situations, encouraging speaking in front of a class, increasing
exercise, control of smoking, and dealing with depression (Watson & Tharp, 2007).
Research on self-management has been conducted in a wide variety of health prob-
lems, a few of which include arthritis, asthma, cancer, cardiac disease, substance
abuse, diabetes, headaches, vision loss, depression, nutrition, and self-health care
(Cormier et al., 2013).
Multimodal Therapy: Clinical Behavior Therapy
Multimodal therapy is a comprehensive, systematic, holistic approach to behav-
ior therapy developed by Arnold Lazarus (1989, 1997a, 2005, 2008a). Lazarus
(2008a) claims that the term “multimodal behavior therapy” is somewhat of a mis-
nomer. Although the assessment process is multimodal, the treatment is cognitive
behavioral and draws upon empirically supported methods. In terms of clinical
practice, behavior therapy and multimodal therapy are very similar (Wilson, 2011).
Multimodal therapy is grounded in social-cognitive theory and applies diverse be-
havioral techniques to a wide range of problems. This approach serves as a major
link between some behavioral principles and the cognitive behavioral approach
that has largely replaced traditional behavioral therapy.
Multimodal therapy is an open system that encourages technical eclecticism in
that it applies diverse behavioral techniques to a wide range of problems. Multi-
modal therapists borrow techniques from many other therapy systems (Lazarus,
2008b). New techniques are constantly being introduced and existing techniques
refi ned, but they are never used in a shotgun manner. Multimodal therapists take
great pains to determine precisely what relationship and what treatment strategies
will work best with each client and under which particular circumstances. The
underlying assumption of this approach is that because individuals are troubled
by a variety of specifi c problems it is appropriate that a multitude of treatment
strategies be used in bringing about change. Therapeutic fl exibility and versatility,
along with breadth over depth, are highly valued, and multimodal therapists are
constantly adjusting their procedures to achieve the client’s goals. Therapists need
to decide when and how to be challenging or supportive and how to adapt their
relationship style to the needs of the client (Lazarus, 1993, 1997a). Multimodal
therapists tend to be very active during therapist sessions, functioning as train-
ers, educators, consultants, coaches, and role models. They provide information,
instruction, and feedback as well as modeling assertive behaviors. They offer sug-
gestions, positive reinforcements, and are appropriately self-disclosing.
t h e b a s i c i . d . The essence of Lazarus’s multimodal approach is the premise
that the complex personality of human beings can be divided into seven major areas
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of functioning: B 5 behavior; A 5 affective responses; S 5 sensations; I 5 images; C
5 cognitions; I 5 interpersonal relationships; and D 5 drugs, biological functions,
nutrition, and exercise (Lazarus, 1989, 1992a, 1992b, 1997a, 1997b, 2000, 2006).
Multimodal therapy begins with a comprehensive assessment of the seven mo-
dalities of human functioning and the interaction among them. A complete assess-
ment and treatment program must account for each modality of the BASIC I.D.,
which is the cognitive map linking each aspect of personality. Table 9.1 outlines
this process using questions Lazarus typically asks.
TA B L E 9 .1 The BASIC I.D. Assessment Process
M O D A L I T Y B E H A V I O R S Q U E S T I O N S T O A S K
Behavior Overt behaviors,
including acts, habits,
and reactions that
are observable and
measurable
What would you like to change?
How active are you?
What would you like to start doing?
What would you like to stop doing?
What are some of your main strengths?
What specifi c behaviors keep you from getting
what you want?
Affect Emotions, moods, and
strong feelings
What emotions do you experience most often?
What makes you laugh?
What makes you cry?
What makes you sad, mad, glad, scared?
What emotions are problematic for you?
Sensation Basic senses of touch,
taste, smell, sight, and
hearing
Do you suffer from unpleasant sensations,
such as pains, aches, dizziness, and so forth?
What do you particularly like or dislike in the
way of seeing, smelling, hearing, touching,
and tasting?
Imagery How we picture
ourselves, including
memories, dreams, and
fantasies
What are some bothersome recurring dreams
and vivid memories?
Do you have a vivid imagination?
How do you view your body?
How do you see yourself now?
How would you like to be able to see yourself
in the future?
Cognition Insights, philosophies,
ideas, opinions, self-
talk, and judgments
that constitute one’s
fundamental values,
attitudes, and beliefs
What are some ways in which you meet your
intellectual needs?
How do your thoughts affect your emotions?
What are the values and beliefs you most
cherish?
What are some negative things you say to
yourself?
What are some of your central faulty beliefs?
What are the main ‘shoulds,’ ‘oughts,’ and
‘musts’ in your life? How do they get in the
way of effective living?
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Interpersonal
relationships
Interactions with other
people
How much of a social being are you?
To what degree do you desire intimacy with
others?
What do you expect from the signifi cant
people in your life?
What do they expect from you?
Are there any relationships with others that
you would hope to change?
If so, what kinds of changes do you want?
Drugs/biology Drugs, nutritional
habits, and exercise
patterns
Are you healthy and health conscious?
Do you have any concerns about your health?
Do you take any prescribed drugs?
What are your habits pertaining to diet,
exercise, and physical fi tness?
Source: Lazarus 1989, 1997a, 2000.
A major premise of multimodal therapy is that breadth is often more important
than depth. The more coping responses a client learns in therapy, the less chance
there is for a relapse. Therapists identify one specifi c issue from each aspect of the
BASIC I.D. framework as a target for change and teach clients a range of tech-
niques they can use to combat faulty thinking, to learn to relax in stressful situ-
ations, and to acquire effective interpersonal skills. Clients can then apply these
skills to a broad range of problems in their everyday lives.
The preliminary investigation of the BASIC I.D. framework brings out some
central and signifi cant themes that can be productively explored using a detailed
life-history questionnaire. (See Lazarus and Lazarus, 2005, for the Multimodal
Life-History Inventory.) Once the main profi le of a person’s BASIC I.D. has been
established, the next step consists of an examination of the interactions among
the different modalities. It is essential that therapists start where the client is and
then move into other productive areas for exploration. Failure to comprehend the
client’s situation can easily leave the client feeling alienated and misunderstood
(Lazarus, 2000). For an illustration of how Dr. Lazarus applies the BASIC I.D.
assessment model to the case of Ruth, along with examples of various techniques
he uses, see Case Approach to Counseling and Psychotherapy (Corey, 2013a, chap. 7).
Mindfulness and Acceptance-Based
Cognitive Behavior Therapy
Over the last decade behavior therapy has evolved, resulting in an expansion of the
behavioral tradition. Newer facets of cognitive behavior therapy, labeled the “third
wave” of behavior therapy, emphasize considerations that were considered off
limits for behavior therapists until recently, including mindfulness, acceptance,
the therapeutic relationship, spirituality, values, meditation, being in the present
moment, and emotional expression (Hayes, Follette, & Linehan, 2004; Herbert &
Forman, 2011). Third-generation behavior therapies have been developed that
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center around fi ve interrelated core themes: (1) an expanded view of psychologi-
cal health, (2) a broad view of acceptable outcomes in therapy, (3) acceptance, (4)
mindfulness, and (5) creating a life worth living (Spiegler & Guevremont, 2010).
Mindfulness involves being aware of our experiencing in a receptive way and
engaging in activity based on this nonjudgmental awareness (Robins & Rosenthal,
2011). In mindfulness practice, clients train themselves to intentionally focus on their
present experience while at the same time achieving a distance from it. Mindfulness
involves developing an attitude of curiosity and compassion to present experience.
Clients learn to focus on one thing at a time and to bring their attention back to the
present moment when distractions arise.
As a clinical intervention, mindfulness shows promise across a broad range of
clinical problems, including for depression, generalized anxiety disorder, relation-
ship problems, and borderline personality disorder (Dimidjian & Linehan, 2008)
as well as being useful in the treatment of posttraumatic stress disorder among
military veterans. Through mindfulness exercises, veterans may be better able to
observe repetitive negative thinking and prevent extensive engagement with mala-
daptive ruminative processes (Vujanovic, Niles, Pietrefesa, Schmertz, & Potter,
2011). Many therapeutic approaches are incorporating mindfulness, meditation,
and other Eastern practices in the counseling process, and this trend seems likely
to continue (Worthington, 2011).
Acceptance is a process involving receiving one’s present experience without
judgment or preference, but with curiosity and kindness, and striving for full
awareness of the present moment (Germer, 2005b). Acceptance is not resigning
oneself to life’s problems; rather, it is an active process of self-affi rmation (Wilson,
2011). Acceptance is an alternative way of responding to our internal experience.
By replacing judgment, criticism, and avoidance with acceptance, the likely result
is increased adaptive functioning (Antony & Roemer, 2011b). The mindfulness and
acceptance approaches are good avenues for the integration of spirituality in the
counseling process.
The subjects of mindfulness and acceptance are only briefl y described in this
chapter. For a useful and extensive discussion of these topics, see Herbert and For-
man (2011), Acceptance and Mindfulness in Cognitive Behavior Therapy: Understand-
ing and Applying the New Therapies.
The four major approaches in the recent development of the behavioral tra-
dition include (1) dialectical behavior therapy (Linehan, 1993a, 1993b), which has
become a recognized treatment for borderline personality disorder; (2) mindfulness-
based stress reduction (Kabat-Zinn, 1990, 2003), which involves an 8- to 10-week
group program applying mindfulness techniques to coping with stress and pro-
moting physical and psychological health; (3) mindfulness-based cognitive therapy
(Segal et al., 2002), which is aimed primarily at treating depression; and (4) accept-
ance and commitment therapy (Hayes, Strosahl, & Houts, 2005; Hayes, Strosahl, &
Wilson, 2011), which is based on encouraging clients to accept, rather than
attempt to control or change, unpleasant sensations. All four of these approaches
use mindfulness strategies that have been subjected to empirical scrutiny, which
is a hallmark of the behavioral tradition.
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d i a l e c t i c a l b e h av i o r t h e r a p y ( d b t ) Formulated by Linehan
(1993a, 1993b), DBT is a promising blend of behavioral and psychoanalytic tech-
niques for treating borderline personality disorders. Like analytic therapy, DBT
emphasizes the importance of the psychotherapeutic relationship, validation of the
client, the etiologic importance of the client having experienced an “invalidating
environment” as a child, and confrontation of resistance.
DBT treatment strategies include both acceptance- and change-oriented strate-
gies. The treatment program is geared toward helping clients make changes in
their behavior and environment, and at the same time communicating accept-
ance of their current state (Robins & Rosenthal, 2011). To help clients who have
particular problems with emotional regulation, DBT teaches clients to recognize
and accept the existence of simultaneous, opposing forces. By acknowledging this
fundamental dialectic relationship—such as not wanting to engage in a certain
behavior, yet knowing they have to engage in the behavior if they want to achieve
a desired goal—clients can learn to integrate the opposing notions of acceptance
and change, and the therapist can teach clients how to regulate their emotions and
behaviors. Mindfulness procedures are taught and practiced to develop an attitude
of acceptance (Fishman, Rego, & Muller, 2011).
DBT employs behavioral and cognitive behavioral techniques, including a form
of exposure therapy in which the client learns to tolerate painful emotions without
enacting self-destructive behaviors. DBT integrates its cognitive behaviorism not
only with analytic concepts but also with the mindfulness training of “Eastern psy-
chological and spiritual practices (primarily Zen practice)” (Linehan, 1993b, p. 6).
Many of the treatment strategies used and skills taught in DBT have roots in Zen
Buddhist principles and practices. These include being aware of the present
moment, seeing reality without distortion, accepting reality without judgment, let-
ting go of attachments that result in suffering, developing a greater degree of accept-
ance of self and others, and entering fully into present activities without separating
oneself from ongoing events and interactions (Robins & Rosenthal, 2011).
DBT is highly structured, but goals are tailored to each individual. Therapists
assist clients in using whatever skills they possess or are learning to navigate crises
more effectively and to address problem behaviors (Robins & Rosenthal, 2011).
Skills are taught in four modules: mindfulness, interpersonal effectiveness, emo-
tional regulation, and distress tolerance (Simpson, 2011). Mindfulness is a funda-
mental skill in DBT and is considered the basis for other skills taught. Mindful-
ness helps clients to embrace and tolerate the intense emotions they experience
when facing distressing situations. Interpersonal effectiveness involves learning to
ask for what one needs and learning to cope with interpersonal confl ict. This skill
entails increasing the chances that a client’s goals will be met, while at the same
time not damaging the relationship. Emotion regulation includes identifying emo-
tions, identifying obstacles to changing emotions, reducing vulnerability, and in-
creasing positive emotions. Clients learn the benefi ts of regulating emotions such
as anger, depression, and anxiety. Distress tolerance is aimed at helping individuals
to calmly recognizing emotions associated with negative situations without be-
coming overwhelmed by these situations. Clients learn how to tolerate pain or
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discomfort skillfully. These skills are the route clients can take in achieving their
goals. “The therapy aims to assist clients to learn to control behavior, fully experi-
ence emotions, improve daily living skills, and achieve a sense of completeness”
(Simpson, 2011, p. 230).
DBT skills training is not a “quick fi x” approach. It generally involves a mini-
mum of one year of treatment and includes both individual therapy and skills train-
ing done in a group. DBT requires a behavioral contract. To competently practice
DBT, it is essential to obtain training in this approach. Because DBT places heavy
emphasis on didactic instruction and teaching mindfulness skills, therapists must
be competent in applying these skills and be able to model specifi c strategies and
attitudes for clients. Therapists who want to employ mindfulness strategies must
also have personal understanding and experience of these interventions to be able
to effectively use them with clients (Dimidjian & Linehan, 2008). A useful resource
for a more detailed discussion of DBT is Robins and Rosenthal (2011).
m i n d f u l n e s s – b a s e d s t r e s s r e d u c t i o n ( m b s r ) The essence of
mindfulness-based stress reduction (MBSR) consists of the notion that much of
our distress and suffering results from continually wanting things to be different
from how they actually are (Salmon, Sephton, & Dreeben, 2011). MBSR aims to
assist people in learning how to live more fully in the present rather than ruminating
about the past or being overly concerned about the future. MBSR does not actively
teach cognitive modifi cation techniques, nor does it label certain cognitions as
“dysfunctional,” because this is not consistent with the nonjudgmental attitude
one strives to cultivate in mindfulness practice.
The approach adopted in the MBSR program is to develop the capacity for
sustained directed attention through formal meditation practice. The skills taught
include sitting meditation and mindful yoga, which are aimed at cultivating mind-
fulness. The program includes a body scan meditation, which helps clients to
observe all the sensations in their body. Clients are encouraged to bring mindful-
ness into all of their daily activities, including standing, walking, and eating. Those
who are involved in the program are encouraged to practice formal mindfulness
meditation for 45 minutes daily. The MBSR program is designed to teach partici-
pants to relate to external and internal sources of stress in constructive ways. MBSR
places a heavy emphasis on experiential learning and the process of client self-
discovery (Dimidjian & Linehan, 2008). MBSR has many clinical applications, and
it is expected that the approach will evolve to address a range of negative psychologi-
cal states, such as anxiety, stress, and depression. This approach has many applica-
tions in the area of health and wellness and in promoting healthy lifestyle changes.
An excellent resource for a more detailed treatment of MBSR is Salmon, Sephton,
and Dreeben (2011).
m i n d f u l n e s s – b a s e d c o g n i t i v e t h e r a p y ( m b c t ) This program
is a comprehensive integration of the principles and skills of mindfulness applied
to the treatment of depression (Segal, Williams, & Teasdale, 2002). MBCT is an
8-week group treatment program adapted from Kabat-Zinn’s (1990) mindfulness-
based stress reduction program, and it includes components of cognitive behavior
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therapy. MBCT represents an integration of techniques from MBSR and teaching
cognitive behavioral interventions to clients. The primary aim is to change clients’
awareness of and relation to their negative thoughts. Participants are taught how
to respond in skillful and intentional ways to their automatic negative thought pat-
terns. Fesco, Flynn, Mennin, and Haigh (2011) describe the essence of the seven
sessions in the MBCT program:
• Therapy begins by identifying negative automatic thinking of people experienc-
ing depression and by introducing some basic mindfulness practices.
• In the second session, participants learn about the reactions they have to life
experiences and learn more about mindfulness practices.
• The third session is devoted to teaching breathing techniques and focused atten-
tion on their present experiencing.
• In session four, the emphasis is on learning to experience the moment without
becoming attached to outcomes as a way to prevent relapse.
• The fi fth session teaches participants how to accept their experiencing without
holding on.
• Session six is used to describe thoughts as “merely thoughts;” clients learn that
they do not have to act on their thoughts. They can tell themselves, “I am not my
thoughts” and “Thoughts are not facts.”
• In the fi nal sessions, participants learn how to take care of themselves, to pre-
pare for relapse, and to generalize their mindfulness practices to daily life.
MBCT emphasizes experiential learning, in-session practice, learning from feed-
back, completing homework assignments, and applying what is learned in the pro-
gram to challenging situations encountered outside of the sessions. The brevity of
MBCT makes this approach an effi cient and cost-effective treatment. For a more
detailed review of MBCT, see Fresco, Flynn, Mennin, and Haigh (2011).
acceptance and commitment therapy (act) Another mindfulness-
based approach is acceptance and commitment therapy (Hayes et al., 2005, 2011),
which involves fully accepting present experience and mindfully letting go of ob-
stacles. In this approach “acceptance is not merely tolerance—rather it is the active
nonjudgmental embracing of experience in the here and now” (Hayes, 2004, p.
32). Acceptance is a stance or posture from which to conduct therapy and from
which a client can conduct life that provides an alternative to contemporary forms
of cognitive behavioral therapy (Eifert & Forsyth, 2005). In contrast to the cognitive
behavioral approaches discussed in Chapter 10, in which dysfunctional thoughts
are identifi ed and challenged, in ACT there is little emphasis on changing the
content of a client’s thoughts. Instead, the emphasis is on acceptance (nonjudg-
mental awareness) of cognitions. The goal is for individuals to become aware of
and examine their thoughts. Clients learn how to change their relationship to their
thoughts. They learn how to accept and distance themselves from the thoughts
and feelings they may have been trying to deny. Hayes has found that confronting
maladaptive cognitions actually strengthens rather than reduces these cognitions.
The goal of ACT is to allow for increased psychological fl exibility. Values are a basic
part of the therapeutic process, and ACT practitioners might ask clients, “What do
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you want your life to stand for?” Therapy involves assisting clients to choose values
they want to live by, designing specifi c goals, and taking steps to achieve their goals
(Wilson, 2011).
In addition to acceptance, commitment to action is essential. Commitment
involves making mindful decisions about what is important in life and what the
person is willing to do to live a valued and meaningful life (Wilson, 2011). ACT
makes use of concrete homework and behavioral exercises as a way to create larger
patterns of effective action that will help clients live by their values (Hayes, 2004).
For example, one form of homework given to clients is asking them to write down
life goals or things they value in various aspects of their lives. The focus of ACT is
allowing experience to come and go while pursuing a meaningful life.
ACT is an effective form of therapy (Eifert & Forsyth, 2005) that continues to
infl uence the practice of behavior therapy. Germer (2005a) suggests “mindfulness
might become a construct that draws clinical theory, research, and practice closer
together, and helps integrate the private and professional lives of therapists” (p. 11).
According to Wilson (2011), ACT emphasizes common processes across clinical
disorders, which makes it easier to learn basic treatment skills. Practitioners can
then implement basic principles in diverse and creative ways. ACT has been effec-
tive for treatment of a variety of disorders, including for substance abuse, depres-
sion, anxiety, phobias, posttraumatic stress disorder, and panic disorder (Eifert &
Forsyth, 2005).
For an in-depth discussion of the role of mindfulness in psychotherapeutic prac-
tice, three highly recommended readings are Acceptance and Mindfulness in Cognitive
Behavior Therapy: Understanding and Applying the New Therapies (Herbert & Forman,
2011), Mindfulness and Acceptance: Expanding the Cognitive-Behavioral Tradition (Hay-
es et al., 2004), and Mindfulness and Psychotherapy (Germer et al., 2005).
Application to Group Counseling
Group-based behavioral approaches emphasize teaching clients self-management
skills and a range of new coping behaviors, as well as how to restructure their
thoughts. Clients can learn to use these techniques to control their lives, deal ef-
fectively with present and future problems, and function well after they complete
their group experience. Many groups are designed primarily to increase the cli-
ent’s degree of control and freedom in specifi c aspects of daily life.
Group leaders who function within a behavioral framework may develop tech-
niques from various theoretical viewpoints. Behavioral practitioners make use of a
brief, active, directive, structured, collaborative, psychoeducational model of ther-
apy that relies on empirical validation of its concepts and techniques. The leader
follows the progress of group members through the ongoing collection of data be-
fore, during, and after all interventions. Such an approach provides both the group
leader and the members with continuous feedback about therapeutic progress.
Today, many groups in community agencies demand this kind of accountability.
Behavioral group therapy has some unique characteristics that set it apart from
most of the other group approaches. A distinguishing characteristic of behavioral
practitioners is their systematic adherence to specifi cation and measurement. The
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specifi c unique characteristics of behavioral group therapy include (1) conducting
a behavioral assessment, (2) precisely spelling out collaborative treatment goals,
(3) formulating a specifi c treatment procedure appropriate to a particular problem,
and (4) objectively evaluating the outcomes of therapy. Behavior therapists tend to
utilize short-term, time-limited interventions aimed at effi ciently and effectively
solving problems and assisting members in developing new skills.
Behavioral group leaders assume the role of teacher and encourage members to
learn and practice skills in the group that they can apply to everyday living. Group
leaders typically assume an active, directive, and supportive role in the group and
apply their knowledge of behavioral principles and skills to the resolution of prob-
lems. They model active participation and collaboration by their involvement with
members in creating an agenda, designing homework, and teaching skills and
new behaviors. Leaders carefully observe and assess behavior to determine the
conditions that are related to certain problems and the conditions that will facili-
tate change. Members in behavioral groups identify specifi c skills that they lack
or would like to enhance. Assertiveness and social skills training fi t well into a
group format (Wilson, 2011). Relaxation procedures, behavioral rehearsal, mod-
eling, coaching, meditation, and mindfulness techniques are often incorporated
in behavioral groups. The experience of being mindful is expanded in the group
setting where people meditate and are still in the presence of others. Most of the
other techniques described earlier in this chapter can be applied to group work.
There are many different types of groups with a behavioral twist, or groups that
blend both behavioral and cognitive methods for specifi c populations. Structured
groups, with a psychoeducational focus, are especially popular in various settings
today. At least fi ve general approaches can be applied to the practice of behavioral
groups: (1) social skills training groups, (2) psychoeducational groups with spe-
cifi c themes, (3) stress management groups, (4) multimodal group therapy, and
(5) mindfulness and acceptance-based behavior therapy in groups.
For a more detailed discussion of cognitive behavioral approaches to groups,
see Corey (2012, chap.13).
b e h av i o r t h e r a p y f r o m a
m u lt i c u lt u r a l p e r s p e c t i v e
Strengths From a Diversity Perspective
Behavior therapy has some clear advantages over many other theories in coun-
seling culturally diverse clients. Because of their cultural and ethnic backgrounds,
some clients hold values that are contrary to the free expression of feelings and the
sharing of personal concerns. Behavioral counseling does not generally place em-
phasis on experiencing catharsis. Rather, it stresses changing specifi c behaviors
and developing problem-solving skills. Some potential strengths of the behavioral
approaches in working with diverse client populations include its specifi city, task
orientation, focus on objectivity, focus on cognition and behavior, action orienta-
tion, dealing with the present more than the past, emphasis on brief interventions,
teaching coping strategies, and problem-solving orientation. The attention given to
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transfer of learning and the principles and strategies for maintaining new behavior
in daily life are crucial. Clients who are looking for action plans and specifi c behav-
ioral change are likely to cooperate with this approach because they can see that it
offers them concrete methods for dealing with their problems of living.
Behavior therapy focuses on environmental conditions that contribute to a client’s
problems. Social and political infl uences can play a signifi cant role in the lives of
people of color through discriminatory practices and economic problems, and the
behavioral approach takes into consideration the social and cultural dimensions of
the client’s life. Behavior therapy is based on an experimental analysis of behavior in
the client’s own social environment and gives special attention to a number of spe-
cifi c conditions: the client’s cultural conception of problem behaviors, establishing
specifi c therapeutic goals, arranging conditions to increase the client’s expectation of
successful therapeutic outcomes, and employing appropriate social infl uence agents
(Tanaka-Matsumi et al., 2002). The foundation of ethical practice involves a thera-
pist’s familiarity with the client’s culture, as well as the competent application of this
knowledge in formulating assessment, diagnostic, and treatment strategies.
The behavioral approach has moved beyond treating clients for a specifi c symptom
or behavioral problem. Instead, it stresses a thorough assessment of the person’s life
circumstances to ascertain not only what conditions give rise to the client’s problems
but also whether the target behavior is amenable to change and whether such a change
is likely to lead to a signifi cant improvement in the client’s total life situation.
In designing a change program for clients from diverse backgrounds, effective
behavioral practitioners conduct a functional analysis of the problem situation.
This assessment includes the cultural context in which the problem behavior
occurs, the consequences both to the client and to the client’s sociocultural envi-
ronment, the resources within the environment that can promote change, and the
impact that change is likely to have on others in the client’s social surroundings.
Assessment methods should be chosen with the client’s cultural background in
mind (Spiegler & Guevremont, 2010; Tanaka-Matsumi et al., 2002). Counselors
must be knowledgeable as well as open and sensitive to issues such as these: What
is considered normal and abnormal behavior in the client’s culture? What are the
client’s culturally based conceptions of his or her problems? What is the potential
role of spirituality or religion in the client’s life? What kind of information about
the client is essential in making an accurate assessment?
Shortcomings From a Diversity Perspective
According to Spiegler and Guevremont (2010), a future challenge for behavior ther-
apists is to develop empirically based recommendations for how behavior therapy
can optimally serve culturally diverse clients. Although behavior therapy is sensi-
tive to differences among clients in a broad sense, behavior therapists need to be-
come more responsive to specifi c issues pertaining to all forms of diversity. Because
race, gender, ethnicity, and sexual orientation are critical variables that infl uence
the process and outcome of therapy, it is essential that behavior therapists pay
careful attention to these factors and address social justice issues as they arise in a
client’s therapy.
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276
In Stan’s case many specific and
interrelated problems can be identi-
fied through an assessment process.
Behaviorally, he is defensive, avoids eye contact,
speaks hesitantly, uses alcohol excessively, has a
poor sleep pattern, and displays various avoid-
ance behaviors in social and interpersonal situ-
ations. In the emotional area, Stan has a number
of specific problems, some of which include
anxiety, panic attacks, depression, fear of criti-
cism and rejection, feeling worthless and stupid,
and feeling isolated and alienated. He experi-
ences a range of physiological complaints such
as dizziness, heart palpitations, and headaches.
Cognitively, he worries about death and dying,
has many self-defeating thoughts and beliefs, is
governed by categorical imperatives (“shoulds,”
“oughts,” “musts”), engages in fatalistic thinking,
and compares himself negatively with others. In
the interpersonal area, Stan is unassertive, has an
unsatisfactory relationship with his parents, has
few friends, is afraid of contact with women and
fears intimacy, and feels socially inferior.
After completing this assessment, I focus on
helping Stan define the specific areas where he
would like to make changes. Before developing
a treatment plan, I assist Stan in understanding
the purposes of his behavior. I then educate Stan
about how the therapy sessions (and his work
outside of the sessions) can help him reach his
goals. Early during treatment I help Stan trans-
late some of his general goals into concrete and
measurable ones. When Stan says, “I want to
feel better about myself,” I help him define more
specific goals. When he says, “I want to get rid
of my inferiority complex,” I reply: “What exactly
do you mean by this?” “What are some situa-
tions in which you feel inferior?” “What do you
actually do that leads to feelings of inferiority?”
Stan’s concrete aims include his desire to func-
tion without drugs or alcohol. I suggest that he
keep a record of when he drinks and what events
lead to drinking. My hope is that Stan will estab-
lish goals that are based on positive markers, not
negative goals. Instead of focusing on what Stan
would like to get rid of, I am more interested in
what he would like to acquire and develop.
Stan indicates that he does not want to
feel apologetic for his existence. I introduce
behavioral skills training because he has trouble
talking with his boss and coworkers. I demon-
strate specific skills that he can use in
approaching them more directly and confidently.
This procedure includes modeling, role playing,
Behavior Therapy Applied to the Case of Stan
Some behavioral counselors may focus on using a variety of techniques in nar-
rowly treating specifi c behavioral problems. Instead of viewing clients in the con-
text of their sociocultural environment, these practitioners concentrate too much
on problems within the individual. In doing so they may overlook signifi cant
issues in the lives of clients. Such practitioners are not likely to bring about benefi –
cial changes for their clients.
The fact that behavioral interventions often work well raises an interesting
issue in multicultural counseling. When clients make signifi cant personal changes,
it is very likely that others in their environment will react to them differently.
Before deciding too quickly on goals for therapy, the counselor and client need to
discuss the complexity inherent in change. It is essential for therapists to conduct a
thorough assessment of the interpersonal and cultural dimensions of the problem.
Clients should be helped in assessing the possible consequences of some of their
newly acquired social skills. Once goals are determined and therapy is under way,
clients should have opportunities to talk about the problems they encounter as they
bring new skills and behaviors into their home and work settings.
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and behavior rehearsal. He then tries more
effective behaviors with me as I play the role of
the boss. I give him feedback on how strong or
apologetic he seemed.
Imaginal exposure and systematic desensi-
tization are appropriate in working with Stan’s
fear of failing. Before using these procedures,
I explain the procedure to Stan and get his in-
formed consent. Stan first learns relaxation pro-
cedures during the sessions and then practices
them daily at home. Next, he lists his specific
fears relating to failure, and he then generates a
hierarchy of fear items. Stan identifies his great-
est fear as fear of dating and interacting with
women. The least fearful situation he identifies
is being with a female student for whom he does
not feel an attraction. I first do some systematic
desensitization on Stan’s hierarchy. Stan begins
repeated, systematic exposure to items that
he finds frightening, beginning at the bottom
of the fear hierarchy. He continues with
repeated exposure to the next fear hierarchy
item when exposure to the previous item gener-
ates only mild fear. Part of the process involves
exposure exercises for practice in various
situations away from the therapy office.
The goal of therapy is to help Stan modify the
behavior that results in his feelings of guilt and
anxiety. By learning more appropriate coping
behaviors, eliminating unrealistic anxiety and
guilt, and acquiring more adaptive responses,
Stan’s presenting symptoms decrease, and he
reports a greater degree of satisfaction.
Follow-Up: You Continue as Stan’s
Behavior Therapist
Use these questions to help you think about how
you would work with Stan using a behavioral
approach:
• How would you collaboratively work with Stan
in identifying specific behavioral goals to give
a direction to your therapy?
• What behavioral techniques might be most
appropriate in helping Stan with his problems?
• Stan indicates that he does not want to feel
apologetic for his existence. How might you
help him translate this wish into a specific
behavioral goal? What behavioral techniques
might you draw on in helping him in this area?
• What homework assignments are you likely to
suggest for Stan?
See DVD for Theory and Practice of
Counseling and Psychotherapy: The Case
of Stan and Lecturettes (Session 7 on behavior
therapy) for a demonstration of my approach
to counseling Stan from this perspective. This
session involves collaboratively working on
homework and behavior rehearsals to experi-
ment with assertive behavior.
s u m m a ry a n d e va l u at i o n
Summary
Behavior therapy is diverse with respect not only to basic concepts but also to tech-
niques that can be applied in coping with specifi c problems with a wide range of
clients. The behavioral movement includes four major areas of development: clas-
sical conditioning, operant conditioning, social-cognitive theory, and increasing
attention to the cognitive factors infl uencing behavior (see Chapter 10). A unique
characteristic of behavior therapy is its strict reliance on the principles of the sci-
entifi c method. Concepts and procedures are stated explicitly, tested empirically,
and revised continually. Treatment and assessment are interrelated and occur si-
multaneously. Research is considered to be a basic aspect of the approach, and
therapeutic techniques are continually refi ned.
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A cornerstone of behavior therapy is identifying specifi c goals at the outset of
the therapeutic process. In helping clients achieve their goals, behavior therapists
typically assume an active and directive role. Although the client generally deter-
mines what behavior will be changed, the therapist typically determines how this
behavior can best be modifi ed. In designing a treatment plan, behavior therapists
employ techniques and procedures from a wide variety of therapeutic systems and
apply them to the unique needs of each client.
Contemporary behavior therapy places emphasis on the interplay between the
individual and the environment. Behavioral strategies can be used to attain both
individual goals and societal goals. Because cognitive factors have a place in the
practice of behavior therapy, techniques from this approach can be used to attain
humanistic ends. It is clear that bridges can connect humanistic and behavioral
therapies, especially with the current focus of attention on self-management ap-
proaches and also with the incorporation of mindfulness and acceptance-based
approaches into behavioral practice. Mindfulness practices rely of experiential
learning as opposed to didactic instruction and client discovery rather than formal
teaching (Dimidjian & Linehan, 2008).
Contributions of Behavior Therapy
Behavior therapy challenges us to reconsider our global approach to counseling.
Some may assume they know what a client means by the statement, “I feel unloved;
life has no meaning.” A humanist might nod in acceptance to such a statement,
but the behaviorist may respond with: “Who specifi cally do you feel is not loving
you?” “What is going on in your life to make you think it has no meaning?” “What
are some specifi c things you might be doing that contribute to the state you are in?”
“What would you most like to change?” The specifi city of the behavioral approaches
helps clients translate unclear goals into concrete plans of action, and it helps both
the counselor and the client to keep these plans clearly in focus. Ledley and col-
leagues (2010) state that therapists can help clients to learn about the contingencies
that maintain their problematic thoughts and behaviors and then teach them ways
to make the changes they want. Techniques such as role playing, relaxation proce-
dures, behavioral rehearsal, coaching, guided practice, modeling, feedback, learning
by successive approximations, mindfulness skills, and homework assignments can
be included in any therapist’s repertoire, regardless of theoretical orientation.
An advantage behavior therapists have is the wide variety of specifi c behavioral
techniques at their disposal. Because behavior therapy stresses doing, as opposed
to merely talking about problems and gathering insights, practitioners use many
behavioral strategies to assist clients in formulating a plan of action for chang-
ing behavior. The basic therapeutic conditions stressed by person-centered thera-
pists—active listening, accurate empathy, positive regard, genuineness, respect,
and immediacy—need to be integrated in a behavioral framework.
A major contribution of behavior therapy is its emphasis on research into
and assessment of treatment outcomes. It is up to practitioners to demonstrate
that therapy is working. If progress is not being made, therapists look carefully
at the original analysis and treatment plan. Of all the therapies presented in this
book, this approach and its techniques have been subjected to the most empirical
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research. Behavioral practitioners are put to the test of identifying specifi c inter-
ventions that have been demonstrated to be effective. Fishman, Rego, and Muller
(2011) acknowledge the evolving nature of these therapies but conclude:
We believe the core of behavior therapy will endure in a commitment to theory that is
scholarly, logically clear, directly linked to data, and primarily rooted in the interactional
worldview; to therapy principles and procedures that are evidenced-based; to measurement
methods designed to ensure accountability; and to a focus on outcomes that result in con-
crete improvement in patients’ lives. (p. 135)
Evidence-based therapies (EBT) are a hallmark of both behavior therapy and cog-
nitive behavior therapy. To their credit, behavior therapists are willing to examine
the effectiveness of their procedures in terms of the generalizability, meaningful-
ness, and durability of change. Most studies show that behavior therapy methods
are more effective than no treatment. Moreover, a number of behavioral and cogni-
tive behavioral procedures are currently the best treatment strategies available for
depression, obsessive-compulsive disorder, panic disorder, social phobia, hypochon-
driasis, generalized anxiety disorder, posttraumatic stress disorder, eating disorders,
borderline personality disorder, bipolar disorder, and childhood disorders (Hollon &
DiGiuseppe, 2011).
A strength of the behavioral approaches is the emphasis on ethical accountabil-
ity. Behavior therapy is ethically neutral in that it does not dictate whose behavior
or what behavior should be changed. At least in cases of voluntary counseling, the
behavioral practitioner only specifi es how to change those behaviors the client tar-
gets for change. Clients have a good deal of control and freedom in deciding what
the goals of therapy will be.
Limitations and Criticisms of Behavior Therapy
Behavior therapy has been criticized for a variety of reasons. Let’s examine four
common criticisms and misconceptions people often have about behavior therapy,
together with my reactions.
1. Behavior therapy may change behaviors, but it does not change feelings. Some critics
argue that feelings must change before behavior can change. Behavioral practition-
ers hold that empirical evidence has not shown that feelings must be changed fi rst,
and behavioral clinicians do in actual practice deal with feelings as an overall part
of the treatment process. A general criticism of both the behavioral and the cogni-
tive approaches is that clients are not encouraged to experience their emotions. In
concentrating on how clients are behaving or thinking, some behavior therapists
tend to play down the working through of emotional issues. Generally, I favor
initially focusing on what clients are feeling and then working with the behavioral
and cognitive dimensions. My reasoning here is that I fi nd when clients are feeling
they are engaged and this seems to me to be a good point of departure. I can still
tie a discussion of what clients are feeling with how this is affecting their behavior
and I can later inquire about their cognitions.
2. Behavior therapy does not provide insight. If this assertion is indeed true, behav-
ior therapists would probably respond that insight is not a necessary requisite for
behavior change. Follette and Callaghan (2011) state that contemporary behavior
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therapists tend to be leery of the role of insight in favor of alterable, controllable,
causal variables. It is possible for therapy to proceed without a client knowing how
change is taking place. Although change may be taking place, clients often can-
not explain precisely why. Furthermore, insights may result after clients make a
change in behavior. Behavioral shifts often lead to a change in understanding or to
insight, which may lead to emotional changes as well.
3. Behavior therapy treats symptoms rather than causes. The psychoanalytic assumption
is that early traumatic events are at the root of present dysfunction. Behavior therapists
may acknowledge that deviant responses have historical origins, but they contend that
history is less important in the maintenance of current problems than environmental
events such as antecedents and consequences. However, behavior therapists empha-
size changing current environmental circumstances to change behavior.
Related to this criticism is the notion that, unless historical causes of present
behavior are therapeutically explored, new symptoms will soon take the place of
those that were “cured.” Behaviorists rebut this assertion on both theoretical and
empirical grounds. They contend that behavior therapy directly changes the main-
taining conditions, which are the causes of problem behaviors (symptoms). Fur-
thermore, they assert that there is no empirical evidence that symptom substitution
occurs after behavior therapy has successfully eliminated unwanted behavior be-
cause they have changed the conditions that give rise to those behaviors (Kazdin &
Wilson, 1978; Spiegler & Guevremont, 2010).
4. Behavior therapy involves control and social infl uence by the therapist. All thera-
pists have a power relationship with the client and thus have control. According to
Wilson (2011), all forms of therapy involve social infl uence; the ethical issue relates
to the therapist’s degree of awareness of this infl uence and how it is addressed in
therapy. Behavior therapy recognizes the importance of making the social infl u-
ence process explicit, and it emphasizes client-oriented behavioral goals. Thera-
pists collaborate with clients to make sure there is a mutual agreement regarding
treatment goals (Antony & Roemer, 2011b), and the client is encouraged to become
an active participant in his or her therapy. Therapy progress is continually assessed
and treatment is modifi ed to ensure that the client’s goals are being met.
Behavior therapists address ethical issues by stating that therapy is basically
a psychoeducational process (Tanaka-Matsumi et al., 2002). At the outset of be-
havior therapy, clients learn about the nature of counseling, the procedures that
may be employed, and the benefi ts and risks. Clients are given information about
the specifi c therapy procedures appropriate for their particular problems. To some
extent, they also participate in the choice of techniques that will be used in dealing
with their problems. With this information clients become informed, fully enfran-
chised partners in the therapeutic venture.
The literature in the fi eld of behavior therapy is so extensive and diverse that it is not
possible in one brief survey chapter to present a comprehensive, in-depth discussion
of behavioral techniques. I hope I have encouraged you to examine any misconcep-
tions you may hold about behavior therapy. I urge you to examine some of the selected
sources in the following section to further your knowledge of this complex approach.
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w h e r e to g o f r o m h e r e
In the DVD for Integrative Counseling: The Case of Ruth and Lecturettes, Session 8
(“Behavioral Focus in Counseling”), I demonstrate a behavioral way to assist Ruth
in developing an exercise program. It is crucial that Ruth makes her own decisions
about specifi c behavioral goals she wants to pursue. This applies to my attempts
to work with her in developing methods of relaxation, increasing her self-effi cacy,
and designing an exercise plan.
Other Resources
DVDs offered by the American Psychological Association that are relevant to this
chapter include the following:
Antony, M. M. (2009). Behavioral Therapy Over Time (APA Psychotherapy
Video Series)
Hayes, S. C. (2011). Acceptance and Commitment Therapy (Systems of Psy-
chotherapy Video Series)
Psychotherapy.net is a comprehensive resource for students and professionals that
offers videos and interviews on behavior therapy. New video and editorial content
is made available monthly. DVDs relevant to this chapter are available at www.
psychotherapy.net and include the following:
Stuart, R. (1998). Behavioral Couples Therapy (Couples Therapy With the
Experts Series)
Association for Behavioral and Cognitive Therapies (ABCT)
305 Seventh Avenue, 16th Floor
New York, NY 10001-6008
Telephone: (212) 647-1890
Fax: (212) 647-1865
E-mail: membership@abct.org
Website: www.abct.org
If you have an interest in further training in behavior therapy, the Association
for Behavioral and Cognitive Therapies (ABCT) is an excellent resource. ABCT
(formerly AABT) is a membership organization of more than 4,500 mental health
professionals and students who are interested in behavior therapy, cognitive
behavior therapy, behavioral assessment, and applied behavioral analysis. Full and
associate memberships are $199 and include one journal subscription (to either
Behavior Therapy or Cognitive and Behavioral Practice), and a subscription to the
Behavior Therapist (a newsletter with feature articles, training updates, and associa-
tion news). Membership also includes reduced registration and continuing educa-
tion course fees for ABCT’s annual convention held in November, which features
workshops, master clinician programs, symposia, and other educational presenta-
tions. Student memberships are $49. Members receive discounts on all ABCT
publications, some of which are:
• Directory of Graduate Training in Behavior Therapy and Experimental-Clinical
Psychology is an excellent source for students and job seekers who want infor-
mation on programs with an emphasis on behavioral training.
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• Directory of Psychology Internships: Programs Offering Behavioral Training describes
training programs having a behavioral component.
• Behavior Therapy is an international quarterly journal focusing on original
experimental and clinical research, theory, and practice.
• Cognitive and Behavioral Practice is a quarterly journal that features clinically
oriented articles.
Recommended Supplementary Readings
Contemporary Behavior Therapy (Spiegler & Guevremont, 2010) is a comprehen-
sive and up-to-date treatment of basic principles and applications of the behavior
therapies, as well as a fi ne discussion of ethical issues. Specifi c chapters deal with
procedures that can be usefully applied to a range of client populations: behavio-
ral assessment, modeling therapy, systematic desensitization, exposure therapies,
cognitive restructuring, and cognitive coping skills.
Interviewing and Change Strategies for Helpers (Cormier, Nurius, & Osborn, 2013)
is a comprehensive and clearly written textbook dealing with training experiences
and skill development. Its excellent documentation offers practitioners a wealth
of material on a variety of topics, such as assessment procedures, selection of
goals, development of appropriate treatment programs, and methods of evaluat-
ing outcomes.
Cognitive Behavior Therapy: Applying Empirically Supported Techniques in Your
Practice (O’Donohue & Fisher, 2008) is a useful collection of edited short chap-
ters describing empirically supported techniques for working with a wide range
of presenting problems.
Behavior Therapy (Antony & Roemer, 2011a) offers a useful and updated overview
of behavior therapy.
Behavior Modifi cation: Principles and Procedures (Miltenberger, 2012) is an excel-
lent resource for learning more about basic principles such as reinforcement,
extinction, punishment, and procedures to establish new behavior.
Acceptance and Mindfulness in Cognitive Behavior Therapy: Understanding and
Applying the New Therapies (Herbert & Forman, 2011) is one of the best resources
for discussion of new developments in the behavior therapy tradition and the
future trends of these therapies.
References and Suggested Readings
*Alberti, R. E., & Emmons, M. L. (2008). Your
perfect right: A guide to assertive behavior
(9th ed.). Atascadero, CA: Impact.
*Antony, M. M., & Roemer, L. (2011a).
Behavior therapy. Washington, DC: American
Psychological Association.
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*Books and articles marked with an asterisk are suggested for further study.
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Antony, M. M., & Roemer, L. (2011b). Behav-
ior therapy: Traditional approaches. In S.
B. Messer & A. S. Gurman (Eds.), Essential
psychotherapies: Theory and practice (3rd ed.,
pp. 107–142). New York: Guilford Press.
Bandura, A. (1969). Principles of behavior
modification. New York: Holt, Rinehart &
Winston.
Bandura, A. (Ed.). (1971a). Psychological
modeling: Conflicting theories. Chicago:
Aldine-Atherton.
Bandura, A. (1971b). Psychotherapy based
upon modeling principles. In A. E. Bergin &
S. L. Garfield (Eds.), Handbook of psychother-
apy and behavior change. New York: Wiley.
Bandura, A. (1977). Social learning theory.
Englewood Cliffs, NJ: Prentice-Hall.
Bandura, A. (1982). Self-efficacy mecha-
nisms in human agency. American Psycholo-
gist, 37, 122–147.
Bandura, A. (1986). Social foundations of
thought and action: A social cognitive theory.
Englewood Cliffs, NJ: Prentice-Hall.
*Bandura, A. (1997). Self-efficacy: The exer-
cise of self-control. New York: Freeman.
Bandura, A., & Walters, R. H. (1963). Social
learning and personality development.
New York: Holt, Rinehart & Winston.
*Beck, A. T. (1976). Cognitive therapy and
emotional disorders. New York: New
American Library.
Beck, A. T., & Weishaar, M. E. (2011).
Cognitive therapy. In R. J. Corsini & D.
Wedding (Eds.), Current psychotherapies
(9th ed., pp. 276–309). Belmont, CA:
Brooks/Cole, Cengage Learning.
*Corey, G. (2012). Theory and practice of
group counseling (8th ed.). Belmont, CA:
Brooks/Cole, Cengage Learning.
*Corey, G. (2013a). Case approach to coun-
seling and psychotherapy (8th ed.). Belmont,
CA: Brooks/Cole, Cengage Learning.
*Corey, G. (2013b). Student manual for theory
and practice of counseling and psychotherapy
(9th ed.). Belmont, CA: Brooks/Cole, Cen-
gage Learning.
*Cormier, S., Nurius, P. S., & Osborn, C.
(2013). Interviewing and change strategies for
helpers (7th ed.). Belmont, CA: Brooks/Cole,
Cengage Learning.
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287
i n t r o d u ct i o n
a l b e rt e l l i s ’s r at i o n a l e m ot i v e
b e h av i o r t h e r a p y
k e y co n c e p t s
• View of Human Nature
• View of Emotional Disturbance
• A-B-C Framework
t h e t h e r a p e u t i c p r o c es s
• Therapeutic Goals
• Therapist’s Function and Role
• Client’s Experience in Therapy
• Relationship Between Therapist and Client
a p p l i c at i o n : t h e r a p e u t i c
t ec h n i q u es a n d p r o c e d u r es
• The Practice of Rational Emotive Behavior
Therapy
• Applications of REBT to Various Settings
• Application of REBT as a Brief Therapy
• Application to Group Counseling
a a r o n b ec k ’s co g n i t i v e t h e r a p y
• Introduction
• Basic Principles of Cognitive Therapy
• The Client–Therapist Relationship
• Applications of Cognitive Therapy
d o n a l d m e i c h e n b a u m ’s co g n i t i v e
b e h av i o r m o d i f i c at i o n
• Introduction
• How Behavior Changes
• Stress Inoculation Training
• The Constructivist Approach to Cognitive
Behavior Therapy
co g n i t i v e b e h av i o r t h e r a p y f r o m
a m u lt i c u lt u r a l p e r s p ect i v e
• Strengths From a Diversity Perspective
• Shortcomings From a Diversity Perspective
co g n i t i v e b e h av i o r t h e r a p y
a p p l i e d to t h e c a s e o f sta n
s u m m a ry a n d e va l u at i o n
• Summary
• Contributions of the Cognitive Behavioral
Approaches
• Limitations and Criticisms of the Cognitive
Behavioral Approaches
w h e r e to g o f r o m h e r e
• Recommended Supplementary Readings
• References and Suggested Readings
c h a p t e r 1 0
Cognitive Behavior Therapy
a p y
y
•
r o m h e
commended Supplemen
References and Suggested
a a r o n b
ntroduction
c Principles o
lient–Therapi
tions of Cogn
•
• Bas
• The
• Appli
Therapy
• Applications of REBT
• Application of REBT as a
• Application to Group Coun
k ’s co g n i t i v
ognitive Thera
elationsh
hip Bet
a p p l i c at i o n :
t ec h n i q u es a
• The P
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Albert Ellis / Aaron T. Beck / Judith S. Beck /
Donald Meichenbaum
A L B E RT E L L I S (1913–2007)
was born in Pittsburgh but
escaped to the wilds of New
York at the age of 4 and lived
there (except for a year in
New Jersey) for the rest of
his life. He was hospitalized
nine times as a child, mainly
with nephritis, and developed renal glycosuria at
the age of 19 and diabetes at the age of 40. Despite
his many physical challenges, he lived an unusu-
ally robust, active, and energetic life until his death
at age 93. As he put it, “I am busy spreading the
gospel according to St. Albert.”
Realizing that he could counsel people skillfully
and that he greatly enjoyed doing so, Ellis decided
to become a psychologist. Believing psychoanalysis
to be the deepest form of psychotherapy, Ellis was
analyzed and supervised by a training analyst. He
then practiced psychoanalytically oriented psycho-
therapy, but eventually he became disillusioned
with the slow progress of his clients. He observed
that they improved more quickly once they
changed their ways of thinking about themselves
and their problems. Early in 1955 he developed
an approach to psychotherapy he called rational
therapy and later rational emotive therapy, and
which is now known as rational emotive behavior
therapy (REBT). Ellis has rightly been referred to as
the grandfather of cognitive behavior therapy.
To some extent Ellis developed his approach as
a method of dealing with his own problems during
his youth. At one point in his life, for example, he
had exaggerated fears of speaking in public. Dur-
ing his adolescence he was extremely shy around
young women. At age 19 he forced himself to talk
to 100 different women in the Bronx Botanical
Gardens over a period of one month. Although
he never managed to get a date from these brief
encounters, he does report that he desensitized
himself to his fear of rejection by women. By apply-
ing rational and behavioral methods, he managed
to conquer some of his strongest emotional blocks
(Ellis, 1994, 1997).
People who heard Ellis lecture often com-
mented on his abrasive, humorous, and flamboy-
ant style. In his workshops it seemed that he took
delight in giving vent to his eccentric side, such as
peppering his speech with four-letter words. He
greatly enjoyed his work and teaching REBT, which
was his passion and primary commitment in life.
It seems that his work was his life, and he gave
workshops wherever he went in his travels. Ellis
proclaimed, “I wouldn’t go to the Taj Mahal unless
they asked me to do a workshop there!”
Ellis married Australian psychologist Debbie
Joffe in November 2004, whom he has called “the
greatest love of my life” (Ellis, 2008). They shared
the same life goals and ideals, and they worked as a
team presenting workshops. If you are interested in
learning more about the life and work of Albert Ellis, I
recommend two of his books: Rational Emotive Behav-
ior Therapy: It Works for Me—It Can Work for You (Ellis,
2004a) and All Out! An Autobiography (Ellis, 2010).
Ph
ot
o
Co
ur
te
sy
of
A
lb
er
tE
lli
s
In
st
itu
te
A A R O N T E M K I N B EC K
(b. 1921) was born in Provi-
dence, Rhode Island. His
childhood, although happy,
was interrupted by a life-
threatening illness when
he was 8 years old. As a
consequence, he experi-
enced blood injury fears, fear of suffocation, and
anxiety about his health. Beck used his personal
problems as a basis for understanding others and
for developing his cognitive theory.
A graduate of Brown University and Yale
School of Medicine, Beck initially was trained as a
neurologist, but he switched to psychiatry during
his residency. Beck attempted to validate Freud’s
theory of depression, but his research resulted
in his parting company with Freud’s motivational
model and the explanation of depression as self-
directed anger. As a result of this decision, Beck
endured isolation and rejection from many in the
psychiatric community for many years. Through
his research, Beck developed a cognitive theory
of depression, which represents one of the most
Co
ur
te
sy
of
Be
ck
In
st
itu
te
fo
rC
og
ni
tiv
e
Be
ha
vi
or
Th
er
ap
y,
Ba
la
Cy
nw
yd
,P
A
.
28549_ch10_rev01.indd 288 20/09/11 3:54 PM
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

289
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E

B
E
H
A
V
I
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T
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Y
J U D I T H S . B EC K (b. 1954)
was born in Philadelphia,
the second of four children.
Both her parents were quite
notable in their fields: her
father, as “the father of
cognitive therapy,” and her
mother, as the first female
judge on the appellate court
of the Commonwealth of Pennsylvania. From an
early age, Beck wanted to be an educator, and she
began her professional career teaching children
with learning disabilities. Her ability to break down
complex subjects into easily understandable ideas,
so critical in the education of children with learning
differences, is characteristic of all her work.
Beck later returned to graduate school, studied
education and psychology, and completed a
postdoctoral fellowship at the Center for Cognitive
Behavior Therapy at the University of Pennsylvania.
In 1994 she and her father opened the nonprofit
Beck Institute for Cognitive Therapy in suburban
Philadelphia, and she is currently president of
the institute. A premier training organization, the
institute is devoted to national and international
training in cognitive therapy through workshop
and supervision programs for students and faculty,
deployed and returning military families, health
and mental health professionals at all levels, and
organizations.
Beck travels extensively in the United States
and abroad, teaching and disseminating cognitive
behavior therapy and assisting a wide variety of
organizations in developing or strengthening their
CT programs. She writes a number of CT-oriented
blogs and edits “Cognitive Therapy Today,” an
e-newsletter. She is coauthor of the widely adopted
self-report scales, the Personality Belief Question-
naire and the Beck Youth Inventories II, which
screens children aged 7–18 for symptoms of
depression, anxiety, disruptive behavior, self-
concept, and anger.
Beck is Clinical Associate Professor at the
University of Pennsylvania and was instrumental
in founding the Academy of Cognitive Therapy,
the “home” organization for cognitive therapists
worldwide. She has written nearly a hundred
articles and chapters on a variety of CT topics
and authored several books on cognitive therapy,
including Cognitive Behavior Therapy: Basics and
Beyond (2011a), Cognitive Therapy for Challenging
Problems: What to Do When the Basics Don’t Work
Co
ur
te
sy
of
Be
ck
In
st
itu
te
fo
rC
og
ni
tiv
e
Be
ha
vi
or
Th
er
ap
y,
Ba
la
Cy
nw
yd
,P
A
.
comprehensive conceptualizations. He found the
cognitions of depressed individuals to be charac-
terized by errors in interpretation that he called
“cognitive distortions.” For Beck, negative thoughts
reflect underlying dysfunctional beliefs and
assumptions. When these beliefs are triggered by
situational events, a depressive pattern is put in
motion. Beck believes clients can assume an
active role in modifying their dysfunctional thinking
and thereby gain relief from a range of psychiatric
conditions. His continuous research in the areas
of psychopathology and the utility of cognitive
therapy has earned him a place of prominence in
the scientific community in the United States. Beck
is the pioneering figure in cognitive therapy, one of
the most influential and empirically validated
approaches to psychotherapy.
Beck joined the Department of Psychiatry of
the University of Pennsylvania in 1954, where he
currently holds the position of University Professor
(Emeritus) of Psychiatry. Beck’s pioneering research
established the efficacy of cognitive therapy for
depression. He has successfully applied cognitive
therapy to depression, generalized anxiety and
panic disorders, suicide, alcoholism and drug abuse,
eating disorders, marital and relationship problems,
psychotic disorders, and personality disorders. He
has developed assessment scales for depression,
suicide risk, anxiety, self-concept, and personality.
He is the founder of the Beck Institute, which is
a research and training center directed by one of his
four children, Dr. Judith Beck. He has eight grand-
children and two great-grandchildren and has been
married for more than 60 years. To his credit, Aaron
Beck has focused on developing the cognitive ther-
apy skills of thousands of clinicians throughout the
world. In turn, many of them have established their
own cognitive therapy centers. Beck has a vision
for the cognitive therapy community that is global,
inclusive, collaborative, empowering, and benevo-
lent. He continues to remain active in writing and
research; he has published 21 books and more than
450 articles and book chapters. For more on the life
of Aaron T. Beck, see Aaron T. Beck (Weishaar, 1993).
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As you saw in Chapter 9, traditional behavior therapy has broadened and largely
moved in the direction of cognitive behavior therapy. Several of the more promi-
nent cognitive behavioral approaches are featured in this chapter, including Al-
bert Ellis’s rational emotive behavior therapy (REBT), Aaron T. Beck’s and Judith
Beck’s cognitive therapy (CT), and Donald Meichenbaum’s cognitive behavior
therapy (CBT). The cognitive behavior therapies, which combine both cognitive
and behavioral principles and methods in a short-term treatment approach, have
generated more empirical research than any other psychotherapy model (Dattilio,
2000a). These approaches all fall under the general umbrella of cognitive behavior
therapies, which is the reason they are grouped together in this chapter.
All of the cognitive behavioral approaches share the same basic characteristics
and assumptions as traditional behavior therapy described in Chapter 9. Although
the approaches are quite diverse, they do share these attributes: (1) a collabora-
tive relationship between client and therapist, (2) the premise that psychological
distress is largely a function of disturbances in cognitive processes, (3) a focus
on changing cognitions to produce desired changes in affect and behavior, (4)
(2005), and the Cognitive Therapy Worksheet
Packet (2011b), as well as trade books with a
cognitive behavioral program for diet and mainte-
nance. Judith Beck has been married for 34 years
and has three adult children, one of whom is a
social worker specializing in CT.
D O N A L D M E I C H E N –
B AU M (b. 1940) was born
in New York City
(the Bronx) and learned
early to be “street smart”
and to be on the lookout
for high-risk situations. He
attended City College of
New York and received his
PhD in clinical psychology from the University of
Illinois. At the University of Waterloo in Ontario,
Canada, he conducted research on the develop-
ment of cognitive behavior therapy (CBT). He is the
recipient of a Lifetime Achievement Award from
the Clinical Division of the American Psychological
Association for his work on suicide prevention. In
1995 Meichenbaum retired from the University of
Waterloo to become the research director of the
Melissa Institute for Violence Prevention, which is
designed to “give science away” in order to reduce
violence and to treat victims of violence.
Meichenbaum attributes the origin of CBT
to his mother, who had a knack for telling stories
about her daily activities that were peppered with
her thoughts, feelings, and a running commentary.
This childhood experience contributed to Meichen-
baum’s psychotherapeutic approach of construc-
tivist narrative therapy, in which clients to tell their
stories and describe what they did to “survive and
cope.” Meichenbaum’s recent work with returning
service members using iPod technology to bolster
resilience is modeled on this approach. When
therapy is successful, Meichenbaum ensures
that clients take credit for the changes they have
achieved. As he observes, “I am at my therapeutic
best when the clients I see are one step ahead of
me offering the observations or suggestions that
I would otherwise offer” (Donald Meichenbaum,
personal communication, October 21, 2010).
Meichenbaum has published extensively,
including Cognitive Behavior Modification: An Integra-
tive Approach (1977), Stress Inoculation Training (1985),
and Treatment of Individuals with Anger-Control
Problems and Aggressive Behaviors (2002). He has
lectured and consulted internationally and frequently
presents workshops at professional conferences.
Co
ur
te
sy
of
D
on
al
d
M
ei
ch
en
ba
um
,U
ni
ve
rs
ity
of
W
at
er
lo
o,
D
ep
ar
tm
en
to
fP
sy
ch
ol
og
y
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a present-centered, time-limited focus, (5) an active and directive stance by the
therapist, and (6) an educational treatment focusing on specifi c and structured
target problems (Beck & Weishaar, 2011). In addition, both cognitive therapy and
the cognitive behavioral therapies are based on a structured psychoeducation-
al model, emphasize the role of homework, place responsibility on the client to
assume an active role both during and outside therapy sessions, emphasize develop-
ing a strong therapeutic alliance, and draw from a variety of cognitive and behav-
ioral strategies to bring about change. Therapists help clients to examine the manner
in which they understand themselves and their world and to experiment with new
ways of behaving (Dienes, Torres-Harding, Reinecke, Freeman, & Sauer, 2011).
To a large degree, both cognitive therapy and cognitive behavior therapy are
based on the assumption that a reorganization of one’s self-statements will result
in a corresponding reorganization of one’s behavior. Behavioral techniques such
as operant conditioning, modeling, and behavioral rehearsal can be applied to the
more subjective processes of thinking and internal dialogue. Cognitive therapy
and the cognitive behavioral approaches include a variety of behavioral strategies
(discussed in Chapter 9) as a part of their integrative repertoire.
See the video program for Chapter 10, DVD for Theory and Practice of Coun-
seling and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you
view the brief lecture for each chapter prior to reading the chapter.
a l b e r t e l l i s ’s r at i o n a l e m ot i v e
b e h av i o r t h e r a p y
Rational emotive behavior therapy (REBT) was the fi rst of the cognitive behavior
therapies, and today it continues to be a major cognitive behavioral approach.
REBT has a great deal in common with the therapies that are oriented toward
cognition and behavior as it also stresses thinking, judging, deciding, analyzing,
and doing. The basic assumption of REBT is that people contribute to their own
psychological problems, as well as to specifi c symptoms, by the rigid and extreme
beliefs they hold about events and situations. REBT is based on the assumption
that cognitions, emotions, and behaviors interact signifi cantly and have a recip-
rocal cause-and-effect relationship. REBT has consistently emphasized all three
of these modalities and their interactions, thus qualifying it as an integrative
approach (Ellis, 2001a, 2001b, 2002, 2011; Ellis & Dryden, 2007; Wolfe, 2007).
Although REBT is generally conceded to be the parent of today’s cognitive be-
havioral approaches, it was preceded by earlier schools of thought. Ellis gave credit
to Alfred Adler as an infl uential precursor of REBT, and Karen Horney’s (1950)
ideas on the “tyranny of the shoulds” are apparent in the conceptual framework of
REBT. Ellis also acknowledged his debt to the ancient Greeks, especially the Stoic
philosopher Epictetus, who said around 2,000 years ago: “People are disturbed
not by events, but by the views which they take of them” (as cited in Ellis, 2001a,
p. 16). Ellis’s reformulation of Epictetus’s dictum can be stated as, “People disturb
themselves by the rigid and extreme beliefs they hold about events.”
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REBT’s basic hypothesis is that our emotions stem mainly from our beliefs,
which infl uence the evaluations and interpretations we make of the reactions we
have to life situations. Through the therapeutic process, clients learn skills that
give them the tools to identify and dispute irrational beliefs that have been ac-
quired and self-constructed and are now maintained by self-indoctrination. They
learn how to replace such ineffective ways of thinking with effective and rational
cognitions, and as a result they change their emotional reactions to situations. The
therapeutic process allows clients to apply REBT principles of change not only to
a particular presenting problem but also to many other problems in life or future
problems they might encounter.
Several therapeutic implications fl ow from these assumptions: The focus is on
working with thinking and acting rather than primarily with expressing feelings.
Therapy is seen as an educational process. The therapist functions in many ways like
a teacher, especially in collaborating with a client on homework assignments and
in teaching strategies for straight thinking; and the client is a learner who practices
these new skills in everyday life.
REBT differs from many other therapeutic approaches in that it does not place
much value on free association, working with dreams, focusing on the client’s past
history, expressing and exploring feelings, or dealing with transference phenomena.
Ellis (2011) maintains that transference is not encouraged, and when it does occur,
the therapist is likely to confront it. Ellis believes the transference relationship is
based on the irrational belief that the client must be liked and loved by the therapist,
or parent fi gure. Although transference and countertransference may spontaneously
occur in therapy, Ellis claims “they are quickly analyzed, the philosophies behind
them are revealed, and they tend to evaporate in the process” (p. 221). Furthermore,
when a client’s deep feelings emerge, “the client is not given too much chance to
revel in these feelings or abreact strongly about them” (p. 221). Ellis believes that
such cathartic work may result in clients feeling better, but it will rarely aid them in
getting better.
k e y c o n c e p t s
View of Human Nature
Rational emotive behavior therapy is based on the assumption that human beings
are born with a potential for both rational, or “straight,” thinking and irrational, or
“crooked,” thinking. People have predispositions for self-preservation, happiness,
thinking and verbalizing, loving, communion with others, and growth and self-
actualization. They also have propensities for self-destruction, avoidance of thought,
procrastination, endless repetition of mistakes, superstition, intolerance, perfection-
ism and self-blame, and avoidance of actualizing growth potentials. REBT encour-
ages people accept themselves even though they will make mistakes.
View of Emotional Disturbance
REBT is based on the premise that we learn irrational beliefs from signifi cant oth-
ers during childhood and then re-create these irrational beliefs throughout our
lifetime. We actively reinforce our self-defeating beliefs through the processes of
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autosuggestion and self-repetition, and we then behave in ways that are consistent
with these beliefs. Hence, it is largely our own repetition of early-indoctrinated
irrational beliefs, rather than a parent’s repetition, that keeps dysfunctional atti-
tudes alive and operative within us.
Ellis contends that people do not need to be accepted and loved, even though
this may be highly desirable. The therapist teaches clients how to feel sad, but not
depressed, even when they are unaccepted and unloved by signifi cant others. A
major goal of the REBT therapist is to encourage clients to be less emotionally re-
active, for example, by feeling sadness and disappointment about life’s adversities
rather than by feeling anxiety, depression, and shame.
Ellis insists that blame is at the core of most emotional disturbances. If we want
to become psychologically healthy, we had better stop blaming ourselves and others
and learn to fully and unconditionally accept ourselves despite our imperfections.
Ellis (Ellis & Blau, 1998; Ellis & Harper, 1997) hypothesizes that we have strong ten-
dencies to transform our desires and preferences into dogmatic “shoulds,” “musts,”
“oughts,” demands, and commands. When we are disturbed, it is a good idea to look
to our hidden dogmatic “musts” and absolutist “shoulds.” Such demands underpin
disruptive feelings and dysfunctional behaviors (Ellis, 2001a, 2004a).
Here are three basics musts (or irrational beliefs) that we internalize that inevita-
bly lead to self-defeat (Ellis & Dryden, 2007):
• “I must do well and win the approval of others for my performances or else I am
no good.”
• “Other people must treat me considerately, fairly, kindly, and in exactly the way
I want them to treat me. If they don’t, they are no good and they deserve to be
condemned and punished.”
• “I must get what I want, when I want it; and I must not get what I don’t want. If I
don’t get what I want, it’s terrible, I can’t stand it, and life is no good for depriv-
ing me of what I must have.”
We have a strong tendency to make and keep ourselves emotionally disturbed by inter-
nalizing and perpetuating self-defeating beliefs such as these, which is why it is a real
challenge to achieve and maintain good psychological health (Ellis, 2001a, 2001b).
A-B-C Framework
The A-B-C framework is central to REBT theory and practice. This model provides
a useful tool for understanding the client’s feelings, thoughts, events, and behavior
(Wolfe, 2007). A is the existence of a fact, or an activating event, or an inference
about an event, of an individual. C is the emotional and behavioral consequence or
reaction of the individual; the reaction can be either healthy or unhealthy. A (the
activating event) does not cause C (the emotional consequence). Instead, B, which
is the person’s belief about A, largely creates C, the emotional reaction.
The interaction of the various components can be diagrammed like this:
A (activating event) B (belief) ® C (emotional and behavioral consequence)
�
D (disputing intervention) ® E (effect) ® F (new feeling)
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If a person experiences depression after a divorce, for example, it may not be
the divorce itself that causes the depressive reaction nor his inference that he has
failed, but the person’s beliefs about his divorce or about his failure. Ellis maintains
that the beliefs about the rejection and failure (at point B) are what mainly cause
the depression (at point C)—not the actual event of the divorce or the person’s in-
ference of failure (at point A). Believing that human beings are largely responsible
for creating their own emotional reactions and disturbances and showing people
how they can change their irrational beliefs that directly “cause” their disturbed
emotional consequences is at the heart of REBT (Ellis & Dryden, 2007; Ellis &
Harper, 1997).
How is an emotional disturbance fostered? It is fed by the self-defeating sen-
tences clients continually repeat to themselves, such as “I am totally to blame for
the divorce,” “I am a miserable failure, and everything I did was wrong,” “I am a
worthless person.” Ellis repeatedly makes the point that “you mainly feel the way
you think.” Disturbed emotional reactions such as depression and anxiety are initi-
ated and perpetuated by clients’ self-defeating belief systems, which are based on
irrational ideas clients have incorporated and invented.
After A, B, and C comes D (disputing). Essentially, D is the application of meth-
ods to help clients challenge their irrational beliefs. There are three components
of this disputing process: detecting, debating, and discriminating. First, clients
learn how to detect their irrational beliefs, particularly their absolutist “shoulds”
and “musts,” their “awfulizing,” and their “self-downing.” Then clients debate their
dysfunctional beliefs by learning how to logically and empirically question them
and to vigorously argue themselves out of and act against believing them. Finally,
clients learn to discriminate irrational (self-defeating) beliefs from rational (self-
helping) beliefs (Ellis, 1994, 1996). Cognitive restructuring is a central technique
of cognitive therapy that teaches people how to improve themselves by replacing
irrational beliefs with rational beliefs (Ellis, 2008). Restructuring involves helping
clients learn to monitor their self-talk, identify maladaptive self-talk, and substitute
adaptive self-talk for their negative self-talk (Spiegler, 2008).
Ellis (1996, 2001b) maintains that we have the capacity to signifi cantly change our
cognitions, emotions, and behaviors. We can best accomplish this goal by avoiding
preoccupying ourselves with A and by acknowledging the futility of dwelling end-
lessly on emotional consequences at C. Rather, we can choose to examine, challenge,
modify, and uproot B—the irrational beliefs we hold about the activating events at A.
Although REBT uses many other cognitive, emotive, and behavioral methods
to help clients minimize their irrational beliefs, it stresses the process of disput-
ing (D) such beliefs both during therapy sessions and in everyday life. Eventually
clients arrive at E, an effective philosophy, which has a practical side. A new and
effective belief system consists of replacing unhealthy thoughts with healthy ones.
If we are successful in doing this, we also create F, a new set of feelings. Instead of
feeling seriously anxious and depressed, we feel healthily sorry and disappointed
in accord with a situation.
In sum, philosophical restructuring to change our dysfunctional personality involves
these steps: (1) fully acknowledging that we are largely responsible for creating our
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own emotional problems; (2) accepting the notion that we have the ability to change
these disturbances signifi cantly; (3) recognizing that our emotional problems largely
stem from irrational beliefs; (4) clearly perceiving these beliefs; (5) seeing the value of
disputing such self-defeating beliefs; (6) accepting the fact that if we expect to change
we had better work hard in emotive and behavioral ways to counteract our beliefs and
the dysfunctional feelings and actions that follow; (7) understanding what the rational
alternative to these irrational beliefs are; and (8) practicing REBT methods of uprooting
or changing disturbed consequences and practicing their healthy alternatives for the
rest of our life (Ellis, 1999, 2001b, 2002).
t h e t h e r a p e u t i c p r o c e s s
Therapeutic Goals
According to Ellis (2001b; Ellis & Harper, 1997), we have a strong tendency not only
to rate our acts and behaviors as “good” or “bad,” “worthy” or “unworthy,” but also to
rate ourselves as a total person on the basis of our performances. These ratings consti-
tute one of the main sources of our emotional disturbances. Therefore, most rational
emotive behavior therapists have the general goal of teaching clients how to separate
the evaluation of their behaviors from the evaluation of themselves—their essence and
their totality—and how to accept themselves in spite of their imperfections.
The many roads taken in rational emotive behavior therapy lead toward the
destination of clients minimizing their emotional disturbances and self-defeating
behaviors by acquiring a more realistic and workable philosophy of life. The proc-
ess of REBT involves a collaborative effort on the part of both the therapist and the
client in choosing realistic and self-enhancing therapeutic goals. The therapist’s
task is to help clients differentiate between realistic and unrealistic goals and also
self-defeating and self-enhancing goals (Dryden, 2007). A basic goal is to teach cli-
ents how to change their dysfunctional emotions and behaviors into healthy ones.
Ellis (2001b) states that two of the main goals of REBT are to assist clients in
the process of achieving unconditional self-acceptance (USA) and unconditional other
acceptance (UOA), and to see how these are interrelated. As clients become more
able to accept themselves, they are more likely to unconditionally accept others.
Therapist’s Function and Role
The therapist has specifi c tasks, and the fi rst step is to show clients how they have
incorporated many irrational absolute “shoulds,” “oughts,” and “musts.” The ther-
apist disputes clients’ irrational beliefs and encourages clients to engage in activi-
ties that will counter their self-defeating beliefs and to replace their rigid “musts”
with preferences.
A second step in the therapeutic process is to demonstrate how clients are
keeping their emotional disturbances active by continuing to think illogically and
unrealistically. In other words, because clients keep reindoctrinating themselves,
they are largely responsible for their own psychological problems.
To get beyond mere recognition of irrational thoughts, the therapist takes a third
step—helping clients modify their thinking and minimize their irrational ideas.
Although it is unlikely that we can entirely eliminate the tendency to think irrationally,
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we can reduce the frequency of such thinking. The therapist encourages clients to
identify the irrational beliefs they originally unquestioningly accepted and demon-
strates how they are continuing to indoctrinate themselves with these beliefs.
The fourth step in the therapeutic process is to challenge clients to develop a
rational philosophy of life so that in the future they can avoid becoming the victim
of other irrational beliefs. Tackling only specifi c problems or symptoms can give
no assurance that new illogical fears will not emerge. It is desirable, then, for the
therapist to dispute the core of the irrational thinking and to teach clients how to
substitute rational beliefs and behaviors for irrational ones.
The therapist takes the mystery out of the therapeutic process, teaching clients
about the cognitive hypothesis of disturbance and showing how rigid and extreme
irrational beliefs lead to disturbed negative consequences. Insight alone does not
typically lead to psychotherapeutic change, but it helps clients to see how they are
continuing to sabotage themselves and what they can do to change.
Client’s Experience in Therapy
Once clients begin to accept that their beliefs underpin their emotions and behav-
iors, they are able to participate effectively in the cognitive restructuring process
(Ellis, Gordon, Neenan, & Palmer, 1997; Ellis & MacLaren, 2005). Because psy-
chotherapy is viewed as a reeducative process, clients learn how to apply logical
thought, participate in experiential exercises, and carry out behavioral homework
as a way to bring about change. Clients can realize that life does not always work
out the way that they would like it to. Even though life is not always pleasant, cli-
ents learn that life can be bearable and that even suffering can be honorable.
The therapeutic process largely focuses on clients’ experiences in the present.
Like the person-centered and existential approaches to therapy, REBT mainly em-
phasizes here-and-now experiences and clients’ present ability to change the pat-
terns of thinking and emoting that they constructed earlier. The therapist does
not devote much time to exploring clients’ early history and making connections
between their past and present behavior unless doing so will aid the therapeutic
process. Nor does the therapist usually explore clients’ early relationships with
their parents or siblings. Instead, the therapeutic process stresses to clients that
they are presently disturbed because they still believe in and act upon their self-
defeating view of themselves, other people, and the world.
Clients are expected to actively work outside the therapy sessions. By working
hard and carrying out behavioral homework assignments, clients can learn to mini-
mize faulty thinking, which leads to disturbances in feeling and behaving. Home-
work is carefully designed and agreed upon and is aimed at getting clients to carry
out positive actions that induce emotional and attitudinal change. These assign-
ments are checked in later sessions, and clients learn effective ways to dispute self-
defeating thinking. Toward the end of therapy, clients review their progress, make
plans, and identify strategies for dealing with continuing or potential problems.
Relationship Between Therapist and Client
Because REBT is essentially a cognitive and directive behavioral process, a warm re-
lationship between therapist and client is not required. As with the person-centered
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therapy of Rogers, REBT practitioners strive to unconditionally accept all clients
and to teach them to unconditionally accept others and themselves. However,
Ellis believes that too much warmth and understanding can be counterproductive
and foster a sense of dependence for approval from the therapist. REBT prac-
titioners accept their clients as imperfect beings who can be helped through a
variety of techniques such as teaching, bibliotherapy, and behavior modifi cation
(Ellis, 2011).
Rational emotive behavior therapists are often open and direct in disclosing
their own beliefs and values. Some are willing to share their own imperfections as
a way of disputing clients’ unrealistic notions that therapists are “completely put
together” persons. On this point, Wolfe (2007) claims “it is important to establish
as much as possible an egalitarian relationship, as opposed to presenting yourself
as a nondisclosing authority fi gure” (p. 186).
a p p l i c at i o n : t h e r a p e u t i c
t e c h n i q u e s a n d p r o c e d u r e s
The Practice of Rational Emotive Behavior Therapy
Rational emotive behavior therapists are multimodal and integrative. REBT gener-
ally starts with clients’ disturbed feelings and intensely explores these feelings in
connection with thoughts and behaviors. REBT practitioners tend to use a number of
different modalities (cognitive, imagery, emotive, behavioral, and interpersonal) to
dispel these self-defeating cognitions and to teach people how to acquire a rational
approach to living. Therapists are encouraged to be fl exible and creative in their
use of methods, making sure to tailor the techniques to the unique needs of each
client (Dryden, 2007).
For a concrete illustration of how Dr. Ellis works with the client Ruth, drawing
from cognitive, emotive, and behavioral techniques, see Case Approach to Coun-
seling and Psychotherapy (Corey, 2013a, chap. 8). What follows is a brief summary
of the major cognitive, emotive, and behavioral techniques Ellis describes (Ellis,
2004a; Ellis & Crawford, 2000; Ellis & Dryden, 2007; Ellis & MacLaren, 2005).
c o g n i t i v e m e t h o d s REBT practitioners usually incorporate a persuasive
cognitive methodology in the therapeutic process. They demonstrate to clients in a
quick and direct manner what it is that they are continuing to tell themselves. Then
they teach clients how to deal with these self-statements so that they no longer
believe them, encouraging them to acquire a philosophy based on reality. REBT
relies heavily on thinking, disputing, debating, challenging, interpreting, explain-
ing, and teaching. The most effi cient way to bring about lasting emotional and
behavioral change is for clients to change their way of thinking (Dryden, 2007).
Here are some cognitive techniques available to the therapist.
• Disputing irrational beliefs. The most common cognitive method of REBT con-
sists of the therapist actively disputing clients’ irrational beliefs and teaching them
how to do this challenging on their own. Clients go over a particular “must,” absolute
“should,” or “ought” until they no longer hold that irrational belief, or at least until it
is diminished in strength. Here are some examples of questions or statements clients
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learn to tell themselves: “Why must people treat me fairly?” “How do I become a total
fl op if I don’t succeed at important tasks I try?” “If I don’t get the job I want, it may be
disappointing, but I can certainly stand it.” “If life doesn’t always go the way I would
like it to, it isn’t awful, just inconvenient.”
• Doing cognitive homework. REBT clients are expected to make lists of their
problems, look for their absolutist beliefs, and dispute these beliefs. They often
fi ll out the REBT Self-Help Form, which is reproduced in Corey’s (2013b) Stu-
dent Manual for Theory and Practice of Counseling and Psychotherapy. They can
bring this form to their therapy sessions and critically evaluate the disputation
of some of their beliefs. Homework assignments are a way of tracking down the
“shoulds” and “musts” that are part of their internalized self-messages. Part of
this homework consists of applying the A-B-C model to many of the problems
clients encounter in daily life. Work in the therapy session can be designed in
such a way that out-of-offi ce tasks are feasible and the client has the skills to
complete these tasks.
In carrying out homework, clients are encouraged to put themselves in risk-
taking situations that will allow them to challenge their self-limiting beliefs. For
example, a client with a talent for acting who is afraid to act in front of an audience
because of fear of failure may be asked to take a small part in a stage play. The client
is helped to replace irrational beliefs—“If I look foolish, this proves I am a fool.”
“If I am not liked, that would be awful.” “I will fail and therefore be a failure.”—
with more positive messages such as these: “Even if I do behave foolishly at times,
this does not make me a foolish person.” “I can act.” “I will do the best I can.” “It’s
nice to be liked, but not everybody has to like me, and if they don’t, that isn’t the
end of the world.” “If I fail, I am human, not a failure.”
The theory behind this and similar assignments is that clients often create
a negative, self-fulfi lling prophecy and actually fail because they told themselves
in advance that they would. Clients are encouraged to carry out specifi c assign-
ments during the sessions and, especially, in everyday situations between sessions.
Clients are expected to take the time to record and think about how their beliefs
contribute to their personal problems. In addition, they need to work hard at up-
rooting these self-defeating cognitions. In this way clients gradually learn to deal
with anxiety and to challenge basic irrational thinking. Making changes is hard
work, and doing work outside the sessions is of real value in revising clients’ think-
ing, feeling, and behaving.
• Bibliotherapy. REBT, and other CBT approaches, can be delivered to some
degree in a bibliotherapeutic format. It is probably best to utilize bibliotherapy as
an adjunctive form of treatment. There are advantages of bibliotherapy, such as
cost-effectiveness, widespread availability, and the potential of reaching a broad
spectrum of populations. Bibliotherapeutic approaches have empirical support for
the treatment of depression, for a variety of anxiety disorders, and for a range of
clinical problems (Jacobs, 2008). Because therapy is seen as an educational proc-
ess, clients are encouraged to read REBT self-help books such as Rational Emotive
Behavior Therapy: It Works for Me—It Can Work for You (Ellis, 2004a) and other
books by Ellis (1999, 2000, 2001a, 2001b).
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• Changing one’s language. REBT rests on the premise that imprecise language
is one of the causes of distorted thinking processes. Clients learn that “musts,”
“oughts,” and absolute “shoulds” can be replaced by preferences. Instead of saying “It
would be absolutely awful if . . .”, they learn to say “It would be inconvenient if . . .”.
Clients who use language patterns that refl ect helplessness and self-condemnation
can learn to employ new self-statements, which help them think and behave differ-
ently. As a consequence, they also begin to feel differently.
• Psychoeducational methods. REBT programs introduce clients to various edu-
cational materials. Therapists educate clients about the nature of their problems
and how treatment is likely to proceed. They ask clients how particular concepts
apply to them. Clients are more likely to cooperate with a treatment program if
they understand how the therapy process works and if they understand why par-
ticular techniques are being used (Ledley, Marx, & Heimberg, 2010).
e m ot i v e t e c h n i q u e s REBT practitioners use a variety of emotive proce-
dures, including unconditional acceptance, rational emotive role playing, modeling,
rational emotive imagery, and shame-attacking exercises. Clients are taught the val-
ue of unconditional self-acceptance. Even though their behavior may be diffi cult to
accept, they can decide to see themselves as fallible human beings. Clients are taught
how destructive it is to engage in “putting oneself down” for perceived defi ciencies.
Although REBT employs a variety of emotive techniques, which tend to be
vivid and evocative in nature, the main purpose is to dispute clients’ irrational
beliefs (Dryden, 2007). These strategies are used both during the therapy sessions
and as homework assignments in daily life. Their purpose is not simply to provide
a cathartic experience but to help clients change some of their thoughts, emotions,
and behaviors (Ellis, 2001b, 2011; Ellis & Dryden, 2007). Let’s look at some of
these evocative and emotive therapeutic techniques in more detail.
• Rational emotive imagery. This technique is a form of intense mental practice
designed to establish new emotional patterns (see Ellis, 2001a, 2001b). Using the
technique of rational emotive imagery (REI), clients are asked to vividly imagine
one of the worst things that might happen to them. They imagine themselves in
specifi c situations where they experience disturbing feelings. Then they are shown
how to train themselves to develop healthy emotions in place of disruptive ones.
As clients change their feelings about adversities, they stand a better chance of
changing their behavior in the situation. Such a technique can be usefully applied
to interpersonal and other situations that are problematic for the individual. Ellis
(2001a, 2011) maintains that if we keep practicing rational emotive imagery several
times a week for a few weeks, we can reach the point that we no longer feel upset
over negative events.
• Using humor. REBT contends that emotional disturbances often result from
taking oneself too seriously, thus, this approach employs a good deal of humor.
One appealing aspect of REBT is that it fosters the development of a better sense
of humor and helps put life into perspective (Wolfe, 2007). Humor has both cogni-
tive and emotional benefi ts in bringing about change. Humor shows the absurdity
of certain ideas that clients steadfastly maintain, and it can be of value in helping
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clients take themselves much less seriously. It teaches clients to laugh—not at
themselves, but at their self-defeating ways of thinking.
• Role playing. Role playing has emotive, cognitive, and behavioral compo-
nents, and the therapist often interrupts to show clients what they are telling them-
selves to create their disturbances and what they can do to change their unhealthy
feelings to healthy ones. Clients can rehearse certain behaviors to bring out what
they feel in a situation. The focus is on working through the underlying irrational
beliefs that are related to unpleasant feelings. For example, Dawson may put off
applying to a graduate school because of his fears of not being accepted. Just the
thought of not being accepted to the school of his choice brings out intense feel-
ings of “being stupid.” Dawson role-plays an interview with the dean of graduate
students, notes his anxiety and the specifi c beliefs leading to it, and challenges his
conviction that he absolutely must be accepted and that not gaining such accept-
ance means that he is a stupid and incompetent person.
• Shame-attacking exercises. The rationale underlying shame-attacking exercis-
es is that emotional disturbance related to the self is often characterized by feel-
ings of shame, guilt, anxiety, and depression. Ellis (1999, 2000, 2001a, 2001b)
developed exercises to help people reduce shame and anxiety over behaving in
certain ways. Ellis asserts that we can stubbornly refuse to feel ashamed by telling
ourselves that it is not catastrophic if someone thinks we are foolish. The exercises
are aimed at increasing self-acceptance and mature responsibility, as well as help-
ing clients see that much of what they think of as being shameful has to do with the
way they defi ne reality for themselves. Clients may accept a homework assignment
to take the risk of doing something that they are ordinarily afraid to do because of
what others might think. For example, clients may wear “loud” clothes designed
to attract attention, sing loudly, ask a silly question at a lecture, or ask for a left-
handed monkey wrench in a grocery store. By carrying out such assignments, cli-
ents are likely to fi nd out that other people are not really that interested in their
behavior. They work on themselves so that they do not feel ashamed or humiliated,
even when they acknowledge that some of their acts will lead to judgments by oth-
ers. They continue practicing these exercises until they realize that their feelings
of shame are self-created and until they are able to behave in less inhibited ways.
Clients eventually learn that they often have no reason for continuing to let others’
reactions or possible disapproval stop them from doing the things they would like
to do. Note that these exercises do not involve illegal activities or acts that will be
harmful to oneself or to others or that will unduly alarm other people.
behavioral techniques REBT practitioners use most of the standard behav-
ior therapy procedures, especially operant conditioning, self-management princi-
ples, systematic desensitization, relaxation techniques, and modeling. Behavioral
homework assignments to be carried out in real-life situations are particularly im-
portant. These assignments are done systematically and are recorded and analyzed
on a form. Homework gives clients opportunities to practice new skills outside
of the therapy session, which may be even more valuable for clients than work
done during the therapy hour (Ledley et al., 2010). Doing homework may involve
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desensitization and live exposure in daily life situations. Clients can be encouraged
to desensitize themselves gradually but also, at times, to perform the very things
they dread doing implosively. For example, a person with a fear of elevators may
decrease this fear by going up and down in an elevator 20 or 30 times in a day.
Clients actually do new and diffi cult things, and in this way they put their insights
to use in the form of concrete action. By acting differently, they also tend to incor-
porate functional beliefs.
Applications of REBT to Various Settings
With its clear structure (A-B-C framework), REBT is applicable to a wide range of
settings and populations, including elementary and secondary schools. REBT can
be applied to couples counseling and family therapy. In working with couples, the
partners are taught the principles of REBT so that they can work out their differ-
ences or at least become less disturbed about them. In family therapy, individual
family members are encouraged to consider letting go of the demand that others
in the family behave in ways they would like them to. Instead, REBT teaches family
members that they are primarily responsible for their own actions and for chang-
ing their own reactions to the family situation.
Application of REBT as a Brief Therapy
REBT is well suited as a brief form of therapy, whether it is applied to individuals,
groups, couples, or families. Ellis originally developed REBT to try to make psycho-
therapy shorter and more effi cient than most other systems of therapy, and it is often
used as a brief therapy. Ellis has always maintained that the best therapy is effi cient,
quickly teaching clients how to tackle practical problems of living. Clients learn how to
apply REBT techniques to their present as well as future problems. A distinguishing
characteristic of REBT that makes it a brief form of therapy is that it is a self-help ap-
proach (Vernon, 2007). The A-B-C approach to changing basic disturbance-creating
attitudes can be learned in 1 to 10 sessions and then practiced at home.
Application to Group Counseling
Cognitive behavior therapy (CBT) groups are among the most popular in clinics
and community agency settings. Two of the most common CBT group approaches
are based on the principles and techniques of REBT and cognitive therapy (CT).
REBT practitioners employ an active role in getting members to commit them-
selves to practicing in everyday situations what they are learning in the group sessions.
They view what goes on during the group as being valuable, yet they know that the con-
sistent work between group sessions and after a group ends is even more crucial. The
group context provides members with tools they can use to become self-reliant and
to accept themselves unconditionally as they encounter new problems in daily living.
REBT is also suitable for group therapy because the members are taught to ap-
ply its principles to one another in the group setting. Ellis recommends that most
clients experience group therapy as well as individual therapy at some point. This
form of group therapy focuses on specifi c techniques for changing a client’s self-
defeating thoughts in various concrete situations. In addition to modifying beliefs,
this approach helps group members see how their beliefs infl uence what they feel
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and what they do. This model aims to minimize symptoms by bringing about a
profound change in philosophy. Ellis (2011) contends that REBT is particularly
applicable to group therapy and is frequently the treatment of choice. Group
work affords many opportunities to agree on homework assignments, to practice
assertiveness skills, to take risks by practicing different behaviors, to challenge
self-defeating thinking, to learn from the experiences of others, and to interact
therapeutically and socially with each other in after-group sessions. All of the
cognitive, emotive, and behavioral techniques described earlier are applicable
to group counseling as are the techniques covered in Chapter 9 on behavior
therapy. Behavioral homework and skills training are just two useful methods
for a group format.
A major strength of REBT and cognitive behavioral groups is the emphasis
placed on education and prevention. Because CBT and REBT are based on broad
principles of learning, these approaches can be used to meet the requirements
of a wide variety of groups with a range of different purposes. The specifi city of
CBT allows for links among assessment, treatment, and evaluation strategies. CBT
groups have targeted problems ranging from anxiety and depression to parent ed-
ucation and relationship enhancement. Cognitive behavioral group therapy has
been demonstrated to have benefi cial applications for some of the following specif-
ic problems: depression, anxiety, panic and phobia, obesity, eating disorders, dual
diagnoses, dissociative disorders, and adult attention defi cit disorders (see White &
Freeman, 2000). Based on his survey of outcome studies of cognitive behavioral
group therapy, Petrocelli (2002) concludes that this approach to groups is effec-
tive for treating a wide range of emotional and behavioral problems. For a more
detailed discussion of REBT applied to group counseling, see Corey (2012, chap. 14).
a a r o n b e c k ’s c o g n i t i v e t h e r a p y
Introduction
Aaron T. Beck developed an approach known as cognitive therapy (CT) as a re-
sult of his research on depression (Beck 1963, 1967). Beck developed cognitive
therapy about the same time that Ellis was developing REBT, yet they appear to
have created their approaches independently. Beck’s observations of depressed
clients revealed that they had a negative bias in their interpretation of certain life
events, which contributed to their cognitive distortions (Beck, 1967). Cognitive
therapy has a number of similarities to both rational emotive behavior therapy and
behavior therapy. All of these therapies are active, directive, time-limited, present-
centered, problem-oriented, collaborative, structured, and empirical. They make
use of homework and require explicit identifi cation of problems and the situations
in which they occur (Beck & Weishaar, 2011).
Cognitive therapy (CT) perceives psychological problems as stemming from com-
monplace processes such as faulty thinking, making incorrect inferences on the basis
of inadequate or incorrect information, and failing to distinguish between fantasy
and reality. Like REBT, CT is an insight-focused therapy with a strong psychoedu-
cational component that emphasizes recognizing and changing unrealistic nega-
tive thoughts and maladaptive beliefs. Cognitive therapy is highly collaborative and
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involves designing specifi c learning experiences to help clients monitor their auto-
matic thoughts; examine the validity of their automatic thoughts; understand the
relationship among cognition, feelings, and behavior; develop more accurate and
realistic cognitions; and change underlying beliefs and assumptions (Dobson &
Dozois, 2010; Dozois & Beck, 2011). Cognitive therapy is based on the theoretical
rationale that the way people feel and behave is infl uenced by how they perceive
and structure their experience. The theoretical assumptions of cognitive therapy
are (1) that people’s internal communication is accessible to introspection, (2) that
clients’ beliefs have highly personal meanings, and (3) that these meanings can
be discovered by the client rather than being taught or interpreted by the therapist
(Weishaar, 1993).
Basic Principles of Cognitive Therapy
Beck, formerly a practicing psychoanalytic therapist for many years, grew inter-
ested in his clients’ automatic thoughts (personalized notions that are triggered by
particular stimuli that lead to emotional responses). As a part of a psychoanalytic
research study, he was examining the dream content of depressed clients for anger
that they were turning back on themselves. He began to notice that rather than
retrofl ected anger, as Freud theorized with depression, clients exhibited a negative
bias in their interpretation or thinking. Beck asked clients to observe their nega-
tive automatic thoughts that persisted even though they were contrary to objective
evidence, and from this beginning he developed one of the most comprehensive
theories of psychopathology in the world.
Individuals tend to maintain their core beliefs about themselves, their world,
and their future. A primary focus of cognitive therapy is to assist clients in ex-
amining and restructuring their core beliefs (or core schema) (Dozois & Beck,
2011). By encouraging clients to gather and weigh the evidence in support of their
beliefs, therapists help clients bring about enduring changes in their mood and
their behavior.
Beck contends that people with emotional diffi culties tend to commit char-
acteristic “logical errors” that distort objective reality. Let’s examine some of the
systematic errors in reasoning that lead to faulty assumptions and misconceptions,
which are termed cognitive distortions (J. Beck, 2011; Beck & Weishaar, 2011).
• Arbitrary inferences refer to making conclusions without supporting and rel-
evant evidence. This includes “catastrophizing,” or thinking of the absolute worst
scenario and outcomes for most situations. You might begin your fi rst job as a
counselor with the conviction that you will not be liked or valued by either your
colleagues or your clients. You are convinced that you fooled your professors
and somehow just managed to get your degree, but now people will certainly see
through you!
• Selective abstraction consists of forming conclusions based on an isolated
detail of an event. In this process other information is ignored, and the signifi –
cance of the total context is missed. The assumption is that the events that matter
are those dealing with failure and deprivation. As a counselor, you might measure
your worth by your errors and weaknesses, not by your successes.
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• Overgeneralization is a process of holding extreme beliefs on the basis of a
single incident and applying them inappropriately to dissimilar events or settings.
If you have diffi culty working with one adolescent, for example, you might con-
clude that you will not be effective counseling any adolescents. You might also
conclude that you will not be effective working with any clients!
• Magnifi cation and minimization consist of perceiving a case or situation in a
greater or lesser light than it truly deserves. You might make this cognitive error
by assuming that even minor mistakes in counseling a client could easily create a
crisis for the individual and might result in psychological damage.
• Personalization is a tendency for individuals to relate external events to them-
selves, even when there is no basis for making this connection. If a client does not
return for a second counseling session, you might be absolutely convinced that
this absence is due to your terrible performance during the initial session. You
might tell yourself, “This situation proves that I really let that client down, and now
she may never seek help again.”
• Labeling and mislabeling involve portraying one’s identity on the basis of
imperfections and mistakes made in the past and allowing them to defi ne one’s
true identity. Thus, if you are not able to live up to all of a client’s expectations,
you might say to yourself, “I’m totally worthless and should turn my professional
license in right away.”
• Dichotomous thinking involves categorizing experiences in either-or ex-
tremes. With such polarized thinking, events are labeled in black or white terms.
You might give yourself no latitude for being an imperfect person and imperfect
counselor. You might view yourself as either being the perfectly competent coun-
selor (which means you always succeed with all clients) or as a total fl op if you are
not fully competent (which means there is no room for any mistakes).
The cognitive therapist operates on the assumption that an important way to
produce lasting change in dysfunctional emotions and behaviors is to modify inac-
curate and dysfunctional thinking. The cognitive therapist teaches clients how to
identify these distorted and dysfunctional cognitions through a process of evalua-
tion. Through a collaborative effort, clients learn the infl uence that cognition has
on their feelings and behaviors and even on environmental events. In cognitive
therapy, clients learn to engage in more realistic thinking, especially if they con-
sistently notice times when they tend to get caught up in catastrophic thinking.
After they have gained insight into how their unrealistic negative thoughts are
affecting them, clients are taught to test these automatic thoughts against reality
by examining and weighing the evidence for and against them. They can begin to
monitor the frequency with which these beliefs intrude in situations in everyday life.
The frequently asked question is, “What is the evidence for _____?” This process of
critically examining their automatic thoughts and core beliefs involves empirically
testing them by actively engaging in a Socratic dialogue with the therapist, carry-
ing out homework assignments, doing behavioral experiments, gathering data on
assumptions they make, and forming alternative interpretations (Dattilio, 2000a;
Freeman & Dattilio, 1994; Tompkins, 2004, 2006). From the start of treatment,
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clients learn to employ specifi c problem-solving and coping skills. Through a proc-
ess of guided discovery, clients acquire insight about the connection between their
thinking and the ways they act and feel.
Cognitive therapy is focused on present problems, regardless of a client’s di-
agnosis. The past may be brought into therapy when the therapist considers it es-
sential to understand how and when certain core dysfunctional beliefs originated
and how these ideas have a current impact on the client’s specifi c schema (Dattilio,
2002a). The goals of this brief therapy include providing symptom relief, assist-
ing clients in resolving their most pressing problems, and teaching clients relapse
prevention strategies.
s o m e d i f f e r e n c e s b e t w e e n c t a n d r e b t In both CT and REBT,
reality testing is highly organized. Clients come to realize on an experiential level
that they have misconstrued situations. Yet there are some important differences
between these two approaches, especially with respect to therapeutic methods
and style.
REBT is often highly directive, persuasive, and confrontational; it also focus-
es on the teaching role of the therapist. The therapist models rational thinking
and helps clients to identify and dispute irrational beliefs. In contrast, CT uses a
Socratic dialogue by posing open-ended questions to clients with the aim of getting
clients to refl ect on personal issues and arrive at their own conclusions. CT places
more emphasis on helping clients identify their misconceptions for themselves
than does REBT. Through this refl ective questioning process, the cognitive thera-
pist attempts to collaborate with clients in testing the validity of their cognitions
(a process termed collaborative empiricism). Therapeutic change is the result of
clients confronting faulty beliefs with contradictory evidence that they have gath-
ered and evaluated.
There are also differences in how Ellis and Beck view faulty thinking. Through
a process of rational disputation, Ellis works to persuade clients that certain of their
beliefs are irrational and nonfunctional. Beck views his clients’ beliefs as being
more inaccurate than irrational and asks his clients to conduct behavioral experi-
ments to test the accuracy of their beliefs (Hollon & DiGiuseppe, 2011). Cognitive
therapists view dysfunctional beliefs as being problematic when they are irrational,
or when they are too absolute, broad, and extreme (Beck & Weishaar, 2011). For
Beck, people live by rules (premises or formulas); they get into trouble when they
label, interpret, and evaluate by a set of rules that are unrealistic or when they use
the rules inappropriately or excessively. If clients make the determination that they
are living by rules that are likely to lead to misery, the therapist may suggest alter-
native rules for them to consider, without indoctrinating them. Although cognitive
therapy often begins by recognizing the client’s frame of reference, the therapist
continues to ask for evidence for a belief system.
The Client–Therapist Relationship
One of the main ways the practice of cognitive therapy differs from the practice of
rational emotive behavior therapy is its emphasis on the therapeutic relationship.
As you will recall, Ellis views the therapist largely as a teacher and does not think
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that a warm personal relationship with clients is essential. In contrast, Beck (1987)
emphasizes that the quality of the therapeutic relationship is basic to the applica-
tion of cognitive therapy. Through his writings, it is clear that Beck believes that
effective therapists must combine empathy and sensitivity, along with techni-
cal competence. The core therapeutic conditions described by Rogers in his
person-centered approach are viewed by cognitive therapists as being necessary,
but not suffi cient, to produce optimum therapeutic effect. A therapeutic alliance
is a necessary fi rst step in cognitive therapy, especially in counseling diffi cult-
to-reach clients. Without a working alliance, applying techniques will not be
effective (Dienes et al., 2011). Therapists must also have a cognitive conceptu-
alization of cases, be creative and active, be able to engage clients through a
process of Socratic questioning, and be knowledgeable and skilled in the use
of cognitive and behavioral strategies aimed at guiding clients in signifi cant
self-discoveries that will lead to change (Beck & Weishaar, 2011). Macy (2007)
states that effective cognitive therapists strive to create “warm, empathic rela-
tionships with clients while at the same time effectively using cognitive therapy
techniques that will enable clients to create change in their thinking, feeling,
and behaving” (p. 171).
Cognitive therapists are continuously active and deliberately interactive with
clients, helping clients frame their conclusions in the form of testable hypotheses.
Therapists engage clients’ active participation and collaboration throughout all
phases of therapy, including deciding how often to meet, how long therapy should
last, what problems to explore, and setting an agenda for each therapy session
(J. Beck & Butler, 2005).
Aaron and Judith Beck conceptualize a partnership to devise personally mean-
ingful evaluations of the client’s negative assumptions (J. Beck, 2005, 2011a). The
therapist functions as a catalyst and a guide who helps clients understand how
their beliefs and attitudes infl uence the way they feel and act. Clients are expected
to identify the distortions in their thinking, summarize important points in the
session, and collaboratively devise homework assignments that they agree to carry
out. Cognitive therapists emphasize the client’s role in self-discovery. The assump-
tion is that lasting changes in the client’s thinking and behavior will be most likely
to occur with the client’s initiative, understanding, awareness, and effort (J. Beck,
2005, 2011a; J. Beck & Butler, 2005; Beck & Weishaar, 2011).
In cognitive therapy, the aim is to identify specifi c, measurable goals and to
move directly into the areas that are causing the most diffi culty for clients (Dienes
et al. 2011). Cognitive therapists aim to teach clients how to be their own thera-
pist. Typically, a therapist will educate clients about the nature and course of their
problem, about the process of cognitive therapy, and how thoughts infl uence their
emotions and behaviors. The educative process includes providing clients with in-
formation about their presenting problems and about relapse prevention. One way
of educating clients is through bibliotherapy, in which clients complete readings
dealing with the philosophy of cognitive therapy. These readings are assigned as
an adjunct to therapy and are designed to enhance the therapeutic process by pro-
viding an educational focus (Dattilio & Freeman, 2007; Jacobs, 2008). Cognitive
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therapy self-help books also provide an educational focus, such as The Beck Diet
Solution: Train Your Brain to Think Like a Thin Person (J. Beck, 2007a) and The
Complete Beck Diet for Life (J. Beck, 2008).
Homework is often used as a part of cognitive therapy because practicing cog-
nitive behavioral skills outside of the offi ce facilitates more rapid gains (Dienes
et al., 2011). Homework is tailored to the client’s specifi c problem and arises out of
the collaborative therapeutic relationship. Tompkins (2004, 2006) outlines the key
steps to successful homework assignments and the steps involved in collaboratively
designing homework. The purpose of homework is not merely to teach clients new
skills but also to enable them to test their beliefs and experiment with different
behaviors in daily-life situations. Homework is generally presented to clients as an
experiment, which increases the openness of clients to get involved in an assign-
ment. Emphasis is placed on self-help assignments that serve as a continuation
of issues addressed in a therapy session (Dattilio, 2002b). Cognitive therapists
realize that clients are more likely to complete homework if it is tailored to their
needs, if they participate in designing the homework, if they begin the homework
in the therapy session, and if they talk about potential problems in implementing
the homework (J. Beck, 2005). Tompkins (2006) points out that there are clear
advantages to the therapist and the client working in a collaborative manner in
negotiating mutually agreeable homework tasks. One indicator of a good therapeu-
tic alliance is whether homework is done and done well.
Applications of Cognitive Therapy
Cognitive therapy initially gained recognition as an approach to treating depres-
sion, but extensive research has also been devoted to the study and treatment of
many other psychiatric disorders. One of the reasons for the popularity of cognitive
therapy is due to “strong empirical support for its theoretical framework and to
the large number of outcome studies with clinical populations” (Beck & Weishaar,
2011, p. 305). According to J. Beck (personal communication, January 1, 2011),
hundreds of research studies have confi rmed the theoretical underpinnings of CT,
and hundreds of outcome trials have established its effi cacy for a wide range of
psychiatric disorders, psychological problems, and medical conditions with psy-
chological components.
Cognitive therapy has been successfully used to treat phobias, psychosomatic
disorders, eating disorders, anger, panic disorders, and generalized anxiety disor-
ders (Chambless & Peterman, 2006; Dattilio & Kendall, 2007; Riskind, 2006);
posttraumatic stress disorder, suicidal behavior, borderline personality disorders,
narcissistic personality disorders, and schizophrenic disorders (Dattilio & Freeman,
2007); personality disorders (Pretzer & Beck, 2006); substance abuse (Newman,
2006); chronic pain (Beck, 1987); medical illness (Dattilio & Castaldo, 2001); crisis
intervention (Dattilio & Freeman, 2007); couples and families therapy (Dattilio,
1993, 1998, 2001, 2005, 2010; Dattilio & Padesky, 1990; Epstein, 2006); child
abusers, divorce counseling, skills training, and stress management (Dattilio, 1998;
Granvold, 1994; Reinecke, Dattilio, & Freeman, 2002). Clearly, cognitive therapy
programs have been designed for all ages and for a variety of client populations.
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For an excellent resource on the clinical applications of cognitive therapy to a wide
range of disorders and populations, see Contemporary Cognitive Therapy (Leahy,
2006a).
a p p ly i n g c o g n i t i v e t e c h n i q u e s Beck and Weishaar (2011) describe
both cognitive and behavioral techniques that are part of the overall strategies used
by cognitive therapists. Cognitive techniques focus on identifying and examining
a client’s beliefs, exploring the origins of these beliefs, and modifying them if the
client cannot support these beliefs. Examples of behavioral techniques typically
used by cognitive therapists include activity scheduling, behavioral experiments,
skills training, role playing, behavioral rehearsal, and exposure therapy. Regard-
less of the nature of the specifi c problem, the cognitive therapist is mainly in-
terested in applying procedures that will assist individuals in making alternative
interpretations of events in their daily living. Think about how you might apply the
principles of CT to yourself in this classroom situation and change your feelings
surrounding the situation:
Your professor does not call on you during a particular class session. You feel depressed.
Cognitively, you are telling yourself: “My professor thinks I’m stupid and that I really don’t
have much of value to offer the class. Furthermore, she’s right, because everyone else is
brighter and more articulate than I am. It’s been this way most of my life!”
Some possible alternative interpretations are that the professor wants to include oth-
ers in the discussion, that she is short on time and wants to move ahead, that she
already knows your views, or that she believes you are self-conscious about being
singled out or called on.
The therapist would have you become aware of the distortions in your thinking
patterns by examining your automatic thoughts. The therapist would ask you to
look at your inferences, which may be faulty, and may investigate whether these
inferences can be traced back to earlier experiences in your life. Then the therapist
would help you see how you sometimes come to a conclusion (your decision that
you are stupid, with little of value to offer) when evidence for such a conclusion is
either lacking or based on distorted information from the past.
As a client in cognitive therapy, you would also learn about the process of mag-
nifi cation or minimization of thinking, which involves either exaggerating the
meaning of an event (you believe the professor thinks you are stupid because she
did not acknowledge you on this one occasion) or minimizing it (you belittle your
value as a student in the class). The therapist would assist you in learning how you
disregard important aspects of a situation, engage in overly simplifi ed and rigid
thinking, and generalize from a single incident of failure. Can you think of other
situations where you could apply CT procedures?
t r e at m e n t o f d e p r e s s i o n Based on his research, Beck (1963) chal-
lenged the notion that depression results from anger turned inward. Instead, he
focuses on the content of the depressive’s negative thinking and biased interpreta-
tion of events. Beck (1987) writes about the cognitive triad as a pattern that triggers
depression. In the fi rst component of the triad, clients hold a negative view of them-
selves. They blame their setbacks on personal inadequacies without considering
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circumstantial explanations. They are convinced that they lack the qualities essen-
tial to bring them happiness. The second component of the triad consists of the
tendency to interpret their personal world in a negative manner. Depressed people
focus on certain facts that conform to their negative conclusions, a process referred
to as selective abstraction by Beck. The third component of the triad pertains to
depressed clients’ gloomy vision and projections about the future. They expect
their present diffi culties to continue, and they anticipate only failure in the future.
Depression-prone people often set rigid, perfectionist goals for themselves
that are impossible to attain. Their negative expectations are so strong that even
if they experience success in specifi c tasks they anticipate failure the next time.
They screen out successful experiences that are not consistent with their nega-
tive self-concept. The thought content of depressed individuals often centers on
a sense of irreversible loss that results in emotional states of sadness, disappoint-
ment, and apathy.
The cognitive therapy approach to treating depressed clients focuses on spe-
cifi c problem areas and the reasons clients give for their symptoms. To assess the
depth of depression, Beck (1967) designed a standardized device known as the
Beck Depression Inventory (BDI). Some of the behavioral symptoms of depres-
sion are inactivity, withdrawal, and avoidance. The therapist is likely to probe with
Socratic questioning such as this: “What would be lost by trying a specifi c activity?
Will you feel worse if you are passive? How do you know that it is pointless to try?”
Therapy procedures include setting up an activity schedule with graded tasks to
be completed. Clients are asked to complete easy tasks fi rst, so that they will meet
with some success and become slightly more optimistic. The point is to enlist the
client’s cooperation with the therapist on the assumption that doing something is
more likely to lead to feeling better than doing nothing.
A central characteristic of most depressive people is self-criticism. Underneath
the person’s negative self-attitudes are themes of weakness, inadequacy, and lack
of responsibility. A number of therapeutic strategies can be used. Clients can be
asked to identify and provide reasons for their excessively self-critical thinking. The
therapist may ask the client, “If your friend were to make a mistake the way you
do, would you be as critical of her as you are of yourself?” The therapist may also
discuss with the client how the “tyranny of shoulds” can lead to increased distress.
Depressed clients typically experience painful emotions. They may say that they
cannot stand the pain or that nothing can make them feel better. One procedure
that may be helpful is to ask them to speak more conversationally about events in
the past week in which their mood lifted even just a little.
Another specifi c characteristic of depressed people is an exaggeration of exter-
nal demands, problems, and pressures. They may express thoughts of being over-
whelmed and that there is so much to accomplish that they can never do it. A cognitive
therapist might ask clients to list things that need to be done, set priorities, check off
tasks that have been accomplished, and break down an external problem into man-
ageable units. When problems are discussed, clients often become aware of how they
are magnifying the importance of these diffi culties. Through rational exploration,
clients are able to regain a perspective on defi ning and accomplishing tasks.
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The therapist typically has to take the lead in helping clients make a list of their
responsibilities, set priorities, and develop a realistic plan of action. Because carry-
ing out such a plan is often inhibited by negative automatic thoughts, it is well for
therapists to use cognitive rehearsal techniques in both identifying and changing
negative thoughts. If clients can learn to combat their self-doubts in the therapy
session, they may be able to apply their newly acquired cognitive and behavioral
skills in real-life situations.
a p p l i c at i o n t o fa m i ly t h e r a p y The cognitive behavioral approach
focuses on family interaction patterns, and family relationships, cognitions, emo-
tions, and behavior are viewed as exerting a mutual infl uence on one another. A
cognitive inference can evoke emotion and behavior, and emotion and behavior
can likewise infl uence cognition in a reciprocal process that sometimes serves to
maintain the dysfunction of the family unit.
Cognitive therapy, as set forth by Beck (1976), places a heavy emphasis on sche-
ma, or what have elsewhere been defi ned as core beliefs. A key aspect of the therapeu-
tic process involves restructuring distorted beliefs (or schema), which has a pivotal
impact on changing dysfunctional behaviors. Some cognitive behavior therapists place
a strong emphasis on examining cognitions among individual family members as well
as on what may be termed the “family schemata” (Dattilio, 1993, 1998, 2001, 2010).
These are jointly held beliefs about the family that have formed as a result of years of
integrated interaction among members of the family unit. It is the experiences and
perceptions from the family of origin that shape the schema about both the immedi-
ate family and families in general. These schemata have a major impact on how the
individual thinks, feels, and behaves in the family system (Dattilio, 2001, 2005, 2010).
For a concrete illustration of how Dr. Dattilio applies cognitive principles and
works with family schemata, see his cognitive behavioral approach with Ruth in
Case Approach to Counseling and Psychotherapy (Corey, 2013a, chap. 8). For a discus-
sion of myths and misconceptions of cognitive behavior family therapy, see Dattilio
(2001); for a concise presentation on the cognitive behavioral model of family ther-
apy, see Dattilio (2010). Also, for an expanded treatment of applications of cognitive
behavioral approaches to working with couples and families, see Dattilio (1998).
d o n a l d m e i c h e n b a u m ’s c o g n i t i v e
b e h av i o r m o d i f i c at i o n
Introduction
Another major alternative to rational emotive behavior therapy is Donald Meichen-
baum’s cognitive behavior modifi cation (CBM), which focuses on changing the cli-
ent’s self-verbalizations. Meichenbaum’s cognitive behavioral approach combines
some of the best elements of behavior therapy and cognitive therapy. According to
Meichenbaum (1977), self-statements affect a person’s behavior in much the same
way as statements made by another person. A basic premise of CBM is that clients,
as a prerequisite to behavior change, must notice how they think, feel, and behave
and the impact they have on others. For change to occur, clients need to interrupt
the scripted nature of their behavior so that they can evaluate their behavior in vari-
ous situations (Meichenbaum, 1993, 2007).
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This approach shares with REBT and Beck’s cognitive therapy the assumption that
distressing emotions are typically the result of maladaptive thoughts. REBT is more
direct and confrontational in uncovering and disputing irrational thoughts, whereas
Meichenbaum’s self-instructional training focuses more on helping clients become
aware of their self-talk and the stories they tell about themselves. Both REBT and CT
focus on changing thinking processes, but Meichenbaum suggests that it may be easi-
er and more effective to behave our way into a new way of thinking rather than to think
our way into a new way of behaving. Furthermore, our emotions and thinking are two
sides of the same coin: the way we feel can affect our way of thinking, just as how we
think can infl uence how we feel. The therapeutic process consists of teaching clients to
make self-statements and training clients to modify the instructions they give to them-
selves so that they can cope more effectively with the problems they encounter. Cogni-
tive restructuring plays a central role in Meichenbaum’s (1977, 1993) self-instructional
training. He describes cognitive structure as the organizing aspect of thinking, which
seems to monitor and direct the choice of thoughts through an “executive processor”
that “holds the blueprints of thinking” that determine when to continue, interrupt,
or change thinking. Together, therapist and client practice the self-instructions and
the desirable behaviors in role-play situations that simulate problem situations in the
client’s daily life. The emphasis is on acquiring practical coping skills for problematic
situations such as impulsive and aggressive behavior, anxiety in social situations, fear
of taking tests, eating problems, and fear of public speaking.
How Behavior Changes
Meichenbaum (1977) proposes that “behavior change occurs through a sequence
of mediating processes involving the interaction of inner speech, cognitive struc-
tures, and behaviors and their resultant outcomes” (p. 218). He describes a three-
phase process of change in which those three aspects are interwoven. According to
him, focusing on only one aspect will probably prove insuffi cient.
Phase 1: Self-observation. The beginning step in the change process consists of clients
learning how to observe their own behavior. When clients begin therapy, their in-
ternal dialogue is characterized by negative self-statements and imagery. A critical
factor is their willingness and ability to listen to themselves. This process involves an
increased sensitivity to their thoughts, feelings, actions, physiological reactions, and
ways of reacting to others. If depressed clients hope to make constructive changes, for
example, they must fi rst realize that they are not “victims” of negative thoughts and
feelings. Rather, they are actually contributing to their depression through the things
they tell themselves. Although self-observation is necessary if change is to occur, it is
not suffi cient for change. As therapy progresses, clients acquire new cognitive struc-
tures that enable them to view their problems in a new light. This reconceptualization
process comes about through a collaborative effort between client and therapist.
Phase 2: Starting a new internal dialogue. As a result of the early client–therapist
contacts, clients learn to notice their maladaptive behaviors, and they begin to see
opportunities for adaptive behavioral alternatives. If clients hope to change what
they are telling themselves, they must initiate a new behavioral chain, one that
is incompatible with their maladaptive behaviors. Clients learn that psychological
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distress is a function of the interdependence of cognitions, emotions, behaviors,
and resultant consequences. In therapy, clients learn to change their internal dia-
logue, which serves as a guide to new behavior.
Phase 3: Learning new skills. The third phase of the modifi cation process consists of
helping clients interrupt the downward spiral of thinking, feeling, and behaving
and teaching them more adaptive ways of coping using the resources they bring to
therapy. Clients learn more effective coping skills, which are practiced in real-life
situations. For example, clients who can’t cope with failure may avoid appealing
activities for fear of not succeeding at them. Cognitive restructuring can help them
change their negative view, thus making them more willing to engage in desired
activities. At the same time, clients continue to focus on telling themselves new
sentences and observing and assessing the outcomes. As they behave differently
in situations, they typically get different reactions from others. The stability of what
they learn is greatly infl uenced by what they say to themselves about their newly
acquired behavior and its consequences.
Stress Inoculation Training
A particular application of a coping skills program is teaching clients stress man-
agement techniques by way of a strategy known as stress inoculation training
(SIT). Using cognitive techniques, Meichenbaum (1985, 2007, 2008) has devel-
oped stress inoculation procedures that are a psychological and behavioral ana-
log to immunization on a biological level. Individuals are given opportunities to
deal with relatively mild stress stimuli in successful ways, so that they gradually
develop a tolerance for stronger stimuli. This training is based on the assumption
that we can affect our ability to cope with stress by modifying our beliefs and self-
statements about our performance in stressful situations. Meichenbaum’s stress
inoculation training is concerned with more than merely teaching people specifi c
coping skills. His program is designed to prepare clients for intervention and
motivate them to change, and it deals with issues such as resistance and relapse.
Stress inoculation training consists of a combination of information giving,
Socratic discovery-oriented inquiry, cognitive restructuring, problem solving, relaxa-
tion training, behavioral rehearsals, self-monitoring, self-instruction, self-reinforce-
ment, and modifying environmental situations (Meichenbaum, 2008). SIT involves
collaborative goal setting that nurtures hope, direct-action skills, and acceptance-based
coping skills. These coping skills are designed to be applied to both present problems
and future diffi culties. Clients are assisted in generalizing what they learn in the
training to daily living, and relapse prevention strategies are taught. Meichenbaum
(2008) describes stress inoculation training as a complex, multifaceted cognitive be-
havioral intervention that is both a preventive and a treatment approach.
Clients can acquire more effective strategies in dealing with stressful situations
by learning how to modify their cognitive “set,” or core beliefs. The following pro-
cedures are designed to teach these coping skills:
• Expose clients to anxiety-provoking situations by means of role playing and
imagery
• Require clients to evaluate their anxiety level
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• Teach clients to become aware of the anxiety-provoking cognitions they experi-
ence in stressful situations
• Help clients examine these thoughts by reevaluating their self-statements
• Have clients note the level of anxiety following this reevaluation
t h e p h a s e s o f s t r e s s i n o c u l at i o n t r a i n i n g Meichenbaum
(2007, 2008) has designed a three-stage model for stress inoculation training:
(1) the conceptual-educational phase, (2) the skills acquisition and consolidation
phase, and (3) the application and follow-through phase.
During the conceptual-educational phase, the primary focus is on creating a
working relationship and therapeutic alliance with clients. This is mainly done by
helping them gain a better understanding of the nature of stress and reconceptual-
izing it in social-interactive terms. The therapist enlists the client’s collaboration
during this early phase and together they rethink the nature of the problem or
the individual’s stress concerns. Initially, clients are provided with a conceptual
framework in simple terms designed to educate them about ways of responding to
a variety of stressful situations. They learn about the role cognitions and emotions
play in creating and maintaining stress through didactic presentations, by curious
questioning, and by a process of guided self-discovery.
Clients often begin treatment feeling that they are the victims of external cir-
cumstances, thoughts, feelings, and behaviors over which they have no control.
As a way to understand the subjective world of clients, the therapist generally
elicits stories that clients tell themselves. Training includes teaching clients to
become aware of their own role in creating their stress and their life stories. They
acquire this awareness by systematically observing the statements they make
internally as well as by monitoring the maladaptive behaviors that fl ow from this
inner dialogue. Such self-monitoring continues throughout all the phases. As is
true in cognitive therapy, clients typically keep an open-ended diary in which they
systematically monitor and record their specifi c thoughts, feelings, and behav-
iors. In teaching these coping skills, therapists strive to be fl exible in their use of
techniques and to be sensitive to the individual, cultural, and situational circum-
stances of their clients.
During the skills acquisition and consolidation phase, the focus is on giving cli-
ents a variety of behavioral and cognitive coping skills to apply to stressful situa-
tions. This phase involves direct actions, such as gathering information about their
fears, learning specifi cally what situations bring about stress, arranging for ways to
lessen the stress by doing something different, and learning methods of physical and
psychological relaxation. The training involves cognitive coping; clients are taught
that adaptive and maladaptive behaviors are linked to their inner dialogue. Through
this training, clients acquire and rehearse a new set of self-statements. Meichenbaum
(1986) provides some examples of coping statements that are rehearsed in this
phase of SIT:
• “How can I prepare for a stressor?” (“What do I have to do? Can I develop a plan
to deal with the stress?”)
• “How can I confront and deal with what is stressing me?” (“What are some ways
I can handle a stressor? How can I meet this challenge?”)
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• “How can I cope with feeling overwhelmed?” (“What can I do right now? How
can I keep my fears in check?”)
• “How can I make reinforcing self-statements?” (“How can I give myself credit?”)
Clients also are exposed to various behavioral interventions, such as relaxation
training, social skills training, time-management instruction, and self-instructional
training. They are helped to make lifestyle changes by reevaluating priorities,
developing support systems, and taking direct action to alter stressful situations.
Through teaching, demonstration, and guided practice, clients learn the skills of
progressive relaxation and practice them regularly to decrease arousal due to stress.
During the application and follow-through phase, the focus is on carefully arranging
for transfer and maintenance of change from the therapeutic situation to everyday
life. Clients practice their new self-statements and apply their new skills to everyday
life. To consolidate the lessons learned in the training sessions, clients participate in a
variety of activities, including imagery and behavior rehearsal, role playing, modeling,
and graded in vivo exposure. Once clients have become profi cient in cognitive and
behavioral coping skills, they practice behavioral assignments, which become increas-
ingly demanding. They are asked to write down the homework assignments they are
willing to complete. The outcomes of these assignments are carefully checked at sub-
sequent meetings, and if clients do not follow through with them, the therapist and
the client collaboratively consider the reasons for the failure.
Relapse prevention, which consists of procedures for dealing with the inevitable
setbacks clients are likely to experience as they apply what they are learning to daily
life, is taught at this stage (Marlatt & Donovan, 2005). Part of relapse prevention
involves teaching clients to view any lapses that occur as “learning opportunities”
rather than “catastrophic failures.” Clients explore a variety of possible high-risk
stressful situations that they may reexperience. Then they rehearse and practice in
a collaborative fashion with the therapist, and with other clients in a group, ways
of applying skills they have learned in the training to maintain the gains they have
made. Follow-up and booster sessions typically take place at 3-, 6-, and 12-month
periods as an incentive for clients to continue practicing and refi ning their coping
skills. SIT can be considered part of an ongoing stress management program that
extends the benefi ts of training into the future.
Stress inoculation training has potentially useful applications for a wide vari-
ety of problems and clients and for both remediation and prevention. The clinical
application of SIT has been individually tailored to specifi c target populations
and includes anger control, anxiety management, assertion training, improving
creative thinking, treating depression, and dealing with health problems. Stress
inoculation training has been employed with medical patients and with psychiat-
ric patients. SIT has been successfully used with children, adolescents, and adults
who have anger problems, anxiety disorders, phobias, social incompetence,
addictions, alcoholism, sexual dysfunctions, social withdrawal, or posttraumatic
stress disorder (PTSD), including use with veterans who experience combat-
related PTSD (Meichenbaum, 1993, 1994a, 1994b, 2007, 2008). Meichenbaum
(2007) contends that the fl exibility of the SIT format has contributed to its robust
effectiveness.
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The Constructivist Approach
to Cognitive Behavior Therapy
Meichenbaum (1997) has developed his approach by incorporating the construc-
tivist narrative perspective (CNP), which focuses on the stories people tell about
themselves and others regarding signifi cant events in their lives. Therapists elicit
stories from their clients that are explored in the therapy process. This approach
begins with the assumption that there are multiple realities. One of the therapeutic
tasks is to help clients appreciate how they construct their realities and how they
author their own stories (see Chapter 13). Meichenbaum describes the constructiv-
ist approach to cognitive behavior therapy as less structured and more discovery-
oriented than standard cognitive therapy. The constructivist approach gives more
emphasis to past development, tends to target deeper core beliefs, and explores
the behavioral impact and emotional toll a client pays for clinging to certain root
metaphors.
Meichenbaum (personal communication, October 21, 2010) claims that we are
all “story tellers” and that we should beware of the stories that we tell ourselves and
others. For example, victimized clients might see themselves as “prisoners of the
past” or as “stubborn victims.” These phrases are not idle metaphors; they are the
organizing schemas that color the ways individuals view themselves, their world,
and their future. Therapists help clients appreciate how they construct reality (story
tell) and examine the implications and conclusions clients draw from their stories.
Telling the “rest of the story”—what they did to survive and cope—bolsters clients’
strengths and helps them develop resilient-engendering behaviors. In this way,
clients can move from being ”stubborn victims” to becoming “tenacious survivors”
and perhaps “impressive thrivers.”Meichenabum works in a collaborative fashion
with clients to develop the coping skills necessary to achieve these treatment goals.
He uses a Socratic discovery-oriented approach and the art of questioning to assist
clients in reaching their goals.
Meichenbaum (1997) uses these questions to evaluate the outcomes of therapy:
• Are clients now able to tell a new story about themselves and the world?
• Do clients now use more positive metaphors to describe themselves?
• Are clients able to predict high-risk situations and employ coping skills in deal-
ing with emerging problems?
• Are clients able to take credit for the changes they have been able to bring about?
In successful therapy clients develop their own voices, take pride in what they
have accomplished, and take ownership of the changes they are bringing about. In
short, clients become their own therapists and take the therapists’ voice with them.
cognitive behavior therapy
from a multicultural perspective
Strengths From a Diversity Perspective
There are several strengths of cognitive behavioral approaches in working with
individuals from diverse cultural, ethnic, and racial backgrounds. If therapists un-
derstand the core values of their culturally diverse clients, they can help clients
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explore these values and gain a full awareness of their confl icting feelings. Then
the client and the therapist can work together to modify selected beliefs and prac-
tices. Cognitive behavior therapy tends to be culturally sensitive because it uses the
individual’s belief system, or worldview, as part of the method of self-exploration.
Because counselors with a cognitive behavioral orientation function as teachers,
clients are actively involved in learning skills to deal with the problems of living. In
speaking with colleagues who work with culturally diverse populations, I have learned
that their clients tend to appreciate the emphasis on cognition and action, as well as
the stress on relationship issues. The collaborative approach of CBT offers clients
the structure they may want, yet the therapist still makes every effort to enlist clients’
active cooperation and participation. According to Spiegler (2008), because of its basic
nature and the way CBT is practiced, it is inherently suited to treating diverse clients.
Some of the factors that Spiegler identifi es that makes CBT diversity effective include
individualized treatment, focusing on the external environment, active nature, empha-
sis on learning, reliance on empirical evidence, concern with present behavior, and
brevity. A strength of CBT is integrating assessment throughout therapy, which com-
municates respect for clients’ viewpoints regarding their progress.
According to Hays (2009), there is an “almost perfect fi t” between cognitive
behavior therapy and multicultural therapy because these perspectives share com-
mon assumptions that make integration possible. Some aspects that contribute to
an integrative framework follow:
• Interventions are tailored to the unique needs and strengths of the individual.
• Clients are empowered by learning specifi c skills they can apply in daily life
(CBT) and by the emphasis on cultural infl uences that contribute to clients’
uniqueness (multicultural therapy).
• Inner resources and strengths of clients are activated to bring about change.
• Clients make changes that minimize stressors, increase personal strengths and
supports, and establish skills for dealing more effectively with their physical and
social (cultural) environments.
Shortcomings From a Diversity Perspective
Exploring values and core beliefs plays an important role in all of the cognitive
behavioral approaches, and it is crucial for therapists to have some understand-
ing of the cultural background of clients and to be sensitive to their struggles.
Therapists would do well to use caution in confronting clients about their be-
liefs and behaviors until they clearly understand their cultural context. On this
matter, Wolfe (2007) suggests that the therapist’s job is to help clients examine
and challenge long-standing cultural assumptions only if they result in dysfunc-
tional emotions or behaviors. She writes that the therapist assists clients in criti-
cally thinking about “potential confl icts with the values of the dominant culture
so they can work toward achieving their own personal goals within their own
sociocultural context” (p. 188).
A potential limitation of REBT is its negative view of dependency. Many cul-
tures view interdependence as necessary to good mental health. According to Ellis
(1994), REBT is aimed at inducing people to examine and change some of their
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most basic values. Clients with certain long-cherished cultural values pertaining
to interdependence are not likely to respond favorably to such forceful methods
of persuasion toward independence. “REBT practitioners often employ a rapid-
fi re active-directive-persuasive philosophical methodology. In most instances, they
quickly pin clients down to a few basic dysfunctional beliefs” (Ellis, 2011, p. 214).
This style may intimidate or alienate clients who value being refl ective. Modifi ca-
tions in a therapist’s style need to be made depending on the client’s culture.
Hays (2009) suggests that therapists avoid challenging the core cultural beliefs
of clients, unless the client is clearly open to this. By emphasizing collaboration over
confrontation, the therapist can avoid seeming to be disrespectful. Hays recom-
mends drawing on the client’s culturally related strengths in developing helpful
ways of thinking to replace unhelpful cognitions. For example, consider an Asian
American client, Sung, from a culture that stresses values such as doing one’s best,
cooperation, interdependence, and working hard. It is likely that Sung may feel that
she is bringing shame to her family if she is going through a divorce, and she may
feel guilt if she perceives that she is not living up to the expectations and standards
set for her by her family and her community. The rules for Sung are likely to be
different than are the rules for a male member of her culture. The counselor could
assist Sung in understanding and exploring how both her gender and her culture
are factors to consider in her situation. If Sung is confronted too quickly on living
by the expectations or rules of others, the results are likely to be counterproductive.
Sung might even leave counseling feeling that she has been misunderstood.
Cormier, Nurius, and Osborn (2013) suggest that therapists refrain from jargon
and use of disrespectful language when describing clients’ cognitions, avoiding terms
such as rational and irrational, or maladaptive and dysfunctional. This is especially im-
portant when interacting with individuals who feel marginalized by the mainstream
culture. They recommend adapting the language presented in cognitive restructur-
ing to the client’s primary language, age, and educational level. These guidelines can
certainly be applied to REBT practitioners who might do well to refl ect on the words
they use and their tone, especially when zeroing in on a client’s core beliefs.
The emphasis of CBT on assertiveness, independence, verbal ability, rationality,
cognition, and behavioral change may limit its use in cultures that value subtle com-
munication over assertiveness, interdependence over personal independence, listen-
ing and observing over talking, and acceptance over behavior change (Hayes, 2009).
In CBT the focus is on the present, which can result in the therapist failing to recog-
nize the role of the past in a client’s development. Cognitive behavioral assessments
involve the investigation of a client’s personal history. If the therapist is unaware of
a client’s cultural beliefs, which are rooted in the past, the therapist may have dif-
fi culty interpreting the client’s personal experiences accurately. Another limitation
of CBT from a multicultural perspective involves its individualistic orientation. An
inexperienced therapist may overemphasize cognitive restructuring to the neglect of
environmental interventions. Hays points out that these potential limitations do not
preclude the integration of CBT and multicultural counseling. Instead, being aware
of these limitations “presents opportunities for rethinking, refi ning, adapting and
increasing the relevance and effectiveness of psychotherapy” (p. 356).
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From a cognitive behavioral perspec-
tive, I want Stan to critically evaluate
and modify his self-defeating beliefs,
which will likely result in Stan acquiring more
effective behavior. As his therapist, I am both
goal oriented and problem focused. From the
initial session, I ask Stan to identify his prob-
lems and formulate specific goals and help him
reconceptualize his problems in a way that will
increase his chances of finding solutions.
I follow a clear structure for every session.
The basic procedural sequence includes
(1) preparing him by providing a cognitive ration-
ale for treatment and demystifying treatment;
(2) encouraging him to monitor the thoughts
that accompany his distress; (3) implementing
behavioral and cognitive techniques;
(4) assisting him in identifying and examining
some basic beliefs and ideas; (5) teaching him
ways to examine his beliefs and assumptions
by testing them in reality; and (6) teaching him
basic coping skills that will enable him to avoid
relapsing into old patterns.
As a part of the structure of the therapy
sessions, I ask Stan for a brief review of the
week, elicit feedback from the previous session,
review homework assignments, collaboratively
create an agenda for the session, discuss topics
on the agenda, and set new homework for the
week. I encourage Stan to perform personal
experiments and practice coping skills in daily life.
Stan tells me that he would like to work on
his fear of women and would hope to feel far
less intimidated by them. He reports that he
feels threatened by most women, but especially
by women he perceives as powerful. In work-
ing with Stan’s fears, I proceed with four steps:
educating him about his self-talk; having him
monitor and evaluate his faulty beliefs; using
cognitive and behavioral interventions; and
collaboratively designing homework with Stan
that will give him opportunities to practice new
behaviors in daily life.
First, I educate him about the importance of
examining his automatic thoughts, his self-talk,
and the many “shoulds,” “oughts,” and “musts”
he has accepted without questioning. Work-
ing with Stan as a collaborative partner in his
therapy, I guide him in discovering some basic
cognitions that influence what he tells himself
and how he feels and acts. This is some of his
self-talk:
• “I always have to be strong, tough, and perfect.”
• “I’m not a man if I show any signs of weakness.”
• “If everyone didn’t love me and approve of me,
things would be catastrophic.”
• “If a woman rejected me, I really would be re-
duced to a ‘nothing.’”
• “If I fail, I am then a failure as a person.”
• “I’m apologetic for my existence because
I don’t feel equal to others.”
Second, I assist Stan in monitoring and evalu-
ating the ways in which he keeps telling himself
these self-defeating sentences. I assist him in
clarifying specific problems and learning how to
critically evaluate some of his faulty thinking:
You’re not your father. I wonder why you con-
tinue telling yourself that you’re just like him? Do
you think you need to continue accepting without
question your parents’ value judgments about your
worth? Where is the evidence that they were right
in their assessment of you? You say you’re such a
failure and that you feel inferior. Do your present
activities support this? If you were not so hard on
yourself, how might your life be different?
Third, once Stan more fully understands the
nature of his cognitive distortions and his self-
defeating beliefs, I draw on a variety of cognitive
and behavioral techniques to help Stan make
the changes he most desires. Through various
cognitive techniques, he learns to identify, evalu-
ate, and respond to his dysfunctional beliefs.
I rely heavily on cognitive techniques such as
Socratic questioning, guided discovery, and cogni-
tive restructuring to assist Stan in examining the
evidence that seems to support or contradict his
core beliefs. I work with Stan so he will view his
basic beliefs and automatic thinking as hypoth-
eses to be tested. In a way, he will become a
personal scientist by checking out the validity of
many of the conclusions and basic assumptions
Cognitive Behavior Therapy Applied to the Case of Stan
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that contribute to his personal difficulties. By the
use of guided discovery, Stan learns to evaluate
the validity and functionality of his beliefs and
conclusions. Stan can also profit from cognitive
restructuring, which would entail his observ-
ing his own behavior in various situations. For
example, during the week he can take a particu-
lar situation that is problematic for him, paying
particular attention to his automatic thoughts
and internal dialogue. What is he telling himself
as he approaches a difficult situation? How is he
setting himself up for failure with his self-talk?
As he learns to attend to his maladaptive behav-
iors, he begins to see that what he tells himself
has as much impact as others’ statements about
him. He also sees the connections between his
thinking and his behavioral problems. With this
awareness he is in an ideal place to begin to
learn a new, more functional internal dialogue.
Fourth, I work collaboratively with him in
creating specific homework assignments to
help him deal with his fears. It is expected
that Stan will learn new coping skills, which he
can practice first in the sessions and then in
daily life situations. It is not enough for him to
merely say new things to himself; Stan needs to
apply his new cognitive and behavioral coping
skills in various daily situations. At one point,
for instance, I ask Stan to explore his fears of
powerful women and his reasons for continuing
to tell himself: “They expect me to be strong and
perfect. If I’m not careful, they’ll dominate me.”
His homework includes approaching a woman
for a date. If he succeeds in getting the date, he
can think about his catastrophic expectations of
what might happen. What would be so terrible if
she did not like him or if she refused the
date? Stan tells himself over and over that he
must be approved of by women and that if any
woman rebuffs him the consequences are more
than he can bear. With practice, he learns to
label distortions and is able to automatically
identify his dysfunctional thoughts and moni-
tor his cognitive patterns. Through a variety of
cognitive and behavioral strategies, he is able
to acquire new information, change his basic
beliefs, and implement new and more effective
behavior.
Follow-Up: You Continue as Stan’s
Cognitive Behavior Therapist
Use these questions to help you think about
how to counsel Stan using a cognitive behavior
approach:
• My therapeutic style is characterized as an in-
tegrative form of cognitive behavioral therapy.
I borrow concepts and techniques from the
approaches of Ellis, Beck, and Meichenbaum.
In your work with Stan, what specific concepts
would you borrow from these approaches?
What cognitive behavioral techniques would
you use? What possible advantages do you
see, if any, in applying an integrative cognitive
behavioral approach in your work with Stan?
• What are some things you would most want to
teach Stan about how cognitive behavior ther-
apy works? How would you explain to him the
therapeutic alliance and the collaborative thera-
peutic relationship?
• What are some of Stan’s most prominent
faulty beliefs that get in the way of his living
fully? What cognitive and behavioral tech-
niques might you use in helping him examine
his core beliefs?
• Stan lives by many “shoulds” and “oughts.”
His automatic thoughts seem to impede him
from getting what he wants. What techniques
would you use to encourage guided discovery
on his part?
• What are some homework assignments that
would be useful for Stan to carry out? How
would you collaboratively design homework
with Stan? How would you encourage him to
develop action plans to test the validity of his
thinking and his conclusions?
See the DVD for Theory and Practice of
Counseling and Psychotherapy: The Case
of Stan and Lecturettes (Session 8 on cogni-
tive behavior therapy) for a demonstration
of my approach to counseling Stan from this
perspective. This session focuses on exploring
some of Stan’s faulty beliefs through the use
of role-reversal and cognitive restructuring
techniques.
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s u m m a ry a n d e va l u at i o n
Summary
REBT has evolved into a comprehensive and integrative approach that emphasizes
thinking, judging, deciding, and doing. This approach is based on the premise of
the interconnectedness of thinking, feeling, and behaving. Therapy begins with cli-
ents’ problematic behaviors and emotions and disputes the thoughts that directly
create them. To block the self-defeating beliefs that are reinforced by a process
of self-indoctrination, REBT therapists employ active and directive techniques
such as teaching, suggestion, persuasion, and homework assignments, and
they challenge clients to substitute a rational belief system for an irrational one.
Therapists demonstrate how and why dysfunctional beliefs lead to negative emo-
tional and behavioral results. They teach clients how to dispute self-defeating
beliefs and behaviors that might occur in the future. REBT stresses action—doing
something about the insights one gains in therapy. Change comes about mainly
by a commitment to consistently practice new behaviors that replace old and
ineffective ones.
Rational emotive behavior therapists are typically eclectic in selecting thera-
peutic strategies. They have the latitude to develop their own personal style and to
exercise creativity; they are not bound by fi xed techniques for particular problems.
Cognitive therapists also practice from an integrative stance, using many methods
to assist clients in modifying their self-talk. The working alliance is given special
importance in cognitive therapy as a way of forming a collaborative partnership.
Although the client–therapist relationship is viewed as necessary, it is not suffi –
cient for successful outcomes. In cognitive therapy, it is presumed that clients are
helped by the skillful use of a range of cognitive and behavioral interventions and
by their willingness to perform homework assignments between sessions.
All of the cognitive behavioral approaches stress the importance of cognitive proc-
esses as determinants of behavior. It is assumed that how people feel and what they
actually do is largely infl uenced by their subjective assessment and interpretation of
situations. Because this appraisal of life situations is infl uenced by beliefs, attitudes, as-
sumptions, and internal dialogue, such cognitions become the major focus of therapy.
Contributions of the Cognitive Behavioral Approaches
Most of the therapies discussed in this book can be considered “cognitive,” in a
general sense, because they have the aim of changing clients’ subjective views
of themselves and the world. The cognitive behavioral approaches focus on un-
dermining faulty assumptions and beliefs and teaching clients the coping skills
needed to deal with their problems. Both Ellis’s REBT and Beck’s CT represent
the most systematic applications of cognitive behavior therapy. Both REBT and CT
are based on a wide range of cognitive behavioral techniques and follow a defi ned
plan of action; they are relatively brief and structured treatments in keeping with
the spirit of cost effectiveness and evidence-based practice (Hollon & DiGiuseppe,
2011). The psychoeducational aspect of CBT is a clear strength that can be applied
to many clinical problems and used effectively in many settings with diverse client
populations.
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ellis’s rebt I fi nd aspects of REBT very valuable in my work because I be-
lieve we are responsible for maintaining self-destructive ideas and attitudes that
infl uence our daily transactions. I see value in asking clients questions such as
“What are your assumptions and basic beliefs?” and “Have you examined the
core ideas you live by to determine if they are your own values or merely in-
trojects?” REBT has built on the Adlerian notion that events themselves do not
have the power to determine us; rather, it is our interpretation of these events
that is crucial. The A-B-C framework simply and clearly illustrates how human
disturbances occur and the ways in which problematic behavior can be changed.
Rather than focusing on events themselves, therapy stresses how clients inter-
pret and react to what happens to them and the necessity of actively disputing a
range of faulty beliefs.
One of the strengths of REBT is the focus on teaching clients ways to carry on
their own therapy without the direct intervention of a therapist. I particularly like
the emphasis that REBT puts on supplementary and psychoeducational approaches
such as listening to tapes, reading self-help books, keeping a record of what they
are doing and thinking, carrying out homework assignments, and attending work-
shops. In this way clients can further the process of change in themselves without
becoming excessively dependent on a therapist.
b e c k ’s c o g n i t i v e t h e r a p y Beck’s key concepts share similarities with
REBT, but differ in underlying philosophy, the process by which therapy proceeds,
and the formulation and treatment for different disorders. Beck made pioneering
efforts in the treatment of anxiety, phobias, and depression. Today, empirically
validated treatments for both anxiety and depression have revolutionized thera-
peutic practice; research has demonstrated the effi cacy of cognitive therapy for a
variety of problems (Leahy, 2002; Scher, Segal, & Ingram, 2006). Beck developed
specifi c cognitive procedures to help depressive clients evaluate their assumptions
and beliefs and to create a new cognitive perspective that can lead to optimism
and changed behavior. The effects of cognitive therapy on depression and hope-
lessness have been demonstrated through research to be maintained for at least
one year after treatment. Cognitive therapy has been applied to a wide range of
clinical populations that Beck did not originally believe were appropriate for this
model, including treatment for posttraumatic stress disorder, schizophrenia, delu-
sional disorders, bipolar disorder, and various personality disorders (Leahy, 2002,
2006a). The credibility of the cognitive model grows out of the fact that many of
its propositions have been empirically tested.
Beck demonstrated that a structured therapy that is present centered and
problem oriented can be very effective in treating depression and anxiety in a
relatively short time. One of Beck’s major theoretical contributions has been
bringing private experience back into the realm of legitimate scientifi c inquiry
(Weishaar, 1993). A strength of cognitive therapy is its focus on developing a
detailed case conceptualization as a way to understand how clients view their
world.
A key strength of all the cognitive behavioral therapies is that they are integra-
tive forms of psychotherapy, and this is particularly true of cognitive therapy. Beck
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considers cognitive therapy to be the integrative psychotherapy because it draws
from so many different modalities of psychotherapy (Alford & Beck, 1997).
m e i c h e n b a u m ’s c o g n i t i v e b e h av i o r m o d i f i c at i o n Meichen-
baum’s work in self-instruction and stress inoculation training has been applied
successfully to a variety of client populations and specifi c problems. Of special note
is his contribution to understanding how stress is largely self-induced through
inner dialogue. Meichenbaum’s integration of the constructivist perspective is a
key strength in that he is able to combine elements of the postmodern interest in
stories clients tell with assisting clients in changing their cognitions, feelings, and
behaviors by drawing on a cognitive behavioral conceptual framework.
A contribution of all of the cognitive behavioral approaches is the emphasis on
putting newly acquired insights into action. Homework assignments are well suited
to enabling clients to practice new behaviors and assisting them in the process of
learning more effective coping skills. Adlerian therapy, reality therapy, behavior
therapy, and solution-focused brief therapy all share with the cognitive behavioral
approaches this action orientation. It is important that homework be a natural out-
growth of what is taking place in the therapy session. Clients are more likely to carry
out their homework if the assignments are collaboratively created. Meichenbaum’s
stress inoculation training places special emphasis on practicing new skills both in
the training itself and in daily life, and homework is a key part of the training proc-
ess. Clients learn how to generalize coping skills to various problem situations and
acquire relapse prevention strategies to ensure that their gains are consolidated.
A major contribution made by Ellis, the Becks, and Meichenbaum is the de-
mystifi cation of the therapy process. The cognitive behavioral approaches are
based on an educational model that stresses a working alliance between therapist
and client. The models encourage self-help, provide for continuous feedback from
the client on how well treatment strategies are working, and provide a structure
and direction to the therapy process that allows for evaluation of outcomes. Clients
are active, informed, and responsible for the direction of therapy because they are
partners in the enterprise.
Limitations and Criticisms of the Cognitive
Behavioral Approaches
The cognitive behavioral approaches focus only limited attention on the role of
emotions in treatment. Although Dattilio (2001) admits that CBT places central
emphasis on cognition and behavior, he maintains that emotion is not ignored in
the therapy process; rather, he believes that emotion is a by-product of cognition
and behavior and is addressed in a different fashion. Some potential limitations of
the various CBT approaches follow.
e l l i s ’s r e b t I value paying attention to a client’s past without getting lost in
this past and without assuming a fatalistic stance about earlier traumatic experi-
ences. I question the REBT assumption that exploring the past is ineffective in
helping clients change faulty thinking and behavior. From my perspective, explor-
ing past childhood experiences can have a great deal of therapeutic power if the
discussion is connected to our present functioning.
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Another potential limitation involves the misuse of the therapist’s power
by imposing ideas of what constitutes rational thinking. Due to the active and
directive nature of this approach, it is particularly important for practitioners
to know themselves well and to avoid imposing their own philosophy of life on
their clients. Because the therapist has a large amount of power by virtue of
persuasion, psychological harm is more possible in REBT than in less directive
approaches.
As Ellis practiced it, REBT is a forceful and confrontational therapy. Some
clients will have trouble with a confrontational style, especially if a strong ther-
apeutic alliance has not been established. It is well to underscore that REBT
can be effective when practiced in a style different from Ellis’s. Indeed, a thera-
pist can be soft-spoken and gentle and still use REBT concepts and methods
effectively. Janet Wolfe, who has supervised hundreds of practitioners in her
30 years at the Albert Ellis Institute, makes the point that therapists do not
need to emulate Ellis’s style to effectively incorporate REBT into their own rep-
ertoire of interventions. Wolfe (2007) encourages practitioners to embrace this
useful therapy approach, but to develop a style that is consistent with their own
personality.
For practitioners who value a spiritual dimension of psychotherapy, Ellis’s views
on religion and spirituality are likely to raise some problems. Historically, Ellis has
declared himself as an atheist and has long been critical of dogmatic religions that
instill guilt in people. Ellis (2004b) has written about the core philosophies that
can either improve our mental health or can lead to disturbances. Although his
tone softened over the years, he was still critical of any philosophies that promoted
rigid beliefs. Personally, I think that a spiritual and a religious orientation can be
incorporated into the practice of REBT if this is meaningful to the client and if
this is done in a thoughtful manner by the therapist. Throughout his life, Ellis was
driven by his passion to teach people about REBT, and he always chuckled when
he said in his workshops that his mission was to spread the gospel according to
St. Albert. Indeed, I would say that his “religion” is embodied in the principles and
practices of REBT. For more on this topic, see The Road to Tolerance (Ellis, 2004b).
b e c k ’s c o g n i t i v e t h e r a p y Cognitive therapy has been criticized for fo-
cusing too much on the power of positive thinking; being too superfi cial and sim-
plistic; denying the importance of the client’s past; being too technique oriented;
failing to use the therapeutic relationship; working only on eliminating symptoms,
but failing to explore the underlying causes of diffi culties; ignoring the role of un-
conscious factors; and neglecting the role of feelings (Freeman & Dattilio, 1992;
Weishaar, 1993).
Freeman and Dattilio (1992, 1994; Dattilio, 2001) do a good job of debunking
the myths and misconceptions about cognitive therapy. Weishaar (1993) concisely
addresses a number of criticisms leveled at the approach. Although the cognitive
therapist is straightforward and looks for simple rather than complex solutions,
this does not imply that the practice of cognitive therapy is simple. Cognitive thera-
pists do not explore the unconscious or underlying confl icts but work with cli-
ents in the present to bring about changes in their core beliefs. However, they do
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recognize that clients’ current problems are often a product of earlier life experi-
ences, and thus, they may explore with clients, especially those with Axis II disor-
ders, the ways their past is presently infl uencing them.
m e i c h e n b a u m ’s c o g n i t i v e b e h av i o r m o d i f i c at i o n Some
practitioners who apply stress inoculation training focus more on techniques to
change a client’s reaction to stress or pay too much attention to the client’s inter-
nal dialogue. Meichenbaum is a high-energy person and is very charismatic in his
workshop presentations. I suspect that much of the success of his approach has to
do with his level of caring and his creativity in implementing CBT interventions.
Practitioners without his wit, energy, personal fl air, and direct therapeutic style
may not get the same results even though they follow his treatment protocol. This
emphasizes the importance of each therapist developing his or her own unique
therapeutic style. Meichenbaum (1986) cautions cognitive behavioral practitioners
against the tendency to become overly preoccupied with techniques. If progress
is to be made, he suggests that cognitive behavior therapy must develop a test-
able theory of behavior change. He reports that some attempts have been made to
formulate a cognitive social learning theory that will explain behavior change and
specify the best methods of intervention.
A potential limitation of any of the cognitive behavioral approaches is the
therapist’s level of personal development, training, knowledge, skill, and percep-
tiveness. Although this is true of all therapeutic approaches, it is especially true
for CBT practitioners because they tend to be active, highly structured, and offer
clients psychoeducational information and teach life skills. According to Judith
Beck (personal communication, May 27, 2011), a limitation in learning cognitive
therapy is that therapists need to learn the specifi c cognitive formulation for each
disorder they treat and learn how to address the key cognitions and behavioral
strategies for each disorder. Macy (2007) stresses that the effective use of cogni-
tive behavior therapy interventions requires extensive study, training, and practice:
“Effective implementation of these interventions requires that the practitioner be
fully grounded in the therapy’s theory and premises, and be able to use a range of
associated techniques and interventions” (p. 159).
w h e r e to g o f r o m h e r e
In the DVD for Integrative Counseling: The Case of Ruth and Lecturettes, I work with Ruth
from a cognitive behavioral perspective in a number of therapy sessions. In Sessions
6, 7, and 8, I demonstrate my way of working with Ruth from a cognitive, emotive, and
behavioral focus. See also Session 9 (“Integrative Perspective”), which illustrates the
interactive nature of working with Ruth on thinking, feeling, and doing levels.
Other Resources
DVDs relevant to this chapter offered by the American Psychological Association
from their Systems of Psychotherapy Video Series include the following:
Beck, J. (2005). Cognitive Therapy
Meichenbaum, D. (2007). Cognitive Behavioral Therapy With Donald
Meichenbaum
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Vernon, A. (2010). Rational Emotive Behavior Therapy Over Time
Dobson, K. S. (2010). Cognitive Therapy Over Time
Persons, J. (2006). Cognitive-Behavior Therapy
Dobson, K. S. (2008). Cognitive-Behavioral Therapy for Perfectionism Over Time
Dobson, K. S. (2011). Cognitive-Behavioral Therapy Strategies
Psychotherapy.net is a comprehensive resource for students and professionals that
offers videos and interviews on cognitive behavior therapy. New video and editorial
content is made available monthly. DVDs relevant to this chapter are available at
www.psychotherapy.net and include the following:
Beck, J. (2010). Cognitive Therapy for Weight Loss: A Coaching Session
Ellis, A. (1996). Rational-Emotive Therapy for Addictions
Ellis, A. (1996). Coping With the Suicide of a Loved One: An REBT
Approach
Freeman, A. (1994). Depression: A Cognitive Therapy Approach
Krumboltz, J. (1997). Cognitive-Behavioral Therapy With John Krumboltz
(Psychotherapy With the Experts Series)
Lazarus, A. (1997). Multimodal Therapy (Psychotherapy With the Experts
Series)
Liese, B. (2000). Cognitive Therapy for Addictions (Brief Therapy for
Addictions Series)
Masek, B. (2002). Cognitive-Behavioral Child Therapy (Child Therapy
With the Experts Series)
Meichenbaum, D. (1996). Mixed Anxiety and Depression: A Cognitive-
Behavioral Approach
Meichenbaum, D. (2000). Cognitive-Behavioral Therapy With Donald
Meichenbaum (Psychotherapy With the Experts Series)
The Journal of Rational-Emotive and Cognitive-Behavior Therapy is published by
Kluwer Academic/Human Sciences Press. This quarterly journal is an excellent
way to keep informed of a wide variety of cognitive behavioral specialists.
For information about the work of Albert Ellis, and current training oppor-
tunities, contact:
Debbie Joffe
Telephone: (917) 887-2006
Website: www.rebtnetwork.org/
The International Journal of Cognitive Therapy, edited by John Riskind, also pro-
vides information on theory, practice, and research in cognitive behavior therapy.
Information about the journal is available from the International Association of
Cognitive Psychotherapy or by contacting John Riskind directly.
Dr. John Riskind
George Mason University
Department of Psychology, MSN 3F5
Fairfax, VA 22030-4444
Telephone: (703) 993-4094
Private Practice Telephone: (703) 280-8060
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Fax: (703) 993-1359
E-mail: jriskind@gmu.edu
Website: www.the-iacp.com
The Center for Cognitive Therapy, Newport Beach, California, maintains a website
for mental health professionals. They list cognitive therapy books, audio and video
training tapes, current advanced training workshops, and other cognitive therapy
resources and information.
Center for Cognitive Therapy
E-mail: mooney@padesky.com
Website: http://www.padesky.com
For more information about CBT workshops, supervision, a CBT blog, and news-
letter, contact the Beck Institute.
Beck Institute for Cognitive Behavior Therapy
One Belmont Avenue, Suite 700
Bala Cynwyd, PA 19004-1610
Telephone: (610) 664-3020
Fax: (610) 709-5336
E-mail: info@beckinstitute.org
Website: www.beckinstitute.org
The “home” organization for cognitive therapists worldwide is the Academy of Cogni-
tive Therapy, which Judith S. Beck was instrumental in founding.
Academy of Cognitive Therapy
Website: www.academyofct.org
The American Institute for Cognitive Therapy is an internationally recognized group
of clinical psychologists and psychotherapists who provide the highest quality cogni-
tive behavioral treatment for depression, anxiety, phobias, eating disorders, person-
ality disorders, child and adolescent problems, and family and marital problems.
American Institute for Cognitive Therapy
Robert L. Leahy, PhD
136 E 57th St., Suite 1101
New York, NY 10022
Telephone: (212) 308-2440
Fax: (212) 308-3099
E-mail: AICT@aol.com
Website: www.cognitivetherapynyc.com
Donald Meichenbaum is research director of the Melissa Institute for Violence
Prevention, a nonprofi t organization designed to “give science away” in order to
reduce violence and to treat victims of violence. The institute is dedicated to the
study and prevention of violence through education, community service, research
support, and consultation.
Melissa Institute for Violence Prevention
Website: www.melissainstitute.org
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Recommended Supplementary Readings
Rational Emotive Behavior Therapy: It Works for Me—It Can Work for You
(Ellis, 2004a) is a personal book that describes the many challenges Ellis has faced
in his life and how he has coped with these realities by applying REBT principles.
The Road to Tolerance: The Philosophy of Rational Emotive Behavior Therapy
(Ellis, 2004b) is a companion book to the book listed above. In this book Ellis
demonstrates that tolerance is a deliberate, rational choice that we can make, both
for the good of ourselves and for others.
Cognitive Behavior Therapy: Basics and Beyond (J. Beck, 2011a) is a main text in
cognitive therapy that presents a comprehensive overview of the approach. An
earlier edition of this book was translated into 20 languages.
Cognitive Therapy for Challenging Problems (J. Beck, 2005) is a comprehensive
account of cognitive therapy procedures applied to clients who present a multi-
plicity of diffi cult behaviors. It covers the nuts and bolts of cognitive therapy with
various populations and cites important research on cognitive therapy since its
inception. There are chapters dealing with topics such as the therapeutic alliance,
setting goals, structuring sessions, homework, identifying cognitions, modifying
thoughts and images, modifying assumptions, and modifying core beliefs.
Cognitive Behavior Therapy: Applying Empirically Supported Techniques in Your Prac-
tice (O’Donohue & Fisher, 2008) is a useful collection of short chapters on applying
empirically supported techniques in working with a wide range of presenting prob-
lems. Most of these chapters can be applied to both individual and group therapy.
Mind Over Mood: Change How You Feel by Changing the Way You Think
(Greenberger & Padesky, 1995) provides step-by-step worksheets to identify
moods, solve problems, and test thoughts related to depression, anxiety, anger,
guilt, and shame. This is a popular self-help workbook and a valuable tool for
therapists and clients learning cognitive therapy skills.
Clinician’s Guide to Mind Over Mood (Padesky & Greenberger, 1995) shows
therapists how to integrate Mind Over Mood in therapy and use cognitive therapy
treatment protocols for specifi c diagnoses. This succinct overview of cognitive
therapy has troubleshooting guides, reviews cultural issues, and offers guidelines
for individual, couples, and group therapy.
References and Suggested Readings
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*Books and articles marked with an asterisk are suggested for further study.
*Alford, B. A., & Beck, A. T. (1997). The inte-
grative power of cognitive therapy. New York:
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Arnkoff, D. B., & Glass, C. R. (1992). Cognitive
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Beck, A. T. (1963). Thinking and depression:
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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

distortions. Archives of General Psychiatry,
9, 324–333.
Beck, A. T. (1967). Depression: Clinical,
experimental, and theoretical aspects. New York:
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*Beck, A. T. (1976). Cognitive therapy and
emotional disorders. New York: International
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Beck, A. T. (1987). Cognitive therapy. In J. K.
Zeig (Ed.), The evolution of psychotherapy
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*Beck, A. T., Rush, A., Shaw, B., & Emery, G.
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*Beck, A. T., & Weishaar, M. E. (2011). Cogni-
tive therapy. In R. J. Corsini & D. Wedding
(Eds.), Current psychotherapies (9th ed.,
pp. 276–309). Belmont, CA: Brooks/Cole,
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Beck, A., Wright, E. D., Newman, C. E., &
Liese, B. (1993). Cognitive therapy of substance
abuse. New York: Guilford Press.
*Beck, J. S. (2005). Cognitive therapy for chal-
lenging problems: What to do when the basics
don’t work. New York: Guilford Press.
Beck, J. S. (2007a). The Beck diet solution: Train
your brain to think like a thin person. New York:
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Beck, J. S. (2007b). Beck diet solution weight
loss workbook. New York: Oxmoor House.
Beck, J. S. (2008). The complete Beck diet for
life. New York: Oxmoor House.
*Beck, J. S. (2011a). Cognitive behavior therapy:
Basics and beyond (2nd ed.). New York:
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*Beck, J. S. (2011b). Cognitive therapy worksheet
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Beck, J. S., & Butler, A. C. (2005). Treating
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*Bond, F., & Flaxman, P. (2010). Acceptance
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*Burns, D. (1988). Feeling good: The new mood
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Chambless, D. L., & Peterman, M. (2006).
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for generalized anxiety disorder and panic
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*Corey, G. (2013a). Case approach to counseling
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*Cormier, S., Nurius, P. S., & Osborn, C. J.
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*Crane, R. (2008). Mindfulness-based cogni-
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*Craske, M. G. (2010). Cognitive-behavioral
therapy. Washington, DC: American Psycho-
logical Association.
*Dattilio, F. M. (1993). Cognitive techniques
with couples and families. The Family Journal,
1(1), 51–65.
*Dattilio, F. M. (Ed.). (1998). Case studies in
couple and family therapy: Systemic and cogni-
tive perspectives. New York: Guilford Press.
Dattilio, F. M. (2000a). Cognitive-behavioral
strategies. In J. Carlson & L. Sperry (Eds.), Brief
therapy with individuals and couples (pp. 33–70).
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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Dattilio, F. M. (2001). Cognitive-behavior
family therapy: Contemporary myths and
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23(1), 3–18.
Dattilio, F. M. (2002a, January–February).
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ferentiating symptoms of anxiety from relapse
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*Dryden, W. (2008). Understanding emotional
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*Dryden, W. (2009a). How to think and
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*Dryden, W. (2009b). Rational emotive behav-
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*Dryden, W., & Neenan, M. (2006). Rational
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*Ellis, A. (1994). Reason and emotion in psycho-
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333
i n t r o d u ct i o n
k e y co n c e p t s
• View of Human Nature
• Choice Theory Explanation of Behavior
• Characteristics of Reality Therapy
t h e t h e r a p e u t i c p r o c es s
• Therapeutic Goals
• Therapist’s Function and Role
• Client’s Experience in Therapy
• Relationship Between Therapist
and Client
a p p l i c at i o n : t h e r a p e u t i c
t ec h n i q u es a n d p r o c e d u r es
• The Practice of Reality Therapy
• The Counseling Environment
• Procedures That Lead to Change
• The “WDEP” System
• Application to Group Counseling
r e a l i t y t h e r a p y f r o m a
m u lt i c u lt u r a l p e r s p ect i v e
• Strengths From a Diversity Perspective
• Shortcomings From a Diversity Perspective
r e a l i t y t h e r a p y a p p l i e d to t h e
c a s e o f sta n
s u m m a ry a n d e va l u at i o n
• Summary
• Contributions of Reality Therapy
• Limitations and Criticisms of Reality Therapy
w h e r e to g o f r o m h e r e
• Recommended Supplementary Readings
• References and Suggested Readings
c h a p t e r 1 1
Reality Therapy

t ec h n i q u es a
• The Practice of
• The Counseling
• Pro
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William Glasser / Robert E. Wubbolding
W I L L I A M G L A S S E R
(b. 1925), currently retired, was
educated at Case Western
Reserve University in Cleve-
land, Ohio. Initially a chemical
engineer, he turned to psychol-
ogy (MA, Clinical Psychology,
1948) and then to psychiatry,
attending medical school
(MD, 1953) with the intention of becoming a psychia-
trist. By 1957 he had completed his psychiatric training
at the Veterans Administration and UCLA in Los
Angeles and in 1961 was board certified in psychiatry.
Glasser was married to Naomi for 47 years, and
she was very involved with the William Glasser Insti-
tute until her death in 1992. In 1995 Glasser married
Carleen, who is an instructor at the institute. Glasser
played tennis often until recently, and now, at age 86,
he enjoys watching basketball on television.
Very early Glasser rejected the Freudian model,
partly due to his observation of psychoanalytically
trained therapists who did not seem to be imple-
menting Freudian principles. Rather, they tended to
hold people responsible for their behavior. Early in
his career, Glasser was a psychiatrist at the Ventura
School, a prison and school for girls operated by the
California Youth Authority. He became convinced
that his psychoanalytic training was of limited utility
in counseling these young people. From these obser-
vations, Glasser thought it best to talk to the sane
part of clients, not their disturbed side. Glasser was
also influenced by G. L. Harrington, a psychiatrist and
mentor. Harrington believed in getting his patients
involved in projects in the real world, and by the end
of his residency Glasser began to put together ideas
that would later be known as reality therapy.
In 1962 Glasser began to present public lectures
on “reality psychiatry,” but few psychiatrists were in
the audience. Most of those attending were educators,
social workers, counselors, and correctional workers,
so Glasser changed the name of his system to “reality
therapy,” which became the title of his groundbreaking
book published in 1965. Educators found the principles
of reality therapy helpful, and he was asked to apply
it to the classroom and the school as an organiza-
tion. As a result of this experience, he wrote Schools
Without Failure in 1968, which had a major impact on
the administration of schools, the training of teachers,
and the way learning is conducted in schools. Glasser
took the position that schools needed to be structured
in ways to help students achieve a success identity as
opposed to a failure identity. He advocated for a
curriculum geared to the lives of learners. Glasser
made significant contributions through in-service
workshops for teachers and administrators. Since the
late 1960s, reality therapy has been further applied
to education and to virtually all other human relation-
ships, especially intimate relationships.
Glasser became convinced that it was of
paramount importance that clients accept personal
responsibility for their behavior. By the early 1980s,
Glasser was looking for a theory that could explain
all his work. Glasser learned about control theory
from William Powers, and he believed this theory
had great potential. He spent the next 10 years ex-
panding, revising, and clarifying what he was initially
taught. By 1996 Glasser had become convinced that
these revisions had so changed the theory that it
was misleading to continue to call it control theory,
and he changed the name to choice theory to reflect
all that he had developed. The essence of reality
therapy, now taught all over the world, is that we
are all responsible for what we choose to do. We
are internally motivated by current needs and
wants, and we control our present behavioral
choices.
R O B E RT E . W U B B O L D –
I N G , E d D (b. 1936), born
and raised in Cincinnati,
Ohio, is the youngest of six
children. He received his
doctorate in counseling from
the University of Cincinnati,
is a member of several
professional organizations, and has licenses as a
counselor and as a psychologist. He taught high
school history, worked as a high school and ele-
mentary school counselor, and served as a consult-
ant to drug and alcohol abuse programs of the U.S.
Army and Air Force. In addition, Bob Wubbolding
began a career in the Catholic priesthood but later
“left the clergy freely and honorably.” He is married
Co
ur
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ub
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g
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i n t r o d u c t i o n
Reality therapists believe the underlying problem of most clients is the same: they
are either involved in a present unsatisfying relationship or lack what could even
be called a relationship. Many of the problems of clients are caused by their inabil-
ity to connect, to get close to others, or to have a satisfying or successful relation-
ship with at least one signifi cant person in their lives. The therapist guides clients
toward a satisfying relationship and teaches them more effective ways of behaving.
The more clients are able to connect with people, the greater chance they have to
experience happiness.
Few clients understand that their problem, which is unhappiness, results from
the way they are choosing to behave. What they do know is that they feel a great
deal of pain or that they are unhappy because they have been sent for counseling
by someone with authority who is not satisfi ed with their behavior—typically a
court offi cial, a school administrator, an employer, a spouse, or a parent. Reality
therapists recognize that clients choose their behaviors as a way to deal with the
frustrations caused by unsatisfying relationships.
Glasser (2003) contends that clients should not be labeled with a diagnosis
except when it is necessary for insurance purposes. From Glasser’s perspective,
diagnoses are descriptions of the behaviors people choose in their attempt to deal
with the pain and frustration that is endemic to their unsatisfying present relation-
ships. Labeling these ineffective behaviors as mental illness is inaccurate. Glasser
to Sandra Trifilio, a former French teacher, who
shares his passion for his work and is administrator
of the Center for Reality Therapy, as well as editor
of his writings.
He is now the director of the Center for Reality
Therapy in Cincinnati and professor emeritus of
Xavier University, where he taught counselor edu-
cation for 32 years. He loved teaching and viewed
his students as being highly motivated, eager to
learn, and experienced. One of his most meaningful
experiences was teaching graduate students in the
counseling department at Xavier University.
After completing his doctorate, Wubbolding
attended training sessions representing a wide
range of counseling approaches, yet he found
reality therapy to be best suited to his interests.
He attended many intensive training workshops
conducted by William Glasser in Los Angeles, and
in 1988 Glasser appointed him director of training
for the William Glasser Institute.
Wubbolding served as visiting professor at the
University of Southern California in their overseas
programs in Japan, Korea, and Germany, thus
fulfilling his lifelong desire to travel and to live in
other countries. He has become an internationally
known teacher, author, and practitioner of real-
ity therapy and has introduced choice theory and
reality therapy in Europe, Asia, and the Middle
East. Among his specialties is adapting choice
theory and reality therapy to various cultures and
ethnic groups. He received the Gratitude Award
(2009) for Initiating Reality Therapy in the United
Kingdom and the Certificate of Reality Therapy
Psychotherapist by the European Association for
Psychotherapy (2009).
Wubbolding has extended the theory and
practice of reality therapy with his conceptualiza-
tion of the WDEP system, which is described later
in the chapter. He has written 11 books and more
than 145 articles, essays, and chapters in textbooks
as well as preparing 12 videos/DVDs, some of
which are referenced in this chapter. His religious
commitment and his life of service to others are
apparent in his work, and he continues his voca-
tion of teacher, counselor, psychologist, and active
member of his church.
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believes mental illnesses are conditions such as Alzheimer’s disease, epilepsy, head
trauma, and brain infections—conditions associated with tangible brain damage.
Because these people are suffering from a brain abnormality, he contends they
should be treated primarily by neurologists.
Reality therapy is based on choice theory as it is explained in several of Glasser’s
(1998, 2001, 2003) books. (In this chapter, the discussion of Glasser’s ideas pertains
to these three books, unless otherwise specifi ed.) Choice theory is the theoretical
basis for reality therapy; it explains why and how we function. Reality therapy pro-
vides a delivery system for helping individuals take more effective control of their
lives. If choice theory is the highway, reality therapy is the vehicle delivering the
product (Wubbolding, 2011a). Therapy consists mainly of helping and sometimes
teaching clients to make more effective choices as they deal with the people they
need in their lives. Glasser maintains that it is essential for the therapist to estab-
lish a satisfying relationship with clients as a prerequisite for effective therapy.
Once this relationship is developed, the skill of the therapist as a teacher assumes
a central role.
Reality therapy has been used in a variety of settings. The approach is appli-
cable to counseling, social work, education, crisis intervention, corrections and
rehabilitation, institutional management, and community development. Reality
therapy is popular in schools, general hospitals, state mental hospitals, halfway
houses, and alcohol and drug abuse centers. Many of the military clinics that treat
substance abusers use reality therapy as their preferred therapeutic approach.
See the video program for Chapter 11, DVD for Theory and Practice of Counseling
and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you view the
brief lecture for each chapter prior to reading the chapter.
k e y c o n c e p t s
View of Human Nature
Choice theory posits that we are not born blank slates waiting to be externally mo-
tivated by forces in the world around us. Rather, we are born with fi ve genetically
encoded needs that drive us all our lives: survival, or self-preservation; love and
belonging; power, or inner control; freedom, or independence; and fun, or enjoyment.
Each of us has all fi ve needs, but they vary in strength. For example, we all have a
need for love and belonging, but some of us need more love than others. Choice
theory is based on the premise that because we are by nature social creatures
we need to both receive and give love. Glasser (2001, 2005) believes the need to
love and to belong is the primary need because we need people to satisfy the other
needs. It is also the most diffi cult need to satisfy because we must have a coopera-
tive person to help us meet it.
Our brain functions as a control system. It continually monitors our feelings
to determine how well we are doing in our lifelong effort to satisfy these needs.
Whenever we feel bad, one or more of these fi ve needs is unsatisfi ed. Although
we may not be aware of our needs, we know that we want to feel better. Driven by
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pain, we try to fi gure out how to feel better. Reality therapists teach clients choice
theory, sometimes subtly and indirectly, so clients can identify unmet needs and
try to satisfy them.
Choice theory teaches that we do not satisfy our needs directly. What we do,
beginning shortly after birth and continuing all our lives, is to keep close track of
anything we do that feels very good. We store information inside our minds and
build a fi le of wants, called our quality world, which is at the core of our life. It is
our personal Shangri-la—the world we would like to live in if we could. It is com-
pletely based on our wants and needs, but unlike the needs, which are general,
it is very specifi c. The quality world consists of specifi c images of people, activi-
ties, events, beliefs, possessions, and situations that fulfi ll our needs (Wubbolding,
2000, 2011a). Our quality world is like a picture album. We develop an inner
picture album of specifi c wants as well as precise ways to satisfy these wants. We
are attempting to behave in a way that gives us the most effective control over our
lives. Some pictures may be blurred, and the therapist’s role is to help the client
clarify them. Pictures exist in priority for most people, yet clients may have dif-
fi culty identifying their priorities. Part of the process of reality therapy is assisting
clients in prioritizing their wants and uncovering what is most important to them
(Wubbolding, 2011a).
People are the most important component of our quality world, and these are
the people we most want to connect with. It contains the people we are closest to
and most enjoy being with. Those who enter therapy generally have no one in their
quality world or, more often, someone in their quality world that they are unable
to relate to in a satisfying way. For therapy to have a chance of success, a therapist
must be the kind of person that clients would consider putting in their quality
world. Getting into the clients’ quality world is the art of therapy. It is from this
relationship with the therapist that clients begin to learn how to get close to the
people they need.
Choice Theory Explanation of Behavior
Choice theory explains that all we ever do from birth to death is behave and, with
rare exceptions, everything we do is chosen. Every total behavior is our best at-
tempt to get what we want to satisfy our needs. Total behavior teaches that all
behavior is made up of four inseparable but distinct components—acting, thinking,
feeling, and physiology—that necessarily accompany all of our actions, thoughts,
and feelings. Choice theory emphasizes thinking and acting, which makes this a
general form of cognitive behavior therapy. The primary emphasis is on what the
client is doing on and how the doing component infl uences the other aspects of to-
tal behavior. Behavior is purposeful because it is designed to close the gap between
what we want and what we perceive we are getting. Specifi c behaviors are always
generated from this discrepancy. Our behaviors come from the inside, and thus
we choose our destiny.
Glasser says that to speak of being depressed, having a headache, being angry,
or being anxious implies passivity and lack of personal responsibility, and it is in-
accurate. It is more accurate to think of these as parts of total behaviors and to use
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the verb forms depressing, headaching, angering, and anxietying to describe them. It
is more accurate to think of people depressing or angering themselves rather than
being depressed or being angry. When people choose misery by developing a range
of “paining” behaviors, it is because these are the best behaviors they are able to
devise at the time, and these behaviors often get them what they want.
When a reality therapist starts teaching choice theory, the client will often pro-
test and say, “I’m suffering; don’t tell me I’m choosing to suffer like this.” As
painful as depressing is, the therapist explains that people do not choose pain and
suffering directly; rather, it is an unchosen part of their total behavior. The behavior
of the person is the best effort, ineffective as it is, to satisfy needs.
Robert Wubbolding (personal communication, September 7, 2010) has added a
new idea to choice theory. He believes that behavior is a language, and that we send
messages by what we are doing. The purpose of behavior is to infl uence the world
to get what we want. Therapists ask clients what messages they are sending to the
world by way of their actions: “What message do you want others to get?” “What
message are others getting whether or not you intended to send them?” By consid-
ering the messages that clients send to others, counselors can help clients indirectly
gain a greater appreciation of messages they unintentionally send to others.
Characteristics of Reality Therapy
Contemporary reality therapy focuses quickly on the unsatisfying relationship or
the lack of a relationship, which is often the cause of clients’ problems. Glasser has
given increasing attention to the role of meaningful relationships in fostering emo-
tional health. Clients may complain of a problem such as not being able to keep
a job, not doing well in school, or not having a meaningful relationship. When
clients complain about how other people are causing them pain, the therapist does
not get involved with fi nding fault. Reality therapists ask clients to consider how
effective their choices are, especially as these choices affect their relationships with
signifi cant people in their lives. Choice theory teaches that talking about what cli-
ents cannot control is of minimal value; the emphasis is on what clients can control
in their relationships. The basic axiom of choice theory, which is crucial for clients
to understand, is this: “The only person you can control is yourself.” Two books
devoted to how choice theory can help people deal with their relationship problems
and enhance their relationships are Getting Together and Staying Together (Glasser &
Glasser, 2000) and Eight Lessons for a Happier Marriage (Glasser & Glasser, 2007).
Reality therapists do not listen very long to complaining, blaming, and criti-
cizing, for these are the most ineffective behaviors in our behavioral repertoire.
Because reality therapists give little attention to these self-defeating total behaviors,
Glasser maintains that they tend to disappear from therapy. What do reality thera-
pists focus on? Here are some underlying characteristics of reality therapy.
e m p h a s i z e c h o i c e a n d r e s p o n s i b i l i t y If we choose all we do, we
must be responsible for what we choose. This does not mean we should be blamed
or punished, unless we break the law, but it does mean the therapist should never
lose sight of the fact that clients are responsible for what they do. Choice theory
changes the focus of responsibility to choice and choosing.
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Reality therapists deal with people “as if” they have choices. Therapists focus
on those areas where clients have choice, for doing so gets them closer to the peo-
ple they need. For example, being involved in meaningful activities, such as work,
is a good way to gain the respect of other people, and work can help clients fulfi ll
their need for power. It is very diffi cult for adults to feel good about themselves
if they don’t engage in some form of meaningful activity. As clients begin to feel
good about themselves, it is less necessary for them to continue to choose ineffec-
tive and self-destructive behaviors.
r e j e c t t r a n s f e r e n c e Reality therapists strive to be themselves in their
professional work. By being themselves, therapists can use the relationship to
teach clients how to relate to others in their lives. Glasser contends that transfer-
ence is a way that both therapist and client avoid being who they are and owning
what they are doing right now. It is unrealistic for therapists to go along with the
idea that they are anyone but themselves. Assume the client claims, “I see you as
my father or mother and this is why I’m behaving the way I am.” In such a situ-
ation a reality therapist is likely to say clearly and fi rmly, “I am not your mother,
father, or anyone but myself.”
k e e p t h e t h e r a p y i n t h e p r e s e n t Some clients come to counseling
convinced that they must revisit the past if they are to be helped. Many thera-
peutic models teach that to function well in the present people must understand
and revisit their past. Glasser (2001) disagrees with this assumption and contends
that whatever mistakes were made in the past are not pertinent now. An axiom of
choice theory is that the past may have contributed to a current problem but that
the past is never the problem. To function effectively, people need to live and plan
in the present and take steps to create a better future. We can only satisfy our needs
in the present.
The reality therapist does not totally reject the past. If the client wants to talk
about past successes or good relationships in the past, the therapist will listen
because these may be repeated in the present. Reality therapists will devote only
enough time to past failures to assure clients that they are not rejecting them. As
soon as possible, therapists tell clients, “What has happened is over; it can’t be
changed. The more time we spend looking back, the more we avoid looking for-
ward.” Although the past has propelled us to the present, reality therapists contend
that it does not have to determine our future. We are free to make choices, even
though our external world limits our choices (Wubbolding, 2011b).
avo i d f o c u s i n g o n s y m p t o m s In traditional therapy a great deal of
time is spent focusing on symptoms by asking clients how they feel and why they
are obsessing. Focusing on the past “protects” clients from facing the reality of un-
satisfying present relationships, and focusing on symptoms does the same thing.
Glasser (2003) contends that people who have symptoms believe that if they could
only be symptom-free they would fi nd happiness. Whether people are depress-
ing or paining, they tend to think that what they are experiencing is happening
to them. They are reluctant to accept the reality that their suffering is due to the
total behavior they are choosing. Their symptoms can be viewed as the body’s way
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of warning them that the behavior they are choosing is not satisfying their basic
needs. The reality therapist spends as little time as he or she can on the symptoms
because they will last only as long as they are needed to deal with an unsatisfying
relationship or the frustration of basic needs.
According to Glasser, if clients believe that the therapist wants to hear about
their symptoms or spend time talking about the past, they are more than willing
to comply. Engaging in long journeys into the past or exploring symptoms results
in lengthy therapy. Glasser (2005) maintains that almost all symptoms are caused
by a present unhappy relationship. By focusing on present problems, especially
interpersonal concerns, therapy can generally be shortened considerably.
c h a l l e n g e t r a d i t i o n a l v i e w s o f m e n ta l i l l n e s s Choice the-
ory rejects the traditional notion that people with problematic physical and psycho-
logical symptoms are mentally ill. Glasser (2003) has warned people to be cautious
of psychiatry, which can be hazardous to both one’s physical and mental health.
He criticizes the traditional psychiatric establishment for relying heavily on the
DSM-IV-TR (American Psychiatric Association, 2000) for both diagnosis and
treatment. Glasser (2003) challenges the traditionally accepted views of mental ill-
ness and treatment by the use of medication, especially the widespread use of psy-
chiatric drugs that often result in negative side effects both physically and psycho-
logically. Wubbolding (personal communication, September 7, 2010) emphasizes
that reality therapy is a mental health system rather than a remediating system. He
incorporates the Ericksonian principle that “people don’t have problems, they have
solutions that have not worked.” By reframing diagnostic categories and negative
behaviors, the counselor helps the client to perceive his or her behaviors in a very
different light, which facilitates the search for more effective solutions and choices.
t h e t h e r a p e u t i c p r o c e s s
Therapeutic Goals
A primary goal of contemporary reality therapy is to help clients get connected
or reconnected with the people they have chosen to put in their quality world.
In addition to fulfi lling this need for love and belonging, a basic goal of reality
therapy is to help clients learn better ways of fulfi lling all of their needs, includ-
ing achievement, power or inner control, freedom or independence, and fun. The
basic human needs serve to focus treatment planning and setting both short- and
long-term goals. Reality therapists assist clients in making more effective and
responsible choices related to their wants and needs.
In many instances, clients come voluntarily for therapy, and these clients are the
easiest to help. However, another goal entails working with an increasing number
of involuntary clients who may actively resist the therapist and the therapy process.
These individuals often engage in violent behavior, addictions, and other kinds of
antisocial behaviors. It is essential for counselors to do whatever they can to get con-
nected with involuntary clients. If the counselor is unable to make a connection, there
is no possibility of providing signifi cant help. If the counselor can make a connection,
the goal of teaching the client how to fulfi ll his or her needs can slowly begin.
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Therapist’s Function and Role
Therapy is often considered as a mentoring process in which the therapist is the
teacher and the client is the student. Reality therapists teach clients how to engage
in self-evaluation, which is done by raising the question, “Is what you are choosing
to do getting you what you want and need?” Here are some other questions that
therapists tend to ask clients:
• How would you most like to change your life?
• What do you want in your life that you are not getting?
• What would you have in your life if you were to change?
• What do you have to do now to make the changes happen?
The role of the reality therapist is not to make the evaluation for clients but to
challenge clients to examine what they are doing. Reality therapists assist clients
in evaluating their own behavioral direction, specifi c actions, wants, perceptions,
level of commitment, possibilities for new directions, and action plans. Clients
then decide what to change and formulate a plan to facilitate the desired changes.
The outcome is better relationships, increased happiness, and a sense of inner
control of their lives (Wubbolding, 2011b).
It is the job of therapists to convey the idea that no matter how bad things are
there is hope. If therapists are able to instill this sense of hope, clients feel that
they are no longer alone and that change is possible. The therapist functions as an
advocate, or someone who is on the client’s side. Together they can creatively
address a range of concerns and options.
Client’s Experience in Therapy
Clients are not expected to backtrack into the past or get sidetracked into talking
about symptoms. Neither will much time be spent talking about feelings separate
from the acting and thinking that are part of the total behaviors over which clients
have direct control. The emphasis in on actions. When clients change what they
are doing, they often change how they are feeling and thinking.
Therapists will gently, but fi rmly confront clients. Reality therapists often ask
clients questions such as these: “Is what you are choosing to do bringing you closer
to the people you want to be closer to right now?” “Is what you are doing get-
ting you closer to a new person if you are presently disconnected from everyone?”
These questions are part of the self-evaluation process, which is the cornerstone
of reality therapy.
Clients can expect to experience some urgency in therapy. Time is important,
as each session may be the last. Clients should be able to say to themselves, “I can
begin to use what we talked about today in my life. I am able to bring my present
experiences to therapy as my problems are in the present, and my therapist will not
let me escape from that fact.”
Relationship Between Therapist and Client
Reality therapy emphasizes an understanding and supportive relationship, or
therapeutic alliance, which is the foundation for effective outcomes (Wubbolding &
Brickell, 2005; Wubbolding, Robey, & Brickell, 2010). The therapist’s skill in
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establishing a trusting relationship is critical. It is also important that the client
perceives the therapist as being skilled and knowledgeable. Although the therapeu-
tic relationship is paramount, it is not an end in itself, and it is not automatically
curative or healing (Wubbolding, 2011a).
For involvement between the therapist and the client to occur, the counselor
must have certain personal qualities, including warmth, sincerity, congruence, un-
derstanding, acceptance, concern, respect for the client, openness, and the willing-
ness to be challenged by others. (For other personal characteristics, see Chapter 2.)
Wubbolding (2010, 2011a, 2011b) identifi es specifi c ways for counselors to create
a climate that leads to involvement with clients. Some of these ways entail using
attending behavior, listening to clients, suspending judgment, doing the unexpected,
using humor appropriately, being oneself as a counselor, engaging in facilitative
self-disclosure, listening for metaphors in the client’s mode of self-expression,
listening for themes, summarizing and focusing, allowing consequences, allowing
silence, and being an ethical practitioner. The basis for therapeutic interventions
to work effectively rests on a fair, fi rm, friendly, and trusting environment. Once
involvement has been established, the counselor assists clients in gaining a deeper
understanding of the consequences of their current behavior.
a p p l i c at i o n : t h e r a p e u t i c
t e c h n i q u e s a n d p r o c e d u r e s
The Practice of Reality Therapy
The practice of reality therapy can best be conceptualized as the cycle of counseling,
which consists of two major components: (1) creating the counseling environment
and (2) implementing specifi c procedures that lead to changes in behavior. The art
of counseling is to weave these components together in ways that lead clients to
evaluate their lives and decide to move in more effective directions.
How do these components blend in the counseling process? The cycle of
counseling begins with creating a working relationship with clients, which was
described in the previous section. The process proceeds through an exploration
of clients’ wants, needs, and perceptions. Clients explore their total behavior and
make their own evaluation of how effective they are in getting what they want. If
clients decide to try new behavior, they make plans that will lead to change, and
they commit themselves to those plans. The cycle of counseling includes following
up on how well clients are doing and offering further consultation as needed.
It is important to keep in mind that although the concepts may seem simple as
they are presented here, being able to translate them into actual therapeutic prac-
tice takes considerable skill and creativity. Although the principles will be the same
when used by any counselor who is certifi ed in reality therapy, the manner in which
these principles are applied does vary depending on the counselor’s style and per-
sonal characteristics. These principles are applied in a progressive manner, but they
should not be thought of as discrete and rigid categories. The art of practicing real-
ity therapy involves far more than following procedures in a step-by-step, cookbook
fashion. Although these procedures are described in jargon-free language, they can
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be challenging to implement (Wubbolding, 2007, 2011b). Counseling is not a sim-
plistic method that is applied in the same way with every client. With choice theory
in the background of practice, the counselor tailors the counseling to what the client
presents. Although the counselor is prepared to work in a way that is meaningful
to the client, the move toward satisfying relationships remains in the foreground.
Robert Wubbolding is a reality therapist who has extended the practice of real-
ity therapy (WDEP system) for both implementing and teaching reality therapy
(Wubbolding, 2009). Over the years he has played a major role in the development
of reality therapy. I especially value Wubbolding’s contributions to teaching reality
therapy and to conceptualizing therapeutic procedures. His ideas render choice
theory practical and useable by counselors, and his system provides a basis for con-
ceptualizing and applying the theory. Although reality therapists operate within
the spirit of choice theory, they practice in their own unique ways and develop their
own individual therapeutic style. This section is based on an integrated summary
and adaptation of material from various sources (Glasser, 1992, 1998, 2001; Wub-
bolding, 1988, 1991, 2000, 2007, 2008, 2011a, 2011b; Wubbolding et al., 1998,
2004). The Student Manual that accompanies this textbook contains Wubbolding’s
(2010) chart, which highlights issues and tasks to be accomplished throughout the
cycle of counseling.
The Counseling Environment
The practice of reality therapy rests on the assumption that a supportive and chal-
lenging environment allows clients to begin making life changes. The therapeutic
relationship is the foundation for effective practice; if this is lacking, there is little
hope that the system can be successfully implemented. Counselors who hope to
create a therapeutic alliance strive to avoid behaviors such as arguing, attacking,
accusing, demeaning, bossing, criticizing, fi nding fault, coercing, encouraging ex-
cuses, holding grudges, instilling fear, and giving up easily (Wubbolding, 2010,
2011a, 2011b). In a short period of time, clients generally begin to appreciate the
caring, accepting, noncoercive choice theory environment. It is from this mildly
confrontive yet always noncriticizing, nonblaming, noncomplaining, caring envi-
ronment that clients learn to create the satisfying environment that leads to success-
ful relationships. In this coercion-free atmosphere, clients feel free to be creative
and to begin to try new behaviors.
Procedures That Lead to Change
Reality therapists operate on the assumption that we are motivated to change (1)
when we are convinced that our present behavior is not meeting our needs and
(2) when we believe we can choose other behaviors that will get us closer to what
we want. Reality therapists begin by asking clients what they want from therapy.
Therapists take the mystery and uncertainty out of the therapeutic process. They
also inquire about the choices clients are making in their relationships. In most in-
stances, there is a major unsatisfi ed relationship, and clients usually do not believe
they have any choice in what is going on in this relationship. In the beginning the
client may deny this is the case. For example, the client might say, “I’m depressed.
My depression is the problem. Why are you talking about my relationships?” The
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client often does not want to talk about the real problem, which is the unsatisfying
relationship or lack thereof.
In the fi rst session a skilled therapist looks for and defi nes the wants of the cli-
ent. The therapist also looks for a key unsatisfying present relationship—usually
with a spouse, a child, a parent, or an employer. The therapist might ask, “Whose
behavior can you control?” This question may need to be asked several times during
the next few sessions to deal with the client’s resistance to looking at his or her own
behavior. The emphasis is on encouraging clients to focus on what they can control.
When clients begin to realize that they can control only their own behavior,
therapy is under way. The rest of therapy focuses on how clients can make better
choices. There are more choices available than clients realize, and the therapist
explores these possible choices. Clients may be stuck in misery, blaming, and the
past, but they can choose to change—even if the other person in the relationship
does not change. Wubbolding (2011a) makes the point that clients can learn that
they are not at the mercy of others, are not victims, are capable of gaining a sense
of inner control, and have a range of choices open to them. In short, clients in real-
ity therapy often acquire a sense of hope for a better future.
Reality therapists explore the tenets of choice theory with clients, helping cli-
ents identify basic needs, discovering clients’ quality world, and fi nally, helping
clients understand that they are choosing the total behaviors that are their symp-
toms. In every instance when clients make a change, it is their choice. With the
therapist’s help, clients learn to make better choices than they did when they were
on their own. Through choice theory, clients can acquire and maintain successful
relationships.
The “WDEP” System
Wubbolding (2000) uses the acronym WDEP to describe key procedures in the
practice of reality therapy. The WDEP system of reality therapy can be described as
“effective, practical, usable, theory-based, cross-cultural, and founded on universal
human principles” (Wubbolding, 2007, p. 204). The WDEP system can be used
to help clients explore their wants, possible things they can do, opportunities for
self-evaluation, and design plans for improvement (Wubbolding, 2007, 2011a, 2011b).
Grounded in choice theory, the WDEP system assists people in satisfying their ba-
sic needs. Each of the letters refers to a cluster of strategies: W 5 wants, needs, and
perceptions; D 5 direction and doing; E 5 self-evaluation; and P 5 planning. These
strategies are designed to promote change. Let’s look at each one in more detail.
wa n t s ( e x p lo r i n g wa n t s , n e e d s , a n d p e r c e p t i o n s ) Reality
therapists assist clients in discovering their wants and hopes. All wants are related
to the fi ve basic needs. The key question asked is, “What do you want?” Through
the therapist’s skillful questioning, clients are assisted in defi ning what they want
from the counseling process and from the world around them. It is useful for cli-
ents to defi ne what they expect and want from the counselor and from themselves.
Part of counseling consists of exploring the “picture album,” or quality world, of
clients and how their behavior is aimed at moving their perception of the external
world closer to their inner world of wants.
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Clients are given the opportunity to explore every facet of their lives, including
what they want from their family, friends, and work. Furthermore, this exploration
of wants, needs, and perceptions should continue throughout the counseling proc-
ess as clients’ pictures change.
Here are some useful questions to help clients pinpoint what they want:
• If you were the person that you wish you were, what kind of person would you be?
• What would your family be like if your wants and their wants matched?
• What would you be doing if you were living as you want to?
• Do you really want to change your life?
• What is it you want that you don’t seem to be getting from life?
• What do you think stops you from making the changes you would like?
Wubbolding and Brickell (2009) now include questions focusing on perceptions:
“How do you look at the situation?” “Where do you see your control?” (p. 51). Peo-
ple have a great deal more control than they often perceive, and these questions
help clients move from a sense of external control to a sense of internal control.
This line of questioning sets the stage for applying other procedures in reality
therapy. It is an art for counselors to know what questions to ask, how to ask them,
and when to ask them. Relevant questions help clients gain insights and arrive at
plans and solutions. Although well-timed, open-ended questions can help clients
identify their counseling goals, excessive questioning can result in resistance and
defensiveness. Part of this phase of counseling involves eliciting a commitment to
counseling. Personal growth will occur to the degree that clients are committed to
making changes in their actions (Wubbolding, 2011b).
d i r e c t i o n a n d d o i n g The focus on the present is characterized by the
key question asked by the reality therapist: “What are you doing?” Even though
problems may be rooted in the past, clients need to learn how to deal with them in
the present by learning better ways of getting what they want. Problems must be
solved either in the present or through a plan for the future. The therapist’s chal-
lenge is to help clients make more need-satisfying choices.
Early in counseling it is essential to discuss with clients the overall direction of
their lives, including where they are going and where their behavior is taking them.
This exploration is preliminary to the subsequent evaluation of whether it is a desir-
able direction. The therapist holds a mirror before the client and asks, “What do you
see for yourself now and in the future?” It often takes some time for this refl ection
to become clearer to clients so they can verbally express their perceptions.
Reality therapy focuses on gaining awareness of and changing current total be-
havior. To accomplish this, reality therapists focus on questions like these: “What
are you doing now?” “What did you actually do yesterday?” “What did you want to
do differently this past week?” “What stopped you from doing what you said you
wanted to do?” “What will you do tomorrow?”
Listening to clients talk about feelings can be productive, but only if it is linked
to what they are doing. When an emergency light on the car dashboard lights up,
the driver is alerted that something is wrong and that immediate action is neces-
sary to remedy a problem. In a similar way, when clients talk about problematic
feelings, most reality therapists affi rm and acknowledge these feelings. Rather than
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focusing mainly on these feelings, however, reality therapists encourage clients to
take action by changing what they are doing and thinking. It is easier to change
what we are doing and thinking than to change our feelings. From a choice theory
perspective, discussions centering on feelings, without strongly relating them to
what people are doing and thinking, are counterproductive.
s e l f – e va l u at i o n Self-evaluation is the cornerstone of reality therapy pro-
cedures. The core of reality therapy, as we have seen, is to ask clients to make
the following self-evaluation: “Does your present behavior have a reasonable
chance of getting you what you want now, and will it take you in the direction
you want to go?” Specifi cally, evaluation involves the client examining behav-
ioral direction, specifi c actions, wants, perceptions, new directions, and plans
(Wubbolding, 2011b). According to Wubbolding (2007), clients often present
a problem with a signifi cant relationship, which is at the root of much of their
dissatisfaction. The counselor can help clients evaluate their behavior by ask-
ing this question: “Is your current behavior bringing you closer to people im-
portant to you or is it driving you further apart?” Through skillful questioning,
the counselor helps clients determine if what they are doing is helping them.
Artful questioning assists clients in evaluating their present behavior and the
direction this is taking them. Wubbolding (2000, 2011a) suggests questions
like these:
• Is what you are doing helping or hurting you?
• Is what you are doing now what you want to be doing?
• Is your behavior working for you?
• Is there a healthy congruence between what you are doing and what you believe?
• Is what you are doing against the rules?
• Is what you want realistic or attainable?
• Does it help you to look at it that way?
• Is it really true that you have no control over your situation?
• How committed are you to the therapeutic process and to changing your life?
• After carefully examining what you want, does it appear to be in your best inter-
ests and in the best interest of others?
Asking clients to evaluate each component of their total behavior is a major task
in reality therapy. It is the counselor’s task to assist clients in evaluating the qual-
ity of their actions and to help them make responsible choices and devise effective
plans. Individuals will not change until they fi rst decide that a change would be
more advantageous. Without an honest self-assessment, it is unlikely that clients
will change. Reality therapists are relentless in their efforts to help clients con-
duct explicit self-evaluations of each behavioral component. When therapists ask a
depressing client if this behavior is helping in the long run, they introduce the idea
of choice to the client. The process of evaluation of the doing, thinking, feeling,
and physiological components of total behavior is within the scope of the client’s
responsibility.
Reality therapists may be directive with certain clients at the beginning of
treatment. This is done to help clients recognize that some behaviors are not
effective. In working with clients who are in crisis, for example, it is sometimes
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necessary to suggest straightforwardly what will work and what will not. Other
clients, such as alcoholics and children of alcoholics, need direction early in
the course of treatment, for they often do not have the thinking behaviors in
their control system to be able to make consistent evaluations of when their
lives are seriously out of effective control. These clients are likely to have blurred
pictures and, at times, to be unaware of what they want or whether their wants
are realistic. As they grow and continue to interact with the counselor, they
learn to make evaluations with less and less help from the counselor (Wubbold-
ing, 2011a; Wubbolding & Brickell, 2005).
p l a n n i n g a n d a c t i o n Much of the signifi cant work of the counseling proc-
ess involves helping clients identify specifi c ways to fulfi ll their wants and needs.
Once clients determine what they want to change, they are generally ready to
explore other possible behaviors and formulate an action plan. The key question
is, “What is your plan?” The process of creating and carrying out plans enables
people to begin to gain effective control over their lives. If the plan does not work,
for whatever reason, the counselor and client work together to devise a different
plan. The plan gives the client a starting point, a toehold on life, but plans can be
modifi ed as needed. Throughout this planning phase, the counselor continually
urges the client to be willing to accept the consequences for his or her own choices
and actions. Not only are plans discussed in light of how they can help the client
personally, but plans are also designed in terms of how they are likely to affect oth-
ers in the client’s life.
Wubbolding (2000, 2007, 2008, 2011a, 2011b) discusses the central role of plan-
ning and commitment. The culmination of the cycle of counseling rests with a plan
of action. Although planning is important, it is effective only if the client has made a
self-evaluation and determined that he or she wants to change a behavior. Wubbolding
uses the acronym SAMIC to capture the essence of a good plan: simple, attainable,
measurable, immediate, involved, controlled by the planner, committed to, and con-
sistently done. Wubbolding contends that clients gain more effective control over
their lives with plans that have the following characteristics:
• The plan is within the limits of the motivation and capacities of the client.
Skillful counselors help clients identify plans that involve greater need-fulfi lling
payoffs. Clients may be asked, “What plans could you make now that would
result in a more satisfying life?”
• Good plans are simple and easy to understand. They are realistically doable, pos-
itive rather than negative, dependent on the planner, specifi c, immediate, and
repetitive. Although they need to be specifi c, concrete, and measurable, plans
should be fl exible and open to revision as clients gain a deeper understanding
of the specifi c behaviors they want to change.
• The plan involves a positive course of action, and it is stated in terms of what the
client is willing to do. Even small plans can help clients take signifi cant steps
toward their desired changes.
• Counselors encourage clients to develop plans that they can carry out independ-
ently of what others do. Plans that are contingent on others lead clients to sense
that they are not steering their own ship but are at the mercy of the ocean.
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• Effective plans are repetitive and, ideally, are performed daily.
• Plans are carried out as soon as possible. Counselors can ask the question,
“What are you willing to do today to begin to change your life?”
• Plans involve process-centered activities. For example, clients may plan to do
any of the following: apply for a job, write a letter to a friend, take a yoga class,
substitute nutritious food for junk food, devote 2 hours a week to volunteer
work, or take a vacation that they have been wanting.
• Before clients carry out their plan, it is a good idea for them to evaluate it with
their therapist to determine whether it is realistic and attainable and whether
it relates to what they need and want. After the plan has been carried out
in real life, it is useful to evaluate it again and make any revisions that may be
necessary.
• To help clients commit themselves to their plan, it is useful for them to fi rm it
up in writing.
Resolutions and plans are empty unless there is a commitment to carry them out.
It is up to clients to determine how to take their plans outside the restricted world
of therapy and into the everyday world. Effective therapy can be the catalyst that
leads to self-directed, responsible living.
Asking clients to determine what they want for themselves, to make a self-
evaluation, and to follow through with action plans includes assisting them in
determining how intensely they are willing to work to attain the changes they
desire. Commitment is not an all-or-nothing matter; it exists in degrees. Wub-
bolding (2007, 2011a, 2011b) maintains that it is important for a therapist to
express concern about clients’ level of commitment, or how much they are will-
ing to work to bring about change. This communicates in an implicit way to
clients that they have within them the power to take charge of their lives. It is
essential that those clients who are reluctant to make a commitment be helped
to express and explore their fears of failing. Clients are helped by a therapist
who does not easily give up believing in their ability to make better choices, even
if they are not always successful in completing their plans. In his workshops,
Wubbolding often mentions this axiom of reality therapy: “To fail to plan is
to plan to fail.”
Application to Group Counseling
With the emphases on connection and interpersonal relationships, reality therapy
is well suited for various kinds of group counseling. Groups provide members
with many opportunities for exploring ways to meet their needs through the
relationships formed within the group. In particular, the WDEP system can be
applied to helping group members satisfy their basic needs. If members talk
about their past experiences or make excuses for their current behavior, the group
leader redirects them to what they are presently doing. From the very beginning
of a group, the members can be asked to take an honest look at what they are
doing and to clarify whether their behavior is getting them what they say they
want. Once group members get a clearer picture of what they have in their lives
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now and what they want to be different, they can use the group as a place to
explore an alternative course of behavior.
This model lends itself to expecting the members to carry out homework
assignments between the group meetings. However, it is the members, with the
help of the leader, who evaluate their own behavior and decide whether they want
to change. Members also take the lead in deciding what kinds of homework tasks
they will set for themselves as a way to achieve their goals. Group leaders often
meet with resistance if they make poorly timed suggestions and plans for how the
members should best live their lives. To their credit, reality therapists keep asking
the members to evaluate for themselves whether what they are doing is getting
them what they want. If the members concede that what they are doing is not
working for them, their resistance is much more likely to melt, and they tend to be
more open to trying different behaviors.
Once the members make some changes, reality therapy provides the struc-
ture for them to formulate specifi c plans for action and to evaluate their level
of success. Feedback from the members and the leader can help individuals
design realistic and attainable plans. Considerable time is devoted during the
group sessions for developing and implementing plans. If people don’t carry out
a plan, it is important to discuss with them what stopped them. Perhaps they
set their goals unrealistically high, or perhaps there is a discrepancy between
what they say they want to change and the steps they are willing to take to bring
about change.
I also like reality therapy’s insistence that change will not come by insight alone;
rather, members have to begin doing something different once they determine
that their behavior is not working for them. I am skeptical about the value of ca-
tharsis as a therapeutic vehicle unless the release of pent-up emotions is eventually
put into some kind of cognitive framework and is followed up with an action plan.
In the groups that I facilitate, group members are challenged to look at the futil-
ity of waiting for others to change. I ask members to assume that the signifi cant
people in their life may never change, which means that they will have to take a
more active stance in shaping their own destiny. I appreciate the emphasis of real-
ity therapy on teaching clients that the only life they can control is their own and
the focus placed on helping group members change their own patterns of acting
and thinking.
For a more detailed discussion of reality therapy in groups, see Corey (2012,
chap. 15).
r e a l i t y t h e r a p y f r o m a
m u lt i c u lt u r a l p e r s p e c t i v e
Strengths From a Diversity Perspective
The core principles of choice theory and reality therapy have much to offer in the
area of multicultural counseling. In cross-cultural therapy it is essential that coun-
selors respect the differences in worldview between themselves and their clients.
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Counselors demonstrate their respect for the cultural values of their clients by
helping them explore how satisfying their current behavior is both to themselves
and to others. Once clients make this assessment, they can formulate realistic
plans that are consistent with their cultural values. It is a further sign of respect
that the counselor refrains from deciding what behavior should be changed.
Through skillful questioning on the counselor’s part, clients from diverse ethnic
backgrounds can be helped to determine the degree to which they have become
acculturated into the dominant society. Is it possible for them to fi nd a balance,
retaining their ethnic identity and values while integrating some of the values and
practices of the dominant group? Again, the counselor does not determine this
balance for clients, but works with them to arrive at their own answers. With this
focus on thinking and acting rather than on exploring feelings, many clients are
less likely to display resistance to counseling.
Glasser (1998) contends that reality therapy and choice theory can be applied both
individually and in groups to anyone with any psychological problem in any cultural
context. We are all members of the same species and have the same genetic struc-
ture; therefore, relationships are the problem in all cultures. Wubbolding (2007,
2011a, 2011b) asserts that the principles underlying choice theory are universal,
which makes choice theory applicable to all people. All of us have internal needs,
we all make choices, and we all seek to infl uence the world around us. Putting the
principles of choice theory into action demands creativity, sensitivity to cultures
and individuals, and fl exibility in implementing the procedures of reality therapy.
Reality therapy principles and procedures need to be applied differently in various
cultures and must be adapted to the psychological and developmental levels pre-
sented by individuals (Wubbolding, 2011b).
Based on the assumption that reality therapy must be modifi ed to fi t the cultural
context of people other than North Americans, Wubbolding (2000, 2011a) and Wub-
bolding and colleagues (1998, 2004) have expanded the practice of reality therapy
to multicultural situations. Wubbolding’s experience in conducting reality therapy
workshops in Japan, Taiwan, Hong Kong, Singapore, Korea, India, Kuwait, Australia,
Slovenia, Croatia, and countries in western Europe has taught him the diffi culty of
generalizing about other cultures. Growing out of these multicultural experiences,
Wubbolding (2000) has adapted the cycle of counseling in working with Japanese
clients. He points to some basic language differences between Japanese and Western
cultures. North Americans are inclined to say what they mean and to be assertive. In
Japanese culture, assertive language is not appropriate between a child and a parent
or between an employee and a supervisor. Ways of communicating are more indirect.
To ask some Japanese clients what they want may seem harsh and intrusive to them.
Because of these style differences, adaptations such as those listed below are needed to
make the practice of reality therapy relevant to Japanese clients:
• The reality therapist’s tendency to ask direct questions may need to be softened,
with questions being raised more elaborately and indirectly. It may be a mistake
to ask individualistic questions built around whether specifi c behaviors meet
the client’s need. Confrontation should be done only after carefully considering
the context.
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• There is no exact Japanese translation for the word “plan,” nor is there an exact
word for “accountability,” yet both of these are key dimensions in the practice of
reality therapy and are central to Japanese culture.
• In asking clients to make plans and commit to them, Western counselors do not
settle for a response of “I’ll try.” Instead, they tend to push for an explicit pledge
to follow through. In Japanese culture, however, the counselor is likely to accept
“I’ll try” as a fi rm commitment.
These are but a few illustrations of ways in which reality therapy might be adapted
to non-Western clients. Although this approach assumes that all people have the
same basic needs (survival, love and belonging, power, freedom, and fun), the
way these needs are expressed depends largely on the cultural context. In working
with culturally diverse clients, the therapist must allow latitude for a wide range
of acceptable behaviors to satisfy these needs. As with other theories and the tech-
niques that fl ow from them, fl exibility is a foremost requirement.
A key strength of reality therapy is that it provides clients with tools to make
the changes they desire. This is especially true during the planning phase, which
is central to the process of reality therapy. The focus is on positive steps that can be
taken, not on what cannot be done. Clients identify those problems that are caus-
ing them diffi culty, and these problems become the targets for change. This type of
specifi city and the direction that is provided by an effective plan are certainly assets
in working with diverse client groups.
Reality therapy needs to be used artfully and to be applied in different ways
with a variety of clients. Many of its principles and concepts can be incorporated
in a dynamic and personal way in the style of counselors, and there is a basis for
integrating these concepts with most of the other therapeutic approaches covered
in this book.
Shortcomings From a Diversity Perspective
One of the shortcomings of reality therapy in working with clients from cer-
tain ethics groups is that it may not take fully into account some very real
environmental forces that operate against them in their everyday lives. Reality
therapy gives only limited attention to helping people address environmental
and social problems. Discrimination, racism, sexism, homophobia, heterosex-
ism, ageism, negative attitudes toward disabilities, and other social injustices
are unfortunate realities, and these forces do limit many individuals in getting
what they want from life. It is important that therapists acknowledge that peo-
ple do not choose to be the victims of various forms of discrimination and op-
pression. If therapists do not accept these environmental restrictions or are not
interested in bringing about social justice as well as individual change, clients
are likely to feel misunderstood. There is a danger that some reality therapists
may overstress the ability of these clients to take charge of their lives and not
pay enough attention to systemic and environmental factors that can limit the
potential for choice.
Some reality therapists may make the mistake of too quickly or too forcefully
stressing the ability of their clients to take charge of their lives. On this point,
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352
Wubbolding (2008) maintains that because of oppression and discrimination,
some people have fewer choices available to them, yet they do have choices. Wub-
bolding sees reality therapy as helping clients to focus on those choices they do
have. Although focusing on choices clients do have is useful, I believe clients
may need to talk about the ways their choices are restricted by environmental cir-
cumstances. Therapists would do well to consider how both they and their clients
could take even small steps toward bringing about societal changes, as do femi-
nist therapists (see Chapter 12).
Another shortcoming associated with reality therapy is that some clients are
very reluctant to directly verbally express what they need. Their cultural values
and norms may not reinforce them in assertively asking for what they want. In
fact, they may be socialized to think more of what is good for the social group than
of their individual wants. In working with people with these values, counselors
must “soften” reality therapy somewhat. If reality therapy is to be used effectively
with clients from other cultures, the procedures must be adapted to the life experi-
ences and values of members from various cultures (Wubbolding, 2000, 2011a;
Wubbolding et al., 2004).
As a reality therapist, I am guided by
the key concepts of choice theory to
identify Stan’s behavioral dynamics,
to provide a direction for him to work toward,
and to teach him about better alternatives for
achieving what he wants. Stan has not been
effective in getting what he needs—a satisfying
relationship.
Stan has fallen into a victim role, blam-
ing others, and looking backward instead of
forward. Initially, he wants to tell me about the
negative aspects of his life, which he does by
dwelling on his major symptoms: depression,
anxiety, inability to sleep, and other psycho-
somatic symptoms. I listen carefully to his
concerns, but I hope he will come to realize that
he has many options for acting differently. I
operate on the premise that therapy will offer
the opportunity to explore with Stan what he
can build on—successes, productive times,
goals, and hopes for the future.
After creating a relationship with Stan, I
am able to show him that he does not have to
be a victim of his past unless he chooses to be,
and I assure him that he has rehashed his past
miseries enough. As counseling progresses,
Stan learns that even though most of his prob-
lems did indeed begin in childhood, there is
little he can now do to undo his childhood. He
eventually recognizes that all of his symptoms
and avoidances keep him from getting what he
most wants. He eventually realizes that he has
a great deal of control over what he can do for
himself now.
I have Stan describe how his life would be
different if he were symptom free. I am inter-
ested in knowing what he would be doing if he
were meeting his needs for belonging, achieve-
ment, power, freedom, and fun. I explain to him
that he has an ideal picture of what he wants
his life to be, yet he does not possess effec-
tive behaviors for meeting his needs. I talk to
him about all of his basic psychological needs
and how this type of therapy will teach him to
satisfy them in effective ways. I also explain that
his total behavior is made up of acting, thinking,
feeling, and physiology. Even though he says
he hates feeling anxious most of the time, Stan
learns that much of what he is doing and think-
ing is directly leading to his unwanted feelings
and physiological reactions. When he complains
of feeling depressed much of the time, anxious
Reality Therapy Applied to the Case of Stan
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at night, and overcome by panic attacks, I let him
know that I am more interested in what he is
doing and thinking because these are the behav-
ioral components that can be directly changed.
I help Stan understand that his depressing is
the feeling part of his choice. Although he may
think he has little control over how he feels, over
his bodily sensations, and over his thoughts, I
want him to understand that he can begin to
take different action, which is likely to change
his depressing experience. I frequently ask this
question, “Is what you are choosing to do get-
ting you what you want?” I lead Stan to begin
to recognize that he does have some, indirect
control over his feelings. This is best done after
he has made some choices about doing some-
thing different from what he has been doing. At
this point he is in a better place to see that the
choice to take action has contributed to feeling
better, which helps him realize that he has some
power to change.
Stan tells me about the pictures in his head,
a few of which are becoming a counselor, act-
ing confident in meeting people, thinking of
himself as a worthwhile person, and enjoying
life. Through therapy he makes the evaluation
that much of what he is doing is not getting
him closer to these pictures or getting him
what he wants. After he decides that he is
willing to work on himself to be different, the
majority of time in the sessions is devoted to
making plans and discussing their implementa-
tion. We both focus on the specific steps he
can take right now to begin the changes he
would like.
As Stan continues to carry out plans in the
real world, he gradually begins to experience
success. When he does backslide, I do not put
him down but help him refocus. We then de-
velop a new plan that we both feel more confi-
dent about. I am not willing to give up on Stan
even when he does not make major progress,
and Stan lets me know that my support is a
source of real inspiration for him to keep working
on himself.
I teach Stan about choice theory, and, if he
is willing to engage in some reading, I sug-
gest that he read and reflect on the ideas in
Counseling With Choice Theory: The New Reality
Therapy (Glasser, 2001) and A Set of Directions
for Putting and Keeping Yourself Together
(Wubbolding & Brickell, 2001). Stan brings
some of what he is learning from his reading
into his sessions, and eventually he is able to
achieve some of his goals. The combination of
working with a reality therapist, his reading,
and his willingness to put what he is learning
into practice by engaging in new behaviors in
the world assist him in replacing ineffective
choices with life-affirming choices. Stan comes
to accept that he is the only person who can
control his own destiny.
Follow-Up: You Continue as Stan’s
Reality Therapist
Use these questions to help you think about how
you would counsel Stan using reality therapy:
• If Stan complains of feeling depressed most
of the time and wants you to “fix” him, how
would you proceed?
• If Stan persists, telling you that his mood is
getting the best of him and that he wants you
to work with his physician in getting him on
an antidepressant drug, what would you say
or do?
• What are some of Stan’s basic needs that are
not being met? What action plans can you
think of to help Stan find better ways of get-
ting what he wants?
• Would you be inclined to do a checklist on al-
coholism with Stan? Why or why not? If you
determined that he was addicted to alcohol,
would you insist that he attend a program
such as Alcoholics Anonymous in conjunction
with therapy with you? Why or why not?
• What interventions would you make to help
Stan explore his total behavior?
See DVD for Theory and Practice of
Counseling and Psychotherapy: The Case
of Stan and Lecturettes (Session 9 on reality
therapy) for a demonstration of my approach
to counseling Stan from this perspective. This
session deals with assisting Stan in forming an
action plan.
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s u m m a ry a n d e va l u at i o n
Summary
The reality therapist functions as a teacher, a mentor, and a model, confronting cli-
ents in ways that help them evaluate what they are doing and whether their behavior
is fulfi lling their basic needs without harming themselves or others. The heart of
reality therapy is learning how to make better and more effective choices and gain
more effective control. People take charge of their lives rather than being the victims
of circumstances beyond their control. Practitioners of reality therapy focus on what
clients are able and willing to do in the present to change their behavior. Practitioners
teach clients how to make signifi cant connections with others. Therapists continue
to ask clients to evaluate the effectiveness of what they are choosing to do to deter-
mine if better choices are possible.
The practice of reality therapy weaves together two components, the counseling
environment and specifi c procedures that lead to changes in behavior. This thera-
peutic process enables clients to move in the direction of getting what they want.
The goals of reality therapy include behavioral change, better decision making, im-
proved signifi cant relationships, enhanced living, and more effective satisfaction
of all the psychological needs.
Contributions of Reality Therapy
Among the advantages of reality therapy are its relatively short-term focus and
the fact that it deals with conscious behavioral problems. Insight and awareness
are not enough; the client’s self-evaluation, a plan of action, and a commitment
to following through are the core of the therapeutic process. I like the focus
on strongly encouraging clients to engage in self-evaluation, to decide if what
they are doing is working or not, and to commit themselves to doing what is
required to make changes. The existential underpinnings of choice theory are
a major strength of this approach, which accentuates taking responsibility for
what we are doing. People are not viewed as being hopelessly and helplessly
depressed. Instead, people are viewed as doing the best they can, or making
the choices they hope will result in fulfi lling their needs. With the emphasis on
responsibility and choice, individuals can acquire a sense of self-direction and
empowerment.
Too often counseling fails because therapists have an agenda for clients. The
reality therapist helps clients conduct a searching inventory of what they are do-
ing. If clients determine that their present behavior is not working, they are then
much more likely to consider acquiring a new behavioral repertoire. Many clients
approach counseling with a great deal of skepticism. Reality therapy can be used
effectively with individuals who manifest reluctance and who are often highly re-
sistant. For example, in working with people with addictions, reality therapy strate-
gies can be used to help clients evaluate where their behavior is leading them and
to provide clients with options to bring about positive changes in their behavior.
Reality therapy has been effectively used in addiction treatment and recovery pro-
grams for more than 30 years (Wubbolding & Brickell, 2005). In many situations
with these populations, it would be inappropriate to embark on long-term therapy
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that delves into unconscious dynamics and an intensive exploration of one’s past.
Reality therapy focuses on making changes in the present and is an effective, short-
term approach, often in 10 sessions or less.
Limitations and Criticisms of Reality Therapy
From my perspective, one of the main limitations of reality therapy is that it does
not give adequate emphasis to the role of the following aspects of the counseling
process: the role of insight, the unconscious, the power of the past and the effect
of traumatic experiences in early childhood, the therapeutic value of dreams, and
the place of transference. Because reality therapy focuses almost exclusively on
consciousness, it does not take into account factors such as repressed confl icts
and the power of the unconscious in infl uencing how we think, feel, behave,
and choose.
Dealing with dreams is not part of the reality therapist’s repertoire. Accord-
ing to Glasser (2001), it is not therapeutically useful to explore dreams. For him,
spending time discussing dreams can be a defense used to avoid talking about
one’s behavior and, thus, is time wasted. From my perspective, dreams are pow-
erful tools in helping people recognize their internal confl icts. I believe that
there is richness in dreams, which can be a shorthand message of clients’ central
struggles, wants, hopes, and visions of the future. Asking clients to recall, report,
share, and relive their dreams in the here and now of the therapeutic session can
help unblock them and can pave the way for clients to take a different course
of action.
Similarly, I have a diffi cult time accepting Glasser’s view of transference as a
misleading concept, for I fi nd that clients are able to learn that signifi cant people
in their lives have a present infl uence on how they perceive and react to others. To
rule out an exploration of transference that distorts accurate perception of others
seems narrow in my view.
As you will recall, Glasser (2001, 2003) contends that chronic depression and pro-
found psychosis are chosen behaviors. Apart from specifi c brain pathology, Glasser
argues that mental illness is the result of an individual’s unsatisfying present rela-
tionships or general unhappiness. I have trouble viewing all psychological disorders
as behavioral choices. People suffering from chronic depression or schizophrenia
are struggling to cope with a real illness. In reality therapy these people may have ad-
ditional guilt to carry if they accept the premise that they are choosing their condition.
I believe reality therapy is vulnerable to the practitioner who assumes the
role of an expert in deciding for others how life should be lived and what consti-
tutes responsible behavior. Wubbolding (2008) admits that reality therapy can
lend itself to fi xing problems and imposing a therapist’s values on clients, es-
pecially by inexperienced or inadequately trained counselors. Wubbolding adds
that it is not the therapist’s role to evaluate the behavior of clients. Generally, cli-
ents need to engage in a process of courageous self-evaluation to determine how
well certain behaviors are working and what changes they may want to make.
It is critical that therapists monitor any tendency to judge clients’ behavior, but
instead to do all that is possible to get clients to make their own evaluation of
their behavior.
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Finally, reality therapy makes use of concrete language and simple concepts.
This can erroneously be viewed as a simple approach that does not require a high
level of competence. Because reality therapy is easily understood, it might appear
to be easy to implement. However, the effective practice of reality therapy requires
practice, supervision, and continuous learning (Wubbolding, 2007b, 2011a). Com-
petent reality therapists have a thorough understanding of choice theory and have
mastered the art of applying reality therapy procedures to working with diverse
clients with a range of clinical problems.
w h e r e to g o f r o m h e r e
In the DVD for Integrative Counseling: The Case of Ruth and Lecturettes, Session 8
(“Behavioral Focus in Counseling”), you will note ways that I attempt to assist Ruth
in specifying concrete behaviors that she will target for change. In this session I
am drawing heavily from principles of reality therapy in assisting Ruth to develop
an action plan to make the changes she desires.
Free Podcasts for ACA Members
You can download ACA Podcasts (prerecorded interviews) at www.counseling.org;
click on the Resource button and then the Podcast Series. For Chapter 11, Reality
Therapy, look for Podcast 18, “Reality Therapy, Choice Theory: What’s the Differ-
ence?” by Dr. Robert Wubbolding.
Other Resources
DVDs offered by the American Psychological Association that are relevant to this
chapter include the following:
Wubbolding, R. (2007). Reality Therapy
Psychotherapy.net is a comprehensive resource for students and professionals
that offers videos and interviews on demonstrating reality therapy working with
addictions, adults, and children. New video and editorial content is made available
monthly. DVDs relevant to this chapter are available at www.psychotherapy.net
and include the following:
Wubbolding, R. (2000). Reality Therapy (Psychotherapy With the Experts Series)
Wubbolding, R. (2000). Reality Therapy for Addictions (Brief Therapy for
Addictions Series)
Wubbolding, R. (2002). Reality Therapy With Children (Child Therapy With
the Experts Series)
The programs offered by the William Glasser Institute are designed to teach the
concepts of choice theory and the practice of reality therapy. More than 7,800 thera-
pists have completed the training in reality therapy and choice theory. The institute
offers a certifi cation process, which starts with a 3-day introductory course known
as “basic training” in which participants are involved in discussions, demonstra-
tions, and role playing. For those wishing to pursue more extensive training, the
institute offers a fi ve-part sequential course of study leading to certifi cation in real-
ity therapy, which includes basic training, a basic practicum, advanced training,
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an advanced practicum, and a certifi cation week. This 18-month training program
culminates in a Certifi cate of Completion. Complete information on this program
can be obtained directly from the institute.
The William Glasser Institute
William Glasser, MD, President and Founder
Attention: Executive Director
22024 Lassen Street, Suite #118
Chatsworth, CA 91311-3600
Telephone: (818) 700-8000
Toll free: (800) 899-0688
Fax: (818) 818-700-0555
E-mail: wginst@wglasser.com
Website: www.wglasser.com
Center for Reality Therapy
Dr. Robert E. Wubbolding, Director
7672 Montgomery Road #383
Cincinnati, OH 45236-4204
Telephone: (513) 561-1911
Fax: (513) 561-3568
E-mail: wubsrt@fuse.net
Website: www.realitytherapywub.com
The International Journal of Choice Theory and Reality Therapy (online journal) fo-
cuses on concepts of internal control psychology, with particular emphasis on re-
search, development, and practical applications of choice theory and reality therapy
principles in various settings. To subscribe, contact:
Dr. Tom Parish
International Journal of Choice Theory and Reality Therapy
4606 SW Moundview Drive
Topeka, Kansas 66610
Telephone: (785) 862-1379
E-mail: Parishts@gmail.com
Recommended Supplementary Readings
Counseling With Choice Theory: The New Reality Therapy (Glasser, 2001) repre-
sents the author’s latest thinking about choice theory and develops the existen-
tial theme that we choose all of our total behaviors. Case examples demonstrate
how choice theory principles can be applied in helping people establish better
relationships.
Reality Therapy (Wubbolding, 2011a) updates and extends previous publications on
choice theory and reality therapy. As a part of the APA theories of psychotherapy se-
ries, this is a well-written and comprehensive overview of reality therapy and choice
theory.
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

American Psychiatric Association. (2000).
Diagnostic and statistical manual of mental
disorders, text revision, (4th ed.). Washington,
DC: Author.
Corey, G. (2012). Theory and practice of group
counseling (8th ed.). Belmont, CA: Brooks/
Cole, Cengage Learning.
*Corey, G. (2013). Case approach to counseling
and psychotherapy (8th ed.). Belmont, CA:
Brooks/Cole, Cengage Learning.
Glasser, W. (1965). Reality therapy: A new
approach to psychiatry. New York: Harper & Row.
Glasser, W. (1968). Schools without failure.
New York: Harper & Row.
Glasser, W. (1992). Reality therapy. New York
State Journal for Counseling and Development,
7(l), 5–13.
*Glasser, W. (1998). Choice theory: A new psychol-
ogy of personal freedom. New York: HarperCollins.
*Glasser, W. (2001). Counseling with choice
theory: The new reality therapy. New York:
HarperCollins.
Glasser, W. (2003). Warning: Psychiatry can
be hazardous to your mental health. New York:
HarperCollins.
Glasser, W. (2005). Defining mental health as a
public health issue: A new leadership role for the
helping and teaching professions. Chatsworth,
CA: William Glasser Institute.
Glasser, W., & Glasser, C. (2000). Getting
together and staying together. New York:
HarperCollins.
Glasser, W., & Glasser, C. (2007). Eight
lessons for a happier marriage. New York:
HarperCollins.
*Wubbolding, R. E. (1988). Using reality
therapy. New York: Harper & Row
(Perennial Library).
*Wubbolding, R. E. (1991). Understanding reality
therapy. New York: Harper & Row (Perennial
Library).
*Wubbolding, R. E. (2000). Reality therapy for
the 21st century. Philadelphia, PA: Brunner-
Routledge.
Wubbolding, R. E. (2007). Reality therapy.
In A. B. Rochlen (Ed.), Applying counseling
theories: An online case-based approach
(pp. 193–207). Upper Saddle River, NJ:
Pearson Prentice-Hall.
Wubbolding, R. E. (2008). Reality therapy.
In J. Frew & M. D. Spiegler (Eds.), Contempo-
rary psychotherapies for a diverse world
(pp. 360–396). Boston: Houghton
Mifflin.
Wubbolding, R. E. (2009). Headline or foot-
note? Mainstream or backwater? Cutting
edge or trailing edge? Included or excluded
from the professional world? International
Journal of Reality Therapy, 29(1), 26–29.
Wubbolding, R. E. (2010). Cycle of psycho-
therapy, counseling, coaching, managing and
supervising (chart, 17th revision). Cincinnati,
OH: Center for Reality Therapy.
*Wubbolding, R. E. (2011a). Reality therapy.
Washington, DC: American Psychological
Association.
*Wubbolding, R. E. (2011b). Reality therapy/
choice theory. In D. Capuzzi & D. R. Gross (Eds.),
Counseling and psychotherapy: Theories and inter-
ventions (5th ed., pp. 263–285). Alexandria, VA:
American Counseling Association.
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*Books and articles marked with an asterisk are suggested for further study.
Case Approach to Counseling and Psychotherapy (Corey, 2013) illustrates how
prominent reality therapists Drs. William Glasser and Robert Wubbolding
would counsel Ruth from their different perspectives of choice theory and real-
ity therapy.
References and Suggested Readings
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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*Wubbolding, R. E., & Brickell, J. (2001). A
set of directions for putting and keeping yourself
together. Minneapolis, MN: Educational Media
Corporation.
Wubbolding, R. E., & Brickell, J. (2005).
Reality therapy in recovery. Directions in
Addiction Treatment and Prevention, 9(1),
1–10. New York: The Hatherleigh
Company.
Wubbolding, R. E., & Brickell, J. (2009).
Perception: The orphaned component of
choice theory. International Journal of Reality
Therapy, 28(2), 50–54.
Wubbolding, R. E., & Colleagues. (1998).
Multicultural awareness: Implications for
reality therapy and choice theory. International
Journal of Reality Therapy, 17(2), 4–6.
Wubbolding, R. E., Brickell, J., Imhof, L., Kim, R.,
Lojk, L., & Al-Rashidi, B. (2004). Reality therapy:
A global perspective. International Journal for the
Advancement of Counselling, 26(3), 219–228.
Wubbolding, R. E., Robey, P., & Brickell, J.
(2010). A partial and tentative look at the
future of choice theory, reality therapy and lead
management. International Journal of Choice
Theory and Reality Therapy, 19(2), 25–34.
28549_ch11_rev01.indd 359 20/09/11 3:55 PM
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

360
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• History and Development
k e y co n c e p t s
• View of Human Nature
• Feminist Perspective on Personality
Development
• Principles of Feminist Therapy
t h e t h e r a p e u t i c p r o c es s
• Therapeutic Goals
• Therapist’s Function and Role
• Client’s Experience in Therapy
• Relationship Between Therapist and Client
a p p l i c at i o n : t h e r a p e u t i c
t ec h n i q u es a n d p r o c e d u r es
• The Role of Assessment and Diagnosis
• Techniques and Strategies
• The Role of Men in Feminist Therapy
f e m i n i st t h e r a p y f r o m a
m u lt i c u lt u r a l a n d s o c i a l
j u st i c e p e r s p ect i v e
• Strengths From a Diversity Perspective
• Shortcomings From a Diversity Perspective
f e m i n i st t h e r a p y a p p l i e d
to t h e c a s e o f sta n
s u m m a ry a n d e va l u at i o n
• Summary
• Contributions of Feminist Therapy
• Limitations and Criticisms of Feminist
Therapy
w h e r e to g o f r o m h e r e
• Recommended Supplementary Readings
• References and Suggested Readings
c h a p t e r 1 2
Feminist Therapy
Coauthored by Barbara Herlihy and Gerald Corey
360
of Men in Feminist T
l i c at i o n : t h e r a p e
t ec h n i q u es a n d p r o c
• The Role of Assessment an
• Techniques and
• The Rol
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Some Contemporary Feminist Therapists
J E A N B A K E R M I L L E R , M D
(1928–2006), was a clinical
professor of psychiatry at
Boston University School of
Medicine and director of the
Jean Baker Miller Training
Institute at the Stone Center,
Wellesley College. She wrote
Toward a New Psychology of
Women (1986) and coau-
thored The Healing Connection: How Women Form
Relationships in Therapy and in Life (Miller & Stiver,
1997) and Women’s Growth in Connection (Jordan
et al., 1991). Dr. Miller collaborated with diverse
groups of scholars and colleagues on the develop-
ment of relational-cultural theory. She made im-
portant contributions toward expanding this theory
and exploring new applications to complex issues
in psychotherapy and beyond, including issues of
diversity, social action, and workplace change.
Co
ur
te
sy
of
Je
an
Ba
ke
rM
ill
er
Tr
ai
ni
ng
In
st
itu
te
C A R O LY N Z E R B E E N N S ,
P h D, is Professor of Psy-
chology and participant in
the Women’s Studies and
Ethnic Studies programs at
Cornell College in Mt.
Vernon, Iowa. Enns became
interested in feminist
therapy while she was
completing her PhD in Counseling Psychology at
the University of California, Santa Barbara. She
devotes much of her work to exploring the pro-
found impact feminist theory has on the manner in
which therapists implement therapeutic practices,
and she discusses this impact in Feminist Theories
and Feminist Psychotherapies: Origins, Themes, and
Diversity (2004). The relationship of theory to
feminist pedagogy is another major interest area
and is the topic of a co-edited book (with Ada
Sinacore) of Teaching and Social Justice: Integrating
Multicultural and Feminist Theories in the Classroom
(2005). Dr. Enns was one of three co-chairs
(with Roberta Nutt and Joy Rice) of the task force
that developed APA’s (2007) “Guidelines for
Psychological Practice with Girls and Women.” Her
most recent efforts are directed toward articu-
lating the importance of multicultural feminist
therapy, exploring the practice of feminist therapy
around the world (especially in Japan), and writing
about multicultural feminist pedagogies.
Co
ur
te
sy
of
Ca
ro
ly
n
Ze
rb
e
En
ns
OLIVA M. ESPIN, PhD,
is Professor Emerita in the
Department of Women’s
Studies at San Diego State
University and at the
California School of Profes-
sional Psychology of Alliant
International University. A
native of Cuba, she did her
undergraduate work in psychology at the Universidad
de Costa Rica and received her PhD from the
University of Florida, specializing in counseling
and therapy with women from different cultures
and in Latin American Studies. She is a pioneer in
the theory and practice of feminist therapy with
women from different cultural backgrounds and
has done extensive research, teaching, and train-
ing on multicultural issues in psychology. Dr. Espin
has published on psychotherapy with Latinas,
women immigrants and refugees, the sexuality of
Latinas, language in therapy with fluent bilinguals,
and training clinicians to work with multicultural
Co
ur
te
sy
of
D
r.
O
liv
a
Es
pi
n,
Pr
of
es
so
r
Em
er
ita
of
W
om
en
’s
St
ud
ie
s,
Sa
n
D
ie
go
St
at
e
U
ni
ve
rs
ity
Feminist therapy does not have a single founder.
Rather, it has been a collective effort by many. We
have selected a few individuals who have made
significant contributions to feminist therapy for
inclusion here, recognizing full well that many other
equally influential scholar-practitioners could have
appeared in this space. Feminist therapy is truly
founded on a theory of inclusion.
Jean Baker Miller / Carol Zerbe Enns /
Oliva M. Espin / Lauara S. Brown
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populations. Espin co-edited Refugee Women and
Their Mental Health: Shattered Societies, Shattered
Lives (Cole, Espin, & Rothblum, 1992) and has
written Latina Healers: Lives of Power and Tradition
(1996) , Latina Realities: Essays on Healing,
Migration, and Sexuality (1997), and Women Cross-
ing Boundaries: A Psychology of Immigration and the
Transformation of Sexuality (1999), which is based
on a study of women immigrants from all over the
world.
L AU R A S . B ROW N , P h D,
is a founding member
of the Feminist Therapy
Institute, an organization
dedicated to the support
of advanced practice in
feminist therapy, and a
member of the theory
workgroup at the National
Conference on Education
and Training in Feminist Practice. She has writ-
ten several books considered core to feminist
practice in psychotherapy and counseling, and
Subversive Dialogues: Theory in Feminist Therapy
(1994) is considered by many to be the founda-
tion book addressing how theory informs
practice in feminist therapy. Her most recent
book is Feminist Therapy (2010). Dr. Brown has
made particular contributions to thinking about
ethics and boundaries, and the complexities of
ethical practice in small communities. Her cur-
rent interests include feminist forensic psychol-
ogy and the application of feminist principles to
treatment of trauma survivors.
Co
ur
te
sy
of
D
r.
La
ur
a
S.
Br
ow
n
i n t r o d u c t i o n
This chapter provides an alternative perspective to the models considered thus far
in this book.* As you will see, feminist therapy puts intersections of gender, social
location, and power at the core of the therapeutic process. Feminist therapy is
built on the premise that it is essential to consider the social, cultural, and political
context that contributes to a person’s problems in order to understand that per-
son. This perspective has signifi cant implications for the development of coun-
seling theory and for how practitioners intervene with diverse client populations.
A central concept in feminist therapy is the importance of understanding and
acknowledging the psychological oppression of women and the constraints im-
posed by the sociopolitical status to which women have been relegated. The fem-
inist perspective offers a unique approach to understanding the roles that both
women and men have been socialized to accept and to bringing this understanding
into the therapeutic process. The socialization of women inevitably affects their
identity development, self-concept, goals and aspirations, and emotional well-
being (Belenky, Clinchy, Goldberger, & Tarule, 1987/1997; Gilligan, 1982; Turner &
Werner-Wilson, 2008). As Natalie Rogers (1995) has observed, socialization
patterns tend to result in women giving away their power in relationships, often
without being aware of it. Feminist therapy keeps knowledge about gender sociali-
zation in mind in the work with all clients.
The majority of clients in counseling are women, and the majority of psycho-
therapy practitioners at the master’s level are women. However, most theories that
*I invited a colleague and friend, Barbara Herlihy, a professor of counselor education at the University of
New Orleans, to coauthor this chapter. We have coauthored two books (Herlihy & Corey, 2006a, 2006b),
which seems like a natural basis for collaboration on a project that we both consider valuable.
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are traditionally taught—including all of the other theories in this book—were
founded by White males from Western (American or European) cultures, with
only Adler taking a pro-feminist stance in early theory development. The need for
a theory that evolves from the thinking and experiencing of women seems self-
evident. Theories are developed from the experiences of the “developer,” and femi-
nist theory is the fi rst therapeutic theory from a female perspective.
Feminist therapists have challenged male-oriented assumptions regarding
what constitutes a mentally healthy individual. Early feminist therapy efforts
focused on valuing women’s experiences, political realities, and the unique issues
facing women within a patriarchal system. Current feminist practice emphasizes
a diverse approach that includes an understanding of multiple oppressions, mul-
ticultural competence, and social justice (American Psychological Association,
2007; Beardsley, Morrow, Castillo, & Weitzman, 1998; Brown & Root, 1990;
Enns & Byars-Winston, 2010). Today’s feminists believe that gender cannot be
considered apart from other identities related to race, ethnicity, socioeconomic
class, and sexual orientation. The contemporary version of feminist therapy and
the multicultural and social justice approaches to counseling practice have a
great deal in common (Crethar, Torres Rivera, & Nash, 2008). All three of these
approaches provide a systemic perspective based on understanding the social
context of clients’ lives and are aimed toward affecting social change as well as
individual change.
See the video program for Chapter 12, DVD for Theory and Practice of Counseling
and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you view the
brief lecture for each chapter prior to reading the chapter.
History and Development
Feminist therapy has developed in a grassroots manner, responding to challenges
and to the emerging needs of women (Brabeck & Brown, 1997). No single indi-
vidual can be identifi ed as the founder of this approach, refl ecting a central theme
of feminist collaboration. Its history is relatively brief. The beginnings of feminism
can be traced to the late 1800s, but it is the women’s movement of the 1960s
that laid the foundation for the development of feminist therapy. In the 1960s
women began uniting their voices to express their dissatisfaction with the limiting
and confi ning nature of traditional female roles. Consciousness-raising groups, in
which women came together to share their experiences and perceptions, helped
individual women become aware that they were not alone. A sisterhood developed,
and some of the services that evolved from women’s collective desires to improve
society included shelters for battered women, rape crisis centers, and women’s
health and reproductive health centers.
Changes in psychotherapy occurred when women therapists participated in
consciousness-raising groups and were changed by their experiences. They formed
feminist therapy groups that operated from the same norms as consciousness-
raising groups, including nonhierarchical structures, equal sharing of resources
and power, and empowerment of women. These women also realized in their
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sharing that they were already working with clients from a feminist lens that had
never been formally defi ned.
Believing that personal counseling was a legitimate means to effect change,
they viewed therapy as a partnership between equals and built mutuality into the
therapeutic process. They took the stance that therapy needed to move away from
an intrapsychic perspective on psychopathology (in which the sources of a wom-
an’s unhappiness reside within her) to a focus on understanding the social, politi-
cal, and cultural forces in society that damage and constrain girls and women, as
well as boys and men.
A profusion of research on gender-bias emerged in the 1970s, which helped
further feminist therapy ideas, and formal organizations began to foster the devel-
opment and defi nition of feminist therapy. Among them were the Association for
Women in Psychology (AWP) and various efforts by the American Psychological
Association (APA).
The 1980s were marked by efforts to defi ne feminist therapy as an entity in
its own right (Enns, 1993), and individual therapy became the most frequently
practiced form of feminist therapy (Kaschak, 1981). Gilligan’s (1982) work on the
development of a morality of care in women, and the work of Miller (1986) and
the Stone Center scholars in developing the self-in-relation model (now called the
“relational-cultural” model) were infl uential in the evolution of a feminist person-
ality theory. New theories emerged that honored the relational and cooperative
dimensions of women’s experiencing (Enns, 1991, 2000, 2004; Enns & Sinacore,
2001). Feminist therapists began to formally examine the relationship of feminist
theory to traditional psychotherapy systems, and integrations with various existing
systems were proposed.
By the 1980s feminist group therapy had changed dramatically, becoming more
diverse as it focused increasingly on specifi c problems and issues such as body im-
age, abusive relationships, eating disorders, incest, and other forms of sexual abuse
(Enns, 1993). The feminist philosophies that guided the practice of therapy also
became more diverse. According to Enns (2004), in the fi eld of feminist therapy
“there is room for diversity of practice and the opportunity for individuals to
articulate a set of beliefs which are personally meaningful and which guide trans-
formational practice” (p. 10). Brown (2010) maintains that feminist therapy is a
technically integrative approach that stresses tailoring interventions to meet clients
with their strengths. Feminist therapists also draw upon strategies from many oth-
er therapy models. There are feminists who identify themselves as person-centered,
Gestalt, Adlerian, cognitive, cognitive-behavioral, existential, and psychoanalytic,
but most feminist therapists do not feel a need to position themselves in a particu-
lar philosophical place.
Enns (1993, 2004; Enns & Sinacore, 2001) identifi es four enduring feminist
philosophies, which are often described as the “second wave” of feminism: liberal,
cultural, radical, and socialist feminism. These philosophies all advocate social
activism and changing society as goals in feminist practice.
Liberal feminists focus on helping individual women overcome the limits and
constraints of traditional gender-role socialization patterns. Liberal feminists argue
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for a transformation from accepting traditional gender roles to creating equal oppor-
tunities for both women and men. These feminists tend to believe the differences
between women and men will be less problematic as work and social environments
become increasingly bias free. For liberal feminists, the major goals of therapy in-
clude personal empowerment of individual women, dignity, self-fulfi llment, shared
power in decision making in relationships, and equality. Another key goal is to
eliminate psychotherapy practices that have supported traditional socialization and
are based on biased views about women and men (Enns, 2004).
Cultural feminists believe oppression stems from society’s devaluation of wom-
en’s strengths, values, and roles. They emphasize the differences between women
and men and believe the solution to oppression lies in feminization of the cul-
ture so that society becomes more nurturing, intuitive, subjective, cooperative, and
relational. Cultural feminism highlights the value of interdependence over indi-
vidualism (Enns, 2004). For cultural feminists, the major goal of therapy is so-
cial transformation through the infusion of feminine values (such as cooperation,
altruism, and connectedness) into the culture.
Radical feminists focus on the oppression of women that is embedded in pa-
triarchy and seek to change society through activism and equalizing power. Radi-
cal feminists strive to identify and question the many ways in which patriarchy
dominates every area of life including household chores, paid employment, inti-
mate partnerships, violence, and parenting. They challenge the many ways that
women are denied power. The major goals are to transform gender relationships,
transform societal institutions, and increase women’s sexual and procreative self-
determination.
Socialist feminists share with radical feminists the goal of societal change. Their
emphasis differs, however, in that they focus on multiple oppressions and believe
solutions to society’s problems must include considerations of class, race, sexual
orientation, economics, nationality, and history. Socialist feminists pay close at-
tention to the ways that work, education, and family roles affect their lives. For
socialist feminists, the major goal of therapy is to transform social relationships
and institutions.
During the past 20 years feminist women of color and postmodern feminists
have found classic feminist theories wanting and have offered new theoretical
perspectives focused on issues of diversity, the complexity of sexism, and the
centrality of social context in understanding gender issues. In 1993 psychologists
who embraced a diversity of feminist perspectives met at the National Confer-
ence on Education and Training in Feminist Practice. They reached consensus
on basic themes and premises underlying feminist practice, thus taking a signifi –
cant step toward integration of a number of feminist perspectives. Enns (2004)
states that this “third wave” of feminism embraces diversity with its inclusion
of women of color, lesbians, and the postmodern and constructivist viewpoints
espoused by many of the most recent generation of feminist women. New devel-
opments in feminism also include global and international perspectives. Enns
(2004) describes some of the key characteristics associated with contemporary
feminist approaches.
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Postmodern feminists provide a model for critiquing other traditional and fem-
inist approaches, addressing the issue of what constitutes reality and proposing
multiple truths as opposed to a single truth. The postmodern perspective is based
on the assumption that “reality is embedded in social relationships and histori-
cal contexts, is socially created or invented, and is reproduced through power
relationships” (Enns, 2004, p. 271). This approach calls attention to the limita-
tion of knowledge and the fallibility of “knowers.” Polarities such as masculine–
feminine are deconstructed, which involves an analysis of how such constructs
are created.
Women of color feminists believe it is essential that feminist theory be broadened
and made more inclusive. Women of color have criticized some White feminists
who overgeneralize the experiences of White women to fi t the experiences of all
women. They challenge feminist theory to include an analysis of the intersections
of multiple oppressions, an assessment of access to privilege and power, to rec-
ognize the importance of the spiritual dimension of human experience, and to
emphasize activism.
Lesbian feminists share commonalities with many aspects of radical femi-
nism. Both perspectives view women’s oppression as related to heterosexism
and sexualized images of women. Lesbians who defi ne themselves as feminists
sometimes feel excluded by heterosexual feminists who do not understand dis-
crimination based on sexual orientation. This perspective calls for feminist theory
to include an analysis of the intersections of a person’s multiple identities and
their relationship to oppression and to recognize the diversity that exists among
lesbians. In recent years, lesbian feminism has been enriched through interac-
tion with queer theory, which emphasizes the fl uidity, fl exibility, and multiple
meanings associated with sex, sexual orientation, and gender. Some individuals
identify “lesbian feminism” with 1970s and 1980s movements. Although queer
theory and lesbian theory are not identical, queer theory seems to be increasingly
integrated with lesbian feminism.
Global international feminists take a worldwide perspective and seek to under-
stand the ways in which racism, sexism, economics, and classism affect women
in different countries. Western feminists are challenged to recognize their eth-
nocentrism and stereotyping of women in different parts of the world. Global
feminists assume that each woman lives under unique systems of oppression.
They see a need to address those cultural differences that directly contribute to
women’s oppression.
The variety in feminist theories provides a range of different but overlapping
perspectives from which to work (Enns & Sinacore, 2001). Brown (2010) defi nes
feminist therapy as a postmodern, technically integrative approach that emphasizes
the analysis of gender, power, and social location as strategies for facilitating
change. Feminist therapists, both male and female, believe that understanding
and confronting gender-role stereotypes and power are central to therapeutic prac-
tice and that addressing a client’s problems requires adopting a sociocultural per-
spective: namely, understanding the impact of the society and culture in which a
client lives.
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k e y c o n c e p t s
View of Human Nature
The feminist view of human nature is fundamentally different from that of most
other therapeutic models. Many of the traditional theories grew out of a historical
period in which social arrangements were assumed to be rooted in one’s biologi-
cally based gender. Men were assumed to be the norm and were the only group
studied or understood within the normative construct. It also was assumed that
because of biological gender differences women and men would pursue differ-
ent directions in life. Worell and Remer (2003) are critical of traditional theories
for being androcentric (using male-oriented constructs to draw conclusions about
human, including female, nature), gendercentric (proposing two separate paths
of development for women and men), heterosexist (viewing a heterosexual orien-
tation as normative and desirable and devaluing lesbian, gay male, and bisexual
orientations), deterministic (assuming that personality patterns and behavior are
fi xed at an early stage of development), and having an intrapsychic orientation (at-
tributing behavior to internal causes, which often results in blaming the victim and
ignoring sociocultural and political factors). To the degree that traditional theories
contain these biased elements, they have clear limitations for counseling females
and members of marginalized groups.
Worell and Remer (2003) describe the constructs of feminist theory as being gen-
der fair, fl exible–multicultural, interactionist, and life-span-oriented. Gender-fair
approaches explain differences in the behavior of women and men in terms of
socialization processes rather than on the basis of our “innate” natures, thus avoid-
ing stereotypes in social roles and interpersonal behavior. A fl exible–multicultural
perspective uses concepts and strategies that apply equally to individuals and
groups regardless of age, race, culture, gender, ability, class, or sexual orientation.
The interactionist view contains concepts specifi c to the thinking, feeling, and
behaving dimensions of human experience and accounts for contextual and envi-
ronmental factors. A life-span perspective assumes that human development is a
lifelong process and that personality and behavioral changes can occur at any time
rather than being fi xed during early childhood.
Feminist Perspective on Personality Development
Feminist therapists emphasize that societal gender-role expectations profoundly
infl uence a person’s identity from the moment of birth and become deeply in-
grained in adult personality. Because gender politics are embedded in the fabric
of American society, they infl uence how we see ourselves as girls and boys and
as women and men throughout the course of our lives. Prochaska and Norcross
(2010) point out that gender-role expectations tend to generate a false sense of self
and force women to accept stereotyped gender roles. “Women are expected to be a
lady, to never swear, hit, or get angry. They should strive to please men and, above
all, never offend or best a man” (p. 379).
Gilligan (1977) recognized that theories of moral development were based
almost exclusively on research with males. As a result of her studies on women’s
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moral and psychosocial development, Gilligan came to believe women’s sense of
self and morality is based in issues of responsibility and care for other people and is
embedded in a cultural context. She posited that the concepts of connectedness and
interdependence—virtually ignored in male-dominated developmental theories—
are central to women’s development.
Most models of human growth and development emphasize a struggle toward
independence and autonomy, but feminists recognize that women are searching
for a connectedness with others. In feminist therapy women’s relational qualities
are seen as strengths and as pathways for healthy growth and development instead
of being identifi ed as weaknesses or defects.
The founding scholars of relational-cultural theory have elaborated on the vital
role that relationships and connectedness with others play in the lives of women
(Jordan, Kaplan, Miller, Stiver, & Surrey, 1991; Miller, 1986, 1991; Miller et al., 1999;
Miller & Stiver, 1997; Surrey, 1991; Trepal, 2010). These scholars suggest that
a woman’s sense of identity and self-concept develop in the context of relation-
ships. They describe a process of relational movement in which women move
through connections, disconnections, and enhanced transformative relationships
throughout their lives (Comstock et al., 2008). As you will see, many of the tech-
niques of feminist therapy foster mutuality, relational capacities, and growth in
connection.
Bem (1993) posits that even very young children develop gender schemas, which
are internalizations of the gender roles perpetuated in a sexist society. In a similar
vein, Kaschak (1992) used the term engendered lives to describe her belief that gen-
der is the organizing principle in people’s lives. She has studied the role gender
plays in shaping the identities of females and males and believes the masculine
defi nes the feminine. For instance, because men pay great attention to women’s
bodies, women’s appearance is given tremendous importance in Western society.
It is easy to see how this perspective gets reifi ed in both eating disorders and vari-
ous forms of depression. Men, as the dominant group, defi ne and determine the
roles that women play. Because women occupy a subordinate position, to survive
and thrive in society they must be able to interpret the needs and behaviors of
the dominant group. To that end, women have developed “women’s intuition”
and have included in their gender schema an internalized belief that women are
less important than men. Females are raised in a culture grounded in sexism, and
they internalize the oppression. Understanding and acknowledging internalized
oppression is central in feminist work.
Feminist therapists remind us that traditional gender stereotypes of women
are still prevalent in cultures throughout the world. They teach their clients that
uncritical acceptance of traditional roles can greatly restrict their range of freedom.
Today many women and men are resisting being so narrowly defi ned. Women and
men in therapy learn that, if they choose to, they can experience mutual behavioral
characteristics such as accepting themselves as being interdependent, giving to
others, being open to receiving, thinking and feeling, and being tender and tough.
Rather than being cemented to a single behavioral style, women and men who
reject traditional roles are saying that they are entitled to express the complex range
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of characteristics that are appropriate for different situations and that they are open
to their vulnerability as human beings.
Principles of Feminist Therapy
A number of feminist writers have articulated core principles that form the foun-
dation for the practice of feminist therapy. These principles are interrelated and
overlapping.
1. The personal is political. This principle is based on the assumption that the per-
sonal or individual problems that individuals bring to counseling originate in a
political and social context. For females this is often a context of marginalization,
oppression, subordination, and stereotyping. Acknowledgment of the political and
societal impact on an individual’s life is perhaps the most fundamental tenet that
lies at the core of feminist therapy. Although feminist therapists emphasize social
context, they also work from a biopsychosocial perspective, attending to the inter-
section of the biological, psychological, and social aspects of people’s lives (Brown,
1994).
2. Commitment to social change. Feminist therapy aims not only for individual
change but for social change. Feminists view their therapy practice as existing not
only to help individual clients in their struggles but also to advance a transforma-
tion in society. Direct action for social change is part of their responsibility as
therapists. It is important that women who engage in the therapy process—clients
and therapists alike—recognize that they have suffered from oppression as mem-
bers of a subordinate group and that they can join with other women to right these
wrongs. The goal is to advance a different vision of societal organization that frees
both women and men from the constraints imposed by gender-role expectations.
This vision of counseling, which moves away from the traditional focus on change
from within the individual out into the realm of social activism, distinguishes fem-
inist therapy from other historically accepted approaches.
3. Women’s and girl’s voices and ways of knowing are valued and their experiences
are honored. Women’s perspectives are considered central in understanding their
distress. Traditional therapies that operate on androcentric norms compare women
to the male norm and fi nd them deviant. Much of psychological theory and research
tends to conceptualize women and men in a polarized way, forcing a male–female
split in most aspects of human experience (Bem, 1993). A goal of feminist ther-
apy is to replace patriarchal “objective truth” with feminist consciousness, which
acknowledges diverse ways of knowing. Women are encouraged to value their
emotions and their intuition and to use their personal experience as a touchstone
for determining what is “reality.” Their voices are acknowledged as authoritative
and invaluable sources of knowledge. The valuing and facilitation of women’s voic-
es in or out of therapy directly counteracts the often forced silence of women and
contributes to an ultimate change in the body politic of society.
4. The counseling relationship is egalitarian. Attention to power is central in femi-
nist therapy. Feminist therapists recognize that there is a power imbalance in the
therapeutic relationship, so they strive for an egalitarian relationship, keeping in
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mind that clients are the experts on their own lives. The intent is to shift power
and privilege to the voices and experiences of those who come to counseling
and away from those who deliver it (Brown, 2010). An open discussion of power
and role differences in the therapeutic relationship helps clients to understand
how power dynamics infl uence both counseling and other relationships and also
invites a dialogue about ways to reduce power differentials (Enns, 2004). Finding
ways to share power with clients and to demystify therapy is essential because
feminist therapists believe all relationships should strive for equality, or mutuality
(a condition of authentic connection between the client and the therapist).
5. A focus on strengths and a reformulated defi nition of psychological distress. Feminist
therapy has a “confl icted and ambivalent relationship” with diagnostic labeling
and the “disease model” of mental illness (Brown, 2010, p. 50). Psychological dis-
tress is reframed, not as disease but as a communication about unjust systems.
When contextual variables are considered, symptoms can be reframed as survival
strategies. Feminist therapists talk about problems in the context of living and cop-
ing skills rather than pathology (Enns, 2004; Worell & Remer, 2003). If a formal
diagnosis is used, it is arrived at collaboratively with the client.
6. All types of oppression are recognized. Clients can best be understood in the context
of their sociocultural environments. Feminist therapists acknowledge that social
and political inequities have a negative effect on all people. Feminist therapists
work to help individuals make changes in their lives, but they also are commit-
ted to working toward social change that will liberate all members of society from
stereotyping, marginalization, and oppression. Diverse sources of oppression, not
simply gender, are identifi ed and interactively explored as a basis for understand-
ing the concerns that clients bring to therapy. Framing clients’ issues within a
cultural context leads to empowerment, which can be fully realized only through
social change (Worell & Remer, 2003).
t h e t h e r a p e u t i c p r o c e s s
Therapeutic Goals
According to Enns (2004), some goals of feminist therapy include empowerment,
valuing and affi rming diversity, striving for change rather than adjustment, equality,
balancing independence and interdependence, social change, and self-nurturance.
Enns adds that a key goal of feminist therapy is to assist individuals in viewing
themselves as active agents on their own behalf and on behalf of others. A goal of
feminist therapy is to empower all people to create a world of equality that is refl ected
at individual, interpersonal, institutional, national, and global levels (Enns & Byars-
Winston, 2010). Perhaps the ultimate goal of this approach is to create the kind
of society where sexism and other forms of discrimination and oppression are no
longer a reality (Worell & Remer, 2003). Feminist therapy strives for transforma-
tion for both the individual client and society as a whole.
At the individual level, feminist therapists work to help females and males
recognize, claim, and embrace their personal power. Empowering the client is
at the heart of feminist therapy, which is the overarching long-term therapeutic
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goal (Gilbert & Rader, 2007). Through this empowerment, clients are able to free
themselves from the constraints of their gender-role socialization and to challenge
ongoing institutional oppression.
According to Worell and Remer (2003), feminist therapists help clients:
• Become aware of their own gender-role socialization process
• Identify their internalized messages and replace them with more self-enhancing
beliefs
• Understand how sexist and oppressive societal beliefs and practices infl uence
them in negative ways
• Acquire skills to bring about change in the environment
• Restructure institutions to rid them of discriminatory practices
• Develop a wide range of behaviors that are freely chosen
• Evaluate the impact of social factors on their lives
• Develop a sense of personal and social power
• Recognize the power of relationships and connectedness
• Trust their own experience and their intuition
Feminist therapists also work toward reinterpreting women’s mental health.
Their aim is to depathologize women’s experiencing and to infl uence society so
that female voices are honored and relational qualities are valued. Women’s and
girls’ experiences are examined without the bias of patriarchal values, and their life
skills and accomplishments are acknowledged.
Therapist’s Function and Role
Feminist therapy rests on a set of philosophical assumptions that can be applied to var-
ious theoretical orientations. Any theory can be evaluated against the criteria of being
gender fair, fl exible–multicultural, interactionist, and life-span-oriented. The therapist’s
role and functions will vary to some extent depending on the particular therapist and
client in the therapeutic relationship. In Case Approach to Counseling and Psychotherapy
(Corey, 2013, chap. 10) three feminist therapists (Drs. Evans, Kincade, and Seem) team
up to demonstrate a variety of feminist interventions in their work with Ruth. They also
conceptualize the case of Ruth from a feminist therapy perspective.
Feminist therapists have integrated feminism into their approach to therapy
and into their lives. Their actions and beliefs and their personal and professional
lives are congruent. They are committed to monitoring their own biases and distor-
tions, especially the social and cultural dimensions of women’s experiences. Femi-
nist therapists are also committed to understanding oppression in all its forms—
including but not limited to sexism, racism, heterosexism—and they consider the
impact of oppression and discrimination on psychological well-being. They value
being emotionally present for their clients, being willing to share themselves dur-
ing the therapy hour, modeling proactive behaviors, and being committed to their
own consciousness-raising process. Finally, although feminist therapists may use
techniques and strategies from other theoretical orientations, they are unique in
the feminist assumptions they hold.
Feminists share common ground with Adlerian therapists in their emphasis
on social equality and social interest, and with existential therapists who emphasize
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therapy as a shared journey, one that is life changing for both client and therapist,
and with their basic trust in the client’s ability to move forward in a positive and
constructive manner (Bitter, Robertson, Healey, & Cole, 2009). Feminist thera-
pists believe the therapeutic relationship should be a nonhierarchical, person-to-
person relationship, and they aim to empower clients to live according to their own
values and to rely on an internal (rather than external or societal) locus of control
in determining what is right for them. Like person-centered therapists, feminist
therapists convey their genuineness and strive for mutual empathy between client
and therapist. Unlike person-centered therapists, however, feminist therapists do
not see the therapeutic relationship alone as being suffi cient to produce change.
Insight, introspection, and self-awareness are springboards to action.
Some feminist therapists share with postmodern therapists (see Chapter 13) an
emphasis on the politics and power relationships in the therapy process and a con-
cern about power relations in the world in general. Both feminist and postmodern
thought asserts that psychotherapists must not replicate societal power imbalances
or foster dependency in the client. Rather, therapist and client take active and equal
roles, working together to determine goals and procedures. A common denomina-
tor of both feminist and postmodern approaches is the avoidance of assuming a
therapist role of all-knowing expert.
Client’s Experience in Therapy
Clients are active participants in the therapeutic process. Feminist therapists are
committed to ensuring that this does not become another arena in which women
remain passive and dependent. It is important that clients tell their stories and give
voice to their experiencing.
Appropriate self-disclosure is affi rmed within feminist therapy. The female thera-
pist may share some of her own experiences including gender-role oppression. As an
analysis of gender-role stereotyping is conducted, the client’s consciousness is raised.
Feminist therapists do not restrict their practice to female clients; they also
work with males, couples, families, and children. The therapeutic relationship is
always a partnership, and the client, male or female, will be the expert in determin-
ing what he or she needs and wants from therapy. A male client will explore ways in
which he has been limited by his gender-role socialization, becoming more aware
of how he is constrained in his ability to express a range of emotions. In the safe
environment of the therapeutic sessions, he may be able to fully experience such
feelings as sadness, tenderness, uncertainty, and empathy. As he transfers these
ideas to daily living, he may fi nd that relationships change in his family, his social
world, and at work.
As mentioned earlier, a major goal of feminist therapy is empowerment, which
involves acquiring a sense of self-acceptance, self-confi dence, joy, and authentic-
ity. Worell and Remer (2003) write that clients acquire a new way of looking at
and responding to their world. They add that the shared journey of empower-
ment can be both frightening and exciting—for both client and therapist. Clients
need to be prepared for major shifts in their way of viewing the world around
them, changes in the way they perceive themselves, and transformed interper-
sonal relationships.
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Relationship Between Therapist and Client
Feminist therapists view the therapeutic relationship as being based on mutuality,
equality, and empowerment (Evans, Kincade, & Seem, 2011). The very structure
of the client–therapist relationship models how to identify and use power respon-
sibly. Feminist therapists clearly state their values to reduce the chance of value
imposition. This allows clients to make a choice regarding whether or not to work
with the therapist. It also is a step in demystifying the process.
As mentioned, although there is an inherent power differential in the therapy
relationship, feminist therapists work to equalize the power base in the relation-
ship by employing a number of strategies (Thomas, 1977). First, they are acutely
sensitive to ways they might abuse their own power in the relationship, such as by
diagnosing unnecessarily, by interpreting or giving advice, by staying aloof behind
an “expert” role, or by discounting the impact the power imbalance between thera-
pist and client has on the relationship.
Second, therapists actively focus on the power their clients have in the therapeu-
tic relationship and make this part of their informed consent processes. Therapists
encourage clients to identify and express their feelings, to become aware of the
ways they relinquish power in relationships with others as a result of socialization
or as a means for survival, and to make decisions with this knowledge as the basis.
Third, feminist therapists work to demystify the counseling relationship by
sharing with the client their own perceptions about what is going on in the re-
lationship, by making the client an active partner in determining any diagnosis,
and by making use of appropriate self-disclosure. Some feminist therapists use
contracts as a way to make the goals and processes of therapy overt rather than
covert and mysterious.
A defi ning theme of the client–counselor relationship is the inclusion of clients
in both the assessment and the treatment process, keeping the therapeutic rela-
tionship as egalitarian as possible. Walden (2006) emphasizes the value of edu-
cating and empowering clients. When counselors keep their clients uninformed
about the nature of the therapeutic process, they deny them the potential for active
participation in their therapy. When counselors make decisions about a client for
the client rather than with the client, they rob the client of power in the therapeutic
relationship. Collaboration with the client in all aspects of therapy leads to a genu-
ine partnership with the client.
a p p l i c at i o n : t h e r a p e u t i c
t e c h n i q u e s a n d p r o c e d u r e s
The Role of Assessment and Diagnosis
Feminist therapists have been sharply critical of the DSM classifi cation system,
and research indicates that gender, culture, and race may infl uence assessment of
clients’ symptoms (Enns, 2000; Eriksen & Kress, 2005). To the degree that assess-
ment is infl uenced by subtle forms of sexism, racism, ethnocentrism, heterosexism,
ageism, or classism, it is extremely diffi cult to arrive at a meaningful assessment
or diagnosis. For a thoughtful discussion of feminist challenges to DSM diagnosis,
see Eriksen and Kress (2005, 2008) and Evans, Kincade, and Seem (2011).
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From the perspective of feminist therapy, diagnostic criteria were established
through a system that views male gender-role traits as “normative.” Thus women’s
behaviors are more prone to becoming pathologized. Feminist therapists refer
to distress rather than psychopathology (Brown, 2010), and they use diagnostic
labels quite carefully, if at all. They believe diagnostic labels are severely limiting
for these reasons: (1) they focus on the individual’s symptoms and not the social
factors that cause dysfunctional behavior; (2) as part of a system developed main-
ly by White male psychiatrists, they may represent an instrument of oppression;
(3) they (especially the personality disorders) may reinforce gender-role stereotypes
and encourage adjustment to the norms of the status quo; (4) they may refl ect
the inappropriate application of power in the therapeutic relationship; (5) they can
lead to an overemphasis on individual solutions rather than social change; and
(6) they have the potential to dehumanize the client through the label. Using diag-
nostic categories may contribute to a victim-blaming stance and dull the therapist’s
sensitivity to external factors that contribute to a client’s symptoms (Enns, 2000;
Eriksen & Kress, 2005).
The feminist approach emphasizes the importance of considering the gender-
normative context of men and women’s lives and points out that many symp-
toms can be understood as coping or survival strategies rather than as evidence of
pathology (Bitter, 2008; Worell & Remer, 2003). Due to the cultural and gender
limitations of diagnoses, Eriksen and Kress (2005) encourage therapists “to be
tentative in diagnosing those from diverse backgrounds, and to, as a part of a more
egalitarian relationship, co-construct an understanding of the problem with the
client, rather than imposing a diagnosis on the client” (p. 104). In keeping with
the focus on client empowerment, diagnosis is a shared process in which clients
are the experts on the meaning of their distress. Reframing symptoms as resist-
ance to oppression and as coping skills or strategies for survival and shifting the
etiology of the problem to the environment avoids “blaming the victim” for her
or his problems. Assessment is viewed as an ongoing process between client and
therapist and is connected to treatment interventions (Enns, 2000). In the femi-
nist therapy process, diagnosis of distress becomes secondary to identifi cation and
assessment of strengths, skills, and resources (Brown, 2010). If a DSM diagnosis
is discussed, feminist therapists may ask questions aimed at deconstructing the
diagnosis: “Who benefi ts from using this label?” “How might this label contribute
to disempowering the person to whom it is assigned?”
Using the DSM-IV-TR (American Psychiatric Association, 2000), depression
is diagnosed twice as often in women as in men. Feminist therapists believe
women have many more reasons to experience depression than do men, and they
often frame depression as a normative experience for women. Women are often
fi nancially disadvantaged or dependent, relationally submissive, and strive to
please others by anticipating their needs. Depression may result from women’s
sense of powerlessness in their subordinate position, along with their experiences
of domestic violence, sexual abuse, poverty, or sexual harassment in the workplace.
Similarly, with eating disorders feminist therapists focus on messages given by
society, and by the mass media in particular, about women’s bodies. The therapist
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uses a gender-role analysis to help clients who suffer from anorexia or bulimia to
examine these societal injunctions and how they have come to accept them. Thera-
pist and client work together on ways to challenge and change these messages.
Perhaps the potentially most damaging diagnosis is borderline personality disor-
der (American Psychiatric Association, 2000), a diagnosis usually assigned to and
critical of women (Bitter, 2008). Since very few women who receive this diagnosis
have escaped physical abuse or sexual molestation, Herman (1992) has argued
that the more appropriate diagnosis would be complex posttraumatic stress disor-
der. The latter diagnosis would certainly generate more compassion and sympathy
in therapists than does the diagnosis of borderline personality disorder.
Feminist therapists do not refuse to use the DSM-IV-TR in this age of managed
care and the prevalence of the medical model of mental health, but therapists who
participate in the process of diagnosis have a responsibility to challenge the current
diagnostic system (Eriksen & Kress, 2008). Diagnosis, when used, results from
a shared dialogue between client and therapist. The therapist is careful to review
with the client any implications of assigning a diagnosis so the client can make an
informed choice, and discussion focuses on helping the client understand the role
of socialization and culture in the etiology of her problems.
Techniques and Strategies
Feminist therapy does not prescribe any particular set of interventions; rather, femi-
nist therapists tailor interventions to clients’ strengths with the goal of empowering
clients while evoking their feminist consciousness (Brown, 2010). Nonetheless, they
have developed several unique techniques, and have borrowed others from tradi-
tional approaches. Particularly important are consciousness-raising techniques that
help women to differentiate between what they have been taught is socially accept-
able or desirable and what is actually healthy for them. Some of the techniques
described by Worell and Remer (2003) and Enns (1993, 2004) are discussed in this
section, using the case example of Alma to illustrate how these techniques might
be applied.
Alma, age 22, comes to counseling reporting general anxiety about a new job she began a
month ago. She states that she has struggled with depression off and on throughout her life
because of bullying as a child and rejection from much of her family after coming out as a
lesbian at age 14. Alma identifi es as Dominican and continues to struggle with the loss of
her place within her family of origin. She now believes coming out was a selfi sh mistake
and is trying to make amends by keeping her feelings regarding her sexual and affectional
orientation hidden. Due in part to past experiences, she is worried that if she comes out to
her coworkers the company might fi nd a reason to fi re her. Alma says, “I would like to cut
my hair short again because it is more manageable and I also prefer to wear what is con-
sidered to be more masculine clothing, but I am worried this will cause people at work to
question my femininity. I really like my job, and I worked very hard to get it. I am afraid if
I show them who I really am, they won’t want me there anymore.”
e m p o w e r m e n t Enns and Byars-Winston (2010) point out that many of the
strategies of multicultural feminist therapy are part of the general umbrella of em-
powerment, which enables people to see themselves as active agents on behalf of
themselves and others. At the heart of feminist strategies is the goal of empowering
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the client. Feminist therapists work in an egalitarian manner and use empower-
ment strategies that are tailored to each client (Brown, 2010; Evans, Kincade, &
Seem, 2011). Alma’s therapist will pay careful attention to informed consent issues,
discussing ways Alma can get the most from the therapy session, clarifying expec-
tations, identifying goals, and working toward a contract that will guide the thera-
peutic process.
The process of feminist therapy begins with the informed consent process,
which Brown (2010) refers to as “empowerment consent.” Informed consent
offers a place to begin a relationship that is egalitarian and collaborative. By explain-
ing how therapy works and enlisting Alma as an active partner in the therapeutic
venture, the therapy process is demystifi ed and Alma becomes an equal partici-
pant. Alma will learn that she is in charge of the direction, length, and procedures
of her therapy. Alma’s therapist might ask her, “What is the most powerful thing
you could do right now?” The intent of this question is to “interrupt the trance
of powerlessness” (Brown, 2010, p. 35) by inviting Alma to notice how power is
actually available to her. Given Alma’s cultural background, it may be particularly
important to address power within the therapeutic relationship because Alma may
view the therapist as an expert who holds the answers she is seeking. In addition,
Alma may view counseling as a weakness and may feel shame associated with her
need for help.
s e l f – d i s c lo s u r e Feminist therapists use therapeutic self-disclosure in the
best interests of the client to equalize the client–therapist relationship, to provide
modeling, to normalize women’s collective experiences, to empower clients, and
to establish informed consent. Believing that there is no such thing as therapist
neutrality or objectivity, therapists who disown the reality of being knowable and
known to clients are at greater risk of abusing their power (Brown, 2010). For
example, Alma’s therapist may disclose her own diffi culties in relating to members
of her family of origin, acknowledging that at times hiding information seems im-
portant in order to keep the peace. The therapist can share how she decides when
to be open about her personal life and how to balance relating in a less open way.
The counselor could then discuss with Alma ways in which they have both experi-
enced cultural and social pressures to conform to a hetero-normative ideal. Alma
benefi ts from this modeling by a woman who does not meet society’s expectations
for female behavior and appearance but is comfortable with the image she has
developed and how it has worked for her, not against her.
Self-disclosure is not just sharing information and experiences. It also involves
a certain quality of presence the therapist brings to the therapeutic sessions. Effec-
tive therapist self-disclosure is grounded in authenticity and a sense of mutuality.
The therapist considers how the disclosures may affect the client by using what
relational-cultural theorists refer to as “anticipatory empathy.” Feminist therapists,
like counselors who subscribe to other theoretical orientations, are ethically com-
mitted to using self-disclosure appropriately to enhance the therapeutic process.
The therapist also clearly states her relevant values and beliefs about society
to allow Alma to make an informed choice about whether or not to enter into a
professional relationship with this therapist. The therapist explains to Alma the
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therapeutic interventions that are likely to be employed. Alma, as an informed
consumer, will be involved in evaluating how well these strategies are working and
the degree to which her personal goals in therapy are being met.
g e n d e r – r o l e a n a lys i s A hallmark of feminist therapy, gender-role analy-
sis explores the impact of gender-role expectations on the client’s psychological
well-being and draws upon this information to make decisions about future gender-
role behaviors (Enns, 2004). Some feminist therapists prefer the term “social iden-
tity analysis” because it refl ects the importance of assessing all relevant aspects of
a client’s identity, including multiple memberships in both socially disempowered
and privileged groups. Hayes (2008) proposes an ADDRESSING model that in-
cludes the elements of age, disability status, religion, ethnicity, race, social class,
and sexual orientation along with gender.
Gender-role analysis begins with clients identifying the societal messages they
received about how women and men should be and act (Remer, 2008). The thera-
pist begins by asking Alma to identify messages she has received related to sexual-
ity and appearance from her culture, society, her peers, the media, and her family.
The therapist talks about how body image expectations differ between females
and males in our culture and how they may differ in other cultures. The therapist
explains how expectations related to appearance could intersect with beliefs about
what it means to be gay or straight in Alma’s culture, family, and society as it
relates to her working environment. Alma decides what messages she would pre-
fer to have in her mind and keeps an open awareness when the discounting mes-
sages play in her head.
gender-role intervention Using this technique, the therapist responds
to Alma’s concern by placing it in the context of society’s role expectations for wom-
en. The aim is to provide Alma with insight into the ways social issues are affecting
her. Alma’s therapist responds to her statement with, “Our society really focuses
on sometimes unrealistic beauty ideals with females. The media bombards girls
and women with the message that they must be thin, have long straight hair, and
wear attractive clothing. The message is so ingrained that many girls are struggling
with self-esteem issues related to their appearance as early as elementary school to
avoid being bullied or to fi t in.” By placing Alma’s concern in the context of societal
expectations, the therapist gives Alma insight into how these expectations have af-
fected her psychological condition and have contributed to her feeling depressed
and anxious about judgment from others. The therapist’s statement also paves the
way for Alma to think more positively about her unity with other women and even
to think about how she might contribute as a role model for girls and young women
in the future.
p o w e r a n a lys i s Power analysis refers to the range of methods aimed at
helping clients understand how unequal access to power and resources can infl u-
ence personal realities. Together therapists and clients explore how inequities or
institutional barriers often limit self-defi nition and well-being (Enns, 2004). With
this technique, Alma will become aware of the power difference between men and
women as well as the power differences associated with sexual orientation in our
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society. Specifi c issues related to Alma’s cultural perspective also are explored. In
Alma’s case the power analysis may focus on helping Alma identify alternate kinds
of power she may exercise and to challenge the gender-role messages that prohibit
the exercise of that kind of power. Interventions are aimed at helping Alma learn
to appreciate herself as she is, regain her self-confi dence based on the personality
attributes she possesses, and set goals that will be fulfi lling to her within the con-
text of her cultural values.
b i b l i ot h e r a p y Nonfi ction books, psychology and counseling textbooks, au-
tobiographies, self-help books, educational videos, fi lms, and even novels can all be
used as bibliotherapy resources. Reading about feminist perspectives on common
issues in women’s lives (incest, rape, battering, and sexual harassment) may chal-
lenge a woman’s tendency to blame herself for these problems (Remer, 2008). The
therapist describes a number of books that address issues of relevance to Alma, and
she selects one to read over the next few weeks. Providing Alma with reading ma-
terial increases knowledge and decreases the power difference between Alma and
her therapist. Reading can supplement what is learned in the therapy sessions, and
Alma can enhance her therapy by exploring her reactions to what she is reading.
a s s e r t i v e n e s s t r a i n i n g By teaching and promoting assertive behavior,
women become aware of their interpersonal rights, transcend stereotypical gender
roles, change negative beliefs, and implement changes in their daily lives. The
therapist and client consider what is culturally appropriate, and the client makes
decisions about when and how to use the new skill of assertion.
Through learning and practicing assertive behaviors and communication,
Alma may increase her own power, which will ameliorate her depression and
anxiety. Alma learns that it is her right to ask for what she wants and needs in the
workplace. The therapist helps Alma to evaluate and anticipate the consequences
of behaving assertively, which might range from criticism to actually getting what
she wants.
reframing and relabeling Like bibliotherapy, therapist self-disclosure,
and assertiveness training, reframing is not unique to feminist therapy. However,
reframing is applied uniquely in feminist therapy. Reframing includes a shift
from “blaming the victim” to a consideration of social factors in the environ-
ment that contribute to a client’s problem. In reframing, rather than dwelling
exclusively on intrapsychic factors, the focus is on examining societal or political
dimensions. Alma may come to understand that her depression and anxiety are
linked to social pressures to behave within hetero-normative gender-role expecta-
tions and to develop an appearance that matches these culturally and societally
prescribed ideals.
Relabeling is an intervention that changes the label or evaluation applied to
some behavioral characteristic. Alma can change certain labels she has attached
to herself, such as being inadequate or socially unwanted because she does not
conform to ideals commonly associated with feminism. An example might be that
Alma is encouraged to talk about herself as a strong and healthy woman rather
than as being “selfi sh” or too “masculine.”
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s o c i a l a c t i o n Social action, or social activism, is an essential quality of femi-
nist therapy (Enns, 2004). As clients become more grounded in their understanding
of feminism, therapists may suggest that clients become involved in activities such
as volunteering at a rape crisis center, lobbying lawmakers, or providing commu-
nity education about gender issues. Participating in such activities can empower
clients and help them see the link between their personal experiences and the
sociopolitical context in which they live. Alma might decide to join and partici-
pate in organizations that are working to change societal stereotypes about beauty
expectations for women or social groups that affi rm people who identify with a
variety of sexual and affectional orientations. Taking this kind of social action is
another way for Alma to feel more empowered.
g r o u p w o r k Group work became popular as a way for women to discuss their
lack of voice in many aspects of society. Historically, group work has been used for
both consciousness-raising and support (Herlihy & McCollum, 2011). Conscious-
ness-raising groups initially provided an avenue for women to share their experi-
ences of oppression and powerlessness. Eventually, these groups evolved into self-
help groups that empowered women and challenged many of the social patterns
of the time (Evans, Kincade, Marbley, & Seem, 2005; Evans et al., 2011). Feminist
therapists often encourage their clients to make the transition from individual ther-
apy to a group format such as joining a support group or a political action group as
soon as this is realistic (Herlihy & McCollum, 2011). Although these groups are as
diverse as the women who comprise them, they share a common denominator em-
phasizing support for the experience of women. The literature reveals that women
who join these groups eventually realize that they are not alone and gain validation
for their experiences by participating in the group. These groups can provide wom-
en with a social network, decrease feelings of isolation, create an environment that
encourages sharing of experiences, and help women realize that they are not alone
in their experiences (Eriksen & Kress, 2005). Groups provide a supportive context
where women can share and begin to critically explore the messages they have in-
ternalized about their self-worth and their place in society. The self-disclosures of
both the members and the leader foster deeper self-exploration, a sense of univer-
sality, and increased levels of cohesion. Members learn to use power effectively by
providing support to one another, practicing behavioral skills, considering social/
political actions, and by taking interpersonal risks in a safe setting (Enns, 2004).
Through their group participation, women learn that their individual experiences
are frequently rooted in problems within the system. In conjunction with the group
members, the group facilitator’s job is to design a group that results in both indi-
vidual and systemic change (Kees & Leech, 2004). Participation in a group experi-
ence can inspire women to take up some form of social action. Indeed, a form of
homework can be to carry out what women are learning in the group to bring about
changes in their lives outside of the group.
Alma and her therapist will likely discuss the possibility of Alma joining a
women’s support group, a gay-straight alliance, or another type of group as a part
of the process of terminating individual therapy. By joining a group Alma will have
opportunities to discover that she is not alone in her struggles. Other women can
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provide her with nurturance and support, and Alma will have the chance to be sig-
nifi cant to other women as they engage in their healing process.
The Role of Men in Feminist Therapy
Men can be feminist therapists, and feminist therapy can be practiced with male
clients. It is an erroneous perception that feminist therapy is conducted only by
women and for women, or that feminist therapy is anti-men because it is pro-women
(Herlihy & McCollum, 2011). Although the original feminist therapists were exclu-
sively women, men are now included among their ranks. Male feminist therapists
are willing to understand and “own” their male privilege, confront sexist behavior
in themselves and others, redefi ne masculinity and femininity according to other
than traditional values, work toward establishing egalitarian relationships, and ac-
tively support women’s efforts to create a just society.
The principles and practices of feminist psychotherapy are useful in working
with male clients, individuals from diverse racial and cultural backgrounds, and
people who are committed to addressing social justice issues in counseling practice
(Enns, 2000, 2004; Worell & Remer, 2003). Social mandates about masculinity
such as restrictive emotionality, overvaluing power and control, the sexualization
of emotion, and obsession with achievement can be limiting to males (Gilbert &
Scher, 1999; Pleck, 1995; Pollack, 1995, 1998; Real, 1998).
Some feminist therapists routinely work with men, especially with abusive
men and in batterers’ groups. According to Ganley (1988), issues that men can
deal with productively in feminist therapy include learning how to increase their
capacity for intimacy, expressing their emotions and learning self-disclosure, bal-
ancing achievement and relationship needs, accepting their vulnerabilities, and
creating collaborative relationships at work and with signifi cant others that are not
based on a “power-over” model of relating. Any presenting issue can be dealt with
from a feminist perspective.
f e m i n i s t t h e r a p y f r o m a
m u lt i c u lt u r a l a n d s o c i a l
j u s t i c e p e r s p e c t i v e
Strengths From a Diversity Perspective
Of all the theoretical approaches to counseling and psychotherapy in this book,
feminist therapy has the most in common with the multicultural and social justice
perspectives. Historically, multicultural approaches evolved in response to societal
oppression, discrimination, and marginalization faced by people of color. Over time,
multicultural counseling has become more inclusive, and contemporary multicul-
tural counselors work to address inequities created not only by racism but also by
other “isms” that limit full participation in society. Social justice counseling aims
to empower the individual as well as to confront injustice and inequality in society.
Although multicultural, feminist, and social justice counseling have been
viewed as disparate models, they have many common threads (Crethar, Torres
Rivera, & Nash, 2008). All three approaches emphasize the need to promote
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social, political, and environmental changes within the counseling context.
Practitioners of all three theories strive to create an egalitarian relationship in
which counselor and client co-construct the client’s problems from a contextual
perspective and collaborate in setting goals and choosing strategies. All three
approaches reject the “disease model” of psychopathology; they view clients’
problems as symptoms of their experiences of living in an unjust society rather
than as having an intrapsychic origin.
The “personal is political” principle is embraced equally in each of the ap-
proaches. None of the approaches rests solely on individual change; they all em-
phasize direct action for social change as a part of the role of therapists.
Culture encompasses the sociopolitical reality of people’s lives, including how
the privileged dominant group (in Western societies: White, Protestant, hetero-
sexual, rich males) treats those who are different from them. Feminist therapists
believe psychotherapy is inextricably bound to culture, and, increasingly, they are
being joined by thoughtful leaders in the fi eld of counseling practice. All cultures
include feminist voices from within them today.
The women’s movement and the multicultural movement, and more recently
the social justice movement, have called to our attention the negative effects of dis-
crimination and oppression on their targets and also on those doing the discrimi-
nating and oppressing. Culturally competent feminist therapists look for ways to
work within the client’s culture by exploring consequences and alternatives. They
appreciate the complexities involved in changing within one’s culture but do not
view culture as sacrosanct (Worell & Remer, 2003). It is important to understand
and respect diverse cultures, but most cultural contexts have both positive and
toxic aspects. Feminist therapists are committed to taking a critical look at cultural
beliefs and practices that discriminate against, subordinate, and restrict the poten-
tial of groups of individuals, which can be either a strength or a shortcoming.
Shortcomings From a Diversity Perspective
Feminist therapists advocate for change in the social structure, especially in the
areas of inequality, power in relationships, the right to self-determination, freedom
to pursue a career outside or inside the home, and the right to an education. This
agenda could pose some problems when working with women who do not share
these beliefs. Remer (2008) acknowledges this practice of critically evaluating soci-
etal values and structures that subordinate certain groups as a shortcoming of the
approach. If therapists do not fully understand and respect the cultural values of
clients from diverse groups, they run the risk of imposing their own values. Remer
claims “a potential danger inherent in feminist counseling is that counselors’ val-
ues will too strongly infl uence clients or will confl ict with clients’ values” (p. 431).
Being aware of the cultural context is especially important when feminist ther-
apists work with women from cultures that endorse culturally prescribed roles that
keep women in a subservient place or that are grounded in patriarchy. Consider
this scenario. You are a feminist therapist working with a Vietnamese woman who
is struggling to fi nd a way to be true to her culture and also to follow her own
educational and career aspirations. Your client is a student in a helping profession
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who is being subjected to extreme pressure from her father to return home and
take care of her family. Although she wants to complete a degree and eventually
help others in the Vietnamese community, she feels a great deal of guilt when she
considers “selfi shly” pursuing her education when her family at home needs her.
In this complex situation, the therapist is challenged to work together with the
client to fi nd a path that enables her to consider her own individual goals without
ignoring or devaluing her collectivistic cultural values. The therapist’s job is not
to take away her pain or struggle, nor to choose for the client, but to be present in
such a way that the client will truly be empowered to make signifi cant decisions.
The feminist counselor must remain aware that the price may be very high if this
woman chooses to go against what is culturally expected of her, and that the cli-
ent is the one to ultimately decide which path to follow. As can be seen from this
example, to minimize this potential shortcoming of imposing cultural values on
a client, it is essential that therapists understand how their own cultural perspec-
tives are likely to infl uence their interventions, especially when they are working
with culturally diverse clients. A safeguard against value imposition is for feminist
therapists to clearly present their values to clients early in the course of the coun-
seling relationship so that clients can make an informed choice about continuing
this relationship (Remer, 2008).
Feminist Therapy Applied to the Case of Stan
Stan’s fear of women and his gender-
role socialization experiences make
him an excellent candidate to benefit
from feminist therapy. A therapeutic relationship
that is egalitarian will be a new kind of experi-
ence for Stan.
Stan has indicated that he is willing and even
eager to change. Despite his low self-esteem and
negative self-evaluations, he is able to identify
some positive attributes. These include his deter-
mination, his ability to articulate his feelings, and
his gift for working with children. Stan knows what
he wants out of therapy and has clear goals: to
stop drinking, to feel better about himself, to relate
to women on an equal basis, and to learn to love
and trust himself and others. Operating from a
feminist orientation, I will build on these strengths.
In the first session I focus on establishing an
egalitarian working relationship to help Stan begin
to regain his personal power. It is important that
the therapeutic relationship does not replicate
other relationships Stan has had with significant
figures in his life. I consciously work to demystify
the therapeutic process and equalize the relation-
ship, conveying to Stan that he is in charge of the
direction of his therapy. I spend time explaining
my view of the therapy process and how it works.
A gender-role analysis is conducted to help
Stan become aware of the influence of gender-
role expectations in the development of his
problems. First, I ask him to identify gender-role
messages he received while growing up from a
variety of societal sources including his parents,
teachers, the media, faith community, and peers.
In his autobiography Stan has written about
some of the messages his parents gave him,
and this provides a natural starting point for his
analysis. He remembers his father calling him
“dumb” and his mother saying, “Why can’t you
grow up and be a man?” Stan wrote about his
mother “continually harping at” his father and
telling Stan how she wished she hadn’t had him.
He describes his father as weak, passive, and
mousy in relating to his mother and remembers
that his father compared him unfavorably with
his siblings. Stan internalized these messages,
often crying himself to sleep and feeling very
hopeless.
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I ask Stan to identify the damaging self-
statements he makes now that are based on
these early experiences. As we review his
writings, Stan sees how societal messages he
received about what a man “should” be were
reinforced by parental messages and have
shaped his view of himself today. For example,
he wrote that he feels sexually inadequate. It
appears that he has introjected the societal
notion that men should always initiate sex, be
ready for sex, and be able to achieve and sustain
an erection. Stan also sees that he has already
identified and written about how he wants to
change those messages, as exemplified in his
statements that he wants to “feel equal with
others” and not “feel apologetic” for his existence
and develop a loving relationship with a woman.
Stan begins to feel capable and empowered as I
acknowledge the important work he has already
done, even before he entered therapy.
I follow this gender-role analysis with a
gender-role intervention to place Stan’s con-
cerns in the context of societal role expectations.
I say, “Indeed, it is a burden to try to live up to
society’s notion of what it means to be a man,
always having to be strong and tough. Those
aspects of yourself that you would like to value—
your ability to feel your feelings, being good with
children—are qualities society tends to label as
‘feminine.’” Stan replies wistfully, “Yeah, it would
be a better world if women could be strong
without being seen as domineering and if men
could be sensitive and nurturing without being
seen as weak.” I raise the question, “Are you sure
that’s not possible? Have you ever met a woman
or a man who was like that?” Stan ponders for a
minute and then with some animation describes
the college professor who taught his Psychology
of Adjustment class. Stan saw her as very
accomplished and strong but also as someone
who empowered him by encouraging him to find
his own voice through writing his autobiography.
He also remembers a male counselor at the
youth rehabilitation facility where he spent part
of his adolescence as a man who was strong as
well as sensitive and nurturing.
As the first session draws to a close, I invite
Stan to talk about what he learned from our time
together. Stan says two things stand out for him.
First, he is beginning to believe he doesn’t need
to keep blaming himself. He knows that many
of the messages he has received from his
parents and from society about what it means
to be a man have been undesirable and one-
dimensional. He acknowledges that he has
been limited and constrained by his gender-role
socialization. Second, he feels hopeful because
there are alternatives to those parental and
societal definitions—people he admires have
been able to successfully combine “masculine”
and “feminine” traits. If they can do it, so can he.
I ask Stan whether he chooses to return for
another session. When he answers in the
affirmative, I give him W. S. Pollack’s (1998)
book Real Boys to read. I explain that this book
descriptively captures the gender-role socializa-
tion that many boys experience.
Stan comes to the following session eager to
talk about his homework assignment. He tells me
that he gained some real insights into his own
attitudes and beliefs by reading Real Boys. What
Stan learned from reading this book leads to a
further exploration of his relationship with his
mother. He finds it helpful to understand his par-
ents’ behavior in the context of societal expecta-
tions and stereotypes rather than continuing to
blame them. I help Stan to see how our culture
tends to hold extreme positions about mothers—
that they are either perfect or wicked—and that
neither of these extremes is true. As Stan learns
to reframe his relationship with his mother,
he develops a more realistic picture of her. He
comes to realize, too, that his father has been
oppressed by his own socialization experiences
and by an idealistic view of masculinity that he
may have felt unable to achieve.
Stan continues to work at learning to value
the nurturing and sensitive aspects of himself.
He is learning to value the “feminine” aspects
of himself as well as the “masculine” side of
his personality. He also continues to monitor
and make changes in his self-talk about what
it means to be a man. He is involved in gaining
ongoing awareness of these messages that come
from current sources such as the media and
friends. Since a number of Stan’s sessions were
devoted to exploring his relationship with his
mother, along with his resentment toward her, I
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suggest another reading assignment—
Caplan’s (1989) book, Don’t Blame Mother.
The aim of this assignment is to assist
Stan in exploring alternatives to blaming
his mother for his present problems.
Throughout our therapeutic relation-
ship, we discuss with immediacy how
we are communicating and relating to
each other during the sessions. I am
self-disclosing and treat Stan as an equal,
continually acknowledging that he is the
“expert” on his life.
Follow-Up: You Continue as Stan’s
Feminist Therapist
Use these questions to help you think
about how you would counsel Stan using
a feminist therapy model:
• What unique values do you see in work-
ing with Stan from a feminist perspective
as opposed to working from the other
therapeutic approaches you’ve studied
thus far?
• If you were to continue working with
Stan, what self-statements regarding
his view of himself as a man might you
focus on, and what alternatives might
you offer?
• In what ways could you integrate cog-
nitive behavior therapy with feminist
therapy in Stan’s case? What possibili-
ties do you see for integrating Gestalt
therapy methods with feminist thera-
py? What other therapies might you
combine with a feminist approach?
• I used bibliotherapy as a form of home-
work assignment. Would you suggest
books or films for Stan? If so, which
ones? What other homework might
you suggest to Stan? What other femi-
nist therapy strategies would you utilize
in counseling Stan?
See DVD for Theory and Practice of
Counseling and Psychotherapy: The
Case of Stan and Lecturettes (Session 10
on feminist therapy) for a demonstra-
tion of my approach to counseling Stan
from this perspective. This session deals
with Stan’s exploration of his gender-role
identity and messages he has incorpo-
rated about being a man.
s u m m a ry a n d e va l u at i o n
Summary
The origins of feminist therapy are connected with the women’s movements of the
late 1800s and the 1960s, when women united in vocalizing their dissatisfaction
over the restrictive nature of traditional female roles. Feminist therapy largely grew
out of the recognition by women that the traditional models of therapy suffer from
basic limitations due to the inherent bias of earlier theoreticians. Feminist therapy
emphasizes these concepts:
• Viewing problems in a sociopolitical and cultural context rather than on an
individual level
• Recognizing that clients know what is best for their lives and are experts on
their own lives
• Striving to create a therapeutic relationship that is egalitarian through the proc-
ess of self-disclosure and informed consent
• Demystifying the therapeutic process by including the client as much as
possible in all phases of assessment and treatment, which increases client
empowerment
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• Viewing women’s experiences from a unique perspective
• Understanding and appreciating the lives and perspectives of diverse women
• Understanding that gender never exists in isolation from other aspects of identity
• Challenging traditional ways of assessing the psychological health of women
• Emphasizing the role of the therapist as advocate as well as facilitator
• Encouraging clients to get involved in social action to address oppressive
aspects of the environment
Feminist therapy is aimed at both personal and social change. The theory is not
static but is continually evolving and maturing. The major goal is to replace the
current patriarchal system with feminist consciousness and thus create a society
that values equality in relationships, values diversity, stresses interdependence
rather than dependence, and encourages both women and men to defi ne them-
selves rather than being defi ned by societal demands.
Instead of being a singular and unifi ed approach to psychotherapy, feminist
practice tends to be diverse. As feminist therapy has matured, it has become more
self-critical and varied. Feminist therapists share a number of basic assumptions
and roles: they engage in appropriate self-disclosure; they make their values and
beliefs explicit so that the therapy process is clearly understood; they establish egal-
itarian roles with clients; they work toward client empowerment; they emphasize
the commonalities among women while honoring their diverse life experiences;
and they all have an agenda to bring about social change.
Feminist therapists are committed to actively breaking down the hierarchy of
power in the therapeutic relationship through the use of various interventions.
Some of these strategies are unique to feminist therapy, such as gender-role analy-
sis and intervention, power analysis, assuming a stance of advocate in challenging
conventional attitudes toward appropriate roles for women, and encouraging cli-
ents to take social action. Other therapeutic strategies are borrowed from various
therapy models, including bibliotherapy, assertiveness training, cognitive restruc-
turing, reframing and relabeling, counselor self-disclosure, role playing, identify-
ing and challenging untested beliefs, and journal writing. Feminist therapy prin-
ciples and techniques can be applied to a range of therapeutic modalities such
as individual therapy, couples counseling, family therapy, group counseling, and
community intervention. Regardless of the specifi c techniques used, the overrid-
ing goals are client empowerment and social transformation.
Contributions of Feminist Therapy
One of the major contributions feminists have made to the fi eld of counseling and
psychotherapy is paving the way for gender-sensitive practice and an awareness of
the impact of the cultural context and multiple oppressions. By focusing attention
on our attitudes and biases pertaining to gender and culture, feminist therapists
have expanded the awareness of therapists of all theoretical orientations regarding
how social justice issues may touch clients. Feminists have had a major infl uence
on therapeutic practice with women and girls; for example, feminist perspectives
are refl ected throughout the American Psychological Association’s Guidelines for
Psychological Practice with Girls and Women (2007). A signifi cant contribution of
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feminist therapy is the emphasis on social change, which can lead to a transforma-
tion in society. Therapists with a feminist orientation understand how important it
is to be fully aware of typical gender-role messages clients have grown up with, and
they are skilled in helping clients identify and examine these messages (Philpot,
Brooks, Lusterman, & Nutt, 1997).
According to Gilbert and Rader (2007), feminist therapists have brought about
signifi cant theoretical and professional advances in counseling practice. Some of
these contributions include power sharing with clients, cultural critiques of both
assessment and treatment approaches, and the validation of women and their nor-
mative experiences. Feminist therapists have also made important contributions
by questioning traditional counseling theories and models of human development.
Most theories place the cause of problems within individuals rather than with
external circumstances and the environment. This has led to holding individuals
responsible for their problems and not giving full recognition to social and politi-
cal realities that create problems. A key contribution feminists continue to make
is reminding all of us that the proper focus of therapy includes addressing oppres-
sive factors in society rather than expecting individuals to merely adapt to expected
role behaviors. This emphasis on social justice issues has expanded the role of
therapists to be advocates for clients. For a discussion of adaptations to traditional
approaches to counseling women, see Enns (2003).
Another major contribution of the feminist movement is in the areas of ethics in
psychology and counseling practice (Brabeck, 2000) and ethical decision making in
therapy (Rave & Larsen, 1995). The unifi ed feminist voice called attention to the extent
and implications of child abuse, incest, rape, sexual harassment, and domestic vio-
lence. Feminists pointed out the consequences of failing to recognize and take action
when children and women were victims of physical, sexual, and psychological abuse.
Feminist therapists work with male clients who are abusive, and increasing numbers
of groups composed of male batterers are led or co-led by feminist therapists.
Feminist therapists demanded action in cases of sexual misconduct at a time
when male therapists misused the trust placed in them by their female clients. Not
too long ago the codes of ethics of all the major professional organizations were
silent on the matter of therapist and client sexual liaisons. Now, virtually all of the
professional codes of ethics prohibit sexual intimacies with current clients and
with former clients for a specifi ed time period. Furthermore, the professions agree
that a sexual relationship cannot later be converted into a therapeutic relationship.
Largely due to the efforts and input of women on ethics committees, the existing
codes are explicit with respect to sexual harassment and sexual relationships with
clients, students, and supervisees (Herlihy & Corey, 2006b).
Feminist therapy principles have been applied to supervision, teaching, con-
sultation, ethics, research, and theory building as well as to the practice of psycho-
therapy. Building community, providing authentic mutual empathic relationships,
creating a sense of social awareness, and addressing social injustices are all signifi –
cant strengths of this approach.
The principles and techniques of feminist therapy can be incorporated in many
other contemporary therapy models and vice versa (Enns, 2003). Both feminist and
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Adlerian therapists view the therapeutic relationship as egalitarian. Both feminist
and person-centered therapists agree on the importance of therapist authenticity,
modeling, and self-disclosure; empowerment is the basic goal of both orientations.
When it comes to making choices about one’s destiny, existential and feminist
therapists are speaking the same language—both emphasize choosing for oneself
instead of living a life determined by societal dictates.
Although feminist therapists have been critical of psychoanalysis as a sexist
orientation, a number of feminist therapists believe psychoanalysis can be an
appropriate approach to helping women. Object-relations theory may help clients
examine internalized object representations that are based on their relationships
with their parents. Therapy might include an examination of unconscious learn-
ing about women’s roles through the mother–daughter relationship to provide in-
sights into why gender roles are so deeply ingrained and diffi cult to change.
Gestalt therapy and feminist therapy share the goal of increasing the client’s
awareness of personal power. Gestalt therapy also is useful for increasing a wom-
an’s sense of herself as a powerful person (Enns, 2003). In many ways the dialogic,
relational, and collaborative model of Gestalt therapy fi ts well with the philosophy
of a feminist perspective (Enns, 1987, 2004).
Cognitive behavioral therapies and feminist therapy are compatible in that they
view the therapeutic relationship as a collaborative partnership, with the client
being in charge of setting goals and selecting strategies for change. These approach-
es are committed to demystifying therapy, and both aim to help clients take charge
of their own lives. Both the cognitive behavior therapist and the feminist therapist
assume a range of information-giving and teaching functions so clients can become
active partners in the therapy process. A feminist therapist could employ action-
oriented strategies such as assertiveness training and behavioral rehearsal, and sug-
gest homework assignments for clients to practice in their everyday lives. A useful
source for further discussion of feminist cognitive behavior therapy is Worell and
Remer (2003).
Limitations and Criticisms of Feminist Therapy
Feminist therapists do not take a neutral stance; they believe therapy is a value-
oriented process. They emphasize the importance of counselors clarifying their
personal and professional values and being aware of the potential impact of these
values on clients. However, there is a danger that therapists may unduly infl u-
ence clients, especially those who lack a strong sense of their own values. Feminist
therapists must remain aware of their own values and explicitly share these values
with clients in an appropriate, timely, and respectful manner to reduce the risk of
value imposition.
Feminist therapists call attention to clients’ unexamined choices, but they must
honor clients’ choices as long as those choices are indeed informed. Once clients
understand the impact of gender and cultural factors on their choices, the therapist
must guard against providing specifi c directions for client growth. Feminist thera-
pists are committed to helping clients weigh the costs and benefi ts of their current
life choices but should not push clients too quickly toward changes they feel are
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beyond their reach. Lenore Walker (1994) raised this issue with regard to working
with abused women. Although Walker focuses on the importance of asking ques-
tions that enable women to think through their situations in new ways and of help-
ing women develop “safety plans,” she emphasizes how critical it is to understand
those factors in a woman’s life that often pose diffi culties for her in making changes.
Looking at contextual or environmental factors that contribute to a woman’s
problems and moving away from exploring the intrapsychic domain can be both a
strength and a limitation. Instead of being blamed for her depression, the client is
able to come to an understanding of external realities that are indeed oppressive.
However, viewing the source of a client’s problem as being in the environment
could contribute to the client not taking personal responsibility to act in the face
of an unfair world. A client can make some internal changes even in those cir-
cumstances where external realities may largely be contributing to her problems.
Therapists must balance an exploration of the outer and inner worlds of the client
if the client is to fi nd a way to take action in her own life.
Because feminist therapists do not assume a neutral stance, they need to iden-
tify any sources of bias and work toward restructuring or eliminating biased
aspects in any theories or techniques they employ. This is indeed a demanding
endeavor, and it should be considered an ongoing process.
Factors that inhibit the growth of feminist therapy include training that is often
offered only sporadically in a nonsystematic way (Brown, 2010) and the lack of qual-
ity control. No credentialing organization confers offi cial status as a qualifi ed femi-
nist therapist, so formalized training and credentialing need to be addressed in the
future. In addition, evidence-based research on the effi cacy of feminist therapy is
lacking, as is an understanding of feminist therapy as an integrative approach that
can inform therapeutic practice for counselors of varied theoretical orientations.
w h e r e to g o f r o m h e r e
The DVD for Integrative Counseling: The Case of Ruth and Lecturettes is especially
useful as a demonstration of interventions I make with Ruth that illustrate some
principles and procedures of feminist therapy. For example, in Session 1 (“Begin-
ning of Counseling”) I ask Ruth about her expectations and initiate the informed
consent process. I attempt to engage Ruth as a collaborative partner in the thera-
peutic venture, and I teach her how counseling works. Clearly, Ruth is the expert
on her own life and my job is to assist her in attaining the goals we collabora-
tively identify as a focus of therapy. In Session 4 (“Understanding and Addressing
Diversity”) Ruth brings up gender differences, and she also mentions our differ-
ences in religion, education, culture, and socialization. Ruth and I explore the
degree to which she feels comfortable with me and trusts me.
Other Resources
DVDs offered by the American Psychological Association that are relevant to this
chapter include the following:
Brown, L. S. (2009). Feminist Therapy Over Time (APA Psychotherapy Video
Series)
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Psychotherapy.net is a comprehensive resource for students and professionals that
offers videos and interviews on feminist therapy. New video and editorial content
is made available monthly. DVDs relevant to this chapter are available at www.
psychotherapy.net and include the following:
Walker, L.(1994). The Abused Woman: A Survivor Therapy Approach
Walker, L. (1997). Feminist Therapy (Psychotherapy With the Experts
Series)
The Jean Baker Miller Training Institute offers workshops, courses, professio-
nal training, publications, and ongoing projects that explore applications of the
relational-cultural approach and integrate research, psychological theory, and social
action. This relational-cultural model is based on the assumption that growth-
fostering relationships and disconnections are constructed within specifi c cultural
contexts.
Jean Baker Miller Training Institute
Stone Center, Wellesley College
106 Central Street
Wellesley, MA 02481
Telephone: (781) 283-3800
Fax: (781) 283-3646
Website: www.wellesley.edu/JBMTI/
The American Psychological Association has two divisions devoted to special inter-
ests in women’s issues: Division 17 (Counseling Psychology’s Section on Women)
and Division 35 (Psychology of Women).
American Psychological Association
750 First Street, N.E.
Washington, DC 20002-4242
Telephone: (202) 336-5500 or (800) 374-2721
Fax: (202) 336-5568
Association Website: www.apa.org
Division 17 Website: www.div17.org
Division 35 Website: www.apa.org/divisons/div35
The Association for Women in Psychology (AWP) sponsors an annual confer-
ence dealing with feminist contributions to the understanding of life experiences
of women. AWP is a scientifi c and educational feminist organization devoted
to reevaluating and reformulating the role that psychology and mental health
research generally play in women’s lives.
Association for Women in Psychology
Website: www.awpsych.org
The Psychology of Women Resource List, or POWR online, is cosponsored by APA
Division 35, Society for the Psychology of Women, and the Association for Women
in Psychology. This public electronic network facilitates discussion of current top-
ics, research, teaching strategies, and practice issues among people interested in
the discipline of psychology of women. Most people with computer access to Bitnet
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or the Internet can subscribe to POWR-L at no cost. To subscribe, send the com-
mand below via e-mail to:
LISTSERV@URIACC (Binet) or LISTSERV@URIACC.URI.EDU
Subscribe POWR-L Your name (Use first and last name)
The University of Kentucky offers a minor specialty area in counseling women
and feminist therapy within the Counseling Psychology graduate programs. For
information, contact:
Dr. Pam Remer
University of Kentucky
Department of Educational and Counseling Psychology
251-C Dickey Hall
Lexington, KY 40506-0017
Telephone: (859) 257-4158
E-mail: Premer@uky.edu
Website: www.uky.edu/Education/edphead.html
Texas Women’s University offers a training program with emphasis in women’s
issues, gender issues, and family psychology. For information, contact:
Dr. Roberta Nutt
Texas Women’s University
Counseling Psychology Program
P. O. Box 425470
Denton, Texas 76204-5470
Telephone: (940) 898-2313
E-mail: rnutt@mail.twu.edu
Website: www.twu.edu/as/psyphil/Counseling_Home.htm
Recommended Supplementary Readings
Feminist Perspectives in Therapy: Empowering Diverse Women (Worell & Remer,
2003) is an outstanding text that clearly outlines the foundations of empower-
ment feminist therapy. The book covers a range of topics such as integrating
feminist and multicultural perspectives on therapy, changing roles for women,
feminist views of counseling practice, feminist transformation of counseling
theories, and a feminist approach to assessment and diagnosis. There also are
excellent chapters dealing with depression, surviving sexual assault, confronting
abuse, choosing a career path, and lesbian and ethnic minority women.
Feminist Theories and Feminist Psychotherapies: Origins, Themes, and Diversity
(Enns, 2004) describes the wide range of feminist theories that inform and infl u-
ence feminist practice. The book includes short self-assessment questionnaires
designed to help readers clarify their feminist theoretical perspective.
Feminist Therapy (Brown, 2010) provides an interesting perspective on the history
of feminist therapy and speculates about future developments of the approach.
Brown clearly explains key concepts of feminist theory and the therapeutic process.
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Introduction to Feminist Therapy: Strategies for Social and Individual Change (Evans,
Kincade, & Seem, 2011) emphasizes the practical applications of feminist theory
to clinical practice. They provide useful information on social change and empow-
erment, the importance of establishing an egalitarian relationship, and interven-
tion strategies when working with people from diverse cultural backgrounds.
The Healing Connection: How Women Form Relationships in Therapy and Life
(Miller & Stiver, 1997) describes how connections are formed between people
and how this leads to strong, healthy individuals. The authors also deal with dis-
connections between people that lead to anxiety, isolation, and depression.
Women’s Growth in Diversity: More Writings From the Stone Center (Jordan, 1997)
builds on the foundations laid by Women’s Growth in Connection (Jordan et al.,
1991). This work offers insights on issues such as sexuality, shame, anger, de-
pression, power relations between women, and women’s experiences in therapy.
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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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i n t r o d u ct i o n to s o c i a l
co n st r u ct i o n i s m
s o l u t i o n – f o c u s e d b r i e f t h e r a p y
n a r r at i v e t h e r a p y
p o stm o d e r n a p p r oac h es f r o m a
m u lt i c u lt u r a l p e r s p ect i v e
p o stm o d e r n a p p r oac h es a p p l i e d
to t h e c a s e o f sta n
s u m m a ry a n d e va l u at i o n
w h e r e to g o f r o m h e r e
c h a p t e r 1 3
Postmodern Approaches
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Some Contemporary Founders of Postmodern Therapies
Insoo Kim Berg / Steve de Shazer / Michael White / David Epston
I N S O O K I M B E R G (1935–
2007) was a co-developer
of the solution-focused
approach. Until her death in
2007, she was the director
of the Brief Family Therapy
Center in Milwaukee,
Wisconsin. As a leader in the
practice of solution-focused brief therapy (SFBT),
she provided workshops in the United States,
Japan, South Korea, Australia, Denmark, England,
and Germany. Among her writings are Family Based
Services: A Solution-Focused Approach (1994), Work-
ing With the Problem Drinker: A Solution-Focused
Approach (Berg & Miller, 1992), and Interviewing for
Solutions (De Jong & Berg, 2008).
Co
ur
te
sy
of
Br
ie
fF
am
ily
Th
er
ap
y
Ce
nt
er
The postmodern approaches do not have a single
founder. Rather, it has been a collective effort by
many. I have highlighted two cofounders of solution-
focused brief therapy and two cofounders of nar-
rative therapy who have had a major impact on the
development of these therapeutic approaches.
STEVE de SHAZER
(1940–2005) was one of the
pioneers of solution-focused
brief therapy. For many
years he was the director of
research at the Brief Family
Therapy Center in Milwaukee,
where solution-focused
brief therapy was developed. He wrote several
books on SFBT, including Keys to Solutions in Brief
Therapy (1985), Clues: Investigating Solutions in Brief
Therapy (1988), Putting Difference to Work (1991), and
Words Were Originally Magic (1994). He presented
workshops, trained, and consulted widely in North
America, Europe, Australia, and Asia. He died in
September 2005 while on a teaching tour in Europe.
M I C H A E L W H I T E (1949–
2008) was the cofounder,
with David Epston, of the
narrative therapy move-
ment. He founded the
Dulwich Centre in Adelaide,
Australia, and his work with
families and communities
has attracted widespread international interest.
Among his many books are Narrative Means to
Therapeutic Ends (White & Epston, 1990), Reau-
thoring Lives: Interviews and Essays (1995), Narrative
of Therapists’ Lives (1997), and Maps of Narrative
Practice (2007). Michael White died in April 2008
while visiting San Diego for a teaching workshop.
DAV I D E P STO N (b. 1944)
is one of the co-developers
of narrative therapy. He is
co-director of the Family
Therapy Centre in Auckland,
New Zealand. He is an inter-
national traveler, presenting
lectures and workshops
in Australia, Europe, and
North America. He is a coauthor of Narrative Means
to Therapeutic Ends (White & Epston, 1990) and
Playful Approaches to Serious Problems: Narrative
Therapy With Children and Their Families (Freeman,
Epston, & Lobovits, 1997). He is well known for his
work with persons affected by eating disorders and
was a coauthor of Biting the Hand That Starves You
(Maisel, Epston, & Borden, 2004).
Co
ur
te
sy
of
Br
ie
fF
am
ily
Th
er
ap
y
Ce
nt
er
Co
ur
te
sy
of
Ch
er
yl
W
hi
te
,D
ul
w
ic
h
Ce
nt
re
,
A
de
la
id
e,
A
us
tr
al
ia
Co
ur
te
sy
of
D
av
id
Ep
st
on
28549_ch13_rev01.indd 396 20/09/11 3:57 PM
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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A
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S
i n t r o d u c t i o n to s o c i a l
c o n s t r u c t i o n i s m
Each of the models of counseling and psychotherapy we have studied so far has
its own version of “reality.” The simultaneous existence of multiple and often con-
fl icting “truths” has led to increasing skepticism of the possibility that a singular,
universal theory will one day explain human beings and the systems in which they
live. We have entered a postmodern world in which truth and reality are often
understood as points of view bounded by history and context rather than as objec-
tive, immutable facts.
Modernists believe in objective reality and assume that it can be observed and
systematically known through the scientifi c method. They further believe reality
exists independent of any attempt to observe it. Modernists believe people seek
therapy for a problem when they have deviated too far from some objective norm.
For example, clients may think they are abnormally depressed when they experi-
ence sadness for longer than they think is normal. They might then seek help to
return to “normal” behavior.
Postmodernists, in contrast, believe that realities do not exist independent of
observational processes. Social constructionism is a psychological expression of this
postmodern worldview; it values the client’s reality without disputing whether it is
accurate or rational (Gergen, 1991, 1999; Weishaar, 1993). To social construction-
ists, any understanding of reality is based on the use of language and is largely a
function of the situations in which people live. Our knowledge about realities is so-
cially constructed. A person is depressed when he or she adopts a defi nition of self
as depressed. Once a defi nition of self is adopted, it is hard to recognize behaviors
counter to that defi nition; for example, it is hard for someone who is suffering from
depression to acknowledge the value of a periodic good mood in his or her life.
In postmodern thinking, forms of language and the use of language in stories
create meaning. There may be as many meanings as there are people to tell the
stories, and each of these stories expresses a truth for the person telling it. Every
person involved in a situation has a perspective on the “reality” of that situation,
but the range of truths is limited due to the effects of specifi c historical events and
the language uses that dominate particular social contexts. In practice, therefore,
the range of possible meanings is not infi nite. When Kenneth Gergen (1985, 1991,
1999) and others began to emphasize the ways in which people make meaning in
social relationships, the fi eld of social constructionism was born. Berger and Luck-
man (1967) are reputed to be the fi rst who used the term social constructionism, and
it signaled a shift in emphasis for individual and family systems psychotherapy.
In social constructionism the therapist disavows the role of expert, preferring a
more collaborative or consultative stance. Clients are viewed as experts about their
own lives. De Jong and Berg (2008) put this notion about the therapist’s task well:
We do not view ourselves as expert at scientifi cally assessing client problems and then inter-
vening. Instead, we strive to be expert at exploring clients’ frames of reference and identify-
ing those perceptions that clients can use to create more satisfying lives. (p. 19)
The collaborative partnership in the therapeutic process is considered more impor-
tant than assessment or technique. Understanding narratives and deconstructing
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language processes (linguistics) are the focus for both understanding individuals
and helping them construct desired change.
Social constructionist theory is grounded on four key assumptions (Burr, 2003),
which form the basis of the difference between postmodernism and traditional psycho-
logical perspectives. First, social constructionist theory invites a critical stance toward
taken-for-granted knowledge. Social constructionists challenge conventional knowl-
edge that has historically guided our understanding of the world, and they caution us to
be suspicious of assumptions of how the world appears to be. Second, social construc-
tionists believe the language and concepts we use to generally understand the world are
historically and culturally specifi c. Knowledge is time- and culture-bound, and our ways
of understanding are not necessarily better than other ways. Third, social construction-
ists assert that knowledge is constructed through social processes. What we consider to
be “truth” is a product of daily interactions between people in daily life. Thus there is
not a single or “right” way to live one’s life. Fourth, negotiated understandings (social
constructions) are considered to be practices that affect social life rather than being
abstractions from it. Therefore, knowledge and social action go together.
See the video program for Chapter 13, DVD for Theory and Practice of Counseling
and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you view the
brief lecture for each chapter prior to reading the chapter.
Historical Glimpse of Social Constructionism
A mere hundred years ago, Freud, Adler, and Jung were part of a major paradigm
shift that transformed psychology as well as philosophy, science, medicine, and
even the arts. In the 21st century, postmodern constructions of alternative knowl-
edge sources seem to be one of the paradigm shifts most likely to affect the fi eld
of psychotherapy. Postmodernist thought is infl uencing the development of many
psychotherapy theories and contemporary psychotherapeutic practice. The creation
of the self, which so dominated the modernist search for human essence and truth,
is being replaced with the concept of socially storied lives. Diversity, multiple frame-
works, and integration—collaboration of the knower with the known—are all part
of this new social movement, which provides a wider range of perspectives in coun-
seling practice. For some social constructionists, the process of “knowing” includes
a distrust of the dominant cultural positions that permeate families and society today
(White & Epston, 1990), particularly when the dominant culture exerts a destructive
impact on the lives of those who live beyond the margins of what is generally consid-
ered normal. Change begins by deconstructing the power of cultural narratives and
then proceeds to the co-construction of a new life of meaning.
Among the best-known postmodern perspectives on therapy practice are the
collaborative language systems approach (Anderson & Goolishian, 1992), solution-
focused brief therapy (de Shazer, 1985, 1988, 1991, 1994), solution-oriented ther-
apy (Bertolino & O’Hanlon, 2002; O’Hanlon & Weiner-Davis, 2003), narrative
therapy (White & Epston, 1990), and feminist therapy (Brown, 2010). The next sec-
tion examines the collaborative language systems approach, but the heart of this
chapter addresses two of the most signifi cant postmodern approaches: solution-
focused brief therapy and narrative therapy.
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The Collaborative Language Systems Approach
A relatively unstructured social constructionist dialogue has been suggested
by Harlene Anderson and the late Harold Goolishian (1992) of the Houston
Galveston Institute. Rejecting the more therapist-controlled and theory-based
interventions of other North American therapeutic approaches, Anderson
and Goolishian developed a therapy of caring and being with the client. Their
stance is similar to the person-centered way of being that originated with Carl
Rogers, but without the theory of self-actualization. Informed by and contrib-
uting to the fi eld of social constructionism, they came to believe human life is
constructed in personal and family narratives that maintain both process and
meaning in people’s lives. These narratives are constructed in social interac-
tion over time. The sociocultural systems in which people live are a product
of social interaction, not the other way around. In this sense, therapy is also a
system process created in the therapeutic conversations of the client and the
listener-facilitator.
When people seek therapy, they are often “stuck” in a dialogic system that
has a unique language, meaning, and process related to “the problem.” Therapy
is another conversational system that becomes therapeutic through its “problem-
organizing, problem-dissolving” nature (Anderson & Goolishian, 1992, p. 27).
It is therapists’ willingness to enter the therapeutic conversation from a “not-
knowing” position that facilitates this caring relationship with the client. In
the not-knowing position, therapists still retain all of the knowledge and person-
al, experiential capacities they have gained over years of living, but they allow
themselves to enter the conversation with curiosity and with an intense interest
in discovery. The aim here is to enter a client’s world as fully as possible.
Clients become the experts who are informing and sharing with the therapist
the signifi cant narratives of their lives. The not-knowing position is empathic
and is most often characterized by questions that “come from an honest, con-
tinuous therapeutic posture of not understanding too quickly” (Anderson, 1993,
p. 331).
Based on the referral or intake process, the therapist enters the session with
some sense of what the client may wish to address. The questions the therapist
asks are always informed by the answers the client-expert has provided. The client’s
answers provide information that stimulates the interest of the therapist, still in a
posture of inquiry, and another question proceeds from each answer given. The
process is similar to the Socratic method without any preconceived idea about
how or in which direction the development of the stories should go. The intent of
the conversation is not to confront or challenge the narrative of the client but to
facilitate the telling and retelling of the story until opportunities for new meaning
and new stories develop: “Telling one’s story is a representation of experience; it
is constructing history in the present” (Anderson & Goolishian, 1992, p. 37). By
staying with the story, the therapist–client conversation evolves into a dialogue of
new meaning, constructing new narrative possibilities. This not-knowing position
of the therapist has been infused as a key concept for both the solution-focused and
the narrative therapeutic approaches.
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s o l u t i o n – f o c u s e d b r i e f t h e r a p y
Introduction
Solution-focused brief therapy (SFBT) is a future-focused, goal-oriented therapeu-
tic approach to brief therapy developed initially by Steve de Shazer and Insoo Kim
Berg at the Brief Family Therapy Center in Milwaukee in the early 1980s. SFBT
emphasizes strengths and resiliencies of people by focusing on exceptions to their
problems and their conceptualized solutions.
Having grown dissatisfi ed with the constraints of the strategic model, in the
1980s de Shazer collaborated with a number of therapists, including Eve Lipchik,
John Walter, Jane Peller, Michelle Weiner-Davis, and Bill O’Hanlon, who each
wrote extensively about solution-focused therapy and started their own solution-
focused training institutes. Both O’Hanlon and Weiner-Davis were infl uenced
by de Shazer and Berg’s original work, and they expanded on this foundation to
create what they called solution-oriented therapy. In this chapter when I discuss
solution-focused brief therapy, solution-focused therapy, and solution-oriented therapy,
I am focusing on what these approaches have in common rather than looking at
their differences.
Key Concepts
u n i q u e f o c u s o f s f b t Solution-focused brief therapy (SFBT) differs from
traditional therapies by eschewing the past in favor of both the present and the
future. Therapists focus on what is possible, and they have little or no interest
in gaining an understanding of how the problem emerged. Behavior change
is viewed as the most effective approach to assisting people in enhancing their
lives. De Shazer (1988, 1991) suggests that it is not necessary to know the cause
of a problem to solve it and that there is no necessary relationship between the
causes of problems and their solutions. Assessing problems is not necessary for
change to occur. If knowing and understanding problems are unimportant, so
is searching for “right” or absolute solutions. Any person might consider mul-
tiple solutions, and what is right for one person may not be right for others. In
solution-focused brief therapy, clients choose the goals they wish to accomplish;
little attention is given to diagnosis, history taking, or exploring the emergence
of the problem (Berg & Miller, 1992; Gingerich & Eisengart, 2000; O’Hanlon &
Weiner-Davis, 2003).
p o s i t i v e o r i e n tat i o n Solution-focused brief therapy is grounded on the
optimistic assumption that people are healthy and competent and have the abil-
ity to construct solutions that can enhance their lives. An underlying assumption
of SFBT is that we already have the ability to resolve the challenges life brings us,
but at times we lose our sense of direction or our awareness of our competencies.
Regardless of what shape clients are in when they enter therapy, solution-focused
therapists believe clients are competent. The therapist’s role is to help clients recog-
nize the competencies they already possess and apply them toward solutions. The
essence of therapy involves building on clients’ hope and optimism by creating posi-
tive expectations that change is possible. SFBT is a nonpathologizing approach that
emphasizes competencies rather than defi cits, and strengths rather than weaknesses
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(Metcalf, 2001). The solution-focused model requires a philosophical stance of ac-
cepting people where they are and assisting them in creating solutions. Solution-
focused brief therapy has parallels with positive psychology, which concentrates
on what is right and what is working for people rather than dwelling on defi cits,
weaknesses, and problems (Murphy, 2008). By emphasizing positive dimensions,
clients quickly become involved in resolving their problems, which makes this a
very empowering approach.
Because clients often come to therapy in a “problem-oriented” state, even the
few solutions they have considered are wrapped in the power of the problem orien-
tation. Clients often have a story that is rooted in a deterministic view that what has
happened in their past will certainly shape their future. Solution-focused practi-
tioners counter this negative client presentation with optimistic conversations that
highlight a belief in achievable and usable goals. Therapists can be instrumental in
assisting clients in making a shift from a fi xed problem state to a world with new
possibilities. One of the goals of SFBT is to shift clients’ perceptions by reframing
what White and Epston (1990) refer to as clients’ problem-saturated stories through
the counselor’s skillful use of language.
lo o k i n g f o r w h at i s w o r k i n g The emphasis of SFBT is to focus on
what is working in clients’ lives, which stands in stark contrast to the traditional
models of therapy that tend to be problem-focused. Individuals bring stories to
therapy. Some stories are used to justify the client’s belief that life can’t be changed
or, worse, that life is moving them further and further away from their goals.
Solution-focused brief therapists assist clients in paying attention to the excep-
tions to their problem patterns. They promote hope by helping clients discover-
ing exceptions, or times when the problem is less intrusive in their life (Metcalf,
2001). SFBT focuses on fi nding out what people are doing that is working and then
helping them apply this knowledge to eliminate problems in the shortest amount
of time possible. Identifying what is working and encouraging clients to replicate
these patterns is extremely important (Murphy, 2008). A key concept is, “Once you
know what works, do more of it.” If something is not working, clients are encour-
aged to do something different, which typically involves drawing on their unique
strengths and successes.
There are various ways to assist clients in thinking about what has worked
for them. De Shazer (1991) prefers to engage clients in conversations that lead to
progressive narratives whereby people create situations in which they can make
steady gains toward their goals. De Shazer might say, “Tell me about times when
you felt a little better and when things were going your way.” It is in these stories
of life worth living that the power of problems is deconstructed and new solutions
are manifest and made possible.
b a s i c a s s u m p t i o n s g u i d i n g p r a c t i c e Walter and Peller (1992,
2000) think of solution-focused therapy as a model that explains how people
change and how they can reach their goals. Here are some of their basic assump-
tions about solution-focused therapy:
• Individuals who come to therapy do have the capability of behaving effectively, even
though this effectiveness may be temporarily blocked by negative cognitions. Prob-
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lem-focused thinking prevents people from recognizing effective ways they have
dealt with problems.
• There are advantages to a positive focus on solutions and on the future. If clients
can reorient themselves in the direction of their strengths using solution-talk,
there is a good chance therapy can be brief.
• There are exceptions to every problem, or times when the problem was absent.
By talking about these exceptions, clients can get clues to effective solutions
and can gain control over what had seemed to be an insurmountable personal
diffi culty. Rapid changes are possible when clients identify exceptions to their
problems and begin to organize their thinking around these exceptions instead
of around the problem.
• Clients often present only one side of themselves. Solution-focused therapists
invite clients to examine another side of the story they are presenting.
• No problem is constant, and change is inevitable. What people need to do is
become aware of any positive changes that are happening. Small changes pave
the way for larger changes. Oftentimes, small changes are all that are needed
to resolve problems that clients bring to therapy. Like tipping the fi rst domino,
one small change leads to another, then another, and so on until the “solution
momentum” outweighs the problem momentum.
• Clients want to change, have the capacity to change, and are doing their best to
make change happen. Therapists should adopt a cooperative stance with clients
rather than devising strategies to control resistive patterns. When therapists
fi nd ways to cooperate with people, resistance does not occur.
• Clients can be trusted in their intention to solve their problems. Therapists as-
sume that clients want to change, can change, and will change under coopera-
tive and empowering therapeutic conditions. There are no “right” solutions to
specifi c problems that can be applied to all people. Each individual is unique
and so, too, is each solution.
Walter and Peller (2000) have moved away from the term therapy and refer to
what they do as personal consultation. They facilitate conversations around the pref-
erences and possibilities of their clients to help them create a positive future. By
avoiding the stance of the expert, Walter and Peller believe they can be interested,
curious, and encouraging in jointly exploring the desires of their clients.
The Therapeutic Process
Bertolino and O’Hanlon (2002) stress the importance of creating collaborative
therapeutic relationships and see doing so as necessary for successful therapy.
Acknowledging that therapists have expertise in creating a context for change, they
stress that clients are the experts on their own lives and often have a good sense
of what has or has not worked in the past and, as well, what might work in the
future. Solution-focused counseling assumes a collaborative approach with clients
in contrast to the educative stance that is typically associated with most traditional
models of therapy. If clients are involved in the therapeutic process from begin-
ning to end, the chances are increased that therapy will be successful. In short, col-
laborative and cooperative relationships tend to be more effective than hierarchical
relationships in therapy.
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Walter and Peller (1992) describe four steps that characterize the process of
SFBT: (1) Find out what clients want rather than searching for what they do not
want. (2) Do not look for pathology, and do not attempt to reduce clients by giv-
ing them a diagnostic label. Instead, look for what clients are doing that is already
working and encourage them to continue in that direction. (3) If what clients are
doing is not working, encourage them to experiment with doing something differ-
ent. (4) Keep therapy brief by approaching each session as if it were the last and
only session. Although these steps seem fairly obvious, the collaborative process of
the client and therapist constructing solutions is not merely a matter of mastering
a few techniques.
De Shazer (1991) believes clients can generally build solutions to their prob-
lems without any assessment of the nature of their problems. Given this frame-
work, the structure of solution building differs greatly from traditional approaches
to problem solving as can be seen in this brief description of the steps involved
(De Jong & Berg, 2008):
1. Clients are given an opportunity to describe their problems. The therapist lis-
tens respectfully and carefully as clients answer the therapist’s question, “How
can I be useful to you?”
2. The therapist works with clients in developing well-formed goals as soon as
possible. The question is posed, “What will be different in your life when your
problems are solved?”
3. The therapist asks clients about those times when their problems were not
present or when the problems were less severe. Clients are assisted in exploring
these exceptions, with special emphasis on what they did to make these events
happen.
4. At the end of each solution-building conversation, the therapist offers clients
summary feedback, provides encouragement, and suggests what clients might
observe or do before the next session to further solve their problem.
5. The therapist and clients evaluate the progress being made in reaching satisfac-
tory solutions by using a rating scale. Clients are asked what needs to be done
before they see their problem as being solved and also what their next step will be.
t h e r a p e u t i c g oa l s SFBT refl ects some basic notions about change, about
interaction, and about reaching goals. The solution-focused therapist believes peo-
ple have the ability to defi ne meaningful personal goals and that they have the
resources required to solve their problems. Goals are unique to each client and are
constructed by the client to create a richer future (Prochaska & Norcross, 2010). A
lack of clarity regarding client preferences, goals, and desired outcomes can result
in a rift between therapist and client. During the early phase of therapy, it is impor-
tant that clients be given the opportunity to express what they want from therapy
and what concerns they are willing to explore. From the fi rst contact with clients,
the therapist strives to create a climate that will facilitate change and encourage
clients to think in terms of a range of possibilities.
Solution-focused therapists concentrate on small, realistic, achievable changes
that can lead to additional positive outcomes. Because success tends to build
upon itself, modest goals are viewed as the beginning of change. Solution-focused
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practitioners join with the language of their clients, using similar words, pacing,
and tone. Therapists use questions such as these that presuppose change, posit
multiple answers, and remain goal-directed and future-oriented: “What did you
do, and what has changed since last time?” or “What did you notice that went bet-
ter?” (Bubenzer & West, 1993).
Walter and Peller (1992) and Murphy (2008) emphasize the importance of
assisting clients in creating well-defi ned goals that are (1) stated positively in the
client’s language; (2) are process- or action-oriented; (3) are structured in the here
and now; (4) are attainable, concrete, specifi c, and measurable; and (5) are control-
led by the client. Counselors should not too rigidly impose an agenda of getting
precise goals before clients have a chance to express their concerns. Clients must
feel that their concerns are heard and understood before they can formulate mean-
ingful personal goals. In a therapist’s zeal to be solution-focused, it is possible to
get lost in the mechanics of therapy and not attend suffi ciently to the interpersonal
aspects.
Solution-oriented therapy offers several forms of goals: changing the viewing
of a situation or a frame of reference, changing the doing of the problematic situa-
tion, and tapping client strengths and resources (O’Hanlon & Weiner-Davis, 2003).
Therapists note the language they use, so they can increase their clients’ hope and
optimism and their openness to possibilities and change. Clients are encouraged
to engage in change- or solution-talk, rather than problem-talk, on the assumption
that what we talk about most will be what we produce. Talking about problems can
produce ongoing problems. Talk about change can produce change.
t h e r a p i s t ’s f u n c t i o n a n d r o l e Clients are much more likely to fully
participate in the therapeutic process if they perceive themselves as determining
the direction and purpose of the conversation (Walter & Peller, 1996). Much of
what the therapeutic process is about involves clients’ thinking about their future
and what they want to be different in their lives. Consistent with the postmodern
and social constructionist perspective, solution-focused brief therapists adopt a not-
knowing position to put clients in the position of being the experts about their own
lives. Therapists do not assume that by virtue of their expert frame of reference
they know the signifi cance of the client’s actions and experiences (Anderson &
Goolishian, 1992). This model casts the role and function of a therapist in quite
a different light from traditionally oriented therapists who view themselves as
experts in assessment and treatment. The therapist-as-expert is replaced by the
client-as-expert, especially when it comes to what the client wants in life and in
therapy. It is important that therapists actually believe that their clients are the
true experts on their own lives. According to Guterman (2006), therapists have
expertise in the process of change, but clients are the experts on what they want
changed. The therapist’s task is to point clients in the direction of change without
dictating what to change.
Therapists strive to create a climate of mutual respect, dialogue, and affi rma-
tion in which clients experience the freedom to create, explore, and coauthor their
evolving stories. A key therapeutic task consists of helping clients imagine how they
would like life to be different and what it would take to make this transformation
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happen. One of the functions of the therapist is to ask questions and, based on the
answers, generate further questions. Examples of some useful questions are “What
do you hope to gain from coming here?” “If you were to make the changes you de-
sire, how would that make a difference in your life?” and “What steps can you take
now that will lead to these changes?”
t h e t h e r a p e u t i c r e l at i o n s h i p The quality of the relationship between
therapist and client is a determining factor in the outcomes of SFBT, so relation-
ship building or engagement is a basic step in SFBT. The attitude of the therapist
is crucial to the effectiveness of the therapeutic process. It is essential to create a
sense of trust so clients will return for further sessions and will follow through on
homework suggestions. The therapeutic process works best when clients become
actively involved, when they experience a positive relationship with the therapist,
and when counseling addresses what clients see as being important (Murphy,
2008). One way of creating an effective therapeutic partnership is for the therapist
to show clients how they can use the strengths and resources they already have to
construct solutions. Clients are encouraged to do something different and to be
creative in thinking about ways to deal with their present and future concerns.
De Shazer (1988) has described three kinds of relationships that may develop
between therapists and their clients:
1. Customer: the client and therapist jointly identify a problem and a solution to
work toward. The client realizes that to attain his or her goals, personal effort
will be required.
2. Complainant: the client describes a problem but is not able or willing to assume
a role in constructing a solution, believing that a solution is dependent on some-
one else’s actions. In this situation, the client generally expects the therapist to
change the other person to whom the client attributes the problem.
3. Visitor: the client comes to therapy because someone else (a spouse, parent,
teacher, or probation offi cer) thinks the client has a problem. This client may
not agree that he or she has a problem and may be unable to identify anything
to explore in therapy.
De Jong and Berg (2008) recommend using caution so that therapists do not box
clients into static identities. These three roles are only starting points for conversa-
tion. Rather than categorizing clients, therapists can refl ect on the kinds of rela-
tionships that are developing between their clients and themselves. For example,
clients who tend to place the cause of their problems on another person or persons
in their lives (complainants) may be helped by skilled intervention to begin to see
their own role in their problems and the necessity for taking active steps in creat-
ing solutions. A visitor client may be willing to work with the therapist to create a
customer relationship by exploring what the client needs to do to satisfy the other
person or “get them off their back.” Initially, some clients will feel powerless and
overwhelmed by their problems. Even clients who are unable to articulate a prob-
lem may change as the result of developing an effective therapeutic alliance. How
the therapist responds to different behaviors of clients has a lot to do with bringing
about a shift in the relationship. In short, both complainants and visitors have the
capacity for becoming customers.
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Application: Therapeutic Techniques and Procedures
Some of the key techniques that solution-focused practitioners are likely to employ
include looking for differences in doing, exception questions, scaling questions,
and the miracle question. If these techniques are used in a routine way without
developing a collaborative working alliance, they will not lead to effective results.
Murphy (2008) reminds us that these solution-focused techniques should be used
fl exibly and tailored to the unique circumstances of each client. Therapy is best
guided by the client’s goals, perceptions, resources, and feedback. Therapy should
not be determined by any absolutes or rigid standards outside the therapeutic rela-
tionship (namely, evidence-based treatments).
p r e t h e r a p y c h a n g e Simply scheduling an appointment often sets positive
change in motion. During the initial therapy session, it is common for solution-
focused therapists to ask, “What have you done since you called for the appointment
that has made a difference in your problem?” (de Shazer, 1985, 1988). By asking
about such changes, the therapist can elicit, evoke, and amplify what clients have
already done by way of making positive change. These changes cannot be attrib-
uted to the therapy process itself, so asking about them tends to encourage clients
to rely less on their therapist and more on their own resources to accomplish their
treatment goals (McKeel, 1996; Weiner-Davis, de Shazer, & Gingerich, 1987).
e xc e p t i o n q u e s t i o n s SFBT is based on the notion that there were times in
clients’ lives when the problems they identify were not problematic. These times are
called exceptions and represent news of difference (Bateson, 1972). Solution-focused
therapists ask exception questions to direct clients to times when the problem did
not exist, or when the problem was not as intense. Exceptions are those past experi-
ences in a client’s life when it would be reasonable to have expected the problem
to occur, but somehow it did not (de Shazer, 1985; Murphy, 2008). By helping
clients identify and examine these exceptions, the chances are increased that they
will work toward solutions (Guterman, 2006). Once identifi ed by an individual,
these instances of success can be useful in making further changes. Change-focused
questions explore what clients believe to be important goals and how they can tap
their strengths and resources to reach their goals (Murphy, 2008). This exploration
reminds clients that problems are not all-powerful and have not existed forever; it
also provides a fi eld of opportunity for evoking resources, engaging strengths, and
positing possible solutions. The therapist asks clients what has to happen for these
exceptions to occur more often.
t h e m i r a c l e q u e s t i o n Therapy goals are developed by using what de
Shazer (1988) calls the miracle question, which is a main SFBT technique. The
therapist asks, “If a miracle happened and the problem you have was solved over-
night, how would you know it was solved, and what would be different?” Clients
are then encouraged to enact “what would be different” in spite of perceived prob-
lems. If a client asserts that she wants to feel more confi dent and secure, the thera-
pist might say: “Let yourself imagine that you leave the offi ce today and that you
are on track to acting more confi dently and securely. What will you be doing differ-
ently?” This process of considering hypothetical solutions refl ects O’Hanlon and
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Weiner-Davis’s (2003) belief that changing the doing and viewing of the perceived
problem changes the problem.
De Jong and Berg (2008) identify several reasons the miracle question is a
useful technique. Asking clients to consider that a miracle takes place opens up a
range of future possibilities. Clients are encouraged to allow themselves to dream
as a way of identifying the kinds of changes they most want to see. This question
has a future focus in that clients can begin to consider a different kind of life that
is not dominated by a particular problem. This intervention shifts the emphasis
from both past and current problems toward a more satisfying life in the future.
s c a l i n g q u e s t i o n s Solution-focused therapists also use scaling questions
when change in human experiences are not easily observed, such as feelings,
moods, or communication, and to assist clients in noticing that they are not com-
pletely defeated by their problem (de Shazer & Berg, 1988). For example, a woman
reporting feelings of panic or anxiety might be asked: “On a scale of zero to 10,
with zero being how you felt when you fi rst came to therapy and 10 being how you
feel the day after your miracle occurs and your problem is gone, how would you
rate your anxiety right now?” Even if the client has only moved away from zero to
1, she has improved. How did she do that? What does she need to do to move an-
other number up the scale? Scaling questions enable clients to pay closer attention
to what they are doing and how they can take steps that will lead to the changes
they desire.
f o r m u l a f i r s t s e s s i o n ta s k The formula fi rst session task (FFST) is
a form of homework a therapist might give clients to complete between their fi rst
and second sessions. The therapist might say: “Between now and the next time we
meet, I would like you to observe, so that you can describe to me next time, what
happens in your (family, life, marriage, relationship) that you want to continue
to have happen” (de Shazer, 1985, p. 137). At the second session, clients can be
asked what they observed and what they would like to have happen in the future.
This kind of assignment offers clients hope that change is inevitable. It is not a
matter of if change will occur, but when it will happen. According to de Shazer,
this intervention tends to increase clients’ optimism and hope about their present
and future situation. The FFST technique emphasizes future solutions rather than
past problems (Murphy, 2008). Bertolino and O’Hanlon (2002) suggest that the
FFST intervention be used after clients have had a chance to express their present
concerns, views, and stories. It is important that clients feel understood before they
are directed to make changes.
t h e r a p i s t f e e d b a c k t o c l i e n t s Solution-focused practitioners gen-
erally take a break of 5 to 10 minutes toward the end of each session to compose
a summary message for clients. During this break therapists formulate feed-
back that will be given to clients after the break. De Jong and Berg (2008) de-
scribe three basic parts to the structure of the summary feedback: compliments,
a bridge, and suggesting a task. Compliments are genuine affi rmations of what
clients are already doing that is leading toward effective solutions. It is impor-
tant that complimenting is not done in a routine or mechanical way, but in an
encouraging manner that creates hope and conveys the expectation to clients
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that they can achieve their goals by drawing on their strengths and successes.
Second, a bridge links the initial compliments to the suggested tasks that will be
given. The bridge provides the rationale for the suggestions. The third aspect
of feedback consists of suggesting tasks to clients, which can be considered as
homework. Observational tasks ask clients to simply pay attention to some
aspect of their lives. This self-monitoring process helps clients note the differ-
ences when things are better, especially what was different about the way they
thought, felt, or behaved. Behavioral tasks require that clients actually do some-
thing the therapist believes would be useful to them in constructing solutions.
De Jong and Berg (2008) stress that a therapist’s feedback to clients addresses
what they need to do more of and do differently in order to increase the chances of
obtaining their goals.
t e r m i n at i n g From the very fi rst solution-focused interview, the therapist
is mindful of working toward termination. Once clients are able to construct a
satisfactory solution, the therapeutic relationship can be terminated. The initial
goal-formation question that a therapist often asks is, “What needs to be different
in your life as a result of coming here for you to say that meeting with me was
worthwhile?” Another question to get clients thinking is, “When the problem is
solved, what will you be doing differently?” Through the use of scaling questions,
therapists can assist clients in monitoring their progress so clients can determine
when they no longer need to come to therapy (De Jong & Berg, 2008). Prior to end-
ing therapy, therapists assist clients in identifying things they can do to continue
the changes they have already made into the future. Clients can also be helped to
identify hurdles or perceived barriers that could get in the way of maintaining the
changes they have made.
Guterman (2006) maintains that the ultimate goal of solution-focused coun-
seling is to end treatment. He adds, “If counselors are not proactive in making
their treatment brief by design, then in many cases counseling will be brief by
default” (p. 67). Because this model of therapy is brief, present-centered, and
addresses specifi c complaints, it is very possible that clients will experience other
developmental concerns at a later time. Clients can ask for additional sessions
whenever they feel a need to get their life back on track or to update their story.
Dr. John Murphy puts many SFBT techniques into action as he illustrates assess-
ment and treatment from a solution-focused brief therapy approach in the case
of Ruth in Case Approach to Counseling and Psychotherapy (Corey, 2013, chap. 11).
a p p l i c at i o n t o g r o u p c o u n s e l i n g The solution-focused group prac-
titioner believes that people are competent, and that given a climate where they
can experience their competency, they are able to solve their own problems, ena-
bling them to live a richer life. From the beginning, the group facilitator sets a
tone of focusing on solutions (Metcalf, 1998) in which group members are given
an opportunity to describe their problems briefl y. A facilitator might begin a new
group by requesting, “I would like each of you to introduce yourself. As you do,
give us a brief idea as to why you are here and tell us what you would like for us
to know about you.” Facilitators help members to keep the problem external in
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conversations, which tends to be a relief because it gives members an opportunity
to see themselves as less problem-saturated. It is the facilitator’s role to create
opportunities for the members to view themselves as being resourceful. Because
SFBT is designed to be brief, the leader has the task of keeping group members
on a solution track rather than a problem track, which helps members to move in
a positive direction.
The group leader works with members in developing well-formed goals as
soon as possible. Leaders concentrate on small, realistic, achievable changes that
may lead to additional positive outcomes. Because success tends to build upon
itself, modest goals are viewed as the beginning of change. Questions used to as-
sist members in formulating clear goals might include “What will be different in
your life when each of your problems is solved?” and “What will be going on in
the future that will tell you and the rest of us in the group that things are better for
you?” Sometimes members talk about what others will be doing or not doing and
forget to pay attention to their own goals or behavior. At times such as this they
can be asked, “And what about yourself? What will you be doing differently in that
picture? As a result of your doing things differently, how would you imagine others
responding to you?”
The facilitator asks members about times when their problems were not present
or when the problems were less severe. The members are assisted in exploring
these exceptions, and special emphasis is placed on what they did to make these
events happen. The participants engage in identifying exceptions with each other.
This improves the group process and promotes a solution focus, which can become
quite powerful. Exceptions are real events that take place outside of the problem
context. In individual counseling, only the therapist and the client are observers of
competency. An advantage of group counseling is that the audience widens and
more input is possible (Metcalf, 1998).
The art of questioning is a main intervention used in solution-focused groups.
Questions are asked from a position of respect, genuine curiosity, sincere inter-
est, and openness. Group leaders use questions such as these that presuppose
change and remain goal-directed and future-oriented: “What did you do and what
has changed since last time?” or “What did you notice that went better?” Other
group members are encouraged to respond along with the group leader to promote
group interaction. Facilitators may pose questions like these: “Someday, when the
problems that brought you to this group are less problematic to you, what will you
be doing?” “As each of you listened to others today, is there someone in our group
who could be a source of encouragement for you to do something different?” The
leader is attempting to help the members identify exceptions and begin to recog-
nize personal resiliency and competency. Creating a group context in which the
members are able to learn more about their personal abilities is key to members
learning to resolve their own concerns.
Solution-focused group counseling offers a great deal of promise for practition-
ers who want a practical and time-effective approach to interventions in school set-
tings. As a cooperative approach, SFBT shifts the focus from what’s wrong in stu-
dents’ lives to what’s working for them (Murphy, 2008; Sklare, 2005). Rather than
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being a cookbook of techniques for removing students’ problems, this approach of-
fers school counselors a collaborative framework aimed at achieving small, concrete
changes that enable students to discover a more productive direction. This model has
much to offer to school counselors who are responsible for serving large caseloads
of students in a K–12 school system. For a more detailed treatment of how SFBT
can be applied to group work in the schools, see Sklare (2005) and Murphy (2008).
They give special attention to the process of goal setting and provides many concrete
examples of how counselors can assist students in identifying well-established goals.
For a more detailed discussion of SFBT in groups, see Corey (2012, chap. 16).
n a r r at i v e t h e r a p y
Introduction
Of all the social constructionists, Michael White and David Epston (1990) are best
known for their use of narrative in therapy. According to White (1992), individu-
als construct the meaning of life in interpretive stories, which are then treated
as “truth.” Because of the power of dominant culture narratives, individuals tend
to internalize the messages from these dominant discourses, which often work
against the life opportunity of the individual.
Adopting a postmodern, narrative, social constructionist view sheds light on
how power, knowledge, and “truth” are negotiated in families and other social and
cultural contexts (Freedman & Combs, 1996). Therapy is, in part, a reestablish-
ment of personal agency from the oppression of external problems and the domi-
nant stories of larger systems.
Key Concepts
The key concepts and therapeutic process sections are adapted from several differ-
ent works, but primarily from these sources: Winslade and Monk (2007), Monk
(1997), Winslade, Crocket, and Monk (1997), McKenzie and Monk (1997), and
Freedman and Combs (1996).
f o c u s o f n a r r at i v e t h e r a p y The narrative approach involves adopt-
ing a shift in focus from most traditional theories. Therapists are encouraged to
establish a collaborative approach with a special interest in listening respectfully
to clients’ stories; to search for times in clients’ lives when they were resourceful;
to use questions as a way to engage clients and facilitate their exploration; to avoid
diagnosing and labeling clients or accepting a totalizing description based on a
problem; to assist clients in mapping the infl uence a problem has had on their
lives; and to assist clients in separating themselves from the dominant stories they
have internalized so that space can be opened for the creation of alternative life
stories (Freedman & Combs, 1996).
t h e r o l e o f s t o r i e s We live our lives by stories we tell about ourselves
and that others tell about us. These stories actually shape reality in that they con-
struct and constitute what we see, feel, and do. The stories we live by grow out of
conversations in a social and cultural context. Therapy clients do not assume the
role of pathologized victims who are leading hopeless and pathetic lives; rather,
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they emerge as courageous victors who have vivid stories to recount. The stories
not only change the person telling the story, but also change the therapist who is
privileged to be a part of this unfolding process (Monk, 1997).
l i s t e n i n g w i t h a n o p e n m i n d All social constructionist theories em-
phasize listening to clients without judgment or blame, affi rming and valuing
them. Narrative practice goes further in deconstructing the systems of normal-
izing judgment that are found in medical, psychological, and educational dis-
course. Normalizing judgment is any kind of judgment that locates a person on a
normal curve and is used to assess intelligence, mental health, or normal behavior.
Because these kinds of judgments claim to be objective measures, they are diffi cult
for individuals to resist and usually are internalized. Narrative therapists argue that
suspending personal judgment is of little value if you participate in normalizing
judgment. Deconstruction involves turning the tables and inquiring what clients
think of the judgments they have been assigned. Narrative practitioners might be
said to invite people to pass judgment on the judgments that have been working
them over.
Lindsley (1994) emphasizes that therapists can encourage their clients to
reconsider absolutist judgments by moving toward seeing both “good” and “bad”
elements in situations. Narrative therapists make efforts to enable clients to modify
painful beliefs, values, and interpretations without imposing their value systems
and interpretations. They want to create meaning and new possibilities from the
stories clients share rather than out of a preconceived and ultimately imposed
theory of importance and value.
Although narrative therapists bring to the therapy venture certain attitudes
such as optimism, respectful curiosity and persistence, and a valuing for the cli-
ent’s knowledge, they seek to listen to the problem-saturated story of the client
without getting stuck. As narrative therapists listen to the client’s story, they stay
alert for details that give evidence of the client’s competence in taking stands
against oppressive problems. Winslade and Monk (2007) maintain that the thera-
pist believes that clients have abilities, talents, positive intentions, and life experi-
ences that can be the catalysts for new possibilities for action. The counselor needs
to demonstrate faith that these strengths and competencies can be identifi ed, even
when the client is having diffi culty seeing them.
During the narrative conversation, attention is given to avoiding totalizing lan-
guage, which reduces the complexity of the individual by assigning an all-embracing,
single description to the essence of the person. Therapists begin to separate the
person from the problem in their mind as they listen and respond (Winslade &
Monk, 2007).
The narrative perspective focuses on the capacity of humans for creative and
imaginative thought, which is often found in their resistance to dominant dis-
course. Narrative practitioners do not assume that they know more about the lives
of clients than their clients do. Clients are the primary interpreters of their own
experiences. People are viewed as active agents who are able to derive meaning
from their experiential world, and they are encouraged to join with others who
might share in the development of a counter story.
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The Therapeutic Process
This brief overview of the steps in the narrative therapeutic process illustrates the
structure of the narrative approach (O’Hanlon, 1994, pp. 25–26):
• Collaborate with the client to come up with a mutually acceptable name for the
problem.
• Personify the problem and attribute oppressive intentions and tactics to it.
• Investigate how the problem has been disrupting, dominating, or discouraging
to the client.
• Invite the client to see his or her story from a different perspective by offering
alternative meanings for events.
• Discover moments when the client wasn’t dominated or discouraged by the
problem by searching for exceptions to the problem.
• Find historical evidence to bolster a new view of the client as competent enough
to have stood up to, defeated, or escaped from the dominance or oppression
of the problem. (At this phase the person’s identity and life story begin to be
rewritten.)
• Ask the client to speculate about what kind of future could be expected from
the strong, competent person who is emerging. As the client becomes free of
problem-saturated stories of the past, he or she can envision and plan for a less
problematic future.
• Find or create an audience for perceiving and supporting the new story. It is
not enough to recite a new story. The client needs to live the new story outside
of therapy. Because the person’s problem initially developed in a social context,
it is essential to involve the social environment in supporting the new life story
that has emerged in the conversations with the therapist.
Winslade and Monk (2007) stress that narrative conversations do not follow the
linear progression described here; it is better to think of these steps in terms of
cyclical progression containing the following elements:
• Move problem stories toward externalized descriptions of problems
• Map the effects of a problem on the individual
• Listen to signs of strength and competence in an individual’s problem-saturated
stories
• Build a new story of competence and document these achievements
t h e r a p y g oa l s A general goal of narrative therapy is to invite people to
describe their experience in new and fresh language. In doing this, they open up
new vistas of what is possible. This new language enables clients to develop new
meanings for problematic thoughts, feelings, and behaviors (Freedman & Combs,
1996). Narrative therapy almost always includes an awareness of the impact of
various aspects of dominant culture on human life. Narrative practitioners seek
to enlarge the perspective and focus and facilitate the discovery or creation of new
options that are unique to the people they see.
t h e r a p i s t ’s f u n c t i o n a n d r o l e Narrative therapists are active fa-
cilitators. The concepts of care, interest, respectful curiosity, openness, empathy,
contact, and even fascination are seen as a relational necessity. The not-knowing
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position, which allows therapists to follow, affi rm, and be guided by the stories of
their clients, creates participant-observer and process-facilitator roles for the thera-
pist and integrates therapy with a postmodern view of human inquiry.
A main task of the therapist is to help clients construct a preferred story line.
The narrative therapist adopts a stance characterized by respectful curiosity and
works with clients to explore both the impact of the problem on them and what
they are doing to reduce the effects of the problem (Winslade & Monk, 2007). One
of the main functions of the therapist is to ask questions of clients and, based on
the answers, to generate further questions.
White and Epston (1990) start with an exploration of the client in relation to
the presenting problem. It is not uncommon for clients to present initial stories in
which they and the problem are fused, as if one and the same. White uses questions
aimed at separating the problem from the people affected by the problem. This
shift in language begins the deconstruction of the original narrative in which the
person and the problem were fused; now the problem is objectifi ed as external to
the client.
Like the solution-focused therapist, the narrative therapist assumes the client
is the expert when it comes to what he or she wants in life. The narrative therapist
tends to avoid using language that embodies diagnosis, assessment, treatment,
and intervention. Functions such as diagnosis and assessment often grant prior-
ity to the practitioner’s “truth” over clients’ knowledge about their own lives. The
narrative approach gives emphasis to understanding clients’ lived experiences and
de-emphasizes efforts to predict, interpret, and pathologize. Narrative practition-
ers are careful not to ascribe the major role of taking initiative in another per-
son’s life or usurping the agency (power) of the client in bringing about change
(Winslade et al., 1997).
When it comes to the effective practice of narrative therapy, there are no set for-
mulas or recipes to follow (Freedman & Combs, 1996; Monk, Winslade, Crocket, &
Epston, 1997; Winslade & Monk, 2007). Monk (1997) emphasizes that narrative
therapy will vary with each client because each person is unique. For Monk, narra-
tive conversations are based on a way of being, and if narrative counseling “is seen
as a formula or used as a recipe, clients will have the experience of having things
done to them and feel left out of the conversation” (p. 24).
t h e t h e r a p e u t i c r e l at i o n s h i p Narrative therapists place great im-
portance on the values and ethical commitments a therapist brings to the therapy
venture. Some of these attitudes include optimism and respect, curiosity and per-
sistence, valuing the client’s knowledge, and creating a special kind of relation-
ship characterized by a real power-sharing dialogue (Winslade & Monk, 2007).
Collaboration, compassion, refl ection, and discovery characterize the therapeutic
relationship. If this relationship is to be truly collaborative, the therapist needs to
be aware of how power manifests itself in his or her professional practice. This
does not mean that the therapist does not have authority as a professional. He or
she uses this authority, however, by treating clients as experts in their own lives.
Furthermore, the therapist is interested in facilitating the articulation of the values
and ethical commitments of the client.
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Winslade, Crocket, and Monk (1997) describe this collaboration as coauthor-
ing or sharing authority. Clients function as authors when they have the authority
to speak on their own behalf. In the narrative approach, the therapist-as-expert
is replaced by the client-as-expert. This notion challenges the stance of the thera-
pist as being an all-wise and all-knowing expert. Winslade and Monk (2007) state:
“The integrity of the counseling relationship is thus maintained while the client
is honored as the senior author in the construction of an alternative narrative
(pp. 57–58).
Clients are often stuck in a pattern of living a problem-saturated story that
does not work. When a client has a limited perception of his or her capacities
due to being saturated in problem thinking, it is the job of the therapist to elic-
it other strength-related stories to modify the client’s perception. The therapist
assists the client in this pursuit by entering into a dialogue and asking questions in
an effort to elicit the perspectives, resources, and unique experiences of the client.
The past is history, but it sometimes provides a foundation for understanding and
discovering news of differences or unique outcomes that will make a difference.
The history of the problem often dominates understanding, but there is another
history that narrative therapists argue should not be neglected. It is the history of
the counter story to the problem story, which is constructed in conversation and
becomes the foundation for a different future. The narrative therapist supplies the
optimism and sometimes a process, but the client generates what is possible and
contributes the movement that actualizes it.
Application: Therapeutic Techniques and Procedures
The effective application of narrative therapy is more dependent on therapists’
attitudes or perspectives than on techniques. In the practice of narrative therapy,
there is no recipe, no set agenda, and no formula that the therapist can follow to
assure positive results (Drewery & Winslade, 1997). When externalizing questions
are approached mainly as a technique, the intervention will be shallow, forced, and
unlikely to produce signifi cant therapeutic effects (Freedman & Combs, 1996;
O’Hanlon, 1994).
Narrative therapists are in agreement with Carl Rogers on the notion of the
therapist’s way of being as opposed to being technique driven. A narrative approach
to counseling is more than the application of skills; it is based on the therapist’s
personal characteristics that create a climate that encourages clients to see their
stories from different perspectives. However, a series of “maps” of narrative con-
versational trajectories can help give structure and direction to a therapeutic conver-
sation (White, 2007). The approach is also an expression of an ethical stance, which
is grounded in a postmodern framework. It is from this conceptual framework that
practices are applied to assist clients in fi nding new meanings and new possibilities
in their lives (Winslade & Monk, 2007).
q u e s t i o n s . . . a n d m o r e q u e s t i o n s The questions narrative thera-
pists ask may seem embedded in a unique conversation, part of a dialogue about
earlier dialogues, a discovery of unique events, or an exploration of dominant cul-
ture processes and imperatives. Whatever the purpose, the questions are often
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circular, or relational, and they seek to empower clients in new ways. To use
Gregory Bateson’s (1972) famous phrase, they are questions in search of a differ-
ence that will make a difference.
Narrative therapists use questions as a way to generate experience rather than
to gather information. The aim of questioning is to progressively discover or con-
struct the client’s experience so that the client has a sense of a preferred direction.
Questions are always asked from a position of respect, curiosity, and openness.
Therapists ask questions from a not-knowing position, meaning that they do not
pose questions that they think they already know the answers to. Monk (1997)
describes this stance as follows:
In contrast to the normative, knowing stance, a narrative way of working invites the coun-
selor to take up the investigative, exploratory, archaeological position. She demonstrates to
the client that being a counselor does not imply any privileged access to the truth. The coun-
selor is consistently in the role of seeking understanding of the client’s experience. (p. 25)
Through the process of asking questions, therapists provide clients with an op-
portunity to explore various dimensions of their life situations. This questioning
process helps bring out the unstated cultural assumptions that contribute to the
original construction of the problem. The therapist is interested in fi nding out how
the problems fi rst became evident, and how they have affected clients’ views of
themselves (Monk, 1997). Narrative therapists attempt to engage people in decon-
structing problem-saturated stories, identifying preferred directions, and creating
alternative stories that support these preferred directions (Freedman & Combs,
1996). For a more complete discussion of the use of questions in narrative thera-
py, see Madigan (2011).
e x t e r n a l i z at i o n a n d d e c o n s t r u c t i o n Narrative therapists believe
it is not the person that is the problem, but the problem that is the problem (White,
1989). These problems often are products of the cultural world or of the power
relations in which this world is located. Living life means relating to problems, not
being fused with them.. Narrative therapists help clients deconstruct these prob-
lematic stories by disassembling the taken-for-granted assumptions that are made
about an event, which then opens alternative possibilities for living (Winslade &
Monk, 2007).
Externalization is one process for deconstructing the power of a narrative. This
process separates the person from identifi cation with the problem. When clients
view themselves as “being” the problem, they are limited in the ways they can effec-
tively deal with the problem. When clients experience the problem as being located
outside of themselves, they create a relationship with the problem. For example,
there is quite a difference between labeling someone an alcoholic and indicating
that alcohol has invaded his or her life. Separating the problem from the individual
facilitates hope and enables clients to take a stand against specifi c story lines, such
as self-blame. By understanding the cultural invitations to blame oneself, clients
can deconstruct this story line and generate a more positive, healing story.
The method used to separate the person from the problem is referred to
as externalizing conversation, which opens up space for new stories to emerge.
This method is particularly useful when people have internalized diagnoses and
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labels that have not been validating or empowering of the change process
(Bertolino & O’Hanlon, 2002). Externalizing conversations counteract oppressive,
problem-saturated stories and empower clients to feel competent to handle the
problems they face. Two stages of structuring externalizing conversations are (1) to
map the infl uence of the problem in the person’s life, and (2) to map the infl uence
of the person’s life back on the problem (McKenzie & Monk, 1997).
Mapping the infl uence of the problem on the person generates a great deal of
useful information and often results in people feeling less shamed and blamed.
People feel listened to and understood when the problem’s infl uences are explored
in a systematic fashion. A common question is, “When did this problem fi rst
appear in your life?” When this mapping is done carefully, it lays the foundation
for coauthoring a new story line for the client. Often clients feel outraged when
they see for the fi rst time how much the problem is affecting them. The job of the
therapist is to assist clients in tracing the problem from when it originated to the
present. Therapists may put a future twist on the problem by asking, “If the prob-
lem were to continue for a month (or any time period), what would this mean
for you?” This question can motivate the client to join with the therapist in com-
bating the impact of the problem’s effects. Other useful questions are “To what
extent has this problem infl uenced your life?” and “How deeply has this problem
affected you?”
It is important to identify instances when the problem did not completely dom-
inate a client’s life. This kind of mapping can help the client who is disillusioned
by the problem see some hope for a different kind of life. Therapists look for these
“sparkling moments” as they engage in externalizing conversations with clients
(White & Epston, 1990).
The case of Brandon illustrates an externalizing conversation. Brandon says
that he gets angry far too much, especially when he feels that his wife is criticizing
him unjustly: “I just fl are! I pop off, get upset, fi ght back. Later, I wish I hadn’t, but
it’s too late. I’ve messed up again.” Questions about how his anger occurs, com-
plete with specifi c examples and events, can help chart the infl uence of the prob-
lem. However, it is questions like the ones that follow that externalize the problem:
“What is the mission of the anger, and how does it recruit you into this mission?”
“How does the anger get you, and how does it trick you into letting it become so
powerful?” “What does the anger require of you, and what happens to you when
you meet its requirements?” “What cultural supports (in your family/community/
world) have shaped the role that anger plays for you?”
s e a r c h f o r u n i q u e o u t c o m e s In the narrative approach, external-
izing questions are followed by questions searching for unique outcomes. The
therapist talks to the client about moments of choice or success regarding the
problem. This is done by selecting for attention any experience that stands apart
from the problem story, regardless of how insignifi cant it might seem to the cli-
ent. The therapist may ask: “Was there ever a time in which anger wanted to take
you over, and you resisted? What was that like for you? How did you do it?” These
questions are aimed at highlighting moments when the problem has not oc-
curred or when the problem has been dealt with successfully. Unique outcomes
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can often be found in the past or the present, but they can also be hypothesized
for the future: “What form would standing up against your anger take?” Explor-
ing questions such as these enables clients to see that change is possible. Linking
a series of such unique outcomes together starts to form a counter story. It is
within the account of unique outcomes that a gateway is provided for alternative
versions of a person’s life (White, 1992).
Following the description of a unique outcome, White (1992) suggests posing
questions, both direct and indirect, that lead to the elaboration of preferred identity
stories:
• What do you think this tells me about what you have wanted for your life and
about what you have been trying for in your life?
• How do you think knowing this has affected my view of you as a person?
• Of all those people who have known you, who would be least surprised that
you have been able to take this step in addressing your problem’s infl uence in
your life?
• What actions might you commit yourself to if you were to more fully embrace
this knowledge of who you are? (p. 133)
The development of unique outcome stories into solution stories is facilitated by
what Epston and White (1992) call “circulation questions”:
• Now that you have reached this point in life, who else should know about it?
• I guess there are a number of people who have an outdated view of who you are
as a person. What ideas do you have about updating these views?
• If other people seek therapy for the same reasons you did, can I share with them
any of the important discoveries you have made? (p. 23)
These questions are not asked in a barrage-like manner. Questioning is an integral
part of the context of the narrative conversation, and each question is sensitively
attuned to the responses brought out by the previous question (White, 1992).
McKenzie and Monk (1997) suggest that therapists seek permission from the
client before asking a series of questions. By letting a client know that they do not
have answers to the questions they raise, therapists are putting the client in control
of the therapeutic process. Asking permission of the client to use persistent ques-
tioning tends to minimize the risk of inadvertently pressuring the client.
a lt e r n at i v e s t o r i e s a n d r e a u t h o r i n g Constructing new stories
goes hand in hand with deconstruction, and the narrative therapist listens for open-
ings to new stories. People can continually and actively reauthor their lives, and
narrative therapists invite clients to author alternative stories through “unique out-
comes,” defi ned as events that could not be predicted from listening to the domi-
nant problem-saturated story. The narrative therapist asks for openings: “Have you
ever been able to escape the infl uence of the problem?” The therapist listens for
clues to competence in the midst of a problematic story and builds a story of compe-
tence around it. Madigan (2011) suggests that a person’s life story is probably much
more interesting than the story being told. He maintains a therapist’s main task
is “to help people to remember, reclaim and reinvent a richer, thicker, and more
meaningful alternative story” (p. 159).
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A turning point in the narrative interview comes when clients make the choice
of whether to continue to live by a problem-saturated story or create an alternative
story (Winslade & Monk, 2007). Through the use of unique possibility questions,
the therapist moves the focus into the future. For example: “Given what you have
learned about yourself, what is the next step you might take?” “When you are act-
ing from your preferred identity, what actions will it lead you to do more of?” Such
questions encourage people to refl ect upon what they have presently achieved and
what their next steps might be.
The therapist works with clients collaboratively by helping them construct
more coherent and comprehensive stories (Neimeyer, 1993). Whether involved
in a free-fl owing conversation or engaged in a series of questions in a relatively
consistent process, narrative therapists seek to elicit new possibilities and em-
bed them in the life narratives and processes of the people they serve. White and
Epston’s (1990) inquiry into unique outcomes is similar to the exception ques-
tions of solution-focused therapists. Both seek to build on the competence already
present in the person. The development of alternative stories, or narratives, is an
enactment of ultimate hope: Today is the fi rst day of the rest of your life. Refer to
Case Approach to Counseling and Psychotherapy (Corey, 2013, chap. 11) for two con-
crete examples of a narrative approach to working with Ruth from the perspectives
of Dr. Gerald Monk and Dr. John Winslade.
d o c u m e n t i n g t h e e v i d e n c e Narrative practitioners believe that new
stories take hold only when there is an audience to appreciate and support them.
Gaining an audience for the news that change is taking place needs to occur if
alternative stories are to stay alive (Andrews & Clark, 1996), and an appreciative
audience to new developments is consciously sought.
One technique for consolidating the gains a client makes is by writing let-
ters. Narrative therapists have pioneered the development of therapeutic letter
writing. These letters that the therapist writes provide a record of the session
and may include an externalizing description of the problem and its infl uence
on the client, as well as an account of the client’s strengths and abilities that are
identifi ed in a session. Letters can be read again at different times, and the story
that they are part of can be reinspired. The letter highlights the struggle the
client has had with the problem and draws distinctions between the problem-
saturated story and the developing new and preferred story (McKenzie & Monk,
1997).
Epston has developed a special facility for carrying on therapeutic dialogues
between sessions through the use of letters (White & Epston, 1990). His letters
may be long, chronicling the process of the interview and the agreements reached,
or short, highlighting a meaning or understanding reached in the session and
asking a question that has occurred to him since the end of the previous therapy
visit. These letters are used to encourage clients, noting their accomplishments in
relation to handling problems or speculating on the meaning of their accomplish-
ments for others in their community. Letters documenting the changes clients
have achieved tend to strengthen the signifi cance of the changes, both for the cli-
ent and for others in the client’s life (Winslade & Monk, 2007).
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David Nylund, a clinical social worker, uses narrative letters as a basic part of
his practice. Nylund describes a conceptual framework he has found useful in
structuring letters to his clients (Nylund & Thomas, 1994):
• The introductory paragraph reconnects the client to the previous therapy session.
• Statements summarize the infl uence the problem has had and is having on the
client.
• Questions the therapist thought about after the session that pertain to the alter-
native story that is developing may be posed to the client.
• The letter documents unique outcomes or exceptions to the problematic story
that emerged during the session. Where possible, the client’s words are quoted
verbatim. Using the client’s words enhances the therapeutic relationship,
resulting in the client feeling empowered and understood. This connection
leads to a more comfortable opportunity for the client to rethink descriptions
and stories and to create new images, leading to change.
Nylund and Thomas (1994) contend that narrative letters reinforce the importance
of carrying what is being learned in the therapy offi ce into everyday life. The mes-
sage conveyed is that participating fully in the world is more important than being
in the therapy offi ce. In an informal survey of the perceptions of the value of narra-
tive letters by past clients, the average worth of a letter was equal to more than three
individual sessions. This fi nding is consistent with McKenzie and Monk’s (1997)
statement: “Some narrative counselors have suggested that a well-composed letter
following a therapy session or preceding another can be equal to about fi ve regular
sessions” (p. 113).
a p p l i c at i o n t o g r o u p c o u n s e l i n g Many of the techniques described
in this chapter can be applied to group counseling. Winslade and Monk (2007)
claim that the narrative emphasis on creating an appreciative audience for new
developments in an individual’s life lends itself to group counseling. They state:
“Groups provide a ready-made community of concern and many opportunities for
the kind of interaction that opens possibilities for new ways of living. New identi-
ties can be rehearsed and tried out into a wider world” (p. 135). They give several
examples of working in a narrative way with groups in schools: getting back on
track in schoolwork; an adventure-based program; an anger management group;
and a grief counseling group. For a detailed description of these narrative groups,
see Winslade and Monk (2007, chap. 5).
p o s t m o d e r n a p p r oa c h e s f r o m
a m u lt i c u lt u r a l p e r s p e c t i v e
Strengths From a Diversity Perspective
Social constructionism is congruent with the philosophy of multiculturalism.
One of the problems that culturally diverse clients often experience is the expecta-
tion that they should conform their lives to the truths and reality of the dominant
society of which they are a part. With the emphasis on multiple realities and the
assumption that what is perceived to be a truth is the product of social construc-
tion, the postmodern approaches are a good fi t with diverse worldviews.
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The social constructionist approach to therapy provides clients with a frame-
work to think about their thinking and to determine the impact stories have on
what they do. Clients are encouraged to explore how their realities are being con-
structed out of cultural discourse and the consequences that follow from such con-
structions. Within the framework of their cultural values and worldview, clients
can explore their beliefs and provide their own reinterpretations of signifi cant life
events. The practitioner with a social constructionist perspective can guide clients
in a manner that respects their underlying values. This dimension is especially im-
portant in those cases where counselors are from a different cultural background
or do not share the same worldview as their clients.
Narrative therapy is grounded in a sociocultural context, which makes this
approach especially relevant for counseling culturally diverse clients. Narrative ther-
apists operate on the premise that problems are identifi ed within social, cultural,
political, and relational contexts rather than existing within individuals. They are
very much concerned with considering the specifi cations of gender, ethnicity, race,
disability, sexual orientation, social class, and spirituality and religion as therapeutic
issues. Furthermore, therapy becomes a place to reauthor the social constructions
and identity narratives that clients are fi nding problematic.
Narrative therapy is a relational and anti-individualistic practice. Michael White
believes that to address a person’s struggles in therapy without a relational and con-
textual understanding of his or her story is entirely absurd (Madigan, 2011). Narrative
therapists concentrate on problem stories that dominate and subjugate at the personal,
social, and cultural levels. The sociopolitical conceptualization of problems sheds light
on those cultural notions and practices that produce dominant and oppressive narra-
tives. From this orientation, practitioners take apart the cultural assumptions that are
a part of a client’s problem situation. People are able to come to an understanding of
how oppressive social practices have affected them. This awareness can lead to a new
perspective on dominant themes of oppression that have been such an integral part of
a client’s story, and with this cultural awareness new stories can be generated.
In their discussion of the multicultural infl uences on clients, Bertolino and O’Hanlon
(2002) make the point that they do not approach clients with a preconceived notion
about their experience. Instead, they learn from their clients about their experiential
world. Bertolino and O’Hanlon practice multicultural curiosity by listening respect-
fully to their clients, who become their best teachers. Here are some questions these
authors suggest as a way to more fully understand multicultural infl uences on a client:
• Tell me more about the infl uence that [some aspect of your culture] has played
in your life.
• What can you share with me about your background that will enable me to more
fully understand you?
• What challenges have you faced growing up in your culture?
• What, if anything, about your background has been diffi cult for you?
• How have you been able to draw on strengths and resources from your culture?
What resources can you draw from in times of need?
Questions such as these can shed light on specifi c cultural infl uences that have
been sources of support or that contributed to a client’s problem.
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421
Shortcomings From a Diversity Perspective
A potential shortcoming of the postmodern approaches pertains to the not-knowing
stance the therapist assumes, along with the assumption of the client-as-expert.
Individuals from many different cultural groups tend to elevate the professional as
the expert who will offer direction and solutions for the person seeking help. If the
therapist is telling the client, “I am not really an expert; you are the expert; I trust
in your resources for you to fi nd solutions to your problems,” then this may engen-
der lack of confi dence in the therapist. To avoid this situation, the therapist using
a solution-focused or a narrative orientation needs to convey to clients that he or
she has expertise in the process of therapy but clients are the experts in knowing
what they want in their lives. The postmodern approaches stress being transparent
with clients and honoring their hopes and expectations in therapy. This emphasis
creates a context for providing culturally responsive services.
I operate from an integrative perspective
by combining concepts and techniques
from the solution-focused and narrative
approaches. From this framework, I am philo-
sophically opposed to assessment and diagnosis
using the DSM-IV-TR model, and I do not begin
therapy with a formal assessment. Instead,
I engage Stan in collaborative conversations
centered on change, competence, preferences,
possibilities, and ideas for making changes in the
future.
I begin my work with Stan by inviting him
to tell me about the concerns that brought him
to therapy and what he expects to accomplish
in his sessions. I also provide Stan with a brief
orientation of some of the basic ideas that guide
my practice and describe my view of counseling
as a collaborative partnership in which he is the
senior partner. Stan is somewhat surprised by
this because he expected that I was the person
with the experience and expertise. He informs
me that he has very little confidence in knowing
how to proceed with his life, especially since he
has “messed up” so often. I am aware that he has
self-doubts when it comes to assuming the role
of senior partner. However, I work to demystify
the therapeutic process and establish a collabo-
rative relationship, conveying to Stan that he is in
charge of the direction his therapy will take.
Soon after this orientation to how therapy
works, I inquire about some specific goals that
Stan would like to reach through the therapy
sessions. Stan gives clear signs that he is will-
ing and eager to change. However, he adds that
he has become convinced that he suffers from
low self-esteem. I begin to externalize the idea
of low self-esteem and inquire into its effects in
his life. Then I start to focus Stan on looking for
exceptions to the problem of low self-esteem.
I pose an exception question (solution-focused
therapy): “What is different about the contexts
or times when you have not experienced low
self-esteem?” Stan is able to identify some
positive characteristics: his courage, deter-
mination, and willingness to try new things in
spite of his self-doubts, and his gift for working
with children. Stan knows what he wants out
of therapy and has clear goals: to achieve his
educational goals, to enhance his belief in him-
self, to relate to women without fear, and to feel
more joy instead of sadness and anxiety.
I invite Stan to talk more about how he has
managed to make the gains he has in spite of
struggling with the problem of self-doubt and
low self-esteem.
I allow Stan to share his problem-saturated
story, but I do not get stuck in this narrative. I
invite Stan to think of his problems as external
Postmodern Approaches Applied to the Case of Stan
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to the core of his selfhood. I help him to notice
the cultural forces that have recruited him into a
story of thinking less about himself. Even during
the early sessions, I encourage Stan to separate
his being from his problems by posing questions
that externalize his problem.
Although Stan presents several problem
areas that are of concern to him, I work with him
on identifying one particular problem. Stan says
he is depressed a great deal of the time, and
he worries that his depression might someday
overwhelm him. After listening to Stan’s fears
and concerns, I ask Stan the miracle question
(solution-focused technique): “Let’s suppose
that a miracle were to happen while you are
asleep tonight. When you wake up tomorrow,
the problems you are mentioning are gone.
What would be the signs to you that this miracle
actually occurred and that your problems were
solved? How would your life be different?”
With this intervention, I am shifting the focus
from talking about problems to talking about
solutions. I explain to Stan that much of his ther-
apy will deal with finding both present and future
solutions rather than dwelling on past problems.
Together we engage in a conversation that fea-
tures change-talk rather than problem-talk.
To a great extent, Stan has linked his identity
with his problems, especially depression. He
doesn’t think of his problems as being sepa-
rate from himself. I want Stan to realize that he
personally is not his problem, but instead that
the problem is the problem. When I ask Stan to
give a name to his problem, he eventually comes
up with “Disabling depression!” He then relates
how his depression has kept him from function-
ing the way he would like in many areas of his
life. I then use externalizing questions (narrative
technique) as a way to separate Stan from his
problem: “How long has depression gotten the
best of you?” “What has depression cost you?”
“Have there been times when you stood up to
depression and did not let it win?” Of course, I
briefly explain to him what I am doing by using
externalizing language, lest he think this is a
strange way to counsel. I talk more about the ad-
vantages of engaging in externalizing conversa-
tions. I also talk with Stan about the importance
of mapping the effects of the problem on his life.
This process involves exploring how long the
problem has been around, the extent to which
the problem has influenced various aspects of
his life, and how deeply the problem continues
to affect him.
As the sessions progress, there is a col-
laborative effort aimed at investigating how the
problem has been a disrupting, dominating, and
discouraging influence. Stan comes to view his
story from a different perspective. I continue
talking with Stan about those moments when
he has not been dominated or discouraged by
depression and anxiety and continue to search
for exceptions to these problematic experi-
ences. Stan and I participate in conversations
about unique outcomes, or occasions when he
has demonstrated courage and persistence in
the face of discouraging events. Some of these
“sparkling moments” include Stan’s accomplish-
ments in college, volunteer work with children,
progress in curbing his tendencies to abuse
alcohol, willingness to challenge his fears and
make new acquaintances, talking back to self-
defeating internal messages, accomplishments
in securing employment, and his willingness to
create a vision of a productive future.
With my help, Stan accumulates evidence
from his past to bolster a new view of himself
as competent enough to have escaped from the
dominance of problematic stories. At this phase
in his therapy, Stan makes a decision to create
an alternative narrative. Several sessions are
devoted to reauthoring Stan’s story in ways that
are lively, creative, and colorful. Along with the
process of creating an alternative story, I explore
with Stan the possibilities of recruiting an audi-
ence who will reinforce his positive changes. I
ask, “Who do you know who would be least sur-
prised to hear of your recent changes, and what
would this person know about you that would
lead to him or her not being so surprised?”
Stan identifies one of his early teachers who
served as a mentor to him and who believed in
him when Stan had little belief in himself. Some
therapy time is devoted to discussing how new
stories take root only when there is an audience
to appreciate them.
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After five therapy sessions, Stan brings up
the matter of termination. At the sixth and final
session, I introduce scaling questions, ask-
ing Stan to rate his degree of improvement on
a range of problems we explored in the past
weeks. On a scale of zero to 10, Stan ranks how
he saw himself prior to his first session and
how he sees himself today on various specific
dimensions. We also talked about Stan’s goals
for his future and what kinds of improvements
he will need to make to attain what he wants. I
then give Stan a letter I wrote summarizing both
the problem story and its effects and also the
counter story that we have been developing in
therapy. In my narrative letter, I describe Stan’s
determination and cooperation in his own words
and encourage him to circulate the news of the
differences he has brought about in his life. I also
ask some questions that invite him to develop
the new story of identity more fully.
Follow-Up: You Continue as Stan’s
Postmodern Therapist
Use these questions to help you think about how
to counsel Stan from a postmodernist approach:
• As Stan’s therapist, I borrowed key concepts
and techniques common to both solution-fo-
cused and narrative orientations. In your work
with Stan, what specific concepts would you
borrow from each of these approaches? What
techniques would you draw from each of the
approaches? What possible advantages do
you see, if any, in applying an integration of
solution-focused and narrative models in your
work with Stan?
• What unique values, if any, do you see in work-
ing with Stan from a postmodern perspective as
opposed to working with Stan from the other
therapeutic approaches you’ve studied thus far?
• I asked many questions of Stan. List some
additional questions you would be particularly
interested in pursuing with Stan.
• In what ways could you integrate SFBT and
narrative therapy with feminist therapy in
Stan’s case? What other therapies might you
combine with the postmodern approaches?
What other therapies would not combine so
well with these postmodern therapies?
• At this point, you are very familiar with the
themes in Stan’s life. If you were to write a nar-
rative letter that you would then give to Stan,
what would you most want to include? What
would you want to talk to him about regarding
his future?
See DVD for Theory and Practice of
Counseling and Psychotherapy: The Case
of Stan and Lecturettes (Session 11 on SFBT and
Session 12 on narrative therapy) for a demon-
stration of my approach to counseling Stan
from this perspective. Session 11 illustrates
techniques such as identifying exceptions,
the miracle question, and scaling. Session 12
focuses on Stan’s work in creating a new story
of his life.
s u m m a ry a n d e va l u at i o n
Summary
In social constructionist theory the therapist-as-expert is replaced by the client-
as-expert. Although clients are viewed as experts on their own lives, they are often
stuck in patterns that are not working well for them. Both solution-focused and nar-
rative therapists enter into dialogues in an effort to elicit the perspectives, resources,
and unique experiences of their clients. The therapeutic endeavor is a highly col-
laborative relationship in which the client is the senior partner. The qualities of
the therapeutic relationship are at the heart of the effectiveness of both SFBT and
narrative therapy. This has resulted in many therapists giving increased attention
to creating a collaborative relationship with clients. Collaborative therapists adjust
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their approach to each client or group instead of requiring clients to adapt to their
approach. Thus therapy may look very different for one client than for another.
The not-knowing position of the therapist has been infused as a key concept of
both the solution-focused and narrative therapeutic approaches. The not-knowing
position, which allows therapists to be curious about, affi rm, and be guided by the
stories of their clients, creates participant-observer and process-facilitator roles for the
therapist and integrates therapy with a postmodern perspective of human inquiry.
Both solution-focused brief therapy and narrative therapy are based on the
optimistic assumption that people are healthy, competent, resourceful, and pos-
sess the ability to construct solutions and alternative stories that can enhance their
lives. In SFBT the therapeutic process provides a context whereby individuals fo-
cus on creating solutions rather than talking about their problems. Some common
techniques include the use of miracle questions, exception questions, and scaling
questions. In narrative therapy the therapeutic process attends to the sociocultural
context wherein clients are assisted in separating themselves from their problems
and are afforded the opportunity of authoring new stories.
Practitioners with solution-focused or narrative orientations tend to engage cli-
ents in conversations that lead to progressive narratives that help clients make steady
gains toward their goals. Therapists often ask clients: “Tell me about times when your
life was going the way you wanted it to.” These conversations illustrate stories of life
worth living. On the basis of these conversations, the power of problems is taken apart
(deconstructed) and new directions and solutions are manifest and made possible.
Contributions of Postmodern Approaches
Social constructionism, SFBT, and narrative therapy are making many contributions
to the fi eld of psychotherapy. I especially value the optimistic orientation of these post-
modern approaches that rest on the assumptions that people are competent and can
be trusted to use their resources in creating better solutions and more life-affi rming
stories. Many postmodern practitioners and writers have found that clients are able
to make signifi cant moves toward building more satisfying lives in a relatively short
period of time (Bertolino & O’Hanlon, 2002; De Jong & Berg, 2008; de Shazer, 1991;
Freedman & Combs, 1996; Miller, Hubble, & Duncan, 1996; O’Hanlon & Weiner-
Davis, 2003; Walter & Peller, 1992, 2000; Winslade & Monk, 2007).
To its credit, solution-focused therapy is a brief approach, of about fi ve sessions,
that seems to show promising results (de Shazer, 1991). In de Shazer’s summary
of two outcome studies at the Brief Family Therapy Center, he reports that 91% of
the clients who attended four or more sessions were successful in achieving their
treatment goals. SFBT tends to be very brief, even among the time-limited thera-
pies. In one study, Rothwell (2005) reports the average number of solution-focused
sessions to be two, in comparison to fi ve sessions for cognitive therapy. Brevity is
a main appeal of SFBT in an era of managed care, which places a premium on
short-term therapy. It should be noted that the brevity comes from the client being
in charge of goal setting and determining which issues are of immediate concern.
This differs from many other models in which the therapist determines the direc-
tion therapy should take. The narrative approach to counseling also tends to be
based on brief methods.
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I think the nonpathologizing stance characteristic of practitioners with a social
constructionist, solution-focused, or narrative orientation is a major contribution
to the counseling profession. Rather than dwelling on what is wrong with a per-
son, these approaches view the client as being competent and resourceful. People
cannot be reduced to a specifi c problem nor accurately labeled and identifi ed with
a disorder. Even practitioners who are expected to formulate a diagnosis can learn
the value of a respectful way to relate to clients.
Research from an “empirical generalizable” perspective is somewhat antithetical
to the social constructionist approach, but how effective is solution-focused brief ther-
apy? Regardless of the specifi c theoretical orientation of the therapist, brief therapy
has been shown to be effective for a wide range of clinical problems. Studies that have
compared brief therapies with long-term therapies have generally found no difference
in outcomes (McKeel, 1996). In a review of research of SFBT, McKeel concludes that
when SFBT techniques have been tested, the results are generally favorable. Although
only a few studies of SFBT exist, outcome studies generally show that most clients
receiving SFBT report accomplishing their treatment goals.
One particular area where the solution-focused approach shows promise
is in group treatment with domestic violence offenders. Lee, Sebold, and Uken
(2003) describe a cutting-edge treatment approach that seems to create effective,
positive change in domestic violence offenders. This approach is dramatically dif-
ferent from traditional approaches in that there is virtually no emphasis on the
presenting problem of domestic violence. The approach focuses on holding
offenders accountable and responsible for building solutions rather than empha-
sizing their problems and defi cits. The process described by Lee and colleagues
is brief when measured against traditional program standards, lasting only eight
sessions over a 10- to 12-week period. Lee, Sebold, and Uken report research that
indicates a recidivism rate of 16.7% and completion rates of 92.9%. In contrast,
more traditional approaches typically generate recidivism rates between 40 and
60% and completion rates of less than 50%.
In their review of 15 outcome studies of SFBT, Gingerich and Eisengart (2000)
found that 5 studies were well controlled, and all showed positive outcomes. The
other 10 studies, which were only moderately controlled, supported a hypothesis
of the effectiveness of SFBT. The review of these studies provided preliminary sup-
port for the idea that SFBT may be benefi cial to clients, but methodological fl aws
did not permit a defi nitive conclusion. For a more detailed review of early research
and outcome measurement of SFBT, see De Jong and Berg (2008, chap. 11).
A major strength of both solution-focused and narrative therapies is the use of
questioning, which is the centerpiece of both approaches. Open-ended questions
about the client’s attitudes, thoughts, feeling, behaviors, and perceptions are one
of the main interventions. Especially useful are future-oriented questions that get
clients thinking about how they are likely to solve potential problems in the future.
Questions can assist clients in developing their story and discovering better ways
to deal with their concerns. Effective questioning can help individuals examine
their story and fi nd new ways to present their story. Winslade and Monk (2007)
note that a therapist’s careful questioning about clients’ early experiences of their
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capabilities and resources tends to strengthen the foundation for clients in build-
ing a new sense of direction and for them to create alternative stories.
Limitation and Criticisms of Postmodern Approaches
To effectively practice solution-focused brief therapy, it is essential that therapists
are skilled in brief interventions. Although it may appear that SFBT is simple and
easy to implement, therapists practicing within this framework must be able to
make assessments, assist clients in formulating specifi c goals, and effectively use
a range of appropriate interventions. Some inexperienced or untrained therapists
may be enamored by the variety of techniques: the miracle question, scaling ques-
tions, the exception question, and externalizing questions. But effective therapy
is not simply a matter of relying on any of these interventions. The attitudes of
the therapist and his or her ability to use questions that are refl ective of genuine
respectful interest are crucial to the therapeutic process.
McKenzie and Monk (1997) express their concerns over those counselors who
attempt to employ narrative ideas in a mechanistic fashion. They caution that
a risk in describing a map of a narrative orientation lies in the fact that some
beginners will pay more attention to following the map than they will to following
the lead of the client. In such situations, McKenzie and Monk are convinced that
mechanically using techniques will not be effective. They add that although nar-
rative therapy is based on some simple ideas, it is a mistake to assume that the
practice is simple.
McKeel (1996) observes that recent research on the importance of the thera-
peutic relationship is consistent with the SFBT view that positive treatment out-
comes are linked to therapists developing effective and collaborative working
relationships with clients. He cautions practitioners that losing sight of the po-
tency of the therapeutic relationship “will only doom SFBT to be remembered as a
disembodied set of clever techniques” (p. 265). Some solution-focused practition-
ers now acknowledge the problem of relying too much on a few techniques, and
they are placing increased importance on the therapeutic relationship and the
overall philosophy of the approach (Lipchik, 2002; Nichols, 2013).
Despite these limitations, the postmodern approaches have much to offer prac-
titioners, regardless of their theoretical orientation. Many of the basic concepts
and techniques of both solution-focused brief therapy and narrative therapy can be
integrated into the other therapeutic orientations discussed in this book.
w h e r e to g o f r o m h e r e
Free Podcasts for ACA Members
You can download ACA Podcasts (prerecorded interviews) at www.counseling.org;
click on the Resource button and then the Podcast Series. For Chapter 13, Post-
modern Approaches, look for the following:
Interview with Dr. John Murphy on Solution-Focused Counseling in Schools
(Podcast 5) Lorraine Hedtke, L. & Winslade, J., Remembering Lives, Conversa-
tions With the Dying and Bereaved
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Other Resources
Psychotherapy.net is a comprehensive resource for students and professionals that
offers videos and interviews on the postmodern approaches. New video and edito-
rial content is made available monthly. DVDs relevant to this chapter are available
at www.psychotherapy.net and include the following:
Madigan, S. (2002). Narrative Therapy With Children (Child Therapy With
the Experts)
Madigan, S. (1998). Narrative Family Therapy (Family Therapy With the Experts)
If you are interested in keeping up to date with the developments in brief therapy,
the Journal of Brief Therapy is a useful resource. It is devoted to developments,
innovations, and research related to brief therapy with individuals, couples, fami-
lies, and groups. The articles deal with brief therapy related to all theoretical
approaches, but especially to social constructionism, solution-focused therapy, and
narrative therapy. For subscription information, contact:
Springer Publishing Company
11 West 42nd Street, 15th Floor
New York, NY 10036
Toll-Free Telephone: (877) 687-7476
Website: www.springerpub.com
Another useful journal is the International Journal of Narrative Therapy and Commu-
nity Work. For more information, contact:
Dulwich Centre
345 Carrington Street
Adelaide, South Australia 5000
Website: www.dulwichcentre.com.au/
Training in Solution-Focused Therapy Approaches
Center for Solution-Focused Brief Therapy
John Walter and Jane Peller
2320 Thayer Street
Evanston, IL 60201
Telephone: (847) 475-2691
E-mail: John Walter@aol.com
O’Hanlon and O’Hanlon Inc.
223 N. Guadalupe #278
Santa Fe, NM 87501
Telephone: (505) 983-2843
Fax: (505) 983-2761
E-mail: PossiBill@brieftherapy.com
Website: www.brief.org.uk
The Solution Focused Institute (SFI) at Texas Wesleyan University was founded in
January 2009 in Fort Worth, Texas, to provide training to mental health practition-
ers and school teachers and counselors who want to implement a solution-focused
approach in their work. The institute provides training on- and off-site in solution-
focused therapy and offers supervision to individuals and groups. For information
on SFI services, contact:
28549_ch13_rev01.indd 427 20/09/11 3:57 PM
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Linda Metcalf, PhD
Solution Focused Institute
3001 Avenue D
Fort Worth, TX 76105
Telephone: (817) 690-2229
Fax: (817) 531-4935
E-mail: lmetcalf@txwes.edu
Website:www.Solutionfocusedinstitute.com
Change-Focused Practice in Schools (CFPS) was initiated by John Murphy in 2005
to translate psychotherapy research into practical applications in schools and oth-
er settings. CFPS offers international training, supervision, and consultation on
solution-focused/outcome-informed approaches to helping young people change
in ways that honor their strengths and resources. For more information, contact:
John Murphy, PhD
Department of Psychology & Counseling
University of Central Arkansas
Conway, AR 72035-0001
Telephone: (501) 450-5450
Fax: (501) 450-5424
E-mail: jmurphy@uca.edu
Website: www.drjohnmurphy.com
Training in Narrative Therapy
Evanston Family Therapy Institute
Jill Freedman and Gene Combs
820 Davis Street, Suite 504
Evanston, Illinois 60201
Dulwich Centre
Cheryl White
345 Carrington Street
Adelaide, South Australia 5000

Bay Area Family Therapy Training Associates
Jeffrey L. Zimmerman and Marie-Nathalie Beaudoin
21760 Stevens Creek Blvd., Suite 102
Cupertino, CA 95015
Telephone: (408) 257-6881
Fax: (408) 257-0689
E-mail: baftta@aol.com
Website: www.baftta.com
The Houston-Galveston Institute
3316 Mount Vernon
Houston, TX 77006
Telephone: (713) 526-8390
Fax: (713) 528-2618
E-mail: admin@talkhgi.com
Website: www.talkhgi.com
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Recommended Supplementary Readings
Interviewing for Solutions (De Jong & Berg, 2008) is a practical text aimed at
teaching and learning solution-focused skills. It is written in a conversational and
informal style and contains many examples to solidify learning of skills.
Solution-Focused Counseling in Schools (Murphy, 2008) is a clearly written and
practical book that offers effi cient strategies for addressing a range of problems
from preschool through high school. Numerous case examples illustrate the
foundations, tasks, and techniques of solution-focused counseling. The book also
describes how the principles of client-directed, outcome-informed practice can be
integrated in solution-focused counseling.
Narrative Means to Therapeutic Ends (White & Epston, 1990) is the most widely
known book on narrative therapy.
Maps of Narrative Practice (White, 2007) is Michael White’s fi nal book, which
brings together much of his work over several decades in one accessible volume.
Narrative Therapy (Madigan, 2011) provides an updated discussion of the theory
and therapeutic process of narrative therapy.
Narrative Counseling in Schools (Winslade & Monk, 2007) is a basic and easy-
to-read guide to applying concepts and techniques of narrative therapy to school
settings.
Narrative Therapy: The Social Construction of Preferred Realities (Freedman & Combs,
1996) is an exceptionally clear explanation of the basic ideas of narrative therapy.
The authors emphasize key concepts and the application of specifi c clinical prac-
tices. This is one of the best sources on the theory and practice of narrative therapy.
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*Winslade, J., Crocket, K., & Monk, G. (1997).
The therapeutic relationship. In G. Monk, J.
Winslade, K. Crocket, & D. Epston (Eds.),
Narrative therapy in practice: The archaeology of
hope (pp. 53–81), San Francisco: Jossey-Bass.
*Winslade, J., & Monk, G. (2007). Narrative
counseling in schools (2nd ed.). Thousand Oaks,
CA: Corwin Press (Sage).
431
P
O
S
T
M
O
D
E
R
N

A
P
P
R
O
A
C
H
E
S
28549_ch13_rev01.indd 431 20/09/11 3:57 PM
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432
i n t r o d u ct i o n
d e v e lo p m e n t o f fa m i ly
syst e m s t h e r a p y a n d p e r s o n a l
d e v e lo p m e n t o f t h e fa m i ly
t h e r a p i st
a m u lt i l ay e r e d p r o c es s
o f fa m i ly t h e r a p y
fa m i ly s y s t e m s t h e r a p y f r o m
a m u lt i c u lt u r a l p e r s p ect i v e
fa m i ly s y s t e m s t h e r a p y a p p l i e d
to t h e c a s e o f sta n
s u m m a ry a n d e va l u at i o n
w h e r e to g o f r o m h e r e
c h a p t e r 1 4
Family Systems Therapy
Coauthored by James Robert Bitter and Gerald Corey
432
a m u lt i l ay e r e d p r o c e
o f fa m i ly t h e r a p y
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433
F
A
M
I
L
Y

S
Y
S
T
E
M
S

T
H
E
R
A
P
Y
Alfred Adler / Murray Bowen / Virginia Satir / Carl
Whitaker / Salvador Minuchin / Jay Haley and Cloé Madanes
ALFRED ADLER (1870–
1937) was the first psy-
chologist of the modern era
to do family therapy using
a systemic approach. He
set up more than 30 child
guidance clinics in Vienna
after World War I, and later
Rudolf Dreikurs brought this
concept to the United States in the form of family
education centers. Adler and Dreikurs conducted
family counseling sessions in an open public forum,
educating parents and professionals in greater
numbers; they believed the problems of any one
family were common to all others in the commu-
nity (Christensen, 2004). As we have seen in the
chapter on Adlerian therapy, the focus of interven-
tions is on the purposes or goals of behavior—and
Adlerian family therapists extend this teleological
focus to family interactions and patterns of com-
munication.
H
ul
to
n
A
rc
hi
ve
/G
et
ty
Im
ag
es
MURRAY BOWEN
(1913–1990) was one
of the original develop-
ers of mainstream family
therapy. Much of his theory
and practice grew out of
his work at the National
Institute of Mental Health
(and later at Georgetown
University) with schizo-
phrenic individuals in families. He believed families
could best be understood when analyzed from a
three-generation perspective because patterns of
interpersonal relationships connect family mem-
bers across generations. Two of his objectives in
therapy were to help family members develop a
rational, nonreactive approach to living (called
a differentiation of self) and to de-tangle family
interactions that involved two people pulling a third
person into the couples’ problems and arguments
(or triangulation). Bowen’s emphasis on a multi-
generational perspective led to the development of
genograms (McGoldrick, Gerson, & Petry, 2008),
family life cycle development (McGoldrick, Carter,
& Garcia-Preto, 2011), and a comprehensive focus
on a multicultural perspective in family therapy
(McGoldrick, Giordano, & Garcia-Preto, 2005).
Co
ur
te
sy
of
Th
e
Bo
w
en
Ce
nt
er
fo
rt
he
St
ud
y
of
th
e
Fa
m
ily
;p
ho
to
by
A
nd
re
a
Sc
ha
ra
Contributors to Family Systems Theory
Family systems therapy is represented by a variety
of theories and approaches, all of which focus on
the relational aspects of human problems. Some of
the individuals most closely associated with
the origins of these systemic approaches are
featured here.
V I R G I N I A S AT I R (1916–
1988) developed conjoint
family therapy, a human vali-
dation process model that
emphasizes communication
and emotional experienc-
ing. Like Bowen, she used an
intergenerational model, but
she worked to bring family
patterns to life in the present through sculpting and
family reconstructions. Claiming that techniques
were secondary to relationship, she concentrated
on the personal relationship between therapist and
family to achieve change. The core of Satir’s model
relied on the power of congruence to help family
members communicate with emotional honesty.
Her presence with people encouraged them to get in
touch with what was significant within, to become
more fully human, to share the individual’s best self
with a significant other: Satir called this experience
“making contact,” and she believed that it extended
the peace one had within to a peace between peo-
ple, and eventually, to a peace among people. From
Satir, family therapy gets it model for empathic lis-
tening, therapeutic presence, and nurturance (Satir,
Banmen, Gerber, & Gomori, 1991).
Co
ur
te
sy
of
Th
e
Vi
rg
in
ia
Sa
tir
G
lo
ba
lN
et
w
or
k
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C A R L W H I TA K E R
(1912–1995) is the creator
of symbolic-experiential
family therapy, a freewheel-
ing, intuitive approach to
helping families open chan-
nels of interaction. His goal
was to facilitate individual
autonomy while retaining
a sense of belonging in the family. He saw the
therapist as an active participant and coach who
enters the family process with creativity, putting
enough pressure on this process to produce change
in the status quo. From Whitaker, the field of family
therapy learned to tolerate and sometimes create
anxiety in families—and then how to join families
in their struggle to become more real and more
transparent.
U
ni
ve
rs
ity
of
W
is
co
ns
in
M
ad
is
on
A
rc
hi
ve
s
SA LVA D O R M I N U C H I N
(b. 1921) began to develop
structural family therapy
in the 1960s through his
work with delinquent boys
from poor families at the
Wiltwyck School in New
York. Working with col-
leagues at the Philadelphia
Child Guidance Clinic in the 1970s, Minuchin
refined the theory and practice of structural
family therapy. Focusing on the structure, or
organization, of the family, the therapist helps
the family modify its stereotyped patterns and
redefine relationships among family members.
He believes structural changes in families must
occur before individual members’ symptoms
can be reduced or eliminated. From Minuchin
and his colleagues, family therapy developed
an understanding of power, organization,
and alignments in family life, and family thera-
pists learned how to use themselves to set
boundaries and even unbalance dysfunctional
family systems.
Co
ur
te
sy
of
Th
e
M
in
uc
hi
n
Ce
nt
er
fo
rt
he
Fa
m
ily
JAY H A L E Y (1923–2007)
and CLOÉ MADANES
(b. 1941) founded the
Washington School of
strategic family therapy
in the 1970s, after Haley
had left the Mental
Research Institute in
Palo Alto, California, and
later the Philadelphia
Child Guidance Center, where he spent a brief
period with Salvador Minuchin and colleagues.
Haley blended structural family therapy with
the concepts of hierarchy, power, and strategic
interventions. Madanes contributed to the
development of a brief, solution-oriented ther-
apy approach. The strategic interventions most
favored by Haley and Madanes were reframing,
family directives, and paradoxical interven-
tions. Strategic family therapy became the
most popular family therapy approach in the
1980s. It is a pragmatic approach that focuses
on solving problems in the present; understand-
ing and insight are neither required nor sought.
The problem brought by the family to therapy
is treated as “real”—not a symptom of underly-
ing issues—and is solved. When the problem is
solved, therapy is finished.
Co
ur
te
sy
of
Ch
lo
e
M
ad
an
es
i n t r o d u c t i o n
434
C
H
A
P
T
E
R

F
O
U
R
T
E
E
N
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The Family Systems Perspective
relationship
therapy
F
A
M
I
L
Y

S
Y
S
T
E
M
S

T
H
E
R
A
P
Y
435
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436
C
H
A
P
T
E
R

F
O
U
R
T
E
E
N
See the video program for Chapter 14, DVD for Theory and Practice of Coun-
seling and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you
view the brief lecture for each chapter prior to reading the chapter.
Differences Between Systemic and Individual Approaches
The individual therapist may: The systemic therapist may:
DSM-IV-TR
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F
A
M
I
L
Y

S
Y
S
T
E
M
S

T
H
E
R
A
P
Y
437
d e v e lo p m e n t o f fa m i ly s ys t e m s
t h e r a p y a n d p e r s o n a l d e v e lo p m e n t
o f t h e fa m i ly t h e r a p i s t
Adlerian Family Therapy
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438
C
H
A
P
T
E
R

F
O
U
R
T
E
E
N
Multigenerational Family Therapy
triangulation,
two-against-one
differentiation
of self,
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439
F
A
M
I
L
Y

S
Y
S
T
E
M
S

T
H
E
R
A
P
Y
Human Validation Process Model
Blaming
Placating
super reasonable
Irrelevance
congruence
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440
C
H
A
P
T
E
R

F
O
U
R
T
E
E
N
Experiential Family Therapy
Structural-Strategic Family Therapy
structural family therapy
structural-
strategic approaches
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441
F
A
M
I
L
Y

S
Y
S
T
E
M
S

T
H
E
R
A
P
Y
Recent Innovations in Family Therapy
feminism, multiculturalism postmodern social construction-
ism
First-order cybernetics
second-order cybernetics;
p o s t m o d e r n p e r s p e c t i v e s i n fa m i ly t h e r a p y
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442
C
H
A
P
T
E
R

F
O
U
R
T
E
E
N
solution-focused therapy.
narrative therapy
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443
F
A
M
I
L
Y

S
Y
S
T
E
M
S

T
H
E
R
A
P
Y
T
A
B
L
E
1
4
.1
A
C
o
m
p
ar
is
o
n
o
f
Si
x
Sy
st
em
ic
V
ie
w
p
o
in
ts
in
F
am
ily
T
h
er
ap
y
A
D
L
E
R
IA
N

F
A
M
IL
Y

T
H
E
R
A
P
Y
M
U
L
T
I-
G
E
N
E
R
A
T
IO
N
A
L
F
A
M
IL
Y

T
H
E
R
A
P
Y
H
U
M
A
N

V
A
L
ID
A
T
IO
N

P
R
O
C
E
S
S

M
O
D
E
L
E
X
P
E
R
IE
N
T
IA
L
/

S
Y
M
B
O
L
IC

F
A
M
IL
Y

T
H
E
R
A
P
Y
S
T
R
U
C
T
U
R
A
L
F
A
M
IL
Y

T
H
E
R
A
P
Y
S
T
R
A
T
E
G
IC

F
A
M
IL
Y

T
H
E
R
A
P
Y
K
ey
fi
gu
re
s
T
im
e
fo
cu
s
T
he
ra
py
g
oa
ls
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444
C
H
A
P
T
E
R

F
O
U
R
T
E
E
N
R
ol
e
an
d
fu
nc
ti
on
o
f
th
e
th
er
ap
is
t
Pr
oc
es
s
of

ch
an
ge
Te
ch
ni
qu
es
a
nd

in
no
va
ti
on
s
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445
F
A
M
I
L
Y

S
Y
S
T
E
M
S

T
H
E
R
A
P
Y
Theory and Practice of Family
Therapy and Counseling
a m u lt i l ay e r e d p r o c e s s
o f fa m i ly t h e r a p y
Forming a Relationship
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446
C
H
A
P
T
E
R

F
O
U
R
T
E
E
N
joining engagement care and concern
how
what why where when
Conducting an Assessment
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

447
F
A
M
I
L
Y

S
Y
S
T
E
M
S

T
H
E
R
A
P
Y
Ralph
Age 30
1/17/81
John
Age 25
2/27/86
Mary
Age 24
12/22/87
m. 2006//d. 2008 m. 2010
John
Age 25
2/27/86
Mary
Age 24
12/22/87
Ralph
Age 30
1/17/81
Mary
Age 24
12/22/87
d. 2008 m. 2006
John
Age 30
2/27/86
John, Jr.
Age 5
4/20/11
Mary
Age 29
12/22/87
Ann
Age 2
3/12/14
m. 2010
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

448
C
H
A
P
T
E
R

F
O
U
R
T
E
E
N
John
Age 30
2/27/86
John, Jr.
Age 5
4/20/11
Mary
Age 29
12/22/87
Ann
Age 2
3/12/14
m. 2010
His Parents Her Parents
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

449
F
A
M
I
L
Y

S
Y
S
T
E
M
S

T
H
E
R
A
P
Y
Hypothesizing and Sharing Meaning
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

450
C
H
A
P
T
E
R

F
O
U
R
T
E
E
N
decentered
Facilitating Change
making change happen
planning techniques
interventions,
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451
F
A
M
I
L
Y

S
Y
S
T
E
M
S

T
H
E
R
A
P
Y
fa m i ly s ys t e m s t h e r a p y f r o m
a m u lt i c u lt u r a l p e r s p e c t i v e
Strengths From a Diversity Perspective
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452
C
H
A
P
T
E
R

F
O
U
R
T
E
E
N
Shortcomings From a Diversity Perspective
In our work with Stan in this modal-
ity, we include examples of forming a
relationship and joining, reading Stan’s
genogram, a multilayered assessment, refram-
ing, boundary setting in therapy, and facilitating
change. There are many useful models and ways
to work with families; this discussion represents
some possible ways to work with Stan from a
multilayered perspective.
At an intake interview, a family therapist
meets with Stan to explore his issues and con-
cerns and to learn more about him and his life
situation. As they talk, the therapist brings an
intense interest and curiosity to the interview
Family Therapy Applied to the Case of Stan
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and wonders out loud about the familial roots of
some of Stan’s problems. It does not take much
of an inquiry to learn that Stan is still very much
engaged with his parents and siblings, no matter
how difficult these relationships have been for
him. This initial conversation involves the devel-
opment of a genogram of Stan’s family of origin
(see Figure 14.1). This map will serve both Stan
and the therapist as a guide to the people and
the processes that influence Stan’s life.
Stan’s genogram is really a family picture,
or map, of his family-of-origin system. In this
genogram, we learn that Stan’s grandparents
tend to have lived fairly long lives. Stan’s maternal
grandparents are both alive. The shaded lower half
of their square and circle indicates that each had
some problem with alcohol. In the case of Tom,
Stan reports that he was an admitted alcoholic
who recommitted himself to Christ and found help
through Alcoholics Anonymous. Stan’s maternal
grandmother always drank a little socially and
with her husband, but she never considered her-
self to have a problem. In her later years, however,
she seems to secretly use alcohol more and more,
and it is a source of distress in her marriage. Stan
also knows that Margie drinks a lot, because he
has been drinking with his aunt for years. She is
the one who gave him his first drink.
453
F
A
M
I
L
Y

S
Y
S
T
E
M
S

T
H
E
R
A
P
Y
Judy
b. 1963
Mary
b. 1963
Joseph
b. 1907
Oris
b. 1938
Matthew
Stan
b. 1988
Frank Sr.
b. 1940
Matt
b. 1960 Frank Jr.
b. 1966
Stan
b. 1970
Karl
b. 1972
Seth
b. 1942
Emma
b. 1917
m. 1937
d. 1977
(Cancer)
d. 1968
(Vietnam)
Martha
b. 1921
Margie
b. 1944
Angie
b. 1942
m. 1940
m. 1962
Tom
b. 1920
= Problem with alcohol
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Angie, Stan’s mother, married Frank Sr. after
he had stopped drinking, also with the help of
AA. He still goes to meetings. Angie is suspi-
cious of all men around alcohol. She is especially
upset with Stan and with Judy’s husband, Matt,
who “also drinks too much.” The genogram
makes it easy to see the pattern of alcohol prob-
lems in this family.
The jagged lines /\/\/\/\ between Frank Sr.
and Angie indicate conflict in the relationship.
The three solid lines === between Frank Sr. and
Frank Jr., and between Angie and Karl, indicate a
very close or even fused relationship. The double
lines ==== between Karl and Stan are used to
note a close relationship only. As we will see,
Karl actually looks up to Stan in this family. The
dotted lines . . . . . between Frank Sr. and Stan
and between Frank Jr. and Stan indicate a distant
or even disengaged relationship.
Since the family therapist believes that the
whole family is involved in Stan’s use of alco-
hol, she spends a good part of the first session
exploring with Stan processes for asking his
other family members to join him in therapy.
Stan may have many difficulties, but at the mo-
ment his difficulty with alcohol is the primary
focus. Alcohol is a negative part of his life, and
as such it has systemic meaning. It may have
started out as a symptom of other problems,
but now the alcohol is a problem in itself. From
a systemic perspective, the questions are “How
does this problem affect the family?” and “Is the
family using this problem to serve some other
purpose?”
In the first therapy session with the family,
the therapist’s main focus is in forming a
relationship with each of the family members,
but even here, a variety of approaches present
themselves.
T H E R A P I ST [to Frank sr.]: I know coming here was
an inconvenience for you, but I want you to know
how appreciative I am that you came. Can you tell
me what it’s like for you to be here? [Forming a
relationship through joining]
F R A N K S R . : Well, I have to tell you that I don’t like
it much. [Pause] Things are a lot different today
than they used to be. We didn’t have counseling
20 years ago. I had a problem with drinking at
one point, but I got over it. I just quit—on my own.
That’s what Stan needs to do. He just needs to
stop.
T H E R A P I ST: So I’m hearing that life is better for
you without alcohol, and you would like Stan’s life
to be better too. [Reframing]
F R A N K S R . : Yeah. I’d like his life to be better in a lot
of different ways.
T H E R A P I ST: Angie, what about you? What is it like
for you to be here? [Forming a relationship with each
member]
A N G I E : It’s heartbreaking. It’s always heartbreak-
ing. He [Referring to Frank Sr.] makes it sound as if
he just summoned up his own personal power and
quit drinking through his own strength of charac-
ter. That’s a laugh. I threatened to leave him. That’s
what really happened. I was ready to get a divorce!
And we’re Catholics. We don’t get divorced.
[Possible face-to-face sequence around family stress
and coping]
T H E R A P I ST: So you’ve been through this before.
A N G I E : Oh my, yes. My father and mother drank.
Dad still does. My sister won’t admit it, but she
drinks too much. She goes crazy with it. Judy’s
husband has a problem. I’m surrounded by alco-
holics. I get so angry. I wish they would all just
die or go away. [Possible transgenerational family
sequence: an entry point for exploring values, beliefs,
and rules]
T H E R A P I ST: So this is something the whole family
has been dealing with for a long time.
ANGIE: Not everyone. I don’t drink. Frankie and
Judy don’t drink. And Karl doesn’t seem to have a
problem.
T H E R A P I ST: Is that how the family gets divided:
into those who drink and those who don’t?
[Possible organization perspective]
J U DY: Drinking isn’t the only problem we have. It’s
probably not even the most important.
T H E R A P I ST: Say more about that.
J U DY: Stan has always had it hard. I feel sorry
for him. Frankie is clearly Dad’s favorite [Frank Sr.
protests, saying he doesn’t have favorites], and things
have always come easily for me. And Karl, he gets
whatever he wants. He’s Mom’s favorite. Mom and
Dad have fought a lot over the years. None of us
have been that happy, but Stan seems to have the
worst of it. [Again, possible sequence and organiza-
tion perspectives]
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F R A N K J R . : As I remember it, Stan gave Dad and
Mom a lot to fight about. He was always messing
up in one way or another.
T H E R A P I ST: Frankie, when your father was talk-
ing earlier, I sensed he had some disappointment
about Stan too, but he also wanted to see things
work out better for him. Is that true for you too?
[Reframing Frankie’s comment, maintaining a focus
on new possibilities and new relations that might be
developed]
F R A N K J R . : Yes. I would like his life to be better.
The initial part of this counseling session
has been devoted to meeting family members,
listening intently to the multiple perspectives
they present, and reframing Stan’s problem into
a family desire for a positive outcome. Although
there is a long way to go, the seeds of change
have already been planted. There is evidence
in these early interactions that Stan’s problem
has a multigenerational context. If this context
is explored, family sequences that support and
maintain alcohol as a problem may be identified.
It is possible to track these interactions and to
work toward more congruent communications.
Evolving relational, organizational, developmen-
tal sequences might be explored as a means of
freeing family members for new possibilities in
their life together. Among other possibilities still
to be explored are perspectives related to gender
and culture. If the therapist were just listening
to Stan, only one point of view would be evident.
In this family session, multiple perspectives and
the entire interactive process become clear in a
very short time.
As the family interview proceeds, a number of
possibilities are presented for consideration. The
therapist considers and may structure therapy
around any or all of the following possibilities:
1. Stan’s parents have not been a well-
functioning leadership team for a long time,
and both their spousal relationship and
their parenting have suffered.
2. The adult siblings need a new opportunity
to function together without the influence
and distractions continually imposed by the
parents.
3. Stan has been reduced to a single part (his
alcoholic part), and his description and ex-
perience of himself needs to be enlarged—
both for his own perspective and in the
eyes of others.
A new place for Stan in the family, a better
way of relating, and an ability to access “lost”
parts of his internal system are all critical to
winning his battle with alcohol. As therapy
continues, it becomes clear that two separate
relational–organization hypotheses must be
explored. One is that the spousal relationship
has been defined by the problem of alcohol
too, and it has not evolved or developed in any
kind of positive way over the years. Second,
the transgenerational sequences have targeted
Stan and assigned him to a fixed role that he
has been expected to play that has blocked de-
velopment past his middle to late adolescence,
which was the period in which he started
drinking.
Follow-Up: You Continue as Stan’s
Family Therapist
Use these questions to help you think about how
you would counsel Stan from a family systems
perspective:
What unique values do you see in working with
Stan from a multilayered, systemic perspective
as opposed to an individual therapy approach?
What internal parts might Stan re-access as
he continues in therapy? What parts of him
might be polarized?
Assuming that Stan was successful in getting
at least some of his family members to an-
other session, where would you begin? Would
you get everyone involved in the sessions? If
so, how would you do that?
What are some specific ways to explore other
perspectives with this family?
What hypotheses are you developing, and
how would you share them with the family?
Are there systemic interventions that you would
find hopeful in terms of facilitating change?
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s u m m a ry a n d e va l u at i o n
Summary
b a s i c a s s u m p t i o n
f o c u s o f fa m i ly t h e r a p y
r o l e o f g oa l s a n d va l u e s
h o w fa m i l i e s c h a n g e
t e c h n i q u e s o f fa m i ly t h e r a p y
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Contributions of Family Systems Approaches
Limitations and Criticisms of Family Systems Approaches
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w h e r e to g o f r o m h e r e
Other Resources
Structural Family Therapy
Family Systems Therapy
The Legacy of Unresolved Loss: A Family Systems
Approach
Internal Family Systems
Journal of Marital and Fam-
ily Therapy,
The Family Therapy Magazine
American Association for Marriage and Family Therapy
112 South Alfred Street
Alexandria, VA 22314-3061
Telephone: (703) 838-9808
Fax: (703) 838-9805
Website: www.aamft.org
Recommended Supplementary Readings
Ethnicity and Family Therapy
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Theory and Practice of Family Therapy and Counseling
Family Therapy: An Overview
Family Therapy: Concepts and Methods
Family Therapy: History, Theory, and Practice
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*Andersen, T. (1991). The reflecting team:
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*Anderson, H., & Goolishian, H. (1992).
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*Becvar, D. S., & Becvar, R. J. (2009). Family
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*Bitter, J. R. (2009b). Theory and practice of
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*Bowen, M. (1978). Family therapy in clinical
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*Breunlin, D. C., Schwartz, R. C., & MacKune-
Karrer, B. (1997). Metaframeworks: Transcend-
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Francisco: Jossey-Bass.
*Carlson, J., Sperry, L., & Lewis, J. A. (2005).
Family therapy techniques: Integrating and
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Cengage Learning.
*Christensen, O. C. (Ed.). (2004). Adlerian
family counseling (3rd ed.). Minneapolis, MN:
Educational Media Corp. (Original work
published 1983)
Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

De Shazer, S. (1985). Keys to solutions in brief
therapy. New York: Norton.
Doherty, W. J., & McDaniel, S. H. (2010).
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Dreikurs, R. (1950). The immediate purpose
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Dulwich Centre.
*Gergen, K. J. (1999). An invitation to social
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*Gladding, S. T. (2010). Family therapy: History,
theory, and practice (5th ed.). Upper Saddle
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*Goldenberg, H., & Goldenberg, I. (2013). Fam-
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Haley, J. (1963). Strategies of psychotherapy.
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Haley, J. (1976). Problem-solving therapy:
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Haley, J. (1984). Ordeal therapy. San Francisco:
Jossey-Bass.
*Haley, J., & Richeport-Haley, M. (2003). The
art of strategic therapy. New York: Brunner
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*Hanna, S. M. (2007). The practice of family
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*Madanes, C. (1981). Strategic family therapy.
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*McGoldrick, M., Carter, B., & Garcia-Preto,
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*McGoldrick, M., Giordano, J., & Garcia-Preto,
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*Nichols, M. P. (with Schwartz, R. C.). (2013).
Family therapy: Concepts and methods (10th
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*Whitaker, C. A., & Bumberry, W. M. (1988).
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White, M. (1997). Narratives of therapists’ lives.
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*White, M. (2007). Maps of narrative practice.
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*White, M., & Epston, D. (1990). Narrative means
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463
p a r t 3
Integration and
Application
1 5 A n I n t e g r at i v e P e r s p e c t i v e 464
1 6 C a s e I l l u s t r at i o n : A n I n t e g r at i v e A p p r oa c h
i n Wo r k i n g Wi t h S ta n 503
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464
i n t r o d u ct i o n
t h e m ov e m e n t to wa r d
p syc h ot h e r a p y i n t eg r at i o n
• Pathways Toward Psychotherapy Integration
• Advantages of Psychotherapy Integration
• Integration of Multicultural Issues in
Counseling
• Integration of Spirituality and Religion in
Counseling
• The Challenge of Developing an Integrative
Perspective
i s s u es r e l at e d to t h e
t h e r a p e u t i c p r o c es s
• Therapeutic Goals
• Therapist’s Function and Role
• Client’s Experience in Therapy
• Relationship Between Therapist
and Client
t h e p l ac e o f t ec h n i q u es a n d
e va l u at i o n i n co u n s e l i n g
• Drawing on Techniques From Various
Approaches
• Evaluating the Effectiveness of
Counseling and Therapy
s u m m a ry
w h e r e to g o f r o m h e r e
• Recommended Supplementary
Readings
• References and Suggested Readings
c h a p t e r 1 5
An Integrative Perspective
464
p e
• Therapeu
• Therapis
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i n t r o d u c t i o n
This chapter will help you think about areas of convergence and divergence among
the 11 therapeutic systems covered in this book. Although these approaches all
have some goals in common, they have many differences when it comes to the best
route to achieve these goals. Some therapies call for an active and directive stance
on the therapist’s part, and others place value on clients being the active agent.
Some therapies focus on experiencing feelings, others stress identifying cognitive
patterns, and still others concentrate on actual behavior. The key task is to fi nd ways
to integrate certain features of each of these approaches so that you can work with
clients on all three levels of human experience.
The fi eld of psychotherapy is characterized by a diverse range of specialized
models. With all this diversity, is there any hope that a practitioner can develop
skills in all of the existing techniques? How does a student decide which theories
are most relevant to practice? Looking for commonalities among the systems of
psychotherapy is relatively new (Norcross & Beutler, 2011). Practitioners have been
battling over the “best” way to bring about personality change dating back to the
work of Freud. For decades, counselors resisted integration, often to the point of
denying the validity of alternative theories and of ignoring effective methods from
other theoretical schools. The early history of counseling is full of theoretical wars.
Since the early 1980s, psychotherapy integration has developed into a clearly
delineated fi eld. It is now an established and respected movement that is based
on combining the best of differing orientations so that more complete theoreti-
cal models can be articulated and more effi cient treatments developed (Goldfried,
Pachankis, & Bell, 2005). The Society for the Exploration of Psychotherapy Inte-
gration, formed in 1983, is an international organization whose members are pro-
fessionals working toward the development of therapeutic approaches that tran-
scend single theoretical orientations. As the fi eld of psychotherapy has matured,
the concept of integration has emerged as a mainstay (Norcross & Beutler, 2011).
In this chapter I consider the advantages of developing an integrative per-
spective for counseling practice. I also present a framework to help you begin to
integrate concepts and techniques from various approaches. As you read, start to
formulate your own personal perspective for counseling. Look for ways to synthe-
size diverse elements from different theoretical perspectives. As much as possible,
be alert to how these systems can function in harmony.
See the video program for Chapter 15, DVD for Theory and Practice of Counseling
and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you view the
brief lecture for each chapter prior to reading the chapter.
t h e m o v e m e n t to wa r d
p s yc h ot h e r a p y i n t e g r at i o n
A large number of therapists identify themselves as “eclectic,” and this category
covers a broad range of practice. At its worst, eclectic practice consists of haphaz-
ardly picking techniques without any overall theoretical rationale. This is known
as syncretism, wherein the practitioner, lacking in knowledge and skill in selecting
465
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interventions, looks for anything that seems to work, often making little attempt
to determine whether the therapeutic procedures are indeed effective. Such an un-
critical and unsystematic combination of techniques is no better than a narrow and
dogmatic orthodoxy. This pulling of techniques from many sources without a sound
rationale results in syncretistic confusion (Lazarus, 1996b; Norcross & Beutler, 2011).
Pathways Toward Psychotherapy Integration
Psychotherapy integration is best characterized by attempts to look beyond and
across the confi nes of single-school approaches to see what can be learned from
other perspectives and how clients can benefi t from a variety of ways of conducting
therapy. The majority of psychotherapists do not claim allegiance to a particular
therapeutic school but prefer, instead, some form of integration (Norcross, 2005;
Norcross & Beutler, 2011). In a survey conducted by the Psychotherapy Networker
(2007), only 4.2% of respondents identifi ed themselves as being aligned with one
therapy model exclusively. The remaining 95.8% claimed to be integrative, mean-
ing they combined a variety of methods or approaches in their counseling practice.
The integrative approach is characterized by openness to various ways of in-
tegrating diverse theories and techniques, and there is a decided preference for
the term integrative over eclectic (Norcross, Karpiak, & Lister, 2005). Although
different terms are sometimes used—eclecticism, integration, convergence, and
rapprochement—the goals are very similar. The ultimate goal of integration is to en-
hance the effi ciency and applicability of psychotherapy. Norcross and Beutler (2011)
and Stricker (2010) describe four of the most common pathways toward the inte-
gration of psychotherapies: technical integration, theoretical integration, assimilative
integration, and common factors approach. All of these approaches to integration look
beyond the restrictions of single approaches, but they do so in distinctive ways.
Technical integration aims at selecting the best treatment techniques for the
individual and the problem. It tends to focus on differences, chooses from many
approaches, and is a collection of techniques. This path calls for using techniques
from different schools without necessarily subscribing to the theoretical posi-
tions that spawned them. For those who practice from the perspective of technical
integration, there is no necessary connection between conceptual foundations and
techniques. One of the best-known forms of technical integration, which he refers
to as technical eclecticism, is Lazarus’s (1997a) multimodal therapy (see Chapter 9).
Multimodal therapists borrow from many other therapeutic models, using tech-
niques that have been demonstrated to be effective in dealing with specifi c clinical
problems. Whenever feasible, multimodal therapists employ empirically support-
ed techniques (Lazarus, 2008a).
In contrast, theoretical integration refers to a conceptual or theoretical crea-
tion beyond a mere blending of techniques. This route has the goal of producing a
conceptual framework that synthesizes the best aspects of two or more theoretical
approaches under the assumption that the outcome will be richer than either theory
alone. This approach emphasizes integrating the underlying theories of therapy
along with techniques from each. Examples of this form of integration are dialecti-
cal behavior therapy (DBT) and acceptance and commitment therapy (ACT), both of
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which were described in Chapter 9. Emotion-focused therapy (EFT), which is in-
formed by the role of emotion in psychotherapeutic change, also can be considered
a form of theoretical integration. Greenberg (2011), a key fi gure of the development
of EFT, conceptualizes the model as an empirically supported, integrative, experi-
ential approach to treatment. EFT synthesizes concepts of person-centered thera-
py, Gestalt therapy, experiential therapy, and existential therapy, viewed through
the lens of modern cognitive and emotion theory.
The assimilative integration approach is grounded in a particular school of
psychotherapy, along with an openness to selectively incorporate practices from
other therapeutic approaches. Assimilative integration combines the advantages
of a single coherent theoretical system with the fl exibility of a variety of interven-
tions from multiple systems. An example of this form of integration is mindfulness-
based cognitive therapy (MBCT), which integrates aspects of cognitive therapy and
mindfulness-based stress reduction procedures. As you may recall from Chapter 9,
MBCT is a comprehensive integration of the principles and skills of mindfulness
applied to the treatment of depression (Segal, Williams, & Teasdale, 2002).
The common factors approach searches for common elements across different
theoretical systems. Despite many differences among the theories, a recognizable
core of counseling practice is composed of nonspecifi c variables common to all
therapies. Lambert (2011) concludes that common factors can be a basis for psy-
chotherapy integration:
The common factors explanation for the general equivalence of diverse therapeutic inter-
ventions has resulted in the dominance of integrative practice in routine care by implying
that the dogmatic advocacy of a particular theoretical school is not supported by research.
Research also suggests that common factors can become the focal point for integration of
seemingly diverse therapy techniques. (p. 314)
Some of these common factors include empathic listening, developing a working al-
liance, opportunity for catharsis, practicing new behaviors, positive expectations of
clients, working through one’s own confl icts, understanding interpersonal and intrap-
ersonal dynamics, and learning to be self-refl ective about one’s work (Norcross & Beut-
ler, 2011; Prochaska & Norcross, 2010). Other common factors that have been shown to
be curative include support, warmth, feedback, reassurance, and credibility (Lambert,
2011). These common factors are thought to be at least as important in accounting for
therapeutic outcomes as the unique factors that differentiate one theory from another.
Among the approaches to psychotherapy integration, the common factors approach
has the strongest empirical support (Duncan, Miller, Wampold, & Hubble, 2010).
Of all of the common factors investigated in psychotherapy, none has re-
ceived more attention and confi rmation than a facilitative therapeutic relationship
(Lambert, 2011). The importance of the therapeutic alliance is a well-established
critical component of effective therapy, and research confi rms that the client–
therapist relationship is central to therapeutic change.
Advantages of Psychotherapy Integration
One reason for the movement toward psychotherapy integration is the recognition
that no single theory is comprehensive enough to account for the complexities
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of human behavior, especially when the range of client types and their specifi c
problems are taken into consideration. Because no one theory contains all the
truth, and because no single set of counseling techniques is always effective in
working with diverse client populations, integrative approaches hold promise for
counseling practice. Norcross and Wampold (2011b) maintain that effective clini-
cal practice requires a fl exible and integrative perspective. Psychotherapy should
be fl exibly tailored to the unique needs and contexts of the individual client. Nor-
cross and Wampold contend that using an identical therapy relationship style and
treatment method for all clients is inappropriate and can be unethical.
The 11 systems discussed in this book have evolved in the direction of broaden-
ing their theoretical and practical bases and have become less restrictive in their
focus. Many practitioners who claim allegiance to a particular system of therapy
are expanding their theoretical outlook and developing a wider range of therapeu-
tic techniques to fi t a more diverse population of clients. There is a growing recog-
nition that psychotherapy can be most effective when contributions from various
approaches are integrated (Goldfried, Glass, & Arnkoff, 2011). Although to date
the bulk of psychotherapy integration has been based on theoretical and clinical
foundations, Goldfried and colleagues suggest that evidence-based practice will
increasingly become the organizing force for integration. Empirical pragmatism,
not theory, will be the integrative theme of the 21st century.
Practitioners who are open to an integrative perspective will fi nd that several
theories play a crucial role in their personal counseling approach. Each theory has
its unique contributions and its own domain of expertise. By accepting that each
theory has strengths and weaknesses and is, by defi nition, “different” from the oth-
ers, practitioners have some basis to begin developing a theory that fi ts for them
and their clients. It takes considerable time to learn the various theories in depth. It
is not realistic for any of us to expect that we can integrate all the theories. Instead,
integration of some aspects of some of the theories is a more realistic goal. Devel-
oping an integrative perspective is a lifelong endeavor that is refi ned with clinical
experience, refl ection, reading, and discourse with colleagues.
Integration of Multicultural Issues in Counseling
Multiculturalism is a reality that cannot be ignored by practitioners if they hope
to meet the needs of diverse client groups. I believe current theories, to varying
degrees, can and should be expanded to incorporate a multicultural dimension.
I have consistently pointed out that if contemporary theories do not account
for the cultural dimension, they will have limited applicability in working with
diverse client populations. For some theories, this transition is easier than for
others.
Clients can be harmed if they are expected to fi t all the specifi cations of a given
theory, whether or not the values espoused by the theory are consistent with their
own cultural values. Rather than stretching the client to fi t the dimensions of a
single theory, practitioners need to tailor their theory and practice to fi t the unique
needs of the client. This calls for counselors to possess knowledge of various cul-
tures, to be aware of their own cultural heritage, and to have skills to assist a wide
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spectrum of clients in dealing with the realities of their culture. Psychotherapy
integration stresses tailoring interventions to the individual client rather than to
an overarching theory, making this approach particularly well suited to consider-
ing cultural factors and the unique perspective of each client. Comas-Diaz (2011)
asserts that cultural competence enables counselors to work effectively in most
clinical settings. Practitioners demonstrate their cultural competence by becoming
aware of their own and their clients’ worldviews, and by being able to use cultur-
ally appropriate interventions to refl ect their cultural beliefs, knowledge, and skills.
She adds:
Culturally competent therapists develop the capacities to value diversity and manage the
dynamics of difference. They also acquire and incorporate cultural knowledge into their
interventions, plus adapt to diversity and the cultural contexts of their clients. (p. 251)
This is a good time to review the discussion of the culturally skilled counselor in
Chapter 2 and to consult Tables 15.7 and 15.8, which appear later in this chapter.
In your role as a counselor, you need to be able to assess the special needs
of clients. Depending on the client’s ethnicity and culture and on the concerns
that bring this person to counseling, you are challenged to develop fl exibility in
utilizing an array of therapeutic strategies. Some clients will need more direction,
and even advice. Others will be very hesitant in talking about themselves in per-
sonal ways, especially during the early phase of the counseling process. What you
may see as resistance could be the client’s response to years of cultural condition-
ing and respect for certain values and traditions. Basically, it comes down to your
familiarity with a variety of theoretical approaches and your ability to employ and
adapt your techniques to fi t the person-in-the-environment. It is not enough to
merely assist your clients in gaining insight, expressing suppressed emotions, or
making certain behavioral changes. The challenge is to fi nd practical strategies
for adapting the techniques you have developed to enable clients to examine the
impact their culture continues to have on their lives and to make decisions about
what, if anything, they want to change.
Being an effective counselor involves refl ecting on how your own culture infl u-
ences you and your interventions in your counseling practice. This awareness is
critical in becoming more sensitive to the cultural backgrounds of the clients who
seek your help. Using an integrative perspective, therapists can encompass social,
cultural, spiritual, and political dimensions in their work with clients.
Integration of Spirituality and Religion in Counseling
The counseling process can help clients gain insight into the ways their core be-
liefs and values are refl ected in their behavior. Current interest in spiritual and
religious beliefs has implications for how such beliefs might be incorporated in
therapeutic relationships (Young & Cashwell, 2011a; Frame, 2003). Survey data
from members of both the American Psychological Association and the American
Counseling Association indicate that spiritual and religious matters are therapeuti-
cally relevant, ethically appropriate, and potentially signifi cant topics for the prac-
tice of counseling in secular settings (Delaney, Miller, & Bisono, 2007; Young,
Wiggins-Frame, & Cashwell, 2007).
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Worthington (2011) asserts that the increasing openness of therapists to clients’
spiritual and religious concerns and interests has been fueled by the multicultur-
al evolution. The emphasis on multiculturalism has empowered people to defi ne
themselves from a cultural perspective, which includes their spiritual, religious,
and ethnic contexts.
Clients who are experiencing a crisis situation may fi nd a source of comfort,
support, and strength in drawing upon their spiritual resources. For some clients
spirituality entails embracing a religion, which can have many different meanings.
Other clients value spirituality, yet do not have any ties to a formal religion. What-
ever one’s particular view of spirituality, it is a force that can help the individual
to fi nd a purpose (or purposes) for living. Spirituality or religious beliefs can be
a major sustaining power that supports clients when all else fails. Other clients
may be affected by depression and a sense of worthlessness due to guilt, anger, or
sadness created by their unexamined acceptance of spiritual or religious dogma.
Counselors must remain open and nonjudgmental in conversations about reli-
gion or spirituality. Furthermore, counselors cannot ignore a client’s spiritual and
religious perspectives if they want to practice in a culturally sensitive and ethical
manner (Young & Cashwell, 2011a; 2011b).
c o m m o n g oa l s In some ways spirituality and counseling have similar goals.
Both emphasize learning to accept oneself, forgiving others and oneself, learn-
ing to love oneself and others, admitting one’s shortcomings, accepting personal
responsibility, letting go of hurts and resentments, dealing with guilt, and learning
to let go of self-destructive patterns of thinking, feeling, and acting.
Spiritual/religious values have a major part to play in human life and strug-
gles, which means that exploring these values has a great deal to do with providing
solutions for clients’ struggles. Because spiritual and therapeutic paths converge in
some ways, integration is possible, and dealing with a client’s spirituality will often
enhance the therapy process. Themes that have healing infl uences include loving,
caring, learning to listen with compassion, challenging clients’ basic life assump-
tions, accepting human imperfection, and going outside of self-oriented interests
(social interest). Both religion and counseling help people ponder questions of
“Who am I?” and “What is the meaning of my life?” At their best, both counseling
and religion can foster healing.
i m p l i c at i o n s f o r a s s e s s m e n t a n d t r e at m e n t Traditionally,
when clients come to a therapist with a problem, the therapist explores all the factors
that contributed to the development of the problem. A background of involvement
in religion can be part of clients’ history, and thus it can be a part of the intake as-
sessment and can be explored in counseling sessions. Frame (2003) presents many
reasons for including spirituality in the assessment process: understanding clients’
worldviews and the contexts in which they live, assisting clients in grappling with
questions regarding the purpose of their lives and what they most value, exploring
religion and spirituality as client resources, and uncovering religious and spiritual
problems. This information will assist the therapist in choosing appropriate interven-
tions. Young and Cashwell (2011a) maintain that counselors must assess clients’ spir-
itual or religious beliefs if they may be exacerbating clients’ psychological problems.
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yo u r r o l e a s a c o u n s e lo r It is critical that counselors not be judgmen-
tal when it comes to their clients’ beliefs and that they create an inviting and safe
climate for clients to explore their values and beliefs. There are many paths toward
fulfi lling spiritual needs, and it is not your role as a counselor to prescribe any par-
ticular pathway. By conducting a thorough assessment on a client’s background,
you will obtain many clues regarding personal themes for potential exploration. If
you remain fi nely tuned to clients’ stories and to the purpose for which they sought
therapy, clients’ concerns about spiritual or religious values, beliefs, and practices
will surface.
To assist clients in clarifying their values and in making their own decisions
requires that you have a clear sense of your own spiritual perspective. Spiritual
self-awareness is the basis for competence in dealing with the worldviews of your
clients (Hagedorn & Moorhead, 2011). Worthington (2011) reminds therapists of
their responsibility to provide informed and sensitive care to all clients, whether or
not they embrace a spiritual or religious worldview:
Given the social changes and openness of both clients and therapists to religion and spiritu-
ality, it is a reasonable supposition that spirituality tailored therapies will increase to meet
clients’ needs. There will also need to be continuing sensitivity to clients who do not want
to attend religiously or spiritually tailored therapy. (p. 541)
Robertson and Young (2011) stress the need to work with a client’s spiritual and
religious concerns, and state that “failure to address these issues, may, in some
cases, be incompetent or unethical practice” (p. 38).
If you are to effectively serve diverse client populations, it is essential that you
pay attention to your training and competence in addressing spiritual and religious
concerns your clients bring to therapy. Ethically, it is important to monitor yourself
for subtle ways that you might be inclined to infl uence clients to embrace a spir-
itual perspective or to give up certain religious beliefs that you think are no longer
functional for them. It is important to keep in mind that clients should determine
the specifi c values they want to retain, replace, or modify.
From my vantage point, the emphasis on spirituality will continue to be impor-
tant in counseling practice, which makes it imperative that you prepare yourself to
work competently with the spiritual and religious concerns that your clients bring
up. For further reading on the topic of integrating spirituality and religion into
counseling, I highly recommend Integrating Spirituality and Religion into Coun-
seling: A Guide to Competent Practice (Cashwell & Young, 2011).
The Challenge of Developing an Integrative Perspective
A survey of approaches to counseling and psychotherapy reveals that no common
philosophy unifi es them. Many of the theories have different basic philosophies
and views of human nature (Table 15.1). As the postmodern therapists remind
us, our philosophical assumptions are important because they infl uence which
“reality” we perceive, and they direct our attention to the variables that we are “set”
to see. A word of caution, then: Beware of subscribing exclusively to any one view
of human nature. Remain open and selectively incorporate a framework for coun-
seling that is consistent with your own personality and your belief system.
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TA B L E 1 5 .1 The Basic Philosophies
Psychoanalytic therapy Human beings are basically determined by psychic energy and
by early experiences. Unconscious motives and confl icts are
central in present behavior. Early development is of critical
importance because later personality problems have their roots
in repressed childhood confl icts.
Adlerian therapy Humans are motivated by social interest, by striving toward
goals, by inferiority and superiority, and by dealing with the
tasks of life. Emphasis is on the individual’s positive capacities
to live in society cooperatively. People have the capacity to
interpret, infl uence, and create events. Each person at an
early age creates a unique style of life, which tends to remain
relatively constant throughout life.
Existential therapy The central focus is on the nature of the human condition, which
includes a capacity for self-awareness, freedom of choice to
decide one’s fate, responsibility, anxiety, the search for meaning,
being alone and being in relation with others, striving for
authenticity, and facing living and dying.
Person-centered therapy Positive view of people; we have an inclination toward
becoming fully functioning. In the context of the therapeutic
relationship, the client experiences feelings that were
previously denied to awareness. The client moves toward
increased awareness, spontaneity, trust in self, and inner-
directedness.
Gestalt therapy The person strives for wholeness and integration of thinking,
feeling, and behaving. Some key concepts include contact with
self and others, contact boundaries, and awareness. The view
is nondeterministic in that the person is viewed as having the
capacity to recognize how earlier infl uences are related to present
diffi culties. As an experiential approach, it is grounded in the
here and now and emphasizes awareness, personal choice, and
responsibility.
Behavior therapy Behavior is the product of learning. We are both the product and
the producer of the environment. Traditional behavior therapy
is based on classical and operant principles. Contemporary
behavior therapy has branched out in many directions.
Cognitive behavior therapy Individuals tend to incorporate faulty thinking, which leads
to emotional and behavioral disturbances. Cognitions are the
major determinants of how we feel and act. Therapy is primarily
oriented toward cognition and behavior, and it stresses the role
of thinking, deciding, questioning, doing, and redeciding. This
is a psychoeducational model, which emphasizes therapy as a
learning process, including acquiring and practicing new skills,
learning new ways of thinking, and acquiring more effective
ways of coping with problems.
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Reality therapy Based on choice theory, this approach assumes that we need
quality relationships to be happy. Psychological problems
are the result of our resisting the control by others or of our
attempt to control others. Choice theory is an explanation of
human nature and how to best achieve satisfying interpersonal
relationships.
Feminist therapy Feminists criticize many traditional theories to the degree
that they are based on gender-biased concepts, such as being
androcentric, gendercentric, ethnocentric, heterosexist, and
intrapsychic. The constructs of feminist therapy include being
gender fair, fl exible, interactionist, and life-span-oriented.
Gender and power are at the heart of feminist therapy. This
is a systems approach that recognizes the cultural, social, and
political factors that contribute to an individual’s problems.
Postmodern approaches Based on the premise that there are multiple realities and
multiple truths, postmodern therapies reject the idea that
reality is external and can be grasped. People create meaning in
their lives through conversations with others. The postmodern
approaches avoid pathologizing clients, take a dim view of
diagnosis, avoid searching for underlying causes of problems,
and place a high value on discovering clients’ strengths and
resources. Rather than talking about problems, the focus of
therapy is on creating solutions in the present and the future.
Family systems therapy The family is viewed from an interactive and systemic
perspective. Clients are connected to a living system; a change
in one part of the system will result in a change in other
parts. The family provides the context for understanding how
individuals function in relationship to others and how they
behave. Treatment deals with the family unit. An individual’s
dysfunctional behavior grows out of the interactional unit of the
family and out of larger systems as well.
Despite the divergences in the various theories, creative syntheses among some
models are possible. For example, an existential orientation does not necessarily
preclude using techniques drawn from behavior therapy or from some of the cog-
nitive theories. Each point of view offers a perspective for helping clients in their
search for self. I encourage you to study all the major theories and to remain open
to what you might take from the various orientations as a basis for an integrative
perspective that will guide your practice.
In developing a personal integrative perspective, it is important to be alert
to the problem of attempting to mix theories with incompatible underlying as-
sumptions. Lazarus (1995) asks, “How is it possible to blend two systems that
rest on totally different assumptions about the meaning, origins, development,
maintenance, signifi cance, and management of problems?” (p. 156). An advocate
of technical eclecticism, Lazarus (2008b) has consistently emphasized that a blend
of different theories is likely to result in confusion and argued against the notion
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of theoretical integration. He adds that basic concepts that may seem compatible
often are, upon closer scrutiny, quite irreconcilable (see Table 15.2). Lazarus stress-
es that psychotherapy integration does not have to rely on a theoretical amalgama-
tion. Clinicians can be technically eclectic (or technically integrative) in that they
can select methods from any discipline without necessarily endorsing any of the
theories that spawned them.
TA B L E 1 5 . 2 Key Concepts
Psychoanalytic therapy Normal personality development is based on successful
resolution and integration of psychosexual stages of
development. Faulty personality development is the result of
inadequate resolution of some specifi c stage. Anxiety is a result
of repression of basic confl icts. Unconscious processes are
centrally related to current behavior.
Adlerian therapy Key concepts include the unity of personality, the need to view
people from their subjective perspective, and the importance of
life goals that give direction to behavior. People are motivated
by social interest and by fi nding goals to give life meaning.
Other key concepts are striving for signifi cance and superiority,
developing a unique lifestyle, and understanding the family
constellation. Therapy is a matter of providing encouragement
and assisting clients in changing their cognitive perspective and
behavior.
Existential therapy Essentially an experiential approach to counseling rather than
a fi rm theoretical model, it stresses core human conditions.
Interest is on the present and on what one is becoming. The
approach has a future orientation and stresses self-awareness
before action.
Person-centered therapy The client has the potential to become aware of problems
and the means to resolve them. Faith is placed in the client’s
capacity for self-direction. Mental health is a congruence of ideal
self and real self. Maladjustment is the result of a discrepancy
between what one wants to be and what one is. In therapy
attention is given to the present moment and on experiencing
and expressing feelings.
Gestalt therapy Emphasis is on the “what” and “how” of experiencing in the
here and now to help clients accept all aspects of themselves. Key
concepts include holism, fi gure-formation process, awareness,
unfi nished business and avoidance, contact, and energy.
Behavior therapy Focus is on overt behavior, precision in specifying goals of
treatment, development of specifi c treatment plans, and
objective evaluation of therapy outcomes. Present behavior is
given attention. Therapy is based on the principles of learning
theory. Normal behavior is learned through reinforcement and
imitation. Abnormal behavior is the result of faulty learning.
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Cognitive behavior therapy Although psychological problems may be rooted in childhood,
they are reinforced by present ways of thinking. A person’s
belief system is the primary cause of disorders. Internal
dialogue plays a central role in one’s behavior. Clients focus
on examining faulty assumptions and misconceptions and on
replacing these with effective beliefs.
Reality therapy The basic focus is on what clients are doing and how to get
them to evaluate whether their present actions are working
for them. People are mainly motivated to satisfy their needs,
especially the need for signifi cant relationships. The approach
rejects the medical model, the notion of transference, the
unconscious, and dwelling on one’s past.
Feminist therapy Core principles of feminist therapy are that the personal is
political, therapists have a commitment to social change,
women’s voices and ways of knowing are valued and women’s
experiences are honored, the counseling relationship is
egalitarian, therapy focuses on strengths and a reformulated
defi nition of psychological distress, and all types of oppression
are recognized.
Postmodern approaches Therapy tends to be brief and addresses the present and the
future. The person is not the problem; the problem is the
problem. The emphasis is on externalizing the problem and
looking for exceptions to the problem. Therapy consists of a
collaborative dialogue in which the therapist and the client
co-create solutions. By identifying instances when the problem
did not exist, clients can create new meanings for themselves
and fashion a new life story.
Family systems therapy Focus is on communication patterns within a family, both
verbal and nonverbal. Problems in relationships are likely to
be passed on from generation to generation. Key concepts vary
depending on specifi c orientation but include differentiation,
triangles, power coalitions, family-of-origin dynamics,
functional versus dysfunctional interaction patterns, and
dealing with here-and-now interactions. The present is more
important than exploring past experiences.
By remaining theoretically consistent, but technically integrative, practi-
tioners can spell out precisely the interventions they will employ with various
clients, as well as the means by which they will select these procedures. Lazarus
(1997a, 1997b) contends that therapists who hope to be effective with a wide
range of problems and with different client populations must be flexible and
versatile. Therapists should ask these basic questions when devising a treat-
ment program: “What works for whom under which particular circumstances?”
“Why are some procedures helpful and others unhelpful?” “What can be done
to ensure long-term success and positive follow-ups?” Lazarus (1993) believes
some clients respond to warm, informal counselors but that others want more
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formal counselors. Some clients work well with therapists who are quiet and
nonforceful, whereas others work best with directive and outgoing therapists.
Furthermore, the same client may respond favorably to various therapeutic
techniques and styles at different times.
Lazarus (1996a) mentions the value of a therapist assuming an active role
in blending a fl exible repertoire of relationship styles with a wide range of tech-
niques as a way to enhance therapeutic outcomes. He maintains that a skilled
therapist is able to determine when to be confrontational, when to be directive,
when to allow the client to struggle, when to be formal or informal, when to
self-disclose or remain anonymous, and when to be gentle or tough. Lazarus
(1993) asserts that relationships of choice are at least as important as techni-
ques of choice. (For a review of multimodal procedures and their rationale, see
Chapter 9.)
One of the challenges you will face as a counselor is to deliver therapeutic
services in a brief, comprehensive, effective, and fl exible way. Many of the theoreti-
cal orientations addressed in this book can be applied to brief forms of therapy.
One of the driving forces of the psychotherapy integration movement has been
the increase of brief therapies and the pressures to do more for a variety of client
populations within the limitations of 6 to 20 sessions. Most forms of short-term
psychotherapy are active in nature, collaborative in relationship, and integrative in
orientation (Norcross & Beutler, 2011).
The main goal of brief therapy is to help clients resolve problems and to move
forward as quickly as possible. Some of the defi ning characteristics of brief therapy
include the following (Hoyt, 2011):
• Rapid working alliance between therapist and client
• Clear specifi cation of achievable treatment goals
• Clear division of responsibilities between client and therapist, with active client
participation and a high level of therapist activity
• Emphasis on client’s strengths, competencies, and adaptive capacities
• Expectation that change is possible and realistic
• Here-and-now orientation with a primary focus on current functioning in
thinking, feeling, and behaving
• Specifi c, integrated, and eclectic techniques
• Time sensitive, including making the most of each session and ending therapy
as soon as possible
The core task is for integrative practitioners to learn how to rapidly and system-
atically identify problems, create a collaborative relationship with clients, and
intervene with a range of specifi c methods. Hoyt puts the challenge to therapists
concisely: “The simple truth is that most therapy is brief therapy and will be
increasingly so; for the sake of our patients and our profession, we should learn to
practice it well” (p. 419).
An integrative perspective at its best entails a systematic integration of underly-
ing principles and methods common to a range of therapeutic approaches. The
strengths of systematic integration are based on its ability to be taught, replicated,
and evaluated (Norcross & Beutler, 2011). To develop this kind of integration, you
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will eventually need to be thoroughly conversant with a number of theories, be
open to the idea that these theories can be connected in some ways, and be will-
ing to continually test your hypotheses to determine how well they are working.
Developing a systematic integrative perspective is the product of a great deal of
study, clinical practice, research, and theorizing.
i s s u e s r e l at e d to t h e
t h e r a p e u t i c p r o c e s s
Therapeutic Goals
The goals of counseling are almost as diverse as are the theoretical approaches.
Some goals include restructuring the personality, uncovering the unconscious,
creating social interest, fi nding meaning in life, curing an emotional disturbance,
examining old decisions and making new ones, developing trust in oneself, be-
coming more self-actualizing, reducing anxiety, reducing maladaptive behavior
and learning adaptive patterns, becoming grounded in the present moment, man-
aging intense emotions, gaining more effective control of one’s life, and reauthor-
ing the story of one’s life (Table 15.3). Is there a common denominator in this range
of goals?
TA B L E 1 5 . 3 Goals of Therapy
Psychoanalytic therapy To make the unconscious conscious. To reconstruct the basic
personality. To assist clients in reliving earlier experiences and
working through repressed confl icts. To achieve intellectual and
emotional awareness.
Adlerian therapy To challenge clients’ basic premises and life goals. To offer
encouragement so individuals can develop socially useful goals
and increase social interest. To develop the client’s sense of
belonging.
Existential therapy To help people see that they are free and to become aware of
their possibilities. To challenge them to recognize that they
are responsible for events that they formerly thought were
happening to them. To identify factors that block freedom.
Person-centered therapy To provide a safe climate conducive to clients’ self-exploration,
so that they can recognize blocks to growth and can experience
aspects of self that were formerly denied or distorted. To enable
them to move toward openness, greater trust in self, willingness
to be a process, and increased spontaneity and aliveness. To fi nd
meaning in life and to experience life fully. To become more
self-directed.
Gestalt therapy To assist clients in gaining awareness of moment-to-moment
experiencing and to expand the capacity to make choices. To
foster integration of the self.
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Behavior therapy To eliminate maladaptive behaviors and learn more effective
behaviors. To identify factors that infl uence behavior and fi nd
out what can be done about problematic behavior. To encourage
clients to take an active and collaborative role in clearly setting
treatment goals and evaluating how well these goals are
being met.
Cognitive behavior therapy To teach clients to confront faulty beliefs with contradictory
evidence that they gather and evaluate. To help clients seek out
their faulty beliefs and minimize them. To become aware of
automatic thoughts and to change them.
Reality therapy To help people become more effective in meeting all of their
psychological needs. To enable clients to get reconnected with
the people they have chosen to put into their quality worlds and
teach clients choice theory.
Feminist therapy To bring about transformation both in the individual client and
in society. To assist clients in recognizing, claiming, and using
their personal power to free themselves from the limitations of
gender-role socialization. To confront all forms of institutional
policies that discriminate or oppress on any basis.
Postmodern approaches To change the way clients view problems and what they can do
about these concerns. To collaboratively establish specifi c, clear,
concrete, realistic, and observable goals leading to increased
positive change. To help clients create a self-identity grounded
on competence and resourcefulness so they can resolve present
and future concerns. To assist clients in viewing their lives in
positive ways, rather than being problem saturated.
Family systems therapy To help family members gain awareness of patterns of
relationships that are not working well and to create new ways
of interacting.
This diversity can be simplifi ed by considering the degree of generality or spe-
cifi city of goals. Goals exist on a continuum from specifi c, concrete, and short term
on one end, to general, global, and long term on the other. The cognitive behavioral
approaches stress the former; the relationship-oriented therapies tend to stress the
latter. The goals at opposite ends of the continuum are not necessarily contradic-
tory; it is a matter of how specifi cally they are defi ned.
Therapist’s Function and Role
In working toward an integrative perspective, ask yourself these questions:
• How do the counselor’s functions change depending on the stage of the coun-
seling process?
• Does the therapist maintain a basic role, or does this role vary in accordance
with the characteristics of the client?
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• How does the counselor determine how active and directive to be?
• How is structuring handled as the course of therapy progresses?
• What is the optimum balance of responsibility in the client–therapist relationship?
• What is the most effective way to monitor the therapeutic alliance?
• What, when, and how much does the counselor self-disclose?
As you saw through your study of the 11 therapeutic approaches, a central issue
of each system is the degree to which the therapist exercises control over clients’
behavior both during and outside the session. Cognitive behavior therapists and
reality therapists, for example, operate within a present-centered, directive, didac-
tic, structured, and psychoeducational context. As a collaborative endeavor, they
frequently design homework assignments to assist clients in practicing new behav-
ior outside therapy sessions. In contrast, person-centered therapists operate with a
much looser and less defi ned structure. Solution-focused and narrative therapists
view the client as the expert on his or her own life; they assist clients in refl ection
outside of the session that might result in self-directed change. Although they are
active questioners, they are not prescriptive in their practice.
Structuring depends on the particular client and the specifi c circumstances he
or she brings to the therapy situation. From my perspective, clear structure is most
essential during the early phase of counseling because it encourages the client to
talk about the problems that led to seeking therapy. In a collaborative way, it is
useful for both counselor and client to make some initial assessment that can pro-
vide a focus for the therapy process. As soon as possible, the client should be given
a signifi cant share of the responsibility for deciding on the content and agenda of
the sessions. From early in the therapy process the client can be empowered if the
counselor expects the client to become an active participant in the process.
Client’s Experience in Therapy
Most clients share some degree of suffering, pain, or at least discontent. There
is a discrepancy between how they would like to be and how they are. Some in-
dividuals initiate therapy because they hope to cure a specifi c symptom or set of
symptoms. They want to get rid of migraine headaches, free themselves of chronic
anxiety attacks, lose weight, or get relief from depression. They may have confl ict-
ing feelings and reactions, may struggle with low self-esteem, or may have limited
information and skills. Many seek to resolve confl icts in their close relationships.
I believe people are increasingly entering therapy with existential problems. Their
complaints often relate to the these existential issues: a sense of emptiness, mean-
inglessness in life, routine ways of living, unsatisfying personal relationships,
anxiety over uncertainty, a lack of intense feelings, and a loss of their sense of self.
The initial expectation of many clients is that results will come quickly. They
often have great hope for major changes in their life and rely on direction from the
therapist. As therapy progresses, clients discover that they must be active in the
process, selecting their own goals and working toward them, both in the sessions
and in daily living. Some clients can benefi t from recognizing and expressing pent-
up feelings, others will need to examine their beliefs and thoughts, others will
most need to begin behaving in different ways, and others will benefi t from talking
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with you about their relationships with the signifi cant people in their lives. Most
clients will need to do some work in all three dimensions—feelings, thoughts, and
behaviors—because these dimensions are interrelated.
In deciding what interventions are most likely to be helpful, it is important
to take into account the client’s cultural, ethnic, and socioeconomic background.
Moreover, the focus of counseling may change as clients enter different phas-
es in the counseling process. Although some clients initially feel a need to be
listened to and allowed to express deep feelings, they can profi t later from ex-
amining the thought patterns that are contributing to their psychological pain.
Certainly at some point in therapy it is essential that clients translate what they
are learning about themselves into concrete action. The client’s given situation
in the environment provides a framework for selecting interventions that are
most appropriate.
Listening to client feedback about the therapy process is of the utmost im-
portance. One of the best ways to improve the effectiveness of psychotherapy is
through client-directed, outcome-informed therapy (Duncan, Miller, & Sparks,
2004). Therapists need to take direction from their clients. If therapists learn to
listen to clients’ feedback throughout the therapeutic process, clients can become
full and equal participants in all aspects of their therapy. In their book, The Heroic
Client, Duncan and his colleagues (2004) emphasize that “it is time to recast the
client as not only the hero or heroine of the therapy drama but also the director of
the change endeavor” (p. 12). Client strengths and perceptions are the foundation
of therapy work, and these authors advocate for systematic and consistent assess-
ment of the client’s perceptions of progress, which allows the therapist to tailor
the therapy to the individual needs and characteristics of each client. Using client
feedback, therapists can adjust and accommodate to maximize benefi cial outcomes.
In essence, Duncan and colleagues are arguing for practice-based evidence rather
than evidence-based practice: “Becoming outcome informed not only amplifi es the
client’s voice but offers the most viable, research-tested method to improve clinical
effectiveness” (p. 16).
Relationship Between Therapist and Client
Most approaches share common ground in accepting the importance of the thera-
peutic relationship. The existential, person-centered, Gestalt, Adlerian, and post-
modern views emphasize the personal relationship as the crucial determinant of
treatment outcomes. Rational emotive behavior therapy, reality therapy, cognitive
behavior therapy, and behavior therapy certainly do not ignore the relationship fac-
tor, yet they place less emphasis on the relationship and more on the effective use
of techniques (Table 15.4).
Counseling is a personal matter that involves a personal relationship, and evi-
dence indicates that honesty, sincerity, acceptance, understanding, and spontaneity
are basic ingredients for successful outcomes. Therapists’ degree of caring, their
interest and ability in helping their clients, and their genuineness infl uence the
relationship. Norcross and Wampold (2011a) stress that psychotherapy is primarily
a human relationship. Both client and therapist bring origins, culture, expecta-
tions, biases, defenses, and strengths to this relationship. They claim that how we
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TA B L E 1 5 . 4 The Therapeutic Relationship
Psychoanalytic therapy The classical analyst remains anonymous, and clients
develop projections toward him or her. Focus is on
reducing the resistances that develop in working with
transference and on establishing more rational control.
Clients undergo long-term analysis, engage in free
association to uncover confl icts, and gain insight by
talking. The analyst makes interpretations to teach clients
the meaning of current behavior as it relates to the past.
In contemporary relational psychoanalytic therapy, the
relationship is central and emphasis is given to here-and-
now dimensions of this relationship.
Adlerian therapy The emphasis is on joint responsibility, on mutually
determining goals, on mutual trust and respect, and
on equality. Focus is on identifying, exploring, and
disclosing mistaken goals and faulty assumptions within
the person’s lifestyle.
Existential therapy The therapist’s main tasks are to accurately grasp
clients’ being in the world and to establish a personal
and authentic encounter with them. The immediacy
of the client–therapist relationship and the authenticity
of the here-and-now encounter are stressed. Both
client and therapist can be changed by the
encounter.
Person-centered therapy The relationship is of primary importance. The qualities
of the therapist, including genuineness, warmth,
accurate empathy, respect, and nonjudgmentalness—
and communication of these attitudes to clients—are
stressed. Clients use this genuine relationship with the
therapist to help them transfer what they learn to other
relationships.
Gestalt therapy Central importance is given to the I/Thou relationship
and the quality of the therapist’s presence. The therapist’s
attitudes and behavior count more than the techniques
used. The therapist does not interpret for clients but
assists them in developing the means to make their own
interpretations. Clients identify and work on unfi nished
business from the past that interferes with current
functioning.
Behavior therapy The therapist is active and directive and functions
as a teacher or mentor in helping clients learn
more effective behavior. Clients must be active in the
process and experiment with new behaviors. Although
a quality client–therapist relationship is not viewed
as suffi cient to bring about change, it is considered
essential for implementing behavioral procedures.
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Cognitive behavior therapy In REBT the therapist functions as a teacher and the client
as a student. The therapist is highly directive and teaches
clients an A-B-C model of changing their cognitions. In
CT the focus is on a collaborative relationship. Using a
Socratic dialogue, the therapist assists clients in identifying
dysfunctional beliefs and discovering alternative rules for
living. The therapist promotes corrective experiences that
lead to learning new skills. Clients gain insight into their
problems and then must actively practice changing self-
defeating thinking and acting.
Reality therapy A fundamental task is for the therapist to create a good
relationship with the client. Therapists are then able to
engage clients in an evaluation of all their relationships
with respect to what they want and how effective they
are in getting this. Therapists fi nd out what clients want,
ask what they are choosing to do, invite them to evaluate
present behavior, help them make plans for change,
and get them to make a commitment. The therapist is a
client’s advocate, as long as the client is willing to attempt
to behave responsibly.
Feminist therapy The therapeutic relationship is based on empowerment
and egalitarianism. Therapists actively break down
the hierarchy of power and reduce artifi cial barriers by
engaging in appropriate self-disclosure and teaching
clients about the therapy process. Therapists strive to
create a collaborative relationship in which clients can
become their own expert.
Postmodern approaches Therapy is a collaborative partnership. Clients are viewed
as the experts on their own life. Therapists use questioning
dialogue to help clients free themselves from their
problem-saturated stories and create new life-affi rming
stories. Solution-focused therapists assume an active role
in guiding the client away from problem-talk and toward
solution-talk. Clients are encouraged to explore their
strengths and to create solutions that will lead to a richer
future. Narrative therapists assist clients in externalizing
problems and guide them in examining self-limiting
stories and creating new and more liberating stories.
Family systems therapy The family therapist functions as a teacher, coach,
model, and consultant. The family learns ways to detect
and solve problems that are keeping members stuck,
and it learns about patterns that have been transmitted
from generation to generation. Some approaches focus
on the role of therapist as expert; others concentrate on
intensifying what is going on in the here and now of the
family session. All family therapists are concerned with
the process of family interaction and teaching patterns of
communication.
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create and nurture this powerful human relationship can be guided by the fruits
of research.
As you think about developing your personal counseling perspective, give con-
sideration to the issue of the match between client and counselor. I certainly do
not advocate changing your personality to fi t your perception of what each client
is expecting; it is important that you be yourself as you meet clients. You also need
to consider the reality that you will probably not be able to work effectively with
every client. Some clients will work better with counselors who have another type
of personal and therapeutic style than yours. Be sensitive in assessing what your
client needs, and use good judgment when determining the appropriateness of the
match between you and a potential client.
Although you do not have to be like your clients or have experienced the same
problems to be effective with them, it is critical that you be able to understand
their world and respect them. Ask yourself how well prepared you are to counsel
clients from a different cultural background. To what degree do you think you
can successfully establish a therapeutic relationship with a client of a different
race? Ethnic group? Gender? Age? Sexual orientation? Spiritual/religious orienta-
tion? Socioeconomic group? Do you see any potential barriers that would make it
diffi cult for you to form a working relationship with certain clients? It is also im-
portant to consider the client’s diagnosis, resistance level, treatment preferences,
and stages of change. Different types of clients respond better to different types of
treatments and relationship styles. Therapeutic techniques and styles should be
selected to fi t the client’s personal characteristics. Norcross and Beutler (2011) sug-
gest that therapists create a new therapy for each client:
We believe that the purpose of integrative psychotherapy is not to create a single or uni-
tary treatment. Rather, we select different treatment methods according to the patient’s
response to the treatment goals, following an established set of integrative principles. The
result is a more effi cient and effi cacious therapy—and one that fi ts both the client and the
clinician. (p. 509)
t h e p l a c e o f t e c h n i q u e s
a n d e va l u at i o n i n c o u n s e l i n g
Drawing on Techniques From Various Approaches
Effective therapists incorporate a wide range of procedures into their therapeutic
style. Much depends on the purpose of therapy, the setting, the personality and
style of the therapist, the qualities of the particular client, and the problems selected
for intervention. Regardless of the therapeutic model you may be working with,
you must decide what relationship style to adopt, what techniques, procedures, or
intervention methods to use, when to use them, and with which clients. Take time
to review Table 15.5 and Table 15.6 on therapeutic techniques and applications of
techniques. Pay careful attention to the focus of each type of therapy and how that
focus might be useful in your practice.
It is critical to be aware of how clients’ cultural backgrounds contribute to their
perceptions of their problems. Each of the 11 therapeutic approaches has both
strengths and limitations when applied to culturally diverse client populations
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TA B L E 1 5 . 5 Techniques of Therapy
Psychoanalytic therapy The key techniques are interpretation, dream analysis, free
association, analysis of resistance, analysis of transference,
and countertransference. Techniques are designed to help
clients gain access to their unconscious confl icts, which
leads to insight and eventual assimilation of new material
by the ego.
Adlerian therapy Adlerians pay more attention to the subjective
experiences of clients than to using techniques.
Some techniques include gathering life-history data
(family constellation, early recollections, personal
priorities), sharing interpretations with clients, offering
encouragement, and assisting clients in searching for
new possibilities.
Existential therapy Few techniques fl ow from this approach because it
stresses understanding fi rst and technique second. The
therapist can borrow techniques from other approaches
and incorporate them in an existential framework.
Diagnosis, testing, and external measurements are not
deemed important. Issues addressed are freedom and
responsibility, isolation and relationships, meaning and
meaninglessness, living and dying.
Person-centered therapy This approach uses few techniques but stresses the
attitudes of the therapist and a “way of being.” Therapists
strive for active listening, refl ection of feelings,
clarifi cation, “being there” for the client, and focusing on
the moment-to-moment experiencing of the client. This
model does not include diagnostic testing, interpretation,
taking a case history, or questioning or probing for
information.
Gestalt therapy A wide range of experiments are designed to intensify
experiencing and to integrate confl icting feelings.
Experiments are co-created by therapist and client through
an I/Thou dialogue. Therapists have latitude to creatively
invent their own experiments. Formal diagnosis and
testing are not a required part of therapy.
Behavior therapy The main techniques are reinforcement, shaping,
modeling, systematic desensitization, relaxation methods,
fl ooding, eye movement and desensitization reprocessing,
cognitive restructuring, assertion and social skills training,
self-management programs, mindfulness and acceptance
methods, behavioral rehearsal, coaching, and various
multimodal therapy techniques. Diagnosis or assessment
is done at the outset to determine a treatment plan.
Questions concentrate on “what,” “how,” and “when” (but
not “why”). Contracts and homework assignments are also
typically used.
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Cognitive behavior therapy Therapists use a variety of cognitive, emotive, and
behavioral techniques; diverse methods are tailored to suit
individual clients. This is an active, directive, time-limited,
present-centered, psychoeducational, structured therapy.
Some techniques include engaging in Socratic dialogue,
collaborative empiricism, debating irrational beliefs,
carrying out homework assignments, gathering data on
assumptions one has made, keeping a record of activities,
forming alternative interpretations, learning new coping
skills, changing one’s language and thinking patterns,
role playing, imagery, confronting faulty beliefs, self-
instructional training, and stress inoculation training.
Reality therapy This is an active, directive, and didactic therapy. Skillful
questioning is a central technique used for the duration of
the therapy process. Various techniques may be used to get
clients to evaluate what they are presently doing to see if
they are willing to change. If clients decide that their present
behavior is not effective, they develop a specifi c plan for
change and make a commitment to follow through.
Feminist therapy Although techniques from traditional approaches are
used, feminist practitioners tend to employ consciousness-
raising techniques aimed at helping clients recognize the
impact of gender-role socialization on their lives. Other
techniques frequently used include gender-role analysis
and intervention, power analysis and intervention,
demystifying therapy, bibliotherapy, journal writing,
therapist self-disclosure, assertiveness training, reframing
and relabeling, cognitive restructuring, identifying and
challenging untested beliefs, role playing, psychodramatic
methods, group work, and social action.
Postmodern approaches In solution-focused therapy the main technique involves
change-talk, with emphasis on times in a client’s life
when the problem was not a problem. Other techniques
include creative use of questioning, the miracle
question, and scaling questions, which assist clients
in developing alternative stories. In narrative therapy,
specifi c techniques include listening to a client’s problem-
saturated story without getting stuck, externalizing and
naming the problem, externalizing conversations, and
discovering clues to competence. Narrative therapists
often write letters to clients and assist them in fi nding an
audience that will support their changes and new stories.
Family systems therapy A variety of techniques may be used, depending on the
particular theoretical orientation of the therapist. Techniques
include genograms, teaching, asking questions, joining the
family, tracking sequences, issuing directives, use of
countertransference, family mapping, reframing, restructuring,
enactments, and setting boundaries. Techniques may be
experiential, cognitive, or behavioral in nature. Most are
designed to bring about change in a short time.
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TA B L E 1 5 . 6 Applications of the Approaches
Psychoanalytic therapy Candidates for analytic therapy include professionals who
want to become therapists, people who have had intensive
therapy and want to go further, and those who are in
psychological pain. Analytic therapy is not recommended for
self-centered and impulsive individuals or for people with
psychotic disorders. Techniques can be applied to individual
and group therapy.
Adlerian therapy Because the approach is based on a growth model, it is
applicable to such varied spheres of life as child guidance,
parent–child counseling, marital and family therapy,
individual counseling with all age groups, correctional and
rehabilitation counseling, group counseling, substance
abuse programs, and brief counseling. It is ideally suited to
preventive care and alleviating a broad range of conditions that
interfere with growth.
Existential therapy This approach is especially suited to people facing a
developmental crisis or a transition in life and for those with
existential concerns (making choices, dealing with freedom
and responsibility, coping with guilt and anxiety, making
sense of life, and fi nding values) or those seeking personal
enhancement. The approach can be applied to both individual
and group counseling, and to couples and family therapy,
crisis intervention, and community mental health work.
Person-centered therapy Has wide applicability to individual and group counseling.
It is especially well suited for the initial phases of crisis
intervention work. Its principles have been applied to couples
and family therapy, community programs, administration
and management, and human relations training. It is a
useful approach for teaching, parent–child relations, and
for working with groups of people from diverse cultural
backgrounds.
Gestalt therapy Addresses a wide range of problems and populations: crisis
intervention, treatment of a range of psychosomatic disorders,
couples and family therapy, awareness training of mental
health professionals, behavior problems in children, and
teaching and learning. It is well suited to both individual and
group counseling. The methods are powerful catalysts for
opening up feelings and getting clients into contact with their
present-centered experience.
Behavior therapy A pragmatic approach based on empirical validation of results.
Enjoys wide applicability to individual, group, couples, and
family counseling. Some problems to which the approach is
well suited are phobic disorders, depression, trauma, sexual
disorders, children’s behavioral disorders, stuttering, and
prevention of cardiovascular disease. Beyond clinical practice,
its principles are applied in fi elds such as pediatrics, stress
management, behavioral medicine, education, and geriatrics.
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Cognitive behavior therapy Has been widely applied to treatment of depression, anxiety,
relationship problems, stress management, skill training,
substance abuse, assertion training, eating disorders, panic
attacks, performance anxiety, and social phobias. CBT is
especially useful for assisting people in modifying their
cognitions. Many self-help approaches utilize its principles.
CBT can be applied to a wide range of client populations with
a variety of specifi c problems.
Reality therapy Geared to teaching people ways of using choice theory in
everyday living to increase effective behaviors. It has been
applied to individual counseling with a wide range of clients,
group counseling, working with youthful law offenders, and
couples and family therapy. In some instances it is well suited
to brief therapy and crisis intervention.
Feminist therapy Principles and techniques can be applied to a range
of therapeutic modalities such as individual therapy,
relationship counseling, family therapy, group counseling,
and community intervention. The approach can be applied
to both women and men with the goal of bringing about
empowerment.
Postmodern approaches Solution-focused therapy is well suited for people with
adjustment disorders and for problems of anxiety and
depression. Narrative therapy is now being used for a broad
range of human diffi culties including eating disorders,
family distress, depression, and relationship concerns.
These approaches can be applied to working with children,
adolescents, adults, couples, families, and the community in
a wide variety of settings. Both solution-focused and narrative
approaches lend themselves to group counseling and to
school counseling.
Family systems therapy Useful for dealing with marital distress, problems of
communicating among family members, power struggles,
crisis situations in the family, helping individuals attain
their potential, and enhancing the overall functioning of the
family.
(Table 15.7 and Table 15.8). Although it is unwise to stereotype clients because of
their cultural heritage, it is useful to assess how the cultural context has a bearing
on their concerns. Some techniques may be contraindicated because of a client’s
socialization. The client’s responsiveness (or lack of it) to certain techniques is a
critical barometer in judging the effectiveness of these methods.
Effective counseling involves profi ciency in a combination of cognitive, affec-
tive, and behavioral techniques. Such a combination is necessary to help clients
think about their beliefs and assumptions, to experience on a feeling level their
confl icts and struggles, and to translate their insights into action programs by
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TA B L E 1 5 . 7 Contributions to Multicultural Counseling
Psychoanalytic therapy Its focus on family dynamics is appropriate for working
with many cultural groups. The therapist’s formality appeals
to clients who expect professional distance. Notion of ego
defense is helpful in understanding inner dynamics and
dealing with environmental stresses.
Adlerian therapy Its focus on social interest, helping others, collectivism,
pursuing meaning in life, importance of family, goal
orientation, and belonging is congruent with the values of
many cultures. Focus on person-in-the-environment allows
for cultural factors to be explored.
Existential therapy Focus is on understanding client’s phenomenological world,
including cultural background. This approach leads to
empowerment in an oppressive society. Existential therapy can
help clients examine their options for change within the context
of their cultural realities. The existential approach is particularly
suited to counseling diverse clients because of the philosophical
foundation that emphasizes the human condition.
Person-centered therapy Focus is on breaking cultural barriers and facilitating open
dialogue among diverse cultural populations. Main strengths
are respect for clients’ values, active listening, welcoming
of differences, nonjudgmental attitude, understanding,
willingness to allow clients to determine what will be
explored in sessions, and prizing cultural pluralism.
Gestalt therapy Its focus on expressing oneself nonverbally is congruent
with those cultures that look beyond words for messages.
Provides many experiments in working with clients who
have cultural injunctions against freely expressing feelings.
Can help to overcome language barrier with bilingual clients.
Focus on bodily expressions is a subtle way to help clients
recognize their confl icts.
Behavior therapy Focus on behavior, rather than on feelings, is compatible
with many cultures. Strengths include a collaborative
relationship between counselor and client in working
toward mutually agreed-upon goals, continual assessment
to determine if the techniques are suited to clients’ unique
situations, assisting clients in learning practical skills, an
educational focus, and stress on self-management strategies.
Cognitive behavior therapy Focus is on a collaborative approach that offers clients
opportunities to express their areas of concern. The
psychoeducational dimensions are often useful in exploring
cultural confl icts and teaching new behavior. The emphasis on
thinking (as opposed to identifying and expressing feelings) is
likely to be acceptable to many clients. The focus on teaching
and learning tends to avoid the stigma of mental illness. Clients
may value the active and directive stance of the therapist.
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Reality therapy Focus is on clients making their own evaluation of behavior
(including how they respond to their culture). Through
personal assessment clients can determine the degree to
which their needs and wants are being satisfi ed. They can
fi nd a balance between retaining their own ethnic identity
and integrating some of the values and practices of the
dominant society.
Feminist therapy Focus is on both individual change and social transformation.
A key contribution is that both the women’s movement and
the multicultural movement have called attention to the
negative impact of discrimination and oppression for both
women and men. Emphasizes the infl uence of expected
cultural roles and explores client’s satisfaction with and
knowledge of these roles.
Postmodern approaches Focus is on the social and cultural context of behavior.
Stories that are being authored in the therapy offi ce need
to be anchored in the social world in which the client lives.
Therapists do not make assumptions about people and
honor each client’s unique story and cultural background.
Therapists take an active role in challenging social and
cultural injustices that lead to oppression of certain groups.
Therapy becomes a process of liberation from oppressive
cultural values and enables clients to become active agents of
their destinies.
Family systems therapy Focus is on the family or community system. Many ethnic
and cultural groups place value on the role of the extended
family. Many family therapies deal with extended family
members and with support systems. Networking is a part
of the process, which is congruent with the values of many
clients. There is a greater chance for individual change if
other family members are supportive. This approach offers
ways of working toward the health of the family unit and the
welfare of each member.
TA B L E 1 5 . 8 Limitations in Multicultural Counseling
Psychoanalytic therapy Its focus on insight, intrapsychic dynamics, and long-term
treatment is often not valued by clients who prefer to learn
coping skills for dealing with pressing daily concerns.
Internal focus is often in confl ict with cultural values that
stress an interpersonal and environmental focus.
Adlerian therapy This approach uses a detailed interview about one’s
family background; this can confl ict with cultures that
have injunctions against disclosing family matters. Some
clients may view the counselor as an authority who will
provide answers to problems, which confl icts with the
egalitarian, person-to-person spirit as a way to reduce
social distance.
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Existential therapy Values of individuality, freedom, autonomy, and
self-realization often confl ict with cultural values of
collectivism, respect for tradition, deference to authority,
and interdependence. Some may be deterred by the
absence of specifi c techniques. Others will expect more
focus on surviving in their world.
Person-centered therapy Some of the core values of this approach may not be
congruent with the client’s culture. Lack of counselor
direction and structure are unacceptable for clients
who are seeking help and immediate answers from a
knowledgeable professional.
Gestalt therapy Clients who have been culturally conditioned to
be emotionally reserved may not embrace Gestalt
experiments. Some may not see how “being aware of
present experiencing” will lead to solving their problems.
Behavior therapy Family members may not value clients’ newly acquired
assertive style, so clients must be taught how to cope
with resistance by others. Counselors need to help
clients assess the possible consequences of making
behavioral changes.
Cognitive behavior therapy Before too quickly attempting to change the beliefs
and actions of clients, it is essential for the therapist
to understand and respect their world. Some clients
may have serious reservations about questioning their
basic cultural values and beliefs. Clients could become
dependent on the therapist for deciding what are
appropriate ways to solve problems.
Reality therapy This approach stresses taking charge of one’s own life,
yet some clients are more interested in changing their
external environment. Counselor needs to appreciate the
role of discrimination and racism and help clients deal
with social and political realities.
Feminist therapy This model has been criticized for its bias toward the
values of White, middle-class, heterosexual women,
which are not applicable to many other groups of women
nor to men. Therapists need to assess with their clients
the price of making signifi cant personal change, which
may result in isolation from extended family as clients
assume new roles and make life changes.
Postmodern approaches Some clients come to therapy wanting to talk about their
problems and may be put off by the insistence on talking
about exceptions to their problems. Clients may view the
therapist as an expert and be reluctant to view themselves
as experts. Certain clients may doubt the helpfulness of a
therapist who assumes a “not-knowing” position.
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Family systems therapy Family therapy rests on value assumptions that are
not congruent with the values of clients from some
cultures. Western concepts such as individuation,
self-actualization, self-determination, independence,
and self-expression may be foreign to some clients. In
some cultures, admitting problems within the family is
shameful. The value of “keeping problems within the
family” may make it diffi cult to explore confl icts openly.
TA B L E 1 5 . 9 Contributions of the Approaches
Psychoanalytic therapy More than any other system, this approach has generated
controversy as well as exploration and has stimulated
further thinking and development of therapy. It has
provided a detailed and comprehensive description of
personality structure and functioning. It has brought
into prominence factors such as the unconscious as a
determinant of behavior and the role of trauma during the
fi rst 6 years of life. It has developed several techniques for
tapping the unconscious and shed light on the dynamics
of transference and countertransference, resistance,
anxiety, and the mechanisms of ego defense.
Adlerian therapy A key contribution is the infl uence that Adlerian
concepts have had on other systems and the integration
of these concepts into various contemporary therapies.
This is one of the fi rst approaches to therapy that was
humanistic, unifi ed, holistic, and goal-oriented and that
put an emphasis on social and psychological factors.
Existential therapy Its major contribution is recognition of the need for a
subjective approach based on a complete view of the human
condition. It calls attention to the need for a philosophical
statement on what it means to be a person. Stress on the I/
Thou relationship lessens the chances of dehumanizing
therapy. It provides a perspective for understanding anxiety,
guilt, freedom, death, isolation, and commitment.
behaving in new ways in day-to-day living. Table 15.9 and Table 15.10 outline the
contributions and limitations of the various therapeutic approaches. These tables
will help you identify elements from the various approaches that you may want to
incorporate in your own counseling perspective.
Evaluating the Effectiveness of Counseling and Therapy
Mental health providers must be accountable and be able to demonstrate the effi cacy
of their services. In the era of managed care, it is even more essential for practitioners
to demonstrate the degree to which their interventions are both clinically sound and
cost-effective. Does therapy make a signifi cant difference? Are people substantially bet-
ter after therapy than they were without it? Can therapy actually be more harmful than
helpful? A thorough discussion of these questions is beyond the scope of this book, but
I will address a few basic issues related to evaluating the effectiveness of counseling.
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Person-centered therapy Clients take an active stance and assume responsibility
for the direction of therapy. This unique approach has
been subjected to empirical testing, and as a result
both theory and methods have been modifi ed. It is an
open system. People without advanced training can
benefi t by translating the therapeutic conditions to both
their personal and professional lives. Basic concepts
are straightforward and easy to grasp and apply. It
is a foundation for building a trusting relationship,
applicable to all therapies.
Gestalt therapy The emphasis on direct experiencing and doing rather than
on merely talking about feelings provides a perspective
on growth and enhancement, not merely a treatment of
disorders. It uses clients’ behavior as the basis for making
them aware of their inner creative potential. The approach
to dreams is a unique, creative tool to help clients discover
basic confl icts. Therapy is viewed as an existential
encounter; it is process-oriented, not technique-oriented. It
recognizes nonverbal behavior as a key to understanding.
Behavior therapy Emphasis is on assessment and evaluation techniques,
thus providing a basis for accountable practice. Specifi c
problems are identifi ed, and clients are kept informed
about progress toward their goals. The approach has
demonstrated effectiveness in many areas of human
functioning. The roles of the therapist as reinforcer,
model, teacher, and consultant are explicit. The approach
has undergone extensive expansion, and research
literature abounds. No longer is it a mechanistic
approach, for it now makes room for cognitive factors and
encourages self-directed programs for behavioral change.
Cognitive behavior therapy Major contributions include emphasis on a comprehensive
and eclectic therapeutic practice; numerous cognitive,
emotive, and behavioral techniques; an openness to
incorporating techniques from other approaches; and a
methodology for challenging and changing faulty thinking.
Most forms can be integrated into other mainstream
therapies. REBT makes full use of action-oriented
homework, various psychoeducational methods, and
keeping records of progress. CT is a structured therapy
that has a good track record for treating depression and
anxiety in a short time.
Reality therapy This is a positive approach with an action orientation
that relies on simple and clear concepts that are easily
grasped in many helping professions. It can be used by
teachers, nurses, ministers, educators, social workers,
and counselors. Due to the direct methods, it appeals to
many clients who are often seen as resistant to therapy.
It is a short-term approach that can be applied to a
diverse population, and it has been a signifi cant force in
challenging the medical model of therapy.
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Feminist therapy The feminist perspective is responsible for encouraging
increasing numbers of women to question gender
stereotypes and to reject limited views of what a woman
is expected to be. It is paving the way for gender-
sensitive practice and bringing attention to the gendered
uses of power in relationships. The unifi ed feminist
voice brought attention to the extent and implications
of child abuse, incest, rape, sexual harassment, and
domestic violence. Feminist principles and interventions
can be incorporated in other therapy approaches.
Postmodern approaches The brevity of these approaches fi t well with the
limitations imposed by a managed care structure. The
emphasis on client strengths and competence appeals to
clients who want to create solutions and revise their life
stories in a positive direction. Clients are not blamed for
their problems but are helped to understand how they
might relate in more satisfying ways to such problems.
A strength of these approaches is the question format
that invites clients to view themselves in new and more
effective ways.
Family systems therapy From a systemic perspective, neither the individual nor
the family is blamed for a particular dysfunction. The
family is empowered through the process of identifying
and exploring interactional patterns. Working with an
entire unit provides a new perspective on understanding
and working through both individual problems and
relationship concerns. By exploring one’s family of
origin, there are increased opportunities to resolve other
confl icts in systems outside of the family
TA B L E 1 5 .1 0 Limitations of the Approaches
Psychoanalytic therapy Requires lengthy training for therapists and much
time and expense for clients. The model stresses
biological and instinctual factors to the neglect of
social, cultural, and interpersonal ones. Its methods
are less applicable for solving specifi c daily life
problems of clients and may not be appropriate for
some ethnic and cultural groups. Many clients lack
the degree of ego strength needed for regressive and
reconstructive therapy. It may be inappropriate for
certain counseling settings.
Adlerian therapy Weak in terms of precision, testability, and empirical
validity. Few attempts have been made to validate
the basic concepts by scientifi c methods. Tends to
oversimplify some complex human problems and is
based heavily on common sense.
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Existential therapy Many basic concepts are fuzzy and ill-defi ned, making
its general framework abstract at times. Lacks a
systematic statement of principles and practices of
therapy. Has limited applicability to lower functioning
and nonverbal clients and to clients in extreme crisis
who need direction.
Person-centered therapy Possible danger from the therapist who remains
passive and inactive, limiting responses to refl ection.
Many clients feel a need for greater direction, more
structure, and more techniques. Clients in crisis may
need more directive measures. Applied to individual
counseling, some cultural groups will expect more
counselor activity.
Gestalt therapy Techniques lead to intense emotional expression; if
these feelings are not explored and if cognitive work is
not done, clients are likely to be left unfi nished and will
not have a sense of integration of their learning. Clients
who have diffi culty using imagination may not profi t
from certain experiments.
Behavior therapy Major criticisms are that it may change behavior but not
feelings; that it ignores the relational factors in therapy;
that it does not provide insight; that it ignores historical
causes of present behavior; that it involves control by the
therapist; and that it is limited in its capacity to address
certain aspects of the human condition.
Cognitive behavior therapy Tends to play down emotions, does not focus on exploring
the unconscious or underlying confl icts, de-emphasizes
the value of insight, and sometimes does not give enough
weight to the client’s past. REBT, being a confrontational
therapy, might lead to premature termination. CBT might
be too structured for some clients.
Reality therapy Discounts the therapeutic value of exploration of the
client’s past, dreams, the unconscious, early childhood
experiences, and transference. The approach is limited
to less complex problems. It is a problem-solving
therapy that tends to discourage exploration of deeper
emotional issues.
Feminist therapy A possible limitation is the potential for therapists
to impose a new set of values on clients—such as
striving for equality, power in relationships, defi ning
oneself, freedom to pursue a career outside the home,
and the right to an education. Therapists need to keep
in mind that clients are their own best experts, which
means it is up to them to decide which values to
live by.
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Postmodern approaches There is little empirical validation of the effectiveness
of therapy outcomes. Some critics contend that these
approaches endorse cheerleading and an overly positive
perspective. Some are critical of the stance taken by
most postmodern therapists regarding assessment
and diagnosis, and also react negatively to the
“not-knowing” stance of the therapist. Because some
of the solution-focused techniques are relatively easy
to learn, practitioners may use these interventions
in a mechanical way or implement these techniques
without a sound rationale.
Family systems therapy Limitations include problems in being able to involve
all the members of a family in the therapy. Some family
members may be resistant to changing the structure of
the system. Therapists’ self-knowledge and willingness
to work on their own family-of-origin issues is crucial,
for the potential for countertransference is high. It is
essential that the therapist be well trained, receive quality
supervision, and be competent in assessing and treating
individuals in a family context.
Evaluating how well psychotherapy works is far from simple. Therapeutic
systems are applied by practitioners who have unique individual characteristics,
and clients themselves have much to do with therapeutic outcomes. For example,
effects resulting from unexpected and uncontrollable events in the environment
can lessen the impact of gains made in psychotherapy. Moreover, practitioners
who adhere to the same approach are likely to use techniques in various ways and
to relate to clients in diverse fashions, functioning differently with different clients
and in different clinical settings. Norcross and Beutler (2011) note that evidence-
based practice refl ects a commitment on “what works, not on what theory applies”
(p. 510).
Most of the outcome studies have been done by two divergent groups: (1) the
behavior and cognitive therapists, who have based their therapeutic practice on
empirical studies, and (2) the person-centered researchers, who have made sig-
nifi cant contributions to understanding both process and outcome variables. Sig-
nifi cant empirical research dealing with how well the therapy works has not been
produced for most of the other models covered in this book.
How effective is psychotherapy? A meta-analysis of psychotherapy outcome
literature conducted by Smith, Glass, and Miller (1980) concluded that psycho-
therapy was highly effective. Prochaska and Norcross (2010) note that controlled
outcome research consistently supports the effectiveness of psychotherapy. They
point out that more than 5,000 individual studies and 500 meta-analyses have
been conducted on the effectiveness of psychotherapy; these studies demonstrate
that well-developed therapy interventions have meaningful, positive effects on
the intended outcome variables. In short, not only does psychotherapy work, but
research demonstrates that therapy is remarkably effective.
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A summary of the research data shows that the various treatment approaches
achieve roughly equivalent results (Duncan et al., 2004). Lambert’s (2011) re-
view of psychotherapy research makes it clear that the similarities rather than
the differences among models account for the effectiveness of psychothera-
py. Reviews of comparative outcome studies reveal the same general conclu-
sion: there is relative equivalence among the various therapeutic approaches.
Interpersonal, social, and affective factors common across therapeutic orienta-
tions are more critical than techniques employed when it comes to facilitat-
ing therapeutic gains. Lambert believes the future direction of theory, practice,
and training will see (1) the decline of single-theory practice and the growth
of integrative therapies, and (2) the increase in short-term, time-limited, and
group treatments that seem to be as effective as long-term individual treatments
with many client populations.
Although it is clear that therapy works, there are no simple explanations of
how it works, and it appears that we must look to factors that are common to all
therapeutic approaches. Hubble, Duncan, Miller, and Wampold (2010) summa-
rized research studies in the fi eld and found that the following four factors account
for change in therapy:
• Client factors: 40%
• Alliance factors (the therapeutic relationship): 30%
• Expectancy factors (hope and allegiance): 15%
• Theoretical models and techniques: 15%
Common factors that are part of all theoretical orientations are critical to thera-
peutic outcome. Wampold (2010) concludes that “there is little evidence that the
specifi c ingredients of any treatment are responsible for the benefi ts of therapy”
(p. 71). Research indicates that a variety of treatments are equally effective—when
administered by therapists who believe in them and when they are accepted by
the client.
The various therapy approaches and techniques work equally well because they
share the most important ingredient accounting for change—the client. Data point
to the conclusion that the engine of change is the client (Bohart & Tallman, 2010),
and we can most productively direct our efforts toward ways of employing the cli-
ent in the process of change (Duncan et al., 2004). Duncan and colleagues further
state that therapists can translate this research into their clinical work by purpose-
fully working to do the following:
• Enhance the common factors across all theories that account for successful
outcomes
• Focus on the client’s perspective and theory of change as a guide to selecting
techniques and integrating various therapy models
• Obtain systematic client feedback regarding the client’s experience of the proc-
ess and outcome of therapy
Hubble, Duncan, Miller, and Wampold (2010) note that monitoring outcome
and adjusting accordingly on the basis of feedback from the client must become
routine practice. Duncan and colleagues (2004) claim that the client’s theory of
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change can be used as a basis for determining which approach, by whom, can be
most effective for this person, with his or her specifi c problem, under this particu-
lar set of circumstances. This approach to practicing therapy places emphasis on
continuous client input into the therapy process. Doing this increases the chances
of active client participation in therapy, which is the most important determinant
of the outcome of treatment.
s u m m a ry
Creating an integrative stance is truly a challenge. Therapists cannot simply pick
bits and pieces from theories in a random and fragmented manner. In forming an
integrated perspective, it is important to ask: Which theories provide a basis for
understanding the cognitive dimensions? What about the feeling aspects? And how
about the behavioral dimension? Most of the 11 therapeutic orientations discussed
here focus on one of these dimensions of human experience. Although the other
dimensions are not necessarily ignored, they are often given short shrift.
Developing an integrated theoretical perspective requires an accurate, in-
depth knowledge of the various theories. Without such knowledge, you cannot
formulate a true synthesis. Simply put, you cannot integrate what you do not know
(Norcross & Beutler, 2011). A central message of this book has been to remain
open to each theory, to do further reading, and to refl ect on how the key concepts
of each approach fi t your personality. Building your personalized orientation to
counseling, which is based on what you consider to be the best features of several
theories, is a long-term venture.
Besides considering your own personality, think about what concepts and tech-
niques work best with a range of clients. It requires knowledge, skill, art, and experi-
ence to be able to determine what techniques are suitable for particular problems.
It is also an art to know when and how to use a particular therapeutic intervention.
Although refl ecting on your personal preferences is important, I would hope that
you also balance your preferences with evidence from the research studies. Devel-
oping a personal approach to counseling practice does not imply that anything goes.
Indeed, in this era of managed care and evidence-based practice, your personal pref-
erences will not likely be the sole determinant of your psychotherapy practice. In
counseling clients with certain clinical problems (such as depression and gener-
alized anxiety), specifi c techniques have demonstrated their effectiveness. For in-
stance, behavior therapy, cognitive behavior therapy, mindfulness-based cognitive
therapy, and short-term psychodynamic therapy have repeatedly proved successful
in treating depression. Your use of techniques must be grounded on solid theoreti-
cal constructs. Ethical practice implies that you employ effi cacious procedures in
dealing with clients and their problems, and that you are able to provide a theoreti-
cal rationale for the interventions you make in your clinical work.
This is a good time to review what you have learned about counseling theory
and practice. Identify a particular theory that you might adopt as a foundation
for establishing your counseling perspective. Consider from which therapies you
would be most inclined to draw (1) underlying assumptions, (2) major concepts,
(3) therapeutic goals, (4) therapeutic relationship, and (5) techniques and procedures.
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Also, consider the major applications of each of the therapies as well as their basic
limitations and major contributions. The tables presented in this chapter are de-
signed to assist you in conceptualizing your view of the counseling process.
w h e r e to g o f r o m h e r e
In the DVD for Integrative Counseling: The Case of Ruth and Lecturettes (Session 9,
“An Integrative Perspective”) you will view my ways of working with Ruth by draw-
ing on techniques from various theoretical models. I demonstrate how the founda-
tion of my integrative approach rests on existential therapy. In this session I am
drawing heavily from principles of the action-oriented therapies.
Other Resources
DVDs offered by the American Psychological Association that are relevant to this
chapter include the following:
Stricker, G. (2009). Psychotherapy Integration Over Time (Psychotherapy
Video Series)
A private group of clinicians and researchers is dedicated to studying “what
works” in behavioral mental health. Members and associates translate the latest
research into guidelines for clinical practice and publish the information in clini-
cally friendly terms on their website. The Institute for the Study of Therapeutic
Change has also developed an outcome management system that uses ongoing
client feedback to monitor and improve retention in therapy and improve outcome
of treatment services.
Scott D. Miller, PhD, Co-director
Institute for the Study of Therapeutic Change
P. O. Box 180147
Chicago, IL 60618-0573
Telephone: (773) 404-5130
Fax: (847) 841-4874
Mobile: (773) 454-8511
Website: www.talkingcure.com
The International Center for Clinical Excellence (ICCE) is a worldwide commu-
nity of practitioners, health care managers, educators, and researchers dedicated
to promoting excellence in behavioral health care services. This online community
facilitates sharing of best practices and innovative ideas specifi cally designed to
improve behavioral health care practice and enable practitioners and managers to
achieve their personal best as helping professionals.
The International Center for Clinical Excellence
www.centerforclinicalexcellence.com
Scott D. Miller’s website has additional information on workshops on clinical
excellence:
Scott D. Miller
Website: www.scottdmiller.com
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Recommended Supplementary Readings
Psychotherapy Integration (Stricker, 2010) is a concise presentation that deals with
the theory, therapeutic process, evaluation, and future developments of integra-
tive approaches.
A Casebook of Psychotherapy Integration (Stricker & Gold, 2006) features master
therapists who demonstrate how they successfully apply their own integrative
approaches.
Handbook of Psychotherapy Integration (Norcross & Goldfried, 2005) is an excel-
lent resource for conceptual and historical perspectives on therapy integration.
This edited volume gives a comprehensive overview of the major current
approaches, such as theoretical integration and technical eclecticism.
The Art of Integrative Counseling (Corey, 2013a) is designed to assist students in devel-
oping their own integrative approach to counseling. This book is complemented by
the DVD for Integrative Counseling: The Case of Ruth and Lecturettes (Corey, 2013c).
Case Approach to Counseling and Psychotherapy (Corey, 2013b) illustrates each of
the 11 contemporary theories by applying them to the single case of Ruth. I also
demonstrate my integrative approach in counseling Ruth in the fi nal chapter.
This book also is designed to fi t well with the DVD for Integrative Counseling: The
Case of Ruth and Lecturettes (Corey, 2013c).
Integrating Spirituality and Religion into Counseling: A Guide to Competent Prac-
tice (Cashwell & Young, 2011) offers a concrete perspective on how to provide
counseling in an ethical manner, consistent with a client’s spiritual beliefs and
practices. The authors help practitioners develop a respectful stance that honors
the client’s worldview and works within this framework in a collaborative fashion
to achieve the client’s goals.
References and Suggested Readings
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*Bohart, A. C., & Tallman, K. (2010). Cli-
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B. E. Wampold, & M. A. Hubble (Eds.), The
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*Cashwell, C. S., & Young, J. S. (2011).
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*Corey, G. (2013a). The art of integrative coun-
seling (3rd ed.). Belmont, CA: Brooks/Cole,
Cengage Learning.
*Corey, G. (2013b). Case approach to counseling
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*Books and articles marked with an asterisk are recommended for further study.
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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

*Corey, G. (with Haynes, R.). (2013c). DVD for
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(2007). Religiosity and spirituality among
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*Duncan, B. L., Miller, S. D., & Sparks, J. A.
(2004). The heroic client: A revolutionary way
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*Duncan, B. L., Miller, S. D., Wampold, B. E., &
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*Frame, M. W. (2003). Integrating religion and
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*Greenberg, L. S. (2011). Emotion-focused
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*Lazarus, A. A. (1993). Tailoring the therapeu-
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*Lazarus, A. A. (1995). Different types of
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*Lazarus, A. A. (1997a). Brief but comprehensive
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Norcross, J. C. (2005). A primer on psycho-
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503
co u n s e l i n g sta n : i n t eg r at i o n
o f t h e r a p i es
co n c l u d i n g co m m e n t s
c h a p t e r 1 6
Case Illustration: An
Integrative Approach in
Working With Stan
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c o u n s e l i n g s ta n : i n t e g r at i o n
o f t h e r a p i e s
The purpose of this chapter is to bring together in an integrative fashion the 11
approaches you have studied by combining thinking, feeling, and acting models
in counseling Stan. The material in Chapter 15 provides a conceptual framework
for my way of counseling from an integrative perspective. Many of the key points
made in Chapter 15 will become clearer as you read about the interventions I am
making with Stan in this chapter. At this point it would be helpful for you to review
the background material and themes in Stan’s life presented in Chapter 1. In addi-
tion, I suggest you consult the Student Manual for Theory and Practice of Counseling
and Psychotherapy (Chapter 16) for an overview and review of the major areas I
focus on for each of the theoretical approaches in my work with Stan.
In this section, I describe how I would integrate concepts and techniques from
the 11 theoretical perspectives in counseling Stan on the levels of thinking, feeling,
and doing. I use information presented in Stan’s autobiography, and I indicate
what aspects from the various theories I would draw on in working with Stan at
the various stages of his therapy. As you read, think about the interventions you
would make with Stan that would be either similar to or different from mine.
Questions in the “Follow-Up” section near the end of the chapter will guide you
as you refl ect on being Stan’s counselor and working with him from your own
integrative perspective.
See the video program for Chapter 16, DVD for Theory and Practice of Counseling
and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you view the
brief lecture for each chapter prior to reading the chapter.
A Place to Begin
I start by giving Stan a chance to say how he feels about coming to the initial ses-
sion. To begin to understand why Stan has sought therapy, I might explore his
thoughts regarding any of the following questions:
• What brings you here? What has been going on in your life recently that made
you want to seek professional help?
• What expectations do you have of therapy? Of me? What are your hopes, fears,
and any reservations? What goals do you have for yourself through therapy?
• Give me a picture of some signifi cant turning points in your life? Who have
been the important people in your life? What signifi cant decisions have you
made? What are some of the struggles you’ve dealt with, and what are some of
these issues that are current for you?
• How would you describe your life in your family? How did you view your par-
ents? How did they react to you? What do you remember about your early
years? (It would be useful to administer the Adlerian lifestyle questionnaire.)
Clarifying the Therapeutic Relationship
I will work with Stan to develop a contract, which involves a discussion of our mu-
tual responsibilities and a clear statement of what he wants from these sessions
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and what he is willing to do to obtain his goals. I believe it is important to discuss
any factors that might perpetuate a client’s dependency on the therapist, so I invite
Stan’s questions about this therapeutic relationship. One goal is to demystify the
therapy process; another is to get some focus for the direction of our sessions by
developing clear goals for the therapy.
In establishing the therapeutic relationship, I am infl uenced by the person-
centered, existential, Gestalt, feminist, postmodern, and Adlerian approaches.
They do not view therapy as something that the therapist does to a passive client.
I will apply my knowledge of these therapies to establish a working relationship
with Stan that is characterized by mutual trust and respect. I will ask myself these
questions: “To what degree am I able to listen to and hear Stan in a nonjudgmen-
tal way? Am I able to respect and care for him? Do I have the capacity to enter his
subjective world without losing my own identity? Am I able to share with him my
own thoughts and reactions as they pertain to our relationship?” I begin by being
as honest as I can be with Stan as the basis for creating this relationship. This rela-
tionship is critical at the initial stages of therapy, but it must be maintained during
all stages if therapy is to be effective. I operate on the assumption that the quality
of our relationship will be critical to the therapeutic outcome.
Clarifying the Goals of Therapy
It is not enough to simply ask Stan what he hopes to gain by the conclusion of thera-
py. Clients are oftentimes vague, global, and unfocused about what they want. With
respect to goals, precision and clarity are essential. There is no progress when you
have directionless sessions. Thus, specifi city is a must. Once we have identifi ed some
goals, Stan can begin to observe and measure his own behavior, both in the sessions
and in his daily life. This self-monitoring is a vital step in any effort to bring about
change. I will be asking for Stan’s feedback throughout the therapeutic process and
will use his feedback as a basis for making modifi cations in our therapeutic alliance.
Here are a few interchanges that focus on the process of defi ning goals that will
give direction to Stan’s therapy:
J E R RY: What would you most hope for, through our work together?
STA N : Well, I know I put myself down a lot. I’d like to feel better about myself.
J E R RY: If you had what you want in your life today, what would that be like? What
would it take for you to feel good about yourself?
STA N : For one thing, I’d have people in my life, and I would be closer to people.
J E R RY: Is this an area you’d be willing to explore in our sessions?
STA N : Yes.
J E R RY: I’ll be glad to provide suggestions of ways to begin, if I know what you want.
STA N : For sure I’d like to get over my dumb fears of being with people.
J E R RY: I like it that you’re willing to challenge your fears. Are you aware that you just
put yourself down by labeling your fears as dumb?
STA N : It’s almost a refl ex response for me. But I would like to feel more comfortable
when I’m with others.
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J E R RY: How is it for you to be here with me now?
STA N : It’s not like me to do something like this, but I feel good. I’m talking, and I’m
saying what’s on my mind.
J E R RY: I hope you will continue to give yourself credit for being different in our con-
versation right now.
Goal setting is not accomplished in a single session. Throughout our time to-
gether, I ask Stan to decide time and again what he wants from his therapy and to
assess the degree to which our work together is resulting in his meeting his goals.
As his therapist, I expect to be active, yet it is important that Stan provide the direc-
tion in which he wants to travel on his journey. Once I have a clear sense of the
specifi c ways Stan wants to change how he is thinking, feeling, and acting, I am
likely to take an active role in co-creating experiments with Stan that he can do both
in the therapy sessions and on his own away from our sessions.
Working With Stan’s Past, Present, and Future
d e a l i n g w i t h t h e pa s t Reality therapy, solution-focused brief therapy,
behavior therapy, and rational emotive behavior therapy place very little emphasis
on the client’s history. The rationale for this lack of attention to the past is that
early childhood experiences do not necessarily have much to do with the mainte-
nance of present ineffective behavior. My inclination, in contrast, is to give weight
to understanding, exploring, and working with Stan’s early history and to connect
his past with what he is doing today. My view is that themes running through our
life can become evident if we come to terms with signifi cant experiences in our
childhood. The use of an Adlerian lifestyle questionnaire would indicate some of
these themes that originate from Stan’s childhood. The psychoanalytic approach,
of course, emphasizes uncovering and reexperiencing traumas in early childhood,
working through the places where we have become “stuck,” and resolving confl icts
that are often out of our awareness.
Although I agree that Stan’s childhood experiences were infl uential in contrib-
uting to his present personality (including his ways of thinking, feeling, and behav-
ing), it does not make sense to me to assume that these factors have determined him.
I favor the Gestalt approach of asking Stan to bring into the here and now those peo-
ple in his life with whom he feels unfi nished. A variety of role-playing techniques in
which Stan addresses signifi cant others through symbolic work in our sessions will
bring Stan’s past intensely to life in the present moment of our sessions.
d e a l i n g w i t h t h e p r e s e n t Being interested in Stan’s past does not
mean that we get lost in history or that we dwell on reliving traumatic situations.
By paying attention to what is going on in the here and now during the counseling
session, I get excellent clues about what is unfi nished from Stan’s past. He and
I can direct attention to his immediate feelings as well as to his thoughts and
actions. It seems essential to me that we work with all three dimensions—what
he is thinking, what he is actually doing, and how his thoughts and behaviors
affect his feeling states. Again, by directing Stan’s attention to what is going on
with him during our sessions, I can show him how he interacts in his world apart
from therapy.
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d e a l i n g w i t h t h e f u t u r e Adlerians are especially interested in where
the client is heading. Humans are pulled by goals, strivings, and aspirations. It
would help to know what Stan’s goals in life are. What does he want for himself?
If he decides that his present behavior is not getting him what he wants, he is in
a good position to think ahead about the changes he would like to make and what
he can do now to actualize his aspirations. The present-oriented behavioral focus
of reality therapy is a good reference point for getting Stan to dream about what
he would like to say about his life 5 years hence. Connecting present behavior with
future plans is an excellent way to help Stan formulate a concrete plan of action.
He will actually create his future.
Identifying Feelings
The person-centered approach stresses the fi rst stage in the therapy process, which
involves identifying, clarifying, and learning how to express feelings. Because of
the therapeutic relationship I have built with Stan, I expect him to feel increasingly
free to talk about feelings that he has kept to himself. In some cases these feelings
are out of his awareness, and I encourage Stan to talk about any feelings that are a
source of diffi culty.
During the early stages of our sessions, I rely on empathic listening. I need
to do more than merely refl ect what I hear Stan saying; I need to share with him
my reactions as I listen to him because doing so helps to build a good therapeutic
alliance. When Stan senses that he is being understood and accepted for the feel-
ings he has, he has less need to deny or distort his feelings. His capacity for clearly
identifying what he is feeling at any moment will gradually increase.
There is a great deal of value in letting Stan tell his story in a way he chooses.
The way he walks into the offi ce, his gestures, his style of speech, the details he
chooses to go into, and what he decides to relate and not to relate—to mention just
a few elements—provide me with clues to his world. If I do too much structuring
too soon, I will interfere with his typical style of presenting himself.
Expressing and Exploring Feelings
The authenticity of my relationship with Stan encourages him to begin to identify
and share with me a range of feelings. But I do not believe an open and trusting
relationship between us is suffi cient to change Stan’s personality and behavior. I
must also use my knowledge, skills, and experiences although my clinical expertise
is not the sole determinant of therapeutic change. Stan is the best expert on his
own life, and I will assist him in coming to value the ways in which he is the expert
in the therapeutic endeavor.
As a way of helping Stan express and explore his feelings, I draw heavily on
Gestalt experiments. Eventually, I ask him to avoid merely talking about situations
and about feelings. Rather, I encourage him to bring whatever reactions he is hav-
ing into the present. For instance, if Stan reports feeling tense, I ask him how he
experiences this tension right now and where it is located in his body. I encourage
him to “be that feeling.” Thus, if he has a knot in his stomach, he can intensify
his feeling of tension by “becoming the knot, giving it voice and personality.” If I
notice tears in his eyes, I may direct him to “be his tears now.” By putting words
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to his tears, he avoids abstract intellectualization about all the reasons he is sad or
tense. Before he can change his feelings, Stan must allow himself to fully experi-
ence them. The experiential therapies provide valuable tools for guiding him to the
expression of his feelings.
Here are some segments of our dialogue in a session where Stan becomes
quite aware of what he is feeling as he talks about his relationship with his
father:
J E R RY: You mentioned that your father often compared you with your brother Frank
and your sister Judy. What was that like for you?
STA N : I hated it! He told me that I’d never amount to anything.
J E R RY: And when he said that, how did that affect you?
STA N : It made me feel that I could never measure up to all the great things that Judy
and Frank were accomplishing. I felt like a failure. [As he says this, he begins to tear up,
and his voice changes.]
J E R RY: Stan, what is going on right now?
STA N : All of a sudden a wave of sadness is coming over me. I’m getting all choked
up. This is hard!
J E R RY: Stay with your feeling. What’s going on?
STA N : My chest is tight, like something wants to come out.
J E R RY: Say more.
STA N : I’m feeling very sad and hurt.
J E R RY: Would you be willing to try something? I’d like you to talk to me as though I
were your father. Are you willing to do that?
STA N : Well, you’re not mean the way he was, but I can try.
J E R RY: How old are you feeling now?
STA N : Oh, maybe 12 years old—just like when I had to be around my father and
listen to all the stuff he told me about how useless I was.
J E R RY: Let yourself be 12 again, and tell me what it’s like for you to be you—speaking
to me as your father.
STA N : There was nothing that I could ever do that was good enough for you. No mat-
ter how hard I tried, I couldn’t get you to notice me. [Crying] Why didn’t I count, and
why did you ignore me?
J E R RY: Stan, I’ll just let you talk for a while, and I’ll listen. So keep on telling me all
the things you may be feeling as that 12-year-old now.
STA N : All I ever wanted was to know that I mattered to you. But no matter how
hard I tried, all you’d do was put me down. Nothing I did was worth anything. I just
wanted you to love me. Why didn’t you ever do anything with me? [Stan stops talking
and just cries for a while.]
J E R RY: What’s happening with you now?
STA N : I’m feeling so sad. As if it’s hopeless. Nothing I can do will ever get his approval.
J E R RY: At 12 it was important for you to get his acceptance and his love. There is still
that part in you that wants his love.
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STA N : Yes, and I don’t think I’ll ever get it.
J E R RY: Tell him more of what that’s like.
Stan continues talking to his “father” and recounts some of the ways in which
he tried to live up to his expectations. No matter what he did, there was no way to
get the acceptance that Frank and Judy got from him.
J E R RY: Having said all that, what are you aware of now?
STA N : I’m feeling embarrassed.
J E R RY: You say you’re embarrassed. Whom are you aware of now?
STA N : Well, right now of you. I feel like a wimp. You’re probably thinking that I’m
weak and dumb for letting this get to me.
J E R RY: Tell me more about feeling weak and dumb.
Stan expresses that he should be stronger and that he is afraid I’ll think he is
hopeless. He goes into some detail in belittling himself for what he has just expe-
rienced and expressed. I avoid quickly reassuring him that he “shouldn’t feel that
way.” Instead, I let him express whatever he is feeling. After telling me many of
the ways in which he is feeling embarrassed, he wonders if I still want to work with
him. At this point I let him know that I respect his struggle and encourage him to
continue revealing aspects that he typically keeps hidden. Because this session is
coming to an end, I talk with Stan about the value of releasing feelings that he has
been carrying around for a long time, suggesting that this is a good beginning. I
am also interested in getting him to do some homework before the next session.
By focusing on his feelings both in the therapy offi ce and in daily life, I hope Stan
can eventually learn to avoid judging himself so harshly.
J E R RY: Stan, I’d like to suggest that you write a letter to your father . . .
STA N : [Interrupting] Oh no! I’m not going to give that guy the satisfaction of knowing
that I need anything from him!
J E R RY: Wait. I was about to say that I hope you’ll write him a letter that you don’t mail.
STA N : What’s the point of a letter that won’t be sent?
J E R RY: Writing him a letter is an opportunity for further release and to gain some
new insights. I hope you’ll let yourself write about all the ways you tried to live up
to his expectations. Let him know what it felt like to be around him. Tell him more
about you, especially how it felt in not getting those things that you so much wanted.
STA N : OK, I’ll do that.
In this session I might have made many different interventions. For the mo-
ment, I chose to let him “borrow my eyes” and talk to me as his father while he was
12 years old. I asked him to stay with whatever he was experiencing, paying par-
ticular attention to his body and to the emotions that were welling up within him.
It would be premature to suggest problem-solving strategies or to attempt to fi gure
everything out. My intent in offering him the homework assignment of writing a
letter is to provide an avenue for Stan to continue thinking about the impact his
father has had on him and to further promote his work during the week. Writing
the letter may trigger memories, and he may experience further emotional release.
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At our next session I will ask Stan about the letter and what it was like for him
to write it. What did he say to his father? How was it to read the letter later? Is
there anything that he wants to share with me? The direction of our next session
will depend on his response. Again, Stan will provide clues to where he needs to
go next.
The Thinking Dimension in Therapy
Once Stan has experienced some intense feelings and perhaps released pent-up
feelings, some cognitive work is essential. To bring in this cognitive dimension,
I focus Stan’s attention on messages he incorporated as a child and on the deci-
sions he made. I get him to think about the reason he made certain early decisions.
Finally, I challenge Stan to look at these decisions about life, about himself, and
about others and to make necessary revisions that can lead him to creating a life of
his own choosing.
After getting basic information about Stan’s life history (by means of the Adle-
rian lifestyle assessment form), I summarize and interpret it with Stan in a ses-
sion. For example, I fi nd some connections between his present fears of developing
intimate relationships and his history of rejection by his siblings and his parents.
I am interested in his family constellation and his early recollections. Rather than
working exclusively with his feelings, I want Stan to begin to understand (cog-
nitively) how these early experiences affected him then and how they still infl u-
ence him today. My emphasis is on having Stan begin to question the conclusions
he came to about himself, others, and life. What is his private logic? What are some
of his mistaken, self-defeating perceptions that grew out of his family experiences?
An Adlerian perspective provides tools for doing some productive cognitive work
both in and out of the therapy sessions.
From rational emotive behavior therapy I especially value the emphasis on
learning to think rationally and am interested in having Stan assess whether or
not his thoughts are rational. I am not imposing my views of rational thinking;
rather, I hope to help Stan examine his behavior and his beliefs about his behavior.
I look for the ways in which Stan contributes to his painful feelings by the process
of self-indoctrination with faulty beliefs that no longer serve him well. I ask him to
test the validity of the dire consequences he predicts. I value the stress put on do-
ing hard work in demolishing beliefs that have no validity and replacing them with
sound and rational beliefs. I do not think Stan can merely think his way through
life or that examining his faulty logic is enough by itself for personality change. But
I do see this process as an essential component of therapy.
The cognitive behavioral therapies have a range of cognitive techniques that
can help Stan recognize connections between his cognitions and his behaviors.
He should also learn about his inner dialogue and the impact it has on his day-to-
day behavior. Eventually, our goal is some cognitive restructuring work by which
Stan can learn new ways to think, new things to tell himself, and new assumptions
about life. This provides a basis for change in his behavior.
I have given Stan a number of homework assignments aimed at helping him
identify a range of feelings and thoughts that may be problematic for him. Follow-
ing are sample pieces of a session in which we focus on his cognitions.
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J E R RY: Several times now you’ve brought up how you’re sure you’d be judged
critically if you allowed yourself to get close to a woman. Is this a topic you want to
explore in more depth?
STA N : Yes. I’m tired of avoiding women, but I’m still scared of approaching a woman.
I’m convinced that if any woman gets to know me, she’ll eventually reject me.
J E R RY: Have you checked out this assumption? How many women have you
approached, and how many of them have actually rejected you?
STA N : They never tell me these things. But in my head I keep telling myself that
if they get to know the real me they’ll be turned off by my weakness, and then they
wouldn’t want anything to do with me.
J E R RY: How about telling me some of the things you tell yourself when you think of
meeting a woman? Just let yourself free associate, listing out loud some of the state-
ments you make to yourself internally. Ready?
STA N : So often I say to myself that I’m not worth knowing. [Pause]
J E R RY: Just rattle off as many of these self-statements as you can. Don’t worry about
how it sounds.
STA N : What a nerd! Every time you open your mouth, you put your foot in it. Why
don’t you just shut up and hide? When you do talk to people, you freeze up. They’re
judging you, and if you say much of anything, they’ll fi nd out what a complete and
utter failure you are. Anything you try, you fail in. You are not very interesting. You’re a
weak and a scared kid. Why don’t you keep to yourself so that others won’t reject you?
Stan continues with this list, and I listen. After he seems fi nished, I tell him
how I’m affected by hearing his typical self-talk. I let him know that it saddens me.
Although I like Stan, I don’t have the sense that he will emotionally believe that I
care about him. I let him know that I respect the way he doesn’t run from his fears
and that I admire his willingness to talk openly about his troubles.
Stan has acquired a wide range of critical internal dialogues that he has practiced
for many years. As he begins to challenge those thoughts, he will discover that his
thinking is grossly inaccurate. Eventually I hope he will change many of the beliefs
that are resulting in problems for him. Along this line, I work with him to pinpoint
specifi c beliefs and then do my best to get him to examine them. I am infl uenced by
the constructivist trend in cognitive behavior therapy. Applied to Stan, constructiv-
ism holds that his subjective framework and interpretations are far more important
than the objective bases that may be at the origin of his faulty beliefs. Thus, rather
than imposing my version of what may constitute faulty, irrational, and dysfunc-
tional beliefs on his part, I pursue a line of Socratic questioning whereby I get Stan
to evaluate his own thinking processes and his conclusions.
J E R RY: Let’s take one statement that you’ve made a number of times: “When I’m
with other people, I feel stupid.” What goes on within you when you say this?
STA N : I hear critical voices, like people are in my head or are sitting on my shoulder.
J E R RY: Name one person who often sits on your shoulder and tells you you’re stupid.
STA N : My dad, for one. I hear his voice in my head a lot.
J E R RY: Let me be Stan for a moment, and you be your dad, saying to me some of
those critical things that you hear him saying inside your head.
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STA N : Why are you going to college? Why don’t you quit and give your seat to some-
one who deserves it? You’re not a good student. You’re wasting your time and the
taxpayers’ money by pretending to be a college student. Do yourself a favor and wake
up to the fact that you are just a dumb kid.
J E R RY: How much truth is there in what you just said as your dad?
STA N : You know, it sounds stupid that I let him convince me that I’m totally stupid.
J E R RY: Instead of saying that you’re stupid for letting him tell you that you’re stupid,
can you give yourself credit for being smart enough to come to this realization?
STA N : OK, but he’s right that I’ve failed at most of the things I’ve tried.
J E R RY: Does failing at a task mean that you’re right holding to the label of being a
failure in life? I’d like to hear you produce the evidence that supports your interpreta-
tion of being stupid and of being a failure.
STA N : How about the failure in my marriage? I couldn’t make it work, and I was
responsible for the divorce. That’s a pretty big failure.
J E R RY: And were you totally responsible for the divorce? Did your wife have any part in it?
STA N : She always told me that no woman could ever live with me. She convinced me
that I couldn’t have a satisfying relationship with her or any other woman.
J E R RY: Although she could speak for herself, I’m wondering what qualifi es her to
determine your future with all women. What study did she conduct that proves that
Stan is utterly destined to be allergic to all women forever?
STA N : I suppose I just bought into what she told me. After all, if I couldn’t live with
her, what makes me think I could have a satisfying life with any woman?
At this point, there are many directions to go with Stan to explore the origin of his
beliefs and to assess the validity of his interpretations about life situations and his con-
clusions about his basic worth. In this and other sessions, we explore what cognitive
therapists call “cognitive distortions.” Here are some of Stan’s cognitive distortions:
• Arbitrary inferences. Stan makes conclusions without supporting and relevant evi-
dence. He often engages in “catastrophizing,” or thinking about the worst pos-
sible scenario for a given situation.
• Overgeneralization. Stan holds extreme beliefs based on a single incident and
applies them inappropriately to other dissimilar events or settings. For in-
stance, because he and his wife divorced, he is convinced he is destined to be a
failure with any woman.
• Personalization. Stan has a tendency to relate external events to himself, even
when there is no basis for making the connection. He relates an incident in
which a female classmate did not show up for a lunch date. He agonized over
this event and convinced himself that she would have been humiliated to be
seen in his presence. He did not consider any other possible explanations for
her absence.
• Labeling and mislabeling. Stan presents himself in light of his imperfections
and mistakes. He allows his past failures to defi ne his total being.
• Polarized thinking. Stan frequently engages in thinking and interpreting in all-
or-nothing terms. Through this process of dichotomous thinking, he has cre-
ated self-defeating labels that keep him restricted.
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Over a number of sessions we work on specifi c beliefs. The aim is for Stan to criti-
cally evaluate the evidence for many of his conclusions. My role is to promote cor-
rective experiences that will lead to changes in his thinking. I am striving to create
a collaborative relationship, one in which he will discover for himself how to dis-
tinguish between functional and dysfunctional beliefs. He can learn this by testing
his conclusions.
Doing: Another Essential Component of Therapy
Stan can spend countless hours gathering interesting insights about why he is the
way he is. He can learn to express feelings that he kept hidden for many years. He
can think about the things he tells himself that lead to defeat. Yet in my view feel-
ing and thinking are not a complete therapy process. Doing is a way of bringing
these feelings and thoughts together by applying them to real-life situations in vari-
ous action programs. I am indebted to Adlerian therapy, behavior therapy, reality
therapy, rational emotive behavior therapy, cognitive therapy, narrative therapy,
and solution-focused brief therapy, all of which give central emphasis to the role of
action as a prerequisite for change.
Behavior therapy offers a multitude of techniques for behavioral change. In
Stan’s case I am especially inclined to work with him in developing self-management
programs. For example, he complains of often feeling tense and anxious. Daily
relaxation procedures are one way Stan can gain more control of his physical and
psychological tension. I have been teaching him a variety of mindfulness tech-
niques, including a combination of meditation and relaxation procedures. Through
mindfulness practice, Stan can get himself centered before he goes to his classes,
meets women, or talks to friends. He can also begin to monitor his behavior in
everyday situations to gain increased awareness of what he tells himself, what he
does, and then how he feels. When he gets depressed, he tends to drink to alleviate
his symptoms. He can carry a small notebook with him and actually record events
that lead up to his feeling depressed (or anxious or hurt). He might also record
what he actually did in these situations and what he might have done differently.
By paying attention to what he is doing in daily life, he is already beginning to gain
more control of his behavior.
This behavioral monitoring can be coupled with both Adlerian and cognitive
approaches. My guess is that Stan gets depressed, engages in self-destructive be-
havior (drinking, for one), and then feels even worse. I work very much on both his
behaviors and cognitions and show him how many of his actions are infl uenced
by what he is telling himself. Together we work on how he is setting himself up
for failure by his self-defeating expectations. True to the spirit of rational emotive
behavior therapy, we explore his faulty assumptions that he must be perfect and
that if he does not get the job, life will be unbearable. There are many opportunities
for Stan to see connections between his cognitive processes and his daily behavior.
I encourage him to begin to behave differently and then look for changes in his
feeling states and his thinking.
With this in mind, I ask Stan to think of as many ways as possible of actually
bringing into his daily living the new learning he is acquiring in our sessions. Prac-
tice is essential. Homework assignments (preferably ones that Stan gives himself)
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are an excellent way for Stan to become an active agent in his therapy. He must
do something himself for change to occur. The degree to which he will change is
directly proportional to his willingness to experiment. I want Stan to learn from
his new behavior in life. Thus, each week we discuss his progress toward meeting
his goals, and we review how well he is completing his assignments. If he does not
like the way he carried out an assignment, we can use this as an opportunity to talk
about how he can adjust his behavior. I hold fi rm about expecting a commitment
from him to have an action plan for change and to continually look at how well his
plan is working.
In the following dialogue, our interchanges deal primarily with Stan learning a
more assertive style of behavior with one of his professors. Although this session
focuses on Stan’s behavior, we are also dealing with what he is thinking and feel-
ing. These three dimensions are interactive.
J E R RY: Last week we role-played different ways you could approach a professor with
whom you were having a diffi culty. You learned several assertive skills that you used
quite effectively when I assumed the role of the critical professor. Before you left last
week, you agreed to set up a time to meet with your professor and let her know about
your diffi culty. When we did the role playing, you were very clear about what you
wanted to say and strong in staying with your feelings. Did you carry out your plan?
STA N : The next day I tried to talk to her before class. She said she didn’t have time to
talk but that we could talk after class.
J E R RY: And how did that go?
STA N : After class all I wanted to do was make an appointment with her so that I
could talk in private and without feeling hurried. When I tried to make the appoint-
ment, she very brusquely said that she had to go to a meeting and that I should see
her during her offi ce hours.
J E R RY: How did that affect you?
STA N : I was mad. All I wanted to do was make an appointment.
J E R RY: Did you go to her offi ce hours?
STA N : I did, that very afternoon. She was 20 minutes late for her offi ce hours, and
then some students were waiting to ask her questions. All I got to do was make an
appointment with her in a couple of days.
J E R RY: Did that appointment actually take place?
STA N : Yes, but she was 10 minutes late and seemed preoccupied. I had a hard time
at the beginning.
J E R RY: How so? Tell me more.
STA N : I feel stupid in her class, and I wanted to talk to her about it. When I ask ques-
tions, she gets a funny look on her face—as if she’s impatient.
J E R RY: Did you check out these assumptions with her?
STA N : Yes I did, and I feel proud of myself. She told me that at times she does get
a bit impatient because I seem to need a lot of her time and reassurance. Then I let
her know how much I was studying for her class and how serious I was about doing
well in my major. It was good for me to challenge my fears, instead of avoiding her
because I felt she was judgmental.
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J E R RY: It’s good to hear you give yourself credit for the steps you took. Even though
it was tough, you hung in there and said what you wanted to say. Is there anything
about this exchange with her that you wish you could have changed?
STA N : For the most part, I was pretty assertive. Generally, I blame people in author-
ity like her for making me feel stupid. I give them a lot of power in judging me. But
this time I remembered what we worked on in our session, and I stayed focused on
myself rather than telling her what she was doing or not doing.
J E R RY: How did that go?
STA N : The more I talked about myself, the less defensive she became. I learned
that part of how she reacts to me is infl uenced by my behavior and when I changed
she also changed. I can still feel good about myself, even if the other person doesn’t
change. That was powerful.
J E R RY: Great! Did you notice any difference in how you felt in her class after you had
this talk?
STA N : For a change, I didn’t feel so self-conscious, especially when I asked questions
or took part in class discussions. I was not so concerned about what she might think
about me, and she seemed more at ease with me.
J E R RY: What did your meeting with her teach you about yourself?
STA N : For one thing, I’m learning to check out my assumptions. That freed me up to
act much more spontaneously. Also, I learned that I could be clear, direct, and asser-
tive without getting nasty. It was possible for me to take care of myself without being
critical of her. Normally, I’d just swallow all my feelings and walk away feeling dumb.
This time I was assertive and was able to let her know that I needed some unhurried
time from her.
Practicing assertive behavior is associated with working with the feeling and
thinking domains. Had Stan not done as well as he did in engaging his professor,
we could have examined what had gone wrong from his vantage point. We could
have continued role-playing various approaches in our sessions, and then with
new knowledge and skills and more practice, he could have tried again. It is essen-
tial that Stan be willing to experiment with new ways of acting, especially outside of
the therapy sessions. In a sense, counseling can be like a dress rehearsal for living.
He exhibited courage and determination in carrying out a specifi c action plan, and
change did take place.
Working Toward Revised Decisions
When Stan has identifi ed and explored both his feelings and his faulty beliefs
and thinking processes, it does not mean that therapy is over. Becoming aware of
early decisions, including some of his basic mistakes and his self-defeating ideas,
is the starting point for change. It is essential that Stan fi nd ways to translate his
emotional and cognitive insights into new ways of thinking, feeling, and behaving.
Therefore, as much as possible I structure situations in the therapy sessions that
will facilitate new decisions on his part on both the emotional and cognitive levels.
In encouraging Stan to make these new decisions, I draw on cognitive, emotive, and
behavioral techniques. A few techniques I employ are role playing, imagery work,
assertion training procedures, and behavioral rehearsals. Both reality therapy and
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Adlerian therapy have a lot to offer on getting clients to decide on a plan of action
and then make a commitment to carry out their program for change.
Here are some examples of experiments I suggest for Stan during the therapy
sessions and homework assignments.
• I engage in reverse role-playing situations in which I “become” Stan and have
Stan assume the role of his mother, father, former wife, sister, older brother, and
a professor. Through this process Stan gets a clearer picture of ways in which he
allowed others to defi ne him, and he acquires some skills in arguing back to self-
defeating voices.
• To help Stan deal with his anxiety, I teach him meditation and other mindful-
ness techniques and encourage him to practice them daily. Stan learns to employ
these relaxation strategies in anxiety-arousing situations. I also teach him a range
of coping skills, such as assertiveness and disputing faulty beliefs. Stan is able to
apply these skills in several life situations.
• Stan agrees to keep a journal in which he records impressions and experi-
ences. After encountering diffi cult situations, he writes about his reactions, both
on a thinking and a feeling level. He also records how he behaved in these situa-
tions, how he felt about his actions, and how he might have behaved differently. He
also agrees to read a few self-help books in areas that are particularly problematic
for him.
• As a homework assignment that we collaboratively design, Stan agrees to
meet with people whom he would typically avoid. For instance, he is highly anxious
over his performance in a couple of his classes. He decides to make an appoint-
ment with each professor to discuss his progress. In one case, a professor took an
increased interest in him, and now he does very well in her class. In the other case,
the professor is rather abrupt and not too helpful. He is able to recognize that this
is more the professor’s problem than anything he is doing.
• Stan wants to put himself in situations where he can make new friends. To-
gether we work on a clear plan of action that involves joining a club, going to social
events, and asking a woman in his class for a date. Although he is anxious in each
of these situations, he follows through with his plans. In our sessions we explore
some of his self-talk and actions at these events.
Encouraging Stan to Work With His Family of Origin
After working with Stan for a time, I suggest that he take the initiative to invite his
entire family for a session. My assumption is that many of his problems stem from
his family-of-origin experiences and that he is still being affected by these experi-
ences. I think it will be useful to have at least one session with the family so that I
can get a better idea of the broader context. The following dialogue illustrates my
attempt to introduce this idea to Stan.
J E R RY: Our sessions are certainly revealing a good deal of diffi culties with several
members of your family. I think it would be useful to bring in as many of them as
you can for a session.
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STA N : No way! That’s way too much.
J E R RY: Are you willing to talk with me more about this idea?
STA N : I’ll talk, but I don’t think it will change my mind.
J E R RY: Why is that?
STA N : They already think I’m nutty, and if they fi nd out I’m seeing a psychologist,
that will be one more thing they can throw in my face.
J E R RY: Would they use this against you?
STA N : Yes. Besides, I can’t see how it would help much. My mother and father don’t
think they have any problems. I don’t see them wanting to change much.
J E R RY: Changing them is not my goal. It is more to give you a chance to express
yourself respectfully to people who are still an important part of your life.
STA N : Maybe, but I’m not ready for that one yet!
J E R RY: I can respect that you don’t feel ready yet. I hope you’ll remain open to the
idea, and if you change your mind, let me know.
My rationale for including at least some of Stan’s family members is to pro-
vide him with a context for understanding how his behavior is being infl uenced
by what he learned as a child. He is a part of this system, and as he changes, it
is bound to infl uence others in his family with whom he has contact. From what
he has told me, I am assuming that his unclear boundaries with his mother have
had an impact on his relationships with other women. If he can gain a clearer
understanding of his relationship with his mother, he may be able to apply some
of these insights with other women. In many ways Stan has allowed himself to
be intimidated by his father, and he still hears Dad’s voice in his head a lot. In
much of his present behavior, Stan compares himself unfavorably with others,
which is a pattern that was established in early childhood with his siblings. If he is
able to deal with the members of his family about some of their past and present
struggles, there is a good chance that he will be able to form the kind of intimate
relationships that he says he would like to have in his life. (For a more complete
description of working with Stan from a family systems perspective, see Stan’s
case in Chapter 14.)
The Spiritual Dimension
Although I do not have an agenda to impose religious or spiritual values on Stan, I
want to assess the role spirituality plays, if any, in his life currently—and to assess
beliefs, attitudes, and practices from his earlier years. When I ask Stan if religion
was a factor in his childhood or adolescence, he informs me that his mother was
a practicing Lutheran and his father was rather indifferent to religion. His mother
made sure that he went to church each week. He tells me what he mainly remem-
bers from his church experiences is feeling a sense of guilt. Stan recalls that his
attitudes about religion fi t in with his low self-esteem. Not only was he not good
enough in the eyes of his parents, but he was also not good enough in the eyes of
God. He also adds that when he went to college he developed a new interest in
spirituality.
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Although formal religion does not seem to play a key role for Stan now, he is
struggling to fi nd a spiritual core as this is missing in his life. He also lets me know
that he is pleasantly surprised that I am even mentioning religion and spirituality.
He was under the impression that counselors would not be too interested in these
areas. Upon further discussion of this area, he informs me of his intention to bring
up his concerns about his spirituality at a future session.
Working With Stan’s Drinking Problem
Although each of the 11 therapeutic approaches address drug and alcohol abuse
in different ways, all probably agree that it is imperative at some point in Stan’s
therapy to confront him on the probability that he is a chemically dependent per-
son. In this section, I describe my approach to working with his dependence as
well as giving some brief background information on the alcoholic personality and
on treatment approaches.
s o m e b a s i c a s s u m p t i o n s Stan has given me a number of signifi cant
clues suggesting that he is a chemically dependent person. From the information
he has provided, it is clear that Stan has many of the personality traits typically as-
sociated with addictions, including low self-concept, anxiety, underachievement,
feelings of social isolation, inability to receive love from others, hypersensitivity,
impulsivity, dependence, fear of failure, feelings of guilt, and suicidal ideation. He
has used drugs and alcohol as a way of blunting anxiety and attempting to control
what he perceives as a painful reality.
Once our therapeutic relationship is fi rmly established, I confront Stan (in a
caring and concerned manner) on the self-deception that drinking is less problem-
atic than taking drugs. He needs to see that alcohol is a drug. I think it is important
that he make an honest evaluation of his behavior so that he can recognize the
degree to which his drinking is interfering in his living.
a s u p p l e m e n ta ry t r e at m e n t p r o g r a m Stan eventually recognizes
and acknowledges that he does indeed have a problem with alcoholism, and he
says he is willing to do something about this problem. Stan needs to know that
long-term recovery is based on the principle of total abstinence from all drugs
and alcohol and that such abstinence is a prerequisite to effective counseling. In
addition to his weekly individual therapy sessions with me, I provide Stan with a
referral to deal with his chemical dependence.
I encourage Stan to join Alcoholics Anonymous and attend their meetings.
The 12-step program of AA has worked very well for many alcoholics. Once Stan
understands the nature of his chemical dependence and no longer uses drugs, the
chances are greatly increased that we can focus on the other aspects of his life that
he sees as problematic and would like to change. In short, it is possible to treat his
alcoholism and at the same time carry out a program of individual therapy geared
to changing Stan’s ways of thinking, feeling, and behaving.
Moving Toward Termination of Therapy
The process I have been describing will probably take months. During this time, I
will continue to draw simultaneously on a variety of therapeutic systems in working
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with Stan’s thoughts, feelings, and behaviors. Eventually this process will lead to a
time when Stan can continue what he has learned in therapy without my assistance.
Termination of therapy is as important as the initial phase, for now the key
task is to put into practice what he has learned in the sessions by applying new
skills and attitudes to daily social situations without professional assistance.
When Stan brings up a desire to “go it alone,” we talk about his readiness to
end therapy and his reasons for thinking about termination. I also share with
him my perceptions of the directions I have seen him take. This is a good time
to talk about where he can go from here. We spend time developing an action
plan and talking about how he can best maintain his new learning. He may
want to join a therapeutic group. He could fi nd support in a variety of social
networks. In essence, he can continue to challenge himself by doing things that
are diffi cult for him yet at the same time broaden his range of choices. Now he
can take the risk and be his own therapist, dealing with feelings as they arise in
new situations.
In a behavioral spirit, evaluating the process and outcomes of therapy seems
essential. This evaluation can take the form of devoting some time to discussing
Stan’s specifi c changes in therapy. A few questions for focus are: “What stands
out the most for you, Stan? What did you learn that you consider the most valu-
able? How did you learn these lessons? What can you do now to keep practicing
new behaviors? What will you do if you experience a setback?” We explore poten-
tial diffi culties he expects to face when he no longer comes to weekly counseling
sessions. At this point, I introduce some relapse prevention strategies to help Stan
cope constructively with future problems. By addressing potential problems and
stumbling blocks that he might have to deal with, Stan is less likely to become
discouraged if he experiences any setbacks. If any relapses do occur, we talk about
seeing these as “learning opportunities” rather than as signs that he has failed. I
let Stan know that his termination of formal therapy does not mean that he can-
not return for a visit or session when he considers it appropriate. Rather than
coming for weekly sessions, Stan might well decide to come in at irregular inter-
vals for follow-up sessions.
Encouraging Stan to Join a Therapy Group
As Stan and I talk about termination, he gives me clear indications that he has
learned a great deal about himself through individual counseling. Although Stan
has been doing well on his own, I believe he would benefi t from a group experi-
ence. I suggest that Stan consider joining a 16-week therapy group that will begin
in 2 months.
To me, progressing from individual therapy to a group seems useful for a cli-
ent like Stan. Because many of his problems are interpersonal, a group is an ideal
place for him to deal with them. The group will give Stan a context for practicing
the very behaviors he says he wants to acquire. Stan wants to feel freer in being
himself, to be able to approach people even when he is fearful, and to be able to
trust people more fully. In addition to a group experience, I will be working with
Stan to fi nd some other ways to continue his growth.
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Commentary on the Thinking, Feeling, and Doing Perspective
In applying my integrative perspective to Stan, I’ve dealt separately with the cog-
nitive, affective, and behavioral dimensions of human experience. Although the
steps I outlined may appear relatively structured and even simple, actually working
with clients is more complex and less predictable. If you are practicing from an in-
tegrative perspective, it would be a mistake to assume that it is best to always begin
working with what clients are thinking (or feeling or doing). Effective counseling
begins where the client is, not where a theory indicates a client should be.
In summary, depending on what clients need at the moment, I may focus initially
on what they are thinking and how this is affecting them, or I may focus on how they
feel, or I may choose to direct them to pay attention to what they are doing. Think-
ing and feeling are two sides of the same coin, and if Stan can change his thoughts,
I believe he is likely to change some of his behaviors and his feelings. If he changes
his feelings, he might well begin to think and act differently. If he changes certain
behaviors, he may begin thinking and feeling differently. Because these facets of hu-
man experience are interrelated, one route generally leads to the other dimensions.
A person-centered focus respects the wisdom within the client and uses it as a
lead for where to go next. My guess is that counselors often make the mistake of
getting too far ahead of their clients, thinking, “What should I do next?” By staying
with our clients and asking them what they want, they will tell us which direction
to take either directly or indirectly. We can learn to pay attention to our own reac-
tions to our clients and to our own energy. By doing so we can engage in a thera-
peutic connection that is helpful for both parties in the relationship.
Follow-Up: You Continue Working With Stan
in an Integrative Style
Think about these questions to help you decide how to counsel Stan from your
own integrative approach:
• What themes in Stan’s life do you fi nd most signifi cant, and how might you
draw on these themes during the initial phase of counseling?
• What specifi c concepts from the various theoretical orientations would you be
most inclined to utilize in your work with Stan?
• Identify some key techniques from the various therapies that you are most
likely to employ in your therapy with Stan.
• How would you develop experiments for Stan to carry out both inside and out-
side the therapy sessions?
• Knowing what you do about Stan, what do you imagine it would be like to be
his therapist? What problems, if any, might you expect to encounter in your
counseling relationship with him?
See DVD for Theory and Practice of Counseling and Psychotherapy: The Case of
Stan and Lecturettes (Session 13 on an integrative approach) for a demonstra-
tion of my approach to counseling Stan from this perspective. This session
deals with termination and takes an integrative view of Stan’s work. This is also
a good time to review the entire program of the 13 sessions with Stan as a way
to think about how you might counsel Stan from your integrative perspective.
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c o n c l u d i n g c o m m e n t s
At the beginning of the introductory course in counseling, my students typically
express two reactions: “How will I ever be able to learn all these theories?” and
“How can I make sense out of all this information?” By the end of the course, these
students are often surprised by how much work they have done and by how much
they have learned. Although an introductory survey course will not turn students
into accomplished counselors, it generally provides the basis for selecting from
among the many models to which they are exposed.
At this point you may be able to begin putting the theories together in some
meaningful way for yourself. This book will have served its central purpose if it
has encouraged you to read further and to expand your knowledge of the theories
that most caught your interest. I hope you have seen something of value that you
can use from each of the approaches described. You will not be in a position to
conceptualize a completely developed integrative perspective after your fi rst course
in counseling theory, but you now have the tools to begin the process of integra-
tion. With additional study and practical experience, you will be able to expand and
refi ne your emerging personal philosophy of counseling.
Finally, the book will have been put to good use if it has stimulated you to think
about the ways in which your philosophy of life, your values, your life experiences,
and the person you are becoming are vitally related to the caliber of counselor you
can become. This book and your course may have raised questions for you regard-
ing your decision to become a counselor. Seeking out at least one of your profes-
sors to explore these questions can be the next step.
Now that you have fi nished this book, I would be very interested in hearing
about your experience with it and with your course. The comments readers have
sent me over the years have been helpful in revising each edition, and I welcome
your feedback. You can complete the reaction sheet at the end of the book and mail
it to Brooks/Cole, Cengage Learning, 20 Davis Drive, Belmont, California 94002.
28549_ch16_rev01.indd 521 20/09/11 3:48 PM
Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

28549_ch16_rev01.indd 522 20/09/11 3:48 PM
Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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X
Adler, A., 10–11, 63, 84, 102–103,
106–108, 115, 120, 128, 143, 291,
433, 437
Ainslie, R., 75–77, 85
Alberti, R., 265
Alford, B., 322
Al-Rashidi, B., 343, 350, 352
American Counseling Association
(ACA), 23, 48–49
American Psychiatric Association,
45, 107, 340, 374–375, 436
American Psychological Association,
363, 385
American Psychological Associa-
tion Presidential Task Force on
Evidence-Based Practice, 46
Andersen, T., 445
Anderson, C., 439, 451
Anderson, H., 398–399, 404, 442,
445
Andrews, J., 418
Angel, E., 143
Ansbacher, H., 103–108, 119, 128
Ansbacher, R., 104–108, 119
Antony, M., 247, 254, 263, 269,
280
Arciniega, G., 123–124
Arkowitz, H., 191–192
Arlow, J., 73–75, 96–97
Arnkoff, D., 468
Arredondo, P., 25
Astor-Lazarus, D., 247
Atkinson, D., 91
Austin, S., 182
Axline, V., 201
Baldwin, M., 446
Bandura, A., 10, 245–247, 249–250
Banman, J., 433
Barber, P., 237
Bateson, G., 406, 415
Beardsley, B., 363
Beck, A. T., 10, 128, 250, 288–289,
291, 302–303, 305–310, 322
Beck, J., 10, 289, 303, 306–307, 324
Becvar, D., 434–435, 441
Becvar, R., 434–435, 441
Beisser, A., 214
Belenky, M., 362
Bell, A., 465
Bem, S., 368–369
Berg, I., 11, 396–397, 400, 403, 405,
407–408, 424–425
Berger, P., 397
Bertolino, B., 398, 402, 407, 416,
420, 424
Beutler, L., 47–48, 465–467, 476,
483, 495, 497
Bhati, K., 47
Binswanger, L., 140, 142
Bisono, A., 469
Bitter, J., 101, 107, 110, 113–114, 115–
119, 121–122, 128, 372, 374–375,
438–441, 445–446, 449, 456
Black, M., 89
Blanchard, L., 121
Blau, S., 293
Blau, W., 79
Bohart, A., 174, 179, 181, 185–186,
195, 201, 496
Borden, A., 396
Boscolo, L., 457
Boss, M., 140, 142
Bowen, M., 11, 433, 438, 438
Bowman, C., 211, 227
Bozarth, J., 174–175, 180, 185–186
Brabeck, M., 363, 386
Bracke, P., 165
Breshgold, E., 227, 236
Brickell, J., 341, 343, 345, 347, 350,
352–354
Brodley, B., 178
Brodsky, A., 51
Bromley, D., 46–47
Brooks, G., 386
Brooks, J., 191, 193, 195
Brown, J., 212, 214, 223
Brown, L., 11, 362–364, 366, 369–
370, 372, 374–376, 388, 398
Brown, S., 25
Brownell, P., 237
Breunlin, D., 445, 450
Bubenzer, D., 441
Buber, M., 140–141, 157, 211
Bugental, J., 140–141, 144–145, 155,
157, 159, 165
Bumberry, W., 440
Burns, A., 46
Burr, V., 398
Butler, A., 306
Byars-Winsston, A., 363, 370, 375
Cain, D., 173–174, 176, 181–186, 190,
194–196, 198–200, 212
Callaghan, G., 250, 279
Callanan, P., 39, 41–42, 44
Cannon, K., 368
Caplan, P., 384
Carlson, J. D., 123, 125, 445
Carlson, J. M., 105, 107, 111–112, 114,
117–119, 121–125, 127–130
Carter, B., 433, 439
Cashwell, C., 469–471
Castaldo, J., 307
Castillo, L., 363
Cavasos, L., 191, 193, 195
Cecchin, F., 457
Chambless, D., 307
Chang, R., 252, 275, 280
Christensen, O., 113–114, 116, 121,
433, 437
Clark, A., 110, 116, 184
Clark, D., 418
Clarkin, J., 89
Clemmer, F., 107
Clinchy, B., 362
Name Index
523
Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

524
Cole, E., 362
Cole, L., 128, 372
Comas-Diaz, L., 469
Combs, A., 199, 201
Combs, G., 410, 412–415, 424
Committee on Professional Practice
and Standards, 41
Comstock, D., 368
Cooper, M., 166, 199, 232
Corey, G., 34, 38–39, 41–42, 44, 46,
49–50, 79, 83, 101, 117, 122, 128,
154, 158, 160, 186, 189, 224, 233,
254, 258, 268, 274, 297–298, 302,
310, 349, 371, 386, 408, 410, 418
Corey, M., 38–39, 41–42, 44, 154
Cormier, S., 253–254, 258–260, 266,
317
Counseling Today, 34
Craske, M., 260, 262
Crawford, T., 297
Crethar, H., 363, 380
Crocket, K., 410, 413–414
Cukrowicz, K., 46
Curtis, R., 75, 77, 79–81
Dattilio, F., 46–47, 165, 245, 249,
258, 304–307, 310, 322–323
Deegear, J., 46
De Jong, P., 396–397, 403, 405,
407–408, 424–425
Delaney, H., 469
De Shazer, S., 11, 396, 398, 400–401,
403, 405–408, 424, 442
Deurzen, E., van, 140, 145, 148, 152,
154, 156–160, 164–166
Dienes, K., 291, 306
Digiuseppe, R., 250, 279, 305
Dimidjian, S., 269, 271, 278
Dinkmeyer, D., 105, 120–121
Dinkmeyer, D., Jr., 112, 119
Di Pietro, R., 110–111, 116, 128
Disque, J., 110, 119
Dobson, K., 303
Donovan, D., 314
Doolin, E., 183
Dozois, D., 303
Dreeben, S., 271
Dreikurs, R., 10, 103, 108–109,
113–114, 120, 433, 437, 450
Drewery, W., 414
Driscoll, K., 46
Dryden, W., 291, 293–295, 297, 299
Duncan, B., 18, 48, 187, 201–202,
424, 467, 480, 496
Edwards, J., 46–47
Eifert, G., 272–273
Eisengart, S., 400, 425
Eldridge, N., 368
Elkins, D., 19, 166, 173–174, 202
Ellenberger, H., 143
Elliott, R., 201, 213
Ellis, A., 11, 128, 288, 291–300, 302,
316–317, 323
Emmons, M., 265
Englar-Carlson, M., 105, 107, 114,
117–118, 123–124, 129
Enns, C., 11, 97, 361, 363–366, 370,
373–375, 377, 379–380, 386–387
Epp, L., 160
Epstein, N., 307
Epston, D., 11, 396, 398, 401, 410,
413, 416–418, 442, 445
Eriksen, K., 373–375, 379
Erikson, E., 64, 69–70, 94
Espin, O., 11, 361–362
Evans, K., 373, 376, 379
Evans, T., 109, 118, 120
Fairhurst, I., 199
Farber, B., 183
Farha, B., 151
Feder, B., 233
Ferguson, K., 258
Fernbacher, S., 233
Fishman, D., 270, 279
Fishman, H., 457
Flynn, J., 272
Follette, V., 268, 273
Follette, W., 250, 279
Forman, E., 268, 273
Forsyth, J., 272–273
Frame, M., 469–470
Frankl, V., 10, 128, 137, 143, 148, 152
Freedman, J., 396, 410, 412–415, 424
Freeman, A., 291, 302, 304,
306–307, 323
Freiberg, H., 175
Fresco, D., 272
Freud, S., 10, 63, 70, 83–84, 94, 102
Frew, J., 215, 218, 223–224, 227,
233
Fromm, E., 103, 128
Fulton, P., 273
Gamori, M., 433
Ganley, A., 380
Garcia-Preto, N., 433, 439
Geller, J., 21–22
Gelso, C., 77–78
Gendlin, E., 201
Gerber, J., 433
Gergen, K., 397, 442
Germer, C., 269, 273
Gerson, R., 433, 439, 446
Gilbert, L., 371, 380, 386
Gilligan, C., 362, 364, 367–368
Gingerich, W., 400, 406, 425
Giordano, J., 433
Gladding, S., 445–446
Glass, C., 468
Glass, G., 495
Glasser, C., 338
Glasser, W., 11, 334, 336, 339–340,
343, 350, 353, 355
Goldberg, N., 362
Goldenberg, H., 435, 456
Goldenberg, I., 435, 456
Goldfried, M., 465, 468
Goldman, R., 177, 179, 198, 213, 220,
225, 237
Goldstein, K., 211
Goodman, R., 212, 220
Goolishian, H., 398–399, 404, 442,
445
Gordon, J., 296
Gottman, J., 446
Gould, W., 142
Grant, S., 91
Granvold, D., 307
Greenberg, L., 177, 179, 195, 198,
200–202, 213, 220, 467
Griffith, J., 115
Gross, A., 259–260
Guevremont, D., 247, 253, 259,
262–263, 269, 275, 280
Guterman, J., 404, 408
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Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

525
Gutheil, T., 51
Guy, J., 18, 34
Hagedorn, W., 471
Haigh, A., 272
Haley, J., 11, 434, 440–441, 457
Hammer, T., 368
Hanna, S., 445
Hardy, K., 451
Harper, R., 293–295
Harris, A., 85
Hawes, C., 113–114, 116, 121
Hayes, J., 77–78
Hayes, S., 268–269, 272–273
Hays, P., 316–317, 377
Hazlett-Stevens, H., 260, 262
Head, L., 259–260
Healey, A., 128, 372
Hedges, L., 87–88
Hefferline, R., 212, 220
Heidegger, M., 140–142
Heimberg, R., 278, 299–300
Herbert, J., 268, 273
Herlihy, B., 38, 41, 49–50, 379–380,
386
Herman, J., 375
Higginbotham, H., 252, 275, 280
Hirsch, I., 75, 77, 79–81
Hogan, T., 47–48, 202
Holden, J., 105
Hollon, S., 250, 279, 305
Hood, A., 116
Horney, K., 103, 128, 291
Houts, A., 269, 272
Hoyt, M., 476
Hubble, M., 18, 48, 187, 201–202,
424, 467, 496
Hummel, A., 77–78
Humphrey, K., 212
Imhof, L., 343, 350, 352
Ingram, R., 321
Jacobs, L., 212, 220, 223–224, 227,
232, 236, 238
Jacobs, N., 298, 306
Jacobson, E., 258
Jennings, L., 19–20
Johnson, J., 160
Johnson, R., 116
Joiner, T., 46
Jones, J., 25
Jordan, J., 361, 368
Josselson, R., 139, 146, 152, 154,
156–157, 160
Jung, C., 63, 83–85, 94, 102
Kabat-Zinn, J., 269, 271
Kaplan, A., 361, 368
Karpiak, C., 466
Kaschak, E., 364, 368
Kazdin, A., 250, 256–257, 280
Kees, N., 379
Kefir, N., 107
Kemper, T., 46
Kendall, P., 307
Kernberg, O., 86, 88–89
Kerr, M., 438
Kersh, B., 191, 193, 195
Keys, S., 199
Kierkegaard, S., 138, 140
Kim, R., 343, 350, 352
Kincade, E., 373, 376, 379
Kirschenbaum, H., 173, 198
Klein, M., 87, 182
Knapp, S., 37
Kohut, H., 86, 88–89
Koldon, G., 182
Koocher, G., 47–48, 202
Korman, L., 201
Kottman, T., 130
Krebs, P., 193
Kress, V., 373–375, 379
Krug, O., 145, 147, 155, 161, 165,
176
Lago, C., 199
Lambert, M., 19, 467, 496
Larsen, C., 386
Latner, J., 215
Lawson, D., 46
Lazarus, A., 10, 246–247, 250, 255,
266–268, 466, 473, 476
Lazarus, C., 247, 268
Leahy, R., 308, 321
Ledley, D., 278, 299–300
Lee, M., 425
Lee, R., 223
Leech, N., 379
Levant, R., 47–48
Levensky, E., 191, 193, 195
Levenson, H., 90–91
Levitsky, A., 228
Lewis, J., 445
Lindsley, J., 411
Linehan, M., 97, 268–269, 269–271,
273, 278
Lipckik, E., 400
Lisiecki, J., 115, 119
Lister, K., 466
Lobovits, D., 396
Locke, D., 25
Lojk, L., 343, 350, 352
Luborsky, E., 73–75, 96–97
Luckman, T., 397
Luepnitz, D., 445
Lusterman, D., 386
MacKune-Karrer, B., 445, 450
MacLaren, C., 296–297
Macy, R., 306, 324
Madanes, C., 11, 434
Madigan, S., 415, 417, 420
Mahler, M., 87–88
Maisel, R., 396
Maniacci, M., 106, 109–112, 114,
117–119, 121–122, 127–128
Marbley, A., 379
Marlatt, G., 314
Martell, C., 251
Marx, B., 278, 299–300
Maslow, A., 128, 177–179
Masterson, J., 89
Maurer, R., 227
May, R., 10, 128, 137–138, 143, 150,
154, 156
McCollum, V., 379–380
McDavis, R., 25
McElwain, B., 166
McGoldrick, M., 433, 439, 446,
451
McKay, G., 120
McKeel, A., 406, 425–426
McKenzie, W., 410, 416–419, 426
Mearns, D., 199, 201
Meichenbaum, D., 10, 290, 310–315,
324
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Melnick, J., 219, 223–225
Mennin, D., 272
Merry, T., 199
Messer, S., 90
Metcalf, L., 401, 408–409
Miller, J. B., 11, 361, 364, 368
Miller, S., 18, 48, 187, 201–202, 396,
400, 424, 467, 480, 496
Miller, T., 495
Miller, W., 191–192, 254, 469
Milliren, A., 107, 109, 118, 120
Miltenberger, R., 247, 253, 256–257,
264
Minuchin, S., 11, 434, 440, 457
Mitchell, S., 86, 89
Monk, G., 410–419, 424–426
Moorhead, H., 471
Morrow, S., 363
Mosak, H., 106, 109–111, 115–117, 119,
128
Mozdzierz, G., 115, 119
Muller, K., 270, 279
Murphy, J., 401, 404–407, 409
Nagy, T., 40–42, 50
Nash, S., 363, 380
Natiello, P., 199, 201
Neenan, M., 296
Neimeyer, 418
Nevis, S., 219, 223–225
Newbauer, J., 109, 118, 120
Newlon, B., 123–124
Newman, C., 307
Nichols, M., 445, 456
Nicoll, W., 113–114, 116, 117–119,
121–122, 128
Nietzsche, F., 140–141
Niles, B., 269
Norcross, J., 18–22, 34, 47–48, 90,
184, 193, 202, 263, 367, 403,
465–468, 476,480, 483, 495, 497
North American Society of Adlerian
Psychology (NASAP), 130
Nurius, P., 253–254, 258–260, 266,
317
Nutt, R., 386
Nye, R., 245
Nylund, D., 419
Nystul, M., 123
O’Hanlon, B., 398, 400, 402, 404,
406–407, 412, 414, 416, 420, 424,
442
O’Reilly-Landry, M., 73–75, 96–97
Orlinsky, D., 21–22
Osborn, C., 253–254, 258–260, 266,
317
Pachankis, J., 465
Padesky, C., 307
Paivio, S., 201
Palmer, S., 296
Panjares, F., 246
Parlett, M., 223
Parsons, J., 368
Patterson, C., 201
Paul, G., 252
Pedersen, P., 42
Peller, J., 400–404, 424
Pelonis-Peneros, P., 122
Peluso, P., 119, 121
Perls, F., 10, 211–213, 220, 222,
227–228, 230, 238
Perls, L., 10, 211–212, 222–223
Peterman, M., 307
Petrocelli, J., 302
Petry, S., 433, 439, 446
Philpot, C., 386
Pietrefesa, A., 269
Pietrzak, D., 113, 119, 123, 127, 129
Pleck, J., 380
Plummer, D., 233
Pollack, W., 380, 383
Polster, E., 10, 212, 215–217, 221–225,
227
Polster, M., 10, 212, 215–217,
222–225, 227
Popkin, M., 120
Potter, C., 269
Powers, R., 115
Prata, G., 457
Pretzer, J., 307
Prochaska, J., 90, 193, 263, 367, 403,
467, 495
Psychotherapy Networker, 466
Rader, J., 371, 386
Raskin, N., 174, 188
Rave, E., 386
Real, T., 380
Rego, S., 270, 279
Reinecke, M., 291, 306–307
Reitzel, L., 46
Remer, P., 376, 370–372, 374–375,
377–378, 380–382, 387
Remley, T., 41
Rennie, D., 201
Rice, L., 201
Richeport-Haley, M., 441
Riskind, J., 307
Roberts, A., 438
Robertson, L., 471
Robertson, P., 128, 372
Robey, P., 341
Robins, C., 270–271
Roemer, L., 247, 254, 263, 269, 280
Rogers, C., 10, 142, 173–175, 177–181,
183, 186, 188–190, 194, 200, 399,
414, 445
Rogers, N., 10, 187–191, 199–201, 362
Rollnick, S., 191–192, 254
Ronnestad, M., 21
Root, M., 363
Rosenthal, M., 270–271
Rothblum, E., 362
Russell, D., 173
Russell, J., 143, 147–148, 154–155,
158, 166
Rutan, J., 83
Salazar, G., 368
Salmon, P., 270
Sanchez, J., 25
Sartre, J., 140, 142, 147
Satir, V., 11, 433, 439, 446, 449
Sauer, A., 291, 306
Scher, C., 321
Scher, M., 380
Schmertz, S., 269
Schneider, K., 145–147, 155, 157, 159,
161, 165, 176
Schultz, D., 83–85, 103
Schultz, S., 83–85, 103
Schwartz, R., 445, 450
Sebold, J., 425
Seem, S., 373, 376, 379
Seeman, J., 174
Segal, Z., 271, 321, 467
526
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Segrin, C., 263
Selvini Palazzoli, M., 457
Sephton, S., 271
Sgambati, R., 258
Shapiro, F., 262–263
Sharf, R., 166
Sharp, J., 140–141, 159
Shay, J., 83
Sherman, R., 105
Shulman, B., 115, 119, 127, 129
Siegel, R., 273
Simpson, L., 270–271
Sinacore, A., 364, 366
Skinner, B., 10, 245
Sklare, G., 409–410
Skovholt, T., 19–20
Slavik, S., 119
Smith, B., 199
Smith, L., 92
Smith, M., 495
Sommers-Flanagan, J., 190–191
Sonstegard, M., 122, 438
Sparks, J., 480, 496
Sperry, L., 42, 112, 119, 121, 445
Spiegler, M., 247, 253, 259–260,
262–263, 269, 275, 280, 294,
316
St. Clair, M., 86–86
Stadler, H., 25
Stebnicki, M., 34
Stern, D., 87
Stiver, I., 361, 368
Stone, W., 83
Strasser, A., 159
Strasser, F., 159
Strentzsch, J., 368
Stricker, G., 466
Strosahl, K., 269, 272
Strumpfel, U., 225, 237
Strupp, H., 89, 96
Sue, D., 25, 42
Sue, D. W., 25, 42
Sullivan, H., 103
Surrey, J., 361, 368
Sweeney, T., 111
Tallman, K., 174, 181, 201, 496
Tanaka-Matsumi, J., 252, 275, 280
Tarule, J., 362
Tausch, R., 174–175, 180, 185–186
Teasdale, J., 271, 467
Tharp, R., 265–266
Thomas, J., 419
Thomas, S., 373
Thompson, C., 91
Thorne, B., 180, 182, 199, 201
Tillich, P., 138, 149–150, 211
Tompkind, M., 304, 307
Toporek, R., 25
Torres-Harding, S., 291, 306
Torres Rivera, E., 363, 380
Trepal, H., 368
Turner, L., 362
Uken, A., 425
Vaihinger, H., 105
Vandecreek, L., 37
Vernon, A., 301
Vontress, C., 149, 152, 157, 160–161,
166
Vujanovic, A., 269
Walden, S., 373
Walker, L., 388
Walker, M., 368
Walsh, F., 439, 451
Walsh, R., 166
Walter, J., 400–404, 424
Walters, R., 245, 249
Wampold, B., 18–19, 47, 165, 187,
201–202, 467–468, 480, 496
Wang, C., 182
Warren, C., 90
Watson, D., 265–266
Watson, J., 177, 179, 181, 184–186,
195, 198–199, 201, 213, 220
Watts, R., 105, 111–114, 118–119,
121–123, 127–129
Watzlawick, P., 128
Weiner-Davis, M., 398, 400, 404,
406–407, 424, 442
Weishaar, M., 250, 289, 291,
302–303, 305–308, 321, 323, 397
Weitzman, L., 363
Werner-Wilson, R., 362
West, J., 441
Westra, H., 191
Whitaker, C., 11, 434, 440
White, B., 46
White, J., 302
White, M., 11, 396, 398, 401, 410,
413, 415–418, 442, 445, 450
Wiggins-Frame, M., 469
Williams, A., 115
Williams, J., 271, 467
Wilson, G., 247, 249–250, 253, 266,
269, 273–274, 280
Wilson, K., 269, 272
Winslade, J., 410–415, 418–419,
424–425
Wiseman, H., 21
Witty, M., 188
Wolfe, J., 291, 293, 297, 299, 316,
323
Wolitzsky, D., 64, 72–77, 81–82, 89,
96
Wolpe, J., 248, 251, 258
Worell, J., 367, 370–372, 374–375,
380–381, 387
Worthington, E., 269, 470–471
Wubbolding, R., 11, 334, 336–348,
350, 352–356
Yalom, I., 10, 97, 138–140, 144, 146,
152, 154, 156–157, 160
Yeomans, F., 89
Yontef, G., 212, 214, 220, 223–225,
227, 232, 236, 238
Young, J., 469–471
Young, M., 471
Zahm, S., 236
Zimring, F., 174–175, 180, 185–186
Zinker, J., 212, 217, 219, 225, 238
Zur, O., 49, 247
527
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A-B-C framework, 293–294, 301
ABC model, 252, 482
Acceptance, 183, 188, 269, 295
Acceptance and commitment
therapy, 272–273, 466
Accommodation, 222
Accurate empathic understanding,
184–185
Action, planning and, 347–348
Actualizing tendency, 178
Adlerian brief therapy, 113
Adlerian family therapy, 437–438
Adlerian therapy, 101–135, 472
application, 120–122, 486
applied to the case of Stan,
125–126
client’s experience, 111–112
contributions, 127–129, 488, 491
key concepts, 103–109, 474
limitations and criticisms, 129,
489, 493
multicultural perspective, 123–125
relationship between therapist
and client, 112, 481
shortcomings, 124–125
strengths, 123–124
therapeutic goals, 109–110, 477
therapeutic process, 109–112
therapeutic techniques and proce-
dures, 113–122, 484
therapist’s function and role,
110–111
Adolescence, 71
Advice, 32
Affect, 267
Aloneness, 150
Alternative interpretations, 308
Ambiguity, 30
Anal stage, 69–70
Analytic framework, maintaining
the, 79
Analytic psychology, 83
Androcentric, 367
Anger management training, 263
Angst, 140
Anima, 85
Animus, 85
Antecedent events, 252
Anxiety, 28, 66, 73, 81, 140, 152–153,
176–177, 181, 230, 261, 262
Anxiety, existential, 152
Anxiety hierarchy, 259–260
Application and follow-through
phase, 314
Approaches, theoretical
Adlerian therapy, 101–135, 472,
477, 486, 488–489, 491, 493
behavior therapy, 244–286, 472,
478, 486, 488, 490, 492, 494
cognitive behavior therapy,
287–332, 472, 478, 487–488,
490, 492, 494
existential therapy, 136–171, 472,
477, 486, 488, 490–491, 494
family systems therapy, 432–461,
473, 478, 487, 489, 491, 493,
495
feminist therapy, 360–394, 473,
478, 487, 489–490, 493, 494
gestalt therapy, 210–243, 472,
477, 486, 488, 490, 492, 494
integrative perspective, 464–521
person-centered therapy,
172–209, 472, 477, 486, 488,
490, 492, 494
postmodern approaches, 395–431,
473, 478, 487, 489–490, 493,
495
psychoanalytic therapy, 62–100,
472, 477, 486, 488–489, 491,
493
reality therapy, 333–359, 473,
478, 487, 489–490, 492, 494
Arbitrary inferences, 512
Archetypes, 84
Aspirational ethics, 37
Assertion training, 264
Assertiveness, 274, 378
Assessment, 44–46, 186, 373–375,
438, 446–449, 470
Assessment process, ethical issues
in, 44–46
Assimilation, 223
Assimilative integration, 467
Authenticity, 148, 165
Automatic thoughts, 303
Autonomy, 176
Autonomy versus shame and
doubt, 70
Awareness, 66, 76, 81, 153–154,
212–213, 217, 219, 225, 232,
236, 316
Basic assumptions, 401–402,
456, 518
Basic ID, 266–268
Basic philosophies, 472–473
Behavior, 105, 267, 465
Behavior therapy, 244–286, 472
application, 255–274, 486
applied to the case of Stan,
276–277
areas of development, 248–250
basic characteristics and assump-
tions, 250–252
client’s experience, 254
contributions, 278–279, 488, 492
historical background, 247–248
key concepts, 250–252, 474
limitations and criticisms,
279–280, 490, 494
multicultural perspective, 274–276
relationship between therapist
and client, 254–255, 481
shortcomings, 275–276
strengths, 274–275
therapeutic goals, 252, 478
Subject Index
528
9, 472, 477,
494
proaches, 395–4
489–490, 493
c therapy, 6
486, 488–4
apy, 333–35
, 489–490,
ences, 512
–100,
9, 491,
473,
92, 494
254
278–279,
cal background, 24
key concepts, 250–252,
limitations and criticism
279–280, 490, 494
mu cultural perspective,
relationship between therapist
and client, 254–255, 481
76
252, 478
y
chetypes, 84
shortcomings, 275–2
strengths, 274–275
therapeutic goals
ence, 71
2
ations, 308
intaining
3
267
s, 150
e interpr
, 30
e, 69–70
framework,
he, 79
alytic psychology
gu
al st
Analy
A
process, 109–112
eutic techniques and proce-
dures, 113–122, 484
herapist’s function and role,
110–111
les
post
473
495
psychoanal
472
Advic
Affect
Alone
Altern
Amb
An
en therapis
and client, 112, 481
shortcomings, 124–125
strengths, 123–124
therapeutic goals
therapeu
the
Ado
Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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therapeutic process, 252–255
therapeutic techniques and proce-
dures, 255–274, 484
therapist’s function and role,
252–254
Behavior, total, 337
Behavioral analysis, 251–252
Behavioral assessment
interview, 253
Beliefs and attitudes, 25–26
Beliefs, self-defeating, 29
Belonging, 107
Bibliotherapy, 298, 378
Birth order, 107–109
Blaming, 439
Blank-screen approach, 73
Blocks to energy, 218–219
Borderline personality disorder,
88–89
Boundaries, 51
Boundary crossing, 51
Boundary disturbance, 218
Boundary violation, 51
Bridge, 408
Brief psychodynamic therapy, 90
Burnout, professional, 33
Change, 119, 193–194, 343–344,
450–451
Change-focused questions, 406
Characteristics, personal, 19
Choice, 212, 264, 339
Choice theory, 336
Circulation questions, 417
Classical conditioning, 248
Classical psychoanalysis, 69, 74
Client-centered therapy, 175
Cognition, 267
Cognitive behavior modification, 310,
322, 324
Cognitive behavior therapy, 249,
287–332, 472
application, 297–302, 307–310,
487
applied to the case of Stan,
318–319
client’s experience, 296
contributions, 320–322, 488, 492
key concepts, 292–295, 475
limitations and criticisms,
322–324, 490, 494
multicultural perspective, 315–317
relationship between therapist
and client, 297, 306–307, 482
shortcomings, 316–317
strengths, 315–316
therapeutic goals, 295, 478
therapeutic process, 295–297
therapeutic techniques and proce-
dures, 297–302, 485
therapist’s function and role,
295–296
Cognitive distortions, 303
Cognitive patterns, 465
Cognitive restructuring, 294
Cognitive therapy, 302–310, 321–324
Cognitive triad, 308
Collaborative empiricism, 305
Collaborative language systems ap-
proach, 399
Collective unconscious, 84
Commitment, 273
Common factors approach, 467
Communication, privileged, 41
Community feelings, 107, 109
Compensation, 68
Complainant, 405
Compliments, 407
Conceptual-educational phase, 313
Confidentiality, 41–42
Confluence, 218
Confrontation, 227–228
Congruence (genuineness), 182–183,
439
Consciousness, 65–66, 146
Consequences, 252
Constructivist narrative perspective,
315
Contact, 217–218
Contemporary psychoanalysis, 69
Contextual factors, 19
Cooperation, 107
Countertransference, 31, 76–78, 82
Courage, 149
Crisis, 69
Crisis intervention, 187–188
Criticisms, limitations and, 489–491,
493–495
Cultural conditioning, 25
Cultural feminists, 365
Culture, 25, 27–28
Customer, 405
Cybernetics, 441
Cycle of counseling, 342
Death and nonbeing, 153–154
Death instincts, 64
Decision making, ethical, 38–40
Decisions, revised, 515–516
Deconstruction, 415–416
Defense mechanisms, 66–68, 74
Deflection, 218
Demands, 30
Denial, 67
Depression, treatment of,
308–310
Desensitization, 259
Despair, integrity versus, 71
Deterministic, 367
Development, summary of stages of,
87–89
Diagnosis, 44–46, 373–375
Dialectical behavior therapy,
269–271, 466
Dialogic encounter, 165
Dichotomous thinking, 304
Differentiation of self, 438
Direction and doing, 345–346
Displacement, 67
Distress tolerance, 270
Diversity, 24, 27
Doing, direction and, 345–346
Dread, 140
Dream analysis, 80–81
Dream work, 230
Drugs, 268
Dual relationships, 48
Early childhood, 70
Early recollections, 110, 115–116
Egalitarian relationship, 369
Ego, 64–66
Ego-defense mechanisms, 66–68, 82
Ego psychology, 69, 85
Electra complex, 70
EMDR. See Eye movement desensiti-
zation and reprocessing
529
Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Emotion-focused therapy, 200,
213, 467
Emotional disturbance, 292–293
Emotional regulation, 270
Empathy, 185, 199–200
Empowerment, 376–377
Empty-chair technique, 228
Encouragement, 118–119
Energy, 218–219
Engendered lives, 368
Ethical decision making, 38–40
Ethical issues, 36–58
Ethical issues, assessment process,
44–46
Ethical issues, multicultural per
spective, 42–44
Ethical obligation, 24
Ethics, 37
Evidence-based practice, 46–48
Exaggeration exercise, 230
Exception questions, 406
Exceptions, 406
Exercises, 224
Existential analysis, 142
Existential anxiety, 152
Existential guilt, 147
Existential therapy, 136–171, 472
application, 157–160, 486
applied to the case of Stan,
162–163
client’s experience, 155–156
contributions, 164–165, 488, 491
key concepts, 145–154, 474
key figures, 143–145
limitations and criticisms,
165–166, 490, 494
multicultural perspective,
160–162
relationship between therapist
and client, 156–157, 481
shortcomings, 161–162
strengths, 160–161
therapeutic goals, 154–155, 477
therapeutic process, 154–157
therapeutic techniques and
procedures, 157–160, 484
therapist’s function and role, 155
Existential tradition, 145
Existential vacuum, 152
Existentialism and humanism,
176–177
Experiential family therapy, 440
Experiments, 224
Exposure therapies, 260
Expressive arts therapy, 189–191
Externalization, 415–416
Externalizing conversations, 416
Externalizing questions, 422
Extinction, 256
Extinction process, 257
Eye movement desensitization and
reprocessing (EMDR), 262–263
Factors, contextual, 19
Family constellation, 110, 115
Family systems perspective, 435
Family systems therapy, 432–461,
473
Adlerian, 437–438
application, 487
applied to the case of Stan,
452–455
contributions, 457, 489, 493
development of, 437–445
experiential, 440
goals and values, 456, 478
human validation process model,
439–440
key concepts, 475
limitations and criticisms,
457–458, 491, 495
multicultural perspective, 451–452
multigenerational, 438–439
multilayered process, 445–451
postmodern perspectives,
442–445
shortcomings, 452
strengths, 451–452
structural-strategic, 440–441
systemic viewpoints in, 443–444
techniques, 456–457, 485
therapeutic relationship, 482
Faulty assumptions, 109
Feeling, 230, 465, 507–510
Feminist therapy, 360–394, 473
application, 373–380, 487
applied to the case of Stan,
382–384
client’s experience, 372
contributions, 385–387, 489, 493
history and development,
363–366
key concepts, 367–370, 475
limitations and criticisms,
387–388, 490, 494
multicultural and social justice
perspective, 380–382
principles of, 369–370
relationship between therapist
and client, 373, 482
shortcomings, 381–382
strengths, 380–381
techniques and strategies,
375–380
therapeutic goals, 370–371, 478
therapeutic process, 370–373
therapeutic techniques and proce-
dures, 373–380, 485
therapist’s function and role,
371–372
Fictional finalism, 105
Field, 213
Field theory, 215
Figure, 214
Figure-formation process, 215,
225, 237
Flexible-multicultural perspective,
367
Flooding, 261–262
Formula first session task, 407
Free association, 73, 79, 292
Freedom, 147–149, 176–177, 336
Friendship, 107
Functional assessment, 251–252
Fundamental rule, 73
Future, 507
Gender-fair approaches, 367
Gender-role analysis, 377
Gender-role intervention, 377
Gender schemas, 368
Gendercentric, 367
Generativity versus stagnation, 71
Genital stage, 71
Genogram, 446–448
Genuineness (congruence), 182–183
Gestalt therapy, 210–243, 472
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application, 224–233, 486
applied to the case of Stan,
234–236
client’s experience, 222–223
contributions, 236–237, 488, 492
interventions, 228–231
key concepts, 213–219, 474
limitations and criticisms,
237–239, 490, 494
multicultural perspective,
233–234
relational, 212
relationship between therapist
and client, 223–224, 481
shortcomings, 234
strengths, 233–234
therapeutic goals, 219–220, 477
therapeutic process, 219–224
therapeutic techniques and proce-
dures, 224–233, 484
therapist’s function and role,
220–222
Global international feminists, 366
Goal oriented, 105
Goals, 23–24, 470, 476, 505–506
Adlerian therapy, 109–110, 477
behavior therapy, 252, 478
cognitive behavior therapy,
295, 478
existential therapy, 154–155, 477
family systems therapy, 456, 478
feminist therapy, 370–371, 478
gestalt therapy, 219–220, 477
integrative perspective, 477–478
person-centered therapy, 179, 477
postmodern approaches,
403–404, 412, 478
psychoanalytic therapy, 72, 477
reality therapy, 340, 478
Goals, mistaken, 109
Ground, 214
Group work, 379–380
Guilt, existential, 147
Guilt, initiative versus, 70
Here-and-now, 145, 216, 219–
220, 231
Heterosexist, 367
Hierarchy of needs, 177
Holism, 214
Holistic concept, 105
Homework, 260, 263, 296, 298,
300, 307, 479, 510
Honesty, 73, 177
Human behavior, 105
Human nature, view of
Adlerian therapy, 103–104
behavior therapy, 250
cognitive behavior therapy, 292
existential therapy, 145–146
feminist therapy, 367
gestalt therapy, 213–214
person-centered therapy,
178–179
psychoanalytic therapy, 64
reality therapy, 336–337
Human personality, 104–106
Human validation process model,
439–440
Humanism, existentialism and,
176–177
Humanistic psychology, 177–178
Humor, 31, 299–300
Hypothesizing, 449–450
Id, 64–66
Id psychology, 69
Ideal self-concept, 180
Identification, 68
Identity, 149–151
Identity versus role confusion, 71
Imagery, 267
Immediacy, 185
Impasse, 216
Inauthenticity, 147
Individual psychology, 104, 107
Individual therapy, 436
Individuation, 84
Industry versus inferiority, 71
Infancy, 70
Inferiority feelings, 104
Inferiority, industry versus, 71
Informed consent, 40–41, 376
Initiative versus guilt, 70
Insight, 117–118
Integrative perspective, 464–521
advantages of psychotherapy
integration, 467–468
applied to the case of Stan,
503–521
challenge of developing, 471–477
client’s experience, 479–480
integration of multicultural issues,
468–469
integration of spirituality and
religion, 469–471
movement toward psychotherapy
integration, 465–477
relationship between therapist
and client, 480–483
techniques and evaluation,
483–497
therapeutic goals, 477–478
therapeutic process, 477–483
therapist’s function and role,
478–479
Integrity versus despair, 71
Internal dialogue, 228–229, 311–312
Interpersonal effectiveness, 270
Interpersonal empathy, 184
Interpersonal relationships, 268
Interpretation, 80, 117
Interruptions in contact, 218
Intervention strategies, skills and, 26
Interventions, gestalt therapy,
228–231
Intimacy versus isolation, 71
Intrapsychic orientation, 367
Introjection, 68, 217
In vivo exposure, 260–261
In vivo flooding, 261
Involuntary clients, 30
Irrational beliefs, 297–298
Isolation, intimacy versus, 71
It talk, 221
Judgment, normalizing, 411
Key concepts
Adlerian therapy, 103–109, 474
behavior therapy, 250–252, 474
cognitive behavior therapy,
292–295, 475
existential therapy, 145–154, 474
family systems therapy, 475
feminist therapy, 367–370, 475
gestalt therapy, 213–219, 474
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Key concepts (continued)
person-centered therapy,
178–179, 474
postmodern approaches,
400–402, 410–411, 475
psychoanalytic therapy,
64–72, 474
reality therapy, 336–340, 475
Labeling and mislabeling, 304, 512
Language, 221
Latency stage, 71
Latent content, 80
Later life, 71
Lesbian feminists, 366
Liberal feminists, 364
Libido, 64
Life instincts, 64
Life-span perspective, 367
Lifestyle, 106
Lifestyle assessment, 111, 115
Limitations, 29
Limitations and criticisms, 489–491,
493–495
Listening, 411
Logotherapy, 143, 152
Magnification and minimization, 304
Maintaining the analytic
framework, 79
Making the rounds, 229
Mandatory ethics, 37
Manifest content, 80
Mapping, 416
Meaning, 176
Meaning, search for, 151–152
Meaninglessness, 152
Metaphors, 221
Middle age, 71
Middle child, 108
Mindfulness, 269–270
Mindfulness-based cognitive
therapy, 271–272, 467
Mindfulness-based stress reduction,
269, 271
Minimization, magnification and, 304
Minor psychotherapy, 113
Miracle question, 406–407
Mislabeling, labeling and, 304, 512
Mistaken goals, 109
Mistrust, trust versus, 70
Moral anxiety, 66
Motivational interviewing, 191–194
Multicultural counseling, 25–26
Multicultural issues, integration of,
468–469
Multicultural perspective, ethical
issues in, 42–44
Multigenerational family therapy,
438–439
Multilayered process of family
therapy, 445–451
Multimodal therapy, 266
Multiple relationships, 48–50
Muscle relaxation, progressive,
257–258
Narcissistic personality, 88–89
Narrative therapy, 410–419, 442
Negative punishment, 257
Negative reinforcement, 256
Negative self-talk, 294
Neurotic anxiety, 66, 153
Nonbeing, death and, 153–154
Nondirective counseling, 174
Nonprofessional relationships, 48
Normal anxiety, 153
Normal infantile autism, 87
Normalizing judgment, 411
Not-knowing position, 399,
404, 412–413, 415, 424,
441–442
Now, the, 215–216
Object-relations theory, 86
Objective empathy, 184
Objective interview, 115
Oedipus complex, 70
Oldest child, 108
Only child, 109
Operant conditioning, 249, 300
Operationally defined, 251
Oral stage, 69–70
Organismic self-regulation, 215
Overgeneralization, 304, 512
Paradoxical theory of change, 214, 219
Past, 506
Perfectionism, 29
Person-centered approach, 175
Person-centered therapy,
172–209, 472
application, 184–189, 486
applied to the case of Stan,
196–197
client’s experience, 180–181
contributions, 177–178, 198–202,
488, 492
development of the approach,
174–176
key concepts, 178–179, 474
limitations and criticisms,
202–203, 490, 494
multicultural perspective, 194–196
relationship between therapist
and client, 181–184, 481
shortcomings, 195–196
strengths, 194–195
therapeutic goals, 179, 477
therapeutic process, 179–184
therapeutic techniques and proce-
dures, 184–189, 484
therapist’s function and role,
180–181
Persona, 85
Personal characteristics, 19
Personal consultation, 402
Personal therapy, 20–22
Personality, 64–65
Personality, development of, 68–71,
83–85
Personality, human, 104–106
Personalization, 304, 512
Phallic stage, 69–70
Phenomenological, 104
Phenomenological awareness, 213
Phenomenological inquiry, 215
Philosophical approach, 139
Philosophical restructuring, 294
Picture album, 337
Placating, 439
Planning and action, 347–348
Pleasure principle, 65
Polarized thinking, 512
Positive ethics, 37
Positive orientation, 400–401
Positive psychology, 177, 401
Positive punishment, 257
Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Positive reinforcement, 256
Postmodern approaches, 395–431,
473
application, 406–410, 414–419, 487
applied to the case of Stan,
421–423
contributions, 424–426, 489, 493
key concepts, 400–402,
410–411, 475
limitations and criticisms, 426,
490, 495
multicultural perspective, 419–421
narrative therapy, 410–419
shortcomings, 421
social constructionism, 397–399
solution-focused brief therapy,
400–410
strengths, 419–420
therapeutic goals, 403–404,
412, 478
therapeutic process, 402–405,
412–414
therapeutic relationship, 405,
413–414, 482
therapeutic techniques and proce-
dures, 406–410, 414–419, 485
therapist’s function and role,
404–405, 412–413
Postmodern feminists, 366
Postmodern perspectives, 442–445
Power analysis, 377
Practice-based evidence, 480
Preschool age, 70
Presence, 185
Present, 339, 506
Pretherapy change, 406
Private logic, 111
Privileged communication, 41
Problem-saturated stories, 401
Professional burnout, 33
Professional role, 32–33
Progressive muscle relaxation,
257–259
Projection, 67, 73, 217
Psychoanalytic therapy,
62–100, 472
application, 82–83, 486
applied to the case of Stan, 92–93
client’s experience, 73–75
contributions, 94–96, 488, 491
counseling implications, 72
key concepts, 64–72, 474
limitations and criticisms, 96–97,
489, 493
multicultural perspective, 91–92
relationship between therapist
and client, 75–78, 481
shortcomings, 91–92
strengths, 91
therapeutic goals, 72, 477
therapeutic process, 72–78
therapeutic techniques and
procedures, 78–83, 484
therapist’s function and role,
72–73
Psychological dynamics, 114–117
Psychological investigation, 109
Psychosexual stages, 68, 70–71
Psychosocial stages, 69–71
Psychotherapy integration, 465–477
Punishment, 257
Purpose, 176
Quality world, 337, 344
Questioning, art of, 409
Questions, 221, 406–407, 409–410,
414–417, 420, 422, 425
Radical feminists, 365
Rational emotive behavior therapy
(REBT), 291–292, 297–302,
321–323
Rational emotive imagery, 299
Rationalization, 67
Reaction formation, 67
Reality, 104, 397
Reality anxiety, 66
Reality principle, 65
Reality therapy, 333–359, 472
application, 342–349, 487
applied to the case of Stan,
352–353
client’s experience, 341
contributions, 354–355,
489, 492
key concepts, 336–340, 475
limitations and criticisms,
355–356, 490, 494
multicultural perspective,
349–352
relationship between therapist
and client, 341–342, 482
shortcomings, 351–352
strengths, 349–351
therapeutic goals, 340, 478
therapeutic process, 340–342
therapeutic techniques and
procedures, 342–349, 485
therapist’s function and role, 341
REBT. See Rational emotive behavior
therapy
Reframing, 378
Regression, 68, 74
Rehearsal exercise, 230–231
Relabeling, 378
Relapse prevention, 314
Relatedness, 150–151
Relational-cultural theory, 368
Relational Gestalt therapy, 212
Relational model, 86–87
Relationship, 113–114, 445–446
Relationship therapy, 435
Relationships, dual, 48
Relationships, multiple, 48–50
Relationships, nonprofessional, 48
Relaxation, 260, 300
Religion, integration of spirituality
and, 469–471
Reorientation, 118
Repression, 67
Research, 199
Resistance, 81–82, 144, 227,
218–219, 227
Responsibility, 32, 176, 212, 339
Restructuring, 294
Retroflection, 218
Reversal exercise, 229
Revised decisions, 515–516
Role confusion, identity
versus, 71
Role playing, 300
Scaling questions, 407
Schema, 310
School age, 71
Search for meaning, 151–152
Second child, 108
Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
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534
S
U
B
J
E
C
T

I
N
D
E
X
Self- acceptance, 213
Self-actualization, 165, 177, 179
Self-awareness, 38, 73, 109,
146–147, 177
Self-care, 34
Self-concept, 180
Self-consciousness, 164
Self-defeating behavior, 216
Self-defeating beliefs, 29
Self-disclosure, 28–29, 158, 376, 385
Self-efficacy, 249
Self-evaluation, 346–347, 354
Self-exploration, 22, 177
Self-instructional training, 311
Self-management, 265
Self-monitoring, 34, 265
Self-observation, 311
Self-psychology, 86
Self-understanding, 117–118
Self-worth, 107
Sensation, 267
Separation-individuation, 88
Shadow, 85
Shame and doubt, autonomy
versus, 70
Shame-attacking exercises, 300
Sibling relationships, 107–109
Significance, 105–106
Silence, 30
Skills acquisition and consolidation
phase, 313
Skills and intervention strategies, 26
Social action, 379
Social constructionism, 397–399
Social interest, 106, 109
Social learning approach, 249
Social skills training, 263–265
Socialist feminists, 365
Socialization, 179
Solution-focused brief therapy,
400–410, 442
Spirituality and religion, integration
of, 469–471
Spiritual dimension, 517–518
Stages of development, 87–89
Stagnation, generativity versus, 71
Stan, case of
Adlerian therapy, 125–126
behavior therapy, 276–277
cognitive behavior therapy,
318–319
existential therapy, 162–163
family systems therapy, 452–455
feminist therapy, 382–384
gestalt therapy, 234–236
integrative approach, 503–521
person-centered therapy, 196–197
postmodern approaches, 421–423
psychoanalytic therapy, 92–93
reality therapy, 352–353
Storied lives, 398
Stories, role of, 410–411
Stress inoculation training, 312–314
Structural-strategic family therapy,
440–441
Student-centered teaching, 175
Subjective empathy, 184
Subjective interview, 114
Sublimation, 68
Suggesting tasks, 408
Superego, 65–66
Superiority, 105–106
Symbiosis, 87
Systematic desensitization,
258–260, 300
Systematic integration, 476
Systemic therapy, 436
Systemic viewpoints in family
systems therapy, 443–444
Technical eclecticism, 266
Technical integration, 466
Techniques, therapeutic, 33
Terminating, 408
Termination, 518–519
Theoretical approaches
Adlerian therapy, 101–135, 472,
477, 486, 488–489, 491, 493
behavior therapy, 244–286,
472, 478, 486, 488, 490,
492, 494
cognitive behavior therapy,
287–332, 472, 478, 487–488,
490, 492, 494
existential therapy, 136–171, 472,
477, 486, 488, 490–491, 494
family systems therapy, 432–461,
473, 478, 487, 489, 491, 493,
495
feminist therapy, 360–394,
473, 478, 487, 489–490,
493, 494
gestalt therapy, 210–243, 472,
477, 486, 488, 490, 492, 494
integrative perspective, 464–502
person-centered therapy,
172–209, 472, 477, 486, 488,
490, 492, 494
postmodern approaches,
395–431, 473, 478, 487,
489–490, 493, 495
psychoanalytic therapy, 62–100,
472, 477, 486, 488–489,
491, 493
reality therapy, 333–359,
473, 478, 487, 489–490,
492, 494
Theoretical integration, 466
Therapeutic core conditions, 182
Therapeutic relationship, 34, 226,
405, 413–414, 481–482,
504–505
Therapeutic techniques, 33
Therapist feedback, 407–408
Therapy, personal, 20–22
Total behavior, 337
Transference, 73, 75–76, 82,
339, 355
Triangulation, 438
Trust versus mistrust, 70
Unconditional other acceptance, 295
Unconditional positive regard,
182–183
Unconditional self-acceptance, 295
Unconscious, 65–66, 79, 231
Unconscious, collective, 84
Unfinished business, 216–217
Value imposition, 23
Values, 22–24, 43, 151, 176, 272
Visitor, 405
Wants, 344–345
WDEP system, 344–348
Wellness, 34
Working-through, 75
You talk, 221
Young adulthood, 71
Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

Nikki
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UPLOADED BY [STORMRG]

Nikki
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About the Author��
Contents��
Preface��
Part 1: Basic Issues in Counseling Practice��
Ch 1: Introduction and Overview��
Introduction��
Where I Stand��
Suggestions for Using the Book��
Overview of the Theory Chapters��
Introduction to the Case of Stan��
Ch 2: The Counselor: Person and Professional��
Introduction��
The Counselor as a Therapeutic Person��
Personal Therapy for the Counselor��
The Counselor’s Values and the Therapeutic Process��
Becoming an Effective Multicultural Counselor��
Issues Faced by Beginning Therapists��
Summary��
Ch 3: Ethical Issues in Counseling Practice��
Introduction��
Putting Clients’ Needs before Your Own��
Ethical Decision Making��
The Right of Informed Consent��
Dimensions of Confidentiality��
Ethical Issues in a Multicultural Perspective��
Ethical Issues in the Assessment Process��
Ethical Aspects of Evidence-Based Practice��
Managing Multiple Relationships in Counseling Practice��
Becoming an Ethical Counselor��
Summary��
Where to Go from Here��
Recommended Supplementary Readings for Part 1��
References and Suggested Readings for Part 1��

Part 2: Theories and Techniques of Counseling��
Ch 4: Psychoanalytic Therapy��
Introduction��
Key Concepts��
The Therapeutic Process��
Application: Therapeutic Techniques and Procedures��
Jung’s Perspective on the Development of Personality��
Contemporary Trends: Object-Relations Theory, Self Psychology, and Relational Psychoanalysis��
Psychoanalytic Therapy from a Multicultural Perspective��
Psychoanalytic Therapy Applied to the Case of Stan��
Summary and Evaluation��
Where to Go from Here��
Recommended Supplementary Readings��
References and Suggested Readings��
Ch 5: Adlerian Therapy��
Introduction��
Key Concepts��
The Therapeutic Process��
Application: Therapeutic Techniques and Procedures��
Adlerian Therapy from a Multicultural Perspective��
Adlerian Therapy Applied to the Case of Stan��
Summary and Evaluation��
Where to Go from Here��
Recommended Supplementary Readings��
References and Suggested Readings��
Ch 6: Existential Therapy��
Introduction��
Key Concepts��
The Therapeutic Process��
Application: Therapeutic Techniques and Procedures��
Existential Therapy from a Multicultural Perspective��
Existential Therapy Applied to the Case of Stan��
Summary and Evaluation��
Where to Go from Here��
Recommended Supplementary Readings��
References and Suggested Readings��
Ch 7: Person-Centered Therapy��
Introduction��
Key Concepts��
The Therapeutic Process��
Application: Therapeutic Techniques and Procedures��
Person-Centered Expressive Arts Therapy��
Motivational Interviewing��
Person-Centered Therapy from a Multicultural Perspective��
Person-Centered Therapy Applied to the Case of Stan��
Summary and Evaluation��
Where to Go from Here��
Recommended Supplementary Readings��
References and Suggested Readings��
Ch 8: Gestalt Therapy��
Introduction��
Key Concepts��
The Therapeutic Process��
Application: Therapeutic Techniques and Procedures��
Gestalt Therapy from a Multicultural Perspective��
Gestalt Therapy Applied to the Case of Stan��
Summary and Evaluation��
Where to Go from Here��
Recommended Supplementary Readings��
References and Suggested Readings��
Ch 9: Behavior Therapy��
Introduction��
Key Concepts��
The Therapeutic Process��
Application: Therapeutic Techniques and Procedures��
Behavior Therapy from a Multicultural Perspective��
Behavior Therapy Applied to the Case of Stan��
Summary and Evaluation��
Where to Go from Here��
Recommended Supplementary Readings��
References and Suggested Readings��
Ch 10: Cognitive Behavior Therapy��
Introduction��
Albert Ellis’s Rational Emotive Behavior Therapy��
Key Concepts��
The Therapeutic Process��
Application: Therapeutic Techniques and Procedures��
Aaron Beck’s Cognitive Therapy��
Donald Meichenbaum’s Cognitive Behavior Modification��
Cognitive Behavior Therapy from a Multicultural Perspective��
Cognitive Behavior Therapy Applied to the Case of Stan��
Summary and Evaluation��
Where to Go from Here��
Recommended Supplementary Readings��
References and Suggested Readings��
Ch 11: Reality Therapy��
Introduction��
Key Concepts��
The Therapeutic Process��
Application: Therapeutic Techniques and Procedures��
Reality Therapy from a Multicultural Perspective��
Reality Therapy Applied to the Case of Stan��
Summary and Evaluation��
Where to Go from Here��
Recommended Supplementary Readings��
References and Suggested Readings��
Ch 12: Feminist Therapy��
Introduction��
Key Concepts��
The Therapeutic Process��
Application: Therapeutic Techniques and Procedures��
Feminist Therapy from a Multicultural and Social Justice Perspective��
Feminist Therapy Applied to the Case of Stan��
Summary and Evaluation��
Where to Go from Here��
Recommended Supplementary Readings��
References and Suggested Readings��
Ch 13: Postmodern Approaches��
Introduction to Social Constructionism��
Solution-Focused Brief Therapy��
Narrative Therapy��
Postmodern Approaches from a Multicultural Perspective��
Postmodern Approaches Applied to the Case of Stan��
Summary and Evaluation��
Where to Go from Here��
Recommended Supplementary Readings��
References and Suggested Readings��
Ch 14: Family Systems Therapy��
Introduction��
Development of Family Systems Therapy and Personal Development of the Family Therapist��
A Multilayered Process of Family Therapy��
Family Systems Therapy from a Multicultural Perspective��
Family Systems Therapy Applied to the Case of Stan��
Summary and Evaluation��
Where to Go from Here��
Recommended Supplementary Readings��
References and Suggested Readings��

Part 3: Integration and Application��
Ch 15: An Integrative Perspective��
Introduction��
The Movement toward Psychotherapy Integration��
Issues Related to the Therapeutic Process��
The Place of Techniques and Evaluation in Counseling��
Summary��
Where to Go from Here��
Recommended Supplementary Readings��
References and Suggested Readings��
Ch 16: Case Illustration: An Integrative Approach in Working with Stan��
Counseling Stan: Integration of Therapies��
Concluding Comments��

Name Index
Subject Index��

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