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Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

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 THE QUICK THEORY REFERENCE
GUIDE: A RESOURCE FOR EXPERT AND
NOVICE MENTAL HEALTH
PROFESSIONALS

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 THE QUICK THEORY REFERENCE
GUIDE: A RESOURCE FOR EXPERT AND
NOVICE MENTAL HEALTH
PROFESSIONALS

KARIN JORDAN
EDITOR
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Nova Science Publishers, Inc.

New York

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 Copyright © 2008 by Nova Science Publishers, Inc.

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Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

AMERICAN BAR ASSOCIATION AND A COMMITTEE OF PUBLISHERS.

LIBRARY OF CONGRESS CATALOGING-IN-PUBLICATION DATA

The quick theory reference guide: a resource for expert and novice mental health
Professionals / [edited by] Karin Jordan.
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978-1-62081-358-4 (eBook)

1. Psychotherapy—Handbooks, manuals, etc. I. Jordan, Karin.

[DNLM: 1. Psychological Theory. 2. Family Therapy. 3. Psychotherapy. BF 38 Q6 2007]
RC480.5.Q53 2007
616.89’14--dc22
2007007504

Published by Nova Science Publishers, Inc. New York

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 CONTENTS

Preface ix
The Goal of this Book xi
Foreword xiii
Chapter 1 Theories in Counseling, Psychotherapy
and Family Therapy 1
Karin Jordan
Chapter 2 Psychoanalytic Theory and Therapy 7
Naomi A. Mandsager and Ralph Beaumont
Chapter 3 Adlerian Psychotherapy 23
Len Sperry
Chapter 4 Jungian Theory and Therapy 31
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Stephen R. Bearden, Michelle J. Cox and Kimberli Freilinger

Chapter 5 Existential Psychotherapy: Philosophy and Practice 47
Claire Arnold-Baker and Emmy van Deurzen
Chapter 6 Client Centered Therapy and the
Person-Centered Approach 63
Jerold D. Bozarth
Chapter 7 Gestalt Therapy 83
Gary Yontef and Mark Fairfield
Chapter 8 Behavior Therapy: A Foundational Overview 107
Karin Jordan
Chapter 9 Rational Emotive Behavior Therapy 127
Albert Ellis
Chapter 10 Acceptance and Commitment Therapy and the
Third Generation of Cognitive Behavior Therapy 141
Steven C. Hayes and Jennifer C. Plumb
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 vi Karin Jordan

Chapter 11 Treating Mental Health as a Public Health Problem:

A New Leadership Role for Counselors 155
William Glasser
Chapter 12 Empowerment Feminist Therapy 167
Pam Remer
Chapter 13 An Overview of Constructivist Theory 183
Sandra N. Rustam
Chapter 14 Adlerian family therapy 197
Jon Carlson and Julia Yang
Chapter 15 Object Relations Theory in Family Therapy 209
Karin Jordan and Richard Shaw
Chapter 16 Contextual Family Therapy 227
Elliot Klearman
Chapter 17 Transgenerational Family Therapy Theories 237
Thorana S. Nelson
Chapter 18 Symbolic-Experiential Family Therapy 251
Karin Jordan
Chapter 19 Two Forms of Gestalt Family Therapy 263
Paul Shane and Karin Jordan
Chapter 20 Emotion Focused Therapy 285
Alberta E. Pos and Leslie S. Greenberg
Chapter 21 Client-Centered Family Therapy 299
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Ned L. Gaylin
Chapter 22 Human Validation Process Model 311
Sharon Loeschen and Margarita Suarez
Chapter 23 Ecosystemic Structural Family Therapy: A Primer 331
C. Wayne Jones and Marion Lindblad-Goldberg
Chapter 24 Strategic Therapy 349
Sabrina Walters and Gena Minnix
Chapter 25 Behavioral Family Therapy for Schizophrenia
and Serious Mental Disorders 361
Robert Paul Liberman
Chapter 26 Solution-Focused Therapy with Contributions
from Existential Theories 387
Mary-Beth Nickel

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 The Quick Theory Reference Guide: A Resource for Expert… vii

Chapter 27 Solution-Oriented Marriage and Family Therapy 401

Pat Hudson
Chapter 28 Collaborative Therapy 417
Harlene Anderson
Chapter 29 Reflecting Talks 427
Tom Andersen
Chapter 30 An Introduction to Narrative Therapy 445
Lorraine DeKruyf
Chapter 31 Integrative Couple and Family Therapy 461
Jay L. Lebow and Kathleen Newcomb Rekart
Chapter 32 Applications of Relational Competence
Theory to Prevention and Psychotherapy 475
Luciano L'Abate
Chapter 33 Medical Family Therapy 493
Colleen M. Peterson and Kathleen Briggs
Chapter 34 Feminist Family Theory and Therapy 501
Toni Schindler Zimmerman and Angie Besel
Index 511
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 PREFACE

Today, many of the mental health disciplines introduce graduate students to both
counseling and psychotherapy theories as well as family therapy. For some, this means taking
separate courses, one in Personality Theory and one in Marriage and Family Therapy,
however some take only one course in Personality Theory and as part of that course are
introduced to systemic thinking and systemic approaches. Textbooks generally focus on
counseling and psychotherapy theories, and if at all only a limited number of marriage and
family theories, whereas textbooks on family therapy seldom include counseling and
psychotherapy theories.
There is currently no textbook or theory reference guide available that covers counseling
and psychotherapy theories as well as family therapy. Therefore, in order to produce a set of
readings that will help students attain knowledge in counseling and psychotherapy theories as
well as family therapy, teachers must undertake a piecemeal process which often involves
multiple textbooks and supplementation with articles. This book is an effort to respond to the
need for a reference guide that offers a balanced presentation of the major theoretical
orientations of counseling and psychotherapy theories as well as family therapy. It is also
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

designed to serve as a resource and reference guide for those outside of academia.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 THE GOAL OF THIS BOOK

The purpose of this book is two-fold. First, it is intended for trainees in psychology,
counseling, school counseling, marriage and family therapy, social work and human services,
to provide an overview of the divergent models found in counseling and psychotherapy as
well as family therapy, without preferential treatment for any. Secondly, it is intended to
serve as a helpful reference guide for practitioners.
The book was written with both the trainee and practitioner in mind. Each chapter was
designed to provide a straightforward overview of the key concepts of each model. The
chapters are not exhaustive reviews of the respective therapy models, but rather provide an
overview of foundational concepts. No single book can give justice to the complexity of each
of these models, therefore, the hope is that the book will provide enough information to entice
the trainee to seek out and learn more about the different theories, and to remind practitioners
of what they already know.
The underlying premise of the book is that trainees and practitioners need to be grounded
in the various models as they provide trainees and practitioners with a framework/blueprint to
operate from. Being intentional is essential to being ethical, but also to being effective, which
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

is important in this era of managed care. Consequently, intentionality requires trainees and
practitioners to be knowledgeable about the models, and will ultimately help them to be
ethical and have a conceptual framework that will help them understand clients’ therapeutic
needs.

THE ORGANIZATION OF THE BOOK

The book is divided into three parts.
Part I: A Brief Overview,
Part II: Counseling and Psychotherapy Theories
Part III: Family Therapy.
Many of the chapters follow a common organizational pattern which was designed to
make it easy for the reader to find information on techniques, process of therapy, etc. Other
chapters, in an attempt to give adequate attention to current trends, follow a different format
in order to provide the reader with the most relevant information.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 xii Karin Jordan

Part I offers a general overview of the difference in counseling and psychotherapy versus
family theories.
Part II deals with twelve counseling and psychotherapy theory models, including
Psychoanalytic, Adlerian, Jungian, Existential, Client-Centered, Gestalt, Behavior, Rational
Emotive Behavior, Acceptance and Commitment/Third Wave, Choice, Feminist, and
Constructivist.
Part III is devoted to twenty-one family therapy models, based on a systems paradigm,
including: Adlerian, Object Relations, Contextual, Transgenerational, Experiential
Humanistic, Symbolic Experiential, Gestalt-Experiential, Client-Centered, Human Validation
Process, Ecosystemic Structural, Strategic, Behavioral, Solution-Focused, Solution-Oriented,
Collaborative, Reflecting Talk, Narrative, Integrative, Relational Competence, Medical, and
Feminist.

ACKNOWLEDGEMENT
First, I thank my husband Wayne for his support and encouragement on this project. I
also thank my students, who inspired me to create a comprehensive reference guide, and my
colleagues for their ongoing quest for better resources. I also cannot forget those who taught
me long ago about the importance of being knowledgeable and well grounded in a broad
range of theories.
I also thank all of the contributors, each of whom was critical in making this book come
to pass. Many are leading experts in their respective fields, yet saw the project as important
enough to make a contribution. I also thank all of those who served as reviewers and lent their
expertise to the project.
Finally, thanks to the editors and staff at Nova Science Publishers, who made this book
a reality. I am especially grateful to Frank Columbus, who was willing to listen to my
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

proposal and to support the concept. I also thank Maya Columbus for working with me
throughout the project, serving as a resource bringing the vision to fruition.

-Karin Jordan

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 FOREWORD

Since the beginning of the concepts of family therapy, mental health professionals have
known that the family - the system - is a powerful source of support for change or a powerful
force for resistance to change. Some professionals work with individuals, some with families
and some with groups. However, all work with the context of the systems – family, group,
community, country, etc. Students, especially beginning students, are overwhelmed and
confused at the variety of approaches to working with clients. Many programs introduce
students to individual as well as systems concepts in the course of training. Students need
assistance in learning this variety of theories. They need to be able to compare and contrast
theories and techniques to determine when and where to utilize the best skills in order to
facilitate client change.
Dr. Karin Jordan has compiled a comprehensive text that enables the students to discover
each theory as it is presented in its purist form. The text is accessible yet the content provides
comprehensive knowledge of each theory. Dr. Jordan has brought together the master
educators and clinicians in our fields to write about their particular expertise.
Each chapter stands alone as an in depth presentation of a theory. Each writer is
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

obviously an expert in his or her particular choice of theory. Students learn in a manner that
informs but does not overpower. As the student continues through the semester or year to
utilize the full text, they begin to grasp the larger context of theory and the importance of
theory to technique. The student integrates the similarities and differences throughout all the
work that we do as social workers, counselors, marriage and family therapists, and
psychologists.
The book is a true training gift and resource for practitioners. It does what has been
sorely needed - integrates individual and family systems theory under one cover. It provides a
complete learning tool for students to become the best and most effective professionals
possible. The book introduces the reader theory by theory to the vast array of methods
available to assist people in making changes in their lives.
Thank you, Dr. Jordan, and all the wonderful authors that so willing gave of their time
and knowledge to produce this book.

Dr. Patricia W. Stevens

Director, Women’s Center for Lifelong Learning
Utah State University
Logan, Utah

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 xiv Karin Jordan

ABOUT THE AUTHORS

Tom Andersen, M.D. is Professor of Social Psychiatry at the Institute of Community
Medicine, University of Tromso, Norway. He has been the initiator of Reflective Processes in
therapeutic practices and is the author of The Reflecting Team: Dialogues and Dialogues
about Dialogues, 1991, and Death Talk: Conversations with Children and Families, 1997.

Harlene Anderson, Ph.D. is a founding member of AccessSuccess, the Houston

Galveston Institute, and the Taos Institute and she is a member of the board of directors of the
Family Business Institute and the Texas Medical Assistance and Development. Her book,
Conversation, Language and Possibilities is widely distinguished as trailblazing and has been
translated into five languages. Among her recognitions are the American Association for
Marriage and Family Therapy's 2000 Award for Outstanding Contributions to Marriage and
Family Therapy and the Texas Association for Marriage and Family Therapy's 1997 Award
for Lifetime Achievement. She holds a doctorate in psychology and is a licensed professional
counselor and marriage and family therapist.

Claire Arnold-Baker, M.A., is the Course Co-ordinator of the New School of

Psychotherapy and Counselling, and graduated with the M.A. in Existential Psychotherapy
and Counselling taught at the New School. She is a visiting faculty member of Schiller
International University and is in private practice in London and Reading.

Stephen R. Bearden, Ph.D. is in private practice and is Assistant Professor at George

Fox University in Salem, Oregon. He has taught and presented on Jungian Spirituality for
over ten years.

Ralph Beaumont, M.D. is a founding faculty member and training and supervising
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

analyst at the Oregon Psychoanalytic Institute. He is on the faculty at the Northwest Center
for Psychoanalysis in Portland, Oregon and is on the clinical faculty at Oregon Health and
Science University. Dr Beaumont is a member of the American and International
Psychoanalytic Associations, he is a frequent contributor to workshops on Analytic Listening
at meetings of the American International Psychoanalytic Association and has extensive
teaching experience in psychoanalysis and psychiatry. Dr Beaumont has served as faculty at
Harvard Medical School’s McLean Hospital from 1981-1994 and did psychoanalytic training
at the Psychoanalytic Institute of New England, East.

Angie Besel, B.S. is a Master’s Candidate at Colorado State University in the Marriage
and Family Therapy Program, Fort Collins, Colorado.

Jerold Bozarth, Ph.D. is Professor Emeritus of the University of Georgia, where his
tenure included Chair of the Department of Counseling and Human Development, Director of
the Rehabilitation Counseling Program and Director of the Person-Centered Studies Project.
He is consultant for person-centred training programmes in the Czech Republic and Portugal;
Scientific Director for the Person-Centred Learning Programme at the Institute for Person-

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 The Quick Theory Reference Guide: A Resource for Expert… xv

Centred Learning in England; and is associated with the Person-Centred Connections

programme, also in England.

Kathleen Briggs, Ph.D. is Department Head and Associate Professor at Oklahoma State
University. Her research interests include psychosocial issues and medical family therapy and
outcomes of marriage and family therapy training.

Jon Carlson, Psy.D., Ed.D. has earned doctorates in counseling and clinical psychology
and also holds an advanced certificate in psychotherapy. He is a distinguished professor in the
Division of Psychology and Counseling at Governors State University in University Park,
Illinois, and director of the Lake Geneva Wellness Clinic in Lake Geneva, Wisconsin.
Dr. Carlson is a Fellow of the American Psychological Association and holds a
Diplomate in family psychology from the American Board of Professional Psychology as
well as a Diplomate in Adlerian Psychology from the North American Society of Adlerian
Psychology. He has been named a Living Legend and received several other awards from the
American Counseling Association. Dr. Carlson was also granted the Vision and Innovation
Award from the Association for Counselor Education and Supervision.
He has authored more than 35 books and produced more than 200 training videos in
psychotherapy and related areas. Dr. Carlson serves as the founding editor of The Family
Journal and past president of the International Association of Marriage and Family
Counseling. His research interests include Adlerian and brief psychotherapy and couple and
family therapy.

Michelle J. Cox, M.A., Doctoral Candidate is Assistant Professor at George Fox

University in Salem, Oregon. She utilizes Jungian theory and techniques, especially dream
analysis.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Lorraine DeKruyf, M.A., Doctoral Candidate is Assistant Professor and Clinical

Director at George Fox University in Portland, Oregon.

Albert Ellis, Ph.D. published his first book on REBT, How to Live with a Neurotic, in
1957. Two years later he organized the Institute for Rational Living, where he held
workshops to teach his principles to other therapists. The Art and Science of Love, his first
really successful book, appeared in 1960, and he has now published 54 books and over 600
articles on REBT, sex and marriage. He is currently President Emeritus of the Albert Ellis
Institute in New York, which provides professional training programs and psychotherapy to
individuals, families and groups.

Mark Fairfield, L.C.S.W., B.C.D. (Board Certified Diplomate in Clinical Social Work),
is on faculty at the Pacific Gestalt Institute, is the Clinical Director at Common Ground-The
Westside HIV Community Center in Santa Monica and is in private practice in West Los
Angeles. He has contributed to the theory of Gestalt group therapy and has developed a
Gestalt model for working with substance-using, multi-diagnosed and indigent persons
without a harm-reduction paradigm. He is the current president of the Gestalt Therapy
Institute of Los Angeles.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 xvi Karin Jordan

Kimberli Freilinger, M.A. is in private practice in Salem, Oregon and adjunct faculty at
a local university.

Ned Gaylin, Ph.D. is Professor Emeritus at the University of Maryland. His career
included creation of the University of Maryland’s Marriage and Family Therapy Master's
program and tenure as the first chair of the department. Dr. Gaylin made pioneering
contributions to the principles and pragmatics of the person-centered approach for healing
individuals, couples, and families. He is internationally recognized for his research on family
therapy process and outcome, and the enhancement of creativity.

Leslie S. Greenberg, Ph.D. is Professor of Psychology at York University in Toronto,

Ontario and Director of the York University Psychotherapy Research Clinic. He is the major
developer of, and has co-authored the major texts on, emotion-focused approaches to
treatment. These include Facilitating Emotional Change (1993), Emotion-focused therapy:
Coaching clients to work through emotions (2002) and Emotion-focused therapy of
depression (2005). He is a past President of the Society for Psychotherapy Research (SPR)
and has been on the editorial board of many psychotherapy journals.

Steven C. Hayes, Ph.D. is Nevada Foundation Professor at the Department of

Psychology at the University of Nevada. An author of twenty seven books and 370 articles,
his career has focused on an analysis of the nature of human language and cognition and the
application of this to the understanding and alleviation of human suffering.

Pat Hudson, Ph.D. is a psychotherapist, author, and lecturer and for 21 years was the
Executive Director of the Hudson Center for Brief Therapy in Omaha, Nebraska, which she
founded with her father, R. Lofton Hudson, in 1975. She now practices in the Corpus Christi,
TX area.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

C. Wayne Jones, Ph.D. is Associate Director, Philadelphia Child and Family Training
Center has had 21 years of experience in the field of mental health as a licensed clinical
psychologist, teacher, trainer and researcher. He is an approved supervisor for the American
Association for Marriage and Family Therapy and a clinical associate professor of
psychology in the Department of Psychiatry, University of Pennsylvania School of Medicine.
Dr. Jones was a senior faculty member of the Family Therapy Training Center of the
Philadelphia Child Guidance Center and a trainer in the Pennsylvania Family-Based Mental
Health Training Initiative for 12 years.

Karin Jordan, Ph.D. is Professor and Chair of the Department of Counseling at The
University of Akron in Akron, OH. She has published over fifty refereed articles and
chapters. She is an Approved Supervisor of the American Association for Marriage and
Family Therapy and is a Licensed Marriage & Family Therapist.

Elliot Klearman, M.A. is a Counselor at Washington County Community Corrections,

Center for Victims’ Services, Hillsboro, Oregon.

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 The Quick Theory Reference Guide: A Resource for Expert… xvii

Luciano L’Abate, Ph.D. is Professor Emeritus of Psychology, Georgia State University,

Atlanta, Georgia. Author and co-author of over 250 articles, chapters and book reviews in
professional and scientific journals. Author, co-author, editor and co-editor of 38 books.
Three additional books are in press. His work has been translated in Argentina, China,
Denmark, Finland, Germany, Italy, Japan, and Korea.

Jay Lebow, Ph.D. is a family psychologist who engages in clinical practice, teaching,
and research. He is Senior Therapist and Research Consultant at The Family Institute at
Northwestern University and Adjunct Associate Professor at Northwestern University,
Evanston, Illinois.

Robert Paul Liberman, M.D. is Distinguished Professor of Psychiatry at UCLA School

of Medicine. He directs the Psych REHAB Program at the UCLA Neuropsychiatric Institute
and is a consultant to the Los Angeles County Department of Mental Health. He has been for
23 years the principle investigator and director of the UCLA Clinical Research Center for
Schizophrenia. He has over 400 publications. Dr. Liberman developed Behavior Family
Therapy and social skills training as an evidenced based service for the mentally disabled
which is used throughout the United States and has been translated in 23 languages.

Marion Lindblad-Goldberg, Ph.D. is Director of the Philadelphia Child and Family

Therapy Training Center, Inc.,and an Associate Professor of clinical psychology in the
Department of Psychiatry, University of Pennsylvania School of Medicine. She was formerly
Director of the Family Therapy Training Center of the Philadelphia Child Guidance Center.
She is also an Approved Supervisor in Marriage and Family Therapy. Dr. Lindblad-Goldberg
has been a clinician, teacher, trainer, and researcher in the mental health field for 33 years.
She has lectured extensively nationally and internationally and presented annually at the
American Association for Marriage and Family Therapy Conference. Dr. Lindblad-Goldberg
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

is an expert on eco-systemic structural family therapy, supervision, step-families, single

parent families, and spontaneity in therapy. She has specialized in innovative research with
single parent families, writing numerous articles about this subject.

Sharon Loeschen, MSW, Clinical Social Worker has been a practicing social worker for
twenty-six years and has trained and taught hundreds of students and interns in social work
and counseling. She serves as Secretary of Avanta The Virginia Satir Network and
occasionally leads classes at the California State University at Long Beach.

Naomi A. Mandsager, Ph.D. is in private practice and is Assistant Professor and

Clinical Director at George Fox University in Portland, Oregon.

Gena Minnix, M.A. is a therapist for Youth Contact, Hillsboro, Oregon. She was trained
by Scott Sells and Eileen Bobrow. She served as a board member for the Oregon Association
for Marriage and Family Therapy.

Thorana S. Nelson, Ph.D. is the director of the marriage and family therapy program at
Utah State University and Associate Professor in the Department of Family, Consumer, and
Human Development. She is in private practice in Logan, Utah. Dr. Nelson is the co-editor of
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 xviii Karin Jordan

several books, including 101 Interventions in Family Therapy and 101 More Interventions in
Family Therapy with Terry S. Trepper, Ph.D., Making the Impossible Difficult with John
Frykman, and Tales from Family Therapy: Life -Changing Experiences with Frank N.
Thomas, Ph.D.

Mary Beth Nichols, M.A. works at Columbia Community Mental Health in St. Helens
Oregon. She provides therapy for sexually abused and sexually reactive children and their
families.

Colleen Peterson, Ph.D. is Graduate Coordinator and Director, Center for Individual,
Couples, & Family Counseling at the University of Nevada, Las Vegas.

Jennifer C. Plumb is a graduate student in the Clinical Psychology Doctoral Program at

the University of Nevada, Reno. Her interests include Relational Frame Theory and applying
Acceptance and Commitment Therapy in clinical practice in ways that are innovative and
progressive.

Alberta Eveline Pos, Ph.D. is a postdoctoral fellow at the Center for Addiction and
Mental Health, in Toronto, Ontario.

Kathleen Newcomb Rekart, Ph.D. is a postdoctoral fellow in the Psychosocial

Rehabilitation Program at the Edith Nourse Rogers Memorial VAMC in Bedford, MA. She
received her B.A. in psychology from Yale University and both her M.S. and Ph.D. in clinical
psychology from Northwestern University.

Pam Remer, Ph.D. is Associate Professor at the University of Kentucky. Her areas of
research interests include factors affecting recovery from rape, effective counseling
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interventions for women, career decision-making counseling, diversity issues in counseling

and effectiveness of counselor responses.

Sandra N. Rustam, M.A. is a clinician at Youth Contact, Washington County, Oregon

Paul Shane, Ph.D. is a student advisor, Access/Disabled Student Services, and adjunct
faculty at Liberty Arts Cuyahoga Community College, Eastern Campus, Highland Heights,
Ohio
Richard Shaw, D.MFT. is in private practice and is Associate Professor and Assessment
Director at George Fox University, Portland, Oregon.
Len Sperry, M.D., Ph.D. is professor and director of the doctoral program in counseling
at Florida Atlantic University as well as clinical professor of psychiatry at the Medical
College of Wisconsin. He is board certified in clinical psychology and psychiatry. Dr. Sperry
is also a Fellow of the American Psychological Association and American Psychiatric
Association. He has numerous publications, including 40 professional books and more than
300 articles and chapters. His writings include Assessment of Couples and Families:
Contemporary and Cutting-Edge Strategies, Family Therapy: Ensuring Treatment Efficacy,
Brief Therapy With Individuals and Couples, Handbook of Diagnosis and Treatment of

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 The Quick Theory Reference Guide: A Resource for Expert… xix

DSM-IV-TR Personality Disorders, and Effective Leadership: Strategies for Maximizing

Executive Productivity and Health.
Margarita Suarez, RN, M.A. is Executive Director of Avanta the Virginia Satir
Network
Emmy van Deurzen, Ph.D., is Professor at the New School of Psychotherapy and
Counselling in London, England. She is a key figure in meaning centered therapy and has laid
a foundation that many existential psychotherapists follow. She is a chartered counseling
psychologist and a registered existential psychotherapist. Dr. van Deurzen is the founder and
director of The New School of Psychotherapy and Counselling, based in Waterloo, London.
She is also the founder and past chair for the Society for Existential Analysis. She created the
School of Psychotherapy and Counselling at Regent’s College in London, where she was
given a chair in psychotherapy and counseling. She is widely published on existential
psychotherapy and counselling.

Sabrina Walters, M.A. is a Youth and Family Therapist for Youth Contact, Hillsboro,
Oregon. She received training at the Mental Research Institute (MRI) Strategic Family
Therapy and Training Center through Eileen Bobrow.

Julia Yang, Ph.D. is Professor at Governors State University in University Park, Illinois.

Gary Yontef, Ph.D., FAClinP., Fellow of the Academy of Clinical Psychology and
Diplomate in Clinical Psychology (ABPP) and Clinical Social Work, has been a Gestalt
therapist since training with Frederick Perls and James Simkin in 1965. Formerly on the
UCLA Psychology Department Faculty, he is in private practice in Santa Monica, California.
He is a past president of the Gestalt Therapy Institute of Los Angeles (GTILA) and for 18
years was chairman of the faculty. He is on the editorial board of the International Gestalt
Journal (formally the Gestalt Journal) and the Gestalt Review and editorial advisor of the
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

British Gestalt Journal. He was the first Chairperson of the International Gestalt Therapy
Association and the faculty member of the Gestalt Therapy International Network (GTIN).
He is a co-founder of the Pacific Gestalt Institute (PGI). He has written over 40 articles and
chapters on Gestalt therapy theory, practice and supervision and is the author of Awareness,
Dialogue and Process Essay on Gestalt Therapy, which has been published in Spanish,
German and Portuguese and is in press in Korea.

Toni Schindler Zimmerman, Ph.D. is Professor in the Human Development and Family
Studies Department and the director of the Marriage and Family Therapy (MFT) Program at
Colorado State University. She is widely published in the areas of women's issues, gender
equity, diversity, parenting, and work-family balance. She serves on the editorial boards of
the Journal of Marital and Family Therapy and the Journal of Couple & Relationship
Therapy. Dr. Zimmerman is a licensed marriage and family therapist in the state of Colorado.

William Glasser, M.D. is an internationally recognized psychiatrist who is best known

as the author of Reality Therapy, a method of psychotherapy he created in 1965 and that is
now taught all over the world. He received his B.S., M.A., and M.D. in Clinical Psychology
degrees from Case Western Reserve University. Dr. Glasser has written seventeen books,

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 xx Karin Jordan

including Reality Therapy, Schools Without Failure, Positive Addiction, The Quality School,
Choice Theory, Reality Therapy in Action, and Counseling with Choice Theory. Dr. Glasser
was a private practitioner of psychiatry in West Los Angeles from 1956-86, while lecturing
and writing on a concurrent basis. Since closing his office, he has devoted himself completely
to writing, lecturing and training people how to use his ideas. He has worked and consulted in
every area of psychiatry and has taught and lectured at universities on every continent. Dr.
Glasser is founder and president of The William Glasser Institute in Chatsworth, California,
an international training organization devoted to teaching his ideas in countries across the
world. Over 45,000 people have received training in Choice Theory and Reality Therapy
since it's inception in 1967. At the present time, Dr. Glasser is focusing much of his attention
on a new project to create a "Choice Theory Community" in Corning, New York.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 In: The Quick Theory Reference Guide ISBN: 978-1-60021-624-4
Editor: Karin Jordan, pp. 1-6 © 2008 Nova Science Publishers, Inc.

Chapter 1

THEORIES IN COUNSELING,
PSYCHOTHERAPY AND FAMILY THERAPY

Karin Jordan

A theory is not built on observation. In fact, the opposite is true.

What we observe follows from our theory.
Albert Einstein

Theories in counseling and psychotherapy as well as in family therapy are designed to

gather information, organize, describe, explain, and predict principles of human behavior,
thinking and emotions. A good theory should help provide guidance as to the problem(s) that
the client (individual, couple or family) is dealing with and/or goals for counseling/therapy,
but also provide strategies and techniques that can be used and will be helpful. In addition, a
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

theory should help make some predictions about which techniques and strategies will be most
fitting for the client(s).
The essence of theory lies in two paradigms, the intrapsychic or individual paradigm, and
the interpersonal or systemic paradigm. The intrapsychic paradigm has been identified with
the formative years of the field of psychology in the late nineteenth century, when the internal
processes of the individual were seen as the root of pathology, and were the focus of therapy.
The thinking of early pioneers of psychotherapy, such as Sigmund Freud, B. F. Skinner and
Carl Rogers was based on Western, positivistic beliefs, reflective of the philosophical
assumptions (basic epistemology) of Sir Isaac Newton, Rene Descartes, and Francis Bacon.
These beliefs were based on four assumptions: (1) the laws for the physical body, as well as
nature and human psychological processes, are the same, (2) scientific measures can be used
to measure behavior and psychological processes, (3) reality can be perceived and measured
objectively, and (4) human behavior and reality can be explained through the mechanistic
cause and effect relationship. This cause and effect relationship can also be explained in
linear (medical or psychoanalytic) terms, and emotional difficulties are historical in cause and
intrapersonal in nature. Nichols and Schwarz (2004) wrote:

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
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 2 Karin Jordan

The medical model assumes that clustering symptoms into syndromes will lead to biological
solutions for psychological problems. In psychoanalytical explanations, symptoms are said to
arise from conflict that originated in the patient’s past. In both models, treatment focuses on
the individual. (p. 8)

Linear (unidirectional) causality, means that A (cause) leads to B (effect) i.e. a linear
cause and effect explanation. Theorists such as Watson (behaviorism) believed that
psychology could only be scientific if they followed more of a scientific model, and accepted
the importance of objectivity, as well as the value of quantifiable, measurable data. Other
theorists believed that human behavior is less subject to deterministic law and that people are
more self-directed (e.g. Rogers’ person-centered approach). Even so, there might be a
difference among these theorists, with some being more scientific or mechanistic, and others
being more humanistic, however there are shared fundamental beliefs such as linear cause and
effect, as well as focus on the individual. Focusing on the individual might fit well with the
belief of individualism and autonomy, something often valued in this country.
The interpersonal paradigm differs from the intrapsychic paradigm in that focus is given
to family systems and family systems problems, rather than the traditional individual and
individual problems. This moving away from the individual perspective of conceptualizing
and resolving problems to the systems perspective of conceptualizing and resolving problems
can be identified as a paradigm shift. Systems (marriage and family) theory was developed in
the 1940’s when focus was given to the structure and function of organized biological units
and mechanical units, with seminal thinkers such as Gregory Bateson, Murray Bowen,
Salvador Minuchin and Jay Haley. It is rooted in mathematics, physics and engineering. The
core characteristics of systems theory have been identified by Gurman and Kniskern (1986)
as: organization (wholeness-the whole is greater than the sum, boundaries-borders that
separate, hierarchy-the vertical structure within a family), control (through feedback
mechanisms, balance is maintained or brought back), energy (entropy-to go into disorder
[Bateson, 1972] and negentropy-to be flexible, open to change [Kantor & Lehr, 1975]) as
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

well as time and space (developed according to cultural and temporal zeitgeist). Focus in
systems theory is given to the interrelationships of the system and their subsystems (e.g.
parental subsystem, sibling subsystem, etc.), as well as patterns of interactions, which is a
dialectical process in which both participants mutually influence each other and therefore can
be identified as noncausual and circular. Circularity means that problems occur within a
relationship context, which is simultaneous and reciprocal cause and effect. Goldenberg and
Goldenberg (1996) report that in circular causality:
The emphasis here is on forces moving in many directions simultaneously,
not simply a single event caused by a previous one. Within a family, a
change in one member affects all other members and the family as a whole.
Such a reverberating effect in turn impacts the first person, and so forth, in a
continuous series of circular loops or recurring chains of influence. (p. 11)
This means that in circular causality each event becomes part of a causal chain, where
each event is being influenced and influences others.
Theories that exemplify intrapersonal paradigm thinking as well as the theories that
exemplify interpersonal paradigm thinking are both rooted within the context of the cultural
and temporal zeitgeist. Clearly all of these theories, regardless of the paradigm, are useful
when chosen carefully, which means understanding that theories with intrapsychic paradigms

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Theories in Counseling, Psychotherapy and Family Therapy 3

as well as those with interpersonal (systemic) paradigms are based on different philosophical
assumptions and have imbedded numerous divergent characteristics, with some having
overlapping characteristics. There are many existing theories in each of the two paradigms,
with some overlapping the two paradigms, and new ones are continually developed.

DEFINING PSYCHOTHERAPY AND COUNSELING:

AN INTRAPSYCHIC PARADIGM
The terms psychotherapy and counseling are often used interchangeably, however,
although they are quite similar in some areas, they are quite different in others.

Psychotherapy

Sigmund Freud is believed by many to be the father of modern psychotherapy. yet there
are many definitions for psychotherapy today and not one is universally accepted. Corsini and
Wedding (2000) suggested that it is not possible to have a specific definition for
psychotherapy. Having a more broad definition might be most appropriate. Norcross’ (1990)
definition is:

Psychotherapy is the informed and intentional application of clinical methods and

interpersonal stances derived from established psychological principles for the purpose of
assisting people to modify their behaviors, cognitions, emotions, and/or other personal
characteristics in directions that the participants deem desirable. (p. 218)

Psychotherapy does encompass a variety of perceptions as to the origin of the problem,

Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

the change process, techniques to be used, duration of treatment and the role of the
psychotherapist, but is derived from existing theories. The goal of psychotherapy is to meet
the needs of a broad range of diverse clients, helping them gain insight into the problem(s),
resulting in behavioral and personal growth. Often, psychotherapists identify themselves as
being eclectic, integrating two or more theories, generally seeing individual clients and
conducting groups. Psychotherapists cannot be identified by their training or skills, but
instead tend to have diverse training backgrounds (e.g. counselors, social workers, marriage
and family therapists, psychologists, psychiatrists, etc.) and diverse skill levels.

Counseling

Similar to psychotherapy, counseling has no one universal definition, and there have been
many definitions and meanings offered. The term can be interchanged with advisor, and it
generally involves that two people work together. The goal of counseling is generally to
resolve a problem, and he actual process of counseling generally also involves advice giving.
The term has been used broadly, in such areas as finances, law, academia, etc.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 4 Karin Jordan

The practice of professional counseling has been identified by the American Counseling
Association (1997) as:
The application of mental health, psychological or human development
principles, through cognitive, affective, behavioral or systemic intervention
strategies that address wellness, personal growth, or career development, as
well as pathology. A professional counselor is a person that holds an
advanced degree in counseling.
In addition the American Counseling Association (1997) identifies the professional
counseling specialization as:
A professional counseling specialty is narrowly focused, requiring advanced
knowledge in the field founded on the premise that all professional
counselors must first meet the requirements for the general practice of
professional counseling.
The professional counselor has the ability to function as a generalist and/or specialist.

Common Areas for Psychotherapy and Counseling

It is important to remember that there are common areas of psychotherapy and

professional counseling:

• working with the individual client

• trying to make a diagnosis
• focusing on the individual client’s experience and perspective
• looking at emotional, behavioral and cognitive processes involved in the problem
development and coping
• identifying appropriate techniques
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Psychotherapy is generally believed to require more skills than counseling, with

treatment generally more long-term, focusing on the client’s thought process as well as
his/her way of being in the world and can be conducted by psychiatrists, psychologists, social
workers and counselors. Counseling is generally shorter in duration than psychotherapy and
focuses on a specific situation or problem. The term counseling is used by counselors, but
also by psychotherapists and is used to describe what occurs in the relationship between the
psychotherapist and client.

DEFINING MARRIAGE AND FAMILY THERAPY:

AN INTERPERSONAL PARADIGM
Marriage and family therapy (MFT) is another mental health profession that according to
the American Association for Marriage and Family Therapy (2006) involves:

A family pattern of behavior influences the individual and therefore may need to be a part of
the treatment plan. In marital and family therapy, the unit of treatment isn’t just the person –

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Theories in Counseling, Psychotherapy and Family Therapy 5

even if only a single person is interviewed – it is the set of relationships in which the person is
imbedded.

MFT is rooted in general systems theory adopted by pioneers of family therapy, and includes
the following common beliefs:
• the whole is greater than the sum
• human behavior occurs within a social system and therefore can only be understood
within this context
• the change in one part of the system effects other parts of the system
• systems generally seek homeostasis to maintain stability, sometimes however
homeostasis serves as a way to prevent change
• systems that lack equilibrium use feedback mechanisms to restore balance,
sometimes the feedback mechanism can become the problem

MFT is practiced by professionals who have earned a degree of higher education in

marriage and family therapy, or by psychiatrists, psychologists, social workers, counselors
and psychiatric nurses who have specialized training in marriage and family therapy and are
certified or licensed in it. “Marriage and family therapists are recognized as a ‘core’ mental
health profession, along with psychiatry, psychology, social work and psychiatric nursing”
(American Association for Marriage and Family Therapy, 2006). MFTs go beyond the
traditional focus on the individual and his or her problems, to focusing on individuals,
couples and families within the context of primary relationships such as the marriage/partner
relationship and/or the family within the context of primary relationships such as
marriage/partner relationship and/or family, with a wide array of problems (e.g. mental,
emotional, behavioral and relational problems). It is important to understand that in MFT,
even if a single person is seeking therapy, focus is given to the relationships that the person is
embedded in, to understand the problem and design treatment. The MFT’s focus on therapy
involves:
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

• assessing who the client is and who should be part of the process of therapy, such as
a couple, family, or family subsystems
• exploring the presenting problem and how others might contribute or gain from it
• focusing on the family and other systems relations that the clients engages in
• exploring and assessing such things as couple or family structure, function, process,
rules, roles, etc.
• exploring transgenerational meaning and transmission of rules, structure, pain, etc.
• choosing interventions that help create change within the larger system rather
focusing on the individual

The duration of treatment can fluctuate from brief (ten or fewer therapy sessions) to more
long-term therapy, depending on the needs of the client(s) and the theoretical model chosen.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 6 Karin Jordan

REFERENCES
American Association of Marriage and Family Therapy (n.d.) FAQ’s on MFT’s. Retrieved on
August 23, 2006 from http://www.aamft.org/faqs/index_nm.asp#who
American Counseling Association Governing Council. (1997, October 17-19). Definition of
Professional Counseling. Retrieved August 22, 2006 from http://www.counseling.org/
Files/FD.ashx?guid+ea369e1d-0a17-411a-bc08-7a07fd908711
Bateson, G. (1972). Steps on an ecology of mind. New York: Chandler.
Corsini, R. & Wedding, D. (Eds.) (2000). Current psychotherapies (6th ed.). Itasca, IL:
Peacock.
Goldenberg, L. & Goldenberg, H. (Eds.) (1996). Family therapy: An overview (4th ed.).
Pacific Grove, CA: Wadsworth, Inc.
Gurman, A. & Kniskern, D. (Eds.) (1986). Handbook of family therapy. New York:
Brunner/Mazel.
Kentor, D. & Lehr, W. (1975). Inside the family. San Francisco, CA: Jossey-Bass
Nicholes, M. P., & Schwartz, R. C. (Eds.) (2004). Family therapy: Concepts and methods (6th
ed.). Boston, MA: Allyn and Bacon.
Norcross, J. C. (1990). An eclective definition of psychotherapy. In J. K. Zeig & W. M.
Munion (Eds.), What is psychotherapy? San Francisco, CA: Jossey-Bass.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
 In: The Quick Theory Reference Guide ISBN: 978-1-60021-624-4
Editor: Karin Jordan, pp. 7-22 © 2008 Nova Science Publishers, Inc.

Chapter 2

PSYCHOANALYTIC THEORY AND THERAPY

Naomi A. Mandsager and Ralph Beaumont

Psychoanalytic theory and therapy are foundational to the mental health field. Though
sometimes deemed antiquated, Freud’s theory of psychosexual development and
methodology of his approach remains the most expansively influential psychological theory
over time. With the rapidly changing social, cultural, and global needs in mental health,
clinical theory, research, and application are changing in kind. As this chapter will indicate,
current trends in psychoanalysis are moving toward a theory of human development grounded
in a relational and personal foundation rather than strictly that of a biological instinctual basis
as in that of classical Freudian theory. The result is a more comprehensive and relevantly
applicable understanding of psychoanalytic thinking and therapy.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

HISTORY
Psychoanalysis emerged amidst a time of great scientific exploration, discovery and
intellectual activity. Originating with Sigmund Freud (1856-1939), this psychological theory
and practice grew out of his engagement in major philosophical, sociological, biological, and
evolutionary movements in turn of the century Europe.
At this time, Freud was an active participant in the scientific and medical community.
Freud was a research biologist at the University of Vienna where he was influenced by the
work of Hermann Helmholtz and Ernest Brucke, among others, whose scientific research
informed such areas as physiology and sensation, mathematics, thermodynamics and physics.
As well, the fields of philosophy and psychology informed Freud’s thinking as he considered
such clinically applicable ideas as free association (Freud, 1911-1915; Kris, 1982) The idea
of free association emerged from the “association” school of psychology which includes such
thinkers as J. F. Herbart, Alexander von Humboldt, and Wilhelm Wundt. Freud further
appreciated Gustav Fechner’s dialectic between physics and questions of psychological
interest (Freud, 1894). Additionally, as Ernest Jones (1953) suggested, the idea of applying
free association in therapy can be linked to Herbart’s work. Mid-nineteenth French

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 8 Naomi A. Mandsager and Ralph Beaumont

neuropsychiatrists, Jean Charcot, Pierre Janet, Ambrose Liebault, and Hippolyte Berheim
pioneered research in split states of consciousnesses such as multiple personalities, fugue
states, hysteria, hypnosis, and somnambulism. Freud was particularly impressed with the
work of Jean Charcot as, ultimately, his development of psychoanalysis evolved through a
dialogue with, and contribution to, the field of neurology.

Basic Concepts

Based in neurology, the operations of the mind and the structure of the ego are
fundamental to psychoanalytic theory. Freud’s thinking is foundational to analytic thinking
and can be examined by three stages which have greatly influenced theory and practice today
(Freud 1895, 1900, 1923; Sandler, 1997). The three stages include: 1) trauma, or the
seduction theory (sexual trauma); 2.) topographic theory; and 3.) structural theory. Structural
theory led into the post-war analytic development of ego psychology.
Another branch of Freudian thinking evolved at about the same time into object relations
theory, which was in part initiated by the work of Melanie Klein. Current derivations of
Freudian ego psychology, Melanie Klein’s object relations, attachment theory (Bowlby 1969,
1973, 1980; Fonagy, 2000), and other developmental theories (Tyson & Tyson, 1990; Fonagy
& Target, 2003), and neuroscience inform contemporary clinical practice. Ego-psychological
object relations is the contemporary mainstream focus for analytic thought.
The basic concepts from a topographic position include the conscious, preconscious, and
unconscious mind (Freud, 1900). Here the idea of the dynamic unconscious is emphasized.
From a structural position the major concepts include the id, ego, and superego (Freud, 1923,
1926). The id comprises the biological based drives, the ego assumes the defense mechanisms
which mediate the inner and outer experience, and the superego incorporates morality, social
rules, ideals, and conscience. In structural thinking, narcissism is an important concept which
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involves a fundamental and necessary deployment of libido, along with investments in object
relations. Object relations theory incorporates this idea in terms of the investment of libido,
aggression, and needs in relationship.
Basic concepts that comprise this theory include: development, ego defenses
psychopathological symptoms--initial focus and use of the Psychoanalytic Diagnostic Manual
(PDM) and the Diagnostic Statistical Manual (DSM) discerning between Axis I and Axis II,
character structures of Axis II diagnoses, symptom formation and regression to points of
fixation, compromise formation (Brenner, 1982), and, distinction between id level primary
process organization (unconscious material, unconscious fantasy) and ego mediated
secondary processes.
In his early work in the 1890’s, Freud observed the bodily hysterical phenomena which
occurred in response to trauma. Freud and Breuer developed the idea of repression and
dissociation as defenses against trauma (Freud & Breuer, 1895) Additionally, Freud (1900,
1911) believed that a fundamental guiding principle of human psychology was the pleasure
principle. Essentially, Freud’s concept of the pleasure principle assumes that humans have a
basic tendency to seek pleasure and avoid pain. The individual’s developmental experience of
this principle subsequently precipitates the reality principle, and shapes the individual’s
psychological structure (i.e., the organized and relatively stable organized patterns of mental
functioning, Freud, 1923).
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 Psychoanalytic Theory and Therapy 9

As indicated by the influence of French neuropsychiatry on Freud’s thinking, both the

unconscious mind and the presence of mental (psychic) conflict serve as motivating functions
of human existence. For the individual in his/her development, the infant must learn to
integrate social values and rules through such social structures as the family. In the context of
social structure, the individual’s mental and physiological needs and desires come into
conflict with parental and societal expectations in the process of acculturation.
Psychoanalytic theory and practice is comprehensive and inclusive of the human inner
and outer experiences as evidenced by Freud’s integration of biology and sociology. Freud’s
integration was further indicative of the merging of humanistic and scientific ideas of the late
nineteenth and early twentieth centuries. Specifically, respect for the integrity of the
individual, together with a rigorous scientific method of clinical observation, lent itself to the
unique formulation of the psychoanalytic situation; whereby psychoanalysis was
simultaneously a method of investigation and a form of therapy.
Arlow (1987) notes that Greek rationalist philosophy, with its injunction, to “know
thyself,” significantly underlies psychoanalysis. “Knowing oneself” however involves
knowing that of oneself which is accessible to the conscious mind. In psychoanalytic thought,
the roots of human neurotic suffering are “unknowable” as they are founded in unconscious
conflicts. However, relatively adequate self-knowledge of symptoms, ensuing behaviors, and
underlying conflicts may be achieved, and can strengthen an individual’s capacity to make
rational choices. The consequence of this may be a more fulfilled, transformative, and
socially generative life. This self-knowledge is discovered, observed, examined, and
interpreted in the psychoanalytic situation (Freud, 1911-1915; Bibring, 1954; Brenner, 1976;
Schwaber, 1983; Schlesinger, 2003) which is both a vehicle and interpersonal encounter for
psychological transformation and self-transcendence. The process of developing “self-
knowledge” in the context of the psychoanalytic therapeutic relationship relies on a basic
understanding of human nature.
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Nature of Persons

People are inherently complex, multifaceted and can only be fully understood
intrapsychically, intersubjectively, and interpersonally in the context of culture and
community. Mental life is crucially interconnected to underlying biological processes on
many levels: neurophysiologically and in terms of one’s relationship with one’s body in
development. Motivation in mental life is predominantly activated by the unconscious. Affect
is understood as foundational and primary, while cognition is seen as secondary, derivatively
following affect. Drives are inferred from affect.
According to Rapaport (1951), there are four models of scientific thought pertinent to the
foundations of Freud’s psychoanalytic theory as it relates to human nature. These four models
are: 1.) the reflex arc model stemming from neurology and referring to an innate connection
between a given kind of stimulation and a subsequent given response (e.g., a reflexive
reaction such as a leg extending when the knee is tapped). Essentially, the idea is that there is
a tendency for organisms to respond when stimulated. In this model, stimulation can come
from an external or internal location. For Freud, the internal stimulation would be considered
drive excitations in the unconscious which would lead to behavior or halt in the organisms
preconscious or unconscious; 2.) the energy model which informs how Freud conceptualizes
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 10 Naomi A. Mandsager and Ralph Beaumont

psychodynamics and the mechanisms of development. As the organism strives to reduce the
tension in his/her drive(s), a behavior is required. With growing internal pressure, the release
of energy becomes increasingly necessary. The goal is to maintain a homeostatic or
equilibrated state in this energy system; 3.) the Darwinian model which is genetic, biological,
and evolutionary and is evident in Freud’s premise that development unfolds due to instincts
which are somatically based. Such instincts are manifest throughout the psychosexual stages
of development and necessitate change in the form of evolutionary adaptation to the
environment. The ways in which human adaptations emerge in early childhood influence
personality and behavior in adulthood. Flight, flight, and freeze defenses are both biological
and psychological adaptations which serve to defend the body and psyche from respective
dangers; and, 4.) the Jacksonian neural-integration hierarchy model lent itself to Freud’s
thinking as well. The nervous system is hierarchical in organization whereby higher levels
impact lower levels by means of inhibiting or facilitating function. The functioning of the
lower levels is dependent on the functioning of the higher levels. According to Freud’s theory
of psychological structure, higher psychological functions (e.g., the ego) control lower
psychological functions (e.g., the id) unless there is an impairment in the higher level such as
an ego overwhelmed by anxiety.
In terms of psychological structure and function, Freud’s enduring perspectives on
personality sometimes called meta-psychological points of view (Rapaport & Gill, 1959),
included: 1.) the topographic, which involves conscious versus unconscious modes of
functioning; 2.) the dynamic, which includes the interaction of psychic forces; 3.) the genetic,
which is concerned with the origin and development of psychic phenomena through oral,
anal, phallic, latency, and genital stages; 4.) the economic, which involves the distribution,
transformation, and expenditure of energy; 5.) the structural, which revolves around the
persistent functional units of the id, ego, and superego; and 6.) the adaptive view, implied by
Freud and developed by Hartmann (1939), which involves inborn preparedness of the
individual to interact with an evolving series of normal and predictable environments.
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These premises may serve to inform present assumptions about human nature which
subsequently influence how we view, understand, and serve the needs of individuals who
seek psychological services.

Human Needs

The underlying fundamental sequence of psychological development is found in Freudian

psychosexual stages: oral, anal, phallic, latency, and genital (Freud, 1905). Stages of life
determine how personalities are developed and respond to intrapsychic conflicts. According
to Freud, the stages of life are determined by the unfolding of sexuality in the oral, anal,
phallic, and genital stages. Differences in experiences during each of these stages are critical
in determining the variety of traits and personality structures (Abraham, 1924; Erikson, 1950)
that form as development is directed by powerful unconscious drives. The expression of these
drives facilitates the development of the ego and superego, which in turn operate
unconsciously. As outlined in Freud (1905), the stages of development occur as follows.

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 Psychoanalytic Theory and Therapy 11

Oral Stage

During the first 18 months of life, the infant’s sexual desires are centered on the oral
region. The child’s greatest pleasure is to suck on a satisfying object, such as the breast. The
instinctual urges are to passively receive oral gratification during the oral-incorporative phase
and to more actively take in oral pleasuring during the oral-aggressive phase. Fixation due to
either depravation or over gratification leads to the oral personality dichotomous traits:
pessimism/optimism, suspiciousness/gullibility, self-minimization/grandiosity, passivity/
manipulativeness, envy/admiration (Abraham, 1924). Fixation at the oral stage brings a
tendency to rely on more primitive defenses when threatened or frustrated.

Anal Stage

Consistent with Freud’s concept of the pleasure principle, Freud believed that children
between the ages of 18 months and 3 years experience the anal area to be a source of
pleasure. Children in the anal stage are apt to learn that intense urges to play with the anus or
its products bring them into conflict with society’s rules of cleanliness. The pleasure of letting
go of anal control must come under the parental rules for bowel continence. Society, as
represented by the parents, demands that the child control the inherent desire for immediate
tension reduction. In Eriksonian terms, the child must now learn to hold on and then to let go.
Not only that, the child must learn the proper timing of holding on and letting go. Hence, the
anal stages involves all kinds of power struggles, not only those associated with toilet
training.
The child is most likely to become fixated at the anal stage if the caretakers are again
either too demanding or overindulgent. The dichotomous traits that develop from anal
fixation have been clearly articulated by Freud (1925), Abraham (1924), and Fenichel (1945):
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

stinginess/overgenerosity, constrictedness/expansiveness, stubbornness/acquiescence, orderli-

ness/messiness, meticulousness/dirtiness, punctuality/tardiness, precision/vagueness.
Conflicts during the anal stage are also assumed to lead to the development of particular
defenses. Reaction formation, or experiencing the opposite of what one really desires,
develops first as a reaction to being very clean and neat, as the parents demand, rather than
expressing anal desires to be messy. Undoing, or atoning for, unacceptable drives or actions,
occurs when the child learns that it is safe to say, “I’m sorry I let go in my pants.” Isolation,
or not experiencing the feelings that would go with the thoughts, emerges in part when the
child has to think about an anal function as a mechanical act rather than an instinctual
experience. Intellectualization, or the process of neutralizing affect-laden experiences by
talking in intellectual or logical terms, is partly related to such experiences as accepting the
reasons for continence, while also continuing an emotional struggle over it.

Phallic Stage

The name of this stage is reflective of Freud’s bias toward male development as he
generalized references of male genitalia to female development. However, for both males and
females the sexual desires during the phallic stage are thought to be focused on the genitalia.
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 12 Naomi A. Mandsager and Ralph Beaumont

From ages 3-6 both sexes are presumed to be very interested in their own genitalia and are
also curious about the opposite sex. Conflict in this stage is over the object of the child’s
sexual desires, which may often be but is not limited to the parent of the opposite sex. From
this understanding, Freud established the oedipal conflict whereby in its positive form the
boy’s desire for his mother is explained as a natural result of her nurturing and gratification of
needs. Castration anxiety eventually causes the son to repress his desire for his mother,
repress his hostile rivalry toward his father, and identify with his father’s rules in order to
avoid castration.
A critical issue is how parents respond to the genital desires of their children. Both
overindulgence and overrejection can produce fixations at the phallic stage that result in the
formation of the following dichotomous traits: vanity/self-hatred, pride/humility,
stylishness/plainness, flirtationess/shyness, gregariousness/isolation, brashness/bashfulness.
Over-rejection, in which parents give their opposite-sex children little affection and no
appreciation for their attractiveness, will likely lead to a low self-image. On the other hand, a
person who has a parent who is overindulgent, whether seductive or actually incestuous, can
more readily develop feelings of vanity.
Conflicts over sexual desires toward one’s parent are not solely due to how the parent
reacts. The child also has to defend against castration anxieties, including the females
supposed anxiety that her rivaling mother might damage her further. The child must defend
against society’s basic incest taboo. These conflicts lead to repression as the major defense
against incestuous desires. By being unaware of fantasies about opposite-sex parents, the
child feels safe from incest and the consequent castration or taboos that would accompany it.
However, as with all conflicted id desires, the impulse is omnipresent and can be kept at bay
only by unconscious defenses.

Latency Stage
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In classical psychoanalytic theory this stage involved no new unfolding of sexuality, but
rather was a stage in which the pregential desires were largely repressed. Freud associated no
new psychosexual development with the latency stage, believing that all pregential
personality formation had been completed by age 6. Latency was seen primarily as a lull
between the conflicted, pregenital time and the storm that was to reemerge with adolescence –
the beginning of the genital stage. In the more recent psychoanalytic formulations, latency is a
time for ego development and learning the social rules of being a citizen. These gains enable
the child to psychologically enter adolescence and to navigate the genital stage when it
arrives.

Genital Stage

In this stage, the libido reemerges – this time in the genitals. Having largely completed
the challenges of the phallic and latency stages, the adolescent must now find appropriate
objects for sex (love) and aggression (work). In Freudian theory, an individual does not
progress to the genital stage without conflict between instinctual desires and both internalized
and external social restraints. Some individuals will be fixated at the oral, anal, or phallic
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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Psychoanalytic Theory and Therapy 13

stage and will demonstrate related personality traits. Others will experience conflicts at each
of the stages and will demonstrate a mixed personality that is a combination of traits and
defenses of each stage. Beyond the conceptualization of psychosexual development, analytic
thinking also incorporates the idea of the nuclear family.
Nuclear family is an assumption (i.e., nurturant mother; protective father) from earlier
psychoanalytic theory. Human needs evolve out of the fundamental need for human
attachment to parental/nuclear family and other attachments later in life. Insofar as people are
understood as object seeking, not only sexually motivated, object relations and attachment
subsume all stages of psychosexual development (Fairbairn,, 1952; Bowlby, 1969, 1973,
1980; Sandler, 1998; Fonagy, 2000). Attachment needs throughout development propel self-
object differentiation, development of a sense of self, and mentalization (i.e., distinguishing
between self and other while recognizing that needs are interdependent) ( Fonagy, et. al.,
2002).
Within the psychoanalytic theoretical frameworks as they address needs, it is important to
consider motivation. People consistently desire immediate gratification of sexual and
aggressive impulses. Given the demands of these motivations, inevitable conflicts emerge as
the individual interacts with social rules, family systems, attachment relationships, norms, and
expectations whereby he experiences intrapsychic conflict. The individual then must develop
defense mechanisms to control drive expression and to modulate dysphoric affects associated
with conflict.
The core of the Freudian personality is the unconscious conflict among the individual’s
sexual and aggressive impulses, society’s rules aimed at controlling those impulses, and the
individual’s defense mechanisms and internalized prohibitions in such a way as to keep guilt
and anxiety to a minimum, while allowing some safe, indirect gratification of the impulses .
The difference between a normal personality and a neurotic one is a matter of degree.
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Defense Mechanisms

Freud’s final theory held that the basic motivating forces of personality were Eros (life
and sex) and Thanatos (death and aggression). These forces are considered instinctual and
serve complementary functions. These dynamic forces are physically based (somatic) but are
expressed in fantasies, desires, feelings, thoughts and actions. According to this dual instinct
theory of motivation, pressure for the immediate gratification of sexual and aggressive
impulses is constant. Given the demands of these motivations, intrapsychic conflict is
inevitable. The individual then must develop defense mechanisms to modulate sexual and
aggressive impulses and the anxiety-laden internal conflicts of which they become a part
(Freud, A., 1936).
Unconscious defenses employed by the ego in intrapsychic conflict during development
can be understood in terms of bodily prototypes. Specifically, denial derives from having to
finally close one’s eyes and go to sleep as a way of shutting out the unmet oral needs.
Cognitively, this defense involves closing off one’s attention to threatening aspects of the
external world. Projection has a bodily basis in the infant’s spitting up anything bad that is
taken in and making the bad things part of the environment. Cognitively, projection involves
perceiving in the environment those aspects of oneself that are bad or threatening.
Incorporation on a bodily level includes taking in food and liquids and making these objects
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 14 Naomi A. Mandsager and Ralph Beaumont

an actual part of oneself. Cognitively, this defense involves making images of others part of
one’s own image. Repression has a central place in Freud’s concept of defense, but
throughout his work and that of many subsequent analysts, a vast array of other defenses have
been described.

Healthy Functioning

According to Freud, healthy functioning is the individual’s capacity to work and to love.
The individual is able to have a fulfilling mature object and self relationship with healthy
narcissism and loving attachment to other people. The individual can understand herself as a
psychobiological being and understand others as psychobiological beings (mentalization) (
Fonagy, et. al., 2002). Additionally, healthy functioning requires a representational world--the
capacity for a rich inner world, including fantasy, which enables one to symbolize and
extrapolate beyond the concrete world (Sandler, 1998; PDM, 2006.) (See the “M Scale.”).
All personalities revolve around unconscious conflicts (Brenner, 1982). However, people
differ in the particular impulses, rules, anxieties, and defenses that are in conflict. The
differences depend on the particular stage of life at which an individual’s conflicts occur. The
“healthy” individual in Freudian psychosexual terms is the person who has attained and can
maintain the genital level of functioning. The “ideal” person has analyzed pregenital fixation
and conflict adequately and is a potent, altruistic, and generous in relationship, work, and
society. It is when the unconscious conflicts become too intense, too painful, and the resultant
defense mechanisms too restrictive that neurotic symptoms begin to emerge.

Unhealthy Functioning
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Unhealthy functioning will sometimes fall into the well-known Diagnostic Statistical
Manual (DSM) symptomatic categories. Pathology is more fundamentally expressed in
characterologic levels of dysfunction as described in the Axis II categories of the DSM and
the PDM. Internal characterologic organization have early childhood roots, and manifest as
enduring patterns which have become structurally fixed since childhood. Characterologic
organization occur s at a variety of levels, including neurotic, narcissistic, borderline, and
psychotic. In unhealthy functioning, a developmental disturbance or pathological compromise
formation has occurred.
All personalities are at least partially immature due to inevitable conflicts and fixations at
early developmental stages. All people are vulnerable to regressing into psychopathology.
Individuals are more vulnerable if conflicts and fixations occurred earlier in life, with the
availability of less elaborated ego structure and more immature defenses for dealing with
anxiety. As well, the more intense our pregential conflicts are, the more vulnerable people
are, as more energy is bound up in defending against pregenital impulses, and less energy is
available for coping with adult stresses and conflicts. The essence of psychopathology lies at
an unconscious level where dynamically enforced lack of awareness, and developmentally
insufficiently mentalized affectivity may impede progressive change toward healthy object
relations and ego development (Fonagy, et. al., 2002). In order to move into change toward

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 Psychoanalytic Theory and Therapy 15

healthy development, it is important to understand the human change process from the
psychoanalytic perspective.

Change Processes

According to psychoanalytic thought, the change process is about resuming blocked

development and overcoming the pathological compromise formations. Unless it is impeded,
development proceeds naturally. The change process aids in the resumption of development.
The pathological compromise may also be addressed so that symptoms no longer impede the
natural forces which seek out progressive development and fulfillment of needs and wishes in
normal developmental object relations activities.
Resistances are the forces which oppose treatment and are assumed to be intrinsically
related (if not identical) to the forces which keep the pathological structures in place (Freud,
1911-1915; Freud, A., 1936). The relationship between resistance and intrapsychic defense is
why change (treatment) is both difficult and why it works.
For Freud, only one process could succeed in making the unconscious conscious. Before
the developing individual can respond to environmental events in a more realistic manner the
individual must first be aware of how pathological responses to the environment derive from
the unconscious, primary-process meaning attributed to environmental events. To remove
symptoms, one must become conscious of resistance to letting go of the symptoms because
they both defend against and give partial release to unacceptable impulses. The individual
must gradually recognize that impulses are not as dangerous as they were once learned in
childhood, and that one can use more constructive defenses to keep impulses under control, in
part, by allowing more mature expressions of our instincts. Finally, to prevent future relapses,
one must use conscious processes to release pregenital fixations so that one can continue to
develop to mature, genital levels of functioning.
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Why is Change Difficult

In psychoanalytic thought, the occurrence of resistance is what makes change difficult.

Menninger defines resistance as, “ the trend of forces within the patient which oppose the
process of ameliorative change.” There are five classical forms of resistance (Freud, 1937;
Menninger, 1958): repression resistance; transference (frustration) resistance; epinosic gain
resistance; repetition compulsion resistance; and, the resistance which emerges from the
superego, deriving from a need for punishment. Further explanation of these forms is beyond
the scope of this chapter. However, to best accommodate and facilitate the treatment process
in response to resistance and to best understand difficult change can be, careful attention to
the experience of the therapeutic environment is imperative.

The Therapeutic Environment

The “frame” of the therapeutic environment is essential. It involves a structure whereby

there are regular scheduled meetings at a prearranged time between patient and therapist in
which the patient is encouraged to put into words everything that comes to mind in the most
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 16 Naomi A. Mandsager and Ralph Beaumont

uncritical way possible (Freud, 1911-1915). In this frame, the therapist is not to take sides in
the patient’s conflicts but to help the patient elucidate all sides in order to support the patient
in finding new and better resolutions to their conflicts (Kris, 1982).
It is inherently understood that within this frame, an unconscious fantasy develops which
is placed on the “other” in the form of transference (patient) and counter-transference
(therapist) (Freud, 1911-1915; Gill, 1982; Gabbard, 1998). The frame has intrinsic boundaries
within which the therapeutic relationship is limited (i.e., the relationship does not include
sexual and aggressive behavior on the part of the dyad). The therapist must abstain from using
the patient to gratify his needs and wishes.
In the psychotherapy dyad there is a basic asymmetry. The patient is there to address her
own best interests through self-understanding and the therapist is there also to address the
patient’s best interest through an understanding of the patient’s mental functioning, or
“psychic reality” (Freud, 1900, Schwaber, 1983). The therapist’s needs are bracketed out
(taken care of elsewhere) as the relationship is all about the patient’s best interest.
In a related vein, Menninger (1958) described the therapeutic contract in the
psychoanalytic treatment situation as a two-party transaction, requiring a two-party
agreement. A mutual compact is made in which each party experiences a fair exchange – a
balance is struck, and needs are reciprocally satisfied. Though psychoanalytic treatment is
different from other therapeutic services, it is nevertheless formalized by a contract. These are
the following ways the psychoanalytic contract differs from others: 1.) The relationship
between the two parties becomes very close to being the goal of the transaction. Specifically,
the relationship is the most tangible element of the transaction. 2.) Typically, transactions
between people have defined time limits, determined by the goal. If the goal for
psychotherapy is betterment, self-transcendence, and a greater experience of wholeness, it is
then by definition an open-ended venture, and not subject to the usual time limits.
Psychotherapy is much like learning, the essence of which is open-ended and can never be
fully consummated. 3.) Though like in other contracts, the focus is on the two party contract
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and its fulfillment, often in the therapeutic process other relations past, present, and future
assume great importance.
According to Mahoney (1991) in the orthodox psychoanalytic tradition, the human
change process involves an emotionally charged “reliving” and “undoing” combined with
insight in the context of transference. However, the neodynamic tradition views change
process in terms of corrective emotional experiences that override deficient or dysfunctional
lessons about the integrity of self and social system. Both traditions inform the relationship
and the psychoanalytic therapeutic environment. The relationship is the vehicle whereby
conscious insight is gained and self-awareness is experienced.
In this context, the pathological responses to the environment derive from unconscious,
primary process meanings we attribute to environmental events. Free association is
employed to elicit undefended material from the unconscious.
Psychoanalysis employs the following four procedures (Bibring, 1954; Menninger,
1958): confrontation, clarification, interpretation, and working through in analyzing the
patient’s resistance to freely associating and the transference that emerges as the patient
regresses and expresses instinctual desires and defensive attitudes toward the analyst.

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 Psychoanalytic Theory and Therapy 17

Therapeutic Process

Basch (1980) identifies the stages of psychoanalytic therapy from the point of first
contact with the patient. The stages of therapy follow the initial interview and include the
initiation and maintenance of therapy, the development and use of transference, and the
termination of the analytic relationship. Four phases of psychoanalytic treatment can be
identified as follows: 1.) the opening phase, 2.) the development of transference, 3.) working
through; and, 4.) resolution of transference. Though these stages have been identified, they do
not imply a given time-frame or specific structure due to the complex nature of the
therapeutic process as it unfolds in the therapeutic relationship.
In addition, the therapeutic process may be understood in terms of Freud’s three models,
the seduction theory, topographic, and structural. According to seduction theory, the catharsis
of unconscious walled-off repressed affect related to pathogenic trauma is a goal of the
therapeutic process. The topographic model suggests that making the unconscious conscious
is the goal. This must include not only the repressed drive derivatives, but also the repressing
forces. The goal necessarily expanded from an initial emphasis on drive derivatives alone to
the inclusion of pathogenic fantasies and resistances which systematically and forcefully
oppose such conscious awarenesses. The structural model considers that “where the id was
there the ego shall be” (Freud, 1923). This model takes into consideration the maturing
capacity to relate to one’s own inner life and others without using primitive defenses. The
reclaiming of disclaimed agency and responsibility with regard to aspects of oneself and
one’s actions can be understood as an aspect of ego mastery and is one way of understanding
Freud’s structural theory (Schafer, 1976).
The therapeutic process is a gradual, piecemeal one which addresses transference, the
patient’s current life, and the dynamically active past. All of this is derived from a “here and
now” emphasis attending to the affective urgency in the moment and the vicissitudes of
transference and resistance. The therapist uses clarification, confrontation, and interpretation
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

in this process. Within the therapeutic environment attention to the therapeutic relationship
aids in the emergence of unconscious material as the most important means of gaining access
and working through (Gill, 1982). Given the piecemeal process and the relatively open-ended
nature of psychoanalytic therapy, the use of assessment and diagnosis is an ongoing feature of
the unfolding nature of the psychodynamic material in the context of the therapeutic
relationship (McWilliams, 1994; Schlesinger, 2003).

Assessment and Diagnosis

Both DSM, or PDM, diagnosis and a more gradual diagnosis of structure of character
development emerges in the transference in the context of the therapeutic relationship. The
nature and constituents of character can only be made fully accessible via the transference.
The assessment process considers defenses and the modulation of affect in terms of the
primitive, neurotic, or mature nature of the mechanisms deployed; reality testing; and the
quality of object relations in both historical and contemporary contexts. Ego psychology takes
the nature of defensive processes and the quality of self and object representations to be
equally important to the process of evaluation as the content of unconscious drive derivatives.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
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 18 Naomi A. Mandsager and Ralph Beaumont

Basch (1980) asserts that the psychotherapeutic process is greatly informed by the initial
interview. In counterpoint to the common medical model practice of gathering a detailed
history, analytic thinking would suggest that a clinical approach which seeks such detailed
information about symptoms may interfere with his ability to assess where and how far the
patient will choose to go when given an open opportunity to express himself. The acquisition
of a symptom report is not needed for treatment as the course of treatment is not contingent
on symptom patterns. This is not to say that patterns of symptomotology are not relevant. The
symptoms should be studied in so far as they reveal the patient’s character formation and
adaptive abilities. This can be done more effectively if the details emerge in the course of
analysis as the context in which they emerge gives invaluable clues to their underlying
significance.
Ultimately, in evaluating a client, the capacity for enduring, progressively deepening,
mature relationships characterized by mutuality, reciprocity, gratification, and an
understanding of separateness and individuality is considered central, and relates to the goals
of treatment.

TREATMENT

Goals

According to Brenner (1976), there are various approaches to goal setting in

psychoanalytic treatment. The goals of treatment may fall within therapeutic, analytic, ethical,
and hedonistic categories. Treatment goals and life goals often intersect with consideration
given to the practical and ideally analytical. Menninger (1966) identifies five models by
which one could conceptualize treatment goals: 1.) a medical model, 2.) a parent-child model,
3.) an educational model, 4.) a life and death model, and 5.) a visiting-an-art-gallery model.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Depending upon criteria for a “cure,” these models may assist one in assessing treatment
effectiveness, or at least, outcome. Given the expansive and continually expanding nature of
psychoanalytic theory and practice, goals for treatment can be as elusive as defining “mental
health.” However, according to Freud, and in the context of the analytic relationship,
resolution of the transference neurosis and internalization of the self-analytic function serve
as the ultimate goals which inform termination of the analysis.
Goal setting is accomplished in on-going dialogue from the beginning of the analytic
relationship. As per Menninger’s discussion on contracting, goals setting is determined by the
nature of the contract and the model by which the goals are being conceptualized. The
purpose of goal setting in the psychoanalytic tradition is to inform criteria for termination.
According to Menninger, the analyzed person either comes to realize that they can, 1.) be
gratified without such exertions as he had previously made or that, 2.) they do not need to be
gratified, or 3.) she has no further feeling of need for such gratification or, 4.) that there is no
prospect of gratifying them and hence they must be renounced without regrets. In this view,
maturity has no need to find satisfaction in childish wishes.

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Psychoanalytic Theory and Therapy 19

STRENGTHS AND LIMITATIONS

Strengths

In ways avowed and not infrequently disavowed, psychoanalysis has laid the foundation
for the theory and practice of psychotherapy in the modern era. In forging the psychoanalytic
situation, Freud and others have created the therapist-patient relationship as we know it.
While many other therapies have flourished, psychoanalysis offers the longest and deepest
continuous tradition among intensive psychotherapies. In addition to its therapeutic value, it
provides a unique and continuously generative methodology for the study of unconscious
motivation and the structural underpinnings of human character. In a poem following Freud’s
death, Auden described Freud as a “climate of opinion.” The field he founded has had far
reaching influence in diverse fields ranging from medicine, psychiatry, and neuroscience, to
anthropology, linguistics, sociology, developmental psychology, philosophy, and literary
criticism. Hypotheses derived from its findings have led to research in many areas, and to
fundamental advances in our knowledge of human development.

Limitations

Like many other developing disciplines, psychoanalysis has encountered criticisms, and
has had to learn about its limitations. It has sometimes suffered from over-reaching ambition
in making claims as an all inclusive general psychology and therapy. Laplanche ironically
refers to the loss of specificity which can follow from this trend as “panpsychoanalyticism”
(p. 66). Psychoanalysis has sometimes been faulted for specific hypotheses, such as Freud’s
emphasis on sexuality in early childhood motivation, and his phallocentrism. Some of the
field’s early hypotheses have stood the tests of time, clinical experience, empirical testing,
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

and cultural change better than others. Karen Horney, for example, responded to Freud’s
notion of penis envy in the early development of girls with the suggestion of “womb envy” in
boys. The flourishing diversity of views within the field has at times led to a “confusion of
tongues” and another possible limitation for psychoanalysis. Without enough agreement on a
common language, psychoanalysts may not be able to communicate in a manner consistent
with a progressive refinement and clarification of the thinking and the theories that constitute
their field. Finally psychoanalysis has been faulted for failing various versions of empirical,
scientific verification as a theory and a therapy. While as a therapy, it has not readily lent
itself to controlled outcome studies, it has in fact generated abundant research (see the PDM,
pp. 511-837). On the other hand, the degree to which it should be considered a hermeneutic
discipline in some or all of its aspects, and therefore not susceptible to the testing of
falsifiable hypotheses, has been a matter of substantial and ongoing controversy.

CONCLUSION
In conclusion, Freud’s innovative, bold, and evolving thought on human psychology has
been historically controversial and continues to be at the center of on-going spirited
intellectual debate. Nevertheless, Freud’s theory of psychosexual development and

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 20 Naomi A. Mandsager and Ralph Beaumont

methodology of his approach to character structure remains the most expansively influential
psychological theory over time. Scharf & Scharf (1998) note that current trends in
psychoanalysis are moving toward a theory of human development which is based in a
relational and personal foundation rather than strictly that of the biological instinctual basis of
classical Freudian theory. Notably, more holistic and integrative approaches are emerging.
And, given many possible directions, such as self-psychology, intersubjectivity, relational
psychology, and object relations theories, many fascinating and accessible applications of
psychoanalysis are developing and will continue to evolve over time as did Freud’s classical
psychoanalysis.

REFERENCES
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mental disorders. In Selected Papers, pp. 418-501. Basic Books, New York.
Arlow, J. (1969a). Unconscious fantasy and disturbances of conscious experience.
Psychoanalytic Quarterly 38, pp. 1-27.
Arlow, J. A. (1987). The dynamics of interpretation. The Psychoanalytic Quarterly, 56:68.
Arlow, J. (1969b). Fantasy, memory, and reality testing. The Psychoanalytic Quarterly 38.
pp. 28-51.
Basch, M. F. (1980). Doing Psychotherapy. Basic Books Inc., Publishers: New York.
Bibring, E. (1954). Psychoanalysis and the dynamic psychotherapies. Journal of the
American Psychoanalytic Association 2, pp. 745-770.
Bowlby, J. (1969). Attachment and Loss, Volume 1. Attachment. Basic Books, New York.
Bowlby, J. (1973). Attachment and Loss, Volume 2. Separation: Anxiety and Anger. Basic
Books, New York.
Bowlby, J. (1980). Attachment and Loss, Volume 3. Loss: Sadness and Depression. Basic
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Books, New York.

Brenner, C. (1982). The Mind in Conflict. I.U.P., New York.
Brenner, C. (1981). Defense and defense mechanisms. The Psychoanalytic Quarterly, 50:557.
Brenner, C. (1987). Working through: 1914-1984. The Psychoanalytic Quarterly, 56:88.
Corsini, R. J., & Wedding, D. (1989). Current psychotherapies (4th Ed.). F. E. Peacock
Publishers, Inc.: Itasca, Illinois.
Erikson, E. (1950). Childhood and Society. Norton, New York.
Fairbairn, W. (1952). An Object-Relations Theory of the Personality. Basic Books, New
York.
Fenichel, O. (1945). The Psychoanalytic Theory of Neurosis. Norton, New York.
Fonagy, P. (2000). Attachment Theory and Psychoanalysis. Other Press, New York.
Fonagy, P., Gergely, G., Jurist, E., Target, M. (2002). Affect Regulation, Mentalization, and
the Development of the Self. Other Press, New York.
Fonagy, P., Target, M. (2003). Psychoanalytic Theories, Perspectives from Developmental
Psychopathology. Brunner-Routledge, New York.
Freud, A. (1936). The Ego and the Mechanisms of Defense. The Writings of Anna Freud,
Volume II. I.U.P., New York.

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Psychoanalytic Theory and Therapy 21

Freud, S., Breuer, J. (1895). Studies in Hysteria. The Standard Edition of the Complete
Psychological Works of Sigmund Freud, Volume II. The Hogarth Press, London.
Freud, S., (1900). The Interpretation of Dreams. The Standard Edition of the Complete
Psychological Works of Sigmund Freud, Volumes IV & V. The Hogarth Press, London.
Freud, S. (1905). Three Essays on the Theory of Sexuality. The Standard Edition of the
Complete Psychological Works of Sigmund Freud, Volume VII, pp. 123-246. The
Hogarth Press, London.
Freud, S. (1911-1915). Papers on Technique. The Standard Edition of the Complete
Psychological Works of Sigmund Freud, Volume XII, pp. 85-174. The
Freud, S. (1923). The Ego and the Id. The Standard Edition of the Complete Psychological
Works of Sigmund Freud, Volume XIX, pp. 1-66. The Hogarth Press, London.
Freud, S. (1926). Inhibitions, Symptoms, and Anxiety. The Standard Edition of the Complete
Psychological Works of Sigmund Freud, Volume XX, pp. 75-176. The Hogarth Press,
London.
Freud, S. (1937). Analysis terminable and interminable. The Standard Edition of the
Complete Psychological Works of Sigmund Freud, Volume XXIII, pp. 209-254. The
Hogarth Press, London.
Freud, S. (1932). Libidinal Types. Psychoanalysis Quarterly, 1, 3-6.
Gabbard, G. (1998). Love and Hate in the Analytic Setting. Jason Aronson, Northvale, NJ.
Gill, M. (1982). Analysis of Transference, Volume 1, Theory and Technique. I.U.P., Madison,
CT.
Gray, P. (1994). The Ego and the Analysis of Defense. Jason Aronson, Northvale, NJ.
Hartmann, H. (1939). Ego Psychology and the Problem of Adaptation. I.U.P., New York.
Kris, A. (1982). Free Association, Method and Process. Yale University Press, New Haven.
Laplanche, J. (1987). New Foundations for Psychoanalysis. Blackwell, New York.
Mahoney, M. J. (1991). Human change processes: The scientific foundations of
psychotherapy. Basic Books, Inc. United States of America.
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Menniger, K. (1958). Theory of Psychoanalytic Technique. Basic Books, Inc. New York.
Miller, P. (1989). Theories of Developmental Psychology (2nd ed.). W. H. Freeman and
Company: New York.
McWilliams, N. (1994). Psychoanalytic Diagnosis, Understanding Personality Structure in
the Clinical Process. The Guilford Press, New York.
Novick, J. (1982). Termination: Themes and issues. Psychoanalytic Inquiry, 2, 329-365.
PDM Task Force (2006). Psychodynamic Diagnostic Manual. Alliance of Psychoanalytic
Organizations, Silver Springs, MD.
Rapaport, D. (1951). The conceptual model of psychoanalysis. In The Collected Papers of
David Rapaport, ed. M. Gill, pp. 405-431. Jason Aronson, Northvale, NJ.
Rapaport, D., Gill, M. (1959). The points of view and assumptions of metapsychology. In The
Collected Papers of David Rapaport, ed. M. Gill, pp. 795-811. Jason Aronson,
Northvale, NJ.
Sandler, J., Holder, A., Dare, C., Dreher, A. (1997). Freud’s Models of the Mind, An
Introduction. I.U.P., Madison, CT.
Sandler, J., Sandler, A.-M. (1998). Internal Objects Revisited. I.U.P., New York.
Schafer, R. (1976). A New Language for Psychoanalysis. Yale University Press, New Haven.
Scharf, J. & Scharf, D. (1998). Object Relations Individual Therapy. Jason Aronson Inc.:
Northvale, New Jersey.
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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
 22 Naomi A. Mandsager and Ralph Beaumont

Schlesinger, H. (2003). The Texture of Treatment: On the Matter of Psychoanalytic

Technique. Analytic Press, Hillsdale, NJ.
Schwaber, E. (1983). Psychoanalytic listening and psychic reality. International Review of
Psychoanalysis 10, pp. 379-392.
Tyson, P., Tyson, R. (1990). Psychoanalytic Theories of Development: An Integration. Yale
University Press, New Haven.
Zetzel, E. (1956). Current concepts of transference. International Journal of Psychoanalysis
37, pp. 369-376.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 In: The Quick Theory Reference Guide ISBN: 978-1-60021-624-4
Editor: Karin Jordan, pp. 23-29 © 2008 Nova Science Publishers, Inc.

Chapter 3

ADLERIAN PSYCHOTHERAPY

Len Sperry

KEY PERSON AND HISTORY

Alfred Adler, M.D. grew up as a weak, sickly child who could not walk until 4 years old
due to rickets. In addition, he was tormented by his older brother. Not surprisingly, he felt
small, unattractive, and rejected by his mother. Nevertheless, over the course of his
adolescence and early adulthood he was able to overcome his handicaps and inferiorities and
became an outgoing and successful physician who developed a theory of personality and
psychotherapy that in many ways reflected his own life circumstances. Early in his
professional career, Adler was invited by Freud to join the Viennese Psychoanalytic Society
and remained friendly with Freud for some 10 years. As he came to view Freud as inflexible
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in his views and obsessed with sex and death, Adler broke with Freud in 1911 and continued
to refine his own theory and psychotherapeutic approach. Subsequently, Adler influenced
many others including Karen Horney, Gordon Allport, Aaron Beck, and Abraham Maslow.
Maslow, Rollo May, and Viktor Frankl all studied under Adler, and all gave him credit for
having influenced their thinking. Adler paved the way for many subsequent developments in
psychology and psychotherapy including humanistic psychology, cognitive therapy and
cognitive behavior therapy, child guidance, group therapy, family therapy, and
constructivism.

KEY CONCEPTS

Overview of Adlerian Theory

Adler considered all behavior as purposive and interactive. Both individuals and social
systems viewed as holistic, and individuals were motived to seek “belonging” or significance
and meaning in their lives by the manner in which they functioned in social systems. He
postulated that it was within the family constellation that individuals first learn how to belong

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 24 Len Sperry

and interact. Adler emphasized the unique and private beliefs and strategies of individuals,
i.e., “ private logic,” that individuals create in childhood and which serve as a reference for
attitudes, private views of self, others and the world, and behavior which he called the
“lifestyle” and “lifestyle convictions.” Individuals form their lifestyle as they endeavor to
relate to others, to overcome “feelings of inferiority” and to find a sense of belonging.
Furthermore, Adler believed that healthy and productive individuals are characterized by
“social interest,” i.e., concern for the needs of others and the community, whereas those with
poor adjustment or psychopathology show little social interest and tend to be self-focused.

Basic Assumptions

Five underlying assumptions of this approach are: (1) individuals are unique, (2)
individual are self-consistent, (3) individuals are responsible, (4) individuals are creative and
determine their attitudes, beliefs and actions, and (5) individuals--in a soft-deterministic way-
-direct their own behavior and control their destinies.

Nature of Persons

This theory views the healthy person as one who engages in life experiences with
confidence and optimism. There is a sense of belonging and contributing and the serene
knowledge that one can be acceptable to others although imperfect. Subjectivity is central for
understanding the client, specifically the individual’s cognitions and beliefs about self, others
and the world. Though it shares much with psychodynamics approaches, Adler’s theory
focuses on conscious rather than unconsciousness, because he was convinced that the most
important life problems are social and relational and thus the individual must be considered
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

within the social context. The theory proposes that a person’s principle motive in life is to
find a sense of belonging and strive for perfection and that the individual’s opinion of self,
and the world, influences all of his or her psychological processes. Furthermore, lifestyle
convictions are influenced by the individual’s family constellation, i.e., one’s birth order,
sibling and parental relationships, and family climate and values.
Once the person has adopted a “mistaken goal” he or she will formulate other
misconceptions to support the “faulty logic.” Accordingly, the goal of psychotherapy for this
approach is to correct mistakes in perception and logic, i.e., faulty life style convictions , that
individuals formed in their effort to relate to others and to overcome feelings of inferiority
Individuals develop four life-style convictions: a self view – the convictions one has
about who they are; a self-ideal – the convictions of what they should be or are obliged to be
to have a place; a world view–their picture of the world or convictions about the not self and
what the world demands of them; and their ethical convictions– a personal moral code. When
there is conflict between the self-concept and the ideal, inferiority feelings develop. It is
important to notefeelings of inferiority are not considered abnormal. However, when the
individual begins to act inferior rather than feel inferior, the individual expresses an
“inferiority complex.” Thus, while the inferiority feeling are universal and normal; the
inferiority complex reflects the discouragement of a limited segment of our society and is
usually abnormal.
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 Adlerian Psychotherapy 25

Healthy vs. Unhealthy/Dysfunctional

According to Adlerian theory, individuals strive to attain goals that provide them with a
place in their world which provide them security and enhance self- esteem. If individuals
strive solely for their own greater glory, Adler considered such individuals socially useless
and possibly pathological. On the other hand, if an individual’s strivings are for the purpose
of overcoming life’s problems, the individual is engaged in the striving for self-realization
and making the world a better place to live which is indicative of psychological health.
Adler proposed this typology of psychological health and psychopathology: good
adjustment or psychological health is striving on the “commonly useful side" while poor
adjustment and psychopathology is striving on the "commonly useless side." Furthermore,
Adler posited that psychopathology represented disturbances or dysfunction not only in the
individual, but in the social situation as well. Adler presumes an innate potential for social
interest. Not to want to help one's neighbor is one of the characteristics of maladjustment. The
person whose social interest is developed finds the solution to problems, feels at home in the
world, and perceives more clearly, whereas individuals with poor adjustment and
psychopathology are individuals who have little or no social interest and are not interested in
others Personality disorders are presumed to stem from faulty lifestyle convictions, or early
maladaptive schemas in the language of Cognitive Therapy.

Change Process

In Adler's theory of change, the therapist uses a variety of strategies that help the client to
identify and change lifestyle convictions and beliefs. Since the client is unique technique used
must fit the situation of the client. Thinking, feeling, emotion and behavior can only be
understood as subordinated to the individual's style of life, or consistent pattern of dealing
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

with life. Adler believed that humans possess the freedom to act, determine heir lifestyle, and
thus determine their fate. Because individuals possess the creative power of self to
consciously shape their personalities, they essentially shape their destinies. Furthermore, this
approach is oriented toward the future and focuses on an individual’s hopes and expectation
rather than to traumas or conflicts the past, to explain and modify behavior.
Psychotherapy foster the process of change by stimulating cognitive, affective and
behavior change. Although the individual is not always fully aware of their specific pattern
and goal, through analysis of birth order, repeated coping patterns and early memories, the
psychotherapist infers the goal as a working hypothesis. Recognitions of this pattern of
limiting schemas and beliefs, the therapist helps the client to see life from another
perspective. Change occurs when the client is able to see his or her problem from another
view, so he or she can explore and practice new behavior and a new philosophy of life.

THE THERAPEUTIC PROCESS

Adlerian Psychotherapy addresses the complete range of human experience, from optimal
to pathological, and sees the therapeutic relationship as a friendly one between equals. Basic

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 26 Len Sperry

to Adlerian theory and practice is an optimism about human nature and the premise that the
primacy of social interest, also referred to community feeling, is an index and goal of mental
health. The assessment and intervention process is focused on lifestyle investigation and
change. The therapist tries to understand the client’s lifestyle, how the individual engages his
life, and how that lifestyle affects the client’s current functioning.

Assessment and Diagnosis

Besides eliciting traditional intake material, e.g., present concerns, mental status exam,
and general social, occupational and developmental history, the Adlerian psychotherapist
collects and analyzes the client’s family constellation and lifestyle convictions. The family
constellation consists of the client birth order, identifications with parents and peers, family
values, and family narrative. Lifestyle convictions are inferred from both habitual coping
patterns and early recollections. Because a client’s recollection of their earliest memories
reflect past childhood events in light of current life style convictions, early recollections are a
powerful projective technique that quickly and accurately provides a working hypotheses of
the way clients views themselves, others and the world. The therapist elicits three or more
memories and the description of these memories are analyzed according to themes and
developmental maturity and from these derives the clients lifestyle convictions which reflect
the impact of the client’s family constellation. Information from the family constellation and
lifestyle convictions are useful in specifying a case formulation, including a diagnostic
formulation and a clinical formulation, i.e., an explanation of why and how the client
perceives, feels and acts in a patterned and predictable fashion.

Treatment Goals
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The goal of treatment is not merely symptom relief, but the adoption of a contributing
way of living. Adlerians view pain and suffering in a client’s life as the result of choices
made. This value-based theory of personality hypothesizes that the values a client holds and
lives their life by, are learned, and when they no longer work as evidenced by suffering or
lack of happiness, the client can re-learn values and life-styles that work more ‘effectively’.
Some Adlerians believe that a client’s life-style is best viewed as a personal schemas or
narratives. Because such maladaptive schemas or basic mistakes are believed to be true for
the individual, the individual acts accordingly. Adler noted that these basic mistakes are
overgeneralizations, e.g., ‘people are hostile’, ‘life is dangerous’ or misperceptions of life,
‘life doesn’t give me any breaks’ which are expressed in the client’s physical behavior,
language, dreams, values, etc. The goal of intervention in Adlerian therapy is re-education
and reorientation of the client to schemas that work ‘better’. The actual techniques employed
are used to this end. Adlerians tend to be action-orientated. They believe the concept of
insight is just a proxy for immobility. Insight is not a deep understanding that one must have
before change can occur. For Adlerians, insight is understanding translated into action. It
reflects the client’s understanding of the purposeful nature of behavior.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Adlerian Psychotherapy 27

Phases of Treatment

Adlerian Psychotherapy is structured around four central objectives. These objectives

correspond to four basic overlapping phases: (1) relationship, (2) assessment, (3) insight, and
(4) reorientation.

1. Relationship
In the relationship phase, the goal is the establish an empathic relationship between
therapist and client in which the clients feels understood and accepted by the therapist.
Establishing a mutual and collaborative relationship is essential for effective therapeutic
outcomes to be achieved. This phase is described in more detail below.

2. Assessment
In this phase, the purpose is to evaluate the client’s concerns and objective and subjective
circumstances. In addition to traditional initial assessment information, the Adlerian therapist
elicits family constellation and lifestyle conviction material. This phase is described in more
detail below.

3. Insight
In this phase the purpose is to explain the client to himself or herself, which is to say to
develop insight into life style convictions, mistaken goals and self-defeating behavior
patterns. While such a corrective cognitive experience is usually necessary for treatment to be
effective it is by no means sufficient to effect a corrective emotional experience or behavior
change. Furthermore, insight does not always precede emotional and behavior change, which
are the province of reorientation. Thus, while theoretically distinct, the insight and
reorientation phases often overlap in clinical practice.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

4. Reorientation
The purpose of this phase is to help clients to consider alternative ss to the problems,
behaviors or situations and to commit to change. It involves strengthening the client’s social
interest.. It attempts to bring each individual to an optimal level of personal, interpersonal,
and occupational functioning. In so doing exaggerated self-protection, self-absorption, and
self-indulgence is replaced with courageous social contribution.

The Nature of the Therapeutic Relationship

Adlerian Psychotherapy favors a therapeutic relationship that is collaborative alliance

among two equals. That means that the therapists attempts to establish and maintain a
relationship that is characterized as a cooperative, supportive, empathic, and non-dogmatic.
While presumably having attained professional expertise in Adlerian psychotherapeutic
methods and techniques, the Adlerian psychotherapist does not assume the role of expert who
interprets and advises the client, but rather joins the client as a fellow jparticipant in the
journey of life. Through a respectful Socratic dialogue, clients are challenged to correct
mistaken assumptions, attitudes, behaviors, and feelings about themselves and the world.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 28 Len Sperry

Techniques

Once the initial analysis has been completed and goals for treatment have been set,
Adlerians employ a variety of techniques to encourage individuals to move forward and elicit
change. Most of the techniques are action-oriented, focusing on facilitating life-style changes
while working to help the individual learn to counteract discouragement, enhancing self-
efficacy and increasing self-esteem. Treatment may occur in the form of multiple
psychotherapy (whereby several therapists treat a single patient), individual psychotherapy,
and/or group therapy. Additional settings and treatment strategies include the Therapeutic
Social Club (as found mental hospital settings), Marriage Counseling, and a focus on broader
social problems via Interindividual and Intergroup Conflict Resolution. Within the therapeutic
relationship, the therapist is said to represent values the patient may attempt to imitate. In
serving as models for their patients, Adlerian therapists therefore characterize themselves as
“being for real”- genuine, fallible, and able to laugh at themselves. An emphasis on humor as
an important asset is frequently utilized in treatment since “if one can occasionally joke,
things cannot be so bad ”. Other verbal techniques include giving advice while taking care to
discourage dependency; frequent use of encouragement and support; and utilizing language
that avoids moralizing by referring to behaviors as “useful” and “useless” as opposed to
“good” and “bad”. Some of the more action-oriented techniques include creative and dramatic
approaches to treatment such as role-play, the empty-Other techniques chair, acting “As if”,
and psychodrama.
Other techniques include task setting, creating images, catching oneself, and the Push-
Button Technique. Task setting has the Adlerian therapist making two suggestions as
necessary for the patient to apply concurrently, outside of the therapeutic setting, over the
course of several weeks. First, “Only do what is agreeable to you”; second, “Consider from
time to time how you can give another person pleasure”. According to Adler, successful
employment of these two tasks are an effective strategy in helping people feel “useful and
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

worthwhile”, thus enhancing their self-esteem and improving their quality of life. Another
task-oriented technique, called catching oneself, requires patients to catch themselves “with
their hand in the cookie jar”. The goals of this approach are not only to increase patient
awareness of their “old” behaviors and provide an opportunity to replace them with new ones,
but to learn to anticipate situations before they occur. Creating images is another technique
utilized by Adlerian therapists in eliciting change. Based on the premise that “one picture is
worth a thousand words” and that remembering an image, the client can remember goals, and
in later stages, can learn to use the image to feel much more at ease and even laugh at oneself.
Accordingly, in the treatment process clients are given or generate images to describe
themselves. The Push-Button Technique also utilizes the clients’ own imagination in service
of therapeutic goals. After being instructed to call upon two specific life experiences- one
pleasant experience, and one unpleasant experience- patients are encouraged to focus on the
feelings each of these incidents evoke. This process is utilized to teach patients that they can
create whatever feeling they wish by deciding what they think about. As a result, the client
finds that she is the creator, not the victim of her emotions, and the power of self-
determination is enhanced .
Expressive techniques such as roleplaying, the empty chair, and acting “as if” may also
be utilized to help the client practice useful skills and behaviors as they engage in new roles
and styles of living. While these techniques provide valuable opportunities for clients to
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Adlerian Psychotherapy 29

rehearse new life-skills, they also allow them to make choices as to which roles they wish to
discard, and which they wish to use in their every day life. In addition, psychodrama is a
technique that Adlerian therapists may utilized in family and group therapy setting, wherein
the internal struggles of one client is worked though dramatically.

STRENGTHS AND LIMITATIONS

In may regards, Adlerian Psychotherapy can be considered the intellectual source or
taproot from which most current psychotherapeutic systems have emerged. These include
cognitive therapy, rational emotive behavior therapy, logotherapy, cognitive-behavioral
therapy or CBT, existential therapy, solution-focused therapy, and various constructivist
therapy approaches. Even object relations therapy and self-psychology owe much to Adlerian
concepts and methods. Adlerian Psychotherapy is applicable to many if not most clinical
presentations and can be provided in both brief and long term treatment contexts, and in
various intervention modalities with individuals, couples, families and groups. However,
while Adler’s approach has directly or indirectly influenced most current therapy approaches,
relatively few students and therapists are aware of this fact. Unlike cognitive behavior therapy
which is arguably the most widely used approach in North America and many parts of the
world largely because of its extensive training programs and empirically demonstrated
efficacy and effectiveness, Adlerian Psychotherapy has relatively few training venues and
only limited research support for its basic constructs.

SUMMARY
Adlerian Psychotherapy is a vigorously optimistic and inspiring approach to
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

psychotherapy. As a values-oriented psychology, it is more than a collection of techniques; it

establishes philosophical ideals for individual and group development. Problems or
dysfunction results from discouragement and a lack of social interest. The treatment process
stresses education to promote growth and change in lifestyle convictions. Therapeutic work
with clients involves short-term and intensive work to increase social interest, to encourage a
greater sense of responsibility for behavior, and to support behavioral change. Insight is used
therapeutically as an analytical tool to facilitate deeper self-understanding and several other
techniques are utilized to promote individual and relational change.
Adlerian psychotherapists attempt to capture the absolute uniqueness of each individual,
while teaching individuals to live in harmony with society. To encourage insight, they work
with early recollections, birth order, dreams and metaphors. This approach favors a
therapeutic relationship that is cooperative, supportive, empathic, non-dogmatic, and through
a respectful Socratic dialogue, clients are challenged to correct mistaken lifestyle convictions
and beliefs. In short, Adlerian Psychotherapy is a system of theory and practice built upon
psychodynamic, cognitive-behavioral, existential, constructivist and humanistic principles.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 In: The Quick Theory Reference Guide ISBN: 978-1-60021-624-4
Editor: Karin Jordan, pp. 31-46 © 2008 Nova Science Publishers, Inc.

Chapter 4

JUNGIAN THEORY AND THERAPY

Stephen R. Bearden, Michelle J. Cox and Kimberli Freilinger

Carl Gustav Jung was one of the most influential and provocative thinkers of our time.
His contributions to the theory and practice of psychotherapy remain foundational to our
understanding of mental health. Building on the work of Freud, Jung introduced a complex
and comprehensive view of the inner workings of the mind. Among his most important ideas
are the Collective Unconscious and its universal symbolism of Archetypal Images; the
importance of Dreams in accessing the wisdom of humankind, the centrality of Spirituality in
the quest for health and wholeness, his passionate interest in Mythology and Eastern
Religions; and his mapping of Personality Typology. While many of his ideas remain
controversial, they continue to be vital to our understanding of human consciousness and
potential. His vast written legacy has proven seminal in the fields of philosophy, art, culture,
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

spirituality, literature, and the evolution of psychoanalysis. With the current interest in all
things spiritual in psychoanalysis, Jung's deep engagement with the spiritual is drawing much
interest and study by theorists and clinicians. Jung and his ideas remain a towering and
relevant force in the art and practice of psychotherapy.

THEORY DESCRIPTION
C.G. Jung was a true humanitarian and an imaginatively free thinker. Recognizing that
mankind must be understood apart from or in addition to the scientific theories predominant
in his time, Jung considered all people enigmas. Man (and woman), lacking a natural ability
as well as correct training for accurate self-judgment, often feed the illusions of psychology
and humanity by living out what they have inherited (Corbett & Slattery, 2000). Jung
challenged both the theoretical psychological principles of his day as well as historical
influences to suggest that an individual’s thoughts, feelings and behavior are the result of the
collective unconscious striving to direct itself in spite of conscious action against it. This
uniting of this split between the conscious and the unconscious, he postulated, was the

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 32 Stephen R. Bearden, Michelle J. Cox and Kimberli Freilinger

essence of life for all human beings and the avenue through which humanity can experience
freedom, spirit, and health (Clift, 1982; Jung, 1960a).
Jung was a preeminent student of Freud, a contemporary and a member of the Vienna
Psychoanalytic Society. He contributed to the development of the psychoanalytic theory,
especially identifying the play of opposites in psychic energies, but later broke with the
society when Freud began to assert control over defining what theories were genuinely
psychoanalytic (Jones, 2002; Prochaska & Norcross, 1999). Where Freud focused on the
analysis of the unconscious as it relates to pregenital fixations and conflicts, Jung questioned
his “emphasis on consciousness as the process of freeing people from psychopathology”
without seriously considering the individual’s freedom to explore the unconscious and its
expanded significance on emotional health (Prochaska & Norcross, 1999, p. 62). Social
context and cultural differences were ignored in Freud’s theories. Freud had also adopted the
many andocentric biases of his predecessors (Jones, 2002). While valuing the significant
impacts and advancements Freud made in the field of psychology, Jung was reticent to deny
the effect of gender, history, and society on an individual. Emma Jung included his words in
her 1957 text on anima and animus:
“If I want to understand an individual human being, I must lay apart all
scientific knowledge of the average man and discard all theories in order to
adopt a completely new and unprejudiced attitude. I can only approach the
task of understanding with a free and open mind, whereas knowledge of a
man, or insight into human character, presupposes all sorts of knowledge
about mankind in general.” (p. 10)
This willingness to allow clients to express themselves without concern for pre-existing
views of pathology allowed Jung to witness humanness and to see both health and pathology
within all.
Among Jung’s many contributions to the field of psychotherapy were his sophisticated
works with clients suffering schizophrenia, the insistence that all therapists continually
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

participate in their own therapy, the value of countertransference in the therapeutic

relationship, and the full understanding and necessity of the mutuality of involvement
between client and therapist (Sedgwick, 2001).

KEY CONCEPTS

Nature of Persons

Jung’s understanding of human nature not only comes from studying his clients, but
much of his theory is derived from his own life experience. He had a deep, spiritual, nearly
psychotic experience (Jung’s description) that lasted about four years (Jung, 1961). He finally
surrendered to this journey and the fruit of what he learned formed the tenets of his theories
on human development and psychological health (Jung, 1961).
One of the best ways to understand Jungian Psychotherapy is to consider the language he
used when describing the condition of his clients and the process of therapy. Jung introduced
new words and concepts, some of which have been integrated into our daily vocabulary. As
some of these terms are either too commonly used or, altogether unfamiliar, it is important to

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Jungian Theory and Therapy 33

define them according Jung’s original intention. An essential place to begin is the ego, the
part of our personality that is conscious. It is our awareness of ourselves and the world we
live in. “The ego [is] extremely limited, subject to all possible self-deceptions, and errors,
moods, emotions, passions, and sins…[it is] childish, vain, self-seeking, defiant, in need of
love, covetous, unjust, sensitive, lazy, irresponsible and so on” (Jung, 1961, p. 57).
The persona is the ego’s mask, or our public selves (Jung, 1915). Identity, being heavily
influenced by the world and by relationships with others, becomes more determined by what
people will think, than by individual calling. “As its name shows, it is only a mask for the
collective psyche, a mask that feigns individuality and tries to make others and oneself
believe that one is individual,” (Jung, 1959, p. 138). In this way, persona often opposes the
unconscious, and emotional problems can arise because of the sacrifice of self-awareness and
personal integrity. In Psychological Types, Jung also described the persona as an outer
attitude that can be identified in dreams via images of definite persons who possess the valued
qualities of the persona (Jung, 1971). Jung does not suggest this is all bad, though. He
believes all people must use this part of personality to effectively deal with others.
The shadow is the part of an individual’s personality the ego naturally refuses to accept.
Much of the time the shadow includes the more negative aspects of the true self. If an
individual remains unaware or out of touch with the shadow side it has the ability to take over
personality in unhealthy and even destructive ways.
Jung believed in balance to create wholeness. One aspect of balance in his personality
theory is the balance of the feminine and masculine parts of the personality. Everyone
possesses the compliment to their gender, with animus being the male side (female
compliment) and anima being the female side (male compliment) (Jung, E., 1957). A person
with an overdeveloped animus will be too analytical and lack emotion, whereas a person with
an overdeveloped anima will not be able to think logically and will be ruled by emotion
(Jung, 1982). Underdeveloped aspects of the anima and animus do not disappear. They call to
us from the unconscious. This is why dream work and other projective techniques become
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

helpful interventions leading the client to wholeness and balance.

The personal unconscious, contains all of the repressed feelings and tendencies collected
over a lifetime. In therapy, the first aspiration is to help clients to become more aware of
repressed information from the personal unconscious. A second level of the unconscious is
the collective unconscious. It is the deepest layer of the psyche. It contains a wealth of
information collected from generations and passed on and shared by all humankind. Depth
psychology utilizes this collected wisdom to help the client integrate aspects of their
personality.
According to Jungian psychology, a person who lacks awareness, represses much of the
true self, and remains unaware of the shadow, is a person who will suffer psychologically and
often physically (Jung, 1933).
Jung believed that all human beings function with both consciousness and a more
powerful and important unconscious. The conscious mind entails those things, ideas, beliefs
and emotions that a person is aware of at any given moment. It is chained to current events.
Though Jung acknowledged the necessity of ego as an awareness of personal existence, he
postulated that it rests on and is supported by the unconscious. Sedgwick (2001) also noted
that the unconscious, as Jung saw it, was terrifically immense and includes:
(1) a vast reservoir of memory based general knowledge and learning, (2) more or less
available and hierarchically arranged memories of life events and relationships that are being

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 34 Stephen R. Bearden, Michelle J. Cox and Kimberli Freilinger

experienced in the present or have been experienced in the past, (3) one’s subjective reactions
to the above events and people, (4) evolving fantasies, under control and not. The memories
themselves and the feeling states associated with them exist in varying degrees of conscious
awareness, depending on their value, intensity, or the passage of time. (p. 30)

According to Jung, the unconscious, while objectively immeasurable, also includes that
which is archetypal, or instinctive to human beings – a universal past that has been carried
biologically through every human generation (Jung, 1915). Often expressing itself in symbol
form, the unconscious sends archetypal messages to humans (Jones, 2001; Pietikainen, 1999).
Additionally, human experience of these archetypal messages can seem overwhelming
because they defy individual logic. They are experiences felt, rather than acted upon. They
are also bi-polar in that, “they incorporate within themselves opposite attributes, the most
important of them being the opposites of instinct and spirit.” (Pietikainen, 1999, p. 95).
Finally, archetypes are ancient and primordial deposits from a history inexperienced by
modern man. Using archetypes, the unconscious constantly acts upon the ego, either by
permeating and altering it, or the ego will create defenses to protect itself (Sedgwick, 2001).
What is healthy functioning? Jung preferred to consider and respect what was healthy in
each individual. He (1993) did not believe, as Freud did, that the nature of the psyche could
be strictly labeled. Rather, he believed true expression of an individual’s psyche was
fundamental to psychological health (Jung, 1933). Stating that Freud’s theory was that of an
unhealthy mind, he used Freud’s unwillingness to critique himself as evidence that when
undifferentiated, the unconscious can take root and cause narrow judgment (Jung, 1933).
Individuation and integration are the therapeutic goals for which clients strive. Human
beings share a common uniqueness, and the only way to be truly unique is through the
individual nature of the personality (Jung, 1954). To find and accept the uniqueness in one’s
own personality through psychotherapy or depth psychology is to work toward becoming
individuated.
Integration is the process by which a client begins to make conscious all that has
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

remained in the personal unconscious. People often seek external explanations for who they
are. They let the media overly influence many features of their lives; where they should work,
what car to drive, and even what God to worship. People also look to the external world to
understand their own behavior. Jung hypothesized this external reasoning will not bring true
healing and understanding. This kind of reasoning leads to what Jung (1961) described as a
cul-de-sac, a dead end, which appears to promise at least a partial answer to core identity
questions. Unfortunately this promise is false and yields answers more significant to
managing one’s persona rather than deeply engaging one’s self. Jung believed that through
psychoanalysis, clients are encouraged to explore repressed parts of self that, once made
conscious, may be integrated into the ego. The therapeutic goal is that the client will become
aware of the possibility of an inner integration, which before was always sought outside the
Self (Jung, 1954). Jung noted, “[Clients] will then find [their] reward in an undivided self”
(1954, p. 197).
Clift (1982) explains that Jung used the word soul to describe a human being’s need for
connectivity. Connection with unconscious and collective history provides a soul-felt
understanding of personal destiny. Likewise, Emma Jung spoke of an essential human
developmental quality when she asserted that like a seed or an egg, all human beings are
meant or designed to become something (Jung, E., 1957). Carl Jung created the term

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Jungian Theory and Therapy 35

individuation to mean the process by which a person becomes one’s unique Self, taking on all
the unique characteristics and human traits that are true to one’s particular person (Jung,
1944; Sedgwick, 2001).
Dysfunction. Jung (1984) asserted that people are, for the most part, highly
undifferentiated beings. While people believe their own experiences are unique to them, their
unconscious experiences are common to the world. To be undifferentiated means to think
collectivity. The undifferentiated psyche experiences a fusing together of parts so that they
become indistinguishable. Jung saw the unconscious as striving to clarify the Self, even if it
was at the expense of the individual’s conscious existence. Pathology, therefore, has purpose
– some kind of unrecognized meaning (Jacoby, 2000). Jungian therapists often view
dysfunction as a failed attempt at personal growth or as potential opportunity for that growth
(Jung, 1960b; Sedgwick, 2001). “The neurotic is ill not because he has lost his old faith, but
because he has not yet found a new form for his finest aspirations” (Jung, 1915, p. 289).
Hence, illness has the potential to lead to healing.
As introduced before, the shadow is one of the most important archetypes of the human
psyche. Jung defined the shadow as “a moral problem that challenges the whole ego-
personality” (Jung, 1969, p.8). It is a dark side that resides in every human being. People fear
their shadow because it contains everything they do not want to see in themselves, good and
bad. Paradoxically, when the shadow is resisted, and banned from the conscious, it takes its
most destructive form. For example, Jung (1945) believed that in Hitler, every German should
have seen their shadow.
The behaviors that develop as a result of shadow suppression are called projections
(Jung, 1969). If clients choose to encounter their shadow side, it can then be brought out of
the unconscious and become assimilated into their conscious life. This process is called
differentiation and is a “moral achievement beyond the ordinary” (Jung, 1969, p. 9). From a
Jungian perspective, psychosis or dysfunctions are symptoms within persons who are
undifferentiated. One of the more difficult and very important goals of depth psychology is to
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

do shadow work. That is, when the client recognizes the aspects of the shadow, and
personally claims them, the shadow is stripped of its destructive power to harm the client as
well as other in the client’s life.
Simply having a shadow or evil side to the personality is not necessarily recognized as a
problem in Jungian psychotherapy. All people have shadow aspects to their personalities. The
shadow becomes especially damaging when its contents are repressed. From the small actions
people do daily that go against their values (telling white lies for example); to the bombing of
the Twin Towers, it is through repressed and projected shadows that evil persists in our
world.
A person can also repress and project positive energy that resides in the shadow. An
example of this might be a client who projects onto another human the archetype of god or
goddess. A person can become so impressed or amazed with another’s abilities or talents that
these personified projections create an image that assumes a pedestal - a pedestal upon which
one projects a repressed potential. Examples include those who proclaim their partner to be
perfect or those who become obsessed with following a guru figure. This may be repressed,
yet positive, shadow energy that can be made conscious through therapy and harnessed for
one’s own integrating work.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 36 Stephen R. Bearden, Michelle J. Cox and Kimberli Freilinger

The Change Process

Jung believed that people change because of “treatment of the soul” (as cited in
Sedgwick, 2001, p.18). Acting as a soul attendant, the therapist creates a working relationship
with the client that is both professional and intimate. Through this relationship, the client
experiences a corrective emotional experience where both the client and the therapist
experience affective change – though perhaps different kinds. Differentiation, according to
Jung, (1971) means separating the parts from the whole. Only after silent and conscious
consideration of feelings can clients determine what they believe to be true versus what the
collective unconscious leads them to believe is true. This transformation of the soul, as Singer
(1972) described it, occurs when the client is no longer satisfied with what society dictates.
Rather, a divergent thinking process develops that brings a balance between the conscious and
unconscious, beckoning the client to follow their own path.
Jung theorized that good and evil are coexistent halves of a moral judgment (Jung, 1969).
Good and evil are not two separate entities within the human soul; they are always together as
a part of the system of human values. Jung expected clients to be their own author of personal
moral value judgments (Jung, 1969). Jung also declared psychologists and therapists
responsible to validate the evil in the world and remind people of how real it is. Jung saw no
benefit, either personally or corporately, to suppressing the shadow side of humanity. It is the
responsibility of clients, through projective work, to identify their own particular shadow
issues and bring them to consciousness by claiming them. It is through this awareness and
synthesis that healing happens. It then becomes less likely that clients will project
unidentified energy that wrecks havoc in their lives (Jung, 1969).
Why is change difficult? Becoming aware of one’s shadow projections can be very
difficult. The ego works very hard to promote the persona. The ego does not want to see the
shadow and is always a strong force in keeping it repressed, even to the point that the shadow
might be expressed in destructive ways. The client and the therapist must have a trusting
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

relationship and an understanding that the container of therapy is sacred space. Kalff (1980)
stressed the importance of the therapist creating a free and protected space, noting that it is
the love of the therapist, which creates it. Likewise, Friedman (2005) and Steingart (1995)
considered love and integral part of the clinical relationship. Likening this clinical love
concept to love of literature, or an artists’ love of their work, Friedman suggested that it is
base on a unique insight that only an analysand could experience because of the pure nature
of the clinical relationship. Friedman even purported that love is a clinician’s deliberate
acceptance a person’s appeal in response to the clinical process, including the style or means
through which the client engages or endears the clinician. (2005). Clients’ work begins after
strengthening the ego to the point that they can confront their shadows. If clients were to
begin shadow work with fragile egos, the damage could be crushing.
The therapeutic relationship? Jungian therapists value transference and
countertransference as evidence that a therapeutic relationship has been established between
the client and the therapist. Using an alchemy metaphor, Jung suggested that, like two
chemicals mixed together, the mix forever alters both the client and the therapist. Rather than
to establish the appearance of trust, interest, and concern, while maintaining an emotional
distance, Jung proposed that real change occurs when the therapist takes on the client’s
difficulties and shares them (Sedgwick, 2001). Management of these affective organisms, the
energies created by client and therapist as they work together, cannot be achieved with
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Jungian Theory and Therapy 37

therapeutic distancing, as the client will sense that the relationship is false and feel rejected.
Jung believed that the emotional relationship between client and therapist hinged on the
connectivity of both the conscious and the unconscious of each participant (Singer, 1972).
Only when the client feels secure in the relationship with the Jungian therapist, will the
interplay between the unconscious of both persons unite them in a dance of metaphors,
allowing for understanding and healing. Such emotional engagement, including the
“therapist’s engagement on a feeling level,” is required for successful therapy (Sedgwick,
2001, p. 3).
The therapist primarily listens as clients reveal themselves. This is an important and
powerful contribution, as most clients need to be heard or need to project unresolved
relationships or issues onto someone they trust to help them work through the difficult
emotions associated with such unresolved issues (Sedgwick, 2001). Often this transference
occurs on the unconscious level. This is the point when the therapeutic evolution truly begins.
When the therapist responds appropriately to the transference, and the countertransference
receives an appropriate amount of consideration by the therapist, a new relationship is formed
that works together to help the client heal old wounds. Sedgwick (2001) described this
interaction as the crucible – the concentrated situation that forces change. Considering the full
implication of therapist involvement means that a significant portion of the therapeutic work
being done is that of the therapist.. This concept is foundational to Jungian psychotherapy.

THE THERAPEUTIC PROCESS

Assessment and Diagnosis

General Assessment Strategy

As Jungian psychotherapy is a feeling-based theory, hinging on management of
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countertransference issues, the therapist holds considerable responsibility during the

assessment. Informing the client of the necessity of their commitment to the process so that
they make themselves accessible to the contents of their unconscious only begins the
assessment process (Singer, 1972). Whereas it is important for the therapist to determine if
the client is able and willing to fully participate in a therapeutic relationship, it is even more
important that the therapist is willing to open up to those issues that may arise as part of the
relationship. For therapists to make these judgment calls, they need to consider more than just
the apparent presenting problem (Sedgwick, 2001).
Jungian therapists vary in their information gathering. Some consider the client’s
language and demeanor. Others use more formal protocol including standard forms or mental
status exams to gain as much data as possible. Some Jungian therapists require a therapeutic
narrative or autobiography from the client. Sedgwick (2001) recommends a considerable
history, not only to ensure that all legal and ethical obligations have been considered, but so
that the therapist understands the challenges to be faced.

Theory-based Assessment Strategy

Jung (1933) believed that accurate psychological diagnosis could only be made at the end
of therapy. Symptoms, according to Jung, are secondary manifestations of the unconscious

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 38 Stephen R. Bearden, Michelle J. Cox and Kimberli Freilinger

and, therefore, not an accurate reflection of an individual’s problems (Jung, 1933). The work
of Jungian therapy, to know the clients and their pain, conflicts with a front-loaded diagnosis
and is counterproductive in that it restricts a natural flow of information. Yet, many
considerations affect the Jungian therapist’s willingness to prepare preliminary diagnoses.
While all diagnoses, in strictly Jungian terms, would be considered provisional, diagnoses can
provide a number of advantages for therapists. First, to identify and consider pathological
symptoms allows for a preview of the types of issues the client avoids discussing. It gives the
therapist a possible direction, as well as preparation for any negative impact of the work to be
done. Second, preliminary diagnoses allow the Jungian therapist to communicate accurately
with other healthcare providers. Using a standard language helps consulting professionals
achieve greater understanding of the client’s issues. Third, initial diagnosis may create a
starting point to measure progress. However, most Jungian therapists prefer to measure
progress void of medical terminology (Sedgwick, 2001). Finally, if a Jungian therapist
chooses to accept insurance, diagnosing and treatment planning are among the requirements
for payment.

REFERENCES TREATMENT

Goals of Therapy

In Jung’s Seminar on Nietzsche’s Zarathustra, Jung clarified the main ingredient needed
for individual therapeutic goal achievement. “A goal can only be realized if there is the stuff
by which and through which you can realize the goal. If the stuff upon which you work is
worth nothing, you cannot bring about your end” (as cited in Jarrett, 1998, p. 1). Goal setting
is often useless when people are very emotionally troubled, too ill, or undifferentiated,
because they are not able to accurately assess their needs or make plans to address these needs
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in order to achieve the desired end.

Generally speaking, in Jungian psychotherapy, a therapist will be looking for the client to
have a stronger ego as evidenced by a lifting of anxiety and depression, increased self-esteem,
increased willingness to engage in a creative process, and the increased ability to accept
challenge and change. Individuation, another goal, would be evidenced by clients who are
accepting and conscious of their strengths and limitations, actively working to integrate
unconscious information from their psyches (incorporating shadow characteristics into the
ego), able to assert their own opinions, live authentically, within their own, chosen belief
systems, increasing their ability to feel secure (although this is not always comfortable), and
feeling more in touch with their true selves.

Therapeutic Process

Analysis in Jungian terms deals primarily with engaging the creative unconscious by
processing dreams, fantasies, visions, imagination, and often, free association (Singer, 1972).
Jungian writers often detail three phases of treatment. During the early phase, the therapists
engage themselves in assessment of the client and the determination of fit with the client.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Jungian Theory and Therapy 39

Therapists use this time to test their ability to empathize by learning about the client’s life
story, conferring with previous mental health providers and establishing boundaries that
frame the process of therapy. These ground rules make up the external frame allowing the
client to learn about the environment of therapy. Ground rules, dependent on the particular
therapist, may include either conscious directives; such as the manner in which the therapist
or client is addressed, how and when payment is made and received, how long the sessions
will last, how the session will wind to a close, or more therapist-driven choices; like how
neutral the therapist will remain when asked direct questions of opinion, and how much self-
disclosure will be appropriate for the relationship with the client (Sedgwick, 2001).
During the middle, or working phase of therapy, an alliance or therapeutic bond dictates
the quality of the work. Depending on the motivation of the client, this phase may be
characterized by a less anxious, serious, and committed devotion to the work. This is not
always true, however, especially when the client remains resistant to the process. The key
variable identifying the middle stage rests with the therapist’s involvement. Sedgwick wrote,
“He also offers attentive listening, clarifications, summaries, emotional and empathetic
responses, a certain kind of emotional involvement, and a continuity of presence and witness”
(2001, p. 153). The therapist’s work indicates a level of understanding that is significantly
more engaged emotionally than during stage one.
The closing phase of therapy can be most difficult to identify and is most often client-
driven. In essence, those therapies that are not prematurely terminated because of life
circumstances, financial pressures, or bad fit, usually end because the incentive for
improvement has faded during the growth process. Jung (1944) wrote, “treatment may come
to an end . . . without one’s always or necessarily having the feeling that a goal has been
reached” (p. 4). Regardless, mutual termination remains desirable when it is not premature.
Sometimes a feeling of relief or inevitability pervades. Termination should be handled with
some instructions as to the normalcy of loss and fear; yet, the clients should be respected and
valued as they embark on life with learned or renewed abilities.
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Goodheart (1980) described these phases in an effective and unique way. Phase one, the
persona-restoring phase, entails the client’s efforts to maintain a persona when challenged by
the process of psychotherapy. In the complex-discharging phase, the work reaches its
pinnacle of productivity. The work is messy, encompassing, and sometimes overwhelming,
yet the commitment of the therapist and client are matched. Finally, the secured-symbolizing
phase is creative and calm. A trusted alliance between therapist and client belies the
significant work they have achieved together. Hence, the therapy moves from a primarily
artificial and structured event to a connected, relaxed interplay between partners invested in a
commonly healthy outcome.

Common Intervention Strategies

Jungian therapists are interested in helping the client to drop the persona, or false self, in
favor of developing the soul. This includes the recognition of the client’s shadow side – that
part of themselves they cannot or do not want to admit exists or cannot even conceive. Singer
(1972) wrote that Jung developed word association experiments as an early projective test in
order to distract the ego from bolstering the persona during therapy. Certain words interfere
with the client’s ability to focus and lead the client to respond unconsciously. Jung recognized
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 40 Stephen R. Bearden, Michelle J. Cox and Kimberli Freilinger

that active listening requires intention and attention. Clients intend to offer certain personas
and when paying attention to the words, they often respond with predictable choices that
promote the persona they intend. Some words, though, cause reaction. Both intention and
attendance are removed and the responses point to complexes (Hall, 1991; Singer, 1972).
Complexes are like a nucleus with certain words and images, opinions, and convictions
constellating towards it (Singer, 1972). Whether based on nature or nurture, these sensitivities
lead to psychological damage when unresolved. Singer (1972) noted a number of indicators
of complexes including reactions to a number of words or instructions, errors in duplication,
reactions indicated by expression or laughter, unease, stammering, repetition of a word,
avoidance of actual word meaning, response in foreign language or complete abreaction. By
opening the unconscious, resolution of psychic pain follows, all the parts begin to come
together in a balanced Self, and individuation can be achieved (Kast, 1992).
Jung later came to believe that a more powerful tool for interpreting unconscious content
existed: dreams. Dreams can tell stories of compensation when people do not measure up in
life to their imagined potential. He also suggested that they offer self-regulation, often bearing
the burden of opposite desires. Dreams hold important symbols for all human beings. They
are, in essence, self-portraits waiting to happen, rather than information concealed as Freud
suggested (Jung, 1933).
Unlike Freud, Jung considered amplification the best approach for working with dreams
(Jung, 1954, 1960c, 1964, 1984). By combining the practices of word association and dream
analysis, Jung developed the technique that leads to amplification of the dream. During the
association process, the original images of the dream are held constant. Rather than
wandering away with the associations or searching for latent meaning, the dream itself
remains the focus, thereby ensuring that the dreamer honor the symbolic messages. From
these word associations, the analysand and the therapist retrieve three important sets of
material. First is information from the client’s personal unconscious, memories and feelings,
which reveal the nature of the soul or the Self (Jung, 1950, 1954, 1960c). The second level of
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material reveals cultural messages assimilated to the image of the dream. The final level, the
archetypal images, brings associations from areas such as myth, folklore, and religion. Often,
the meaning of the dream becomes clear during the first level, and analysis can then help the
client to recognize what changes must be made in order to balance the conscious and
unconscious mind or to achieve differentiation. If not, the therapist can assist the client in
reviewing the cultural material, and finally, the archetypal material for answers. Thus,
amplification only proceeds as far as necessary for the client to understand the message of the
dream (Singer, 1972).
Jung extended the practice of dream analysis to include work during the waking hours.
The difficulty with dream analysis, he postulated, is its passivity. Dreams come at their own
time and when people are sleeping. In order to pursue the unconscious more actively, Jung
developed a process that allows the individual to consciously seek information. Jung wrote of
a third element between the ego and the conscious that he labeled the transcendent function.
When relations between the ego and unconscious are strained, there exists an ability to
transcend the conscious and converse with the unconscious directly. Jung termed this ability
active imagination (Jung, 1960c; Singer, 1972).
Jung contributed additional theoretical content widely used in clinical treatment today.
He believed that improved communication between individuals could be achieved with an
understanding of their general personality type, which is labeled as either introversion or
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Jungian Theory and Therapy 41

extroversion. Viewing both types as equally valuable, he provided the world with a way to
generally classify two main groups of people based on the way in which they view the world
(Jung, 1971). Based on the theories of Aristotle and Plato, as well as on work by Freud and
Adler, Jung defined introverts as mainly basing their understanding of the world on
perceptions, and extroverts basing their understanding on practical considerations (Jung,
1971; Singer, 1972).
Jung then expanded his theory to suggest that both types can be grouped by functions:
thinking, feeling, intuition, and sensation. According to Singer, “These four functions
represent ways in which we perceive and process the information that we receive, whether it
comes from the external environment or from within ourselves” (1972, p. 329). By
determining the client’s type, the clinician can then orient the questions, responses, tone, and
attitude in a manner that will either accommodate or challenge the client to move forward.

Nature of the Therapeutic Relationship

In Jungian psychotherapy, the therapist’s mind and personality are of primary importance
to the work and success of the therapeutic relationship. Sedgwick (2001) noted that this
includes the reactions to the client and client transference.
In Jungian psychotherapy, as with many therapy modalities, relationship is primary. True
change happens in the client/ therapist relationship. Success is not scientific or prescribed. It
is the development of a dynamic relationship that is critical. Kalff (1980) stressed the
importance of the therapist creating a free and protected space, noting that it is the love of the
therapist, which shapes this space. This atmosphere is created psychologically, physically,
and relationally in the symbiotic exchange between the two. The therapist is the catalyst and
container, offering safety to the client. As the client begins to trust and experience this safety,
a freedom in being is released resulting in the exposure of the Self and the ultimate
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recognition and assimilation of the shadow. This is how the integration process develops. It is
the foundation of the therapeutic relationship.
Because Jungian psychotherapy is founded on the personal dimension, from the point of
view of the therapist, this dimension primarily consists of two components previously
mentioned – empathy and wounded healing. Together, these can form the internal work of the
therapist in therapy – what can be called, in expanded terms, countertransference (meaning all
the fantasies, feelings, thoughts of the therapist about the client and the therapeutic
relationship). Hence the therapist’s commitment to the relationship primarily determines the
success or failure of the process. This commitment forms out of an intricate balance of respect
and professional boundaries.
Included in the personal dimension is the Jungian idea of a profound empathic reaction to
the client. This type of empathy requires that therapists find love for their clients even when
they are not loveable – when they are difficult, mean, annoying, or depressing. For the clients,
it is this unconditional acceptance that builds their trust in the therapist. Eventually, it is
hoped and believed that clients will begin to accept themselves as the therapist has accepted
them, learning self-care and self-love (Sedgwick, 2001).
This can be challenging for the therapist, as well as the client, however. Since empathy is
“thought as well as felt,” both the client and the therapist can begin to conceptualize the
parental imago (Sedgwick, 2001, p. 91). Whereas the client should begin to internalize the
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 42 Stephen R. Bearden, Michelle J. Cox and Kimberli Freilinger

parental role of self-care, she can wind up looking to an empathetic therapist to provide an
improved parental role. Some therapists, missing the important countertransference clues,
may even invite this role. In attempts to avoid this misfire of duty, it remains vitally important
that the Jungian therapist consider empathy an art rather than a theory to be maintained.
Empathy is a simple, demanding, subtle response to the clients’ conscious statements, but it is
also an unconscious reaction to them based on an understanding of its value (Sedgwick,
2001). Empathy is introjections and projection (countertransference) used mutually to
understand the client.
Getting from empathy to countertransference to wounded healing becomes the challenge
for the therapist. When empathy becomes complicated, that is, when empathy becomes about
the therapist’s issues rather than about the client’s, closer self-exploration is required
(Sedgwick, 2000 & 2001). According to Jung (1946), this is the beginning of the real work as
the therapist and client unite in a common struggle. By working through a problem mutually,
the therapist takes on the client’s pain and creates healing for both client and Self.

STRENGTHS AND LIMITATIONS

Strengths

The strengths of this approach can be considered in two contexts. First, the value of the
theory and practice for client outcome determines its overall usefulness. According to
Leuzinger-Bohleber and Target (2002), two key questions must be posited in order to make
this determination: what changes took place for the client as a result of the therapy, and how
did those changes come about? In 1917, Coriat (as cited in Leuzinger-Bohleber and Target,
2002) reported results from 93 cases suggesting that 73% of the clients experienced recovery
or improvement. However, clinician self-reporting and small samples call into question the
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accuracy of these types of studies. In the 1930’s and 1940’s, larger studies suggested similar
positive outcomes, but were again questioned because of an absence of definitive definitions
of terms and behaviors and consideration of individual therapist skill level. These and similar
issues cast doubt on results of studies made through the 1950’s.
During the next three decades, the second and third generation of studies occurred
concurrently. These studies significantly improved their research protocol, included extensive
follow-up, combined resources, maintained standard definitions and considered the skill level
of the clinician. The Menninger Foundation Psychotherapy Research Project (PRP) was the
most impressive in its class (Leuzinger-Bohleber & Target, 2002).
“Its intent was to follow the treatment careers and the subsequent life careers
of a cohort of patients, half in psychoanalysis, and half in other
psychoanalytic psychotherapies – and each in the treatment deemed
clinically indicated – to follow them from the initial pre-treatment
comprehensive psychiatric evaluation, through the entire natural span of
their treatments, and then into formal follow-up inquiries at several years
after the treatment terminations.” (Leuzinger-Bohleber & Target, 2002, p.
41)

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Jungian Theory and Therapy 43

The results of the PRP were significant. The researchers found that this type of
expressive therapy worked as well as most other expressive analytic therapies. It also found
that among the expressive therapies, more support of the client was achieved than was
anticipated, leading to more change for the client. Additionally, researchers recognized the
significant value of the supportive environment in treatment. Finally, it showed the difficulty
tying the positive changes to specific techniques (Leuzinger-Bohleber & Target, 2002). This
generation of study helped confirm the holistic value of psychoanalytic, expressive therapies
even if they could not assign values to each technique.
Whereas first, second, and third generation psychoanalytic research studies remain
valuable historically, more recent studies, like that which invited the participation of the
German Society of Analytic Psychology (Keller, Westhoff, Dilg, Rohner, & Studt, 2002),
have been able to control the research to a more finite degree.. In this study, 111 patients
followed for a period of six years after completion of Jungian psychoanalytic treatment
demonstrated a reduction in the use of health care including hospitalization, dependence on
intrapsychic medications and doctor visits when compared to pre-treatment conditions.
Though only 24% of clients completed the lengthy study, those clients’ self-reports of
emotional and mental health accurately matched the external procedures used to measure
mental health (Keller et al., 2002).
The second consideration as to the strength of this particular type of therapy must be the
goodness of fit for the clinician. As reported earlier, in this writing, the involvement of the
therapist in Jungian psychoanalytic treatment is significant. Jungian therapists must remain
willing to be exposed, more than the average clinician, to emotional pain and conflict. They
must commit to long-term personal analytic treatment. Jungian therapists must truly believe,
via their experiences, the efficacy of the individuation process.
Many clinicians are drawn to Jungian work for a number of reasons. One reason is that it
is a creative process. Jungian psychotherapy invites others into a creative form of therapy.
Another reason many are drawn to this theory is because of the belief in the power of the
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unconscious. Clients and professionals who have engaged in personal depth work know first
hand the profound healing it brings. To make conscious what was once unconscious is to see
a new light dawn within a client, (the Self) and it is intensely gratifying for both client and
clinician. They are both a witness to healing realized.

Limitations

Limitations for embracing this theory and therapy should be seriously considered by any
interested clinician. Jung’s psychological system is incredibly complex and technical. The
sheer volume and variety of Jung’s writing makes the mastery of his thought daunting. Added
to this is Jung’s constant evolution of thought, which predicts for confusion as students
attempt to solidify their understanding of Jungian concepts. For the aspiring clinician, the
process of becoming a Jungian Analyst includes several years of post-doctoral studies. Also
challenging is Jung’s dependence on his own subjective reality for wisdom and direction.
Additionally, the lifework of individuation continues to personally challenge the clinician, as
well as often being lengthy, painful and expensive for clients. The financial considerations are
especially challenging in light of the current climate of brief therapy modalities insisted upon
by Health Management Organizations (HMO) and Managed Care Organizations (MCO)
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 44 Stephen R. Bearden, Michelle J. Cox and Kimberli Freilinger

(Miller, 1996). Clinicians relying on third party payment, in most cases, have to amend the
length of treatment, and focus the client on presupposed goals provided by the HMO or
MCO. Such a conscious and pragmatic process may contradict the very nature of Jungian
therapy and dilute its effectiveness (Graybar & Leonard, 2005; Talan, 2005).

SUMMARY
Carl Gustav Jung was a bold and courageous thinker, a groundbreaking psychotherapist
and a pastor of souls whose life and ideas provide compelling and fruitful content for the art
and practice of psychotherapy. Perhaps no other figure in the history of psychology and
psychiatry has had such a catalytic effect on the development of Psychology, especially Depth
Psychology. Jungian thought and therapy remain a significant stimulus to the consideration
and practice of modern psychotherapy. His work continues to prompt novel and fruitful
research and writing in abundance and depth.
Yet among the most important features of his legacy are Jung’s call for persons to
exercise the discipline and courage required to apply the exacting test of personal experience
in defining and shaping one’s therapeutic reality. Recognizing the usefulness of remaining
open to the unconscious allows the therapist to exist in a perpetual state of self-learning. This
coupled with his belief that reliance on one’s intuitive impressions for personal as well as
professional guidance is essential for therapeutic wisdom and direction mark Jung’s work as
profoundly personal and yet imminently practical.
Finally, Jung demonstrated a broad systemic approach to the science of psychology,
believing that the effective clinician would bring the study of history, archeology, religion,
literature, comparative anatomy, and other disciplines to the therapeutic process. Jung
believed that the development of the clinician was crucial to the success of redemptive
psychotherapy. His life and work are a powerful testimony to his belief as well as a call for
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the rest of humanity to undertake the lifelong task of Individuation.

REFERENCES
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Crossroads.
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Goodheart, W. (1980). A theory of analytic interaction. San Francisco Jung Institute Library
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Graybar, S. R., & Leonard, L. M. (2005). In defense of listening. American Journal of
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Hall, J. A. (1991). Patterns of dreaming: Jungian techniques in theory and practice. Boston:
Shambhala Publications.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
 Jungian Theory and Therapy 45

Jarrett, J. L. (Ed.). (1998). Jung’s seminar on Nietzsche’s Zarathustra. (Vols. 1 – 2).

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NJ: Princeton University Press
Jung, C. G. (1950). The integration of the personality. London: Routledge and Kegan Paul
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Press.
Jung, C. G. (1959). The basic writings of C. G. Jung. New York: Random House Inc.
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Inc.
Jung, C. G. (1960c). Synchronicity. Princeton, NJ: Princeton University Press.
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Jung, C. G. (1961). Memories, Dreams, Reflections. New York: Vintage Books.

Jung, C. G. (1964). Man and his symbols. New York: Dell Publishing Company, Inc.
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Publications.
Kalff, D. (1980). Sandplay: A psychotherapeutic approach to the psyche. Santa Monica, CA:
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Kast, V. (1992). The dynamics of symbols: Fundamentals of Jungian psychotherapy. New
York: Fromm International Publishing Corporation.
Keller, W., Westhoff, G., Dilg, R., Rohner, R., & Studt, H. H. (2002). The study group on
empirical psychotherapy research in analytic psychology. In M. Leuzinger-Bohleber and
M. Target (Eds.). Outcomes of psychoanalytic treatment: Perspectives of therapists and
researchers. London/Philadelphia: Wuhrr.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 46 Stephen R. Bearden, Michelle J. Cox and Kimberli Freilinger

Leuzinger-Bohleber, M., & Target, M. (Eds.). (2002). Outcomes of psychoanalytic

Treatment: Perspectives of therapists and researchers. London/Philadelphia: Wuhrr.
Miller, I. J. (1996). Time-limited brief therapy has gone too far: The result of invisible
rationing. Professional Psychology: Research & Practice, 27(6), 567–576.
Pietikainen, P. (1999). C.G. Jung and the psychology of symbolic forms. Finland: Academia
Scientaria Fennica.
Prochaska, J., & Norcross, J. (1999). Systems of Psychotherapy: A transtheoretical analysis.
Pacific Grove, CA, Brooks/Cole Publishing.
Sedgwick, D. (2000). Answers to nine questions about Jungian psychology. Psychoanalytic
Dialogues, 10(3), 457-472.
Sedgwick, D. (2001). Introduction to Jungian Psychotherapy: The therapeutic relationship.
England: Brunner-Routledge.
Singer, J. (1972). Boundaries of the soul: The practice of Jung’s psychology. New York:
Doubleday.
Steingart, I. (1995). A thing apart: Love and reality in the therapeutic relationship.
Northvale, NJ: Jason Aronson.
Talan, J. (2005). Upsetting psychotherapy. Scientific American Mind, 16(3), 12-13.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 In: The Quick Theory Reference Guide ISBN: 978-1-60021-624-4
Editor: Karin Jordan, pp. 47-62 © 2008 Nova Science Publishers, Inc.

Chapter 5

EXISTENTIAL PSYCHOTHERAPY:
PHILOSOPHY AND PRACTICE

Claire Arnold-Baker and Emmy van Deurzen

The existential approach to psychotherapy and counseling has its grounding in existential
philosophy and is concerned with human existence and the way in which humans live and
exist in the world. Although Kierkegaard is usually considered to be the founding father of
the existential tradition the roots of existential thinking can be found in the work of Socrates,
Plato and Aristotle. Existential philosophy blossomed on the European continent from 1844
to the 1970’s. The main existential philosophers were Sören Kierkegaard (1813-1855),
Friedrich Nietzsche (1844-1900), Martin Heidegger (1889-1976), Jean-Paul Sartre (1905-
1980), and Maurice Merleau-Ponty (1908-1961). Other prominent philosophers include
Edmund Husserl (1859-1938), Martin Buber (1878-1965), Karl Jaspers (1883-1969), Paul
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Tillich (1886-1965), Simone de Beauvoir (1908-1986) and Albert Camus (1913-1960).

Although these philosophers’ views diverge a great deal from each other they are all
concerned with the concrete existence of human beings.
Existential philosophy addresses questions we all ask ourselves. What does it mean to be
alive? Why is there something rather than nothing? What is the purpose of my existence?
This differs from traditional psychology which focuses on defining personality or explaining
behavior. Existential philosophy has identified common themes or issues that human beings
experience in their everyday living, which are highlighted below.

DEATH
Death is a central theme of existential philosophy, as it is our death and our temporality
that put our lives into perspective making them meaningful and purposeful. The one certainty
we have is that we are going to die, that we have a finite period of time, which is unknown.
Existential philosophers believe that death and our temporality permeate our lives, either
directly or indirectly. Heidegger (1927) believed that for the most part we try to avoid

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 48 Claire Arnold-Baker and Emmy van Deurzen

thinking about our own death and live in an inauthentic way. Yet despite this we are always
moving towards death and death will finally complete us. Heidegger talks of an awareness of
death as shifting us from one mode of existence to another. He states that there are two
different ways of looking at death. The first is the forgetfulness of being, where Dasein1 flees
from itself, falls in with others, and is tranquillized by trying to find all kinds of securities in
life. In this way Dasein tries to escape death by immersing itself in the everyday diversions of
life and by thinking that death is something that happens to other people.

“The ‘they’ has already stowed away an interpretation for this event. It talks of it in a fugitive
manner, either expressly or in a way that is mostly inhibited, as if to say ‘one of these days
one will die too, in the end, but right now it has nothing to do with us’” (Heidegger, 1927:
297).

However, Heidegger believed that rather than trying to avoid death we should face our
mortality, which is a reality of our existence right now, since we are dying a little bit
everyday and are fundamentally mortal, temporal and temporary beings. We should embrace
the possibility of death as well as the limitations that it entails. Having an awareness of your
own death brings an awareness of life and shifts trivial preoccupations towards things that
really matter. Inevitably awareness of death evokes a certain amount of anxiety.

ANXIETY
Kierkegaard (1844) is probably best known for his writing on Angst or anxiety. He turned
his back on the objective scientific view of his day to concentrate on examining the kind of
life people lived. He queried whether there is an adequate life, i.e. whether the person is living
with subjectivity and individuality or whether they are somehow wasting their life and
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following the crowd. Kierkegaard saw human life as an effort that is not easy, one full of
anxiety. Kierkegaard claims that there are no rules to life and that our life is determined by
ourselves rather than by some external force or law. For Kierkegaard a person does not exist
in the mode of being but of becoming, and what we become is our own responsibility even
though frequently we conceal this from ourselves. When we do not live up to our own
possibility we experience existential anxiety, which reminds us of our fundamental freedom
and the vastness of our responsibility in the face of infinity.

FREEDOM AND CHOICE

Sartre developed this theme of freedom. He stated that “Man is condemned to be free”
(Sartre, 1943: 632). With this statement he captured the paradoxical problem with freedom,
that we are both enslaved and liberated by it at the same time. We have the freedom to choose
what to do, who to be but this freedom comes with the price of responsibility. Sartre believed
that everything about our life has to be chosen. We have no choice but to choose, even if we

1
Dasein literally means ‘Being there’ and is used as a shorthand for “human being”, Heidegger never speaks of the
“self” but only of “Dasein”.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Existential Psychotherapy: Philosophy and Practice 49

are living our lives passively and by default, this is a choice we have made. Therefore the way
we live our life is down to us, it is our responsibility. However this freedom to choose causes
us to feel anguish because the future is open to all possibilities, it is undetermined by our past
or the external world. It is this freedom to choose our future, which is our obligation to create
meaning and create our own world. The anxiety we experience in relation to our life is a sign
we are alive, and that we need to make a choice about our lives. By recognizing the
responsibility we have towards ourselves and our lives we enable ourselves to make
deliberate choices. We can determine the path we want our life to take and re-examine the
way we have lived before, reassessing our values and beliefs and having the courage to follow
our original project.

GUILT
Freedom to choose not only carries with it anxiety but also guilt. Heidegger elucidates
this as existential guilt, which is where we are indebted to ourselves, where we have failed to
live up to our own potential. “Dasein is guilty because of a lack in its own being” (Heidegger,
1927). Existential guilt is about our being and what we haven’t done rather than about
something we have done wrong. Heidegger states that this guilt is inescapable; it is an
inherent part of our existence. When we choose there is always an alternative that we reject
and therefore another possibility that we are not able to follow. We can not pursue all our
potentials and so our experience of guilt is over those that we have failed to realize.
Something always remains to be done.

MEANING
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If we are to create a life for ourselves, we have to create a meaningful one. Many people
reach a point when their lives have become meaningless and they question what they are
doing and where they are going. This happens mainly when a person has not been reflecting
on their life or when they have reached a low point in their lives. The stark reality of life sinks
in and we wonder what the point of continuing is. Viktor Frankl (1905-97) discovered the
importance of meaning when he was a prisoner in the Nazi concentration camps at Auschwitz
and Dachau. He discovered through his experiences at the camps that those who were able to
create a meaning for all the suffering they were experiencing were better able to survive.
Nietzsche expressed a similar sentiment when he wrote “He who has a why to live for can
bear with almost any how” (Frankl, 1984, p. 97). After the war Frankl’s work focused on the
meaning of human existence and man’s search for it. He saw this as the primary focus of life,
as we are creatures who try to find meaning. Frankl developed a therapeutic approach called
Logotherapy2 to help clients find a purpose in life.

2
‘Logos’ is the Greek term for meaning

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 50 Claire Arnold-Baker and Emmy van Deurzen

TIME AND LIMIT SITUATIONS

For Heidegger (1927), time is not a linear progression, where past, present and future
appear as separate points on a time-line. Instead the past is always part of the present and
projects into the future, so that both our past and our future are part of our present experience.
Our past is also not something that is fixed and determines our present. Rather our
relationship with our past changes by our present experiences in the same way that our
present can be influenced by our past experiences. For both Heidegger (1927) and Sartre
(1943) we are always in a process of becoming and therefore in terms of time we are always
projecting ahead into the future. We are never the finished article and our death sets a time
limit on our existence. As we are limited in time we are also limited by other boundary
situations. Jaspers (1951) spoke of limit situations, the limits of human existence which are
imposed upon us by the world and which we can not change. Jaspers believed that we must
accept these limits and live our life within them as they are part of human existence. These
ultimate situations include our historicity, i.e. our parents/family, culture, gender and past,
and the fact that we must die, suffer and experience conflict in our lives as well as the fact
that we have to accept imperfection and failure as part of life. Jaspers believed that we must
engage in the tasks of life without illusion, accepting the limits to our life, both the general
limitations and our own personal limitations and that we must at the same time go forward in
spite of them.

EXISTENTIAL PSYCHOTHERAPY
Existential philosophy, with its focus on human nature, lends itself well to therapeutic
work. The early existential practitioners, Karl Jaspers (1883-1969), Ludwig Binswanger
(1881-1966) and Medard Boss (1904-1990), were all psychiatrists who had become
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disillusioned with the medical model. They found in the writings of existential philosophers a
new way of approaching their patients, looking at their patients’ problems as life issues rather
than as pathology. Binswanger and Boss were particularly influenced by the work of
Heidegger; in fact Heidegger gave a series of lectures to Boss’ psychiatric students.3 Jaspers
took his inspiration from the work of Kierkegaard and Nietzsche. Further practitioners
followed in their footsteps and these included Viktor Frankl (1905-1997), Rollo May (1909-
1994), Thomas Szasz (1920- ), Ronald Laing (1927-1989) and Irvin Yalom (1931- ). Today
there is a burgeoning movement of existential practitioners in the UK, which include Hans W.
Cohn (1916-2004), Emmy van Deurzen (1951-) and Ernesto Spinelli (1949-). Existential
therapists are concerned with helping clients to understand their issues as problems in living,
clarifying where the difficulties lie and enabling clients to find new and meaningful ways of
living.

3
These lectures have been published in Zollikon Seminars: Protocols – Conversations – Letters, M. Boss (ed.)
(2001) Evanston, IL: Northwestern University Press.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Existential Psychotherapy: Philosophy and Practice 51

KEY CONCEPTS

Nature of Persons

The existential approach considers human nature to be open-ended, flexible and capable
of an enormous range of experience. Although existential practitioners would not talk about
human nature per se instead they would focus on human existence and the ontological
concerns that we all share. The existential approach contends that there is no fixed self and
that we are continually in a process of becoming. This means that existential therapists do not
have a theory of personality, nor do they pathologize or label the individual. Rather existential
therapists aim to describe the various levels of existence that we operate with in the world.
Heidegger believed that individuals were not just isolated subjects who inhabit a world, rather
that they are interconnected with the world; Heidegger (1927) called this Being-in-the-World.
Binswanger (1946) was particularly interested in Heidegger’s idea of Being-in-the-World and
set out three basic dimensions of human existence, May (1983) further elucidated these
dimensions and van Deurzen (1988) added a fourth dimension which had been inferred in
earlier work.

Umwelt – Physical Dimension

The Umwelt is the physical dimension and it relates to the natural world around us and
our environment. It is the dimension of our bodily needs, our senses and our embodiment. It
is also the dimension that we are born into, which includes our gender and heredity. This
dimension also relates to our health, wealth and fitness, as well as our relationship to the
climate and our physical environment, including our relationship to animals. This dimension
is about life and death, feelings of safety or lack of it and about learning to adapt to the limits
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of the physical world.

Mitwelt – Social Dimension

The Mitwelt is the social dimension and represents our relationships with other human
beings. These include relationships with our family, extended family, friends, work
colleagues, acquaintances and interactions with others that we do not know. This dimension is
not just about relationships, it is about our public domain so includes our relationships with
our language, culture and society. It covers our attitudes to our country of origin, race and
social class. This dimension is about intimacy and isolation, feelings of love and
acknowledgement or rejection.

Eigenwelt – Personal Dimension

The Eigenwelt is the personal dimension, the world of the self. It is about our identity and
our relationship to our self. It includes our feelings, thoughts and personal characteristics. Our

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 52 Claire Arnold-Baker and Emmy van Deurzen

sense of who we are develops out of our interactions with other people and the world around
us. Our self is not fixed but continues to be refined and adapted as we live our lives. This
dimension concerns finding out about our strengths and weaknesses and finding an authentic
way of living.

Überwelt – Spiritual Dimension

The Überwelt is the spiritual dimension and represents the world of our beliefs and
aspirations. It is our ideal world, our original project and it is where we make sense of our
lives. The spiritual dimension does include our relationship to religion but it is also about how
we create meaning and purpose in our lives. This dimension is about truth and wisdom.
Human needs can be looked at from a number of perspectives, since we have physical,
social, personal and spiritual needs. The satisfaction of some physical needs is essential to our
survival; other needs are secondary and their satisfaction enables us to live a fulfilled life. The
first kind of needs center on basic biological needs such as hunger, thirst, warmth and a level
of security. These days, in the west, these needs are easily met for most people and do not
concern our daily existence even though we all have to work hard for our living. However, in
third world countries, particularly those struggling with natural disasters or famine, meeting
these basic biological needs can become deeply problematic. With our basic needs met, our
attention turns to secondary needs such as those of social stability and personal fulfillment or
even meaning and truth. From an existential perspective all these needs can be seen in terms
of poles of existence. We constantly go between the poles that exist on each dimension of
existence, for instance between strength and weakness, truth and lies, highs and lows. We are
rarely at one pole or the other but oscillate between the two. Typical poles include health vs
sickness, closeness vs distance, active vs passive and happiness vs sadness.
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THEORIES AND/OR PHILOSOPHICAL UNDERPINNINGS

The existential approach to psychotherapy is most closely related and informed by
positive psychology. Positive psychology (Seligman, 2002) emphasizes people’s strengths
and what is going well in their life rather than focusing on an individual’s weaknesses or
problems. Positive psychology aims for optimal human functioning, by helping people to
realize their strengths. Clients are encouraged to re-look at their life in view of these
strengths, which allows them to start living in a different way. The aim is for human
happiness, well-being and living a good life.
Other disciplines that inform the approach include anthropology, politics and sociology.
These are important as they take the social context of living into account and provide insights
into the relational aspects of human beings.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Existential Psychotherapy: Philosophy and Practice 53

HEALTHY VS. UNHEALTHY/DYSFUNCTIONAL

Healthy Functioning

From an existential perspective healthy functioning and dysfunction are seen as opposite
poles on the same continuum. Healthy functioning would be seen as a person living an
authentic life. What this means is that they are being true to themselves and accepting life’s
limitations as well as their own personal limitations. Well-being is about being open to what
life can bring both good and bad. Authentic living involves daring to stand in the unknowing
and anxiety of human being and to become as Heidegger (1927) states, a “being towards
death”; as it is only by accepting our own mortality as a real possibility that we can live
authentically. Authentic living also involves recognizing our freedom and responsibility for
ourselves, which invariably means making choices that realize our true potential. Ultimately
authentic living is about wisdom and truth. It is about seeing our lives and ourselves in a
truthful and honest way and tuning into our feelings of existential anxiety and guilt and what
it tells us about what is lacking. Authentic living is also about seeking wisdom about the
world and human being, being open to all that that implies.

Dysfunction

If healthy functioning were seen as authentic living then dysfunction would be seen as
inauthentic living. Inauthentic living is where we are closed off to the reality of life or living
in a self-deceived way about ourselves or about the world. Heidegger (1927) saw inauthentic
living as being ‘the They’, this is like Nietzsche’s (1969) ‘herd mentality’, where we fall into
averageness and live our lives like ‘They’ do. This involves not questioning what we are
doing but accepting other people’s values and ways of living. It is about living your life by
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

default, going along with the crowd, not daring to be different or think for yourself. This
means living by other people’s standards and rules and not thinking about the rules and
standards that you want to determine your life. Heidegger believed that most of us live our
lives in this way for the majority of the time. It is only when we are confronted by our
conscience, or as Heidegger (1927) said ‘where we hear the call of conscience’ that we are
able to overcome this inauthentic way of being. This is where we become more open to the
possibilities that are available to us. In addition we often experience feelings of anxiety and
guilt about the way we are living our lives, which can prompt us to make changes in the way
we are living.
The existential approach does not pathologize or seek to categorize individuals. All of us
live in both authentic or inauthentic ways; there is no value judgment involved in recognizing
this. Life is seen as a struggle and clients’ issues are seen as problems in living, however the
more open and reflective we are then the more likely we will be to experience a sense of well-
being and ownership over our lives.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 54 Claire Arnold-Baker and Emmy van Deurzen

THE CHANGE PROCESS

Change

Change happens all the time. Human beings are always in transformation. Change for the
better is not a direct goal of existential psychotherapy but it is a by-product, which comes
about when a person truly examines their life in an open and honest manner. Existential
psychotherapy focuses on helping clients to explore their life and way of living. It is a
descriptive process, which involves an examination of their relationships to the world and
others and of themselves. Clients are encouraged to reflect on their attitudes, values and
beliefs and reassess them in light of their present context. It is through this process of
reflection and re-examination of their life that clients begin to choose a more purposeful way
of living. This may involve a change in the way that they live their life but more importantly
it will involve a change in how they think and reflect on their way of living and how they
experience themselves and others.
Change is difficult because the way we think about ourselves and our lives is often
ingrained and solidified. Rather than face the anxiety of knowing that we are free to choose
ourselves we try to create a fixed view of who we are, and repeat patterns of behaviors and
interactions to make us feel we are something substantial rather than nothing. To embrace this
existential anxiety and all that it means is difficult. It is impossible to do it all the time. To go
about the daily process of living involves, as Heidegger put it, “a forgetfulness of being.”
However much of the time we are making small changes in our lives without really knowing
it. This is quite simply inevitable, since change and transformation are the root of human
living. Every choice that we make will have its impact. Often clients are not aware that
change is taking place and it is through psychotherapy that they are able to recognize and
acknowledge this change and enhance it. However there are times in people’s lives when big
changes occur and these often coincide with some kind of crisis, such as bereavement,
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redundancy or some natural disaster or event. These moments of crisis shake the individual
out of their sedimented way of being and make them reassess everything that they stand for.
In these moments individuals are able to make changes to their lives that either did not seem
possible before, or did not seem warranted.

Therapeutic Environment

The existential approach to psychotherapy aids the process of change by challenging the
client to examine their worldview, attitudes and values. This is a collaborative process. The
existential therapist will embark on a real relationship with the client encouraging self-
reflection and a questioning stance to their experience and world. Both therapist and client
will enter into a dialogue, seeking to find the truth and reality of the client’s life. Existential
therapists help clients to come to terms with the contradictions of life as well as accepting its
limitations. Existential therapists will highlight self-deception about responsibilities to others
and to oneself. In particular they will focus on times when clients are not accepting their role
in what is happening in their lives. Existential therapy can help clients to understand life and
its ensuing struggles and to find creative and courageous ways of dealing with the things that

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Existential Psychotherapy: Philosophy and Practice 55

life throws up. In this way clients are able to face their difficulties rather than shy away from
them and in doing so will be able to make choices for how they are to proceed. Through these
choices and by living in a purposeful rather than reactive way, change can occur.

THE THERAPEUTIC PROCESS

Assessment and Diagnosis

Theory-Based Assessment Strategies. Existential psychotherapists do not clinically assess

or diagnose their clients as practitioners from other approaches might do, as it suggests that
there is a problem that can be assessed, diagnosed and treated, which goes against the
philosophy of the existential approach. Instead existential therapists prefer to use description
and understanding in place of assessment and interpretation, allowing the individual’s
situation and worldview to unravel in the therapeutic process. This is often referred to as the
phenomenological process of taking stock. This includes bringing to awareness the
assessments, assumptions and judgments people make about themselves and the world around
them. This awareness will also allow therapists to question how their judgments might impact
on the therapy and their ability to understand the client from their perspective.
The only other type of assessment that may be undertaken is whether existential therapy
is suitable for a particular client. Clients will need to accept that their problems are about
living rather than a form of pathology and they need to have a desire to question and reflect
on their life, coming up with their own answers. Clients who want to be diagnosed or to be
told what to do might be better suited to other forms of therapy. Existential therapy suits those
clients who feel a sense of alienation or who feel their life lacks meaning. In particular those
who have recently suffered some kind of crisis or who are embarking on a new phase of their
life or who are facing death would be particularly suited to existential therapy and its focus on
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

existence. Clients for existential therapy should be able to articulate their feelings, emotions
and views about themselves and their world, which on the whole makes the approach more
suited to adults rather than children, though some children may be quite capable of
philosophical thinking.
Existential therapists will look for a client’s ability to question and reflect on their life;
for an openness and commitment to search for meaning and purpose. No specific assessment
tools would be used other than the dialogue that takes place during the therapeutic
relationship. A systematic structured analysis on the four-world model is sometimes done.

TREATMENT

Goals

The goals of existential therapy are:

− To enable people to become truthful with themselves again
− To widen their perspective on themselves and the world around them

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 56 Claire Arnold-Baker and Emmy van Deurzen

− To find clarity on how to proceed into the future whilst taking lessons from the past
and creating something valuable to live for in the present. (van Deurzen, 1990, p.
157).

These can be seen as the overall aims of existential therapy, however individual goals
may be set along the way. An individual goal may involve clients returning to their original
project or discovering their motivation to pursue a new course in life. It could also entail
helping clients to clarify for themselves what they really want out of life. Any individual
goals will be set through dialogue between the therapist and the client and will always come
from the client. The setting of goals often comes about as a natural result of the exploration
that clients undertake in therapy. As clients gain greater clarity on their life and what is
important to them they find new directions to go in or other avenues to explore.
With regard to the overall aims of existential therapy the purpose would be to enable
clients to live a more authentic life, where they are living up to their full potential and gaining
a deeper understanding of the life they have created for themselves. Although authenticity can
never be fully achieved, clients can strive for a more reflective and open attitude where they
are able to weather most things that are thrown at them, by drawing on their inner resources
and strengths. The purpose of setting individual goals will be down to the individual client.
Most clients come to therapy with a particular problem to sort out or an issue to explore.
Many will want their progress to be charted in some way and may set goals for themselves as
a way of doing this. Any goals that are set will be discussed at length in the therapy session to
determine the motivation behind them and the purpose they fulfill. This dialogue will also
ensure that the client’s goals are realistic ones. Clients may come to therapy saying ‘I want to
change my life’ or ‘I don’t like the life I am living’, through the therapy clients can explore
exactly what they do want to change or how they want to live, therefore refining their goals or
aspirations to realistic and achievable ones, rather than blanket statements which are hard to
live up to. So goal setting is more seen as a continuous search for direction, enabling clients
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

to get more in tune with their original project whilst tackling concrete and real issues in their
lives in a specific way.

DETAILED PHASES OF TREATMENT

Joining Phase

As with all therapeutic approaches a clear contract needs to be established at the

beginning of existential therapy. This includes the duration of the therapy, whether it is short-
term or long-term, where and when the therapy will take place and the fee involved. It is
important that the physical setting of the therapy is welcoming and conducive to therapy.
Equally important is how well the therapist fits with the client. Often initial sessions are an
opportunity for both therapist and client to establish whether they can work together. The
therapist will usually describe his/her way of working to enable the client to get an
understanding of what is involved and whether they want to continue. Usually the therapist
will not take a formal case history, instead they will encourage clients to give a detailed
description of what is concerning them, as well as information about themselves and their

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Existential Psychotherapy: Philosophy and Practice 57

world. The way in which the client opts to present their life story is as significant as what they
leave out. The therapist may explore obvious gaps or merely point out that they exist. Initial
sessions are concerned with establishing trust and developing a working alliance. Clients need
to feel that their views are taken seriously and are valid ones. Often clients seeking therapy
for the first time are apprehensive about what will happen and need to be reassured and
encouraged. This can come about by therapists explaining that it is the client rather than the
therapist that holds the answers and that these can be found through exploring the client’s
world together. By emphasizing the joint nature of the exploration, the therapist is
demonstrating the equality in the relationship and empowering clients to find their own
answers. At the same time the therapist is unafraid of showing the need for direction or in
pointing out contradictions in the client’s discourse or consequences of actions.

Working Phase

The main body of the work in existential psychotherapy involves enabling clients to
describe in great detail their life, issues and resulting concerns. Therapists will systematically
map the client’s experience onto the four dimensions of human experience. Discovering
which dimension the client feels at home with, which cause unease or difficulty and which
dimension they have mastery over. Through this process the client discovers their strengths
and the therapist helps the client to draw on these when dealing with their weaknesses. The
therapist will encourage the client to clarify their values, beliefs and attitudes and to work out
how these impinge on the way they live. This may lead to the client reassessing or
reformulating previously held beliefs and values. Existential therapists will enable clients to
examine their relationships, to see which relationships they are happy in, which are difficult
and what part the client plays in these relationships and their interactions with others. Clients
will also be challenged to look at areas of their life where they are not making active choices
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

or not taking responsibility for themselves. This will also include where they are self-
deceived and the therapist will help them to reflect openly and honestly on this. Allowing
clients to get in touch with their emotions can assist them in understanding these emotions
and what they say about the person at that time.
Through this process of clarification and exploration clients can get in touch with their
original project. They can find the motivation and purpose to create a more fulfilling and
meaningful life. Throughout this process the therapist will be listening out for the existential
themes that were discussed at the beginning of the chapter. These themes will guide the
therapist in understanding where the client’s difficulties lie and how the client responds to the
givens of life. Inevitably the client will experience the anxiety of existence at some point in
the therapy. The aim of the therapist is not to try and lessen the anxiety or find ways to get rid
of it, rather the client will be encouraged to face the anxiety and all that it means. Existential
psychotherapy is about helping clients to confront those aspects of their lives that they wish to
avoid or run from so that they learn to cope with the unpredictability of life and face the
difficulties that lie ahead.

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 58 Claire Arnold-Baker and Emmy van Deurzen

Termination Phase

As with most therapies the ending of the therapy will enable clients to get in touch with
other endings they have had in their life and inevitably their own ending. Therapy, with its
finite time limit and definite ending, mimics the life span, although it differs in that the ending
is often known in advance. Enabling clients to think about their own mortality and death helps
them to make decisions about what is important in their life. Clients can start living more
urgently and with purpose. Heidegger (1927) believed that it was only as ‘being towards
death’ that we can start to live authentically. The anxiety that is experienced in relation to our
own death can be used creatively to ensure that clients are living up to their full potential in
the time they have left.
In practical terms the decision to end the therapy is usually a joint one but guided by the
client. Existential therapy is about getting clients back on track so they can live their lives in a
better more meaningful way. This means that therapists do not try to prolong the therapy but
encourage them towards independence. As clients become more proficient at the art of living,
therapists may suggest that sessions become more spaced out, or that an ending is set with
follow up sessions if needed.

THE NATURE OF THE THERAPEUTIC RELATIONSHIP

“Existential counseling can be seen as a process of exploration of what can make life
meaningful” (Deurzen, 1988: 3). This statement encapsulates the existential approach to
counseling and psychotherapy. It implies that the therapy is both a process and an exploration
that is undertaken by both client and therapist. As well as it being a life-centered approach it
is a client centered approach, in that the focus is on the client to bring up and explore
particular issues, rather than directing the client to speak about certain things. It is also a
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

relationship centered approach in that the therapeutic relationship is an important aspect of

the approach not just because it aims at a more equal relationship but also in that it proposes a
two way process. It is as essential for the therapist to monitor his/her feelings, assumptions
and motivations in relation to a client as it is for the client to examine his/her feelings,
assumptions and motivations. The bias of each will be under constant scrutiny. The
phenomenological attitude will enable a collaborative looking at reality from both
perspectives so that the client gains more understanding of the various aspects of reality and
of the multiple connections of their life. The importance of the therapeutic relationship also
highlights the relational aspect of existential philosophy. What happens between the therapist
and client, i.e. the dialogue, is paramount. Martin Buber (1923) in this respect represents the
existential approach very accurately, with his contention that there is never an ‘I’ in isolation,
because there is always a ‘you’ or an ‘it’ the ‘I’ relates to. His I-Thou relationship signified a
meeting where both individuals are fundamentally changed by the experience, “My Thou
affects me, as I affect it” (Buber, 1923, p. 30), thus both client and therapist can be changed
by the therapeutic relationship. In final analysis therapy happens in the in-between created by
therapist and client together. Fundamentally the therapeutic relationship is about the
relationship the client has with himself or herself. The therapy allows a space for clients to
discover themselves, their lives, their hopes and fears, their possibilities and their limitations.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Existential Psychotherapy: Philosophy and Practice 59

The therapeutic relationship is an uncovering of the layers that we build around ourselves so
that the client is brought face to face with themselves, warts and all.

TECHNIQUES

Techniques Used

The existential approach does not have a specific set of techniques that can be used;
instead it uses a philosophical method. The existential approach is often called an existential-
phenomenological approach to psychotherapy. This highlights the importance of Husserl’s
phenomenological method, which was later advocated by Heidegger as a method of
answering the question of Being. The phenomenological method was developed to clarify the
essence of experience, to go back to “the things themselves”. Spinelli (1989, 2005) adapted
Husserl’s phenomenological method for use in psychotherapy. He proposed three steps to
follow in working phenomenologically, step 1 is “The Rule of Epoché”, the second step is
“The Rule of Description” and the third step is “The Rule of Horizontalisation”.
The Rule of Epoché is a way of approaching something as if it were new to you, all initial
biases and prejudices are put aside and the phenomena is then revisited. Epoché is about
bracketing our expectations and assumptions temporarily, as far as it is possible, so that the
focus is purely on the experience. This can only be a partial bracketing as it is impossible to
totally bracket our assumptions and biases. The therapist needs to be quite clear what their
assumptions are and how they are influencing how the therapist is understanding and seeing
the client. Therapists do this through reflection and self-questioning while listening to the
client. Often when we think we understand the client we are closing something down or not
looking at the whole picture. It is about imposing an openness on our immediate experience,
looking at the situation naively as though it was the first time you had come across it. We
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

normally make judgments about what we perceive in our everyday lives and accept that what
we perceive is actually there. Epoché is a way of looking at things anew, to learn to see what
is before our eyes rather than thinking that we know the answer.
The Rule of Description can be summed up as “Describe, don’t explain” (Spinelli, 1989,
p. 17). What is important is the description of an experience rather than trying to make sense
of it in terms of different theories, as this will limit the experience. As with the first step the
limitation of this step is that a totally explanation free description is impossible to achieve.
The aim of this step is to open up the clients experience, enrich it with lots of detail so that the
client is fully present in the experience. Enabling the client to enter into this description will
ensure that possibilities are not closed down prematurely and that each avenue is explored
fully. The therapist should remain with the description and engage in a dialogue with the
client through clarifying assumptions and helping them to articulate what they mean by the
narrative they use.
The Rule of Horizontalization or the Equalization Rule requires that initially the therapist
does not try and impose hierarchies or significances to what is heard. All information is
treated as equally important, of equal value and significance. Again this is an ideal rather than
an aim of this step. Instead the therapist should avoid making hierarchically based judgments
that could be misleading and take the client away from other potentially important aspects of

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 60 Claire Arnold-Baker and Emmy van Deurzen

their narrative. It is only through a thorough exploration of the clients’ situation that the
importance of each experience will come to the forefront.
The three steps highlighted above make up the phenomenological method, but they
should not be used in a step approach as suggested by their titles, rather therapists will
consider them simultaneously as points of focus when listening to their clients. This
phenomenological method requires a certain attitude of the existential therapist and his/her
approach to working with clients. The therapist needs to be open to what the client brings, to
free themselves of their assumptions and prejudices, as far as it is possible, and to develop an
enquiring attitude. This stance towards the client will allow the client’s world to unfold and
they can explore in detail their situation and way of living. By not closing down parts of the
clients narrative the therapist enables them to see the full picture of their life and all its
richness, complexity and implications. By treating everything that the client says as equally
important, allows the client to come up with their own formulation of what matters to them.
Again this process keeps the dialogue open and does not lead to interpretations, which can
close aspects of the narrative down. In the process meaning will emerge for the client as they
get a better understanding of themselves and their life.

STRENGTHS AND LIMITATIONS

Strengths of this Theory

The strengths of the existential approach lie in the fact that the therapeutic relationship is
a real relationship and not based on a transferential one. The dialogue between therapist and
client involves frank and open discussions. This means that clients are not burdened by
psychological theory, which they may not fully understand, or focused on past events that
may seem distant and not relevant to their present day context and concerns. The existential
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

approach encourages clients to become independent thinkers and to find their own solutions
to their difficulties, thus reducing the reliance on the therapist for their well-being and ability
to cope.
Undoubtedly the biggest strength of the existential approach is its focus on life issues and
the things that really matter to clients, allowing them to grapple with the things that are
troubling them at that moment in time. The main philosophical themes discussed at the
beginning of this chapter, really are issues that concern us all and that we are confronted with
on a daily basis. Clients coming to therapy often see life for what it is, they see the struggle
that is involved, the randomness and often unfairness of life and they often feel that their life
has lost meaning. For them to see that what they are experiencing is part of what it is to be
human is hugely empowering, as they learn about the paradoxes and intricacies of life. To be
able to find a way through all the difficulties that life brings without going under gives clients
a sense of agency and control in their life.

Limitations of this Theory

In terms of limitations the approach has often been thought of as somewhat intellectual
and indeed some clients like to philosophize about the world and their life without reference

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Existential Psychotherapy: Philosophy and Practice 61

to their emotional life. Clients sometimes avoid paying attention to their emotions, which
closes down an avenue of potential exploration. In fact emotions can provide clients with a
much needed direction in life and can give a lot of information about what is really
concerning the client at that moment. Heidegger and Sartre both considered emotions to be an
important mode of being and sought to understand how emotions can be made more active
and articulate rather than remaining passive and reactive. Van Deurzen (1988) has set out a
cycle of emotions that shows the direction in which emotions lead us. Once clients are able to
read and understand their emotions they will feel more in control and see them as signposts to
their emotional life rather than as being at their mercy and out of control.
A further limitation of the approach centers on the client’s ability to think about their
issues in existential or philosophical terms. As mentioned earlier in the section on assessment,
some clients are not suitable for existential psychotherapy, either because they want a more
directive approach or are not able or willing to examine their life and question the way that
they live.
The existential approach has been criticized for not having a theory of human
development or human sexuality and that it is not a psychologically approach. However
because the existential approach has a philosophical rather than a psychological focus this
does not mean that these aspects of human functioning are not considered by the approach. In
fact Kirby (2005) and Smith-Pickard and Swynnerton (2005) elucidate an existential
approach to human development and human sexuality in the recently published book
Existential Perspectives on Human Issues (van Deurzen & Arnold-Baker (Eds.), 2005), which
seeks to answer critics of the approach. The existential approach has much to say on how we
develop, not just in terms of aging but also how we develop ethically and in terms of
morality. An existential theory of human sexuality will focus on our relationships to others
and how we relate to others sexually, Merleau-Ponty (1962) has written much on this subject.
The final limitation is in relation to the training of practitioners. Many new trainees find
the apparent lack of technique and tools difficult to cope with when trying to work in an
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

existential way. Part of the training is to help trainees develop a new attitude and way of
looking at the world and others. Through immersing themselves in the existential literature
and focusing on the existential issues that emerge trainees can find their own way of working.
There are as many ways of working existentially as there are practitioners and each person
has to find their own particular way. Many practitioners will use the existential approach as
an integrative framework, which allows them to apply other techniques and methods within
an existential perspective. To do so effectively it is important to use both the method,
phenomenology, and the philosophical literature as a background. Each encounter will be
unique to that therapist and that client at that particular time, therefore each session will be as
though they are meeting for the first time.
The existential approach does not really have a theory on health and illness and so does
not explain or provide a theory for mental health problems. The existential approach however
helps clients live in the best way that they can within their personal limitations (i.e. mental
health problems) and the general limitations of the world. This limitation is therefore seen as
a strength by existential practitioners themselves. The approach also does not classify or
diagnose clients and so does not seek to explain disorders in the same way that other
approaches would, for this reason there is a dearth of research in this area and this is
something that needs to be addressed urgently.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 62 Claire Arnold-Baker and Emmy van Deurzen

SUMMARY
The existential approach provides not an alternative technique or yet another method of
therapy but a philosophical dimension of enquiry which can complement other approaches. It
has an important role to play in an increasingly technological and alienated society and
provides clients with a direct and intensive way of re-examining their lives and finding new
meaning.

REFERENCES
Binswanger, L. (1946) ‘The Existential Analysis School of Thought’. In R. May et al (Eds.)
Existence, New York: Basic Books.
Buber, M. (1923) I and Thou, Trans. W. Kaufmann, Edinburgh: T&T Clark.
Frankl, V. (1984) Man’s Search for Meaning, New York: Washington Square Press.
Heidegger, M. (1927) Being and Time, Trans. J. Macquarrie & E. S. Robinson, New York:
Harper & Row.
Jaspers, K. (1951) The Way to Wisdom, Trans. R. Manheim, New Haven and London: Yale
University Press.
Kierkegaard, S. (1844) The Concept of Anxiety, Trans. R. Thomte, Princeton, N.J.: Princeton
University Press.
Kirby, S. (2005) Existential Perspectives on Human Issues: A Handbook for Therapeutic
Practice, E. van Deurzen & C. Arnold-Baker (Eds.), Basingstoke: Palgrave.
May, R. (1983) The Discovery of Being: Writings in Existential Psychology, New York:
Norton.
Merleau-Ponty, M. (1962) The Phenomenology of Perception, Trans. C. Smith, London:
Routledge.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Nietzsche, F. (1969) On the Genealogy of Morals, Trans. W. Kaufmann & Hollingdale, New
York: Vintage Books.
Sartre, J-P. (1943) Being and Nothingness: An Essay on Phenomenological Ontology, Trans.
H. Barnes, London: Routledge.
Seligman, M. (2002) Authentic Happiness: Using the New Positive Psychology to Realize
your Potential for Lasting Fulfillment, New York: Free Press.
Smith-Pickard, P. & Swynnerton, R. (2005) Existential Perspectives on Human Issues: A
Handbook for Therapeutic Practice, E. van Deurzen & C. Arnold-Baker (Eds.),
Basingstoke: Palgrave.
Spinelli, E. (1989, 2005) The Interpreted World: An Introduction to Phenomenological
Psychology, London: Sage.
Van Deurzen, E. (1988) Existential Counselling in Practice, London: Sage.
Van Deurzen, E. (1990) In W. Dryden (ed.) Individual Therapy: A Handbook, Milton
Keynes: Open University Press.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 In: The Quick Theory Reference Guide ISBN: 978-1-60021-624-4
Editor: Karin Jordan, pp. 63-81 © 2008 Nova Science Publishers, Inc.

Chapter 6

CLIENT CENTERED THERAPY

AND THE PERSON-CENTERED APPROACH

Jerold D. Bozarth

Carl R. Rogers developed the theory of Client-Centered Therapy during the 1940’s and
1950’s. Rogers was identified as the most influential psychologist in American history by a
survey of the American Psychological Association (Smith, 1982). His influence included
leadership and research in individual therapy, encounter groups, community groups, conflict
resolution groups, education, and human development. Rogers’ extrapolation of the theory to
these multiple areas led him to use the term ‘Person-Centered Approach’ to refer to the
principles implemented in areas beyond psychotherapy.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

HISTORY AND DEVELOPMENT

The “birthday” of client-centered therapy occurred in a lecture by Rogers at the
University of Minnesota on December 11, 1940 titled “Newer Concepts in Psychotherapy”.
This thesis was elaborated upon in the book, Counseling and Psychotherapy: Newer Concepts
in Practice (Rogers, 1942).

Books and Articles: Foundations and Nature of the Theory

Rogers’ publications provide a synopsis of the development of Client-Centered Therapy

theory. Rogers’ writings include books read by the public such as On Becoming a Person: A
Therapist’s View of Psychotherapy (1961) and “A Way of Being” (1980). Another book
oriented to the public was that of the “politics” of the person-centered approach titled: “Carl
Rogers on Personal Power: Inner Strength and its Revolutionary Impact” (Rogers, 1977).
Six of Rogers’ 200 articles and 16 books constitute the foundations of his theoretical
contributions. These publications are (1) Client-Centered Therapy: Its Current Practice,
Implications, and Theory (1951); (2) The Necessary and Sufficient Conditions For
Therapeutic Personality Change (1957); (3) A Theory of Therapy, Personality, And

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 64 Jerold D. Bozarth

Interpersonal Relationships As Developed In The Client-Centered Framework (1959); (4)

The actualizing tendency in relation to motives and to consciousness (1963); (5) Empathic:
An Unappreciated Way of Being (1975/ 1980); and (6) The Foundations of a Person-
Centered Approach (1978/1980, pp. 113-136).
The first complete presentation of client-centered therapy is generally considered to be
Rogers’ 1951 book. However, the definitive theory was the 1959 presentation. Rogers
considered the 1959 book chapter to be his magnum opus work. The formal theory evolved
from 1951 to 1959 with a major difference being that of greater precision in the concepts;
especially, in relation to the clarification of the “actualizing tendency” as the motivational
foundation of therapy. Also, unconditional positive regard was formulated as the curative
factor. Theoretical presentations after 1959 are significant contributions but are primarily
clarifications of the 1959 document. Other publications reiterate the theory for different
readerships or report specific aspects of practice (Raskin & Rogers, 1989/2005; Rogers, 1970,
1977, 1980, 1986/1993; Rogers & Ryback, 1984; Rogers & Sanford, 1984). One publication
(Rogers, Gendlin, Kiesler, & Truax, 1967) reports a research project with hospitalized
“psychotic” individuals. This project was considered “disappointing” by Rogers and is
discussed later.
The 1957 article on the “Necessary and Sufficient Conditions” was slightly different from
the 1959 theory, and was considered to be, “one very small segment” of the theory (Rogers,
1957, p. 95). It was written during the formulation of the theory but was actually published
two years prior to the 1959 theory statement. The 1957 article was especially important in that
it was an “integration” proposal for all therapies. The postulate was that there were common
identifiable ‘necessary and sufficient conditions’ for all therapies and helping relationships
that has the goal of therapeutic personality change. The therapist conditions were identified as
congruence, unconditional positive regard, and empathic understanding. This article
generated over four decades of psychotherapy research on the therapist conditions in relation
to psychotherapy outcome.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

The Theory and the Man

Client-centered theory is integrally related to Rogers’ personal contributions as well as to

his publications. A few of his accomplishments are reflective of the theory as well as the man.
It has been asserted with documentation that: “Carl R. Rogers was the most influential
psychologist in American history” (Kirshenbaum & Henderson, 1989, p. xi). Among his
contributions are the following:

1. Rogers revolutionized the field of psychotherapy by being the catalyzing force for
multiple professionals to practice psychotherapy (Kirshenbaum & Henderson, 1989,
p. xi-xii).
2. Rogers was a major figure in demystifying psychotherapy, mainly through the use of
audio recordings and films.
3. Rogers was one of the first individuals to apply scientific method, hypothesis testing,
and research results on the work of the therapist.
4. Rogers is one of the few theorists who have delineated their therapeutic approaches
in a scientific method format that permits it to be tested through scientific inquiry
(Rogers, 1959).
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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Client Centered Therapy and the Person-Centered Approach 65

5. Rogers’ (1957) integration hypothesis concerning the necessary and sufficient

conditions for therapeutic personality change was the impetus for research on
psychotherapy for nearly four decades and is still a relevant and discussed topic.
6. The influence of Rogers’ work permeates the work of therapists of most persuasions.
(Bozarth, 1998, pp. 14-15)

As Kirshenbaum and Henderson indicate, Rogers was also ‘a leader in the development
and dissemination of the “encounter group”.’ He was “a leader in the humanistic psychology
movement of the 1960’s through 1980’s.” “He was a pioneer in applying the principles of
effective interpersonal communication to resolving intergroup and international conflict” (p.
xi).
Previous students and colleagues of Rogers as well as others have continued his seminal
work. Some have deviated from the postulate of the “sufficiency” of the therapeutic
conditions by adding their ideas (Gendlin, 1974; Gordon, 1970). Others in the United States
have maintained allegiance to the conditions being necessary and sufficient (Bozarth, 1998;
Brodley, 1993; Merry, 2004; Raskin, 2004; Shlien, 1971; Zimring, 1974). Several authors
from countries other than the United States are aligned with Rogers’ fundamental premise of
the “Necessary and Sufficient” conditions while adding their own particular frames of
reference (Barrett-Lennard, 1998; Greenberg, Rice, & Elliot, 1993; Mearns, 1994; Schmid,
2001; Thorne, 1991). Others have emphasized the approach in different areas (Devonshire,
1991; O’Hara, 1984; Prouty, 1994; Wood, 1982, 1984).
It is significant that nearly fifty years after Rogers wrote his self-proclaimed magnum
opus theory and after continuous research that there has been little substantial data to suggest
revision of the theory. Rogers’ revolutionary assertions are as radical and relevant today as
they were six decades ago. Client-Centered Therapy is the only theory of therapy that has its
sole focus on the person as the director of her own life. It is the only theory where the
therapist’s only intent is to facilitate the client’s direction, way, and pace of growth and
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change.

Theoretical and Early Philosophical Influences

The radical proposal that the client is the locus of control and the director of her own
healing separates client-centered therapy from other theoretical and philosophical
underpinnings. Further separation is augmented by the hypothesis that there is only one single
motivating factor, i.e. the actualizing tendency
Rogers acknowledged being influenced by Rank’s “will therapy” but indicated that he
was more influenced from contacts with “people who had been to the Pennsylvania School of
Social Work” (Rogers & Russell, 2002, p. 113). He also noted that Jesse Taft’s book, The
Dynamics of Therapy in a Controlled Relationship, was influential in shaping his ideas about
therapy. He went so far as to say that he only carried their ideas further, spelled them out and
carried them through “in more extreme fashion” (ibid, p. 113). He suggested that “there were
things” in Kierkegaard and Buber in which he “resonated” (ibid, 2002, p. 169). It is, however,
clear that Rogers did not consider his ideas to come from any particular philosophical base.
Contrary to some assumptions, he reveals that William James did not have much impact on
him (ibid, p. 169). However, it is also clear that Rogers’ assumptions emerged from his

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 66 Jerold D. Bozarth

personal experiences and observations of clients in therapy. This led him to further empirical
inquiry as well as further theoretical development.

INDIVIDUAL CONTRIBUTIONS
Thousands of individuals throughout the world contributed to the development and
growth of the client-centered/person-centered approach. These individuals include notable
psychologists with impeccable national and international credentials. A few of these
individuals were cited as contributing specifically to the written theory (Rogers, 1959). These
individuals were Victor Raimy, Richard Hogan, Stanley Standal, John Butler, and Thomas
Gordon. Rogers also acknowledged the influence of Oliver Bown, Desmond Cartwright,
Arthur Combs, Eugene Gendlin, A. H. Maslow, Julius Seeman, John Shlien, and Donald
Snygg (ibid, p. 216). Other major contributors who were periodically mentioned by Rogers
are Nat Raskin, Fred Zimring, and Godfrey Barrett-Lennard. Standal’s (1954) dissertation on
the need for “Positive Regard” became a major part of client-centered theory.
Other than Rogers, C. H. Patterson (2000) was the most prolific author of client-centered
therapy theory for nearly sixty years.
There were also individuals who contributed through the development of person-centered
training programs. Bill Coulson, Doug Land, and Bruce Meador initiated the LaJolla
program. Chuck Devonshire established the first training programs in Europe. Reinhard and
Ann Marie Tausch facilitated psychotherapy and education training programs and directed
research projects in Germany.
In addition, there were contributions to the areas of individual therapy, encounter groups,
large community groups, international peace initiatives, and education. Basic assumptions of
the person-centered approach have been extended to education (Aspy, 1972; J. Cornelius-
White & C. Cornelius-White, 2005; Rogers, 1969; Rogers & Freiberg, 1994; Tausch, 1978),
to participatory management (Plas, 1996; Rogers, 1977) and to collaborative rhetoric for oral
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

and written communication (Teich, 1992) among other areas.

No single individual can be recognized as the standard bearer of client-centered theory
after Rogers. Rogers encouraged his students and colleagues to follow their own directions
and ways of thinking and of “being”. This is quite consistent with the theory in terms of the
importance of individual freedom and personal empowerment. Nevertheless, Rogers was the
dominating figure in the development of Client-Centered Theory in spite of his inclination to
include others as major contributors.
Rogers was actively engaged in all of the areas extrapolated from his theory of therapy
(Rogers, 1959). Specific areas that revolved around the theory of therapy were the theories of
(1) personality, (2) interpersonal relationship, and (3) the fully functioning person (Rogers,
1959). Areas identified in the theory of Interpersonal Relations were family life, education
and learning, group leadership, and group tension. Most of his colleagues focused on one or
two of these areas.

KEY CONCEPTS
The key concepts of client-centered therapy theory can be cast as (1) the actualizing
tendency as the central motivational hypothesis; (2) the self-concept and (3) the necessary and

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 Client Centered Therapy and the Person-Centered Approach 67

sufficient conditions of the therapeutic process. The relationship of the therapist/client and
emphasis on the client’s self-direction and self-resources are tantamount in the theory. It is
within these three conceptualizations that specific terms are relevant. Terms that attend to the
details of the theory include: experiencing, congruence, unconditional positive regard,
empathy (empathic understanding), self-concept, and self-actualization and the actualizing
tendency.

The Foundations

The foundations of the approach became increasingly clear in 1959, elaborated upon four
years later (Rogers, 1963), re-stated 21 and 27 years later (Rogers, 1980, 1986) and confirmed
by Rogers in posthumous publications (Raskin & Rogers, 1989/2005; Rogers & Russell,
2002). These foundations are discussed further in the following discourse.

The Actualizing Tendency

It is important to realize that there “is only one expression of the general tendency of the
organism to behave in ways that maintain and enhance itself” (Rogers, 1959, p. 196). The
actualizing tendency is “the inherent tendency of the organism to develop all its capacities in
ways which serve to maintain or enhance the organism” (Rogers, 1959, p. 196).
The actualizing tendency (AT) (a characteristic of organic life) and the formative
tendency (characteristic of the universe as a whole) are the foundations of client-centered
therapy and the person-centered approach. (Rogers, 1980, p.114). The actualizing tendency is
a first principle in Client-Centered Therapy (CCT) (Brodley, 1999). As such, it has a
functional role in CCT practice (Bozarth & Brodley, 1991). The AT leads client-centered
therapists “to hold two fundamental beliefs. These beliefs are: “(1) The therapist can trust the
client’s tendency to grow, develop, and heal. (2) All of the therapist’s actions must express
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

respect for the client, viewing the client as a person who is capable of self-determination with
capacities for self-understanding and constructive change” (Brodley, 1999, p. 117). The
organism is viewed as “always motivated, always up to something, always seeking” (Rogers,
1963, p. 7). In more pragmatic terms, Rogers states:
Individuals have within themselves vast resources for self-understanding and for altering their
self-concepts, basic attitudes, and self-directed behavior; these resources can be tapped if a
definable climate of facilitative psychological attitudes can be provided. (Rogers, 1980, p.
115)
The single motivational factor of the actualizing tendency in client-centered therapy
emerged from Rogers’ observations of the tendency of organisms to adjust to adverse
conditions, and from observations of the growth of clients in psychotherapy. A metaphor
demonstrates his observations. He recalled observing potatoes stored in a cellar and subject to
growth under unfavorable circumstances, describing the process in the following way:

The conditions were unfavorable, but the potatoes would begin to sprout—pale white sprouts,
so unlike the healthy green shoots they sent up when planted in the soil in the spring. But
these sad, spindly sprouts would grow 2 or 3 feet in length as they reached toward the distant
light of the window. The sprouts were, in their bizarre, futile growth, a sort of desperate
expression of the directional tendency I have been describing. They would never become

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 68 Jerold D. Bozarth

plants, never mature, never fulfill their real potential. But under the most adverse
circumstances, they were striving to become. Life would not give up, even if it could not
flourish. (Rogers, 1980, p. 118)

Rogers continued with his observations of individuals who were incarcerated in the back
wards of state hospitals, noting that they were striving, in the only way they could, toward
growth in search of their potential.
It was after he reached conclusions from his pragmatic observations that other theories
were observed in relation to his own experiential discoveries. Notably, the theories of
Maslow, Goldstein, Angyal and Seyt-Gyoergyi buttressed the theory of actualization (Rogers,
1959, 1963). Angyal describes the organism as follows:

Life processes do not merely tend to preserve life but transcend the momentary status quo of
the organism, expanding itself continually and imposing its autonomous determination upon
an ever increasing realm of events. (cited in Rogers, 1959, p. 196)

The organism behaves in its natural direction, guided by its’ actualizing tendency. The
tendency involves: “development toward the differentiation of organs and functions,
expansion and enhancement through reproduction. It is development toward autonomy and
away from heteronomy, or control by external forces” (Rogers, 1959, p. 196). In more
pragmatic terminology, the process of client change can be described “as moving in the
direction of actualization of their potentialities, moving away from rigidity and toward
flexibility, moving toward more process living, moving toward autonomy, and the like”
(Rogers, 1963, p. 8). Individuals perceive themselves with more positive value and exhibit
more socially mature behavior.
It is inaccurate to identify the actualizing tendency as a direction toward “good” rather
than “evil”. Rather, it is the tendency of the organism to develop in ways that maintain and
enhance itself in a constructive direction to reach its’ potentialities. The direction of the
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

process of growth exists in a context of diverse specific behaviors. Any given behavior can be
determined by the striving of the organism in relation to the external and/or internal
circumstances of the particular organism. For example, one person might decide to divorce.
Another person might consolidate his/her marriage. A student might work harder to obtain
better grades or develop a willingness to accept poorer grades (Rogers, 1963, p. 8).
Rogers (1942) observed that clients changed in constructive directions when they were
free of “introjections” (later labeled as “Conditions of Worth”) by significant others and
society.

Self, Concept of Self, Self-Structure, Ideal Self

Rogers used interchangeable terms related to self, often to identify specific aspects of
self. The self and self-concept are the terms most often used when referring to the person’s
view of herself. Ideal self refers to the self-concept that is given the highest value by the
individual.
The self-concept is an important part of client-centered therapy in relationship to the
actualizing tendency and, as well, an indication of therapeutic personality change. The
individual is congruent when the self-concept is comprised of self-experiences that are

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Client Centered Therapy and the Person-Centered Approach 69

integrated with organismic experiences. The client in therapy is incongruent with self-
experiences being discordant with organismic experiences.

Self-Actualization

The self is also always actualizing. However, the actualization of self might take a
different direction from the actualizing tendency of the organism. When this occurs, the
person is incongruent, subsequently, organismic experiences are denied or distorted (Rogers,
1959, p. 203).
This construct changed significantly during the evolution of client-centered theory from
1951 to 1959. Summaries and critiques of the theory are often unclear and misleading about
this difference (Geller, 1982; Patterson, 2000, p. 126). In 1951, self-actualization was the
central motivational construct and focused on optimal functioning of the individual (Rogers,
1951, pp. 487-488). In 1959, the construct no longer represents optimal functioning of the
self. Rather, it is the congruence of self experiences and organismic experiences that
represents optimal functioning (ibid, 1959, p. 203). This integration of organismic and self-
experiences is identified as the unitary actualizing tendency (Rogers, 1963).

Congruence/Unitary Actualizing Tendency

Congruence is one of the therapist conditions identified in the “conditions of the

therapeutic process” (Rogers, 1959, p. 213). The close proximity of congruence to the
actualizing tendency makes it relevant at this juncture. Congruence of the individual’s self-
experiences and organismic experiences result in the individual being attuned to the
actualizing tendency.
Congruence is symbolic of the term, unitary actualizing tendency (UAT). That is, UAT is
the tendency of simultaneous constructive directionality of self and organismic experiences.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Congruence defines the integration of organismic experiences and self-experiences.

Congruence is generally synonymous to being integrated, whole, and genuine.
Self-Concept is most often used when reference is to the “person’s view of himself”
(Rogers, 1959, p. 200), and self-structure is more often used when viewing the person “from
an external frame of reference” (ibid, p. 200). Specifically, congruence is defined as the
individual “revising his concept of self to bring it into congruence with his experience,
accurately symbolized” (Rogers, 1959, p. 206). When self-experiences are accurately
symbolized as part of the self-concept, there is congruence of self and experience. If a state of
congruence could totally exist between organismic experiences and all self-experiences, the
individual would achieve the hypothetical state of being a fully functioning person. That is,
the individual would then be fully receptive to the constructive direction of the organism; i. e.,
the actualizing tendency.
When the therapist’s self-concept and organismic experiences are congruent in the
therapeutic relationship with a client, the therapist is also embodying the necessary and
sufficient conditions for personality change to take place. Part of the therapist’s congruence
includes experiencing of unconditional positive regard toward the client and experiencing
empathic understanding towards the internal frame of reference of the client.
Characteristics associated with the concept of congruence are: (1) Openness to
experience; (2) Psychological adjustment; that is, congruence viewed from a social point of
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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 70 Jerold D. Bozarth

view; (3) Extensional behaviors, e. g., the capacity to evaluate in multiple ways; and (4)
Maturity, which describes personality characteristics and behaviors of congruent individuals.
Congruence is discussed further in relation to the conditions of the therapeutic process.

NATURE OF THE THERAPEUTIC RELATIONSHIP

The therapeutic relationship in client-centered therapy is based upon a specific
delineation of postulates identified in the following discourse.

The Necessary and Sufficient Conditions

The therapeutic process and thrust of client-centered therapy (and the person-centered
approach) is predicated upon a simple delineation but integrally complex set of postulates
depicted as the “Necessary and Sufficient Conditions”. These conditions are presented in
slightly different words in two major publications (Rogers, 1957, 1959). It might be
remembered that the conditions are designated as the “Conditions of the Therapeutic Process”
for Client-Centered Therapy (Rogers, 1959, p. 213). They are, essentially, the “instructions”
for the client-centered therapist. In 1957, the conditions were suggested to be universal
conditions found in all successful therapy and all helping relationships. The following
conditions are quoted from 1959 with differences from 1957 noted in italics. The necessary
and sufficient conditions for therapeutic personality change are:

1. That two persons are in (psychological) contact.

2. That the first person, whom we shall term the client, is in a state of incongruence,
being vulnerable, or anxious.
3. That the second person, whom we shall term the therapist, is congruent in the
relationship.
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4. That the therapist is experiencing unconditional positive regard toward the client.
5. That the therapist is experiencing an empathic understanding of the client’s internal
frame of reference (and endeavors to communicate this to the client).
6. That the client perceives, at least to a minimal degree, conditions 4 and 5, the
unconditional positive regard and empathic understanding. (The communication to
the client of the therapist’s empathic understanding and unconditional positive
regard is to a minimal degree achieved). (Rogers, 1959, p. 213; Rogers, 1957, p. 96,
cited in Wyatt, 2001, p. iii)

The specific definitions of the therapist conditions that are designated to be perceived by the
client are conditions (1) unconditional positive regard, and (2) empathic understanding. These
are defined by Rogers (1959) as follows:

Unconditional Positive Regard ––“To perceive oneself as receiving positive regard is to

perceive that of one’s self-experiences none can be discriminated by the other individual as
more or less worthy of positive regard.” (p. 208)
Empathy (Or empathic understanding) –– “to perceive the internal frame of reference of
another with accuracy, and with the emotional components and meanings which pertain
thereto, as if one were the other person, but without ever losing the “as if” condition”. (p. 210)

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 Client Centered Therapy and the Person-Centered Approach 71

Rogers’ (1957) postulates in the “integration” statement identifies the core conditions as
referring to ALL therapies and helping relationships that have the goal of therapeutic
personality change. The conditions can even be communicated through various therapeutic
activities such as interpretation, dream analysis, and other therapeutic approaches. However,
it is clear that Rogers considered such therapeutic tools and techniques as irrelevant other than
to the extent that these conditions of unconditional positive regard and empathic
understanding, are perceived by clients (ibid, 1957).
In client-centered therapy, ‘The Necessary and Sufficient Conditions’ are the “Conditions
of the Therapeutic Process”. It is the existence of these conditions that are the sole factors that
facilitate the change process. Specifically, it is the condition of unconditional positive regard
through empathic understanding that corrects the introjected conditional self-regard of the
client to result in unconditional positive self-regard by the client (Bozarth, in press).
Congruence, the integration of the organismic and self-experiences, incorporates the
individual’s capacity to resolve problems and function more fully.

Healthy Function and Dysfunction

Healthy function of client and therapist is accounted for in Client-Centered therapy by the
concept of Congruence. Dysfunction is accounted for by the opposite concept of
Incongruence. Individuals become dysfunctional when their self-experiences of conditional
positive regard are incongruent with their organismic experiences. They become anxious,
distort their experiences, and deny their experiences when their assessment of self is
dependent upon “conditions of worth” (or “introjected” values) posed by society and
significant others.
Healthy functioning is defined by the individual’s acceptance of her organismic
experiences; that is, being more congruent, open to her experiences, less defensive.
Consequently, healthy function includes psychological adjustment, tension reduction in
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multiple areas including physiological, tension, psychological tension, and anxiety. The client
perceives his “behavior as being more within his control” and others perceive his behavior as
“more socialized, more mature” (Rogers, 1959, pp. 218-219) The ideal of healthy functioning
is characterized as the hypothetical “Fully Functioning Person”, a periphery theory emanating
from the theory of therapy (Rogers, 1959, p. 234).

The Change Process

In short, the organism is “always up to something”, always adjusting to maintain and

enhance itself in ways that meet it’s potential. Change occurs when conditional positive self-
regard is replaced with unconditional positive self-regard. That is, the person acquires
unconditional positive self-regard and perceives herself as being worthwhile as an
experiencing individual. This change occurs when the client perceives the therapist (or a
significant other) as a person who is receiving her with unconditional positive regard and
empathic understanding. The individual becomes more congruent having fewer conditions of
worth, a continuing organismic valuing process, and higher level of psychological adjustment.

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 72 Jerold D. Bozarth

The Therapeutic Process

It is important to remember that the therapeutic process in client-centered therapy differs

from most theories of therapy due to the radical assertion of the client as the determinant of
her own direction, way, and pace of therapeutic development. This assertion, for example,
results in diagnosis and assessment as being eschewed in Client-Centered Therapy. Likewise,
goals may or may not be defined in therapy sessions, dependent upon the client’s direction
and determination.
Patterson (2000) refers to the actualizing process as an ultimate goal and mediate goals as
specific goals of clients. However, he clarifies that “the ultimate goal is, in effect, a given and
is not chosen by either the therapist or the client, mediate goals are chosen by the client”
(ibid, 2000, p. 120). The fact remains that client-centered therapy is not a goal-oriented or
problem centered therapy. It is oriented towards therapeutic personality change that enables
the client to develop her own goals and resolve her own problems. The therapist’s only
functional goal is to experience the conditions of unconditional positive regard toward the
client and empathic understanding of the client’s internal frame of reference.

The Nature of the Therapeutic Relationship

The client-centered therapeutic relationship is explained in the application to family life.

The following can be considered a succinct summary of the theory of client-centered therapy
by substituting “client” for “child” and “therapist” for “parent”.

1. The greater the degree of unconditional positive regard which the parent (or read as
therapist) experiences toward the child (or read as client):
a. The fewer the conditions of worth in the child.
b. The more the child will be able to live in terms of a continuing organismic
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valuing process.
c. The higher the level of psychological adjustment of the child.
2. The parent experiences such unconditional positive regard only to the extent that he
experiences unconditional self-regard.
3. To the extent that he experiences unconditional self-regard, the parent will be
congruent in the relationship.
a. This implies genuineness or congruence in the expression of his own feelings
(positive or negative).
4. To the extent that conditions 1, 2, and 3 exist, the parent will realistically and
empathically understand the child's internal frame of reference and experience an
unconditional positive regard for him.
5. To the extent that conditions 1 through 4 exist, the theory of the process and
outcomes of therapy... and the theory of the process and outcomes of an improving
relationship... apply. (Rogers, 1959, p. 241)

This theory can be stated more succinctly at a macro-level: The therapist’s congruence
(related to the extent of the therapist’s unconditional positive self-regard) induces UPR
toward and EU of the client’s frame of reference) and this facilitates client congruence. In the
macro sense, therapist congruence begets client congruence; and, suggests that Client-
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 Client Centered Therapy and the Person-Centered Approach 73

Centered Therapy could be considered an existential theory. In other contexts, it might be

designated a self-theory (due to the central role of the self) and/or as an organismic theory
(due to designation of the actualizing tendency as the organismic “Foundation Block” of the
theory). The linear delineation of the theory has also lent itself to behavioral interpretations
within contexts such as “Interpersonal Skills” and “Human Relations” training (Carkhuff,
1969; Gordon, 1970).
The underlying assumptions of CCT also eschew the use of techniques. However, the
research and clinical work of Rogers and colleagues as well as Rogers’ clinical
demonstrations have led some to conclude that certain response techniques are more apt to
communicate the therapeutic conditions. Rogers and colleagues used the term “reflection”
and “reflections of feeling” in earlier deliberations (Raskin, 2004). Various other terms were
used to describe therapist’s statements. Terms that have been used include: “. . . clarification
of feeling, reflection of feeling, restatement of content, simple acceptance, structuring . . .”
(Rogers, 1951, p. 289).
“Empathic Understanding Responses” (Brodley, 1999) are often considered
representative of the therapist’s attitudes. Brodley considers unconditional positive regard and
empathic understanding to be attitudes, but this acceptant empathic attitude is viewed as
generally communicated by a particular response style. There is still controversy in the
“person-centered community” concerning response styles (Bozarth, 1984; 1998; Brodley,
1999; Frankel & Sommerbeck, 2005). However, Rogers was clear throughout his writings
that the attitudes of the therapist and not techniques were central to the theory
Other differences exist among “the schools of therapy related to the person-centred
approach” (Sanders, 2004). These schools are identified as Classical (referring to Rogers’
theory statement of 1959), Focusing, Experiential, and Integrative (ibid, 2004). The major
difference between the Classical approach and the other “person-centred” theories is that the
latter do not consider the conditions of the therapeutic process as “sufficient” and revert to
directive actions to encourage particular ways to help clients (Bozarth, in press). Thus, the
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focus on the client’s way, direction, and pace is compromised in the “neoclassical” therapies.

LIMITATIONS AND STRENGTHS

Limitations concerning client-centered therapy have been expressed most often from
other theoretical frames of reference and, often, from misrepresentation of the approach.

Perceived Limitations by Critics

Critics of client-centered therapy have noted their views of the limitations of the
approach. For example, one critique suggests the limitation of universally applicable factors
as being “the product of myopic schoolism and violates the principle of tailor-making the
therapy to the needs of the patient” (Fay & Lazarus, 1992). These authors perceive the
limitation to reside in the approach itself. They say: “if Rogers were correct, there would be
no point in bothering to learn any specific techniques-be warm, genuine, congruent and
empathic and establish a good therapeutic alliance-period!” (ibid, 1992, p. 3). The authors are
correct that specific techniques are not important and that the conditions of therapist
congruence incorporating unconditional positive regard and empathic understanding are

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 74 Jerold D. Bozarth

central to the theory. Therapeutic alliance has seldom, if ever, been referred to in client-
centered theory.
Less acerbic writers offer similar critiques. One author states: “At its worst, Rogers’
contentions perpetuated simplistic formulations and singular treatments for all clinical
encounters” (Norcross, 1991; cited in Norcross, 1992, p. 2). Similarly, notable adherents of
client-centered therapy speculate limitations: “the potential of client-centered counseling is
severely limited because of the relative paucity of information that is being incorporated”
(Cain, 1993, p. 135). The veracity of these speculated limitations is questionable in that the
limitation is “a non-sequitur from the meaning of Rogers’ theory” (Bozarth, 1995, p. 12).
That is, the process of posing limitations is “… that of dismissing or ignoring the fundamental
assumptions of the approach (that of the actualizing tendency and the self-authority of the
client) as untenable or questionable and proceeding with criticism of the theory from other
frames of reference” (Bozarth, 1995, p. 19). The limitations are predicated on the assumption
that the therapist is the expert for the treatment, process, and behavior change of the client.

A Specific Proclaimed Criticism

One alleged limitation emerged from the ambitious research project with hospitalized
“psychotic” individuals (Rogers et. al., 1967). The failure of the project to identify significant
statistical results was interpreted as ample evidence that client-centered therapy was limited
and not viable with “psychotics”. The interpretation added to decades of conclusions that the
client-centered approach “worked” with only neurotic, Caucasian, middle class clients.
However, there is evidence that contradicts such conclusions. For example, certain analyses
of the Wisconsin project reported positive change results (Truax & Mitchell, 1971). In
addition, there are demonstrations of therapy sessions (Farber, Brink, & Raskin, 1996;
Rogers, 1954; Shlien, 1971) with “psychotic” clients.
Prouty (2005) has focused on Rogers’ first condition concerned with “contact” as the
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

stimulus for developing a theory and method of contact with severely impaired psychotic and
mentally retarded clients. Sommerbeck (2005) also discusses her work as a client-centered
therapist with hospitalized psychotics.
Sommerbeck (2002) identified several flaws that she believes influenced the results of the
Wisconsin Research Project. She included a concern about the extent of dedication by some
of the therapists to the client-centered approach.
Bozarth (1998, 2005) reports that working with long term hospitalized “psychotics” led
him to learn client-centered practice before he ever heard of Carl Rogers. Unpublished studies
by Bozarth revealed significant improvement for hospitalized “psychotics” on multiple
criteria of independent living, employment, satisfaction, diminished symptoms of illness, and
personal satisfaction. These informal investigations led Bozarth to further examine the
Wisconsin Research Project. The examination revealed that the small number of clients
involved in the analysis (eight in each of the randomly assigned categories) were further
diminished in size in the treatment group. Two successful clients in the Wisconsin study did
not complete the final evaluations. One client (“Ed”) was later an employee who Bozarth
supervised. “Ed” became a highly productive member in the work place and in the
community.
Another client identified as “Jim Brown” (Farber et. al., 1996, pp. 231-239) who was in
therapy with Rogers demonstrated considerable progress. Rogers states that the client was so
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Client Centered Therapy and the Person-Centered Approach 75

glad to be out of the hospital that it was unfair to ask him to take the post-therapy exams.
Rogers states: “I’m sure it would have changed the results of the research; there was a small
enough number of clients in the research that one extreme success like that would have
weighted the results” (Rogers & Russell, 2002, p. 176)
Expressed limitations of client-centered therapy are questionable.

General Referents to Limitations

One general limitation periodically expressed is that client-centered therapy is “fuzzy

minded” and has no empirical support. This is a somewhat ironical assertion since Rogers and
colleagues stimulated and presented the first comprehensive research efforts (Rogers &
Dymond, 1954). Rogers (1951, 1959) was an enthusiastic adherent of both quantitative
scientific method research and of qualitative research (Rogers, 1959, 1964).
In a review of research reviews, Patterson (1984) evaluated and summarized nearly two
decades of research studies on the core conditions to conclude that there is strong evidence
for the therapist conditions as necessary and sufficient. Recent reviews support Patterson’s
conclusion (Bozarth, Zimring, & Tausch, 2002; Farber & Lane, 2002; Page, Weiss, & Lietaer,
2002; Watson & Steckley, 2001).
There are theories of therapy that have become identified as “Person-Centred Therapies”
because of their interest in the self-direction and self-authority of clients. In part, the theories
were developed by students or colleagues of Rogers or by individuals who were especially
interested in Rogers’ way of therapy. These theories have been categorized as: Focusing,
Experiential, Existential, and Integrative (Sanders, 2004). The basic theory of Rogers’ (1959)
is identified as “Classical” and considered as one of the “Person-Centred” therapies (Sanders,
2004). As previously suggested, the limitations concerning client-centered therapy have been
expressed most often from other theoretical frames of reference and from theories that tacitly,
if not explicitly, view Rogers’ theory as limited because they do not consider the conditions
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

as “sufficient”. They also relegate the role of unconditional positive regard to a preliminary
attitude rather than view it as the essential curative factor.

Limitation of the Radical Assumption of Client-Directivity

Perhaps, the greatest limitation of client-centered therapy is that the mental health system
has not assimilated the radical assumption of client-directivity; that is, the adherence to the
assumption for the therapist to go with the client’s way, pace, and direction.

Strengths of Client-Centered Therapy

The strengths of the theory are summarized by one advocate as:

They lie in the belief in the capacity of clients for self-actualization (as the unitary actualizing
tendency), the person-centered conditions offered by the therapist and the therapist's own
person, apart from these conditions. Also, the experience of the therapist and his/her
willingness not to be bound by any set of rules. (N. Raskin, personal communication, August,
2005)

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 76 Jerold D. Bozarth

The strengths of the theory for practice is captured by a client-centered therapist who has
worked in mental health centers with adults, practiced as a client-centered play therapist, and
worked with abused clients. She states:

Even though experiencing the attitudes seems to me to take some complex learning over
time, I find the simplicity of the theory to be very freeing. Since my understanding of the
theory means following the client's lead in any direction, I find that clients and I are able to
work together to meet their goals, including in terms of time limits, crisis, involuntary nature
of the session. As I am better able to understand their culture as they understand it, there is
less need for diagnosis or assessment, etc. If this is what the client wants, then we can usually
make it happen in ways that feel ethical and client-centered to me. One of the virtues of the
theory that comes to mind for me is that its simplicity and clarity free the therapist to be with
and enjoy the client. The job assignment, to experience unconditional positive regard and
empathic understanding, can relieve the therapist from other burdens, what I might describe as
false responsibilities.
Of course, to enjoy the full effect of this escape into a truly unique kind of relationship,
one needs to be fully engaged within the approach, trusting of the client's capacity and deeply
respectful of the client's potential and right to self-determination. (K. Moon, PCI e-mail
network, August 25, 2005)

One client-centered therapist pointed out that the question of limitations and strengths are
inappropriate because client-centered therapists do not seek specific outcomes. Since CCT is
not a problem-oriented therapy but is directed toward therapeutic personality change,
limitations and strengths can not be viewed in the same way as most other theories.
The central tenet of the theory; that is, an inherent natural tendency of individuals toward
actualization identifies the assumptions as beyond therapy. Thus, the approach has been
directed to human functioning in general. Human function includes educational functioning
(Aspy & Roebuck, 1977; J. Cornelius-White & C. Cornelius-White, 2005; Rogers, 1969;
Rogers & Freiburg, 1994), physical functioning dealing with such areas as mental retardation
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

(Prouty, 2005); disabled clientele (Bozarth & Rubin, 1975), and psychotic individuals
(Bozarth, 2005; Prouty, 2005; Rogers et. al, 1967; Sommerbeck, 2005). In addition,
interpersonal development (Rogers, 1959), intercultural conflicts (Rogers, 1977, pp. 115-140)
and international peace efforts (Rogers & Ryback, 1984) have been areas facilitated on the
premises of the person-centered approach.

SUMMARY
Client-centered therapy/person-centered approach is a radical theoretical philosophy and
unique therapeutic approach. Developed in the 1940’s and concretized in 1959, the theory of
therapy extended to peripheral theories that include a theory of personality, theory of
interpersonal relationships, and theory of the fully functioning person. Applications of the
theory have been extended to group therapy, education, family life, multicultural concerns
and international conflicts.
The founder of the theory, Carl R. Rogers, and colleagues were the first to record
psychotherapy sessions with audio technology. They were the first to apply empirical
quantitative research to the field of psychotherapy. As well, qualitative observation of
therapy was a mainstay of the approach (Rogers, 1951; Snyder, 1947). Rogers (1959)
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Client Centered Therapy and the Person-Centered Approach 77

delineation of a theory of psychotherapy and interpersonal relationships from the client-

centered framework is the most rigorous scientific theory explication in the field of
psychotherapy, if not the only such presentation.
Client-centered therapy demands that the therapist trust the client’s direction, way, and
pace. It is by being congruent in the relationship and experiencing unconditional positive
regard toward and empathic understanding of the client’s internal frame of reference that the
client is able to perceive unconditional positive regard of the therapist through which the
client increases her own unconditional positive self-regard.
Formulations such as diagnoses, pathology, and assessment are antithetical to the
practice. The therapy is predicated upon one motivational force identified as the actualizing
tendency. This is the tendency for human beings to move in a constructive direction to
maintain and enhance themselves and move toward actualizing potentialities. The only
formulation important to promoting this natural constructive direction is the creation of a
facilitating psychological environment.
The role of an individual’s self-concept in relation to the actualizing tendency is also a
crucial part of the theory. The self-concept actualizes in a direction to maintain and enhance
itself. However, this actualization may be incongruent with the experiences of the organism.
It is this incongruence between self experiences and organismic experiences that perpetuates
denial, distortion, and deviant behavior. Psychological problems, symptoms, and anxiety are
representations of client incongruence. The goal of the therapist is to facilitate client
congruence by allowing the individual to become free of “introjected” values by society and
significant others. The client’s perception of the therapist’s unconditional positive regard
precipitates client congruence; namely, the integration of the client’s organismic experiences
and self-experiences.
Hence, client-centered therapy is not a problem-centered therapy. Rather, it is oriented
toward therapeutic personality change that enables the client to have fewer conditions of
worth, live within a more organismic valuing process, and develop a higher level of
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

psychological adjustment.

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Gendlin, E. T. (1974). Client-centered and experiential psychotherapy. In D. A. Wexler & L.

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management. London: Sage.

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 80 Jerold D. Bozarth

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 Client Centered Therapy and the Person-Centered Approach 81

Snyder, W. U. (1947). Casebook of non-directive counseling. Boston: Houghton Mifflin.

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Zimring, F. N. (1974). Theory and practice of client-centered therapy: A cognitive view. In D.

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Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 In: The Quick Theory Reference Guide ISBN: 978-1-60021-624-4
Editor: Karin Jordan, pp. 83-106 © 2008 Nova Science Publishers, Inc.

Chapter 7

GESTALT THERAPY

Gary Yontef and Mark Fairfield

Gestalt therapy was founded by Frederick (“Fritz”) and Laura Perls and Paul Goodman.
Fritz Perls is often credited singly as the founder of Gestalt therapy and was certainly the face
that gestalt therapy presented to the world in its first several decades. Nevertheless, the
broader origins of gestalt theory and practice extend beyond the work of one man, and include
theoretical and cultural trends of many other important thinkers from the worlds of
psychoanalysis, existentialism, gestalt psychology, and eastern philosophies. The
development of gestalt therapy emerged then as a new and viable option in a field once
dominated by classical psychoanalysis and behaviorism.
Perls was already laying the groundwork for gestalt therapy in the 1940s through his
efforts to modify psychoanalysis (Perls, 1942/1969), giving greater priority to the process of
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

the patient’s actual experience than to the analyst’s interpretations. This would not only
support the patient’s perspective as valid, but would ultimately shift the therapeutic
methodology from the traditional mode of analyzing content to an exploration of the
unfolding process in the moment between therapist and patient. Even the basic
epistemological assumptions of psychoanalysis and behaviorism—Newtonian, positivist—
were critiqued by gestalt therapy’s process-oriented, multiperspectival assumptions more
consistent with field theory.
The first comprehensive presentation of gestalt therapy theory was published in 1951 in
the book Gestalt Therapy by Perls, Hefferline and Goodman (1951/1994). This formative
volume articulated gestalt therapy’s unique conception of the human being as part of an
organism/environment field, a dynamic web of interconnections from which each self
emerges. Challenging traditional psychological models of the self, gestalt theory defined self
as the integrative function of this organism/environment field. Furthermore, all human
experience was understood to be organized into unified wholes or gestalten (i.e., gestalts). In
this framework “reality” is always defined in terms of relationships among multiple factors.
Gestalt therapy would therefore consider that, by virtue of being in relation to the patient, the
therapist actually makes a contribution to the way the patient’s experience is organized.
With these basic assumptions, priorities in gestalt therapy shifted from diagnosing and
treating to meeting the patient in a horizontal, dialogic process. Behavior change would no
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 84 Gary Yontef and Mark Fairfield

longer be the primary objective of therapy; the goal would become awareness. With expanded
awareness, the patient would be free to fine-tune his relationships with his world and find
increasingly more creative adjustments to satisfy unmet needs and grow.
The gestalt therapist is therefore actively engaged with the patient. The course of the
therapy is determined by the patient’s needs as they emerge in the current situation rather than
by goals predetermined by treatment protocols or formulaic intervention strategies. The
therapist and patient are free to experiment with whatever emerges in the therapeutic work,
using various processes of affect, sensation, cognition, action and interaction in a holistic
integration. The gestalt therapist’s methods derive from each unique context and ultimately
serve to increase the patient’s awareness of various methods available to be used for
expanded awareness, freedom and creativity.

KEY CONCEPTS

Nature of Persons

In order to understand the differences between the gestalt therapy conception of the
human self and classical psychoanalytic or behavioral constructs, it is important first to
appreciate the radical paradigm shift that took place among those thinkers who influenced the
development of gestalt therapy theory. While psychoanalytic and behavioral theorists were
essentially proponents of determinism, i.e., understanding all human behavior as caused by
the forces of biological drives or social conditioning, gestalt therapy theorists relied on a field
theory paradigm that understood phenomena as emergent from complex webs of interrelated
and mutually influencing conditions. There is no simple, one-way causation; behavior is
influenced by multiple factors and not predetermined.
Gestalt therapy theory characterizes human beings as striving to integrate these complex
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interactions between organismic and environmental conditions. The self does not refer to the
organism per se, intact and separate from its environment. It is not in a vacuum, moving
across empty space to encounter objects in an outside world. Rather, the self is an ongoing
function of a dynamic, ever-shifting web of relationships. The conditions which give rise to
the self are a lively interplay of organismic and environmental influences. The self is the
integration of these interacting conditions—the product of relationships. There is no
possibility of being oneself and being outside of relationship.
This paradigm shift was a radical one at the time gestalt therapy was first introduced and
continues to challenge the positivist assumptions still held by many contemporary theorists
and practitioners. Whereas classical psychoanalytic and behavioral systems characterized the
self as a structure situated in the predicament of forging relationships with others while
maintaining proper boundaries to fend off annihilation, gestalt therapy understood the self to
be emergent from the foregoing relationships of organism and environment. Relatedness
preexists the self. If relationships of organism and environment change, the self also changes.
Relatedness is not something achieved by will; it is a given by sheer virtue of being.
Contact with and withdrawal from others are both functions of relatedness. Marital
partners can divorce, family members and friends can be estranged, and yet all these persons
remain in relation to one another. The nature of relationship may change, but the fact of

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Gestalt Therapy 85

relationship will not. In life, relationships cannot be dissolved, only altered. A breakup
between two persons who have been in an enduring relationship is actually only the ending of
contact between those persons. The relationship remains because they both still relate to each
other, only now the relationship is defined through the choices that distance each from the
other. The relationship goes on, but with different priorities.
The self organizes and integrates all experience. Experience can be unified into
meaningful wholes only because the self exists to unify and integrate diverse conditions
(Perls, Hefferline and Goodman, 1951/1994). A feeling or sensation is a signal that various
conditions are having effect. The self registers this signal as part of its integrative work.
Awareness is a self-process; awareness is more than knowing about something – it is itself an
integration.
There are four important implications that follow from this theory of self. First, a view of
the self as an integrative function of the field represents a radical shift from the ideas about
human nature held by gestalt therapy’s contemporary rivals. Our common notion in the West
of the ‘individual’ as an independent entity has been deconstructed by field theory. Human
beings do not start out separate and then later attach to objects in the world. They emerge
from a preexistent relatedness and from that condition awareness then develops to fine-tune
connections. In gestalt therapy, a boundary is not like a hedge or a fence constructed in
advance to protect the individual from intrusion; a boundary is the whole field’s organ of
contact (i.e., the function of the field that allows for differentiation, a system wherein contact
is discovered, navigated and experienced). Boundaries emerge to separate and connect ‘self’
and ‘other’; they signal the potential for engagement, protection and exchange.
A second implication regards the notion of experience. All experience is always an
experience ‘of’ something. It is intentional—i.e., it reaches toward otherness. One simply
cannot be aware without something to be aware of. This is because awareness emerges from
relatedness; contact preexists the possibility of awareness. Even the most complete isolation
possible—say, the conditions of an isolation tank—will not eliminate contact with something
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(e.g., the fluid in the tank, the surrounding darkness, digestive sensations, sensations of
movement of the musculature and of the pulmonary and circulatory systems, recall/memory
functions, etc.). A person inclined to withdraw is always withdrawing from one thing toward
another. In fact, all experience is some form of contact. To be aware is to notice contact with
something. Additionally, my perception of something (e.g., of you!) is the product of our
interactions and is thus shaped by my own participation.
Third, all perception is motivated and meaningful. Human beings cannot help but make
meaning of their experience since the most basic perception has already been organized by
the field. Experience is ordered into patterns as part of the basic processes of awareness. In
fact, when what is experienced makes no sense, the human person will be compelled to
reorder experience into something meaningful. When a pattern seems to be forming, there
will be motivation to complete it. Where there is no simple resolution, the unfinished pattern
will loom, energizing perception, reserving and diverting energy to support continued
engagement, and ultimately impinging on the quality of the next emerging pattern. When
interrupted, human beings are motivated by a fundamental impulse to finish what is
unfinished.
Finally, the personality functions of the self emerge in contrast to the contemporaneous
nature of the self as a whole (“self”). Whereas the self contacts what is novel and integrates
emergent conditions, the personality functions systematize and automate contact so that it can
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 86 Gary Yontef and Mark Fairfield

go on without awareness. But personality is not merely a blueprint that predetermines

experience, nor is it a repository of genetic characteristics or traits awaiting activation by
interactions with the environment. In gestalt therapy, the personality is an ongoing process
that functions as a basic life support. The personality creates a sense of self, e.g., a verbal
picture of self, that tends to migrate across time, space, and situation. Personality functions
support contact with others but limit that contact to a range within which it is safe for the
organism to venture and give predictability to others. In some cases, this range is quite narrow
and very little novelty can be assimilated; in others, the range is wider and more can be risked
to experiment with the unfamiliar.
Personality relates to the conservative functions of the organism, narrowing awareness to
include those interactions that bring the most satisfaction or demand some critical response to
ensure safety. For example, a person’s tendency to split the complex experience of
disappointment into the classic ‘abandonment/rescue’ scenario could be understood as the
personality’s automation of organismic responses to loss. Judging the loss as a form of
abandonment guarantees a well-rehearsed, practically automatic sequence of actions with
little or no deliberation. The response might be a total withdrawal from the injurious
conditions, or a full-throttle attack, or an impassioned appeal. This automation sequence is
efficient (since the person does not require much awareness to sort out what has happened)
and conservative (since the person is protected from the worst case scenario). On the other
hand, without some negotiation or creative compromise, the person may become overly
protected even from the possibility of some nourishment. Also, this pattern may reinforce a
persistent belief that loss and disappointment are always intolerable, a belief which will likely
postpone more sustained awareness of the various and complex dimensions of loss and grief.
To the degree that complexity and richness are valued by the person, these automatic
responses will be undesirable. To the degree that satisfaction and safety are appreciated, the
conservative strategies of the personality will be felt as supportive. When the automatic
process is not working, then figural awareness is needed.
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Needs

Given gestalt therapy’s understanding of human consciousness as emergent from webs of

relationships, the fundamental needs experienced by human beings point to adjusting contact
with others to facilitate optimal nourishment and growth. In fact, under normal conditions
human experience is shaped and energized by the dominant organismic needs at play in any
given moment. Needs generally determine perception: in other words, when a person notices
something (hears, sees, smells, tastes or feels it), it is usually because awareness of that thing
holds the potential for satisfaction of some prevailing need. Needs also influence the horizon
of each person’s perspective which ultimately limits what can be perceived. The organizing
needs can be biological (hunger), interpersonal (loneliness), creative or recreational
(boredom), or spiritual (need for peace and understanding of the universe). The need may
organize such activities as eating, contacting another person, engaging in creative activity,
meditating or praying, and so forth.
Needs are experienced through embodied sense. When needs are thwarted, they are felt
more acutely and impinge on the possibility of any other sense. It is critical for human beings
to meet their needs; when needs go unmet an emergency arises and energy is activated to
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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Gestalt Therapy 87

mobilize them toward some adjustment (either of self or environment, or both). The inherent
capacity to recognize needs and conditions, find available supports, and achieve successful
adjustments in relation to the environment is called organismic self-regulation. This includes
finding a way to resolution when needs are recognized but the resources for meeting the
needs are insufficient in the organism/environment field.
Gestalt therapy understands this process to be a function of the organism/environment
field. People are part of the field and regulated by the current conditions of that field (the field
that they are a part of regulating). Field conditions override any intervention that does not
support resolution of the dominant organismic need (including relevant environmental
demands and the needs of others or the society). Conditions of the current field influence the
range of adjustments possible for any person. Information about prevailing field conditions is
available through sensed/felt needs and observation of the field.
This understanding of needs and their influence on perception and adjustment is crucial
to appreciating a key difference between both classical psychoanalytic and behavioral
interventions and gestalt therapy. Whereas these other therapeutic systems viewed the patient
as sick or maladjusted, gestalt therapy understands the prevailing character style and coping
behaviors as observable manifestations of dominant organismic needs in relation to salient
environmental resources and demands. The patient is not “maladjusted”, but rather adjusting
with environment in the wisest possible fashion of which he is capable given the current field
conditions, including his own developed knowledge and skill. This phenomenon is referred to
as the law of Prägnanz, i.e., that the field forces will be organized in the best way possible
given the circumstances.

Philosophical Underpinnings

In 1920’s Frankfurt, Fritz and Laura Perls found themselves in the company of an
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impressive group of thinkers that included gestalt psychologists, phenomenologists,

existentialists, psychoanalysts and liberal theologians. Fritz was himself a training analyst
who appreciated Freud’s revolutionary notion that human behavior is motivated in part by
processes out of our awareness. But Perls also valued the ideas developed by others in his
contemporary circles and he determined to integrate these strands of thought into a coherent,
multidimensional therapeutic system.
One crucial point of convergence among these various disciplines was an interest in the
meaning of human existence. In the tension between Freud’s drive theory (i.e., human
behavior is determined by biological drives fundamentally at conflict with each other and
needing constraint) and the existentialist notions of freedom and responsibility (i.e., human
beings choose their paths and are ultimately responsible for their choices), Perls was pulled to
a greater degree toward brands of thinking that privileged the human capacity to make aware
choices in the present moment. The avant-garde ideas of psychoanalysts such as Otto Rank
and Wilhelm Reich offered more purchase to Perls than did the notions of more orthodox
analysts of that time. This is evident by virtue of what Perls would later emphasize in his own
work that clearly draws heavily on the ideas of Rank and Reich (e.g., the body as the site for
struggle between environmental demands and organismic needs; the focus on process over
content; the wisdom of the individual to heal himself).

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 88 Gary Yontef and Mark Fairfield

Fritz and Laura Perls were also influenced by new perspectives in the physical sciences
and philosophy that triggered a radical paradigm shift that critiqued the Cartesian dualism
underpinning the systems to which they took exception. Gestalt therapy integrated various
approaches that grew out of this paradigm shift, including the work of gestalt psychologists
Max Wertheimer (1938), Kurt Koffka (1935) and Wolfgang Kohler (1938), the philosophy of
Ludwig Wittgenstein (1922/1974), the holism of Jan Smuts (1926/1996), the pragmatism of
William James (1907/1975) and John Dewey (1903), the psychology of Kurt Goldstein
(1939/1963), the field theory of Kurt Lewin (1938), and the existential theology of Martin
Buber (1923/1958).
The word "gestalt" means a unified whole and refers to the holistic configuration of all
human experience. Human perception is not a summation of distinct pieces; rather, people
perceive in whole patterns that cannot be grasped by a mere analysis of separate elements.
The relationships of the parts to each other and to the whole must be identified and
understood. Max Wertheimer, Kurt Koffka and Wolfgang Kohler took the lead in the
development of gestalt psychology principles. Kurt Lewin applied these principles outside of
the psychology of perception and further developed the theory of gestalt psychology,
especially the theory of phenomenological fields.
Lewin (1938) discussed the principles of field theory as contrasted with the positivist
assumptions of Newtonian physics. Field theory considered phenomena to be studied as
emergent from a systematic web of relationships that are continuous in time. The world is not
studied through the analysis of its ‘discrete’ particles. From a field theory perspective,
everything is in the process of becoming; nothing is static. Reality is understood as co-
emergent from the relationship between the observer and the observed. Reality is not a ‘fact’;
reality is experienced as a ‘perspective’. In a field view there are multiple realities of equal
validity (Yontef & Jacobs, 2000).
Gestalt therapy was also profoundly influenced by the work of the dialogic existential
thinkers, especially Martin Buber, with whom Laura Perls studied. Buber believed that the
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human self is always and unavoidably a ‘self-with-other’ (Buber, 1928/1958). This belief was
an obvious complement to the field view of gestalt therapy and so, through the teachings of
Laura Perls, the I-Thou relating of dialogue took root as the foundation for the gestalt
therapeutic relationship.

HEALTH VS. DYSFUNCTION

Healthy Functioning

In gestalt therapy, health is defined as creative adjustment: human beings adjust their
environments and adjust to their environments in ways that reflect the available supports and
resources of the current field. An adjustment is creative to the extent that new possibilities are
considered when action is being taken. It is an adjustment to the extent that movement is
allowed that facilitates a profitable fit between organism and environment, including
changing the environment. If there is too much adjusting with little creativity (e.g., over
accommodation at one extreme) or too much creativity that ignores or overreaches the

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 Gestalt Therapy 89

standard of good fit (e.g., acting on impulse without regard for the circumstances), then the
balance of creative adjustment has not been struck.
Locating supports often requires increased awareness, especially when adjustments are
particularly challenging or complex. Awareness is itself a condition of the field and its
possibility depends on various field conditions supporting and energizing contact so that it
sharpens and captures one’s attention. When awareness is expanded, attention may be drawn
to a variety of alternative possibilities for contacting. Awareness of novelty excites and
mobilizes the organism toward a variety of choices. The position of noticing a range of
options and being free to choose from among them is considered a sign of optimal
functioning. Of course, this optimal functioning includes learning from the choices made so
future choices can be more successful.
Choices are limited by the immediate ground (what supports one’s awareness) and
ultimately by the enduring contexts of one’s experience (language practices, cultural customs,
historical material). When choices lead to resolution of needs and demands, excitement is
diminished and perception is simplified to make way for new needs/demands to gain in
interest.
Experience is organized into the relation between a figure of interest and the background;
the relation between figure and ground is the gestalt therapy definition of meaning. Interest
determines what will become foreground and what will be background. The continual flow of
contact with and withdrawal from figures of interest is sometimes referred to as gestalt
formation/destruction or the cycle of experience and unfolds in ways that are idiosyncratic to
each individual’s perspective. Experience and behavior are organized by relevant needs,
problems or challenges and the potential for solutions; even adjustment patterns that appear
indefensible or meaningless from another perspective are thought to embody wisdom that can
only be understood from the perspective of the person making the adjustments.
In other therapeutic systems, the notion of ‘health’ generally refers to a qualitative
distinction that depends on standardized measurements from a privileged perspective. Gestalt
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therapy moves away from privileging only one perspective and therefore seldom qualifies
experience using terms like health or disease. Instead, process variables such as degrees of
flexibility and creativity supplant the medical standards of health vs. illness and are defined
according to multiple perspectives. In traditional psychoanalysis, the analyst is empowered to
qualify the patient’s functioning as healthy or not healthy; generally in behaviorism, the
therapist has the privilege of evaluating the degree of the patient’s social adjustment. In
contrast, the gestalt therapist and patient together can recognize the principles that organize
the patient’s pattern of adjustment in a given context. The therapist does not aim to directly
restore health to clients but rather to influence field conditions to increase support for healing,
growth, and especially expanded awareness that will reveal a wider range of options from
which clients may choose. Clients seek help from others when their own choices have not
served them; they often do not understand why they do what they do and why it does not
work for them. Increased awareness establishes or restores a patient’s faith in his own
capacity for self-regulation.

Dysfunction
The field paradigm reframes the concept of dysfunction so that it can be understood as an
attempted adjustment between organism and environment. In other words, the ‘dysfunction’
is a functional idiosyncrasy of a particular organism/environment field. When a behavioral
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 90 Gary Yontef and Mark Fairfield

response is repetitive or persistently conservative in the face of challenges that require more
creative solutions, the behavior is often nevertheless maintained. The current field actually
supports the response until conditions allow other alternatives. Support is a crucial idea in
gestalt therapy: it is any condition that serves as ground for contact with what is needed.
Adjustments may be overly creative (attempting to assimilate too much novelty at one time)
or overly conservative (avoiding potentially nourishing novelty). In either case, rather than
judge these adjustments as unhealthy or dysfunctional, the gestalt therapist explores the
personal and environmental conditions that give rise to each adjustment to understand what is
in fact being reached for as a support and to understand what stands in the way of a more
satisfactory adjustment. When behavior is regarded by others as unhealthy or maladaptive,
this is often because they notice the negative aspects of the outcome and do not notice how
the behavior reaches for satisfaction of some important need or interest.
Generally, judgments made about other people’s behaviors come from moral systems that
prioritize certain interests over others. For example, in most societies, people are expected to
take an interest in the health and wellbeing of the larger community. This would be
demonstrated by considering the public health when choosing how to behave. When someone
makes choices that facilitate his interest in something that altogether violates public safety,
socialized people usually reproach that behavior and the interests that lead to it. This is a
natural and necessary process; however, it is not the best approach for psychotherapy of an
individual or family. A strong example of this conflict is sociopathic behavior. The
perspective shaped by a moral hierarchy that privileges public safety over individual
satisfaction will necessarily interfere with supports that would enable one to regard the
function of the sociopathic behavior. The task in psychotherapy is not to condone or
condemn, but to explore and understand creative options.
Because of gestalt therapy’s understanding of individuals as emergent from relational
fields, and owing to its pragmatic origins (James, 1907/1975), judgments about what is
desirable behavior depend on a moral framework that takes into account both individual
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satisfaction and public safety. Nevertheless, a judgment about what is desirable behavior
should be held apart from an appreciation for the Prägnanz of a patient’s total experience.
While each mental health practitioner is duty bound to uphold certain standards of public
health and safety, the gestalt therapist is also influenced by a theory which frames the
patient’s behavior as an integration of some need or interest with a reach for what will support
its satisfaction. Optimal functioning would permit the patient the greatest possible
appreciation for the range of options to find satisfying contacts and the impact that each
choice makes in the total situation (which includes the larger society).
Aside from appreciating the structural integrity of the patient’s situation and the moral
dilemmas that may arise from certain behavior patterns, the gestalt therapist may choose to
focus on the patient’s fixed gestalten. Remember that a gestalt is a unified whole of
experience that integrates current field conditions, including organismic needs and
environmental demands, and the self is the function that integrates these conditions. The self
is dynamic, fluid, alive and available for reorganizing as the dominant need dictates, whereas
personality forms from continuous acquired contacts and is experienced as fixed patterns that
endure over time, resist destruction, and impinge on the fluid emergence of new patterns. The
obvious benefits of personality function relate to the capacities for learning, systematization,
economy, and efficiency. The potential drawbacks include obstinacy, rigidity, and stagnation.
Personality patterns integrate contextual and historical material, maintaining a shape and tone
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Gestalt Therapy 91

that resonate with longstanding environmental demands (dangerous or exciting), repetitive

organismic needs, pervasive sociocultural cues and customs and enduring relational themes.
When fixed patterns interfere with the emergence of novel gestalten that would initiate
optimal creative adjustments, those patterns become a focus of therapy. The patient is
encouraged to explore what is unfinished in his current experience and determine the degree
to which adjustments satisfy the needs/demands of the total situation. If a patient decides he is
not satisfied with the current adjustment, an expanded awareness of the total situation may
give rise to various alternative ways of organizing experience and that may in turn lead to
destructing or disorganizing fixed gestalten and supporting experimenting with more creative
patterns.

THE CHANGE PROCESS

Change

Gestalt therapy theory considers the origin of change to be a paradox. One does not grow
by trying to be who one is not. The targeted rejection of certain aspects of one’s experience
interferes with the inevitability of change and paradoxically reinforces the undesired
repetition. The paradoxical theory of change (Beisser, 1970) asserts that identifying with
one’s experience of the total current situation, including those aspects of the experience that
are undesirable, will paradoxically create conditions that support growth; self-awareness and
acceptance allow the continuous flow of emergent gestalten, thereby contributing to the
possibility of change. The gestalt therapist does not aim to change the patient; the gestalt
therapist aims for a meeting between therapist and patient that supports the patient to name
and identify with his own lived experience as an actuality of the current field, and to
experiment with new possibilities.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

All phenomena are processes, i.e., they change over time and space. Change is
emergence; new gestalten emerge from complex and dynamic relationships. When conditions
impinge on the dynamic flow of gestalten, the process becomes repetitive and does not adjust
to emerging needs and possibilities. In some cases, self-regulation tends toward conservation
of organismic functions, diminishing receptivity to environmental cues and promoting risk
avoidance. Awareness is minimized to eliminate contact with frustrating or threatening
stimuli. Attention becomes fixed on certain aspects of the total situation and action is aimed at
rejecting those aspects.

Why Change is Difficult

Gestalt therapy understands everything as already in process. Change is constant and

inevitable: one cannot stop all change. Even if one could stop change, he would still change
relative to his ever changing environment. Also, one change may counteract another. For
example, one may increase rigidity, itself a change, in response to changes in the
environment. Why does the changing process sometimes not change toward healthier
functioning?

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 92 Gary Yontef and Mark Fairfield

The apparent fixedness of any pattern that is labeled as ‘stuck,’ actually represents the
integration of changes that contribute to the ensuing emergence of a repetitive pattern. The
pivotal factor underscored in the paradoxical theory is the effect of identifying with, rather
than rejecting, what is emerging now. Disowning one’s part in relation to the current situation
creates internal conflict and conditions that change the flow of gestalten such that the current
pattern cannot be fully disorganized. This disowning prevents the conflicting parts of the self
from dialectically moving to an integrated synthesis. When the current pattern cannot be
destructed, energy is not made available for novel experience or experimenting with novel
solutions and the current pattern reasserts its influence on the next emergent situation. The
similarity of patterns of organization gives the illusion of no change, but in fact a change has
occurred in the flow of gestalten, interfering with the destruction of the current pattern and the
energizing of a new one. Under these conditions, the change is often not in a direction desired
by either patient or therapist.
Paradoxically, the repetition of old patterns and failure to experiment with new
possibilities often occur because the emergence of new patterns requires identification with
all elements of the old pattern – even the undesirable elements. If one rejects what is actually
happening, he will prevent the destruction of the current pattern and the emergence of a new
one, and potentially contribute to a circular, repetitive pattern. On the other hand, if one
accepts what is actually happening, he does not create an internal conflict that will prevent the
completion of the old gestalt. This makes way for new organizations of experience. Although
it feels counterintuitive to identify with what is rejected, not to do so prevents the emergence
of novelty because parts of one’s current experience are alienated. Accepted aspects become
part of the flowing stream of experience; alienated aspects become barriers, rocks in the
stream of experience.
Patients usually come to therapy with judgments about where they are, what they want,
how they feel and even who they are. They orient to the therapeutic encounter by asking for
help ‘to change’. The gestalt therapist will usually not aim for specific changes by setting
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

goals or employing techniques designed to directly alter the patient’s situation. The singular
change aimed for is an expansion of awareness both of the conditions of the patient’s life,
including aspects being rejected, and of the patient’s own awareness process, i.e., how he
becomes aware, what he becomes aware of, how his awareness is limited and by what, and
how awareness can be increased and new possibilities allowed into awareness.
The gestalt therapist meets the patient in a way that leads to both of them developing a
greater appreciation for what is emerging and how emergent events fit into a meaningful
whole. Usually beginning patients have not previously grasped the complexity of their
situation, especially possibilities not previously engaged and an understanding of how they
interfere with creative change. With the effect of the therapeutic relationship and increases in
awareness, the patient may now accept what is happening and identify with more of the needs
and feelings expressed in the current situation. If a truly new pattern is organized, it is only
possible because the current pattern has been integrated and what is unfinished has been
finished.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Gestalt Therapy 93

Therapeutic Environment

The gestalt therapist ideally creates an office environment that is private, ensures
confidentiality, is as free of extraneous stimuli as practical, and that offers the possibility of
movement, comfortable furniture, and other potentially supportive conditions. However, the
gestalt therapist does not attempt to sanitize the environment and eliminate risk, conflict, and
inconsistency. The impact of the environment is different with each patient and has to be
explored as it becomes salient.
While it is important to acknowledge the effects that certain environmental conditions are
having on the patient’s experience, especially unexpected changes or differences (e.g.,
changes in the configuration of office furniture, rescheduling of appointment times,
transformations in the therapist’s appearance, etc.), the gestalt therapist is not required to
avoid change. She does, however, have the responsibility to track the effects of the
environment, be open to how the patient’s reaction may influence her, and explore what the
patient wants to do about it.
The environmental conditions attended to most often in gestalt therapy are those
conditions influencing and being influenced by the therapeutic relationship. Since the theory
of gestalt therapy understands all experience to be emergent from current interactions of
interrelated events, it stands to reason that the gestalt therapist would be interested in how her
unfolding relationship with the patient influences the patient’s experience and behavior (see
below for a discussion of the nature of the therapeutic relationship in gestalt therapy).

THE THERAPEUTIC PROCESS

Assessment and Diagnosis

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Theory Based Assessment Strategies

The objective of assessment is the richest possible appreciation of contextual factors,
background conditions and foreground phenomena that collectively influence the emergence
of the total current situation. Background material such as developmental history and themes,
patterns of using various supports (e.g., relationships with people, things, substances, etc.),
medical and psychiatric records, cultural/ethnic identification, socioeconomic conditions,
sexual history, cognitive abilities, and vocational/educational history and functioning, is
gathered as needed to enrich the gestalt therapist’s understanding of what shapes the current
situation. The patient’s choices when faced with dilemmas and challenges are understood to
reflect a unique relationship to the whole. The assessment is itself a gestalt, an integration of
these diverse factors into a coherent, meaningful whole.
Without such a holistic framework for appreciating the complexity of the patient’s total
situation, the gestalt therapist would not have sufficient ground for truly understanding the
patient and relating the here-and-now moment to the patient’s enduring patterns. Without this
understanding, the patient would not be met in a way that supports awareness and growth.
The purpose of a holistic assessment in gestalt therapy is to make relevant experience,
including background factors, the focus of therapy.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 94 Gary Yontef and Mark Fairfield

There are no specific tools for assessment, no diagnostic scales or evaluative tests
specific to gestalt therapy. The method used to gather information derives from one of gestalt
therapy’s theoretical foundations, field phenomenology. More than a mere assessment tool,
phenomenology is an orientation to experience, an epistemological framework that guides the
gestalt therapist’s pursuit of knowledge. The phenomenological method of enquiry requires
following three basic rules: epoché, description, and horizontalization (Spinelli, 1989;
Yontef, 1993).
The rule of epoché is sometimes referred to as bracketing. Phenomenological enquiry
depends on holding one’s assumptions, biases, preconceived notions and ensuing
interpretations ‘lightly’ enough so that they can be reversed if necessary. Bracketing is an
attempt to open oneself as much as possible to what presents itself uniquely in this situation.
Since anything that is known is known from some perspective, bracketing should not be
confused with objectivity, a condition which gestalt therapists believe is impossible. Bias is
inevitable; it cannot be eliminated, but it can be acknowledged, and its effects accounted for.
This requires that the therapist be open to self-awareness and have enough therapy and
training to be aware of personal and cultural bias and to differentiate this bias from objective
fact.
The rule of description is followed by focusing on fully describing the most immediate
variables of one’s subjective experience rather than on explaining those variables. Describing
experience begins with reporting the most concrete elements of sensory information. The
more concrete one’s focus, the more straightforward the experience; the more abstract one’s
focus, the more reflective the experience. Experience is on a continuum with ‘concrete’ and
‘abstract’ as extremes. One can never be entirely concrete in one’s focus, nor can one achieve
pure abstraction. Phenomenological enquiry requires starting with the concrete as much as
possible before moving toward the abstract.
The rule of horizontalization, also called the equalization rule, discourages eliminating or
ignoring some variables of experience in favor of others. Of course, the number of variables
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one could attend to is unlimited, but if something has been noticed, it is important not to
ignore it. Human beings notice what they need to notice. If something has become figural, it
should be valued horizontally against all other noticeable phenomena initially. Any
experience may be relevant to understanding the structure of the current situation, even if the
relevance or importance is not immediately obvious. In this approach, no variable is excluded
or minimized in appearance a priori. Details of the patient’s experience, observations of the
therapist and other members of the family or group, the experience of others in reaction to the
patient, sensory experience, cognition, details of behavior, are all valued as they come into
awareness.
Following this method, the gestalt therapist engages openly with information as it occurs
to her from moment to moment. This new information, together with the therapist’s relevant
education, training and experience, becomes the ground for the clinical judgments that will
help to elucidate the links between multiple factors of the patient’s life and his current total
situation.

What is Being Diagnosed

Gestalt therapists try to understand the pattern of contact of the patient and others,
especially the pattern between the therapist and the patient, and the pattern of awareness and
unawareness, i.e., what the patient does not become aware of. Gestalt therapy resists
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Gestalt Therapy 95

diagnostic nomenclature as a static formulary. Useful diagnosis is pattern recognition that

comes as the result of an ongoing process of phenomenological tracking. An appreciation
develops for relationships between certain observable phenomena and generally known
patterns. This may be consistent with accepted categories of pathology or dysfunction, but
formal diagnoses are approached cautiously and held loosely prior to gathering sufficient data
through direct experience with the patient. When there is a strong correlation between a
particular diagnostic formulation and what has been encountered directly and repeatedly in
interactions with the patient, the diagnosis can help the therapist be clearer about how what is
present is a part of a larger pattern. Ultimately, the focus of assessment (and consequently of
all clinical judgments and meaning-making) is the here-and-now self-reported experience of
the patient in conjunction with the here-and-now experience of the therapist.
As important details about the patient’s history, culture, life space, etc. are revealed in the
dialogue, the gestalt therapist continues to focus awareness at least as much on the process as
on the content. In fact, it is more accurate to say that diagnosis really captures what can be
known about the patient’s awareness process through tracking the interactive exchange with
the patient. If there are relevant character styles, developmental themes, or interpersonal
conflicts, gestalt therapists trust that these will become evident in the here-and-now
experience of the patient in relation to the therapist. Knowing characteristic personality
patterns helps the therapist be sensitive to the here-and-now manifestation of broader patterns.

Treatment

Goals
The gestalt therapist has a main goal of meeting the patient so that the therapist
understands what the patient experiences and how the patient behaves and so that the patient
can experience himself in light of being met, understood, and accepted. Thus, in gestalt
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

therapy, a focus on problems is eclipsed by attention to needs, while goal-setting is

supplanted by experiments. The goal is awareness and experiments are a way of actively
working on awareness.
Whereas in many therapies the patient presents with a given problem and work ensues
either to develop insight about the problem or solve the problem, in gestalt therapy problems
are not ‘problematized’; they are expected, deconstructed, and become the focus of continued
therapeutic contact and awareness. A problem is a challenging adjustment, a difficult contact
of organism and environment that calls for increased support and awareness. Problems occur
constantly in life and, despite the reactions a patient will have to them, the therapist should
not be pulled into solving them. The gestalt therapy process orientation focuses on that
patient’s process of recognizing and solving problems and/or how he succeeds or fails to do
so. What is of concern to the gestalt therapist is the patient’s awareness process as it unfolds
with regard to whatever he may focus on at the moment, whether it is a problem, a need, a
longing, an excitement, a satisfaction, a dream, etc. For this reason, the therapeutic work
centers around using problems that arise, especially those problems encountered between
therapist and patient, as opportunities to experiment and discover something not previously
noticed that is central to the patient’s functioning.
It is important to mention here that gestalt therapy can be a support for working with
various issues and is not limited only to working with those patients who are sophisticated
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 96 Gary Yontef and Mark Fairfield

and verbal. As with all psychological treatment, specific problems call for a thorough
understanding of the theory and research relevant to their assessment and treatment. For
example, gestalt therapists who work with the chronic and persistently mentally ill will rely
heavily on their appreciation for current research about and past experience with this
population. Gestalt therapists working with families or couples need to understand how these
systems function. In some cases it may be appropriate to initiate more structure than in others
and this could include goal-setting in a way that is reminiscent of other therapeutic systems.
Nevertheless, with a gestalt therapy orientation the clinician would recognize goals as choice
points in the work, indications that a decision was made that influenced the next several steps
but does not eliminate the possibility of making different decisions later that may reflect
different intentions. This orientation provides an overall framework that brings together a
clinician’s professional knowledge and clinical experience with gestalt therapy’s field
paradigm, clinical phenomenology and dialogic-existential philosophy.

How Goal Setting is Accomplished

The question in gestalt therapy is more a matter of focus, i.e., what and how to focus and
work on awareness, than on future goals. At this point it would be instructive to focus on the
more central question of how a gestalt experiment evolves rather than on the subject of goal-
setting, a virtually unused strategy in gestalt therapy. The focus on experiment incorporates
an interest in “work” and how tasks are negotiated between therapist and patient. Work is the
gestalt therapy term referring to phenomenological focusing, being aware of the awareness
and relating process. The work orients on the present moment, especially how it is a
manifestation of general patterns of functioning and the emerging moment of possibility that
is supported or interfered with. This supports growth rather than setting goals to organize
around.
When an interactional sequence becomes interesting to either the patient or the therapist,
one of them may suggest setting up an experiment. Experiments are agreed-upon, here-and-
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

now, focused discovery periods during which the patient tries some new action (such as
scanning the environment, attending to some sensory experience, attempting some movement
pattern, expressing anger at the therapist, repeating a word or a phrase, creating a guided
fantasy, meditative breathing, etc.) while both the patient and the therapist report on their
experiences during the action. Sometimes the therapist will also participate in the action and
report what she notices as well.
The awareness that comes from the experiment as well as from further reflections on the
experiment is then integrated into the next moment in the therapeutic work. Data from
experiments are not used prescriptively; that is, the idea is not to discover something that will
then dictate how to act or not to act in the future. Instead, the new data are part of an
expanded awareness that will highlight and assimilate aspects of the current situation that
were previously hidden or ignored. It is the growing awareness itself that the therapist and
patient learn to trust and value in their work.
It is crucial to understand that setting up an experiment happens in the context of
emergent process; it is seldom if ever designed in advance of a specific moment in the work.
It is never forced upon the patient, though the therapist may suggest something as a
possibility and then work with the reaction the suggestion stirs for the patient. In that case, the
reaction has now become the part of the interactional sequence to be focused on and some
new experiment may suggest itself to the patient or therapist. What was offered prior to the
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Gestalt Therapy 97

reaction would then be relinquished, though the therapist may hold the idea as background
and may suggest it again in another interactional sequence. What should be underscored is
that these small goals, these fluid plans for action, can be dissolved as quickly as they are
created. So goal-setting does not happen during a particular phase of treatment and then get
codified into a treatment plan which dictates what happens from then on in the treatment. The
patient can embrace a goal at one point and then later let go of it.
The relationship, the dialogic contact between therapist and patient, is in itself an
experiment. This experiment is the most important one in gestalt therapy. Both the patient and
the therapist observe what emerges from this kind of contact and how it differs from the
contact in which the patient is usually engaged.

Phases of Treatment
While there are certainly transitional themes and important developmental tasks that tend
to dominate the progression of any therapeutic work, gestalt therapy does not anticipate in
advance a particular sequence of treatment phases. Obviously, the early part of the therapeutic
work will involve a beginning and the last part will involve an ending. Whatever the therapist
and patient agree to work on will necessarily trigger a series of tasks specific to the themes or
struggles that come from that work. But there is no prescribed sequence to which the therapist
stays in formulating interventions. Where they are in their relationship is a developmental
factor among many factors having effect in the current situation. So it would be inaccurate to
suggest that the gestalt therapist anticipates that, for example, the patient needs more rapport
building in the early part of the therapeutic work and can tolerate more confrontation or
conflict in the middle phase of treatment. This may be true and even a useful frame for what
is actually happening in the work, but the gestalt therapist will be careful not to allow an
expectation of this sequence to impose on her awareness of something different happening.
The usual cookbook generalizations about how to relate to patients is put in brackets so the
unique patient, the unique moment, the unique sets of supports and opportunities can organize
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the work.
Still, the passing of time and frequency of interaction will support a growing appreciation
of enduring themes for the patient’s awareness process and characteristic styles of the
patient’s contact with others. More contact with increased and multiple supports will bring
more awareness for both the patient and the therapist. The whole picture (literally, the gestalt)
of the patient’s life and aliveness as experienced with and by the therapist will become richer,
more vivid, and more nuanced over time. It will also change and develop into several
variations of the same picture. This gestalt looms large for the therapist and hopefully the
patient, shaping their perceptions of what emerges between them and elsewhere in the
patient’s life space. The developmental process of therapy can be understood in terms of this
overarching pattern of gestalt formation.
The critical difference between gestalt therapy’s understanding of treatment phases and
other ideas held by alternative therapeutic systems is the phenomenological basis for
articulating how the therapy is evolving. Rather than approaching the therapy from the
privileged perspective of a theoretical model of development, the therapist allows a pattern to
emerge from the actual lived experience of the patient. Essentially, in gestalt therapy the
patient defines the model for the developmental phases of treatment. The model is the
forming gestalt, the coherent and meaningful pattern that becomes increasingly more obvious
as the work progresses. Whatever order various tasks follow and whatever themes become
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 98 Gary Yontef and Mark Fairfield

most salient in the patient’s work will reflect the unique situation of that patient in relation to
this therapist. So rather than discuss developmental phases of treatment, it would be more
appropriate to the theory of gestalt therapy to highlight tasks that are clearly related to the
evolving therapeutic relationship but not in any prescribed order or with any predetermined
trajectory.
Joining is not a term specific to gestalt therapy, although some gestalt therapists may
utilize the term to refer to one aspect of inclusion. Inclusion, discussed below, refers to the
therapist experiencing as much as possible what the patient experiences. The task of including
the patient in his world of experience is not peculiar to the beginning of the therapeutic work;
it pervades the therapy and, as one of the essential conditions of dialogue (Hycner and Jacobs,
1995; Yontef, 1993), it supports the patient’s own developing awareness process and
underscores the relational structure of all experience. Nor is inclusion a technique employed
to put the patient at ease or build trust. The gestalt therapist does not aim to make the patient
comfortable any more than she aims to frustrate the patient. The aim is to track experience,
both her own and the patient’s, and report on it. If trust develops out of this process of open
sharing, as it usually does, then this growing trust will become support for more sharing and
some risk taking. If the patient reacts with fear or resistance to sharing, then those reactions
will be tracked and appreciated as part of a relational whole not yet fully articulated.
In a sense, inclusion is related to beginnings in gestalt therapy to the extent that every
encounter begins with the therapist attempting to grasp as fully as possible the patient’s
experiential world. Before taking any further deliberate action, the gestalt therapist begins by
identifying with her own emergent experience (presence) and reaching to identify with the
patient’s emergent experience (inclusion). Inclusion marks the beginning of every
interactional sequence, whether that sequence is initiated at the outset of the therapeutic
treatment, the start of a particular session, or the beginning of a transition within a session.
The therapeutic work happens continuously, the focus on being aware of the ongoing
creative adjustment the patient makes with his environment. It involves finding contact with
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available supports, using awareness to fine-tune adjustments, assimilating nourishment and

rejecting toxins or avoiding danger. In the process of work on focusing, there is an attempt to
increase the patient’s repertoire or skill set at being aware and making contact. For example,
the patient learns the difference between present experience and preconception, between
inference and observation, between talking about feelings and directly expressing feelings to
another, between expressing feeling (affect) and case building or explanatory efforts. These
are supports that the patient learns early in gestalt therapy and that then enable deeper work
later in the therapy.
Technically the patient always has the task of working on awareness. The therapist’s task
is to notice the work or the avoidance of work, underscore it in the patient’s awareness, and
meet the patient in the process. Again, work begins at the beginning; it is, in fact, already in
progress from the moment the patient walks into the consulting room. It continues throughout
each session, in between sessions, through the middle and end of treatment, and beyond.
It would be inaccurate to characterize the middle phase of gestalt therapy as ‘working’
any harder than at any other point. What may mark the quality of the work over time is the
quality of contact the patient and therapist make with forming gestalten and the patient’s skill
set at doing deeper work. As the patient has acquired new skills at awareness work and as the
relationship between patient and therapist progress, deeper and more core work is possible.
The patient may have developed an increased tolerance for and interest in complexity,
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Gestalt Therapy 99

increased tolerance of painful memories and feelings, and come to accept himself and his
needs and feelings with more understanding and compassion. Ultimately, the work gets
deeper when the patient and therapist have support for it.
Ideally termination occurs by an understanding of the patient and therapist that they have
come to a place in the work when it would be beneficial for the patient to discontinue
treatment. However, in gestalt therapy the patient’s wisdom and ability to self-regulate is
respected and the ultimate decision on termination is made by the patient. The gestalt
therapist does not view the patient’s expressed wish to discontinue therapy as necessarily
being a sign of unhealthy avoidance or resistance, but rather usually thinks of it as a choice to
disengage at a moment when he is experiencing an important need or wish. This need may be
a need for healthy withdrawal to assimilate the work, it may be to avoid something that is
truly overwhelming, it may be because the work is truly finished, it may be a need to
withdraw from this particular therapeutic relationship because a different kind of relationship
is needed, and so forth.
Neither should the therapist employ passive acceptance of the patient’s withdrawal
without further exploration as a cover for insufficient trust in the process of
phenomenological exploration of the patient’s commitment to the ongoing work. It is critical
for the patient to be supported in his movements both toward and away from parts of his
environment (including the therapist!), while providing opportunities for the patient’s
increased awareness of what energizes those movements and what impact they have in his
experience and the experience of others.
Since therapeutic work never really ceases, the termination of the treatment per se is in
some sense artificial. The contact in the therapeutic relationship may come to an end, and this
is significant and should be taken seriously. But it is equally as important to underscore the
ways in which therapeutic work continues in the patient’s life. This gets at the underlying
premise that therapy is meant to support the patient to expand his own awareness skills so that
he himself can notice options, experiment with available supports, and fine-tune adjustments
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with his environments. The gestalt therapist does not want the patient to develop a
dependency that restricts growth; but dependency is in itself unavoidable and so the point is
to identify which supports the patient can depend on for deeper exploration and growth.
Termination thus becomes a transition from the support of the therapy to the support of other
experiences in the patient’s life.

Therapeutic Relationship
The therapeutic relationship creates conditions that influence the possibility of expanded
awareness of self and other in relation to each other. Awareness helps by highlighting what
belongs to the current total situation and what looms in the patient’s experience that has been
disowned, carried over from the past without awareness or good fit in the current situation, or
unsupported. The conditions which foster this expanded awareness are described by gestalt
therapy as the conditions of dialogue (Hycner and Jacobs, 1995; Yontef, 1993), a term
borrowed from Martin Buber (1928/1958). These conditions are initiated by the gestalt
therapist and include presence, inclusion and commitment to dialogue.
Presence refers to the therapist meeting the patient with her actual experience rather than
seeming to be something else. Presence means authentically being present and
communicating fully and unreservedly (subject to clinical discrimination). The therapist is
present with the patient by identifying with her own experience (i.e., with the emergent flow
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 100 Gary Yontef and Mark Fairfield

of her own gestalten), i.e., rather than identifying with some ideal of how she should be. She
is free to voice or otherwise express to the patient what she is experiencing as it relates to the
task of the therapy and the therapeutic encounter.
Inclusion refers to the therapist experiencing as much as possible what the patient
experiences, even as if it happened in the therapist’s own body, while at the same time
maintaining a clear sense of her separate identity. This is very similar to Carl Rogers’ notion
of empathy; the therapist tries to put herself in the shoes of the patient, to embody the
patient’s felt experience, and to confirm the validity and reality of that experience from the
patient’s perspective.
Finally, the therapist commits to the dialogue by staying with these tasks without
considering as a viable option the rejection of either her own or the patient’s experience.
Commitment to dialogue means a surrender to an emerging reality in which the therapist is
changed as well as the patient.
Dialogue is a meeting of separate persons with two different perspectives; this meeting
influences what unfolds for both patient and therapist. The therapist allows herself to be
influenced and reports on the impact of the encounter. This reporting creates conditions that
expand the patient’s own awareness of their mutual influence. Expanded awareness of this
sort, awareness of the pattern of relationships influencing the structure of the current
situation, increases the patient’s capacity to accept his part in the situation, identify with his
felt experience (needs, interests, feelings), finish what remains unfinished for any gestalt, and
free energy to flow into the next novel pattern.
Contemporary trends in Gestalt therapy have emphasized the relational process in therapy
to a much greater degree than was the norm in the 1960s and 1970s. More recently, special
attention has been given to the potentially shaming effects the therapist can have on her
patients when she ignores or disavows her own contributions to how events are shaped (Lee
& Wheeler (1996; Yontef, 1993). For example, evaluating the patient as overly dependent and
not taking full responsibility for his needs and feelings can completely ignore how the power
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

dynamics between therapist and patient and/or the therapist’s refusal to look at aspects of her
own experience may be helping to block a patient’s access to choices (and therefore
responsibility) in the therapeutic relationship. The focus has widened, especially in the mid
1990s through the present, to include the way that various sociocultural factors, in particular
the pervasive individualism of Western Europe and North America, tend to define need as a
weakness, to limit the supports available to some patients while also interfering with any
rigorous investigation of how these limits are widely reinforced (see especially Wheeler,
2000). An appreciation for how people share responsibility for the outcome of a relational
endeavor has further articulated what was already inherent but not focused on in the gestalt
therapy theory publicized in the 1950s and 1960s.

Techniques Used

Gestalt therapy uses various techniques, all of which are a part of some experiment that
emerges organic to specific moments in the therapeutic work. It matters very little which
technique is chosen, just as long as it is used in the service of experimental phenomenology
and is accepted by the patient. It is not advantageous for the gestalt therapist to develop a
fixed formulary of techniques to be used prescriptively; creativity with a fluid range of
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Gestalt Therapy 101

experimental techniques is valued and even encouraged (Jacobs and Yontef, 2000; Zinker,
1977).
The most commonly used experimental technique in gestalt therapy is awareness
focusing. Focusing is a function of the phenomenological method, requiring the therapist and
patient to bracket assumptions, to describe experience directly and concretely, and to treat all
that is noticed as relevant. Questions such as ‘What are you experiencing right now?’ or
‘What are you feeling as you say that?’ are focusing experiments which the patient can
choose to use or not use.
Focusing awareness on the body is a particular kind of focusing technique often used in
gestalt therapy, especially awareness of breath and breathing patterns. Anxiety is understood
by gestalt therapists to be the byproduct of excitement, i.e., arousal or any emotional
coloration, which does not have enough support (e.g., interruption of breath support and a
focus on the future rather than the present moment) (Yontef, 1995). Focusing awareness on
the pattern of breathing is an experimental technique that aims to bring the patient’s contact
with support (air) into the foreground. Any movement pattern can become the center of a
body awareness experiment and provides an entrée into the patient’s relationship to
fundamental environmental conditions (i.e., space, gravity and resistance). Working with
breathing or other coordinated movement patterns can happen in the context of any
therapeutic sequence or can become the central focus of a thoroughly body-oriented Gestalt
therapy (Kepner, 1987; Frank, 2001).
The practice of inclusion is itself an experimental technique that offers the therapist the
chance to notice what she experiences when she empathizes with the patient. The therapist
may also engage in a focusing experiment by attuning to what she is aware of as she repeats
words or phrases the patient has expressed or imitates movement patterns initiated by the
patient.
This last example utilizes expression and enactment techniques as well as focusing and
demonstrates the potential synergy of multiple techniques. Expression and enactment
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

techniques are simply ways of using voice and body movement to bring needs and feelings,
especially hidden or unnoticed experiences, into the foreground. This is often accomplished
through the exaggeration of something already said or done, or the translation of one form of
expression into another. For example, the patient may lightly slap his knee while mentioning
something about his boss and so the therapist might highlight the knee-slap, ask the patient if
he was aware of it, suggest that he repeat the movement, augment the force of the movement,
or even translate it (e.g., from slapping his knee to slapping a pillow, or putting words to the
movement). Or the therapist can slap her own knee, attend to what she notices and report on
her experience as part of the experiment. Whatever techniques are used in the experiment, the
aim is to enlarge the patient’s awareness of what is being felt or sensed. The aim is not to get
a cathartic experience or teach the right way to be expressive: it is an experiment.
Loosening and integrating techniques bring awareness of processes the patient holds
tightly together or keeps firmly apart. Loosening techniques engage the patient’s imagination
to construct a fantasy of the very opposite of what he assumes or believes to be true.
Loosening is helpful when the patient struggles to consider possible alternatives to the current
structure of things. For example, when the patient has a fixed idea of himself as shy, the
fantasy of himself behaving in an outspoken way may enlarge his awareness of aspects of his
self experience that may be considered bold. Integrating techniques, on the other hand, bring
together in the patient’s awareness processes what he actively separates. The therapist
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 102 Gary Yontef and Mark Fairfield

suggests that the patient hold together in a single frame what he has previously polarized. The
patient may be asked to say in one phrase two dissonant ideas which he has separately
endorsed (e.g., ‘I am undesirable and I want to be desired.’). This can be especially difficult,
necessary, and powerful with patients with certain character disorders in which there is a total
splitting of opposites. Bridging ideas and feelings with physical sensations is another potent
integrating technique (e.g., ‘Where in your body do you feel angry?’).
There are also numerous uses of fantasy experiments in gestalt therapy. These
experiments can work on early developmental issues (e.g., imagining a perfect loving
mother), spiritual issues, anticipating situations in order to clarify fear, and so forth.
Gestalt therapy also utilizes homework assignments in which the therapist makes
suggestions on how the patient can continue the exploration between sessions. These may
include journaling, periods of meditation, reading, and creative work (poetry, art, music).

STRENGTHS AND LIMITATIONS

Strengths of this Theory

With its pragmatic roots and its emphasis on creativity, gestalt therapy has introduced
innovations in theory and practice that have been quite useful in the general psychotherapy
field, while contemporary gestalt therapists continue to elaborate and refine these innovations.
Whether as a complete system of theory and practice, or as a lens through which practitioners
of other systems may look for support, gestalt therapy offers many important strengths to the
psychotherapist.
The principles of existential dialogue provide guideposts that correct for a tendency that
is quite pervasive in the social sciences to privilege the perspective of an ‘expert’. If a
practitioner values an orientation that supports a more horizontal relationship between
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

therapist and patient, the conditions of dialogue as understood in gestalt therapy will provide
an indispensable support, as will the experimental phenomenology, an epistemological frame
and methodology which works against the pull towards privileging one’s own perspective.
The phenomenological method will also provide support for the therapist who is
interested in a more present-centered focus on single moments of unfolding process. Present
moments are treated as holographic representations of the structure of the whole situation and
so learning to engage more skillfully with present experience gives the therapist access to a
wealth of lively material with which to work.
Finally, gestalt therapy’s trust of organismic self-regulation and its paradoxical theory of
change will counterbalance the temptations to judge or change the patient’s behavior and will
resonate with those practitioners who favor a humanistic model of human development. There
is also considerable freedom granted to the therapist to trust her own creativity and to lean on
the meaningful supports assimilated from past experience, training, education and
appreciation for other theories and models. Gestalt therapy gives the therapist support for
being flexible and creative in working in a wide variety of settings, and with a wide variety of
patients and situations.
Gestalt therapy is an integrative system. It was born out of the need to cope with a
complexity of perspectives. It emerged in a historical period of conflicts between prevailing

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Gestalt Therapy 103

epistemological assumptions and newer developments in the sciences; it constructed a cogent

framework that could support ongoing grappling with diverse sources of knowledge. It
therefore offers the contemporary psychotherapist considerable support when she confronts
the availability of multiple theories and the extensive literature on the subject of ‘effective’
intervention strategies.
One case in point is the popularity of cognitive-behavioral therapy (CBT) interventions,
especially in the context of managed care systems where brevity has become the soul of
therapeutic effectiveness. On the one hand, CBT provides a solid framework for tracking and
identifying aspects of a patient’s cognitive process, underscoring links between certain beliefs
or cognitive sets and pervasive themes and moods shaping the patient’s ongoing experience.
On the other hand, CBT also encourages the therapist to impose a privileged perspective on
the subject of what is a ‘normal’ or ‘rational’ or ‘healthy’ way to think; consequently, the
CBT practitioner has little alternative but to confront the patient’s ‘irrational beliefs’ and
attempt to help the patient ‘reshape’ cognition to take forms that tend to accompany more
adaptive behaviors and euthymic mood states.
Gestalt therapy offers an alternative scenario. The gestalt therapist is very interested in
the patient’s cognitive process, along with other processes that can be tracked (e.g., emotional
process, body process, interpersonal process). The complexity of the situation must be
investigated, elements differentiated, and continuity tracked. But rather than evaluate
cognitive process as ‘irrational’ or ‘maladaptive’, the gestalt therapist invites the patient to re-
examine the beliefs and methods of thought; the patient and therapist have the option of
exploring how that process relates to the various concurrent elements of the patient’s
experience and learn how the patient’s cognitions relate to the unique perspective he holds. In
some very profound way, the Gestalt therapist learns how truly ‘rational’ the patient’s
cognitive frames can be from the patient’s point of view and the patient may learn not only
that there are other ways of thinking and believing, but more importantly, that old beliefs can
be re-examined.
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Limitations of this Theory

Gestalt therapy is meant to provide a framework that integrates a complexity of

experience and knowledge critical for the treatment of various conditions. When it is used as
though it provides in and of itself a comprehensive qualification for practice, the result will
likely be very limited and unequal to the complex problems with which a clinician is likely to
be faced. Training in gestalt therapy is not intended to be a complete qualification for the
competent practice of psychotherapy. Nor will the theory of gestalt therapy in and of itself
suffice to prepare clinicians for the specific problems associated with certain patient
populations, especially those with quite severe pathology
Diagnosis and treatment planning are examples of widely accepted dimensions of the
therapeutic process which do not have sufficient foundation in gestalt therapy theory. While
gestalt therapy provides excellent support for understanding people in general and particular
individuals, it does not provide enough information on types of dynamic personality patterns.
Since gestalt theory has not elucidated categories of illness, the proper classification of
specific psychopathology and its corresponding intervention strategies will require familiarity
with diagnostic nomenclature and standards of practice acknowledged by the professional
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 104 Gary Yontef and Mark Fairfield

discipline from which each therapist’s qualifications derive. This enables gestalt therapists to
benefit from the accumulated wisdom of the general professional community. Common
sense, experience and creativity are also important. Gestalt therapy alone (i.e., apart from the
knowledge and sensibilities it is so well capable of integrating and using) will not adequately
address many problems. Other auxiliary resources and supports are often necessary based on
what is being emphasized in the work (e.g., parenting classes, medication evaluation,
occupational therapy, guidance counseling, day treatment, nutritional counseling, etc.).
Given the broad discretion permitted to the gestalt therapist to be creative and
experimental in the work, it is important to maintain a working knowledge of other theories,
methodologies and research to guide and shape spontaneous creativity (Yontef and Jacobs,
2000). Gestalt therapy does not lay forth a curriculum for technical strategies, nor does it
offer a unique code of conduct. These are critical limitations of the theory (though they can
also been understood as strengths to the degree that they offer freedom to integrate technical
and ethical systems that fit for the therapist). The therapist is expected to make modifications
suited to the unique style and personality of the therapist as well as the personality and needs
of the patient in light of the diagnostic considerations. The gestalt therapist bears full
responsibility to execute professional judgment and fulfill legal and ethical obligations, and
this responsibility must at times limit creativity.
Gestalt therapy’s focus on the here and now has offered support in discriminating the
nuances of moment-to-moment process, while not directing the therapist’s attention fully
enough to questions about long-term developmental themes and character styles. The
contributions of psychoanalytic theory, especially newer developments in contemporary
relational trends (e.g., intersubjectivity theory in self-psychology) provide some additional
ground on which gestalt therapists can lean when thinking about a patient’s developmental
strivings. Some work has emerged that discusses how contemporary analytic theory can
expand the possibilities for gestalt therapists and vice versa (Hycner and Jacobs, 1995).
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

ASPECTS OF HUMAN FUNCTIONING NOT ADEQUATELY ADDRESSED

Gestalt therapy is a process theory; it can be used effectively with whomever the therapist
understands and relates. The basic principles of gestalt therapy must be adjusted to fit the
particular needs of each patient. As long as the therapist understands this, she can successfully
apply the principles of gestalt therapy theory and methodology (Yontef & Jacobs, 2000). The
advantage of gestalt therapy over many other systems is that these general principles can be
tailored in each clinical situation and to each patient's needs. There is no population or
problem with which gestalt therapy will not work, provided the therapist is familiar and
comfortable in those situations.
Gestalt therapy has been applied in a wide variety of settings, ranging from intensive
individual therapy several times per week to brief crisis stabilization. There is a long tradition
in gestalt therapy of working with groups, for purposes of both psychotherapy training and
ongoing clinical treatment (Frew, 1988; Yontef, 1990), though gestalt therapists have been
slow to articulate a clear and theoretically consistent model for group work (Fairfield, 2004).
In addition to the constricted, anxious and/or depressed patient generally thought to benefit
from gestalt therapy (Shepherd, 1970), patients with more serious problems are also treated,

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Gestalt Therapy 105

including psychotics and individuals with personality disorders (Yontef, 1993),

psychosomatic disorders, and post traumatic stress disorders. Gestalt therapists have also
worked as consultants to organizations and there is a substantial subculture of gestalt
practitioners exclusively devoted to organizational development (e.g., at the Gestalt Institute
of Cleveland).
Even with the here-and-now focus mentioned above, the patient’s character process will
certainly come into the foreground as a result of attending to what is happening and how it is
happening in each moment. Still a framework is needed to understand typical themes in
human development and how they are incorporated into patterns of self-regulation. Attention
to developmental themes will necessarily expand the enquiry beyond questions of ‘what’ is
happening and ‘how’ it is happening to include the question of ‘why’ it is happening.
Motivational states are not well discussed in the theory of gestalt therapy beyond the
consideration of dominant organismic needs and self-regulatory processes. Attention to
developmental strivings and how they continue to energize behavior will lead to a richer
appreciation for why for a particular patient certain supports are more usable than others
(despite any logic or common sense).

SUMMARY
The gestalt therapy movement was pioneered in the early 1950s (Perls, Hefferline, and
Goodman, 1951/1994) by a relatively small group of people based on theory first published in
1942 (Perls, 1969/1942) and has since flourished into a widely practiced model of
psychotherapy with hundreds of training institutes across the globe. Today there are
thousands of practicing gestalt therapists who have been thoroughly trained and supervised in
the gestalt therapy model. At the same time, there are unfortunately some who claim to be
gestalt therapists after having attended a handful of workshops but without undergoing a
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

systematic training in gestalt therapy. For this reason, it is critical for anyone who is
interested in working with a gestalt therapist, either for training or treatment, to make
enquiries into that person’s past training and experience. If well-trained, the therapist will
have much to offer. The use of phenomenological tracking of the experiences of both patient
and therapist, the unwavering trust in organismic self-regulation, the focus on awareness and
experimentation, the principles of existential dialogue, the paradoxical theory of change and
the emphasis on contact between therapist and patient all contribute to a model of effective
psychotherapy that will continue to support many therapists in their work and in their lives.

REFERENCES
Beisser, A. (1970). Paradoxical theory of change. In J. Fagan & I. Shepherd (Eds.). Gestalt
therapy now (pp. 77-80). New York: Harper.
Buber, M. (1958). I and thou (R. G. Smith, Trans.). New York: Charles Scribner’s Sons.
(original work published 1923).
Dewey, J. (1903). Studies in logical theory. Chicago: University of Chicago Press.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
 106 Gary Yontef and Mark Fairfield

Fairfield, M. (2004). Gestalt groups revisited: A phenomenological approach. Gestalt Review,

8(3), 336-357.
Frank, R. (2001). Body of awareness: A somatic and developmental approach to
psychotherapy. Cambridge, MA: Gestalt Press/The Analytic Press.
Frew, J. (1988). The practice of gestalt therapy in groups. The gestalt journal, 11(1), 77-96.
Goldstein, K. (1963). The organism. Boston: Beacon. (original work published 1939).
Hycner, R. & Jacobs, L. (1995). The healing relationship in gestalt therapy: A dialogic/self
psychology approach. New York: Gestalt Journal Press.
James, W. (1975). Pragmatism: A new name for some old ways of thinking. Cambridge, MA:
Harvard University Press. (original work published 1907).
Kepner, J. (1987). Body process: A gestalt approach to working with the body in
psychotherapy. New York: Gestalt Institute of Cleveland Press.
Koffka, K. (1935). Principles of gestalt psychology. New York: Harcourt, Brace & World.
Kohler, W. (1938). Physical Gestalten. In W. Ellis (Ed.), A sourcebook of gestalt psychology
(pp. 17-54). London: Routledge & Kegan Paul.
Lee, R. & Wheeler, G. (1996). The voice of shame: Silence & connection in psychotherapy.
San Francisco: Jossey-Bass Publishers
Lewin, K. (1938). Will and needs. In U. Ellis (Ed.), A sourcebook of gestalt psychology (pp.
283-299). London: Routledge & Kegan Paul.
Perls, F. (1969/1942). Ego, hunger and aggression. New York: Vintage Books. (originally
published 1942).
Perls, F., Hefferline, R. & Goodman, P. (1994/1951). Gestalt therapy: excitement and growth
in the human personality. New York: The Gestalt Journal Press. (originally published
1951).
Shepherd, I. (1970). Limitations and cautions in the gestalt approach. In J. Fagan and I.
Shepherd (Eds.), Gestalt therapy now. Palo Alto, CA: Science and Behavior Books.
Smuts, J. (1996). Holism and evolution. New York: Viking. (original work published 1926).
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Spinelli, E. (1989). The interpreted world: An introduction to phenomenological psychology.

London: Sage Publications.
Wertheimer, M. (1938). Gestalt therapy. In W. Ellis (Ed.), A sourcebook of gestalt
psychology. London: Routledge & Kegan Paul.
Wheeler, G. (2000). Beyond individualism: Toward a new understanding of self, relationship
and experience. Hillsdale, NJ: Gestalt Press/The Analytic Press.
Wittgenstein, L. J. J. (1974). Tractatus Logico-Philosophicus (D. F. Pears & B. F.
McGuinness, Trans.) London: Routledge & Keegan Paul. (original work published 1921).
Yontef, G. (1990). Gestalt therapy in groups. In I. Kutash & A. Wolf (Eds.), Group
psychotherapist's handbook. New York: Columbia University Press.
Yontef, G. (1993). Awareness, dialogue & process: Essays on gestalt therapy. New York:
The Gestalt Journal Press.
Yontef, G. (1995). Gestalt Therapy. In A. Gurman, & S. Messer (Eds.), Essential
psychotherapies: Theory and practice (pp.261-303). New York: The Guilford Press.
Yontef, G. & Jacobs, L. (2000). Gestalt therapy. In R. Corsini & D. Wedding (Eds.), Current
psychotherapies (6th ed., pp. 303-339). Itasca, IL: F. E. Peacock Publishers.
Zinker, J. (1977). Creative process in gestalt therapy. New York: Brunner/Mazel.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 In: The Quick Theory Reference Guide ISBN: 978-1-60021-624-4
Editor: Karin Jordan, pp. 107-125 © 2008 Nova Science Publishers, Inc.

Chapter 8

BEHAVIOR THERAPY: A FOUNDATIONAL OVERVIEW

Karin Jordan
Behavior therapy had its origin in the 1950s and early 1960s and has not only undergone
important changes, but also has expanded considerably (Spiegler and Guevremont, 1998;
Wilson, 2005). During the 1950s, psychoanalysis was popular and the introduction of
behavior therapy, was a radical shift. In the early 1950s, based on Hullian learning theory as
well as Pavlovian experiential research on classical conditioning with animals, Joseph Wolpe,
Arnold Lazarus and others used these findings to work with phobic clients. Wolpe (1958)
developed systematic desensitization -- one of the techniques still used today based on the
principles of classical conditioning and laboratory learning. It was during this time that
Burrhus Frederick Skinner studied operant conditioning as a way to modify, change and
control behavior. He believed that behavior change calls for some kind of positive or negative
reinforcement (Skinner, 1938).
Albert Bandura developed a social and cognitive learning theory, which was based on
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combining classical and operant conditioning while stressing the importance of cognitions,
and the value of modeling, imitation and self-efficacy. This was something that had been
rejected by Skinner. It was during the 1970s that several cognitive behavior approaches (e.g.
rational emotional behavior therapy [REBT] [Ellis, 1973], cognitive therapy [CT] [Beck,
1976], cognitive behavior therapy [CBT] [Meichenbaum, 1977]) were developed. It was also
in the 1970s that behavior therapy came to the forefront, when it was incorporated into social
work, psychology, and psychiatry. It was also being used in education, child rearing and
business. The approach kept on growing in the 1980s, especially in the area of behavior
medicine. According to Chambliss et al. (1998), empirical research has continued to
characterize behavior approaches to therapy and almost all behavior interventions have
obtained the status of being ”empirically supported” and “empirically validated”. In addition,
behavior therapy, unlike any other theoretical model, has developed specific treatment
techniques for specific treatment procedures to specific clinical problems (Hersen, 2002). It is
important to recognize that behavior therapy has changed since its inception, and today
encompasses a variety of conceptualizations and a vast array of treatment procedures. What
unites behavior therapy today is the focus on conducting a rigorous assessment and evaluation
(Kazdin, 1994). There are over 50 journals focusing primarily on behavior approaches to
research and therapy (Fishman & Franks, 1997), as well as behavior societies that have
formed all over the world.
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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 108 Karin Jordan

THEORY DESCRIPTION

Key People

There are several people that can be associated primarily with a behavior approach to
therapy, such as B.F. Skinner, who through his research determined that human behavior is a
function of its consequences. The responses that follow a behavior will tend to strengthen or
weaken it. Skinner also addressed the role played by one’s genetic make up. He also
encouraged focusing on observable and therefore verifiable behavior. In 1953, he wrote
Science and Human Behavior. Skinner was one of the most controversial pioneers in the field
of behavior therapy, and has been very influential in radical behaviorism, which posits that
“A person is first of all an organism, a member of a species and a subspecies, possessing a
genetic endowment of anatomical and physiological characteristics which are the product of
the contingencies of survival to which the species has been exposed in the process of
evolution. A person acquires a wide repertoire of behavior under the contingencies of
reinforcement to which he or she is exposed during his or her lifetime. The behavior that one
exhibits at any moment is under the control of a current setting. All organisms are able to
acquire such a repertoire because of processes of conditioning, to which it is susceptible
because of its genetic endowment.” (Skinner, 1974, p. 213)
Wolpe’ s significant contributions to behavior therapy included systematic
desensitization, which he first wrote about in Psychotherapy by Reciprocal Inhibition (Wolpe,
1958). The term “reciprocal inhibition” was later changed to “counter conditioning,”and
described by Wolpe:

As the therapy procedure has evolved, the anxious patient is first trained in progressive
muscle relaxation exercises and then gradually exposed imaginally or in vivo to feared stimuli
while simultaneously relaxing (Wolpe & Plaud, 1997, p. 969).
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Wolpe’s work attracted the attention of Arnold Lazarus and Gerald Davison, G. Terence
Wilson, and others who all contributed significantly to behavior approaches to therapy. For
example, Lazarus was a strong advocate for the integration of scientific procedures and
clinical practice (Lazarus, 1958). He also claims to have first used the term behavior therapy
(Lazarus, 1971):

The first time the term behavior therapy and behavior therapist appeared in a scientific journal
was when I endeavored to point out the need for adding objective, laboratory-derived
therapeutic tools to more orthodox psychotherapeutic techniques (p.2).

Lazarus, who early on embraced eclecticism, also developed a multimodal behavior

therapy approach (Lazarus, 1973b; 1989; 1997, 2005). Eysenck’s (a British psychologist and
personality theorist) primary contributions were two edited volumes of behavior therapy in
the 1960s, Behavior Therapy and the Neuroses and Experiments in Behavior Therapy. The
publication of both was instrumental in the dissemination of behavior therapy Eysenck, 1960,
1964). The interested reader might want to peruse the book edited by O’Donohue et al.,
(2001), A History of the Behavior Therapies: Founders’ Personal Histories.

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 Behavior Therapy: A Foundational Overview 109

Basic Concepts
Some core beliefs about behavior therapy and problem definition include: (a) problematic
behavior is learned and maintained in a way similar to healthy behavior, (b) assessment is an
ongoing process focusing primarily on the here and now, (c) treatment is uniquely designed
for each person and is chosen after a mutually established goal/contract between client and
therapist, (d) research is used to assess treatment methods which are specific and replicable,
and (e) outcome is assessed based upon the initial induction of behavior changes (O’Leary &
Wilson, 1987). Spiegler and Guevremont (1998) identified additional core beliefs: (1)
treatment is action oriented, and behavior is monitored in and outside the therapy session and
applied to real life situations, (2) if possible, treatment is conducted in the client’s natural
environment, (3) homework is generally an important part of the process of therapy, and (4)
self-management skills are taught for clients to apply to different areas of their life. Another
core belief is that treatment is designed to fit the unique needs of each client, by asking
important questions, such as: “What treatment, by whom, is the most effective for this
individual with that specific problem and under which set of circumstances?” (Paul, 1967, p.
111).
It is important to understand that behavior therapy has changed over the years, however
two things that have remained consistent in behavior therapy are that it is rooted in modern
learning theory and that it is based on empirical research. These tenets, while consistent, have
been challenged. For example, Lazarus (1997) reported that behavior therapy is not only
rooted in modern learning theory, but also draws from neuroscience, social psychology rather
should be identified as learning theories.

KEY CONCEPTS

Nature of the Person

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The view of human nature has changed in behavior therapy. Traditional behavior therapy
emphasizes genetic, neurochemical, and physiological factors and emphasizes that behavior is
shaped and determined by sociocultural conditioning. More specifically, behavior is the
product of environmental contingencies, i.e. behavior is the result of what has happened,
therefore all behavior is the product of learning through conditioning, modeling and
reinforcement. Radical behavior therapy, therefore does not encourage self-determination and
free will (Skinner, 1971).
There has, however, been a shift in behavior therapy. More specifically, modern behavior
therapists typically believe that people are the product and producer of their environment.
Behavior is learned, and therefore if people lack skills, they can learn to be more skillful, and
in situations of maladaptive behavior, people can learn new behavior. Learning new behaviors
gives people opportunities to choose from a variety of behaviors and therefore increase their
freedom (Kazdin, 1978).

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 110 Karin Jordan

Other Theories and/or Philosophical Underpinnings of this Theory

There are three theoretical underpinnings within traditional behavior therapy used to
describe human behavior. They are (1) classical conditioning, (2) operant conditioning and
(3) social learning theory.

Classical Conditioning
Ivan Pavlov, commonly associated with classical conditioning, showed in the early
twentieth century that while a stimulus generally would not result in an automatic response, it
could be made into one. He demonstrated that by ringing a bell (neutral stimulus) and then
feeding his dog some food (unconditional stimulus), the dog would salivate (conditioned
response). He repeated this process several times. Subsequently, he rang the bell without
giving any food, and the dog still salivated (conditional response). The bell had become a
conditional stimulus which elicited a conditional response. Classical conditioning was also
studied by Wolpe (1948), working with cats. He used a buzzer (neutral stimulus) and paired it
with shock (unconditional stimulus) and classically conditioned anxiety to the buzzer. When
the buzzer was on, food was inhibited. His belief was that if anxiety conditioned in cats
resulted in inhibited eating, then it would perhaps be possible to use this inhibited eating to
decrease the cat’s anxiety. He tested that belief by feeding the cats gradually, in cages that
looked drastically different from those in which they developed anxiety. Over time, when
feeding the cats, the cages when changed systematically to become more and more similar to
the ones in which they had developed anxiety, and they eventually ate in the original cages
(Wolpe & Plaud, 1997). This process can be identified as counterconditioning the cats by
substituting the eating response for the anxiety response. Wolpe concluded that under the
right conditions, the eating responses could be used to decrease anxiety. He then used the
same approach while working with clients with anxiety, although he did not use eating
responses to assuage anxiety but drew on progressive relaxation skills (Wolpe & Plaud,
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1997).

Operant Conditioning
Operant conditioning grew out of the belief that there is more to learning than using
classical conditioning to change behavior. Skinner (1938) focused on positive and negative
reinforcement. The underlying belief of operant conditioning is that every behavior is either
encouraged or not encouraged, depending on what happens after the behavior. Positive
reinforcement refers to an increase in the frequency of a response followed by a favorable
event (reward). Negative reinforcement refers to an increase in behavior as a result of
avoiding or escaping from an aversive event (e.g., a child studies harder so his teacher will
stop criticizing him). In punishment, an aversive event is contingent on a response, and this
tends to result in a decrease in the frequency of that response. Skinner (1938) conducted
recurring research with rats and pigeons, and through positive and negative reinforcement he
modified the animals’ behavior. He also used the Skinner box (which generally contains one
or more levers designed for an animal to press and one or more stimulus lights as well as
several spots where reinforcers such as food are delivered) to confine the animals and teach
them new behaviors. He later used operant conditioning with humans in clinical conditions to
either reinforce or eliminate behavior (Skinner, et al., 1953).

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 Behavior Therapy: A Foundational Overview 111

Social Learning Theory

Social learning theory was developed by Bandura (1963) and is often described as
building on both classical and operant conditioning. Subsequently, Bandura (1986) referred to
his approach as a social cognitive theory. From its inception, social learning theory rested on
classical conditioning, operant conditioning and cognition (observational learning and self
directed responses). Observational learning is based on the belief that observing others can
result in vicarious learning, and has been well documented in Bandura's experiments with
Bobo dolls (Bandura, 1971). An example of Social Learning Theory is people learning to
slow down on the highway when they see flashing lights and another car pulled over in front
of a police car. In this situation, people have learned that speeding gets punished with a
speeding ticket. Vicarious learning can occur from observing others. In addition, Bandura
believed that people learn from reciprocal behavior and environmental interactions (1978),
meaning that people can learn to change their behavior, and that these behavior changes are
self-directed. The most important concepts of social learning theory are that people are self-
determined and are self-efficacious, which means that a person has the ability to manage a
situation adequately (Bandura, 1977; Bandura & Adams, 1977). Social learning theory
generally focuses on helping clients develop more self-efficacy in areas that they have
difficulty mastering through the use of a wide range of behavior techniques.

HEALTHY VERSUS UNHEALTHY/DYSFUNCTIONAL

In behavior therapy, healthy function is defined as adaptive behavior, whereas
unhealthy/dysfunction is identified as maladaptive behavior. Behavior therapists believe that
anxiety is the key to most maladaptive behavior. According to Wolpe (1973), anxiety can be
learned and occurs when:
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a response has been evoked in temporal contiguity with a given stimulus and it is
subsequently found that the stimulus can evoke the response although it could not have done
so before. If the stimulus could have evoked the response before but subsequently evokes it
more strongly, then too, learning may be said to have occurred, (p. 5).

Therefore, people can learn to respond with anxiety to any stimuli, such as bugs, dirt,
certain sounds, some smells, and/or some people, even though these stimuli may not have
evoked anxiety in the past. More specifically, through conditioning a previously neutral
stimulus such as a spider can be paired with a threatening stimulus such as being bitten by a
spider. In this example, the anxiety evoked by being bitten is triggered by seeing the spider,
and the spider then becomes the stimulus that evokes anxiety. Primary stimulus
generalization relates to similar stimuli that evoke anxiety, such as in the example given, i.e.
other spiders will also elicit anxiety. It is important to remember that the more similar the
stimuli, the higher the level of anxiety, and the more dissimilar the stimuli to the original
anxiety producing experience, the less anxiety is evoked.
As described above, anxiety is a learned behavior that can become habitual to a specific
stimulus or be pervasive. In either situation, secondary symptoms generally follow, and can
include irritability, tremors, sweating, memory and thinking impairment, or stomach pain,
colitis and other untoward responses. Some of these behaviors might also elicit social
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
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 112 Karin Jordan

responses that are embarrassing to the client, and can lead to additional anxiety and add to an
already difficult situation. Some clients will deal with their anxiety through physical
avoidance and develop phobias, while others might terminate the anxiety through substances
such as alcohol, narcotics and other drugs. In those situations, it is the phobia and/or drug use
that can add to the anxiety and intensify a difficult situation. In addition, when entering
therapy these clients might not report struggling with anxiety, but rather report physiological
symptoms related to the anxiety or report having a phobia.
For behaviorally-oriented counselors and clinicians, psychopathology is mainly the result
of having acquired maladaptive behavior which is reinforced through the process of learning.
In addition, psychopathology can be the result of not having been able to learn enough,
resulting in a lack of skills to manage situations, e.g. a client presenting with either a deficit in
assertiveness skills or having learned maladaptive skills. Assertiveness training is introduced
to the client in the hope of either adding to existing skills or learning new skills.

THE CHANGE PROCESS

When considering the therapeutic change process, it is important to remember that the
underlying belief of behavior thinking is that human behavior is learned through conditioning,
imitation and reinforcement. The assumption is that all behavior is learned, both effective and
ineffective behavior, and is largely influenced by consequences such as attention giving or
other rewards, known as reinforcement. Therefore, in behavior therapy, change can also occur
in many situations wherein rewards are taken away (and do not follow a response). The belief
is that over time, maladaptive behavior can be extinguished through this process. In other
situations that entail a deficit in responding, the change process can include learning new
skills leading to adaptive behavior. In situations of anxiety causing the client’s behavior
disorder, change can occur through counter-conditioning, by pairing the anxiety-inhibiting
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responses with the anxiety-evoking stimuli. With enough pairing, this process can lead to
more adaptive responses and eventually will lead to the extinction of the maladaptive
response.
Finally, this approach focuses on scientific and empirical information. The change
process in behavior therapy can be seen as being a scientific process in which information
about unhealthy/dysfunctional behavior is carefully gathered and a plan is developed to help
clients unlearn maladaptive behavior and/or learn new adaptive behavior. In addition, it is
important to remember that empiricists only test that which can be observed and tested,
therefore their focus is generally on present behavior rather than past events. Behaviorists
therapists follow a systematic process of: (1) assessing the identified unhealthy/dysfunctional
behavior, (2) developing some hypotheses about the cause of the behavior being maladaptive
or a lack of skills, (3) setting up a plan of how to address the unhealthy/dysfunctional
behavior, (4) selecting behavior techniques (Hersen, 2002), based on empirical research
(Chambless, et. al., 1998), (5) assessing if the techniques chosen bring about the desired
behavior changes and (6) changing the behavior techniques when necessary. This occurs in a
collaborative atmosphere – the client is informed what will transpire, and his or her informed
consent is obtained.

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Behavior Therapy: A Foundational Overview 113

`Contemporary behavior therapy has evolved with a growing understanding that an

environment of sensitivity and compassion is needed to assist clients in the change process
fostered in a warm therapeutic relationship. Traditional beliefs that behavior changes can
occur simply through conditioning and reinforcement (since all behavior is learned) are
missing an important component in the change process. This was addressed by Goldfried and
Davison (1976) who reported that “any behavior therapist who maintains that principles of
learning and social influences are all one needs to know in order to bring about behavior
changes is out of contact with client reality” (p. 55). Lazarus supported the idea and stated
that change can only occur “in a non-coercive context of human dignity, empathy,
authenticity, and warmth” (Lazarus, 1971, p.205). Fishman and Franks (1997) reported that
the change process in behavior therapy has always been based on developing a sensitive and
caring environment. In this kind of an environment the client can learn appropriate behavior
such as how to be a competent asserter, expression of positive feelings, etc. by observing the
behavior therapist modeling that kind of behavior. In behavior therapy, the therapeutic
relationship is part of the change process, therefore behavior therapists must attend to it, as
well as to what behavior they model to their clients (Bandura, 1969; Perry & Furukawa,
1986).

THE THERAPEUTIC PROCESS

When considering the therapeutic process of behavior therapy, it is important to
remember that this approach has always been time-efficient and therefore cost efficient. This
has been true since its inception and is not the result of managed care mandated time-limited
treatment. Behavior therapy generally is problem focused and treatment is problem specific,
and the problem behavior is seen as the problem, rather than assuming that some underlying
cause must be unearthed, and therefore should be the target of therapy. Behavior techniques
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are not believed to be valid until they have been established to be reliable and valid, therefore
empirically supported techniques are used whenever feasible. In addition, process and
outcome evaluations are conducted in behavior therapy, so it could be considered one of the
most congenial therapy approaches for today’s managed care requirements.

Assessment and Diagnosis

In behavior theory, the assessment should be done in the client's natural environment and
could include using the ABC’s identified by Sommers-Flanagan and Sommers-Flannagan
(2003):

− A=antecedents (what happened just prior to the maladaptive behavior)

− B=behavior (the maladaptive behavior as described by the client using behavior
terminology [e.g. an “assertiveness problem” would be described in behavior terms
as being very “quiet”])
− C=consequence (what happened after the maladaptive behavior)

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 114 Karin Jordan

Doing naturalistic observations is not always feasible, and clients might not agree to
being observed and, it is important to remember that if they would give permission, that
having someone observe them would change the client’s behavior.
Assessment strategies commonly used in behavior therapy include: (1) Clinical
Interview, (2) Diagnostic Interview, (3) Standardized Questionnaires, (4) Self
Observations/Monitoring, and (5) Other.
Clinical Interview. This is one of the most commonly used assessment procedures.
Behavior therapists like to use this procedure as it gives them an opportunity to directly
observe clients as they talk about their problems. During a clinical interview, clients are asked
to put their problems in behavior terms. It is not enough for a client to report that he/she is
“anxious”, “lonely” or “sad.” The behavior therapist would ask questions that provide more
specific information about what the client is experiencing internally (physiological responses
and mood) as well as how he/she externally behaves. To elicit this kind of information, the
behavior therapist might ask the following questions:

− Please tell me what you are feeling in your body when you are anxious. How do you
behave when you are feeling anxious?
− Please tell me what being lonely looks like. What would I see if I was observing you
that would let me know that you are lonely?
− Please tell me what you do in a typical day when you are feeling sad? Start from the
time that you wake up…..what happens when you go to bed. Also tell me about your
night and how you are sleeping.

These kinds of clinical interviews, while valuable, are very subjective and can fluctuate
greatly from interview to interview.
Diagnostic Interview is a more objective interview process. The Structured Clinical
Interview has been specifically designed for the Diagnostic and Statistical Manual of Mental
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Disorders, Fourth Edition (DSM-IV) (First, Spitzer, Gibbon & Williams 1997). This
structured interview has a higher inter rater reliability.
Standardized Questionnaires are instruments with an established reliability and validity.
The standardized instruments should be objective, and for the radical behaviorist, assessment
should be limited to observable behaviors only, and not include internal mental processes.
Overall however, it can be stated that behavior therapists do use standardized instruments, as
they can be used to monitor client’s progress (Cormier & Nurius, 2003).
Self Observations/Monitoring asks clients observe and monitor their own behavior
outside of the therapy session. Since it is generally not feasible for the behavior therapist to
observe a client’s behavior in their natural environment, the self observation/monitoring
technique is used. The client is asked to monitor their own behavior, such as their smoking,
food, anger, etc., and they might be asked to keep a log of their:

− emotions-emotional disturbance
− behavior-behaviors associated with the emotional disturbance
− thoughts-thoughts that occurred with the emotional disturbance

While this approach can be cost effective, the data collected might also be inaccurate and
less comprehensive, as it is self-reported.
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 Behavior Therapy: A Foundational Overview 115

Other. Client maladaptive or partial learned behavior can also be assessed, and behavior
therapy can be monitored through audio or video taped recordings of client behavior.
Photographs have also been used for the same purpose. Additionally, in behavior medicine,
measures that register the client’s heart rate or blood pressure have been used (Gottman, et al.,
1995).

TREATMENT

Therapeutic Goals

The goal(s) of behavior therapy is to learn new behaviors which will ameliorate
maladaptive behavior. Goals in behavior therapy are straightforward, concrete and
measurable as specific behaviors are addressed that are relevant to the client. The goal is to
change the behavior, as it is the behavior that is believed to be the problem. The notion has
been rejected that the problem behavior is only the symptom of an underlying disorder and
therefore should not be focused upon. This also will prevent the development of new
symptoms or return of old symptoms. The goal therefore, is to deal with the maladaptive
behavior and/or inadequate learning. Emphasis is placed on present behavior problems rather
than past problems, as behavior therapists emphasize direct observation and assessment of the
problem behavior and how it is affecting the client’s everyday life, with goals focusing on
present behavior problems. The process of goal setting in behavior therapy, according to
Cormier and Cormier (1998), is a collaborative process between the client and the therapist
and needs to be agreed upon. Reaching an agreement might involve negotiation between the
client and behavior therapist. According to Cormier and Cormier (1998) there are seven steps
involved in the goal setting process:
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1. The counselor provides a rationale for goals, explaining the role of goals in therapy,
the purpose of goals, and the client’s participation in the goal setting process.
2. The client specifies the positive changes he or she wants from counseling. Focus is
on what the client wants to do rather than what the client does not want to do.
3. The client and the counselor determine whether the stated goals are changes “owned”
by the client.
4. Together, the client and the counselor explore whether the goals are realistic.
5. The cost-benefit effect of all identified goals are explored, with counselor and client
discussing the possible advantages and disadvantages of the goals.
6. Clients and counselor then decide (1) to continue seeking the stated goals, (2) to
reconsider the client’s goals, or (3) to seek a referral.
7. Once goals have been agreed upon, a process of defining them begins. The counselor
and client discuss the behaviors associated with the goals, the circumstances required
for change, the nature of sub-goals, and a plan of action to work toward these goals.
(pp. 228-231)

As seen above, goal setting is part of the collaborative relationship between the client and
behavior counselor (Spiegler & Guevremont, 1998). This process often makes clients feel

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 116 Karin Jordan

empowered because they are active participants in the goal setting process. In addition,
focusing on specific behaviors that the client wants to work on contributes to the feeling of
empowerment.

Specific Techniques

In behavior therapy, there are a variety of techniques used that are based on classical
conditioning, operant conditioning and social learning theory. Since the underlying
assumption of behavior therapy is that all behavior is learned, the goal is to help the client to
change the environment and behavior consequences. There are a variety of behavior
techniques reported in the literature (Corey, 2004; Day, 2004; Ivey, Ivey & Simek-Downing,
1987) including such procedures as:

− Reinforcemen t- “… a response, in the form of a reward or of punishment, intended

to change the probability of the occurrence of another person’s previous response.”
(Goldenberg & Goldenberg, 1990, p. 329)
− Modeling - in behavior therapy means modeling successful coping which clients
vicariously learn, however it is important that modeling is done in an appropriate and
sensitive way. This means that the behavior therapist uses models of successful
coping behavior and provides an opportunity for the client to acquire new skills at the
same time. A good example of this is a group for clients with panic disorders which
has been proven to be an effective place to model behavior, as well as new skill
acquisition (Craska, 1999).
− Systematic desensitization - is believed to be a combination of Jones’
de-conditioning approach along with Jacobson’s Progressive Muscle Relaxation
(PMR) (Jones, 1924). Jacobson (1978) identified this technique of helping anxious or
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

disturbed clients. Clients must first be trained in PMR, and after that, they are asked
to build a fear hierarchy, ranging from no distress (rated as 0) to total distress (rated
as 100), (Cormier & Nurius, 2003; Goldfried & Davison 1994). In the therapy
session, the client first engages in PMR to reach deep relaxation and then in vivo
(exposure to the actual feared situation) or through imagination, the client is exposed
to the least feared item. Gradually the client is exposed to the more feared item to
eventually reach the most feared item on the hierarchy. During this process, should
the client experience severe anxiety, he/she will use PMR until he/she has overcome
the anxiety through relaxation. Desensitization sessions generally last from 15 -30
minutes, as the process of concentration and relaxation as is required with this
technique is difficult to maintain for longer time periods.
− Aversion therapy - this technique is rooted in classical conditioning and used
effectively to decrease or eliminate behavior. This is achieved by pairing the
maladaptive behavior (e.g. fingernail biting) with something un-enjoyable (e.g. chili
powder under the nails). This kind of pairing will hopefully soon result in the person
associating the undesirable behavior (fingernail biting) with something un-enjoyable
(chili powder taste) and result in a change of behavior (decreased or elimination of
fingernail biting).

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Behavior Therapy: A Foundational Overview 117

− Relaxation technique s- Edmund Jacobson was the first scientist to write about this
technique (Jacobson, 1924). In his book Progressive Relaxations he described
techniques that are still used today (Jacobson, 1938). Progressive Muscle Relaxation
(PMR) is a technique in which the client is asked to tense (for 10-20 seconds) and
then relax (for 10-20 seconds) certain muscles groups, to achieve deeper relaxation.
Clients should be provided with instructions for where and how often to practice
PMR. Using a PMR audiotape or CD is helpful for practicing this technique. It is
important to remember that PMR is only one of today’s many other relaxation
techniques (e.g. breathing retaining, meditation, autogenic training, imagery, etc)
(Benson, 1976; Bernstein & Borkovec, 1973; Hersen, 2002)
− Assertiveness training - behavior therapists believe that assertiveness is learned
behavior (Alberti & Emmons, 1970; Lazarus, 1973; Wolpe, 1973). There are
generally three behavior styles: passive, aggressive and assertive. In the 1970s, more
focus was placed on assertiveness, and less on the other two styles. It was during this
time that several self help books were also published, including Your Perfect Right:
Assertiveness and Equality in your Life and Relationships, which has had eight
revisions since its original publication (Alberti & Emmons, 2001). Assertiveness
training focuses on introducing oneself to others, engaging in social conversation,
giving and receiving compliments, making requests as well as saying no, and letting
others know one’s own opinion. The process of going through assertiveness training
includes raising the client’s awareness and practicing what tone of voice to use, body
posture, and appropriate eye contact. Feedback is provided immediately.
Assertiveness is practiced through role-plays, with the behavior therapist serving as a
coach by whispering feedback and instructions. At other times, assertiveness training
is modeled by the behavior therapist, and if the training occurs within the context of
an assertiveness group, by group members. Social reinforcement is provided by the
behavior therapist and in assertiveness groups, by group members through positive
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feedback. In addition, relaxation techniques are taught as part of the assertiveness

training to help the client reduce his/her anxiety in social situations. Today,
assertiveness training is used in situations such as social phobias. The behavior
treatment protocol has changed very little (McNeil, Sorrell, Vowles & Billmeyer,
2002).
− Token economic s- this intervention is based on giving small rewards for
appropriate/desirable behavior. The small tokens can later be traded for a large
reward, such as special story time, an outing with one or both parents, or getting
something material such as a toy or book, etc.

There are many other techniques that behavior therapists use today, to list just a few:
education, self-monitoring, scheduling, satiation, charting, contracts, and homework.

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 118 Karin Jordan

Phases of Treatment

There are several phases of treatment in behavior therapy:

− The first phase is assessment, when the behavior therapist will gather information
about situational antecedents through the use of assessment tools, including the
severity of the problem and (possible) consequences of the problem.
− The next step in the assessment phase is to ask the client to clarify the problem.
− During the assessment phase, the client also is asked to identify what his/her target
behavior is.
− The next phase, goal setting, is a collaborative effort in which the therapist and client
set the goal for therapy (Spiegler & Guevremont, 1998).
− The problem maintenance phase is next, when the client is asked to identify what the
present conditions are that help maintain the problem.
− The change plan phase consists of three parts: (1) developing a change plan, (2)
implementing the change plan, and (3) monitoring the change plan as it is
implemented.
− The next to last phase, known as the evaluation phase, is a time to assess the success
of the change plan.
− The final phase focuses on follow-up assessments

The Nature of the Therapeutic Relationship

As the behavior approach has evolved, there has been some controversy as to the
changing role of the behavior therapist (Franks & Barbrack, 1983; Goldfried & Davidson
1976; Lazarus, 1971). Today’s behavior therapists are compassionate, warm, empathic and
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

sensitive, rather than stiff and scientifically inclined individuals with lab coats. They are
respectful of the client’s dignity and freedom and see the client as an important part in the
process of therapy. The relationship is one in which the client and behaviorist are partners,
who are in open communication and work closely together on goal setting and reaching goal
achievement, which can include unlearning old maladaptive behavior and learning new
behavior. Interventions are openly discussed with the client and practiced in the therapy
session as well as outside of therapy. The behavior therapist encourages clients to ask
questions, and his/her responses to them are open and direct. Therefore the best way to
describe the therapeutic relationship in behavior therapy is with the term “partnership”. Glass
and Arnkoff (1992) reported that clients engaged in behavior therapy rated their therapist as
empathic, understanding and generally warm. Slone et. al. (1975) compared behavior therapy
with psychoanalytic psychotherapy by reviewing tapes, and noticed that behavior therapists
were rated significantly higher in accurate empathy, genuineness and depth of interpersonal
contact. These findings are not surprising, considering that the behavior therapist must
establish a secure precondition based on trust and positive expectations when introducing
behavior techniques such as modeling or systematic desensitization.

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Behavior Therapy: A Foundational Overview 119

EFFECTIVENESS, LIMITATIONS, FUTURE DIRECTION

Effectiveness of this Theory

The effectiveness of behavior therapy has been tested with various populations and
disorders. The effectiveness of behavior techniques has been assessed with children and
adults. Two studies conducted by Weisz and his colleagues (Weisz et al., 1987; Weisz et al.
1995) examined the effectiveness of behavior therapy with children. In the first study, a meta
analysis was conducted on 108 well-designed studies published between 1958 until 1984,
focusing on clients in behavior therapy between the ages of 4 and 18 years of age. The results
indicated that behavior therapy was more effective than other approaches. A second study
was conducted by Weisz and colleagues, again a meta-analysis, on 150 new studies published
between 1983 until 1993. The criteria of these studies were similar to those used in the first
meta-analysis, and the results were again positive, indicating behavior therapy was more
effective than other approaches. It is important to remember that neither of these meta-
analyses adequately represented other forms of child therapy, such as play therapy, and this
should be assessed in the future.
Smith, Glass and Miller (1980) also conducted a meta-analysis to assess the effectiveness
of behavior therapy with adults, using 101 studies that focused on systematic desensitization.
Study results indicated a better outcome in comparison to those with placebo treatment.
Shapiro and Shapiro replicated this study in 1982. They used a better design, including only
studies that had two treatment groups and one control group. In addition, only studies
conducted within the previous five years were included. Although it appeared that treatment
outcome was more related to the type of behavior problem presented, Shapiro and Shapiro
concluded that behavior therapy modestly, but undeniably was superior to other approaches.
Grawe and colleagues conducted another study in 1998, a meta-analysis of controlled
outcome studies of over 3,400 clients, and found that behavior therapy was superior to client
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centered and psychodynamic therapy.

There have been a variety of studies conducted to assess the effectiveness of behavior
therapy with specific disorders, such as panic disorders, eating disorders and obsessive-
compulsive disorder. The effectiveness of behavior therapy with panic disorder was studied
by van Balkom and associates (1997) by conducting a large meta analysis of 106 studies,
involving 5,011 clients and over 200 treatment conditions. Results revealed that multiple
methods of behavior therapy and exposure methods were effective with clients with panic
disorders. There have been four meta-analyses (Hartman, Herzog & Dinkman, 1992;
Lewandowski et al., 1997; Whitbread & McGowan, 1994; Johnson, Tsoh & Vernado, 1996)
assessing the effectiveness of behavior therapy in eating disorders. Results revealed that
cognitive behavior therapy was superior over behavior therapy, but not superior to using other
treatment approaches outperforming pharmacological (generally antidepressant) treatment.
There have been several studies conducted on the effectiveness of behavior therapy and
obsessive-compulsive disorder (OCD). One of these meta-analyses (including 86 studies) was
conducted in 1994 by van Balkom and associates. The results revealed that on clients self-
ratings, behavior therapy was more effective than antidepressants, and behavior therapy in
combination with antidepressant was more superior to only antidepressants. Abramowitz
(1997) reported that the findings of van Balkom and associates were similar to other studies,

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 120 Karin Jordan

indicating that the behavior therapy approach is appropriate for OCD and can be used with
and without antidepressants.
The effectiveness of various behavior methods includes, but is not limited to social skills
training and relaxation techniques. Social skills training was assessed by Corrigan (1991) who
conducted a meta-analysis on 73 studies. These studies included four client populations: the
developmentally disabled, legal offenders, psychotic and non-psychotic. One study revealed
that social skills training was most effective with the developmentally disabled and least
effective with legal offenders. Relaxation training has been assessed by Hyman and associates
(1989), who included 48 experimental studies in which relaxation training was used to treat
health-related symptoms such as hypertension, headaches and insomnia. Study results
revealed an effectiveness ranging from .43 to .66.
All of these studies reveal that behavior therapy is an effective approach, not only with
different populations, but also with different disorders. In addition, the effectiveness of
behavior techniques has been demonstrated with different populations. All of these findings
are indicators of the many strengths of behavior therapy.

Limitations of this Theory

Behavior therapy has been criticized in several areas. For example, from a
psychoanalytical perspective, much of the existing research in behavior therapy focuses only
on short-term success and is generally limited to a specific behavior, not an underlying cause
such as an unconscious conflict. Psychoanalysts often see this kind of research as superficial,
as it only focuses on behavior rather than an enhanced insight or deeper self-understanding.
They also believe that there is no difference in outcome between psychoanlytical and
behavior therapy (Sloane et al., 1975). Humanists believe that behavior therapy is missing the
human sense of values, such as happiness or harmony, not only in their treatment, but also in
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assessing outcome of therapy. They also believe that behavior approaches are mindless
reconditioning of contemporary problems. From a contextual perspective, behavior therapy is
limited because maladaptive behavior is generally viewed as context free. It also raises the
question of what is normative behavior. Is it how the dominant culture, which generally
means white middle class, behaves (Kantrowitz & Ballou, 1992)? Also, if maladaptive
behavior is treated without knowing the context in which it occurs, it might be problematic.
For example, consider a woman reporting assertiveness difficulties who is also in an abusive
relationship. Teaching this woman assertiveness skills might have negative consequences,
such as increased abuse, raising the question of what is successful treatment outcome. In
addition, from a contextual perspective, behavior therapy fails to see the larger system (e.g.
the couple system or family system) as the therapeutic unit. They believe that treatment will
alter behavior patterns both in the individual as well as the system they function in. Finally,
from an integrationist perspective, there is no one single therapy approach that is complex
enough to be used with clients’ complexities. An integrationist might therefore say that
behavior therapy is merely classical eclecticism.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Behavior Therapy: A Foundational Overview 121

Future Directions

Over the last three decades, the development of new behavior therapy techniques has
been explosive. Today however, the focus is not on developing more behavior techniques, but
rather to fine-tune and improve existing techniques. In addition, emphasis is placed on
developing operationally explicit treatment manuals for specific clinical disorders. Behavior
therapy, while not developing new behavior techniques, will grow in three new areas: (1)
pharmacotherapy, (2) health care, and (3) realistic behavior changes.

1. Pharmacotherapy- refers to using behavior therapy to increase medication

compliance. It also refers to combining behavior therapy with pharmacotherapy, as a
way to maximize change (Glass & Arnkoff, 1992).
2. Health care-Behavior therapy use is two fold: first, it can be used to prevent certain
medical conditions (e.g. obesity through learning to comply with better health habits
such as exercise, low fat diet and limited food intake) as well as helping in the
recovery process (e.g. cardio problems by learning to comply with better health
habits such as exercise, stopping to smoke, relaxation and stress management) (Glass
& Arnkoff, 1992).
3. Realistic behavior changes-focus on developing realistic goals with the client on
what can and should be changed (Goldfried & Davidson, 1994). This also means that
there are things that the client might not be able to change and therefore must learn to
accept (Jacobson & Christianson, 1998; Wilson, 1996). Techniques used in this
process include such things as an accepting therapeutic relationship, education, etc.

CONCLUSION
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The behavior zeitgeist as described above was rooted in the work of Skinner, Wolpe and
others. Behavior therapy can be described as flexible in its behavior techniques, which in
general have been empirically validated. Behavior therapy research has resulted in having a
good understanding of which specific behavior techniques are most effective for which
specific problems. Some limitations to this approach are that behavior therapy does not look
at maladaptive behavior within a larger context and empirical research is generally limited to
specific behaviors. Today, behavior therapy development means improving existing behavior
techniques, developing treatment manuals, and consolidating its gain of three decades of rapid
growth. Growth in behavior therapy is expected to continue in the areas of pharmacotherapy,
health care and realistic behavior changes.

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 124 Karin Jordan

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 Behavior Therapy: A Foundational Overview 125

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Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 In: The Quick Theory Reference Guide ISBN: 978-1-60021-624-4
Editor: Karin Jordan, pp. 127-139 © 2008 Nova Science Publishers, Inc.

Chapter 9

RATIONAL EMOTIVE BEHAVIOR THERAPY

Albert Ellis

Rational Emotive Behavior Therapy (REBT) is the first of the modern cognitive behavior
therapies (CBTs) and was developed from 1953 to 1955, after I had abandoned the practice of
psychoanalysis, which I had been doing since 1947. I was always skeptical of Sigmund
Freud’s classical theory and practice of psychoanalysis, and published a monograph in 1950,
An Introduction to the Scientific Principles of Psychoanalysis.
I was therefore a neo-Freudian--and more of a neo-Adlerian--who followed the
procedures of Karen Horney, Erich Fromm, and other analytic revisionists. I also used the
humanistic-existentialist teachings of my training analyst, Dr. Richard Hulbeck. I decided in
1953 to stop calling myself an analyst and became much more active-directive and behavioral
than I had previously been. So I reviewed the more than 200 systems of psychotherapy that
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were being practiced at that time, produced a monograph in 1955, New Approaches to
Psychotherapy Techniques, and reread many ancient and modern philosophers before
formulating REBT. My philosophic leanings went back to 1928, when I was about to enter
college at the age of 15. I had my own emotional problems--largely with performance
anxiety--and I thought that the answer to them could be found in the more rational thinking of
the ancient and modern philosophers.
During my teens, I devoured Asian, Greek, and Roman philosophy, especially that of
Confucius, Lao-Tsu, Siddharta Gautama Buddha, Socrates, Epicurus, Epictetus, and Marcus
Aurelius, and started formulating my own rational principles. Unfortunately, my
psychoanalytic training and practice sidetracked me somewhat. So when I largely abandoned
psychoanalysis for more cognitive-behavioral methods, I reread considerable philosophy and
came up with REBT, which combines behaviorism with philosophy.
When cognitive behavior therapy started to follow my lead in the mid-1960s, with the
writings of Aaron Beck, William Glasser, Donald Meichenbaum, Albert Bandura, and others,
it consisted largely of cognitive informational processing and of practical homework
assignments, while REBT included these methods but has always been highly philosophical.
In addition, REBT always included highly forceful and emotional methods, since I
emphasized, in my first major paper on REBT in 1956, that thinking includes emotion and
behavior, that emotion includes thinking and behavior, and that behavior includes thinking
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 128 Albert Ellis

and feeling. We often falsely see them as disparate processes; but actually, they are combined
and integrated; they strongly influence each other; and they all have to be changed if people
are to minimize their emotional dysfunctioning and live more happily. Recently, the cognitive
behavioral therapies are beginning to take integrated thinking-feeling-acting approaches, but
REBT has done so for several decades.
My emphasis in REBT on thinking, feeling, and action was probably distinctly influenced
by my perusal of Buddhist teachings. For Buddhism first posits Enlightenment or hard-
headed conscious thinking about yourself and your dysfunctions. Simultaneously, it
encourages you to be emotionally, strongly, and determinedly committed to changing
yourself and it gives you evocative-experiential exercises to help you do so. It also
recommends your following, being attached to, and having faith in a guru or teacher. Finally,
it firmly pushes you to act against your passive tendencies, to practice rigorous training and
retraining, to do rather than stew. So it is anti-habitual and highly behavioral. It actively-
directively uses, therefore, all three of your healthy functioning processes--cognition,
emotion, and behavior. Even when it uses inactive methods--such as calm meditation--it
recommends active elements such as mindfulness meditation. You actively watch yourself
while meditating; and you often achieve a highly emotional state. REBT and Buddhism, of
course, also stress perception: You perceive “reality” in order to change it.
Although some forms of Buddhism--such as extreme Zen Buddhism--are too mystical
and romantic for my realistic leanings, Buddhism’s main principles significantly overlap with
Rational Emotive Behavior Therapy basic philosophies. This, I have found in recent years, is
particularly true of the similarities between Tibetan Buddhism and REBT. Since the 1980s,
Tensin Gyatso, His Holiness The 14th Dalai Lama has collaborated with psychological,
physiological, and social scientists to test and possibly validate some of the main Buddhist
hypotheses. He has consistently worked with the psychiatrist Howard Cutler, the psychologist
Daniel Goleman, and many other scientists to integrate Buddhism with Western science.
Similarly, Ron Leifer, another psychiatrist, Jon Kabat-Zinn, a physicist, and several other
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Western scientists have steadily used Tibetan mindfulness meditation in their own life, have
studied with reputable Buddhist gurus, and have integrated Buddhism with Western
psychotherapy and science. Very good--but also subject to human prejudice. When the
followers of one religious or philosophic discipline are converted to another system--such as
Paul, reared as a Jew, was converted to Jesus’ Christianity--they almost inevitably become
overly prejudiced in favor of the new system, and fanatically fail to see its shortcomings. So
the faith of the 14th Dalai Lama and other Buddhists is to be viewed with some skepticism
when it strongly favors poetic and romantic principles and practices.
My own favoring of Buddhism is--I hope--more impartial. I am certainly not a Buddhist
and only lightly practice a relaxing form of meditation that is not Vipashyana or mindfulness
meditation. Moreover, I have a long history of being skeptical of psychoanalysis, pure
behavior therapy (à la B.F. Skinner and Joseph Wolpe), Gestalt Therapy (of Fritz Perls),
Rogerian psychotherapy, extreme post-modern therapy, and even radical constructivist
therapy. I use elements of all these systems but am hardly devout in my adherence to or
practice of them. I think I am a born and reared skeptic and tolerator. I hope I am also not a
devout REBTer, since I do not think it is an unmitigated cure for everyone and do accept its
distinct limitations.
I have described what REBT is almost ad nauseam in over 50 books and about 500
articles, so I shall be brief about its main aspects now. You can get more details, if you wish,
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Rational Emotive Behavior Therapy 129

in Overcoming Destructive Beliefs, Feelings, and Behaviors; Feeling Better, Getting Better,
and Staying Better; and The Road to Tolerance. Assuming that you have not read these
books, here in highly summary form, is what Rational Emotive Behavior Therapy is about.

THE TYRANNY OF THE SHOULDS AND MUSTS

I formulated one of the fundamental ideas about how people largely construct their own
emotional disturbances and dysfunctioning from combining the stoic philosophy of Epictetus
with the idealized image notions of Karen Horney. Epictetus, after serving as a Greek slave to
his Roman master, was freed during the first century A.D. and founded the stoic school in
Rome. He had many wise things to say, but I was particularly impressed with his statement,
“It’s never the events that happen that make us disturbed, but our view of them.” That is why I
practiced psychoanalysis from 1947 to 1953, but never emphasized Freud’s theory that your
early childhood happenings and experiences make you anxious, depressed, and raging.
Epictetus strongly held that your view of these (and later) events disturbed you; and that you
could, as an adult, change this view. So he was one of the first constructivists.
In 1950 I read Karen Horney’s notion that most of us invent an idealized image or picture
of ourselves, and afflict ourselves with “the tyranny of the shoulds.” “Right on!” I said to
myself--and lost more faith in Freud and in the conditioning theories of J.B. Watson and B.F.
Skinner. Horney, noted, agreed with Epictetus--we humans largely construct our neuroses and
can deconstruct and reconstruct them. How? By realistically and logically rethinking our
notion of how we make ourselves neurotic; by being strongly (emotionally) determined to
revise them; and by forcefully and persistently acting against them.
There I had it--the first essentials of REBT. So I began to teach this REBT view of good
mental health to my clients--together with less and less psychoanalytic interpretations of how
they became upset and could, with these insights, manage to unupset themselves. I also--
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

because, from 1943 to 1947, I was an active-directive eclectic therapist--and included some of
my prior eclectic techniques into my liberal--very liberal!--psychoanalytic explanations.
Finally, by the end of 1953, I realized that all the talk in the world wouldn’t help my
clients with severe personality disorders unless they were also determined to take some
action--such as in vivo desensitization--against their habitual thoughts, feelings, and
behaviors. So I stopped my psychoanalytic practice and began to develop an integration of
thinking, feeling, and behavioral methods that later turned in to REBT.

THE VAST DIFFERENCE BETWEEN DESIRING AND MUSTURBATING

As I began to see that absolutistic shoulds and musts were tyrannical and almost always
led my clients to construct self-defeating behaviors, I also saw that their having strong desires
could not be eliminated, since people stay alive and fulfill themselves by desiring, and often
strongly desiring, food, clothing, shelter, love, sex, and other goals; and therefore, if they had
little or no desires, they could hardly survive and be happy. So I formulated the REBT
proposition that healthy desires and preferences are useful but destructive desires and
obsessive desires can easily create trouble. Healthy desires include, “I distinctly want such

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 130 Albert Ellis

things as sex and love, and may strongly desire them; but if I am deprived of them, I will feel
frustrated and annoyed, but will hardly die.” So I held that your being thwarted in your
desires would usually lead you to healthy feelings of frustration and regret, but not to the
unhealthy, destructive feelings of anxiety, depression, and rage. “Because I want sex and
love, I also absolutely must get them,” is a belief that frequently will create anxiety,
depression, and rage.
Even extreme healthy desires--such as your wanting someone to solely love you forever--
are risky, since they are easily thwarted and will bring you great sorrow and sadness when
they are not fulfilled. So some Buddhist groups view strong desires as foolish, while REBT
views them as risky but okay if you’re willing to take the risk. However, extreme demands--
e.g., “I need you to love me more than anyone was ever loved”--are too risky, and may lead
you to feel depressed.
It is hard to draw an exact line between extreme desires and demands. But you can
usually do so by recognizing the obsessive-compulsive quality of the latter. Thus, if you keep
joyfully making more money after you have already gained a million, we could say that you
are engaging in healthy strong desire. But if you have millions and you still fight others for
every extra penny and you have no interest in life other than amassing more money, we could
say you were desperately and commandingly greedy. Your desires are frantic and obsessive,
and you have probably turned them into needs and insistences. REBT views nonobsessive
desires as healthy even when you have them strongly. Indeed, your strong desire to write the
Great American Novel, to help impoverished people, or to be tennis champion may provide a
vital absorbing interest that gives you much healthy enjoyment and, if it it not obsessive, little
anxiety and depression when you only make second best.
REBT, then, unlike some forms of Buddhism, encourages your desires but not your dire,
exaggerated needs. Like Epicurus, it favors happiness and pleasure but also favors long-range
hedonism and discipline that are usually required to achieve your future gains. Moderate
eating and drinking may add to your life; addiction to gluttony and alcohol will often
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

sabotage you.

THE PROFOUND DIFFERENCE BETWEEN JUDGING YOUR BEHAVIORS

AND RATING YOUR SELF

REBT from the start has favored rational judging and has soundly opposed irrational,
global judging. Why? Because I learned from several philosophers--such as Bertrand Russell
and Gilbert Ryle--not to make category errors before I graduated from college at the age of
20. My doing badly in social affairs doesn’t make me a bad person; nor does my failing at
work make me a complete failure. This notion was reinforced for me in my twenties by my
reading Stuart Chase’s Tyranny of Words and Alfred Korzybski’s Science and Sanity. Also,
my nonreligious views, starting at the age of 12, got me thinking that the human soul didn’t
exist and could not be deified or damned.
Obviously, however, human thoughts, feelings, and actions can be evaluated once you set
a goal or purpose for them to be assessed by. Thus, if your goal is to earn a comfortable
living, you had better rate productive work as “good” for that goal. If your purpose is to get
along well with others, you had better treat them with some degree of kindness. So you rate

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Rational Emotive Behavior Therapy 131

your productivity and kindness as “good” traits and your laziness and nastiness as “bad” ones.
That kind of rating aids your goals.
From my childhood onward, however, I saw that I was also rating my self, my being, my
totality in terms of my performances--at school, at sports, and in my social life. What child
doesn’t? So I not only wanted to do well in these respects, but thought that I needed to do so.
Result: I was often anxious and sometimes depressed when I performed “badly.” Who isn’t?--
especially when you tell yourself, “I have to always perform well.” Which, as an anxious
child, I often did. So I sometimes made myself less anxious by telling myself, “Well, I failed
to perform well this time, but maybe I’ll do so next time.”
I almost got rid of my anxiety when I was 24 and was madly in love with Karyl, a
marvelous girlfriend of 19, who was most erratic about her love for me. So I frequently made
myself panicked and depressed about her inconsistency. One eventful midnight, however, as I
was ruminating in Bronx Botanical Gardens about my beloved’s fickleness, I suddenly
realized that I didn’t merely strongly desire her love. I thought that I completely needed it.
How idiotic! I obviously didn’t need what I wanted. I could live and even be reasonably
happy without it. I could, I could!
This brilliant insight greatly changed my life; and when I developed it in detail when I
became a practicing therapist 15 years later, it blossomed into a basic principle of REBT: I
and other people do not really need what we want, we only foolishly think and feel that we
do! Again, how idiotic! How unrealistic!
From its start, REBT has taught these interrelated propositions: (1) People almost all have
the goals of staying alive and being reasonably happy. (2) They therefore have several desires
to perform important prospects well, to relate to other people, and to do things that help them
reach their goals. (3) When they strongly (emotionally) desire to achieve or to avoid
something, they frequently escalate their wishes and insist that they are needs or necessities.
(4) Along with thinking that they need what they want (and must avoid what they don’t want),
people frequently (and falsely) convince themselves, “I am what I think, feel, and do. If I
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

perform satisfactorily, I am a good person, and if I perform poorly, I am bad.” (5) In addition
to globally rating themselves as “good” or “bad,” they frequently rate other people’s
behaviors as “good” or “bad” and then rate other persons as “great” or “damnable.” (6) They
also rate world events as “good” or “bad” and then globally rate the world or life as a whole
as “good” or “bad.”
By thinking, feeling, and acting in these inaccurate ways, REBT hypothesizes, people
often healthily fulfill their main goals and purposes, but they also often unhealthily defeat
these same goals and purposes and needlessly create emotional-behavioral problems,
especially, severe anxiety, depression, and rage.
As long as they have an underlying tendency to rate their performances and their self,
which they all seem to some extent to have, they also have underlying anxiety. This is
sometimes called existential anxiety because the fact that they exist and want to continue to
exist leads them to sensibly rate what they do and inaccurately rate their self for doing it.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 132 Albert Ellis

PEOPLE’S TENDENCY TO ACT CONSTRUCTIVELY

AND DESTRUCTIVELY

REBT hypothesizes that people innately and by their social upbringing have some degree
of choice (so-called free will or self-determination) in how they conduct their lives. Their
constructivism is hardly complete, since they have biological tendencies that set limits for
them. Thus, they have a limited life span and are genetically predisposed to have ailments,
diseases, and handicaps. They also live in families, groups, communities, and nations that
restrict them and teach them to restrict themselves. Nonetheless, they have some degree of
choice or decision-making in what they do and don’t do; and they can, with some degree of
effort, change themselves considerably. Once they behave in a certain way, they often
become habituated to keep acting that way. But they also can dehabituate themselves and
make themselves prone to behave in other ways. They almost always keep changing and
become somewhat habituated to changing. So, again, their “free will” is far from complete!
Because of their constructivism, people can motivate and force themselves to change, and
can do so more than other animals. Because they have highly developed language systems,
they can think, think about their thinking, and think about thinking about their thinking. Their
thinking, feeling, and action, often seems to be separate or disparate, but they actually
significantly influence each other and are rarely, if ever, pure. When people think, they also
feel and act. When they feel, they also think and act. When they act, they also think and feel.
They therefore have the ability to push themselves to think, feel, and behave differently.
Consequently, REBT teaches people many kinds of thinking, feeling, and acting
techniques to investigate their dysfunctional behaviors and to work at changing them. It is
multimodal in its methods. It also holds that steady work and practice is usually required to
change destructive tendencies and acts and to maintain the desired changes. REBT stresses
insight, reasoning, and logic; but holds that these “rational” elements, without strong emotion
and action, are not enough.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

REBT is highly educational and believes that direct, didactic teaching of its theories and
practices often works. So it uses dialogue, arguing, and disputing of irrational beliefs with
clients. It also uses other educational approaches, such as articles, books, lectures, workshops,
audio cassettes, and videotapes. But it recognizes that indirect teaching methods work best
with many people and therefore uses Socratic dialogue, stories, fables, plays, poems, parables,
and other forms of communication. It particularly acknowledges that all people are
individuals and may have various modalities of learning that work best for them.

MULTIMODAL ASPECTS OF REBT

As noted above, REBT is concerned with the cognitive, emotional and behavioral aspects
of the clients (and other people’s) emotional and practical problems. It therefore is widely
multimodal in its teachings, as Arnold Lazarus has recommended for effective therapy. It has
invented a number of intellectual, affective, and action techniques that it uses regularly; but it
also uses and adapts many methods taken from other therapies, such as Rogerian, Existential,
Transactional Analysis, Psychoanalytic, and Gestalt therapy. It thereby integrates several of
these approaches with REBT.
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Rational Emotive Behavior Therapy 133

In its simplest form, REBT teaches people its ABCDE procedures. Whenever any
unfortunate event or Adversity (A) happens to them and they feel and behave dysfunctionally
at C (Consequence), it shows them that A significantly contributes to but doesn’t directly
cause C. Instead, their disturbances (C) are also created by their Belief System (B). So both A
and B “cause” C; or A x B = C. B is largely their Beliefs--but these importantly include their
thoughts plus their feelings plus their actions. Why? Because, as I noted above, people think
and feel and act interrelatedly.
People’s Belief Systems includes functional or rational beliefs (RBs) and dysfunctional
or Irrational Beliefs (IBs), and includes them strongly (emotionally) and behaviorally
(activity-wise). Their RBs, as I noted above, tend to be preferences or wishes (“I want to
perform well and be approved by significant others or else my behaviors are faulty”). Their
IBs tend to include absolutistic musts, shoulds, and demands (“I have to perform well and be
approved by significant others, else I am worthless!”).
To use the ABCs of REBT, clients are taught to distinguish their rational from their
irrational Beliefs, to keep their preferences but change their musts by arguing with and
Disputing (D) the latter.
Disputing (D) largely consists of three kinds of rational questions: (1) Realistic
questioning: “Why must I perform well? Where is it written that I have to be approved by
significant others?” Answer: “There is no evidence that I must or have to, but it would be
highly preferable if I did.”
Logical questioning: “Does it follow that if I perform badly and lose the approval of
significant others, that will make me an inadequate person?” Answer: “No, it will only make
my deeds inadequate; but my performance isn’t me or my total personhood.”
Pragmatic questioning: “What results will I get if I believe that I absolutely must perform
well and always be approved by significant others?” Answer: “I will make myself anxious
and depressed” “Do I want to get these results?” Answer: “No!”
When clients persistently retain their Rational Beliefs (RBs) and Dispute their Irrational
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Beliefs (IBs), and when they strongly (emotionally) act against them, they tend to wind up
with answers that include Effective New Philosophies (E), such as: “I never really need to do
well, but I’d very much like to and will do my best to do so.” “No matter how badly or
foolishly I act, I am never a bad person, just a person who acted foolishly this time.” “Some
conditions in my life are unfortunate right now, but that doesn’t mean that the world is bad or
that my whole life is rotten!”
Clients then create other suitable rational coping statements that aid them to enjoy their
healthy preferences and surrender their dysfunctional demands. They also agree with their
therapists to do cognitive, experiential, and activity homework assignments that will
counterattack their dysfunctional behaviors. One of the main cognitive assignments they do is
to regularly fill out the REBT Self-Help Form which are shown in Figures 1 and 2.
Rachel, a 40-year-old bookkeeper, was angry at her boss for not giving her a raise that
she thought she well deserved and at her husband, Jim, for not sympathizing with her “terrible
predicament.” She contended that both of them were making her angry and wouldn’t accept
the REBT position that they may have been wrong, but that her demands on them were also
making her upset. She and I argued for several REBT sessions about this and I (naturally!)
almost won--but Rachel held on to her anger.
I finally gave Rachel several of our REBT Self-Help Forms to fill out and kept correcting
them when she filled them out incorrectly. Finally, after four weeks she correctly did her
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 134 Albert Ellis

seventh form and got it “right.” She delightedly said, “Oh, I see now!--that changing my
wishes for my husband’s and boss’s backing me up to an insistent demand that they do so,
that is what makes me angry at them. Of course! Hereafter, I’m going to stop my childish
demanding!”
Rachel’s seventh REBT Self-Help Form is shown in figures 1 and 2.

REBT EVOCATIVE-EMOTIVE AND BEHAVIORAL EXERCISES

As noted above, REBT includes several special exercises of an evocative-emotive and
behavioral nature. One of its main exercises is my famous shame-attacking exercise, which I
invented for myself when I had little money when I was 23 and ashamed to eat with my
friends in a cafeteria and present an empty receipt to the cashier. I “knew” from my
philosophic readings that my shame was self-created and unnecessary, because obviously the
cashier was merely going to think badly of me and not arrest or kill me. So I vigorously tried
to convince myself that I was not a worm, no matter what the cashier thought of me; and I
forced myself to go to many cafeterias in New York, take a drink of water, and present a
blank receipt to the cashier when I left. Within a few weeks, my shame-attacking exercise
made me quite shameless! So, years later, I frequently encourage my clients to perform it.
When, for example, my client Dorothy was ashamed of speaking poorly in public and
showing how anxious she was, I encouraged her to do several “shameful” things and refuse to
put herself down when people criticized her doing them. She did two of the REBT main
shame-attacking exercises: (1) Yell out several stops in the subway--and stay on the train. (2)
Stop a perfect stranger on the street and say, “I just got out of the mental hospital. Will you
please tell me what month this is?” She did these “risky” exercises several times, put up with
people thinking she was crazy, and would up feeling unashamed.
Using REBT, I also encourage my fearful clients to do various other “dangerous”
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

exercises that help them overcome their anxieties--such as going for difficult job interviews,
dancing badly in public, speaking about a topic that they are not prepared to present, and
being assertive with difficult people. They thereby desensitize themselves to criticism by
seeing that their actions may indeed be uncomfortable but they are hardly fatal.
REBT has also created a number of emotional-evocative exercises, like Maxie
Maultsby’s 1971 creation of rational emotive imagery. Soon after Maxie created it, I used it
with a client, Rob, who wouldn’t risk having sex with a new woman because he might not get
and keep an erection and might be rejected by her. I showed him, first, using regular REBT
that he was telling himself, “I absolutely must be perfectly potent with all women I go to bed
with, and I am a complete loser if I an unarousable!” When he changed this to, “I’d like to be
fully potent with every woman, but I don’t have to be,” he became much less anxious about
failing sexually. But he still was afraid to fail.
So as an emotive-experiential technique, I gave Rob rational emotive imagery. With his
eyes closed, he was to imagine risking intercourse with a new woman, failing to get an
erection, and having her bawl him out for being so hopelessly inept. “Maybe,” he was to
imagine her saying, “you’d better give up sex and join a monastery!”

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Figure 1. Sample REBT Self-Help Form.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice Mental
Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112.
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Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Figure 2. REBT Self-Help Form.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice Mental
Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112.
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 Rational Emotive Behavior Therapy 137

“As you vividly imagine this woman’s damning you,” I asked Rob, “how do you
honestly feel?”
“Very depressed and almost suicidal.”
“Good! You’re really using this rational emotive imagery (REI) technique well. Okay,
allow yourself to feel very very depressed. Feel it as deeply as you can. Feel very depressed
and suicidal. Get fully in touch with your feelings. Don’t suppress, but feel them.”
“Oh, I do. I really do!”
“Fine. Now, keeping the same vivid image of the woman’s putting you down, make
yourself feel the healthy negative emotions of regret and frustration, but not the unhealthy
ones of depression and suicidalness. Feel only healthily regretful and frustrated but not
depressed and suicidal.”
“I’m trying to do what you say, but I can’t do it. I can’t!”
“You damned well can! Anyone can change his feelings. Because you create them
yourself, you always can choose to change them. Now do it! You can!”
Rob did so, and as I predicted, made himself feel regretful and frustrated but not
depressed and suicidal.
“Great!” I said. “How did you change your feelings? What did you do to change them?”
“First, I said to myself, “To hell with her! She’s very hostile.” Then I said, “That’s her
opinion. I’ll find another woman who’s not like her and can be sexually satisfied even if I
never get an erection! That really made me unhostile and unanxious. Just sorry and
frustrated.”
“Beautiful!” I said. “I told you that you could do it.”
Anyone can change his disturbed feelings to healthy ones if he only changes his irrational
musts and shoulds into realistic preferences.”
As usual, since Rob only lightly believed that it was good to be erect with the women but
it wasn’t necessary, and that he could accept himself in spite of a woman’s putting him down
for his failing, I encouraged him to practice rational emotive imagery once a day for 30
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

consecutive days until he solidly believed and felt his new philosophy. He did so and after 20
days of using this method, he lost his fear of going to bed with new women.
In addition to this imagery technique, I use several other highly emotional-evocative
methods with my anxious, depressed, and raging clients--such as role playing. Thus, they
role-play taking an important interview, let themselves feel anxious about its outcome, stop
the role-play to discover what they are telling themselves to make themselves anxious, correct
their anxiety-creating shoulds and musts, and then practice going on with the role-play.
Let me repeat: Though REBT uses a good many behavioral and emotive-evocative
exercises, it simultaneously cognitively discovers the absolutistic shoulds and musts brought
out in these exercises, actively and persistently disputes them, and thereby employs combined
thinking, feeling, and action methods to help people minimize their disturbances. Again: All
three!
Teaching the Basic Philosophy of Unconditional Self-Acceptance (USA), Unconditional
Other Acceptance (UOA), and Unconditional Life-Acceptance (ULA)
To help my clients (and others) achieve the three basic REBT philosophies of
unconditional self-acceptance, other-acceptance, and life-acceptance, I use all the cognitive,
emotional, and behavioral therapy methods described in this chapter. But, so that they will
change the important habits of thinking-emoting-behaving dysfunctionally, I constantly keep
reminding people that they can easily fall back to dangerous self-rating, other-rating, and life-
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 138 Albert Ellis

rating. Buddhism seems to be just as skeptical of its adherents as I am of REBT followers and
it never lets them forget how vulnerable they are to re-neglecting its four basic truths even
after they have presumably accepted them and healthfully used them for years.
It has just occurred to me as I think about this point that that is probably why all the
major religions have their monastic side. Thus, the Jewish religion has its rabbis and its
Talmudic scholars and its saints (such as David and Job). The Christian religion has priests,
ministers, and saints (such as St. Augustine and Joan of Arc). The Muslim religion has its
priests, prophets, true believers, and of course Mohammed. These accredited and holy
teachers serve as good models for the normal followers of the religion, who frequently fail to
maintain devout observance of their basic tenets, and who therefore have to be reminded by
outstanding models to avoid retrogressing.
In other words, when a religion has core philosophers that people can “agree with” but
still inconsistently follow (because they require much self-discipline), a few devout followers
are practically deified so that they can serve as models for its more lax and inconsistent
adherents.
This goes for Buddhism, too. Most Buddhists seem to have a hard time consistently
following its Four Noble Truths. So Buddhism has a long training program for establishing
gurus who are its elite members and who only comprise one out of several thousand
Buddhists. Tibetan Buddhists also have His Holiness, The Dalai Lama, who is selected from
scores of possible candidates, rigorously trained from childhood onward, and is the
recognized head of Buddhism. In addition, it has a few outstanding scholars who are widely
read and quoted for centuries after their writings first appear. Quite a hierarchy! And some
unusual models for the Buddhist laity to follow.
Parenthetically: The field of psychotherapy has its prophets, too--such as Freud, Adler,
Jung, Reich, Rogers, and Perls. But most of their followers do not exactly see them as saints.
Let me hope that Albert Ellis does not achieve sainthood either! For sainthood implies
absolute truth--which doesn’t really exist.
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Returning to the basic philosophies of REBT, they are often held in a slippery manner
and get confused with and contaminated by conditional self- and other-esteem. For it seems
right to hold yourself and others as responsible for their crimes and to denounce wrong-doers
for their evil deeds. They, as REBT says, are not their antisocial acts. But they still do them--
and often wreak great harm. How can we not blame them?
Answer: By applying REBT forgiveness and Buddhist compassion--and still not
condoning human wrongs and injustices. REBT and Buddhism agree on this. Both
philosophies steadily reveal and accept human fallibility.
REBT teaches, first, unconditional self-acceptance (USA). You damn your misdeeds--but
not your self. You revile your sins but not you as the sinner. You denigrate some of your
thoughts, feelings, and actions--but not your totality, your youness.
Second, REBT teaches you to unconditionally accept all other humans (and animals)--
especially when they act evilly. Again, they often sin but are not damnable sinners.
Third, you unconditionally accept life and the world--that frequently provide rotten
conditions. You deplore and try to better the conditions; but you gracefully accept--no, not
condone--what you cannot presently change. Yes, gracefully, unresentfully.
Pretty simple, isn’t it? Yes and no: For REBT philosophy has its complications.
Therefore, it has to be taught and retaught. But I--prejudicedly--say it’s worth it!

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Rational Emotive Behavior Therapy 139

REFERENCES
Adler, A. (1929). The science of living. New York: Greenberg.
Beck, A.T. (1976). Cognitive therapy and the emotional disorders. New York: International
Universities Press.
Berne, E. (1972). What do you say after you say hello? New York: Grove.
Chase, S. (1964). The tyranny of words. New York: Harcourt Brace Jovanovich.
Dryden, W. (1999). How to accept yourself. London: Sheldon Press.
Dryden, W., Walker, J., and Ellis, A. (1996). REBT self-help form. New York: Albert Ellis
Institute.
Ellis, A. (1957). How to live with a neurotic: At home and at work. New York: Crown.
Hollywood, CA: Wilshire Books.
Ellis, A. (1958). Rational psychotherapy. Journal of General Psychology, 59, 35-49.
Reprinted: New York: Albert Ellis Institute.
Ellis, A. (1962). How to make yourself happy and remarkably less disturbable. Atascadero,
CA: Impact Publishers.
Ellis, A. (2001). Feeling better, getting better, staying better. Atascadero, CA: Impact
Publishers.
Ellis, A. (2001b). Overcoming destructive beliefs, feelings, and behaviors. Amherst, NY:
Prometheus Books.
Ellis, A. (2002). Rational emotive behavior therapy: It works for me, it can work for you.
Amherst, NY: Prometheus Books.
Epictetus. (1890). The works of Epictetus. Boston: Little Brown, 1899.
Glasser, W. (1965). Reality therapy. New York: Harper & Row.
His Holiness, The Dalai Lama, and Cutler, H.C. (1998). The art of happiness. New York:
Riverside Books.
Horney, K. (1950). Neurosis and human growth. New York: Norton.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Korzybski, A. (1933/1990). Science and sanity. Concord, CA: International Society for
General Semantics.
Lazarus, A.A. (1989). The practice of multimodal therapy. Baltimore, MD: Johns Hopkins.
Leifer, R. (1997). The happiness project. Ithaca, NY: Snow Lion Publications.
Maultsby, M.C., Jr. (1971). Rational emotive imagery. Rational Living, 6(1), 24-27.
Meichenbaum, D. (1992). Evolution of cognitive behavior therapy: Origins, tenets, and
clinical examples. In J.K. Zeig, (Ed.), The evolution of psychotherapy: The second
conference. (pp. 114-128). New York: Brunner/Mazel.
Perls, F. (1969). Gestalt therapy verbatim. New York: Delta.
Rogers, C.R. (1961). On becoming a person. Boston: Houghton-Mifflin.
Skinner, B.F. (1971). Beyond freedom and dignity. New York: Knopf.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 In: The Quick Theory Reference Guide ISBN: 978-1-60021-624-4
Editor: Karin Jordan, pp. 141-154 © 2008 Nova Science Publishers, Inc.

Chapter 10

ACCEPTANCE AND COMMITMENT THERAPY

AND THE THIRD GENERATION OF COGNITIVE
BEHAVIOR THERAPY

Steven C. Hayes and Jennifer C. Plumb

Looking back over the past few decades, one can see three distinct generations of
cognitive behavior therapy. First, in the early to mid 1900’s until the 1970’s, traditional
behavior therapy was the standard, addressing overt behavior with empirically validated
principles. Behavior therapy then gave way to cognitive therapy and cognitive behavior
therapy (CBT) in the 1970’s when clinicians called for attention to a core part of the human
experience: cognition. Over the past three decades this approach has evolved, but it has been
remarkably consistent in its basic thrust and approach over that time: that cognitions, along
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

with behaviors, need to be changed in order for clinical progress to be made.

Yet, examining the state of the evidence in CBT has given many scientists and clinicians
pause. The organizing principle that clinical change generally requires modification of the
content of specific dysfunctional beliefs has been challenged empirically and clinicians have
noted a lack of continuity between changing cognitions and clinical improvements. The third
generation of CBT, with a focus on contextual variables, has emerged to address this
discontinuity and the resultant shift in focus has moved modern cognitive behavioral
therapists toward a more coherent science and practice of psychotherapy that is adequate to
the challenge of the human condition. Acceptance and Commitment Therapy is one example
of such a third generation approach that has been shown to be effective in a number a clinical
arenas.

BEHAVIOR THERAPY
Early behavior therapists believed that theories should be built upon a foundation of
scientifically well-established basic principles, and that applied technologies should be well-
specified and rigorously tested. In contrast, existing clinical traditions (e.g., psychodynamic

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 142 Steven C. Hayes and Jennifer C. Plumb

and Rogerian theories) had a very poor link to scientifically established basic principles,
vague specification of interventions, and weak scientific evidence in support of the impact of
these interventions. Franks and Wilson (1974) showed this dual metatheoretical and empirical
concern when they defined behavior therapy in terms of "operationally defined learning
theory and conformity to well established experimental paradigms" (p. 7). In place of these
traditions, they hoped to create a clinical approach that was based both on carefully controlled
studies of treatment outcome and on experimentally demonstrated principles of learning.
The behavior therapy movement began with two key commitments. Behavior therapy
was to be a field designed to 1) produce a scientifically based analysis of behavioral health
problems and their treatment cast in terms of basic psychological processes, and 2) develop
well-specified and empirically validated interventions for such problems. Despite this
commendable commitment to empirically based principles and interventions, the pendulum
appeared to swing too far in the other direction. Some early behavior therapists sometimes
seemed to be ridiculing the very idea of a form of psychotherapy that could address some of
the deeper clinical or human questions. Instead, in order to avoid the conceptual excesses of
the day, the focus was to be steadfastly on first-order change – overt behaviors that were not
adaptive would be modified into forms that were.
Even in the earliest days, however, authors of behavioral principles texts realized that
these principles needed to expand beyond operant and classical conditioning principles to
include those focused on human cognitive processes (Bandura, 1968). Unfortunately,
behavior analysis was unable to supply an empirically adequate account of cognition, despite
taking private events seriously.

Cognitive Behavior Therapy

It is worth remembering that the behavior therapy approach was surprisingly successful,
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despite its self-imposed limitations. By the early 1970’s however, very few clinicians were
comfortable with the idea that overt behavior could be addressed without dealing with
cognition as a central focus, and they saw no way to do that well using the behavioral
principles of the day. Clinicians realized that a simple and more satisfying solution was to add
cognitive targets to the more common behavioral and emotional targets of the early behavior
therapists, and this insight was at the core of the second generation of traditional cognitive
therapy and cognitive behavior therapy (e.g., Beck, Rush, Shaw, & Emery, 1979).
A number of creative change methods were subsequently developed, and a list of
clinically focused measures of unhealthy cognitive processes soon emerged. But this shift
also meant that CBT was not based on basic principles in the same way as traditional
behavior therapy. The dominant cognitive model was simply not conducive to application.
Instead, CBT researchers were successful in defining and measuring specific patterns of
cognitions characteristic of specific forms of psychopathology (e.g., Beck, Brown, Steer, &
Weissman, 1991). The terms used to describe these patterns were sometimes loosely linked to
basic cognitive psychology (e.g., schemas), but often they were not (e.g., Ellis, 1962). Despite
the clinical utility of these terms and measurement tools, the actual content of the processes
(e.g., over-generalization; black and white thinking; emotional reasoning; irrational
cognitions) were of little importance to basic cognitive science and the previously close
relationship between basic scientists and clinicians eroded very quickly.
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Acceptance and Commitment Therapy and the Third Generation… 143

While CBT loosened its link to basic science of the kind found in behavior therapy, CBT
was (and continues to be) strongly committed to empirically validating its interventions.
Traditional CBT interventions, especially those focused on circumscribed problems, have
been impressively supported, and dominates lists of empirically supported treatments. It has
remained virtually unchallenged in empirical clinical circles for over 30 years.

Changing the Core Focus

CBT has dominated clinical psychology for the past three decades with impressive force.
In spite of its overall effectiveness, it has become clear that CBT’s effectiveness is best
illustrated in the treatment of circumscribed problems rather than complex or multiproblem
cases, and its effectiveness at preventing relapse is less than favorable (Westen & Morrison,
2001). In addition, there has been a recent focus on developing interventions for “treatment
resistant” clinical problems. Modern CBT researchers have responded to these limitations by
rigorously examining not only the intervention as a whole, but also the processes of change
and components within CBT. The organizing principle that is now being examined is whether
clinical change generally requires modification of the content of specific dysfunctional
beliefs.
Recently, researchers have been analyzing the impact of each component of CBT
interventions and attending to process through mediational analyses. Component and process
analysis studies have generally failed to find support for the importance of direct cognitive
change strategies (Gortner, Gollan, Dobson, & Jacobson, 1998; Addis & Jacobson, 1996;
Zettle & Hayes, 1987). Two component analyses have directly examined CBT for depression.
The first found that there was no additive effect of cognitive change strategies on outcome
(Jacobson, Dobson, Truax, Addis, Koerner, et al, 1996). The second study is even more
dramatic. When a greater focus was put on detecting and challenging avoidance, the
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behavioral activation component of CBT was shown to be more efficacious than the complete
cognitive behavioral therapy package (Dimidjian, Hollon, Dobson, Schmalling, Kohlenberg,
et al, 2006). Furthermore, support for the hypothesized mediators of change in CBT is weak
(e.g., Burns & Spangler, 2001; Morgenstern & Longabaugh, 2000), particularly in areas that
are causal and explanatory rather than descriptive (Beck & Perkins, 2001; Bieling & Kuyken,
2003).
Well-known cognitive therapists have been forced to conclude that in some important
areas there is “no additive benefit to providing cognitive interventions in cognitive therapy”
(Dobson & Khatri, 2000, p. 913). The largest response to traditional CBT occurs before its
putative critical component, efforts to change thinking patterns, typically occur (Ilardi &
Craighead, 1994).
There are also broader cultural and intellectual changes, which may in part explain such
findings. Support for mechanistic theories have been undermined by the more pragmatic and
contextualistic sensibilities of the popular and scientific culture. The culture has absorbed the
wisdom that is in traditional CBT and many clients now arrive having tried some of the CBT
methods known to be helpful. Treatment resistant clients commonly are skeptical of CBT
simply because they have already tried and failed using these approaches. Something new
seems needed.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 144 Steven C. Hayes and Jennifer C. Plumb

In addition to recognizing the shaky foundational leg traditional CBT was standing on,
modern clinical psychology has also seen cohort changes. The leaders of traditional CBT
have reached retirement age or higher. They cut their intellectual eye teeth in the 1950’s and
early 1960’s. But behind them are a group of clinicians who grew up in the upheaval of the
late 1960’s and early 1970’s. The contextual nature of human experience is far more familiar
and more at the forefront of their work than in their traditional behavior therapy and cognitive
behavioral therapy predecessors.

The Third Wave: Focusing on Context

A little more than a decade ago the changes began to be seen. Articles began to appear in
CBT journals on the costs of emotion and thought suppression (e.g., Purdon, 1999; Gross &
Levenson, 1997), on the importance of acceptance (e.g., Hayes, Wilson, Gifford, Follette &
Strosahl, 1996), on metacognitive perspectives (e.g., Wells, 1995), and the impact of
mindfulness (Borkovec & Roemer, 1994; Teasdale, Segal & Williams, 1995). A new
possibility was emerging inside these developments big and small: perhaps it is not the
content of thoughts, feelings, memories, or bodily sensations that was central to human
functioning so much as the person’s relationship to these experiences. Evidence began to take
shape that it was possible to alter the function of thoughts without first altering their form
(e.g., Teasdale, Moore, Hayhurst, Pope, Williams, & Segal, 2002). In short, this new cohort
of clinicians seemed to come together under the notion that content and form was less
important than context and function.
In essence, such a stance calls for a functional contextual philosophical approach as
opposed to the earlier mechanistic and organismic approaches found in early behavior therapy
and CBT. Functional contextualism is a kind of pragmatism and has the following
assumptions: (1) a focus on the whole event, (2) sensitivity to the role of context in
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

understanding the nature and function of an event, (3) emphasis on a pragmatic truth criterion,
and (4) specific scientific goals of prediction and influence (Biglan & Hayes, 1996; Hayes,
Hayes, & Reese, 1988). This set of assumptions opens up the field to a far more fluid
relationship between specific psychological events. In a mechanistic conception an irrational
cognition directly impacts emotions and actions. From a contextualistic perspective, that very
relationship is contextually determined, and there may be different ways to conceptualize it,
depending on ones purpose.
Directly applied to the practice of CBT, one can see the shift in focus. Perhaps it is not
their form or frequency of difficult thoughts or feelings that is the problem so much as how
one responds to them. Perhaps it is not the presence or intensity of emotions like anxiety that
determines outcome so much as what you do with these feelings. This orthogonal shift in
perspective colors everything, right down to the way we define and think about problems.
A number of organized examples of third generation CBT approaches have emerged.
Examples include Dialectical Behavior Therapy (DBT; Linehan, 1993), Functional Analytic
Psychotherapy (FAP; Kohlenberg & Tsai, 1991), Integrative Behavioral Couples Therapy
(IBCT; Jacobson & Christensen, 1996) and Mindfulness Based Cognitive Therapy (MBCT;
Segal, Williams, & Teasdale, 2002), among several others (e.g., Borkovec & Roemer, 1994;
McCullough, 2000; Martell, Addis, & Jacobson, 2001; Roemer & Orsillo, 2002) including the

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Acceptance and Commitment Therapy and the Third Generation… 145

one we will focus on in this chapter; Acceptance and Commitment Therapy (ACT; Hayes,
Strosahl & Wilson, 1999).
What is common among these approaches is that they all have ventured into areas
traditionally reserved for the less empirical wings of clinical intervention and analysis,
emphasizing such issues as acceptance, mindfulness, cognitive defusion, dialectics, values,
spirituality, and relationships. Their methods are often more experiential than didactic and the
underlying philosophy is more contextualistic than mechanistic. Many of these approaches
have returned to their behavior therapy roots, but still lacking in these third generation
approaches was a basic, principle-driven science of language and cognition as was called for
at the start of the second generation.

Relational Frame Theory: A Contextual Science of Language and Cognition

The great strength of behavior therapy was not just a commitment to scientific evaluation.
It was a commitment to procedures based on principles. However, behavioral principles
simply could not account for language and cognition in a way that held up empirically.
Additionally, behavioral principles were inherently sensitive to context, and thus allowed
clinicians to extrapolate appropriately targeted interventions aimed directly at behavior
change. The translation seemed impossible in the field of cognition. Other than the material
causality of the brain (and despite recent advances in psychopharmacology, we are still
unsure how to change brain chemistry with any specificity or utility) it was all dependent
variables – thoughts, feelings, overt action. Clinicians had to make do and hope that targeting
these dependent variables in myriad ways would not just change them, but would do so while
retaining their natural interrelationships. Unfortunately, information processing and similar
approaches did not specify how to do that.
In the early 1980’s we developed and began to test a new approach, based on acceptance
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

and mindfulness. Early tests showed that this approach (then called Comprehensive
Distancing) was superior to cognitive therapy and the process of change was both different
and theoretically coherent (Zettle & Hayes, 1986; 1987). We then put further outcome
research on hold for nearly 15 years.
Acceptance and mindfulness-based methods delve into territories that have been part of
our spiritual and religious traditions for thousands of years and simply validating them did not
seem to be progressive (Hayes, 1984). Instead, a deeper understanding seemed necessary.
Specifically, a contextual theory of cognition was needed to explain why relating differently
to private experience without changing its content (an inherently contextual intervention)
could have such a profound impact.
Relational Frame Theory (RFT; Hayes, Barnes-Holmes & Roche, 2001) was the eventual
result. It was our idea that human infants learn to relate one event to another so that a relation
in one direct produced relations in both directions, beginning with multiple examples with
receptive and productive names (if this is a “ball,” when hearing “ball” orient toward this),
but quickly expanding out into relations of difference, opposition, before and after,
comparative relations, and deictic relations (e.g., “I-you”) among others. We found that
children learn to combine these different forms of mutual relations into networks, and to do so
under the control of arbitrary contextual features, not just the form of related events. A very

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 146 Steven C. Hayes and Jennifer C. Plumb

young child will prefer a nickel over a dime because it is absolutely bigger. An older child
will prefer a dime over a nickel because it is bigger by arbitrary attribution.
Due to the effort of labs around the world we now we have a substantial amount of
developmental, behavioral, and neurobiological evidence that the core of language and
cognition is learned “arbitrarily applicable relational responding.” Children who don’t derive
these relations don’t show receptive language abilities (e.g., Devany, Hayes, & Nelson,
1986). Even infants show these relational skills (Lipkens, Hayes, & Hayes, 1993), and we
now know that they do so because of explicit training (e.g., Barnes-Holmes, Barnes-Holmes,
& Smeets, 2004; Berens & Hayes, in press; Luciano, Gómez, & Rodríguez, in press). Further,
there is a growing base of neurobiological support for the functional similarity between
derived relational responding and natural language (e.g., Barnes-Holmes et al., 2005).
The core idea that learned arbitrarily applicable relations can alter the functions of related
events is of great utility to both basic scientists and clinicians. If a dime can be bigger than a
nickel, so too can uncomfortable shoes be preferred over comfortable ones because they are
“stylish,” one group of human beings can be preferred over another because they are “better,”
an idealized self can be preferred over an actual self, or even death preferred over life. The
basic RFT laboratories have been able to model processes such as these, finding for example
that there is greater fear shown toward a novel stimulus that is framed as “worse” than an
known stimulus directly associated with bad events such as shock (Dougher, Hamilton, Fink,
& Harrington, in press).
Clinically, relational frames begin to explain why humans became so entangled in their
cognitive lives – because the same cognitive relations (e.g., time, evaluation) that create
human misery are central to human problem solving. Further, and most important for
clinicians, RFT explained why human beings tend to try to deal with pain by avoidance and
suppression of emotion itself rather than purely through situational change. The arbitrary
contextual control of cognition makes it possible for human beings to be in pain anywhere
and anytime. How can situational cures work when a human can cry at the sight of a beautiful
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

sunset because someone dear who died recently “should have been here to see this”? Unable
to control pain by controlling situations, avoiding painful experience itself is an obvious this
to try. Unfortunately, this very process is very harmful psychologically (Hayes et al., 2004).
RFT also provided an explanation for why targeting private experience for change was
difficult. If cognitive relations are learned and historical, then it follows that like any
behavior, once learned they never truly disappear (even extinction does not remove previous
learning, it only inhibits it). The control efforts driven by the verbal rule “I don’t want ___” or
“don’t think of ___” evoke the very thing feared because these rules contain still more verbal
relations that bring the targeted event into the psychological present. But the biggest clinical
implication came when we learned that the contexts that control what is related to one another
(e.g., learning that an “apple” is this thing) are different than the ones that control the
functions of these related events (e.g., mentally tasting, feeling, seeing, or smelling the apple).
Direct change efforts focused on private experience often did not work because these very
efforts were increasing the functions of negative private experiences (e.g., painful memories).
At the very least they were making them more important and more salient.
This was the turning point. We focused on what could be done clinically to make difficult
experiences less important and less impactful, without trying to change their occurrence,
form, frequency, or the situations in which they occur. RFT indicated that in order to do that,
we had to change the functional context of clinically relevant variables such as thoughts and
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Acceptance and Commitment Therapy and the Third Generation… 147

feelings. Whereas logic dictates running from or trying to change private experiences directly,
the theory suggested an alternative approach: acceptance and mindfulness. If one were to be
aware of and accept private experiences, a new question emerged: what would be a guide for
overt behavior? Values and committed action was our answer.

ACCEPTANCE AND COMMITMENT THERAPY

By the late 1990’s this package had been assembled under the rubric Acceptance and
Commitment Therapy (ACT; Hayes, Strosahl & Wilson, 1999). ACT (said as one word) is a
psychological intervention that applies mindfulness and acceptance processes, and
commitment and behavior change processes, to the creation of psychological flexibility. ACT
is more a model of psychological intervention linked to certain theoretical processes, than a
specific technology. It contains many components that are original to the approach but it also
borrows a wide variety of method that fit the overall model.
The general goal of ACT is to increase psychological flexibility – the ability to contact
the present moment more fully as a conscious human being, and to change or persist in
behavior when doing so serves valued ends. Since the overarching goal is to increase
psychological flexibility and the model is based upon a science of language and cognition,
these procedures are inherently contextual and are more than merely a technology for
alleviating symptoms such as anxiety or depression. Indeed, the evidence to date suggests that
ACT can be applied to a wide variety of situations.
Psychological flexibility is established through six core ACT processes. Each of these
areas is conceptualized as a positive psychological skill, not merely a method of avoiding
psychopathology. The following details the essence of each of these processes, but it is by no
means intended to be a procedural guide to the treatment.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Acceptance

Acceptance is taught as an alternative to experiential avoidance. Acceptance involves the

active and aware embrace of those private events occasioned by one’s history without
unnecessary attempts to change their frequency or form, especially when doing so would
cause psychological harm. For example, anxiety patients are taught to feel anxiety, as a
feeling, fully and without defense; pain patients are given methods that encourage them to let
go of a struggle with pain, and so on. However, acceptance in ACT is not an end in itself.
Rather acceptance is fostered as a method of increasing values-based action.

Cognitive Defusion

Cognitive defusion techniques attempt to alter the undesirable functions of thoughts and
other private events, rather than trying to alter their form, frequency or situational sensitivity.
Said another way, ACT attempts to change the way one interacts with or relates to thoughts
by creating contexts in which their unhelpful functions are diminished. There are several

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 148 Steven C. Hayes and Jennifer C. Plumb

techniques that have been developed for a wide variety of clinical presentations. For example,
a negative thought could be watched dispassionately, repeated out loud until only its sound
remains, or treated as an externally observed event by giving it a shape, size, color, speed, or
form. A person could thank their mind for such an interesting thought, label the process of
thinking (“I am having the thought that I am no good”), or examine the historical thoughts,
feelings, and memories that occur while they experience that thought. Such procedures
attempt to reduce the literal quality of the thought, weakening the tendency to treat the
thought as what it refers to (“I am no good”) rather than what it is directly experienced to be
(e.g., the thought “I am no good”). The result of defusion is usually a decrease in believability
of, or attachment to, private events rather than an immediate change in their frequency.

Present Moment Awareness

ACT promotes ongoing non-judgmental contact with psychological and environmental

events as they occur. The goal is to have clients experience the world more directly so that
their behavior is more flexible and thus their actions more consistent with the values that they
hold. This is accomplished by allowing workability to exert more control over behavior; and
by using language more as a tool to note and describe events, not simply to predict and judge
them. The process of awareness is actively encouraged in hopes of fostering a stance for
noticing the defused, non-judgmental ongoing description of thoughts, feelings, and other
private events.

Self as Context

As a result of relational frames such as I versus You, Now versus Then, and Here versus
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There, human language leads to a sense of self as a locus or perspective, and provides a
transcendent, spiritual side to normal verbal humans. This idea was one of the seeds from
which both ACT and RFT grew and there is now growing evidence of its importance to
language functions such as empathy, theory of mind, sense of self, and the like. In brief the
idea is that “I” emerges over large sets of exemplars of perspective-taking relations (what are
termed in RFT “deictic relations”), but since this sense of self is a context for verbal knowing,
not the content of that knowing, it’s limits cannot be consciously known. Self as context is
important in part because from this standpoint, one can be aware of one’s own flow of
experiences without attachment to them or an investment in which particular experiences
occur: thus defusion and acceptance is fostered. Self as context is fostered in ACT by
mindfulness exercises, metaphors, and experiential processes.

Values

Values are chosen qualities of purposive action that can never be obtained as an object
but can be instantiated moment by moment. ACT uses a variety of exercises to help a client
choose life directions in various domains (e.g. family, career, spirituality) while undermining
verbal processes that might lead to choices based on avoidance, social compliance, or fusion
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Acceptance and Commitment Therapy and the Third Generation… 149

(e.g. “I should value X” or “A good person would value Y” or “My mother wants me to value
Z”). In ACT, acceptance, defusion, being present, and so on are not ends in themselves; rather
they clear the path for a more vital, values consistent life.

Committed Action

Finally, ACT encourages the development of larger and larger patterns of effective action
linked to chosen values. In this regard, ACT looks very much like traditional behavior
therapy, and almost any behaviorally coherent behavior change method can be fitted into an
ACT protocol, including exposure, skills acquisition, shaping methods, goal setting, and the
like. Unlike values, which are constantly instantiated but never achieved as an object,
concrete goals that are values consistent can be achieved and ACT protocols almost always
involve therapy work and homework linked to short, medium, and long-term behavior change
goals. Behavior change efforts in turn lead to contact with psychological barriers that are
addressed through other ACT processes.
Taken as a whole, each of these processes supports the other and all target psychological
flexibility: the process of contacting the present moment fully as a conscious human being
and persisting or changing behavior in the service of chosen values. The six processes can be
grouped into two useful sets. Mindfulness and acceptance processes involve acceptance,
defusion, contact with the present moment, and self as context. Indeed, these four processes
provide a workable behavioral definition of mindfulness. Commitment and behavior change
processes involve contact with the present moment, self as context, values, and committed
action. Contact with the present moment and self as context occur in both groupings because
all psychological activity of conscious human beings involves the now as known.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Process and Outcome: Overview of the Evidence

ACT has been shown to be effective for a wide array of problems, some of which are not
traditionally targeted by clinical psychology. We will only provide a brief overview of the
evidence as a recent meta-analytic article has been published detailing all of the studies to
date using ACT and ACT-related processes (Hayes, Luoma, Bond, Masuda & Lillis, 2006).
While ACT does not directly target symptom reduction but rather psychological
flexibility and value-consistent behavior, existing measures of process and outcome
traditionally only capture such changes. Somewhat surprisingly, it appears that despite the
fact that ACT does not directly target symptom reduction, even short courses of ACT produce
both clinically meaningful and statistically significant reductions in symptoms across several
domains of psychopathology even when compared to treatments tailored to reduce specific
symptoms (see Hayes et al, 2006 for a full review).
What is interesting is not just that ACT appears to be effective, but that it appears to be a
powerful technology than produces meaningful change in small doses across diverse and
difficult areas of psychology. For example, 4 hours with pain patients reduced work absence
due to pain to about 1 day every six months (Dahl, Wilson, & Nilsson, 2004), 3 hours with
psychotic patients reduced rehospitalization rates by 50% over the next four months (Bach &
Hayes, 2002), 3 hours with poor, mostly minority diabetics put 50% more under glucose
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 150 Steven C. Hayes and Jennifer C. Plumb

control 3 months later (Gregg, 2004), and 9 hours with South African epileptics produced a
90% reduction in seizures one year later (Lundgren, 2004; Lundgren & Dahl, 2005). The
evidence is clear even if a bit unexpected: ACT seems to help burnout, stigma, anxiety,
depression, substance abuse, chronic pain, worksite stress, prejudice, resistance to learning,
smoking, and self-injury (see Hayes et al, 2006 for a meta-analytic review).
Process research is still young, but there is support for the idea that ACT produces an
unusually rapid decrease in the believability (but not necessarily the frequency) of negative
thoughts (e.g., Bach & Hayes, 2002; Zettle & Hayes, 1986), the opposite of what is usually
found in CBT. These decreases in the believability of negative thoughts are specifically
associated with positive ACT outcomes (e.g., Bach & Hayes, 2002). ACT also produces an
increased willingness to experience negative private events – a process that is also associated
with positive ACT outcomes (e.g., Bond & Bunce, 2000).
Most importantly, many studies have supported the model as a whole (see Hayes et al,
2006). Our measures of acceptance and flexible behavior account for about 20% to 25% of
the variance in outcome across many clinical domains, including depression (Zettle & Hayes,
1987) and living with chronic pain (McCracken, 1998; 2004) to name a few. Over a dozen
studies showed that these processes were either a mediator or moderator of ACT outcomes.
(e.g., Gaudiano & Herbert in press; Gregg, 2004; Gifford, Kohlenberg, Hayes, Antonuccio,
Piasecki, et al, 2004; Bond & Bunce, 2000; Hayes, Bisset, Roget, Padilla, Kohlenberg, et al,
2004; Hayes, Masuda, Bisset, Luoma, & Guerrero, 2004).

ACT and the Third Generation

What is important to remember about ACT and RFT is that they are theories and
interventions designed to make a particular difference, and they are “true” only to the degree
that they do so. In a parallel way, ACT clients are encouraged to abandon any interest in the
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

literal truth of their own thoughts or evaluations, and instead to embrace a passionate and
ongoing interest in how to live according to their values. Since they are founded on a
philosophical stance of functional contextualism – holistic and context focused – no event
affects another in a mechanical way as has been seen in previous generations of clinical
psychology. In ACT there is a conscious posture of openness and acceptance towards all
psychological events even if they are formally “negative,” “irrational,” or even “psychotic” –
the issue is not the presence of any particular event, but in its contextually established
function and meaning. The foundational nature of goals in contextualism is also reflected in
the ACT emphasis on chosen values as a necessary component of a meaningful life (and
indeed a meaningful course of treatment).
ACT – and third generation contextual CBT generally – are hard to categorize and pin
down. These procedures remind people of Gestalt therapy, existential therapy, neoanalytic
therapy, Logotherapy, Morita Therapy, systems therapy, paradoxical interventions, and so on
and on. When many different clinical perspectives converge on a common point, however, it
suggests that there is something of value there. Clinicians have known about and used
contextualistic approaches from the beginning, but until recently they have generally not been
linked to basic behavioral science or to the empirically supported approach to treatment
development. That is new, and it is one of the things that makes third generation approaches
to CBT of such broad interest to the field.
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Acceptance and Commitment Therapy and the Third Generation… 151

Cognitive behavioral therapy needs to commit to a psychology that:

− Is more sensitive to the context and functions of psychological phenomena, not just
their form, and thus tend to emphasize contextual and experiential change strategies
in addition to more direct and didactic ones;
− Seeks the construction of broad, flexible and effective repertoires over an eliminative
approach to narrowly defined problems;
− Emphasizes the relevance of issues faced by clinicians as well as clients;
− Reformulates and synthesizes the behavior therapy era and the traditional CBT era so
that the distinctions between cognitive and behavioral thinking narrow;
− Maintain the commitment to scientifically validated techniques based on
experimentally derived principles; and
− Improves both understanding and outcomes, carrying CBT forward into the deepest
clinical and human questions, issues, and domains previously addressed primarily by
other traditions (Hayes, 2004).

The third generation of CBT seems to be moving toward such psychological models. To
the extent that it does so, it seems to have a greater chance of creating a psychology more
adequate to the challenge of the human condition.

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Beck, R. & Perkins, T. S. (2001). Cognitive content-specificity for anxiety and depression: A
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Smoking Cessation: An Initial Trial of Acceptance and Commitment Therapy. Behavior
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 Acceptance and Commitment Therapy and the Third Generation… 153

Hayes, S. C. (1993). Analytic goals and the varieties of scientific contextualism. In S. C.

Hayes, L. J. Hayes, H. W. Reese, & T. R. Sarbin (Eds.), Varieties of scientific
contextualism (pp. 11-27). Reno, NV: Context Press.
Hayes, S. C. (2002). Buddhism and Acceptance and Commitment Therapy. Cognitive and
Behavioral Practice, 9, 58-66.
Hayes, S. C. (2004). Acceptance and Commitment Therapy, Relational Frame Theory, and
the third wave of behavior therapy. Behavior Therapy, 35, 639-665.
Hayes, S. C., Barnes-Holmes, D., & Roche, B. (Eds.). (2001). Relational Frame Theory: A
post-Skinnerian account of human language and cognition. New York: Plenum Press.
Hayes, S. C., Bissett, R., Roget, N., Padilla, M., Kohlenberg, B. S., Fisher, G., Masuda, A.,
Pistorello, J., Rye, A. K., Berry, K., Niccolls, R. (2004). The impact of Acceptance and
Commitment Training on stigmatizing attitudes and professional burnout of substance
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Hayes, S. C., Hayes, L. J., & Reese, H. W. (1988). Finding the philosophical core: A review
of Stephen C. Pepper's World Hypotheses. Journal of the Experimental Analysis of
Behavior, 50, 97-111.
Hayes, S. C., Masuda, A., Bissett, R., Luoma, J. & Guerrero, L. F. (2004). DBT, FAP, and
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Polusny, M., A., Dykstra, T. A., Batten, S. V., Bergan, J., Stewart, S. H., Zvolensky, M.
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Hayes, S.C., Luoma, J.B., Bond, F.W., Masuda, A., & Lillis, J. (2006). Acceptance and
Commitment Therapy: Model, processes and outcomes. Behaviour Research & Therapy,
44, 1-25.
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therapy for depression. Clinical Psychology: Science & Practice, 1, 138-156.
Jacobson, N. S., Dobson, K. S., Truax, P. A., Addis, M. E., Koerner, K., Gollan, J. K.,
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for Behavior Analysis, Chicago.
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 154 Steven C. Hayes and Jennifer C. Plumb

Martell, C. R., Addis, M. E., & Jacobson, N. S. (2001). Depression in context: Strategies for
guided action. New York: W. W. Norton.
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in persons with chronic pain. Pain, 74, 21-27.
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disorder. Behavioural and Cognitive Psychotherapy, 23, 301-320.
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Westen, D., & Morrison, K. (2001). A multidimensional meta-analysis of treatments for

depression, panic, and generalized anxiety disorder: An empirical examination of the
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Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 In: The Quick Theory Reference Guide ISBN: 978-1-60021-624-4
Editor: Karin Jordan, pp. 155-166 © 2008 Nova Science Publishers, Inc.

Chapter 11

TREATING MENTAL HEALTH

AS A PUBLIC HEALTH PROBLEM:
A NEW LEADERSHIP ROLE FOR COUNSELORS

William Glasser

The first definition of health in the dictionary is being sound in body, mind and spirit. The
second is freedom from physical disease or pain. From my experience in medical school,
doctors evaluate people as either sick or healthy - sick if pathology is present in the body,
healthy if none can be found. Health, separate from disease, is rarely a concern of physicians
including psychiatrists.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

PHYSICAL HEALTH
When health is defined by physicians or even by the general public, it is almost always
physical health. Vigor, strength, fitness and endurance are the attributes most frequently
mentioned. Physical education is taught in schools and there are many gyms and fitness clubs
where people exercise to improve their physical health.

MENTAL HEALTH
Unlike physical health, mental health is almost never mentioned as an entity in and of
itself. When it is mentioned it is almost always in conjunction with what psychiatrists define as
mental illness. For example, there are hundreds of mental health associations that dot the country
but all of them focus on mental illness. If you went to one, told them you were not mentally ill but
would like to improve your mental health, very few of them would know what you were talking
about.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 156 William Glasser

Psychiatrists, psychiatric nurses, psychologists, social workers and counselors pay lip
service to mental health but what really concerns them is mental illness. They may even use the
term mental health when they refer to the DSM-IV which accurately describes a wide and
growing variety of psychological symptoms with few exceptions such as Parkinson's, which is
a neurological disease.
That much is reasonable but the DSM-IV goes much further than describing psychological
symptoms. It assumes that these symptoms individually or grouped together are mental illnesses or
disorders even though there is no proof of brain pathology in any of them to support this
assumption. That this assumption has yet to be proved has not stopped psychiatrists and many other
physicians from prescribing a wide variety of brain drugs all aimed at curing a pathology that so far
has not been found. As far as I know, none of the professionals who follow the DSM-IV have ever
attempted to define mental health as an entity completely separate from what they call mental
illness. I believe that mental health can be accurately defined in that way and I will offer such a
definition here.
From my personal experience of thinking about mental health completely separate from what
is called mental illness in the DSM-IV, I believe we need an accurate definition. We need it to help
the people we counsel who are not mentally ill but are not as mentally healthy as they would like to
be to improve their own mental health without drugs. This would be analogous to helping people
who are not physically ill but not as physically healthy as they would like to be to improve their
physical health without drugs. I am hoping that at least one large and influential group of counselors
(members of the ACA), who have counseled without drugs successfully for over fifty years, will
join me in leading this effort. I invite them to join me because like them, I have successfully
counseled people toward better mental health since the beginning of my practice in 1957. During
that time, I have become a board certified psychiatrist but have still restricted my practice to
counseling. I have never diagnosed anyone with a DSM-IV diagnosis unless forced to do so by a
legal or reimbursement requirement and I have never prescribed a brain drug.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Defining Mental Health as Completely Separate from Mental Illness

Mental health is far more than living without psychological symptoms. You are mentally
healthy if you enjoy being with most of the people you know, especially with the important
people in your life such as family and friends. Generally, you like people and are more than
willing to help an unhappy family member, friend, or colleague to feel better. You lead a
mostly tension-free life, laugh a lot, and rarely suffer from the aches and pains that so many
people accept as an unavoidable part of living. You enjoy life and have no trouble accepting that
other people are different from you. The last thing that comes to your mind is to criticize or try
to change anyone. You are creative in what you attempt and may enjoy more of your potential
than you ever thought was possible. Finally, even in difficult situations when you are unhappy
- no one can be happy all the time - you'll know why you are unhappy and attempt to do
something about it. You may even be physically handicapped as was Christopher Reeve, and still
fit the criteria above while what I have just explained may seem very difficult to do, if you look
around among your friends and family you will find people who fit this description. The purpose
of this article is to explain that people who have learned choice theory and then made an effort to
use this theory in their lives will improve their own mental health. How far they go is up to them
but in my experience, once they start they tend to continue to improve. I will now explain why so
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Treating Mental Health as a Public Health Problem 157

many people are unable to do what I have just suggested. It will be difficult to improve our mental
health as long as we use the medical model Right now the treatment of all symptoms, physical and
psychological, is based on one of two models: the medical model or the public health model. In
the medical model physicians are in charge. They discover the pathology which is the cause
of the symptoms, use the pathology to diagnose the disease and then provide specific
medication or surgery to treat this particular pathology. All the patient has to do is follow the
doctor's orders. Whether they do, depends on how well the doctor and the patient relate to
each other and if the doctor takes the time to explain why his orders are important. Because of
all the tests, procedures, medication, surgery and doctor fees, the medical model is many times
more expensive than the public health model. The medical model, however, has serious flaws.
Because all medical treatment is based on finding specific pathology to explain the symptoms
and specify their treatment, the model breaks down completely when no pathology can be
found. So far, no pathology has been found in any of psychiatric DSM-IV diagnoses. When
the medical model is used for these diagnoses, as it almost always is, the psychiatrist or
physician diagnosing them will claim specific pathology is present because that has been a
traditional belief for over a hundred years.
An example of the misuse of the medical model is in the treatment of over six million
people, ninety percent of whom are women, suffering from severe muscular pain associated
with chronic fatigue - without pathology to explain their suffering. This group has been given the
diagnosis of fibromyalgia as if it were a disease. But to treat it, physicians are pretty much on
their own. There is no specific treatment. They tend to prescribe exercise along with a variety of
psychiatric drugs and pain medication but none of these has led to a "cure." This is a perfect
example of a condition for which the public health model can lead to improved mental health and
be much more effective than current practice.

The Public Health Model

Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

There are several different versions of the public health model but what is consistent with each
version is physicians are not in charge. It is a much less expensive model because there are no
individual tests, procedures, medication or surgery to treat conditions such as fibromyalgia and, of
course, there are no physicians' fees. In one version, the physician may point out what is needed
such as safer drinking water or an immunization procedure but in the drinking water sanitary
engineers take care of cleaning up the water supply and immunization can be done by nurses or
other medical technicians. All the public has to do is drink the clean water or show up for the
immunizations. In another version, physicians can warn of a health hazard but that's all they
can do. They have no cure for the diseases. For example, smoking kills a lot of people but it is up
to the public health system to educate the public about the dangers of smoking. This
education has been put into place, it has been very effective and because of it, many people
have quit smoking. Education is a very important component of the public health model.
In a third version, I will add millions of people who have psychological symptoms such as
depression, anxiety, mania, phobias, psychoses, obsessions, compulsions and panic who are
now diagnosed as mentally ill or disordered and treated almost exclusively with the expensive
and ineffective medical model. (Remember, no specific pathology to explain these symptoms
has ever been found). These symptomatic people may be less than mentally healthy but they
are not mentally ill. We could help many more people if we used a public mental health
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 158 William Glasser

education model such as one based on choice theory to teach to these people to improve their own
mental health. Still the use of the medical model for these DSM-IV symptoms seems so sensible to
the psychiatrists and physicians who use it as well as to the people they treat and their
families, that this model is now accepted as common sense practice. Here common sense has
replaced science, and billions of health care dollars are wasted in the process. There are many
well-researched scientific books cited at the end of this article, to support my claim of no
pathology, but here I would like to mention what I believe is the most important reference: the
2002 book by Robert Whitaker, Mad in America. It will be hard to read this book and still deny
what I have been explaining.

Why People with Psychological Symptoms should be Treated as Public

Health Problems

One definition of a public health problem is that it adversely affects the health of millions of
people but cannot be effectively treated by the medical model because there is no pathology. I
believe that through using choice theory, people with psychological symptoms can be taught to
improve their own mental health in the same way that couch potatoes can be taught to improve
their physical health. Neither group is ill as there is no pathology to account for their symptoms.
The difference between couch potatoes and people who have serious psychological symptoms
is that couch potatoes are usually aware of what to do, eat less and exercise more, and their
symptoms will disappear. The problem is they don't want to do it because it's unpleasant.
But from my experience, people with serious psychological symptoms such as depression,
would like to help themselves but they don't know what to do. But when they learn choice theory
(unlike diet and exercise), putting what they have learned into practice is very pleasant. But
unfortunately they are reluctant to start because they believe that they have pathology in their
brains and need brain drugs. Although choice theory is easy to learn it is not as easy as taking a
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

pill. The multi-billion dollar advertising campaign financed by the drug companies has not
served these people well. In a sense, they are being told there is a pill for mental health which
there is not. Any pill that makes you feel better is potentially addicting.
The first thing a public health education program led by counselors would do is teach all the
people they now see who are diagnosed as mentally ill, that they have no pathology in their brains;
they are not mentally ill. But as in the case of smoking, this public health information can be
made available to the general public. The people who are told this ask, "If there is nothing
wrong with our brains, what is the cause of our symptoms?" The public health answer to that
question would be to explain that their symptoms are caused by their unhappiness. People with
psychological symptoms know they are unhappy. What they want to know is what they can do
about it. That is a core question that I will now begin to answer.

Replacing External Control with Choice Theory

As I explain choice theory to the people I counsel, they find it hard to believe that
something as simple as unhappiness can lead to all the painful and disabling symptoms they
experience. They keep saying something must be wrong with their brain, I must be mentally ill.
The drug companies have done a good job of getting that message across. But what gets through
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Treating Mental Health as a Public Health Problem 159

to them, is when I teach them something very new, that few of them have ever thought about, I
explain how much happier they will be if they are willing to replace the external control they are
using now in some of their important relationships, with choice theory. I do the same thing
when I talk to an audience. I say, "Right here in this room there are a lot of divorced people. When
you were going through the divorce I don't think you knew why you went from some of the
happiest times of your life to the pain and bitterness of divorce." Then I go on to say it was
because there was too much external control in their marriage. As soon as I mention this to an
individual or to a group, everyone wants to know what external control is. To answer that question
I explain that choice theory teaches that we are social creatures who need each other. The need
for love and belonging is encoded in our genes. After a loving start, so many people find that their
love has disappeared. While they are thinking about this, I go on to explain that choice theory
also teaches that there are three more needs encoded in our genes: survival, freedom and fun. To
be happy we must find ways to satisfy these needs too, but it is the loss of love that is so puzzling
to people who are divorced.
I focus on the need to love because to satisfy that need we have to find another person to love
us which makes it more difficult to satisfy than the needs to survive, find freedom and have fun.
For a' relationship to last, both partners have to work to keep the love going but with choice
theory, as soon as one partner stops using external control, the marriage can begin to improve.
But what will come as a surprise to most readers of this article as well as to almost all the people
we counsel, is that humans have a fifth need, power, that is unique to us. No other creature
has this need. As we evolved, this may have been the last need encoded into our genes and
probably came with the onset of civilization. When we began to live near each other in large
numbers, competition and the need to control others, increased. More of the powerful who could
control others survived and passed on their power genes to their children.
It was from the need for power that all human beings on earth have learned to use
external control when they can't get along with each other, or failing that, have tried to learn how
to escape from the control of those who use it on them. But keep in mind, power is encoded in
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

our genes, external control is not. It is learned and we can learn through mental health
education to use choice theory to replace it. The world is filled with external control and most
of us learn it from parents, grandparents and school teachers most of whom use it most of the
time. It was external control that destroyed your marriage if you are divorced, and if you don't
learn how to deal with it better than you did, you may be unhappy the rest of your life. External
control is very simple. It tells us that in a relationship what we do is right and what someone
else does that is different, is wrong. Husbands know what's right for their wives and wives for
their husband. That external control, / know what's right for you which almost all people use
when they are in an unhappy relationship, harms any relationship. One or both may use it but
even if only one uses it, it will eventually destroy that relationship. We are social creatures. We
need each other. Teaching everyone the dangers of external control and how it can be replaced
with choice theory, is the heart and soul of a successful public mental health program.
To help you learn more about external control I have grouped together what I call the
seven deadly habits that destroy our relationships. We have all learned these habits no matter
what part of the world we came from. They are criticizing, blaming, complaining, nagging,
threatening, punishing and bribing or rewarding to control. There are more than seven but if you
can stop using these, you will be well on the way to a mentally healthy life. You may ask,
"What can I replace them with?" I suggest the seven caring habits that improve all relationships:
supporting, encouraging, listening, accepting, trusting, respecting and negotiating differences.
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 160 William Glasser

I predict that everyone reading this article has had bad experiences with the deadly habits. If
you even begin to replace them with a few of the caring habits, especially respect, you will
immediately feel a distinct improvement in the quality of your life. Getting rid of the deadly habits
in all of your relationships is central to mental health. As you learn to get external control out of
your life, you will begin to notice a few people around you who are very different from most
because they seem to be happy so much of the time. What you will notice if you get to know them
is they are not controlling. They don't try to change anyone. They have learned to live and let live.
If people try to control them they will have learned a variety of ways to escape that control. These
are people to get to know. They can be a model of what we all should be. A good counselor is
that model. What they are modeling is the choice theory way to live their lives. The brain drugs
psychiatrists or physicians prescribe may act as placebos There are, however, some medications,
or pills that resemble medications that relieve symptoms not supported by pathology. They
shouldn't provide relief but they do. They are called placebos because there is no medical reason
for their effectiveness. Physicians have known about placebos for thousands of years. Of course,
they work best when both the patient and the doctor believe they are effective and the doctor
shares this belief with the patient. Doctors are important people in our lives. A warm, satisfying
doctor- patient relationship has a lot to do with patients getting relief from a wide variety of
symptoms even some where pathology may be present The relationship is what makes the
placebo work.
Since there is no brain pathology in what is called mental illness, almost all brain drugs
prescribed with a lot of doctor and advertising support have a strong placebo effect. This effect is
seen when double blind studies are conducted and neither the patient nor the doctor knows
which is the placebo and which the medication. Often the placebo works better than the drug
with the added benefit that the placebo can do no harm. Unhappy people pay thousands of
dollars a year for medications that are no better than sugar pills. Many of the drugs are not only
ineffective but some can harm you. Keep in mind that when a placebo works to relieve a
symptom that should be a strong indication there is no pathology. Where there is pathology,
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

placebos may also work for a while because they provide hope but will soon lose their
effectiveness.
There are also a variety of non-medical healers who do good work as long as there is no
actual pathology. The personal concern they show for people who want concern, is a placebo
effect. These healers are well aware of the importance of a good relationship. But I have no
problem admitting that I don't know a lot about many of these healing procedures. They may
also have some mysterious healing power that some day may be explained by science.
Practitioners such as acupuncture professionals, yoga teachers, herbal healers, massage
therapists and other hands-on practitioners, are often very effective because they provide both
the relationship and the information - scientific or not - that people want to hear. The close
attention and support of people whom you believe in and whom you believe care about you -
especially if they touch you- has always had a healing effect. But there is a great difference
between going to a licensed psychiatrist or a medical doctor to get help with a symptom (which
is not supported by pathology) and going to a healer. If you go to medical doctors or psychiatrists
and tell them you are suffering from a well known psychological symptom they will go through
the whole medical model regime: basically they will inform you that you are mentally ill and
need brain drugs. They may not tell you they can cure you but they certainly infer this is a
strong possibility.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Treating Mental Health as a Public Health Problem 161

The healer on the other hand does not have a medical license. He may be careful not to
claim that you are ill and that he can cure you. He will rarely attempt to cite much scientific
evidence but he will give you an explanation he believes in. I can't say that what the healer
does is harmful. But I can say that when the psychiatrist or medical doctor tells you there is
pathology in your brain, he is wrong. If you ask if he has a blood test an X-ray or any other test
like an MRI or a CAT scan to support his diagnosis, he won't be able to cite any because so far,
none have been found.
We are presently struggling unsuccessfully with a huge epidemic of misdiagnosed mental
illnesses because the psychiatric establishment as well as many other "mental health"
professionals who deal with unhappy symptomatic people, not only believe in the medical
model themselves but almost all the people who come to see them believe in it too. If they watch
television advertising, they get plenty of support for their beliefs. History is filled with examples of
common sense gone wrong. The world is no longer flat and the earth circles around the sun.
Examples in medicine are widespread. George Washington was bled to death by physicians
using common sense. More recently millions of tonsils and adenoids were unnecessarily
removed based on common sense. This practice continued well after antibiotics became widely
available and still continues. The list goes on and on. Today, psychiatric common sense is the main
offender.

Counseling and Teaching Are Important Parts of the Mental Health Model

Even though I have been a psychiatrist for a long time, I have restricted my practice to
counseling or psychotherapy. I use these terms interchangeably. I reject the medical model for
all the reasons I have explained so far. The people I counsel are not mentally ill. They are
unhappy. When you are unhappy, you may suffer from one or more of the hundreds of
psychological symptoms, or even from what seems to you to be medical symptoms such as
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

what occurs in fibromyalgia.

Despite what you may have been taught, the symptoms that bring you to a counselor are
almost all caused by a present unhappy relationship. In some instances you have no relationship
at all. Many people I have counseled only want to talk about their symptoms. I will be very polite
but I won't allow this very long. Talking about symptoms is the medical model and if I talk
extensively to clients about them, I will infer they are real and I can get rid of them, which I can't.
They may also want to tell me at length about an unhappy childhood relationship. I will listen
politely and ask if that person is still in their lives. In very few instances he or she is the present
unhappy relationship but in most cases, that person is no longer involved in their lives.
Clients try to avoid talking about the present unhappy relationship by focusing on the past or
on their symptoms. It is uncomfortable to talk about the real problem but I am a reality therapist
and that's where I think we need to be. In a warm, polite, supportive way I'll keep moving our
discussion away from symptoms and the past and on to the present unhappy relationship
because the thrust of the mental health model is to teach you to get along better with that person
and improve your mental health in the process. When you learn to do this, your symptoms will
disappear. I counsel by talking to my clients and getting to know them because in my
experience, they want to talk with me as much as I want to talk with them. The warm
supportive relationship we create by talking and listening leads them to be receptive to learning
how they can improve their own relationships. Because of what I believe, I have never told a
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 162 William Glasser

client that he or she is mentally ill. That's hardly the way to start a warm supportive
relationship.
If you are paid for your counseling by an HMO or other health care provider, I realize you
may have to make a DSM-IV diagnosis to get paid. Because the medical model is so accepted and
brain drugs are so much a part of the treatment, you will have to teach your clients about the
mental health model and the importance of need-satisfying relationships in their lives. Some of
them ask, how will we know if this new model works? I tell them they will know when they are
happy and the quality of their lives improve. It does not take long to help clients to reach that
point. It takes a little longer for them to get external control out of their lives.
You can also explain that using the mental health model you can counsel them
successfully whether they are on medication or not as long as they are able to talk with you.
Even when they are hallucinating or expressing delusions you can talk with them. You have to
be patient, but they need the relationship with the counselor to get the counseling started. If
they are psychotic don't try to get them to stop their symptoms. That would be external
control and you cannot counsel successfully if you use any external control. It may be that
they are creating their symptoms to avoid that control. I have had a lot of experience with what I
am now describing but I can only mention a few-things here. All my books written since 1998
cover these techniques in detail. In all the years I counseled I never had a person ask for
medication once the counseling started. I had some clients who wanted to stop the medication but
I always recommended that they go back to the prescribing physician to get weaned off it.
Some had a little discomfort but nothing serious. Since counselors who read this article cannot
prescribe drugs, I believe they will be protected legally if they refer clients who want drugs to
psychiatrists.
I call the way I presently counsel: counseling with choice theory, the new reality therapy
By replacing the medical model with the mental health model, I have significantly helped almost
every client I have dealt with using the reality therapy I developed starting in 1962. Beginning
in 1979 I expanded this therapy and increased its effectiveness by adding what I now call
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

choice theory to my counseling. In 1998, I published the basic book. Choice Theory. The
material in this book is the guide for the way I conduct both my personal and professional life. I
will describe some of the specifics of this counseling as much as I can in this short article but to
get a feel for the whole process, I suggest you read my 2001 book, Counseling With Choice
Theory, the New Reality Therapy as well as Choice Theory.
I begin my counseling by asking, "What's happening" or say, "Tell me the story." My
clients like those questions. They want to tell me what's on their minds. They have no trouble
answering these questions because everyone who comes to me has a story and is anxious to tell
it. These questions tell them I'm interested in their story, which means I'm interested in them and
that interest helps get the counseling relationship started. In the rare instance where they may be
reluctant to tell me the story, I encourage them by saying their story is very important and I have
plenty of time to listen to it. Many of them have heard from friends or family members that
psychiatrists are too busy to spend much time with them so hearing I have plenty of time, is a
pleasant surprise. Counselors have this time. Being in a hurry is not your problem.
Telling me about unhappy relationships is almost always a part of their story. Mostly they will
tell me that they are not getting along as well as they would like with their spouse, children,
parents or other family members. At times it may be a friend, a lover, a teacher an employer or a
fellow worker. It is always someone important and in most instances as the story progresses, they

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
 Treating Mental Health as a Public Health Problem 163

also tell me it's not their fault. It's the fault of the other person saying, "I'd be fine if he or she
would treat me better."
They then ask me if there is anything I can do to change the way the other person is
treating them. When we get to that point (and it is often in the first session of the counseling), I
begin to explain choice theory and how teaching them to put choice theory to work in their lives is
the most important part of the way I counsel. Using many examples I will teach them that the
only person's behavior I can help them to change is their own. This then leads to an important
discussion. They ask why I only help them to change the way they behave. Since it's the other
person's fault, why can't I help them to change the other person's behavior? But as we continue
to talk, I explain the basic choice theory concept that we can only control our own behavior,
that we can only live our own lives, and that we can't live anyone else's life or control them. As
we talk I ask them if they have ever been successful in changing anyone who doesn't want to
change and they begin to see my point.
It may come out that if they use enough pressure other people will change but only as
long as the pressure is continued. Nothing changes in the way the other person is thinking and as
soon as the pressure is lifted they go back to the way they were. I also tell them that if they will
start to behave in ways that improve the relationship, no matter what the other person is doing,
there is a chance the other person will want to change in the same way.
For example, if there is a lot of criticizing going on and one person stops the other may stop
too. If this happens, the relationship will change for the better. But if you are the one who chooses
to stop, I suggest you explain the choice theory reasoning that led to your choice. I encourage
the people I counsel to use every chance they can to explain the choice theory they are
beginning to use as they deal with the important people in their lives.

Creating a Public Mental Health Delivery System Based on Choice Theory

Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

In 1967, 1 was so impressed by the positive response I received from both counselors and
teachers to my 1965 book, Reality Therapy, that I created The Institute for Reality Therapy.
The initial purpose of The Institute was to teach and train people to use reality therapy as they
counseled, taught and managed children in school. By 1996, after many more books, I gradually
became aware that my theoretical thinking should now be called choice theory. In 1998, I
published the basic book. Choice Theory, and began to devote most of my thinking to the ideas in
this article. When I did this I changed the name of the institute to The William Glasser Institute.
But when I look back I can see that even before I wrote Reality Therapy, I was already
thinking about mental health as separate from mental illness. That thinking has now
crystallized in my 2003 book. Warning, Psychiatry Can Be Hazardous to Your Mental Health.
That book contains almost all that is in this article. It is a self-help book dedicated to teaching
readers choice theory so they can improve their own mental health. What has led me to think
seriously about creating The Public Mental Health Delivery System has been the forty years of
experience. The Institute has been teaching my ideas to counselors, school teachers and school
managers. We do this with small groups of people who are going through the Institute's
Intensive Week Training in reality therapy, choice theory and lead management. As of now, about
65,000 people, mostly counselors and school teachers, have taken at least one week of our three
week training. Around 7,100 people have completed the whole program and have become

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 164 William Glasser

Reality Therapy Certified. Almost a thousand more people have gone on and become instructors
for The Institute.
From all these people, no matter whether they completed the whole program or not we have
continuous feedback telling us how surprised they were by the experience. They took the
training to become better counselors, teachers and managers but they are now getting along
better with everyone especially with their spouses, their family and with the people at work. Now
that many of them know of my interest in mental health they tell me that they are mentally
healthier and are teaching some choice theory to their family at home. I became more
interested in mental health as I realized that learning to use choice theory in their lives was a very
pleasant experience.
In the Warning book, I created what I called a Choice Theory Focus Group in which about
a dozen people meet twice a month to discuss how they could put choice theory to work in their
own lives and help others in the group to put it to work in theirs. What I am describing is
education with a teacher and which uses the Warning book as a text book. I suggest that the
teachers be counselors as most of the teachers in our program have been and still are. The Choice
Theory Focus group is a very easy way to deliver Public Mental Health.

I Encourage ACA Members to Offer Choice Theory Focus Groups

A few counselors or small groups of counselors could get together and offer a public
mental health program and the one I suggest is a Choice Theory Focus Group. The counselors
could see the clients individually and counsel them toward better mental health using the
public health model that I have already explained. They could also explain to clients the
advantage of being a part of small Choice Theory Focus Groups. They explain and even advertise
that they do not believe in the mental illnesses the psychiatrists diagnose and, of course, they
do not use brain drugs. Because of a lot of adverse publicity (this is continuing as I write this
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

article), there are a lot of people who want help without drugs but they could also be helped if
they are on them. Counselors could charge their regular fees for individual mental health
counseling and reasonable fees for participating in their focus groups.
It would probably take time to build a public mental health practice and you might be
required to provide DSM-IV diagnoses for a while to get reimbursements. But if the group
could show how more effective and less expensive this model is, they could attract HMO case
managers to send clients. Keep in mind that this program can only help; it can do no harm to help
clients get along better with the important people in their lives. If counselors had some focus
groups going, they could make this service available to HMOs, public and private counseling
services, pain climes, social service agencies, college and university health services and private
physicians all of whom are using the medical model to treat people for both psychological and
medical symptoms not supported by pathology. I have already explained that by continuing to
use the medical model instead of the public health model, these organizations are spending huge
sums of money and delivering much less care than their subscribers or clients need. By doing this
the counselors could take the lead in promoting real mental health and gain much status in the
process.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Treating Mental Health as a Public Health Problem 165

Invite the Mental Health Associations to Get Involved

Choice Theory Focus Groups could be a low cost but effective addition to the services
offered by the many Mental Health Associations that are located all over the country. By
supporting these groups, they could offer better mental health directly to the public.
Counselors trained in choice theory could run the groups and explain how they are using choice
theory in their own lives. I invite any Mental Health Association interested in better mental
health to contact The William Glasser Institute. We would be happy to walk them through the
process and provide any training they need at a very reasonable cost. Since this new model is easy
and pleasant to learn, people could enjoy attending these meetings and attendees would spread
the word. Once in operation, this delivery system could offer better mental health to millions of
unhappy people who are not mentally ill but are not as mentally healthy as they or their families
would like them to be.

A Final Very Important Word

In this article I have explained the flaws of the medical model and suggested that it be
replaced by the public mental health model. I have also suggested that choice theory is a tested
method to teach mental health both in individual counseling and in small groups. It can be learned
easily, it is pleasant, and most people find it very useful. But I recognize that there are other
well accepted counseling models such as Alfred Adler's, Aaron Beck’s and Albert Ellis's.
These models could also be very effective if they would recognize that there is such a
thing as mental health separate from mental illness and if their methods could be adapted to teach
people how to improve their own mental health. I by no means suggest choice theory is the only
model or the best model but is a tested model that has worked successfully for many years.
Finding the best counseling model is not the problem. The problem is to persuade health care
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

providers and mental health providers to replace the medical model they are using now with
millions of people, with a public mental health model. Literally billions of dollars are being
wasted now with a model that not only does not work but is increasing the problems we are trying
to solve.

The William Glasser Institute

The William Glasser Institute teaches and trains people all over the world. We would love
to have some of the readers of this article get involved with our training. I have also written many
books all aimed at helping counselors, teachers and managers put choice theory to work in what
they do. For much more information on our training, on other books and materials such as tapes
and DVD's, go to our website: wglasser.com

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 166 William Glasser

REFERENCES
Whitaker, R. (2002). Mad In America, Cambridge, MA: Perseus Publishing.

BIBLIOGRAPHY
All books, except Mad in America, cited in this article, are written by William Glasser and
published by Harper Collins. I highly recommend the following books by other authors.

Peter Breggin (1991). Toxic Psychiatry. New York: St. Martin's Press.
Peter Breggin and David Cohen (1999) Your Drug May Be Your Problem. Cambridge, MA:
Perseus Books.
Richard Gosden (2001) Punishing the Patient. Melbourne, Australia: Scribe Publications.
Joseph Glenmullen (2001) Prozac Backlash. New York: Simon and Schuster.
Lucy Johnstone (1989) Users and Abusers of Psychiatry. London: Routledge Publishers.
Terry Lynch (2004) Beyond Prozac. Bath, UK: Bath Press.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 In: The Quick Theory Reference Guide ISBN: 978-1-60021-624-4
Editor: Karin Jordan, pp. 167-181 © 2008 Nova Science Publishers, Inc.

Chapter 12

EMPOWERMENT FEMINIST THERAPY

Pam Remer

21st century mental health practitioners must be able to deliver culturally competent
services to an increasingly diverse range of clients. Culturally competent therapists
understand their clients’ socio-political and cultural contexts (American Psychological
Association, 2002; Division 44/Committee on Lesbian, Gay, and Bisexual Concerns Joint
Task Force on Guidelines for Psychotherapy with Lesbian, Gay, and Bisexual Clients, 2000).
These external contexts include cultural values, norms, socialization processes, and social
institutions. Because diverse clients are often from subordinate, oppressed societal groups
(e.g., People of Color, women, sexual minorities, people with disabilities, individuals from
lower socio-economic groups, older individuals), understanding clients within their cultural
contexts also means being knowledgeable about the impact of discrimination and oppression
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

in their lives. Thus, counseling theories that guide therapeutic work must have constructs and
interventions that enhance counselors’ awareness of clients’ cultural contexts and the impact
of those contexts on their lives.
Most counseling theories focus on clients’ internal landscapes seeking to change clients’
dysfunctional thoughts, behaviors, and/or feelings. Feminist therapies were originally
developed to address the negative effects of societal sexism on the lives of women and later
were expanded to focus on the impacts of all forms of oppression on people’s lives (Enns,
1997; Worell & Remer, 2003). Further, feminist therapists assert that because cultural
contexts and societal oppressions can be a major cause of what appear to be individual
problems, then changing internal landscapes is both insufficient and inappropriate. Rather
feminist therapies emphasize the need for changing social and cultural landscapes. That is,
feminist therapists advocate and work for social change. In this chapter, a brief overview will
be given about the four major types of feminist therapies and then, one specific feminist
counseling approach, Empowerment Feminist Therapy (Worell & Remer, 1992, 2003) will be
described in detail.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 168 Pam Remer

THEORY DESCRIPTION

History

Feminist therapies are relatively recent phenomena that emerged out of the United States’
women’s movement of the 1960’s and 1970’s. During this movement, feminists asserted that
women’s problems in living were created by their cultural and institutional contexts (e.g., by
institutionalized sexism, cultural norms that dichotomize appropriate behaviors for men and
women). Many women participated in leaderless consciousness-raising groups where they
discussed their lived experiences, discovered commonalities in these experiences (e.g., the
prevalence of violence against women), and connected these experiences and issues to their
socio-political contexts and to society’s subordination of women. Mental health practitioners
were among the women who participated in these groups. These practitioners brought these
CR perspectives into their work with women and criticized existing therapeutic approaches
for ignoring the negative effects of societal oppression on women. For example, feminist
therapists challenged traditional perspectives that blamed women for their victimization (e.g.,
rape, childhood sexual abuse, sexual harassment). Thus, feminist therapies were created as an
alternative to and challenge of existing traditional psychotherapies for their failure to
acknowledge the socio-cultural contexts of women’s lives. Consciousness-raising about how
these socio-cultural contexts create many of women’s problems in living was the major theme
of the women’s movement and forms the foundation of most feminist therapeutic approaches.
In contrast to traditional therapies’ intrapsychic focus on changing clients’ thoughts, feelings,
and behaviors, feminist therapies focus on social pathology and the need for social change.
Over the past thirty years, multiple feminist therapies emerged, each founded on different
feminist philosophies (Enns, 1997). Enns has categorized these feminist therapies into modal
types. Four of the major modal types of feminist therapies are: Liberal, Radical, Cultural, and
Women of Color.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Liberal feminist counselors emphasize the problems caused by traditional gender-role

socializations that proscribe certain traits and behaviors as only appropriate for men or for
women. These proscriptions restrict the potential development of both women and men. At a
social change level, they assert that positive change will be accomplished by eliminating
gender bias, changing how women and men are socialized, and by equalizing societal
opportunities for women. At the individual level, they help clients examine and change their
internalized, learned gender messages.
Radical feminist counselors critique societies for their sexist, racist, classist, heterosexist,
ableist, and ageist institutional structures. They believe that personal issues are created from
oppressive social pathology. Thus, at a social change level, major restructuring of patriarchal
(male dominated) and other oppressive societal institutions is required to foster the mental
health of all people. All societal oppressions must be reduced and eliminated. At a more
individual level, they help clients become aware of these oppressions and how they have
negatively affected their lives and contributed to their counseling issues.
Cultural feminist counselors attribute women’s problems to the societal devaluation of
women’s traits, abilities, and values. Cultural feminists acknowledge female and male
biological and psychological differences and believe social change should be aimed at
societal revaluing of traditional female traits, values, and abilities (e.g., subjective ways of

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Empowerment Feminist Therapy 169

knowing, cooperation, interdependence). At the individual change level, counselors aid

women in learning to value their gender-related qualities and to identify their strengths.
Women of Color feminist counselors emphasize the negative effects of multiple forms of
oppression, especially racism, on individuals from subordinate societal groups. They also
assert that most types of feminist counseling have not focused enough on all forms of
oppression, have assumed that White women’s perspectives apply to diverse women, and
have focused too much on sexism. They describe the interacting negative impacts of multiple
seats of oppression (e.g., an African-American lesbian woman). They discuss the importance
of honoring diverse cultural values. Similar to Radical feminist counselors, at a social change
level, Women of Color feminist therapists work on altering social and political structures that
create and maintain oppression. On an individual level, they help clients identify how they
and their issues have been negatively impacted by negative stereotyping and experiences with
oppression. Women of Color therapists also help clients learn coping skills for combating
oppression on a daily basis.
The various types of feminist therapy differ in their emphasis and each contributes unique
dimensions while sharing a common belief that societies’ treatment of women is a significant
source of the problems women bring to counseling. They all share the belief that “The
Personal Is Political”, yet differ in what social changes are necessary and how they should be
accomplished. With their focus on the need for social change, most types of feminist therapy
that emerged represented a major divergence from traditional intrapsychic (internally
focused) psychological perspectives.
Unlike many counseling theories, feminist therapies have been developed by multiple
contributors and thus, do not have a single founder. Feminist therapies’ history represents a
synergy across the various feminist theories, a synergy that has been supported by feminist
researchers who provided data and findings about women’s lived experiences and
perspectives. For example, prior to the 1970’s, little to no research had been conducted on the
effects of rape on women and the professional literature generally blamed women for being
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

raped. Feminist researchers used women-centered perspectives to document the negative and
traumatic effects of being raped and to challenge societal myths about rape with data about
the realities of rape. Feminist researchers also documented the existence of gender bias in
therapy (American Psychological Association, 1975). This documentation eventually led to
“Principles Concerning the Counseling/Psychotherapy of Women” being developed
(Fitzgerald & Nutt, 1986).
It is beyond the scope of this chapter to give a detailed description of the various types of
feminist therapies and the history of these therapies. Rather one specific feminist therapy,
Empowerment Feminist Therapy (EFT) (Worell & Remer, 1992, 2003) will be described.
EFT was chosen because it integrates aspects of the four major types of feminist counseling
and integrates diversity, multicultural perspectives into its tenets.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 170 Pam Remer

PRINCIPLES OF EMPOWERMENT FEMINIST THERAPY

Empowerment Feminist Therapy (Worell &Remer, 2003) integrates aspects of Liberal,
Radical, Cultural, and Women of Color feminist approaches. EFT was recently revised to
structurally integrate diversity perspectives into its feminist framework. As the name
suggests, the ultimate goal of EFT is to empower clients to be able to influence both their
internal and external landscapes. EFT is comprised of four principles: I. Personal and social
identities are interdependent, II. The personal is political, III. Relationships are egalitarian,
and IV. Women’s perspectives are valued. These four principles form the skeletal structure of
the theory from which all practice and interventions emanate.

Principle I: Personal and Social Identities are Interdependent

One critical aspect for understanding clients’ socio-cultural contexts is knowing about
their intersecting social identities. EFT therapists assert that every culture is comprised of
socially constructed groups of people (social locations) (Remer, Worell, & Remer, 2005;
Worell & Remer, 2003). Social locations include race/ethnicity, gender, socio-economic
status, sexual orientation, immigration status, age, religious orientation, and physical and
mental abilities. These social locations lie on an oppressed to privileged continuum.
Individuals who come from groups that are subordinate or oppressed have very little power
within that culture, are often negatively stereotyped by the culture, and are often
discriminated against (e.g., People of Color, women, sexual minorities). Conversely,
individuals who come from dominant or privilege groups (e.g., White people, men,
heterosexuals) usually occupy positions of power within the culture, are stereotyped as having
desirable, valued characteristics, and have “invisible” privileges that facilitate their
achievement within the society (McIntosh, 1989). Privileged group members are seen as
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

fitting the norms of the culture while oppressed group individuals are viewed as deviant or
deficient when compared to the standards of the dominant groups. Both experiences
associated with being privileged and those associated with being oppressed affect the
development of individuals and affect the relationships among people. Further, beliefs about
social groups within a culture are taught and maintained by socialization and are structured
within a culture’s institutions (Worell & Remer, 2003).
Individuals do not uniformly view their social locations the same way. While theorists
(e.g., Diller, Houston, Morgan, & Ayim, 1996) have depicted certain locations as privileged
and others as oppressed in U.S. society, individuals may not identify themselves with a
particular social location that others see them fitting and/or may appraise a particular social
location as more privileged or oppressed than others see that location. For example, a woman
may not identify herself as being oppressed or disadvantaged because she is female. Thus,
individuals’ perceptions of their social locations are as important as the social locations
themselves. Individuals’ perceptions of their social locations comprise their social identities.
Individuals’ perceptions of their social locations are also influenced by their identity
development related to each location. Identity development models depict how individuals’
development is impacted by the privileged or oppressed statuses of their social locations. A
variety of identity development models have been created for specific social locations. For

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Empowerment Feminist Therapy 171

example, Cross (1980) has a model for Black identity development, Cass (1979) has one for
sexual minority identity development, and Helms (1995) developed one for White identity
development. These models postulate stages or levels of identity development representing
individuals’ awareness of and ways of dealing with the oppression or privilege associated
with each social location.
Since individuals occupy multiple social locations about which they have varying
perceptions and identifications with, their self-identity is composed of multiple, intersecting
social identities. Within the same individual, identity development levels for each social
identity can vary. Worell and Remer (2003) have developed a “social identity development”
model that applies to all social locations and accounts for the intersecting and varying nature
of social identities. Both individuals’ social locations and their social identities affect their
views of themselves, how others perceive them, and their interactions with others.
The principle that social identities are intersecting and interdependent is the primary
theoretical vehicle for integrating feminist and diversity perspectives in Empowerment
Feminist Therapy. An adequate understanding of clients’ cultural context begins with an
assessment of their social identities, the identity development levels associated with these
identities, and the impact of their social identities on their lived experiences and struggles. By
focusing on intersecting social identities, counselors honor their clients’ diversity and
acknowledge the importance of these identities in their clients’ lives. Thus, counseling begins
with an overt acknowledgement of the cultural context of clients’ lives.

Principle II: The Personal is Political

The main unifying theme across different types of feminist therapies is that women’s
personal struggles are created or impacted by social or cultural factors (Enns, 1997, Worell &
Johnson, 1997). Thus, the second principle of Empowerment Feminist Therapy is The
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Personal Is Political. Empowerment Feminist therapists believe that toxic social

environments contribute significantly to women’s problems in living and that many of the
problems common to groups of women are primarily the result of societal oppression of
women and other subordinate groups.
This focus on social pathology is a radical departure from most therapy approaches that
locate problems in clients and work to change clients’ dysfunctional thoughts, feelings, and
behaviors. Instead, feminists assert that if institutionalized oppression and toxic socialization
processes create and/or contribute to individuals’ problems, then social change is needed.
Thus, feminist therapists (and often their clients) work to alter oppressive social structures
and socialization processes that restrict the development of individuals. Changing the toxic
elements of social contexts prevents future generations from having to cope with the same
problems. In addition to advocating social change, EFT counselors educate their clients about
all forms of privilege and oppression and explore how the client’s socio-political, cultural
environment has impacted them. This consciousness-raising facilitates clients’ movement in
their identity developments and helps them to stop blaming themselves and their personal
inadequacies. Clients are also encouraged to identify how they have internalized the norms
and beliefs of their cultural contexts and to assess if they want to continue to live in
accordance with these beliefs and structures. The primary goal of EFT and of most feminist
therapies is to end all oppressions (Wyche & Rice, 1997; Worell & Remer, 2003).
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 172 Pam Remer

Principle III: Relationships are Egalitarian

For EFT therapists, one important part of social pathology is the hierarchical arrangement
of societal relationships where some privileged groups enjoy power and resources while
others are subordinated, oppressed, and denied equal access to societal resources. Thus,
patriarchy and other forms of hierarchical relationships are viewed as unhealthy because they
sustain privilege and oppression. Thus, egalitarian relationships are considered desirable in
society and in therapeutic relationships. Egalitarian therapeutic relationships counter the
destructive hierarchical relationships prevalent in society and create environments where
clients are treated as experts on their lives, where clients from oppressed groups experience
not being in subordinate positions, and where clients have enough safety to begin to voice
their phenomenological truths. Egalitarian therapeutic relationships provide a model for the
desirable relationships between all people. EFT counselors help their clients consider the
value of establishing more egalitarian relationships in their lives and if clients so choose,
feminist counselors aid clients to acquire the skills for achieving these relationships.

Principle IV: Women’s Perspectives are Valued

As described earlier, Cultural feminists believe that the major source of social pathology
rests in society’s devaluation of female-related traits, characteristics, values, and ways of
knowing and that androcentric, White, heterosexual, male-normed ways of perceiving are
valued and rewarded. Both women and men internalize these beliefs and values. Further,
women of most cultural, ethnic groups are taught to behave in gender-specific ways, are
rewarded in some ways for complying with these cultural rules, and yet, are also devalued for
not acting like men. For example, women from many U.S. ethnic groups (e.g., White women,
Asian-American women, Latina women) are taught to attend first to the needs of their
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

husbands and children and yet may be diagnosed as “enmeshed” when they act in accordance
with this cultural value. This creates a double bind for most women (Broverman, Broverman,
Clarkson, Rosenkrantz, & Vogel, 1970). Devaluation of traditional female-related traits also
hurt societies because this devaluation restricts societies’ flexibility to develop a full range of
solutions to social problems. Further, feminist counselors believe that women’s and other
subordinate groups’ values and characteristics (e.g., cooperation, subjective ways of knowing,
interdependence) offer healthier alternatives to the White, heterosexual, male values (e.g.,
competition, objective ways of knowing, independence). Note that multiple perspectives are
valued and diverse women’s perspectives are acknowledged. At a macro, societal, level, EFT
therapists believe that embracing these alternate values would result in fewer wars and
reduced violence against women. At a micro, individual level, this re-evaluation process
results in women identifying and appreciating their strengths and societal contributions and in
men expanding their role repertoires and appreciating the strengths and contributions of
women.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Empowerment Feminist Therapy 173

KEY CONCEPTS

Nature of Persons

In Empowerment Feminist Therapy, women and men are not viewed as having an
inherent nature based on gender. Rather all tasks, roles, abilities and personality styles are
viewed as available for both women and men. Gender-role socialization and institutionalized,
gendered cultural values are responsible for observed differences in men and women (Worell
& Remer, 1992, 2003). Similarly, socialization processes and institutionalized oppressions
are seen as creating observed differences between societal groups. That is, apparently
observed differences between groups and the meaning attached to these differences are
socially constructed (Porter, 2005). An implicit assumption of EFT is that human beings have
an inherent tendency toward growth and that social environments introduce restrictions to this
development.

Healthy and Unhealthy Functioning

EFT personality theory is not intrapsychically (internally) based as in many other

theories. Instead EFT practitioners view people’s development as a complex interaction of
external, cultural factors and personal factors (an interactionist approach) (Worell & Remer,
2003). Within this interactionist approach, more emphasis is given to the impact of socio-
cultural factors on human development. EFT therapists assert that in any culture dominant,
privileged and subordinate, oppressed groups are created by societies and that these
hierarchical arrangements negatively affect personal development.
More specifically, individuals are viewed as situated in complex, multi-leveled socio-
political, cultural contexts and that individual development and behavior is a result of
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

complex interactions between individuals and these cultural environments. Thus, EFT has an
interactionist view of personality development
Healthy societies or cultures are ones that value egalitarian relationships and eschew
hierarchical relationships. Healthy societies would have an absence of oppressed and
privileged groups, would value diverse perspectives and values, and would facilitate all
citizens’ access to societal resources. Thus, the primary language of both healthy and
unhealthy functioning in EFT is focused on the societal level. The assumption is that societal
health will result in the maximum opportunity for the health of all individuals in that society.

Change Process

Empowerment Feminist Therapy emphasizes the need for social change, especially social
change aimed at ending all forms of oppression. Because societal oppressed and privileged
structures and associated socialization processes are viewed as a major source of people’s
problems in living, these societal structures and processes must be changed in order for
people to function optimally. Involvement in social change endeavors is a central
commitment for EFT practitioners. They work in their communities in a variety of ways to

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 174 Pam Remer

change their social environments. They also are supportive and encouraging of their clients
being involved in social change projects. However, they do not insist or push their clients to
work for social change. Rather, in raising their clients’ awareness about the contributions of
their social contexts to their issues, they empower their clients to effect changes both in
themselves and in their environments. EFT clients often spontaneously decide to challenge
the external sources of their problems because they find personal meaning in helping prevent
their experiences happening to others.
Both therapists’ and clients’ social change efforts can range from micro to macro level
changes. An example of macro level change would be an EFT therapist who counsels rape
survivors working to change the exclusion of marital rape in a state’s laws. An example of a
micro level social change is a client who has struggled with accepting the lesbian sexual
orientation of his daughter deciding to confront his best friend’s homophobic remarks.
On the individual level, client change is focused on helping clients become more aware
of their social contexts, the existence of oppression and privilege, and their socialization
processes. In examining their social contexts, clients begin to separate the external from the
internal sources of their problems. Clients then decide what changes they want to make in
themselves and in their environments. On the personal level, they may decide to challenge
their internalized cultural messages about their social locations. For example, a woman who
was date raped realizes that the gender-role messages she received (e.g., “women are
responsible for men’s sexual behavior” and “women secretly desire to be raped”) were both
inaccurate and unfair. As a result of this analysis, she decides to rewrite these messages for
herself.
EFT’s approach to therapeutic change is quite different from the intrapsychic focus of
many mainstream therapies. For EFT practitioners, “the focus is on changing the unhealthy
external situation and the internalized effects of that external situation, rather than on helping
the client adapt to a dysfunctional environment” (Worell & Remer, 2003, p.68).
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

THE THERAPEUTIC PROCESS

Assessment and Diagnosis

Traditional approaches to assessment and diagnosis locate problems and pathology in

individuals (Santos de Barona & Dutton, 1997), a focus which is incompatible with
Empowerment Feminist Therapy’s conceptualizations about social pathology. The current
mainstream approach to assessment and diagnosis is to assess for dysfunction in individuals
and then to assign pathological diagnoses to individuals who are in distress. Feminists assert
that this mainstream approach has several deficiencies and biases. First, mainstream
assessment and diagnostic strategies disregard or minimize environmental contexts and the
impact of cultural contexts on clients’ lives (S. R. Lopez & Guarnaccia, 2000; Ridley, Li, &
Hill, 1998; Santos de Barona & Dutton, 1997; Worell & Remer, 2003). This disregard can
lead to blaming and stigmatizing clients from subordinate groups for their responses to
oppression. Second, feminists point out that therapists often have unexamined biases about
societal groups that may lead them to see symptoms in and apply a diagnostic label to one
group while not perceiving these phenomena in another group. For example, research has

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Empowerment Feminist Therapy 175

shown that clinicians are more likely to apply a Borderline Personality diagnosis to female
clients than to male clients displaying the same behaviors (Becker & Lamb, 1994). Thus,
feminist therapists try to avoid using individual-based diagnostic systems (e.g., Diagnostic
and Statistical Manual of Mental Disorders) because they locate dysfunction in individuals.

Feminist Perspectives of Purposes of Assessment and Diagnosis

From a feminist viewpoint, the purposes of assessment and diagnosis are to: (a) assess
cultural contexts, (b) assess the impact of cultural contexts on clients’ lives, and (c) assess
clients’ ways of coping with toxic social elements.

Feminist Tools

Consistent with Principle I, Personal and Social Identities Are Interdependent, EFT
therapists assess for clients’ social locations, social identities, and social identity development
levels. Consistent with Principle II, The Personal Is Political, EFT therapists help clients
assess their social environments for unequal power relationships (power analysis) and for the
presence of negative stereotyping and discrimination (cultural analysis). Clients are taught to
reflect on their socialization processes and on the cultural messages they have received and
internalized (e.g., gender-role analysis). Their feminist counselors help them evaluate the
impact of these messages and cognitively restructure the internalized cognitions that do not fit
them or that have detrimental effects on their lives. Consistent with Principles III,
Relationships Are Egalitarian, and Principle IV, Women’s Perspectives Are Valued, EFT
counselors help clients identify the skills they have used to cope with oppressive elements in
their cultural surroundings.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Feminist therapists do not view subordinate group clients’ reactions to toxic social
environments as “symptomatic”. What other therapist may label as symptoms, feminist
therapist regard as “coping strategies”, skills for coping with social discrimination, negative
stereotyping, and devaluation. Thus, symptoms are often relabeled as strengths by EFT
therapists. This re-labeling of symptoms as coping strategies is a hallmark of feminist
approaches to assessment and diagnosis (Santos de Barona & Dutton, 1997; Sturdivant,
1980).

What is Diagnosed?

Taken as a whole, feminist assessment and diagnostic strategies shift the label of
pathology from individuals to socio-cultural factors. Societal structures and socialization
processes are examined for evidence of the existence of oppressed and privileged groups.
Client issues are examined for cultural underpinnings that create and/or maintain the issue.
For example, a feminist analysis of sexual harassment asserts that societal myths about
women’ lack of competencies for the workplace, patriarchic leadership structures in the
workplace, and women being viewed as primarily sexual objects contribute to the existence of
sexual harassment, to the relative lack of consequences for perpetrators, and to women
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
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 176 Pam Remer

perceiving sexual harassment as “normal” (Koss, Goodman, et al., 1994). Shifting the
pathology focus from individuals to social contexts is crucial to empowering clients from
disadvantaged, oppressed groups because they become aware they are not innately deficient.
Further identification of toxic elements in external context highlights the need for social
change.

TREATMENT

Nature of Therapeutic Relationships

The nature of therapeutic relationships is governed by Empowerment Feminist Therapy’s

Principle III, Relationships Are Egalitarian. EFT therapists build egalitarian relationships
with their clients in order to “not reproduce the power imbalances women and other
subordinate groups experience in society” (Worell & Remer, 2003, p. 71). Egalitarian
therapeutic relationships also reduce the probability of counselors imposing their values on
clients.
In order to build egalitarian relationships with clients, EFT therapists employ several
strategies. First, they do not pathologize their clients, but rather treat their clients as experts
on their lived experiences (Worell & Remer, 2003). Potential power imbalances between
therapists and clients are addressed by informing clients about what to expect from the
counseling process and by EFT therapists self-disclosing about their relevant values and life
experiences. EFT therapist do not believe any therapist or theoretical orientation can be value-
free and thus, clients as informed consumers, have a right to know about counselor values. To
facilitate clients’ understanding that the “The Personal Is Political”, EFT counselors self-
disclose about their relevant life experiences. And, in accordance with Principle I’s social
identities focus, EFT therapists also self-disclose to clients about their social identities.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

EFT Counseling Goals

The primary goals of Empowerment Feminist Therapy are directly tied to its four
principles (Worell & Remer, 2003). The major goals of EFT are to: (a) to reduce and
eventually eliminate all societal oppressions ( Principle II); (b) to increase clients’ awareness
of their social locations and social identities (Principle I); (c) to facilitate clients’ social
identity development (Principle I); to increase clients’ awareness of societal oppression and
privilege and their impact on people’s lives (Principles I and II); to increase clients’
appreciation of female-based values (Principle IV); to identify client strengths (Principles III
and IV); to increase clients’ sense of personal and social power (Principles I, II, III, and IV).
All of these goals are consistent with EFT’s focus on client empowerment. Worell and Remer
(2003) define empowerment as, “…a broad goal of feminist intervention that enables
individuals, families, and communities to exert influence over the personal, interpersonal, and
institutional factors that impact their health and well-being” (p. 24).

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Empowerment Feminist Therapy 177

Detailed Phases of Treatment

Most feminist therapy approaches, including EFT, have not explicitly described their
phases of treatment. However, given the importance of egalitarian relationships to EFT, it can
be inferred that therapeutic feminist work begins with building a trusting, egalitarian
therapeutic relationship where clients are treated as experts on themselves. Identification of
social locations and social identities also receives attention in the earliest phase of counseling
because it facilitates raising clients’ awareness of the importance of their cultural contexts.
During the next working phase of counseling, EFT counselors continue raising their clients’
awareness of their cultural contexts using tools like cultural analysis, power analysis, and
gender-role analysis. They collaboratively define clients’ issues as involving both internal and
external components and identify areas of desired change. With support from therapists,
clients begin making these changes in themselves and/or their environments. In the final
phase of therapy, EFT therapists help their clients transition out of therapy and to identify and
own their strengths.

EFT Techniques

Feminist therapists often embrace a second theoretical orientation that they integrate into
their feminist foundational principles or they borrow and customize techniques from other
theoretical orientations. In these feminist transformations of other theories or in these
borrowing of techniques, EFT therapists are careful to evaluate both the theories and
interventions for their compatibility with feminist values and perspectives (Worell & Remer,
2003). Given the range of integration possibilities, the range of possible feminist
interventions is almost infinite. However, it is beyond the scope of this chapter to describe
this range. Rather, in this section some of the main and unique techniques of EFT are briefly
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

described. The feminist interventions presented here are described in more detail by Worell
and Remer (2003).

Social Identities Analysis

Social identities analysis helps clients become more aware of their multiple, intersecting
social locations and social identities (Worell & Remer, 2003). Clients are given a list of social
locations (e.g. gender, race/ethnicity, sexual orientation, age, socio-economic status, religious
affiliation, immigration status) and asked to give themselves a label for each social location.
These labels reflect how they perceive themselves in that location and so are used as a
representation of their social identities. Next, clients are asked to locate each identity on an
oppressed to privileged continuum that represents clients’ perception of how privileged or
oppressed each social identity is. Thus, social identity analyses begin to raise the awareness of
both counselors and clients to the existence of hierarchical relationships in society and the
impact of them on clients’ issues. These analyses also open a dialogue between counselors
and clients about their similar and different social locations and the potential impact of them
on the therapeutic relationship.

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 178 Pam Remer

Gender-role Analysis
The technique of gender-role analysis focuses on raising clients’ awareness of their
socialization as males and females. EFT therapists believe cultures implicitly and explicitly
teach women and men how to behave within cultural gender-role norms and reward
appropriate behavior and discourage and punish behavior that deviates from these gender-role
norms.
The first step in a gender-role analysis is for clients to reflect back across their life spans
and identify the implicit and explicit messages they received about how they should be and
act as a male and a female (Worell & Remer, 2003). They next identify the sources of those
messages and evaluate the impact of those messages on their development and on the issues
that they have brought to counseling. They also evaluate the possible impact of these
messages on society. Clients must then decide if they want to continue to live by each
message and for ones they decide to change, they next construct a new message that fits them
better. They develop an action plan for integrating this new rule-for-living into their
identities. A similar process can be used for each social identity that is explored in therapy.
That is, clients can reflect about the messages they have received for each of their social
locations (e.g., societal stereotypes of a location) , evaluate the impact of those internalized
beliefs, and make a decision about whether to embrace or restructure that cognition.

Power Analysis
At the heart of hierarchical relationships in any society is power. That is, privileged social
locations tend to have power and access to societal resources while oppressed social groups
tend to have less power and blocked access to these same resources. Power analysis helps
clients become aware of the manifestations of these power differentials between groups and
their impact on how individuals behave (Worell & Remer, 2003). With the help of their
therapist, EFT clients explore hierarchical relationships in their social environments and the
differential use of power by dominant and subordinate group members (Johnson, 1976).
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Clients then examine how their actions are influenced by the amount and kind of power they
have related to their social identities and how environmental sexism, racism, ethnocentrism,
heterosexism, ageism, ableism, classism, and other forms of oppression affect their use of
power. Clients are also encouraged to expand their use of various types of power.

Consciousness-raising Groups
The term, consciousness-raising, has its origins in the women’s movement. Simply it
means to increase people’s awareness of any issue. More specifically to EFT, consciousness-
raising is usually applied to awareness of privilege, oppression, socialization processes, and
cultural values and practices. Consciousness-raising groups for women focus on women
sharing about their lives, identifying their common themes, and identifying how they have
been impacted by sexism and other forms of oppression.

Counselor Self-disclosure
Counselors’ sharing about their life experiences and social identities is discouraged by
many mainstream theoretical orientations. For EFT therapists, counselor self-disclosure
facilitates the development of egalitarian therapeutic relationships, models trusting knowledge
acquired through subjective ways of knowing and lived experiences, and helps clients

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Empowerment Feminist Therapy 179

recognize how the personal is political as they identify common themes with their therapists
(Remer & Rostosky, 2002; Worell & Remer, 2003).. The key to therapeutic self-disclosure
for feminist counselors is evaluating the relevancy and potential impact of the disclosure for
each individual client. Counselor self-disclosure must always be guided by client needs.

STRENGTHS AND LIMITATIONS OF

EMPOWERMENT FEMINIST THERAPY

Strengths

The greatest strength of feminist therapies in general and Empowerment Feminist

Therapy specifically is that they focus on the impact of oppression and privilege on
individuals, relationships, and societies and stress the importance of understanding clients
within the framework of their cultural contexts. An additional strength of Empowerment
Feminist Therapy is its attention to intersecting social identities. It emphasizes that
individuals may have both privileged and oppressed social locations that dynamically interact.
Its model of multiple social identities development allows for comparison of levels of identity
development across all of an individual’s social identities.
Very recently, guidelines have been developed by the American Psychological
Association for counseling sexual minorities, people from diverse racial and ethnic groups,
and for older individuals. Guidelines for counseling women and girls and men and boys are
currently underdevelopment. These guidelines stress the importance of counselor competency
for working with specific groups and the need to understand clients’ cultural contexts and
social identities. The emergence of these professional guidelines reflects an increased
awareness of counselors needing specific competencies for diverse groups and for
understanding the cultural contexts of clients’ lives. EFT is a theory that can be used for
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

diverse clients from a variety of subordinate groups. EFT’s awareness-raising techniques help
make more visible the cultural contexts and hierarchical relationships of the societies in
which people live. The societal sources of clients’ issues can be identified with EFT
techniques and needed social changes can be addressed.

Limitations and Challenges

Feminist therapies were developed to address the societal oppression of women.

Although most feminist therapies focused primarily or exclusively on gender issues and
emphasized White, heterosexual women’s concerns, most feminist therapies now focus on
multiple forms of oppression, not just sexism. They also acknowledge the importance of
honoring a diverse range of cultural values. Thus, feminist therapies have focused primarily
on helping women and clients from other subordinate groups heal from the negative effects of
oppressions. Much less focus has been given to using feminist therapies, including EFT, with
individuals from privileged groups. Although feminist perspectives and interventions have
value for counseling individuals with privileged social locations (e.g., gender-role analysis
with men), more development is needed in this area and is a major current limitation for

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 180 Pam Remer

feminist therapeutic approaches. An additional potential limitation of EFT is its focus on

social change. Attending primarily to the external sources of clients’ problems can result in
minimizing or ignoring individuals’ contributions to their problems.

SUMMARY
Feminist therapies were originally developed to address the harmful effects of sexism on
women’s lives and were later expanded to focus on multiple forms of oppression. While
many types of feminist therapy now exist, one specific type of feminist therapy,
Empowerment Feminist Therapy, was described in this chapter because of its incorporation of
several types of feminist therapies and its integration of feminist and diversity perspectives.
Because EFT focuses on understanding clients’ cultural contexts and on examining the impact
of oppressions on clients’ lives, it fits well for counseling clients from diverse, subordinate
groups.

REFERENCES
American Psychological Association. (2002). Guidelines on multicultural education, training,
research, practice, and organizational change for psychologists. Retrieved June 2005,
from www.apa.org.
American Psychological Association. (1975). Report of the task force on sex bias and sex-
role stereotyping in psychotherapeutic practice. American Psychologist, 30, 1169-1175.
Broverman, I. K., Broverman, D. M., Clarkson, F. E., Rosenkrantz, P. S., & Vogel, S. R.
(1970). Sex-role stereotypes and clinical judgments of mental health. Journal of
Counseling and Clinical Psychology, 34, 1-7.
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Cass, V. (1979). Homosexual identity formation: A theoretical model. Journal of

Homosexuality, 4, 219-235.
Cross, W.E. (1980). Models of psychological nigressence. In R.L. Jones (Ed.), Black
psychology (pp. 81-98). New York: Harper & Row.
Diller, A., Houston, B., Morgan, K. P., & Ayim, M. (1996). The gender question in
education: Theory, pedagogy, and politics. Boulder, CO: Westview Press.
Division 44/Committee on Lesbian, Gay, and Bisexual Concerns Joint Task Force on
Guidelines for Psychotherapy with Lesbian, Gay, and Bisexual Clients. (2000).
Guidelines for psychotherapy with lesbian, gay, and bisexual clients. American
Psychologist, 55, 1440-1451.
Enns, C. Z. (1997). Feminist theories and feminist psychotherapies. Origins, themes, and
variations. Binghamton, NY: Harrington Park Press.
Fitzgerald, L. F., & Nutt, R. (1986). The Division 17 principles concerning the
counseling/psychotherapy of women: Rational and implementation. Counseling
Psychologist, 14, 180-216.
Helms, J. (1995). An update of Helm’s White and people of color racial identity models. In J.
G. Pomeratto, J. M. Casas, I. A. Suzuki, & C. M. Alexander (Eds.), Handbook of
multicultural counseling (pp. 181-198). Thousand Oaks, CA: Sage.

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
 Empowerment Feminist Therapy 181

Johnson, P. B. (1976). Women and power: Toward a theory of effectiveness. Journal of

Social Issues, 32, 99-100.
Koss, M. P., Goodman, L. A., Browne, A., Fitzgerald, L. F., Keita, G. P., & Russo, N. F.
(1994). No safe haven: Male violence against women at home, at work, and in the
community. Washington, DC: American Psychological Association.
Lopez, S. R., & Guarnaccia, P. J. J. (2000). Cultural psychopathology: Uncovering the social
world of mental illness. Annual Review of Psychology, 51,571-598.
McIntosh, P. (1986). Unpacking the invisible knapsack. Wellesley, MA: Stone Center
Working Papers.
Porter, N. (2005). Location, location, location: Contributions of contemporary feminist
theorists to therapy theory and practice. Women & Therapy, 28(3-4), 143-160.
Remer, P., & Rostosky, S. (2002). Practice talk: Challenges in implementing feminist
egalitarian relationships. The Feminist Psychologist, 29, (3), 25-26.
Remer, P., Worell, J., & Remer, R. ((2005, January). Feminist psychological practice
strategies for exploring the intersection of multicultural identities. Workshop presented at
the National Multicultural Conference and Summit, Hollywood, CA.
Ridley, C.R., Li, L. C., & Hill, C. L. (1998). Multicultural assessment: Reexamination,
reconceptualization, and practical application. Counseling Psychologist, 26, 827-910.
Santos de Barona, M., & Dutton, M. A. (1997). Feminist perspectives on assessment. In J.
Worell & N. G. Johnson (Eds.), Shaping the future of feminist psychology: Education,
re4search, and practice (pp. 37-56). Washington, DC: American Psychological
Association.
Sturdivant, S. (1980). Therapy with women: A feminist philosophy of treatment. New York:
Springer.
Worell, J., & Remer, P. (1992). Feminist perspectives in therapy: An empowerment model for
women. Chichester, England: Wiley.
Worell, J., & Remer, P. (2003). Feminist perspectives in therapy: Empowering diverse
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women. Hoboken, NJ: Wiley.

Wyche, K. F., & Rice, J. K. (1997). Feminist therapy: From dialogue to tenets. In J. Worell &
N. G. Johnson (Eds.), Shaping the future of feminist psychology. Education, research,
and practice (pp. 57-72). Washington, DC: American Psychological Association.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 In: The Quick Theory Reference Guide ISBN: 978-1-60021-624-4
Editor: Karin Jordan, pp. 183-195 © 2008 Nova Science Publishers, Inc.

Chapter 13

AN OVERVIEW OF CONSTRUCTIVIST THEORY

Sandra N. Rustam

Constructivism is a metatheory with roots traced to the 6th century. Constructivist theory
is found in the writings of philosophers Lao Tzu, Buddha, Kant, and William James
(Mahoney, 2003). People are viewed as actively experiencing and constructing their own
realities, rather than observing reality. Constructivists understand that change and growth
require intrinsic motivation rather than an external source to encourage change. “Human
beings are viewed as self-organizing entities, determined more by the structure of their own
systems than by environmental perturbations” (Neimeyer, 2002, p. 113). When people
change, they not only change their way of thinking, but also the underlying meaning they
have given in a specific context. Constructivist therapists listen carefully, paying attention to
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

patterns in cognitions. The patterned cognitions are the evidence of core beliefs. People
actively seek experiences that validate their belief systems. “This proactive and generative
feature of mentation is a cardinal principle of constructivism” (L. Johnston, personal
communication, February 14, 2005).

THEORY DESCRIPTION
Constructivism has been an evolving theory for hundreds of years. In western
civilization, the roots of constructivism are noted in the writings and philosophies of Vico,
Kant, Schopenhauer, and Vaihinger (Mahoney, 2003). Furthermore, constructivism can be
traced to supporters in the 6th century BC, “…Lao Tzu (6th century BC), Buddha (560-477
BC), and the philosopher of endless change, Heraclitus (540-475 BC)” (Mahoney, 2003, p.
3). The practice of constructivism has its roots as far back as Socrates. Socrates said,
“Knowledge is only perception,” (Murphy, 1997).
Constructivism can be described as a “meta-theory” that includes developments in many
clinical theories, such as attachment theory, system theory, and lifespan development theory
(Neimeyer & Mahoney, 1995). The constructivist’s view of knowledge, or human knowing,

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 184 Sandra N. Rustam

is viewed as an active theory of the mind - an epistemology, a theory of knowledge.

Constructivists believe in the active participation of people in construing reality, rather than
the existence of a permanent “…external reality from which absolute meanings are drawn”
(L. Johnston, personal communication, February 14, 2005).
“Constructivism emphasizes developmental processes” (Mahoney, 2003, p. 8). Piaget
describes the purpose of one’s “experiencing” is to create disequilibrium, which is
uncomfortable and challenging (Mahoney, 1991). This disequilibrium is an opportunity to
create new forms of understanding. Constructivist theory extends this, saying that this process
is ongoing, with dialectical tensions spiraling across a person’s life span (Mahoney &
Gabriel, 2002).
According to Mahoney (2003) three interrelated principles of human experience are
found within constructivist therapies:

• Humans are proactive (and not passively reactive) participants in their own
experience; that is, in all perception, memory, and knowing;
• That the vast majority of the ordering processes organizing human lives operate at
tacit (unconscious) levels of awareness; and
• That human experience and personal psychological development reflect the ongoing
operation of individualized, self-organizing processes that tend to favor the
maintenance (over the modification) of experiential patterns. Although uniquely
individual, these organizing processes always reflect and influence social systems.

KEY CONCEPTS

Nature of Persons
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Theory
Constructivist theory is similar to Kant’s philosophy stressing the active, form-giving
nature of human knowing. The “truth” within the context of therapy is therefore not in how it
is objectively understood but whether it is of use to the client (Mahoney & Gabriel, 2002).
Processes are viewed to be anticipatory in nature, or proactive, envisioning hypothetical or
possible worlds as a means of regulating one’s activity (Kelly, 1955). In this sense, human
beings are viewed as self-organizing individuals, determined more by the organization of his
or her own systems than by environmental perturbations (Maturana & Varela, 1987).
Constructivist therapists treat client’s language and disclosures “as if” they were fitting from
the individual’s standpoint rather than “cognitive distortions” or “unconscious dynamics”
(Neimeyer & Raskin, 2001). It is not the job of the therapists to “fix” clients – rather, the
therapist guides the client in finding meaning and order in what they are experiencing as
distressing. Hence, constructivists do not approach therapy as corrective intervention.
Constructivist theory posits there are endless ways to understand the world. Kelly (1955)
is the pioneer of personal construct theory, in which underpinnings of constructivism are
found. To acquire a different and possibly changing perspective, individuals need to relax
their constructions of something, ponder new ways for construing it, and then experiment
with new possibilities by acting as if these new constructions are true. If the experiment does

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 An Overview of Constructivist Theory 185

not provide useful results, then one can try on another experiment by construing the same
event in a different manner. This allows for a less threatening attempt at changing one’s
thoughts, behaviors, and feelings.

1. Ongoing structuring (organizing) processes are the conceptual center of

constructivism. Core ordering processes (COPs), are “the deeply abstract processes
that are central to [one’s] psychological experiencing” (Mahoney, 2003, p. 49). COPs
are essentially where a person holds his or her worldviews – his or her values,
beliefs, and morals. These COPs are what define one’s sense of identity and mode of
relating to others (Neimeyer, 1995). There are four overlapping themes found within
core ordering processes (Mahoney, 2003, p. 50):
2. Reality (the construction of perceptions; such as within the scope of stable–unstable,
real-false, possible-impossible, and meaningful-meaningless).
3. Value (the construction of emotional judgments; dimensions as pleasant-painful,
good-bad, positive-negative, right-wrong, and approach-avoid).
4. Self (the construction of a sense of personal sameness or continuity; dimensions as
body-world, me-not me, I-Thou, and us-them).
5. Power (the construction of a sense of agency; within the scope of able-unable,
hopeful-hopeless, engaged-disengaged, and in-out of control).

COPs are central and key to human change processes. When a person changes in
significant and lasting ways, what changes most are his or her ways of organizing personal
experiencing. COPs are not easy to change. People do not develop a self-concept or value
system over a short period. Similarly, one does not change core processes quickly (Mahoney,
2003).
Constructivist therapy is process-oriented, viewing cognitions in systemic terms.
Constructivists recognize that a “real world” exists outside of human consciousness or
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

language; however, constructivism is more concerned with the nuances in people’s

construction of the world, rather than evaluating the probability of constructions as “true” in
representing an external reality (Neimeyer & Mahoney, 1995). The constructivist view of
therapy is not solipsistic, which locates reality entirely in the mind of the beholder
(Krippendorff, 1986). Rather, knowledge is constructed by the individual through his or her
interactions with the environment (Glasersfeld, 1987). Reality is considered created rather
than apprehended or understood (Mahoney & Gabriel, 2002).
Constructivist theory identifies five basic themes, which can be found in the variety of
theories expressing constructivism (Mahoney, 2003). These themes are (1) active agency, (2)
order, (3) identity/self, (4) social-symbolic relatedness/relationships, and (5) lifespan
development/dynamic dialectic development (Mahoney, 2003). The language and terms may
differ amongst therapies, yet the meanings are the same. First, constructivists have proposed
that the way humans move through the world is in a continuous, active, experiencing way.
Second, human activity is focused or devoted to ordering processes – the organizational
patterning of experience by means of unconscious, emotional meaning-making processes
(Mahoney, 2003). Third, the organization of personal activity is essentially self-referent or
recursive. “This makes the body an ongoing exploration of experiencing – there is a deep
phenomenological sense of selfhood or personal identity” (Mahoney, 2003, p. 39).
Additionally, people live and grow through their relationships. Fourth, individuals are
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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 186 Sandra N. Rustam

understood in relation to their embeddedness in social and symbolic systems or relationships.

The fifth theme combines all of this active, meaningful, and social-interrelated self-
organization. This is evidence of a continuing developmental path in which dynamic
dialectical stressors are crucial. Order and disorder co-exist in lifelong quests for balance
which are never quite attained. Together, these five themes express a constructive view of
human experience, where one is in an ongoing process of his or her developing “self” in
comprehensive and involving relationships (Mahoney, 2003).

Healthy vs. Unhealthy/Dysfunctional Functioning

“A distinctive feature of constructivist theory is that it focuses less on disorders of

construct content (e.g., having negative beliefs about the self, world, and future) than on
disorders of construct system processes and structures” (Neimeyer & Raskin, 2001, p.398).
The constructivist therapist’s explanation for healthy versus unhealthy functioning is
understood in what makes sense for the client through experience and constructive action.
According to Mahoney (2003), cycles of distress and dysfunction are not viewed as
pathologies.
In Constructive Psychotherapy: A Practical Guide, Mahoney (2003) describes the basis
for understanding the processes of human functioning:

Clients organize their lives into patterns of activity that are meaningful and what has worked
for them. [One’s] personal realities function without [his or her] awareness, and anticipate that
the future will resemble the past. When [people] experience challenges in [their] lives and are
not helped by old and familiar methods of coping, they are likely to experience disorder and
disorganization in many dimensions of life. Disorder and disorganization are often paralleled
by strong negative emotions and a sense of confusion…[emotions] serve as patterns of
organizing [one’s] experience as preparations for actions and ways of communicating with
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

self and others. Emotions are natural expressions of people’s attempts to protect or regain a
sense of meaning, order, and control in their lives (p. 35).

Although it may be stressful, disorder can be seen as an opportunity and create changes in
old patterns of experiencing. This allows the necessary space to experience new forms of
adapting. Clients often seek therapy as an attempt to change or regain a sense of order,
meaning, or balance in life. When there is lack of meaning or a sense of loss, this is
experienced as chaos (Neimeyer & Mahoney, 1995). “Human potential and client strengths
are emphasized in the elaboration of meanings” (L. Johnston, personal communication,
February 14, 2005).
Chronic distress and dysfunction often reflect less movement and feeling stuck as a result
of unconscious patterns turned to habits (including thinking and feeling). These patterns may
have been useful or helpful in earlier life circumstances; however, they no longer work and
are old, worn-out. “Disorders” are viewed as patterns in which people are rigidly and orderly
stuck. When people are stuck in a rigid pattern the possibility to experience a new way of
functioning may not be apparent to them. “Human evolution inherently involves DISORDER,
which is not construed as pathology or the enemy of mental health or personal well-being” (L.
Johnston, personal communication, February 14, 2005).

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 An Overview of Constructivist Theory 187

One’s relationships with the “self” are critical to life quality. These include self-concept,
body image, self-esteem, and capacities for self-reflections and self-comfort. The sense of self
can become unhealthy when it is fragmented. Individual’s abilities for balance and coherence
are not well developed. Difficulties also occur when an individual identifies with a problem
or rigidly resists the changing aspects of life. Limiting oneself and inflexibility of the self can
lead to painful patterns feeling isolation, unworthiness, or insufficiency. A person’s sense of
self and relationship with self usually develop and change in the context of strong emotional
relationships with others. Therapy can provide a secure base for examining and changing self
and interpersonal relationships (Mahoney, 2003).

The Change Process

The processes of change are complex and multifaceted. The human change processes are
understood as an ongoing, explorative, fluid set of processes (Mahoney, 2003).
Constructivists view change processes as more dynamic, allowing for more freedom in
understanding how change is experienced. The following paragraph explores the change
processes, explaining the dynamics involved in those processes.
People’s experience of change is usually non linear, integrated with mixes of mostly slow
small steps; revisiting often to earlier patterns and intermittent large, sudden movements
(Mahoney, 2003). Change processes may be structured/organized within guidelines; however,
each person’s experience of change cannot be predicted (e.g., how long it will take, the
consequences and repercussions of a particular course of actions, the degree of difficulty or
effort required). The reordering and restructuring of life patterns often come about in waves
or fluctuations of success and failure, progress and regress, and expansion and contraction
(Mahoney, 2003). When a person initiates a small change, it may be increased into large and
lasting ones. Changes of any degree in any area of functioning can affect all other areas.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Thus, change is systemic or holistic.

Failure to change is usually called resistance (Mahoney, 2003). Resistance to change is
common, natural, and most intense when core-ordering processes are involved. Resistance is
viewed as an expression of self-protection (Mahoney, 2003). Old and new patterns of coping
battle for power and control within the individual. This “battling” is often experienced as an
internal struggle or conflict, which is characteristic of change. Even after new patterns are
situated and appear to be stable, old patterns of activity are never completely eliminated. Old
patterns are most likely to reappear when one experiences fatigue, prolonged stress, and new
challenges. Resistance is the individuals attempt to protect COPs, and control the pace of
change.
The constructivist therapist views resistance as essential and unavoidable. According to
Mahoney (1991), “Resistance to change is common (even when the change is desired) and
reflects basic self-protective processes that influence the pacing and direction of change” (p.
269).
It is a human need to seek order and structure (Neimeyer & Mahoney, 1995). Internally,
people hold patterns forming a sense of order, which help to support their COPs. In order to
change, people must challenge their COPs, and tolerate disorder. Patterns are familiar and
appealing as they offer the order and conservative functioning people seek. Change is often
painful and very difficult. Many changes can lead to a more full and engaging life. During
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 188 Sandra N. Rustam

and after therapy there are common and significant changes in self-relationships that occur.
Some of these changes are

“… increased self-awareness, increased comfort with emotional experience and its expression,
greater openness to experience, greater self-acceptance or improved self-esteem, increased
capacities to self-comfort and to receive and give affection, a greater sense of personal agency
or empowerment, and a sense of more hopeful or grateful engagement with life” (Mahoney,
2003, p. 37).

THE THERAPEUTIC PROCESS

Assessment and Diagnosis

General Assessment Strategy

A primary purpose of assessment is to develop estimated sketches of these patterns, so
that their results can be evaluated and their interrelationships can be measured (Mahoney,
2003). With such estimates a therapist can help clients to realize how such patterns may be
limiting their functioning or well-being and, more importantly, how they might begin to
explore with small experiments and then progress toward more bold experiments in
alternative ways of being (Mahoney, 2003). The professional goal in assessment is to pay
attention to fluctuations of rhythms, and styles of experiencing (Mahoney, 2003, p. 42).
In therapy, the focus of concentration is within three interwoven levels of focus: (1)
problems, (2) patterns, and (3) processes (Mahoney, 2003). The constructivist interviewing
type of assessment helps to provide a clearer understanding of the client’s three levels of
focus (Neimeyer, 2002). “A problem is a felt discrepancy between the way things are and the
ways things ought to be” (Mahoney, 2003, p. 45). Many individuals with problems are best
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

helped in developing skills that (1) bridge the difference between immediate and delayed
response, and (2) adjust the meaning of the activity in agreement with this larger frame of
time and well-being (Mahoney, 2003). Of the three levels of focus, clients most often come to
therapy wanting to focus on the level of the problem. This is the level, which is probably most
familiar (Mahoney, 2003).
Usually, problems are not a result of an isolated incident, but rather an expression of
patterns. Pattern is the level of recurring and related problems. A client working on the
pattern level is asking questions reflecting his or her search for cause and explanations: “Why
do I always find myself falling back into bad habits?”, “Why am I the only one in my family
who struggles with self-esteem?”, “Why is it so hard for me to trust people?” (Mahoney,
2003, p. 45). These questions reflect quests for understanding. The client is gaining more of
an understanding of his or her problem, even though he or she may be focusing on specific
problems.
The level of process is among the most difficult challenges for therapists as well as
clients (Mahoney, 2003). “Problems and problematic patterns are always expressions of
processes” (Mahoney, 2003, p. 46). Working with clients at the level of process is done in the
present moment. Clients are taught to look inward, and remain nonjudgmental. This kind of
introspection can be overwhelming, yet also create new possibilities for clients. Process work
is not forced in therapy, just as constructivist therapists do not push for strong emotions. This
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 An Overview of Constructivist Theory 189

is second-order therapy. Neither therapist nor client can accurately anticipate what may result
in the process.
Process work can be both risky and promising. During process work the client suspends
his or her beliefs and values, while considering and exploring other viewpoints. The client
must be able to tolerate the challenge of exploring other ways of experiencing. Change occurs
when the client can put aside their beliefs, if only temporarily, allowing the space for other
viewpoints. This suspension creates a state of ambivalence, where one may be more likely to
try new ways of experiencing. When one briefly suspends their beliefs, they have already
begun challenging their worldview. Therefore, process work should only be done after
confidence in the client’s ability to hold onto or return to a sense of center has been
established. A client who is not ready to tolerate this state of ambivalence or ambiguity may
become highly frustrated, which could possibly result in therapy that is more harming than
helping. Therefore, most pure Constructivists might prefer not to use diagnostic labels from
the Diagnostic and Statistical Manual 4th ed., and Text Revision, (DSM-IV-TR)
Constructivist therapists are more likely to use interview techniques as an assessment that
allows for deeper exploration of how one constructs their reality (Neimeyer, 2002). During
and after informed consent and background information have been gathered, the constructivist
therapist is interested in developing the therapy relationship, “…preferring instead to
emphasize the critical role of the therapeutic relationship in enabling and initiating human
change” (Mahoney, 1991, p. 253). Whether or not the therapist uses a particular assessment
procedure will be dependent on the needs of individual client. “Only recently has attention
been given to developing and utilizing psychological instruments that focus on the strengths,
creativity, and resourcefulness of person” (Mahoney, 2003, p. 39).
Journal work can be a type of assessment, where the client shares journaling excerpts in
session with the therapist. This helps create greater self-awareness on the part of the client,
and also serves as a tool to foster change (Neimeyer, 2002). Constructivists may use “mirror
time” and “stream of consciousness” as methods for assessment, which foster growth for the
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

client and therapist (Neimeyer, 2002). Mirror time (Williams et al., 2002) is a technique that
attempts to “…enhance self-understanding and self-knowing by having clients look at
themselves in the mirror while describing their experience spontaneously or responding to
questions about feelings or self perceptions” (p. 2). Mahoney (2003) defines the method of
stream of consciousness reporting as “…a technique intended to help clients explore and
attempt to communicate inner life in the living moment (p. 141). Streaming is a powerful
exercise, which produces greater awareness for the client, and is helpful for the therapist to
gain a better sense of the client’s viewpoint.

Theory-based Assessment Strategy

In constructivist therapy the assessment process is more of an interviewing style rather
than a formal measurement tool. “Just as constructive therapy is not something done ‘to’ a
client, constructive assessment is not something that is separate from constructive therapy”
(Mahoney, 2003. p. 38). The constructivist emphasis in assessment is on the relationships
among constructs. The primary purpose to constructivist assessment is to find out what it is
like to be the client – how he or she experiences him or herself and in the world.
Constructivists concentrate on identifying and “reformulating” the key metaphors that inform
the client’s self-narrative. Assessment is conducted in an interviewing style of questioning.

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 190 Sandra N. Rustam

An appreciation for the cycles of experiencing is an important aspect of constructive

assessment. The five themes of constructivism outlined below help the therapist organize the
focus in assessment. The therapist thinks in terms of the levels of focus – problems, patterns
and processes – in accordance with the five themes, and then develops a sense of where the
client wants to invest there energy in therapy (Mahoney, 2003). It is useful to conceptualize
the ongoing process of assessment in terms of the five themes of constructivism. Within each
theme, there are certain questions that facilitate the gathering of information and learning the
client’s language (Mahoney, 2003). The five themes, according to Mahoney (2003, pps. 5-7)
are stated in the following:

− Activity: The therapist asks the client questions with curiosity, about how one’s day
is structured. Questions are presented in session and in homework assignments. The
therapist is noticing the client’s tones, and the client’s focus of attention.
− Order: The therapist listens to the language of the client, which reflects the meaning
in his or her life. This allows the therapist to imagine how the client construes his or
her world. How the client expresses himself or herself, and the emotion in his or her
words are very important. Also important are the client’s facial expressions, gaze,
and changes in the client’s voice.
− Self: The therapist may ask the client how he or she feels about himself or herself.
This helps to understand the client’s ego strength, esteem, and confidence. Questions
about relationships are significant in learning about patterns in the client’s life. As
the therapy relationship becomes more trusting, the relationship questions are asked
more extensively.
− Relationship: How the client uses metaphors, images, and symbols of expression
allows the therapist to develop the language, which mirrors the client’s worldview.
Listening to the client’s story helps the therapist to understand how the client has or
has not learned to trust.
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− Development: This is a compilation of the previous four themes. After some time of
getting to know the client, the therapist needs to pay attention to the client’s cues,
how the client patterns his or her life, which will tell the therapist what the client
needs. Attention to the client’s cues is held from session to session. The therapist
maintains awareness on the frequency, intensity, and range in such cycles.
Commitment and caring are clearly expressed by the therapist at all times.

Treatment

Goals of Therapy according to Constructivist Theory

Constructivists see the basic goal of therapy as the encouragement or promotion of
meaning-making activity and experiencing rather than attempting to “fix” or correct
dysfunctions or “wrong” thinking (Neimeyer, 1993a). The goals of constructive therapy are
(1) to help the client better to understand and appreciate himself and others, (2) to help
develop skills in solving problems and coping with challenges in life, and (3) to encourage
efforts to develop in directions that the client finds fulfilling and meaningful (Mahoney,

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 An Overview of Constructivist Theory 191

2003). According to Neimeyer (2002), “…constructivist therapy is creative rather than

corrective, in that the client is encouraged to explore the hypothetical ‘as if’ worlds” (p. 118).

Common Intervention Strategies

Intervention strategies used by constructivist therapists attempt to access one’s core
beliefs, which represents one’ sense of self. These interventions tend to be exploratory rather
than directive, using metaphors and personal images, due to the unconscious nature of COPs
(Neimeyer, 1995). To facilitate the client’s change process, and work at the client’s level of
focus, constructivists offer techniques, which can be paired to the level of focus. Many
therapeutic techniques involve creative reconstructions of clients’ life stories in a manner that
modifies the meaning or meanings of their past and change clients’ depiction of self, their
sense of agency (power), and their awareness of alternative possibilities and hope. Some
interventions are (Mahoney, 2003):

• Basic Centering Techniques: “the essence of centering is a process associated with

safety, peace, and well-being” (Mahoney, 2003, p. 59).
− Breathing Exercises; three breathing exercises aid in the process of centering: 1)
Release Breathing, 2) Pause Breathing, and 3) Alternate Control and Surrender
Breathing (pps. 242 – 243).
− Body Balance Exercises; this technique involves physical balance by utilizing
the body – “it has the advantage of moving beyond the limits of language and
coming back to a basic bodily sense of equilibrium” (p. 62).
• Problem Solving: skills which “…involve capacities to make careful observations, to
generate ideas, and to construct experiments” (p. 74).
− Cognitive Restructuring; recognizing and changing unhealthy thoughts and
attitudes.
• Pattern Work: techniques to help identify and interrupt unhealthy patterns and
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incorporate new ways of behaving and being.

− Personal Journaling; to include the clients “…expressions – doodlings, drawings,
single words in the language of their own life experience” (p. 90). Daily self-
reflection may eventually lead toward the weaving of a life story (p. 90).
− Life-Review Exercises; to review ones past “…to give meaning to present
circumstances and to create new possibilities for future experiences” (p. 95).
− Narrative Reconstruction; “…an endeavor in which therapists are attempting to
help clients reclaim their author-ity and write different and more fulfilling
dimensions into their lives” (p. 100).
• Basic Process Work: “Involves an attunement to shifts in experiencing and a
refinement of skills that allow those shifts to take place” (p. 110).
− Meditation; helps to “…foster the development of skills in attention…a valuable
component in the process of change” (p. 110)
− Embodiment Exercises; a form of meditation that focuses on body movement.
• Drama, Fantasy, and Stream of Consciousness
− Role Playing “As If”; valuable for many reasons including preparing for future
events, and “ …enactment of a past or possible challenge [which] can stimulate

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 192 Sandra N. Rustam

the same emotional patterns as the actual occurrence” (p. 130). It is sometimes
role-playing a hypothetical being.
− Stream of Consciousness Reporting; “…a technique intended to help clients
explore and attempt to communicate inner life in the living moment” (p. 141).
Clients are asked to explore their thoughts, similar to “free association” while
however, the therapist does not presume authority in interpretation (p. 142).
Mahoney (2003) introduces streaming in the following: “First I will ask you to
relax and to set positive intentions for learning more about yourself. I will ask
you to close your eyes and to pay attention to what is going on inside you from
moment to moment” (p. 144).
• Self-Relationship and Spiritual Skills
− Mirror Time; “…a technique that offers a remarkably clear and simple picture of
a person’s relationship with himself….requires he stand or sit in front of a mirror
and pay attention to what he thinks and feels” (p. 153).
− Spiritual Skills and Personal Development.

Constructivist therapists utilize rituals, also called techniques, exercises, and homework
assignments, which are viewed as “…structured experiments in experiencing” (Mahoney,
2003, p. 36). Rituals represent people’s meaning or purpose in wanting to change. Rituals are
experiments in trying new behaviors. Rituals usually reflect “…symbolic meanings regarding
past wants, present experiences, and future directions of development. These meaning may be
more important than the actual content or form of the ritual itself” (Mahoney, 2003, p. 36).
The purpose of several rituals is to develop skills, such as “…attention or awareness,
communication, conceptualization, emotional regulation, experiential risk taking, impulse
control, perspective taking, and self-relationship – especially self-comforting” (Mahoney,
2003, p. 36). Rituals, which are created specifically for an individual, are often useful in
exploring different ways of being.
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Nature of the Therapeutic Relationship

The style of therapeutic relationship in constructivist therapy is collaborative and non-
authoritarian. The therapist and client work together, developing an egalitarian relationship.
Both client and therapist share the responsibility for the process and outcome of this venture.
The quality of the relationship relies highly on the therapist’s ability to communicate
compassion, caring and empathy. The foundation of the therapeutic relationship is built on
confidentiality, safety, consistency and stability, where the client is able to explore, examine,
and practice with new ways of understanding. “The constructivist therapist’s attitude is more
inquisitive than disputational, more approving than disapproving, and more exploratory than
demonstrative” (Neimeyer, 1995, p. 115). The constructivist therapist exemplifies or is
characterized by their ongoing “… personal development, authenticity, tolerance for
ambiguity, patience, comfort with emotionality, and faith in the possibilities of human
development (Mahoney, 2003, p. 34). The therapist pays attention to the client’s strengths,
resources, and capacities to change in personally meaningful ways (Mahoney, 2003). What
matters most in constructive therapy is the human relationship, which is the therapy.
The constructivist therapist understands the relationship established as unique and close.
Throughout the therapy relationship, there are times the therapist joins, follows, and guides,

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 An Overview of Constructivist Theory 193

but never leads. This relationship will allow for the supporting, holding, and gentle space
where clients can construct and reconstruct meaning. Constructivist therapists respectfully
acknowledge that this developmental process will continue long after formal therapy ends
(Mahoney, 2003).

STRENGTHS AND LIMITATIONS

Strengths

Practicing therapy from a constructivist viewpoint offers wide application to numerous

therapy approaches, with the variety of clients’ problems. Constructivism works well with all
modalities of therapy (i.e., individual, couple, family and group) (Neimeyer, 1995). Research
supports constructivist therapy is able to help a diverse population and culture (Mahoney,
2003; Neimeyer & Mahoney, 1995). The flexibility and creativity in practicing, as a
constructivist therapist, is both exciting and challenging. Constructivist therapy relies on the
ability of the therapist to tolerate ambivalence, ambiguity and resistance, while not trying to
impose a “correct” view of reality onto the client. The constructivist therapist accepts the
client’s understanding of his or her reality. It requires critical thinking, therapist self-
reflection, and a willingness to allow an enormous amount of ongoing, internal challenges.
Constructivist theory is fluid, dynamic, and creative, giving the therapist much freedom to
structure therapy in a way that best meets the needs of clients.

Limitations

Although the all-encompassing view of constructivism is applicable and useful to many

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psychotherapy approaches, it may also be hard to grasp. Some may find constructivism to be
too vague, especially with therapists who prefer a more methodical, planned therapeutic
approach. Some therapists might feel overwhelmed when practicing constructivism rather
than a more structured therapy process. “The theory is expandable, it may not satisfy some
people’s idea of how a theory should work, i.e. be complete in and of itself. I see this as a
strength and space for growth in constructive thought, but others may not” (M. P. Dunlap,
personal communication, January 27, 2005). One may find constructivism to be elusive.
It is not the role of the constructivist therapist to “fix “the client. Constructivism does not
assume an exact view of reality to which clients much adapt. For some therapists, this may
not reflect genuinely how they understand their role as therapist. Additionally, the
constructivist postmodern way of thinking may not match the viewpoint on the therapist. The
constructivist approach seems to move against the short-term therapy trends of managed care
attempting to help only in first-order change processes. Current tendencies in agencies to treat
client’s problems with medication, and pathologize, diagnose and treat in a limited amount of
sessions are counterproductive to constructivist therapy (Mahoney, 2003).

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 194 Sandra N. Rustam

CONCLUSION
This chapter demonstrates that constructivist theory is an ongoing developing theory
whose implications are far reaching. Constructivism is a way people create meaning in their
lives, through the process of practicing and understanding that with which they resonate. The
Constructivist has a positive view of clients and does not pathologize them.
The constructivist therapist actively fosters and acknowledges the dynamic, healing
processes of the therapy relationship. Questions posed by the constructivist therapist
encourage clients to explore, compare, and experiment with thoughts and beliefs. Meaning-
making is understood through clients viewpoints. Research outcomes confirm the healing
therapeutic relationship as significant for people in growth and change processes (Wampold,
2002). This supports the constructivist movement as more therapy approaches consider and
apply constructivist concepts. Constructivist theory is adapting and evolving, continuously
moving forward with more discoveries of its origins and widespread applications.

ACKNOWLEDGMENT
The author would like to acknowledge the contributions of Michael J. Mahoney,
Ph.D., whose brilliant mind, powerful writings, and example of self directly influenced the
chapter and author's view of psychotherapy and being human. More so, his beautiful heart,
warmth, and kindness are felt simply in reading his words. Mahoney is a leading proponent
of Constructivist Theory.

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psychotherapy: Theory and application (pp. 110-126). New York: Springer Publishing
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Neimeyer, R. A., & Mahoney, M. J. (Eds.) (1995). Constructivism in psychotherapy.
Washington, DC: American Psychological Association.
Neimeyer, R. A., & Raskin, J. D. (2001). Varieties of constructivism in psychotherapy. In K.
S.Dobson (Ed.), Handbook of cognitive-behavioral therapies (2nd ed., pp. 393-430). New
York: The Guilford Press.
Sexton, T. L. (1997). Constructivist thinking within the history of ideas: The challenge of a
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

new paradigm. In T. L. Sexton & B. L. Griffin (Eds.), Constructivist thinking in

counseling practice, research, and training (pp. 3-18). New York: Teachers College
Press.
Walsh, F. (1999). Spiritual resources in family therapy. New York: The Guilford Press.
Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings.
New Jersey: Lawrence Erlbaum Associates, Inc.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 In: The Quick Theory Reference Guide ISBN: 978-1-60021-624-4
Editor: Karin Jordan, pp. 197-208 © 2008 Nova Science Publishers, Inc.

Chapter 14

ADLERIAN FAMILY THERAPY

Jon Carlson and Julia Yang

Alfred Adler was the first psychologist of the modern era to do family therapy. His
approach was systemic long before systems theory had been applied to psychotherapy. He
conducted public demonstration therapy sessions with families in front of an audience. These
open forum counseling sessions were attended by parents, teachers and members of the
community. The audience would watch the demonstration family deal with their problems
and through the process of “spectator therapy” develop solutions to their issues. Rudolf
Dreikurs brought this process to the United States and created family education centers in
many locations. Dreikurs also systematized and refined Adler’s early work with family
constellation and purposeful behavior, delineating the goals of children’s misbehavior and
developing an interview and goal-disclosure process that produced a “recognition reflex” in
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

children (Terner & Pew, 1978).

According to Adler, all behavior is purposive and interactive. Both individuals and social
systems are holistic, and individuals seek significance by the manner of their behavior in
social systems. The basic social system is the family and it is from the family that individuals
learn how to belong and interact. Problems, or dysfunctions, in families result from
discouragement or a lack of acceptance within the family. The treatment process stresses
education to promote growth and change. In Adlerian family therapy, the therapist addresses
the interaction within the family system and changes the interpersonal system. Family
dynamics include a wide variety of concepts related to the interplay of structural and
functional components in a family system.

KEY CONCEPTS OF ADLERIAN PSYCHOLOGY

Alfred Adler’s psychology is often called “Individual Psychology.” The Greek origin of
the term ‘individual’ refers to the uniqueness of the individual and their ‘indivisible’ nature.
Individuals can’t be understood by a study of their parts and must be understood as a
psychological whole (or holism). Individual Psychology is not, however, the opposite of its

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 198 Jon Carlson and Julia Yang

name but is a social psychology emphasizing the understanding of the individual, the family,
and the enhancement of social interest (Ansbacher & Ansbacher, 1979). When applied to
counseling, an individual is best understood as embedded in one’s society and cannot be
studied in isolation. Adlerian therapists and counselors look behind the manifestation of
human actions, explore the premise on which the individual operates to reach his or her
ultimate goal of significance. Among the many Adlerian concepts are social interest,
purposiveness, private logic, holism, choice and consequences, and encouragement.

Social Interest

Among the various Adlerian concepts, the most important proposition is that all of us are
striving to achieve significance and belonging. Within the context of social interest, all
human problems are social problems. It is the interactions of the individual toward what is
within and around her/his world that counts. For Adlerians, all behaviors have social
significance. It is from the need to be accepted by the group of our membership, that we
develop the sense of superiority and inferiority, and corresponding useful or useless behavior.
Social interest (also called community feeling) measures how people operate in the social
world. Social integration is the most unique contribution of Adler. In order to understand
what goes on in the individual, it is necessary to consider how one develops, how one
changes, how one relates, and what makes one human. The concept of social interest provides
the basis on which Adlerian psychology develops its theory and practice of counseling as an
educational and correctional approach toward the changing of behavior and personality.

Private Logic
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Adlerian psychology is a phenomenological or subjective psychology (Mosak, 1979). An

Adlerian therapist deals with the client’s “subjective reality,” “private logic” or “apperceptive
schema.” (Milliren, Evans, & Newbauer 2003) Reality is defined by each individual’s
impression and perception. Individuals creatively use their mental and emotional faculties to
interpret the environment, draw conclusions, and choose goals (Carlson, Watts, & Maniacci,
2006). The “Psychology of Use” is the term used by Adler to distinguish his psychology from
that of Freud’s “Psychology of Possession.” (Yang and Milliren, 2003). A psychology of use
explains the dynamic use of the individual’s psychological and physiological characteristics
as tools for the creative self and as response to the objective conditions. Therefore, the
therapist assesses the individual’s viewpoints and attitudes about themselves and the social
world in order to understand the various behaviors used to move toward their life goals.

Purposiveness

Adler's socio-teleological approach views human beings as responsible and rational

beings, who are moving toward self-created. The goals are created from one's own
interpretation of their living situation. This interpretation gives purpose to one's actions. This
principle accounts for Adlerian psychology as teleological goal-oriented theory of human
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Adlerian family therapy 199

behavior. An individual uses her or his mental and emotional faculties to interpret the
environment, draw conclusions, and choose goals. This explains why every individual is
different and unique. An individual also operates to overcome one’s feelings of inferiority and
to attain his or her ideals or sometimes, fictional goals.
To understand an individual, we must explore his/her goals and the strategies for reaching
those goals. Four misdirected goals are often associated when an individual is striving toward
his/her fictional perfection without realizing that it is unreachable. The four mistaken goals
are (1) undue attention, (b) power struggle, (c) revenge (get even), and (d) withdrawal. The
task of therapy/counseling is to facilitate the individual to "redirect" the goals into a practical
and constructive goal. The hope is that after an individual's goals are correctly assessed and
redirected, his/her misbehavior will stop.

Life Style

The life style is the subjective view of the self and the world that directs one’s thinking,
acting, and feeling in response to the tasks of social living (i.e. work, love, friendship). The
development an individual’s life style remains unconscious but becomes apparent when he or
she is confronted with problems and challenges that require the use of one’s total mental and
emotional capacities. Although typologies of life style were not a primary interest of Adler,
various descriptors of life style appear in the Adlerian psychology literature. For example,
Adler discussed four attitudes of social interest: ruling, getting, avoiding, and being socially
useful (Adler, 1979). Mosak (1977) suggested types such as the pleaser, the getter, and the
controller. Sonstegard and Bitter (2004) pointed out a relationship between the Adlerian
personality priorities and Satir’s communication stances. The Adler-Satir comparable types
are: placating-pleasing, blaming-significance, super-reasonable-control, and irrelevant
(distract)-comfort. For Adlerians an individual’s life style is observable and leads to his or her
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

probable behaviors. The Adlerian therapist collects information by a life style analysis which
is completed by understanding birth order, early recollections, the family constellation, family
atmosphere, family values, and gender guidelines.

Choices and Consequences

Adlerians contend that social interest needs to be viewed within the contexts of equality
and democracy (Dreikurs, 1971). Each person chooses his or her response to various
situations of social living with freedom and responsibility. Human beings operate in a
consistent manner achieving a certain goal. People are self-directed, creative, able to make
decisions, and to accept consequences. In the Adlerian view, an individual is independent and
responsible within the limits of his or her heredity and environment. The individual can be
understood through his or her decision making processes. When applied to family therapy, the
concept of choice and consequences often leads to the practical implications of democratic or
autocratic interpersonal relationships, family atmosphere, parenting methods, and the creative
use of natural and logical consequences.

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 200 Jon Carlson and Julia Yang

Holism

The principle of viewing people holistically implies the notion of Gestalt and systems
theory: The total is more than the sum of its parts. The holistic point of view of persons was
originated by Smuts and developed by Adler and others (Yang, 2006). Adlerians know that an
individual is a unified whole moving toward a goal. An individual is understood by
considering cognitive, emotional, and behavior aspects of the individual’s view of life in
relation to their goals. Every person is “indivisible” and cannot be divided into different parts
for the purpose of understanding.

Encouragement

Everyone experiences discouragement from time to time whether in pursuing their self-
ideal or chasing after misdirected goals. Encouragement is the essential tool for the Adlerian
therapist to help each family member challenge his or her misdirected goals and bringing
change in a realistic way. It is through encouragement that the therapist can “give courage”
and empower the individual to see a new direction and take actions. By encouragement the
Adlerian family therapist facilitates the discouraged individual to activate social interest and
create meaning and purpose in life.

ADLERIAN PSYCHOLOGY APPLIED TO MENTAL HEALTH

Normality, for the Adlerian, is subjective and is often referred to as common sense. The
judgment of an individual’s normality or psychopathology is symptomatic. Pathological
symptoms are viewed as functional and serving a purpose for the individual (i.e. safeguard or
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

defensive mechanism). According to Stein (1998), an exaggerated inferiority feeling and a

lack of concern for the community are often present in discouraged individuals. Individuals
who are not properly prepared for normal life challenges may use their discouragement as a
safeguarding device by overrating or underrating their sense of self.
Adlerian psychology views the ideal individual mental health or normalcy as “the extent
to which the individual embodies social interest in his or her characteristic approach to life
and life problems. It is this conceptualization that describes the ideal state of the individual’s
mental health “(Milliren, Evans, & Newbauer 2003, p.105). To function in the day to day
social living, one must have an accurate understanding of self and the world and seek to move
away from the inferiority feeling while consciously acquiring useful ways of striving toward
one’s life goals. Social interest motivates the individual to overcome the life long
contradictions of wishes and actions. The healthy individual meets the demands of
cooperation and contribution with others and the community to which they belong. Adlerian
psychology advocates the humanistic and democratic approach of mental health with a focus
on positive changes and reorientation.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Adlerian family therapy 201

APPLICATION OF ADLERIAN PRINCIPLES TO FAMILY THERAPY

The following summary of Adlerian principles is adapted from Sherman and Dinkmeyer
(1987). The principles highlight the main understandings needed by an Adlerian therapist
when working with families.
The family therapy process begins with the knowledge that all persons are socially
embedded and seek personal significance through belonging in social systems. Most
problems in therapy reflect some form of alienation or feeling of lack of worth and
acceptance among the family members
The power drive is generated by the need of both the individual and the family to
improve, or protect them. The therapist watches the process of action and the methods used to
reach their goal. The therapist begins to understand the individual beliefs and goals.
When social interest is present, the power drive is directed toward the caring of others
and the behaviors will be constructive. If the social interest is under-developed, the power
will be against or away from others. The families mutual interdependence requires that they
be concerned about one another and learn to cooperate and work together. Developing social
interest and overcoming alienation are the major focus of therapy.
Behavior and personality are viewed as being created and defined in the family
interaction and each person’s place in the group. This is what leads to both individual and
family life styles. The multigenerational legacy of the family also influences the life style of
the current family and its members. The life style includes beliefs, values, goals, and the
means used to attain those goals. The therapist needs to assist the family to understand and
evaluate its life style.
The family interactions are guided by the goals, life style, and private logic of each
member and the family as a unit. The therapist has to work with both the family as a unit and
the individual members that create the family. The family is a separate dynamic entity created
by the interaction among its members. It is a unit that is different from any and all of its
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

members. The family interactions are mediated by values held in common, the negotiation of
differences, and interdependency among members for survival, development and significance.
Differences between people in the family provide for growth through negotiation and
cooperation. When tension and stress are elevated a power conflict is occurring while
repeated problems signal that a standoff is taking place. The therapist needs to model and
teach the negotiation of differences.
Family members hold both biological and assumed roles and places in the system. Birth
order, gender and generation are examples of biological roles. Examples of assumed roles are
good child, initiator, peacemaker and scapegoat. Each person based on their subjective
perceptions, personal goals and achievements creates assumed roles. An individual attempts
to elicit reciprocal behavior in others that conforms to their perceptions and goals. The family
as a unit also assigns roles to members based on its goals. The actual roles arise as a result of
cooperation, conflict and negotiation.
The dynamic family system constantly evolves out of the interactions, just mentioned
with its own characteristic private logic, life style, goals and methods of striving toward those
goals – its unique line of movement.
Characteristic ways of pursuing the challenges of life and solving problems evolve as part
of the family’s life style through the development of rituals, myths and rules. They are

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 202 Jon Carlson and Julia Yang

expressed over time as continuing patterns and themes of behavior. An example of a ritual is
we all gather when a family member has a birthday. A common myth is that “blood is thicker
than water” and “you depend more on family than strangers”. A typical rule accompanying
such a myth is that “we must stick together”. The symptomatic behavior will involve ritual,
myth and rules that need to be modified or changed.
Assumptive values and expectations fuel the demands made upon the family members.
They also serve as criteria in measuring how satisfying the relationships are and what
improvements are occurring. An example is that my child is very bright and should be in the
honors class. If he doesn’t keep up I will be very disappointed and punish him. The therapist
helps the family to identify, clarify, negotiate or change those expectations.
The family is organized as a unitary whole. Each member contributes more or differently
than the system requires, the system is disrupted and must obtain conformity or reorganize.
For example, if one person with a fertile mind insists that everyone else act upon his constant
flow of ideas and demands regardless of their wishes, the family will either acknowledge that
member as boss and leader or act to place some limits on him so that the family can pursue
other needs as well. The therapist assists the family to reorganize so that each person
contributes to the whole in a meaningful way and that the family contributes to the
development of each member.
The family constellation describes the place occupied by each person multigenerationally
and each person’s roles and relationships. The subjective view of their family and world
varies with the places occupied. It is different to be the oldest or the youngest, a parent or a
child, employed or economically dependent. Knowing the place gives the therapist important
clues about behavior and relationships. Reorganizing places in the family will change
behavior and relationships.
According to Walsh & McGraw (1996), the family interacts around the following nine
dynamic qualities.
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Power: The lines of movement through which the family and each of its members strive
toward goals. Mechanisms in the family through which power is channeled include
decision-making, manipulation, and negotiation.
Boundaries and Intimacy: The degree of physical and emotional closeness and inclusion
or exclusion among family members.
Coalitions: Two or more people joined together for mutual support or to oppose one or
more other individuals. These arrangements may take the form of open alliances or
hidden coalitions.
Roles: Reciprocal characteristic patterns of social behavior that members of the social
system expect from one another.
Rules: Implicit or explicit guidelines that determine what behavior is acceptable or not
acceptable in a family. Rules are related to a family value system and many very with
different roles in the family. Natural or logical consequences provide the corrective
feedback.
Complementarity and Differences: Dissimilar roles in a family that may be integrated by
a process of cooperative reciprocity. Individual differences among members of a
system can lead to an interaction of theses and antitheses, and ultimately result in a
new synthesis.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Adlerian family therapy 203

Similarities: Qualities of a family, including a shared vocabulary and a common

perception of experience that enhances family cohesiveness and identity.
Myths: A family’s subjective representational model of reality. Rules and roles in a
family arise from the family’s myths.
Patterns of Communication: Verbal and nonverbal communications that form the basis of
interactions in a family. Faulty communication due to double messages, withholding
information, or over generalizing can lead to misunderstandings and problems in the
system (pp. 104-105).

To summarize, in Adlerian family therapy, behavior makes sense within the private logic
of the family no matter how it appears to an objective observer. Since behavior is purposive
and goal directed, the therapist carefully examines the goals and the subjective perceptions
that support them and the unique meaning of the behavior to the participants. Treatment is
based upon helping the clients observe their behavior, understand its purpose and discover
goals, or means of attaining goals, which were in error. New options for behaving are then
identified or created and implemented.
The therapist creates a new system that includes the family and him or herself. The new
system is organized according to democratic principles, with the therapist assuming the role
of the initial leader of the group based upon the therapist’s expertise. All of the above
principles will also apply to this new group. Similarly, if a supervisor is involved, still another
system is created.
Therapeutic change takes place in the system as a result of new subjective perceptions,
goals, information, skills; improved communication patterns; and the reorganization of places
and roles in the system.

THE ADLERIAN CHANGE PROCESSES

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AND THERAPEUTIC ENVIRONMENT

Adlerian therapy is based on the premise that once the individual understands his specific
life style and mistaken goals, he can cultivate the social interest and gain courage and will no
longer have needs to make those mistakes. Ansbacher and Ansbacher (1956) first proposed
three major components of understanding and treating the individual: understanding the
specific life style problems and symptoms, explaining the patient to himself, and
strengthening social interest. In general, there are four change processes in Adlerian therapy.
They are (a) the establishment and maintenance of relationships, (b) an examination of the
purpose of each action and behavior, (c) revealing the goals to the client, in other words,
psychological disclosure, and (d) a reorientation and redirection (Sonstegard and Bitter, 2004;
Mosak, 1977). Among these processes, the individual’s insight of his or her life goals and
intentions is the key therapeutic agent. Such insight is only made possible by encouragement
that restores and empowers the individual’s self worth, strength and ability, and social interest
that lead to the freedom of choices and positive changes.
Alfred Adler would counsel or advise a family in public forum, not in private. This was
in stark contrast to other approaches to working with families. In the counseling
demonstrations, the therapist might work with members of the family as subsets; for example,

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 204 Jon Carlson and Julia Yang

beginning with the parents, then all of the children at once, followed by the parents again, and
then the entire family. The purpose of these demonstrations was threefold: to help the family;
to demonstrate to other professionals how to work with families; and to help others
understand that their concerns are similar to (or universal) to those being raised by the
demonstration family. (Evans & Milliren, 1999).
A basic assumption of Adlerian family therapy is that both parents and children become
locked in repetitive, negative interactions based on mistaken goals. Further, these negative
interactional patterns are a reflection of the autocratic/permissive dialectic that has permeated
much of our social/familial heritage. In most cases, the problems of any one family are
common to all others in the community. Although much of Adlerian family therapy is
conducted in private sessions, Adlerians also use an educational model to counsel families in
public in an open forum at schools, community agencies, and specially designed family
education centers (Bitter, Carlson, & Kjos, 1999; Bitter, Roberts, & Sonstegard, 2002).

THE ADLERIAN THERAPIST

There is no one “Adlerian way” of doing counseling. Adlerians are not limited to any one
style of function. A counselor needs to be human first and professional second. This implies
that an Adlerian counselor carries out the proper counseling procedures in practice, but most
importantly, they are a warm human being in keeping with the positive aspects of a
personality theory. An Adlerian counselor acts as a whole person in social interest,
encouraging confidently with feeling, sensitivity and social purpose. They view counseling as
a learning process and see themselves as a facilitator, educator and encourager. The ideal
Adlerian therapist is a person who is outgoing, self-confident, relaxed, firm, and responsible,
emotionally strong, warm, friendly, caring, courageous, good-humored, positive, behaviorally
quick, alert, paces properly, competent; and cognitively knowledgeable, intuitive, clear-
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

thinking, keen (Yang, 2006).

ASSESSMENT AND TREATMENT

The treatment process of Adlerian family therapy is organized into four phases, parallel
to the Adlerian framework of change processes. In the first phase, the therapist gains access to
the family and uses joining and structuring to set the stage for the remainder of the therapeutic
process. The second phase is devoted to assessment. In this phase information is gathered,
and tentative hypotheses about the family dynamics are formulated. During the third phase,
the family gains an increased understanding of their problems, develops their awareness, and
commits to reorientation. In the fourth phase, the changes achieved in therapy are solidified,
and the therapist begins to disengage from the family system and develop a process of relapse
prevention.

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Adlerian family therapy 205

Goals

The general goal of Adlerian family therapy is to promote changes in both individuals
and the family as a whole. The specific goals differ with each family; however the basic ones
are (a) to promote a new understanding and insight about purposes, goals and behaviors; (b)
to enhance skills and knowledge in such areas as communication, problem solving and
conflict resolution; (c) to increase social interest and positive connections with others; and (d)
to encourage the commitment to ongoing growth and change.
These goals may be attained by changes at several levels including: perceptions, values
and goals; play, structure and organization; social interest, feelings and participation; skills
and behavior; and the use of power.

Techniques

Adlerian family therapists have adapted various techniques to gain individual information
about the family members. They carefully acquire data by direct observation and lifestyle
investigation. They follow specific guidelines for interpreting family constellation and early
recollections. The Adlerian family therapist looks for clients’ expressive behavior, and gains
significant information about clients by making assumptions, guessing, clarifying and
explaining. The key techniques of Adlerian family therapy (Carlson, Sperry, & Lewis, 2005)
are as follows:

Family constellation: Information obtained about birth order of all family members;
siblings; the relationships to and between parents; the family climate; additional
parental models; physical, academic, sexual/gender, and social development in
childhood; and life meanings during childhood. The role of the adult is often formed
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by his or her birth order and the influence of the personalities of siblings and parents.
Early recollections: Each family member is asked to share eight memories from early
childhood. The description of these memories is analyzed according to theme and
developmental maturity. Often family members construct memories, but they are still
helpful in identifying the unconscious psychological goals of the person and ideal
self.
Typical day: Parents or other family members are asked to detail events in a complete
typical day.
Encouragement: Techniques are used that convey respect and equality, and that support
understanding, having faith in family members, asking for help, using logical
consequences, honesty, the right to make decisions, setting goals, the right to give
encouragement, consistency, and the use of encouraging words.
Paradoxical intention: A therapist assigns the presenting problem or symptom as a
homework assignment.
Use of the family council: Family meetings are held on a regular basis in which all family
members participate in the discussion of issues so that each person’s views are taken
into consideration when making decisions.

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 206 Jon Carlson and Julia Yang

Use of logical consequences: Parents are taught how to use natural and logical
consequences with their children without arguing or criticizing them. For example, a
child who is late for dinner may not eat until the next meal.
Confrontation: The therapist points out mistaken personal logic.

STRENGTHS AND LIMITATIONS

Because the Adlerian approach is both insight and action oriented, the therapist would not
be shy in helping clients to convert their self-declared goals into specific homework
assignments or tasks that can be completed between sessions. Throughout every step in the
process, a collaborative and supportive relationship would be used as leverage to keep the
client motivated and making progress.
It is not so much that Adler himself tried to make his theory into something for everyone,
as it is his followers who have found ways to do so. You can find within this theory a little bit
of everything that you will recognize from other approaches. One reason for this, of course, is
so many other therapists have borrowed and adapted Adler’s ideas for their own purposes.
Nevertheless, you could get the distinct impression from studying this model that it seems to
wander all over the place, from attention to the past to a focus on the present, from a cognitive
to a behavioral to an affective approach. This is quite a good thing actually because the
Adlerian theory provides an overall framework from which to use a host of other methods.
Some might be inclined to criticize Adler’s theory because it is another that looks too
much at the development of the self rather than the self in relationship to the larger culture
and a person’s subcultures (Slavik & Carlson, 2006). Although it is a method that clearly
values the role of the past in present behavior, it is somewhat narrowly focused on the
influence of one’s nuclear family and especially one’s siblings. Although this might be
especially important for some individuals, others might be far more influenced by peer
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

relationships, school or early work relationships, or the larger popular culture of computer
games, movies, and television.
Most of the criticisms of the Adlerian approach show a lack of understanding of how the
approach has evolved. For example, contemporary Adlerians do not undertake a complete
lifestyle assessment. Adlerian approaches are tailored to the client and will rely on verbal
interventions, logic, and insight dependent on the client’s level of understanding. Adlerians
do very effective brief therapy (Carlson & Sperry, 2000) and are able to code for a full range
of psychopathology (Sperry & Carlson, 1996).
Finally, Adler was pragmatic and spent more time training and treating than theorizing;
therefore the theory is a not well defined (Slavik & Carlson, 2006). His ideas are somewhat
vague and general. This makes it hard to research the basic concepts.

CONCLUSION
Adlerian family therapy is based on the ideas of Alfred Adler and Rudolf Dreikurs. It has
an emphasis on a systemic view of each individual’s style of living. The model has a variety
of therapeutic processes that can be used in both private and open forum sessions.

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 Adlerian family therapy 207

REFERENCES
Adler, A. (1979). Typology of meeting life problems. In Ansbacher, H. L. and Ansbacher, R.
R. (Eds.). Superiority and Social Interest. New York, NY: Norton & Company.
Ansbacher, H. L., & Ansbacher, R. R. (1973). Superiority and Social Interest (3rd ed.). New
York: Viking Press.
Bitter, J., Roberts, A., & Sonstegard, M.A. (2002) Adlerian family therapy. In Carlson, J. &
Kjos, D. Family therapy. Boston: Allyn & Bacon.
Bitter, J., Carlson, J. & Kjos, D. (1999) Adlerian therapy with James Bitter. In Family
Therapy with the Experts: Instruction, demonstration & discussion. [videotape] Boston:
Allyn & Bacon.
Carlson, J., Watts, R. & Maniacci, M. (2006) Adlerian therapy: Theory and practice.
Washington DC: American Psychological Association Books.
Carlson, J., Sperry, L. & Lewis, J. (2005) Family therapy techniques. New York: Routledge.
Carlson, J. & Sperry, L. (2000) Brief therapy. Phoenix: Zeig, Tucker & Theisen.
Dreikurs, R. (1989). Fundamentals of Adlerian psychology. New York: Greenberg.
Dreikurs, R (1971). Social equality: The challenge of today. Adler School of Professional
Psychology, Chicago, IL.
Evans, T. D. & Milliren, A. P. (1999). Open-forum family counseling. In R. E. Watts & J.
Carlson (Eds.). Interventions and strategies in counseling and psychotherapy (pp. 135–
160). Levittown, PA: Accelerated Development/Routledge.
Milliren, A. P., Evans, T. D., & Newbauer, J.F. (2003). Adlerian counseling and
psycholotherapy. In Capuzzi & Gross (Eds). Counseling and Psychotherapy (pp 91-132).
Mosak, K. H.(1977). The tasks of life I. Adler’s three tasks. In H. H. Mosak (Ed.). On
Purpose. Adler School of Professional Psychology (pp. 93-99). Chicago, IL: Author.
Sherman, R. & Dinkmeyer, D. (1987) Systems of family therapy: An Adlerian integration.
New York: Brunner Mazel.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Slavik, S. & Carlson, J. (2006) Readings in the theory of Individual Psychology. New York:
Routledge.
Sonstegard, M.A, & Bitter, J. R. (2004). Adlerian group counseling and therapy. NY: Taylor
& Francis.
Sperry, L. & Carlson, J. (1996) Psychopathology and psychotherapy (2nd Edition). New York:
Routledge/Taylor & Francis,
Stein, H.T. and Edwards, M.E. (1998). Classical Adlerian theory and practice Originally a
chapter in Psychoanalytic Versions of the Human Condition: Philosophies of Life and
Their Impact on Practice. Retrieved November 21, 2004, from Alfred Adler Institute of
San Francisco Web Site: http://ourworld.compuserve.com/homepages/hstein/
theoprac.htm
Terner, J. & Pew, W. (1978) The courage to be imperfect: The life and work of Rudolf
Dreikurs. New York: Hawthorn.
Yang, J. (2006). The courage of social living. Unpublished manuscript, Governors State
University, University Park, Illinois.
Yang, J. & Milliren, A. P. (2004, June). Yin, Yang & Social Interest: In Search of Laws of
Social Living Across Cultures (With A. Milliren). Paper presented at the meeting of
North American Society of Adlerian Psychology, Myrtle Beach, SC.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 208 Jon Carlson and Julia Yang

Walsh, W.M. & McGraw, J.A. (1996) Essentials of family therapy: A therapist’s guide to
eight approaches. Denver: Love.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 In: The Quick Theory Reference Guide ISBN: 978-1-60021-624-4
Editor: Karin Jordan, pp. 209-225 © 2008 Nova Science Publishers, Inc.

Chapter 15

OBJECT RELATIONS THEORY IN FAMILY THERAPY

Karin Jordan and Richard Shaw

Object relations family therapy is an adaptation of Freud’s basic principles for application
to family life, and is one of the psychodynamic family therapy approaches (Kohut, 1977). It
serves as a bridge between classic Freudian thinking, with a focus on individual drives (e.g.
sexual and aggressive inborn impulses) emanating from the id, and family therapy with its
emphasis on social relationships (e.g. interpersonal relationships) (Slipp, 1988). According to
Dicks (1963) object relations theory in family therapy helps to explain spouse/partner choices
and couple/committed relationship and/or family interaction patterns.
Freud believed that the psyche consists of three parts, the id, ego and superego (Freud,
1923). He believed that the id is the source of psychic energy and the person’s individual
drives, and is largely unconscious and ruled by the pleasure principle, which is designed to
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

avoid pain, reduce tension and seek pleasure. It is driven to meeting the individual’s drives
(Freud, 1923). The ego is the rational and intelligent part that is in contact with the world. It is
the part that controls the individual’s drives, i.e. the impulses of the id (Freud, 1923). The
superego is responsible for personal morals (what is good or bad, right or wrong) (A. Freud,
1936). These are societal morals that have been handed down from the parent(s) to the
child(ren) and are related to the psychological rewards and punishments from significant
others. According to Slipp (1988), dysfunction grows out of the structural conflicts between
the drives found in the id, ego and superego.
Psychoanalytic object-relations theory, also known as self-psychology, is a more
contemporary trend in the field of psychotherapy. According to psychodynamic theorists, the
term object refers to the significant person(s) or thing(s) that gratifies needs or targets a drive.
The term object in object relations theory can also be exchanged with the term other, since it
refers to an important person that the child (primary first caregivers-mother/motherly figure)
and later the adult (spouse/partner) gets attached to and thus satisfies the needs and longings
of deep connection and relationship. Object relations, which has diverged from orthodox
psychoanalysis, has been identified as:

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 210 Karin Jordan and Richard Shaw

…relations between persons involved in ardent emotional attachments. These attachments can
exist in the outer world of reality or as residues of the past – that is, inner presences, often
unconscious, that remain vigorous and very much alive within us. (Scarf, 1995, p. xxxvii)

Object relations theory was initiated by a number of theorists, including Ferenczi, Klein,
Fairbairn, Bion, Winnicott, Guntrip, Dicks, Kernberg, Mahler, Kohut and Sullivan (Friedman,
1980). They focused on the infant’s primary need for attachment with a safe and caring
person, often the parents, but especially the mother or motherly figure, as she generally is
primary caregiver (Fairbairn, 1957; Klein, 1948), intending to replace Freudian beliefs that
personality development is primarily influenced by drives. More specifically, the stage theory
of object relations emphasizes the importance of the first three years of life, when the infant,
and later the toddler, moves toward becoming more independent and seeing others as real and
complex people. These are the stages when the infant moves from being dependent and
having no awareness of being separate from the mother or mothering figure, to the toddler
moving toward some independence and self directed exploring. According to Fairbairn
(1941), these stages can also be described as moving from demand-and-take, also known as
taking, to give-and-take, also known as giving to others. The mother or motherly figure is
very important during these stages, as s/he must be good enough but not perfect, for
responding to child’s needs (Winnicott, 1965). “Good enough” in this context means that the
need for physical and emotional contact, food and comfort are being met consistently. “Not
perfect” in this context relates to the infant’s needs not being fully met because no one can be
the perfect parent, therefore allowing him/her to experience frustration as well as learn to
develop trust that they will eventually be met. For the toddler’s needs to be met “(dropped
not) good enough” will result (at about age three, when the toddler is becoming more
independent) in the toddler seeing his/her mother/motherly figure and him/her self as
separate, but also as being reliable and close. The toddler will also learn that s/he, as well as
his/her mother/mothering figure, have both good and bad sides (Kernberg, 1980/1994). These
images of self and others (introjection) become the psychological structures associated with
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

thoughts and feelings, existing consciously and unconsciously, and serving as the
foundational subjective experience throughout a person’s life (Hanson, 2000). There are other
situations when early relationships are disrupted or never developed (e.g. birth of another
child, possibly with post-partum depression, death, etc.), or when the mother/motherly figure
is unpredictable, unstable, anxiety ridden, hostile or unconfident (Mahler, 1968). These
negative early relationship experiences not only can lead to various dysfunctions in
adulthood, but can influence how the person sees themselves and others, i.e. they might
perceive others to be untrustworthy or unreliable, and self-centered in relationships, believing
that others will abandon them. In addition, there are mothers who are too helpful in meeting
all of the needs of their two and three year old children, which can result in the child, and
later the adult, expecting others to meet all of their needs. Object relations theory focuses on
the development of individuals in relation to others (Hamilton, 1989) and on how people
relate in present relationships, which to some extent is based on early relationship experiences
of toddlers under three years of age (Nichols, 1987).
Object relations theory in family therapy can be used to help explain couple choices and
family communication patterns (Dicks, 1963). More specifically, it focuses on the
unconscious (out of awareness and out of conscious control), and unresolved early object
relations that adults bring into their couple and family relationships, which can develop into

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Object Relations Theory in Family Therapy 211

dysfunctional dependent relationships (Napier & Whitaker, 1978). These dysfunctional

patterns of interaction are continued until one or both partners learn new patterns of behavior,
which requires an intra-psychic focus on internalized object relations. For the purpose of this
chapter, focus will be on object relations and family of origin (Framo) as well as object
relations family therapy (Scharff & Scharff).

OBJECT RELATIONS AND FAMILY OF ORIGIN

James Framo is generally identified as one of the first generation family therapists who
developed the object relations and family of origin therapy. He was born in 1922, raised in
South Philadelphia. (Framo, 1991). He described himself as being the “risk taker, adventurer
and academic achiever” in his family of origin and knew that he would go to college and to
war (Framo, 1991, p.220). He went to Penn State, and during his first semester, Pearl Harbor
was attacked. He joined the army and served for 450 days with the 88th Division and 913th
Field Artillery Battalion in the Italian Campaign (Kramer, 2001). He was impacted by his war
experiences (e.g. the chaos, deaths of fellow soldiers, etc.), and after he returned home,
decided to return to Penn State. He married Mary in 1946 and they had four children, two of
whom died at age 9 from congenital heart defect, something that Framo also had (Framo,
1991). He identified the losses of his two sons as the greatest tragedies of his life.
Framo was trained as a clinical psychologist and affiliated himself with the Eastern
Pennsylvania Psychiatric Institute (EPPI) in Philadelphia. It was during that time that he
started to believe that the origin of family dysfunction was the larger family system. However
he did not want to disregard psychoanalytic understanding of individuals’ intrapsychic world,
recognizing that psychoanalytic theory lacked understanding individuals within the social
(more specifically, family) context. Framo believed that people need both intrapsychic and
interactional aspects (Framo, 1982), and did not believe that systems theory could completely
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

explain family transactions. He did however believe that it was important to consider each
individual family member’s inner experience (internalized toddler object relations) and
present family interaction. His work was grounded theoretically in Fairbairn’s (1954) and
Dicks’ (1967) theory of object relations.
Framo moved to California in 1983. He and his wife Mary divorced in 1986, and later
Framo married his second wife Felise Levine (Framo, 1991). He taught at United States
International University (USIU) in San Diego (Kramer, 2001) from 1981 to 1982. Framo was
the founder and president of the American Family Therapy Academy (AAFT), as well as a
fellow and supervisor of the American Association for Marriage and Family Therapy
(AAMFT) (Kramer, 2001). In 1992, he was designated as a Founder in the Field by the
American Association for Marriage and Family Therapy (Kramer, 2001). He presented
numerous workshops in the United States and around the world, served on several editorial
boards, and published extensively. For example: Boszormenyi- Nagy and Framo published
Intensive Family Therapy in 1965, which was translated into six languages. In 1972, he
published a classic book entitled Family Interactions: A Dialogue Between Family
Researchers and Family Therapists. He wrote a chapter in 1976 entitled Chronicles of a
Struggle to Establish a Family Unit within a Community Mental Health Center, focusing on
resistance to him and the emerging paradigm shift. In 1982 he wrote a book on his theoretical

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 212 Karin Jordan and Richard Shaw

work entitled Explorations in Marital and Family Therapy: Selected Papers of James L.
Framo. He also co-authored with Robert Green in 1982 a book entitled Family Therapy:
Major Contributions. In 2003 he wrote with Tim Weber and his wife Felise Levine a book
entitled Coming Home Again: A family of Origin Consultation. In addition, he published over
60 chapters and articles. Framo died in 2001.

Nature of Persons

Framo, similar to Fairburn (1954) and Dicks (1967) believed that humans are relationship
(object) seeking. More specifically, he believed that people have the need to be in satisfying
and safe relationships. He also believed that toddlers interpret their parents’ (object’s)
behavior. These objects’ introjections (imprint or memories of the person’s parents) are most
difficult to change. Framo (1981) believed that they tend to be retained, serving as a blueprint
for later relationships with the person’s spouse/partner and child(ren). It is almost like a
shadow stand-in for old ghosts. This is done attempt to find satisfaction in present
relationships, to make up for the unsatisfactory relationship with his/her parents during the
first few years (before age three) of life. In object relations and family of origin theory, it is
believed that people choose spouses/partners are that are willing to participate in the re-
experience of unresolved family of origin issues, allowing the person to recreate his/her
childhood family of origin experiences through his/her present spouse/partner and child(ren).

HEALTHY FUNCTION VS. DYSFUNCTION

Healthy Functioning
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Healthy functioning is rooted in the family of origin and goes back to early parent
(objects)-infant relationships, in which an emotional interactional bond was created and the
infant’s needs (physical and emotional contact, food and comfort) were not fully, but
eventually met and interpreted as reliable and good. This also results in the child seeing
him/herself and his/her objects (introjects) as having both good and bad sides (they coexist),
which becomes the foundational subjective experience for future intimate relationships with
one’s spouse/partner, child(ren) and others. Instead of seeing some people/objects as all good
and others as all bad. Having the ability to integrate feelings (good and bad) about an object
(spouse/partner, child[ren]) into a realistic view results in having a satisfying and mature
relationship.

Dysfunction

Framo (1992) wrote that “intrapsychic conflicts stemming from the family of origin are
repeated, defended against, lived through, or mastered in relationship with one’s spouse,
children, or any other current intimate” (p.111). More specifically, when early parent-infant
relationships were negative (e.g. disrupted, unstable, anxious, hostile, etc) or too helpful and

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Object Relations Theory in Family Therapy 213

intrusive (during two to three years of age), the result was the child’s inability to synthesize
good and bad, (known as splitting). This means that the child, and later the adult, views all
objects as either all good or all bad and often projects unrealistic expectations of behavior on
an object (spouse/partner, child[ren]), causing conflict and confusion.

THE THERAPEUTIC PROCESS

Change Process

The process of change in object relations family of origin therapy includes the person
understanding what issues or agendas from his/her family of origin are projected onto the
current family. For change to occur, the person must have an opportunity in which s/he can
have a corrective experience with his/her parents and siblings. Framo (1991) believed that it
is important that a person does that before his or her family of origin has died, so that the
person can address both past and present issues with his/her family of origin and overcome
his/her parents introjection. This most likely will liberate the person to make changes in
his/her present relationships with his/her spouse/partner and/or child(ren).

Therapist Behavior/Role

In object relations family of origin therapy, the therapist creates a safe and solid
relationship with each person and looks to create a strong bond on purpose at the beginning,
as premature interpretations might result in losing the clients (Framo, 1991). Trust is an
important aspect in this relationship and the therapist tries to build it within the first few
sessions of therapy. The object relations family of origin therapist also takes on the role of
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

teacher, educating each person about how past (childhood) experiences with his/her family of
origin have influenced his/her present relationships (spouse/partner and/or child[ren]). In
addition, the object relations family of origin therapist asks circular questions, draws
attentions to significant statements, summarizes, and is supportive.

Assessment

Assessment of the couple occurs during conjoint therapy and can extend over several
sessions (Framo, 1982). Information is gathered by having the therapist ask relevant circular
questions, and gather information about the couple’s present family and couple relationship,
including:

• Demographics
• Length of current, and if applicable, previous marriage(s)/partner relationship(s)
• Age of children from this and/or previous marriage(s)/partner relationship(s)
• Reason for choosing spouse/partner
• Satisfaction with spouse/partner

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 214 Karin Jordan and Richard Shaw

• Sexual relationship with spouse/partner (e.g. satisfaction, etc.)

• Characteristics of present marriage/partner relationship
• Commitment to present marriage/partner/relationship by each partner
• Patterns of conflict/conflict resolution
• Previous therapy
• Problem description by each spouse/partner
• Commitment and motivation toward therapy by each spouse/partner

This process of information gathering might take several sessions, after which focus is
given to each spouse/partner’s family of origin, by asking such questions as (Framo, 1991):

• Which parent were you closer to?

• What was your relationship with each parent and with each of your brothers and
sisters?
• What was your parents’ marriage like?
• What was the family atmosphere?
• What kind of family was it? (p. 17)

After each person has described his/her family of origin through these and other
questions, his/her spouse/partner is asked questions such as (Framo, 1991):

• What is your reaction to your spouse/partner’s account of his history?

• How do you see your spouse/partner’s mother, father or siblings? (p. 17)

Generally, asking spouses/partners these and other questions is helpful, as they tend to be
more objective in their observations, but also they are often are more willing to disclose
information that has been omitted, such as an incarceration, suicides, substance abuse, etc.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

(Framo, 1991). This assessment process not only serves as an information gathering process
for the object relations family of origin therapist, but also as a way to develop a trusting and
safe relationship.

Treatment Goals

According to Framo (1976), looking more generically at the goal of therapy is to give
adult clients an opportunity to deal with both past and present family of origin issues. More
specifically, the goal is to give the etiology of the problem back to the family of origin during
the family of origin session. This will allow the person to come to terms with his/her parents
before they die. In addition to dealing with the family of origin as real people, it also creates
an opportunity to decrease the intensity of the internalized objects, which should allow the
person to behave differently in present relationships with his/her spouse/partner and/or
child(ren).
In addition to the more generic goals, there are also specific goals for each couple. These
goals are established by having the therapist ask each spouse/partner to identify what his/her
goal is for therapy. Based upon the different stages of therapy that the couple goes through
(conjoint therapy, couples group therapy and family of origin therapy) these identified goals
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Object Relations Theory in Family Therapy 215

might change. In addition to the goals identified by the couple, the therapist also has goals for
the couple. For example, during the conjoint therapy, the therapist’s goal might be to help
defuse intense conflict.

Detailed Phases of Treatment

Families often enter therapy because the couple or one of the children is in crisis, and
initially, several sessions are conducted to control the crisis. If it is the child that has brought
about the crisis, Framo (1976) stressed focusing on detriangulating (no longer serving as a
buffer between his/her parents) the child from his/her parents. This is especially important in
families in which one child is the identified patient, serving as a way to deflect the attention
from the couple’s conflict. The therapist dismisses the child from the process of therapy, and
the couple is given the option of exploring and correcting underlying issues that could be the
reason for the couple or child crisis. This process of therapy involves three stages: (1)
conjoint therapy, (2) couple group therapy and (3) family of origin (intergenerational)
conferences. It is important to remember that the object relations family of origin therapist
does not see one spouse without the other.

Conjoint Therapy
It is believed that conjoint therapy will help maintain the integrity of the relationship
because it will help avoid suspicions and the conflict of loyalty, as well as confidentiality
(Framo, 1981). The therapist focuses on building trust with the couple and having each
spouse/partner identify the goal for therapy, and gather information (present couple and
family as well as family of origin). This is also the stage after which some trust has been
established, i.e. the therapist will help the couple defuse some of their couple conflict as well
as educate them about object relations theory and how unresolved family of origin issues may
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

be the reason for present relationship problems. In addition, the importance of couple group
therapy and family of origin (intergenerational) conferences are introduced.

Couples Group Therapy

This is generally limited to three couples matching in age and life cycle, as Framo (1991)
believed that it is helpful for couples to see other couples act out similar behavior patterns as
they do, meaning that there are other couples with similar problems, which can help
normalize their relationship with their family of origin. In addition, couples benefit by
receiving feedback regarding their behavior, from the therapist, and from other couples. This
can assist couples in exploring how realistic their expectations are regarding their
spouse/partner and their goal for therapy (Framo, 1991). Couple group therapy has the
additional benefit of decreasing resistance toward meeting with the family of origin, as
partners are being supported by other couples and hear about other people’s experiences in
meeting with their family of origin.
(Important: The next stage does not occur at the same time for each couple, nor does it
occur at the same time for each spouse/partner of the couple. Couples stay in the group when
they are ready for the next stage, to get the support before and after the next stage, but also to
report back to the group on their experience.)

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 216 Karin Jordan and Richard Shaw

Family of Origin (Intergenerational) Conferences

These consist of two 2-hour sessions and are preferably done with opposite gendered co-
therapists, to alleviate gender alliance fears. They are done individually (i.e. without
spouse/partners) to avoid focusing on the spouse/partner or couple relationship. The person
meets with his/her family of origin so that he/she can share his/her view(s) with them, which
perhaps were not previously discussed (Framo, 1992). More specifically, the goal of these
meetings is to give the person a “corrective experience” with their family of origin (Framo,
1981). The focus of these sessions is on past dissatisfactions and misunderstandings, however
it is not a time of giving blame or condemnation. It is during the end of this stage that the
therapist helps the person understand how the old attachments, unresolved issues, mistakes
(real and perceived) and introjections from the past have impacted present relationships with
the person’s spouse/partner and/or child(ren). This allows the person to treat his/her
spouse/partner and/or child(ren) in a more healthy manner and as individuals. Family of
origin conferences can enhance present relationships, especially when the person recognizes
that their marriage is based on projection and unresolved family of-origin issues. This insight
can result in positive change if the couple is willing to work on it. Some couples (one or both
spouse[s]/partner[s]) may choose to not work on it and decide to disolve the relationship.
Framo (1981) warns that family of origin conferences are like “major surgery,” and therefore
are not without risk. Clients should be made aware of these potential risks, which might
include the relationships getting worse, rather than better.

Techniques Used

• Using humor-humor is used at appropriate times in an attempt to defuse or to

detoxify anger (Framo, 1991)
• Getting past anger and negative images-the adult is encouraged to find out about and
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

understand what situation/circumstance the parents were dealing with during the time
that the anger or negative images were built (most likely when the person was a
child). This process might help the adult to evaluate this experience differently and
reframe the parent’s behavior (Framo, 1991).
• Reducing expectations-if a person has difficulty forgiving his/her parents, then
asking the person to expect absolutely nothing, as well as making no demands on
them, creates a situation in which the parents can give, even in a small way, and the
person can accept it (Framo, 1991).
• Telling the good things-is used in situations when families are alienated. The parents
tell the adult/child) what they like and appreciate about him/her, and the adult/child
tells each parent what good things that s/he got from them.
• Sessions without anger-are used when an adult/child does not have negative feelings
or residual anger toward parents, but has strong positive feelings and wants to share
those with his/her parents. During the session, warm family memories are shared and
any disappointments are stated as something the person does understand (Framo,
1991).
• Detriangulation-is the process in which the therapist helps the child, who has
previously functioned as the buffer between his/her parents deflect the attention from

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Object Relations Theory in Family Therapy 217

the couple relationship, to withdraw. This creates an opportunity for the couple to
focus on their relationship directly, without using the child.

STRENGTHS AND LIMITATIONS

Strengths

Object relations and family of origin therapy has a number of strengths. First, the person
has the opportunity to deal with family of origin issues directly, with their family of origin
being in the session. Healing can occur as the person sees his/her family of origin as real
people, and since the person is now an adult, he/she can also interpret (or reinterpret) his/her
family of origin’s intentions more accurately. It also creates an opportunity for forgiveness
and resolution. This therapy helps the person, as well as his/her family of origin, to reconnect
and restore function. Second, this therapy provides insight that the couple’s difficulties are
rooted in unfinished business in the person’s family of origin. Group counseling, the second
stage of object relations and family of origin therapy, is part of the process of therapy. It
serves as a way for the individual to get support in preparation for their family of origin
(intergenerational) conference, but also helps the couple to see that they are not alone in the
way that they interact, as they observe similar patterns in other couples.

Limitations

Framo (1981) recognized that object relations family of origin therapy is not a panacea.
According to Framo (1992), it might not create the drastic change desired by some, and
therefore a family of origin session should not be used with couples who are dealing with
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

minor family of origin issues. Some people might have high hopes for how their family will
behave during the family of origin session, and that might not happen. Some couples or
individual spouses/partners might not have access to their family of origin, or the family of
origin might refuse to come to the session. Finally, since the underlying assumption of object
relations family of origin therapy is that present problems are the result of past experiences in
the person’s family of origin, and this might be something that some couples might not
believe, nor would be willing to work on, as their couple relationship is in such a crisis that it
is too overwhelming to have to deal with family of origin issues.

OBJECT RELATIONS FAMILY THERAPY

David E. Scharff, M.D. and Jill Savege Scharff M.D. are husband and wife psychiatrists
and clinical professors at Georgetown Medical School. David Scharff is also clinical
professor at the Uniformed Services University of the Health Sciences. He received his
medical degree from Harvard University and is a board certified adult and child psychiatrist.
He has also been a sex therapist and was the president of the American Association of Sex
Educators. From 1988-1994, he was the director of the Washington School of Psychiatry, and

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 218 Karin Jordan and Richard Shaw

from 1988-1993, Chair of the Object Relations Theory and Therapy Program. (IIORT Faculty
Positions). Jill Scharff received her training in Scotland and at London’s Travistock Clinic
and received membership of the Royal College of Psychiatrists in Britain. She immigrated to
the United States and became board certified in adult and child psychiatry, becoming certified
by the American Psychoanalytic Association in child and adolescent psychoanalysis. In the
early to mid 1990s she was the Chair-Elect and Chair of Object Relations Theory and
Therapy at the Washington School of Psychiatry. (IIORT Faculty Positions)
The Scharffs developed object relations family therapy which ties object relations theory
to family development. Concepts of psychoanalytic thinking are related to the family as a
system (made up with relationships), rather than individual family members (Scharff &
Scharff, 1987). More specifically, this theory is based on the belief that “object relations
theory provides the possibility of an analytic family systems approach, because it is an
intrapsychic psychoanalytic theory that derives from an interpersonal view of development”
(Scharff & Scharff, 1987, p. 16). The Scharff’s are the editors, authors and coauthors of
multiple articles and books, such as Object Relations Family Therapy in Context (1987),
Foundations of Object Relations Family Therapy (1989), and The Development of Object
Relations Family Therapy (1989).

Nature of Persons

In object relations family therapy, a person’s intrapersonal as well as interpersonal levels

of functioning are constantly interacting. More specifically, the intrapersonal level focuses on
the person’s early mother/mothering figure-child attachment, relationship and possible early
separation, which will impact the ability of how the ego relates to others and what level of
growth they want to achieve. Whereas the interpersonal level of functioning not only relates
to people seeking a permanent attachment as adults, but that they are seeking partners who
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

will allow them to replicate early attachment relationships, which can have disturbances
going back to early infantile experiences influencing how a couple or family deals with
developmental transitions.

HEALTHY FUNCTION AND DYSFUNCTION

Healthy Functioning

In object relations family therapy, healthy functioning is rooted in having the

mother/motherly figure meet the child’s fundamental human need for attachment and to be in
a safe and satisfying relationship. When this occurs early in life, it permits the ego to relate
freely to others. This kind of relating can be interpreted as being an open system that is in
contact with the world, allowing for new experiences and the potential to become an
opportunity for growth. During adulthood, the early satisfying mother/motherly figure-child
relationship creates an opportunity for the person to contain the projections of the undesirable
aspects of the self on his/her family and instead allow the person to respond to individual
family members, as they are in reality (Scharff & Scharff, 1987). The concept of containment

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Object Relations Theory in Family Therapy 219

is key for this approach and is related to one’s ability to hold difficult emotional and relational
truths and experiences while maintaining an emotionally stable ego and sense of self.

Dysfunction

In object relations family therapy, when early attachment between the mother/motherly
figure and child is broken, a separation is created which is believed to lead to repression,
anxiety, stress and a more limited ego expression (Scharff & Scharff, 1987). The repression
experienced as a result of the early infantile separation from one’s mother/motherly figure,
when the attachment is broken, can result in repression and a less healthily defined ego later
in life, making it more difficult to relate to others. This can hinder the person’s reaching out
and therefore missing out on opportunities for new experiences and growth. Instead, the
person will seek out interpersonal relationships in which they can respond to introjects from
the past rather than to how family members really are. Since families are interpersonal
systems, in object relations family therapy individual problems are viewed as family system
disturbances and not as an individual family member disturbance.

THE THERAPEUTIC PROCESS

Change Process

The object relations family therapist operates under the assumption that changes in
individual family members can produce change in the family system, which is different from
other contemporary family therapy approaches. The change process involves focusing on
family relationships and family function, as well as individual family members as they move
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

through the family developmental stages (Scharff & Scharff, 1987). Unconcious materials are
brought up and then interpreted for the family. The therapist helps the family through his/her
interpretation to explore and gain insight about both transference and countertransference
issues. Transference has been described as the person relating repeatedly, in present here and
now relationships, with unresolved feelings, attitudes and drives of his/her earlier experience
with his/her mother/motherly person. Greenberg and Mitchell (1983) wrote that transference
is:

…people reach to and interact with not only the other actual person, but also the internal
other, a psychic representation of a person which in itself has the power to influence both the
individual’s affective states and his overt behavioral reactions. (p.10)

Countertransference has been identified as being the reciprocal interaction of the other
person in transference situations, where each person brings his/her internalized object
relationship patterns from early mother/mothering person-child relationships, in an attempt to
achieve gratification. Countertransference experienced by the object relations family therapist
is an unconscious emotional response from early child/mother relationships to his/her client
relationship in a parallel process Parallel process suggests that what is happening in key

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 220 Karin Jordan and Richard Shaw

family member relationships is also happening between therapist and client(s) and needs to be
addressed as part of the on going therapy.
Transference occurs between family members as well as between each individual family
member and the therapist. The therapist takes on a neutral stance with the family, replicating
the infantile relationship of each spouse/partner with caregivers in their family of origin,
which is also called “object hunger.” Not surprisingly, the object relations family therapist
responds to the family’s struggles with countertransference. It is believed that greater
empathy can be provided for the family by object relations family therapists who have
previously engaged in their own personal analysis. In addition, object relations family
therapists can also benefit from close supervision. David Scharff (1998) described this
process as the therapist allowing him/herself to “be the substrate for a newly emerging
understanding, which they then feed back to the family in the form of interpretation” (p. 424).
This process helps families work through chronic interaction patterns as well as defensive
projective identifications, and needs to occur before they can change the behavior in their
present family. In this process, therapists “use” themselves and their own work to assist and
come along side clients in helping them to accomplish their goals.

Assessment

Object relations family therapy can be identified as being an “analytic family systems
approach,” in which focus is on the continuous interaction between the intrapsychic and
interpersonal levels (Scharff & Scharff, 1987). Therefore, the central components of
assessment should include the historical analysis of each family member, along with the
present relationship difficulties. Information is gathered through both history-taking and
observing the family interacting. According to Scharff and Scharff (1987), history-taking
involves, but is not limited to, getting information about the:
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

• individual family member’s history of internalized objects

• present family’s psychosexual development and various defense mechanisms
• present family’s shared object relations
• family’s pattern recognition
• family’s understanding of their mutual impact on the system

In addition, the object relations family therapist will observe family interactions and use
this as part of the assessment process.

Goals

The goal of object relations family therapy is not simply to decrease the problem
behavior of one family member, but rather to help the family gain understanding and resolve
unconscious object relations that are problematic in current, here and now relationships. This
will allow the family to function more effectively with developmental stresses, as well as
support growth, attachment and individuation. Scharff and Scharff (1987) specifically
identified the goal of object relations family therapy as:
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Object Relations Theory in Family Therapy 221

1. The cognition and reworking of the defensive projective identifications that have
previously been required in the family.
2. The treatment of the family’s capacity to provide contextual holding for its members
so that their attachment needs and conditions for growth can be met.
3. The overall reinstatement or construction of a series of centered holding relationships
between each of its members to support their needs for attachment, individuation,
and growth sufficient to allow each individual to “take it from here.”
4. The return of the family to the overall developmental level appropriate to its tasks as
set by its own preferences and by the needs of the family members.
5. The classification of remaining individual needs in family members so that they can
get them met with as much support as they need from the family. By this we
specifically include individual needs for psychotherapy, as well as more general
needs for other growth endeavors. (p. 448)

Ultimately, the goal of therapy is not symptom relief, but to help the family move
through family developmental phases with improved abilities of working together, which
should also lead to better support individual family members in their self fulfillment and
individuation process, which in turn will bring symptom relief as a by product of the deeper
therapy work.

Process of Therapy

Therapy starts out with the object relations family therapist focusing on developing a
therapeutic alliance that allows early ego function to manifest. More specifically, it is for the
family and the object relations family therapist to get a better understanding of the family’s
psychosexual development and the various defense mechanisms against anxiety. The object
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

relations family therapist will point out/describe inadequate internalized patterns, since the
underlying premise is that insight is necessary for change to occur. Working through chronic
interaction patterns is necessary to fully master the gains made from changed patterns of
dealing with current realities in the here and now.

Nature of the Therapeutic Relationship

The object relations family therapist needs to take a neutral stand and be impartial,
known as the holding environment (Winnicott, 1965). This neutral and impartial stance allows
the family members to project unfinished problems from the past onto the therapist. The
object relations family therapist also needs to stay outside the family system, to allow him/her
to report what they observe (and interpret) happening in the family system (transference
between family members) as well as with him/herself (countertransference between the
family system and the therapist). In addition, the object relations family therapist offers
empathy to the family, and tries to develop a nurturing and safe atmosphere (through the
holding environment) for the family. David Scharff (1989) believes that this kind of
atmosphere allow families to explore, and later, work through chronic interaction patterns and
defensive projective identification. This is important so that the family can learn how to deal

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 222 Karin Jordan and Richard Shaw

with each other in current here and now relational realities rather than unconscious object
relations.

Techniques

There are a variety of techniques that are used in object relations family therapy. Some of
them are:

• Holding environment - means that the therapist has created an atmosphere that
creates trust and caring among all of the family members as well as the therapist
(Scharff & Scharff, 1987).
• Life history taking - is an assessment technique written in either a narrative or
abbreviated version. The focus of the life history is on past and present interactions
within the family. This technique serves to build trust with the therapist as families
are not judged. It also helps the family gain insight (Friedman, 1980).
• Working in the here and now - means that events occuring in the session, rather than
experiences from the last week or before that, are explored by the family. This
provides an opportunity for the therapist to observe emotional exchanges (D. Scharff,
1989).
• Questions about feelings - through affect and non-verbal communication observed,
as well as through commenting on and directly questioning of feelings by the
therapist (D. Scharff, 1989).
• Modeling ways of working together - the therapist makes suggestions as to how a
family might be able to work better. The family might not have thought about these
ways of interacting with each other in the past.
• Transference - is a technique used to help the therapist: (a) understand dominant
feelings within a family unit, as well as (b) delineate which emotions are directed at
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

which person. More specifically, transference occurs when the family has developed
an attachment with the therapist, and the therapist is non-reactive, taking a neutral
stance. The family can then project their suppressed emotions on the therapist, which
is a replay of an infant relating with his/her mother (mothering person), also called
“object hunger” (D. Scharff, 1989).
• Countertransference - is experienced by the therapist in response to the family’s
difficulties by triggering his/her own unconscious old struggles, which can result in
the therapist having greater empathy with the family. This requires that the therapist
has gone through psychoanalysis and received extensive supervision (D. Scharff,
1989).
• Feedback of therapist observations and interpretations - is used to help the family
gain awareness, which is essential to bringing about change (Scharff & Scharff,
1987).

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Object Relations Theory in Family Therapy 223

STRENGTHS AND LIMITATIONS

Strengths

Object relations family therapy has several strengths. First, it builds a bridge between
individual psychology and family therapy. It focuses on the unconscious, influencing both
intrapersonal and interpersonal relationships. Second, it examines basic defense mechanisms
and how they influence here and now relevant relationships. This is a unique contribution to
the family therapy field. Third, it helps explain early child-mother (mothering person)
relationships and present function in relevant relationships, something that has not been
focused on in other family therapy approaches. Fourth, change in an individual family
member can create change in the family system – a unique way of thinking, as other
contemporary family therapy approaches posit that it requires the whole family to change
before individual change can occur.

Limitations

Similar to object relations family of origin therapy, object relation family therapy is not a
panacea. In object relations family therapy, individual family member’s problems are viewed
as a manifestation of family systems disturbances, something that some families might not
believe, nor be willing to work on. Some people might not see the need or not want to explore
the roots of their disturbance, which means looking at their family history, specifically early
child-mother (mothering person) relationships. Some families will be unable to make the time
and money commitment involved in this. Also, this therapy requires the ability to do some
abstract thinking, which can be especially challenging to people that are more concrete.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

SUMMARY
Object relations family of origin therapy and object relations family therapy are bridges
between classic Freudian theory and family therapy, focusing on analyzing a person’s history
as well as looking at relations between people. More specifically, it is believed that people
with disturbances relate to others in the here and now based upon early formed expectations,
rather than on how the other person truly behaves. This means that people’s past experiences
(their internalized objects) are alive in present close relationships, and have a strong
influence. Through the help of the therapist, the family members learn how the past
influences their present, here and now relationship(s). Finally, the goal is to have each person
engage more fully in relevant relationships.

REFERENCES
Boszormeny-Nagy, L., & Framo, J. (Eds.). (1965). Intensive family therapy: Theoretical and
practical aspects. New York: Harper & Row.
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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 224 Karin Jordan and Richard Shaw

Dicks, H. V. (1963). Object relations theory and marital studies. British Journal of Medical
Psychology, 36, 125-129.
Fairbairn, W. R. D. (1941). A revised psychopathology of the psychoses and psychoneuroses.
International Journal of Psychoanalysis, 22, 250-279.
Fairbairn, W. R. (1954). An object-relations theory of personality. New York: Basic Books.
Framo, J. L. (1972). Family interaction: A dialogue between family researchers and family
therapists. New York: Springer.
Framo, J. L. (1976). Family of origin as a therapeutic resource for adults in marital and family
therapy: You can and should go home again. Family Process, 15, 193-210.
Framo, J. L. (1981). The integration of marital therapy with sessions with family of origin. In
A. S. Guerman & D.P. Kniskern (Eds.), Handbook of family therapy. New York:
Brunner/Mazel.
Framo, J.L. (1982). Explorations in marital and family therapy: Selected papers of James L.
Framo. New York: Springer.
Framo, J. L. (1992). Family-of-origin therapy: An intergenerational approach. New York:
Brunner/Mazrel.
Framo, J. l., Weber, T. T., & Levine, F. B. (2003). Coming home again: A family of origin
consultation. New York: Brunner-Routledge.
Freud, A. (1936). The ego and mechanisms of defense. New York: International University
Press.
Freud, S. (1923). The ego and the id. (Standard Edition, Vol. 18). London: Hogarth Press.
Friedman, L. J. (1980). Integrating psychoanalytic object-relations understanding with family
systems intervention in couple therapy. In J. K. Pearce & L. J. Friedman (Eds.), Family
therapy: Combining psychodynamic and family systems approaches (pp. 63-79). New
York: Grune & Stratton.
Green, R. J., & Framo, J. L., (Eds.). (1982). Family therapy: Major contributions. New York:
International University Press.
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Greenberg, J. R., & Mitchell,S. (1983). Object relations and psychoanalytic theory.
Cambridge, MA: Harvard University Press.
Hamilton, N.G. (1989). A critical review of object relations theory. American Journal of
Psychiatry, 146(12), 1552-1560.
Hanson, J. T. (2000). Psychoanalysis and humanism: A review and critical examination of
integrationist efforts with some proposed resolutions. Journal of Counseling and
Development, 78, 21-28.
IIORT Faculty Positions. Retrieved July 26, 2006, from http://www.iiort.org/mission.htm
Kernberg, O. F. (1994). Internal world and external reality. Northvale, NJ: Jason Aronson.
(Original work published in 1980)
Klein, M. (1948). Contributions for psychoanalysis. 1921-1945. London: Hogarth.
Kohut, H. (1977). The restoration of the self. New York: International University Press.
Kramer, S. Z. (2001). In memory of James L. Framo. Newsletter of the American Family
Therapy Academy, (84). Retrieved from http://www.afta.org/newsletters.html
Mahler, M.S. (1968). On human symbiosis and the vicissitudes of individuation. Journal of
the American Psychoanalytic Association, 740-763.
Napier, A. Y., & Whitaker, C. A. (1978). The family crucible. New York: Harper & Row.
Nichols, W. G., (1984). Family therapy: Concepts and methods. New York: Gardener Press.
Scarf, M. (1995). Intimate worlds: Life inside the family. New York: Random House.
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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Object Relations Theory in Family Therapy 225

Scharff, D. E., & Scharff, J. S. (1987). Object relations family therapy. Northvale, NJ: Jason
Aronson.
Scharff, D. E. (1989). Transference, countertransference, and techniques in object relations
family therapy. In J. S. Scharff (Ed.), Foundations of object relations family therapy,
Northvale, NJ: Aronson.
Slipp, S. (1988). The technique and practice of object relations family therapy. Northvale,
NJ: Jason Aronson.
Winnicott, D. W. (1965). The maturational process and the facilitation of environment.
London: Hogarth.
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Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 In: The Quick Theory Reference Guide ISBN: 978-1-60021-624-4
Editor: Karin Jordan, pp. 227-236 © 2008 Nova Science Publishers, Inc.

Chapter 16

CONTEXTUAL FAMILY THERAPY

Elliot Klearman
Contextual Family Therapy (CFT) begins with a philosophy illuminating why humans
were created. It stretches into a model of individual, couples, and family therapy based on the
bedrock of healthy functional principles delineating how people are to live in relationship.
CFT is a profound and comprehensive theory which lends itself to reshaping human
relationships using the strengths of trust, fairness, and freedom (Hargrave & Pfitzer, 2003).

THEORY DESCRIPTION
CFT arose out of a philosophy and a way of life based on the idea that humans were
made for relationship (Buber, 1958). A model of therapy was birthed from this philosophy.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

The basic components of CFT begin with love, trust, and justice expressed by the give and
take of relationship (Boszormenyi-Nagy & Krasner, 1986). Intertwined with this idea is the
concept that a person’s health is shaped by the past, present, and continues in future
(Boszormenyi-Nagy & Krasner, 1986; Boszormenyi-Nagy & Spark, 1973; Hargrave &
Pfitzer, 2003; and van Heusden, van den Ferembeemdt & Boszormenyi-Nagy, 1983).
According to CFT, the essential construct of Love respects the vulnerability and total
dependency of children as they form crucial attachments to the significant caretaker or
caretakers. Thus, as a person grows, love helps form a person’s perspective in the context of
connectedness, warmth, passion, and sexual excitement (Hargrave & Pfitzer, 2003) Also, in
the context of interactions, love creates a foundation for friendship, enjoyment, assistance,
respect,acceptance, understanding, and admiration, which are basic elements needed for
friendship (Hargrave & Pfitzer, 2003).
Trust is another essential construct of CFT. When a person in a relationship has an innate
sense of justice, he or she demands a fair balance in what he or she is entitled to receive from
others in the relationship and what he or she is obligated to give (Hargrave & Pfitzer, 2003).
Trust occurs when this fair balance is maintained over a substantial period of time, creating
stability. Two elements of this stability are responsibility and reliability (Hargrave & Pfitzer,
2003).

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 228 Elliot Klearman

Another essential construct of CFT, alluded to in the description of trust, is described as

justice in the give and take of relationship, or Relational Ethics. Justice is fairness and the
balance of obligation (give) and merit (take). This can be illustrated in CFT by a bookkeeping
account ledger. On one side is merit or take, which is characterized by what an individual is
entitled to by way of respect, care, and intimacy. On the other side, obligation, or give, which
is characterized by what an individual is obliged to give in the way of respect, care, and
intimacy. A fair balance of give and take is described as relational justice (Hargrave and
Pfitzer, 2003).
In order to explore the constructs of Love, Trust, and Relational Ethics, four dimensions
of individual personhood are viewed. Facts, Individual Psychology, Systemic Interactions,
and Relational Ethics all describe the process through which Love, Trust, and Relational
Ethics are communicated ((Boszormenyi-Nagy & Krasner, 1986). CFT is built around the
premise that consequences flow from the way people relate, from person to person,
generation to generation,and from one system to its next successive system (Boszormenyi-
Nagy & Krasner, 1986).
The first dimension, Facts, includes genetic input, physical health, basic history, events in
an individual’s life and other basic objective information about the individual. The next
dimension, Individual Psychology, involves how an individual takes in and uses information
from his or her surroundings, then processes that information into beliefs, experiences,
emotions, feelings, and memories (Boszormenyi-Nagy & Krasner, 1986). The third
dimension, Systemic Interactions, involves the communication patterns within relationships.
It is based on the concept that the system is an entity, just as individuals in the system are
entities. The individual patternsof action and reaction concerning individuals in the system
influence the function of the total system. In this dimension, behaviors linked to the family of
origin are viewed, as well as patternsof communication and action within a relationship
(Hargrave & Pfitzer, 2003). The last dimension, Relational Ethics, deals with the balance of
what an individual in a relationship givesto the other as opposed to what he or she is entitled
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to get from the other. According to CFT, equal balance of give and take constitutes a healthy
aspect of the relationship (Boszormenyi-Nagy& Krasner, 1986).
There are many other concepts embedded within the broader concept of Relational
Ethics. These affect and intertwine with the broad concept. Also, the first three concepts of
Facts,Individual Psychology, and Systemic Interactions, all act upon and influence the last
concept of Relational Ethics. One concept embedded in Relational Ethics is Destructive
Entitlement (Boszormenyi-Nagy & Krasner, 1986). Imbalances in relationship, where the
caretaker takes much more respect, love, intimacy, nurture, and fidelity than he or she gives,
constitutes Destructive Entitlement. As the person who is the original victim in this kind of
relationship grows into adulthood, many times he or she becomes the victimizer. Revenge is
visited upon the next generation by the one who was the original victim, thus victimizing his
or her son or daughter in the same way, resulting in a cyclic dysfunction carried through
many generations(Boszormenyi-Nagy & Krasner, 1986). This consequence is referred to as a
Revolving State (Hargrave & Pfitzer, 2003). Goldenthal (2002) describes another kind of
Destructive Entitlement involving siblings. As one sibling takes from the other’s bank
account and does not deposit, the relationship can be stressed to the point where siblings stop
relating for years.
Also embedded within the broader concept of Relational Ethics is Loyalty, which can be
best defined as a preferential attachment to relational partners who are entitled to a priority of
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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Contextual Family Therapy 229

“bonding” (Boszormenyi-Nagy & Krasner, 1986). At a minimum, Loyalty is a triadic

relational configuration; including the preferring one, and the one who is not preferred
(Boszormenyi-Nagy & Krasner, 1986). Loyalty is powerful in relationship because it
proclaims an individual’s priority and, thereby, suggests an organization or a hierarchy of
how the individual will go about meeting obligations and receiving entitlements. Specifically,
Split Loyalty is a predicament that occurs when a child is forced to choose one parent’s love
at the cost of betraying his or her other parent (Boszormenyi-Nagy & Krasner, 1986). The
concept of Parentification is usually connected with Split Loyalty (Hargrave & Pfitzer, 2003).
Parentification describes an adult’s maneuver to turn a child into a functional “elder”, i.e.,
someone who takes more than age-appropriate responsibility for a relationship. In this
context, the child becomes the adult while the parent or caregiver becomes the child
(Hargrave & Pfitzer, 2003).
The first component of Relational Ethics is love, originally described by Buber (1958),
where “I” and “Thou” were explained. I, meaning the Self, was made for relationship with
Thou, meaning the Other. The second component, trust, is based on the premise the inner
structure of close relationship is based on trust (Boszormenyi-Nagy & Krasner, 1986, pp. 74-
75). The third component, justice, according to van Heusden and van den Eerenbeemt (1987),
relates to long term fairness, and is the foundation of trustworthiness in relationships. Also, it
concerns “give and take”. Embedded in this concept of “give and take” is another concept of
“ledgers”. Each person in a two person relationship has a “ledger”. On one side of the ledger
is the word, “give”. On the other side is the word, “take”. In a two person relationship the
interaction consists of one person giving love and trust with the other person giving an equal
amount of love and trust. The ledgers are balanced, and the entitlement for each person has
been met in a constructive way (Boszormenyi-Nagy & Spark, 1973).

KEY CONCEPTS
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Nature of Persons

Theory. CFT arises out of a philosophy that humans are designed for the purpose of
relationship (Buber, 1958). Boszormenyi-Nagy states throughout his books that man was
meant for relationship (Boszormenyi-Nagy & Krasner, 1986; Boszormenyi-Nagy & Spark,
1973; & van Heusden & van den Eerenbeemt, 1987). This relationship, as stated by numerous
authors espousing CFT (Boszormenyi-Nagy & Krasner, 1986; Boszormenyi-Nagy & Spark,
1973; & van Heusden, van den Eerenbeemt, & Boszormenyi-Nagy,1987) must be grounded
in love, trust, and justice.
As a person grows, he or she must have unconditional love and nurture as the foundation
upon which to build healthy attachments. The person needs connectedness and warmth within
the caretaker relationship (Boszormenyi-Nagy & Krasner, 1986). From that loving care
comes feelings of respect, acceptance, understanding, admiration, assistance, and enjoyment.
Ongoing nurture, love, respect, care, and intimacy, facilitate trust in the relationship. As the
balance of give and take in these areas of relationship continues to be fair and just, healthy
relationship is produced and continued (Boszormenyi-Nagy & Krasner, 1986).

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 230 Elliot Klearman

Healthy vs. Unhealthy/Dysfunctional Functioning

CFT is built around the premise that consequences flow from the way people relate, from
person to person, generation to generation, and from one system to its successive system
(Boszormenyi-Nagy & Krasner, 1986). Healthy or unhealthy functioning is characterized by
the balance of what an individual in a relationship gives to the other as opposed to what he or
she is entitled to get from the other. Equal balance of give and take creates healthy
functioning. When unequal balance of give and take occurs, a dysfunction emerges
(Boszormenyi-Nagy & Krasner, 1986).
Specifically, healthy or unhealthy functioning is characterized by the way the three key
premises of love, trust, and justice are met. When children are deprived of nurture and love as
they grow, unhealthy relational functioning results and is carried from one generation to the
next. When respect, care, and intimacy are not given and received in balance, dysfunction
results. When trust is not a part of the relationship, or has been abused in a relationship,
dysfunction results. When healthy relational justice in give and take is not adhered to,
dysfunction results. The language for dysfunction within Relational Ethics includes the
following names; Destructive Entitlement, Split Loyalty, Revolving Slate, Parentification,
Mistrust, and Relational Injustice Concerning Give and Take (see pp. 3-4).

The Change Process

Two principles are the foundation for the change process. First, the change process
cannot take place unless an individual sees a need for change (Corey & Corey, 2003). Second,
no individual can effect change in another individual (Martin, 1983).
Systems interaction creates change. When one individual in a system comes to the
realization he or she needs to change in his or her perceptions of thoughts, feelings, emotions,
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

or behavior, and proceeds to do so, this sets off a chain reaction in which others in the system
react in different ways to the changed action of the first person. To illustrate this
conceptualization, this set of interactions is likened to a ping pong game where the players
begin by hitting the ping pong ball the same way back and forth. When one of the players
decides to hit the ball at a different angle, the other player hits the ball back in a completely
different way at another angle. Thus, the game strategies change completely each time a
player changes the angle of the ball.
Conceptualizing change can also involve stress as seen from a contextual view. Boss
(2002) defines stress as change. According to Boss (2002), when a stressor event takes place,
the family changes in response to the stressor in either a positive or negative way. The
interventions used in the change process involve looking through the lens of the Contextual
Model of Family Stress (Boss, 2002). This involves the external context, comprised of
culture, history, economy, development, and heredity. These are classified as objectifiable
facts. This lens also involves the internal context, which is comprised of the structure of the
family, individual psychological factors, and the family’s value system or philosophical
outlook (Boss, 2002).
Using Ruben Hill’s (Boss, 2002) ABC-X model of family stress as a heuristic model,
Boss (2002) joins the external context and the internal context to give a model of stress
management. or, as she defines stress, change management. Boss (2002) demonstrates the
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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Contextual Family Therapy 231

change process as the stressor event, the family’s perceptions of the stressor event, and the
family’s resources, interacting together with the internal and external context to produce a
varying degree of stress, or crisis. The degree of stress becomes the degree of change, which
is either positive or negative. Crisis occurs when the degree of stress reaches a point where
the disturbance in the family equilibrium is so overwhelming, severe, or acute, that the family
system is blocked, immobilize3d, and incapacitated (Boss, 2002.)
Individual Psychology also creates change. This lens involves a view through the
foundations of Motivational Interviewing, where change occurs in a stage related way
(Prochaska & Norcross, 1999). There are five stages involved: (1) Precontemplation, (2)
Contemplation, (3) Preparation, (4) Action, and (5) Maintenance. Using this view of change
in conjunction with substance dependence, alcohol dependence, or any other addiction, there
is a sixth stage known as (6) Relapse. (Prochaska & Norcross, 1999). This view of change is
not specifically outlined in CFT, but may be easily integrated.
The first stage is Precontemplation. At this stage an individual does not feel he or she has
a problem. He or she sees others actions or reactions to his or her thoughts, feelings, and
behavior as the problem. At this stage, the individual does not see a need for change. The
second stage, Contemplation, occurs when an individual becomes aware of his or her
dysfunction and the pain or discomfort caused by that dysfunction. The third stage,
Preparation, begins when discomfort and pain intensify the view of dysfunction, and the
individual gets ready to do something to change the state of dysfunction. The fourth stage,
Action, occurs when the individual does something to foster change. The individual might act
to understand unhealthy thinking processes and change those processes. As the thinking
processes are changed, the individual changes his or her behavior. The fifth stage is called
Maintenance. This stage involves the maintenance of the new behavior so that healthy
function occurs (Prochaska & Norcross, 1999).
This stage related process of change can also be viewed in a contextual manner, where a
person’s motivational context determines in what stage of change he or she resides. In the
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Precontemplation stage, the person’s motivational level is low or known. He or she sees no
need to change. As the person realizes there is a problem, his or her motivational context
changes from low to none to some awareness of the need for change. There is some change
from no consideration of the problem to some awareness of problem. Thus, the person
migrates to the Contemplation stage. The person’s motivational context changes again as pain
and discomfortintensify consideration of the problem. This intensity starts the person toward
the third stage of Preparation. The person’s motivational context again changes as he or she
progresses to the next stage, where Action occurs so that major change is fostered.
Maintenance involves the person changing motivational context so that he or she is motivated
to prolong and continue the new behavior (Prochaska & Norcross, 1999).

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 232 Elliot Klearman

THE THERAPEUTIC PROCESS

Assessment and Diagnosis

Theory Based Assessment Strategy

There is a purpose for assessment in any mode of treatment. That is to use all safe,
effective, and non-harmful means within the therapist’s level of competency to find out what
areas of relational interaction need to be addressed and/or changed in order to help the client
effect a healthier, more functional relationship. Thus, the therapistusing assessment is able to
craft interventions to help the client obtain a more satisfying and productive life within the
boundaries of society’s laws and moral codes. This author believes relationship embodies the
purpose for which humans were created. The contexts in which relationship takes place define
whether that relationship is healthy or unhealthy. Assessment should be designed to help
clients strengthen their abilities to relate to others in healthier ways.
One of the most important tools which can be used as an adjunct for assessment and
diagnosis is the Diagnostic and Statistical Manual of Mental Disorders, 4th Ed., Text
Revision, 2002 (DSM-IV-TR, American Psychiatric Association, 2002). One function is
providing mental health providers a way to categorize mental health disorders. This allows
the therapist, as he or she looks at constellations of symptoms, to recognize what disorder is
evident and to pick the best means of treating that disorder4. Another function of the DSM-
IV-TR (2002) is to provide a common language and way of classifying disorders by symptom
constellation so that each provider can understand other providers as they provide information
to one another. The DSM-IV-TR (2002) also enables mental health providers to supply
insurance payers information for payment of services. The DSM-IV-TR (2002) additionally
informs the treatment process by allowing the provider to better assess the client and
categorize the assessment in an understandable and meaningful way, and allows the provider
to judge which mode of therapy orwhat interventions will be more efficacious. Since mental
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

health disorders affect the way persons relate to one another in all domains of CFT, this
adjunctive tool can greatly enhance the therapists ability to understand what areas of
relational interaction need to be addressed.

Theory-based Assessment Strategy

Evaluation of the facts and their consequences is in order. using these facts, the therapist
can help people develop remedial and reparative options. Assessment of facts, as they are
reported in a comprehensive intake form and conversation in session, can yield important
therapeutic options even though certain factual circumstances are irreversible by nature.
Moreover, their consequences may be mitigated by an affected person’s option for action
(Boszormenyi-Nagy & Krasner, 1986).
In the dimension of Individual Psychology, the contextual approach views self-validation
via personal responsibility in relationships as the most significant criterion of individuation
and differentiation (Krasner & Joyce, 1995). The therapist should make a full assessment
using observation, appropriate trait and personality inventories, and an Initial Biopsychosocial
Inventory (Barbur, 1997). These assessment tools allow the therapist to understand how the
client constructs ideas about him or herself and actions toward the environment. They give

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Contextual Family Therapy 233

the therapist the ability to focus on the causes of behaviors and to view symptomology in
terms of responses to violations of love and trust.
In the dimension of Systems Interactions, the therapist must assess, using observation and
conversation in session, information from the intake form, genogram, and timeline, those that
are based in complex balances of fairness in relationship. Using Multidirected Partiality as an
intervention allows the therapist to assess the patterns of relational dialogue affected by
ethical concern. Multidirected Partiality is a n attitude and technique of understanding and
crediting all relational parties for the different concerns, efforts, and impacts of what people
have done in relationships and what has been done to them. It may be described as a
sequential siding with and recognition of the story of each family member and is not
neutrality or impartiality (Goldenthal, 1996). The question becomes, “How can therapists help
couples establish effective patterns of cooperation for themselves and their children
(Boszormenyi-Nagy & Krasner, 1986, p. 171).”
The dynamics of fairness, reliability, and trustworthiness are primary. Assessment in
these areas is made by the therapist, using a comprehensive intake form, observation of
dynamics of interrelationship between family members, and conversation and observation
between therapist and each family member in session. A redistribution of credits, benefits,
and burdens comes next.The therapist can use family clues and draw out implications within a
strictly psychological or transactional framework, or he or she can choose to incorporate the
ethical plane as well. The therapist must use multidirected partiality and be open to questions
of fairness between parent and child or between husband and wife (Boszormenyi-Nagy &
Krasner, 1986).

Goals of Therapy according to CFT

Goals of therapy are involved with the concept of relational ethics. They are based on the
premise that, if love, trust, and ethical justice are exchanged in fairly equal amount in a
relationship, the relationship will be functional and healthy. Therefore, the primary goal of
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

therapy is to help the clients adjust these qualities and characteristics in the relationship in
such a way as to balance the give and take in these areas.
Enclosed within these broad goals are a number of narrower goals which, when
addressed, help the client to reach the broader goals. One is Exoneration, which means
recognition that there is no clearing from guilt of the self without the exculpation of the other
(cited in Boszormenyi-Nagy & Spark, 1973, p. 95). It means “lifting the burden of culpability
that crushes and fragments life in common” (cited in Boszormenyi-Nagy & Spark, 1974, p.
95).
Another narrower goal which, when addressed, helps the client reach the broader goals, is
Differentiation. This concept involves the ability of a person to be an individual while, at the
same time, respecting the needs of his or her partner. As the therapist is able to help members
in a relationship strengthen the ability to balance individual/togetherness needs in a
relationship, the clients are able to gain clear boundaries while choosing to give of themselves
to relational intimacy. This balance, differentiating, is also viewed as a primary
goal.(Hargrave, 1994).

Therapeutic Process: Detail Phases of Treatment

The phases of treatment consist of Assessment of Facts, Individual Psychology, Systems
Interactions, and Relational Ethics. After these dimensions are assessed and a collaborative
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 234 Elliot Klearman

treatment plan is formulated to address areas of dysfunction within these areas, the therapist
begins to address each area of dysfunction. Sometimes areas overlap, so the work in each area
does not necessarily occur in stages. However, the therapist formulates interventions designed
to address each area of dysfunction. As healthy function is restored, the clients become more
functional and healthy in a relational context. When all work is done, within one’s
capabilities, termination begins. Since termination is a process, the therapist should be
thinking, planning, and talking about this phase from the first session until the last session.
The client should be prepared for this phase long before he orshe reaches it (Goldenthal,
1993).

Common Intervention Strategies

In CFT there are a variety of interventions, but only some of the most important
interventions are described. One of the most important intervention strategies is (1)
Multidirected Partiality (Goldenthal, 1993), which refers to the therapist working hard to see
a situation form the perspective of each of the individuals who are likely to be affected by the
course of therapy. This typically includes parents, separated spouses and potentially, children
and grandchildren. Another intervention, (2) Giving Room, is about giving opportunities for
all family members to earn credit and build up constructive entitlement by considerate giving
(Goldenthal, 1993). Lending Weight (3) is another intervention the therapistutilizes by
lending his or her weight to the side on one person or another. In the case of marital therapy,
this may be the person who will be more capable of stating his or her side with the therapist’s
assistance (Goldenthal, 1993). Exoneration (4) is described as an intervention in which the
client works to understand his or her parents and their developmental contexts, thus accepting
others, including one’s shortcomings (Goldenthal, 1993). These four interventions arepeculiar
to CFT, and can affect the give and take and the building of trust in relationship (Goldenthal,
1993).
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Nature of the Therapeutic Relationship

The nature of the therapeutic relationship should be one where the therapist engenders
trust. The therapeutic alliance depends on the therapist placing clients at ease where they feel
they are in a safe place with a professional who will act with the utmost honesty, integrity,
and care. The client should feel that the therapist is well trained, prepared, and capable. Also,
the client should also feel the room where therapy takes place is special where he or she is
honored and where the space of therapy is sacred. In CFT, emphasis is placed on love, trust,
and ethical justice. Therefore, the therapist must display all of these characteristics in order to
be able to model healthy functional behavior to the client.

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 Contextual Family Therapy 235

STRENGTHS AND LIMITS

Strengths

CFT has a variety of strengths that have been well documented. First, the contextual
approach is profound and offers a comprehensive theory integrating and balancing concerns
of individuality and togetherness (Hargrave & Pfitzer, 2003). Second, CFT emphasizes the
importance of understanding how harm which has befallen individuals in the past an lead to a
reliance on destructive entitlement and to a tendency to parentify others, especially children
(Goldenthal, 1993). Third, this approach also emphasizes the importance of helping people to
identify and uses resources for giving and receiving in their families (Goldenthal, 1993).
Fourth, this approach focuses on resources rather than pathology, on acknowledgement rather
than blame, and on future possibilities rather than past errors (Goldenthal, 1993). As the
clinician capitalizes on these strengths, CFT offers real solutions to both families and the
global community (Hargrave & Pfitzer, 2003).
There are some limitations when using CFT, although the strengths far outweigh the
limitations. One limitation is that, because of the philosophical underpinnings of this model, it
has gone unnoticed by many psychotherapists and mental health workers. Perhaps this is due
to the confusion about the language definition and philosophy behind this type of therapy
(Hargrave and Pfitzer, 2003, p. 3). A second limitation is that the terminology of the
interactions may restrict students of therapy rather than invite them into the therapeutic
dialogue (Hargrave & Pfitzer, 2003). The underpinnings of this statement lie in the
understanding that students of therapy have been aware of the CFT approach as an important
addition to the literature, but are somewhat confused about the language, definition, and
philosophy behind this type of therapy. It is as if people know CFT has something important,
even profound, to say about individuals and relationships, but they are not quite sure what
that something is all about (Hargrave & Pfitzer, 2003, p. 3). A third stated limitation by some
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who view themselves as more “purely” systemic in their thinking criticizes Boszormenyi-
Nagy’s work because he integrated psychodynamic object relations thinking with systems
formulations (Goldenthal, 1993, p. 2-3). Hoffman (1981) for example, criticizes the
contextual approach for incorporating psychodynamic thinking and for being” historical” and
“linear” in contrast to “those who made a sharper break with the therapeutic establishment;
the ecological, structural, strategic, and systemic schools” (p.255). Although there are some
limitations, CFT is a powerful tool for reshaping human relationships (Hargrave & Pfitzer,
2003).

CONCLUSION
CFT is built on the foundational relational philosophy that humans are designed for
relationship. As this philosophy is examined, three aspects of relationship are revealed as
instrumental in determination of functional versus dysfunctional relationship. These three
aspects of relationship are Love, Trust, and the Justice of Give and Take in relationship. As
they are explored, the domains of Objective Facts, Individual Psychology, Systems
Interactions, and Relational Ethics become key areas of assessment. Objective Facts,

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 236 Elliot Klearman

Individual Psychology, and Systems Interactions feed into the more prominent area of
Relational Ethics.
As the clinician and family explore the three aspects of relationship, and information is
gained from assessment of Objectifiable Facts, Individual Psychology, System Interactions,
and Relational Ethics, a number of interventions may be crafted using this information by the
therapist to encourage change. Among these are (1) Multidirected Partiality, (2 Giving Room,
(3) Lending Weight, and (4) Exoneration. Interventions from other models of therapy can be
easily integrated into use with CFT, allowing more useful and creative intervention styles.

REFERENCES
American Psychiatric Association (2002). Diagnostic and statistical manual of mental
disorders, 4th ed.; text revision. Washington, DC; American Psychiatric Association
Barber, P. (1997). Initial biopsychosocial assessment inventory. Portland, OR: Peter Barbur.
Unpublished.
Boss, P. (2002). Family stress management: A contextual approach, 2nd ed. Thousand Oaks,
CA: Sage Publications.
Boszormenyi-Nagy, I., & Krasner, B. R. (1986). Between give and take: A clinical guide to
contextual therapy. Bristol, PA: Brunner/Mazel Publishers.
Boszormenyi-Nagy, I., & Spark, G. M. (1973). Invisible loyalties. New York: Harper and
Row Publishers.
Buber, M. (1958). I and thou, 2nd ed. (Smith, R. G. Trans.) New York, NY: Charles Scribner.
Corey, C. S., & Corey, G. (2003). Becoming a helper, 4th ed. Pacific Grove, CA:
Brooks/Cole.
Goldenthal, P. (1993). Contextual family therapy: Assessment and intervention procedures.
Sarasota, FL: Professional Resource Press.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Goldenthal, P. (2002). Why can’t we get along? New York, NY: John Wiley and Sons, Inc.
Hargrave, T. D. (1994) Families and forgiveness: Healing wounds in the intergenerational
family. Levittown, PA: Brunner/Mazel Publishers.
Hargrave, T. D., & Pfitzer, F. (2003). The new contextual therapy. New York, NY: Brunner-
Rutledge.
Hoffman, L. (1981). Foundations of family therapy: A conceptual framework for systems
change. New York, NY: Basic Books.
Krasner, B. R., & Joyce, A. J. (1995). Truth, trust, and relationships: Healing interventions in
contextual therapy. New York, NY:Brunner/Mazel Publishers.
Martin, D. G. (1983). Counseling and therapy skills, 2nd ed. Prospect Heights, IL: Waveland
Press, Inc.
Prochaska, J. O., & Norcross, J. C.(1999). Systems of psychotherapy: A transtheoretical
analysis. Pacific Grove, CA: Brooks/Cole Publishing Co.
van Heusden, A., & van den Eerenbeemt, E. (1987). Balance in motion. New York:
Brunner/Mazel Publishers.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 In: The Quick Theory Reference Guide ISBN: 978-1-60021-624-4
Editor: Karin Jordan, pp. 237-249 © 2008 Nova Science Publishers, Inc.

Chapter 17

TRANSGENERATIONAL FAMILY THERAPY THEORIES

Thorana S. Nelson

Transgenerational theories in family therapy have been a part of the backbone of the field
of marriage and family therapy from its inception. Developed in disparate parts of the world,
each brings its own perspective to the importance that family dynamics in the past bear on
individual, couple, and family functioning in the present. Most were developed by
psychiatrists who were trained in various psychodynamic models of thinking and therapy and
who found limitations in this way of working. Finding that a sole focus on intrapsychic
functioning was insufficient to either understanding current concerns or to helping people
change, these theorists discovered in various ways that family patterns of interaction,
intergenerational themes, and unresolved issues in families of origin were critical components
of the context of present functioning and meaning.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Key figures discussed in this chapter include Murray Bowen (Bowen Family Systems
theory; 1978), Ivan Boszormenyi-Nagy (Contextual Family Therapy; e.g., Boszormenyi-Nagy
& Sparks, 1973}), and James Framo (1982). Carl Whitaker’s theory (Napier & Whitaker,
1978) sometimes is considered a transgenerational model because of its focus on multiple
generations in both ideas of how problems develop and how they can be resolved. Whitaker’s
ideas are discussed in Chapter 18 on Experiential Family Therapy.
In one way or another, all of the transgenerational models suggest that family dynamics
from the past form a context in which values, beliefs, myths, and ways of interacting have
powerful impact on present and future functioning. Because family is typically the most
important context of early life and later serves as a way of interpreting events, we tend to hold
onto early training in subtle and sometimes insidious ways, using this training as a lens
through which all experience is perceived, interpreted, and responded to. This training can be
both a resource and a source of dysfunction or difficulty.

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 238 Thorana S. Nelson

KEY CONCEPTS
Transgenerational theories tend to describe human nature as growing out of a
combination of nature and nurture. That is, we are handed certain characteristics and
vulnerabilities through genetics. Boszormeny-Nagy (1973) calls these “facts.” However, in
terms of psychological functioning and human interaction, the theories focus on
psychological functioning and family dynamics as forming the context and training for
behavior, beliefs, cognitive functioning, and emotional experience. As children, we learn how
the world is and how it is supposed to be from the “soup” of the family in which we swim.
We are indoctrinated, so to speak, and develop perspectives that influence what we believe
about thinking and interaction. Much of this training becomes integrated and invisible,
rendering certain beliefs and reactions automatic. The theories also suggest, however, that
examining these dynamics and beliefs can help people determine what they think and believe
for themselves. This process includes making decisions and engaging in actions anew that
lead to changes in beliefs, behaviors, emotions, and relationships.

Philosophical Underpinnings

Because these theories were formulated by people who were trained in psychiatry and
psychodynamic ideas, they tend to include strong doses of intrapsychic functioning, thinking,
and individual decision making. This is tempered, however, by understanding how early
family experiences influence both psychological functioning and interpersonal dynamics.
Systemic understanding of how the interplay of individual dynamics of two or more people in
relationships provides a backdrop and sometimes a foreground of how two people come to
understand each other, form beliefs about both the other and how the relationship should be,
and how they then interact with each other. For example, a person who learned about
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

relationships from an abusive father may integrate the abusive nature in a defensive reaction
that makes that person very sensitive to anything that might even remotely resemble abuse or
mistreatment. Another person from a background of family debating and lively conversation
that sometimes includes strong language or tone might provoke defensive reactions in the first
person, leading to withdrawal from the relationship. The second person, not having
experienced withdrawal in conversation, might become confused by this behavior and attempt
to engage through even faster or louder conversation, further frightening the first person.
Intergenerational theorists, through experience and exposure to systems thinking moved
beyond psychodynamic understandings of human functioning and believed that analysis –
uncovering and understanding early influences – was insufficient when working toward
change. Clients (or “patients” as they are commonly called) benefit from insight into this
material. However, in order to make desired changes, they must also understand how these
psychological factors interact with others’ psychology and behavior, and make moves to
change present interactions in order to improve both those relationships and their own
psychological functioning in recursive or systemic fashion.

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Transgenerational Family Therapy Theories 239

Healthy vs. Unhealthy/Dysfunctional Behavior

Healthy functioning from transgenerational perspectives is evident through an ability to

separate thinking from emotional functioning (Bowen, 1978); to consider a complex dynamic
of legacies, loyalties, debts, and entitlements (Boszormenyi-Nagy, 1973) as they affect both
present relationships as well as future generations; and to understand how internalized objects
influence inter-relational perceptions and behavior (Framo, 1982) and to continuously work to
separate other from family members. That is, a healthy person is able to separate past from
present, to separate emotional and thinking functioning, to think for self, and to interact in
relationships in ways that clearly separate others from family members. According to
Boszormenyi-Nagy, healthy functioning also requires a sense that who one is and what one
does affects future generations and that we must behave in relationships in fair and just ways
as an ethical imperative.
Transgenerational theorists seldom discussed healthy functioning as something that just
happens. When it does, however, it comes from families that also function well and pass those
abilities on to their children and future generations. These families teach independence of
thinking and interdependence of relating in reciprocal actions of fairness, respect, and
affection.
When people are not trained in healthy families, they are prone to develop difficulties
that hamper functioning, lead to all sorts of mental, emotional, behavioral, and interpersonal
problems, and typically require therapy to help them find their ways into healthy functioning.
Therapy can help bring insight into family dynamics that affect current functioning and help
people make different decisions about how they perceive things, think, and act in
relationships. Healthy functioning is maintained by practice in terms of new ways of thinking
and behaving.
From a transgenerational viewpoint, dysfunction is seen as a result of faulty family
functioning. Ineffective patterns of coping and interacting are transmitted through processes
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

that Bowen (1978) calls the nuclear family process. We tend to be given or take on roles in
families that we carry into other relationships. We observe good and bad modeling in our
families that lead to beliefs about relationships and to actions that tend to perpetuate those
beliefs.

Bowen Family Systems Theory

According to Bowen (1978), an inability to think for self (lack of self differentiation)
leads to tendencies to please others, to give in to their ideas and requests, and to be
emotionally reactive and anxious. This reactivity comes out in every day behavior, but mostly
in situations where tension is high and emotions tend to be prevalent. The undifferentiated
person is unable to think for self and make rational decisions about behavior and tends to
respond in automatic, often unproductive ways. An example is someone who is faced with a
situation that results in anger. Everyone gets angry. However, the undifferentiated person is
more likely to lash out and do something that he or she will later regret.
According to Bowen, function or dysfunction is a continuum. That is, even the most
differentiated person is likely to be reactive with enough stress. However, this person is likely
to be less vulnerable and, if dysfunctional behavior appears, it is likely to be short-lived.
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 240 Thorana S. Nelson

Functioning under stress in relationships takes on four different patterns: withdrawal,

symptom, conflict, or triangling.
Withdrawal, in mild forms takes the form of “time out.” It is temporary and carries no
tones of hurt, anger, or disgust. Rather, it allows the person to calm down and think more
rationally. The person is then able to return to the relationship, either deciding that the issue is
not problematic (really letting it go) or more able to discuss it. In extreme forms, withdrawal
leads to divorce or cutting off from the relationship.
Symptoms can take a form of psychological, physical, or social impairments. Examples
include depression, headaches, or acting out in public. In mild forms, this mean temporary
“blues,” mild physical ailments that go away quickly, or saying something inappropriate. In
extreme forms, symptoms can take the form of psychoses, cancer and heart failure, or doing
something illegal such as abusing drugs.
Conflict also can be seen along a continuum of mild to extreme. Mild forms are
disagreeing but resolving the dispute. Extreme forms include homicide and war.
Finally, triangling involves a process wherein two people in an unstable relationship
involve a third person or activity as a way of focusing attention elsewhere and stabilizing the
relationship. All relationships have times of instability in oscillating fashion; Bowen (1978)
would say that relationships are seldom stable. Mild forms of triangling, like the other
“dysfunctions” can actually be helpful to relationships. This can include a common interest or
asking for help from a mediator, clergy, or therapist. If that person can maintain their own
differentiation of self and stay calm but outside the relationship, the focus of the anxiety can
remain with the couple and they can resolve the difficulty.
Sometimes, triangling becomes extreme, however, and may focus on a child. One or
another partner may attempt to bring a child into the relationship as an ally, siding with a
parent to the detriment of their own stability and functioning. Being the third person in such a
triangle feels good because of its special function and can be very appealing. However, once
the dyad resolves the issue or returns to a more moderate level of anxiety, the third person
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

becomes “outside” and may have difficulty with this position and act out as a way of
regaining the special position. For example, children often are triangled during divorce. Mom
or dad may treat one of the children in a special way as a confidant or witness to the distress.
That child takes on a special role in the family. However, once the role is not needed, the
child is left without the sense of being special and may develop his or her own physical,
emotional, or behavioral symptom as a way of regaining the special position. The child who
used to be special to mom and who now perceives herself cast aside when the mother
develops post-divorce interests, finds herself in an unstable relationship with her mother and
may develop her own triangle by accusing the mother of being abusive, “tattling” to the father
about the mother’s new interests, or even worse, using drugs, doing poorly in school, or
otherwise engaging in risky behavior. Bowen believed that children’s problems were an
indication of triangling in the parents’ relationship and that even couples’ problems were a
part of triangles in families of origin.
As stated, none of the coping mechanisms for dealing with anxiety are bad in and of
themselves. Rather, when one is used to the exclusion of others or when they take on extreme
forms, they are indications of dysfunction and a need for intervention.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Transgenerational Family Therapy Theories 241

Contextual Family Theory

Nagy, as he often is referred to, suggested that dysfunction is a result of misplaced

loyalties, destructive entitlement, and legacies of imbalanced ledgers of relational debts and
entitlements that lead to attempts to balance them through self and other-destructive behavior.
Loyalties refer to the tendency of people to remain loyal to parents and family themes even
when they do not work for an individual or are destructive to relationships. It may seem
paradoxical or perverse, but this idea explains how children who have been abused by parents
still prefer to live with them. Even children who have been adopted and have a sense of being
abandoned maintain some sense of loyalty to their birth parents for bringing them life.
Destructive entitlements refer to the ways that people attempt to balance their ledgers by
developing fairness and justice in relationships in negative ways. These also seem perverse
except when viewed from the perspective of the individual. Each of us is entitled to certain
care when we are born and, when denied this care, develop entitlements. Entitlements in
healthy families are paid forward by being kind to others and to future generations.
Destructive entitlements are ways of getting “paid back” by asserting one’s entitlement to the
detriment of others. This also can take the form of a revolving slate and asserting loyalty to a
parent by acting out their entitlements also. What some people see as modeling, e.g., a child
whose father stole cars also breaking the law and hurting other people, is, from this
perspective, a way of showing allegiance and loyalty to the father. Legacies also can be
destructive when they come out of imbalanced ledgers of care and consideration. For
example, children who take on the profession of many generations in a family may do so out
of a sense of an invisible loyalty rather than desire. In this case, the child’s needs were not
met and, as an adult, the child attempts to gain the good graces of the parents by doing what
engaging in what s/he believes is the “family thing to do,” or, conversely, escaping the legacy
by failing.
As with Bowen Family Systems Theory, none of the behaviors are necessarily inherently
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

bad. Rather, we all are constantly engaging in relationships of “give and take,” managing
ourselves and current relationships in the shadow of our families of origin, and doing our best
to be ethical in our relationships and fair to others while, at the same time, getting our own
needs met. Difficulty comes when the ledger is not balanced over time, legacies are not open
to discussion and difference, and debts are continually paid in ways that are destructive to self
or others.

Framo

James Framo (1982) used a psychodynamic theory called object relations (Slipp, 1984)
to explain functioning, particularly in couples’ relationships. In this way of thinking, we
internalize both good and bad aspects of our primary caregivers, but tend to “split,”
developing patterns of seeing others in ways that were necessary as a child for getting needs
met. Other aspects of the self or parent are suppressed, but nevertheless internalized as
introjects. Then, as we develop relationships outside the family, we tend to evoke patterns
that are familiar, projecting the introjects onto others, who, because of their own object
relations, tend to cooperate by showing characteristics of these introjects (called projective
identification). We thus develop superficial relationships that are based in one-dimensional
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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 242 Thorana S. Nelson

senses of our parents. Disagreements tend to come about because people are relating to each
other through limited lenses of each other, rather than understanding the other as a complex
person in their own right, separate from introjects and projections.

THE CHANGE PROCESS

In Bowen’s family systems theory, change occurs as individuals are able to differentiate
themselves from their families of origin and differentiate thoughts from feelings.
Differentiation does not mean that people no longer are connected to their families or that
they don’t respect the ideas and feelings of others. On the contrary, a well-differentiated
person is quite connected or intimate with her family, but also is able to maintain a strong
sense of autonomy and is able to make decisions based on many factors, including the
family’s ideas. However, these ideas do not rule an individual’s decisions and, instead, are
part of the whole mix. Such a person also is able to distinguish between his thoughts and
feelings or emotions and is less reactive in situations of emotional stress. We tend to be pulled
back into our families’ ways of thinking and doing things when we are with them. However a
person who has resolved differentiation issues, who is aware of her feelings but is not ruled
by them, is more able to stay out of family triangles but, at the same time, maintain close
connections. Such a person might say to his mother, “that’s a good idea, mom, and I’ll take it
into consideration.” This person most likely was able to take actions in the family that
allowed detriangling and, at the same time, learned how to distinguish thoughts from feelings.
The two processes go together, with each influencing increasing differentiation in the other in
reciprocal fashion.
In Nagy’s theory, change occurs as people are able to examine the complex web of felt
debts, entitlements, legacies, and loyalties. As the web becomes untangled, people are able to
make decisions from a vantage point of looking at many factors of fairness and justice,
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

considering the needs of all, including themselves, before making decisions to act. Change
takes place in therapy through examining extended family patterns of interaction,
distinguishing debts and entitlements, owning one’s own responsibilities in life, and taking
action to both exonerate (understand and forgive) parents and others from the past and, at the
same time, rectify present relationships in movement toward balanced interactions.
Both models involve action, described more fully below, and also require insight and
rational thought in the process of making decisions, acting with others differently, and using
the results of these actions to develop new actions or continue with others. The recursive
process is lengthy in both models and requires much examination and re-examination of
family and self.
Framo’s model of change is similar in that it requires re-examination of family of origin
dynamics to uncover new meanings and new awareness. Framo’s thinking, however, suggests
that change is most likely going to occur through conversation with parents and siblings,
learning more about them as whole human beings rather than through introjects that were
limiting. For example, it is not uncommon for people to be able to describe each parent in one
word or short-phrase ways, as in, “she was controlling.” What this person is not seeing is the
reasons for the “controlling” behavior or, more importantly, the aspects of the mother’s
personality that did not become part of the description. She may also have been generous, for

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Transgenerational Family Therapy Theories 243

example, a softer and more positive construction. Understanding this complexity then leads to
new perspectives of people in current relationships and, thus, new ways of relating to them.

THERAPEUTIC ENVIRONMENT
In Bowen’s theory, the therapeutic environment requires a therapist who has worked on
his or her own differentiation of self. Bowen strongly believed that the therapist is the agent
of change and that clients cannot differentiate to higher levels than the therapist. The
differentiated therapist is able to maintain calmness, even in the face of heated discussion.
However, the most important aspect of this role is that the therapist is able to help people talk
about their issues in calm ways. To accomplish this, keeping anxiety low, requires that the
clients talk with the therapist. By talking to the therapist rather than each other, clients are
able to avoid anxious emotional engagement and to remain calm, allowing the therapist to
help guide or coach them into new ways of thinking about their families of origin and each
other. Thus, the atmosphere in the therapy room is one of calmness and conversation with the
therapist. Allowing anxiety to go unchecked would mean that emotions were flooding the
clients, rendering them unable to think about the situation, what each other is saying, and
making rational decisions about change.
Nagy’s theory also calls for calmness, but less deliberately so than Bowen’s theory. In
this model, the therapist teaches the concepts to the clients and then leads them in discussions
about their families of origin. Interaction between partners in a couple is seldom requested
except as one might be able to help the other by shedding light on some family interaction or
another. The interaction is very intellectual and focuses on emotional aspects of life as objects
of discussion rather than feelings. This then leads to decisions about actions, requiring an
atmosphere of trust in the therapist so that different options may be carefully considered.
Framo’s therapy room is likely to be rather calm and intellectual in the initial stages as
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

couples (sometimes in couples groups) discuss issues and factors about families in an
atmosphere of discovery. Emotions in these settings are likely to be controlled in favor of
talking about things rather than experiencing them. Later, Framo would encourage couples to
invite their parents and siblings into sessions to confront stereotypes and discuss old feelings.
These sessions were more likely to be lively and emotional, even confrontive, although
controlled by the therapist. The therapist would not believe that intensity would be required
for change. Rather, controlled intensity may lead to change by breaking through stereotypes
and reproachment into understanding of whole persons and forgiveness for past perceived and
real hurts. This then frees clients to be their own persons and to interact with their partners as
whole persons rather than introjects and projections.

THE THERAPEUTIC PROCESS

Assessment and Diagnosis

Bowen assessed for family patterns of interaction related to the mechanisms by which
people interacted during times of high stress or anxiety. These patterns, especially fixed ones,

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 244 Thorana S. Nelson

would be perceived as reasonable ways that clients learned also to deal with anxiety and
stress. Bowen also looked for indications of lack of differentiation of self in the clients and
other key family members. By using a genogram or family map, the Bowen therapist helps
the client look for patterns of conflict, withdrawal, symptoms, and triangling, especially as
they moved around during times of high stress. Thus, the Bowen therapist might ask how a
parent responded in a certain situation such as a move, job loss, or death. Process questions
would help the client focus on thoughts at that time or thoughts about emotions so as to avoid
excessively evoking emotions during therapy that might prevent the client from being able to
thoughtfully examine the genogram and patterns. Process questions also would help the client
to relate past patterns to present ones and patterns in one’s own family to those in the
partner’s. Bowen believed that these patterns intertwined in particular ways, often keeping
partners’ caught in dynamics of relating to each other as their families had rather than with
flexibility of thought and emotion.
Nagy’s purpose during assessment was to use questions to understand extended family
dynamics of oscillating patterns of give and take that resulted in balanced or imbalanced
ledgers of debts and entitlements over time (balance in motion). He would then assess for the
client’s role in these dynamics, how they were chosen or foisted upon the client, how
conscious or subconscious they might be, and where energy of entitlement, particularly
destructive entitlement, lay in the family system. The client’s difficulties and actions would
be seen as part of this complex whole and in reaction to it rather than as a sign of pathology or
lack of character. Nagy also would assess for clients’ abilities to see their family members,
particularly parents, with compassion and to exonerate them for past hurts. The chief tools in
Nagy’s work are questions that reveal patterns over time.
As one might imagine, Framo focused in the early stages of therapy on explaining the
theory and, through questions and interpretation, to uncover hidden introjects and projections.
Couples would be challenged to learn more about each other through exploration of beliefs
about and perspectives on extended family members. Assessment focused on understanding
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

how these introjects were preventing people from seeing each other as unique and whole
human beings. In later stages, in sessions with family members, there would be little
discussion or assessing of the family as a whole. Rather, as the clients’ advocates, Framo
would assist them in talking with family members about their perceptions and hurts and then
to listen to responses that would help clients to see them as whole persons rather than as one-
dimensional.

Goals

The goal of Bowen (1978) family therapy is differentiation of self. Intermediate goals,
often the places where clients decide to complete therapy, include detriangling, separating
thoughts from feelings, and maintaining new relationships with family members that allow
for self-thought during times of emotional intensity. For example, clients may decide that
being able to visit family during holidays or special events without coming home distressed is
a sufficient goal. Similarly, couples may decide that being able to discuss most issues calmly
is sufficient, knowing that there are remaining “hot” topics that are difficult to discuss.
According to Bowen, few people are able to resolve family of origin lack of differentiation
and that differentiating is a life-time process rather than a goal. Detriangling and learning how
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Transgenerational Family Therapy Theories 245

to be satisfied in family of origin interactions without either losing a sense of self or cutting
off from the family are laudable goals of therapy and most therapists satisfy themselves with
this improved quality of life for their clients. Some clients may continue to visit therapists a
few times each year to maintain progress and to develop more ideas for further
differentiation.
The ultimate goal of Contextual Family Therapy is a exoneration of past family members
and a balanced ledger that will provide a context for health for present and future generations.
Intermediate goals include discovering aspects of entitlements and debts over time as well as
legacies and loyalties that hold people in unconscious patterns, particularly destructive ones.
Understanding these aspects of humanity and a particular family dynamic allows people to
make new decisions. These decisions may lead to higher quality of life for clients. The
Contextual Family Therapist, however, is more interested in broader goals of balanced
ledgers, exoneration, and the giving and taking in life that, over time, leads to healthy
environments for individuals.
Framo worked with couples toward goals of understanding each other as non-
stereotypical, whole persons with whom they could interact without projecting split-off parts
of families of origins. In this way, couples would be able to resolve whatever difficulties
brought them to therapy on their own. Intermediate goals included understanding the
principles of object relations theory, discovering each other’s introjects and projective
behaviors, and relating these to suppressed family of origin object relations. At times, an
intermediate goal of Framo’s was healing in a family of origin group through direct
interaction with each other.

Phases of Treatment

Bowen’s model of therapy grows out of the differentiated therapist. Bowen’s work does
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

not include details of how therapy is conducted beyond a few techniques described below.
Therapists begin with clients by using genograms or family maps to understand family
dynamics and patterns. This process is both assessment and intervention as family members
learn about their families through questions about things of which they haven’t thought,
noticing patterns of behavior and reactions, triangles and correlations with events over time.
The therapist coaches clients in working on limiting emotional reactivity in favor of thinking
about their lives and families. The therapist then coaches them in making decisions about
different ways of interacting in their families that will increase differentiation as well as
understanding of family dynamics. Each move is carefully discussed both before and after the
fact. Therapists warn clients that family members may act in ways that encourage them to
change back to old patterns of behavior that would maintain family stability to the detriment
of the client’s health. After each foray into discovering more about families or interacting
differently with them, therapists discuss repercussions with clients and then plan more actions
based on this feedback. Bowen therapists would prefer to not terminate therapy with clients,
preferring to continue over a lifetime to enhance their differentiation of self. However, most
clients are content to quit therapy when the anxiety of a particular crisis is past. A few may go
further into understanding their family dynamics somewhat without making therapy a lifetime
process.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 246 Thorana S. Nelson

Nagy joins with his clients in a particular way called “multidirected partiality.” This
requires that the therapist join with everyone so that each feels understood. In this way, Nagy
joins with both the system and with individuals, favoring everyone and no one at the same
time. As a conjoint way of working, Contextual therapy then helps each person tell her story,
being careful to elicit information about felt senses of indebtedness, loyalty, and entitlement.
The therapist does not allow others to defend their actions in the face of these sentiments;
rather, the therapist helps each individual speak and listen in a way that elicits the overall
picture of the family’s ledger and the trustworthiness of each relationship. When blocks from
families of origin are uncovered, Nagy helps the family members understand their families’
contexts, and their own unbalanced ledgers that led to destructive entitlements and
untrustworthy relationships. The therapist then coaches individuals in exonerating these
family members and to approach them in ways that may lead to healing of relationships. It is
important to understand that success is not defined by how others respond or whether the
relationship actually is mended. Rather, the simple act of attempting healing (rejunction) is all
that is called for to balance the ledger and free the individual from destructive legacies. Such
moves can made toward rejunction in relationships with dead relatives through letters and
role-play. As in Bowen’s therapy, termination is not something that therapists strive toward.
Because it is not possible for ledgers to be completely balanced, these processes are life-long.
Clients, however, tend to quit therapy when the crisis is over and life is moderately satisfying.
They may return, however, when another problem appears in order to examine it within the
context of the family’s sense of fairness and justice.
Framo’s therapy begins by listening to clients about their concerns that are then framed as
communication problems that develop through misunderstandings about who each partner is
beyond projections. Framo liked to work with couples in groups, believing that they could
learn from each other about the concepts of the theory and about how stereotypes and flat
understandings could be enhanced through seeing others struggle with their own and their
families’ issues. When couples reached a point of understanding each other in more complex
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

ways, Framo encouraged them to invite family members to sessions. These sessions were
conducted from the viewpoint of the client although other family members were supported.
The aim of these sessions was to help the client confront parents and siblings and then to
listen so that they could understand from the others’ points of views what had happened and
why. When successful, these sessions enhanced the work with the couple, often in conjoint
rather than group couple work, to even more fully understand each other and learn to relate to
each other as unique and caring human beings. Framo’s work tended to end before family
sessions or soon thereafter, when couples indicated that they could face each other honestly
and openly without family “baggage” hindering them.

The Therapeutic Relationship

In each of the models discussed, the therapeutic relationship is one of distance. The
therapists remain experts, explaining the concepts and dynamics of the clients. The role of the
therapist in each model is to assist the client in a direction toward the respective goals. The
therapist does not see himself or herself as part of the system as in collaborative models, but
as acting upon the system as one who knows what’s best.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Transgenerational Family Therapy Theories 247

Techniques

Bowen Theory
In Bowen family systems theory, techniques arise out of the calm, differentiated
therapist who can manage anxiety in the face of the clients’ presenting problems and anxiety.
That is, the person of the therapist is the chief technique. Four other practices are common:

1. The genogram. By drawing a family map with each generation on one plane, the
therapist and client get a picture of family dynamics that are impacting the client and
his or her nuclear family. Monica McGoldrick (McGoldrick, Gerson &
Shellenberger, 1999) , a student of Bowen’s, has developed a system for using the
genogram to uncover and understand family dynamics from the client’s point of
view. By mapping the family dynamics over time as reactions to anxiety-provoking
events, the therapist and client discover coping mechanisms, triangles, patterns of
distance and closeness, and patterns around specific issues. The therapist then
coaches the client in detriangling herself or himself and developing autonomy at the
same time as maintaining intimacy with the family.
2. Process questions. Process questions invoke the abilities of the clients to separate
thoughts from feelings, aiding in differentiation of self. Asking partners what they
think of what the first partner was just talking about, what clients think is their role in
patterns of interaction, or how they think their parents developed certain
characteristics are examples of process questions.
3. Revisiting the past. In order to understand family of origin dynamics into three and
four generations, it sometimes is necessary for clients to go on expeditions, asking
questions of family members, visiting neighbors and friends, or searching old
documents to uncover clues about emotional relating. These excursions help clients
understand family members, learn how the family developed certain patterns, and
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

discover ideas for changing their own roles in the family.

4. Coaching. Therapists coach clients by helping them first understand their family
dynamics and then to change them. The therapist makes suggestions for small steps
that clients can take that will help them differentiate from their families, gaining
autonomy and strengthening intimacy. For example, a therapist might coach a client
about different behavior (rather than getting caught up in old family dynamics) when
visiting family for a holiday or celebration. If the client or couple usually stay at a
parents’ house even though it’s uncomfortable for them, the therapist helps them
make plans for telling the parents that they will stay in a hotel or for fewer days. This
sometimes requires that the client practice talking to the parents, developing
confidence and polishing their part in the conversation, and that the partner help
make plans for helping the client stay calm and centered. The therapist helps the
client think about ways the family may discourage such changes and plan for
responses. After the event, the therapist helps the client debrief, looking for ways to
fine-tune the process and, when successful, to plan the next step.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 248 Thorana S. Nelson

Contextual Family Therapy

Nagy’s therapy also was considered to flow from the person of the therapist, one who
has examined his or her own family of origin, ledger, loyalties, and entitlements. Questions
are the primary techniques for helping clients understand their family dynamics and their part
in them. Client complaints are connected to the family legacies of debts and entitlements so
that clients are not allowed to simply complain. That is, they must learn more about their
families, putting all behaviors and relationships in a context of loyalties, legacies, justice,
fairness, and trustworthiness. This allows them to distance themselves and begin a process of
exoneration and rejunction. Negative behaviors are framed within an effort to be loyal,
although in misguided or self-destructive ways. Therapists also coach clients in making
efforts to repair relationships, encouraging efforts even when results are not as hoped for.

Framo
As with other transgenerational perspectives in family therapy, Framo’s chief techniques
included teaching, asking questions, interpreting, and coaching. Often rather forceful, Framo
believed so much in his theory that he sometimes would contradict clients when they denied
certain feelings. These confrontations sometimes pushed clients into further examining their
own relational behaviors in the context of understanding their relationships with their families
of origin differently. Two unique techniques included the couples group, in which couples
examined their relationships in front of other couples, learning from each other in preparation
for the second unique technique: family of origin meetings. By inviting parents and siblings
into therapy, clients were able to confront them and, by listening to their responses, learn
about them in ways that made them whole rather than one-dimensional persons. When
successful, this allowed the client to let go of internalized objects that were distorted and thus
destructive to current relationships.
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STRENGTHS AND LIMITATIONS

The strengths of the transgenerational theories lie in their attention to family of origin and
extended family dynamics from the past that act in the present to maintain old habits and
learned patterns of interaction. By knowing more about family myths, rules, and dynamics,
clients are better able to place themselves in a context of interaction. This makes it easier for
them to think about and understand their roles in their current relationships so that they can
make choices about their behavior. Because much of whom we are and how we behave is
learned in families that are steeped in generations of dynamics, understanding this helps us
free ourselves of the negative parts and enhance the positive.
The strengths are, at the same time, the limitations. Clients usually come to therapy
wanting relief from current pain and do not understand how lengthy (sometimes, years)
therapy can help them. Their anxiety and fears press them toward therapies that provide relief.
Neither do these models do not take into account biological aspects of certain symptoms such
as depression and psychosis. At the time these theories were developed, medical science was
not much help to those suffering emotional or mental difficulties and the medicines that were
available had serious side effects. Although it is possible to understand the concepts of these
models with developing information about brain functioning and effects on mood and

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Transgenerational Family Therapy Theories 249

behavior, only Bowen’s followers studied the connections between mental and physiological
functioning.

SUMMARY
Transgenerational theories of family therapy provide a richness to therapy that is missing
in briefer, present-oriented therapies. By focusing on the past and defocusing on the present,
clients are able to learn about themselves as small parts of very large wholes, caught up in
dynamics that often go far beyond their own sense of their choices and behavior.
Understanding the complexity of the fabric of which they are one thread, they gain a
perspective of a tapestry of dynamics over many generations, not so that they feel hopeless to
change their situations, but so that they may take charge as weavers of their own lives, using
the threads and fibers of those who came before them.

REFERENCES
Boszormenyi-Nagy, I. (1987). Foundations of contextual therapy: Collected papers of Ivan
Boszormenyi-Nagy. New York: Brunner/Mazel.
Boszormenyi-Nagy, I., & Krasner, B. (1986). Between give and take: A clinical guide to
contextual therapy. New York: Brunner/Mazel.
Boszormenyi-Nagy, I., & Spark, G. (1984). Invisible Loyalties: Reciprocity in
intergenerational family therapy. New York: Brunner/Mazel.
Bowen, M. (1978). Family therapy in clinical practice. New York: Jason Aaronson.
Framo, J. L. (1982). Explorations in marital and family therapy: Selected papers of James L.
Framo, Ph.D.. New York: Springer.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Framo, J. L. (1992). Family-of-origin therapy: An intergenerational approach. New York:

Brunner/Mazel.
Kerr, M. E., & Bowen, M. (1988). Family evaluation: An approach based on Bowen theory.
New York: W. W. Norton.
McGoldrick, M., Gerson, R., & Shellenberger, S. (1999). Genograms: Assessment and
intervention. New York: W. W. Norton.
Napier, A. Y., & Whitaker, C. (1978). The family crucible. New York: Harper & Row
Publishers.
Slipp, S. (1984). Object relations: A dynamic bridge between individual and family treatment.
Northvale, NJ: Jason Aronson.
van Heusden, A., & van den Eerenbeemt, E. (1987). Balance in motion: Ivan Boszormenyi-
Nagy and his vision of individual and family. New York: Brunner/Mazel.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
 In: The Quick Theory Reference Guide ISBN: 978-1-60021-624-4
Editor: Karin Jordan, pp. 251-262 © 2008 Nova Science Publishers, Inc.

Chapter 18

SYMBOLIC-EXPERIENTIAL FAMILY THERAPY

Karin Jordan

Symbolic Experiential Family Therapy (S-EFT) is a development and growth oriented,

multigenerational approach, focusing on both the individual family member and family
relational patterns with a phenomenological existential conception of human development.
The emphasis in S-EFT is on promoting development and “the natural growth tendency in
families, and recognizing the struggle between autonomy and interpersonal belonging within
the family group” (Walsh & McGraw, 1996, p. 132). S-EFT is not a traditional theory driven
approach. Instead, the focus of therapy is on what the family is experiencing in the here and
now, and how they express their emotions. There are no pre-planned therapeutic techniques
and it is not ecological and/or communication oriented. Instead it is a growth oriented and
relational interactive process in which techniques are chosen spontaneously and based on
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current experiences, using creativity such as metaphorical language. The belief is that the S-
EFT therapist is fully present in the process of therapy, encouraging clients to be real.

THEORY DESCRIPTION

Key Person

Carl Whitaker was originally trained as an obstetrician/gynecologist in the early 1940s,

but was also interested in psychology, and spent his final year of training in a psychiatric
hospital (1938-1939) working with schizophrenic clients (Simon, 1985). This placement was
significant, as his placement in a small diagnostic site with an outdated care system, unlike
the usual placements at large state institutions, did not provide Whitaker with either
psychodynamic or psychoanalytic training. Later, he was put under the supervision of a social
worker at the Louisville Child Guidance Clinic, as well as a treatment center for delinquent
adolescents called Ormsby Village. It was during this time that Whitaker developed
techniques that focused on the “here and now” and seemed to be effective with clients (Neill
& Kniskern, 1982). In 1941, at the onset of World War II, Whitaker was asked to treat

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 252 Karin Jordan

patients at Oak Ridge Hospital in Tennessee (1944-1946), carrying a high client case load of
as many as 12 clients a day (Keith & Whitaker, 1991). It was during this time that Whitaker
was introduced to dual co-therapy by John Warkentin (who held a doctorate in
psychophysiology and had also been trained as a child therapist). Whitaker saw co-therapy to
be of great value when working with schizophrenic families, as it prevented the therapist from
getting entangled with the family. According to Roberto (1991), this early use of dual co-
therapy is the forerunner of the observation team, which was later developed and used in
systemic therapy.
Whitaker was invited to move to Atlanta, Georgia to establish a psychiatry department at
Emory University and serve as the chair (1946-1955). It was at Emory that he, in
collaboration with Warkentin and later Thomas Malone (a trained adult psychoanalyst)
continued the work on dual co-therapy. Whitaker and Malone also co-authored a landmark
book entitled The Roots of Psychotherapy in 1953. When Whitaker worked with
schizophrenic clients, he recognized that families played an important role in the etiology of
schizophrenia and saw schizophrenia as both an interpersonal (enmeshment of the family) and
interpsychic problem. Whitaker eventually believed that “there is no such thing as a person,
that a person is merely the fragment of a family,” as well as that “marriage is not really a
combination of two persons; rather it is the product of two families who send out a scapegoat
to reproduce themselves” (Whitaker & Ryan, 1989, p. 116). He therefore decided to not treat
only the schizophrenic client, but instead to involve the whole family in therapy. He pushed
for an epistemological shift in which the therapist is an active participant in the process of
therapy, dealing experientially with the client’s interactional dysfunction rather than
following a then-prevalent psychoanalytic position of searching for internal conflicts merely
to help clients gain insight and understanding (Roberto, 1991). Whitaker also believed that
the process of change requires that all participants in the therapy process (therapists as well as
clients) have to take on the role of being the client and therapist to one another. He believed
that both need to be willing to be vulnerable and regress, as this will result in client and
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therapist growth. In addition, he believed that each person must be individually responsible
for his or her own, and not others’, maturing process, including the therapist’s. This,
according to Whitaker, requires that the therapist be committed to growth.
In 1955, Whitaker assembled the Emory-sponsored Sea Island Conference, which was a
time when techniques used with individual clients, as well as with families in therapy, were
demonstrated. Eventually, Whitaker’s revolutionary view of how to treat schizophrenia
resulted in his dismissal from Emory University in 1955. He then established and worked in a
private practice from 1955 to 1965 at the Atlanta Psychiatric Clinic, in collaboration with
John Warkentin and Melanie and Richard Felder. They saw individual clients with
schizophrenia, as well as their families. In 1965, Whitaker defined himself as a family
therapist, and went to the University of Wisconsin School of Medicine in Madison. During
his time at Wisconsin, he worked collaboratively with Augustus Napier (psychologist) and
later David Keith (child psychiatrist). It was through this collaboration that Whitaker explored
how to work with a variety of families, and not only those with psychotic members (Keith &
Whitaker, 1982). It was during this time that Whitaker made the transition to systemic
thinking (Neill & Kniskern, 1982). In the early 1990s, Whitaker resigned from the University
of Wisconsin and conducted national workshops focusing on his insights, writing, “While
education can be immensely helpful, the covert process of the family is the one that contains
the most power for potential changing” (Keith & Whitaker, 1982, p. 43).
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Symbolic-Experiential Family Therapy 253

Whitaker believed that therapy operates similarly to the infrastructure of a city, in which
the operation and functioning could not occur if the things underneath the surface did not
exist (Whitaker & Bumberry, 1988). He also believed that people’s functioning is impacted
by their infrastructure of emotions, impulses and evolving symbols, and therefore the person’s
external reality is given meaning through his/her internal reality. In addition, he believed that
the therapist should help the family expand their inner symbolic world by accessing his/her
own inner world of impulses and symbols and going beyond the spoken words. Keith &
Whitaker (1991) wrote:
We presume that it is experience, not education that changes families. The
main function of the cerebral cortex is inhabitation. Thus, most of our
experience goes on outside of our consciousness. We gain best access to it
symbolically. For us “symbolic” implies that some things or some process
has more than one meaning. While education can be immensely helpful, the
covert process of the family is the one that contains the most power for
potential changing. (p.108)
Whitaker tried to find the symbolic meaning of what was happening between him and the
family, and shared his own impulses and fantasies with the family, and helped individual
family members do the same. He did not pathologize, but instead de-pathologized, and was
known for his sometimes outrageous behavior with families, which Minuchin (1982)
described as “humor, indirection, seduction, indignation, primary process, boredom, and even
falling asleep as equally powerful instruments of contact and challenge” (p. ix). Whitaker
(1975) called his therapeutic style “the psychotherapy of the absurd.” He died in 1995,
however David Keith and Gus Napier, two of Whitaker's colleagues and co-authors, continue
to use and teach S-EFT today.

Basic Concepts
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S-EFT is pragmatic and not overly reliant on theory and techniques, as Whitaker believed
that theorizing and creating a systematic model tends to be constricting (Whitaker, 1976).
Because of this, it has been challenging for many therapists to understand, as well as to
imitate. Whitaker saw therapy as an art, with the process of therapy unfolding itself via an
authentic, genuine way. In S-EFT, the therapist does not have the power to change the
system, but rather believes that the family must be responsible for their own destiny
(Whitaker, 1976). More specifically, in S-EFT families are believed to have internal drives
that will help them resolve the problem(s) that they are dealing with, and it is the therapist’s
responsibility to actuate this process (Keith, Connell & Whitaker, 1991). The therapist does
not treat families, but rather is the catalyst for change with the family. In S-EFT, growth does
not imply that the family is gaining insight and understanding, but rather that the family is
able to function better on an interpersonal and intrapersonal level.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 254 Karin Jordan

HEALTHY VERSUS UNHEALTHY/DYSFUNCTIONAL

It is important to understand that in S-EFT, health and dysfunction exist on a continuum,
and all families can develop dysfunction. It is believed that enough stress, occurring
persistently over time, can overwhelm a family which functions relatively healthily, if it lacks
resiliency, and can then become dysfunctional.

Healthy Functioning

In S-EFT, healthy functioning means that families are self-actualized and have flexibility
and a certain amount of openness to dealing with live events and growth as they move
through the different life cycle stages. Families are ever-changing and evolving. They are not
symptom-free, but are able to deal with problems successfully. Healthy families come in all
shapes and sizes (e.g. two parent family, single parent family, etc.) and demonstrate some
level of family identity and family cohesion, while also encouraging individual autonomy and
personal development, which includes a sense of self and the capacity to be intimate. In these
well functioning systems, coalitions are formed only temporarily and do not threaten others,
serving as a way to get support when conflict arises. They also present with a structure in
which external and internal boundaries are clearly defined, which helps to create a sense of
belonging and identity. The external boundaries help the family separate from the
environment, while the internal boundaries serve to distinguish between the different
generations, as well as the different subsystems. The boundaries should not be rigid, but
permeable enough to let others in and allow networking. Subsystems, which are distinguished
through boundaries in healthy families, generally function with clearly defined roles. These
roles are flexible and allow various family members to experience problems as well as
successes. Roberto (1991) wrote that “role flexibility allows individuals to express differences
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

and to change behavior or beliefs without disqualification, making use of their own live
experiences, familial legacies, and developing preferences” (p. 44). According to Roberto
(1991), in healthy families, “bonding and intimacy exists between parent and child, between
marital partners, and between siblings” (p. 448). In addition, healthy functioning involves
tolerance of conflict so that family members can become overt and explicit, as well as
negotiate and resolve conflict (Roberto, 1991). Healthy families are ever-changing as they go
through family development, with family members entering and exiting the family through
marriage, birth, adoption, death, etc. As families move through the various stages of the
family life cycle, they have to manage complex tasks that can result in stress. Expected and
unexpected life cycle transitions can be chaotic and difficult for families, requiring family
members to struggle together. Healthy families do not avoid these struggles, but rather
address them together. Healthy families such as described above have clear, flexible
boundaries, and are tolerant of ambiguity and able to revert from the “we” ness to the “I”
ness.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Symbolic-Experiential Family Therapy 255

Unhealthy/Dysfunctional

Dysfunction can be developed by healthy families as they move through lifecycle

transitions and are unable to manage the complex tasks associated with each stage.
Dysfunction occurs when the integrity of the family or an individual family member is
threatened and/or overwhelmed. Dysfunction should be viewed as involving an interactive
multi-person system, often resulting from the family engaging in a self-protective function.
Families that are self-protective will try to avoid taking risks, and are often unwilling to
engage in confrontation and conflict out of fear that this will destroy them. However it is this
unwillingness to engage in confrontation and conflict that will most likely cause the family to
stop growing, as they are unable to deal with life events and life-cycle transitions and become
stuck. This kind of stuckness is often manifested through both intrapsychic problems and
interpersonal relationship issues. It can also result in structural impairments such as
enmeshment, disengagement, scapegoating, triangulation, destructive coalitions, or process
difficulties. If this kind of structural impairment exists over an extended time, it may be the
type of family that “has excessive calluses and no craziness but is massively inhibited, or the
family with ‘nobody-in-it’ in which the family members live back-to-back” (Keith &
Whitaker, 1982, p. 52). These dysfunctional families can be characterized as egocentric,
overburdened and/or apathetic often with non-rational impulses resulting in the breakdown of
their adaptability, and are always the result of unconscious behavior patterns within families
and are important symbolic expression of the underlying family dynamic (Keith & Whitaker,
1980). The dysfunction becomes the organizing feature of the system.

THE CHANGE PROCESS

Change
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A critical change factor in S-EFT is the existential encounter and not intellectual
understanding. More specifically, it is based on the interactive process which involves the
therapist and family, and both of them being real when they are together, i.e. with no social
pretense. It is the family’s relational process that creates the most powerful opportunity for
change. For this change process to be initiated and maintained, therapists must closely
observe and be attuned to the verbal and non-verbal expression of emotions, addressing them
as they emerge in the here and now, since the family’s dysfunction can only be understood
within the context that it occurs. It is through the relational experience between the family and
the therapist that the family’s capacity to learn and teach themselves is increased, which is the
greatest source for potential change. The therapist only serves as the catalyst in this process,
since the belief in S-EFT is that families have a “built in drive” wanting to resolve their
problems (Keith, Connell & Whitaker, 1991).

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 256 Karin Jordan

Therapist Role

An S-EFT therapist is spontaneous, “real”, “fully present”, and authentic when engaging
with a family. This means responding to the family and their emotions spontaneously versus
using predetermined techniques or processes. This kind of therapist needs to learn how to do
therapy and be in a therapeutic relationship, which can be achieved through practice and
experience. It initially involves the therapist engaging in an active process of studying and
reading. The second step is engaging in co-therapy and observation. The final step requires
the therapist to have obtained the ability, through experience and maturity, to be in the
moment with the family and individual family members and to be real during this process. It
is the therapist’s humanness, experience, values and beliefs that influence this process of
therapy. The S-EFT therapist always tries to integrate the family’s behavior into the context
of the family’s life, There are several phases of the process of S-EFT therapy providing
something of a roadmap for the therapist, as well as the three stages that the therapist goes
through. Techniques are chosen carefully throughout the process of therapy and are not
merely random, or based on an “anything goes” philosophy, but instead are carefully selected
to help the family grow. There are three stages the therapist goes through as part of the
process of therapy. The first stage is the therapist setting clear structures and limitations.
During this time, the therapist is responsible for the therapy and how it works, which does not
mean that the therapist is also responsible for the family. The second or middle stage is when
the therapist uses creative ways to activate stress for the family and stimulate growth. During
this stage, self-disclosure by the therapist is important, as it encourages families to self-
disclose too. The third and final stage is when the family is the initiator. During this stage, the
therapist has two tasks: to create time and space for the family so that they can do what they
need to do, and to be available to the family as needed.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Therapist Self-Care

In S-EFT, it is important that the therapist takes care of his/her personal needs. Some
loose rules for good self-care were established by Whitaker (1976):

1. Relegate every significant other to second place.

2. Learn how to love. Flirt with any infant available. Unconditional positive regard
probably isn’t present after the baby is three years old.
3. Develop a reverence for your own impulses, and be suspicious of your behavior
sequences.
4. Enjoy your mate more than your kids, and be childish with your mate.
5. Fracture role structures at will and repeatedly.
6. Learn to retreat and advance from every position that you take.
7. Guard your impotence as one of your most valuable weapons.
8. Build long-term relations so you can be free to hate safely.
9. Face the fact that you must grow until you die. Develop a sense of the benign
absurdity of life - yours and those around you - and thus learn to transcend the world
of experience. If we can abandon our missionary zeal we have less chance of being
eaten by cannibals.
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Symbolic-Experiential Family Therapy 257

10. Develop your primary process living. Evolve a joint craziness with someone you are
safe with. Structure a professional cuddle group so you won’t abuse your mate with
the garbage left over from the day’s work.
11. As Plato said, “practice dying.” (p. 164)

These rules of good self care are important, as the therapist needs to be committed to
taking care of him/herself in this highly personal approach. More specifically, it means that
the therapist needs to be willing to take risks, to explore, to discover, to be involved, to share
and to grow. This is different from other models, in which therapists address family problems
as a way to assist the change process. In S-EFT as described above, it is the therapist’s own
personal experience during the therapist-client relationship (in the here and now of the
therapy session) and consequent modeling for the family, that brings about change for the
family.

TREATMENT

Goals

The primary goal of S-EFT therapy is not to resolve problems and achieve stability, but
rather to assist everyone involved in the process of therapy to grow and change
intrapsychically (e.g. becoming more of their own self) and interpersonally (e.g. affective
investment with each other), but also to translate family history into symbolic history.
According to Whitaker and Malone (1953), growth is the “natural orderly emergence of
potential forms and capacities of the total individual organisms through maturation,
differentiation, and integration” (p.232). Goal achievement is reached when families have
developed better tools to deal with life experiences, not necessarily meaning they have
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

reached stability or resolved their presenting problem.

Assessment

In S-EFT, the assessment process is conducted in the earliest therapy sessions. It has been
called a “trial of labor” (Whitaker & Keith, 1981), and according to Roberto (1991),
assessment focuses on “the context of intact competencies and resources for change,” not on
symptoms and dysfunction (p. 452). The therapist must be attentive and skillful in order to do
a good assessment, considering the family’s transgenerational belief systems as well as what
stage of the life cycle the family is in and how they are dealing with a possible transition. The
S-EFT therapist does that by being alert to the overall mood and demeanor of the family and
individual family members, as well as their verbal and non-verbal behavior. The therapist
tries to get a better understanding of the family by considering such areas as internal and
external boundaries, coalitions (two people aligning to avoid conflict), conflict (avoidance,
chronic or premature closure), role rigidity, delegation (“scapegoat” or “white night”), lack of
parental empathy, pseudomutuality (poor internal boundaries) and/or emotional cutoff

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 258 Karin Jordan

(withdrawing from parents). The assessment occurs in the here and now as the family
interacts with each other and the therapist, rather than engaging in history-gathering

Techniques

There are seven techniques in S-EFT:

• Augmenting the despair of a family member – When the therapist heightens the
despair of one family member, other family members will rally and support that
person. This is unusual behavior, as these families generally lack a supportive
environment.
• Affective confrontation – When the therapist feels genuine affect for family members.
If one of the family members engages in activities within the session that the rest of
the family cannot control, the therapist will confront that person and change will
occur.
• Treating children like children, and not adults – Acknowledging that there is a
difference, based upon generations, and that boundaries must be clear. This maintains
a sense of order.
• Play –Involving the therapist and the child(ren) in the family playing a game, playing
with puppets, etc. It is a way to involve the children in the process of therapy at an
appropriate level. In addition, it creates a way for the child(ren) to express their
perceptions and experiences by bringing up topics spontaneously, and no confessions
of other family members are needed. This technique, just as all techniques, must be
chosen carefully as to when and for how long to use it, as it is powerful. Families that
are rigid might dismiss the value of play, and in that case play should be used with on
a time-limited basis.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

• Deviation amplification – This technique can be used to disrupt the status quo within
the family by producing anxiety though playful paradoxical maneuvering. More
specifically, the therapist expands on the family’s existing problem perception by
making some outlandish predictions. This gives voice to the unspoken consequences
should the family not change and engage in more of the same behavior, creating an
opportunity for the family to think more seriously about themselves and develop
creative solutions not previously considered.
• Redefine symptoms toward growth – Through the use of metaphor and stories,
families can see their problem from a new perspective.
• Modeling fantasy – According to Whitaker and Malone (1953), fantasies have been
described as non-reality intrapsychic experiences.” (p. 321) Fantasies can be used to
request absurd behavior: “For example, a father may be told, ‘Maybe if you took
your son’s clothes, he couldn’t go out and buy drugs.” (Roberto, 1991, p. 463)
Another way fantasy can be used in stressful situations is by imagining “What if….”
• Separating interpersonal and intrapersonal stress – The process of separating the
relationship problems from a person’s reactivity (intrapersonal).
• Activating constructive anxiety – According to Whitaker and Ryan (1989), there are
two kinds of anxiety that create growth and negative anxiety. “Symbolic-experiential
therapy tends to focus more on positive anxiety (i.e. fear of failing to accomplish
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Symbolic-Experiential Family Therapy 259

what one is capable of) by positively reframing symptoms as efforts toward

competence and by overtly addressing the life-cycle transition each family member is
facing.” (Roberto, 1991, p. 454).

The Therapeutic Process

The process of S-EFT therapy has been described by Whitaker and Bumberry (1988):
“The journey of family therapy begins with a blind date and ends with an empty nest.” (p.
53). More specifically, the process begins with the joining process, during which the therapist
must define his/her professional self and professional structure. It is during this phase of
therapy that the therapist should be active and responsible, as this is when the tone of the
encounter is set. It is during the initial phase of therapy that there is a battle for structure
between the therapist and the family. The therapist must be attentive and skillful and in
charge of the structure of therapy, starting from the first contact with the family in order to
make the process productive. The therapist cannot present anxiety, because families are such
a powerful force and they would most likely replicate their problematic behavior pattern in
the therapy session. Therapy is based on the therapist maintaining an “I” stand, caring both
about him/herself, and the family. The “I” stand of the therapist is believed to foster a “we”
(togetherness) stand with the family. This concept can be better understood by using the
symbolism of playing baseball, a metaphor often used by Whitaker (Whitaker & Bumberry,
1988). Using this symbolism, the therapist functions in the role of coach and the family
members are the team. Since the therapist is the coach, he/she would never take any position
on the team. This is important, because the underlying belief is that if the therapist would take
on anyone’s role in the family, it would indicate that certain family members are not able to
manage their positions. However, as a coach, the therapist can help the family gain a better
sense of family belonging, along with individual family members’ separateness/autonomy,
and play more effectively. This also means that the therapist needs to win the battle for
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

structure, but that the family must win the “battle for initiative.” More specifically, it means
that the families must be willing to face themselves, and work on becoming in charge of their
lives and determining what directions they want to grow in (Napier & Whitaker, 1978).
In S-EFT, it is often standard practice to do co-therapy and be inclusive, and invite three
generational family systems to therapy. This was described by Whitaker (1976) who wrote:

When the three-generation system has been assembled, whether as a preventive experience, a
healing force, as consultant to the frustrated therapist, or to mediate a three-generation civil
war, the long-range benefits may outweigh the immediate ones. Increased flexibility in role
demands is almost automatic; frequently loyalty debts and covert collusions are altered.
Involvement in the metagame of change allows new visual introjections of individuals and
subgroups, thus altering each person’s intrapsychic family. Discovering that one belongs to a
whole, and that the bond cannot be denied, often makes possible a new freedom to belong,
and of course thereby a new ability to individuate. (pp. 191-192)

Inviting the three generational family system allows the family as a whole to go through
the process of therapy jointly. The process of therapy in S-EFT consists of four phases,
identified by Whitaker (1977) as:

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 260 Karin Jordan

• The pretreatment (or engagement) phase, which is also called a “battle for
structure” is a time when the whole family meets with the therapist or co-therapists.
During this phase, the therapist is attentive and alert to the way that the family
interacts and the mood they present. This helps the therapist, on an experiential level,
gain some feeling of who the family is. Different family members may present with
strong emotions, which may be a way to distract the therapist from the real issue.
Therefore the therapists should not become bogged down early in the process of
therapy, focusing on one family member or one issue, but instead should wait until
they sense a gestalt. In addition, they need to be aware of transference and
countertransference issues. More specifically, during this phase of therapy, the S-
EFT therapist’s task is to move the focus from the identified patient to the whole
family, since they are participants in maintaining the problem and are not victims of
it. Problems should be reframed and information should be gathered from the whole
family by asking questions and through observations. During this process, the
therapist must maintain a balance of getting to know the family without having the
family feel controlled, creating an opportunity for the family to be more expressive.
• The middle phase, which is also called a “battle for initiative”, is a phase that starts
after the therapist has won the battle for structure. The therapist now encourages the
family to be more in charge. It is generally during this phase of therapy that family
members have difficulties being responsible for themselves, and family dysfunction
becomes more obvious. It is also during this phase that the family is responsible for
the content of the session, while the therapist makes comments and shares
observations in an attempt to keep the process going. More specifically, it means that
the therapist has become an ambiguous destabilizing member of the family, an ally
strong enough to tolerate the family dysfunction. This kind of therapeutic alliance
can best be described as a parallel process when the family and the therapist work
side by side, and the therapist’s communication is based on his/her self-awareness
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

and capacity, all within the context of the therapy session. This takes the therapist out
of the expert role, and instead is truly present in the moment and shares his/her
experiences with the family. This is believed to be important for the family to
experience, as it creates an opportunity for them to experience their own
vulnerabilities.
• The late phase, which is also called “trial of labor”, is when old patterns of behavior
re-emerge in therapy. In this phase, humor, play and deviation amplification are
useful in lowering defenses, since the underlying premise is that through thoughts
and feelings of absurdity, rather than reasoning and logic, ambiguity is increased, and
perception and interactions are enriched. The goal is to stimulate self-questioning as
well as promote communication between family members.
• The separation phase (empty nest) which is also called “termination” is when the
family’s anxiety, which once fueled the therapy session, has diminished and
responsibility has increased, focusing more and more on their own resources. In S-
EFT, when a family decides to terminate the therapist does not interfere with this
decision, regardless of where the family is in the process of therapy, because trying
to discourage them from termination means taking away their authority. Instead the
belief is that families are terminating because they got what they needed from
therapy.
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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Symbolic-Experiential Family Therapy 261

Therapy generally starts out with weekly sessions, and toward the end of therapy, might
be less frequent, such as once a month. Roberto (1991) describes S-EFT to be “time
unlimited” (p. 459). Generally however, the duration of S-EFT ranges from six months to two
years.

Strengths and Limitations

In S-EFT, the core ingredient is the therapist’s humanness as well as the therapist and
family interaction. The pattern and practice of S-EFT is replicable, as various phases of
therapy have been identified which create a road map for the S-EFT therapist. However the
possibilities for intervention are endless, which can be a strength and a limitation. In addition,
they are filtered through the person of the therapist and the family, making replication
difficult. This also makes it difficult to conduct research on this approach, which may be the
reason there is little empirical support in the literature, despite much being written about this
approach.

SUMMARY
S-EFT is a developmental and growth oriented multigenerational approach. Carl
Whitaker is generally identified as the founder of S-EFT, and although he originally worked
only with individual clients, he eventually involved the whole family in therapy. He believed
that the S-EFT therapist’s and the family member’ personal involvement, in combination with
techniques is necessary for families to feel safe and to explore problems, and develop
increased competencies which will result in grow for the family both intrapersonally and
interpersonally.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

REFERENCES
Keith, D. V., Cornell, G., & Connell, L. (2001). Defiance in the family: Finding hope in
therapy. New York: Brunner/Mazel.
Keith, D. V., Connell, G., & Whitaker, C. (1991). A symbolic-experiential approach to the
resolution of therapeutic obstacles in family therapy. Journal of Family Psychotherapy,
2(3), 44-56.
Keith, D. V., & Whitaker, C. A. (1980). Add craziness and stir: Psychotherapy with a
psychoticogenic family. In M. Andolfi and I. Zwerling (Eds.). Dimensions of family
therapy (pp. 139-160). New York: The Guilford Press.
Keith, D. V., & Whitaker, C. A. (1982). Experiential/symbolic family therapy. In A. M.
Horne & M. M. Ohlsen (Eds.), Family counseling and therapy (pp. 43-74) Itasca, IL: F.
E. Peacock.
Keith, D. V., & Whitaker, C. A. (1991). Experiential/symbolic family therapy. In A. M.
Horne & J. L. Passmore (Eds.), Family Counseling and therapy (pp. 107-140) Itasca, IL:
F. E. Peacock.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
 262 Karin Jordan

Minuchin, S. (1982). Foreword. In J. R. Neill & D. P. Kniskern (Eds.), From psyche to

system: The evolving therapy of Carl Whitaker. New York: Guilford Press.
Neill, J. R., & Kniskern, D. P. (1982). From psyche to system: The evolving therapy of Carl
Whitaker. New York: Guilford Press.
Roberto, L. G. (1991). Symbolic-experiential family therapy. In A. S. Gurman, & D. P.
Kniskern (Eds.), Handbook of family therapy, volume 2 (pp. 444-476). New York:
Brunner/Mazel.
Simon, R. (1985). Structure is destiny: An interview with Humberto Maturana. The Family
Therapy Networker, 9(3), 37-43.
Walsh, W. M. & McGraw, J. A. (1996). Essentials of family therapy: A therapist’s guide to
eight approaches. Denver, CO: Love Publishing Company.
Whitaker, C. A. (1975). Psychotherapy of the absurd: With a special emphasis on the
psychotherapy of aggression. Family Process, 14, 1-15.
Whitaker, C. A. (1976). The hindrance of theory in clinical work. In P. J. Guerin, Jr. (Ed.),
Family therapy: Theory and practice. New York: Gardener Press.
Whitaker, C. A. (1977). Process techniques of family therapy. Interaction, 1, 4-19.
Whitaker, C. A., & Bumberry, W. A. (1988). Dancing with the family. New York:
Brunner/Mazel.
Whitaker, C. A., & Keith, D. V. (1981). Symbiotic experiential family therapy. In A. S.
Gurman, & D. P. Kniskern (Eds.), Handbook of family therapy, volume 2 (pp. 187-224).
New York: Brunner/Mazel.
Whitaker, C. A., & Malone, T. P. (1953). The roots of psychotherapy. New York: Blakiston.
Whitaker, C. A., & Ryan, M. D. (1989). Midnight musings of a family therapist. New York:
Norton.
Whitaker, C. A., Malone, T. P., & Warkentin, J. (1956). Multiple therapy and psychotherapy.
In F. Fromm-Reichmann & J. L. Moreno, Progress in Psychotherapy. Oxford, England:
Grune & Stratton.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 In: The Quick Theory Reference Guide ISBN: 978-1-60021-624-4
Editor: Karin Jordan, pp. 263-283 © 2008 Nova Science Publishers, Inc.

Chapter 19

TWO FORMS OF GESTALT FAMILY THERAPY

Paul Shane and Karin Jordan

Gestalt therapy is a method of psychotherapeutics initially developed by Frederick

“Fritz” Perls, (1893-1970) and his wife, Laura Perls (1905-1990), and later elaborated by Paul
Goodman (1911-1972). It is an integrated approach that eclectically combines a variety of
principles drawn from Gestalt psychology1, Freudian psychoanalysis, existential philosophy,
phenomenology, holism, Taoism, and by some estimates, 21 other sources as well (Barlow,
1983). It made its formal appearance with the publication of Gestalt therapy: Excitement and
growth in the human personality (Perls, Hefferline, & Goodman) in 1951, became prominent
in the human potential movement of the 1960s, remains an integral part of humanistic
psychology, but now resides mainly on the fringe of contemporary mainstream psychology.
Gestalt therapy itself is actually more of a psychotherapeutic perspective or approach
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

rather than a technical system. Laura Perls gives her definition of Gestalt therapy by saying:

The basic concepts of Gestalt therapy are philosophical and aesthetic rather than technical.
Gestalt therapy is an existential-phenomenological approach and as such it is experiential and
experimental… Why do we call our approach Gestalt therapy? ‘Gesalt’ is a holistic concept
(ein Ganzheitsbegriff). A gestalt is a structured entity that is more than, or different from, its
2
parts. It is the foreground figure that stands out from its ground, it ‘exists’ (L. Perls, 1992, p.
5).

Part of its reputation is based its application of a variety of techniques—several of which

have become part-and-parcel of mainstream, eclectic psychotherapy--and it still offers

1
That Gestalt therapy is even related to Gestalt therapy has been denied by many historians of psychology
beginning with Henle (1978). Henle’s analysis ignored the fact that Laura Perls studied under Adhémar Gelb
(1887-1935) at the University of Frankfurt, where she and Fritz met in 1926. That Laura Perls is the historical
bridge between Gestalt Psychology and Gestalt therapy was established by Shane (2002, 2003).
2
We wish to clarify what has been a historical misunderstanding of the phrase, “The whole is greater than its parts.”
The actual view of the German Gestalt psychologists was the whole determines the nature of its parts. The
former phrase originates with Aristotle when he wrote the whole is prior to its parts. More generally, however,
the saying has long been mistakenly rendered as the whole is greater than the sum of its parts; an entirely
different concept altogether.

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 264 Paul Shane and Karin Jordan

especially creative tools, but these can only be had after a practitioner understands its
principles and philosophical concepts. To view Gestalt therapy strictly as a technique would
be foolish of a practitioner, misleading to a client, limited in scope, and, well, be very un-
Gestalt, if you will. That Gestalt therapy is so closely identified with—indeed, some might
say “synonymous with”—the “empty chair” technique is a tragedy in the history of
psychology.
The problem of Gestalt therapy usually being identified with a given technique—e.g., the
“empty chair;” e.g., “the here and now”—begins with its founders. Gestalt therapy was
developed by the Perlses, and Goodman, and each of them expressed themselves in their work
and teachings with three different styles: Fritz Perls valued individual power, autonomy, and
personal boundary as ideal human characteristics3; Laura Perls included those concepts as
well, but was particularly sensitive to the principles of support and relationship; Goodman,
the author and social philosopher, was interested in community and personal meaning4. After
their marital separation in the late 1950s, Fritz migrated to the West coast to take up residence
at the Esalen Institute just in time to catch the crest of the human potential movement that was
soon to briefly engulf American psychology and the country5. Perls, given his dominating
personality and deep desire for fame and personal acclaim, essentially turned the popular
notoriety of Esalen into his own bully-pulpit for Gestalt therapy. Meanwhile, Laura Perls and
Goodman remained in New York City while traveling to Cleveland, Ohio training therapists
in both locales. Consequently, within the Gestalt therapy community there came to be known
the “West coast,” “East coast,” and “Midwest” styles of Gestalt therapy, but these distinctions
are little known or understood outside of the Gestalt community.
The use of the Gestalt approach to intervene in family systems came from the students of
the Perlses, Goodman, and others. The first application was made by Walter Kempler on the
West coast, and then, later, it was taken up by Sonia March Nevis, the late William Warner,
and Joseph Zinker in Cleveland, and now, more recently, by Joseph Melnick and Penny
Backman working in conjunction with Nevis and Zinker in Cape Cod, MA6.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

For simplicity’s sake, this chapter will not engage in the somewhat subtle distinctions
between Kempler, on the one hand, and Nevis-Zinker-Melnick-Backman, on the other,
because, bearing in mind that Gestalt therapy is a psycho-philosophical approach, there is far
more common ground shared by the students of Fritz and Laura Perls than differences in
opinion. In the text, the differences in approach will be identified as the “Kempler model” and
the “Cape Cod model.”

3
While not wanting to analyze Perls or his motives, it is commonly acknowledged by those who knew him that he
was a very difficult individual with his own personal conflicts which most likely originated in his troubled
childhood and military experiences in WWI. For more information, see: Gaines (1979), Perls (1969/1992),
Shepard (1975), and Wysong & Rosenfeld (1982). The Shepard reference should be approached with caution as
it contains many inaccuracies according to Fritz and Laura’s daughter, Renate (personal communication with the
author).
4
It terms of philosophical analogies, it might be helpful to suggest that Fritz Perls reflected Frederick Nietzsche
(1844-1900), Laura Perls valued Martin Buber (1878-1965), and Goodman relied on Aristotle (384-322 BC) and
Pierre-Joseph Proudhon (1809-1865).
5
For the history of the human potential movement, and the history of Esalen Institute in particular, see: Anderson
(1983) and Kripal & Schuck (2005). Taylor (2000) is also recommended.
6
The authors are indebted to contributions made to this chapter by Walter Kempler and Joseph Melnick.

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Two Forms of Gestalt Family Therapy 265

THEORY DESCRIPTION

Key Persons

Walter Kempler
A pioneer in family therapy, Kempler was originally trained as a general physician. In
1959 he completed a residency in psychiatry at the University of California and then worked
for several years in private practice. It was during this time that he became more interested in
working with families. Kempler trained on the West coast under Fritz Perls and James
Simkin, and is universally acknowledged as the first therapist to adapt Gestalt therapy in the
context of family systems. He also established the Kempler Institute for the Development of
the Family. He has been a freelance teacher and trainer in the United States and northern
Europe (Kempler, 1981).
His philosophy and orientation derive from Fritz Perls and the theoretical position of
Gestalt psychology that people do not see isolated events, but rather see the meaningful
wholes, or Gestalten, which are believed to contain qualities that cannot be found in an event
or individual part7 (Capra, 1983). This theoretical position is most often associated with
individual focus and Frederick (Fritz) Perls’s work, which is generally—although
erroneously--credited with having initiated the Gestalt movement in the United States. In
1961, when Kempler opened the Kempler Institute for the Development of the Family in Los
Angeles, he inaugurated the “idea of Gestalt therapy as a clinically viable basis for the
treatment of families” (Kempler, 1982, p. 144).
Kempler’s model focuses on expanding self-awareness as well as personal responsibility,
both of which are believed to help individuals achieve maturity. More specifically, one of its
main roots originates in existential therapeutic thinking; one of the main theoretical
wellsprings of Gestalt therapy. The defining principle of existential therapy is, according to
Sommers-Flanagan & Sommers-Flanagan (2004):
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The I-am experience is the experience of being, of existing…..the experience of being is often
referred to as ontological experience (onto means “to be” and logical means “the science of”).
Literally, then, a major focus of existential therapy consists of exploring the immediate
individual human experience. (p. 142).

The focus in existential therapy is on the here-and-now, based upon the belief that the
past is gone and the future has not yet come, therefore, only the present can be changed.
Gestalt therapy located itself within humanistic psychology; the so-called “third force” in
psychology after the psychodynamic and behavioral approaches. However, on most Gestalt
therapy publications, only Fritz Perls name appears which may be the reason why Gestalt
therapy is generally credited to Fritz Perls and not his partner, Laura Perls8.

7
For what remains one of the most cogent explanations of Gestalt psychology, see Koffka (1935/1963).
8
It is generally accepted that Laura was not inclined to write and so published precious little in her lifetime. The
fact that Perls attempted to take single-handed credit for the development of Gestalt therapy is valid given the
biographical accounts versus what is historically known. A telling example is Perls’s first book, an obscure little
work entitled Ego, Hunger, and Aggression (1947/1969), which included Perls’s 1932 psychoanalytic notion of
“oral resistances” and “dental aggression” which was originally co-written with Laura after escaping Europe and
while they were living in South Africa during WWII. The book was revived in 1969 at the height of Perls’s fame
without any reference to his wife.

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 266 Paul Shane and Karin Jordan

Gestalt therapy promotes the belief emphasized by Fritz Perls “…that people must find
their own way in life and accept personal responsibility if they hope to achieve maturity”9
(Corey, 1986, p. 120). The goal in Gestalt therapy is to help the client gain awareness (of the
environment, of knowing and accepting oneself, of making contact) and, therefore, being able
to make more informed and responsible choices (Corey, 2001).
Gestalt therapy is based on the positive view of human nature, specifically, the drive for
humans to develop their creative potential10. Gestalt therapy also emphasizes the importance
of the relationship between both the observer and the observed. Gestalt therapy is
experiential, with its focus being on the client needing to come to terms with his/her actions,
thoughts and feelings when interacting with others (Corey, 1986). Kempler’s therapy is a
blend of concepts and procedures from family therapy and Gestalt therapy. Kempler wrote in
1982 that his model:

…focuses attention on the immediate - what people say, how they say it, what happens when
it is said, how it corresponds with what they are doing, and what they are attempting to
achieve. Regardless of whether discord is found within an individual or is manifest between
two or more persons, treatment consists of bringing discordant elements into mutual self-
disclosing confrontation. The conversational anchor point is the current conflict of the day and
what can be done to resolve it in place of more analytical understanding (seeking why)
orientation. (p. 141)

Kempler believes that the interaction between the client and his/her family, or the whole
system of which they are a part, is important for the client’s growth and development. The
therapist’s active, spontaneous interaction with the client is also important in his/her growth
and development. Gestalt-experiential family therapy is a very personal, as well as a very
powerful family therapy approach with several fundamental concepts: (a) psychological
reality, (b) integration, and (c) encounter. Psychological reality, according to Kempler (1970)
is a combination of the individual person’s experience as well as awareness in the here-and-
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

now. It is through the person’s awareness that they develop a concept of who they are, as well
as about others and the world. These concepts are validated (or not) by the individuals the
person chooses to serve as validators. Therapy can serve as a place in which individuals can
gain awareness that other’s perceptions might be different from their own.
A second concept, integration, in Kempler’s mind, has three meanings. The first refers to
an individual’s identification, recognition, and embracing of one’s own being. Second, it
refers to the psychic assimilation of projected or disowned parts of the personality made
conscious through awareness. Third, there is the notion of the family and its members
experiencing themselves as a cohesive whole. Kempler (1981) wrote, “The goal of
experiential psychotherapy within the family is the integration of each family member within
the family.” (p. 27). This means that through the guidance of the therapist, family members
learn how to interact in ways that are mutually beneficial. The underlying goal is that families
develop the potential to support individual family members’ growth and development.

9
This is also Perls’s own erroneous definition of existentialism, and its overemphasis in Gestalt therapy in the
1960s delayed its exploration and application of intimacy and relationship in a Gestalt context.
10
The emphasis on human growth as a key value in Gestalt therapy derives not from Abraham Maslow (1908-
1970), but from his teacher, Kurt Goldstein (1878-1965). As a young neurologist after WWI, Perls worked
briefly under Goldstein in the latter’s brain trauma clinic for veterans in Frankfurt. See Goldstein (1935/2000)
with a new forward by Oliver Sacks.

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 Two Forms of Gestalt Family Therapy 267

The third fundamental concept of Gestalt-experiential family therapy is encounter, which

can best be described as an encounter with the Other at the boundary of the self; to experience
or meet something novel, new, or unknown11. Therapy serves as a place to experience an
effective encounter. The therapist can model effective encountering and have the client be
part of this experience. There have been a multitude of publications on.

GESTALT COUPLES AND FAMILY THERAPY

Gestalt therapy with couples and families originates in the Midwest of the United States
at the Gestalt Institute of Cleveland, and is a reflection of influences, interests, and concerns
different than those of the Gestalt community of the West coast.

Key Persons

Sonia March Nevis

Nevis was originally trained in Gestalt therapy by the Perlses, Paul Goodman, and Isidore
From. Since 1977, she has been chair of the Cape Cod Couple and Family training program at
the Gestalt Institute of Cleveland. Nevis is currently the director of the Center for the Study of
Intimate Systems at the Gestalt International Study Center (GISC). She founded the Center
with her husband, Edwin Nevis, a Gestalt organizational development trainer and consultant.
She maintains private practices in Boston and in Cape Cod working with individuals, couples,
and families, and providing professional supervision.

Joseph Zinker
Zinker and his family immigrated as European refugees to the United States in 1949. He
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studied psychology and literature at New York University, and graduated from Western
Reserve University (now Case-Western Reserve University). While at Case-Western, he
concentrated in learning theory and clinical psychology. His 1966 doctoral dissertation based
on Maslowian concepts explored the dying process as a growth experience. In 1958, while
still a graduate student, he entered the circle of the early Gestalt therapists in Cleveland and
began studying with Fritz and Laura Perls, Paul Goodman, and Isidore From. This group of
students later founded the Gestalt Institute of Cleveland which remains the largest training
center in the world. Combining his interests in art, creative experiment, and human
movement, Zinker published what remains one of the more influential texts in Gestalt
therapy: Creative Process in Gestalt Therapy (1978). During this period, he worked with
Nevis in developing and teaching the Gestalt approach to couples and family therapy. In
1994, he wrote what is considered by many to be the essential presentation of theory and
practice of Gestalt couples and family therapy (Zinker, 1994). He and the Nevises left
Cleveland in the late 1990s and have continued working on Cape Cod at GISC.

11
The concept is the cornerstone of the dialogical philosophy of Martin Buber (1878-1965) and originates with his
experience as a very young boy of caring for a horse on his grandfather’s farm. See Friedman (1991).

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 268 Paul Shane and Karin Jordan

Joseph Melnick
Melnick, a former university professor trained at the Gestalt Institute of Cleveland, is a
clinical and organizational psychologist who lives in Portland, ME where he maintains a
private practice in couples and family therapy as well as organizational consultation. He is an
internationally-recognized trainer and teacher of Gestalt family therapy, editor of the Gestalt
Review, and is a member of the professional staff of the GISC, and the Gestalt Institute of
Cleveland.

Penny Backman
Originally trained as a nurse, Backman later turned to social work after developing a
fascination with family systems. She traveled the country studying under Salvador Minuchin
and Jay Haley, and co-led training sessions with Carl Whitaker (1912-1995)12. Currently, she
is a trainer at GISC, and has published on the topic of intimacy (Wheeler & Backman, 1994).
As opposed to Kempler, who worked mainly by himself, the Cape Cod model of Gestalt
family therapy was developed through the collaborative efforts of several therapists. Their
influences, however, were not limited to just Gestalt therapy, but included training with
Virginia Satir (1916-1988), Whitaker, and Minuchin.
The Cape Cod Model builds on the Gestalt approach to focus on relationship, generating
a practice for intervening in couples, families, groups and organizations. Incorporated in this
model are many basic Gestalt principles, to which are added concepts developed by GISC’s
Center for the Study of Intimate Systems over the past 30 years. This model supports all
members of a system, including the therapist, viewing growth as development of new
understanding and skills, rather than as changing oneself. Although it originated in work with
couples and families, over the years it has been adapted to work with organizations, most
recently focusing on its application to larger and more complex systems. This approach has
several unique characteristics (Melnick & Backman, 2000; Melnick, Nevis, & Nevis, 2006;
Nevis, Backman & Nevis, 2003).
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• Its stance is very optimistic. It seeks to increase awareness of what people do well
and what their strengths are.
• It assumes that people are doing the best they can at any given time.
• Influence is directed toward enhancing awareness of how people relate to each other,
recognizing the process of a relationship or a group, and one’s contribution to that
process.
• Issues such as power, hierarchy, intimacy, cultural differences, and resistance to
change are best understood as occurring in relationship, as opposed to being
attributes of individuals.
• An appreciation for the creative potential of multiple realities and teaching people
how to appreciate differences to minimize conflict.
• Behavior can either be strategic, meant to achieve a goal, or intimate, intended to
enhance connection among people.

12
See Whitaker (1989).

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Two Forms of Gestalt Family Therapy 269

HEALTHY VS. UNHEALTHY/DYSFUNCTIONAL

Healthy Functioning

Conscious Awareness of One’s Experience within the Family System

Awareness within the Gestalt context was originally defined as “…characterized by
contact, by sensing, by excitement, and by Gestalt formation. Its adequate functioning is the
realm of normal psychology; any disturbance comes under the heading of psychopathology”
(Perls, Hefferline, & Goodman, 1951, p. viii). As the previous passage strongly implies, the
cardinal principle of Gestalt therapy—indeed, it is the raison d’etre—is that awareness in and
of itself is healing. The notion of awareness occurring in a cycle of formation, resolution, and
re-formation was first posed in Perls, Hefferline, & Goodman (1951) and later elaborated by
the Cleveland school of Gestalt therapy in Polster & Polster (1974) as the “cycle of
experience.” The cycle of experience can be envisioned as a circle of sine wave of actions: (a)
awareness of something, (b) mobilization of energy, (c) action, (d) contact, (e)
resolution/closure, and (f) withdrawal from contact and formation of a new awareness. As a
psychotherapeutic ideal, how a person moves through the cycle—i.e., how fast or slow or if
there are interruptions or fixations at any phase—indicates the degree of individual awareness
and psychological functioning. The work of Nevis and Zinker took this cycle and applied it in
interactive relationship within couples and families to show how relational systems move
through the cycle when transacting business within them. How the cycle of awareness is
manifested within family members and within the system as a whole is a fundamental aspect
of how Gestalt family therapy defines “family process.” Given his artistic background, Zinker
tends to view family interactions using the cycle of experience as one “aesthetic” lens.
When a family as a system lacks the skills to manage change and conflict, or when its
process is fixed rather than fluid, then family members—as individuals and a group—become
troubled. The system as a whole tends to exhibit anxiety as energy detached from awareness
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

and action. Healthy functioning is a function of the awareness and interest of individual
members of not only their own needs and wants, but those of their fellow family members as
well. Positive changes in awareness tend to lead to more efficient and satisfying interactions,
especially as interruptions and resistances to contact within the cycle of experience are
engaged and changed.

Healthy Relationships Are a Function of Good Interpersonal Contact

Contact is the awareness of a difference—once termed by Goodman (Perls, Hefferline, &
Goodman, 1951) as the “novel”—at the boundary of contact between an organism and its
environment. Contact carries with it qualities of energy (excitement) and “intentionality” in
the Husserlian sense.13 Contact is the moment of the meeting between two boundaries—two
persons—and the place where interpersonal business is exchanged. Good contact is marked
by energy, heightened awareness, insight, understanding, satisfaction, and the visceral
experience of touching and being touched by another. Poor contact is marked by feelings of
superficiality, being rushed or forced, incompletion, and dissatisfaction or confusion.

13
Edmund Husserl (1859-1938), the founder of phenomenology, adapted the notion of intentionality from his
teacher, Franz Brentano (1838-1917)--who borrowed it from the medieval Scholastics--that consciousness is
always directed toward something—it always has an object—thus possesses intention.

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 270 Paul Shane and Karin Jordan

Balance between Healthy Dependence and Independence

According to Gestalt family therapy, a healthy family is one in which individual family
members receive support. It is also a place where they are accepted for who they are, which
includes accepting their differences from the rest of the family, and the ways they function.
Family members achieve individuation (individual growth and sense of self), when they can
express their desires and autonomy within a relational space of love and commitment.
Healthy functioning not only means reaching individuation, but also that individual family
members develop vital relationships with other family members (Hatcher, 1978; Kaplan &
Kaplan, 1978).
The balance of health in the family system is also reflected in the judicious and mature
sharing of power among the various members and subsystems. Strong discrepancies in power
can lead to abuse, rigidity, and stagnation. Naturally, the holding of power is an adult
responsibility until children reach the appropriate level of maturity.

The Family Is a Holistic Event with Myriad Relationships that Support its Life,
Growth, and Self-expression
Every part of the family lives in relation to every other (including those who are deceased
or physically distant); plus, the family itself is part of the greater system of its community.
Each healthy families—as well a dysfunctional one--has has a unique “we-ness” in relation to
itself and the outside world.

Unhealthy/Dysfunctional

Family Dysfunction is Often Caused by Poor Boundaries—either too Rigid or too

Permeable-- between Members or the Family as a Whole in Relation to the Community
According to Nichols (1984), the presence of dysfunction is found in individual family
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members who often avoid expressing their feelings, as well as intimacy. According to this
theory, dysfunctional families generally emphasize togetherness and loyalty, with both being
more important than focusing on individual family members’ needs. On the other hand, the
opposite type of family system is also dysfunctional: one whose boundaries are too
permeable, such as those of families wounded by divorce, poverty, criminal behavior, mental
illness, or substance abuse. Certainly, any individual member “becoming lost in the crowd” of
a family with an inflexible structure, so to speak, is a cause for alarm and intervention.
Conversely, with the too-permeable system, members and outsiders come and go in kind of
chaotic free-for-all. Gestalt family therapy frames this type of situation and the necessary
intervention strategies in terms of boundaries and their management.

“Stuckness” in the System: Inflexible, Repetitive Family Processes

According to Kempler (1973), the “stuck process” in one family member can best be
described as, “Ouch! I have a pain in my family,” (p. 19). Kempler (1982) explains,
“…symptomatic behavior tells us that a person has a stuck process somewhere inside that
obstructs his integrated flowing; that the undulating flow of some process has congealed and
the two poles are deadlocked.” (p. 155). More specifically, it means that the family has not
been functioning as a resource for the individual family members so that they can grow. The

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Two Forms of Gestalt Family Therapy 271

family is therefore perceived as being dysfunctional, in that they are not able to help the
individual family member who is “stuck” to get “unstuck.”
Many of these stuck processes are due to family members essentially being incompetent
in communicating their needs and wants; they are poorly educated in the art of family life.
Second, these stuck processes are often transmitted from one generation to the next as a kind
of “family style” (dysfunctional as it might be). Finally, and most importantly, there might be
awareness of the problem within the system (to varying degrees), but a definite lack of
awareness as to how to correct the system.
In closing, what does a “healthy” family look like through the theoretical lenses of
Gestalt family therapy? Zinker (1994, p. 84) delineates seven essential qualities:

1. Clear flexible boundaries that enable “graceful contact.”

2. Expression, toleration, and appreciation of differences among members.
3. Mutual support and encouragement.
4. Mutual respect and loyalty; an appreciation for their own struggles and the struggles
of others.
5. The ability to stay in the present and complete interpersonal transactions while being
able to identify interruptions to awareness and contact.
6. The strength and wisdom to persist in life’s difficulties, while knowing when to let
go.
7. Genuine curiosity about one another’s feelings and views while being able to
creatively change when circumstances call for it.

THE CHANGE PROCESS

Change
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In Gestalt therapy, change can only occur after one accepts who one is, rather than what
one is not. That is, change is blocked by lack of awareness and ownership (i.e., denial,
repression, projections, etc.) of one’s problem, and occurs naturally and spontaneously after
the problem is accepted; in some ways akin to the AA model of “hitting bottom.” This is the
“paradoxical theory of change,” originally proposed by Beisser, and has been absorbed into
mainstream therapeutic practice sans acknowledgement.14 Therefore, a key technique in
Gestalt family therapy is for the therapist to effect change by supporting the resistance to
change in others, and there are a variety of ways—directly and indirectly--to pursue this end.
In considering the change process, it is important to remember that in Gestalt family
therapy, the family--consisting of two or more persons--is the client; as such, the family as
system is greater than the sum of its members and has a distinct personality of its own. Zinker
(1994) calls this the “third person” of the system; i.e., the relational space of the dyad or
family itself. The Gestalt family therapist acts as the catalyst for change by encouraging

14
The notion apparently originates with the Greek poet, Pindar (518?-438? BC) and was borrowed by Nietzsche, a
major influence upon Fritz Perls, in the former’s The Gay Science (1974). A similar notion turned into a
technique was also developed by Viktor Frankl (1905-1997) and called “paradoxical intention.”

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 272 Paul Shane and Karin Jordan

individual family members to interact in new ways that increase awareness that, in turn, leads
to healthy contact. The therapist acts as a guide or coach in helping them through the process.
Change, according to Kempler (1981), is based on a completely honest interaction
between the family therapist and the family, but also among family members. According to
Nevis, however, the therapist must teach the family members how to tell the truth; i.e., as
Zinker (1994) would put it, there is a “good form” to telling the truth. Indeed, one of the main
problems is that family members have been telling each other the truth for years without
positive results because how they had been telling the truth undermined good open contact
and the positive reception of the communication. Telling the truth with bad intentions or in
poor form negates the value of truth as a force for positive change within the system.
Therapy provides an opportunity for the family/family members to engage in an intimate
personal experience, which leads to greater awareness of one another’s experience and, in
turn, results in change and growth. In the session, focus is on what each family member is
experiencing from moment to moment in the therapy session. The change process does not
occur because the Gestalt family therapist tells the clients why they act the way they act, or
because they focus on historical reports provided by the clients. (To do such a thing would be
an unhealthy imposition of power, an unwanted psychic artifact in the psychological space of
the family, and would shut down any possibility for new awareness regarding the issue as
“the expert has spoken.”) Each client is asked to become aware and own the feelings they
experience as they experience them in the nowness from moment to moment.
If a client tries to avoid these experiences, the Gestalt family therapist will engage them
as to their experience of resistance.15 In Gestalt therapy, resistances are not framed as ego
defenses in the Freudian sense, but more as means to block or diminish awareness and
contact in the present moment. One major aspect of family dynamics in the Gestalt view is
the nature and variety of resistance styles used within the system. As with individuals, family
systems are marked by chronic patterns of resistance. In Gestalt therapy, there are a number
of resistances including:
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• Desensitization: family members interact superficially with little interest; there are
unspoken assumptions of predictability of the other’s behavior; there is little or no
listening to one another; members appear bored, uninvolved, or intellectually asleep.
• Projection: filling in information for another or acting for another without first
checking to see if the information or action is wanted or needed, with passive
complicity on the part of the other; family relationships appear stereotyped, lack
variation, and have a lethargic energy; agreements are made, but rarely kept, or
subtly sabotaged.
• Introjection: the “lazy” system’s way of avoiding contact; typically a dominant
personality force-feeds information or actions on the group; the system is rule-bound,
although no one can usually remember when or how a rule came about; great
conformity among members.
• Retroflection: the inversion of energy into the source rather than releasing it outward;
family members tend to turn inward on themselves, become isolated, and each tends

15
The term “resistances” carries with it the unconscious implication that these are phenomena that the therapist
must somehow overcome, and this was a basic belief in the early course of Gestalt therapy. Contemporary
Gestalt therapists in the Midwest and East coast now tend to think in terms of “contact styles,” a far less negative
and potentially provocative frame of reference. See Wheeler (1991) for the original exposition.

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 Two Forms of Gestalt Family Therapy 273

to act independently of the others; emotions are withheld; while all seems calm on
the surface, the system is under intense pressure.
• Deflection: the communication style within the system is to avoid anxiety-provoking
topics or situations, but changing the subject or re-directing attention;
communications tend to ricochet off of one another; the system unconsciously
collaborates to not complete business; boundaries are vague; there is much “crazy-
making” within the system given its ineffective and convoluted communications.
• and Confluence: the premature jumping to agreement or knee-jerk actions to avoid
conflict; the essential style for minimizing or negating differences within the system;
there is a tendency for poor decision-making as there is always little relevant
discussion; confluent families also tend to be retroflective.

Once the resistances to contact are explored and resolved, there is an increase in honest
and ongoing exchange of thoughts and feelings; gradually, as the experience of individual
members changes, so too does overall change in the system as a whole. In addition, during
this process each client/family member (including the “identified patient”16) becomes aware
of how they influence one another; i.e., the degree of awareness within the system rises. It is
within this context that family members become gradually more in touch with themselves and
with their subjective and shared realities.

Therapeutic Environment

The therapeutic environment, according to Kempler, is one in which the Gestalt family
therapist is being real with the client(s). He/she knows him/herself in regard to what his or her
needs are, and who he/she is, throughout each moment of the therapy session. During this
process, the therapist helps individual family members to engage in self-exploration,
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spontaneity and risk taking, all of which serve to encourage self-discovery and help families
deal with fears of self-disclosure. It is an attempt to help clients experience that they can be
self-disclosing within the context of family therapy/the family, and not only in front of the
therapist, since self-disclosure does not have to be dangerous (Kempler 1982). The type of
assistance the therapist provides is through the development and execution of behavioral
17
“experiments” in which key family members play a part as needed.
The focus in Gestalt family therapy is on the here-and-now. The effective therapeutic
encounter, according to Kempler (1981), possesses several key characteristics:

1. A clear knowledge of the “who I am” at any given moment. This requires a dynamic
awareness of what I need from moment to moment.
2. A sensitive cognition or appraisal of the people I am with and the context of our
encounter.
3. The development and utilization of my manipulating skills to extract, as effectively
as I am capable, what I need from the encounter. This aspect is expressive.
16
The concept of the “identified patient” is considered pathological in Gestalt family therapy; there is no “sick” one
in the system, only an individual member who has been consciously or unconsciously shouldered with the burden
of carrying the sickness of the family as a whole by the other family members.

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 274 Paul Shane and Karin Jordan

4. The capacity for finishing an encounter (p. 38).18

In the Cape Cod model, there is no attempt at interpreting or explaining to families why
they act the way they act. Focus is placed on helping clients gain insight through increased
awareness and more conscious contact by (a) examining their current chronic behavior
patterns, and then (b) experimenting with behaving differently with one another. The family
process itself—how it is--in the moment is the focus of change; the content of its issues—
what it is dealing with—is of far less importance. Historical information and memories, while
valuable content and reference points, are irrelevant in promoting change.
Another tactic that assists in the change process is the therapist’s motive to create enough
intensity to create a “treatable crisis” (Kempler, 1967). It is during this time that the therapist
creates a meaningful connection with the family/family member by being genuine, even
somewhat provocative, honest and uncompromising when interacting with the client(s).
Kempler believes that such forceful behavior on the part of the therapist motivates the
family/individual family member as a way to reach one another, and, therefore, encourages
not only full participation, but also full personality expression of each family member.
However, in situations of family violence, there is an exception made to this expression,
to avoid potential escalation. The extent of the therapist’s involvement with the family within
its system in the therapy situation may be one aspect in therapeutic style that differentiates
Gestalt-experiential family therapy from Gestalt family therapy. In the latter, the therapist
maintains firmer boundaries with an emphasis on support and alliance with the family rather
than provocation and confrontation; a small, but crucial distinction.19

THE THERAPEUTIC PROCESS

Assessment
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Assessment focuses on the here-and-now in Kempler’s method. Therefore, assessment

focuses not on gathering family of origin information or exploring future goals. Kempler
believes that the issue first presented during the assessment is not the real issue, but rather is a
signal of the pain in the family (Kempler, 1973). Assessment focuses on the family rather
than the individual, as the family is the client who can either produce pain (pathology) or
resolve problems (health). The assessment process starts with an interview of the family about
their direct interpersonal experience, and not their intellectual knowledge, by listening to the
clients and watching them interact. This is also a time when both the family and Gestalt-
experiential family therapist bring themselves forth to resolve the presenting problem.

17
To see how creative experiments are devised and conducted in Gestalt therapy, see Zinker (1978).
18
It must be pointed out, however, that while Kempler emphasizes these four qualities as being essential for effective
transactions at the interpersonal boundary, they are inherent in any moment of good contact between two or more
individuals.
19
The crux of the matter is in what Zinker (1994) calls the “presence” of the therapist. His view is that a therapist
must be present as a witness to the system, a concerned “being with” rather than a “doing to.” His view, while
almost spiritual in its implications, to our minds points to the Taoist concept of “wu-wei” or non-action. That is,
the aim of the therapist’s presence is to evoke rather than to provoke in the old Perlsian style of Gestalt therapy.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Two Forms of Gestalt Family Therapy 275

Kempler (1973) also believes that the original problem presented is generally not the real
issue, but rather is representative of the pain that the family is experiencing.
In a kindred spirit, but in a different style, the Gestalt family therapy model of Cape Cod
approaches the system in a gentle, yet systematic way (Zinker, 1994). One typical session
might follow this pattern.

1. Make small talk and welcome the members.

2. Ask each individual to describe how he or she experiences the family’s problem.
3. Observe the members’ behavior with one another.
4. Offer a major intervention that names a theme and a strength of the family.
5. Discuss the theme/strength, and suggest the family needs to learn a new skill or
refine and existing one.
6. Suggest an experiment and discuss how it could be executed to obtain group
consensus.
7. Conduct the experiment and observe the members in action with new behaviors, and
support them when they become stuck.
8. Have each member describe what they experienced, learned, and see if are willing to
practice their new skill at home (p. xxxi).

It is seen here that the Cape Cod approach values supportive, collegial relations between
therapist and family, and aims at supporting awareness in all steps, but especially in steps 5,
7, and 8; the promotion of self-responsibility underlies steps 2, 6, and 8. It is also important to
note that the “theme” proposed by the therapist always includes the system’s hidden strength.
The creation of hope, confidence, and an appreciation of self-competence are inherent goals
in the Cape Cod model.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Treatment Goal

The treatment goal of Gestalt family therapy is to increase awareness of the family’s
process as the via regia to positive change and healing. Typically, families are not aware of
their own process. They are not aware of its tempo, rhythm, cognitive flow, its energies, or
relational contours. They are, however, very much in contact with their own day-to-day
content: chronic problems, everyday business, routines, and whatnot. More deeply, however,,
they are in contact with their unspoken pains, frustrations, and fears. Often families present a
vague, but heartfelt statement that “something just isn’t right anymore” indicative of the
system’s underlying despair.
As the system’s awareness of its process is unknown to its members, so too it is unknown
to the therapist. As each family member talks about what is going on for him or her, a figure
of awareness begins to slowly grow and evolve within the group; likewise, as the therapist
sits witnessing the interactive exchange, a figure of awareness slow develops and, when it is
ripe, he or she shares it with the family. Such interventions are aimed at widening the family’s
group awareness, highlighting something that was lingering in the group’s unconscious
background, and then exploring it and digesting it in detail. Zinker (1994) offers some
“aesthetic” goals that therapist aims at in attempting to move the family from:

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 276 Paul Shane and Karin Jordan

1. pessimism to hope;
2. helplessness to increased competence;
3. confusion to clarity;
4. futile, repetitive motions to a feeling of direction for future movement
5. mutual blaming and projection to self-responsibility and appreciation of one
another’s dilemmas, struggles, and pain (p. 28).

In situations where there is a specific problem with a single member, the family engages
in therapy because they have not been able to mobilize their assets to help the member that is
“stuck” become “unstuck. Rather than focus on the “problem” member, the focus is on the
system as a whole, perhaps offering a thematic metaphor of the situation for group
exploration.
Conversely, the goal of Kempler’s model is to help the family establish (or re-establish)
the ability to serve as a resource for individual family members to work toward well-being
and continuing skill development. Kempler aims to help each client recognize, appreciate and
express his or her personal sense of meaning.

Process of Therapy

The process of therapy in the first session involves gaining an understanding of what each
client/family member wants and from whom they want it. During this process of gaining
understanding, the Gestalt family therapist asks the family members to be as specific as
possible. They might also encourage the client to not only talk to him/her, but often will
encourage the client/family to interact with the therapist, but this is done more often in the
Kempler model. Cape Cod model relies mainly on observing within-group interactions while
therapist involvement is kept to a minimum.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

When individual family members are hesitant and/or hopeless about talking to each other,
the emotions of hopelessness and hesitations are explored. The Gestalt family therapist
generally sets some basic ground rules for the family and him/herself, during the first therapy
session, which includes such things as: self-disclosure, openness and honesty. The Cape Cod
model also includes these parameters, but also touches upon the need for mutual respect,
patience, and effective listening; often these skills need to be formally taught, or generally
modeled by the therapist.
In both models, however, there is a need for an honest and complete encounter between
family members and with the therapist, as individual’s perceptions might be different from
those of others. Focus is present-centered when dealing with ineffective behavioral patterns
(i.e., process), and not on historical reports or memories (i.e., content).
In future sessions, Kempler likes to focus on individual family members to help them to
achieve individuation along with promoting relationships among various family members.
Again, as has been mentioned earlier, this focus on individuation and personal power was a
central feature of Fritz Perls’s approach to therapy, or the West coast style. The Midwest and
East coast schools of Gestalt therapy value individual expression, but balance it with the
values of mutual contact and support for deepened relationship.
Kempler values the qualities of spontaneity and courage in the therapist so as to take risks
while engaging in self-exploration early on in the therapy process to role model that behavior
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Two Forms of Gestalt Family Therapy 277

to the clients. He/she is being “real” with the family by expressing emotions and feelings, and
encourages clients to do the same.20 It is through this process of being real, when new
behavior is used, and not when insight was gained, that growth occurs. There are, of course,
limitations to this type of therapist style and the “Fritzian” West coast manner has long been
known for its extremely assertive, confrontational, free-wheeling manner. This style may be
appropriate in family situations where there are dominant members who must be confronted,
but, for the most part, the style itself is limited. The East Coast style can be just as
confrontational, but only as the situation calls for. Most family systems have been
traumatized or have had bad experiences with authoritarian figures. One cannot effectively
use a confrontational method without having first established mutual trust and respect which
can only come about after establishing the therapeutic alliance.

Techniques

According to Kempler (1968), in Gestalt-experiential family therapy there are “no

techniques, only people” (p. 99). More specifically, Kempler (1981) wrote:
…no technique “works.” There is no behavior that, of itself, is therapeutic.
All rules or actions must be filtered through the therapist-person to emerge
tailored to the context. The most therapeutic intervention is the total and
current pertinent “I” statement imparted so that it will be experientially
heard. (p. 227)
As opposed to other forms of Gestalt therapy applied to couples and families, Kempler’s
Gestalt-experiential family therapy is markedly “therapist-centric” in that it values the
therapist as a strong, assertive member of the system with a relatively thin boundary between
his/herself and the system. Consequently, strength of personality and therapist’s own personal
characteristics play a central role in effecting therapeutic change. The Gestalt-existential
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

family therapist not only stays in the present, but also uses his/her total personality when
working with clients, by emphasizing such qualities as:

• Self disclosure-both the Gestalt-experiential family therapist (as a role model), as

well as each family member, is asked to self disclose what they experience moment
by moment in the therapy session. Openness and self-disclosure is valued in the Cape
Cod model—indeed, it’s the cornerstone for any type of psychotherapy—but only
when the awareness, self-responsibility, and proper support has been generated.
• Open and honest exchange-both the Kempler and Cape Cod methods engage with the
family by being open and honest in what they experience in the therapy session.
• Active attentiveness-both the Kempler and Cape Cod models give verbal and/or non-
verbal responses, as well as makes comments (although these are aimed more at
provocation in Kempler’s approach) or give personal reflections. The therapists in
the Cape Cod model also share how they are being affected by the family’s

20
The concept of “authenticity” as used in psychotherapy is a particularly knotty issue. As used in Gestalt therapy,
it originates in Jourard’s studies of self-disclosure, but then becomes melded with the “let it all hang out” value
of the 1960s that became an excuse for all sorts of irresponsible behavior and acting-out. The notion originates in
existential philosophy where it is actually a technical principle, and usually confused with “sincerity” in the
minds of both the general public and psychotherapists.

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 278 Paul Shane and Karin Jordan

interactions, and might, if appropriate, share some of their thinking as to their

strategies for intervention.
• Self-exploration-Both the Cape Cod model and the Kempler approach support
sharing by the therapist as to what he/she is experiencing moment by moment of the
therapy session because this kind of modeling demonstrates to the clients that it is
safe to do this kind of risk taking.
• Spontaneity-the Gestalt-experiential family therapist and the family’s subsurface
materials (which might be any topic) are allowed to come into the therapy session.
• Intensity- the Gestalt-experiential family therapist must present with enough intensity
to create a “treatable crisis” (Kempler, 1967). Of course, this is only applicable
where the creation of a “crisis” is deemed therapeutically necessary. The Cape Cod
approach uses the application of creative experiments that promote tolerable “mini-
crises” in a safe and manageable context.21
• Present experience-the Gestalt-experiential family therapist focuses on immediate
perceptions and concerns. History is only addressed if it is brought up spontaneously
and can help with the family or family members’ present ability to function.
• Tolerance- the Gestalt-experiential family therapist is accepting of differences of
feelings, perceptions and behavior of the family members.
• Willing to take risks-following closely in the footsteps of Fritz Perls, Kempler values
the willingness on the part of the therapist to not simply take on the role of being the
therapist, but rather is fully present by sharing personal observations or making
provocative statements. The Cape Cod model, on the other hand, tends to view this
as being too-risky of an intervention, and, at worst, a demonstration of poor boundary
management on the part of the therapist.
• Challenging, emotionally intense, assertive, courageous and frank-consequently,
Kempler’s style can be challenging, emotionally intense, assertive and, at times,
brutally frank about what he/she is feeling moment by moment in the process of the
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

therapy session, in the hope that it will impact the family. The Cape Cod model tends
to eschew such extreme interventions, valuing not intensity, but evocative change
through partnership, support and awareness.

We now turn to examine in more detail how interventions are formed and presented
within the system from the Cape Cod approach. First, interventions are difficult for many
therapists to devise because the amount of information they are witnessing is so complex.
They can be better understood if one has a lens or frame-work within which to view it. One
lens used by the Gestalt family therapist is to (a) observe the strengths and weaknesses of the
family system and its members. Second, the therapist (b) focuses on the process of the
interactions rather than the content. Third, (c) he/she looks for the obvious imbalances in the
system: polarizations of power, opinion, actions, etc. Lastly, (d) the therapist looks for actions
and relationships that are complementary as these relationships tend to share system functions
or mirror undeveloped sides of the personality within one another.

21
The concept that the purpose of therapy is to create a “safe emergency” originates with Paul Goodman’s
theorizing in 1951. The concept is greatly emphasized in the West coast style of psychotherapy, and there is the
danger of creating emergencies that overwhelm rather than mobilize and educate. As an aside, however, the
notion can be traced back to the existential philosophy of Karl Jaspers (1883-1969) with his notion of personal
crises as “boundary situations.”

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 Two Forms of Gestalt Family Therapy 279

Interventions made by the therapist are made with energy and confidence, and are always
based on phenomenological evidence of the group’s behavior. These observations always
describe what is concretely there, includes all the members (either overtly or tacitly), and
implies a potential action or direction out of the problem situation.
The role of the therapist is decidedly different in the Cape Cod view as it values the
therapist as a supportive presence who makes interventions to increase the awareness and
interests of the family’s members in their own group process, and posing creative experiments
to safely and responsibly explore new behaviors. What qualities make for an effective
therapist in the Cape Cod model? Zinker (1994) offers the following:

1. Respect for the clients’ experience as it is.

2. Positive regard for every “symptom” as a creative effort to restore systemic balance.
3. Support for disagreement with the therapist as a sign of healthy power and self-care.
4. Support for individual and group resistance.
5. Establishing and maintaining clear boundaries and sets clears rules and limits.
6. Support for competence by acknowledging what the members do right.
7. Provide a safe environment in which even the worst behaviors can be safely
acknowledged and explored.
8. Have compassion for both the victim and the victimizer.
9. Provides protection for members until they are able to find their own power.
10. Takes a stand against abusive behavior.
11. Respect and curiosity for the family’s history and ethnic roots.
12. Models being a good patient and teacher (p. xxvii).

STRENGTHS AND LIMITATIONS:

GESTALT-EXPERIENTIAL FAMILY THERAPY (KEMPLER)
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Following the principles of Gestalt therapy—(as well as those of the Tao)--it is

understood and appreciated that every strength carries within it a weakness and vice versa.
We now examine both the Kempler and the Cape Cod orientations.
In Kempler’s Gestalt-experiential family therapy approach, the therapist is seen as being
totally involved with the clients in the therapy process. This can be viewed as both a
limitation and a strength. There might be fear that some therapists will be so involved that all
objectivity is lost. In addition, total involvement can be problematic if the therapist is not
tolerant of differences and/or does not acknowledge his/her mistakes and/or is not self-critical
and/or does not understand others. On the other hand, the total involvement by the Gestalt-
experiential family therapist can be seen as a strength, as he/she serves as the catalyst that
encourages individual clients to be more open and direct, even confrontive. It is active
participation by the Gestalt-experiential family therapist that is believed to be the catalyst for
change, by being totally involved in the therapy process.
A second strength is that through the Gestalt-experiential family therapist’s involvement,
there is an opportunity to develop an effective therapeutic encounter of free floating affect,
safety and caring between the therapist and the client(s). Given that Kempler’s approach is
such a close reflection of Fritz Perls’s group therapy format in which individual members

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 280 Paul Shane and Karin Jordan

took turns working directly with the therapist, it may be more appropriate in family systems
that are highly dysfunctional, chaotic, and unstable.
In addition, the lack of any prescribed technique might be a limitation in that it provides
fewer tactics for the therapist to encounter with the client(s). However the strength of not
using techniques, unlike other theories, results in Gestalt-experiential family therapists
following their immediate perceptions and creating an opportunity for doing therapy that is
experiential. Dealing with the here and now can be viewed as a limitation in that there is a
lack of not having reference to the outside environment or historical perspectives, however it
can also be viewed as a strength, in that the focus on the here-and-now creates an opportunity
for the client(s) to experience new or different behavior, versus gaining insight at that
moment. This is especially important if different behavior is perceived as growth.
Kempler’s method is effective because the therapist is free to engage with the system at
the individual and group basis with great power, vigor, and authority. Consequently, change
does occur and the method is considered productive, but change is had at a definite price; i.e.,
change can be rapid, dramatic, and often quite anxiety-provoking, and the system may be
temporarily destabilized, and will need time between every therapy session to integrate what
it has experienced. On the other hand, and depending on the character of the family system,
such a powerful and aggressive approach may result in feelings of being overwhelmed,
discounted, ignored, and passive-aggressive resistance.
More so, and this is a critical caveat, because the method is intuitive it requires the
therapist to be highly trained, skilled, and competent. A novice therapist should not use this
method unless he has been extensively trained, is being directly supervised, or working in
partnership with a senior therapist.

GESTALT COUPLES AND FAMILY THERAPY

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Next, the contrasting view of the Cape Cod model of Gestalt Couples and Family
Therapy is presented. The summary difference between the two styles is (a) the power and
role of the therapist and (b) how the therapist interacts with the family system. In the Cape
Cod model, the therapist plays the role of a partner or coach or interested bystander with the
energy of a “friendly uncle or aunt.” The therapist’s commitment is to the health of the
system as a whole. Clearly, power is shared, except in those cases where rules and limitations
need to be set and enforced. The therapist does not directly engage within the family system
as a participant unless it is appropriate and welcomed. The strength here is that the therapist
works within the context of a gentle, therapeutic alliance.
Second, his or her interactions are confined to witnessing group interactions, making
insightful observations about process, and suggestions for possible experiential experiments
to bring new awareness to chronic problems and fixed ways of relating to one another. Also,
the therapist is there to support the strengths and competence of the system and its members,
while modeling good functioning his/herself.
The strengths of this approach is that change is organic, relatively gradual—sometimes
punctuated by moments of sudden dramatic insight—and always supported by heightened
group awareness and consensus. Given its gentler, and more respectful way of working with
the family system, it is most likely is not applicable for highly dysfunctional families as it

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Two Forms of Gestalt Family Therapy 281

requires a minimal degree of competence among family members to be effective. Individual

therapy is usually not performed within the family therapy sessions—although short pieces of
work are sometimes appropriate—as individual therapy is viewed as being more appropriate
in private sessions.

SUMMARY
This chapter is intended to capture not only two basic means of applying the Gestalt
approach to working with family systems, but also to provide information about those who
have developed it over the past four decades. The focus was divided between the work of
Walter Kempler, a Gestalt therapist based on the West coast, and originally trained under
Fritz Perls and his protégés. He, unlike Fritz Perls (who used Gestalt therapy with individual
clients in a group format) saw its viability when working with families. Furthermore, the
importance of staying in the here-and-know was emphasized, a very important tenet of
Gestalt-experiential family therapy. In addition, the role of the Gestalt-experiential family
therapist taking an active stance and being the catalyst for change, using his/her total
personality rather than techniques was addressed. More specifically, the basic belief in
Gestalt-experiential family theory is that focus needs to be given to people, rather than a
preconceived model of therapy.
The focus of this chapter also included a related and parallel form of Gestalt family
therapy, but one that arises from sources other than Fritz Perls, that is, the other co-founders
of Gestalt therapy—Laura Perls and Paul Goodman—and was developed in the Midwest and
East coast by Sonia Nevis, Joseph Zinker, Penny Backman, and Joseph Melnick. This is
known as Gestalt couples and family therapy—or the “Cape Cod model”—and qualitatively
differs from Kempler’s method even though both arise from the same historical and
theoretical ground. The main goals of Gestalt family therapy are the heightening of awareness
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

of the group on the individual, subsystem, and system levels. This is done through
observations about the group’s process--not content--and the application of creative
experiments in which members can explore undeveloped aspects of their personalities, and
engage in new behaviors regarding old problems. These experiments, however, are not forced
on the group, but conducted after the group has voiced its approval and interest. The role of
the therapist is that of a supportive observer or coach and the focus is exclusively on group
dynamics rather than the therapist; the therapist’s role is far less intrusive and more subtle
than “traditional” Gestalt therapy as practiced by Fritz Perls and his later students on the West
coast.
In all, it is hoped that this chapter provides the reader with a sense of two very powerful
experiential approaches to family therapy.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 282 Paul Shane and Karin Jordan

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Research and Practice, 4(4), 166-172.

Kempler, W. (1968). Experiential psychotherapy with families. Family Process, 7(1), 88-99.
Kempler, W. (1970). A theoretical answer. Psykologen. Costa Mesa, CA: Kempler Institute.
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Hogan (eds.), Family therapy: An introduction to theory and technique (pp. 336-346).
Monterey, CA: Brooks/Cole.
Kempler, W. (1973). Principles of gestalt family therapy. Costa Mesa, CA: Kempler Institute.
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counseling and therapy. Itasca, IL: F.E. Peacock.
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Melnick, J., Nevis, S., & Nevis, E. (2006). Organizational change through powerful micro-
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Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 In: The Quick Theory Reference Guide ISBN: 978-1-60021-624-4
Editor: Karin Jordan, pp. 285-298 © 2008 Nova Science Publishers, Inc.

Chapter 20

EMOTION FOCUSED THERAPY

Alberta E. Pos and Leslie S. Greenberg

Emotion focused therapy (EFT), also known as process experiential therapy (PE) (Elliott,
Watson, Goldman, & Greenberg, 2004; Greenberg, 2002; Greenberg, Rice & Elliott, 1993;
Greenberg & Watson, 2006; Johnson, 1996) is an empirically supported humanistic treatment
that views emotions as centrally important in the experience of self, in both adaptive and
maladaptive functioning, and in clinical change. As opposed to cognitive and psychodynamic
approaches that focus more on reasoning, insight, and conceptual understanding in promoting
clinical change, EFT proposes that emotions themselves have an innately adaptive potential
that if activated can help clients change problematic emotional states or unwanted self
experiences. This view of emotion is based on the belief, now gaining ample empirical
support, that emotion, at its core, is an innate and adaptive system that has evolved to help us
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

survive and thrive. Emotions are connected to our most essential needs. They rapidly alert us
to situations important to our well being. They also prepare and guide us in these important
situations to take action towards meeting our needs. As a therapy, EFT’s most general aim is
to help clients become more intelligent in relating to and using their emotional experience
(Greenberg, 2002). Clients are helped to better identify, experience, explore, make sense of,
transform, and flexibly manage their emotions. As a result, clients become more skillful in
accessing the important information and meanings about themselves and their world that
emotions contain, as well as become more skillful in using that information to live vitally and
adaptively.

KEY CONCEPTS

Nature of Persons

EFT is an integration of person-centered, gestalt, and experiential therapies, within a

theoretical frame that also includes contemporary constructivist and dynamic views on human
functioning. Added to these influences, is a specific theory of emotional functioning that has

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 286 Alberta E. Pos and Leslie S. Greenberg

been informed by both clinical and neuropsychological research on emotion. As such, EFT
could best be called a “neohumanistic” theory. The humanistic principals that inform EFT
practice will be discussed first. Following this, the EFT formulation of emotional functioning
will be explicated.

Theoretical Underpinnings

EFT theory incorporates aspects of and therefore shares humanistic-phenomenological

principals (Rogers, 1961, 1957; Perls, Hefferline, & Goodman, 1951) concerning human
nature. Five of these principals are important in EFT.

1. Principle one is that experiencing is the basis of thought, feeling and action. The
gerund, verb-as-noun form, experiencing is intentionally used here, because it best
communicates the constant, dynamic, and active integration of perception, memory,
emotion, sensation, meaning, behaviour, and conceptual thought, that constructs our
experience of a particular moment, and then dynamically and continuously changes
to construct our next moment of experiencing.
EFT views experiencing as the door to an individual’s lived reality. To access
this reality, however, it must be attended to in awareness. From the EFT perspective
individuals are active processors of information who generate their own experience
by attending, not attending, or selectively attending to a variety of sources of
information whether it be sensory-motor, emotional, or conceptual. A central
assumption in EFT is that language plays an important role in the experiences that we
have. In each of us there is a constant dialectic between ongoing bodily-felt
experience and the meaning we give to it by reflecting on it in language. EFT sees
clients’ experience being potentially constrained in two ways. One is by what aspects
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

of experience get into the field of our attention. These will have the potential to be in
our conscious experience. What does enter conscious experience can then be
symbolized in language or image. Linguistic thought orders, explains, interprets, and
makes explicit, parts of our implicit experience. So, in the case of emotion, for
example, while emotional experience is an ever present process, the subjective
experience of emotion will first be constrained by how much we attend to it, and then
by processes we use to symbolize it in awareness, mainly by the language and
narratives we author to explain these experiences to ourselves and others.
2. EFT also views human beings as fundamentally free to choose what to do and how to
construct their worlds. While genetics, biology, and environment constrain human
freedom, they do not eliminate it (Elliott, Watson, Goldman, & Greenberg, 2004).
Therefore EFT views clients as capable of both self-direction and self-determination
and encourage these capacities in clients. Clients are treated as active participants in
establishing the direction of their change process, and EFT therapists do not view
themselves as authorities on their clients’ experience.
3. EFT assumes that human beings are wholes that at the same time are made up of
many parts, or self-organizations, each of which may be associated with quite
distinctive thoughts, feelings and self-experiences. While constituted by many parts,
EFT also assumes that people function best when they have an integrated
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Emotion Focused Therapy 287

understanding of and relationship to all their parts. Achieving this integrated

awareness of ourselves maximizes our potential for personal choice and
adaptiveness. EFT values all parts of an individual and promotes a somewhat
‘democratic’ awareness of all self aspects. In this process of attaining integrated self-
understanding, marginalized aspects of self, are attended to, given a voice, and
explored. In EFT, clients’ experience of conflict is viewed, therefore, as conflict
between different parts, or self organizations, that are associated with different needs,
thoughts and feelings.
4. The fourth is that people function best and are best helped by a therapist who is
psychologically present and who establishes an interpersonal environment that is
empathic, unconditionally accepting, and authentic.
5. The fifth principal is that growth and development are potentially and optimally life-
long processes. When in supportive environments people not only maintain their
coherence but continue to develop more sophisticated and flexible capacity to deal
with what faces them as they pursue important life goals.

The View of Emotion in Emotion Focused Therapy

Emotion is central to this therapeutic approach. Far from solely being the source of
problematic experiences, EFT views emotion as a fundamentally adaptive innate process.
Recent research has shown that emotion alerts us to events important to our well-being, and
both guides and prepares us to take adaptive action to ensure that important needs are
protected, met, or ensured (Damasio, 1994; Frijda, 1986; Greenberg, 2002; Le Doux, 1996).
For example, when faced with a threat in a dangerous situation, fear alerts us to the danger
and organizes us to run away, therefore meeting our need for safety. All human beings have
this innate emotional responding system.
In addition, we know that emotional responses are constructed in the moment by the
automatic and integrated involvement of several component processes. These include:
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

perceptions or appraisals of the situation at hand; bodily expressions such as sensations,

physiological responses and facial expressions; symbolic and conceptual representations in
conscious awareness; autobiographical memory; and motivation related to needs (Scherer,
1984; Elliott, Watson, Goldman & Greenberg, 2004). In EFT, this response, activated within
a situation and synthesized from the coordinated integration of these many components, is
called an emotion scheme. Emotion schemes function implicitly, rapidly, and automatically to
organize our higher order experiences, including self experience. Because they function
implicitly and automatically, emotion schemes themselves are not available to awareness.
However, they can be understood through the experiences they produce, which are available
to awareness, and can be attended to, explored, and made sense of by a process of reflection.
In EFT it is thought that every person has many emotion schemes. Some are universal
innate emotional responses that we all share, others are highly individual, effected by
development, culture, and autobiographical history. A central concept in EFT is that these
emotion schemes are the meaning-producing networks that produce a higher order sense of
self in the world (Greenberg & Safran, 1987). Dynamic syntheses of emotion schemes
activated moment to moment are considered to be at the core of the dynamic changing senses
of ourselves in these moments. In this view then, although we do have recurring self-
organizations these are not conceptualized as static personality structures but as recurrently
synthesized sets of emotion-schemes that generate recurrent experiencing selves.
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 288 Alberta E. Pos and Leslie S. Greenberg

EFT also suggests that emotion schemes whether innate or highly individualistic, can also
be organized into four distinct classes of emotional response. Of these four, only one is
considered truly adaptive. The other three are considered problematic to adaptive functioning.
Primary adaptive emotion responses are uncomplicated and immediate emotional responses
that are consistent with an immediate situation and help an individual take appropriate action.
For example, anger at violation helps one to assertively set boundaries that may prevent
future violation. Primary maladaptive emotion responses are also immediate, but involve
over-learned responses from previous, often traumatic, experiences. Once useful in coping
with a maladaptive situation in the past, they no longer are the source of adaptive coping in
the present. For example it may have made sense for a child to show fear and to hide from
and abusive parent’s caring advances if those advances had always led to being abused by the
parent in the past. However, as an adult, to experience automatic fear at caring and affection
in a loving relationship is no longer helpful, and interferes with healthy bonding. Secondary
emotion responses are emotional reactions to primary emotional experiences. For example, a
man may feel initially afraid in a dangerous situation (primary adaptive) and then feel
ashamed of being afraid (secondary), because he believes it is unmanly. Finally, instrumental
emotion responses are emotional responses that are used to influence and control others.
These may be habitual learned responses, and may or may not be deliberate or conscious.
Using anger displays to intimidate, or sadness displays to elicit help are two common ones.
These distinctions in emotional responding are important because each emotion category is
worked with differently in therapy.

HEALTHY VERSUS UNHEALTHY FUNCTIONING

From the EFT perspective the self is seen as an agent, constantly and fluidly manifesting
itself in response to a particular environmental moment with which the self is in contact
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(Perls, Hefferline & Goodman, 1951). As such, a person is a dynamic responding system
within which a set of internal emotion schemes are continuously being synthesized, forming
and reforming a current "self-in-the-situation." (Greenberg & Watson, 2006).
Psychological health is seen as a “process of becoming” in which self coherence, agency,
and needs for attachment continuously operate, along with the tendencies towards mastery
and choice, in creatively adjusting to life situations. This healthy process results when we are
able to function in the moment using both the emotional and rational sides of ourselves. To be
capable of this adaptive functioning, an individual must be in good contact with their fluid,
‘in-the-moment’ lived experience. If an individual has this, they can be aware of, focus on,
and verbally articulate feelings, sensations, attitudes, beliefs and meanings that relate to the
current moment. Emotional experience, including urges to act, and needs that are important in
the situation, are allowed and experienced as belonging to the self. They are ‘owned’. The
individual feels self-coherence and volition, and a sense of being the true agent of their own
experience. Finally, healthy individuals, while allowing emotional experience, also have
control over how an emotion’s tendency to promote action will be ultimately expressed.
Healthy individuals have good emotional regulation, or can self-regulate. They use their
emotions as information, but are not slaves to emotion. They can tolerate experiencing
emotion while still having command over when, where, and how their emotions are expressed

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Emotion Focused Therapy 289

in the world. Also, as psychological health and functioning increases, emotional responses
become increasingly primary and adaptive, while maladaptive, secondary or instrumental
emotional responding decreases. That is, healthy individuals have good regulation of affect in
the sense that they will have adaptive emotion responses in the right amount, and will not
have the unhelpful problematic emotion responses, or at least will have much less of them.
In dysfunction individuals do not completely attend, or are unable to stay in good contact
with, on-going fluid experience. Therefore there is in-coherence or in-congruence between
what the individual is aware of and relates to in consciousness, and the actual range of
experienced possibilities that are occurring in the moment within that individual. This can
result in dysfunction through various mechanisms. For example, individuals may relate to
their environment using predominantly logical and conceptual processes to guide behavior, to
the exclusion of perception and feeling related to important needs. As a result, the meaning
given to situations, or the autobiographical narrative that results from them, can be rigid and
limited, as well as dysfunctional because they inadequately reflect the individual’s needs as a
whole. Alternatively, if experience of the present is incompletely perceived, individuals may
maladaptively respond to a present situation as a repeated instance of a problematic past.
Activation of primary maladaptive emotion schemes are the source of this dysfunction. A lack
of integration and understanding between aspects of self may also be a source of dysfunction.
When more than one part of self is activated in a particular situation and no integration exists
between them, this can result in experiences of problematic internal conflict or splits. A
number of possible experience-limiting problems cause these dysfunctions. Parts of
experience may be habitually unattended to, avoided, or disclaimed because they do not fit in
with an individual’s sense of themselves. Individuals may be afraid of, or have other
secondary emotional reactions to aspects of their experience, due to cultural beliefs
concerning their validity or utility. Or, they may be an unable to tolerate experience, such as
in the case of intense emotional pain. As well, individuals may not be able to articulate
experiences, that is, they may have no words for them. This un-symbolized experience
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

remains inaccessible to their narrative of themselves, and therefore can not be consciously
reflected on. Dysfunction also arises when experience is of such intensity that an individual
becomes overwhelmed by it, and is unable to regulate ensuing behaviour.

THE CHANGE PROCESS

From the EFT perspective real change means emotion scheme change, and for this to
occur optimal emotional processing must take place. Optimal emotional processing is best
explained if one considers four central emotional processing principals: awareness,
regulation, reflection, and transformation. Of first importance is awareness of emotion, and
then the ability to tolerate and regulate having that emotional experience. Only then can we
use attention to explore an emotion’s many threads and reflect on them consciously. We
discover its meanings, unpack its connections to present and past situations, and experience
the senses of self that are connected to them. We reconnect to the needs that are being
signaled by emotion, and experience how emotion motivates us to meet and/or protect our
needs. This exploring and reflection also leads to uncovering of emotional layers and to
potential transformation when we find deeper alternate adaptive emotional resources within

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 290 Alberta E. Pos and Leslie S. Greenberg

that we didn’t know we had. EFT therapists support emotional change in clients by helping
them negotiate and become more adept within each of these four emotional domains.
In the domain of awareness individuals are helped to attend not to a selective and narrow
band of their experience, but to the whole band of experience available to them. Therapists
model approaching and valuing of emotion by attuning to clients’ emotionally poignant
experience. By making empathically evocative responses to the client’s story, clients’
attention is encouraged towards the emotional poignancy in their life. Therapists use language
carefully in this process, avoiding theoretical talk or external narrative, instead making
empathic conjectures that employ the language of clients’ internal worlds, describing
particular not general experiences, in sensory not conceptual terms. Over time clients learn to
attend inwardly and their awareness of the emotional significance of their experience grows.
If emotional experience is very blocked, attending inward may also require gaining more
awareness of the bodily felt experience connected to emotion. A safe, accepting working
relationship, free from worry about any therapist’s judgment, supports this move inward.
Regulation of emotional experience is also simultaneously strengthened. Relationship
safety plays a critical role in this also. Safe relationships by their very nature are soothing. As
infants we needed relationships to help us regulate our emotions. In EFT the therapist helps
clients contain and regulate emotional experience in much the same way. The accepting EFT
therapist understands and respects the intimate nature of clients’ emotions, readily welcomes
them, thereby reducing clients’ shame and fear of their emotionality. Therapists also
importantly help clients find words for their feelings. Clients learn that words can ‘contain’
feelings and lessen their intensity. If necessary, EFT therapists may also teach clients ways of
regulating emotional experience. Grounding, self-soothing, and safe-place exercises are
practiced during a series of graded exposures to emotional arousal. Therapists may even teach
a client how to move away from emotion by engaging in conceptual processing or by using an
external focus. This increases clients’ confidence in having some control over the intensity of
the experience they will have.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Exploration of emotional experience and reflection on what is discovered then becomes

possible. The experienced meaning of the world and the self that emotion contains is now
available for conscious exploration and reflection. This results in ‘sorting’ of experience.
Thoughts, feelings, needs, self-experience, and aims of different parts of the self are
identified. How parts of the self are connected can be experienced and understood. The
meanings of situations that have evoked emotion are made sense of. The result of this
reflection is deep experiential self knowledge. Reflection can eventually lead to the potential
for deep emotional change only if it has lead to clients’ core primary emotion. EFT assumes
that within each of us there is a resource of innate and primary adaptive emotion. If the core
emotion underlying the client’s problems is primary adaptive emotion, it is healthy emotion.
This is the most fortunate scenario. All that is needed is staying with such emotion because it
is innately valid. Exploring and expressing it is therefore helpful and reconnects the client to
important needs and goals. Clients get clear on what they need and/or want in the present and
future, find motivation and a new path to travel.
More often, the core emotion at the heart of distress is a primary maladaptive emotion,
and clients now must face their life’s struggle with core feelings of worthlessness,
powerlessness, ‘badness’, or fundamental insecurity. Finally arriving at these feelings and
putting them into words by itself provides a paradoxical initial relief. Understanding their
origins is also important to validate these experiences as once having made sense. However,
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Emotion Focused Therapy 291

this is not enough. Maladaptive emotional experiences need to be transformed. In EFT

transformation comes from the client accessing a new emotional state in the session. The
therapist attends to subdominant emotions that are currently being expressed ‘on the
periphery’ and helps the client attend to and experience innate and adaptive primary emotions
and needs that will provide inner resilience. These newly accessed resources challenge the
validity of the perceptions of self/other connected to maladaptive emotion and weaken their
hold on the client.
The difficulty in changing emotional experience, and restructuring emotional responses,
is that emotional change can not occur through a rational process of understanding or
explanation alone. Emotion schemes must be activated in the therapy session for chance to
occur. EFT works on the basic principle that one must first arrive at a place before one can
change it or leave it. In more distressed clients this will mean accessing a primary
maladaptive emotion scheme, in order to expose it to and then transform it by newly accessed
primary adaptive emotions.
In EFT the therapeutic environment plays an important role in making the activation of
emotion possible and productive. The therapist is unconditionally accepting, empathic, and
genuine (Rogers, 1957; Greenberg & Watson, 2006). Non-contingent regard, empathy and
genuineness all provide real human contact that reduces clients’ feelings of isolation. By
reducing client isolation and increasing the experience of being accepted, interpersonal safety
is enhanced. This creates the optimal environment for focused attention to turn within, and
eliminates the client’s need to attend to any interpersonal process occurring between them and
the therapist (Rice, 1974). Added to this, therapists are in constant empathic attunement with
clients’ affect and meaning. At all times, the therapist tries to make psychological contact
with and convey a genuine understanding of the client's internal experience (Rogers, 1961;
1957). This involves the therapist actively entering into the client's internal frame of
reference, resonating with the client's experience, and guiding the client's attentional focus to
what the therapist hears as most poignant for the client at a particular moment (Rice, 1974).
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

This communicates a companionship that also strengthens the experience of human contact
and safety. Once this safe, relationship environment is established, various therapeutic
interventions or tasks can be employed to activate and work with the client’s emotional
issues.

THE THERAPEUTIC PROCESS

Assessment and Diagnosis

The EFT approach to case formulation has also been influenced by the humanistic
tradition, specifically Client-centered and Gestalt therapy. Rogers (1957), for example, was
opposed to most forms of formal assessment because he thought diagnosis created a potential
power imbalance between therapist and client that could be detrimental to the therapeutic
process. We are largely in agreement with Roger's concerns, that expertness creates a power
imbalance and interferes with the formation of a genuine relationship. Our particular
approach to case formulation approach, therefore, fundamentally stays within the bounds of
the experiential therapy tradition from which it emerges.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 292 Alberta E. Pos and Leslie S. Greenberg

Having said this, EFT does use an initial diagnostic interview process to identify clients
suitable for EFT treatment. If strong biological factors (i.e. a biochemical disorder) or
systemic factors (that would deem the person more appropriate for marital or couples
therapy), are judged as being primary problem determinants, the client is considered
inappropriate for this treatment. In addition, people who are psychotic, or have a schizoid,
schizotypal, borderline, or antisocial personality disorder are not suitable for short-term EFT
treatment (16-20 weeks). Long-term EFT treatment is not appropriate for psychosis or
antisocial personality disorders.
Once suitability has been established, however, case formulations in EFT are never
performed a priori based on this early assessment. We believe that the most therapeutically
productive focus is co-constructed by client and therapist and that that which is most
problematic, poignant and meaningful will emerge progressively, within the safe context of
the therapeutic environment. Optimal thematic focus occurs as core issues are collaboratively
identified (Bordin, 1979). We do not attempt to establish what is dysfunctional or presume to
know what will be most salient or important for the client. As far as specific diagnoses are
concerned, we believe that knowledge of certain nosological categories or syndromes are of
course useful to EFT therapists, but that these are most meaningfully conceived as guides to
patterns of functioning rather than as descriptions of types of people. Thus, we prefer to think
about anxious, obsessive or borderline processes rather than people, and we privilege process
diagnosis over person diagnosis.
This is the defining feature of our approach to case formulation and assessment, that it is
process diagnostic (Greenberg et al., 1993) rather than person diagnostic. EFT’s diagnostic
focus is on the problematic processes in which clients are currently involved. Case
formulation is a dynamic process that tracks clients’ current process states, such as how they
are currently experiencing their problems or how they are impeding or interfering with their
own experience. A differential process diagnosis involves the therapist attending to a variety
of different in-session markers at different levels of client processing. These may include
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

markers of clients’ emotional processing style, markers of problems that can be addressed
with particular therapy tasks, markers of clients’ characteristic styles of responding and micro
markers of client process. In the earliest stages of therapy the fundamental requirement to
allow process diagnosis to occur is that the client perceive as relevant, and agree to engage in
the initial therapy tasks (Horvath & Greenberg, 1994) of disclosure, exploration, and
deepening of experience. Once the client is engaged in these, process diagnosis and a
concurrent exploration for a focus begins.
The first steps in developing a case formulation involve the identification of the
presenting problem communicated within the client’s narrative of their concerns. The
therapist empathically reflects and explores how the client views their problems and gathers
information about relevant life circumstances in order to assess and understand the client’s
current levels of functioning, relationships, and attachment and identity histories.
While gathering this important information EFT therapists are also performing a process
diagnosis of the most global aspects of the client’s emotional or experiential processing style.
The therapist observes whether the client is emotionally over-regulated or under-regulated, by
noting clients’ vocal quality and degree of emotional arousal. The therapist notices whether
the client has the capacity to articulate, explore, and have interest in their internal experience,
and whether they can reflect on and make sense of emotion. Therefore, attention is paid to
how clients are presenting their experiences in addition to what they are saying.
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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Emotion Focused Therapy 293

At the same time the therapist and client move towards the development of a treatment
focus. To do this the EFT therapist follows one fundamental initial directive, which is to
follow what is most poignant and emotionally alive for the client, in particular the client’s
pain which is seen as a signal that alerts the therapist to the important areas for exploration.
Our approach to case formulation involves identifying the client’s core pain and using that as
a guide towards the development of a focus on underlying determinants generating the
presenting concerns (Greenberg & Watson, 2006). At this early stage of treatment
formulation, empathic attunement to affect and meaning is the therapist's primary medium of
engagement.
While EFT therapists are knowledgeable in theories of determinants that contribute to
disorders, this stage of treatment focus is not driven by a theory of the causes of, say,
depression or anxiety. Rather a sense of the determinants is built from the ground up using the
client as a constant touchstone for what is true. Treatments therefore are custom made for
each person, and clients are understood in their own terms. Understanding of the client is also
held tentatively and is open to reformulation and change as more exploration takes place.
Usually over time, intra-personal or interpersonal themes that are contributing to clients’
pain emerge. While always personally unique, research has shown that themes of clients in
EFT treatment fall into four broad categories: 1) a general inability to symbolize internal
experience; 2) problems in intrapersonal relations; 3) problems in interpersonal relations; 4)
existential concerns; or some combination of these four (Greenberg & Paivio, 1997).
Intrapsychic issues generally relate to self-esteem, self-criticalness, or perfectionism.
Interpersonal issues often relate to attachment and interdependence, and over dependency.
Existential issues often involve loss, choice, freedom and death.
As these themes of treatment emerge therapists are also continuously attuned to markers
of clients’ process that point to underlying determinants of their difficulties. This is the
second defining feature of the EFT approach, that intervention is marker driven. Research has
demonstrated that clients engage in specific problematic emotional processing states that are
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

identifiable by markers in clients’ statements and behaviour (Greenberg et al, 1993). EFT
therapists are trained to identify the most common markers of problematic emotional
processing problems. To date we have identified and studied the following markers: 1)
problematic reactions expressed through puzzlement about emotional or behavioral responses
to particular situations; 2) an unclear felt sense in which the person is on the surface of, or
feeling confused, and is unable to get a clear sense of his/her experience; 3) conflict splits in
which one aspect of the self is critical or coercive towards another; 4) self-interruptive splits
in which one part of the self interrupts or constricts emotional experience and expression; 5)
unfinished business involving the statement of a lingering unresolved feeling toward a
significant other; and 6) vulnerability in which the person feels deeply ashamed, or insecure
about some aspect of his/her experience. Establishing focused goals of treatment depends on
establishing a collaborative understanding of how one or more of these underlying emotional
processing difficulties relate to the client’s problems and core pain.
Identifying these markers not only help focus treatment, but also focus the therapist on
opportunities for engaging in particular in-session therapeutic tasks. When client
communication contains a marker it signifies to the therapist that a particular affective
processing problem is currently activated and amenable to intervention. This directs the
therapist towards interventions that match the marker and that will most fruitfully explore and

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 294 Alberta E. Pos and Leslie S. Greenberg

resolve the emotional processing difficulty. In this way treatment focus responds to clients’
present emotional processing difficulties in the moment from sessions to session.
Once a particular intervention is initiated the therapist also is attending to and assessing a
finer level of in-session micro-markers as interventions proceed. Deflections, rehearsed
descriptions, rambling, poignancy, internal focus, silence and many other indicators, alert
therapists to clients’ moment by moment processing so as to enable them to adjust their
interventions in order to be maximally responsive to their clients. It is during intervention that
the therapist must also assess whether emotion is secondary or instrumental, as well
distinguish primary adaptive from maladaptive emotional responses. This is essential because
each class of emotional response is worked with in a different fashion. Formulation and
intervention are, in EFT are therefore inseparable, span the entire course of treatment, and
occur constantly at many levels. Formulation thus never ends.

PHASES OF TREATMENT
EFT treatment can be broken into three major phases. The first phase of bonding and
awareness, is followed by the middle phase of evoking and exploring. Finally therapy
concludes with a transformation phase that involves constructing alternatives through
generating new emotions and reflecting to create new meaning.

Phase One: Bonding and Awareness Phase. From the first session the therapist deeply
holds a therapeutic attitude of empathy and positive regard to help create the safe
environment for the evocation and exploration of emotion that will later take place.
In the early phase of therapy it is also necessary to provide clients with a rationale as
to how working with emotion will help, and obtain clients’ collaboration with the
aim to work on emotions. The therapist also helps the client start approaching,
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

regulating, and valuing their emotional experience. The focus of treatment also
begins to be established. Therapists and clients collaboratively develop an
understanding of the person’s core pain, agree on the underlying determinants, and
discuss the tasks that will be fruitful to engage in.
Phase Two: Evocation and Exploration Phase. During this phase, emotions are evoked,
and if necessary intensified. The goal of the evocation and exploration of emotion is
to eventually arrive at the deepest core level of primary emotion. Many techniques
can be used to do this such as empathic evocation, focusing, and psycho-dramatic
enactments. Before activating emotion, therapists assess the client’s readiness for
evoked emotional experiences and ensure that the client has the internal support to
make therapeutic use of them. Once assured of this, EFT therapists during this phase
help people experience and explore what they feel at their core.
Interruption and avoidance of emotional experience is also worked through in
this phase. The therapists focuses on the interruptive process itself and help clients
become aware of, and experience the cognitive (catastrophic expectations), physical
(stopping breath), and behavioral (changing the topic) ways they may be stopping
feeling.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Emotion Focused Therapy 295

Phase Three: Transformation and Generation of Alternatives. Having arrived at core

emotion the emphasis shifts to the construction of alternative ways of responding
emotionally, cognitively and behaviourally. This is done both by accessing new
internal resources in the form of adaptive emotional responses. Clients have new
experiences of self and start to create new meanings and a new self-narrative from
their transforming emotional experiences, that reflect a more resilient and integrated
sense of self. The therapist acknowledges and validates the client and helps them use
their newly found sense of self- validation as a base for action in the world. The
therapist and client collaborate on the kinds of actions that could consolidate the
change.

THE NATURE OF THE THERAPEUTIC RELATIONSHIP

Throughout all stages of EFT the working relationship is a central component in its
effectiveness. The therapy is built on a genuinely prizing empathic relationship and on the
therapist being highly present, respectful and responsive to the client's experience. At the
same time, EFT therapists share expert knowledge with the client concerning in-therapy tasks
that can be engaged in to promote optimal emotional processing. These are offered in a non-
imposing manner, as possible experiments, not as expert pronouncements.
In EFT, the combination of providing a relationship of safety as well being process
directive while pursuing in-session tasks leads to a creative tension that makes it possible to
combine the benefits of both styles while softening the disadvantages of each. Optimal active
collaboration between client and therapist allows each to feel neither led nor simply followed
by the other. Still, disjunction or disagreement can occur. In such moments we believe that
human compassion offers more hope to another than the most sophisticated psychological
techniques. Therefore the relationship always takes precedence over the pursuit of a task, and
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

the therapist always defers to the client’s expertise on their own experience. Potential
‘disjunctions’ are closely attended to not only in clients’ verbal statements but also in clients’
subtle nonverbal behaviour. The therapist constantly monitors the state of the therapeutic
alliance and the current therapeutic tasks in order to balance responsive attunement and active
stimulation.

TECHNIQUES/INTERVENTION
In EFT there are two fundamental techniques used across all therapy stages, the
relationship and empathic exploration/evocation. As described, the EFT relationship promotes
safety, and removes interpersonal risk, allowing client to attend to the emotional processing
task at all phases of therapy. Empathic exploration is a fundamental intervention of EFT. By
sensitively attending to the client’s spoken and non-spoken (non-verbal) narrative, a
therapist’s verbal empathic exploration can capture the client’s experience more richly than
clients’ own descriptions can (Rice, 1974), and gives the client a ‘handle on’ their experience.
The client can now bring further attention and reflection to it. In this process, the client is
encouraged to internally check the felt ‘goodness of fit’ sensation of such reflections, and to

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 296 Alberta E. Pos and Leslie S. Greenberg

evaluate their usefulness. This teaches the client that they are the final arbiters of their own
experience, and that they are the only ones who can evaluate the accuracy of the therapist’s
attempt to capture and symbolize it with them. In this process EFT therapists are constantly
broadening and moving clients’ attention to help them focus on the edges of their
experiences, to bring more experience into consciousness, so it can be put in words and be
reflected on.
After a focus of treatment and the client’s resources for aroused emotional experience are
both established, six marker related interventions are used. These are fully described in detail
in various manuals to EFT (Elliott, Watson, Goldman, & Greenberg, 2003; Greenberg, Rice
& Elliott, 1993; Greenberg & Watson, 2006) and can only be touched on briefly here.

1. Problematic or puzzling emotional reactions call for systematic evocative unfolding.

This involves vivid reconstructions of these experiences, to establish the connections
among the situation, thoughts, and emotional reactions, to finally arrive at the
implicit meaning of the situation that makes sense of the reaction.
2. An unclear felt senses calls for focusing (Gendlin, 1996). When clients report feeling
blocked or unable to get a clear sense of their experience they are guided in
mindfully accepting the embodied aspects of their experience and to approach them
with curiosity and willingness to experience them. The client is also helped to put
words to these experiences.
3. Splits in the self, where one part of the self is either self-critical or self-interruptive,
call for two-chair work. The two parts of the self are put into alive contact with each
other. Thoughts, feelings, and needs within each part of the self are explored and
communicated in a real dialogue to achieve a softening in the self critical voice, or a
more allowing attitude in the experience-interrupting self. An experience of a more
integrated self often emerges.
4. Unfinished business involving lingering bad feelings toward a significant other calls
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

for an empty-chair intervention. Using an empty-chair technique, the individual

activates their internal view of the other and explores the implicit meaning of past
events with them. They experience and explore their emotional reactions to the other
and make sense of them. Shifts in views of both the other and self may occur.
5. Vulnerability calls for empathy. When a person feels deeply ashamed or insecure
about some aspect of his/her experience, above all else, clients need secure contact
with a non-rejecting other. This always calls for empathic affirmation from the
therapist who must warmly accept the client and both validate and normalize their
experience.

STRENGTHS AND WEAKNESS OF EFT

Short-term EFT has been demonstrated as an effective treatment for both depression and
emotional trauma in several research projects (see Greenberg and Watson, 2006 for a review).
It also has been identified by Marsha Linehan as the Phase 2 treatment of choice for
borderline personality disorder (Linehan, 1993) although no research has yet been done to
explore this. EFT is one of the few approaches that effectively activates emotion during

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Emotion Focused Therapy 297

treatment in order to change automatically-functioning emotion schemes that are frequently

the sources of problems. Limitations of EFT are that there is no evidence exploring it’s
effectiveness with panic, anxiety disorders, personality disorders, or psychosis, and it does not
focus on teaching coping skills. Also, to become an EFT therapist requires learning complex
attunement and intervention skills.

SUMMARY
EFT combines both following and guiding clients’ experiential process, while
emphasizing the importance of both relationship and intervention skills. It takes emotion as
the fundamental datum of human experience. EFT also views emotion and cognition as
inextricably intertwined and important to meaning making. Ultimately EFT’s central focus is
on accessing and utilizing adaptive emotional functioning within individuals to promote
growth and change.

REFERENCES
Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working
alliance. Psychotherapy: Theory, Research and Practice, 16(3), 252-260.
Damasio, A. R. (1994). Descartes' error: Emotion, reason, and the human brain. New York:
G. P. Putnam.
Elliot, R., Watson, J.E., Goldman, R.N., & Greenberg, L. S. (2004). Learning Emotion-
focused therapy: The Process–Experiential approach to change. Washington, DC,
US: American sychological Association.
Frijda, N. H. (1986). The emotions. Cambridge, UK: Cambridge University Press.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Gendlin, E. (1996). Focusing oriented psychotherapy. New York:Guilford.

Greenberg, L. S. (2002). Emotion-focused therapy: Coaching clients to work through their
feelings. Washington, DC, US: American Psychological Association.
Greenberg, L. S. & Paivio, S. C. (1997). Working with emotions in psychotherapy. New
York: Guilford Press.
Greenberg, L. S., & Watson, J. C. (2006). Emotion-focused therapy for depression.
Washington, DC: American Psychological Association.
Greenberg, L. S., Rice, L. N., & Elliott, R. K. (1993). Facilitating emotional change: The
moment-by-moment process. New York, NY, US: Guilford Press.
Greenberg, L. S., & Safran, J. D. (1987). Emotion in psychotherapy: Affect, cognition, and the
process of change. New York, NY, US: Guilford Press.
Horvath, A. & Greenberg, L. (Eds.) (1994). The Working Alliance: Theory, Research and
Practice. New York: John Wiley.
LeDoux, J. (1996). The Emotional Brain: The Mysterious Underpinnings of Emotional Life.
New York: Simon & Schuster.
Linehan, M. M. (1993). Cognitive-behavioural treatment of borderline personality disorder.
New York: Guilford.
Perls, F., Hefferline, R.F. & Goodman, P. (1951). Gestalt therapy. NY: Dell.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
 298 Alberta E. Pos and Leslie S. Greenberg

Rice, L. N. (1974). The evocative function of the therapist. In D. Wexler & L.N. Rice (Eds.).
Innovations in client-centered therapy (pp. 289-311). New York: Wiley.
Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality
change. Journal of Consulting Psychology, 21, 95-103.
Rogers, C. R. (1961) On becoming a person. Boston, MA: Houghton Mifflin.

SUGGESTED READING
Elliot, R., Watson, J.E., Goldman, R.N., & Greenberg, L. S. (2004). Learning Emotion
focused therapy: The Process–Experiential approach to change. Washington, DC:
American Psychological Association.
Greenberg, L. S. (2002). Emotion-focused therapy: Coaching clients to work through their
feelings. Washington, DC: American Psychological Association.
Geenberg, L. S. & Paivio, S. C. (1997). Working with emotions in psychotherapy. New York:
Guilford Press.
Greenberg, L. S., & Watson, J. C. (2006). Emotion-focused therapy for depression.
Washington, DC: American Psychological Association.
Greenberg, L. S., Rice, L. N., & Elliott, R. K. (1993). Facilitating emotional change: The
moment-by-moment process. New York: Guilford Press.
Johnson, S. M. (1996). The practice of emotionally-focused marital therapy. Creating
connection. Florence, KY: Brunner-Routledge.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 In: The Quick Theory Reference Guide ISBN: 978-1-60021-624-4
Editor: Karin Jordan, pp. 299-309 © 2008 Nova Science Publishers, Inc.

Chapter 21

CLIENT-CENTERED FAMILY THERAPY*

Ned L. Gaylin

At the twilight of the nineteenth century the world eagerly anticipated its entry into the
“century of science.” At the dawn of the twentieth century humankind naively believed that
science would enable the ushering in of a utopian millennium wherein the frontiers of the
unknown would come under the control of a growingly omniscient technology.
Within the infant field of clinical psychiatry, in 1899 Sigmund Freud had just completed
his first major opus, The Interpretation of Dreams (Die Traumbedeutung). However, he
convinced his publishers to change the publication to the year 1900, so that he could be seen
as the patriarch of the science of psychology for the 20th century. Indeed, he was. For the first
half of the last century, psychodynamic psychology dominated thinking in medical
psychiatry, the social sciences, and even the arts in both Europe and America.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Meanwhile, in the animal laboratories of American universities, the condition-response

theory of Ivan Pavlov was empirically tested and elaborated. Ensuing refinements by B. F.
Skinner (among others), enabled Behaviorism, (as it came to be called), to establish itself as a
legitimate branch of the growing science of psychology. Indeed, with as much confidence as
Freud, Skinner believed that Behaviorism offered the pathway to trouble free idyllic society
(Walden II, 1948).
Thus, by the middle of the twentieth century two forces—Behaviorism and
Psychoanalysis—pervaded psychological thinking.
However, in the middle the last century neither Freud nor Skinner controlled our
anxieties. Rather, we became aware that letting the technology genie out of the bottle had its
dark side. With the unleashing of the atom in the bombing of Hiroshima, our optimism was
shaken into foreboding. Also shaken was our naïve faith in science’s abilities to create
paradise. Psychoanalysis had not only failed in its promise of bettering the human condition,
it seemed to have sullied it. Even our most creative endeavors became suspect as neurotic
“sublimations” of our more primitive instincts. Neither were we optimistic that Skinnerian
conditioning might enhance the quality of our lives as such novelists as Huxley, (Brave New

*
A German version of this chapter first appeared in Keil, W. and Stumm, G. (Eds.), 2000, The Person-Centered
Approach in Psychotherapy. Wien: Springer. Reprinted by permission of the author.

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 .

300 Ned L. Gaylin

World, 1932) and Orwell (1984, 1949) emphasized. Furthermore, giving names to, and
etiological explanations for our neuroses did not seem to improve our mental health, but
rather exponentially augmented the need for a larger mental illness industry.
In this uncertain environment the “Third Force” in psychology had its birth. Seeking a
more holistic, less pathological/mechanistic view of the human condition, some theorists of
the time advocated a more positive conception of mental health (Jahoda 1958), and a nobler
image of the human condition (Maslow, 1961). This was the climate in which Carl Rogers
(1951) conceptualized, introduced, and nurtured the practice of Client-Centered therapy.
The heart of Rogers’ special genius was his ability to integrate complex ideas, distill their
essence, and communicate this pith with elegance and charisma. Nonetheless, halfway
through the 20th century, when behavioral and psychodynamic psychotherapy were
considered standard, Rogers’ ideas seemed both iconoclastic and simplistic—indeed, even
unscientific. Despite heavy criticism from the mainstream, Rogers continued to advocate a
brand of therapy in which the therapist would learn the client’s language, rather than vice-
versa (see Fancher, 1995).
Rogers’ earliest endeavors (1939) reflected his attention to the philosophical foundations
of William James (1890) the organismic theories of Kurt Goldstein, (1940) and the
therapeutic style of Jesse Taft (1933), as well as an interest in children and families. His
theoretical base—“the necessary conditions” for therapeutic change (Rogers, 1957)
emphasized the interpersonal nature of the therapeutic relationship, and the importance of
empathy and caring by the therapist for the client.
First called “non-directive therapy,” its proponents soon recognized that the name was
misleading: Virtually everything the therapist did, from a simple “unh-huh” to a nod of the
head, could be considered by clients as directive, albeit veiled. Thus, Rogers introduced the
term “Client-Centered Therapy” (Rogers, 1951), which is still used today. Later “Person-
Centered” was coined to extend the use of Rogers’ approach beyond the limits of the therapy
hour.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Client-Centered therapy introduced and incorporated empirical techniques such as tape

recordings as a way to better observe and quantify client and therapist behaviors during
sessions (Rogers and Dymond, 1954). Ipsative (Gaylin, 2001) versus normative
methodological techniques were developed and employed which allowed for heretofore
unheard of investigations of psychotherapy process and outcome. Despite its relatively short
history, Rogers’ ideas have been incorporated not only into virtually all psychotherapeutic
endeavors, but are now seen as inherent and basic to the process—self evident.
Finally, Person-Centered Therapy has expanded, once again, and now includes family
therapy which, ironically, is without portfolio in the systems oriented family therapy
community. Such a twist is particularly remarkable when history notes that Rogers’ first
published volume concerned the treatment of troubled children and their families (1939), and
the most widely read and still published volumes on therapy with children come out of the
Client-Centered framework (Axline, 1947 and 1967).

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Client-Centered Family Therapy 301

THE FAMILY AS CLIENT

When I began the application of Rogers’ ideas to the practice of family therapy I
preferred the term Client-Centered Family Therapy or Family-Centered Therapy (Gaylin,
1990). It seemed natural to look upon the family unit as the client, and this vantage point was
in keeping with the systems-oriented world of family therapy. The various systems
approaches to family therapy--be they cybernetic or evolutionary in orientation--derive from
the view that the family unit, rather than its individual members, is the client (see Becvar and
Becvar, 1988). Later, I chose to use the term Person-Centered Family Therapy (1993) as
more descriptive of my practice and to distinguish Client-Centered work with families from
the traditional systems approaches.
The practice of family therapy in context of the Person-Centered Approach is both
natural and appropriate. It follows all of the same ideology and methods of the Person-
Centered Approach in working with individuals. Person-Centered family therapists, unlike
their systems oriented counterparts, deal with each individual in the context of their most
intimate environment—the family. But the Person-Centered family therapist’s central concern
is the experiential realm of the family members as individuals from which their shared
meaning as a family derives.
For Person-Centered therapists experienced in working with individual clients, few
conceptual or methodological modifications are required to practice marriage and family
therapy. Theoretically the concept of the actualizing tendency is broadened to include a
family actualizing tendency, and methodologically the core conditions are expanded to
include the therapist’s relationship with more than one individual.

The Actualizing Tendencies, Self Esteem, and the Centrality of the Family

Most discussions of the actualizing tendencies include only one—self actualization.

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Rogers drew upon the concept from the Organismic theory of Kurt Goldstein (1940). For
Goldstein every organism has a biological destiny to fulfill: Each actualizes its potential. We
human beings, because of our consciousness of who we are in relationship to others—our self
awareness—develop a self actualizing tendency. Furthermore, as a consequence of our
uniquely long dependency period, and our discernment of past, present and future, a part of
our self actualizing tendency includes the conception of family.
The family is so indigenous to who we are—how we think of ourselves in relationship to
others—that it is incorporated into our concept of self and therefore becomes a part of our self
actualizing tendency. A part of our fulfilling our destinies includes our leaving our families of
orientation and creating new families of our own—our families of procreation. As a species
we are unique regarding our lifelong awareness of our predecessors and our acute
mindfulness of our potential for successors. Thus one might think of a family actualizing
tendency as the press to fulfill our biological destinies.
Our sentience, that is, our awareness of self, is intimately connected to our cognizance of
our actualizing tendencies. This awareness of who we are, where we came from, and perhaps
most importantly, where we are going, creates a complex set of expectations of ourselves.
These aspirations, if fulfilled, produce a sense of accomplishment and self worth, and if
unfulfilled or thwarted, a sense of failure and self criticism. Correspondingly, our feelings of

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 302 Ned L. Gaylin

self worth—our self esteem—may be raised either by increasing our successes or lowering
our expectations for ourselves (see W. James, 1890).
Our lifelong mutual interdependence on others, particularly those whose intimacy we
seek, empowers them with significant impact regarding our aspirations. Our intimates
virtually always include our family members: first our parents, siblings and extended family
members, later our spouses, children, and eventually grandchildren. Thus, thoughts of who
we are and how we feel about ourselves are invariably connected to those who helped shape
and continue to shape our image of ourselves and our self worth. For this reason, the family
may be seen as crucible in which the self is formed and the metal of which we are made
(Gaylin, 1996). The centrality of the family to our lives is also what makes it the ideal milieu
in which to conduct restorative measures when things go awry.

PSYCHOLOGICAL WELL BEING

The term psychological well being is more aptly suited to the Person-Centered Approach
than are the notions of mental health and its reverse, mental illness. The idea of mental
illness, or psychopathology, derived from the medical model, implies deviance from a certain
norm. Psychopathology implies more than observation of specific symptoms.
Psychopathology presumes knowledge of specific etiology, which enables differential
diagnosis, which in turn specifies explicit treatment. Except in the most extreme cases these
parameters are usually totally unavailable, or at best vague when dealing with individuals in
psychological distress who come for psychotherapy (Gaylin, 1974).
Furthermore, psychological well being is a state that suggests more than the mere absence
of mental illness: It implies a kind of robust mental state. Because of the unpredictable
vicissitudes of life, it would not be accurate to equate psychological well being with
happiness. Rather psychological well being is a state which enables a resilience to life’s
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

experience (pleasant or not) and also includes a lack of defensiveness or an “openness to

experience” (Rogers, 1959) in dealing with the world.
Psychological well being also incorporates the idea of self-esteem discussed above—a
balanced attitude towards our appraisals and our expectations of self. However, as with
happiness, self-esteem, in and of itself, cannot be equated with psychological well being.
Indeed, without a sense of responsibility to others—including a sense of duty and
obligation—self esteem may even be counterproductive to an individual’s psychological well
being. It is in the bosom of the family that our noblest of human attributes, altruism, is
learned. It is this notion which stands as the most persuasive argument for performing
psychotherapy in the intimate context of the family, where the individual’s needs are always
juxtaposed against the needs of the other family members.

THE NECESSARY AND SUFFICIENT CONDITIONS

FOR THERAPEUTIC CHANGE

Person-Centered therapists need not modify the basic premises of their method to practice
family therapy. Nor does the inclusion of more than one client change the conditions for
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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Client-Centered Family Therapy 303

effective therapy laid down by Rogers (1957) over half a century ago. Indeed, the need for a
relationship between client(s) and therapist, the motivation of the client(s), the transparent full
presence of the therapist, the therapist’s empathy, and the perception of that empathic caring
on the part of the client(s), all remain the same (Gaylin, 1989a). What does change is the
enriching of all those conditions, which in turn leads to an efficacious, often powerful, and
rewarding therapy experience for all participants.
The first condition—that of the therapeutic relationship—is perhaps, even to this day, the
least understood variable of the psychotherapeutic process. Neither Rogers, nor Jesse Taft
(1933), from whom Rogers borrowed the idea, say much about it other than it must exist and
is crucial to the restorative power of psychotherapy. In fairness, the other five conditions do
afford some understanding of the additional attributes of the therapeutic relationship, but they
do not help explain its power.
The process of family therapy sheds additional light on the therapy relationship. Whereas
in individual therapy, the therapist and client must be in “psychological contact,” (Rogers,
1957) the family therapist must maintain a relationship with all individual family members
concurrently. The therapist must do so in a manner which engenders trust and demonstrates
respect for each and every family member, regardless of age or gender. In the vernacular of
family therapy, this is called “joining” with the family. As joining implies, the family
therapist, at some level becomes a part of the family group, a part of the interactivity of the
unit.
To join with the family the Person-Centered family therapist must not only convey
respect for the individual members, but for the family culture, i.e., its mores and values, as
well. For example, families virtually always follow some kind of age grading wherein the
parents (sometimes grandparents) are accorded respect by dint of both their age and position
as parents. Older children may also be accorded more respect than younger siblings. But
despite these issues of deference for the family ethos, the overriding issue is the separate and
special regard for the individual family members each as a unique person, irrespective of age
or position within the family.1
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The second condition is that the client be in a state of incongruence. For an individual,
incongruence is traditionally defined as that disjunctive state wherein the person’s perception
of self and the experience of self are at odds. This disparity can result in anxiety and
behaviors that appear both contradictory and odd to the individual and to others. This
vulnerable and uneasy, unsteady state is often what impels individuals into therapy. With
families, incongruence is far more complex.
It is not unusual for a family to enter therapy because one of its members—often a
child—is experiencing incongruence severe enough to adversely affect his or her behavior.
The incongruence may manifest itself in many ways—e.g., withdrawal, or acting out
behavior, underachievement, or poor social relations. But the situation is rarely solely an
individual problem. Thus, if a child is suffering debilitating incongruence, the level of
congruence/incongruence of other—probably all—family members is affected. The distress

1
I have found that joining, or connecting with all family members of a multigenerational family involves a two-
stage process. First, I meet with the parents, who invariably initiate the entry into therapy. I hear their
concerns, and encourage them to tell their child(ren) about me and the session. The second session I meet with
the entire family. In that second session I begin with the children and ask them to tell me what they have
heard. When I have not proceeded in this manner, issues surrounding control, side taking, etc. have often led
to the premature termination of therapy.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 304 Ned L. Gaylin

of each family member augments the stress within the assemblage. The complexity is
compounded by the probability that each individual member suffers his or her own
incongruence not necessarily directly related to the family’s identified troubled member.
Traditionally incongruence is thought of as internal to the individual—intrapersonal.
However, families may also enter into therapy over interpersonal incongruence. Often this is
the case with married couples who are having difficulties. Their individual experiences of
events and even the relationship itself may vary so greatly that the integrity of the union
becomes at risk, and their love for each other seriously compromised.
The third condition addresses the congruence of the therapist within the relationship. The
ability of the therapist to be fully present and transparent defines the condition. Therapist
congruence should not be construed as the need for the therapist to be superhuman, i.e.,
without troubles, and happy. Rather, while in the service of the client, therapists must be
deeply aware of their own inner experience in relation to their client(s). During the therapy
hour the therapist must be sufficiently free of internal struggles as to be able to maintain focus
and concentration on the client(s).
The heart of Person-Centered work, be it with individuals or families, lies in the next two
conditions: The therapist must be empathic (condition four), and must be caring (condition
five). What differs for the family therapist is the need to maintain empathy with all family
members simultaneously—even when those members may have (at least tentatively) lost
empathy for each other. Indeed, the therapist may serve as both model and entree to empathic
understanding where deep hurts between or among family members may have created barriers
to compassion or even tolerance for each other.
The sixth and final of Rogers’ necessary and sufficient conditions is that the therapist’s
empathy and caring be, at some level, perceived by the client(s). It may not always be
possible to maintain equal levels of intimacy with all family members all of the time.
However, if the therapist conveys equitable caring and concern for family members,
invariably the condition is perceived, and the therapist is accepted and incorporated into the
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

family as confidant, ally, and helper.

THE FAMILY THERAPY PROCESS

The family, through repeated, shared experiences, accretes an experiential history, which
in turn, creates a culture replete with shared meanings, inculcated values, and expectations
regarding the future. In addition to the shared meanings, each individual member develops a
world-view unique to that individual member. These family histories replete with both shared
and individual meanings, are the life voyages, the odysseys that the families bring to therapy.
The therapist, with caring empathy, listens and reflects his or her understanding of each
individual member’s experiences surrounding the various events comprising the family’s
history. The therapist maintains an empathic stance with each family member’s separate
world-views and associated affect—reflecting them back in turn to the family member.
Through empathic reflection, an atmosphere of trust and safety is created, where family
members can have their world-view validated—each in turn. As each individual client begins
to trust the therapist’s nonjudgmental empathic caring, as well as the therapist’s ability to

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Client-Centered Family Therapy 305

create an atmosphere wherein the speaker is protected from other members’ potential
attributions or attacks, individual intrapersonal incongruences begin to surface.
Furthermore, as the various tales unfold, imbedded contradictory perceptions are
discerned within the commonly shared and understood experiences. These contradictory
experiences invariably define the interpersonal incongruences that have led to previous
misunderstandings that, in turn, have created hurt, anger, and conflict within the family. This
unfolding process is what enables the working through of conflicts that have heretofore
disabled the family from functioning effectively.
In this disclosing process, the therapist first gleans a sense of the whole and then offers it
back to the family. This unfolding of reflected awareness of both individual members’
intrapersonal incongruences as well as the interpersonal incongruences and consequent
conflictive interaction patterns enables an altering of experience on the part of family
members, which, ideally frees the barriers to both the individuals’ as well as the family’s
actualizing tendencies.
With family members witnessing the opening of their personal incongruences in an
empathic atmosphere, once-lost mutual empathy and understanding for each other may be
rekindled. Conflictive knots pulled tight over the years are loosened and a re-experiencing of
life events, with greater understanding, further facilitates the family’s own habilitative
powers. In turn, the therapy process becomes a part of the family’s history to be drawn upon
as a restorative experience.

SPECIAL ISSUES WITHIN FAMILY THERAPY HOUR

Although the methods employed in family therapy differ little from those in individual
therapy, there are some subtle differences in the process of the two contexts. Individual
therapy is primarily a form of introspection. While the therapist acts as an interpersonal
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

mirror to the individual client, clients in a family therapy situation are clearly in an
interpersonal venue. Thus, internal dialogue is supplanted by dialogue directed at others in a
communal, albeit intimate, space. The family therapist is continuously shuttling between the
intrapersonal and the interpersonal dynamics presented in the family therapy hour.
Thus, when, for example, two or more family members are engaged in a dialogue, after
empathically addressing each, the therapist may deal with the interaction between them. I
have called this an interspace reflection (Gaylin, 1990). The following scenario demonstrates
first, simple reflection of each family member’s feelings and then an interspace reflection.
Father: I am sick and tired of having to remind him to do his chores.
Therapist: You are exasperated that he never remembers his jobs.
Son: He never gives me a chance. He wants me to do them on his schedule.
Therapist: Dad is impatient and unreasonable.
Father: If I don’t keep after him all the time the jobs just don’t get done.
Son: They’d get done if you’d give me a chance.
Therapist: It seems that it’s hard for the two of you to have confidence and respect for
each other.
Often just laying out the situation, hearing another person reflect the difficulties between
the individuals, is sufficient to help both realize that they share responsibility for the problem.

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 306 Ned L. Gaylin

The individual empathic responses help, not only to validate each speaker’s feelings, but also
to facilitate communication and understanding between the parties. Reflecting the interactive
process often is an additional step in defusing an incendiary situation. It is crucial that the
therapist be evenly empathic and maintain a nonjudgmental stance lest any party feel that the
therapist is taking sides, which would mitigate the therapist’s effectiveness in dealing with the
party who felt slighted.
Within the interpersonal situation however, the therapist sometimes may feel impelled to
speak empathically for family members who, for whatever reasons, may not seem able to
speak for themselves. Thus, I might reply to a father who has just called his son a “lazy good-
for-nothing bum,” accordingly: “You must be very hurt or angry with your son, and if I were
sitting in his chair I guess I would be pretty hurt hearing my dad call me names like that.”
Indeed, I have even used this empathic method when an absent family member is talked
about in the session. I might hazard an empathic guess as to how I would feel in a given
situation were I that family member. I call this method ghosting (see Gaylin, 1993). I find that
present family members are usually intrigued with my feelings. They often report my
reactions to the absent member, who regularly validate them as accurate. Not infrequently,
family members are surprised to learn that the absent member is grateful for absentee
representation.
The same method is useful when family members who regularly attend may have to be
absent. I will often make an effort to keep their presence alive in the hour by saying
something like, “I wonder how John would feel if he were here and heard such and such,” or,
similarly, “I think if John were here he would feel...” I believe standing in for the absent
members also enhances my credibility with all family members, who know that I make an
effort at representing them empathically even when they are not there to represent themselves.
Intergenerational echoing (Gaylin, 1993) is another phenomenon unique to the family
therapy hour. On occasions when I am working with parents and children on certain issues, a
parent will have a dramatic recognition of a parallel experience between themselves as
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children and their own parents. These powerful and emotional revelations often surround
childhood feelings of resentment of the child towards the parent regarding felt injustices.
These echoes often signal a turning point in therapy, where the parent develops an
experiential empathy for the child, which thus enables understanding of each for the other.

WORKING WITH CHILDREN

Working with children in the family context entails special consideration, both when the
children are seen individually and when they are a part of the family therapy session. My
entry into the practice of psychotherapy was with children, and I believe there is no better
training for any therapist than to work with children. Troubled young people are often wary of
strange adults. Before they entrust adults with their deeply personal thoughts and feelings
they need to believe the adult worthy of that trust. Children are masters of nonverbal
communication—more so than adults—and thus can sense deception and guile. Simply put,
young people of all ages demand congruence in their therapists if therapy is to be effective.
Traditionally when we think of children in therapy—particularly young children—we
think of play therapy. Indeed, perhaps the most popular book on the subject is that written out

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Client-Centered Family Therapy 307

of the Person-Centered approach, by Virginia Axline, and is entitled Play Therapy (1947).
Unfortunately, however, when we think of play therapy, we also generally think of particular
equipment such as a sandbox, dolls, puppets, etc., which tends to deter many from working
with children in their offices. Although many of these items are valuable additions to the
therapy environment, few are crucial.
Children of all ages are most inventive in creating toys out of virtually anything. Indeed,
parents who are concerned about encouraging violence often prohibit their children from
playing with guns. These same parents are aghast when they see their children on the
playground, thumb erect and forefinger extended, proclaiming to their playmates “Pow! Pow!
You’re dead.” Very young children will often reject designer toys for simple household
objects, like pots and pans, keys. Virtually all children love to be read to and look at books.
Similarly, most children like to draw and make up stories about their drawings. Thus, an
office with a few interesting books, pencil and paper or crayons, and similar simple objects of
interest to children are sufficient tools with which to begin engaging children.
I generally like to see children alone for a part of the session. I explain to the parents and
the child at the outset that my sessions with children are confidential—that is, they may ask
the child what transpired in our sessions, but that I would not divulge session content. The
exception to this rule is when I believe there to be potential for exposing the child or the
community to danger. The parents must be told if the child is using drugs, harming or
contemplating harming himself or others. Should I learn of problems of this nature, I
encourage the child to share this information with parents, explaining the importance of the
disclosure. I also say that if the child finds it difficult to reveal such information to parents
single-handedly, I will be there to help. Otherwise I will have to disclose the information
myself. With this understanding at the beginning of the therapy relationship, I have rarely had
a problem with establishing trust with all family members.
At the beginning of therapy when I see children alone I ask them if they have any
concerns and/or what events of the week may have been problematic. In the initial stages of
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

therapy children generally say little, e.g., “Things were OK.” I then suggest we bring the
parents in. Invariably one of the parents will say something like “Did Johnny tell you what
happened in school this week?” I then reply that if they want to know what happened in
session they need to ask Johnny. Children become better observers when they realize what to
expect regarding what is likely to happen in the sessions. They begin to realize that, not only
can the therapist facilitate communication between them and their parents, but even act as a
friend and ally. Children begin sharing their concerns when they experience the empathic and
facilitative role of the therapist.
One final point regarding therapy with families in which there are children. Neither the
Person-Centered approach nor family therapy, in general, sees individual diagnosis as
facilitative of the treatment of either individuals or families. However, in working with
children there are some caveats. Children with learning and other developmental disabilities
may be suffering from constitutional problems, e.g., visual, auditory, or central nervous
system. Although, certainly therapy may help them deal with the secondary emotional distress
that these disabilities create, therapy alone cannot mitigate the problem. Psychotherapy alone,
no matter how inspired, is not likely to make a reader of a dyslexic child without addressing
the reading problem per se. Therefore, with children, a psycho-educational diagnostic
evaluation from an outside source may well be in order. Likewise, it is desirable for those

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 308 Ned L. Gaylin

working extensively with children to have a basic knowledge of child development to better
ascertain if children may need special help.
Thus, when working with families wherein a child suffers a developmental disability, I
distinguish between the processes of child guidance and therapy. In child guidance, there are
certain developmental norms, which if not attended to, could adversely affect the child’s
future development and well being. The identification and discussion surrounding these issues
differs greatly from the therapy process described above.

SUMMARY AND CONCLUSIONS

Working with families within the Person-Centered approach is totally consistent with,
and a natural parallel to individual Person-Centered therapy. Theoretically and
methodologically there are few differences except those resulting from the presence of more
than one client. The Person-Centered family therapist attends to individual family members in
a nonjudgmental, caring, and empathic manner. Additionally, the Person-Centered family
therapist attends to and reflects the family members’ interaction patterns. The application of
Person-Centered methods in the family milieu enables a natural and efficacious way to help
people become more fully functioning as both individuals and as families.

REFERENCES
Axline, V. M. (1947). Play therapy. Boston: Houghton Mifflin.
Becvar, D. S. and Becvar, R. J. (1988) Family Therapy, A Systemic Integration. Boston:
Allyn and Bacon.
Fancher, R. T.(1995). Cultures of Healing. New York: W. H. Freeman.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Freud, S. (1915) Die Traumdietung. Vienna.

Gaylin, N. L., (1974). On creativeness and a psychology of well being. In Wexler, D. and
Rice, L. N. (Eds.) (1974). Innovations in Client-Centered therapy, pp339-366. New
York: John Wiley and Sons.
Gaylin, N. L. (1989a). The necessary and sufficient conditions for change: Individual versus
family therapy.The Person-Centered Review, 4, 263-279.
Gaylin, N. L. (1989b). Ipsative measures: In search of paradigmatic change and a science of
subjectivity. The Person-Centered Review, 4, 429-445.
Gaylin, N. L. (1990). Family-centered therapy. In Lietaer, G., Rombauts, J., & Van Balen,
(Eds.) (1990). Client-Centered and Experiential Psychotherapy towards the Nineties,
pp813-828. Leuven: University of Leuven Press.
Gaylin, N. L. (1993). Person-centered family therapy. In Brazier D. (Ed.) (1993). Beyond
Carl Rogers: Towards a psychotherapy for the 21st century, pp181-200. London:
Constable.
Gaylin, N. L. (1996). The self, the family, and psychotherapy. The Person-Centered Journal,
3, 31-43.
Gaylin, N. L. (2000) The Person-centered approach to family therapy. In Keil, W. and
Stumm, G. (Eds.). The person-centered approach in psychotherapy. Vienna: Springer.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
 Client-Centered Family Therapy 309

Gaylin, N. L. (2001). Family, Self and Psychotherapy: a person-centered approach. Ross-on-

Wye: PCCS Books.
Goldstein, K. (1940). The organism. Boston: Beacon Press.
Huxley, A. (1932). Brave new world. London: Chatto and Windus
Jahoda, M. (1958). Current concepts in positive mental health. NY: Basic Books.
James, W. (1890). The principles of psychology. New York: Holt.
Maslow, A. H. (1962). Toward a psychology of being. Princeton, NJ: Van Nostrand.
Orwell, G. (1949). 1984. New York: New American Library.
Rogers, C. R. (1939). The clinical treatment of the problem child. Boston: Houghton Mifflin.
Rogers, C. R. (1942). Counseling and psychotherapy. Cambridge, Mass: The University
Press.
Rogers, C. R. (1951). Client-Centered therapy. Boston: Houghton Mifflin.
Rogers, C. R. (1957). The necessary and sufficient conditions for psychotherapeutic
personality change. Journal of Consulting Psychology, 21, 95-103.
Rogers, C. R. (1959). A theory of therapy, personality, and interpersonal relationships, as
developed in the Client-Centered framework. In Koch, S. (Ed.) Psychology: A study of a
Science, Vol. 3. Formulations of the Person and the Social Context, pp184-256. New
York: McGraw-Hill.
Rogers, C. R. (1961). On becoming a person. Boston: Houghton Mifflin.
Rogers, C. R. and Dymond, R. F. (Eds.) (1954). Psychotherapy and personality change.
Chicago: University of Chicago Press.
Skinner, B. F. (1948). Walden II. New York: Macmillan.
Taft, J. (1933). The dynamics of therapy in a controlled relationship. New York: Macmillan.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 In: The Quick Theory Reference Guide ISBN: 978-1-60021-624-4
Editor: Karin Jordan, pp. 311-329 © 2008 Nova Science Publishers, Inc.

Chapter 22

HUMAN VALIDATION PROCESS MODEL

Sharon Loeschen and Margarita Suarez

This chapter will offer a description of the Human Validation Process Model, including
the history of its development, key concepts, and the processes used for assessment and
treatment. The reader will note that integrated into the discussion at relevant points are
references to research from others. This is due to the fact that one of the criticisms of the
model has been that there has not been sufficient research to support the assumptions of the
model. The authors have addressed this by including research that they believe lends validity
to the philosophy and therapeutic approach of the model.

History
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The Human Validation Process Model, also known as the Satir Growth Model, was
developed by Virginia Satir (1916-1988). The Psychotherapy Networker dedicated an entire
issue to Satir after her death entitled, “Virginia’s Legacy.” It began:

For many people Virginia Satir was Family Therapy . . .She was the very embodiment of
the optimistic, can-do spirit that launched the family therapy movement. In her books, her
workshops, and her innumerable demonstration interviews, she made a profound impression
on the mental health field, turning the introspective, gloomy process of therapy into a
celebration of people’s ability to transform their lives.
You didn’t just go to listen to Virginia Satir present a workshop or interview a family.
Even as you sat hidden in the anonymity of a large audience, she had a way of slipping past
your guard and getting to you. Whether she was making you squirm by having you stare
deeply into the eyes of the complete strangers sitting around you or just going on in that
friendly, enormously reassuring voice about the untapped potential in every person, she
refused to let you remain at arm’s length.
When the news came this past fall that she had died of pancreatic cancer, the reaction was
immediate and very personal. It wasn’t only that a well-known spokesperson for a clinical
point of view or the developer of some interesting therapeutic methods had passed away. Her
loss was far more palpable than that. An extraordinary presence had ceased to exist. It was as

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 312 Sharon Loeschen and Margarita Suarez

if a familiar force of nature had suddenly disappeared” (Psychotherapy Networker,

January/February, 1989, p.27-28).

How did Virginia Satir develop this belief in the “untapped potential” of each human
being? Her writings reveal that it came from her early experiences.

Growing up on a dairy farm in Wisconsin. . .Everywhere I saw growing things. Very early, I
understood that growth was life force revealing itself, a manifestation of spirit. I looked at the
tiny seeds I planted and watched them grow into big plants. Little chickens emerged from
eggs and little piglets came from a sow’s belly. Then I saw my brother born. I marveled. This
was something grand and wonderful. I felt the mystery, the excitement, and the awesomeness.
Those wondrous feelings remain with me today, and I think they have guided me in finding
ways to help people grow” (Satir, 1988, p. 334).

In addition to being impacted by the experiences of farm life, Satir was greatly impacted
by her family. Satir attributes her resourcefulness and creativity to the modeling of her mother
whom she described as being able to create beautiful dresses out of “hand-me-downs.” She
stated that she felt loved by her parents and supported in anything she wanted to do. However,
she was the first born of five, with twin brothers and another sister and brother following
closely after and she said she felt as if she had to grow up quickly describing herself as the
“old woman in the shoe who had too much to do.” (Loeschen, 1999, p. 5)
Satir also experienced the pain of her parent’s marriage. Her mother was a Christian
Scientist but her father was not and according to her, they had horrible arguments over what
appeared to be the subject of religion. She realized later on that the real cause of the pain
between her parents was that her father believed that her mother was more interested in
religion than in him. It was out of that disharmony that she decided to become a family
therapist, stating, “at five I decided to become a detective on parents” (Loeschen, 1999, p. 5).
Initially, Satir focused on helping families but later on she expanded her horizons,
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

applying her concepts to working with individuals, couples, groups and even international
relations, describing her mission as promoting, “Peace Within, Peace Between and Peace
Among.”
In her book The New Peoplemaking, she wrote the following:

Creating peace in the world strongly resembles making peace in the family. We are
learning how to heal families and we can use those learnings to heal the world. Our global
family is dysfunctional and in effect, operates with the same themes as any other
dysfunctional family. In many governments, power is concentrated in one person or role.
Identity is seen in terms of conformity and obedience, and autonomy is subject to someone
else’s approval.
In and between countries, conflict is often dealt with by blame and punishment. Solutions
are reached by decree, threat, force and avoidance. Trust is frequently betrayed and therefore
suspect. Relationships are based on dominance and submission.
We know that the child who discovers he or she gets results by threat, force, or
manipulation will likely use those methods as an adult, unless there has been an intervention.
The threat used by a child might be a fist or a stick. As an adult, it might be a gun or a bomb;
it will still be the same process.
I wonder what would happen if suddenly during one night, all five billion persons in the
world learned the essentials of congruent living:

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 Human Validation Process Model 313

• to communicate clearly,
• to cooperate rather than compete,
• to empower rather than subjugate,
• to enhance individual uniqueness rather than categorize,
• to use authority to guide and accomplish,
• to love, value, and respect themselves fully,
• to be personally and socially responsible,
• and to use problems as challenges and opportunities for creative solutions.
I think we would wake up in a different world, a world in which peace is possible. It is
only a matter of consciousness” (Satir, 1988, p.368-70).

KEY CONCEPTS
Satir presented her concepts in many writings including, Conjoint Family Therapy (Third
Edition,1987), Satir Step by Step (1983), The New Peoplemaking (1988) and The Satir Model
(1991). The reader is encouraged to read these works, as well as those referenced at the end of
the chapter, for a greater understanding of her concepts and process. What will be offered in
this chapter is the author’s view of the key concepts of the model.

• Concept 1: The way to effect change in human systems is to focus on health and
growth rather than pathology and sickness.
• Concept 2: Persons are born with inner resources and the role of the psychotherapist
is to help people more fully use their resources to handle their own lives and have
relationships that work.
• Concept 3: Inner resources can be constrained through constrictive rules/beliefs, rigid
roles, inappropriate expectations and wounds resulting in symptoms and defensive
behavior.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

• Concept 4: Systems operate with universal principles that can be applied to working
with persons at all levels from the individual, to couples, to families, and larger
groups.
• Concept 5: Change/growth is always possible and is most effectively facilitated by
intervening at the level of “process” rather than “content.”

A discussion of each of these concepts follows.

Concept 1

The way to effect change in human systems is to focus on health and growth rather
than pathology and sickness.
The focus of the Human Validation Process (HVP) model is on helping people cope
more effectively by more fully using their inner resources, as opposed to focusing on
symptom-reduction.
This non-pathological approach is now being affirmed by research according to
Hubble, Duncan and Miller (1999). They describe the shift from a pathological to a non-
pathological approach as “encompassing changes in perspective from clients as slow-witted

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 314 Sharon Loeschen and Margarita Suarez

plodders (or pathological monsters) to resourceful, motivated hunters of more satisfying

lives.” (p. 425)

Concept 2

Persons are born with inner resources and the role of the psychotherapist is to help people
more fully use their resources to handle their own lives and have relationships that work.
Although the theory of the importance of focusing on inner resources and strengths had
not been scientifically researched at the time of the development of the HVP model, research
is now validating this orientation. According to Lambert, “40% of what contributes to
successful change is related to the client’s personal strengths, resources, beliefs, social
supports, spontaneous remission, and fortuitous events in the client’s life.” (Lambert, 1992).
Furthermore, this is also supported by the more recent research of Martin Seligman, founder
of the school of Positive Psychology, who states that “well-being comes from engaging our
strengths and virtues.” (Seligman, 2002, p.9).
To highlight the resources that the HVP model focuses on, a graphic entitled “The
Resource Wheel” has been created.

Feelings
Contact
Courage

Acceptance
Compassion /
Love

Awareness
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Curiosity
Your
Unique Choice
Self /
Spirit
Growth /
Change
Intellect /
Wisdom

Humor
/ Fun
Hope

Breath
Expression
Leadership

©”Enriching Your Relationship with Yourself and Others” by Sharon Loeschen.

A Publication of Avanta The Virginia Satir Network, 2005.

The Resource Wheel.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Human Validation Process Model 315

The Self/Spirit

In the center of the resource wheel is the Spirit/Self. Satir believed that the miracle and
mystery of life is that there are no two Spirits alike, that each human being has her or his own
unique Spirit and that this Spirit is pure. She spoke of it this way:

The question for me was never whether (people) had spirits, but how I could contact them. . .It
was as though I saw through to the inner core of each being, seeing the shining light of the
spirit trapped in a thick dark* cylinder of limitation and self-rejection. My effort was to enable
the person to see what I saw; then, together, we could turn the dark cylinder into a large,
lighted screen and build new possibilities” (Satir, 1988, p. 340-341). *Author has substituted
the word “dark” for “black.”

Within the Spirit/Self resides a sense of one’s worth and value. The HVP model focuses
on helping people to reclaim their sense of worth. A basic assumption of the model is that
each person is born with a sense of their worth and value and yet this can be eroded through
constricting family systems. The therapeutic process is one of validating people so that they
can reconnect more fully with their sense of worth and value. The following poem written by
Satir reflects this validation of Self:

To Be More Fully Me
I need to remember
I am me
And in all the world there is no one like me.
I give myself permission
to discover me and use me
lovingly,
I look at myself and see
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

a beautiful instrument
in which that can happen.
I love me
I appreciate me
I value me.

As this occurs, healthy functioning increases, communication is more centered, clear, and
open and persons have more energy for creativity and productivity. At the same time that
there is this emphasis on self-worth, however, the HVP model also stresses personal and
social responsibility.

The Breath

The conscious use of one’s breathing is an important resource for helping people slow
down, become aware, get re-centered and connect with others. When persons are reactive or
feeling anxious their breathing is usually shallow and fast. With awareness of the breath, there
can be a shift in depth and pace bringing more of a sense of calm.

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 316 Sharon Loeschen and Margarita Suarez

The Capacity for Awareness

The HVP model purports that using the resource of awareness is the first step toward
change. Awareness is important for recognizing defensive versus centered communication.
Satir identified four common defensive or communication stances. They are (1) blaming, i.e.,
placing fault on the other; (2) placating, i.e., placing fault on oneself; (3) being super-
reasonable, i.e., focusing only on facts to avoid feelings and (4) distracting, i.e., taking the
focus away from uncomfortable situations or topics. To these four defensive stances, the
authors have added one more, that of “withdrawing,” i.e., emotionally or physically
distancing oneself from another.
Awareness can also be used to develop a more in-depth understanding of the individual’s
inner process or levels of experience. Using the metaphor of an iceberg, the levels can be
thought of as that which is visible above the water line, i.e., behavior and coping stances, and
that which is below the water line, i.e., feelings, perceptions, expectations, yearnings and the
Self (Satir Model, 1989).
Bringing awareness regarding any of these levels can begin the process of change. This
can be done through heightening the awareness of healthy, centered behaviors as well as
defensive behaviors. Similarly, bringing awareness to client(s) regarding their feelings,
perceptions, expectations and yearnings is seen as vital for helping client(s) express
themselves and update their perceptions, expectations and/or yearnings if they are unhelpful..

The Capacity for Acceptance

Acceptance of oneself is necessary for change to take place. Non-acceptance or self-

rejection binds up the energy needed for change. Paradoxically, the acceptance of one’s
deficits is necessary before one can move forward to change them.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

The essence of wholeness is the acceptance of one’s many parts. People have parts and
these parts have a positive aspect even when they may be negative in their extreme. For
example, a critical part can have an aspect of discernment or a stubborn part can have as
aspect of determination. The HVP model works to help people find a form in which all of
their parts can be useful to them.
Acceptance of others is also an important ingredient in effecting change in a system. The
work of Jacobsen and Christensen entitled, Acceptance and Change in Couple Therapy
(1996) validates this concept. They state, “acceptance means, in part, letting go of the struggle
to generate change in one’s partner. Therefore, truly letting go of that struggle is often the
best way to generate change” (p. 14).

The Capacity for Choice

The capacities for awareness and acceptance lead to greater choice. Conscious choice is
viewed as a key resource for healthy functioning in the HVP model. In his book Choice
Theory, William Glasser concurs stating, “To achieve and maintain the relationships we need,
we must stop choosing to coerce, force, compel, punish, reward, manipulate, boss, motivate,
criticize, blame, complain, nag, badger, rank, rate, and withdraw. We must replace these
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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Human Validation Process Model 317

destructive behaviors with choosing to care, listen, support, negotiate, encourage, love,
befriend, trust, accept, welcome, and esteem.” (Glasser, 1998, p. 21) Choice is liberating,
empowering people to be able to move from unhealthy to healthy attitudes and behaviors.

The Capacity for Intellect/Wisdom

The resource of intellect is valued for the many ways in which it contributes to the
healthy functioning of an individual such as the ability to reason, conceptualize, plan,
imagine, create, envision and be wise.
Using one’s inner wisdom is seen as important in the process of making healthy choices.
Satir described inner wisdom, as “that part which you sense sometimes giving direction;
sometimes called a still, small voice” (Satir, 1991, p. 295). The HVP model purports that
defensiveness and fear are barriers to the use of wisdom and therefore an important
therapeutic task is removing these barriers.

The Capacity for Hope

Hope gives people energy for change and so it was one of the first resources focused on
in this model. After connecting with clients, it is recommended that the therapist begin to
engender hope by asking something like, “What do you hope to have happen here today?”
The assumption of the importance of connecting people to their hope early on in the therapy
process has now been validated as reported in, The Heart and Soul of Change, where the
authors state, “research confirms the importance of hope and expectation in psychotherapy”
(Hubble, Duncan and Miller, 1999).
In the HVP model, hopes are often paired with dreams. Helping people to become aware
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

of and articulate their dreams is a means of helping people more fully honor themselves and
their longings. Facilitating the sharing of dreams between couples and/or family members
often deepens the bond in a positive direction. As John Gottman, a preeminent researcher on
marital success and failure states, “The degree to which a marriage enables both partners to
feel that their life dreams are supported can make or break it” (Gottman, 1999, p.108).

The Capacity for Emotions/Feelings

Emotions are viewed as possible sources of energy that can be used for creativity and
productivity when appropriately accessed and regulated. The HVP model promotes
developing awareness of emotions, accepting them without judgment, and choosing how to
respond to them.
Corrective emotional experiences are central to the model, such as helping clients in
relationships share their heartfelt feelings with each other. The recent research based work of
Susan Johnson, developer of the Emotionally Focused Therapy Model, emphasizes the
importance of the resource of emotions in effecting change. She writes, “Emotion is seen as
the primary player in the drama of marital distress and in changing that distress. It is emotion

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 318 Sharon Loeschen and Margarita Suarez

that organizes attachment behaviors, orients and motivates us to respond to others, and
communicates our needs and longings to them” (Johnson, 1996, p. 8).

The Capacity for Leadership

Leadership of oneself involves both the ability to lead one’s internal process as well as
one’s external process. In a sense, it is the integration of awareness, acceptance, choice and
wisdom. It provides one with perspective, such as the ability to step back and view oneself
from a wider lens. For example, helping oneself to be less shaming and more accepting of
mistakes as one is trying to change a behavior. It could also mean helping oneself to respond
rather than react during an interpersonal conflict.
With perspective comes the ability to view situations in terms of fairness and justice. This
can be applied to family interactions as well as the larger community. At times the HVP
model might be seen as just a feel good model, but an intrinsic part of the model is the belief
that taking responsibility for oneself and being responsible for the betterment of society is
crucial.

The Capacity for Humor and Fun

The ability to be humorous and have fun is a resource. It brings light and balance to our
bodies and to relationships. There can be a “virtuous cycle” of healing occurring for as one
experiences oneself having fun, burdens feel lighter and as burdens are healed, there is more
energy for having fun.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

The Capacity for Growth and Change

The foundation of the HVP model is the assumption that people are capable of growth
and change. The traditional concept of resistance is viewed not as a negative but as the natural
defense against the fear of the unknown. It is seen as a lifeline to be respected. Creating an
alliance with the client that conveys respect, safety, trust and a willingness to be with the
clients, as they venture into new emotional territory is seen as the most effective way to help
people let down their defenses and connect with their desire for growth.

The Capacity for Compassion and Love

The capacity to be compassionate and loving is vital in developing healthy relationships.

When compassion and love are accessed, there is a deepening of connection and both the
sender and the receiver feel enriched. Similarly, when compassion and love towards oneself is
accessed and felt, there is a greater sense of self-acceptance which leads to more joy, energy
and productivity.

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 Human Validation Process Model 319

The Capacity for Curiosity

The resource of curiosity is extremely helpful in that it can help one be open to exploring
before judging. When there are differences and/or conflicts, the ability to be curious about
another’s point of view can facilitate greater understanding. There are times in relationships
when one cannot access compassion toward another but one can use one’s curiosity to explore
their views.

The Capacity for Courage

Courage is the last resource to be discussed here; however, there is no hierarchy of

importance implied. Courage is considered an extremely important resource, therefore
helping people become aware and appreciate their courage is a significant piece of the model.
Courage is highlighted by helping people see how they have overcome challenges, as well as
helping them honor ways in which they are currently taking risks.

Concept 3.

Inner resources can be constrained through constrictive rules/beliefs, rigid roles,

inappropriate expectations and wounds resulting in symptoms and defensive behavior.
Constrictive beliefs, or as they are sometimes referred to, “survival rules,” often govern
the family system; that is, messages (overt or covert) are given as to what is acceptable and
not acceptable to think, feel, or do. In hierarchical families, rules such as “someone must
dominate,” “differences are bad,” “someone must be to blame,” and “change is to be resisted”
are usually present. Furthermore, these rules are often accompanied by the rules that “it’s not
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

okay to see, hear, feel, want, ask, or comment on what you see, hear, feel or want.” These
rules constrain the use of self and lessen family members’ sense of worth.
All human systems lend themselves to the need for roles, however, if these roles are
inappropriate or rigid, they can be constraining. Children, for example, who are brought into
the role of “ersatz mate,” “mom or dad’s ally,” “the messenger between the parents,” or the
“pacifier” can develop symptomatic behavior and get labeled as the “bad one,” “the sick one”
or the “crazy one” (Satir, 1987).
Unrealistic expectations can constrain a child in that the parent may expect a child to be
able to perform beyond her or his developmental capacity or may expect a child to stay at a
developmental stage longer than is appropriate. A child can also be the recipient of the
unrealistic expectations related to the parent’s projection, whereby the parent attributes traits
to the child that belong to someone else and then expects the child to behave accordingly.
Wounds from past traumas can be constraining as well, if negative self-perceptions are the
result, as is often the case with victims of abuse. The HVP model mobilizes the resources of
the individual to free themselves from these constraints. The process used will be discussed in
the latter half of this chapter.

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 320 Sharon Loeschen and Margarita Suarez

Concept 4

Systems operate with universal principles that can be applied to working with persons at
all levels from the individual, to couples, to families, and to larger groups.
The HVP model hypothesizes that there are systemic principles at work within all human
units. The original hypothesis was developed by Satir when she was working with a young
woman who had been labeled schizophrenic. During their work together, the young woman
began to improve, but when her mother was introduced into the therapy, the system fell apart,
which happened once again when the father was brought into the therapy. It was only when
Satir brought in the final member of the family, the son, that she began to understand the
dynamics of the family. She could clearly see that the parents worshipped the son, and as a
result, the daughter was disempowered (Satir et al., 1991).
The family is a system with a governing process which includes leadership, rules and
roles. Each of these functions has the potential for promoting the health or dysfunction of the
system. For example, the leaders can be visionary and effective guides or they can be over-
controlling or under-controlling.
Rules (overt or covert) can be supportive giving containment and boundaries to the
system or they can be constrictive to the members’ development. Similarly, roles can add to
the functioning of the family or they can be rigid and be burdens for members. For example,
families need to have fun and need members who can clown around at times but if a member
is expected to always be the clown and never allowed to be serious, then the role becomes a
burden.
Although, the HVP model identifies the constraints heretofore mentioned, such as
constrictive rules and rigid roles, the model also purports that the family system has the
potential to become the provider of a safe, nurturing foundation for the development of
healthy, creative, responsible, and productive adults.
As was described earlier, this understanding of family systems was later applied to
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

understanding larger systems such as nations as well as smaller systems such as the inner
process of the individual. Satir viewed each person’s inner system as having parts and saw
those parts as operating as a system. For example, she described people as having universal
parts such as a judge, a manager, and a child part. She searched for the inner dialogue among
parts, knowing that internal conflicts often are resolved through greater awareness and
acceptance of these inner dynamics.
Richard Schwartz, in his book, Internal Family Systems (1995), has elaborated on the
concepts of parts as a system, however, he states that, “Satir (1972, 1978), cleared much of
the brush along this path of combining the study of intra-psychic sub-personalities with
systems theory. (p.7)

Concept 5

Change/growth is always possible and is most effectively facilitated by intervening at the

level of “process” rather than “content.”
The HVP model describes the process of change as having stages. The understanding of
these can aid the therapist in knowing what stage the client is experiencing and what kinds of
therapeutic interventions would be most supportive to effect further desired change.
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 Human Validation Process Model 321

The first stage is described as “Status Quo,” where no change is occurring but there is
sense of a need for change. Stage two comes in the form of a “New Element.” This could be a
positive event such as a promotion or a negative one such as a child getting in trouble at
school. In either case, the usual way of being is disrupted. The disruption leads to the third
stage entitled, “Chaos,” where the client(s) may feel out of control, anxious, depressed,
confused, etc., because the old ways of being can no longer be maintained or the problem can
no longer be hidden. With chaos there comes a choice point where there can be a return to the
previous way of coping or there can be a decision to do something differently. This is
identified as stage four, “New Options.”
In order to reinforce new ways of coping, the client(s) move into stage five, or
“Implementation” where they practice being different and gather support for doing so. An
example of this process might be having a client come into counseling because he has
discovered his partner is having an affair. He has been stuck in (Status Quo) knowing that
there were problems in the relationship, but finding it difficult to confront them. This
changed, however, when he found an email revealing that his partner was having an affair.
(New Element) He went into (Chaos) feeling very distressed and anxious and then sought out
a therapist.
With the help of the therapist, the client was able to see that he needed to be more open
with his partner. (New Options) He then invited his partner to join him in therapy and asked
for his partner’s support as he learned how to open up and share more of his heart.
(Implementation) With the stages of change as a framework, the HVP model focuses on the
process for effecting change rather than on the content of the problem. The use of “process”
as opposed to “content” interventions will be discussed more fully in the next section.

The Therapeutic Process of the HVP Model

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Assessment. In actuality the process of assessing is not a separate stage in the therapeutic
process but rather one that is on-going and is intertwined with the treatment process. For
purposes of clarity, however, the areas that are considered important for assessment are
identified below.
Awareness of strengths and resources. Do client(s) feel their worth and value? Do the
client(s) have an awareness of and appreciation for their strengths and resources?
Quality of communication. Are the client(s) able to make contact? Are the client(s) able
to be centered in their interactions, as opposed to reactive and defensive? If defensive, how is
this manifesting itself? Is the communication clear, respectful, open, and honest?
Awareness of choices regarding interpersonal interactions and inner process. Are the
client(s) aware of how they are relating interpersonally? Are the client(s) aware of how their
behavior is being influenced by their perceptions, i.e., the meaning they give to events? Are
the client(s) aware of expectations or yearnings that are no longer helpful and out-of-date?
Are client(s) aware of their choices for up-dating their expectations and yearnings?
Acceptance of self and others. Do the client(s) feel accepting and loving of themselves or
are they extremely self-critical and self-rejecting? Do the client(s) view themselves as having
a contribution to make to life? Do the client(s) appreciate differences in the developmental
needs, style, temperament, etc. of others?

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 322 Sharon Loeschen and Margarita Suarez

Effective leadership. Does the leadership provide nurturance and guidance for growth and
change? Do the client(s) feel equal in personhood even if they have different roles? Do
client(s) feel free to be themselves? Do client(s) feel empowered? Is an atmosphere of
cooperation rather than competition engendered? Are members encouraged to see problems
as opportunities for creative solutions?
Acceptance of responsibility. Are the client(s) aware of their contributions to the quality
of relationships? Do they see how their choices and interactions positively or negatively
affect the level of connection in relationships?
Availability of support for change. Is there an environment of encouragement and support
for client(s) as they grow and change? Are client(s) open to giving and receiving support? Is
there an environment of appreciation?

Treatment Goals

The goals of treatment are directly related to the assessment areas:

1. To affirm client(s) strengths and resources in order to facilitate coping with the
presenting problem.
2. To facilitate centered communication in order to deepen meaningful and loving
connections.
3. To bring awareness to client(s) of their choices.
4. To promote acceptance of self and others.
5. To enable effective leadership.
6. To foster responsibility.
7. To provide support for growth and change.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Treatment Process

The process of therapy for accomplishing these goals has six phases as described below.

Phase 1-Making Contact

To begin to develop a therapeutic alliance, the therapist works to make contact with the
client(s) at the deepest level, i.e., from her or his Spirit to the Spirit of the client(s). In
addition to working toward a spiritual connection, the therapist reaches out to the client both
physically and mentally. This involves facing the person, if possible, and paying careful
attention to not only their words but also their body language and voice tone. The process of
making contact and attending is important for establishing a safe, trusting relationship
between the therapist and the client. This high level of attention is also important for the
therapist in order to observe the client(s). These observations are used to bring awareness to
both the therapist and the client(s) as to the quality of communication in their relationships,
their use of their inner resources and any constraints that are blocking their use.

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Human Validation Process Model 323

Phase 2-Validating

Validating client(s) is central to the treatment process of the HVP model and involves
affirming resources and conveying a valuing of the client through empathy and acceptance.
This focus appears to be affirmed according to the to research review of (Hubble, Duncan,
and Miller, 1999). They site Lambert (1992) as determining four factors that contribute to
successful change and the percentage of influence. They were:

• Client (factor), (40%, strengths, talents, resources, beliefs, social supports,

spontaneous remission, and fortuitous events in the client’s life);
• Relationship (factor), (30%, perceived empathy, acceptance, and warmth);
• Expectancy (factor), (15%, the client’s hope and expectancy of change as a result of
participating in therapy);
• Model/technique (factor), (15%, theoretical orientation and intervention techniques
used by the practitioner.) (p.362).

In addition to the basic philosophical orientation of valuing each client, some of skills
that can be used to validate are:

Appreciating, i.e., acknowledging client’s efforts, pain, etc.:

• “I can really appreciate what you have had to cope with.”
• “I can really appreciate the efforts the two of you have put forth trying to deal
with your conflict.”
• “I can really appreciate the pain this family has experienced.”
Affirming, i.e., pointing out client’s resources and strengths:
• “Did you know that you could have that much courage?”
• “So you used your resourcefulness to help you get through this tough time.”
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

• “You just expressed yourself so beautifully to your mother, were you aware you
had that in you?”
Individualizing, i.e., highlighting each client’s uniqueness and importance:
• “Carl, what is your point of view about how the two of you make decisions?”
• “Maria, Jorge believes that a wife is responsible for seeing to it the family runs
smoothly. What is your belief?”
• “Grandma, tell me your name. I know that the family calls you “Grandma,” but I
want to call you by your name.”
Engendering hope, i.e., helping client(s) regain a sense of their ability to make life better
for themselves:
• “Although it feels pretty hopeless to you at this moment, I see new possibilities
for you.”
• “I would like to hear from each of you what you hope will happen here today.”
• “I see that this family can work out ways to have more pleasure and less pain.”
Reflecting, i.e., stating the client’s feelings and points of view:
• “This has turned out to be disappointing to you.”
• “Your perception is that you get the brunt of the work in your relationship.”
• “I hear that you feel proud of the way you have provided for your family.”
Clarifying, i.e., inquiring about client’s feelings and meanings:
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 324 Sharon Loeschen and Margarita Suarez

• “Are you saying that you feel stuck because what you have tried hasn’t worked?
• “I want to check this out. You would like more support from your partner. Is that
it?”
• “Do you mean that you don’t think your son is saying what he feels?”

Phase 3: Facilitating Awareness

The foundation of a therapeutic alliance is formed through phases 1 and 2, leading to the
next step of bringing greater awareness to both the client(s) and the therapist. Some of the
skills that can be used to aid in facilitating awareness include:

Mapping, i.e., taking a three generational history, exploring for strengths, stressors, and
patterns of communication:
• “How did your parents help each other survive after the loss of their second
child?”
• “How did you know when your mother was mad?”
• “Were there other people outside of your family who were significant in your
growing up experience, positive or negative?”
Educating, i.e., giving new information:
• “Within you are many wonderful resources like your breath, so take a nice deep
breath to help with those butterflies.”
• “People can’t see their own backsides, so tell your wife how you see her being
with your daughter.”
• “You learn from your models, so let’s take a look at how your parents’
parented.”
Shifting from content to process, i.e., helping client(s) look at how they are being with
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

each other as opposed to joining them in problem-solving:

• “So you are feeling scared about this. What are you saying to yourself that is
making you scared?”
• “You both have shared your pain over your son’s behavior. I am wondering how
the two of you are talking to each other about your pain.”
• “How do people in this family find out what makes each other happy?”
Identifying process, i.e., articulating beliefs, expectations, etc., which appear to be helpful
as well as unhelpful:
• “So when you are able to share your heart with your partner, you feel more
connected.”
• “You think your husband is too hard on the kids but you don’t tell him.”
• “Sometimes you are able to stay centered and hear each other and at other times
you get protective and then it is hard to hear each other.”
Sculpting, i.e., positioning people in relationship to each other to reveal the essence of
their emotional relationship(s):
“I think it might be helpful if each of you share your picture of your relationship. What I
would like for you to do is show me without words. Place your partner and yourself in
relation to each other the way you experience the relationship. You can be standing,

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Human Validation Process Model 325

sitting, kneeling, facing toward, facing away, close, distant, whatever will express how
you experience the relationship.”
Exploring, i.e., identifying the various levels of the Self in a non-judgmental manner:
• Feelings.
− “How do you feel about the fact that you graduated in spite of people telling
you that you couldn’t do it?”
− “How are you feeling as you hear your husband’s pain?”
− “Now that you see your wife sharing with your son, how do you feel?”
• Perceptions
− “How do you see yourself being with your boss?”
− “What meaning do you give to what your partner just said?”
− “As your son shares with you, what is your picture of what he is saying?”
• Feelings about feelings
− “How do you feel about feeling relieved?”“As you feel more connected,
how do you feel about that?”
− “How is it for you being angry with your mother?”
• Beliefs.
− “It sounds like you believe it’s dangerous to ask for what you want. Is that
so?”
− “I hear you believing that your wife doesn’t love you if she differs with you
on this. Is that what you are saying to yourself?”
− “What do you believe will happen if you share your feelings?”
• Yearnings
− “What is it you are longing for from your father?”
− “I hear you longing to know he will be there for you. Is that right?”
− “You long to feel respected by her, if I am hearing you correctly.”
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Phase 4-Promoting Acceptance

Along with awareness, the acceptance of oneself and/or others is a key to the process of
change. As was discussed earlier, the paradox of effecting change is that acceptance precedes
change. The assumption that criticizing and shaming will cause oneself or others to change is
usually not the case. People tend to change more readily when they feel accepted. Some of the
skills used in the HVP model to promote acceptance include:

Normalizing, i.e., letting client(s) know that their feelings are normal and human:
• “Making mistakes is part of being human. Mistakes give us information for our
learning and growing.”
• “You are now aware that part of you wanted to get married for security. Well,
that’s par for the course.”
• “I think all of us know about the struggle of being a teen.”
Bridging, i.e., identifying similar feelings between client(s) who are in conflict:
• “I’m hearing that you also know something about the sense of isolation your
daughter is talking about.”

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 326 Sharon Loeschen and Margarita Suarez

• “As you heard your wife talk about her fear for your son’s future, is that
something you know about as well.”
Reframing, i.e., casting a negative perception in a more positive light:
• “You call yourself stubborn. In what areas of your life do you think your ability
to stand firm on things helps you?”
• “I hear you seeing your son as bad. Perhaps his behavior is a reflection of the
pain he is in.”

Phase 5-Making Choices/Changes

With awareness and acceptance, client(s) can come to a point of choice regarding making
changes. Some of the skills used for this phase include:

Challenging, i.e., questioning unhelpful beliefs or expectations of client(s):

• “Now that you see you have an expectation of your daughter that doesn’t fit, are
you willing to let go of it?”
• “Do you really believe that you don’t contribute anything to the family?”
Guiding, i.e., giving client(s) direction for making changes:
• “As you imagine yourself speaking up, see yourself breathing and keeping
centered.”
• “Share with your partner those appreciations of him that you just shared with
me.”
Breaking the rules, i.e., helping client(s) to free themselves from unhelpful rules such as
it’s not okay to feel or talk about what you see:
• “What are you feeling?”
• “What do you see going on between your husband and your son?”
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Activating dialogs, i.e., helping client(s) share from their deeper selves with each other:
• “How about turning toward your daughter and telling her what is in your heart
about how much you treasure her?”
• “How is it for you to hear your father talk from his heart to you?”

Phase 6-Reinforcing Changes

Once client(s) have taken the step of making a change, there are skills used to reinforce
the positive change. Some of those skills include:
Anchoring, i.e., positively reinforcing the client(s) change through supportive words and
voice tone:
• “I’m so glad you were able to get out those things that have been stuck inside.”
• “Be with that new feeling of having shared your truth.”
Using imagery, i.e., inviting client(s) to use their power of imagery to see themselves
continuing their new way of being:
• “Would you be willing to close your eyes and see yourself continuing to talk to
yourself in this kinder way?”
• “Could you see yourselves continuing to be appreciative to each other?”
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Human Validation Process Model 327

Gathering support, i.e., brainstorming with the client(s) about possible ways in which
they can get support.
• “Who in your life could support you as work on this new way of being?”
• “Would you be open to seeking a support group for stepparents?”

The six phases and the accompanying skills described here were presented in a linear
fashion for the purpose of clarity, however, in reality, the therapist often flows back and forth
between the phases as needed. Note how this process is reflected in the graphic below.

PHASE I
M AKING
CONTACT

PHASE VI PHASE II
REINFORCING VALIDATING
CHANG ES
PHASES OF
SATIR’S
PROCESS
FOR
CHANG E

PHASE V PHASE III

M AKING FACILITATING
CHANG ES AWARENESS

PHASE IV
PROM OTING
ACCEPTANCE
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

©”The Satir Process by Sharon Loeschen.

A Publication of Avanta The Virginia Satir Network, 2002.

STRENGTHS
As previously indicated the HVP model offers a positive, growth orientation, helping
client(s) access their resources more fully through the experience of a nurturing therapeutic
relationship. And these factors, i.e., focusing on the client’s strengths and developing a strong
therapeutic relationship, along with creating an environment of expectancy and hope, have
been identified as some of the most important in effecting change (Hubble, Duncan, and
Miller, 1999)
The model is an integrative model in that all aspects of the person, i.e., behavioral,
cognitive, and affective, are included in the assessment and treatment process. Examples of
interventions at each of these levels of experience were delineated in the discussion on
therapeutic process. The model is also integrative in the sense that both the present and the

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 328 Sharon Loeschen and Margarita Suarez

past are taken into consideration. Histories are taken to highlight strengths as well as
understand patterns of coping and any past traumas. Furthermore, the model can be applied to
working with different modalities such as individuals, couples, families and groups, as well to
different issues such as diversity, grief and trauma.

LIMITATIONS
The model has traditionally promoted direct expression. When this is taken as the only
way to communicate, it seems to ignore that in some cultures there can be intimacy without
direct communication. Direct expression can also be unsafe in cases of domestic violence or
where persons are living under oppressive governments.
Since the model was developed in the latter part of the twentieth century, instances may
have occurred in the original literature regarding the concepts of the model where there was a
lack of awareness regarding denigrating language. For example, the reader may have noted an
asterisk after the word “dark” in the first quote of Satir. The original quote read, “It was as
though I saw through to the inner core of each being, seeing the shining light of the spirit
trapped in a thick black cylinder of limitation and self-rejection.” Due to our awareness now
that this negative use of the word black is damaging, the authors’ chose to update the quote
and change the word to “dark.”
Somewhat related to this limitation is the attention paid to differences. Satir was known
for working with people from many, many cultures and, to be sure, connected with them on a
deep human level. Now, however, having a greater understanding of the need for cultural
competence, understanding the importance of appreciating these differences may not have
been emphasized enough.
And finally, in the authors’ opinion, there is the limitation that the model does not
sufficiently acknowledge the importance of being able to recognize serious mental disorders.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

There appears to be a need for a balanced approach, where therapists are trained in working
from a positive, growth orientation but with an understanding of serious mental disorders at
the same time.

SUMMARY
The Human Validation Process Model was developed by Virginia Satir and is a growth
model, purporting that the way to effect change in human systems is to focus on health and
growth rather than pathology and sickness. Persons are viewed from a positive frame as
having inner resources to handle their lives; however, they may carry constrictive
rules/beliefs, rigid roles, inappropriate expectations and wounds which constrain their full use
of their resources. These constraints may result in symptoms and defensive behavior.
The therapeutic process focuses on helping people become: more aware of strengths and
resources; more centered when communicating; more aware of choices and process, both
interpersonally and intra-personally; more accepting; more responsible, and more able to
gather support for growth and change.

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Human Validation Process Model 329

REFERENCES
Glasser, W. (1998). Choice theory. New York, NY, HarperCollins Publishers, Inc.
Gottman, J. (1999). The marriage clinic. New York, NY, W.W. Norton and Company.
Hubble, M., Duncan, B, & Miller, S. (1999). The heart & soul of change, Washington, D.C.:
American Psychological Association.
Jacobson, N., & Christensen, A. (1996). Acceptance and change in couple therapy. New
York, NY, USA: W.W. Norton and Company.
Johnson, S. (1996). Creating connection. Florence, KY, Bruner/Mazel.
Loeschen, S. (1997) Systematic training in the skills of Virginia Satir. Pacific Grove, CA,
USA: Brooks/Cole.
Loeschen, S. (2002). The Satir process. Fountain Valley, CA, Halcyon Publishing Design.
Satir, V. (1987). Conjoint family therapy. Palo Alto, CA, Science and Behavior Books.
Satir, V (1988). The new peoplemaking. Palo Alto, CA, Science and Behavior Books.
Satir, V., Banmen, J., Gerber, J, & Gomori, M. (1991). The Satir model. Palo Alto, CA,
Science and Behavior Books.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 In: The Quick Theory Reference Guide ISBN: 978-1-60021-624-4
Editor: Karin Jordan, pp. 331-347 © 2008 Nova Science Publishers, Inc.

Chapter 23

ECOSYSTEMIC STRUCTURAL FAMILY THERAPY:

A PRIMER

C. Wayne Jones and Marion Lindblad-Goldberg

Ecosystemic Structural Family Therapy (ESFT), an empirically supported adaptation of

the widely influential Structural Family Therapy (Minuchin, 1974), has been developed to
treat children and adolescents with severe emotional or behavioral problems and their families
within the context of their communities. The children and adolescents targeted by ESFT are
either “at risk” of out-of-home placement or they have already spent time in inpatient or
residential settings. The families of these children tend to be compromised by serious parental
emotional disturbance, substance abuse, severe conflict, financial issues, and the absence of
dependable instrumental or emotional support.
The ESFT model is based on the fundamental assumption that both the child’s and their
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

parents’ functioning is inextricably linked to their relational environments. Therefore, ESFT

practitioners give particular attention to the recurring, often enduring, patterns of interaction
that organize and structure daily family life, particularly with respect to caregiving functions
and emotion regulation. The hallmarks of practice in this model include the emphasis on
working from within the family system and its here-and-now practical, action orientation to
helping.

THEORETICAL FOUNDATIONS
Both Structural Family Therapy (SFT) and the ESFT adaptation of the model were
developed in response to the pragmatic needs of a specific population who were not
responding to currently available treatment approaches. For example, Minuchin and his
colleagues formulated SFT at the Wiltwyck School for Boys in the 1960s when confronted
with behaviorally disordered children and adolescents living in inner-city, impoverished
minority families who demanded a more concrete, action oriented treatment that would meet
them where they lived (Minuchin, Montalvo, Guerney, Rosman, & Schumer, 1967). Between

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 332 C. Wayne Jones and Marion Lindblad-Goldberg

1965 and 1981, Minuchin and his collaborators, such as Jay Haley, Braulio Montalvo,
Charles Fishman, and Bernice Rosman, further elaborated the concepts and techniques of SFT
while at the Philadelphia Child Guidance Clinic (e.g. Minuchin, 1974; Minuchin, Rosman &
Baker, 1978; Minuchin & Fishman, 1981; Haley, 1987). Minuchin established a training
center at the Philadelphia Child Guidance Clinic where thousands of practitioners from
around the world have been trained in the model.
Between 1985 and 2000, the SFT model spawned several research-based, integrative
variants targeting specific child and adolescent clinical problems, such as substance abuse
(Liddle, 2002), depression (Diamond, Siqueland, & Diamond, 2003), delinquency
(Henggeler, et al, 1998; Robbins & Szapocznik, 2000), and chronic illness (Wood, Klebba, &
Miller, 2000). It was within this context that Lindblad-Goldberg, director of the Training
Center at the Philadelphia Child Guidance Clinic, began developing ESFT in 1988 to treat
children who were showing severe emotional and behavioral disturbances. Traditional
treatment models available at the time separated children from their families and
communities, created fragmentation of services, neglected family needs, and left many
children trapped in a revolving door of out-of-home placements and chronic mental illness.
Lindblad-Goldberg adapted SFT to meet these challenges, developing a time-limited, team-
delivered approach to family therapy that could be delivered in the home and facilitate
collaborative linkages with other community helpers (Jones & Lindblad-Goldberg, 2002;
Lindblad-Goldberg, Dore, & Stern, 1998). This model is currently implemented in Family-
Based Mental Health treatment programs throughout the state of Pennsylvania.

Key Concepts and Assumptions

In contemporary SFT and ESFT, assumptions about human nature, problem formation,
development and adaptation, and family processes are informed most broadly by a synthesis
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

of general systems theory (Bertalanffy, 1968), Structural Family Therapy (Minuchin, 1974;
Minuchin & Fishman, 1981), developmental-contextual theory, currently embraced in the
discipline of “developmental psychopathology” (Cummings, Davies, & Campbell, 2000;
Sameroff & Emde, 1989; Cicchetti & Cohen, 1995), and theories of human ecology
(Bronfenbrenner, 1979; Auerswald, 1968). There are seven basic principles derived from
these philosophical and theoretical traditions that guide the theory and practice of ESFT.
Discussed below in conjunction with these principles are four interrelated constructs that
guide ESFT therapists in their understanding of clinical problems: family structure, family
emotion regulation, individual differences, and family development.
The first principle is that people are assumed to be multifaceted and continually in the
process of becoming. Human nature is assumed to be neither basically good/sane nor
basically bad/crazy, but instead it is about potentialities or possibilities, shaped by biology,
experience and context --- and the ongoing stories that people construct about their lives. The
relationship environments in which people live evokes, cultivates and reinforces certain
aspects of self and potential, while ignoring or inhibiting others (Wachtel, 2001). The story of
the self evolves through ongoing interactions and interpretations of meaning derived from this
experience, a view influenced by social constructivism (Watzlawick, Weakland, & Fisch,
1974) and embraced by narrative therapists (Anderson, 1997; Freedman & Combs, 1996).
Family members’ perceptions or images of themselves and of one another tend to be self-
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 Ecosystemic Structural Family Therapy: A Primer 333

perpetuating, which either limits or promotes possibilities. ESFT therapists’ interventions aim
to create alternative ways for family members to relate to one another and to create meaning,
so that personal traits and characteristics previously unavailable for problem resolution can
emerge and grow.
The model does not view individuals as passive victims of their relational environments,
however, but as active co-creators of it. This highlights a second important assumption of the
model. That is, individuals actively create the relationship system in which they live and are
governed by it at the same time. This means that to some extent children contribute to the
creation of their families, in as much that families contribute to who their children become.
For example, a child with biologically-based tendencies, such as learning or processing
differences, anxiety-proneness, intense temperaments, or attentional issues seeks out specific
types of interactions and will necessarily evoke certain responses from their parents that may
or may not have been typical of them prior to becoming a parent. Individual difference is one
of the four major constructs guiding assessment and case formulation in ESFT.
Understanding the unique characteristics and needs of each individual family member
determines whether the family system that has evolved is functional. A functional family
system promotes the growth and development of all its members, accommodating
appropriately to individual differences.
A third principle is that families are organized open systems in which members relate to
one another in patterned, structured ways that are observable and predictable. A major
construct in SFT and ESFT, Family structure, refers to the recurring, enduring, and regulating
patterns of interaction that develop over time as family members manage the common day-to-
day tasks, needs, and connections of family members. Although there is considerable
structural variation across families, all families tend to organize into subsystems and have
some type of hierarchy, usually organized along generational lines (Minuchin, 1974). The
subsystems of interest in ESFT include the individual, the couple, the parents, each parent-
child dyad, the siblings, the grandparents, the grandchildren, and the relatives or the non-
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

biological kin. Subsystems can create a context for learning a range of important life skills
through experiencing different types of challenges, patterns of closeness and distance,
emotional relationships, and levels of power --- as long as there are appropriately constructed
boundaries between the subsystems.
The concept of boundaries is used to describe how families regulate who participates in
any given family operation and boundary permeability describes how easy or difficult it is to
enter it. The two poles of the continuum of boundary permeability are “diffuse” and “rigid.”
Boundaries are used to describe markers that distinguish responsibilities between generational
roles, such as grandparent, parent, and child. This concept is also used to determine whether
family members are excessively involved or under-involved with one another in matters
relating to physical and psychological space, such as contact time, personal space, emotional
space, information space, and decision space (Wood, 1985; Goffman, 1971). Boundary
permeability or level of involvement in these domains affects the natural struggle among
family members between autonomy and dependency, shaping the development of individual
identity.
The emotional dimension of family structure is affective proximity, which refers to the
subjective internal experience of emotional connection and the security of attachment
between family members (Jones & Lindblad-Goldberg, 2002; Lindblad-Goldberg et. al.,
1998). Secure attachments soothe and calm (Bowlby, 1988; Siegel, 1999) and they provide
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 334 C. Wayne Jones and Marion Lindblad-Goldberg

the foundation for more effective family communication, problem-solving and intimacy
(Wynne, 1984). When emotional connections are inadequate, inconsistent, or ruptured, the
perceived distance can generate considerable stress and anxiety in the family. Family
interactions can then become increasingly organized by efforts to restore the relationship, as
well as the regulation and stabilization of individual emotions.
These structural aspects of families, affective proximity and boundary integrity, operate
in concert with how families think about and modulate strong emotions. This is because
families are self-correcting systems that are motivated to maintain emotional stability,
control, and internal coherence. This fourth principle of ESFT is influenced in part by
cybernetics and communications theorists’ ideas related to positive and negative feedback
loops in regulating relationships (Watzlawick, Weakland, & Fisch, 1974), but in this model is
applied strictly to intense “negative” emotions. It is assumed that there is significant variation
among people in their capacities for experiencing strong emotions (either their own or that of
others) while maintaining a sense of internal organization, calm, and connection. It is adaptive
for family members to avoid exposure to emotional states that create reactivity, a
disorganized thought process, or a feeling of being out-of-control. Their strategies for
achieving this aim, however, can range from functional to dysfunctional. Families tend to
have predictable preferences in how they regulate this internal comfort level, with some
tending to move toward greater involvement with one another and others toward greater
distance.
Family Emotion Regulation, another of the four major constructs in ESFT, refers to the
interactional strategies focused on the regulation of individual member emotional states,
especially their intensity, duration, and expression in relation to the family’s threshold of
tolerability. Emotion regulation is in part mediated by individual autonomic-nervous-system
arousal processes and in part by the assumptions the family makes about which emotions are
favored or discouraged, attitudes about the role of emotions, preferred styles of expression,
and perceived capacities for tolerating strong emotions (Jones & Lindblad-Goldberg, 2002;
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Gottman, Katz, & Hooven, 1996). In less adaptive families, fear that a member or the family
itself may spiral into chaos and fragmentation often leads to excessive intolerance or
restrictions on the expression of the emotions with strong demand characteristics, such as
anger or sadness. In families with a good capacity for distress tolerance and management of
conflict, members are more likely to be emotionally available to one another, which promote
secure attachments. How families approach the task of emotion regulation greatly influences
the development of emotional competencies in children (Gottman et al., 1996).
While the latter principle would suggest that families tend toward homeostasis and may
resist change, the fifth major principle of ESFT suggests that children and families are also
naturally oriented toward mastery and adaptation, despite how poorly they may appear to be
functioning at a particular point in time. The normal process of both child and family
development involves an oscillating process between homeostasis and change, both at a micro
day-to-day routine level and at the more macro level of major life cycle change. If children
enter the world wired to move forward and adapt, as emphasized in the developmental work
of Fraiberg (1959) and R. W. White (1959), then so must families. Children and families are
assumed to be active agents in their own learning and development, continually exploring,
experimenting, and practicing new ways of handling emotional demands. This is a powerful
motivating force and key to the strengths-based approach of ESFT. Therapists working in this

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Ecosystemic Structural Family Therapy: A Primer 335

model tap into this often dormant mastery orientation to help children and families overcome
barriers to moving forward toward greater competency and adaptation.
A sixth principal in ESFT is that meaningful growth and development for both children
and adults is interactional and interpersonal by nature. New demands or emotional
challenges require individual family members to think or behave differently, which stimulates
a corresponding demand for accommodations from someone else within the family
relationship system and then plays out in their ongoing interactions together. In this way,
structural rearrangements in families are ongoing as new external demands are faced and as
the needs of individual members change. This change process across time is captured in the
fourth major construct of ESFT, Family Development. There are predictable physical and
emotional challenges that children confront along the way toward maturity. A family-life-
cycle perspective informs therapists of the normative and non-normative demands that
children and their families face in the present, along with those they have encountered over
the course of time, possibly over generations (Carter & McGoldrick, 1989).
The crucible of change and adaptation is in those emotionally charged moments where
family members meet one another in interaction around a demand for change, each bringing
with them personal resources and vulnerabilities, as well as historically based expectations of
their relationships. The outcomes of these interactions over time can promote greater personal
competency, maintain the status quo, or trigger a maladaptive coping trend. Therefore, the
majority of ESFT interventions are directed at interactions between family members related to
individual and collective emotional challenge.
A seventh principle of ESFT is that relationship structures and emotional dynamics tend
to replicate themselves across intrafamilial subsystems, as well as in interactions between
families and professional systems. This is referred to as isomorphism (Bateson, 1979;
Lindblad-Goldberg, Dore, & Stern, 1998). For example, an overwhelmed teacher locks horns
with a 10 year old boy showing severe behavioral problems and disrespect at school in a
similar manner that the overwhelmed single parent mother locks horns with him at home. The
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school counselor recognizes the boy’s internal vulnerability and need for connection so she
intervenes to soften the usual consequences, replicating the typical pattern of the out-of-home
father. Problem-maintaining interactions can extend well beyond the family and can
potentially organize the therapist to respond in a manner that maintains the status quo. ESFT
therapists, therefore, include themselves and the larger community ecosystem in their
assessment, planning and interventions. The goal is to create a collaborative, coordinated, and
focused relationship with other service providers and the family so that the entire relationship
ecosystem supports change.

Healthy and Unhealthy Family Adaptations

In ESFT, no particular family arrangement is considered inherently healthy or unhealthy.

Minuchin (1974, p.16) speaks instead about the typical or ordinary family in which “the
couple has many problems relating to one another, bringing up children, dealing with in-laws,
and coping with the outside world. Like all normal families, they are constantly struggling
with these problems and negotiating the compromises that make a life in common possible.”
Rather than looking for the presence or absence of problems in families, ESFT therapists
focus on the degree to which a family living within a given cultural and community context,
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 336 C. Wayne Jones and Marion Lindblad-Goldberg

at a particular point in time, can organize themselves to effectively meet the situational or
developmental needs of its members. Below, the relational or organizational processes
generally associated with growth-promotion and those that compromise family effectiveness
are described.

Growth-Promoting Family Processes

Well-functioning, healthy families are growth-promoting and effective. Individual
members tend to feel good about the family, feel their needs are mostly being met, and
relationships between one another develop smoothly. Clarity of the family structure (e.g.
boundaries, roles, and rules) is considered a significant facilitator of growth and development.
Well-functioning, healthy families are characterized by clear, appropriately permeable
boundaries between them and the external environment and between intra-familial
subsystems. In addition, the family will have clear rules that govern which members comprise
a particular subsystem and how they are to function in that subsystem. Like any effective
organization, family members need to know who is in charge of which tasks and how these
tasks will be accomplished. This is particularly important for the parental subsystem in
families with children, where there should be little ambiguity with respect to who participates
in parenting, the nature of their expectations for behavior, and their methods for encouraging
it through monitoring and accountability.
The security of attachments in the family, particularly between parents and their children,
is also considered a significant facilitator of growth and development in well functioning
families. These families demonstrate a high degree of closeness and caregiving, including
warmth, nurturance, spending time together, expressing affection, and maintaining
consistency. Family members communicate effectively, are able to solve problems together,
and can experience intimacy with one another. Parents are attuned to the unique needs of each
other and the individual children, and family members receive an appropriate and timely
supportive response when distressed. In adaptive families, members have capacity to tolerate
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

a normal range of distress and conflict, such that differences and disagreements are not
prematurely shut-down. Likewise, they are able to manage conflict by regulating out-of-
control feelings or thoughts, thus decreasing exposure to negative emotional states.

Growth-Inhibiting Family Processes

Boundary problems are common in poorly functioning, less healthy families. For
example, diffuse boundaries create a lack of clarity as to who should participate in a
subsystem, allowing subsequent intrusion by other family members or those outside the
family. This would be termed a “violation of function boundary.” Cross generational
coalitions, where a grandparent or child teams up with one parent to systematically undermine
the other parent, are one example of this type of boundary violation. In families that tend to
function at the “enmeshed” or over-involved end of the boundary permeability continuum,
diffuse boundaries between family members and subsystems create a heightened commitment
to rules of family loyalty, which may curtail the individual’s attempt to develop autonomy
and secure attachments.
Conversely, rigid boundaries hinder contact with one another and restrict the flow of
information among other family members or between the family and the outside world. In
disengaged families, rigid or impermeable boundaries between family members often reduce
the family’s socializing functions of control, guidance, and support. The tasks of parenting
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Ecosystemic Structural Family Therapy: A Primer 337

tend to be emphasized over the emotional connection. When emotional connections are
inadequate, inconsistent, or ruptured, the perceived distance can generate a sense of
aloneness, along with considerable stress and anxiety among family members. Attachments
tend to be insecure or disrupted.
Unhealthy families may also demonstrate problems related to power within the parental
subsystem. The inconsistent or ineffective implementation of rules and routines is referred to
as “weak executive functioning,” while the relative absence of a functioning parent due to
addiction, mental illness, or emotional disengagement is termed “parental abdication.” The
family may appear under-organized and chaotic, creating an environment with insufficient
structure to engender a sense of emotional security or the development of self-regulatory
skills. “Overprotection” is a pattern in which a parent over-manages or over-controls a child’s
exposure to physical or emotional risks, thereby inhibiting the development of internal
resiliency and normal distress tolerance.
A third characteristic of less adaptive families is diminished capacity for regulating
strong, negative affect and managing interpersonal conflict. Often these families alternate
between excessive intolerance for the expression of negative emotions and out-of-control
demonstrations of strong emotion. This may result in triangulation of third parties into
conflicts to defuse tension between other family members. Maladaptive structural alignments,
such as “stable coalitions” or “detouring coalitions,” also occur in families unable to manage
normal interpersonal tension between two or more members. Problem-solving conversations
either never get started or prematurely terminate as a result of emotional reactivity or
excessive fears related to negative emotions. This often leaves normal problems and conflicts
unable to be solved, keeping background tensions high in the family.

The Change Process

Most evidence-based family therapy models share common factors assumed to underpin
treatment effectiveness (Sprenkle & Blow, 2004). SFT and ESFT share five of these common
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

factors of change, although the emphasis and sequencing of each of these factors is unique to
the model. The factor considered most critical to change in SFT and ESFT is the quality,
strength and depth of the therapeutic alliance with individual family members, relevant
subsystems, and the family as a whole. No meaningful treatment can occur without this in
place. The therapist’s commitment to creating a safe, caring, and trustworthy relationship is
considered a powerful intervention in and of itself when treating families with histories of
disrupted attachments, trauma, and repeated failure. Therapists establish credibility and
expectancy for change through skillfully overcoming common barriers to relationship
development, such as discouragement, hopelessness, distrust and ambivalence about therapy.
Therapists engage and motivate families through empathic listening, validation, respect,
acceptance, partnership, and accommodation to the family’s needs, preferences, and cultural
values.
A second major factor in the change process is the intense efforts of ESFT therapists to
identify and include in treatment as many people as possible who directly impact the
identified patients and who are impacted by them. When key members of the family or
community systems are active participants in assessment, goal setting, and change efforts,
therapists have immediate access to ongoing interactions that can be directly observed and
influenced. This increases the likelihood that relevant and meaningful interaction patterns are

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 338 C. Wayne Jones and Marion Lindblad-Goldberg

being addressed, as well as increasing the sense of shared responsibility, support, and
accountability for change among participants.
A third important factor in the change process is “changing the viewing” of the problem
by translating it into relational terms. Rather than suggesting that families cause problems,
however, relational reframing calls attention to the impacts family members have on one
another and on the power of family relationships to influence or solve individual problems.
The focus is on the way families go about doing things, which is something that families can
control and therefore can be changed. Blame and negativity are reduced through changing
family members’ maladaptive perceptions and beliefs about the nature of the problem, their
potential for change, and their definition of who they are as a family. The reduction of blame
and negativity is considered essential prior to implementation of interventions directly
addressing other treatment goals.
A fourth change mechanism that is central in ESFT is “changing the doing” of
relationships through behavioral enactments, task-setting, and homework exercises. It is not
enough to talk about relationships and gain new insights. Instead, ESFT therapists create
opportunities in sessions for family members to interact with one another in more healthy and
effective ways by monitoring and enforcing boundaries during conversations, amplifying and
encouraging positive interactional trends, interrupting unhealthy patterns, and fostering
emotional listening that connects family members. In this way, sessions are somewhat akin to
a learning laboratory where family members experiment with different aspects of themselves
in relation to one another.
A fifth highly related factor in the change process is facilitation of emotional processing
and emotion regulation among family members. Behavioral enactments are designed to not
only facilitate experimentation with alternative behavioral responses, but also to provide an
opportunity for family members to experience aspects of themselves and others they may
have heretofore avoided or not known existed. The ESFT therapist creates a context in which
primary emotions underlying maladaptive coping patterns in the family can be explored and
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processed in such a way that the family learns to tolerate and to manage a wider range of
upsetting emotions.

THE THERAPEUTIC PROCESS

Treatment in ESFT is organized into four overlapping stages or meta-processes. These
overlapping stages include: (1) constructing a therapeutic system (2) establishing a
meaningful therapeutic focus, (3) creating key growth promoting interpersonal experiences,
and (4) solidifying changes and termination (Jones & Lindblad-Goldberg, 2002). These
stages are neither linear nor discreet in nature. That is, each new stage builds on and enriches
the other. For example, building a strong therapeutic relationship with family members is
necessarily a major goal of the first stage of treatment, but it is understood that this
relationship must be continuously massaged, resulting in a deepening over the course of
therapy. In addition, the processes of each stage often repeat themselves over the course of
treatment. Assessment and diagnosis are primarily conducted in the first two stages.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Ecosystemic Structural Family Therapy: A Primer 339

Assessment and Diagnosis

In ESFT practice, there is considerable overlap between the two functions of assessment
and intervention (Jones & Lindblad-Goldberg, 2006). While assessment has a clear data-
gathering purpose, it is also considered interventional because it both sets the stage for change
and activates the change process. Assessment allows family members to teach the therapist
about the nature of their challenges and how their family works. Through the types of
questions asked and the content areas given focus, assessment also allows the therapist to
teach family members about the nature of the therapy they will be providing. While more
formal assessments may be confined to the initial stages of treatment, ESFT assessment is
actually an ongoing process throughout treatment in that every intervention reveals more
information about family members, the nature of their challenges, and their relational system.
Therapists are encouraged to adopt an inductive, quasi-experimental attitude throughout
treatment which involves the following self-correcting sequence: data gathering,
hypothesizing, intervention, family response (which becomes data gathering for the therapist),
and then the sequence starts over again (Aponte & Van Deusen, 1991). In ESFT, categorical
diagnosis of the family is de-emphasized; therefore, it is not usually an outcome of
assessment.
The ESFT Model uses assessment to develop an understanding of the
bio/developmental/systemic context wherein the strengths and difficulties of the identified
patient, other family members, and the family as a whole are manifested. While the identified
concerns of a particular child or adolescent becomes the point of entry into the family unit,
the focus of assessment and treatment planning involves all family members and often the
family’s extended social network. An “Eco-map” is used as an assessment tool to highlight
the positive, negative, and/or neutral relationships between family members, extended family,
and extra-familial resources (Lindblad-Goldberg et. al., 1998). All family members living in
the home and significant extended family members invited by the parent(s) are asked to
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attend the initial family assessment interviews.

There are five major objectives of assessment in ESFT, all of which directly relate to
treatment implementation (Jones & Lindblad-Goldberg, 2006). The first is to strengthen the
therapeutic alliance and sense of partnership with the family. The data required to create a
strong therapeutic alliance is derived informally throughout the initial interviews as the
therapist attunes to verbal and nonverbal clues about what makes family members feel
comfortable, safe, important, and heard. This objective is also facilitated by keeping formal
and informal data-gathering family-centered. Generic, broad-based clinical assessments are
eschewed in favor of those that are specifically related to what is important to the family in
relationship to their presenting concerns. For example, if parents’ concerns primarily focus on
their son’s truancy from school, then this will also be the initial focus of the therapist, but
with a slant toward the relationships the boy has with the school, his parents, and himself as
they connect to the problem. The family brings the problem they want to be solved and the
therapist elicits the context family members need to understand in order to solve it.
A second related objective is to identify sources of motivation for change within the
family. The data required to achieve this objective is also derived informally, but is elicited
more directly via questions to individual family members about their idealized selves. This
can be facilitated via questions about areas of their lives that are functioning well, where there
is an experience of personal and collective competency. Another method for eliciting this type
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 340 C. Wayne Jones and Marion Lindblad-Goldberg

of information is through a version of the “miracle question,” in which family members are
asked to describe a future time when the problem has been resolved (Selekman, 1997). In
addition to suggesting that change is possible, an elaboration of this question enables
therapists and family members to gain insights into what roles individuals prefer, how they
like to spend their time, how they may prefer to think of themselves, and how they may
characterize optimally functioning relationships. This information is used to create common
ground between the therapist and the family and to heighten emotional engagement with the
process of change.
A third objective is to contextualize the presenting problem(s). This is usually
accomplished through a combination of focused family interviews and informal descriptive
tools, such as genograms and family timelines. ESFT therapists often start with the big
picture of the family system. Three-generational genograms are helpful because they provide
the therapist with a pictorial of who is in the family, the biological or legally sanctioned
relationships across generations, and dates of significant events (Carter & McGoldrick, 1989).
A genogram also may show relationship patterns across the generations, which both
normalizes the problem for the child and generates curiosity in the family about themselves as
a system. Presenting problems are further contextualized in family interviews where detailed
descriptions of the child’s presenting symptoms are elicited, along with information about the
impact of the symptoms on the child’s functioning in the family and in other social contexts,
such as in school, with peers, and in the community. Significant attention is given to eliciting
the complementary responses of others to the child’s symptoms across context, beginning the
process of identifying cycles of interaction around the problem and highlighting interpersonal
interconnectedness.
To address the “why now” question regarding problem formation, the therapist develops
a timeline as the child and his or her family tell their story. The timeline contextualizes the
problem by providing a chronological sequencing of critical life events in both the child’s and
the family’s history. This informal tool helps to establish the interrelationships between life-
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cycle transitions, personal experiences and the onset or intensification of problems (Lindblad-
Goldberg, et al. 1998).
A fourth objective of assessment in ESFT is to develop a clearly articulated circular
hypothesis regarding the core negative interactional pattern maintaining the problem. The
information utilized to meet this objective is primarily derived from behavioral enactments
(Minuchin & Fishman, 1981; Haley, 1987; Nichols & Fellenberg, 2000) and clinical
interviews based on relational or circular questioning techniques (Tomm, 1988; Nelson,
Fleuridas, & Rosenthal, 1986). An enactment refers to the in-session playing out of an
important family interaction pattern. It is considered highly valuable data because it goes
beyond verbal description and is directly experienced by the therapist. The therapist is able to
directly observe the verbal and nonverbal ways family members signal to one another, ranges
of tolerable affect, and strategies family members use for regulating intense affect. Relational
or circular questioning involves the systematic use of questions that highlight interpersonal
connection and impacts of family members on one another, differences and similarities
between family members, and changes across time in their relationships. The working
hypothesis about relevant family interaction patterns maintaining the problem are revised and
grow in complexity and detail as the therapist incorporates the ongoing feedback from
enactments, relational questioning, and the family’s responses to interventions.

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Ecosystemic Structural Family Therapy: A Primer 341

A fifth objective of assessment is to identify (1) individual or family strengths that can be
harnessed for change and (2) individual and family barriers that need to be addressed for
change to occur. A wide range of formal and informal assessment tools are used to address
this objective which covers processes and characteristics related to the individual child, the
family structure and the fit between them. Standardized questionnaires and psychological
evaluations may be used that provide information regarding the child’s development, health,
medication history, social-emotional skills, academic performance, behavioral concerns,
strengths, and interests. To assess family structure, family interaction is observed during the
interviews and structural maps are diagrammed to depict the family’s unique patterns of
organization with regard to (1) hierarchy and power, (2) boundary functioning, and (3)
emotional relationships (Minuchin, 1974; Lindblad-Goldberg et. al., 1998).
Particular focus is given to the operations related to caregiving functions. This involves
identifying the following: (1) who is involved in the caregiving subsystem and how
permeable are the boundaries separating this subsystem from the child and extended family
subsystems? (2) What is the nature of the alliance between caregivers and does it support
effective parenting? (3) What are the expectations for the children and are they appropriate
for their developmental level? (4) Do the caregivers have sufficient power and executive
skills to implement appropriate monitoring, limits and consequences? And (5) How secure is
the attachment between each parent and child?
The initial data collection phase culminates in the establishment of a meaningful
therapeutic focus. This is an integrative co-constructed summary statement grounded in
individual and family data that clarifies the problem to be addressed in treatment and pulls for
specific goals and actions. Individual child symptoms are reframed in relational and
developmental terms, setting in motion the process themes that will drive treatment.

Treatment
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The focus of the third stage of treatment in the ESFT model is embodied in its name –
creating key growth-promoting interpersonal experiences that lead to incremental changes.
The treatment process includes (1) family members that may be a part of the sequence of
interaction around the problem and/or those who may be impacted by it, and (2) those that
may have the potential to create relationships that support growth and development (Jones &
Lindblad-Goldberg, 2002). Treatment planning incorporates short-term, concrete, practical,
action-oriented solutions that meet the identified patient and family’s needs, while
simultaneously helping to shift a particular pattern of behavior, attitude, or perception among
individual family members and/or between the family members and members of the extended
network.

Goal Setting
Specific treatment goals and objectives are developed collaboratively with the child and
parents, and flow naturally from the frame of the co-constructed problem established in the
assessment stage. There is generally an individualized goal developed with the family that
relates to each of the four broadly stated desired outcomes of ESFT treatment. These
outcomes include the following: (1) resolve presenting problems and eliminate negative
interaction cycles; (2) shift the developmental trajectories of children, such that they are
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 342 C. Wayne Jones and Marion Lindblad-Goldberg

moving toward greater capacity for self-regulation and social-emotional competence; (3)
enable a family to organize and emotionally connect in such a way that they become more
growth-promoting in their interactions with one another; (4) enable relevant community
systems to organize in such a way that a family’s efforts toward creating a growth-promoting
context are nurtured (Jones & Lindblad-Goldberg, 2006).
For example, the initial assessment of a family with a socially immature 9-year-old boy
diagnosed with ADHD presenting with severe temper meltdowns suggested an enmeshed
mother-son relationship and a peripheral, harsh father. The first set of stated goals, therefore,
would (1) address the boy’s need to establish better control of his temper and (2) address the
parents’ reactive response to the boy’s meltdowns that reinforce this negative coping pattern.
The second goal is an individual one and relates to helping the boy achieve the “next step” in
his social-emotional development, which is to learn tolerance and patience when facing
disappointments. The third goal must address the structural arrangement in the family that
compromises the boy’s ability to learn tolerance and patience, a developmental task already
made more challenging by a biological propensity for impulsivity. This involves increasing
the father’s involvement in a more soothing way with both his son and his wife, while
improving the mother’s ability to be an executive and set firmer boundaries with her son, and
strengthening the co-parenting alliance. One of the emotional themes of this entire therapy
might revolve around increasing tolerance, patience, and acceptance, not only for the boy but
also in each of the subsystem relationships in the family.

Nature of the Therapeutic Relationship

In ESFT, the therapeutic alliance with each individual family member and the family as a
unit is central to all change efforts. Elaborating on Bordin’s (1979) conceptualization, a
therapist has a therapeutic alliance to the degree that: (1) there is a perceived bond between
the family and the therapist, (2) the family and therapist agree on the goals and tasks of the
therapy, (3) the family and therapist are committed to these goals and tasks, and (4) the family
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

experiences themselves as contributing partners with the therapist. This is an action-oriented,

non-hierarchical relationship based on mutual respect, collaboration and partnership.
There are four major principles guiding the development and maintenance of a strong
therapeutic alliance with family members (Jones & Lindblad-Goldberg, 2006). The first
focuses on the therapist’s assumptions about the family and highlights the importance of
“presuming the positive,” even though the family may not be able to demonstrate competency
or caring at this juncture in time. A second principle focuses on the therapist’s posture toward
the family, which involves talking with family members as though they are partners in the
change process. A third principle calls attention to therapist communication style as it relates
to individual level processing of information. This involves therapists’ accommodation to
family members’ learning styles and preferred styles of communication. Guideline four
emphasizes the importance of focusing on and building upon individual and family strengths.
These principles about the therapeutic alliance are embodied in the concept of “joining,”
which is defined as a set of attitudes and actions signaling to family members that the
therapist likes, understands, and accepts them as both individuals and as a family system. It is
a process by which the therapist accommodates to the family system sufficiently, such that
he/she is invited or admitted into the inner circle of the family system (Minuchin & Fishman,
1981). Change is created from the therapist’s position within the family system.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Ecosystemic Structural Family Therapy: A Primer 343

Techniques

Creating key growth-promoting interpersonal experiences are accomplished both through

actions the therapist takes with families (“doing with”) and through the way the therapist
relates with families (“being with”). The former involves the use of concrete methods or
techniques while the latter involves the emotional posture or stance the therapist assumes with
families. In this way, therapists create a relational context both between family members and
between themselves and the family that is designed to evoke change.
Since ESFT is a relationally oriented therapy, it is of critical importance that the therapist
interacts or relates to the family in a manner that is congruent with the type of relationships
the therapist is attempting to forge among family members. This is “the therapist as an
instrument of change,” behaving in an isomorphic manner with the treatment goals. For
example, if the objective is to help parents take a more assertive leadership position with their
children, then the therapist’s posture toward the parents must be direct, firm and empowering.
Should the therapist make suggestions without creating some intensity, then the therapist
would become isomorphic with the negative pattern between parent and child, thereby
diminishing the possibility of change.
The most common method used by ESFT therapists to create change is behavioral
enactments (Minuchin & Fishman, 1981; Haley, 1987; Nichols & Fellenberg, 2000). This
refers to the spontaneous in-session playing out of a core family interaction pattern. These
interactions create rich opportunities for therapists to help family members become more
aware of self-defeating patterns as well as to practice “in vivo” relating in an entirely different
way with one another, particularly with respect to emotional regulation. Enactments are
similar to exposure techniques in that family members must engage in what they most often
avoid, interpersonal conflict and negative emotions. This involves another often-used
technique, adjusting intensity (Minuchin & Fishman, 1981). Therapists can increase intensity
by prolonging an interaction beyond the usual comfort zone of family members, by creating
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

boundaries that prevent other family members from entering interaction, and by sharpening
the focus of the conversation on a highly sensitive topic. Therapists can decrease intensity by
using encouraging words about the importance of what family members are doing or
translating and clarifying miscommunications.
ESFT incorporates techniques from many different models of psychotherapy to create
relational change. It is the relational objective that determines its appropriateness. Techniques
that are unique to the model and that are commonly used to re-organize or re-structure the
way family members relate to one another include boundary-making, rebalancing power or
clarifying hierarchy, and adjusting emotional proximity. Boundary-making involves the
therapist directing the flow of communication in the session, insuring that only the family
members responsible for solving a particular conflict or performing a specific task are
involved in the conversation until some resolution is reached. The therapist blocks intrusions
or efforts at conflict detouring. Rebalancing power or clarifying hierarchy involves the
therapist temporarily joining with a disempowered family member and providing support in a
family operation requiring unambiguous leadership. It is a shifting or re-alignment of
responsibility for certain tasks among family members. Adjusting emotional proximity
involves the use of activities that either increase or decrease involvement between two or
more family members.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 344 C. Wayne Jones and Marion Lindblad-Goldberg

Other commonly used techniques in ESFT address thinking, beliefs, or knowledge in the
family. Reframing, for example, is designed to change the explanation or attribution a family
makes about an event, problem, themselves, or a situation (Jones, 1986). Although it is a
therapist initiated activity, the new attribution is co-constructed with the family as
information family members do not usually attend to is spotlighted. Psycho-education about
various issues is also common practice. This might include a focus on parenting skills, child
development, strategies for handling strong emotions, communication skills, and problem-
solving methods. Homework tasks are often provided between sessions to facilitate the
practice of new patterns of relating.

STRENGTHS AND LIMITATIONS OF ESFT

One of the greatest strengths of the original Structural Family Therapy model has been its
ability to inspire significant process and outcome research, descriptive studies of various
clinical populations, as well as the development of population-specific treatment models over
the last 48 years. A recent review of outcome studies using randomized clinical trials
establish family-based treatment in general as viable and efficacious either as a stand-alone
treatment or as an augmentation to other treatments for a wide variety of child and adolescent
disorders (Diamond & Josephson, 2005). This review concludes there is solid evidence that
engaging parents in the treatment process and reducing the toxicity of a negative family
environment can contribute to better treatment engagement, retention, compliance,
effectiveness, and maintenance of gains. These are clear strengths of the ESFT model.
A seven-year study of treatment outcomes for the time limited Home –Based version of
ESFT treatment targeted 1,968 families (Lindblad-Goldberg et. al., 1998). In this study,
children and adolescents in the targeted families all showed severe emotional and behavioral
disturbance and were considered at risk for out-of-home placement. Pre and post-treatment
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

measures showed significant reductions in presenting symptoms and use of out-of-home

placement. Significant positive changes were also found in family functioning and in the child
or adolescent’s psychosocial functioning that were maintained up to one year post-treatment.
The development of a treatment manual is currently underway that provides greater
specification of the concepts and interventions used at each stage of the model (Jones &
Lindblad-Goldberg, 2006).
Another area of strength of SFT and its variants, such as ESFT, is its flexibility in
approach and wide applicability. Treatment is individualized, which means that the approach
is tailored to fit the unique needs, values, and configuration of each family and the special
circumstances related to the presenting clinical problem. The model has been used
successfully with families across a wide spectrum of ethnicity, race, religious background,
socio-economic status, and sexual orientations. Neither is the model limited by family
structure or the number of family members willing to participate in the treatment. The
approach is adapted to fit the composition and configuration of the family whether single-
parent, two-parent, three-generational, or families headed by same-sex couples. In cases
where a family member initially refuses to participate in the treatment, the therapist works
with those who do participate while trying to engage the reluctant ones.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Ecosystemic Structural Family Therapy: A Primer 345

A wide range of child and adolescent clinical problems across all levels of severity have
been addressed with this model (Jones & Lindblad-Goldberg, 2002). In part, this is because
this model does not revolve around specific techniques, but instead is grounded in systemic
principles of change that can guide the implementation of any procedure. Empirically
demonstrated techniques for specific, narrowly defined child and adolescent clinical
symptoms, many of which are derived from Cognitive Behavior Therapy, can easily be
incorporated into the relationally-based practice of ESFT. The model can be adapted and
applied in a variety of therapeutic environments including outpatient, home-based, day
treatment, inpatient, or residential.
One limitation of the model is that it requires the willingness of at least one caregiver
(biological or non-biological) to work toward the possibility of developing a parenting
relationship with a child or adolescent. Since the model relies on leveraging intra-familial
relationships to create change, this is not possible when there is no functioning caregiver
available and the identified patient is a child or adolescent. For example, the model would be
inappropriate for adolescents placed in residential settings who have no identifiable caregiver
expressing the desire to become involved in an effort to support their development. Even
when there is no family to work with, however, thinking systemically about the problem in
context can still be advantageous in the development of interventions.

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Diamond, G. S., Siqueland, L., Diamond, G. M. (2003). Attachment-based family therapy for
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Liddle, H. A. (2002). Multidimensional Family Therapy Treatment (MDFT) for Adolescent

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Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 In: The Quick Theory Reference Guide ISBN: 978-1-60021-624-4
Editor: Karin Jordan, pp. 349-360 © 2008 Nova Science Publishers, Inc.

Chapter 24

STRATEGIC THERAPY

Sabrina Walters and Gena Minnix

This chapter offers an in-depth look at the history, principles and advances of strategic
therapy. Strategic therapy was originally developed and researched in the United States
thereby establishing it as unique in its roots and the manner in which it evolved. Family
systems theory, the concepts of hypnosis, and hierarchical structural analysis are some of the
key fundamental developments that contributed to strategic therapy becoming what it is
today.
The ideas of strategic therapy are deceptively simple. For therapy to be called strategic,
the therapist must initiate what happens during therapy, and design a particular approach to
address each problem (Haley, 1986). The emphasis is not on a method, but on addressing
each problem with specific techniques, for the situation. The therapist’s task, then, is to
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

formulate a presenting problem clearly, to contract with the client to solve that problem, and
then to design an intervention in the client’s social situation to bring about a desired change
(Haley, 1976, Haley & Richeport-Haley, 2003).
Strategic therapy is based on the theory that action is the root of change and that insight
may come later, but is not essential to solving problems. This is a practical theory, stating that
if change is to take place the therapy must be planful, purposeful, task oriented and the
therapist is responsible for the outcome (Bobrow, 2003; Haley, Richeport-Haley, 2003).
Therapeutic directives are frequently used to strategically effect change. Some directives may
be presented overtly, while others are presented more covertly. Covert “indirect” directives
are chosen when the therapist senses a resistance to authority in the family, or the problem
has such a useful function to the family that members are unable to consciously allow the
necessary changes to take place. Examples of indirect directives include restraining people
from changing, advising them to remain the same, imposing a paradox, or using metaphoric
communication to talk indirectly about the problem (Bobrow, 2003; Haley, Richeport-Haley,
2003; Haley, 1976, 1986; Sells, 1998).
Strategic therapy is concerned with the problem’s origins only as it relates to the here and
now. Gathering information concerning the sequence, onset and nature of the behavior is
crucial as it informs the therapist’s intervention plan. Information gathered from family
interactions and descriptions of the problem serves to enlighten the therapist as to what the
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 350 Sabrina Walters and Gena Minnix

underlying problem might be. The therapist then makes an individualized therapy plan to
address each problem (Haley, 1980).
The strategic approach requires an exploration of hierarchal structures both within and
outside the family. Strategic therapists observe the family’s hierarchical structure and
subsequent communication patterns. The symptoms with which clients present to counseling,
often indicate there might be a problem in the hierarchy. Therefore, a structural change in the
family dynamics may be necessary to change problematic behavior (Haley, Richeport-Haley,
2003).
External family systems such as grandparents and peripheral family members, the school
system and community agencies, all influence and affect a family’s functioning. Therefore,
strategic therapy also required an adequate assessment of every system to which a client or
family is connected (Sells, 1998). Extended family, school staff, as well as legal or
community service agencies can all be powerful forces in a client’s life. Failure to examine
the ways in which outside systems might serve to maintain a client’s problems opens the
therapy up to risk of being sabotaged by those forces (Madanes, 1983).

HISTORY OF STRATEGIC THERAPY

Strategic therapy is a uniquely American therapy. Strategic therapy is one of the only
therapies that has been developed and researched in the United States. Many authors over the
last fifty years have contributed to the metamorphosis of family therapy, systems therapy and
co-joint therapy into what it is today. However, Milton Erickson (1976) introduced concepts
of hypnosis, reframing, and directives into work with family systems and family life cycles.
This could be considered the emergence of viewing family therapy through a strategic lens
(Haley, 1986).
Well-known family therapist Jay Haley (1986) first became intrigued by Erickson’s work
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with hypnosis in the 1970’s. Erickson was developing unique methods of effecting helpful
change on people’s behavior indirectly, often outside of their conscious awareness (Erickson,
1976, 1998). Erickson developed a style of working with families, couples and individuals
using both formal hypnosis and a wide range of strategies that ultimately became adopted by
family therapists seeking a method of helping clients who seemed “stuck” in old ways of
behaving (Erickson, 1976; Haley, 1986).
From the 1970’s to the late 1980’s strategic therapy flourished. What made strategic
therapy so popular was that it offered a simple framework for understanding how families
falter and a clever set of techniques to help them move ahead. Some might say the problem
that strategic therapy faced was that many people became weary of using the same techniques
over and over and it came to be questioned as manipulative, gimmicky and inauthentic
(Barker, 1998). The essence of the theory which states that every family and every problem
deserves a unique approach, places a high demand on a therapist’s creativity. When taught
and practiced properly, it can be a dynamic, exciting and highly effective model. However,
the fact that the theory was easy to summarize and teach, lead practitioners to believe that
effective results were easy to replicate, which turned out to be far from the truth (Haley &
Richeport-Haley, 2003). As a result, during the 1990’s, certain aspects of pure strategic

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Strategic Therapy 351

therapy spawned such postmodern models as collaborative therapy, narrative therapy, and
solution-focused therapy (Barker, 1998).
While newer theories were being developed, current work was being done within
strategic therapy to tailor the model to our changing culture. Most recently Haley and
Richeport-Haley (2003) have updated strategic therapy through the lens of cultural awareness.
Scott Sells (1996, 1998) has conducted extensive research with Jay Haley and Neil Schiff and
provided evidence to the effectiveness of strategic therapy with difficult adolescent cases.
Lastly, Cloé Madanes’ informative work Violence of Men (1995) describes a viable model for
dealing with violence and sexual abuse cases.

KEY CONCEPTS OF STRATEGIC THERAPY

Nature of Persons

Strategic Theory
In strategic therapy, the core belief about the nature of persons is highly benevolent
(Madanes, 1981). It is a view that hypothesizes that symptoms, problems and misbehavior are
merely a metaphoric representation of another problem within the family system. Therefore,
the strategic therapist views symptoms or misbehavior as helpful and not malevolent, even
thought the family may view it negatively. This perspective thereby gives the therapist an
attitude of respect and empathy toward every client and every member of the family (Bobrow,
2003). Craziness is reframed as confusion, criminality is viewed as serious misbehavior, and
client’s are believed to be “acting depressed”, rather than diagnosed with persistent disorders
(Madanes, 1981, 1984).
The problem therefore, does not define the person. For example, if a child is acting out by
using drugs, strategic therapists reframe this drug use to the parents and the child as serious
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

misbehavior that can be controlled. The child using the drugs is assumed to have some helpful
intention toward the family, in that the child is either trying to help the family system by
maintaining status quo, or sacrificing herself so that the family will be activated to change
(Haley, 1996). The child’s behavior may be reflecting a disruption in the marital relationship,
or a problem with a sibling (Madanes, 1984). In some cases, one child chooses to be the
“problem child” thereby freeing up his or her siblings to succeed in life (Haley, 1976). In this
way, the symptom, however it may be presented, can be viewed as a metaphor for the larger
family situation.
Strategic therapists understand that during times of transition from one family life stage
to another, such as leaving home, births, marriages, divorces and deaths, problems often arise
(Haley, 1976). When a client is blocked at one of these stages they may need help to move
beyond it. If a family is struggling with a particular life change, often one member will
develop a symptom that indicates this, and that symptom can guide the family therapist to a
specific approach. Psychological problems do not generally tend to occur randomly in the life
of a family, but rather, they usually cluster at certain points in the life cycle (Haley,
Richeport-Haley, 2003; Sells, 1998).

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 352 Sabrina Walters and Gena Minnix

HEALTHY VS. UNHEALTHY/DYSFUNCTIONAL FUNCTIONING

Healthy Functioning

Within the strategic family therapy model, healthy families are thought to be organized
hierarchically according to generations, and capable of differentiating between roles within
the generational boundaries (Haley, 1976). The parents’ roles are to manage the home,
nurture their children, set limits and financially support the family. The child’s role is to
attend and succeed in school and function according to rules set by the family system
(Bobrow, 2003). Strategic therapy sees healthy behavior as each member functioning
successfully within his or her specific role or job. Sometimes people choose to take on a role
in their family that is not their natural role, which tends to be viewed by strategic therapy as
unhealthy because such behavior often causes an imbalance in family dynamics (Madanes,
1984), and at the same time, Haley (1976) admits that family patterns are simply too varied
and flexible to fit one set definition of “healthy”.
For families to function most effectively, it is clear that parents must establish rules and
consequences for their children (Sells, 1998). Parents are often puzzled when the rules do not
work or their children misbehave in ways that were unexpected, and this is assumed to be
because children often know how to play “the game” of defiance and rule-breaking better
than their parents (Sells, 1998). For this reason, in order to establish adequate hierarchy in the
home, parents often need assistance. Learning the “soft” and “hard” sides of authority
becomes the parent’s task. Children require “soft” nurture and “hard” firm boundaries, and
when parents learn how to be “hard” by establishing and maintaining order in the home, but
practice the “soft” side of parenting by nurturing and soothing their children, symptoms and
misbehavior often disappear (Bobrow, 2003; Sells, 1998).
Normalizing the expected hardships of each stage of a family’s life cycle also helps
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

parents plan and prepare for future troubles (Haley, 1996). Healthy functioning, therefore, is
achieved first by helping families solve the problems they have identified, the ones that
brought them into counseling in the first place. Once this has been accomplished, families and
individuals can be taught how to maneuver through difficult transitional points of
development in the future (Haley 1976). To achieve this task, strategic therapists tend to
begin the therapeutic process by portraying themselves as the experts who can resolve a
family’s problems, but by using innovative methods such as reframing and paradox, by the
end of therapy, the family begins to believe they have solved their problems on their own, and
can do so again in the future (Sells,1998).

Unhealthy Functioning

Strategic therapists choose to view problems and symptoms as a form of communication

between two or more members of a family or system (Haley 1986). This communication
serves as a contract between those people and serves some helpful or well-intended function
within their interpersonal network. A symptom usually occurs when that contract, that form
of communication between persons is no longer helpful or effective, but a person does not

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 Strategic Therapy 353

know how to change it. That person is though to be caught therefore in an impossible
situation and the symptom or problem is their attempt to break free (Haley 1986).
Furthermore, the symptom can also evolve in order to serve as a homeostatic mechanism
regulating marital or family interactions (Stanton & Todd, 1982). As such, the presenting
problem or dilemma is seen merely as a sequence of behaviors or patterns involving certain
family members that has been put into motion because the family members care about each
other and see no other way to function (Madanes 1983).

CHANGE PROCESS

How People Change

Strategic therapy differs from traditional approaches in that insight and interpretation are
viewed as fine--but not necessary--for change to occur. Rather, the strategic therapist takes
the responsibility for affect change onto him or herself, through planned actions in sessions
and strategically-devised homework assignments between sessions (Madanes, 1983). Haley
(2003) states that interpretation and insight can, in some cases, even be a negative
intervention such as when a therapist’s interpretation of an event is laden with blame toward
the client. The result of such an effort toward insight can be shame, unhelpful guilt, and/or
confusion, perhaps confounding the situation further. A therapist’s grasp at an explanation of
the problem can also be unintentionally hurtful or rude toward the family, and at times when a
therapist overtly shares insight into the family interactions, it can even be counterproductive
or harmful, driving a family into more of a rigid, static unyielding position (Haley, 1976).
Insight therefore is helpful to the therapists in their efforts to plan interventions, but insight is
not considered necessary or always helpful to a family trying to make behavioral changes
(Madanes, 1983).
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

In order for change to take place, the strategic therapist takes responsibility for the
change (Haley 1976). If the therapist tries an intervention, and change does not occur, then
therapist must reevaluate the tasks, the interruption of sequence and their understanding of the
family’s hierarchy (Bobrow, 2003). Perhaps, the therapist was moving to quickly, or the
function of the problem was more helpful to the overall system than anticipated and therefore,
it was too risky for change to take place at this time (Bobrow, 2003).
Bobrow (2003) suggests that change happens when the family is finally convinced to
alter the story about each member that they have held for a long time. However, the in-road to
beginning to affect change can have many entry points (Haley, 1976). For instance, the
therapist might choose to begin by reframing or presenting a metaphor that challenges the
family’s story about itself. However, another possible entry point might be a slight and subtle
change to the sequence of interactions, i.e. the order in which words are habitually changed
between members. A third possible starting place might be the structure of the household
duties, the structure of the rules and consequences, or the structure of the family’s finances.
Sometimes, all it takes is for one of these variables to shift slightly, and the result is that the
family finds more effective ways of addressing their problems, and no longer needs continued
therapy (Madanes, 1983, 1984).

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 354 Sabrina Walters and Gena Minnix

How Environment Aids Change

Strategic therapists consider that the therapeutic environment needs to be as thoughtfully

planned out as the therapeutic process itself (Bobrow, 2003). In strategic therapy, it is
considered important to create an atmosphere in sessions, conducive to humor and playful
interventions (Sells, 1998). The strategic therapist strives to feel comfortable experimenting
with interventions during sessions, using humor, play and make-believe to illustrate points,
and formulating creative playful interventions to be carried out at home (Bobrow, 2003).
For this reason, building a therapeutic relationship with the family is like dancing with all
the members of the family (Madanes, 1984). The manner in which therapists achieve such
rapport varies, but strategic therapists tend to meet together with as many members of the
family as possible, as early on in therapy as possible (Madanes, 1995). The therapist
establishes himself or herself as the expert on the therapy process—the one who is capable of
helping the family solve its problems. It is generally useful therefore to spend a bit of time
alone with each member of the family initially because by doing so, the therapist has a better
chance of understanding the original problem, the overall concerns and any family secrets that
might be present, from each person’s perspective (Bobrow, 2003; Haley, 1986; Stanton &
Todd, 1982).

THE THERAPEUTIC PROCESS

Assessment and Diagnosis

Strategic Therapy Assessment Strategies

Strategic therapy asserts that the traditional assessments and diagnostic tools often creates
an insolvable dilemma for clients by means of labeling their problems as illnesses that are
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

static and irresolvable (Bobrow, 2003). In place of this, strategic therapists assess patterns of
interaction and assume a benevolent intent behind symptoms, problems and family conflicts
(Madanes, 1984). It is therefore the job of the therapist to understand the symptom through
the use of metaphor, reframe and paradox. However, it is not necessary for the metaphor to be
entirely accurate or “true”, so long as it helps the therapist to develop an effective strategy to
solve the problem (Madanes, 1984).
Major contributors to strategic therapy tend to agree that the naming or labeling of
client’s behavior in terms of diagnostic categories does not usually help to solve the problem
(Bobrow, 2003; Haley, 1976, 1986; Sells, 1998). What is assumed helpful is to assess the
patterns of interactions within the family, the family’s view of the problem, the sequence of
the problem, who will invest in solving the problem, who will sabotage the problem, and to
identify the overall hierarchy of the family (Bobrow, 2003; Haley, 1976, 1986; Sells, 1998).
With this type of assessment, it is thought that the strategic therapist can then begin
hypothesizing about the function that a symptom serves within the larger family system.
Madanes (1984) suggests that it is helpful to conceptualize the problem into one of five
categories. The first category asks whether a behavior is seen as voluntary or involuntary.
Strategic therapists tend to view the majority of problems as voluntary and under the control
of the client. The second category asks whether a person is helplessness or powerful. Those in

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Strategic Therapy 355

power tend to be seen as somehow dependent on the powerless in order to maintain their
status within the system. When those in power start to take responsibility for fixing the
problem, symptoms tend to resolve themselves. The third category asks whether a symptom
takes on a metaphorical meaning or a literal meaning: Symptoms can be viewed as a
metaphor for problems at another leveling the hierarchy or in another relationship. For
instance, if a child is acting out in school, it may be because he is trying to bring his parents
together to solve his problem in order to help them with a troubled marriage. The therapist
must determine whether to focus on the symptom at the metaphorical level or purely literally.
The fourth category asks whether this is a problem of hierarchy or equality: The therapist
must make the decision whether or not to focus on building equality relationships, for
instance, elevating a wife to the same status as her husband, or if the problem lies in
disorganization within the hierarchy, as in the case of parents being told what to do by their
children. The fifth and final category asks whether a client is motivated by personal gain or a
sense of altruism. Assessing the symptomatic person’s motivation for their behavior can
determine the proper strategy for change (Madanes, 1984).
In assessing troubled teens and their families, Sells (1998) has outlined a comprehensive
system of gathering relevant information. Sells draws heavily upon Madanes’ (1984) model,
but he tailors the approach more a specifically to adolescents and their families. Sells places
an emphasis on inquiring about parental power, specific tactics teens use in effort to assert
inappropriate power over their parents, and how to neutralize teens’ misbehavior. Sells also is
careful to examine the outside systems affecting the teen and the teen’s parents including
medical, social, academic, religious and community organizations that might present a
support and help to parents trying to regain appropriate power (Sells, 1998).
Although it was said before that strategic therapists tend to view diagnostic labels as
unhelpful, and at times harmful, the DSM-IV-TR is used when necessary in order to
collaborate and cooperate with such entities as insurance companies, community agencies,
and county mandates. However, toward the client and family, strategic therapists tend to
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

avoid at all cost labeling problems as permanent, static, persistent and incapable of being
changed. Haley (2003) states that it would be unethical for any therapist to attempt therapy
with anyone they personally define as incurable.

Genograms
Strategic therapists, as a rule, do not concern themselves with the past, except as it relates
to the present, therefore Haley and Richeport-Haley (2003) do not ordinarily use genograms.
However, Bobrow (2003) recommends using them to understand all the dynamics of the
family’s system. The genogram can be generated outside of the session, and then brought in
so the family can check it for accuracy. Genograms can provide a tangible and graphic
assessment of complex family patterns and they also allow the therapist to map the family
structure clearly, noting and updating the family picture as it emerges. By scanning the family
system historically, and assessing previous life cycle transactions, the strategic therapist can
place present issues in the context of the family’s evolutionary patterns (McGoldrick, Gerson
& Shellenberger, 1999).

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 356 Sabrina Walters and Gena Minnix

Treatment

Goals of Strategic Therapy

The goal of strategic therapy is to define the problem, design an intervention plan
uniquely fitted for the problem, and then become an agent of change within the family (Haley
1986). In strategic therapy it is essential to negotiate a contract of a solvable problem with the
clients, and then work to uncover what social situations exist that make the problem necessary
for the family to maintain (Bobrow, 2003). The very act of intervening in the family
dynamics often is just the tool to bring out problems and relational patterns that must be
changed (Haley, Richeport-Haley, 2003; Haley, 1986).

Therapeutic Process: Phases of Treatment

There tend to be ten phases of treatment in strategic therapy as identified by Haley &
Richeport-Haley (2003). During the initial few sessions, the therapist establishes a
relationship defined as one intended to bring about change. The therapist also works to build
rapport with each influential family member. The family identifies the problem for which
they have sought treatment and each person is given the opportunity to precisely define the
problem. The therapist patiently gathers as much information about the problem as possible
including the onset, exceptions to the problem, the sequence of interactions, who would
notice it first if it were to change, and who would resist change the most were it to take place.
It is assumed that the more precisely defined the problem is, the simpler it is to identify a
solution. During the goal-setting stage, each member of the family is asked what they want to
change and the goal is clearly identified. Bobrow (2003) utilizes this stage to ask each family
member, in their heart, what they want to see change. In this way, each person is given
permission to ask something different of the therapist and a contract is established with each
client.
In the middle phase of treatment, sessions consist of the therapist setting up the
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

framework to offer a directive (Haley & Richeport-Haley, 2003). In doing so, it is deemed
necessary to understand the metaphor that the problem presents and the therapist loosely
holds in mind hypothesis for what the function of this problem might be. Strategic therapists
tend to believe that the problem maintains a useful or helpful function, so during sessions, the
therapist works to redefine the symptomatic member as being benevolent and trying to be
helpful to other members. Between sessions, the therapist gives directives and homework to
expedite change; however, in some cases the directive is essentially asking the family to
remain unchanged (Madanes, 1983). This would be an example of a paradoxical technique,
with the belief that the family will reject this suggestion, and in essence, change in spite of
itself.
Regardless of the directive given, the therapist observes the family’s response and
continues to encourage appropriate behavior as it emerges (Haley, Richeport-Haley, 2003).
As change continues, the strategic therapist works hard to avoid taking any credit for progress
and gain, in effort always to shift the ownership of change to the client. One way to do this is
to act puzzled by the change and question with curiosity what the client did that was so
successful (Haley & Richeport-Haley, 2003; Bobrow, 2003; Madanes, 1984).
As change takes place, the family may want to re-negotiate for a new contract in which
marital problems or hierarchical issues are discussed (Haley & Richeport-Haley, 2003).

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Strategic Therapy 357

However, if the family and therapist both agree that there are no other problems to address,
and the family is convinced that they are equipped and capable of handling future problems,
then therapy moves to the disengagement and termination stage. The therapist often begins to
move toward termination by spreading out the sessions further and further, and observing the
consistency of change. When the change is stable, as evidenced by the family successfully
handling relapses by relying on the skills gained in therapist, the process will be considered
complete (Haley & Richeport-Haley, 2003; Bobrow, 2003; Madanes, 1984).

Nature of Therapeutic Relationship

The relationship that the strategic therapist establishes with the client and/or family is one
of unconditional positive regard (Madanes, 1983). For interventions to be useful, the family
must trust the therapist as an expert in the field of solving problems, as well as, one who has
their best interest at heart. Family members must have faith in the therapist’s ability to help
them with their dilemma (Bobrow, 2003; Haley & Richeport-Haley, 2003). Haley (2003) was
asked what a therapist should be like and he answered with the following.

The clientele coming to a therapist are in trouble and in despair. They need a therapist who
will take their troubles seriously. Yet, the most important attitude of a therapist is the spirit of
play. In his training and in his work the therapist must be able to transcend human suffering
and rejoice in a playful and innovative spirit. A therapist must be serious about the grim
situation of his clientele while being free to change the framework of the situation in the spirit
of the day (Haley, 2003).

Common Intervention Strategies

One of the main interventions in strategic therapy is giving directives (Haley &
Richeport-Haley, 2003). The main goal of giving directives is to convince people to behave
differently, but directives also serve to intensify the relationship between the therapist and
client. When the therapist takes the role as a task-giver, this sends the message to the client
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

that the therapist is willing to go to great lengths to help the family (Madanes, 1984).
Furthermore, giving directives allows the therapist to gather crucial information about the
problem, the family, and the function of the symptom, according to the response the family
members have toward any given assigned task (Haley, 1986). A directive is frequently
packaged as a respectfully playful instruction given directly or indirectly to the family
members at the end of the session. It is common to frame directives in questions about
change, such as, asking a family if they wish to change slowly or quickly (Madanes, 1894). In
so doing, this links the directive to the fact that change is inevitable—in fact this is the very
reason they have come into therapy.
Metaphoric interventions are also frequently used in strategic therapy (Haley &
Richeport-Haley, 2003). The use of metaphor can be very powerful with intuitive families or
those who do not take direct interventions well because of anxiety, burdensome guilt, or other
uneasy emotions surrounding following a direct instruction (Bobrow, 2003). Haley (1976)
and Madanes (1984) both suggest that therapists formulate for themselves a hypothesis
regarding a metaphor that the presenting symptom might represent within the larger family. In
doing so, the therapist might find helpful interventions otherwise hidden. However, Haley
(1976) and Madanes (1984) also both state that they do not believe that revealing the
metaphor outright to the family commonly produces the desired change, but merely that

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 358 Sabrina Walters and Gena Minnix

discussing the problem in terms of the metaphor can serve to convince the family that a
problem can and must be changed somehow.
Paradoxical interventions are sometimes used in strategic therapy when the family is
unable to defer to the therapist’s authority, or when the problematic behavior is so useful to
the family that relinquishing the problem becomes too threatening (Bobrow, 2003). Paradox
is a way of establishing a playful, experimental atmosphere in order for the family to “try-on”
a new way of being (Sells, 1998). Strategic directives can include paradoxical tasks such as
asking the clients to amplify the symptom in order to solve it, giving two very contradictory
directives, or asking the client to pretend to have the symptom on a specified schedule.
Paradoxical directives might also include prescribing the symptom, predicting relapse,
cautioning the family against change, and slowing down progress (Madanes, 1983, 1984;
Haley 1976, 1986, 1996).
Paradoxical intervention can be especially useful when the function of the problem is
extremely powerful and family members are stuck in rigid patterns that maintain the status
quo (Madanes, 1983). At the same time, the use of paradox in session can also be a way to
accomplish perhaps the most important element in any form of successful therapy: creating a
positive therapeutic atmosphere (Madanes, 1983, 1984). By maintaining a kind, lighthearted,
and inventive a therapist can not only think creatively and devise paradoxical interventions
that might be effective, but this frame of mind also serves the indirect benefit of helping the
therapist to avoid being inducted or drawn into a family’s unproductive way of seeing things
(Haley & Richeport-Haley, 2003).

Strengths and Limitations of Strategic Therapy

Strengths
One of the greatest strengths of strategic therapy is that the therapist takes great
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

responsibility for the results of treatment, and therefore the model is highly outcome-based. In
recent years, research has emerged that evidences strategic therapies as effective in producing
desired change in specific high-risk populations such acting-out teenagers, drug abusers, and
those at risk of criminal behavior (Henggeler & Sheidow, 2003; Robbins & Szapocznik,
2000; Hervis, 2006). In addition, Madanes’ (1995) strategic model for sexual abuse reparation
has also been tested as an effective treatment for victims, as well as, victimizers. Out of
seventy-five cases closed by November 1, 1992, the research team was able to track and
obtain follow-up information for seventy-two clients. The results revealed that after two years
there were only three out of seventy-two who had re-offended. This signifies a 96% success
rate of strategic therapy with sex offenders as well (Madanes, 1995).
The strength of strategic therapy may lay in its refusal to label clients with un-solvable
problems such as depression or personality disorders (Madanes, 1995). This benevolent
framework enables therapists, as well as, clients to keep a hopeful perspective. Strategic
therapists generally try to maintain a positive outlook on human nature, and use common
sense and social justice as a fundamental lens through which to view solutions. Strategic
therapists usually believe that people are able to control their actions, thoughts, and impulses
(Madanes, 1995). This reassurance frequently offers hope to families with members who
appear out of control (Madanes, 1990).

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Strategic Therapy 359

Furthermore, the playful manner in which therapists are taught to administer tasks can
serve to take the gloom and doom out of therapy (Sells, 1998). Families tend to enter therapy
with heavy burdens and a humorous, playful approach allows therapists to lighten the load
(Madanes, 1983). Furthermore, the wide range of available techniques and methods by which
to affect change is limited only by the confines of the imagination and creativity of the
playful, humorous therapist (Haley & Richeport-Haley, 2003).

Limitations
Breunlin, Schwartz and MacKune-Karrer (2001) suggest that the search of the function of
the problem in families, rather than internalization of problems, can potentially lead therapists
to blame the parents, or other members of the system, who are seen as the reason for the
problem. This might be a danger, if, for instance, the therapist divulges too much information
about their hypotheses regarding the origin of the problem, their ideas about the metaphor of
the problem, or their hunches regarding marital problems or other issues that might be under
the surface but not directly volunteered by the clients (Bobrow, 2003). Furthermore, the use
of humor and paradox can appear to be inappropriately manipulative of clients. If therapists
have not developed an adequate therapeutic relationship for such interventions, they run the
risk of contributing to the client feeling patronized, minimized or misunderstood by the
therapist (Sell, 1998).
Another limitation of strategic therapy may result from a rejection of a strictly medical
framework by which to view problems (Bobrow, 2003). A flat-out rejection of medical facts
limits the responsiveness of therapists to the benefit of certain medications and treatments
other than family therapy. For instance, there is much research to suggest that the occasional
use of pharmaceutical interventions is indicated especially in the areas of depression and
anxiety (Barker, 1998). Therapists must to be aware of the possibility of several hypotheses
when formulating possible reasons for misbehavior in children or dysfunction in families in
order that this limitation may be avoided (Barker, 1998).
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

SUMMARY
Strategic therapy is a distinctive and unique approach different that emphasizes action
and behavior to affect a desired change. Whether dealing with issues of teenage disrespect,
sexual misconduct, or somatic symptoms, the therapists patiently gathers information and
then devises a strategic intervention to move people toward change. Strategic therapists make
use of play, humor, metaphor and paradox in effort to ease clients into a change that might
otherwise feel scary, risky, or threatening. Since paradox, metaphor, and play have no basis in
any one particular culture or population, they are potentially effective tools within the context
of various socioeconomic, religious and ethnic groups. Strategic therapists generally refuse to
accept the notion that certain clients are incurable. Instead, strategic therapists draw upon
common sense, creativity, and responsibility for change, to achieve effect therapeutic results
with populations of clients who otherwise might be considered beyond hope.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 360 Sabrina Walters and Gena Minnix

REFERENCES
Barker, P. (1998). Basic Family Therapy. Oxford, England: Blackwell.
Barret, B. & Logan, C. (2002). Counseling gay men and lesbians: A practice primer. Pacific
Grove, CA: Brooks/Cole.
Beagle, D. (2003) Professional Development Seminar on Poverty: August 28, 2003.
Becvar, D., & Becvar, R. (4th ed., 2000). Family therapy: Systemic integration. Boston, MA:
Needham Heights/Allen & Bacon.
Bobrow, E. (2003). MRI Conference, October 24-25, 2003. Palo Alto, CA.
Breunlin, D., Schwartz, R. & MacKune-Karrer, B. (2001). Metaframeworks: Transcending
the models of family therapy. San Francisco, CA: Jossey-Boss Publishers.
Carter, B., & McGoldrick, M. (2nd ed., 1989). The changing family life cycle: A framework
for family therapy. Boston: Allyn and Bacon.
Carter, B., & McGoldrick, M. (3rd ed., 1999). The expanded family life cycle: Individual,
family and social perspectives. Boston: Allyn and Bacon.
Erickson, M. (1976). Hypnotic Realities. New York: Irvington Publishers.
Erickson, M. (1998). Life reframing in hypnosis. London: Free Association Books.
Haley, J. (1976). Problem-solving therapy. San Francisco, CA: Jossey-Bass Publishers.
Haley, J. (1986). Uncommon therapy. New York: Norton Publishers.
Haley, J. ( 2nd ed., 1996). Leaving home. New York: Brunner/Mazel.
Haley, J., & Richeport-Haley, M. (2003). The art of strategic therapy. New York: Brunner-
Routledge.
Henggeler, S. W. & Sheidow, A. J. (2003). Conduct disorder and delinquency. Journal of
Marital and Family Therapy, 29(4): 505-522.
Hervis, O. (2006). Brief Strategic Family Therapy. http//www.helpingamericasyouth.gov/
program detail. Retrieved May 12, 2006, from Helping America’s Youth.
Madanes, C. (1983). Strategic family therapy. San Francisco, CA: Jossey-Bass Publishers.
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Madanes, C. (1984). Behind the on-way mirror. San Francisco, CA: Jossey-Bass Publishers.
Madanes, C. (1990). Strategic family therapy. In Gurman, A. & Kniskern, D. (Ed.),
Handbook of Family Therapy, v2.(pp. 396-316). New York: Brunner/Mazel.
Madanes, C. (1995). The violence of men. San Francisco, CA: Jossey-Bass Publishers.
Mason, M. (1991). Family therapy as the emerging context for sex therapy. Gurman, A. &
Kniskern, D. (Ed.), Handbook of Family Therapy, v2.(pp. 479-507). New York:
Brunner/Mazel.
McGoldrick, M., Gerson, R., & Shellenberger. (1999). Genograms: Assessment and
interventions (2nd Ed.). New York: W.W. Norton & Company.
Robbins, M. & Szapocznik, J. (2000). U.S. Department of Justice: Juvenile Justice Bulletin
(April):1-11.
Sells, S., Smith, T. & Moon, S. (1996). An ethnographic study of client and therapist
perceptions of therapy effectiveness in a university-based training clinic. Journal of
Marital and Family Therapy, 22(3), 321-343.
Sells, S. (1998). Treating the tough adolescent. New York: Guilford Press.
Stanton, D. & Todd, T., (1982). The family therapy of drug abuse and addiction. New York:
Guilford Press.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 In: The Quick Theory Reference Guide ISBN: 978-1-60021-624-4
Editor: Karin Jordan, pp. 361-386 © 2008 Nova Science Publishers, Inc.

Chapter 25

BEHAVIORAL FAMILY THERAPY FOR

SCHIZOPHRENIA AND SERIOUS MENTAL DISORDERS

Robert Paul Liberman

“Relatives must learn not to be consumed by their family member’s illness.
But this is easier said than done because living with schizophrenia is like
living on the edge of a volcano.”
Donald Richardson
Past-President, National Alliance for the Mentally Ill

Several converging movements during the past two decades have produced family-based
approaches to the care of individuals with schizophrenia and other serious mental disorders
that have brought a new optimism into the management of disorders that had carried a poor
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

prognosis. The optimism is not generated by faddish attachment to a new ideology or

philosophy of treatment, but rather by well-replicated, empirical data documenting highly
significant reductions in relapse rates in patients living in different cities the world over.
Focusing on schizophrenia as the most disabling of the mental disorders, structured and
educationally oriented therapies have been developed from two confluent conceptual streams:
(1) social psychological studies of stress-related relapse in the context of family relations, and
(2) learning theory and behavior analysis. Replicated findings are scarce in psychiatry, so
when clinical researchers using behaviorally-oriented treatments report reductions in relapse
of schizophrenia from over 50 percent to less than 10 percent in the 9 to 12 months following
a hospitalization, mental health and rehabilitation professionals have taken notice.
The conceptual and clinical movements converging to promote the use of family
treatment and management strategies in the care of schizophrenia include:

1. Deinstitutionalization, which has produced a mass exodus from mental hospitals,

reduced accessibility to hospitals for even floridly ill psychotic patients, and
increased responsibilities for care and support of the mentally ill by their relatives.
2. Rejection and disavowal of psycho-analytic views that families cause schizophrenia
and other serious mental disorders as a result of the growth and empirical validation
of neurodevelopmental, genetic and vulnerability-stress concepts of etiology.
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 362 Robert Paul Liberman

3. Stress and burden experienced by families who are unequipped to manage their
mentally ill relatives at home or cope with their unpredictable, deviant and
sometimes violent behavior.
4. Growth of vital advocacy and self-help organizations by relatives of mentally ill
persons--the National Alliance for Mental Illness, Depression and Bipolar Support
Alliance and the National Alliance for Research on Schizophrenia and Depression--
which have organized nationally and spawned hundreds of local chapters and
hundreds of thousands of members.
5. The assertive and persistent expectations by family members to be actively involved
in the diagnosis and assessment, treatment planning and treatment implementation of
their seriously mentally relatives.
6. Disenchantment with reliance solely on maintenance antipsychotic medications, with
their noxious side effects, for the treatment of schizophrenia.
7. Development of behavioral and educational methods for clinical problems in
psychiatry that offer practical help for all social classes and that supersede less
anachronistic psychodynamic and insight therapies that have been found to lack
efficacy.
8. Reduction of stigma of mental illness and increased public awareness and acceptance
of mental disorders as bona fide, biomedical illnesses that deserve and respond to
treatment.
9. Recovery from schizophrenia and other mental disabilities is now a realistic prospect
but only if families are actively involved in treatment as partners with patients and
mental health professionals.
10. The ascendance of the vulnerability-stress-protective factors model of schizophrenia
and other serious mental disorders which has led to significant improvements in the
treatment outcomes accruing to persons with serious mental disorders when
treatment builds supports for family members along with pharmacotherapy and other
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forms of psychosocial rehabilitation.

FAMILY BURDEN OF MENTAL ILLNESS

With the deinstitutionalization of the severely and chronically mentally ill and the
contraction of public mental hospital beds throughout the United States, the burden of caring
for the hundreds of thousands of patients with chronic schizophrenic and affective disorders
has shifted from hospitals to the family and other community-based agencies. Each year, an
estimated one million families receive a mentally ill person back into the home after a
psychiatric hospitalization. Approximately 65 percent of discharged mental patients return to
their families, either on a full-time or part-time, intermittent basis (Minkoff, 1978; Goldman,
1982). Since long-term institutional care is becoming rarer, patients tend to spend more time
in proximity to their relatives. For example, in the current era of brief, revolving-door
hospitalizations for psychotic and other severe disorders, three times as many patients return
to live with their relatives than do patients who are hospitalized for six months or longer
(Lamb & Goertzel, 1977).

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Behavioral Family Therapy for Schizophrenia and Serious Mental Disorders 363

Since the 1950s, psychiatric researchers have documented the emotional, physical, and
financial strain imposed upon family members who have the responsibility of caring for a
mentally ill person. There are a number of elements to this strain, first termed "family
burden" by Grad and Sainsburg (1968). One source of family burden derives from the
pervasiveness and severity of the symptoms of mental illness and their associated
impairments in most spheres of life. Schizophrenia, for example, presents family members
with immense challenges to understand\react to, contain, and cope with-thought disturbances,
delusions, hallucinations, and incoherence; in addition, the impairments in work, recreation,
affects, habits, activities of daily living, and socializing create even more difficult dilemmas
for caring relatives. How are family members to cope with inappropriate or bizarre behavior,
tenaciously held false beliefs, extreme social withdrawal, unpredictable moodiness and
irritability, and even violence?
Even for families that survive intact, the intrusive impact of harboring a severely and
chronically mentally ill person is intrusive and unwieldy. There is a major price to pay
beyond dollars and cents. Anxiety and tension, guilt, demoralization and depression, grief,
and frustration are great emotional costs on the family members and have inevitable
repercussions on the clinical status of the ill relative as well.

IMPORTANCE OF CONTACTS AND COMMUNICATION

WITH PROFESSIONALS

The stress and dysfunctional coping efforts of such a large number of American families
harboring a seriously mentally ill relative are compounded by the indifference of many
professionals to the needs of families. Too many professionals continue to ignore relatives,
rather than involve them in treatment planning, partly in obeisance to a misguided conception
of privacy and confidentiality. Relatives are lucky if they get in to see the professional
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

responsible for the patient's treatment, much less hear of the diagnosis and prognosis. Plainly
speaking, relatives are ignored by mental health professionals.
Despite the still prevalent if fallacious views of professionals that families are breeding
grounds for schizophrenia and other major mental disorders, and despite the indifference of
professionals to the needs of family members for support and counseling, relatives still
express a strong desire for contact and communication with professionals, especially the
psychiatrist responsible for the patient's care. Because of the great stress and anxiety
associated with living with a person suffering from schizophrenia or other severe mental
illnesses, relatives regularly articulate a need for information and assistance from professional
caregivers. For example, in one survey (Hatfield, 1984) 138 families ranked their needs for
professional guidance in the following order of priority: (1) motivating the patient to do more,
(2) understanding appropriate expectations for patient, (3) assisting in times of crisis, (4)
comprehending the nature of mental illness, (5) accepting the illness, (6) locating housing and
financial support resources, and 7) understanding use of medications and their side effects.
The author of this survey, who has also served as President of the National Alliance for
the Mentally Ill, pointed out that professionals and family members have profoundly different
"world views" of mental disorder that contribute to a harmful schism and to obstacles in
developing therapeutic alliances (Hatfield, 1984). The professional sees the patient as his or

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 364 Robert Paul Liberman

her primary concern and will often try to "protect" the patient from putative harmful family
influences by withholding information from the family and hiding behind the cloak of
confidentiality. There is a blind spot in the vision of many professionals, who forget that the
family directly shares in the care giving functions. In fact, except for time spent with a
therapist, psychiatrist, case manager, or outpatient treatment and rehabilitation facility, the
patient with a chronic mental disorder receives the bulk of his or her care giving from family
members.
What are the specific needs of relatives for information and contact with professionals?
In summary, relatives want to know:

• Whether there is a cure for mental illness.

• In the absence of a cure, what can be done to limit deterioration and optimize
function?
• About the nature of mental illness and its treatments.
• About practical management techniques.
• Whether the patient should live at home or elsewhere.
• How to ensure consistency and continuity of treatment.
• The diagnosis, prognosis, and changing clinical status of the patient.
• How to obtain crisis services and respite from escalating disruptive behavior or
symptoms.
• About the role of genetics and inheritance in major mental disorders and how this
information can be shared with other relatives of the patient who are in the
childbearing period.

Despite their frustration and bitterness toward professionals, families continue to see
professionals as key resources in their times of need. They want more information, translated
to their level of comprehension, so they can grasp the reality of their present and future
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

situation with an ill relative. A survey conducted in Philadelphia found that relatives made
requests for gaining more information about psychiatric illness, medication and early warning
signs of relapse. They also strongly desired “how to” strategies for managing common
problems and disturbing behavior, such as withdrawal, aggression, mood swings, drug and
alcohol abuse and inadequate daily living skills. One of the most urgent needs in this survey
was a desire to have more of their needs met by the mental health professionals with whom
they were in treatment relationships (Mueser, Bellack, Wade, Sayers & Rosenthal, 1992).
With some exceptions, even now, professionals have not been prepared or trained for
responding to these needs of families.

BEHAVIORAL FAMILY THERAPY: A NEW WAY

OF HELPING FAMILIES COPE WITH MENTAL ILLNESS

Behavioral family therapy is a new approach, initially introduced by Robert P. Liberman

and Ian R.H. Falloon at the UCLA Clinical Research Center for Schizophrenia & Psychiatric
Rehabilitation, for assisting the family and the patient jointly to improve their coping with
severe and persisting mental disorder. The ultimate, long-term aim of this treatment strategy

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Behavioral Family Therapy for Schizophrenia and Serious Mental Disorders 365

is to strengthen the patient's competencies so that the highest feasible level of independent
functioning becomes possible. The short-term aim of family management strategies is to
provide education and coping abilities to families and patients, and much of this effort does
focus on intrafamilial relationships. This does not mean that family management techniques
are supportive of the abdication of professional and public responsibility for the care of the
seriously mentally ill. It does mean that effective communication and problem solving among
members of a family can be a potent first step toward liberating the mentally ill family
member for a fuller and more independent role in society.
Recent developments in psychiatry and mental health have shown that many patients with
schizophrenia and related disabling mental disorders can recover (Liberman & Kopelowicz,
2005). While there is no “cure” for these disorders given the field’s ignorance of their causes,
remission of symptoms and recovery of psychosocial functioning is now a realizable
treatment goal if comprehensive, coordinated, consistent, collaborative and competent
services are available (Liberman & Kopelowicz, 2002). It is fatuous to consider any one
treatment for the seriously mentally ill to be sufficient as a stand-alone intervention; thus,
Behavioral Family Therapy must be carried out in a system of care that includes medication
management, social skills training, intensive case management, supported employment and
supported housing (Liberman et al., 2004).
Behavioral family therapy is among the evidence-based services for this disabled
population, a treatment that is required for patients to proceed on the road to recovery.
Numerous controlled studies have been conducted with family therapies and psycho-
educational programs during the past two decades (Dixon et al., 2001). These have been
highly encouraging and demonstrate that the techniques of Behavioral Family Therapy are
eminently adaptable to different types of disorders, mental health systems, minority
subcultures and nations (Dixon et al., 2000: Lefley & Johnson, 2002). For example, a support
and education program for family members of patients with a wide variety of disorders, such
as post-traumatic stress disorder, mood disorders, addictive and personality disorders and
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

schizophrenia. This program, termed “Support and Family Education” meets the needs of
family members for learning about their relatives’ illnesses and how to cope with them to
improve their morale and sense of empowerment (Sherman, 2002).
There are a variety of approaches and adaptations of Behavioral Family Therapy which
comprise different intervention elements, goals, durations, settings, participants and timing of
services. The component techniques of this therapeutic approach - behavioral assessment,
psycho-education and training in communication and problem-solving skills - have been
implemented with individual families as well as in multi-family groups (McFarlane, 2002).
Recent innovations in using behavioral techniques have included families teaching other
families about the causes of mental disorders, their long-term course, coping skills and how to
carve out a life for themselves while, at the same time, providing support for their ill relative.
This peer support and educational effort is called, “Family to Family” and has been used with
thousands of family members throughout the United States. Results indicate that the
emotional burden is reduced in the participating families and their perception and attitudes
toward their seriously mentally ill relatives improves with a more realistic set of expectations
for their functioning (Pickett-Schenk, et al., 2006).
Alternatively, when family interventions are not sufficient to overcome the stress and
duress of the patient and family living together, therapists can encourage constructive
separation between patient and family. In this fashion, the patient lives apart from the family
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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 366 Robert Paul Liberman

in supervised, semi-independent or independent housing. However, there are two caveats

associated with constructive separation. First, families continue to have interpersonal contact
with the patient as well as offering emotional and financial support; thus, it is important for
Behavioral Family Therapy to continue even if only at times of crisis, friction, frustration or
antagonism. Second, constructive separation requires the professional to absorb many of the
care-giving and case management functions that the family had been providing. To encourage
separation of the patient from the family without concomitant provision for a wide range of
supportive services would be destructive and possibly unethical.
Other family management approaches, with the concordance of the relatives involved,
aim to facilitate the family's role in case management. Case management functions that can be
assumed, at least in part, by family members include assisting patients' linkages and
engagement with needed services, being aware of the comprehensive needs of the patient,
monitoring the quality of the services being rendered, helping the patient with meeting daily
living needs, being available in times of crisis, and engaging in advocacy efforts to enhance
services (Intagliata et al., 1986).
Table 1 lists the kinds of assistance that can be provided by relatives and the things for
relatives to avoid. Professional and family caregivers can work in partnership to optimize the
quality of services provided to patients with chronic mental disorders. In this partnership,
professionals must respect the needs and desires of family members for the type and amount
of involvement in the care and management of the patient's illness.

Table 25.1. Ways for family members to assist in the treatment and rehabilitation
of a chronically mentally ill relative

Functions to Serve Traps to Avoid

Assist in locating, linking, and sustaining Overinvolvement with ill relative and trying
treatment and rehabilitation services too hard to help and comfort
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Supportive use of medication Nagging or excessive criticism

Advocate for better services Isolation from family and friends
Maintain tolerant and low key home Taking for granted small signs of progress
atmosphere
Reduce performance expectations to a Expecting too much improvement too quickly
realistic level
Encourage participation in treatment and low Depriving self and other family members of
stress activities fun, recreation, vacations, and personal
activities

THE BASIC COMPONENTS OF BEHAVIORAL FAMILY THERAPY

Behavioral family therapy was designed by the author during prototype experiences with
families of persons with schizophrenia, starting in 1968 (Liberman, 1970) and further
elaborated by him in systematic evaluations in California and London during the early 1970’s
(Liberman, 1972; Liberman & DeRisi, 1972; Liberman et al., 1976; Liberman et al., 1984).
Since that time, the approach has been further developed by Falloon and others in the United
States, England, Australia, China, Spain and Germany (Falloon et al., 1984; Falloon et al.,
1985, Hogarty et al., 1991; Falloon et al., 1999).
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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Behavioral Family Therapy for Schizophrenia and Serious Mental Disorders 367

This treatment modality has sometimes been called behavioral family management
because the term “therapy” has an objectionable connotation to some families who associate
it with their being mentally ill themselves, needing “treatment” instead of education and
support and having a dysfunctional and pathological effect on their mentally ill relative. This
concern is a somewhat anachronistic attitude derived from the oppression felt by families a
generation ago when they were viewed by mental health professionals as “sick” and blamed
for being the cause of their relative’s illness. In this chapter, the term Behavioral Family
Therapy will be used as it has become acceptable to families who participate in contemporary
mental health services.
It is informative to learn about Behavioral Family Therapy in modular fashion since it is
possible to disassemble and reassemble the treatment components to fit the prevailing
resources and constraints of any one clinical site. The components of this form of family
therapy are as follows:

1. Behavioral or functional assessment of each individual and the family as a whole.

2. Education on the nature of mental disorders and their modern treatment.
3. Training in communication skills, including expressing and acknowledging positive
feelings, actively listening, making positive requests, and expressing negative
feelings directly.
4. Training in systematic and structured problem solving.
5. Special behavioral techniques used to help individual family members or the family
group to overcome distress, dysphoria, symptoms or motivational problems that do
not respond readily to the educational strategies noted above in components 2, 3, or
4.

Each of the components of behavioral family management are described in this chapter
and highlighted with clinical examples and learning exercises. It should be understood that
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

one or more of the components can be used with any given patient and family. Some families
and patients might only be able to accept or manage the educational components, while others
would have time and resources for engaging in the skill-building components as well. The
components can be given in a variety of formats, including multiple family groups, seminars,
or workshops, and with patients together with or separate from family members. Flexibility is
desirable in considering how best to apply the components of Behavioral Family Therapy in
module fashion with the exigencies of families and clinical facilities determining the service
delivery.

BEHAVIORAL ASSESSMENT OF THE FAMILY

The specific nature of the patient's and relatives' problems and goals should shape the
scope and focus of Behavioral Family Therapy. Therefore, it is essential to begin with a
comprehensive and sensitive assessment of each person's needs in the family as well as the
strengths and deficits of the family as a whole. The process of behavioral assessment and
analysis is inextricably interwoven with the process of therapy and behavior change.
Accordingly, it continues throughout the duration of the treatment rather than being limited to

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 368 Robert Paul Liberman

the initial sessions. Analyzing and pinpointing problems, setting goals and priorities, and
selecting interventions go hand in hand with monitoring of progress.
Since the patient and relatives may come to a therapist for family intervention with little
or no previous contact, it is essential to have a method for collecting and sorting information
efficiently. Each individual member of the family should be assessed for his or her behavioral
assets and deficits, self-defined problems and goals, reinforcers, and motivation for change.
These assessments can be carried out using a variety of questionnaires, interview formats,
therapist observation, or self-monitoring by the individual. Meeting individually for at least
one session with each member of the family, or for a portion of a session, helps the rapid
assembly of these data and fortifies the development of the therapeutic alliance.
Meeting with the family as a whole permits assessment and analysis of family strengths
and deficits, their problem-solving styles and their ability to communicate. The power
structure (for example, who makes the decisions), status, and role of the family members can
be assessed through questionnaires, role-plays, structured family interaction tasks, and
naturalistic observation of the family process. For example, family questionnaires are
available that inquire about the patterns of decision making and the degree of satisfaction that
members of the family have about the existing mechanisms for allocating family resources
(Stuart 1980).
Interview instruments or questionnaires are available to assess the quality of the
emotional relationships among patient and relatives (Snyder & Liberman, 1981). Questions
center around the patient's and relatives' perception of the development of the mental
disorder, their understanding and views about the disorder, conflicts, quarrels, and irritability,
the family time budget, management of household tasks and responsibilities, and subjective
attitudes expressed by each member of the family about each other. In evaluating the family
interaction relationships, the therapist looks for signs of unrealistic expectation for
improvement and functioning, criticism, intrusiveness, and emotional over-involvement.
For example, are there deficits in communication between parents and a young adult
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schizophrenic son who secludes himself in his room? How well do the family members deal
with a major problem, such as unexpected denial of Social Security benefits to the sick
relative? Are the family members spending excessive time together, to the exclusion of their
own, independent needs for recreation and socialization? Are relatives inadvertently
reinforcing maladaptive or symptomatic behavior in their sick family member through over-
protectiveness and over-solicitousness? A major aim of the family assessment and behavior
analysis is to take the "temperature" of the family emotional climate and specify the
individual and interpersonal problems, deficits, and assets that contribute to the "fever."
A highly productive way of gaining an assessment of the abilities of a family to engage in
constructive communicating and problem solving is to identify a problem or issue that each
member has endorsed as being current and marked by disagreement. The therapist then can
ask the family, who is being observed in a session, to spend five minutes attempting to solve
the problem or reach a consensus. What unfolds in front of the therapist's eyes are the
capabilities and deficiencies of the communication and problem-solving style of each family
member and of the family as a whole. More detailed descriptions of how to conduct
behavioral assessment and analysis are available (Taylor et al., 1982; Patterson et al., 1975;
Falloon et al., 1984).
Whatever the problems are, the assumption of the therapist, shared with the family, is that
the family is coping with the problems as best they can, given their present resources and
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Behavioral Family Therapy for Schizophrenia and Serious Mental Disorders 369

capabilities. The aim of Behavioral Family Therapy and the responsibility of the therapist are
to enhance the family's capacities through goal setting, education about the nature of the
disorder and how to obtain needed treatment and rehabilitation, communication, and problem-
solving skills training.

EDUCATE THE FAMILY ABOUT SCHIZOPHRENIA

The element common to all of the newer forms of family intervention with chronic
mental disorders is education about the nature and treatment of the disorder. This education
can be given in many different ways; for example, some therapists and clinics offer half-day
or full-day "survival skills workshops" to relatives and patients with serious mental
disabilities. The aims of the workshop are to give information; familiarize families with
available treatment, rehabilitation, and social services; connect the patient and relatives to the
clinicians and the agency for continuing care; and promote social support among the families.
Other formats are equally effective in accomplishing these aims, such as meeting with
relatives and patient separately for education; providing the education in brief increments as
part of an ongoing family therapy program; conveying education through self-help and
advocacy organizations like the National Alliance for Mental Illness; and providing
educational seminars for multifamily groups.

Table 25.2. Examples of Information on Schizophrenia Provided to Families in

Educational Sessions

1. Schizophrenia is a major mental illness that affects 1 in 100 people.

2. The symptoms include delusions-false beliefs; hallucinations-false perceptions,
usually voices, difficulties of thinking, feeling, and behavior.
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3. The exact cause is not known, but appears to produce an imbalance of the brain
chemistry.
4. Stress and tension make the symptoms worse and possibly trigger the illness.
5. People who develop schizophrenia possibly have a weakness, which may run in
families, that increases their risk of getting schizophrenia.
6. Some people recover from schizophrenia completely, but most have some difficulties
and may suffer relapses.
7. Although there are no complete cures available, relapses can be prevented and life
difficulties overcome.
8. Family members and friends can be most helpful by encouraging the person suffering
from this illness to gradually regain his or her former skills and cope with stress more
effectively.

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 370 Robert Paul Liberman

Table 25.3. Information on Antipsychotic Drugs Presented to Families During

Educational Sessions on Schizophrenia

1. Regular tablet taking is the mainstay of treatment of schizophrenia. Motivating

techniques for adherence.
2. Major tranquilizers are very effective medicine for the treatment of schizophrenia.
3. In low doses, they also protect a person from relapse of symptoms.
4. Side effects are usually mild and can be coped with.
5. Street drugs make schizophrenia worse.
6. Other therapies and rehabilitation facilitate drug effects.

Educational efforts are facilitated by high-quality media for translation of technical

information to a layperson's level of comprehension. This is particularly important for
families with limited education or in cases in which literacy is marginal. Videotape
productions on schizophrenia have been produced (Backer & Liberman, 1986), and diagrams,
brochures, and informational handouts are useful supplements to verbally transmitted
information (National Institute of Mental Health, 1986). The content of the education focuses
on what is currently known about the disorder in question and its causes, course, and
treatment. In Tables 2 and 3 are shown a selection of information provided to patients and
relatives through lecture, discussion, and brochures.
During the educational sessions, the therapist turns the patient and the relatives into the
real "experts," by soliciting their experiences and personalizing the learning experience.
When the symptoms of the disorder are described, each person in the family gives his or her
own perspective on the specific symptoms of the patient in the family. Some patients are
surprised that anyone would want to know about how they coped with the distressing and
fearsome symptoms. Relatives show gratitude that a professional would spend time going
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

over the basics of knowledge of the disorder or even explain the rudimentary facts of mental
illness, its genetics, and how it is diagnosed. Many of these educational sessions have a
cathartic effect, and families learning the material together often form spontaneous mutual
help and support groups that long transcend the end of the family educational program.

TRAINING IN COMMUNICATION SKILLS

While psychoeducational approaches to family management can give information,
promote cognitive mastery and demystification of mental disorders, permit emotional
abreaction, and facilitate social support, a more active effort at inculcating skills to patients
and relatives is necessary for enduring effects on stress reduction, relapse prevention, and
social adjustment. Behavioral family therapy represents a skills development approach to
patients and relatives alike. Two of the skills required by patients and relatives who are
coping with a chronic and severe mental disorder are effective means of communication and
constructive problem-solving techniques. As was noted above in the section of this chapter on
stress and relapse, the tensions and conflicts that embroil patients and relatives in high
expressed emotion households can have deleterious effects on both. Since communication and

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Behavioral Family Therapy for Schizophrenia and Serious Mental Disorders 371

problem-solving skills are not taught in schools, it is only through incidental learning from
influential models that anyone learns such skills for use in human relations. The aim of
Behavioral Family Therapy is to provide training in these interactional skills so that stress and
relapse may be reduced while social adjustment and quality of life may be enhanced.

KEY COMMUNICATION SKILLS

In almost all areas of human relations, the interactions between individuals are mediated
by generic skills for expressing emotions and obtaining instrumental and affiliative needs.
These skills are:

• Initiating positive statements and suggestions

• Acknowledging positive actions of others
• Making positive requests of others
• Active listening and empathic responsiveness
• Expressing negative feelings constructively

If the discrete verbal and nonverbal behavioral components of these skills can be
pinpointed, it would be far easier to teach them to patients and relatives. The assumption of
BFM is that by building behavioral competencies in communication through repeated
practice, the subjective, internalized emotional congruence experienced by the individual will
gradually develop. As an example of the specific verbal and non- verbal components inherent
in communication skills, those relevant for "making a positive request" are listed in Table 4.
Since a core deficit in many chronic mental patients is lack of initiative and motivation,
learning how to effectively request actions and responses can be helpful for relatives'
overcoming obstacles induced by the patient's behavioral inertia and apathy.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Table 25.4. The Verbal and Nonverbal Components of the Communication Skill
"Making a Positive Request"

Making a positive request

• look at the person.
• use pleasant facial expression and tone of voice.
• say exactly what you would like them to do. Tell how it would make you feel.
In making positive requests, use phrases like:
• "I would like you to ___________ ."
• “I would really appreciate it if you would do ______" .
• "it's very important to me that you help me with the ___"

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 372 Robert Paul Liberman

FAMILY THERAPIST AS TEACHER AND TRAINER

Behavioral Family Therapy is a highly structured, relatively brief treatment requiring an
active, directive therapist. In many ways, the behavioral competencies of the therapist more
resemble those of athletic or drama coaches than they do the skills of a traditional
psychotherapist. Structuring the session is key if the goals of Behavioral Family Therapy are
to be met. Pacing the session-almost like an orchestra conductor-as well as setting rules and
guidelines that determine the behavior and interactions of family members, as well as the
therapist provide structure. The therapist actively intervenes to prompt and shape adherence
to the agenda set for a particular session. For example, if family members violate the rule, "no
blaming is allowed," the therapist must consistently interrupt and redirect any blaming
statement.
Behavioral Family Therapy also places a heavy emphasis on instigating behavior change
in the home environment. Effective instigation involves the induction and maintenance of
collaboration between therapist and family members, compliance with homework
assignments, and positive changes in the family interactions made quickly and early in the
series of sessions. Compliance with homework is abetted by the therapist's emphasizing the
importance of the task, gaining commitment from the family members to do the assignment,
anticipating potential excuses or obstacles in the completion of the assignment, and providing
adequate prompts for doing the assignment in the home itself. The communication skills diary
or log that aids the generalization of the skills into the family home is shown in Figure 2.
Failure to complete homework assignments should not be reinforced by a "business as usual"
response or by supportive understanding from the therapist. If necessary, family members
should be required to complete their homework assignments during a therapy session.
A good behavioral family therapist is a good teacher. In explaining principles and
guidelines to patients and relatives, therapists frequently overestimate their capacity for
processing information. Even highly educated patients and relatives, because of the stress
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

they are experiencing and other intrinsic learning disabilities, need information that is
transmitted simply and clearly in their own language. Frequent repetition is required, along
with inquiries that ascertain how well the therapist's communications are being decoded by
family members. In addition, the therapist must make sure that patients and relatives are
learning principles rather than simply enacting new behaviors in response to the expectations
of the therapy program.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Behavioral Family Therapy for Schizophrenia and Serious Mental Disorders 373

Keeping the patient and relatives on track during structured sessions can be facilitated by
the therapist who evokes a positive climate at the start of each session and who clears away
distracting and intrusive preoccupations of the family members. For example, the complete
behavior therapist starts each session by effusively greeting the patient and relatives,
acknowledging positively their attendance, smiling, and putting them at ease with small talk.
The therapist solicits information regarding any crisis facing the family since the last meeting
and specifies how and when attention will be given to it. If the family group is expected to
complete homework assignments, then they must be reinforced for doing so by having the
homework focused on as soon as possible in the therapy session. Review of the quality and
quantity of completed homework provides an opportunity to reinforce approximations to
successful in vivo use of the communication skills being taught and to determine which I
family members will require attention to remediate deficiencies implicit in the evaluation of
the homework. Just as it begins each session, homework ends the session as well.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Figure 25.1. Diary form used in behavioral family management to encourage and reinforce all family
members to practice the communication skill "Acknowledging pleasing and positive actions." Each
day, Paul's mother noted at least one pleasing event or comment initiated by another family member
and acknowledged verbally how that positive action made her feel.

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 374 Robert Paul Liberman

Figure 25.2. Role of the family in protecting a person with schiophrenia or other chronic mental
disorder from relapse. Lack of communication and problem-solving skills leads the family and the
mentally ill member to cycles of failure in reducing stress and ambient tension in the household. As
stress continues to mount, the vulnerability threshold of the mentally ill family member is exceeded and
relapse ensues.

TRAINING IN PROBLEM SOLVING

Once the family unit has gained some experience and skill in communicating using the
verbal and nonverbal elements described above, the therapist can proceed to teaching them
systematic problem solving. The communication skills serve as building blocks for
subsequent efforts at problem solving: Without the ability to listen to each other,
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

acknowledge positive efforts, make positive requests of each other, and express unpleasant
feelings non-critically, family members will not be able to engage in constructive problem
solving.
What are the problems that face patients and relatives who are dealing with a chronic
mental disorder? They include all the stressors and painful events of everyday life plus the
special burdens added by a pervasive and unrelenting illness, marked by symptoms and
disability. The following problems are particularly common in families harboring a
chronically mentally ill relative. It should be noted that each problem affects all members of
the family, albeit to different degrees and in different ways.

• Social withdrawal, irritability, suspiciousness, erratic eating and sleeping patterns,

mood swings, and aggression.
• Excessive supervision, nagging, and monitoring of the patient.
• Poor grooming and self-care, lack of initiative or desire to participate in activities.
• Frustration in obtaining needed help from professionals in a timely and sufficient
manner.
• Stigma of mental illness felt with friends, siblings, relatives, co-workers, and others
in the local community.
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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Behavioral Family Therapy for Schizophrenia and Serious Mental Disorders 375

• Lack of appropriate housing and vocational alternatives for the person with the
mental disorder.
• Frustration and obstacles in obtaining disability benefits through Social Security
Administration and state vocational rehabilitation agencies.

While elements of the problem-solving sequence, depicted in Table 5, are implicitly used
by everyone, a highly structured and systematic teaching of the entire sequence is felt to be
important with the chronically mentally ill, for two reasons. First, unless the training is
thorough, with over-learning of the steps and sequence, the information-processing deficits of
persons with schizophrenia and the stress experienced by relatives of the mentally ill will
inevitably interfere with effective problem solving. Second, the problem-solving strategy
taught in this phase of Behavioral Family Therapy will serve as the principal vehicle for
generalization and durability of clinical gains beyond the direct intervention period itself.
Thus, the careful and systematic training of problem-solving skills-built upon previously
learned communication skills-becomes the single most important component in this approach
to chronic mental disorders. The key role of the problem-solving phase in the overall
therapeutic model is depicted in Figure 2.
In the actual training of problem-solving skills, each session begins with the therapist
soliciting the report of previous problem-solving (the homework assigned from the last
session) efforts by the family unit. If the problem previously pinpointed has not been
adequately dealt with, the family is asked to consider continued work on that problem before
proceeding to another one. In all cases, however, the family members are given the
responsibility to designate problems and their priority for solution. Using a worksheet similar
to the outline depicted in Table 5, the family works through each of the problem-solving
steps. One member of the family takes a turn at being the "scribe" for the family unit and fills
in the spaces on the worksheet as the family generates alternatives, weighs pros and cons of
each alternative, and works toward an implementation plan.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Table 25.5. Form Used to Guide Families in Six-Step Process of Problem Solving During
Weekly Family Meetings

STEP 1: What is the problem?

Talk about the problem, listen carefully, ask questions, get everybody’s opinion, than
write down what the problem is.

STEP 2: List all possible solutions.

Put down all ideas, even bad ones. Get everybody to come up with at least one
possible solution.
1) _____________________________________________________________________

2) _____________________________________________________________________

3) _____________________________________________________________________

4) _____________________________________________________________________

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 376 Robert Paul Liberman

5) _____________________________________________________________________

6) _____________________________________________________________________

STEP 3: Discuss each possible solution.

Go down the list of possible solutions and discuss the advantages and disadvantages
of each one.

STEP 4: Choose the best solution or combination of solutions:

________________________________________________________________________

________________________________________________________________________

STEP 5: Plan how to carry out the best solution.

Step 1 __________________________________________________________________

Step 2 __________________________________________________________________

Step 3 __________________________________________________________________

Step 4 __________________________________________________________________

STEP 6: Review implementation and praise all efforts.

Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

SPECIAL BEHAVIORAL TECHNIQUES

Professionals experienced in the use of behavior analysis and therapy are able to
interpolate these methods into the Behavioral Family Therapy approach. Specific problems
faced by one or another family member may not be remediable through the modules listed
above; they may require more focused and definitive interventions drawn from the repertoire
of a skilled behavior therapist. Examples of problems that have responded to behavioral
techniques include phobias, psychogenic pain, enuresis, extreme social withdrawal, and
aggression. Social skills training techniques are frequently employed by professionals in the
course of therapy to improve the social functioning and role skills of individual family
members.

WHAT IS DISTINCTIVE ABOUT BEHAVIORAL FAMILY THERAPY?

Several variants of family management approaches have been developed and found
effective. All have in common an educational and supportive effort with relatives, teaching
them about the nature of schizophrenia (or other severe mental disorders) and how to cope

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Behavioral Family Therapy for Schizophrenia and Serious Mental Disorders 377

with the disorder. One particular variant mixes families from high- and low-stress households
in a group with the aim to promote mutual sharing of coping methods. In this mixed group, it
is hoped that a learning process develops through which relatives under great stress can
acquire coping skills and strategies from their counterparts who are successful in managing
stress. Another variation on the family management theme encourages networking among
families, facilitating their joining together in self-help and social support activities.
While educational programs, social support, empathic outreach, practical advice
grounded on current best knowledge of schizophrenia, and accessible and responsive
professionals are hallmarks of all family management approaches. Behavioral Family
Therapy also emphasizes systematic skill building through behavioral training techniques.
The structured behavioral methods of skill building are the major distinctiveness of
Behavioral Family Therapy. Equipping family members and patients with skills they can use
to solve their problems and achieve their goals - inside and outside the family milieu - is a
major plus for this approach.
It should be clearly understood that the three major elements or modules of Behavioral
Family Therapy---(1) family education, (2) training in communication skills, and (3) training
in problem solving---are not sufficient in themselves for the effective management of
schizophrenia. These elements must be embedded in a comprehensive array of services that
can meet the wide- ranging needs of chronic mental patients. Services such as crisis
intervention, case management, advocacy, psychoactive medications, medical care,
supportive psychotherapy, vocational rehabilitation, and social skills training are all needed at
some time or another in the optimal treatment and rehabilitation of the chronic mental patient.
These services can be provided by the same person or by a team that delivers the Behavioral
Family Therapy, or can be offered by other service providers who are closely linked and
coordinated with the family management professionals.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

THE WHERE, HOW, AND BY WHOM

OF BEHAVIORAL FAMILY THERAPY

While Behavioral Family Therapy requires special training - usually through workshops
and supervised, on-the-job practice - a wide variety of mental health professionals have been
indoctrinated into leadership roles. These include psychiatrists, psychologists, social workers,
nurses, and occupational therapists. The particular disciplinary background is not as important
as a directive and assertive style, openness and candid comfort in dispelling myths and
mystifications about schizophrenia, and a practical and down-to-earth approach with patients
and relatives. Previous experience working with people having chronic mental disorders is
very important. Adherence to complex and sophisticated conceptualizations of mental
disorders may interfere with learning the treatment techniques.
Behavioral Family Therapy can be offered to patients together with their relatives or can
be offered separately. Both separate and conjoint sessions can be offered as well. Some
professionals feel that it is best to start the educational process shortly after the patient is
admitted to a hospital in relapse, whereas others wait until the patient has stabilized on
medication as an outpatient. Some educational programs are offered as "mini-marathons"
lasting up to a full day, whereas others are spread out in two-hour weekly programs. It does

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 378 Robert Paul Liberman

seem important to give relatives a chance to ventilate and abreact their strong feelings about
the stress and strain of harboring a mentally ill person at home, and this may be best done
without the patient present. Unless such abreaction is given vent, stored-up feelings can
interfere with the later work aimed at more constructive goals and communication.
Behavioral Family Therapy sessions have been conducted in the home, in the hospital, in
clinics and mental health centers, and in store-fronts in shopping malls. Multimedia aids are
helpful in the teaching process: Videotapes have been produced that convey educational
material and highlight coping strategies, and flip-charts and blackboards are the constant
companions of professionals plying the family management approach. Recently, internet chat
rooms with video-streaming have been established to allow family members to communicate
and share ideas with one another without having to travel to meetings.

COMBINING MEDICATION AND BEHAVIORAL FAMILY MANAGEMENT

Clinicians who work with schizophrenic persons and their families have left the old
ideological battlefields where advocates of drug therapy versus psychotherapeutic approaches
once jousted. We have outgrown the "either drugs or psychotherapy" dialectic. Modern,
effective treatment of schizophrenic patients requires both, depending on the patient's
characteristics, the point in the patient's course of disorder, the characteristics of the family
emotional climate, the intensity of treatment environments, the pharmacokinetics and dose-
response of neuroleptic drugs, and the availability of psychosocial interventions, like
Behavioral Family Therapy, that are more specific, efficacious and practical than the
psychotherapies of decades ago. It is time for contemporary treatment of schizophrenia to
catch up with current concepts of the nature of the disorder, which include both biological and
psychosocial determinants.
Here are some guidelines for appropriate use of drug therapy and Behavioral Family
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Therapy.

1. Antipsychotic drugs should be used with most schizophrenic individuals to control

and stabilize the florid symptoms of psychosis prior to introducing the patient into
BFM sessions. Medication facilitates cognitive functions and improves the patient's
ability to learn from his or her treatment environment.
2. Whether conducted in groups or with individual family units, BFM is most effective
when containing practical suggestions for coping with everyday challenges and
specific goal setting for engaging in attainable tasks.
3. A continuing positive relationship is central in the overall management of a patient
with schizophrenia and improves the patient's constructive engagement in the
therapeutic enterprise, whether it be drug or psychosocial treatment. Medication is
never given in a vacuum, and its effects can be facilitated or impeded by the nature
of the patient-therapist and family relationships.
4. Medication needs to be titrated to the changing needs of the patient for protection
against stress. For example, stress can rise when, after successful psychosocial
treatment, the patient takes on new social and vocational challenges. Stress can also

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Behavioral Family Therapy for Schizophrenia and Serious Mental Disorders 379

increase when a patient and family agree to separate and the patient attempts
independent living.
Medication needs may decrease when the patient is involved in a supportive and
constructive rehabilitation program, such as Behavioral Family Therapy. If small
steps are taken and liberal use of positive reinforcement is made, stress is reduced
and so may the patient's need for antipsychotic drugs.
5. Psychosocial rehabilitation such as Behavioral Family Therapy should be placed in a
time frame of years. When the initial goals of Behavioral Family Therapy have been
achieved (that is, reduction of stress and burden within the family, stabilization of the
patient's symptoms, engagement of the patient and family members in a working
alliance with professionals), it may be desirable to increase the scope of
rehabilitation efforts to include vocational training, job placement, and friendship
building. These psychosocial goals are ambitious and require lengthy periods of
gradual progress to attain. It is likely that indefinite, if not lifelong, psychosocial sup-
port and guidance are optimal for most persons with schizophrenia. Just as
neuroleptic drugs are most effective in maintaining symptomatic improvement when
continued indefinitely, it should not come as a surprise that psychosocial
interventions are similarly optimized by continuity.

HOW EFFECTIVE IS FAMILY MANAGEMENT?

Behavioral Family Therapy and its structured, behavioral variants have been carefully
evaluated in more than 25 controlled clinical trials in many countries throughout the world
(Falloon et al., 1999). In these studies, treatment extended for at least 6 months with a
minimum of one year follow-up. Outcome variables included all major psychotic and
affective episodes, deaths, hospital admissions and serious non-compliance or withdrawal
from drug or psychosocial interventions as indices of poor outcome. The pooled results
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

showed significantly better results for the Behavioral Family Therapy approach. Although
fewer studies examined social and family benefits, the findings that were available supported
the superiority of the behavioral family modes of treatment.
As an exemplar of a particularly astute and well-controlled clinical experiment, 36 young
adult schizophrenic individuals who were living at home in stressful and tense relationships
with parents were randomly assigned to in-home Behavioral Family Therapy or clinic-based
supportive individual therapy (Falloon, Boyd, McGill, Williamson, Razani, Moss &
Gilderman, 1982). Before entering therapy, all patients had their psychotic symptoms
stabilized with at least one month of neuroleptic drug treatment.
Regardless of treatment condition, all patients followed the same treatment schedule:
weekly visits during the first three months, biweekly visits for the next six months, and
monthly visits thereafter for a total of two years. In addition to their Behavioral Family
Therapy or individual therapy-which was conducted by mental health professionals. Al1
patients were seen monthly at the clinic by a psychiatrist or clinical pharmacist who was blind
to the type of psychosocial therapy and was responsible for prescribing optimal doses of
neuroleptic drugs.

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 380 Robert Paul Liberman

The comparative effectiveness of the Behavioral Family Therapy and individual therapy
was assessed by a battery of outcome instruments, including ratings of psychotic symptoms,
community tenure, social functioning, family burden, and cost-effectiveness.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Figure 25.3. Comparison of outcomes of schizophrenic patients randomly assigned to behavioral family
management or individual supportive therapy (N = 18 in each group) for 9 and 24 months after entry
into the respective treatment programs. By the end of 24 months, 66 percent of family-treated patients
were in full remission of their psychotic symptoms, compared with only 17 percent of the individually
treated patients. Adapted from Falloon, I. R. H., Boyd, J. L., McGi11, C. W., Williamson, M., Razani,
J., Moss, H.B., Gilderman, A.M. & Simpson, G.M. (1985). Family management in the prevention of
morbidi1y of schizophrenia. Archives of General Psychiatry, 42, 887-896.

Statistically significant advantages of Behavioral Family Therapy were noted in each of

the outcome dimensions. The results for clinical outcome are depicted in Figure 3. While only
6 percent of the patients receiving Behavioral Family Therapy suffered a relapse or
exacerbation of their schizophrenic symptoms during the first nine months of treatment, 44
percent of those receiving individual therapy did so. The 44 percent relapse rate actually
compares favorably with the approximately 55 percent relapse rate in nine months of patients'
returning to live in households marked by stress (Vaughn et al., 1984). The 6 percent relapse

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Behavioral Family Therapy for Schizophrenia and Serious Mental Disorders 381

rate accounted for by a single patient among the group of 18 assigned to Behavioral Family
Therapy placed in even more hopeful light by the 56 percent of Behavioral Family Therapy
patients who were in full remission of their schizophrenic symptoms at the nine-month point,
many of them functioning relatively normally in social and vocational roles.
Two years after treatment had begun, at the point where the Behavioral Family Therapy
had entered a "maintenance" stage, the relapse rates for the two treatment conditions were 11
percent for the Behavioral Family Therapy condition and 83 percent for those in individual
therapy. For patients hospitalized during the two-year period, the average number of days
spent in hospital for the Behavioral Family Therapy patients was 1.8 days per year versus
11.3 days per year for those receiving individual therapy.
Since symptoms are only one dimension of outcome, what did the Behavioral Family
Therapy do for patients' social adjustment? Whether one evaluated overall social adjustment,
leisure activities, family life, self-neglect, work, or friendships outside the family, the patients
in the behavioral condition had significantly better outcomes. Family burden was vastly
reduced for the relatives receiving Behavioral Family Therapy, but little changed for relatives
of patients getting individual therapy. Even though the costs for time and transportation of
therapists to the Behavioral Family Therapy home sessions were higher than the clinic-based
program, the much lower rates of re-hospitalization and other clinical services for the
Behavioral Family Therapy patients yielded a much greater cost-effectiveness for Behavioral
Family Therapy (Falloon et al., 1985; Falloon, 1985).
At first glance, the results of this research study suggest a major breakthrough in the
treatment of schizophrenia. Another interpretation might be, however, that Behavioral Family
Therapy merely improved the medication compliance of patients, which in turn resulted in
lower rates of relapse. Data from many other studies of treatment of schizophrenia, however,
controvert this interpretation, since approximately 30 to 40 percent of patients relapse in a
year even when reliable neuroleptic medication is assured. Moreover, in this controlled study,
the actual amount of medication ingested by patients in Behavioral Family Therapy was about
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

100 mg per day less, in chlorpromazine equivalents, than that ingested by their counterparts in
individual therapy. Thus, even though the treatment outcomes for the behavioral approach
were much superior, they were obtained with patients requiring much less antipsychotic
medication.
Do not rush to the conclusion, however, that medication is not important for patients
participating in Behavioral Family Therapy. That would be a false lead. Most patients in this
treatment study did require continuation of their maintenance antipsychotic drug, albeit at a
lower dose level. In fact, the only patient in the Behavioral Family Therapy cohort who
relapsed during the first nine months was an individual who failed to take his medication
regularly. The important lesson from this study that can be carried back into our clinics and
mental health centers is that a combination of optimal drug therapy with family management
can be a potent approach to the treatment and rehabilitation of chronic mental patients.

SUMMARY
Families of patients with chronic mental disorders are ill equipped to manage the primary
caretaking responsibilities that have fallen to them because of deinstitutionalization.

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 382 Robert Paul Liberman

Practitioners in hospital and community-based facilities for the severely and chronically
psychiatrically disabled are only beginning to educate families about the nature of illnesses
such as schizophrenia, to train them in specific skills that are helpful in coping with the long-
term management of the mentally ill, and to provide support for the families burdened by the
stress and tension of chronic illness.
For those handicapped mentally ill persons who live with or near their families, the
importance of the family can scarcely be overstated. Family members often represent the
patient's primary source of companionship, involvement in activities, and assistance in coping
with day-to-day problems.
The responsibilities for providing case management for their mentally ill relatives often
creates stress and conflict within the family unit. Relatives can become over-involved with a
mentally ill family member who appears to be helpless to fend for himself. Without support
and education from professionals, relatives can also lack the understanding of the nature of
chronic schizophrenia that enables them to lower their performance expectations of the
patient to a more realistic level.
The goals of Behavioral Family Therapy are to reduce tension and stress in the family
system by transmitting to the patient and his or her relatives a clear understanding of
schizophrenia or other major mental disorders in lay terms; to teach problem-solving and
communication skills; and to increase the patient's adherence to antipsychotic medication and
psychosocial rehabilitation programs. A further aim of Behavioral Family Therapy is to
enhance the social adjustment and quality of life of the patient and relatives through teaching
them the functional skills for meeting their needs and obtaining required mental health and
social services.
Behavioral Family Therapy is highly structured and systematically employs principles of
learning and behavior change. However, it is conducted in a nurturing manner by therapists
who aim to maintain a warm and encouraging learning environment for the patient and
relatives. The therapist's firm and directive, yet gentle and supportive, style keeps the family
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

on track through the various educational objectives inherent in the therapy.

In the initial phase of Behavioral Family Therapy, information is presented to families
through a didactic format, using visual aids and handouts on the nature, course, and treatment
of schizophrenia. Family members are asked to share their perceptions and experiences, and
the patient is encouraged to discuss symptoms as the "expert" in that area. Schizophrenia is
presented by the therapist as a disorder marked by severe problems in living, working, self-
care, socializing, thinking, and feeling. Education on the etiology and treatment of the
disorder is tailored to the level of sophistication of each family. The educational process,
offered in a supportive manner, helps families to lighten their burden of guilt, over
responsibility, confusion, and helplessness. Relatives become less judgmental, intrusive, and
critical of the patient's behavior and learn to set more realistic goals for themselves and the
mentally ill family member.
Since the stress of chronic mental disorders poses continuing challenges for problem
solving over the long haul, patient and relatives alike are helped to learn how to communicate
effectively with each other and the world around them. Effective coping, communicating, and
problem solving together have the potential for reducing impairments and disabilities of
major mental disorders, reducing the burden of illness on the family, and maximizing social
and instrumental role functioning. Communication and problem-solving skills are taught
systematically by providing a rationale for each targeted skill, step-by-step instruction in the
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Behavioral Family Therapy for Schizophrenia and Serious Mental Disorders 383

use of the skill, demonstrations and practice through behavioral rehearsal, and homework
assignments aimed at generalization and over- learning. Unqualified praise for each step
taken toward acquiring and using the skills and knowledge imparted in BFM reinforces the
learning process.
Results from well-designed and controlled-outcome studies suggest that Behavioral
Family Therapy and its analogues can reduce family stress and burden and relapse in the
mentally ill family member. Marked improvements in social functioning can accrue to
patients and relatives alike. Optimism can be gained from the impact of family-based
approaches to psychiatric rehabilitation when therapies harness available principles of
learning and methods for facilitating interpersonal relationship skills. By equipping patients
and their relatives with coping and problem-solving skills, they can be protected from the
noxious effects of stress and psychobiological vulnerability.
Much progress can be expected by expanding family involvement in the community
management of schizophrenia and other chronic mental disorders. It is obvious that family
members having extended contact with a patient have the potential for magnifying the
positive impact of anti-psychotic medication, social skills training, intensive case
management and other mental health services. By teaching patients and relatives a conceptual
and factual understanding of mental illness and how to better cope, communicate, and solve
problems, mental health professionals can increase their efficacy in a manner that will prove
cost-effective and, more importantly, bring a better quality of life to those suffering from
serious mental illness and their relatives.

REFERENCES
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guide]. Available from R. Liberman, Camarillo-UCLA Research Center, Box A,
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Camarillo, CA 93011.
Backer, T., & Liberman, R. P. (1986). What is Schizophrenia? [videocassette with discussion
guide]. Available from R. Liberman, Camarillo-UCLA Research Center, Box A,
Camarillo, CA 93011.
Creer, C. (1978). Social work with patients and their families. In J. R. Wings (Eds.).
Schizophrenia: Towards a new synthesis. London: Academic Press.
Dixon, L., Adams, C., & Lucksted, A. (2000) Update on family psycho-education for
schizophrenia. Schizophrenia Bulletin, 26, 5-20.
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Miklowitz, D., Solomon, P., & Sondheimer, D. (2001) Evidence-based practices for
services to families of people with psychiatric disabilities. Psychiatric Services, 52, 903-
910.
Doll, W. (1976). Family coping with the mentally ill: An unanticipated problem of
deinstitutionalization. Hospital & Community Psychiatry, 27,183-185.
Falloon, I. R. H. (1985). Family management of schizophrenia. Baltimore, MD: Johns
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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 384 Robert Paul Liberman

Falloon, I. R. H. & Liberman, R. P. (1983). Behavioral family interventions in the

management of chronic schizophrenia. In W. R. McFarlane (Eds.). Family therapy in
schizophrenia. New York: Guilford Press.
Falloon, I. R. H., Boyd, J. L. & McGill, C. W., Razani, J., Moss, H.B. & Gilderman, A.M.
(1982). Family management in the prevention of exacerbation of schizophrenia. New
England Journal of Medicine, 306, 1437-1440.
Falloon, I. R. H., Boyd, J. L., & McGill, C. W. (1984). Family care of schizophrenia. New
York: Guilford Press.
Falloon, I. R. H., Boyd, J. L., & McGi11, C. W., Williamson, M., Razani, J., Moss, H.B.,
Gilderman, A.M. & Simpson, G.M. (1985). Family management in the prevention of
morbidity of schizophrenia. Archives of General Psychiatry 42, 887-896.
Falloon, I.R.H., Held, T., Coverdale J.H., Roncone, R., & Laidlaw, T.M. (1999) Family
interventions for schizophrenia: a review of long-term benefits of international studies.
Psychiatric Rehabilitation Skills, 3, 246-267.
Grad, J. & Sainsbury, P. (1968). The effects that patients have on their families in a
community care and control psychiatric service. British Journal of Psychiatry, 114, 265-
278.
Goldman, H.H. (1982). Mental illness and family burden: A public health perspective.
Hospital & Community Psychiatry, 33, 557-560.
Hatfield, A. (1984). The family. In J. Talbott (Ed.). The chronic mental patient: Five years
later. Orlando, FL: Grune and Stratton.
Hogarty, G.E., Anderson, C.M., Reiss, D.L., Kornblith, S.J., Greenwald, D.P., Javna, C.D., &
Madoia, M.J. (1986) Family psycho-education, social skills training and maintenance
chemotherapy in the aftercare treatment of schizophrenia. Archives of General
Psychiatry, 43, 633-642.
Intagliata, J., WilIer, B., & Egri, G. (1986). Role of the family in case management of the
mentally ill. Schizophrenia Bulletin, 12, 699-708.
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Kreisman, D. E. & Joy, V. D. (1974). Family response to the mental illness of a relative.
Schizophrenia Bulletin, 10, 34-57.
Lamb, H. R. & Goertzel, V. (1977). The long-term patient in the era of community treatment.
Archives of General Psychiatry, 34, 679-682.
Lefly, H. & Johnson, D. (2002) Family interventions in mental illness: International
perspectives. Westport, CT, Praeger Publishers.
Leff, J. P. & Vaughn, C. E. (1981). The role of maintenance therapy and relatives' expressed
emotion in relapse of schizophrenia: A two year follow-up. British Journal of Psychiatry,
139, 102-104.
Liberman, R.P. (1970) Behavioral approaches to family and couple therapy. American
Journal of Orthopsychiatry, 40, 106-118.
Liberman, R.P. (1972) Behavioral methods in group and family therapy. Seminars in
psychiatry, 4: 145-156.
Liberman, R.P., DeRisi, W.J. & King, L.W. (1973) Behavioral interventions with families. In
J. Masserman (Ed.) Current psychiatric therapies. New York: Grune & Stratton.
Liberman, R.P., King, L.W., & DeRisi, W.J. (1976). Behavior analysis and therapy in a
community mental health center, In H. Leitenberg (Ed.) Handbook of behavior therapy
and modification. Englewood Cliffs, NJ: Prentice-Hall.

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 Behavioral Family Therapy for Schizophrenia and Serious Mental Disorders 385

Liberman, R.P., Falloon, I.R.H., & Aitchison, R.A. (1984). Multiple family therapy for
schizophrenia: A behavioral approach. Psychosocial Rehabilitation Journal, 4, 60-77.
Liberman, R.P. & Kopelowicz, A. (2002). Recovery from schizophrenia: a challenge for the
21st century. International Review of Psychiatry, 14, 1-12.
Liberman, R.P. & Liberman, D.B. (2003). Involving families in rehabilitation through
behavioral family management. Psychiatric Services, 54, 633-635.
Liberman, R.P., Kopelowicz, A., & Silverstein, S. (2004) Psychiatric rehabilitation, In B.
Sadock & V. Sadock (Eds.) Comprehensive textbook of psychiatry, 8th edition. Baltimore,
Lippincott, Williams & Wilkins.
Liberman, R.P. & Kopelowicz, A. (2005) Recovery from schizophrenia. Psychiatric Services,
56, 735-742.
Minkoff, K. (1978). A map of chronic mental patients. In J. Talbott (Eds.). The chronic
mental patient. Washington, DC: American Psychiatric Association.
Mueser, K.T., Bellack, A.S., Wade, J.H., Sayers, S.L., & Rosenthal, C.K. (1992) An
assessment of the educational needs of chronic psychiatric patients and their relatives.
British Journal of Psychiatry, 160, 674-680.
National Institute of Mental Health: Schizophrenia and the Role of the Family [brochures],
1986. Available from Schizophrenia Research Branch, National Institute of Mental
Health, 5600 Fishers Lane, Rockville, MD 20857.
Patterson, G. R., Reid, J. B. & Jones, R. R. (1975). A social learning approach to family
intervention. Eugene, OR: Castalia.
Pickett-Schenk, S.A., Cook, J.A., Steigman, P., Lippincott, R., Bennett, C., & Grey D.D.
(2006) Psychological well-being relationship outcomes in a randomized study of family-
led education. Archives of General Psychiatry, 63, 1043-1050.
Sherman, M.D. (2003). The support and family education (SAFE) program: mental health
facts for families. Psychiatric Services, 54, 35-37.
Snyder, K. S. & Liberman, R. P. (1981). Family assessment and intervention with
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schizophrenics at risk for relapse. In M. J. Goldstein (Eds.). New directions in mental

health services: New developments in interventions with families of schizophrenics. San
Francisco, CA: Jossey-Bass.
Stuart, R. B. (1980). Helping couples change. New York: Guilford Press.
Taylor, C. B., Liberman, R. P., & Agras, W. S. (1982). Treatment evaluation and behavior
therapy. In J. M. Lewis (Eds.). Treatment Planning in Psychiatry. Washington, DC:
Amerian Psychiatric Association.
Tessler, R. C. & Goldman, H. H. (1982). The chronically mentally ill in community support
systems. Hospital & Community Psychiatry, 33, 208-211.
Vaughn, C. E., Snyder, K. S., Freeman, W.B., & Falloon, I.R.H. (1984). Family factors in
schizophrenic relapse. Archives of General Psychiatry, 41,1169-1177.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 In: The Quick Theory Reference Guide ISBN: 978-1-60021-624-4
Editor: Karin Jordan, pp. 387-400 © 2008 Nova Science Publishers, Inc.

Chapter 26

SOLUTION-FOCUSED THERAPY WITH

CONTRIBUTIONS FROM EXISTENTIAL THEORIES

Mary-Beth Nickel

Solution-focused therapy (SFT) originated in part from the brief therapy model
developed in the 1970s at the Mental Research Institute in Palo Alto by Satir, Jackson,
Weakland, Fisch, Watzlawick, and others (Lipchik, 2002). Quick (1996) credits Watzlawick
in particular with articulating the theory’s constructivist perspective that there are multiple
views of reality rather than one, fixed truth. In the late 70's and 80s, Berg, Miller, de Shazer,
O’Hanlon, & Weiner-Davis of the Brief Family Therapy Center in Milwaukee, elaborated a
similar collaborative, ecosystemic model of therapy, based on the assumption that clients
possess the ability to generate solutions to their problems (Friedman & Lipchik, 1999). Both
approaches emphasized current behavioral sequences and family communication patterns
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over the historical roots of pathology favored by psychodynamic models (O’Hanlon, 1998).
Therapeutic interventions were designed to interrupt problematic interactional patterns,
conceptualized as maladaptive attempts at solutions. In session, therapists viewed the
interaction of their own, individual systems with that of client families as a third, recursive
system, wherein the therapist was positioned to influence the client system and facilitate
generation of new, more productive behaviors (Quick, 1996).
Contemporary SFT practitioners Friedman, O’Hanlon, and Lipchik advocate a
therapeutic style enriched with elements from existential theories. Their approach combines
the solution-focused optimism for the future with the existentialist search for meaning and
value in painful experiences, both past and present (Lipchik, 2002; O’Hanlon, 1992, 2003a).
This blended approach operates from several presuppositions. Friedman and Lipchik (1999)
note that each person, and thus, every human relationship is unique. Likewise, as elucidated
by constructivist thought, each person’s construction of reality is unique, generated through
the course of relational interactions, life experiences, and, most importantly, the individual’s
interpretations of them (Zinnbauer & Pargament, 2000). Given the multiple, potential
interpretations for any given situation, Lipchik (2002) observes that nothing in human
existence is entirely negative. As such, SFT staunchly rejects the categorization of clients as
pathological or sick. Rather, solution-focused therapists firmly believe that, despite life’s

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 388 Mary-Beth Nickel

vicissitudes, all people possess strengths and resources that can be marshaled to improve the
quality of their lives (Lipchik, 2002). Since events of the past cannot be changed, solution-
focused therapists prefer to concentrate primarily on the present and future, wherein change is
seen as inevitable, constant, and subject to influence (Friedman & Lipchik, 1999). Therapists
are not viewed as experts with the knowledge and power to concoct the best solutions for
their clients. Rather, as described by social constructionism, therapists and their clients co-
create and direct change within the context of their conversations together (Lipchik, 2002).

KEY CONCEPTS

Nature of Persons

Theory
Existential theories elaborate on human psychosocial functioning and dysfunction with
detail that complements and further enriches classical solution-focused thought. Both theories
stress a phenomenological approach to human experience. When viewed from this common
perspective, people’s responses to environmental stimuli are seen to arise from their
subjective perceptions and the meanings they attach to them (Amato, 1990; Lipchik, 1994).
According to existential theorist, Wubbolding (2001), cognizance of a discrepancy between
one’s preferred reality and the person’s perception of current circumstances prompts the
generation of behaviors intended to produce desired changes in the environment. Human
beings actively regulate their subsequent actions in keeping with self-assessments of their
capabilities, aspirations, anticipated outcomes, and perceived environmental opportunities and
obstacles (Madsen, 1999). For good or ill, these perceptions of self, others, and environment
often become self-fulfilling prophesies, because people tend to choose environs and
relationships commensurate with their beliefs about the nature of the world (Nhat Hanh,
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

1999; O’Hanlon, 2003a).

People are more than individuals responding to internal and environmental stimuli in
isolation, however. As a systemic theory, SFT acknowledges that people function within the
context of family and community systems. Each system is an identifiable whole comprised of
individual, but interrelated persons, functioning within a boundary that delineates their
relational unit from others around it (Balswick & Balswick, 1999). Solution-focused theory
conceptualizes causality within these systems as recursive rather than linear. Intrapersonal
factors (cognitive, affective, and biological), environmental circumstances, and manifested
behaviors in a given system all operate as interactive determinants that influence one another
bidirectionally (Friedman & Lipchik, 1999).

Healthy vs. Unhealthy/Dysfunctional Functioning

Healthy Functioning
Fox (1999) and Wubbolding (2001), writing from an existential viewpoint, share the
conviction that actively giving and receiving love in meaningful, intimate relationships is
both the source and ultimate expression of psychological health. Their belief is compatible

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Solution-Focused Therapy with Contributions from Existential Theories 389

with SFT’s systemic perspective that these social affiliations strengthen and empower well
people to care for themselves and others in active, nourishing ways (Madsen, 1999). Healthy
others are, in turn, empowered to reciprocate. Theologian and philosopher, Thich Nhat Hanh
(1999) coined the term “interbeing” to describe this interrelatedness and bidirectional
influence. “You are the way you are,” he writes, “because I am the way I am” (p. 108).
Existing in the context of these supportive, reciprocal social connections, healthy people
can access effective coping skills, both intra and interpersonal, for dealing with life’s
challenges (O’Hanlon, 2003a). Interpersonal factors contributing to healthy coping include
effective communication, productive problem solving skills, a balance between relational
cohesion and individual autonomy, adaptability, and a solid sense of commitment to self,
others, and relationships (Hudson & O’Hanlon, 1991). At the individual level, healthy people
are able to recognize and utilize their strengths and abilities while remaining aware, but not
overly constrained by obstacles and personal limitations (McNeilley, 2000).
Attig (2001) observes that the human spirit holds the capacity to reach beyond present
circumstances, strive for excellence, and search for transcendent understanding. Through
transcendence, human beings can move beyond mere endurance to discover meaning and a
sense of purpose in the midst of life’s struggles (Hojjat, 1997). In this way, trials and troubles
can become transforming experiences, enabling people to pursue the best qualities of their
humanity (Walsh, 1998). Fox (2000) believes that, ultimately, psychosocial well-being hinges
upon finding such meaning and value in oneself, in others, and in existence in general. As
meaning makers, healthy people are able to apply their capacity for imagination and
inspiration to envision more positive futures (O’Hanlon, 2003a).

Dysfunction

Solution-focused therapists maintain that all people possess the capacity to improve the
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

quality of their lives. Implicit in this credo is the understanding that existence necessarily
entails trials and challenges (Quick, 1996). This assertion aligns with the existential
perspective that one unavoidably encounters pain and suffering intermingled with the joys
and wonders of life (Nhat Hanh, 1999). In simplest terms, human beings live in a broken
world, influenced by wounds and wrongs, dating as far back as human history records (Smith,
1991). Human beings possess, not only wondrous potential and capabilities, but this worldly
brokenness as well, which finds multiform expression in human experience. Biological
predispositions, troubled family upbringing, interpersonal conflict, maladaptive coping
responses, distorted perceptions, habitual ineffective behaviors, and others may all play
etiological roles in psychological ill-health. Human behavior and existence are simply too
complex to explain with a single hypothesis, because causation is multiply determined and
reciprocally interactive (Friedman & Lipchik, 1999). A few conceptualizations, however,
seem particularly salient from the SFT frame of reference.
Returning to Nhat Hanh’s concept of interbeing, one perceives that people are
inescapably interconnected and influence one another bidirectionally (1999). Optimally, these
interrelationships yield positive consequences, but in our broken world, they may lead to
negative effects as well. The actions taken by one individual tend to invite complementary
responses from others that, in turn, reinforce the original act (Snyder, 1981). Rather than
achieving positive goals and fulfilling needs, however, maladaptive behaviors and
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 390 Mary-Beth Nickel

interactions may instead result in psychological distress, relational dysfunction, even somatic
complaints (Kollar, 1997).
Even so, such behaviors commonly represent people’s best attempt to find solutions,
given environmental, relational, and intrapersonal constraints (McNeilley, 2000).
Unfortunately, these constraints can interfere with the ability to conceive of better, more
effective options (Madsen, 1999). People tend to gravitate toward the familiar, even when it is
negative. At least in familiar territory, people derive a measure of security from knowing the
rules of engagement and more or less, what to expect from their environments (Smith, 1993).
As a consequence, when attempted solutions fail, relational systems often persist in doing
more of the same at an increased level of intensity. Over time, these recursive dynamics can
become entrenched as chronic, interactional patterns, even in families desiring change.
Eventually, feeling caught in a cycle of counterproductive thought and behavior patterns leads
to feelings of helplessness and despair (O’Hanlon & Hudson, 1996).
Once again, at the heart of the matter lies the powerful impact of perception. For good or
for ill, perception influences the meanings attributed to events, the choice of one’s goals, the
results expected from efforts to pursue them, and resiliency in the face of obstacles
(McNeilley, 2000). O’Hanlon and Bertolino (1998) note that struggling people tend to
perceive their world with tunnel vision that overlooks strengths and resources, and focuses
instead on the weaknesses in self and others. From this frame of reference, a person can miss
small, positive changes that embody the potential for healing and growth. Dwelling on
shortcomings, pessimistic predictions, and the painful events of past and present can destroy
hope and the wherewithal to envision and tenaciously pursue a better future (O’Hanlon,
2003a).

The Change Process

Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

How people change. If perception is the heart of human experience, it follows then, that
the ability to expand one’s awareness beyond perceived negatives in the past and present
opens up fresh possibilities for the future. People who can apprehend meaning in their
struggles and imagine a better future are more able to conceive of solutions to their problems
(Lemley, Chasma, & Coughlin, 2001). What is more, envisioning and thinking about that
future promotes a sense of well-being and empowers taking action in the present (Lester &
Stone, 2001). The effect is actually bidirectional. Taking positive actions, even small ones,
provides new glimpses into the future’s possibilities. Increasing hope for the future
concurrently fuels endurance as people strive to develop the positive potential in their
circumstances (Carver & Scheier, 1999).
Hart (1995) cites Pannenberg’s assertion that people must experience as reality whatever
they are attempting to build upon. Taking concrete action is one means by which people may
increase their fund of experiential knowledge. Experiencing positive effects from one’s own
actions promotes self-efficacy and concomitantly hones self-assessment (Smith, 1996). Even
small behavioral changes serve to interrupt counterproductive patterns of thinking, acting, and
perceiving, which frees people to focus increasingly on more beneficial approaches to their
problems (Friedman & Lipchik, 1999). Walsh (1998) adds that collaboration, shared effort,
and mutual support within a system increases the potential that actions undertaken will make
a positive difference.
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Solution-Focused Therapy with Contributions from Existential Theories 391

How the Therapeutic Environment aids the Change Process

Bruenlin, Schwartz, and Kune-Karrer (1997) observe that people in pain experience a
narrowing of options. SFT aims to broaden the menu of alternatives by assisting clients to
expand their perception and view events from other vantage points (O’Hanlon, 2003b).
Directing clients’ attention toward available strengths and resources helps them look beyond
habitual, ineffective patterns toward more productive ways of perceiving and acting (Berg,
1994a).
Madsen (1999) conceptualizes therapy as a journey in which therapists foster clients’
migration from constraining perceptions of self and environment toward a preferred future.
According to the tenets of social constructionism, such constructs are formed and modified
through conversation (Lipchik, 2002). The institution of therapy temporarily creates an
interactional system comprised of therapist and client(s), within which the subsequent dialog
influences the original client system and facilitates change (Quick, 1996). Within any
conversation, there are multiple potential meanings for any given event. This subjectivity
provides the key to the creation of new possibilities. Rather than uncovering objective truths,
therapeutic conversation allows for the co-construction of realities in ways that open up room
for new perspectives and solutions (Friedman & Lipchik, 1999).

THE THERAPEUTIC PROCESS

Assessment and Diagnosis

General Assessment Strategy

Initial assessment entails two primary tasks: joining with clients and collecting
information. Collected data includes demographic information, referral source, presenting
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

problem(s), current living situation and support systems, psychosocial stressors, past and/or
present substance use, relevant medical history, any current legal issues or social service
agency involvement, and a mental status exam (Davidson, 2000). The therapist gathers
information by asking questions as well as observing clients’ appearance, behavior, and
reactions to one another (Weeks & Treat, 2001). Worthington (1989) suggests having clients
log their pertinent behaviors at home. Efron, Clouthier, and Lefcoe (1994) stress the
importance of investigating both client problems and strengths. Negative matters embody
learning experiences and motivation for change, while strengths represent potential resources
for change. During exploration, the therapist encourages consideration of multiple dimensions
of awareness including sensory input; cognitions; affective responses; wants for self and
others; past, present, and future action plans (Shaw, 2001). Circular questioning from
different systemic vantage points reveals information about family dynamics, precipitating
stressors, and current life stage transitions, while indirectly educating clients about multiple
causality (Michael, 2003).
Systemic assessment should include four levels of consideration: individual,
interactional, intergenerational, and sociocultural (Weeks & Treat, 2001). Queries regarding
individual matters illuminate intrapsychic dynamics, both healthy and counterproductive,
together with individual values and goals (Bruenlin et al., 1997). Investigation of interactional

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 392 Mary-Beth Nickel

dynamics reveals strengths and deficits in communication and conflict resolution skills,
attributions, and patterns of emotional expression (Hudson & O’Hanlon, 1991). Repetitive
patterns of interaction observed in therapy suggest that similar sequences have become
entrenched at home and are superceding alternative behaviors. Delineating a family’s
organizational structure further illuminates how its members function together (Bruenlin, et
al., 1997). Cooperation among family members, willingness to sacrifice some, but not all of
one’s individual interests for the greater good, expressions of care and appreciation, and a
balance between unity and separateness provide evidence of effective functioning (Garrett &
Garrett, 1998). In contrast, coercion, oppression, strife, rigid and inflexible rules,
inappropriate allocation of roles and responsibilities to parental and child subsystems all call
attention to dysfunctional organization (Michael, 2003). Intergenerational exploration places
clients’ current situations in a broader historical and cultural context (Weeks & Treat).
Thorough cultural assessment includes consideration of, not only ethnicity, but other
sociocultural factors such as economics, spirituality, education, and acculturation. The nature
of these variables can either empower or constrain the functioning of a client system
(Bruenlin, et al., 1997).

Theory-based Assessment Strategies, which Simultaneously Serve as

Interventions

During assessment, solution-focused therapists seek to create a context which

preferentially elicits client resources, competence, and potential. The emphasis on positive
factors does not ignore the presence of pain and dysfunction within a family system. (Madsen,
1999). SFT imbued with contributions from existential theories aims to keep a balance
between considering problems and constraints, positive potential and strengths (O’Hanlon,
1992).
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

The existence of a problem client’s wish to change points to a corresponding preferred

future. The therapist seeks illuminate this future and its specific characteristics by asking what
clients would like to be different in their lives. Investigating what a client sees as criteria for
termination is another means to this end (Berg & Reuss, 1998). The answer to such questions
helps identify therapeutic goals. Open-ended and circular questioning about specific
behaviors in the client system that either facilitate or hinder progress promotes articulation of
these goals in tangible, behavioral terms (Berg, 1994a).
Berg and Reuss (1998) promote the use of scaling questions to make clients’ assessments
of their lives more concrete. Clients are prompted to rate their experiences, commitment level,
and degree of confidence on a scale of 1 to 10. Then the therapist can follow up with
questions as to how the client might be able to move one notch up the scale. Scaling provides
a concrete means of tracking and documenting progress toward goals (Friedman & Lipchik,
1999).
However intractable a situation seems, SFT asserts that all problems have exceptions, that
is, times when clients succeed in avoiding problematic behaviors and choose more productive
options. These successes, however small, represent the potential for self-improvement (Berg
& Reuss, 1998). A solution-focused therapist actively pursues detailed information about
these exceptions by asking clients to describe prior, even partial solutions to their problems.
Exploration of the contexts in which clients already feel competent likewise highlights
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
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 Solution-Focused Therapy with Contributions from Existential Theories 393

strengths and resources (O’Hanlon & Bertolino, 1998). When clients are unable to generate
exceptions, SFT’s hallmark “miracle question” invites them to imagine a future in which their
presenting problem is gone (de Shazer, 1991). Detailed inquiry concerning what each member
of the client system would notice and be doing differently helps create a road map toward the
preferred future (Lipchik, 2002).
In place of attempting to diagnose the etiology of dysfunctional behavior, therapists can
seek to discover what is constraining their clients from choosing more productive options. As
is the case with general assessment strategies, asking questions as well as observing clients
during session provides information (Weeks & Treat, 2001). Constraints may manifest at any
level of a system, including biological, individual, family, community, or sociocultural
domains. Wherever they exist, constraints typically impact the interrelated realms of action
and meaning (Madsen, 1999).

Treatment

Goals. In general terms, SFT should help clients envision a better future, discover
resources for pursuing that future, and anticipate possible obstacles (Madsen, 1999). In so
doing, therapy helps clients activate competencies and coping skills that they can apply to
both current and future life challenges (Hudson & O’Hanlon, 1991). The therapist ideally
helps clients generalize their skills such that, in the end, the therapist is no longer needed by
the client system (Worthington, 1989).

Therapeutic Process

The first step is establishing a working relationship with the client(s) and conducting
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

initial assessment. From the first session on, listening to, discussing, and affirming each
client’s story supports development of a therapeutic alliance (Friedman & Lipchik, 1999). At
the same time, Berg (1994b) recommends clarifying presenting issues by inquiring what
brought the client(s) in for therapy that day. When a person describes current, problematic
behaviors of self or others, the therapist listens for the corresponding, positive hopes and
desires underlying them. Once uncovered, these features suggest potential goals and
motivation to pursue change (Berg & Reuss, 1998).
As therapy proceeds through the initial phase, therapists elicit solution patterns by asking
clients to discuss the concrete, behavioral details of times and situations in which their
presenting problems do not occur. In the absence of discernable exceptions, family members
can be asked the miracle question or invited to explore why their existing problems are not
worse. Such questions normalize the family’s experience and help bring coping strategies to
light (O’Hanlon, 1998).
The creation and clarification of goals and plans for pursuing them takes place
throughout the initial and working phases of SFT. Objectives may be explicitly set by clients
or emerge through therapist-client collaboration (Hudson & O’Hanlon, 1991). Guided by
information gathered from the therapeutic conversation, therapists and their clients then
collaborate in creating an action plan, construed in concrete, behavioral terms, to put into

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 394 Mary-Beth Nickel

practice as homework (Friedman & Lipchik, 1999).To make tasks more robust, Hudson and
O’Hanlon (1991) suggest that therapists invite objections and contingency planning.
The primary task of SFT’s working phase is the amplification and reinforcement of
positive change. Berg and Reuss (1998) promote an approach abbreviated by the acronym,
EARS. E designates the eliciting of improvements noticed by the family since the last
session. During step A, the therapist amplifies positive change in clients’ minds by probing
for further details. R stands for reinforcing the value of said changes by attending to them
with acknowledgments and compliments. S designates starting back at the beginning of the
solution-focused process in order to build upon initiated changes and motivate further efforts.
Quick (1994) cautions that follow-up sessions must be structured according to clients’
current needs and status. If circumstances have improved, the therapist can solicit details
about behaviors that helped. If nothing seems to have changed, the therapist asks instead how
the clients prevented their situation from deteriorating. If matters are in fact worse, the
therapist might explore how the family’s behaviors affected the outcome. Even apparent
failures embody potential, because experiences can always be learned from (Berg & Reuss,
1998).
At the end of each session, therapist and clients decide together whether additional
services would be beneficial. Options for further care may include participation of additional
family members or support networks in therapy, classes, group therapy, referrals for medical
assessment, or assistance from social service agencies (Berg & Reuss, 1998). Spacing
contacts between sessions allows the normal restorative processes of life to operate and
allows clients the opportunity to implement homework suggestions (Friedman & Lipchik,
1999).
Termination proceeds when presenting complaints have been resolved to clients’
satisfaction. Closure in an ending appointment includes giving compliments, discussing and
celebrating positive gains, confirming the future availability of the therapist, and making any
appropriate referrals (Friedman & Lipchik, 1999). Quick (1996) comments that termination in
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

SFT is approached much more casually than in some other models because the door remains
open for future services, if needed.

Common Intervention Strategies

Because SFT views assessment as being a powerful intervention as well as a tool for data
collection (O’Hanlon, 1992), a number of SFT treatment techniques are outlined in the
assessment section of this chapter. In addition to these, SFT utilizes several other
interventions centered around the use of language for the facilitation of positive change.
Using language that presupposes change, emphasizes solutions, and client strengths promotes
optimism and helps clients seize upon their potential for growth and improvement (Efron et
al., 1994). For example, when a client says, “I’m depressed,” the therapist may reflect the
statement in past rather than present tense: “So you’ve been depressed” (O’Hanlon, 1998).
Discussion of positive change can be stated in terms of when rather than if. The therapist can
reframe family members’ blaming statements as requests for different, more positive
behaviors. Disliked personality traits can be reconstrued as potential assets, for example,
intense emotional reactions evidencing strong commitment to one’s family (Lipchik, 2002).
When clients seem caught in a pattern of blaming, Friedman and Lipchik (1999) suggest
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Solution-Focused Therapy with Contributions from Existential Theories 395

externalizing problems by referring to them as outside forces that are constraining progress.
Externalization reduces shame, blame, and defensiveness, while promoting clients’ sense of
personal agency in their lives (Madsen, 1999).
SFT also advocates the interruption of problematic behavioral patterns by encouraging
clients to change either the “viewing” or the “doing” of their behaviors (O’Hanlon, 2003b).
Changing the viewing means shifting one’s focus of attention in a given situation. The
therapist may facilitate this process by discussing the meanings or emotions underlying each
system member’s actions or by commenting on observed regularities in behavioral sequences
(Berg & Reuss, 1998). Then, clients can seek to change the doing of the sequence by
experimenting with small alterations in time, place, or behavioral components (Hudson &
O’Hanlon, 1991).

Nature of the Therapeutic Relationship

In SFT, therapists are not primarily history takers, diagnosticians, or purveyors of

wisdom and advice. Rather, they serve as curious facilitators who seek to uncover their
clients’ own resourcefulness (De Jong & Berg, 2002). In the course of a therapeutic
conversation, the therapist poses questions that prompt clients to create fresh understanding,
meaning, and action plans (Friedman & Lipchik, 1999). Madsen (1999) describes effective
solution-focused therapists as appreciative allies who elicit and elaborate clients’ resources
and abilities to pursue their preferred futures. After all, clients are the experts on their own
lives, in which therapists serve only a temporary role.
Clearly, SFT promotes collaborative, egalitarian relationships between therapists and
clients. More important than rote application of technique, Lipchik (1994) upholds openness,
authenticity, acceptance, respect, empathy, curiosity, and hopefulness as therapist
characteristics that build the kind of trusting, relational connection upon which productive,
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

therapeutic dialog is predicated.

STRENGTHS AND LIMITATIONS

Strengths

In the view of this author, one of the greatest assets of the SFT approach is its optimistic,
strengths-based worldview, that preferentially brings positives and possibilities into the
foreground. A correlational study by Gingerich, de Shazer, and Weiner-Davis (1988) supports
the premise that eliciting and amplifying client strengths and competencies facilitates
therapeutic progress. In a similar vein, post hoc groups research by Shields, Sprenkle, and
Constantine (1991) demonstrated that early discussion of solutions and goals in therapy
correlates significantly with positive treatment outcomes.
Studies like these bolster Madsen’s (1999) assertion that problems can be transcended as
selective attention rests primarily on a more positive vision of the future rather than
pessimistic ruminations about regrets and failings. By simply focusing on and believing in
positive possibilities, clients can dramatically increase the likelihood that they will occur. As

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 396 Mary-Beth Nickel

Carver and Scheier (1999), point out, human expectations and beliefs about self, others, and
the world powerfully shape goal-directed behavior and its eventual outcomes in the manner of
a self-fulfilling prophesy.
The constructivist position of SFT affords a number of benefits as well. As a collaborator
who cooperates with clients in the co-creation of new perspectives and future possibilities, an
SFT therapist is not solely responsible for conceptualizing and generating change. In their
review of psychotherapy outcome research, Whiston and Sexton (1993) observe that this kind
of collaborative stance represents a primary factor in successful therapeutic outcomes.
Remembering that the sources and solutions to human problems are multiform and complex
lends further credence to the constructivist approach and supports its application in culturally
diverse populations. The SFT stance of acceptance and respect for client values, beliefs, and
communication style matches the qualities Garrett and Garrett (1998) list as particularly
important to many ethnic minority groups. What is more, Sweeney (1999) comments that
ethnic minorities in America generally tend to prefer briefer, task-oriented, systemic
interventions in therapy.

Limitations

Like every human endeavor, SFT is not without limitations. Some mental health
professionals deem the approach to be formulaic and shallow. Nylund and Corsiglia (1994)
agree that SFT can batter clients with a barrage of serial questions if the relational and
emotional aspects of therapy are not sufficiently attended to. The potential also exists for a
premature focus on exceptions and possible solutions to hinder the establishment and/or
maintenance of the therapeutic relationship. Out of a zeal to identify exceptions and pursue
change, SFT therapists may inadvertently minimize or trivialize clients’ experience of their
problems (Lipchik, 1988). Although they do not acknowledge the trait as a shortcoming,
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Friedman and Lipchik (1999) also concede that SFT is a “minimalist” approach that does not
pursue in-depth relationship and personality reconstruction, nor involve intensive exploration
of clients’ unconscious material or historical pasts.
Another potential problem stems from the fact that SFT relies on extensive verbal inquiry
and cognitive processing. These requirements can negatively impact its applicability for some
situations. Logan (1987) notes that children require more concrete modes of expression in
therapy, since they lack the abstract thinking and language skills to articulate and process
their experiences verbally. Families in which members have been traumatized, lack
communication skills, or employ intellectualizing and verbalization as defense mechanisms
may likewise flounder in talk therapies like SFT (Dale & Lyddon, 2000).

Response

In response to the charge that SFT is formulaic and inflexible, Efron (1994) reminds
therapists to avoid confusing psychotherapy with a rigid, simplistic application of counseling
techniques. He goes on to argue that SFT need not be mechanical so long as the therapist
remains savvy to the relational and emotional aspects of the treatment process. Friedman and
Lipchik (1999) insist that appropriately implemented SFT emphasizes the client-therapist
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Solution-Focused Therapy with Contributions from Existential Theories 397

relationship over and above the application of techniques. Nylund and Corsiglia (1994)
remind their readers that skilled solution-focused therapists utilize pacing and attend to their
clients’ nonverbal and paraverbal behaviors. During outpourings of client emotion, such
therapists are able to put intervention techniques aside for the moment in favor of simply
offering support.

CONCLUSION
Solution-focused theory promotes an optimistic view that human beings possess inherent
resourcefulness and a capacity to create positive change and enhance their lives (Berg &
Reuss, 1998; Madsen, 1999). Practitioners of SFT seek to activate this innate potential by
identifying and accentuating clients’ present strengths, resources, and visions for the future
(O’Hanlon, 2003b). A number of theorists, however, mark the apprehension of meaning and
value in one’s past and present struggles as another important factor in the development of
hope and confidence (Amato, 1990; Attig, 2001; Lester & Stone, 2001; Walsh, 1998). In
response to this observation, some solution-focused practitioners, including Lipchik and
O’Hanlon, have enriched their methodology with elements of existential theory. This
expanded SFT approach seeks to strike a more inclusive balance between consideration of
clients’ strengths and struggles, past experiences and future potential (O’Hanlon, 1992).

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Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 In: The Quick Theory Reference Guide ISBN: 978-1-60021-624-4
Editor: Karin Jordan, pp. 401-416 © 2008 Nova Science Publishers, Inc.

Chapter 27

SOLUTION-ORIENTED MARRIAGE
AND FAMILY THERAPY

Pat Hudson

In family therapy there was a trend for some time towards two main streams of influence
that lead to Solution-Oriented Marriage and Family Therapy. One was the philosophy of
constructivism, the idea that reality and certainly psychological reality, was constructed—
made up (Minuchin and Fishman, 1981, p.268). The second was the very creative work of
Milton H. Erickson who utilized whatever complaint the client presented in amazingly
creative ways (Rossi, 1980, and Haley, 1963, 1973). Out of these influences came the concept
that the way to find solutions was to help clients make changes by asking questions that lead
them to see their problems in a new way or to make assignments. These tasks would have the
couples and families discover how changing actions could influence both future changes in
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

actions and feelings about one another within the couple and family. A simple way to say this
is that Solution-Oriented therapists want to change the viewing and the doing.
What I am sure most readers are interested in is adding to their skills and acquiring new
ways to treat challenging couples and families. Having used Solution-Oriented therapy and
taught Solution-Oriented therapy since the mid- 1980 's, I have distilled the strategies of the
Solution-Oriented therapist to practical ways that you can change couples and families
perceptions and behaviors for the better.

LISTENING TO THE PROBLEMS

Problems that couples and families talk about fall into the following three groups: stories
about the family, actions that are complained about, or experience—feelings or emotions-of
the speaker.
Stories, theories about why family members act the way they do, are the most common
complaint. When I began doing therapy in 1975, the complaints were often simple, such as
"She's a nag;" "He's a brat." After years of Oprah on American television and self-help books

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 402 Pat Hudson

influencing our culture, the complaints evolved to such things as "She's an adult child of an
alcoholic;" "He's co-dependent;" "We think our child might be the strong-willed child you
read about;" or "He's passive-aggressive." The average adult and even child now has enough
pop-psychology to be dangerous, so the stories have become much more sophisticated.
Labels are obvious stories, but stories can also be about things such as: "We don't
communicate," or "We can't communicate with our son." Without labeling, those are still
stories. You can identify stories by simply asking yourself, "Could I see or hear the complaint
on a video recording?" If a couple says they "don't communicate," I don't know if they mean
that they fight often; they just don't talk; or that it seems that what they say is not reacted to
by the spouse or partner. You can assume, therefore, that one of the first steps to take as the
therapist is to translate what has been said into something we can usually all agree happens or
doesn't happen—actions.
The second category of complaints that the family opens with maybe actions: "We can't
get Ashley to go to school." That is something we could see on a video recording. Ashley is
either in school or not in school. Of course, you would need to find out whether she goes and
sneaks out the back or just won't leave the house, but here are actions to which we can react.
To further clarify this distinction between stories and actions, let's imagine a scene: Mary
comes home from work before her husband John does and starts to cook dinner. John comes
home a little later from work; says "hi" from the other room; and sits down to read the paper.
These are the actions. Mary can make up stories about these actions. She might say to herself that
she loves this cozy scene of John nearby reading the paper while she cooks; she might think
that it is unfair that John didn't make dinner— after all, she worked too; she might make up
the story that John was not trained well by his mother to be a cook. These would all be stories. As
you can see we make up hundreds of stories every day and in many ways our happiness is
determined by the stories we make up.
The third filter or category that I listen to clients through is the question, "Is a client
talking about what is broadly referred to as "experience?" That is the term used when clients
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say they are "depressed," "lonely"—a common complaint in marriages, "sad," "distant," etc.
Generally it includes fantasies and random thoughts—just those things that float through our
heads. The most important thing to do initially with an experience-complaint is to
acknowledge the individual who is complaining and, if possible, get the other clients-spouse
or family members, to acknowledge the experience-complaint. This does not require agreeing
with the client necessarily, but more often, using the technique of simply reflecting what the
client said. For example, if the client said he or she was discouraged about her son's behavior,
the therapist might reflect, "You've felt discouraged about Jason's behavior." It has amazed
me to see spouses and other family members relax when they feel heard by others. That
acknowledgment may not completely resolve the problem, but it does makes a great start.

A GOOD START
This idea of a great start is very important. Solution-Oriented Marriage and Family
therapists pride themselves in doing brief, short-term therapy where possible. At the counseling
center that I ran for twenty-one years, the average stay in therapy was five sessions, which is
three less than the national average of eight (Glass & Smith, 1976). To be brief, you need to

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Solution-Oriented Marriage and Family Therapy 403

begin the therapy in a way that moves the conversation in a direction of solutions. Here are
five ways you can do that:

1. Move from the global to partial:

If a client makes a statement that is global such as, "He's never thoughtful," The
therapist can respond in a more limiting way by saying, "He's not very thoughtful at
times."
2. Use the past tense:
If a parent says something that labels a child in the present such as "He's a selfish
child," the therapist can repeat back, "He's been selfish." You can see that this opens
the possibility that the child may not always be selfish.
3. Change statements that are made as though they are "facts" to statements of
perceptions:
If a client makes a definitive negative statement such as, "She's cold," the
therapist can respond back with something more limiting such as, "She seems cold to
you." There is acknowledgment of the client for how the client experiences the
woman, but it is changed from a factual statement to a viewpoint.
4. Clarification of vague blaming words:
If a client complains that his wife nags, the therapist can say "What would I see
her doing if she were "nagging?" He might say that she repeats herself. Which could
help move the complaint from a label about the wife to some actions that the
therapist can help with—not repeating oneself.
5. Reorient from a focus on the past to a focus on the future:
Using language that moves the couple or family from the past to the future can
be a simply as saying "So far you haven't found a way to motivate Nathan to come
home by curfew." The words "so far" imply that we will be able to find something to
make it worthwhile for the son to come home on time.
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An even stronger reorientation from the past to the future would be a statement
about the problem put in future terms as with the nagging complaint earlier: "If she
stopped nagging, what would she be doing instead?"

UNDERSTANDING COMPLAINTS
After the initial complaints are made in a session and the therapist has responded in a way
that opened up the possibility of solutions, what do you do next? The first and most important
step is to understand the complaint. As I said earlier, if the complaint is an experience-
compliant then I will acknowledge the client. But more often the complaint is a negative label
of a family member or a description of what is missing.
A good analogy for clarifying a complaint is that the compliant is like a package that is
delivered to you. On the outside is written a vague word such as, "unsupportive,"
"irresponsible," "selfish," or "mean." Inside the box are actions that the complainant has seen
or wants to see that equal in his mind what is wrong in the marriage or family. Some years
ago I had a couple who came in for an initial session. The wife complained that the husband
wouldn't let her have her "freedom." I didn't know if that meant that she wanted to leave the

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 404 Pat Hudson

marriage and he was resisting, or if that meant that she wanted to do some actions that he
didn't approve of. As we spent some time unpacking that word, it became clear that what she
wanted was to spend time with her friends. I asked, "What would freedom look like in this
marriage, one night a week out with your friends?"
She replied, "No, once a month out with my friends. He can pick the friends; and I won't
go to a bar."
I was surprised by how reasonable this seemed and also had the thought that she didn't
quite appreciate the freedom that many women experienced, but I had already finished
counseling school and knew to keep my personal values to myself. I turned to him thinking
that this might be a very short treatment and asked if she went out once a month, with the
friends he specified, and didn't go to a bar could he be supportive?
He replied, "Absolutely not!" I was stunned for a moment as I had been certain this
would be fine with him, but we had run into another "packaged" word, "marriage." To him
"marriage" meant that every moment spouses were not at work they were to be together.
Needless to say, this was a very difficult case and, in fact ended in the couple divorcing.
Step two, then, after acknowledgement, is to unpack the words that are used in the
complaint or the desired outcome. It is easy to assume you know what the couple or family
wants and be a little surprised at the definition that the client has put on a term. Sometimes
the parents may say we want Alison to "clean her room." Does this mean returning plates of
moldy food to the kitchen and removing clothing from the floor, or does this mean
vacuuming and dusting and washing sheets, or all the above?
One couple came in saying that they didn't feel "intimate" any more. My mind wandered
to sex or private conversations over a long dinner, but when I asked the woman when she felt
intimate with her husband, she said when they went for a walk. You never really know what a
vague word means until you "unpack" it.
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MAKING ASSIGNMENTS
Once the complaint or request has been made clear, the therapist can make assignments
about what to do or not do based upon these either undesirable actions or the actions that the
couple or family wants as an outcome. The assignment for the parents of Alison might be to
not allow her to use the telephone until the desired "clean-room" outcome has occurred or for
the couple wanting intimacy to go for a walk between now and the next session.
Keep the assignments as concrete as you can. Avoid assignments that have to do with
internal states. If the mother of Alison suddenly said, "But I want her to want to clean her
room," I would try to use humor about not wanting to clean my room and deflect requests for
changes in internal states. Change in feelings will likely occur as a result of the family feeling
more effective, but that will be achieved more indirectly as the family successfully completes
assignments.
Refinements on complaints-and-requests-clarification intervention are that the therapist
be certain that all parties agree on who is to do what actions. If a child is to be told what a
consequence will be, who will do the telling and who will be responsible for the follow-
through. If a couple plans to have an outing without the children, who is going to make the

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Solution-Oriented Marriage and Family Therapy 405

call to get the baby sitter, reservations, or whatever might be needed to create the time away
from the children.
A second refinement is to watch carefully for any confusing words. For example, if the
family agrees to all be at the table for dinner as a way of increasing their connection, it would
be a good ideas to specify exactly what time dinnertime would occur.
Whenever any assignments are made, it is always a good idea to ask, "Can you think of
anything that might keep you from doing this assignment?" Try to elicit any objections so
they don't arise between sessions.

WHEN THE REQUESTS ARE REFUSED

The above sequence of steps sounds so straightforward and sometimes therapy actually
can be that easy. More often, however, the person who is asked to make a change in behavior
says that the requested behavior is not acceptable to him or her. There are four things to do
when this happens.
The first is to return to the vague, packaged word and see if there is another action in that
box of actions that equals the desired results. A couple I saw a number of years ago illustrates
this technique. The husband's complaint was that the wife was not "sexy enough." In her
defense I should point out that they had six children. However, he said that to him being sexy
meant being willing to engage in oral sex, which she was unwilling to do. At first, I made a
respectful attempt to find out if some arrangements could be made for her to comply with his
request, such as both bathing first, but she said that she was concerned that the children might
catch them having oral sex and she would be mortified. When she turned down my
recommendation for a good locksmith, I turned back to the husband and asked if there was
something else that he would consider "sexy" that she might do. He said that he would like
for her to wear a teddy—sexy underwear, and a garter belt and hose. She was fine with that. I
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

wondered what the kids were going to think when they found those items in mom's wardrobe,
but I kept that thought to myself. We had returned to the vague word of "sexy" and
successfully found an alternative behavior that would satisfy both parties.
The second action the therapist can take when the action requested is rejected is to look
for compromise. These issues come up more in marital situations where more equal power
necessitates compromise and there is more room for refusal, but sometimes an older teen may
also take a stance requiring the parents to negotiate. For example, I have had parents who
might be very focused on an adolescent's friend and said, "I don't want you to have any
contact with Chris." If the adolescent decides to be honest and not sneak to see Chris, she
might say, "I will not have any contact outside of school hours, but if I want to sit with him at
lunch at school then I am going to and I don't want to you to forbid me to see him at school."
This would be a compromise and often these are seen as reasonable by all parties.
The third thing to do if the initial behavioral request is refused is to do what your mother
told you to do as a child, "take turns." Couples may be arguing in sessions about how often to
see in-laws and so turn-taking is often the suggestion. "If you are going to spend the winter
holiday with Mary's mother this year, then next year it will be John's parent's turn to have you
for the holidays."

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 406 Pat Hudson

My father was a liberal minister in a conservative faith. He would often conduct

conferences where there would be a section for couples. He would frequently be asked,
"Don't you think that the husband has to have the final say on things?" My father said that in
his many years of marriage—in the end, he was married to my mother for 67 years, he had
never found an issue that there could not be a compromise between the spouses. In my thirty
years of being a therapist, I have only found one issue about which a couple cannot
compromise: having a baby. You can't just do it a little; you either have a baby or you don't.
When couples come in with this as the issue, I try not to groan, because I know this is going
to be tough. Two very well-intentioned people can both have good, logical reasons why they
do or do not want to have children. What I have done with the baby-issue on the several
occasions I have had to work with it is to shelve the baby decision putting it aside to work on
the relationship. Many times working on the relationship has lead the couple agreeing to have
a child, because the fragility of marriage is often one of the main reasons why people hesitate,
hi general, I see therapy as a process where people hire me to help them work on coming up
with particular solutions to particular problems. But when the baby issue arises, I negotiate
for another problem I can solve—marital satisfaction. So the fourth and final alternative when
a request is refused is to shelve the issue.

CHANGING PATTERNS
Another fruitful place to search for change as a Solution-Oriented therapist is in patterns.
As early as the 1960's theoreticians and family therapist began to note that behavior always
occurs in a context and that patterns in families are repeated often on a daily basis.
Intervention in patterns is another way that the Solution-Oriented therapist can be effective.
We all live in patterns in our families. In my own family I was struggling with getting my
second grade son out of bed and off to school in the mornings. (He is now a grown man.). I
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noticed that the trigger that usually lead to the morning get-ready-for-school battle was that he
would just not respond to my request to get out of bed, then I would begin to raise my voice. I
decided to change to pattern and make getting out a bed a completely different experience. I
drew him a "ticket to breakfast." This ticket had a picture of a comb in one corner; a picture
of clothes in the other; a picture of a bar of soap in a third corner; and in the final corner was a
picture of pajamas. All these tasks were to be completed before coming to breakfast. This
turned getting ready for school into a game. It completely changed the pattern and eliminated
the stressful before-school time, well, at least until high school.
One of the first things to do as a therapist is to look for the trigger that starts the pattern.
It was hard to say if my son was triggering the pattern issue by not getting up or I was
triggering a problem by losing my patience, but sometimes the family or a couple is actually
able to say who really started it. For example, I was working with a delightful couple who
was not on the brink of divorce and just wanted to stop the pattern of evening bickering that
they had established. I asked if either of them was aware of what started the pattern. The
husband said he usually came home from work and sat at the kitchen table while she was
cooking. He stated that, without provocation, "She gives me that get-out-of-my-kitchen look."
She was completely unaware of this and I assigned his letting her know whenever he saw this
look, so that she could tell him what she actually was thinking at that moment. On three

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Solution-Oriented Marriage and Family Therapy 407

occasions between the first and second session she had given him "the look." The first time
she was thinking about hearing the children in the next room watching a television show she
disapproved of. The second time she was annoyed that she was making a dish for which she
did not have the right spice. The third time she was thinking "get out of my kitchen!" but they
did not go into a big bickering session over this because he just left the kitchen and they
talked later. They were able to identify a trigger and change the sequence of events that
comprised their pattern.
Another couple, seen at my counseling center, was able to identify the trigger that was
the sign that there was about to be violence. The husband would sit on the couch with his
arms folded tightly across his chest and his legs straight out in front of him crossed at the
ankles. The wife was able to say that that was the sign he was about to rage so they agreed
that he would leave the house for an hour when she saw this.
One of the interventions that is useful in patterns is to look for exceptions. On several
occasions I have worked with families who were frustrated because the child was failing in
school. If we looked for successful times when the child did homework, we often discovered
patterns that work. For example, by asking the question, "When have you gotten your child to
do his homework?" it became clear that if the homework was done as soon as the child came
home from school, it got done. In another case the parents remember that when they made
sure that the child studied in the dining room where there were few distractions, then the
homework was successfully completed. Look for circumstances when the undesirable pattern
does not occur and take those more successful actions.
I often say to families, "Let's do anything different that is not illegal, harmful, or
unethical." If I can inject some humor into the session I will. I have a son who was a
relentless negotiator. I tell clients that he taught me one of the secrets of parenting. Instead of
getting into the pattern of arguing with a teen, he taught me by providing a context where I
could practice resisting the pattern, that no one could make my lips move. No matter what
provocative thing was said, I could leave that juicy bait untouched and keep my lips from
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moving.
Another straightforward intervention in the fighting patterns that families and couples can
utilize is to have them, rather than arguing and defending a point of view, simply ask, "Do
you have a request?" If the pattern has been to defend and counter attack, this simple
statement can be a powerful shift in the pattern. It gets the family or couple out of the anger
pattern and back to actions that can be done or where compromises can be found.
When you are stuck and not able to get results in a family, working with just one part of
the system can make a difference. I was once working with a co-therapist trying to help a
family of five. The mother was lively and talkative and the father seemed like a nice guy but
said little. The presenting problem was that the third daughter would not go to school. We
found ourselves not getting anywhere with this family so I decided that perhaps a session
alone with the father might be in order, since he said little in the mother's presence. I asked
him alone about the marriage and he said she would say awful things to him. When I asked
him to get more specific he said that there were times that she would say to him that he wasn't
a man and threaten to castrate him. I asked, in looking for the full pattern, what he usually did
when she did this. He said that he would not say or do anything. I asked where these
harangues usually occurred and he said in the kitchen. After pondering on the proximity of
sharp objects for a moment, I asked if there was a table in the kitchen. He said there was. I
began to think of all the things he might do in response to these harangues. I made four
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 408 Pat Hudson

suggestions all of which he experimented with successfully. I suggested he crawl under the
table, which made her laugh and stopped the harangue. I suggested that he get a water gun
and squirt her. He did that and she thought that was funny and got into a playful water-fight
with him. The woman had a good sense of humor. I suggested that he announce that he was
leaving for one hour. He did that and she stopped berating him. Finally I asked if he had ever
said, "That hurts me when you talk to me like that?" He said that in their more than twenty
years of marriage he had never said that to her. He did that also and I think that was most
effective. It happened that fifteen years later at a book signing for one of my books, the wife
attended and told me that their time with me had made a big change in their marriage and that
the daughter had successfully completed school. I am sure the pattern intervention helped
resolve this family's issues.
Patterns occur in locations. The therapist can make specific suggestions about changing
the location of the conflicts to see if that changes the patterns. I have made assignments that if
the couple starts to go into the unhelpful pattern of fighting that they stop the fight and move
it to the car, the garage, or the attic. The rationale may be that the kids don't have to hear it,
but the point will be to make the pattern conscious and to make it more challenging to go into
the old pattern. As the therapist, you can get more specific. I told one couple that they were to
go into their bathroom and she was to recline in the tub while he was to sit on the toilet when
they were having their fights. Needless to say that distracted them from the usual fight
pattern.
Timing is another aspect of patterns in which you can intervene. I was working with a
single mother of two boys: ten and eleven years old. On her way home form work she would
pick the boys up at day-care. She reported that she felt overwhelmed immediately. Her sons
would bombard her with questions and talk of the day and she would feel depressed at the
burden of taking care of them. I asked her if it started to get better after she had been home
for a while. She reported that after she had on her sweat pants and a tee shirt she felt she
could handle them and became more relaxed. I asked if it would be possible to stop by home
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first and put on her sweat pants and then pick up the boys. She said that would be easy
because day-care was only two blocks from home. This rather small change in her evening
pattern made a big difference in her feelings about being a single mother. Patterns may have
to do with non-verbal behavior, like the couple mentioned earlier who had the problem with
"the look." If often comes up in sessions that someone does some body language that creates
a problem pattern, such as pointing a finger at someone or pounding on the table. Looking for
the physical patterns that keep problems from being resolved and making assignments about
those can be very helpful. When a couple is not combative I will often suggest that they hold
hands or touch each other on the leg when they're having conflict to remind each of the
parties that they are connected and that this difficulty is temporary.
Look for patterns in other settings. Often we reserve our least charming behaviors for the
people we love the most. I ask family members and spouses what they would do in other
settings as that helps them generate solutions in troublesome patterns, since often we have
more talent for civility outside the walls of our homes. For example, asking, "What would
you do if your teacher asked you to clean off the chalk board?" or "What if your co-worker
had said that same thing to you?" When I asked the chalk-board question of a thirteen-year-
old, she said, "I would have done it because the teacher would have said 'please.'" Her
stepmother then worked at asking, not demanding, more household chores from her

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Solution-Oriented Marriage and Family Therapy 409

stepdaughter, with the understanding that the stepmother could move to a level of
consequences if needed. It worked.
Many families have forgotten the use of humor to change patterns and promote solutions.
Sometimes the therapist can simply ask, "Does teasing work?" My mother was standing at the
sink washing vegetables when my father walked by and gave her an affectionate pat on her
bottom. She continued what she was doing without acknowledging the pat. He then
proceeded to the refrigerator and gave it a pat. She asked what he was doing and he replied, "I
was checking to see if I could get more response from the refrigerator." She laughed and
stopped washing vegetables long enough to give him a hug.
Reminding clients of patterns that work is often the task of the Solution-Oriented
therapists. I was working with a couple whose children had just completed college. They
would have divorced but part of what kept them together was that they both loved the dog.
She said in exasperation, "He pays more attention to the dog than he pays to me!" I suggested
that both the husband and the wife try to act more like the dog and see what would happen to
their relationship. After all, the dog doesn't stay in the other room thinking, "Why aren't they
paying attention to me?" If the dog wants attention, the dog comes up offering affection…
man's best friend, after all. The dog seems to have very few judgments and is ready for
playfulness whenever it's offered. When I made this assignment both spouses thought it
would be fun and changed their isolating pattern. As therapist we can look for patterns that
work and encourage those.

LABELS AS CLUES
A general principle is, if you feel that you are not grasping the patterns in the family, is to
look for the labels that they apply to one another. If they call a child "disruptive," then it may
be that the child gets into a pattern that generates negative attention.
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If a spouse has a label for the other, it may be a tip off to the patterns in the relationship.
A man called me twice telling me that his wife insisted on coming in alone and he wanted me
to be clear that he was very motivated to save the relationship. They had been married
fourteen years and had two sons. He did not want to give up the family. During my session
with his wife she labeled her husband as a "wimp." She said that whenever she was upset with
him, he would leave the room as quickly as possible and then try to do indirect things to
please her like clean the house and cook for her. I asked permission to talk to him before the
next session, knowing that it was very likely that he would call me as soon as my session with
her was over. She gave me permission and, sure enough, he called.
I told him the she labeled him a wimp and he said in a timid voice "I know." I told him
that we would work on the anger pattern in this relationship but that between now and the
next session he might be aware of doing some non-wimp behavior that was not harmful, but
made the point that he was willing to engage with her. At their first joint session, they told me
about the evening after the husband and I had had our brief non-wimp conversation during the
day. When the wife had gotten home from the late shift at the hospital where she worked as a
nurse, he had said, "Close your eyes. I have a surprise for you." He then threw a banana
cream pie in her face. She hadn't initially been pleased with this, but it did make her wonder if
he could possibly change his pattern with her. After all, he had taken a big chance at making

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 410 Pat Hudson

her angry by throwing the banana cream pie. We then proceeded to discuss what he was
going to do the next time she was angry with him. He was to look at his watch and stay in the
room facing her for ten minutes. Since the old pattern was she would show anger and he
would leave the room, this was a definite step in the right direction.

INTEGRITY ISSUES
Until this point I have been writing about motivated families where both the parties are
engaged in the process of making things better. But what about families where someone has
seriously violated another family member's boundaries, for example, where there has been
sexual abuse, violence, or affairs? First, I will cover what to do with the person who is out of
control but motivated to change, even if the motivation is provided by the courts. Then I will
present what to do about an out-of-control family member when the family member is not
showing any motivation nor attending family therapy.
The word integrity comes from the same root as the work integer, meaning being one or
whole and the word integration, that is, not segregated. This need for wholeness comes up
frequently in couples and in families. So how do we coach someone to act with integrity?
Integrity is some ways is rather simple. It is keeping your word and not doing what you
say you won't do and doing what you say you will do. Making the actions that are violations
of integrity absolutely clear may be a first step. For example, I make it very clear that any
touching in anger, be it pushing or throwing things, is not acceptable. Violence is any
physical act in anger. It needs to be clear to all family members that touching of any private
parts is not acceptable, with the exception of affectionate souses, of course. These seem
obvious, but saying these things out loud is making the boundaries absolutely clear.
Safety must be a primary consideration. This may mean removing someone from the
home, which the authorities will often have done even before a therapist is involved. If there
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

has been violence, have a safety plan for the person who has be the victim, to prevent future
violence. A safety plan may involve such things has having a few necessities and money
hidden somewhere that a person can get to if she or he has to make a quick escape from a
dangerous violent person. If there is a women's shelter in the area, having that number in the
potential victim's purse could save her life in an emergency.
Having the person whose has behaved inappropriately acknowledge what he or she has
done is an important part of the healing. I coach the transgressor to say what he or she did was
wrong leaving out any excuses or anything else that implies lack of responsibility and having
the transgressor, either in my presence or in writing, ask for forgiveness. Even in less heinous
actions such as lying, getting the lying party to acknowledge without saying, "I lied because I
knew you would get mad," would be the object of the acknowledgment.
I was working with a stepfamily when the wife asked for a session on her own. Her
second husband was extremely tight with money and when her son from her first marriage
needed money for college, she secretly borrowed $10,000 without her husband's knowledge. I
knew that sometime in the future the husband would be pursuing something such as a car loan
and would discover that she had made the loan secretly. I coached her to tell her frugal
husband and acknowledge that it was wrong to do behind his back, which resulted in his

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Solution-Oriented Marriage and Family Therapy 411

being angry, but less angry than he would have been if he had been sitting in front of his loan
officer at his bank and discovered the loan.
Alcoholics Anonymous advocates that one make amends for the damage he or she has
caused. When I am working with a couple or family, where there has been a violation such as
an affair, I know there is really no way that the one who had an affair can truly make up for
the hurt caused, but they can be hyper-accountable. For example, he or she can let the spouse
see the cellular phone bill so that they know to whom and from whom calls are being made.
They can have the spouse who feels violated open the credit card bill first to see if there are
any suspicious charges for flowers or hotels. A child who has been violated can be given a
sliding bolt latch on her door at night. These are all just practical steps that will lead to the
sense of safety and trust to be rebuilt in the home.
In sum, working with the family and the person who lacked integrity, clarify the
boundaries; take actions to protect anyone who needs protection; have the violator
acknowledge the violation and offer to make amends; and take any steps that will allow the
reestablishment of trust by being accountable.
All this assumes that the person who is out of control is present and is willing to make
some changes. Often, however, the person who is out of control is either not there or is not
willing to acknowledge the violation. That is when the therapist coaches the family member
or member present to set out a plan.
The first step is to escalate the consequences. I was working with a woman who was a
factory worker. I had seen her through a divorce. She returned when she was about to remarry
to ask for my advice. When she told me about her fiancé I suggested she not go through with
this yet. Her fiancé was two months out of in-patient chemical dependency treatment, which I
knew was a bad sign. He was asking her to take her life savings of $30,000 and invest in his
country-western music career, hi spite of my attempts to discourage her, she married the man
anyway. A few months later she returned and reported that he was taking money out of their
joint account for drugs, pun intended. She, with my coaching, began a plan of escalating
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

consequences. First, she transferred money to an individual account. Then discover that her
husband was removing household items and selling them to raise money for drugs. Her
second escalating consequence then was to not let him live with her. She still hesitated to get
a divorce. She kept hoping things would improve. Finally he hit her and pushed her out of the
car, so, finally, she escalated to the consequence of divorce. I asked her later if she had felt
that I should have encouraged her to leave him sooner and she replied that she felt determined
to give him plenty chances to turn things around and that she did not regret her attempts to
save the marriage.
Even if the offending party is not present the strategy of clarifying boundaries can still
work. I was working with the wife of a man who gambled. She had said that he denied being
addicted to gambling. She insisted that he only gamble from a separate bank account
established for his gambling budgeting $200 per month for that purpose and that he leave the
family money alone. To my surprise, he was able to stay within these boundaries.
On rare occasions the use of personal power, that is telling the person that you love him
or her and that it is breaking your heart to see them killing themselves through drugs or
alcohol has worked. To be most effective, this can't have been used before.
The idea of doing something new is at the heart of Solution-Oriented therapy. If sharing
compassion and concern is not the typical pattern that the family has used to try to effect
change, then that would be something new and possibly effective. The main thing is not to
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 412 Pat Hudson

keep repeating patterns that have not been effective in the past, hi a conversation with the late
therapist John Weakland, someone said in passing, "Life is just one damn thing after another,
John." He replied, "Except for our clients. For them it is the same damn thing over and over.
Our job is to get them to do the one damn thing after another." If someone is out of control,
that is the time to be inventive and avoid repeating patterns that have historically been
ineffective.
As a family therapist, I do all I can to avoid cut offs where family members shun one
another or people divorce. This is always a last resort, but there are times when the suffering
is so great that divorce or shunning of a dangerous family member is the only alternative.
If we go down the path that the person who violated the relationship or the family has
taken the steps to heal the relationship, what other steps might we take to complete the
healing after some trust has been reestablished? It should be clear by now that Solution-
Oriented Therapy is very task oriented. Consistent with a task focus, Solution-Oriented
therapists often give assignments to do rituals.

RITUALS
There are two forms of rituals: stability rituals and transitional rituals. Stability rituals
have to do with keeping a family or a couple connected. Families who have regular things
that they do together such as eating Sunday dinner as a family, holiday rituals, or daily rituals,
such as bedtime rituals of saying goodnight to each other, stay more connected in a healthy
way and are often able to overcome such difficulties as alcoholism and not pass it on to the
next generation (Wolin and Wolin, 1993). Therefore assigning some form of ritual is a way of
helping families heal and is often one of the tasks given in family and couple sessions. A
family may be assigned eating pizza on Sunday night or a parent, particularly a non-custodial
parent, may be assisted to establish rituals that will connect him or her with the child. These
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

can be something as simple as making pancakes with happy faces of chocolate chips for the
children on Sunday mornings.
Stability rituals might include rituals of protection of a family member such as installing
a lock that the child could use to lock his or her door at night. Safety issues would need to be
planned as part of this, but the point would be to symbolically let the children know that
protection was available for them within the family.
Transition rituals are particularly helpful when there has been a trauma to the family
relationships, such as an affair or a death of a family member. There are six steps in a
transitional ritual. The first is to clarify the purpose of the ritual. Is it to integrate what
happened in a family or to finish some painful time? These may overlap, but the therapist and
the client family will need to discuss the purpose of the ritual. In the case of an affair it might
be finalize the third party's being completely out of the couple's life and reconnecting the
couple, in the case of a death it might be a time to allow the children to have a funeral of their
own for a deceased sibling.
Step two in planning and executing a ritual is to select a symbol for the event. The client
may already have a symbol or you suggest an object that makes the client or clients think of
the event the family is healing from. A photograph or rock might do. The symbol might be
created, such as everyone in the family writing a letter to the dead family member. Or it might

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Solution-Oriented Marriage and Family Therapy 413

be purchased by working with a family where the teenage daughter had had an abortion, I
suggested the mom and daughter go to a craft store and select a small doll as a symbol of the
aborted baby that the daughter could bury in the backyard. Step three is to plan what they are
going to do, where they are going to do the ritual, and details such as which family members
will be included and maybe even what clothing will be warn. One of my single parent clients
decided that she would travel back to the camping spot in Estes Park in Colorado and take her
marriage license to the place where her now-former husband had proposed to her and burn the
license in that location.
Step four is to do the ritual. Parents came to see me about their four-year-old daughter.
They were having trouble with her lack of compliance. As we talked about this the trouble
had begun after the stillbirth of what would have been her baby brother a year ago. The
deceased child had been severely deformed and there had not been a funeral for the baby. The
mother had been unconscious for the delivery and had not seen the child. The father had been
present and had been haunted by the images of the deformed baby. He had kept a journal at
the time and had written about the event. I suggested that they plan a ritual, bury a small doll
as a symbol of this loss, and that they include the little girl in the ceremony. They did this and
the little girl's acting out stopped.
Rituals generally should include a transition, which is step five. This would be an action
that sets the ritual apart a little more from daily experience such as going for a walk or a short
trip. It could be combined with step six which is to have a celebration. Just as when our
typical social and religious rituals, such as funerals weddings, are completed by a meal or a
party, a therapeutic ritual should be finished by something that is a celebration. At the end of
the private family funeral where the father had read part of his journal to his wife and child,
they went out to the little girl's favorite restaurant as the end of the ritual. Since rituals are one
of the seven tasks that are given by Solution-Oriented therapist it is a good time to summarize
the other six. The first is pattern intervention. This was mentioned previously when patterns
were discussed. Specifically the assignment will be something that introduces a change in the
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

pattern. The assignment can be where the pattern will be done, such as "only fight in your
parked car," or when the pattern will be performed, such as "only discuss the rules in the
evening with Carrie in the living room sitting down, not in the car." The point being to
introduce any change in the pattern that will help permanent alter the pattern and most
importantly the family's awareness of what is not working for them.
Skill building tasks are another type of task assignments. A simple task aimed at getting a
child to not cuss is to put coins of the same denomination in a jar and then remove one every
time the child cusses. At the end of the week, the child may have the money in the jar minus
the coins that were removed because of the cussing. This could work for thumb-sucking or
whining, or other behaviors that are simple and that the parents wish to see eliminated. The
skill, of course, is that the child learns to inhibit behavior as society will require.
Although I rarely use this, paradoxical interventions are another form of assignments. I
don't use this often because I personally don't like to be tricky with clients and say anything I
don't really mean. However, if I feel stuck with a client who perhaps is obsessing over their
child, I might assign some way to do it more, if assigning some way to do it less has been
ineffective. With an anxious mom who frets over their child's bodily functions I might have
her start writing down all the observations. The goal would be to make the symptom more of
an ordeal.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 414 Pat Hudson

Milton Erickson loved to give assignments that were vague and on occasion I have
followed this idea. He might have a couple climb Squaw Peak, but, since I live by the ocean, I
might give an assignment to take some particular path by the sea as part of an assignment.
These ambiguous function tasks simply allow the family or couple to project whatever
meaning or solution they might have onto the intervention.
I often use perceptual tasks. Families who are having problems are looking for more and
more evidence that something is wrong. My goal is to have them look for something that is
going right. I might say, "This week I want you to see how many things you can find Jason
doing that you like. I want you to make a list and when we get back together next week I
would like for you to read the list to Jason." This shifts the family's efforts from what their
teenager is doing wrong to what they like about him. If he is present, he may be also focused
on what he can get caught doing right. To support this I might also suggest that motives that
family members have might have alternative motivations. Such as "Jason might be wanting
you two [the parents] to have a reason to get together and be closer. Some therapists think that
is why kids act up." Suggesting a possible positive motivation changes the focus from Jason-
the-culprit to Jason-the-rescuer-of-the-marriage. I used that exact approach to a family where
the parents were in a contentious divorce and their son had been caught shop-lifting. I thanked
the child for sacrificing himself to get them in my office so we could negotiate a more
peaceful divorce. He stopped acting out and his parents became more cooperative, validating
my therapeutic explanation of his behavior. Perceptual changes in and out of sessions can be
very effective.
Symbolic tasks in or not in a ritual can be helpful assignments. As I am writing this, just
yesterday I had a client who had been married for eight months and was very annoyed with
her husband. We both agreed that sharing each annoyance was not going to be very
productive because, when she tried that pattern, things just escalated. I assigned a few pattern
changes such as saying "that hurts my feelings," and "thank you for being so generous" when
he complained about taking care of her financially instead of pointing out that it was she who
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

owned their house. I also suggested the symbolic task of writing down and tearing up all the
hateful things she felt like saying. She surprised me by saying that that was exactly what she
had done with her mean, strict father. She would write a letter to him and the tear it up putting
the shreds in different trashcans so that the letter could not be reconstructed. We both
chuckled at that the image of her as at teen going from trash can to trash can in the house. She
agreed to do the same with her unproductive anger towards her husband.
The seven tasks that are typical of Solution-Oriented therapy are then pattern
intervention, skill building tasks, paradoxical tasks, ambiguous tasks, perceptual tasks,
symbolic tasks, and rituals.

STORIES THAT HEAL

Besides trying to get clients to do things differently, most solution-oriented therapists try
to inspire their clients. I have noticed how many latent preachers there are in the therapy field
and many therapists came to therapy through the ministry. My father R. Lofton Hudson,
Ph.D. was considered one of the founders of pastoral counseling (Hudson, 1963) and his

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Solution-Oriented Marriage and Family Therapy 415

supervision when I first became a therapist definitely informed my work and influenced the
therapy I was drawn to.
Parables in religion and the tradition of Milton Erickson influenced therapists to tell
stories. This tradition pervades Solution-Oriented therapy. Here is an example of a story I
often tell my clients. I start by illustrating clarifying vague words. I start by telling the story
from the first of this chapter wherein the woman wanted her "freedom" which meant that she
wanted to go out with her friends once a month, her husband could pick the friends, and she
wouldn't go to a bar. You may recall he refused because he thought that every minute you
weren't at work you were to be together. Well, one remembers their failures sometime better
than their successes. This couple sticks in my mind, because they divorced. Several months
after the wife had left, the husband came to see me saying that he missed his family terribly
and that he would now be thrilled for her to go out once a week with her friends, but that she
would have nothing to do with him. He said, "What I realize now is that I loved my ideas
more than I loved my wife." I tell this story to couples and families, who have gotten stuck on
the concept that some behavior has to be a particular way or they don't want to be in the
family. This is a clear example of how I want to inspire, or, if you wished to put it less
graciously, manipulate people to be the best they can be and to rise above their pettier
motives.
When my daughter was finishing her Masters in counseling someone who had a
completely different treatment method from Solution-Oriented therapy supervised her. My
daughter was seeing a couple who reported that they often felt closer when they went for a
walk. She suggested that they go for a walk between now and the next meeting. The
supervisor of my daughter became upset that she had "interfered with the couple's process."
This experience and others caused my daughter to become a successful speech therapist
instead, but I think it illustrates how different Solution-Oriented therapy is from traditional
approaches. We set out to doggedly "interfere with the family's process." If they could have a
loving, productive "process", they would not be seeing us. This, of course, implies that we
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

push our values on the clients and I can't deny that. We are on the side of loving, non-violent
families—there's that latent preacher stuff again, and we make no bones about it. I would say
that as a group we try not to push smaller values on the clients such as exactly how things
should be done, just the big-picture values such as respect and safety for all family members.
I am sure many of the readers of this chapter have already adopted a therapeutic model
and may have established therapeutic techniques which are pretty successful with their
clients. For you, Solution-Oriented therapy may be what you use when you are stuck with
someone who seems not to understand that therapy is about change. I invite you to use some
of the task assignments and stories that inspire you, taking what is useful for you in the model
and ignoring what doesn't fit for you, in creating solutions for the families and couples in your
practice.

REFERENCES
Glass, G. V., & Smith, M. L. Meta-analysis of Psychotherapy outcomes studies. Paper
presented at the Society for Psychotherapy Research, San Diego, 1976.
Haley, J. (1963). Strategies of Psychotherapy. New York: Grune & Stratton.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
 416 Pat Hudson

Haley, J (1973) Uncommon Therapy: The Psychiatric techniques of Milton H. Erickson, M.D.
New York: W.W. Norton.
Hudson, R. L. (1963) Marital Counseling. Englewood Cliffs, NJ: Prentice-Hall.
Minuchin, S., & Fishman, C. (1981) Family Therapy Techniques. Cambridge, MA: Harvard
University Press.
Rossi, E., Collected papers of Milton H. Erickson on hypnosis (4 volumes). New York:
Irvington.
Wolin, S. J., & Wolin, S., The Resilient Self: How survivors of troubled families rise above
adversity. (1993) New York: Willard Books

SUGGESTED FURTHER READING

Greene, J. G., & Lee, M-Y (2005) Solution-Oriented Social Work: A Practice Approach to
Working With Client Strengths.
Hudson, P. (1996) The Solution-Oriented Woman: Creating the Life You Want. New York:
Norton.
Hudson, P. O., & O'Hanlon, W. H., (1991) Rewriting Love Stones: Brief marital therapy.
New York: Norton.
Miller, S.D., Hubble, M., & Duncan, B. L., (1996) Handbook of Solution-Focused Brief
Therapy, San Francisco: Jossey-Bass.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
 In: The Quick Theory Reference Guide ISBN: 978-1-60021-624-4
Editor: Karin Jordan, pp. 417-426 © 2008 Nova Science Publishers, Inc.

Chapter 28

COLLABORATIVE THERAPY

Harlene Anderson
How can therapists create the kinds of conversations and relationships with
their clients that allow all participants to access their creativities and develop
possibilities where none seemed to exist before?

AN EVOLVING POSTMODERN PHILOSOPHICAL

AND PRACTICE PERSPECTIVE

Collaborative Therapy, sometimes referred to as Collaborative Language Systems

(Anderson & Goolishian, 1988) is an evolving philosophical and practice perspective. Its
roots trace back to the early Multiple Impact Therapy (MIT) approach to working with
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

children and adolescents and their families that was pioneered at the University of Texas
Medical Branch in the 1950’s and 60’s (McGregor, Ritchie, Schuster, McDanald, Serrano &
Goolishian, 1964). Over the years, what began as a family therapy approach evolved as an
ideological perspective that has applicability across people, situations, and contexts such as
individual, couples, family, and group therapy, and in education, research, consultation, and
coaching. The development of Collaborative Therapy was a reflexive process of practice and
theory and involved a continuous exploration for more effective ways to work with clients. It
was also largely influenced by over 25 years of what was learned in interviews with clients
about their experiences and descriptions of successful and unsuccessful therapy (Anderson,
1997). Clients described particular ways that therapists listened, heard, and spoke—indicating
therapists’ manners, actions, and responses that communicated to clients that they were
important and respected and that what they had to say was worth hearing. Clients’ voices
highlighted the significance of the “relationship-in-dialogue” and influenced the heart of the
approach, a “philosophical stance:” a “way of being” in relationships and conversations.
We live in a fast changing world that is shrinking, becoming enormously more complex
and uncertain and in which our societies and cultures are increasiongly more diversified and
intertwined as well. Many familiar psychological explanatory concepts are not as useful as
they once were for helping us account for the complexities of these changes or address the

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 418 Harlene Anderson

impact they have on human beings and our everyday lives. What was learned from clients led
to questioning the relevance of some well-known concepts such as: universal truths,
knowledge and knower as independent, language as representative, and meanings are in the
words. Historically, these concepts have been legitimizing “truths” that placed human
behavior into frameworks of understanding that seduced therapists into hierarchical expert-
non-expert structures, into discourses of pathology and dysfunction, and into a world of the
known and certain.

The Postmodern Challenge

Collaborative Therapy, though its development over the years was influenced by various
theoretical perspectives, is currently associated with a body of perspectives referred to as
postmodernism (Anderson & Goolishian, 1988; Anderson 1997). This postmodern umbrella
includes social construction and narrative theory and contemporary hermeneutic
philosophical concepts as well.1 The thread that connects these perspectives is a similar
viewpoint of knowledge and language that places central importance on language and
knowledge as relational and dialogical activities that give us meaning and understanding for
making sense of our lives and navigating our worlds.
Postmodernism challenges the “truths” that we often passively accept or unwittingly
take-for-granted, challenging the foundations on which they are generally based and the
assumptions that flow from them as well. Specifically, it advocates a questioning stance
toward truths: the centrality of individual knowledge, an objective knowable world, and
language as the carrier of truth (Gergen, 2001). Truth questioning does not suggest
abandonment but rather deconstruction. In addition to this questioning stance, postmodernism
places value on what is referred to as local knowledge, knowledge created within a
community of people that has relevance and usefulness for its members and their tasks at
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hand.
Though the postmodern family branches in diverse directions, there is a common
consistent trait: the notion that knowledge and language are relational and generative. This
notion markedly contrasts with the Western tradition of individualism: the individual as an
autonomous knower who can create or discover knowledge that can be passed on to others. In
this tradition, knowledge (truth, reality, expertise, etc.) represents an objective reality that is
observer-independent: the knower is separate from that which he or she observes, describes,
and explains. It is fixed and tangible; it is conveyed in language; and language can correctly
represent it.
Knowledge (what we think we know or might know), in contrast, from postmodern
perspective is linguistically constructed, its development and transformation is a communal
process, and the knower and knowledge are interdependent. Knowledge therefore is not static
or out there waiting to be discovered; rather, it is fluid and created. From this perspective,
authoritative pervasive discourses recede and give way for knowledge constructed on the
local level that has practical relevance for the participants involved.

1
Collaborative Therapy draws from the writings of authors such as Mikhail Bahktin, H.G. Gadamer, Kenneth
Gergen, Francios Lyotard, John Shotter, Lev Vygotsky, and Ludwig Wittgenstein.

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Collaborative Therapy 419

Language (spoken and unspoken communication or expression) is the primary vehicle

through which we construct knowledge, try to understand, and make meaning about our
world and ourselves. As philosopher Richard Rorty (1979) suggests, language does not mirror
what is; for instance, language is not an outward description of an internal process and does
not describe accurately what actually happened. Rather, language allows a description and an
attribution to what happened. It gains its meaning and its value through its use: the meaning
of a word is in its use rather than in the word itself. That is, words are not representative,
instead they give meaning. We use words to create our worlds, our truths. Language thus
shapes, limits, and allows possibilities in our thoughts, our expressions, and our lives. For
instance, think of the effect that the words we use in therapy can have: our words create
realities; realities create labels; labels create identities; and identities create boxes. All can
obscure the person. All can create “challenging” clients. All can limit future possibilities.
Closely associated with postmodernism is the concept of “the social construction of
reality”: what is created in and through language (realities such as knowledge, truth, and
meaning) is multi-authored among a community of persons. That is, the reality that we
attribute to the events, experiences, and people in our lives does not exist in the thing or
person itself; rather, it is a socially constructed attribution that is shaped and reshaped within
a particular culture and within language. What is created, therefore, is only one of multiple
perspectives (realities such as narratives or possibilities). Language, like knowledge, is fluid
and creative. This does not suggest that nothing exists outside linguistic constructions;
whatever exists, exists irrespective of linguistic practices (Gergen, 2001). This suggests that
the focus is on the meanings of these existences and the actions that they inform, once we
begin to describe, explain, and interpret them.
Transformation (e.g. new knowledge, expertise, identities, and futures), therefore, is
inherent in the inventive and creative aspects of language. Combined, the above perspectives
have influenced the notion of human beings as systems in language or language systems
(Anderson & Goolishian, 1988). More specifically, they are generative or language meaning-
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

making systems. Therapy becomes one kind of meaning-making system in which

transformation is more rather than less possible.

Healthy vs Unhealthy: An Appreciative View

A postmodern collaborative perspective offers a broad challenge to the culture, traditions,

and practices of the helping professions in general and therapists in particular. It invites us to
re-examine and re-imagine our traditions and the practices that flow from them, including
how clients, client-therapist relationships, the process of therapy, and therapists’ expertise are
conceptualized (Anderson, 1999). This also includes the ways that we understand a person
and attribute meaning to their words and actions, how we develop descriptions of them that
are arrived at from those understandings and meanings, and the influence these have on our
roles, relationships, and processes. Likewise, it includes how “problems” and “solutions” are
conceptualized.
A “problem” is from a Collaborative Therapy perspective is:

. . . a position that someone takes. It is a meaning that someone attributes, a narrative that
someone has developed . . . it is an entity, a person or a thing, defined in language, that

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 420 Harlene Anderson

someone is troubled, concerned, complaining, or alarmed about; would like to change; and
may have been attempting to change (Anderson, 1997, pp. 73).

The universalizing of problems such as categorizing them into types, kinds or nosologies
can obscure the complexity, uniqueness, and richness of the people involved and the events of
their lives. As well, it can obscure the development of meanings and understandings through
which problems dissolve. Said differently, problems are believed to be “solved,” but instead
dissolve in language. In therapy, the means of dissolution is the therapeutic or change
process.2
Inherent in Collaborative Therapy is an appreciative belief in the good and the positive:
most human beings value, want, and strive toward healthy successful relationships and
qualities of life. Both therapists and clients report finding hope and freedom where none
seemed to exist before (Anderson, 1997; Anderson & Gehart, 2007). Similar to psychologist
Martin Seligman and Mikhail Csikszentmihali’s emphasis on positive-based psychology as
more promising than deficit-based psychology, this belief invites an appreciate view of
human beings, valuing their resiliency and potential.

THE THERAPEUTIC PROCESS

Philosophical Stance

The postmodern conceptualizations of knowledge and language discussed above inform

the heart of Collaborative Therapy: its philosophical stance. Philosophical stance refers to a
way of being: a way of thinking about, experiencing, being in relationship with, talking with,
acting with, and responding with the people we meet in therapy. The notion of “with” cannot
be over emphasized: two (or more) human beings encountering each other as they engage in
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

the social community and activity we call therapy. Collaborative Therapy can be thought of
as a “withness therapy.”3

Client as Expert
The collaborative therapist considers the client as the expert on his or her life and as the
therapist’s teacher. The therapist respects and honors the client’s story and takes seriously
what the client has to say and how they choose to say it. This includes the many ways that the
client may express, for instance, their story, their knowledge or their problem. That is, the
therapist does not have expectations that a story should unfold in chronological order, at a
certain pace, or contain certain details and not others. The therapist does not expect particular
answers and does not judge whether an answer is direct or indirect, right or wrong, or
sufficient or not.
This does not mean that therapist knowledge is not valued, it simply means that the
therapist is not regarded as the expert on the client’s’ life. Instead, the therapist’s competence
is in establishing and fostering an environment and conditions that invite collaborative
relationship and generative conversational processes, creating a culture in which participants

2
For a fuller discussion of “problems” from a collaborative perspective see Anderson, 1997, pp. 73-92.
3
Please see Shotter (2004) for a discussion of the notion of “withness” versus “aboutness.”

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Collaborative Therapy 421

share expertise or knowledge as they strive to explore and understand the task at hand and
achieve desired futures. In and through this joint community and activity, newness in
meanings, understanding, and agency—newness in expertise and knowledge—that has local
relevance and usefulness is jointly created. The prominence of client expertise in the
collaborative approach contrasts with its place in other approaches in which professional
knowledge externally defines problems, solutions, outcomes, and success—creating expert-
non-expert dichotomies.
Often a therapist works with more than one person such as a member of the client’s
personal relationship or professional helper system. The therapist appreciates, respects, and
values each of these voices and their realities. The multiple voices and their various realities
are viewed as holding the richness of differences in which the seeds of infinite possibilities
are inherent.

Not-Knowing
Not-knowing refers to the way that the therapist thinks about knowledge (e.g., expertise,
wisdom, truth, reality), the intent with which they use it, and the manner in which they
introduce it. The collaborative therapist privileges “knowing with” or creating together over
“knowing about” or pre-knowing (see Shotter, 2004). To know with requires that the therapist
not believe they have superior knowledge or a monopoly on the truth. The therapist brings
and offers their knowledge; however, they hold it tentatively and pay careful attention to the
manner, timing, attitude, and tone with which it is introduced. That is, the therapist offers his
or her voice, including previous knowledge, questions, comments, opinions, and suggestions
as a way of participating in and facilitating the conversation. The therapist remains willing
and able to have their knowledge (including professional and personal values and biases)
questioned, disregarded, and changed. Not-knowing should not be mis-understood as the
therapist knows nothing, pretends ignorance, or forgets/does not using what they have
learned.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Being Public
Therapists often maintain and work from invisible private thoughts—professionally/
personally and theoretically/experientially informed thoughts such as diagnoses, judgments or
hypotheses--that influence how they listen, what they hear and that guides their questions.
The collaborative therapist, in contrast, is open and makes their invisible thoughts visible.
They share inner ideas such as what might me thought of as “what’s behind my question,”
offering it, as mentioned above, as food for thought and dialogue. Keeping therapists’
thoughts public gives the client the opportunity to respond to it. The client’s response to the
therapist’s thought—in the many forms that a response may take such as expressing interest,
confirming, questioning, or disregarding—will affect the thought. All is part of the generative
process.
Importantly, putting private inner talk or thoughts into spoken words produces something
other than the thought or understanding itself. The thought is organized and re-formed as it is
expressed; it is fine-tuned and altered in the process of articulation. The presence of the client
and the context among other things, influence the words chosen and the manner in which they
are used.
Making therapist’s thoughts public also minimizes the risk of therapist and therapist-
client monologue; for instance the chance that either or both persons will remain occupied by
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 422 Harlene Anderson

one idea to the deafness of others. Therapist monologue can lead to participating in, creating,
or maintaining characteristics of the relationship or what are viewed from some therapy
theories as internal characteristics of clients such as ‘resistance’ and ‘denial.’

Trusting Uncertainty
Collaborative Therapy invites and entails uncertainty. When a therapist accompanies a
client on a journey and walks along side them instead of leading or nudging them in a
therapist-established direction, where they end up and how they get there cannot be pre-
determined. The paths explored and the newness created (e.g. solutions, resolutions, and
outcomes) are mutually developed from within the local conversation and are uniquely
tailored to the person or persons involved. How transformation occurs and what it looks like
will vary from client to client, from therapist to therapist, and from situation to situation. Put
simply, there is no way to know for sure the direction in which the client’s story will unfold
or the outcome of the unfolding when client and therapist are involved in a dialogical
conversation and collaborative relationship.

Mutually Transforming
The collaborative therapist is not considered an expert agent of change; that is, a therapist
does not change another person. Instead, the therapist’s expertise is in creating a space and
facilitating a process for collaborative relationships and dialogical conversations (discussed
below). When involved in this kind of process, both client and therapist are shaped and
reshaped – transformed – as they work together.

Everyday Ordinary Life

Collaborative Therapy resembles more the everyday common ways of talking and
relating that most people prefer. This does not mean chitchat, without agenda, or a friendship.
Therapy conversations and relationships occur within a specific context and have a particular
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

agenda: put simply, a client wants help and a therapist wants to help. Clients and problems are
not categorized as types or kinds or as challenging or difficult. Each client is simply thought
to present with a circumstance of everyday ordinary life that any person could have the
misfortune to encounter.

THE “CHANGE”4 PROCESS

Mutual Inquiry
Central to Collaborative Therapy are the concepts collaborative relationship and
generative conversation. A collaborative relationship refers to a particular way in which the
therapist orients him- or herself to be, respond, and act with another person that invites the
other into a shared engagement and join action. It is a relationship in which the participants
connect and create with each other. They become a “community” wherein each person has a
sense of participation and ownership. A generative conversation refers to a particular kind of

4
Collaborative therapists prefer the words “transformation” or “transforming” instead of change. In contrast to a
collaborative perspective, in our psychotherapy tradition change has come to refer to the therapist as an agent of
change and changing from, to.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
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 Collaborative Therapy 423

dialogue or form of talk in which participants engage with each other (out loud) and with
themselves (silently) - using any form of communication such as words and gestures - to
mutually inquire about the issues at hand.
The client and therapist join in a mutual inquiry about the issues or tasks at hand: jointly
examining, questioning, wondering, reflecting, etc. The therapist invites and initiates this
inquiry by entering the relationship as a learner: the client is the therapist’s teacher. The
therapist wants to be taught about and understand the client and his/her story from the client’s
perspective and preferences. It is as if the client begins to hand the therapist a “story ball.” As
the client puts the ball toward the therapist and with the client’s hands still on it, the therapist
gently place their hands on it but does not take it from the client. The therapist begins to
participate with the client, trying to learn about and understand their story by responding to
them. The therapist responds by being curious, asking questions, making comments, etc. This
therapist learning position acts spontaneously to engage the client as a co-learner; it is as if
the therapist’s curiosity is contagious. In other words, what begins as one-way learning
becomes two-way learning. Client and therapist join in a mutual process that involves a back-
and-forth, give-and-take, in-there-together connection and activity in which they talk “with,”
not to, each other. As they co-explore the familiar, the client’s story unfolds. In this process
the story is told and re-told in a way that clarifies, revises, expands, shifts it, and so forth. The
newness is created, is co-constructed, from within the relational and conversational process in
contrast to the newness being imported from outside of it. In this kind of conversation and
relationship all members have a “sense of belonging.” A sense of belonging invites
“participation,” which in turn invites “ownership and ownership in turn invites “shared
responsibility.”
Learning about another person is key to connecting with them. Learning requires active
listening, listening in a way that shows that you are hearing. Listening to hear entails offering
responses that indicate interest, curiosity and inquisitiveness regarding the other’s
perspective. It entails responses that help the therapist check-out that they have heard
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

(understood) what the other person wants them to hear. Connecting with another person
through being open and willing, through learning. and through joining in a shared inquiry
naturally leads to collaboration and generativity.

Techniques
The therapist’s ability to invite and facilitate collaborative relationships and dialogical
conversations is based in a belief in the postmodern perspective discussed above. When a
therapist holds this belief, they assume an authentic and natural way of being, connecting, and
constructing with others: a philosophical stance. It is a matter of a assuming this stance and
not a matter of exercising techniques.
The mutual inquiry process, and therefore the process of “change,” is related to other
characteristics of the philosophical stance: the client is the expert, not-knowing, being public,
mutually transforming, trusting uncertainty, and therapy as everyday ordinary life. Combined
these invite the opportunity for a therapy that is more participatory and collaborative and less
hierarchical and dualistic. And importantly, though the stance may have common identifiable
expressions, it is unique to each therapist and human system, the circumstances, and what is
required.

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 424 Harlene Anderson

TREATMENT, ASSESSMENT AND GOALS

Nature of the Therapeutic Relationship

Conversational Partners
The collaborative therapist signals to the client - through an attitude, a posture, a tone,
body gesture, word choice, etc - the importance the client holds for the therapist. The therapist
communicates to the client that the client is valued as a unique person not as a category of
people or problems, and that the client has something worthy to say and hear. The therapist
also communicates that they are meeting the client without prior judgment of past, present, or
future and that they do not hold a secret agenda, investigative or other wise.
This positioning invites the client to join with the therapist as a conversational partner
who engages with them in dialogical conversations and collaborative relationships. A
conversational partnership is a two-way relationship and process, involving a back-and-forth,
give-and-take, in-there together activity and connection where people talk with each other
rather than to each other. Inviting this kind of partnership requires that the client’s story take
center stage. It requires that the therapist constantly learn, listen to, and try to understand the
client from the client’s perspective and in their language.
In this kind of conversation and relationship all members have a sense of belonging. This
sense of belonging invites participation and shared responsibility. Dialogical conversations
and collaborative relationships go hand in hand: the kinds of relationships we have form and
inform - enhance and limit - the kinds of conversations we have and vice versa.

Assessment and Goals

“Problem” assessment and goal setting are collaborative activities that respect the client’s
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

expertise on their life and rely upon the expertise and knowledge of both the client and the
therapist. An on-going assessment or evaluation of therapy, including the usefulness and
relevance of the original problem and goal definitions becomes part of everyday practice
instead of task at or after the conclusion of therapy. That is, the therapist and client evaluate
their work together during the course of therapy. They use what they learn to inform their
work, appreciating and building on what is useful and reconsidering what is not (Anderson,
1997). This is part of the assurance that the therapy is tailored to and has continuous utility for
the client. Collaborating in these endeavors is related to the interrelated characteristics of the
philosophical stance discussed above.

STRENGTHS AND LIMITATIONS

Clinically, early evidence of the strength and evidence of effectiveness of Collaborative
Therapy has focused on clients’, therapists’, and students’ experiences of therapy, mostly

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Collaborative Therapy 425

based in anecdotal reports and qualitative research.5 The usefulness of the approach is
illustrated in articles on child abuse and other types of domestic violence, eating disorders,
substance abuse, and supervision (Anderson, 1997; Anderson & Levin, 1997, 1998;
Anderson, Burney & Levin, 1999; Chang, 1999; Levin, 1992; London, Ruiz, Gargollo & MC,
1998; Roberts, 1990; St. George & Wulff, 1999; Swim, Helms, Plotkin & Bettye, 1998). In
departure from the usual practice of therapist-determined therapy success or failiure, some of
these accounts are from the clients themselves (London, Ruiz, Gargollo & MC, 1998; Swim,
Helms, Plotkin & Bettye, 1998). Qualitative research includes study of the effectiveness of
Collaborative Therapy and analysis of whether therapists’ behaviors and attitudes were
consistent with their therapy philosophy (Gehart-Brooks & Lyle, 1999; Swint, 1995), and the
application of the ideas in supervision and education (Anderson, 1984; St. George, 1994;
Tinez, 2002). Finnish psychologist Jaakko Seikkula and his colleagues have aptly
demonstrated the effectiveness of an “open dialogue” approach through a
quantitative/qualitative research project with a five-year follow-up with psychotic patients
and their families (Sekkula, 1993; Seikkula, Aaltonen, Alakare, Haarakangas, Keranen &
Sutela, 1995; Kauko Haarakangas, Birgitta Alakare, Jukka Aaltonen, & Jaakko Seikkula, in
press).
Clients report a newfound sense of freedom and hope. They also repost a sense of
belonging, participation, and ownership which, in turn, invites shared responsibility for the
process and the outcome. The outcome--whether it is something tangible and doable or
whether it is simply a sense of something like a sense of freedom or hope—strikingly
becomes a feeling that I (we) can go on from here. Interestingly, therapists report that
learning to live with uncertainty and trusting their client’s expertise gives them an increased
sense of competency.
Equally important, therapists report improved relationships with clients, more enthusiasm
for their work, and less burn-out. They also report improved relationships with colleagues as
well. As they live the philosophical stance with their colleagues, as they do with their clients,
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

they are able to see possibilities previously unrealized by being open and curious about
differences. Supported by the belief that there is no one or right way to view or do any thing,
potential or once awkward or tense relationships become less troublesome, more compatible
and sometimes even enjoyable ones (St. George and Wulff, in press). Therapists also report
that the collaborative approach has utility in systems and contexts other than therapy,
especially in their personal lives. Collaborative therapists also suggest that they create the
limitations of Collaborative Therapy rather than the limitations being in the approach itself,
and therefore they create their own limitations.

REFERENCES
Anderson, H. (2003) Social construction therapies. In G. Weeks, T. L. Sexton & M. Robbins
(Eds.) Handbook of family therapy. New York: Brunner-Routledge.
Anderson, H. (2001) Postmodern collaborative and person-centered therapies: What would
Carl Rogers say? Journal of Family Therapy. 23:339-360.

5
We invite readers engaged in research on the effectiveness of collaborative therapy, or who know of others who
are, to contact the editors and we will place the information on a website.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
 426 Harlene Anderson

Anderson, H. (2001) Becoming a postmodern collaborative therapist: A clinical and

theoretical journey, Part II. Journal of the Texas Association for Marriage and Family
Therapy. 6(1):4-22.
Anderson, H. (2000) Becoming a postmodern collaborative therapist: A clinical and
theoretical journey, Part I. Journal of the Texas Association for Marriage and Family
Therapy. 5(1):5-12.
Anderson, H. (2000) Supervision as a collaborative learning community. Supervision
Bulletin. Fall 2000. Washington, D.C.: American Association for Marriage and Family
Therapy.
Anderson, H. (1999) Reimagining family therapy: Reflections on Minuchin's invisible family.
Journal of Marital and Family Therapy. 25(1):1-8.
Anderson, H. (1997) Conversation, Language and Possibilities: A Postmodern Approach to
Therapy. New York: Basic Books.
Anderson, H. (1997) What we can learn when we listen to and hear clients’ stories. Voices:
The Art and Science of Psychotherapy. 33(1):4-8.
Anderson, H. (1994) Rethinking family therapy: A delicate balance. Journal of Marital and
Family Therapy. 20:145-150.
Anderson, H. & Gehart, D. (in press) Collaborative Therapy in Action: Ways of Being in
Relationship and Conversation. New York: Routledge.
Anderson, H. & Goolishian, H.A. (1988) Human systems as linguistic systems: Evolving
ideas about the implications for theory and practice. Family Process 27:371-393.
Anderson, H., Burney, P. & Levin, S.B. (1999) A postmodern collaborative approach to
therapy. In D. Lawson (Ed.). Casebook in Family Therapy. Brooks/Cole Publishing
Company: Pacific Grove, CA.
Bakhtin, M. (1993). Toward a philosophy of the act. Austin, TX: University of Texas Press.
Gergen, K.G. (1985) The social constructionist movement in modern psychology. American
Psychologist.40:255-275
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Gergen, K.G. (1999) An Invitation to Social Construction. Newbury Park, CA: Sage
Publications.
MacGregor, R., Ritchie, A. Serrano, A., Schuster, E., McDanald, E., & Goolishian, H.A.
(1964) Multiple impact therapy with families. New York: MacGraw-Hill.
Rorty, R. (1979) Philosophy and the Mirror of Nature. Princeton, NJ: Princeton University
Press.
Seligman, M.E.P., & Csikszentmihalyi, M. (2000). Positive psychology: An introduction.
American Psychologist, 55, 5-14.
Shotter, J. (1993) Conversational realities: Constructing life through language. Newbury,
CA: Sage Publications.
Vygotsky, L. (1988). Thought and language. Cambridge, MA: MIT Press.
Wittgenstein, L. (1953). Philosophical investigations. Oxford Blackwell.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 In: The Quick Theory Reference Guide ISBN: 978-1-60021-624-4
Editor: Karin Jordan, pp. 427-443 © 2008 Nova Science Publishers, Inc.

Chapter 29

REFLECTING TALKS

Tom Andersen

INTRODUCTION
Theories and methods are not mentioned in this chapter, and I have these comments for
not doing so. The problem with theories has the longest comment. Theory stems from the
Greek verb ‘theoreïn’ which means ‘to look’ and the Greek noun ‘theors’ means ‘an envoy
comes home and tells what he saw in a foreign country’. Theory is strongly related to seeing,
and to see is to see the visible. Two of three parts of reality are visible, of which one is non-
moving and the other is moving. Example of the first is a mountain, and the second a man
who walks on the mountain. The third part is invisible, the loneliness of the man who walks
on the mountain. We cannot see his loneliness, but we can feel in our bodies how his look and
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

movement of loneliness impact on us. We can have assumptions of what loneliness is, not
theories. In this chapter is assumption a bigger word than theory, and actually include theory
as one rational part of assumptions, but assumptions also include a feeling part.
Methods will neither be mentioned. The problems with methods are that they are pre-
planned in another context and at an other point in time than where the practice goes on.
Reflect is a latin word, re-flectere, that means to bend back. I think of bending back
’something’ to what this ‘something’ was connected to and make the ‘bending back’
reconnect and impact on ‘what’ was originally expressed. The immediate reaction in March
1985, when we did a reflecting talk the first time, was that this was different from all I had
done before, and it appealed to be done again. Before the first article appeared in 1987 in
Family Process I considered that this kind of talk both might ignite and also be used in many
ways, even misused. I therefore asked myself if I was willing to travel in order to reduce the
misuses, and when the answer was yes, the article was written. When an idea has let go
everybody ‘owns’ it and make it their own. It will not be good if one person should own an
idea, as that makes the person defend it instead of let it unfold.
We who have participated in reflecting talks in ’the Tromsoe-group’, have consisted of
many who, each of them, have made important contributions. Who we have comprised has
varied, some come and some go. I myself have been there all the time. Several times in this

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 428 Tom Andersen

chapter where I write ‘we’ I could have written ‘I’. Tromsoe is a small city in the north of
Norway far north of the arctic circle.
Discomfort and doubt has been of much help in developing this way of working. The
discomfort is what we feel in the body when we experience others’ reaction of what we do.
We experience first on the body by what we see, hear, smell, taste and sense as strokes or
blows to the body. The discomfort sometimes make us feel shame or disgust or distaste or
despair or disappointment or urge to give in etc, and make us think ’I must not do that again!’
We experience first on the body, and the reactions, for instance discomfort, do we experience
in the body. Thereafter the words and formulations come to help us grasp an understanding of
what happened in the experiencing moment. The doubt reminds us all the time that what we
do might be done different, maybe even ought to be done differently. Belief without doubt
becomes dangerous, as doubt without belief becomes impossible. Doubt and belief must be
there simultaneously, as two friends.
My version was developed together with many others. However I have noticed that my
version of ‘bending back’ contains something that does not appear in other versions. During
the first years after 1985 I was occupied of not instructing; people should find their own way.
The wider frames were only mentioned. However, over the years, experiencing various
others’ reflecting talks and having noticed that many possibilities were lost, I say more and
more what I do, and not at least what I avoid to do, without being instructive.
A walk is an expression I like to use to describe how it all came about. On this walk,
which has the speed one has when collecting mushrooms, one reaches road forks. One cannot
proceed on both roads but have to choose one and leave the other, or opposite; give up one
such that the other is left to continue on. On my walk the last has most often happened. That
means that certain forms of practices had to be given up. Such decisions were mostly
emotional and related to the feeling of discomfort. The walk started as a general medical
country doctor.
The most common and the most difficult were attracting. The most common was aching
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and tense, poorly movable muscles. The most difficult were the conversations in situations
where the usual talking and thinking habits did not suffice. They looked like refugees they
who, in the 1960s, came far from to the psychiatric hospital in Tromsoe where I landed after
the general practitioner period. When they were disconnected from their homes reconnections
were almost not possible. A rational response to that was that we had to be ‘out there’ in order
to prevent disconnections. The discomfort we felt when we saw how much they longed for
home, did also contribute to ‘going out’, and left the road that was named ‘remain in the
centers’.
Courage and fear shall also be considered as friends. Courage alone does not do, neither
fear alone; they must be there all the time, to support each other. The courage helps to turn a
corner or jump off a rim when one does not know what to meet or where one will end, as the
fear helps to hesitate and by that take the time that is needed before daring the unusual.
The language they used in the local communities was different from that we used inside
the institutions. Out there we used a daily language, and we talked mostly of successes. In the
hospital, helped by the expert language; the pathological language, we spoke more of what
was wrong and of failures. Talking that way felt uncomfortable and was put behind us.
The perspective of relationships was a natural consequence of this moving out. That
meant we understood that what people did and said being related to what other did and said to
them. The individual perspective, that means that what people said was related to what went
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Reflecting Talks 429

on inside them, came in the background and was given up. We became more interested to
look for what the spoken was related to in the moment of speaking, rather than searching for
explanations inside people. Therefore we stopped asking questions that started with why.
Instead it was more natural to use; who; when; where; what; how and if. Combinations of
these might make questions very powerful; when with who?; how with who?; if not with him,
who with? etc.
From either or to both and became a dramatic practical and philosophical turn. In the
beginning of the 1980s we were influenced of what was common at that time, namely to give
interventions. Most therapists thought that when the way people handled their problems did
not reduce them or even them, their failed attempts of solving the problems actually
maintained them. Many therapists still think this way. However, it is often difficult to let go
are the answers to the two ‘big’ questions; ‘what is this?’ and ‘what shall I do?’ An answer to
the first one might be; ‘our problem is that my husband is too stubborn’, or the answer to the
second might be; ‘it is of no use to speak, therefore I have stopped to talk’. There were such
answers, namely meanings and opinions, we ‘attacked’ with our ‘interventions’, and we could
say; ‘instead of what you have thought, we have thought this’, or ‘instead of what you have
been doing, do this’! Hopefully we said it more shaded, but in principle we ‘intervened’ like
that. It felt increasingly uncomfortable to be with people that way and there were often
tension in the room. In hindsight it is easy to understand that they rejected our interventions;
we actually told them how they should live their lives.
Some time in the fall of 1984 we started to say; “In addition to what you have thought,
we have thought this,” and “in addition to what you have tried to do, might you consider to
try our idea of what to do?” The discomfort and tension in the room almost disappeared. The
shift from “instead of” to “in addition to” might seem small, but is actually to go from either
or to both and, or from giving a request to point to a possibility.
Changes occurs from within and not from outside as we believed, maybe without being
fully aware of it. A box on the ear which was still burning, and made thoughts about change
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emerge. When I was offered a professorship at the university in 1976, that position was a
starting point for a group of seven; a psychologist, three psychiatric nurses and three
psychiatrists. The group was to meet people with psychiatric difficulties in the room of the
first line services and work with them. These services comprised general medical doctors and
social workers in the local community. We hoped that we could reduce the admission to the
mental hospital in town. The psychiatrists in charge at the mental hospital did not like it and
wanted it to be adapted under their charge. However, the project that needed the seven of us
to work as freely as possibly, was supported and also funded by the federal government. The
local authorities could not reject the federal funding and the project became real, without the
psychiatrists blessings. When the project period of three years ended in turned out that the
admissions to the hospital had decreased, and the first line services, which liked the
collaboration with us wanted us to continue. The authorities asked the psychiatrists at the
hospital for advice, and after having their advice the authorities turned down the project. It
was clearly a box on the ear, and I deserved it. Now, when the shift from ‘instead of’ to ‘in
addition to’ had occurred, I understood what I had not understood some years before, namely
that a living system; either a single person or a family or an institution, can only change from
inside by their own understanding and strength.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 430 Tom Andersen

Many believe that changes can come from outside, either through advice or order or
prohibition or threats or even coercion. We did not have that belief any more and strategic
manners in therapy had to be extinguished.
The living has to be treated as living and not as dead; ”Our attitude to what is alive and to
what is, is not the same dead. All our reactions are different.”(Ludwig Wittgenstein, 1953; #
284). Our descriptions in ‘either-or’ form made us treat families as non-living but static.
Meeting two female Norwegian physiotherapists, first Gudrun Oevreberg and thereafter
Aadel Bülow-Hansen had a significant impact on my further walk. Earlier in this chapter I
wrote: “The common was aching and tense, poorly movable muscles” (page 3). These two
learned me much about that. First; that muscles have two functions; make movements and
stop movements, and second; that all movements are related to the movements of breathing,
which are the most important movements in the body; ‘if we tense up somewhere in the body,
for instance pressing the tongue against the back side of the teeth we will notice that the
breathing movements in the abdomen stop. If we let the press of the tongue go, the abdominal
breathing becomes immediately free again.
We have muscles that have bending function, for instance those on the back of the knee
and those on the front side of the hip, and those with stretching functions are on the front side
of the knee and the back side of the hip. When these muscles, which have opposite function
are in activity at the same time the body is in balance; for instance we can stand in balance. In
certain life situations, as when we become afraid, we tend to ‘pull ourselves together’, the
‘bending’ muscles dominate over the ‘stretching ones’ and the whole body tends to ‘creep’
together. Simultaneously the breathing is constrained. Bülow-Hansen died in 2001, but
Oevreberg is in full activity. When they are described here I chose the presence forms of
verbs because, even though Bülow-Hansen has passed away, it feels like she is still present.
Tense muscles become both stiff and painful, and Aadel and Gudrun make a massage
grip of the muscle that produces a pain which influences a stretching that stimulates
inhalation that stimulates stretching which stimulates more inhalation etc until the chest is
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

filled with air. When the air goes some of the tension in the body disappears. The breathing
movements, and not the massaging hand, exhale away the muscle tension.
When this happens the two encourage the person “to let air come”. It is like hearing, “let
life come”. They follow carefully how the breathing movements respond to the massaging
hand. If they see that the breathing excursions increase and also that the air goes, they are
satisfied. If their hands are too carefully there will be no breathing response. But if the hands
are too abrupt or too strong or hold too long there can be seen a big inhalation, but it is not
followed by any exhalation; the breathing stops. If so happens they let their hands
immediately go. These observations were formulated in principles that were taken straight
over to the field of psychotherapy; if our contributions in psychotherapy are too close to how
our clients talk, little happens. If however they are ‘appropriate’ unusual, life comes to the
conversation. If our contributions are too unusual, for instance that they make people fearful
or create pain, the flow of the conversation stops. We must therefore carefully watch their
way to participate in the talk to see if it is of value or not, which means how they respond to
what we say.
Gudrun and I made a book of Aadel’s work; we first filmed her in action, thereafter
transcribed all that happened during her time with the patients (Øvreberg, 1986 in
norwegian). She was send the manuscript as it unfolded, read it carefully and expressed often
in surprise; ‘it is so interesting to read because I did not know that I was doing this’, which
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Reflecting Talks 431

made us say; ‘that is why we write.’ Her words reminded us of Ludwig Wittgenstein, 1953, #
66; ”Consider for example the proceedings that we call “games”. …... What is common for
them all? – Don’t say: ”There must be something common, or they would not be called
’games’ ” – but look and see whether there is anything common to all. – For if you look at
them you will not see something that is common to all, but similarities, relationships, and a
whole series of them at that. To repeat: don’t think but look!”
Her eyes and hands worked well together and they seemed to suffice without the
thoughts’ help. She had such great sensitivities for connections, for instance how the person’s
body she worked on responded to her working hands. An other citation of Wittgenstein seems
to fits well what she was doing; ”…. And we must not advance any kind of theory. There must
not be anything hypothetical in our considerations. We must do away with all explanation,
and description alone must take its place. …. ” (Ludwig Wittgenstein, 1953, # 109)
She had six rich years of collaboration with the famous norwegian psychiatrist Trygve
Braatøy until he died in 1953. They were both interested in the breathing functions, and
sometimes he asked her to investigate this or that on this or that person; “… and come back to
me and tell what happened!”. Other times he said; “I lie down and I want you to do this or
that on my body, and will tell you what happens”. It was a fascinating research design, and I
believe Wittgenstein would praise them; ”The aspects of thing that are most important for us
are hidden because of their simplicity and familiarity. (One is unable to notice something –
because it is always before one’s eyes.) …. ” (Ludwig Wittgenstein, 1953, # 129).
Working on the book took place in the period 1983 to 86, and I believe that Bülow-
Hansen’s sensitivities ’contaminated’ us such that either-or was left and both-and came in its
place, and we became ready in March 1985 to bring an idea to life. That idea had emerged in
1981, under the Milan team’s first summer conference on the small island Montisola on Lago
d’Iseo in northern Italy; “how come we left the families during a meeting and went to our
closed room to discuss the ‘intervention’ we were to give them? How come that we did not
remain in the room to discuss with the families present and listening to our discussions?
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Maybe our way to discuss the situation could be of value for them?” I mentioned the idea to
Aina Skorpen whom I worked with, but we did not dare. We thought, and actually were
convinced that we might hurt or humiliate as we thought we would talk openly as we did in
the closed room without the families present. There, in the closed room, we could say; “what
a talkative man …”, or “what a stubborn woman …”. In addition it also felt uncomfortable to
be separated from the families and talking about them in a way just illustrated. The idea
hibernated three and a half year, until a Thursday afternoon in March 1985, when time was
ripe.
To open the room and let our thoughts be given freely was suggested in a meeting where
a young psychiatrist, Trygve Nissen, talked with a mother and a father in their fifties and their
daughter, in her thirties. The mother had been in dark shadows for a long while and had been
hospitalized several times, some of them because she tried to commit suicide. We, Magnus
Hald, Eivind Eckhoff and myself were behind the one-way-mirror following the rather sad
conversation between the family and Trygve; they had difficulties in seeing any future.
Suddenly I discovered that there were double set of microphones and loudspeaker, one in
their room and one in ours. We had been working in the rooms for almost a year without
noticing this.
I asked Magnus and Eivind if they could think of ….. , and they said yes, and I went to
the door of their room and asked if they would be interested to listen to us talking about the
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 432 Tom Andersen

talk they just had had. There was a hidden wish that they would say no, but they said yes. In
the moment I closed their door Trygve stood up in order to follow me ‘behind the mirror’, as
we had done up to this day, but I said: “No, you belong here now!” The look on his face made
me think that he felt betrayed and left alone, but I felt right for him to stay with the family.
Their loudspeakers were turned on, ours off. Their microphones were turned off, ours on.
Their light was turned off, ours on. I can still hear the clicks when the neon light came on, and
thought; what have I done? The others’ eyes were big, filled with fear. Mine looked most
probably the same. When we talked we followed a form we later have had; we started to
repeat some of what they said; ‘all was difficult’ … ‘no energy left’ … ‘where will this end?’
Thereafter we talked in a questioning manner; ‘maybe the situation has taken all their energy?
… maybe there is no energy to search for possibilities? … if a day comes when the energy
came back? … how could they search? … is there any that could provide an advice? … ”
Light and sound was turned again, and on the other side the family talked lively with Trygve
of what they thought they might do during the Easter holidays … they even saw further into
the future.
Some thoughts came crushing in; ‘this is something totally new’; this must be done from
now on’; ‘it was very easy to talk without hurting or humiliating’. The closed room and the
closed talks, were left forever.
The conversation creates the system, not the opposite. Trygve belonged to the
conversation about the difficulties. This conversation made up one system. We belonged to
the conversation about their conversation about the difficulties, a different conversation and
another system. When Harry Goolishian, when he spoke of the ‘problem created and problem
resolving system’ on his first visit to North Norway in June 1985, he gave formulations for
what we had felt in our bodies some months before. He spoke of a ‘language-system’, and
what he thought of was that a difficult situation attracts attention from those who want to do
something. When those persons talked with each other they tried to find answers to the two
questions what is this? and what can we do?(or how can we go on?). Talking with others aim
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to find answers. The system was not any longer a static structure, as it could look like when
we drew a ‘family map’, but constantly shifting constellations related to what we talked about
and not at least how we talked.
After the happening in March 1985 spontaneous changes occurred; new forms introduced
themselves and became ‘natural’. We did not talk with each other behind the mirror as before,
when we tried to find one intervention. Instead, each of us listened quietly and noticed what
happened with us when we listened. When we reflected on what we had heard, there were
many and different comments.
For a period we thought of how our reflections affected those who listened, either it had
‘a good effect’ and talked correspondingly ‘strategic’; ‘if mother does a bit more of that, what
will happen?’
During a three year period we formulated our metaphors. In a family a father worried for
what might happen because his wife and teenage daughter had started to search for new ways
of living and a new language, as he preferred to be back home and hold on to the old habits.
In the reflection one could hear; ‘I had an image of some being out finding and picking
flowers and brought them home, and there was one at home to receive and keep the flowers,
which after a while became a big and beautiful bouquet’. In another conversation there was a
couple in difficulties because she, inspired but eastern philosophy to reach for the possible
beyond what she saw, and he, inspired by western pragmatism, did not connect with each
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Reflecting Talks 433

other. One reflection was; ‘I saw a high sky with two bright suns, one came from east, one
from west, and both lightened up and warmed.’ Such reflections certainly created changes but
a gnawing feeling of discomfort followed. As I see now, in hindsight, by using our metaphors
we made ourselves too central and influential. That way of working created a discomfort that
made us stop using our metaphors, and only stick to the metaphors of those we met with.
Our ambitions have always been to keep our own experiences and stories on distance. If
we had given ours we would be too central and significant. Our ambitions have always been
to stay as peripheral as possible and as bypassing as possible; which means quick in and
quick out, and only speak of and reflect on what they say. Another big spontaneous change
was that we listened more and talked less.
Descriptions and understanding occupied our thinking all the time. We wanted to
describe and understand our own practice, and we thought that our way of understanding,
(which was called ’epistemology’ and as we thought of as a kind of filter inside our heads)
contributed to and formed our descriptions. We called on Gregory Bateson’s circular
‘epistemology’ and language (that human beings influence each other mutually), thereafter
‘constructivism’ (we are active constructors of our descriptions) and its engineer language,
thereafter ‘social constructionism’ (descriptions are created through conversations) which
itself, in spite of its great enthusiasm for daily language, had a pretty intellectual language and
hard to comprehend.
We organized big conferences in the Nordic North and invited central ‘epistemologists’
to describe our practical work, which was presented on video films, by their languages; for
instance Humberto Maturana, Ernst von Glasersfeld, Heinz von Foerster, Stein Bråten, Lynn
Hoffman, Fredrik Steier, Kenneth Gergen, Jan Smedslund. It was not easy to fulfill our
wishes and we had to revise our basic assumptions and continue with the assumption that
practice, which means to participate in the reality (by help of one’s expressions) comes first,
where after the description of that reality comes by itself.
“You don’t know what you think before you have said it.” was one of many of Harry
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Goolishian’s grains of gold. He was the first to leave the engineer language, and we followed
him. Words like ‘structure’ became too static and ‘coordination of actions’ too mechanic. We
had bluntly to put expressions in the center, and let practice come before theories and
understanding. By that we left the traditional academic way where theory comes first from
which practice should be derived.
In our practice we now met less prepared. At the beginning of a meeting we first had to
clarify who wanted to talk and who wanted to be silent. Also what they wanted to talk about,
and never speak of any other. Making plans before a meeting which had done before had to
be given up.
The talk in advance of the reflecting conversation is the most important. As mentioned
before is of greatest significance that those we meet determine what we shall talk about, and
how.The person who is most eager to start talking, starts. Thereafter the others come, one by
one. It is important that they undisturbed chose their own words and expressions to describe
what they want to describe. Undisturbed means that we avoid to interrupt and also wait to
speak until the other is ready with the pause that comes after her or his talking and during the
pause re-think of what they said. It happens that some member in a family interrupts the
speaker and talk simultaneously. Then we avoid interrupting the interrupting person. When
the interruption is finished we continue to talk with the person we talked to. If the other
interrupts once more, we might say to the person we speak with, “I understand you have more
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 434 Tom Andersen

to say, but at this moment this person also want to speak. May I speak with her for a moment
and then come back to our talk?” Until this day all have accepted that.
During a talk I constantly remind myself on; ‘Don’t be so occupied with understanding
what they are talking about! Concentrate rather on how you yourself shall go on! It is the best
if you look for who at each moment is most eager to be heard, and look for what is said
affects the others’.
It may suffice that the other can speak undisturbed, without me contributing so much. I
must all the time remind myself that when the other speaks, she first of all speaks to herself.
When she listens to her own description she can peacefully think it over, and maybe change
it, for instance strong opinions, as she speaks.
I am not occupied with finding a new story or finding a new solution. All that comes by
itself when people are given the chance to search through their own words and own
expressions. I am neither occupied with causes nor explanations. The words and expressions
which are used to make descriptions are therefore of central interest in this work. The
following sketch and text shows what is central.

THE SKETCH
The person to the left talks to the person to right. The listener not only listens to every
spoken word, but does also look how the speaker receives her own words. The listener will
notice that some of the spoken words are not only heard by, but also touch the speaker. The
speaker’s responses to the touches can be seen and/or heard; sometimes as a shadow moving
over the face or hands that open and close or a cough or a tear or a sigh or there can be a
pause etc. The listener understands that the word carries a meaning that makes the person
relive what she has experienced before, without the listener understanding what that was. The
conversation has brought the person back to the movements of the moments when what she
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

now relive was experienced. Not seldom the listener is drawn into the feelings of experience
and get moved by seeing the person being moved by her own expressions. Those moments,
when both are moved, are good moments to investigate what was said that moved the other.
Widening up or making nuances in those expressions may contribute to a changed
description and understanding, or new ideas how to go on from this difficult moment to a
hopefully less difficult next moment. Some words touch so strongly that they shall not be
investigated. We must therefore look carefully how the words touch. To be sure that the
person is ready to investigate the words we want to investigate, it is often useful to ask some
general, ‘superficial’, questions; ‘you mentioned the word … is that a word you often use?’
or; ‘you mentioned the word … is it a big word or small word?’ or ‘you mentioned the word
… does it feel well to speak of it? If it looks easy to answers these ‘superficial’ questions I
think the person is ready to investigate. If they hesitate or say; ‘I dislike that word’ or in other
way indicates that they do not want to stay with the word, I refrain from continue.
One example may illustrate. Mary, who had been sick and tried to take care of herself .
(T: me, M: Mary)
T: How do they .. your family .. see you? Do they see you as a person who should never
ask for something .. or do they see as a person who deserves to ask for something for
yourself... How do they see you?

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Reflecting Talks 435

M: I am not sure.. I.. uhm.. I don’t think that they look in terms of that.. I think that.. you
know.. look at.. I guess that the family I grew up in.. we were supposed to be self-reliant ....
independent was the big word in my family … Self-reliant? What? Independent? (nods) yes.
Independent was the really big word. And.... You know I feel that I got the message there. I
am sorry, You feel that... I feel that I got that message there... right .. and I feel that that was
something I did really incorporate in my life............... I have ..no... as soon as they were not
responsible for me, it became... there was no longer an issue, I mean they don’t talk of that
any more, you know.. ..but it is still there..
The word independent had been mentioned two times, and as she said and heard the word
the voice went down, and a sad look came over her face. It was as if she was hit and moved
by the word. I determined to investigate that word, but had to wait since she wanted to say
something first. Then asked;.
How was that word independent expressed? Was it in the open or was it implicit? Or..?
How was it expressed? Well .. it was verbally Verbally? The word independent? Yes In the
way you should be independent or independence in general, or..? We should be independent.
They wanted us to be independent .. and ..... we should be independent. They wanted us to be
independent .. and .....
So how... along the route when you came to be acquainted with the word and let that
word be part of yourself .. what do you see in that word if you look into the word
independent? I don’t like it. I personally don’t like that word very much. Partly ... (she starts
to move on the chair) Do you see thing that ... say more, what don’t you like when you see
into the word, or look into the word? Well I see (she starts to cry)...talking about loneliness is
so hard for me...you know I just...this was something I tried to not to think too much about ..
uhm... I guess the word independent does mean staying alone... and for me that is gotten to be
lonely... being alone ...... uhm ... that’s what the word... we used to talk about being
independent and I finally said; don’t use that word about me anymore. It is reinforcing
something that I really don’t like. Having to do everything myself. Having to ... I have always
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felt it has been forced on me... for me ... what I would like to do is just...I don’t think
independent is a virtue. I don’t think so at all. I mean staying alone ... uhm .... (she is slightly
bend forward as if she falls together and one hand holds the other hand.) Having to cope with
things myself... uhm ... .I just don’t.. I don’t think... I don’t think I treat other people like
that... but I treat myself like that ... I feel that I treat other people as ... I try to provide support
at least when I can... When it comes to me I ...it’s like I don’t seek support...instead of ...
maybe I do ... I think about a year ago I finally realized that thing independence about me ... I
constantly used that to describe me and I finally ... I am not independent, no I am not
independent like you think I am ... I may have grown up with the idea that I should be, but
that is not what I believe in now ... (she stretches her back and moves her hands to the sides
and opens the upper part of the body again) ... I believe that people shall be supportive, I
believe in being co-operative. You know always strong all the time. So that is something that I
feel I ... it is really worth for me coming here and talking about things I wouldn’t talk about.
If your mother was to look into the word independent, what would she see?
She would see strength … And you father? Also strength (she paused for a while and
laughed) … that was interesting, because he will see another kind of strength than my mother
… And your sister? She will see what I see.
Two questions above were important; 1) ‘How was it (the word independent)
expressed?’, and 2) In the way you should be independent or independence in general, or..?’
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 436 Tom Andersen

The way she answered indicated that she could stay with the word and was ready to
investigate the word. If she had answered the questions in a way of disgust; ‘that word
destroys me’ or ‘I hate that word’, investigating it would not have happened.
Another example was a meeting where the mother, the father, their son of seven and the
local therapist were present. The mother had just said that the father got easily irritated and in
such situations hit his son. Therefore to the father: ‘So you also hit him?’ ‘Sometimes’. There
became a silence in the room and I had to look carefully to see if the father closed off or was
willing to go on: ‘How do you beat?’ ‘When he does not behave well’. ‘How do you beat?’ ‘I
beat.’ ‘How do you beat him?’ ‘I beat’. The boy was very restless at this moment and sat on
his knees on the floor with his back to us. I continued to ask the father: ‘Do you use your
hand?’ He lifts and looks at his right hand. ‘Do you hit with an open hand or a closed hand?’
‘I don’t know.’ ‘What do you think you do?’ ‘I don’t know.’ I turned to the boy who now was
on his knees with head and arms on the chair: ‘When your dad hits you, does he hit with an
open or closed hand?’ And I opened and closed my to help him understand the question, and
he indicated with his closing and opening hand that the father did both. The boy was at this
moment very uneasy and answer in high pitch voice: ‘I can stop his hand now ... I don’t mind
..’. I said to myself in an inner talk: ‘I mind, but maybe this talk is too tough for the boy. Shall
I stop it? Maybe I could talk with mother to learn if this was too hard for the boy? It is
important to come through this, so we go on, but you are responsible now (I told myself)’.
The boy was asked: ‘What hurts you the most? The open hand or the closed hand?’ ‘The
closed.’ Then back to the father as I moved my closed hand through the air: ‘When your hand
is on its way to hit, if that hand could stop and talk, what would the words be?’ He did not
understand the question and it had to be repeated several times until he finally said: ‘Stop
what you are doing because that is not what you shall do’. ‘And, how would you say it?’ He
needed much time and this question was repeated even more until he said: ‘I will say it
clearly .. calmly .. with conviction’. During this talk where the father was brought back to the
hitting moments, it was extremely important to go slow and all the time see if he followed the
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movements of the talk or stopped. At the same time, when he was back in the hitting moment,
he could take part in investigating other expressions than hitting.
It may be useful to talk of the reactions to what has been expressed by somebody in the
meeting. A thirteen years old girl, her mother, aunt, grandmother and local therapist was
present. The therapist wanted the meeting because she and the family did not know how to
proceed. The mother was very much in favor of the local therapist’s proposal of including
me.
There was much noise and uneasiness from the very first moment, and the mother said as
she came into the room; ’It is important that all of us are here.’ The grandmother walked
restlessly back and forth in the room and gave an impression of feeling uncomfortable. The
aunt said: ‘I am just the driver.’ The thirteen year old and the aunt laughed strongly at a
couple of occasions, and following this laughter carefully it could be noticed that it came as
an answer to something the grandmother said, particular when she said something unclear: ‘I
don’t know what I shall do here.’
Here I felt responsible to answer these expressions; 1) the mother saying it was important
that all were there; 2) the grandmother uneasiness and restlessness; 3) the strong laughter; 4)
the aunt saying she was only the driver. There became four short talks around these
expressions. The first was repeating the mother’s word to indicate that she was heard. The
next was to answer the grandmother’s uneasiness, which according to the mother’s saying
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Reflecting Talks 437

was related to the grandmother being persuaded to come, without wanting it. I asked the
grandmother: ‘Do you think they will accept if you sit quietly and listen for a while?’ She
found that possibility useful and the mother, the grandmother’s daughter, accepted. The story
they told was very sad; many violent men that left the women after long periods of these men
expressing themselves brutally. Finally the grandmother wanted to talk and the laughter rose
as she talked, and the noise of the laughter made it hard to hear what the various tried to say. I
therefore turned to the therapist and said: ’When we have talked I have noticed a laughter in
the room, even what we speak about is very serious’. The therapist had noticed the same, and
I asked her; ‘If this laughter could speak what would the words be?’ The therapist became
uncertain and I asked her: ‘Would there be happy words or sad words?’ Without hesitation
she said: ‘Sad words’. ‘Are the words so sad that we shall not speak of them?’ ‘I don’t know,
‘I use to be protective of her (the granddaughter)?’ I you don’t speak of these sad things, how
can you proceed?’ ‘That is the impasse! That is the impasse!) The granddaughter broke the
silence and said ; ‘ We can not put it under the cover any more, just to protect my
granddaughter. We must get it out in the open and talk about it!’ There was a big silence and
the grandmother spoke of her having cancer that all knew about but could not talk about. Now
they could.
What I never speak of are all the bodily expressions that are not followed by words. I
would never from the other’s expression of the face say: ‘you look angry.’ It is better to ask:
‘How are you?’
It is the most safe to speak from what the others say.
The reflecting talk may have different forms and styles. They can be formed of one
person to a full audience. All can happen in the same room, but the family and therapist can
be separated from the team with a one-ways screen. When the team reflects the family and
therapist swap room with the team, and after the team has reflected they swap back.
Up here north we often have a team of two, and we don’t use one-mirror any more. One
of the two talks with the family, and the other only listens. When the family has told what
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they want to be heard, the two in the team turn to each other and talk about what they heard.
Before an eventual reflecting talk we always ask the persons, for instance the family, if
they would be interested to hear ‘what those who have listened have been thinking when they
heard our talk.’ If the therapist is alone she can say; ‘Out of our talk some thoughts have
come to me. Do you want to hear?’They shall always be asked, because it happens that they
have had enough of the talk they just finished.
If they want to hear they are encouraged to do what feels best; ‘either 1) listen, or 2) let
the thoughts go other places if that feels best, or 3) just rest, or 4) do something else’. It is
said in this way, and ‘rest’ gives the possibility to neither listen nor ; ‘something else’ gives
the possibility to leave the room or interrupt or protest etc
I have noticed often that this orientation is left out, which I regret.
When all happens in the same room, those who are to reflect are encourage to talk to each
other, that means that ‘you don’t speak to them (for instance the family) or look at them when
you talk. If you do so they are forced to listen to you and can thereby not let their mind go
other places if that feels best’. I have very often noticed that many therapist do not encourage
this. Up here it is usual that those who are to reflect have the sketch, shown above, in mind;
we reflect on the words we saw were important words for the various persons. When we
reflect we start with repeating what we heard and what we later will reflect on. In this
summary it is important to use the words that were used in the talk. I think that the person
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 438 Tom Andersen

who spoke the words by that is brought back to the speaking moment. The person who spoke
the words and now is listening to the reflecting talk will most probably feel that her
expressions were heard and acknowledged.
We underline strongly that reflections should be on what was said, and not on what the
reflecting person thought about that what was said. The reflections relate only to what was
said in the talk, and not from something that happened in another context, for instance the
reflecting person’s life outside this talk. The reflections come in a questioning manner.
Opinions are avoided. Judgments and categorizations must not be given.
After the reflections the family, or those who listened, are always asked: “Would you like
to make any comments, or do you prefer to keep your thoughts for yourself?” An example
will hopefully clarify. The relationships between Anna and her husband Peter was tense and
in danger. She disliked him not giving enough attention to her and their two children. He
rather preferred two have a glass of wine or look at TV or read the newspaper when he came
home. That made her very angry. He excused himself for having ADHD (attention deficit
hyperactivity disorder) and he hoped that ‘a magic’ pill’ could ‘unlock him’. In these
speaking moments he put his hand behind his neck and tried to stretch the upper part of the
body. He repeated intensively the word ‘unlock’ several times. She said he could pull himself
together and said that her anger filled all her awareness; ‘I am angry all the time, I don’t think
of anything else’. She talked angrily and look at him as she talked; ‘Maybe I have my anger
from my father. He could be very furious’. Then she told laughingly about her father’s anger
when she was thirteen years old: ‘He had a jar … filled with pickles and he loved pickles … it
was his, and only his … one day somebody pushed the jar and it fell to the floor and crushed
… my mother run out in the street and found a new jar and filled it with pickles and we were
all relieved … but when he came home he saw that the jar was not his jar, so he took the new
car and crushed it to the floor …’ She laughed much, and Peter smiled and said that he could
understand that Anna was angry and he wanted try to change what made her angry. But he
also repeated that he hoped that the ‘magic pill would unlock’
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Parts of the reflections that followed were: ‘I heard two big words … anger and …
unlock … and Anna said that anger fills all her life … she cannot think of anything else … I
wonder is it only anger in her anger or are there other feelings in the anger as well?… if there
are, which colors do they have? … are they warm or cold? … and here father who crushed the
new jar … had he noticed how much they had try to do to replace the first broken one? …
maybe his anger made him blind so he could not see what they had try to do? … and Peter’s
wish to unlock … he hope so strongly that that will happen … but if the unlocking happened
and he actually was unlocked, what would he see? … should one think of that unlocking not
necessarily is a wise thing to do? … who should be with him to give him attention if he
unlocked the word ‘unlock’? Peter wondered what might happen if he ‘unlocked’, and Anna
said; ‘we assume that change is a good thing, but it is not sure that everything will be pinky
after unlocking … you must be ready to do … you might open more doors and reach into pain
… you must be ready’.
Their relationship was less tense after the meeting and they came closer to each other in
many ways.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Reflecting Talks 439

ASSUMPTIONS ABOUT REALITY, LIVING HUMAN BEINGS,

AND LANGUAGE.

What I write here is very condensed compared to the sources it refers to. The written
sources have been Ludwig Wittgenstein (Wittgenstein, 1953, 1980; von Wright, 1990, 1994;
Grayling, 1988; Gergen, 1994; Shotter, 1996), Lev Vygotsky (Vygotsky, 1988; Morson, 1986;
Shotter, 1993,1996), Jacques Derrida (Sampson, 1989), Michael Bakhtin (Bakhtin, 1993;
Morson, 1986; Shotter, 1993,1996) and Harold Goolishian (Anderson, 1995).
The collaboration with physiotherapists over the years, especially meeting Aadel Bülow-
Hansen and Gudrun Øvreberg has had major influence on the development of these ideas
(Øvreberg, 1986; Ianssen, 1997). The sources have also been my own experiences to put
these assumption into pratice. Participating in a number of reflecting processes in very
different circumstances have been significant in formulating these ideas. These processes are
open conversations where questions and answers come from all the perspectives that are
present (Andersen 1995).

A Few Assumptions about Reality

Reality comprises three parts; 1) the visible but non-moving, for instance a bone in a
hand; 2) the visible and moving, for instance the hand that in one moment opens and let go,
and in the next moment closes and holds on; and 3) the invisible but moving, for instance the
handshake. We can explain what the bone is, but we can only explain what the hand might be.
The handshake we don’t know what is, but that is not so important as long as we know how to
related to it.
Some will say: ‘I know what a handshake is; it is a meeting between two hands!’ But
where does the meeting take place? In the skin? In the touches against the bones? In the looks
that follow the handshake? 1 and 2 can be described so that the thought can grasp it, and 3 can
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only be experienced by the body. The descriptions of 1 will be best done by using numbers
and nouns, as descriptions of 2 will benefit of verbs, and in our attempts to describe 3 we will
be most helped by using metaphors that help us feel what we are in touch with.

A few assumptions about human beings.

The first we do in life is to breathe in, in sacred words; spirit in, before the first scream
comes. The last we do in life is to pass out; let the spirit go. Between the first spiriting in and
the last spiriting out, the breathing goes; inspiration following exhalation following
inspiration following exhalation and so on When something happens to us the movements of
inhaling are affected; ‘I lost my breath’, ‘ I gasped’, ‘I got a lump in the throat’, ‘my stomach
aches (when the breathing movements in the abdomen stops)’ etc. The exhaling movements
assist many of the expressions, for instance the feelings and the words that are the reactions to
what we feel, and they can be, talking, laughing, crying, shouting and so on. The child’s first
scream is an answer of meeting the chill reality ‘out there’; it was warmer and more
comfortable inside the mother’s womb. Those who are around the child receive the scream
and give back what the child need in order to stop screaming. Bakhtin thought of life being a
constant ‘answering’ activity; the one’s expression is an answer of the other’s just given

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 440 Tom Andersen

expression, and he said; ’The soul is a gift that my spirit bestows upon the other’ (Bakhtin,
1990, p. 132).
For me therefore, the soul is the meeting place where the one’s expression (spirit) is
received by the other and answered by the other’s expression (spirit). One’s contribution to
the soul, that is situated between the one and the other, is to receive and respond to the other’s
expression. Sacred and serious.

Ten Assumptions about Language

1. Language is here defined as all expressions, which are regarded to be of great

significance in the mentioned communal perspective. They are of many kinds, for
instance, to talk, write, paint, dance, sing, point, cry, laugh, scream, hit etc, are all
bodily activities. When these expressions, which are bodily, take place in the
presence of others, language becomes a social activity. Our expressions are social
offerings for participating in the bonds with others.
2. We need the expressions to create meanings. If one of the kinds of expressions, for
instance the words or talking is not available, another kind of expression, for
instances painting could make the creation of meaning possible.
3. The expressions come first, then follow the meanings. Meanings are created. Harry
Goolishian used to say: ”We don’t know what we think before we have said it”.
4. The meaning is in the expression, not under or behind. The meanings in the
expressions, as for instance in the words, are very personal, and some of the words
will, when we hear them, bring us back to and re-experience something we have
experienced before.
5. The expressions are informative, which means that they tell something about us to
others and also to ourselves. At the moment, I think that when I speak out loud, first
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

of all I speak to myself. Since the words I express are so strongly connected to my
understanding, I may, by listen carefully to what I say, investigate my own
understanding. The expressions are also formative: we become those we become
when we express ourselves as we do it. It would be more appropriate to say;
”grandfather did always something kindly, so he became kind all the time”, instead
of saying ”grandfather was kind” or ”grandfather had so much kindness”. By using
the verbs to be and to have without including time and context one can easily be
bewitched by one’s own talking to believe that the described is static: ’grandfather is
kind’; he has that character, or; ’grandfather has much kindness’; he has a kind
personality. When we talk such to ourselves we can easily be supplied with the ideas
that a human being both have character and personality.
6. The expressions, both in the inner and personal talks and those in the outer and social
talks are accompanied by movements. Those who follow the inner talks are smaller
and nuanced, as those that follow the outer talks are bigger, for instance waving
hands Sometimes both therapists and researchers misunderstand when they say that
the spoken does not ’match the body language’, for instance when somebody says
with a sad look on the face; ”I am so happy”. I see it such that the words ”I am so
happy” is the social offer to the bonds with the other, as the sad look on the face
belongs to an inner and most probably sad talk which the person most probably is not
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Reflecting Talks 441

interested to tell the other. Therefore, as long as the other does not wish to tell from
his inner talk I see it as ordinary politeness neither to see how the inner talk is
presented in the bodily expressions. According to that it should be a running
challenge for the therapist and researcher to evaluate which of a person’s expressions
are offers to his participating in the social bonds and which are not. Laurence Singh,
a psychotherapist and participant at a workshop I held in Johannesburg, march 2001,
offered me a phrase, "a social offering," to describe those expressions that
contributes to a social bond, different from the expressions that are personal and not
meant for a social bond.
7. The movements of the expressions, not at least the breathing movements, which form
and bring forth the inner and outer voices are personal. The breathing movements are
as personal as finger prints. Lev Vygotsky said: ”We are the voices that have
inhabited us” (Morson, 1986, p 8). Maybe one could nuance that to: ”We are the
movements that form and bring forth the voices that have inhabited us.”
8. In his time Heraclitus said, ”Everything is in change, but the change happens
according to an unchangeable law (logos), and this law comprises a mutual interplay
between opposites, but however such that the interplay between the different forces
makes a harmony, in total” (Skirbekk, 1980, p 29). Maybe one could dare to make
some small changes to: ”A person is in movements, but the movements happen….”
or even to: ”A person is movements, but ……..”. When we stand, and stand in
balance, those muscles that bend in the knees and the hips are active at the same time
as those muscles that stretch the knees and the hips are active.
9. When one speaks out loud one tells something to both others and oneself. At the
moment I think that the most important person I speak to is myself. As mentioned,
the expressions are formative and also forming our understanding. Ludwig
Wittgenstein and Georg Henrik von Wright wrote that our own speaking bewitches
our understanding. We cannot not be bewitched by our own speaking. When we
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belong to a community, for instance a professional community, we certainly have to

talk the language of that community. One has to be willing to let oneself be occupied
by that language if one wants to stay there. If this language uses the verbs to be and
to have without simultaneously indicate context and time, one may, as said before,
easily come to understand that human beings are static. Different kinds of language;
the language of competition, the language of strategic management, the language of
pathology etc. have all their consequences, both for those who are described and for
those who describe.
10. In 1985 Harry (Harold) Goolishian launched the concept of “the problem-created
system.” He said that a problematic situation quickly attracts many persons’
attention. The attracted persons usually makes up meaning of “How can I understand
this?” and ”What shall I do?” Two pages ahead in this chapter, Maria, who did not
want to go to school any more, will be mentioned. That is an example of a problem
that creates meanings by others, a system of meanings is created. If two or more
persons have the same meaning a talk between them will easily make them repeat
and confirm their meanings, and very little new is developed. If two or more people
have somewhat different meanings and are able to listen to each other, a talk
amongst them will easily create new and useful meanings. If two or more persons
have very different meanings, they might find it difficult to listen to each other and
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 442 Tom Andersen

may even interrupt and correct each other. When that happens not seldom the talks
break down, and if that happens the really big problem is created.
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SUMMARY
During this writing it has once again been interesting to notice that the feelings and
recognition of discomfort have been the main contributors to the change of practice. I was
also once again struck that the difficulties in speaking and writing have been to find good
formulations. The last few years John Shotter’s suggestions of formulations, when he refers to
Wittgenstein, Vygotsky, Merleau-Ponty and Bakhtin, have been helpful, and I end with
encourage the reader to pay attention to his website; http://pubpages.unh.edu/~jds

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Reflecting Talks 443

REFERENCES
Andersen, T (1995). Acts of forming and informing. In Friedman, S (ed): The Reflecting
Team in Action. New York: The Guildford Press.
Andersen, T (2001). Uttryckens betydelse i behandling och forskning. I: Kjellberg, E (red):
Man kan inte så noga veta… Stockholm: Mareld forlag.
Anderson, H (1995). Från påverkan till medverkan. Stockholm: Mareld forlag
Bakhtin, M (1990). Art and answerability: Early philosophical essays. Austin,TX: University
of Texas Press
Bakhtin, M (1993). Toward a Philosophy of the Act. Austin: University of Texas Press.
Gergen, K J (1994) Toward Transformation in Social Knowledge. Second edition. London:
Sage publ.
Grayling, A C (1988). Wittgenstein. New York: Oxford University Press.
Ianssen, B (1997). Bevegelse, liv og forandring. Oslo: Cappelen Akademiske forlag.
Kolstad, A (1995). I sporet av det uendelige. En debattbok om Emmanuel Levinas. Oslo:
H.Aschehougs forlag.
Lysack, M (2004). Reflecting processes as practitioner education in Andersen and White
through the lenses of Bakhtin and Vygotsky. Unpublished doctoral thesis at McGill
University, Montreal
Morson, A C (1986). Bakhtin. Essays and Dialogues on His Work. Chicago and London: The
University of Chicago Press.
Shotter, J (1993). Conversational Realities. London, New York: Sage publ.
Shotter, J (1996). Some useful quotations from Wittgenstein, Vygotsky, Bakhtin and Volosinov
Presented at the Sulitjelma conference in North Norway, June 13th to 15th 1996.
Shotter, J (2004). On the edge of social constructionism: ‘Withness’-thinking versus
‘Aboutness – thinking. Kan kjøpes ved å kontakte [[email protected]]
Shotter, J (2205). Wittgenstein in practice: His philosophy of Beginnings, and Beginnings,
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

and Beginnings. Kan kjøpes ved å kontakte [[email protected]]

Skirbekk, G (1980). Filosofihistorie I Oslo: Universitetsforlaget.
von Wright, G H (1990). Wittgenstein and the Twentieth Century. In Haaparanta, L et al.
(eds): Language, Knowledge and Intentionality Helsingfors: Acta Philosophica Fennica
49.
Von Wright, G H (1994). Myten om fremskrittet. Oslo: Cappelen’s forlag.
Vygotsky, L (1988). Thought and Language. Cambridge, MA: MIT Press.
Wittgenstein, L (1953). Philosophical Investigations. Oxford Blackwell.
Norsk utg (1997). Filosofiske undersøkelser. Oslo: Pax forlag.
Wittgenstein, L (1980). Culture and Value. Oxford: Blackwell.
Øvreberg, G (1986): Aadel Bülow-Hansen’s fysioterapi. Tromsø, Oslo: I kommisjon med
Norli forlag.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
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Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 In: The Quick Theory Reference Guide ISBN: 978-1-60021-624-4
Editor: Karin Jordan, pp. 445-460 © 2008 Nova Science Publishers, Inc.

Chapter 30

AN INTRODUCTION TO NARRATIVE THERAPY

Lorraine DeKruyf
We live our lives according to the stories we tell
about ourselves and the stories that others tell about us.
John Winslade and Gerald Monk

Counseling* in a narrative way is a way of seeing, hearing, and thinking about clients’
problems as shaped and given meaning by stories or narratives. Problems are not hard
realities that permanently define people; rather, they are problem stories by which people
know themselves and are known by. This separating of the problem from the person opens up
space for seeing the problem and thinking about it in new ways, and opens up the possibility
of authoring a better story—a better way of being and doing, and is based on what has
become a narrative mantra: “The problem is the problem. The person is not the problem”
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

(Winslade & Monk, 1999, p. 2).

HISTORY
First introduced by Australian Michael White and New Zealander David Epston about 20
years ago, narrative therapy is based on the ideas of a wide variety of postmodern thinkers
(Zimmerman & Beaudoin, 2002). Among them is Gregory Bateson (1979), anthropologist
and psychologist. His concepts about the subjective nature of reality and “news of a
difference” (p. 79) influenced White’s work with clients. He found that many clients needed
their attention drawn to the subtle changes that accompanied their work on problems. In
sharing this “news,” he found he could foster new insights about their own resourcefulness
and help them gain a clearer picture of how to move forward in a different, more productive
way (Monk, 1997). Seeing differences and drawing distinctions between one set of
experiences and another allows people to evaluate which experience is preferred. They are

*
The terms counseling and therapy will be used interchangeably in this chapter.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 446 Lorraine DeKruyf

then able to see they have the ability to choose to act in a different way (Winslade & Monk,
1999).
The story or narrative metaphor came by way of ethnographer Edward Bruner (see
Turner & Bruner, 1986), who showed that people construct stories as a way of making
meaning of their experiences, and showed that these stories will strongly influence which
experiences will be chosen for further expression and performance. In other words, people’s
stories allow them to know themselves and guide their behavior (Monk, 1997; White &
Epston, 1990).
French historian and philosopher Michel Foucault’s (1975/1979) ideas about society’s
controlling and ever present evaluative “gaze,” led White to develop a variety of therapeutic
approaches that seek to allow people to lead lives of their own design, rather than lives
confined and constrained by discourses or standards that may not fit their context (Monk,
1997; White & Epston, 1990). One such approach is the idea that the person and the problem
are separate from each other.

KEY CONCEPTS
The ideas of these and other thinkers gave rise to key narrative concepts which Wendy
Drewery and John Winslade (1997) have grouped under the headings of language,
knowledge, power, and the self. A very condensed synopsis will be given for each.

Language

“Language is not simply a representation of our thoughts, feelings, and lives. It is part of
a multilayered interaction” (Drewery & Winslade, 1997, p. 34). The words we choose
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

influence the ways we think and feel about the world, which in turn influence what we speak
about. “How we speak is an important determinant of how we can be in the world. So what
we say, and how we say it, matter” (p. 34).

Knowledge

From a narrative perspective, knowledge is “something we make—rather than something

that is given, separate and apart from us” (Drewery & Winslade, 1997, p. 48). This post-
modern making of sense “asserts that there are many truths, and that what one person holds as
sensible and true may not be so for another” (p. 49). The therapeutic implications of this
include clients being the experts of their own lives rather than the therapist being the expert
on client problems.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 An Introduction to Narrative Therapy 447

Power

In narrative therapy, “a major therapeutic emphasis is placed on helping people escape

the subjugating grasp of the dominant discourses [or standards] of the culture” (Gergen, 1999,
p. 173) that may not fit their personal context. This liberation aim is achieved by exposing or
deconstructing the discourses or ultimate truth stories that dictate how people are to live and
behave (Monk & Gehart, 2003).

Self

The self, rather than being understood as an entity inside of a person, is as seen as “a
process or activity that occurs in the space between people” (Freedman & Combs, 1996, p.
34). Therefore, “what we do matters, but we do not have full control over our circumstances.
We have a major part to play in our own becoming, but we cannot simply decide who we will
be” (Drewery & Winslade, 1997, p. 47). Note that this perspective emphasizes the influence
of context—of the circumstances of people’s lives—in producing who they can be, but also
leaves some agency or choice with the person.*
These key concepts of language, knowledge, power, and self provide a foundation from
which to view narrative therapy. They will re-emerge in the context of the ideas and
suggestions that follow.

HEALTH VERSUS DYSFUNCTION

Given the tension between the external contexts that shape people and their self-efficacy,
how does one emerge as healthy? As an alternative to the widely held Western view of people
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

as beings who can rationally control themselves and their world, Drewery and Winslade
(1997) described this possible path to health: “what most people do is muddle along, making
sense as best they can, making decisions and acting on them in the face of the uncertainty,
complexity, and novelty of the situations that are constantly arising and demanding a
response” (p. 48). Healthy people can identify and pursue preferred identities and ways of
living, and in the course of their muddled meaning making, they have the ability to forgive
themselves when the story line moves from mere muddle to malfunction (Drewery &
Winslade, 1997).
Dysfunction is seen as a problem-saturated story external to a person. Rather than the
person being the problem, the problem is the problem (Winslade & Monk, 1999). And where
do problems originate? From a narrative perspective, problems are “manufactured in a social,
cultural, and political context…, and they come together through the medium of human
language to construct and produce our experiences” (Monk, 1997, p. 27). When this happens
in people’s lives, their stories can feel like they are being written by outside forces and life

*
Note that this does not do away with personal responsibility. Although from a social constructionist point of view,
a social, rather than an individual lens is the primary optic through which humans may be understood, humans
cannot shrug off moral responsibility for the way things are in the world. We are co-constructors—“participants
in producing other people’s worlds as well as our own” (Drewery & Winslade, 1997, p. 41).

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 448 Lorraine DeKruyf

can feel overwhelmingly out of control. This is often when people enter therapy. Their focus
is on what is wrong, and their stories become saturated by the problem (Combs & Freedman,
1994). This powerfully influences perceptions. As Freeman, Epston, and Lobovits (1997)
described it, “The problem-saturated story limits perspective, edits out threads of hope and
positive meaning, and precludes refreshing possibilities and potentials. Change may…seem
impossible in spite of a person’s best efforts to take control of a problem” (p. 48).

THE CHANGE PROCESS

How do people change? Simply put, through re-authoring their stories. How people speak
and what they speak about are their tools for interpreting their experiences—for meaning
making (White, 2000). “The argument…is that these ways of making sense are susceptible to
change” (Drewery & Winslade, 1997, p. 34). When people change the ways they speak, they
can also change much about the way they organize and understand their worlds. Language
directs the attention of both the therapist and client, as well as their understanding, their
being, and doing (DeSocio, 2005; Drewery & Winslade, 1997; Morgan, 2006b; Muntigl,
2004). The implications of this have everything to do with change.
For therapists it means using language and being vigilant for life stories people would
prefer, given that we tend to find what we are looking for. When therapists view the problem-
saturated story as separate from the person and his/her preferred experiences, and use
language that communicates this, it opens up room for and can orient therapist and client
toward “inspiring histories, present strengths, and future dreams and hopes. [Gradually] the
way a problem works as a restraint to these is then brought to life” (Freeman et al., 1997, p.
49).
Change can be difficult. Language traditionally used around some of its difficulties, such
as resistance or denial, is avoided in narrative therapy—even in consultations with other
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

professionals. According to Winslade et al. (1997), these “internalizing concepts… suggest

that we know clients better than they know themselves, [and] locating ‘resistance’ in the
person of the client is a blaming response that lays at the feet of one person what has
happened in a relationship” (p. 57). When counselors invite clients to join them in examining
any restraints or ruptures between them, it is an acknowledgment that relationships are bi-
directional. Jointly examining discourses that position counselor and client in relation to each
other and to the culture around them paves the way for a therapeutic environment which
honors the client’s position as co-author of a preferred story.

THE THERAPEUTIC ENVIRONMENT

A respectful and optimistically curious orientation is central to a collaborative therapeutic
environment (Monk, 1997). The therapist is neither the expert nor a neutral participant, but
rather takes an “investigative, exploratory, archaeological position…consistently in the role of
seeking understanding of the client’s experience” (Monk, 1997, p.25). The client is an equal
partner with local knowledge that may initially be inaccessible—much like an artifact at a dig

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 An Introduction to Narrative Therapy 449

buried in centuries of soil. Together counselor and client sift, probe, excavate, dust off, and
name.
An awareness of and respect for each person’s culture is imperative (Winslade et al.,
1997). As human beings, our cultures locate us in positions relative to others through how we
talk, what we look like, where we live, and who we know (Monk & Gehart, 2003). Before we
even open our mouths we embody our cultural location—our place in society, which in turn
offers “a limited range of position for the other” (Winslade et al., 1997, p. 58).
Acknowledging and deconstructing these positions of relative power or of powerlessness are
important tasks in creating a therapeutic environment (Kogan & Gale, 1997).
Two obvious positioners include the fact that clients come to counselor’s offices and pay
for their services, thus creating an uneven balance of power (Winslade et al., 1997). The age
difference that exists between counselors and clients who are children also introduces a power
differential (Morgan, 1999). Other positioners may include race, ethnicity, gender, sexual
orientation, spirituality, or socio-economic status. All clients have need of a respectful
orientation from the counselor.

THE THERAPEUTIC PROCESS

The map is not the territory.
Alfred Korzybski

While maps are useful as guides, they are no replacement for the actual territory traveled.
This is true for any sort of therapeutic orientation as well. An orientation can provide
direction for the therapeutic process, but it is the people therapists work with who will
ultimately shape that process. Therapy is never the same twice. In that spirit the following
overview of the therapeutic process is offered.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Assessment and Diagnosis

Language shapes people’s thinking and doing (Muntigl, 2004), and therefore caution is
used when choosing words. Terms like assessment and diagnosis put the assessor and
diagnostician in a position of power, and “grant precedence to professional ‘regimes of truth’
over clients’ knowledge about their own lives” (Winslade et al., 1997, p. 56; also see
Simblett, 1997). This runs counter to seeing clients as experts on their own lives and offering
them the position as first author in the collaborative re-storying of their lives (Eron & Lund,
1996). As Drewery and Winslade (1997) have said, “people work all the time to make sense
of their own lives and…it is not up to the counselor to do this work for them” (p. 41).
Labels resulting from diagnoses generally focus on individual deficits rather than
strengths, and can powerfully influence the dominant story about a person (Freeman et al.,
1997; Nylund, 2000). Internalizing of this diagnosis label can paradoxically take a well-
intended focus on what is “wrong,” and feed into maintaining the very problem they are
trying to eliminate. Clients see themselves as being the label, as do others. “I am ADHD.”
“She is anorexic.” Other important aspects of clients’ identities, such as their skill in

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 450 Lorraine DeKruyf

sometimes managing the problem successfully, are overshadowed by these totalizing

descriptions. When the focus is on the problem, it can obscure what is right, and can limit
people’s vision-horizon for a better way (Nylund, 2000).
This is not to say that assessment is nonexistent, nor that the problem story is ignored, but
rather than a focus on deficits, the therapist will use listening and observational skills to help
develop an alternative story (Monk, 1997; Simblett, 1997). “Unlike the Rogerian therapist,
whose active listening is intended to reflect back the client’s story like a mirror without
distortion, the narrative therapist looks for hidden meanings, spaces or gaps, and evidence of
conflicting stories” (Drewery & Winslade, 1997, p. 43). To that end, Nylund (2000)
developed the SMART Rating Scale for eliciting this sort of less obvious or hidden
information from parents and teachers in his work with children diagnosed with Attention
Deficit/Hyperactivity Disorder (ADHD). “The scale is a subjective questionnaire to identify a
child’s strengths and abilities” (p. 59), and helps to fill in the deficit oriented picture typically
obtained from symptom checklists. This broader perspective can help create space between
the problem and the client, which then opens up room for noticing what is right and for seeing
possible preferred storylines. Hoyt (1994) said it well: “How you see is what you get” (p. 2).

Treatment Goals

The objective of narrative therapy is not to find a “solution.” Rather, it is to help clients
reclaim the authority to author their own stories, or as Drewery and Winslade (1997) have put
it, “to enable clients to speak from subjective positions rather than as subjected persons” (p.
43).
Problems can steal people’s sense of agency, their sense of “I can do this,” and can leave
them feeling disabled and at the mercy of seemingly immovable forces. People tell
themselves problem-saturated stories in which they are “positioned, or subjected: …not the
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

actor but the passive recipient of the given positioning” (Drewery & Winslade, 1997, p. 42).
In order to help clients reclaim authorship, “the narrative counselor looks for alternative
stories that are enabling” (p. 42), freeing clients to speak in their own voices and to work on
self-identified problems themselves.

Phases of Treatment

Even before clients meet with therapists, professional disclosure statements can already
begin to set a cooperative tone. With a narrative approach, language used in a therapist’s
professional disclosure statement will avoid claims of expert status. This does not at all mean
there is no training in or knowledge of the problem area, but there is less likelihood that the
contract will be based on an assumption of privilege because of that training or knowledge
(Winslade et al., 1997). Rather, therapists would want to present to clients their preference for
a collaborative horizontal counseling conversation, and make it clear that they “would want to
explore clients’ abilities and talents so that these [become] more available for use in
addressing … concerns” (Winslade et al., 1997, p. 62).

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 An Introduction to Narrative Therapy 451

Following is an overview of the phases that narrative sessions might move through. A
more detailed description of several pieces, such as externalizing conversations and mapping
the influence of the problem, will be given in the section on techniques.
A first session typically begins with a conversational exchange with each person
present—small talk, if you will—a start at building bridges with each member. This joining
conversation often moves into mapping the development of the problem as well as its
influence on all concerned, including those not present. This is done in an externalizing way
to help people see that “their own lives and the life of the problem [are] distinct” (Monk,
1997, p. 12). The session ideally comes to a close with client(s) and counselor aligned
together on one side against the problem on the other side. The alternatives may then be laid
out: is the preference to continue coping with the current problem story or to explore
alternatives? Between sessions, clients might be invited to focus on the ongoing effects of the
problem-saturated story and consider any events occurring that are free of those effects
(Monk, 1997; Winslade & Monk, 1999).
During session two, client(s) and counselor explore what happened since the last session
as well as prior to the start of therapy as a way of identifying any subtle shifts in the clients’
relationship to the problem. A useful question for drawing attention to these shifts is: “What
sort of thoughts or changes have you noticed since I last saw you” (M. Massey, personal
communication, March 26, 2005)? Minimal or contemplated changes are explored as
examples of the strength of the dominant story or as signs of the emergence of a new story.
Just as the history and influence of the problem story is carefully mapped, so it is with the
preferred story. Persistence and curiosity on the part of the therapist is essential, as often
clients discount or minimize exceptions (Winslade & Monk, 1999).
Gerald Monk (1997) likened the process to building a fire. First tiny twigs are found and
ignited, and only slowly and strategically can more twigs be added or the first sparks will go
out. Eventually larger sticks can be carefully added, and “soon the fire has a life of its own”
(p. 17). Monk identified the twigs and sticks as the client’s “positive lived moments” (p. 17).
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

It is the counselor’s task “to identify these favored moments and bring them into the
awareness of the client. The art in this approach lies in both knowing where to look and
recognizing the unstoried moment when you see it” (p. 17).
Setbacks are a reality and preparing the client for the problem’s attempted return is
important (Freeman et al., 1997; Winslade & Monk, 1999). Sometimes it can be helpful to
encourage the client not to overdo it (Monk, 1997). Enlisting the encouragement of a wider
audience can also be helpful. One way to accomplish this is through documenting the changes
that have occurred and drawing the attention of an appropriate audience to these changes
(Freedman & Combs, 1996; Morgan, 2006a; Winslade & Monk, 1999).
Inviting a client to become a consultant is yet another way to expand the audience, and is
a recognition of the client’s status as first author in the coauthoring of the preferred story.
This recognition of expert status replaces the “helpless, dependent person who needs to be
fixed” (Monk, 1997, p. 23), the role previously engaged in by the client in relation to the
problem. S/he has something to offer others grappling with similar difficulties.
Termination often comes about when clients find themselves living more and more in
their preferred way—the problem-saturated story no longer dominates. Instead the client is
authoring the preferred story, and the “fire has a life of its own” (Monk, 1997, p. 17). For
those times when the fire may burn low, the door can be left open for occasional future
consultations (Freedman & Combs, 1996).
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
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 452 Lorraine DeKruyf

Nature of the Therapeutic Relationship

It may be fair to say that most people entering the counseling profession do so because
they want to help others. Indeed, the group term “helping professions” has emerged to
identify counselors, therapists, social workers, and others of similar stripe. Therefore this
perhaps surprising caution from Winslade, Crocket, and Monk (1997) in their discussion of
the therapeutic relationship:

The compelling desire to be of help is one we take care to avoid in our work with clients, as it
can produce harm in the therapeutic relationship. The danger is that it will focus the counselor
on her own position of power and blind her to opportunities for helping the client to connect
fully with his own competencies and talents. In the quest to be needed, the counselor can be
seduced into seeing herself as the only competent and resourceful party in the therapeutic
relationship, the client being regarded as fragile and weak. (p. 73)

Truly believing in the agency of clients is important if counselors are to genuinely

collaborate, and not merely do lip-service to a shared responsibility for shaping the
counseling conversation. In the narrative way, counselor and client are coauthors, and as
Winslade et al. (1997) have said, “to be an author is to have the authority to speak - especially
in one’s own terms and on ones’ own behalf” (p. 55). For clients this means an ever growing
sense of themselves as major agents in producing a beneficial counseling process, as well as a
growing sense of agency in their lives outside of the counseling office. For counselors, this
“stance on coauthoring does not need to imply that we give up our authority as
professionals…, but we do endeavor to use our authority in ways that put our weight behind
the client’s preferences for agency in his own life” (p. 63).

Techniques
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Narrative therapy does not follow a formula, nor is it so much a collection of techniques
as a different way of thinking and seeing, yet there are “techniques” that have come to be
identified with the narrative perspective. Some of the more commonly followed narrative
approaches or techniques follow. The listing is by no means exhaustive.
Counselors working out of a narrative perspective still use basic counseling skills, but
sometimes for different reasons. Questions, for example, are composed and used to
“…generate experience rather than to gather information. When they generate experiences of
preferred realities, questions can be therapeutic in and of themselves” (Freedman & Combs,
1996, p. 113; also see Zimmerman & Dickerson, 1996, pp. 303-306, for sample questions).
Listening, reflecting, summarizing, and paraphrasing are all used to invite clients to hear their
own stories—to be an audience to their own life stories. The telling of their stories opens a
door for the development of a new relationship with themselves and with their stories
(Winslade et al., 1997).

Externalizing Conversations
One of the ways people develop a new and different relationship with themselves and
their life stories is done through externalizing problems. Externalizing seeks to separate

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 An Introduction to Narrative Therapy 453

people’s sense of identity from the problems for which they are seeking help, and is a way of
seeing and then speaking that indicates and invites respect for “people struggling to develop
the kinds of relationships they would prefer to have with the problems that discomfort them”
(Roth & Epston, 1996, p. 149).
To help therapists start thinking in an externalizing way, Morgan (2000) suggested
imagining the problem as a “thing” perched elsewhere in the room—perhaps on the shoulder
of the client, perhaps on a separate chair. Talking about the problem starts with listening
carefully for clients’ descriptions of their problem experiences. A client may talk about
feeling alone and depressed. The therapist may ask, “How long has the Loneliness been
influencing you?” Asking questions where the verbs or adjectives clients use are changed into
nouns helps separate the problem from the person, as does putting “the” in front of the
capitalized problem name. “How does the ADHD influence your child?” “Where has the
Fighting taken your relationship?” Other useful and even playful ways of externalizing the
problem that can be particularly useful with children include giving it a name of its own or
drawing a picture of what the problem looks like (Carey & Russell, 2002; Morgan, 2000;
Nylund, 2000). “When is Mr. Squirmy the strongest?” “What happens when Bossy Cow is in
charge?”
Externalizing can have a potent effect on both counselor and client. It can help counselors
remain in a position of respect and alertness to clients’ abilities in struggling with common
human problems. It also “offers a way to listen closely and join with the [client], without
confirming limited or pathologizing descriptions” (Freeman et al., 1997, p. 48). For clients,
stepping back and separating from the problem changes the footing of their relationship with
the problem, and can return a sense of agency. The door opens to hope and to exploring their
capabilities in addressing the effects of the problem (Carey & Russell, 2002; White, 2006).
As noted earlier, externalizing does not do away with personal responsibility (White &
Epston, 1990). As Carey and Russel (2002) have stated:
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Externalizing is not about separating people from their actions, or the real effects of their
actions. A key element of externalizing conversations involves exploring in detail the real
effects of the externalized problem on the person’s life and also all others who are being
affected by the problems. By thoroughly detailing these effects, externalizing conversations
are used to enable people to take a position in relation to the externalized problem and then to
engage with others in addressing its effects and reducing its influence. (p. 6)

Mapping the Influence of the Problem

Mapping the effects of the externalized problem is done in detail so as to gain a nuanced
sense of the history of the problem and its negative and positive effects on the lives of the
person, their family, and their broader context. Its past and current cost is mapped out as well
as its predicted future, should the story continue in its current direction (Freeman et al., 1997).
Questions used in mapping the influence of the problem often inquire into its length,
breadth, and depth of influence (Winslade & Monk, 1999). “When did you first notice the
problem?” “How was life different before the problem?” “When has the problem seemed to
be the strongest?” “The weakest?” “What percentage of your life is influenced by the
problem?” “Where in your life is the problem’s influence the greatest?” “The least?” More
concrete approaches include drawing pictures of the problem that represent its size in a
child’s life, using fractions to indicate the extent of its influence, labeling and shading in a pie

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 454 Lorraine DeKruyf

chart of the problem’s areas of influence, or graphing its intensity over time (Morgan, 2000;
Winslade & Monk, 1999).

Landscape-of-Action Questions and Landscape-of-Consciousness Questions

Using psychologist Jerome Bruner’s (1986) metaphor of landscape, White (White &
Epston, 1990) addressed the landscapes of action and meaning. Important stories take shape
in both of these landscapes. Asking landscape-of-action questions probes what clients have
done or considered doing that would not be expected given the problem’s influence. “What
did you do to outsmart the Temper Tiger?” Landscape-of-consciousness questions help
clients reflect on their own agency and how they considered doing or did what they did.
“What does this tell you about yourself?”
Landscape-of-action questions and landscape-of-consciousness questions aid in
uncovering clients’ values, commitments, beliefs, desires, intentions, and competencies, all of
which may be explored in a “gathering together and sequencing…of unique outcomes”
(McKenzie & Monk, 1997, p. 109). These unique outcomes or sparkling moments can
emerge at any point, and can initially seem insignificant. Winslade and Monk (1999) bulleted
several possibilities to be alert to:

• actions
• thoughts
• intentions to act
• moments when the effects of the problem don’t seem so strong
• areas of life that remain unaffected by the problem
• special abilities
• knowledge about how to overcome the problem
• problem-free responses from others
• relationships that defy the problem’s persuasions (p. 42)
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Questions about clients’ actions and agency are asked when such exceptions to the
problem are noticed. Gently persisting in fleshing out how clients move counter to the
problem helps them experience themselves as being actors in their own lives. McKenzie and
Monk (1997) offered a number of sample questions: “What preparations did you make for
taking that next step?” “What has been happening in your life that has given you the energy to
make the kind of progress you have been making?” “What does this say about the kind of
person you are when you can consider going to school even when your world had completely
turned upside down?” “What does this say about what you want from your life” (p. 109)?
When people respond to these questions, they are in essence telling new stories about
themselves. They begin authoring alternative stories.

Therapeutic Documenting
One way of adding to or thickening the new alternative plot is documenting client
progress. While this tracking of progress is done regularly via note taking, a variety of
powerful therapeutic documents can be generated for clients that can thicken the plot by
making their new stories somehow more real by allowing them to see proof of them in living
color or in black and white. This documentation can include audio or videotapes, drawings,
declarations, certificates, awards, letters, or whatever your imagination can dream up
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 An Introduction to Narrative Therapy 455

(Freedman & Combs, 1996; Freeman et al., 1997; McKenzie & Monk, 1997). Often
documents are generated in consultation with the client. Some remain private; others are
meant to be public. Following are brief discussions of some types of therapeutic documents
(for ideas about using all manner of therapeutic documents see Freedman & Combs, 1996;
Freeman et al., 1997; Morgan, 2000, 2006a; Nylund & Thomas, 1994; and "Therapeutic
documents revisited" in White, 1995).

Note Taking
What therapists choose to write in their notes matters, because as McKenzie and Monk
(1997) have said, “what gets written down tends to be given more value or weight” (p. 113).
For this reason, detailed descriptions of symptoms and problems are not preferred. Freedman
and Combs (1996) suggested that therapists divide their note pages in half. On the left side
note things related to the problem story using externalizing language. On the right side note
things related to the developing alternative story, marking unique outcomes with an asterisk.
It is useful to write direct client quotes here, as this aides in creating letters to clients later.
Narrative therapists will ask for permission to take notes during a session, explaining
their method, and then along the way checking in for accuracy (Morgan, 2000; Winslade &
Monk, 1999). Many narrative therapists consider notes to be the property of the client, and
will make them available for clients to take home, perhaps requesting a copy themselves if
desired. These notes can be useful between-session reminders for clients of what has been
talked and thought about (Morgan, 2000).

Letters
Client surveys have suggested that a well-written letter from a therapist to a client is the
equivalent of three to five good sessions (Nylund & Thomas, 1994; White, 1995). Such letters
have a distinctive style and usually consist of the following ingredients:
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

• a record of a session or sessions that may include an externalizing description of the

problem and its impact on the client
• an account of the client’s abilities and talents as identified in the session
• the struggle the client has had with the problem
• distinctions between the problem story and the developing preferred story.
(McKenzie & Monk, 1997, p. 113)

Certificates and Awards

Certificates and awards can be used to mark important occasions such as turning points or
times of celebration (Morgan, 2000). Freedom from the old problem and celebrating the new
story can be proclaimed in a format that can be referred to again and again.

Video or Audiotape
One playful way of using video or audiotape is for young persons to tape themselves as
live reporters, telling about their newly discovered knowledge and abilities. Reviewing
themselves on tapes they have made can be a useful booster for themselves if the old problem
story attempts a comeback. With permission, these tapes can also become potential
“consulting” tools. Asking clients to be consultants to other young people struggling with

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 456 Lorraine DeKruyf

similar problems can help them consolidate gains they have made (McKenzie & Monk,
1997). It sends a strong message that the client is not just a helpless victim needing fixing, but
is a person who has much to offer by way of learned experience and expertise.
Therapeutic documents can provide concrete reference points for clients—signposts
along the path of progress, and when shared, for their chosen audience as well. And as
Morgan (2000) said:

Whereas the intricacies of a conversation can so easily be forgotten, therapeutic documents

can be referred to over and over again. Each reading (or playing or drawing) can act as a
retelling of the alternative story, and this in turn contributes to new possibilities. (p. 99)

Widening the Audience

Another way to retell the new story is to share it with a wider audience. Family, friends,
and people clients work or go to school with have often been audience to their problem-
saturated stories. They can also be powerful supporters of clients’ emerging preferred stories.
The witness of a wider audience somehow validates the changes clients are making and the
new description they are beginning to live by (McKenzie & Monk, 1997; Morgan, 2006a).
Monk (1997) stated it strongly: “In order for the client to make a successful departure from
the identity offered by the problem account, an audience needs to be recruited to bear witness
to the emergence of the client’s new description of himself” (p. 21).
There are various ways of widening the audience. One way is to ask clients to identify
someone in their lives they admire who would be the least surprised at the changes they are
making. Often a family member is identified, sometimes it is an important friend or teacher.
Asking clients to imagine what this person might say or do in response to the changes they
are making can help clients gain a sense of the effects of their changes. The client also has the
option of actually communicating with this person about the changes being made or of
showing the new story behaviorally (Freedman & Combs, 1996; Winslade & Monk, 1999).
Sometimes the sense of proving the opposition wrong can be attractive (McKenzie & Monk,
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

1997), so asking clients who would be most surprised by the changes being made can also be
useful.
Writing a letter or declaration to a person or persons is a more concrete way of widening
the audience. Co-authoring a description of the new developments that are occurring, and
sending it to people can be powerful (Morgan, 2006a). For example, students describing
evidence of the changes they have made, and sending this to teachers and principals in a
school can often shift this audience’s attention to a more supportive stance.
A supportive stance from others for the alternative stories clients are telling about
themselves is important. Others’ stories about them shape how they see themselves and
impact how they live their lives. For others to tell new stories about clients, they have to hear
new stories. Widening the audience helps clients live their lives according to these new and
developing alternative stories.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 An Introduction to Narrative Therapy 457

STRENGTHS AND LIMITATIONS

A narrative approach to therapy is a transparent, collaborative, and even political way of
working with clients (Hayward, 2003; Monk & Gehart, 2003; Tomm, 1993). More than a
specific sequence or collection of techniques, it is a perspective, a way of seeing, hearing, and
thinking about clients and their problems. This is at once a strength and a difficulty—a
strength in that it can flex to many settings, people, and problems, but it also means there is
no step-by-step path marked out to follow in order to “do” narrative therapy. It takes time and
effort to integrate a narrative perspective into one’s personal therapeutic style (McKenzie &
Monk, 1997).
Narrative therapy doesn’t always look much like therapy. Often it looks very much like a
regular conversation. This too, can be construed as a strength, but can also present difficulties.
A teacher said to a school counselor: “I thought you were going to work with that student I
sent you. He says you’re not doing any counseling—just talking. What’s going on?”
Educating your colleagues may be necessary for them to understand you are indeed doing
your job (M. Massey, personal communication, March 26, 2005).
Research on the utility of a therapy modality may point to its strengths and weaknesses;
however, the research on narrative therapy is very limited. One reason is that it is a “young”
therapy so there has not been time for a body of research to accumulate. In textbooks it is still
listed as emerging or evolving (Goldenberg & Goldenberg, 2004). Yet an even more basic
reason for this dearth of outcome studies may be due to the assumptions about objective truth
inherent in empirical research, which are at odds with the social-constructionist assumptions
inherent in narrative therapy (Etchison & Kleist, 2000; Prochaska & Norcross, 2003).
In a review of the studies that do exist, Etchison and Kleist (2000) found positive
outcomes, summarizing that “narrative approaches to therapy have useful application when
working with a variety of family therapy issues” (p. 65). These issues included conduct
disorders, family violence, grief related to death as well as divorce, school problems such as
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

academic failure, sibling aggression, ADHD, parent/child conflict, and eating disturbances.
Devotees of any therapy modality tend to see its strengths more easily than its limitations
(Hayward, 2003). Indeed, this is to be expected, and perhaps White (1995) is no exception.
When asked about the limitations of the narrative approach, rather than responding about the
approach, he responded with a list of his own personal limitations. As humans, we all share
them.

These are limitations with regard to language, limitations in my awareness of relational

politics, limitations in my capacity to negotiate some of the personal dilemmas that we are
confronted with at every turn in this work, limitations of experience, limitations in my
perception of options for the expression of certain values that open space for new possibilities,
and so on. (p. 38)

For all counselors, extending beyond limitations calls for exploration of them—through
personal reflection, reading, and talking with others—both clients and colleagues (White,
1995). Awareness of one’s limitations and a transparency with one’s clients about them is one
way of stretching beyond them.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 458 Lorraine DeKruyf

SUMMARY
This brief overview of narrative therapy offers but an incomplete map of a vast territory
that includes ideas, ways to work with people, and actual people. Winslade et al. (1997)
cautioned about this very sort of mapmaking. A map has an uncanny power to draw our focus
onto itself rather than the actual ground covered—that is to say the actual people we work
with. To minimize this risk, we need to realize, along with White (1995), that narrative
therapy is more than a therapeutic approach. Perhaps it is a “world-view, [or] perhaps it’s an
epistemology, a philosophy, a personal commitment, a politics, an ethics, a practice, a life,
and so on” (p. 37).
And so onward.

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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Nylund, D., & Thomas, J. (1994). The economics of narrative. Family Therapy Networker,
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 460 Lorraine DeKruyf

White, M. (2006). Narrative practice with families with children: Externalizing conversations
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archaeology of hope (pp. 53-81). San Francisco, CA: Jossey-Bass.
Winslade, J., & Monk, G. (1999). Narrative counseling in schools: Powerful and brief.
Thousand Oaks, CA: Corwin Press.
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Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
 In: The Quick Theory Reference Guide ISBN: 978-1-60021-624-4
Editor: Karin Jordan, pp. 461-473 © 2008 Nova Science Publishers, Inc.

Chapter 31

INTEGRATIVE COUPLE AND FAMILY THERAPY

Jay L. Lebow and Kathleen Newcomb Rekart

Clients enter treatment for a variety of reasons. Some clients present with a set of
problems that can be classified as a disorder, such as Dysthmic Disorder or Attention Deficit
Disorder. For others, the reason to seek out treatment has its origins in other kinds of
problems, such as relational difficulties, or in the desire to learn more about themselves and
generally to function better.
Consumers report that over one half of their mental health concerns and the reasons they
seek therapy center on difficulties with a family relationship (Johnson & Lebow, 2000).
Spouses may present with marital problems, a mother and daughter may be experiencing
relational difficulties, or an entire family system might be coping with the changes in a family
member suffering from bi-polar disorder. Couple and family therapies (CFTs) are among the
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

most widely practiced treatment modalities and are clearly the treatment of choice for a
variety of family relational disorders surrounding issues such as communication, problem
solving, and attachment (Lebow & Gurman, 1995a). And when an individual’s psychological
difficulties are treated in the social context of the family, family members can facilitate
treatment and create a family environment that prevents relapse. As a result, couple and
family therapies are also now frequently core ingredients in comprehensive treatment
packages aimed to ameliorate individual disorders and difficulties (Lebow, 2003).
The approach to psychotherapy described in this chapter builds on a multi-level bio-
psycho-social understanding of human functioning. Diverse theories of change in
psychotherapy abound, and each contributes to the understanding of human problems and
suggests ways to help resolve difficulties. Integrative couple and family therapy (ICFT) is a
theory and set of methods that integrates the wisdom from diverse therapeutic approaches.
Integrative couple and family therapy (ICFT) is a treatment that aims to be applicable to
all variants of problems that arise in the life of couples and families. Components of strategies
and interventions are added to the treatment in relation to the nature and severity of the
problems being faced by the couple/family. This model does not distinguish between methods
for working with couples and with families (or for that matter for working with individuals).
Instead it aims is to apply and adapt generic effective methods of intervention to the relevant
context, drawing on those methods that have been best demonstrated to be efficacious in that
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 462 Jay L. Lebow and Kathleen Newcomb Rekart

specific context. Within the umbrella of this framework, a treatment plan is created for each
case to intervene efficaciously.
The approach is open-ended in viewing therapy as a resource that can be utilized over
time. It also is science-based in drawing extensively from research assessing families in
shaping the specific intervention strategies. We are heir to now over 50 years of insights from
research about what helps make for successful life in families. Treatment must remain
consistent with these insights and with the research available on couple and family therapy.

KEY CONCEPTS

The Nature of People and Problems

A core issue with which all theories of personality, psychopathology, and psychotherapy
wrestles is the nature of human kind (Corsini, 1989). IPCT is integrative in its viewpoint in
drawing from the wisdom of 2500 years of philosophical inquiry and 100 years of
psychological theory, yet also remains anchored in the findings of research assessing
personality and psychopathology. From an ICFT perspective, people are viewed as subject to
both positive and negative forces in their lives, and they are subject, based on their individual
development, to inner forces that move them to both more evolved behaviors (such as
altruism) and more base behaviors (such as conflict). Some of these are the product of biology
and some of learned behavior.
ICFT views problems as arising from multiple causes, so that there is no single
explanation for human difficulties. Dysfunction takes a multitude of forms and may have a
multitude of origins, and thereby may have a simple cause and may be easy to change, or may
have deep roots in character and system pathology and difficult to change. Sometimes
problems have roots that lie in life long developmental pathways, sometimes in biology,
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

sometimes in difficult circumstance, and sometimes in responding to stresses that are the
product of accidental occurrences.
At a theoretical level, ICFT is neutral as to whether the innate nature of human kind
moves toward health or pathology. However, at the level of the pragmatics of intervention
based in what has been demonstrated to be successful in psychotherapy, ICFT is a strength-
based approach building on client competencies. Quite simply, strength-based approaches
engage clients more readily and have better outcomes. ICFT also is attuned to broad issues of
justice and fairness, to diversity of people, and to individual values in deciding their goals in
therapy, in part because these values fit well in the world of the 21st century, but also because
being tuned into these values also helps engagement and outcome. It is designed to maximize
clients’ abilities to solve the problems they are facing through dealing in the most efficacious
way be those methods primarily focused on biology, cognition, affect, the social system, or on
psychodynamics.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Integrative Couple and Family Therapy 463

An Integrative Framwork

ICFT takes a broad approach to the integration of theoretical perspectives, techniques,

strategies, and interventions from the couple and family therapies as well as the individual
therapies that have gained broad acceptance and been established to be effective. ICFT
creates a generic framework that can accommodate these diverse ways of working. Different
frameworks are viewed as relevant at different levels of the clients’ experience. Although
some frameworks are more germane in some instances, many frameworks will have relevance
to problem generation and problem resolution in any specific case. The task of the therapy is
to arrive at a working plan for which explanation will have greatest utility in a particular
instance. Behavioral, cognitive, emotional, psychodynamic, and family systems theories all
contribute unique insights to the understanding of a couple or family’s difficulties. The
interaction between individual personalities and the systems they are a part of is of particular
interest to the integrative couple and family therapist.
Another assumption of ICFT is that clients presenting for therapy show very diverse
processes in how problems developed, and are likely to benefit most from different strategies
and interventions. A therapist working from an ICFT perspective utilizes empirically
supported techniques as much as possible when faced with particular presenting situation.
Although maintaining coherence in approach is seen as an essential ingredient of effective
therapy, ICFT regards the elegance of theoretical explanation as less important than
developing effective means of intervention.
Most couples and families who seek treatment look for help in attempting to handle
difficult situations and to build competencies that will help improve their functioning.
Although the specific strategies of intervention may differ across different target problems,
there are ultimately a generic core set of strategies from which to draw. Examples of
interventions at the couple/family level include communication skills training, problem
solving training, affective stimulation to nurture attachment, psycho-education, reorganizing
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

family structure, and shaping appropriate reinforcement contingencies. And a parallel list of
strategies similarly underlie individual work in therapy. ICFT is anchored in simple language
and avoids overly complex terminology that typifies brand named orientations. It adopts a
pragmatic, cost-effective view of intervention, utilizing the best-established methods for
targeting the problems that bring couples and families into treatment.

Common Factors

Psychotherapy research has shown a shared set of common factors to be part of

successful psychotherapy regardless of type of client, therapist, or problem (Norcross, 2002).
One key aspect of ICFT focuses on explicitly working to build and strengthen the common
factors that contribute to treatment gains. These common factors include such well-
established principles as creating a therapeutic alliance, instilling hope and positive
expectancies, goal setting, and continuous tracking of treatment progress.
Forging satisfactory therapeutic alliances with all parties involved in treatment is the first
important task of the ICF therapist. The therapist in ICFT aims to establish the kind of multi-
partial alliance described by Boszormenyi-Nagy (Boszormenyi-Nagy, 1974). The goal is to
be experienced as caring, fair, and involved. Achieving this proximate goal in treatment is not
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 464 Jay L. Lebow and Kathleen Newcomb Rekart

an easy task. One aspect of the role of the therapist is to bring issues into focus and label and
work with the problems that require attention. The therapist provides honest direct feedback,
but looks to reframe the changes sought in a way that will do not unduly provoke resistance
(Alexander, Waldon, Newberry, & Liddle, 1990). A frame is established that highlights client
strengths and that does not unduly pathologize family members (Walsh, 1998; Walsh, Jacob,
& Simons, 1995). Problematic behaviors related to the conflict are directly confronted, but the
positive aspects of the intent of each client is always underscored. The therapist
communicates that most difficult behaviors can be understood in the context of the stresses of
family life and the ongoing circular processes at work, while simultaneously working to
highlight alternatives. When presented in this context, clients much more readily accept their
difficulties as appropriate targets for change in the setting of treatment goals. The therapist
employs strategies derived from structural family therapy (Minuchin, 1974) to “join” with the
family in a way that does not challenge the family system and reframes aspects of the
resistance that prevents family members from participating in the therapy process.
Promoting positive expectancies and hope is another set of essential common factors in
most successful therapies and a foundation of ICFT. The therapist invokes solution oriented
language (Duncan, Hubble, & Miller, 1997) to convey the possibility of building on strengths
already present to resolve difficulties and to help clients recognize that they do have some
control over the problem. In this way, the old focus on who started the problem is replaced
with one on how it can be resolved.
Goal setting is another important common factor that helps enable treatment progress that
is emphasized in ICFT. Treatment goals are basically set by clients for themselves. In ICFT,
clients who seek psychotherapy are viewed as consumers, who typically are in the best
position to as informed consumers decide not only whether to seek therapy but also what the
goals of therapy should be. This assumption is made even in the presence of psychopathology
or other signs of major dysfunction except when this pathology blocks a balanced view of self
and the problem. However, when such a block to a balanced view of self and problem is
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present, ICFT views it as an intrinsic part of the role of the therapist to help the client be able
to recognize and respond to the problem; that is, to move beyond client goals. At such times,
other stakeholders have a key role in goal setting. In such cases, therapists assume leadership
in helping direct clients to useful goals. The stages of change model informs much of the
work of the ICF therapist, since it is clear that clients must be helped to recognize significant
problems themselves before they can take action to improve those problems.
When dealing with disorders, reducing the impact of symptoms on functioning is always
one ultimate treatment goal. However, individuals engage in couple and family therapy for a
wide array of reasons, and the goals of treatment vary accordingly. Often, client goals in
couple and family therapy focus on some improvement in their relational lives, rather than on
improved individual functioning. Typically, to achieve a set of ultimate goals involves
achieving a number of proximate goals along the way (Gurman, 1979). In ICFT, therapists
collaborate with clients in the setting of proximate as well as ultimate goals. A good deal of
explanation is involved to help clients understand the choices available in proximate goals.
Another common factor invoked is emphasizing the value of feedback about progress in
treatment. In ICFT, the continuous tracking of therapy progress keeps the outcome sought
continually in focus. Feedback to the client about progress is utilized as an mechanism for
helping clients understand what is working and for exploring why treatment is not effective

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 Integrative Couple and Family Therapy 465

and changing treatment strategy to one that is more beneficial when therapy proves to not be
sufficiently helpful.

Choice of Treatment Modality and Focus

Following a tenet of Pinsof’s Integrative Problem Centered Therapy (Pinsof, 1995), all
family members are viewed as part of the client system but who participates in sessions varies
based in the specific goals set in that case. Session formats are chosen based on an algorithm
for which session formats impact most in relation to particular kinds of problems. In family
therapy, a strong argument can be made for many sessions in every possible treatment format:
family, couple, other sub-system, and individual sessions. However, resources are limited and
clients are only typically available for so much therapy. Therefore, pragmatic decisions about
the choice of modality are made based on what constitutes effective intervention in similar
cases.
Client acceptability of treatments is regarded as an essential ingredient in choices of who
to include in treatment, the level of the system on which to focus, and the framework in which
to intervene. As already has been noted, some clients begin treatment at what Prochaska and
Norcross (Prochaska & Norcross, 2001) call the pre-contemplative stage, having not yet
identified any role they have in the problem or any personal goals for change. For such
clients, treatment begins in ways that follow Prochaska and his colleagues’ notions of the
kinds of intervention appropriate at this stage of change, that is with efforts to first grasp that
there is a problem.
Even those who accept they are part of the problem often begin with a clear notion of
how treatment can best proceed. ICFT creates an alliance between clients and therapist that
includes a collaboration about pragmatic choices about whether intervention will focus on the
family, the couple, or on individuals, and whether it will focus on the level of biology,
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behavior, cognition, affect, or internal process. ICFT allows for the selection of therapy
formats and intervention strategies not only in terms of where the problem resides but also in
terms of what format is most acceptable to clients in order to maximize treatment
acceptability. A parent, for example, may only be willing to have a child be in therapy and not
be in therapy themselves. In such an instance, ICFT begins with this premise and tries to
work to include the parent as treatment progresses. And, as Pinsof (1995) has suggested, each
effort at intervention can be regarded as an experiment to determine its effectiveness in a
particular case. When strategies fail, this can then be utilized as a demonstration to the clients
of the need to try what they initially regarded as less acceptable strategies of change.

THE THERAPEUTIC PROCESS

Change Process

From an ICFT perspective, people change in many different ways; there is no single path
toward change. Due to the multi-level process that underlies behavior, change can be difficult.
Most clients seek therapy about problems or issues that are difficult to change; if these

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 466 Jay L. Lebow and Kathleen Newcomb Rekart

changes were easy, they would be unlikely to be seeking professional help for these particular
problems.
Different therapeutic strategies are differentially useful with different presenting
situations including: kinds of problems, personality types, client stage of change, life
situations, treatment delivery setting, systemic factors, and culture. In particular, in ICFT the
client’s stage of change is regarded as an essential marker for setting the proximate goals for
intervention.
As Breunlin and his collleagues (Breunlin, Schwartz, & Kune-Karrer, 1992) suggest,
constraints that limit the process of change may exist at each system level. Some constraints
are biological; some are psychological; and some are social (Lebow, 1997; Pinsof, 1983).
Much of the skillfulness of therapists lies in their ability to adapt to successfully choose
treatment strategies that take into account such constraints and to adapt those strategies when
either the proximate goals of successfully delivering the intervention or achieving the ultimate
goals of clients for treatment are not being achieved. ICPT is a treatment that is intended to be
open and transparent to clients and that maximizes their choices as consumers in their
treatment. The kinds of choices about treatments are explained to clients and clients in this
way are brought into a collaboration about the strategies that will be incorporated in the
treatment. When a strategy does not prove productive, the evaluation of the treatment is
shared with the client, and other alternatives for intervention are explored.
Families also differ among themelves in their expectations, and conjoint therapies largely
focus on working with and negotiating these expectations. Some family therapy centers on
accepting the difficulties of others in the family system, while other work focuses on the need
to work to change problematic behaviors. The balance between acceptance and behavior
change is determined by a combination of what family member’s expectations are and what
can and can’t be readily changed.
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Assessment and Diagnosis

Assessment has a crucial role in ICFT. The purpose is to be able to describe the problem
and to understand it from bio-psycho-social perspectives and thereby identify the most
efficacious and acceptable routes to accomplish the goals clients have in therapy. Assessment
is an ongoing process that begins with the first contact therapists have with individuals who
will be involved in therapy. Initial phone contacts help in formulating hypothoses about
useful formats for the first meeting or meetings. As soon as possible, the therapist develops a
blueprint for the change process,. Yet, these blueprints are by definition malleable’ they are
formed early in treatment before all the relevant factors have typically emerged. Following
Pinsof (1995), these assessments are not seen as fixed and unchangeable, and the response of
clients to various interventions is seen as providing information that will add to the
assessment and possibly modify the blueprint.
Assessment in ICFT, focuses on each system level: family, couple, other sub-systems,
and the individuals. Individual behaviors are viewed in the context of the interactional
pathways in which these behaviors are nested as in the tradition of family systems, but also
through the lens of individual psychology. Contexts, sequences, and circular causal pathways
influence clients’ behavior, and understanding these processes is essential to understanding
the behavior of individuals (Lebow & Gurman, 1995b; Minuchin & Nichols, 1998). Yet,
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Integrative Couple and Family Therapy 467

individual personality typically also exercises a potent effect, and individual contributions
also need to be understood. In each case, an assessment is made of how much of the problem
us rooted in individual behavior and how much in circular process.
The assessment in ICFT, not unlike that in Lazarus BASIC ID or Pinsof’s problem
centered therapy, examines what occurring across a number of levels: behavior, cognition,
emotion/attachment, and client internal process. For example, if a family reports a great deal
of acrimonious arguing, the ICF therapist would want to assess each family members’
behaviors (i.e. who fights with who and what do these fights look like – screaming, hitting,
name-calling, withdrawing), cognitions (i.e. what are the causal attributions and judgments
made about individuals involved in the fighting), attachments (i.e. what alliances and bonds
are formed or severed as a result of the ongoing battles), and internal processes (i.e. to what
extent is each individual able to manage and tolerate fighting and conflict and who has a
history/risk of violence or what does fighting mean to each family member). To the extent
that couple and family difficulties are also influenced by other systems, such as work or
school, peer, or the cultural context, these influences are also included in the assessment. Self-
report measures are viewed as valuable tools for screening and for more specific assessment
of particular behaviors in focus in treatment. ICFT draws from the now several decades of
development of state of the art self reports instruments to assess individual, couples, and
families (Snyder, Abbott, & Castellani, 2002).
ICFT begins with an assessment phase for targeting problems and treatment goals. The
goal is to be able to gather the necessary information to arrive at the blueprint for treatment in
as expedient a way as possible while also allowing for the vital early treatment goal of forging
strong alliances with clients. Therefore, there is not one set plan for the structure of the first
few treatment sessions. In some contexts, utilizing only one therapy modality such as conjoint
couple sessions provides the best balance of information of assessment and alliance, while in
others (such as in the presence of family violence) multiple session formats are intrinsic to the
assessment. Family and individual interviews and self-report instruments help to elaborate
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

key factors to target in the intervention. The measures gathered are also used to track change
over time. When multiple session formats are utilized, the issues that can lead such strategies
to go astray, such as the sharing of secrets, are explicitly discussed as part of the transparent
strategy of this approach. Ultimately, a working case formulation is generated about the
factors that appear to have generated and, even more importantly, to be maintaining the
present problem.

Intervention

How to intervene in ICFT flows from what emerges in the assessment. The intervention
strategy varies in relation to the key factors in each case. In the first few sessions, a treatment
plan is created for the format of future sessions, that is, who will participate in what
combinations at what time focused on what issues. Initial strategies for intervention are also
part of this formulation. The key question for the therapist is, “What needs to change to allow
clients to achieve their goals?” The assessment of where the problem is located helps to
inform the selection of treatment strategies. The assessment is also utilized to anticipate
where blocks to therapy progress are likely to occur so that treatment can be structured to
enable these blocks to be transcended.
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 468 Jay L. Lebow and Kathleen Newcomb Rekart

Therapy executes the design of the treatment plan, but the plan remains flexible; it will be
augmented and sometimes substantially altered as information accrues from the responses of
various family members to intervention. Following one of Pinsof’s (1995) concepts from
Integrative Problem Centered Therapy, the formulation and the consequent interventions are
modified if new data emerges that changes the assessment as therapy evolves. It is rare that an
initial treatment plan is not augmented or modified over the course of treatment in the wake
of the information accumulating.

Therapy Contract

ICFT begins with an explicit statement of the therapy contract. This contract builds on
the broad understandings of contracts in psychotherapy (Orlinsky & Howard, 1987). The
contract is modified depending on the evolving goals of treatment.
The key matters to clarify in the contract include:

1) Who is expected to participate in the therapy and at what frequency and times?
Typical contracts outline who will be participating in the therapy in light of the
presenting problem on a schedule to be suggested by the therapist.
2) Who has access to information about the treatment? The therapeutic contract
specifies who has access to what information, how information will be shared across
formats (e.g. between individual sessions with adults and with children).
3) Who will pay what fees?

INTERVENTION STRATEGIES
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ICFT draws on a wide array of intervention strategies. Strategies are incorporated at each
of the various system levels.

Psycho-educational

Psychotherapy research indicates that almost wherever psycho-education is employed as

part of psychotherapy, it is useful. In couple and family therapy, in particular, clients often do
not fully understand aspects of the problems involved or how typically these problems are
encountered. Well presented, psycho-education provides not only understanding but also
leads to enhanced hope for change.

Behavioral

Behavioral strategies number among the best-established evidence based methods in

couple and family therapy. Behavior methods include skill development, the use of
conditioning, and the promotion of social exchange.

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 Integrative Couple and Family Therapy 469

Skill building strategies are employed to help clients enhance competencies when there
are skill deficits or where particularly high levels of competency may be desirable (as when,
for example, life regularly includes dealing with highly stressful challenges). Problem
solving, conflict resolution, parenting, and communication skills training (e.g. the speaker-
listener technique [Renick, Blumberg, et al., 1993]) are among the key skill focused
strategies. Techniques that promote negotiation and positive exchange also have an important
place in couple/family work as do techniques that promote mindful-focusing and relaxation.

Cognitive

Integrative family therapy draws from techniques from cognitive and narrative therapies
(Beck & Freeman, 1990; Giblin & Combs, 2003) to create new ways of thinking about the
problems that are occurring. The process goal becomes the creation of narratives describing
events that are not blaming or destructive. The therapist actively questions dysfunctional
beliefs and works to build new narratives. Ultimately, the success of this kind of treatment
lies more in the changes of core beliefs, narrative, and schemas than in changes in specific
beliefs.

Emotion/Attachment

Intervention that promote the dealing with emotion take on special importance in relation
to couple/family problems. Life in families is largely an emotional life with an underpinning
of attachment (Johnson, 2004). Treatments strategies focused on emotion vary. Some efforts
such as the utilization of focusing and catharsis aim for emotional heightening; such
interventions are particularly vital when emotion is not experienced. Other efforts focus on
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diminishing unprocessed emotion, as in anger management.

Client Internal Process

Perhaps the oldest form of intervention, the exploration of underlying dynamics, often
leads to insight and cognitive/emotional transformation. Such exploration of the meanings of
events not only promotes individual change, but that work can also have great meaning to
other family members in helping to enable their understanding and attachment.

Social System

We are heir to the brilliant insights of the first generation of family therapists who
developed an understanding of how social systems affect individuals. ICFT draw from the
range of interventions developed by these pioneers to promote understanding of the power of
the system on the individuals in that system and efforts to change core aspects of social
systems such as alliances, boundaries, and the distribution of power. Systemic strategies

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 470 Jay L. Lebow and Kathleen Newcomb Rekart

typically focus on breaking dysfunctional feedback cycles. When problems extend beyond the
individual and family, intervention may also focus on other relevant systems such as school,
work, or peers.
A tenet of ICFT is that there is not only one “right” formulation or effective means for
intervening in any specific case. Instead, the research on which treatments are most effective
with problems of various kinds is utilized to suggest what are likely to be the most effective
methods for achieving client goals. Clients are told the various treatment options and involved
as informed consumers in treatment decision making. Progress in achieving desired outcomes
is tracked throughout treatment and the intervention strategy is continually subject to revision
based on the progress made.

Ending Ttreatment and The Open-Ended Strategy

Clients are viewed in ICFT as the principal decision-makers of when treatment will end.
Clients participate in psychotherapy to accomplish a range of goals and treatment success is
determined by particular clients accomplishing their goals. Thus, what may be a successful
psychotherapy for one set of clients may be regarded as less successful by another set, given
different goals. Some clients enter therapy to feel better, some for symptom change, some to
experience, some to understand, and some for personal growth. Each of these purposes speaks
to a valid set of goals for psychotherapy. Clients are seen as the ultimate evaluators of when
treatment goals have been accomplished and whether additional goals emerge over the course
of the treatment.
At termination, a plan is formed for clients to maintain the changes they have achieved
during therapy. ICFT also envisions psychotherapy not as an isolated event, but the creation
of a resource that can be utilized to in further growth and/or in preventing and ameliorating
future difficulties. Throughout treatment, an open ended philosophy is described, centered on
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

therapy as a resource that can be reengaged when useful (Lebow, 1995).

The Role of Values

Values are intrinsic to work in couple and family therapy. Although some problems may
not touch on client values (for example, helping a family cope with the bi-polar disorder of a
family member), most issues in couples and families do. The meta-frameworks articulated by
Breulnin and colleagues (Breunlin, Schwartz, & Mac Kune-Karrer, 1997), such as gender and
culture, are ever-present in couple/family therapy and vital value laden choices are frequently
encountered: How much does the therapy promote family cohesiveness vs. individual
autonomy? How much of the work promotes acceptance vs. behavioral change? How much
should those in less powerful cultural positions adapt to the majority culture? And what of the
relative roles of men and women?
ICFT is not grounded in specific positions about most issues of personal values but does
suggest it is essential for therapists to understand their positions about such issues and, when
these positions have relevance for the work at hand, to communicate about this to clients.
Thereby, clients can distinguish the personal position of the therapist from their own decision
process about how to live their lives.
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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Integrative Couple and Family Therapy 471

Having said this, it also must be added that responsible practice in the 21st century must
take into account our increased understanding of the importance of gender and culture to our
work and the wide range of ways families can thrive. And as a science based method, ICFT
emphasizes the importance of the information being shared by therapists remaining consistent
with state of the art knowledge, even if that information challenges clients.

STRENGTHS AND LIMITATIONS

Strengths

ICFT is an integrative approach that is designed to respond to the many diverse problems
facing couples and families. ICFT utilizes a bevy of strategies that target problematic aspects
of dysfunction and promote growth, and builds on strengths of the individual, couple, and
family (J. L. Lebow, 1984). This approach is science-based and has proven useful with very
complex case presentations.

Limitations

One potential limitation is that ICFT requires a skilled provider who has mastered many
techniques. Case conceptualizations from an ICFT perspective can be quite complex, and
often the therapist is intervening with individuals, couples, and families simultaneously,
which requires a high level of skillfulbness.

SUMMARY
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This chapter describes a generic integrative approach to couples and family therapy,
Integrative Couple and Family Therapy. This approach highlights the need for a clear therapy
contract, assessment, clear goal setting with clients, the utilization of multiple therapy session
formats, holding both a systemic and individual focused perspective, maintaining a solution
oriented focus, creating a multi-partial alliance with all parties, and the utilization of a wide
range of intervention strategies and interventions.

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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Boszormenyi-Nagy, I. (1974). Ethical and practical implications of intergenerational family

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Mikesell, Richard H (Ed); Lusterman, Don-David (Ed); McDaniel, Susan H (Ed).

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Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Integrative Couple and Family Therapy 473

Pinsof, W. M. (1983). Integrative problem-centered therapy: Toward the synthesis of family

and individual psychotherapies. Journal of Marital & Family Therapy, 9(1), 19-35.
Prochaska, J. O., & Norcross, J. C. (2001). Stages of change. Psychotherapy: Theory,
Research, Practice, Training, 38(4), 443-448.
Snyder, D. K., Abbott, B. V., & Castellani, A. M. (2002). Assessing couples. [References]. In
J. N. Butcher (Ed.), Clinical personality assessment: Practical approaches (2nd ed )
Oxford textbooks in clinical psychology, vol 2 (pp. 225-242). London: Oxford
University Press.
Walsh, F. (1998). Strengthening family resilience: New York, NY, US: The Guilford Press.
(1998).
Walsh, F., Jacob, L., & Simons, V. (1995). Facilitating healthy divorce processes: Therapy
and mediation approaches. In Jacobson, Neil S. (Ed); Gurman, Alan S. (Ed). (1995).
Clinical handbook of couple therapy. (pp. 340-365). New York, NY, US: The Guilford
Press.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

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Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 In: The Quick Theory Reference Guide ISBN: 978-1-60021-624-4
Editor: Karin Jordan, pp. 475-492 © 2008 Nova Science Publishers, Inc.

Chapter 32

APPLICATIONS OF RELATIONAL COMPETENCE

THEORY TO PREVENTION AND PSYCHOTHERAPY

Luciano L'Abate

This chapter summarizes a contextual, developmental, and relational theory of

personality socialization in intimate relationships, called competence theory.This theory has
been frequently revised and refined over the years, since its inception (L'Abate, 1976), even
though its basic models have remained unchanged (L'Abate, 1986, 1994, 2002, 2003, 2005,
2006b, 2006c, in preparation; L'Abate & Baggett, 1997; L'Abate & De Giacomo, 2003;).

DESCRIPTION OF THE THEORY

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This theory consists of (a) three basic requirements, (b) three meta-theoretical
assumptions, (c) two major theoretical assumptions and one corollary to the two assumptions,
(d) four major models, (e) four applied models, and (f) two integrative models (L’Abate,
2005). As shown in Table 1 this theory is no different from tables of organization in business,
industry, medicine, or the military.
The three basic requirements for this theory have been: (1) verifiability and applicability
in (a) the laboratory by developing a variety of paper-and-pencil self-report tests, (b) creation
of a classification of low-cost interventions to promote physical and mental health (L'Abate,
2007a), not included here, (c) primary prevention through theory-derived enrichment
programs (L'Abate & Weinstein, 1987; L'Abate & Young, 1987), (d) secondary prevention
through theory-derived self-help mental health protocols or workbooks (L'Abate, 2004a,
2004b, 20007b), and (e) tertiary prevention, i. e., psychotherapy, through the administration
of theory-derived prescriptive tasks (Table 2); (2) creation of models that encompass both
functional and dysfunctional aspects of personality socialization in intimate relationships by
(3) giving relational meanings to traditionally monadic, non-relational and a-contextual
psychological terms.

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 476 Luciano L'Abate

Table 32.1. Summary of a Relational Competence Theory and Psychiatric Classification

Requirements
Verifiability Applicability
Meta-theoretical Assumptions about Relationships
Width Depth Occurring
Models ERAAwC 1 Levels of Interpretation2 Settings3
Emotionality Description Home
Rationality Presentational School/work
Activity Phenotypical Transit
Awareness Explanation Transitory
Context Genotypical
Generational/
developmental

Models Theoretical Assumptions about Relationships

Dimensions Ability to Love4 Ability to Negotiate5 Both Abilities 6 Contents7
Distance Control Functionality Life Triangle
Approach/Avoid Discharge/Delay High/Middle/ Being /
ance Low Doing/Having
DSM-IV Axis II, Cluster Axis II, Cluster B GAS (100 to 0) Sexual
C Deviations et al.,

Models of the Theory

Models Self- Relational Styles9 Selfhood10 Priorities11
Dimensions differentiation 8
Likeness AA/RR/CC Self-Other Survival/
Continuum Importance Enjoyment
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a. Symbiosis/ a. Abusive/ a. Selfullness Horizontal/

Alienation Apathetic
b. Sameness/ b. Reactive/ b. Selflessness Settings
Oppositeness Repetitive
c. Similarity/ c. Conductive/ c. Selfishness Vertical/
Differentness Creative
d. No-self Self
Partner
Children
Parents/
Siblings
In-laws
DSM-IV a, Axis I a. Codependencies / a. 100 to 70 on
Addictions GAS
b. Axis II, b. Conflict high b. & c. 69 to 40
Cluster B on GAS
c. No diagnosis c. Conflict low d. Below 39 on
GAS

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 Applications of Relational Competence Theory to Prevention and Psychotherapy 477

Models Applications of the Theory

Dimensions Distance Drama Triangle13 Intimacy14 Negotiation15
Regulation12
Pursuer/Distancer/ Victim/ Sharing Joys & Structure/
Regulator Persecutor/Rescuer Hurts Process

Table 32.2. Evaluating Assumptions and Models of Relational Competence Theory

A. Requirements
1. Verifiability & Accountability in the Laboratory, in Health Promotion, Primary
(Enrichment), Secondary (Workbooks), and Tertiary (Psychotherapy) Prevention (Tasks).
2. Inclusion of functional and dysfunctional aspects of personality socialization
3. Reducibility to known psychological constructs with added relational meaning

Levels of Prevention
Models Tests Primary Secondary Tertiary
Enrichment Workbooks Tasks
B. Meta-theoretical
Assumptions
1. Horizontality in RAQa Negotiation Negotiation Face-to-face
Relationships Potential Planned Parenting Interviews
2. Verticality of Relationships Not yet
Levels of Observation/ evaluated
Interpretation2 in Relationships
3. Settings3 Time estimates
Semantic
Differential
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C. Theoretical Assumptions
4. Ability to Love4 WATMTIAW?b
5. Ability to Negotiate5 WATMTIAW?b Negotiation Negotiation
Potential
6. Abilities to Love & to Planned Parenting
negotiate6
7. Modalities7 Assignment
in
Negotiation
D. Models derived from Meta-
theoretical and Theoretical
Assumptions
8. Continuum of Likeness8 Likeness Scalec Who Am I?
Likeness Gridd
WATMTIAW?b
CMSLQe
9. Styles in Relationships9 PIRSf Negotiation Negotiation Face-to-face
Potential assignment interviews

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 478 Luciano L'Abate

Table 2. (Continued)

10. Selfhood10 SOPCg

PIRSf
DRTh Self-Other Drawing
Co-dependency lines
11. Priorities11 Gridi Inventoryj Negotiation Negotiation
Potential assignment
Planned Parenting
E. Applications of the Theory
12. Distance Regulation12 Depression 3HCl
assignment
13. Drama Triangle13 Depression
assignment
14. Intimacy14 SOHSk Intimacy Sharing hurts
15. Negotiation15 Helpfulness Negotiation
Note: Updated from L'Abate & De Giacomo, 2003. Reprinted with permission.
a
Relational Answers Questionnaire (L'Abate, 2005)
b
What Applies To Me that I Agree With? (L'Abate & De Giacomo, 2003).
c
(L'Abate, 1994).
d
(L'Abate, 1994).
e
Cusinato-Maino-Scilletta Likeness Questionnaire (L'Abate, 2005).
f
Problems in Relationships Scale (L'Abate, 1992, 1996, McMahan & L'Abate, 2001).
g
Self-Other Profile Chart (L'Abate, 1992, 1994, 2001, 2002; L'Abate & De Giacomo, 2003).
h
Dyadic Relationships Test (Cusinato & L'Abate, 2005a, 2005b).
I
Priorities Grid (L'Abate, 1994).
j
Priorities Inventory (L'Abate, 1994).
k
Sharing of Hurts Scale (Stevens & L'Abate, 1989).
l
Hugging, Holding, Huddling, & Cuddling (L’Abate, 2001; L'Abate & De Giacomo, 2003).
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

NATURE OF PERSONS
To elaborate on the third requirement, instead of relying on mentalistically intrapsychic
or even behavioral constructs left-over from the 19th and 20th centuries respectively, this
theory aims at seeing, describing, understanding, and possibly helping persons relationally.
None of us live in a vacuum. We all live in relationships either with intimates and non-
intimates and/or with objects. None of us grew up in a vacuum of relationships. We are the
products and producers of intimate communal (close, committed, interdependent, and
prolonged) and non-intimate (distant, opportunistic, and short-lived) exchange relationships.
Whether and how these relationships are functional or dysfunctional is explained through
various models of the theory.

Human Needs: Meta-theoretical Assumptions

Beyond the need for warmth, shelter, food, and clothes, that is survival, this theory does
not use traditionally intrapsychic motivational concepts, except a model of priorities reviewed

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Applications of Relational Competence Theory to Prevention and Psychotherapy 479

below that starts with physical survival as a primary priority and enjoyment as a secondary
priority.
Some models exist above and beyond the theory itself, that is, they consist of meta-
theoretical assumptions that preceded the theory before its inception. Some models derive
directly from theoretical assumptions basic to the existence of the theory. Some models derive
directly from both meta-theoretical and theoretical assumptions. All models are interrelated
with each other. A continuum of functionality-dysfunctionality is imbedded in each model of
the theory, following the structure summarized in Table X.1.
Models derived from three meta-theoretical assumptions are basic to the theory and
consist of existing knowledge and literature necessary to any theory of personality.
Functionality-dysfunctionality may occur in just one model, in more than one model, or in all
models, producing a continuum of functionality-dysfunctionality, specific to just one area of
functioning, i.e., one model or generalized to many areas, i.e., other models.

Width of Relationships: Model I

The first meta-theoretical assumption is based on a circular relational Model1 of

information processing that includes five major components that views relationships
horizontally : Emotionality, Rationality, Activity, Awareness, and Context (ERAAwC). These
basic components and a model of Priorities explained below (Table 1) are sufficient to
describe, explain, and, if necessary, help improve, how one uses the five components and how
one aligns priorities , i. e., "needs," to survive and enjoy life.
The ERAAwC Model1 includes and integrates most if not all the major theoretical
schools of the past that in some way or another relate to motivation: E includes
phenomenology, humanism, and existentialism, R includes psychoanalysis, emotion-rational
and reality theories, including cognitivism. A includes behaviorism and pragmatism. Aw
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includes introspectivism, insight, and Gestalt approaches. C includes contextualism, family,

environmental, and ecological approaches stressing proximal and distant variables in
relationships. Thus, this model underpins the theory and its models derived from the theory
that are still related, either directly or indirectly, to this primary model.
Functionality in the ERAAwC model is reached when its five components are balanced
appropriately, according to internal and external demands and task requirements within
different stages of the life-span. If and when one component is used too frequently, too
intensely, and at the expense of the other four components, dysfunctionality will ensue. For
instance, if E overshadows R, A, Aw, and C, as in some personality disorders, all the other
four components will suffer. If C is overused and relied upon when E is necessary , as in
losses and traumas, then A, Aw, and C might not be used as appropriately as required by the
circumstances. If A is used intensely, as in impulsive and acting out personality disorders, at
the exclusion of the other four components, dysfunctionality will ensue. The same process
applies to Aw and C. One component used or overused at the expense of the other four will
lead into dysfunctionality. Overuse in one component will produce underuse in the other
components. There are dysfunctional extremes in each of these five components. Excessive or
insufficient use of one component will lead toward some type or degree of dysfunctionality,
because ascendancy of one component will influence the role, position, and function of the
other components of the model. This model has been evaluated in the laboratory by the
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 480 Luciano L'Abate

Relational Answers Questionnaire (L'Abate, 2005). It is available online (L'Abate, 1996) and
in primary prevention with a Negotiation Potential Enrichment Program and the Negotiation
and Planned Parenting workbooks in secondary prevention (Table X.2).

Depth of Relationships: Model II

While the ERAAwC model allows to understand relationships on a flat, width dimension,
relationships must be also observed, understood, and possibly explained in depth, vertically,
according to a Model 2 that includes two major levels: description and explanation.
Description is subdivided into a public presentational facade, as in impression formation and
management, and a private phenotypical sublevel, how we really relate within the privacy
and relative protection of the home, outside of public scrutiny and judgment. The second level
of explanation is divided into a genotypical sublevel, using non-relational, hypothetical, or
inferred traits or states, such as self-esteem, introversion-extraversion, ego, superego, etc., and
an historical/developmental, and situational sublevel, how we are socialized by
intergenerational and generational influences, and by our families of origin and of procreation
(Serbin & Karp, 2004).
Functionality in this model is achieved when levels of description and explanation are
positively congruent with each other: (1) when one's intergenerational, generational,
developmental and situational background is composed of mainly positive and even creative
relationships; and (2) when one's sense of self genotypically is positive, relating positively
with one's intimates and non-intimates, without trying desperately to make a good impression
on others to impress them with one's "goodness " or "niceness" or “competence.”
Dysfunctionality is present when there are discrepancies between levels and negativity
within each level. When one's family of origin is chaotic, abusive, neglectful, or conflictual, it
may produce a sense of self that is confused, chaotic, negative, incomplete, or isolated from
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

reality. Under those conditions, one may try to overcome felt deficits in self by trying to
present and overdo an overly obedient or passively conforming façade, on one hand, while
being abusive or neglectful in intimate relationships, or else, on the other hand, acting out
destructively against self and others, as in addictions and criminalities.
Reviews of the literature relating to the four sublevels have been performed consistently
in previous publications.

Settings: Model III

A third meta-theoretical assumption (in some ways related also to human needs) includes
settings, classified as home, school/work, transit (roads, cars, airplanes, buses, etc.) and
transitory (barbershops, beauty saloons, grocery stores, churches, etc.). All three models will
be elaborated below in terms of a continuum of functionality-dysfunctionality.
This model distinguishes among settings where intimate and non-intimate relationships
occur: home, school/work, and surplus time, as in transitory (bars, barber-shops, beauty
saloons, grocery stores, etc.) and transit settings (airports, buses, car, hotels, etc.). They
furnish the Context of the theory. These settings are relevant to one's sense of identity ("I am
a housemaker," an "engineer," a "runner, etc."). Functionality occurs when all settings are
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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Applications of Relational Competence Theory to Prevention and Psychotherapy 481

used appropriately according to life-cycle stages, station in life, age, gender, and other
variables. Indeed, settings (rather than paper-and-pencil, self-report questionnaires) are
relevant to distinguish among three levels of functionality: superior, intermediate, and
adequate, depending on how well one functions in one or more settings. Borderline or
inadequate levels of dysfunctionality are evaluated by how one functions in each setting,
when one setting is used at the expense of the others. If one spends more time in a bar than a
home, one cannot expect the welcome mat when returning home. If a workaholic continues to
spend more time at work than at home, consequently neglecting partner and family,
eventually someone will protest this lopsided involvement. Settings can be evaluated
objectively by time analyses, how much time one spends in each setting, as well as by the
semantic differential to measure the experiential meaning that each setting may have for the
individual.

Assumptions of the Theory

These assumptions are the bases for other models of the theory. In addition to two
assumptions about the abilities to love and to negotiate, which are processes, a corollary about
what is exchanged during both processes is necessary.

Ability to Love: Model IV

This model is based on an assumption of space, that includes the ability to love, as
defined by distance, how close or how far we approach or avoid self, others, or objects.
Functionality is achieved when one loves self as much as intimates, approaching self and
intimate others at various levels of description and explanation reviewed above. Approach is
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

achieved through self-awareness and knowledge of self and context obtained through life
experiences and/or through psychotherapy and other types on interventions described below.
There are many other, perhaps, more efficient, if not more effective ways to achieve self-
awareness and knowledge than just through face-to-face talk with a professional helper
(L’Abate, 2006a).
Dysfunctionality occurs when extremes in approach-avoidance are present, as seen in
prototypes of personality disorders included in Cluster C of Axis II in the DSM-IV-TR
(American Psychiatric Association, 1994). The dependent personality would be the prototype
for extreme approach, while the avoidant personality, among others, like procrastination and
phobias, represents the prototype for avoidance. This model, together with most models of the
theory, can be evaluated with a 200 item questionnaire: "What Applies To Me that I Agree
With?" (WATMTIAW?; L'Abate, 1996; L'Abate & De Giacomo, 2003).

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 482 Luciano L'Abate

Ability to Negotiate: Model V

This model is based on an assumption of time. It includes the ability to bargain, negotiate,
and problem solve with both intimates and non-intimates, according to a dimension of control
or self-regulation defined by extremes in discharge or disinhibition and delay or constraint,
how fast or how slow we approach or avoid others, situations, or objects (Baumeister &
Vohs, 2004). Functionality is achieved when one is able to negotiate successfully with others,
controlling and avoiding extremes of discharge or delay, as described in model of negotiation
described below that derives in part from to this dimension.
Dysfunctionality is present when no negotiation is possible, or, when attempted, it fails
miserably, as in the case of most personality disorders included in Cluster B of Axis II. These
disorders are oriented toward discharge at one extreme, while most disorders in Cluster C
tend to be oriented toward middle to extreme side of delay. This model can be evaluated in
the laboratory with the WATMTIAW? Test, by the Negotiation Potential Enrichment
program and by the Negotiation workbook.

Combination of Both Abilities: Model VI

The combination of both preceding models allows a classification of intimate

relationships according to a fourfold 2X2 model where the two abilities are viewed as
orthogonal with each others. Functionality is present when abilities to love and to negotiate
are both high. Borderline functionality is present when one ability is high and the other is
low. Dysfuntionality is present when both abilities are low.
Evaluation of this model in the laboratory would require using tests to measure the ability
to love and the ability to negotiate or problem solve as independent variables and level of
functionality as the dependent variable. In secondary prevention, this model can be evaluated
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

with a Planned Parenting workbook that should be compared with workbooks dealing with
the same topic (L'Abate, 1996, 2997b).

Modalities of Living: Model VII

While the two preceding models relate to processes without contents, this model is
derived from Foa and Foa's (1974) resource exchange theory about what is exchanged
between and among intimates and non-intimates, namely: love, status, services, information,
goods, and money. Love and status were changed respectively into intimacy and importance,
as discussed below. When combined, conceptually both resources constitute a modality of
Being Present and becoming available emotionally to self and intimate others especially when
one is needed. Combining services with information produces a modality of Doing or
Performance. Combining goods with money produces a modality of Having or Production.
Functionality is present when all three modalities are used discriminately according to
age-stage-gender- appropriate demands. Dysfunctionality is present when there is deficiency
or excess in either modality. For instance, Being completely Present emotionally, using E
exclusively would make it impossible to think (R) and to perform and produce positively (A),
as in the case of Indian saints who live on beds of nails and depend on charity to survive.
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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Applications of Relational Competence Theory to Prevention and Psychotherapy 483

Inadequate Being Present would increase Doing and Having into an obelisk, found in
cemeteries. One could survive physically and materially by just Doing and Having, but one
would die emotionally without being able to enjoy life with intimate others.
This model has been used also to classify functional and dysfunctional sexual
relationships. Sexual relationships based on shared Being have a higher chance of being
functional and of lasting longer than sexual relationships based solely on Performance ("How
often do you do it?") or Production, as in pornography or in sexually substitute objects.
Sexual deviations and disturbances derive from perpetrators being unable to Be and become
emotionally available to self and to their victims.
To evaluate this model one could use Foa and Foa's original six scales combining scores
from each scale into three scores to evaluate the three modalities as independent variables,
with measures of emotional availability, activity, and production, as well as sexual attitudes
and performance, as dependent variables. One assignment in the Negotiation workbook
(L'Abate, 1986, 1996, 2002, 2005) includes this model (Table 2).

MODELS DERIVED FROM THE THEORY

The models explained below derive from the previous meta-theoretical and theoretical
assumptions and corollary.

Identity Differentiation: Model VIII

This model deals with developmental identity-differentiation along a curvilinear,

continuum of likeness. This continuum is composed of six dialectical ranges: symbiosis,
sameness, similarity, differentness, oppositeness, and alienation. Symbiosis /alienation are the
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

two most dysfunctional levels of differentiation, sameness/oppositeness are next in

dysfunctionality, while similarity/differentness are functional. Examples of symbiosis/
alienation are found in schizophrenic or borderline relationships. Examples of sameness are
found in authoritarian, dogmatic, conservatively rigid relationships, where only two choices
are allowed, either joining in the same perspective, conforming blindly, or opposing that
perspective rebelliously, as in the case of many juveniles or revolutionaries in totalitarian
countries.
This continuum can be evaluated in the laboratory with the Likeness Scale, Likeness
Grid, the WATMTIAW?; and the CMS-Likeness Questionnaire. In secondary prevention, it
can be evaluated with the "Who am I" workbook (L'Abate, 1996; L'Abate & De Giacomo,
2003).

Styles in Intimate Relatioships: Model IX

The three combinations of ranges encompassed by the previous model produce three
distinguishable styles in intimate relationships: (1) by combining Symbiosis with Alienation
produces an Abusive-Apathetic (Neglectful) style (AA); (2) by combining Sameness with

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 484 Luciano L'Abate

Oppositeness produces a Reactive-Repetitive style (RR); and (3) by combining Similarity

with Differentness produces a Creative-Conductive style (CC). The latter is the most
functional of the three styles, with RR being borderline as far a functionality, and AA being
clearly the most dysfunctional.
These styles can be evaluated with: (1) the Problems-in-Relationships Scale (PIRS), a
240 item questionnaire (L'Abate, 1992; McMahan & L'Abate, 2001), in which 20 partner
conflict dimensions match parallel written homework assignments; (2) a Negotiation Potential
Enrichment Program; (3) one assignment in a Negotiation workbook, and (4) one assignment
in the Planned Parenting workbook (L'Abate, 1986, 1996). Both AA and RR styles can be
observed in most clinical and chronic relationships, where, by definition, it would be difficult
to observe and find a CC style.

Selfhood; Model X

This is probably the most important model of the theory in so far that it has been
subjected to evaluation more frequently than any other model. From the two fundamental
dimensions of distance and control, a Selfhood model can be developed. Here, balancing
approach-avoidance and discharge-delay tends to produce a personality propensity named
Selfulness, where a sense of importance is ascribed, attributed, and asserted toward self and
intimate s through care, compassion, consideration, and concern. When approach is greater
than avoidance and discharge greater than delay a personality propensity named Selfishness
tends to develop, where a sense of importance is attributed positively to self and negatively
toward intimate and non-intimate others. When avoidance is greater than approach and delay
is greater than discharge, a personality propensity named Selfless tends to develop, where a
sense of importance is attributed positively to others and negatively toward self. When
approach-avoidance and discharge-delay are expressed in extreme, contradictory and
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inconsistent fashion, a personality propensity named No-self tends to develop. Here a sense of
importance is expressed negatively or even denied toward self and others. Selfulness is the
most functional personality propensity. Selfishness and Selflessness are borderline in
functionality, while No-self is clearly dysfunctional.
Selfulness can be distinguished along three levels of functioning, according to how well
one functions in settings, as reviewed earlier. Superior Selfulness means assuming leadership
positions in at least three settings. Intermediate Selfulness means functioning extremely well
in at least one setting. Adequate Selfulness means functioning relatively well in most settings,
without a leadership position. Prototypes for Selfishness are anger, hostility and aggression,
criminality, and murder (Cluster B). Prototypes for Selflessness are anxiety, depression, and
suicide (Cluster C). Prototypes for No-self are Cluster A disorders of Axis II and disorders
contained in Axis I of the DSM-IV.
This model can be evaluated in the laboratory with the Self-Other-Personality-Chart
(L'Abate,1992, 1996, 2002, 2003; L'Abate & Baggett, 1997; L'Abate & De Giacomo, 2003),
the PIRS, and the Dyadic Relationships Test (Cusinato & L'Abate, 2003, 2005a, 2005b), and
in secondary prevention with a Self-Other and a What are your Concerns? workbooks.

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 Applications of Relational Competence Theory to Prevention and Psychotherapy 485

Priorities: Model XI

This model applies to conscious, and oftentimes unconscious automatic Priorities: what
relationships, activities, settings, or objects, in addition to Self and Others as considered in the
previous model, are important? Vertical Priorities relate to Self, Partner, Children, Parents,
Siblings, Relatives, Friends, Co-workers, and Neighbors. Horizontal Priorities relate to how
one ranks home, school/work, leisure and surplus time. A balanced order of Priorities
according to appropriate age-stage-gender, and other variables is functional. Mixed, non-
existent, unclear, or confused Priorities lead toward dysfunctionality.
Similar constructs in the literature are: goals, needs, intentions, values, and attitudes. All
these constructs eventually need to be ranked hierarchically according to a criterion, which, in
most cases would include their importance, going back to the same dimension of importance
implicit in the construct of Priorities.
Priorities can be evaluated in the laboratory with the Priorities Grid and Inventory,
(L'Abate, 1994), with the Negotiation Potential Enrichment program, and with one
assignment in the Negotiation workbook (L'Abate, 1986).

APPLIED MODELS
The models in this section are less abstract than the preceding ones and apply directly to
clinical situations.

Distance Regulation; Model XII

This model deals with Distance Regulation and is a direct application of Model4. It is
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

composed by three roles: (1) Distancer, who avoids either emotional or sexual closeness, or
both; (2) Pursuer, who wants either emotional or sexual closeness or both, and (3) Regulator,
who wants and, at the same time, is also afraid of closeness , i.e., "Come here, help me. Go
away you did not help me." The latter role is usually found in some depressed relationships.
This model can be evaluated with a written assignment in the Negotiation workbook
(L'Abate, 1996).

A Pathogenic Triangle: Model XIII

This model, called the Drama Triangle, because of its universality in religion, fiction,
and reality, forms the basis for the beginning of dysfunctional relationships. It is usually not
found or visible in functional ones, except under stress or in crises, but it is present and
visible in dysfunctional relationships.It is based mainly on discharge rather than on delay
(Model5). It is composed of three circular roles, all pathogenic (1) Persecutor, who needs a
(2) Victim, who needs a (3) Savior to be rescued. In some relationships, involved parties play
all three roles, switching continuously from one role to another. In extreme relationships,
parties may keep the same role, regardless of what other roles other parties play. In the

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 486 Luciano L'Abate

written homework assignment where this model is applied (L'Abate, 1986, 1996, 2007c), this
Triangle was expanded into more specific and detailed subroles. For instance, the Persecutor
may be a judge, a detective, or an executioner, among others. The Victim may play "Poor
little me, " and become a Martyr, among other subroles, while the Savior may be a therapist, a
caretaker, or a Red Cross nurse, among others.

Intimacy: Model XIV

This model deals with Intimacy is defined behaviorally by the sharing of joys and hurts
and fears of being hurt rather than by paper-and-pencil self-report tests. It is derived from the
ERAAwC model. Functionality is achieved and present when past hurts are expressed and
shared between partners and among intimates. Dysfunctionality is present when past hurts are
kept inside and used as ammunition to ruminate, blame either self or others, or act out against
self or others. Intimacy can be evaluated in the laboratory with the Sharing of Hurts Scale
(Stevens & L'Abate, 1989) as well as with an entire workbook devoted to this topic (L'Abate,
1986, 1996, 2007c).

Negotiation: Model XV

This model of Negotiation is last, because it applies mainly to functional or semi-

functional relationships. Most dysfunctional relationships cannot negotiate at all or cannot
negotiate successfully. Only functional relationships can negotiate problem solving
successfully. This model is a direct application of Models V & VIII. To negotiate
successfully, one needs to be in control of self allowing and encouraging control in other
negotiating parties. Excessive or inadequate discharge-delay would sabotage the process of
negotiation. This process can be taught through a Negotiation or a Planned Parenting
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workbooks (L'Abate, 1986, 1996, 2007c).

SUMMARY AND INTEGRATIVE MODELS

There are two models that attempt of summarize and compare models of the theory with
models external to the theory (L’Abate, 2003, 2005; L’Abate & De Giacomo, 2003).

Integration of All Models XVI

This model summarized all the previous models into a grand scheme that cannot in any
way be evaluated, except perhaps with the Planned Parenting workbook (L'Abate, 2007c). It
may serve as a tally to evaluate which model is valid and which is not on the basis of accruing
evidence.

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 Applications of Relational Competence Theory to Prevention and Psychotherapy 487

Integrating Models of the Theory with External Models: Model XVII

This model, using a dimension defined by extremes in internality-externality, integrates

similar models external to the theory that possess one functional dimension, two borderline
ones, and one dysfunctional dimension. The circumplex model, for instance, shows friendly
for functional, dominant/submissive for borderline, and hostile for dysfunctional. By the same
token, the attachment model has a secure functional working style, two borderline insecure
styles, preoccupied and dismissing, and one dysfunctional one, disorganized. Other models
integrated into this one are: (1) Selfhood; (2) De Giacomo's Elementary Pragmatic (L'Abate,
2003a; L'Abate & De Giacomo, 2003); (3) family paradigms; and (4) family types.

APPLICATIONS OF THE THEORY TO THE CHANGE PROCESS

Some people change on their own, with a minimum of external help. Some change with
some external help. Some people change with a great deal of external help. Some, especially
those who need help the most, do not change at all, no matter what. Nonetheless, some people
do change when they do not want to continue hurting themselves and loved ones and
acknowledge the need for external interventions.
The change process takes place when there is an awareness and admission of personal
responsibility, acknowledging our: (1) neediness to love and to be loved reciprocally; (2)
fallibility in hurting those very intimates we love without wanting to hurt them; and (3)
vulnerability, in being hurt by the very people we loves and who love us in return.
Once an admission and a commitment to change are made, change takes place because of
the regularity and predictability of appointments with oneself, and with external sources of
help, who could be professional, semi-professional, or sub-professional helpers. This process,
as expanded below, can occur through face-to-face talk as well as through distance writing at
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

regularly pre-ordained and pre-determined appointments with oneself, with partner, and with
family members (L'Abate, 1992, 2002, 2003a, 2004a, 2004b, 2007c). Duration, frequency,
intensity or strength of external interventions will also necessitate a direction established by
priorities stated initially at the outset of a relationship, with oneself and with helping sources.

THE THERAPEUTIC PROCESS

This theory does not limit itself just to psychotherapy, as a process requiring solely
prolonged face-to-face (f2f) talk. In addition to f2f talk, it includes the two other media of
communication, writing and non-verbal. People who want and need help can be helped
through four tiers of intervention: (1) promotion of physical and mental health through low-
cost prescriptive approaches (L'Abate, 2007b); (2) primary prevention of negative
relationships before they happen, such as Enrichment programs and normative protocols or
workbooks; (3) secondary prevention of negative relationships, using targeted workbooks;
and (4) tertiary prevention of critical or chronic dysfunctionalities that cannot be treated
solely by f2f talk but need also the other three tiers of preventive approaches.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 488 Luciano L'Abate

Instead of f2f talk, the prevailing treatment paradigm of the last century, this theory relies
on distance writing before, during, or after or instead of f2f talk. Talk is too expensive,
inefficient, unpredictable, uncontrollable and difficult to evaluate. Admittedly, it can and
should be used sparingly to lower the level of intensity in crises and decrease the influence of
referral symptoms. However, distance writing is and will be the major medium of healing in
this century. It will become even more frequent through computers and the Internet (L'Abate,
1999, 2003b). The presumed and ascribed power of talk, personal contact, presence, and
personality of the therapist are being replaced and will be increasingly replaced with the
power and efficiency of the written word. Combining distance writing with empirically
verified therapeutic approaches will prevail over the whims and wills of therapists. If an
approach is replicable, then it can be administered in writing online. Words and the
personality of the therapist are not replicable or are very difficult and expensive to replicate.
Hence, distance writing, away from the presence of the therapist, is becoming the primary
medium of communication and healing with talk being secondary. Write first, talk second.
Words are cheap. Anybody can talk but will talk lead to more positive actions? If an approach
is cheaper than another, given the same level of effectiveness, which one should we use?

Toward a Classification of Distance Writing

Once writing is classified by its structure, four levels are available: (1) open-ended, as in
journal and diaries; (2) focused, as in autobiographies and in Pennebaker's expressive writing
paradigm (Esterling, L'Abate, Murray, and Pennebaker, 1999); (3) guided, as in answering in
writing written questions; and (4) programmed, as in self-help mental health protocols or
workbooks (L'Abate, 1992, 1996, 2002, 2003, 2004a, 2004b, 2007c; L'Abate & De Giacomo,
2003).
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Self-help Mental Health Protocols to Test the Validity of Models

This theory stresses the latter approach, workbooks, as being more relevant to evaluate
and apply the theory interactively rather than statically. There are workbooks independent of
the theory, but that are conceptually similar to some of its models. There are workbooks that
are related to some models of the theory, and there are workbooks, as shown above, that are
directly derived from models of the theory. The latter serve as a method to evaluate the
validity of models of the theory interactively rather than statically, relying solely on
laboratory instruments. Workbooks may be cost-effective, can be mass-administered, are
versatile, and can be evaluated less expensively than talk.

Therapeutic Prescriptions
In psychotherapy, three major, non-verbal tasks can be prescribed , like drawing lines to
create limits in co-dependent individuals, sharing hurts in couples, and hugging, holding,
huddling, and cuddling (3HC) in both couples and families (Table 2).

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Applications of Relational Competence Theory to Prevention and Psychotherapy 489

ASSESSMENT AND DIAGNOSIS

Theory-derived assessment instruments have been already described above. Once
workbooks are accepted as one theory-testing approach, they can be constructed from existing
testing instruments for normative purposes to answer referral questions, and from profile or
single score tests. For instance, workbooks for adults are classified (L'Abate, 1996, 2002,
2003a, 2003b, 2004a, 2004b, 20007c) according to either internalization (anxiety, depression,
and fears) or externalization (anger, hostility, and aggression) problems. Each category is then
subdivided by referral reason or by test profile or single score tests. For instance, workbooks
were developed from the Content Scales of the Minnesota Multiphasic Personality Inventory -
2 (MMPI-2) the dimensions of Personality Assessment Inventory (PAI), the Neuroticism-
Extraversion-Openness (NEO) tests, and many others. Among single score tests, workbooks
were developed from the Beck and Hamilton Anxiety and Depression Inventories, among
many others. Any list of items developed from either clinical experience or from factor
analyses can be transformed into a written protocol or workbook through definitions,
examples, and rank-orders (L’Abate, 2005, 2007c).
Once an assessment and a label is assigned to a condition, with the written consent of
participants, a workbook can be matched with either: (1) the referral reason; or (2) the highest
score in a test profile; or (3) the score in a single-score test. Hence, through the programmed
writing medium, evaluation and treatment become isomorphic with each other. Treatment
matches evaluation. Advantages , disadvantages, and dangers of this approach have been
considered from the outset of this approach (see publications listed above). However, it will
be impossible to find out its shortcomings unless this approach is applied by others.

Treatments
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Treatment using workbooks has been evaluated by L'Abate (L'Abate, and Maino, 2005)
with individuals, couples, and families. Contrary to expectations, and predictions about their
cost-effectiveness, workbooks increased (rather than decreased!) significantly the number of
sessions in all three samples, suggesting, perhaps, a greater involvement by respondents in the
process of therapy. These results, therefore, raise questions about the cost-effectiveness of
workbooks, but more data will be necessary before reaching a definite conclusion. Therapists,
at this juncture, therefore, need not be afraid that workbooks will decrease their incomes!
Indeed, workbooks may increase the therapist's effectiveness and increase the range of
clinical conditions that can be helped.

Techniques

Administration of workbooks, either offline or online, needs to follow established criteria

of legal, ethical, and professional practices, involving: (1) an interview or an objective
substitute for an interview, as in the structured Social Information Form (L'Abate, 1992,
1996); (2) an objective evaluation of the reason for referral or symptom; (3) a signed consent

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 490 Luciano L'Abate

form (L'Abate, 1996, 2004a); and (4) a follow-up, using perhaps a questionnaire about the
usefulness of workbook administration (L'Abate, 2004b).

STRENGTHS AND LIMITATIONS

The theory’s strengths may be also its limitations.

Strengths

This theory is complex but it aims at accounting for as many functional and dysfunctional
relationships as is humanly possible. It is detailed and specific. It avoids unfounded and
grandiose hypotheses and generalizations. It adheres, as much as possible to an empirical
paradigm: it is better to be found "wrong" in one’s specificity than to claim being "right" in
one’s generalities without any evidence. Specific hypotheses are easier to evaluate than wild
speculations.

Limitations

In this regard, the theory may be seem grandiose and, in some cases, appear
overwhelming to some readers. It has not achieved as much popularity in the USA as in some
Italian universities. In the University of Padua, for instance, thanks to the influence of one
collaborator, Prof. Mario Cusinato (personal communication, January, 3, 2003), over 50
dissertations he mentored have produced new, original ways to evaluate models of the theory
and test their validity (Cusinato & L’Abate, 2003, 2005a, 2005b).
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Another limitation of this theory lies in the marketplace of existing and already
established theories like psychoanalysis, that , for instance, even though relatively untested
and untestable, after a whole century, is still deeply ingrained in some psychiatric and clinical
circles. Hence, necessary comparative competition and evaluation with external theories and
models is one of the many limitations facing this theory. If models from the theory are found
valid over time, ultimately the theory will prevail. If the models will be found invalid the
theory will disappear into obscurity.

Unaddressed Issues

Therefore, the major issue facing this theory is dissemination, that is: to make the theory
and its applications more available to students and professionals who will want to evaluate the
validity of its models in the laboratory as well as in prevention and treatment settings.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Applications of Relational Competence Theory to Prevention and Psychotherapy 491

CONCLUSION
The purpose of this chapter has been to outline and summarize a competence theory of
personality socialization in intimate relationships and other settings. Since this chapter is
already a summary, it is impossible to summarize it even further. However, models of the
theory apply directly or indirectly to prevention and psychotherapy of clinical conditions
through homework administration of written protocols or workbooks.

REFERENCES
American Psychiatric Association (1994). Diagnostic Statistical Manual-IV. Washington,
DC: Author.
Baumeister, R. F., & Vohs, K. D. (Eds.).(2004). Handbook of self-regulation: Research,
theory, and applications. New York: Guldord
Cusinato, M., & L'Abate, L. (2003). Evaluation of a structured psychoeducational
intervention with couples: The Dyadic Relationships Test (DRT). American Journal of
Family Therapy, 31, 79-89.
Cusinato, M., & L’Abate, L. (2005a).The Dyadic Relationships Test: Creation and validation
of a model-derived, visual-verbal instrument to evaluate couple relationships. Part I of II.
American Journal of Family Therapy, 33, 195-206.
Cusinato, M., & L’Abate, L. (2005b). The Dyadic Relationships Test: Creation and validation
of a model-derived, visual-verbal instrument to evaluate couple relationships. Part II.
American Journal of Family Therapy, 33, 379-394.
Esterling, B. A., L'Abate, L., Murray, E., & Pennebaker. J. M. (1999). Empirical foundations
for writing in prevention and psychotherapy: Mental and physical outcomes. Clinical
Psychology Review, 19, 79-96.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Foa, U. G., & Foa, E. B. (1974). Societal structures of the mind. Springfield, IL: Thomas.
Kazantzis, N., & L'Abate, L. (Eds.).(2007). Handbook of homework assignments in
psychotherapy: Theory, research, and prevention. New York: Springer.
L'Abate, L. (1976). Understanding and helping the individual in the family. New York: Grune
& Stratton.
L'Abate, L. (1986). Systematic family therapy. New York: Brunner/Mazel.
L'Abate, L. (1992). Programmed writing: Self-administered interventions for individuals,
couples, and families. Pacific Grove, CA: Brooks/ Cole.
L'Abate, L. (1994). A theory of personality development. New York: Wiley.
L'Abate, L. (1999). Taking the bull by the horns: Beyond talk in psychological interventions.
The Family Journal: Therapy and Counseling for Couples and Families, 7, 206-220.
L’Abate, L. (1996). Workbooks for better living <www.mentalhealthhelp.com>
L'Abate, L. (2002). Beyond psychotherapy: Programmed writing and structured computer-
assisted interventions. Westport, CT: Ablex.
L'Abate, L. (2003a). Family psychology III: Theory building, theory testing, and
psychological interventions. Lanham, MD: University Press of America.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
 492 Luciano L'Abate

L'Abate, L. (2003b). Treatment through writing: A unique new direction. In T. L. Sexton, G.

Weeks, & M. Robbins (Eds.), The handbook of family therapy (pp. 397-409). New York:
Brunner-Routledge.
L'Abate, L. (2004a). A guide to self-help workbooks for clinicians and researchers.
Binghamton, NY: Haworth.
L'Abate, L. (Ed.).(2004b). Using workbooks in mental health: Resources in prevention,
psychotherapy, and rehabilitation for clinicians and researchers. Binghamton, NY:
Haworth.
L'Abate, L. (2005). Personality in intimate relationships: Socialization and psychopathology.
New York: Springer.
L’Abate, L. (2006a). A completely preposterous proposal: The dictionary as an initial vehicle
of change in the family. The family psychologist, 23(2).
L’Abate, L. (2006b). A theory of personality socialization in intimate relationships.
Manuscript submitted for publication.
L'Abate, L. (2006c). Toward a relational theory for psychiatric classification. American
Journal of Family Therapy, 34, 1-15.
L'Abate, L. (Ed).(2007a). Low-cost interventions to promote physical and mental health:
Theory, research, and practice. New York: Springer
L’Abate, L. (2007b). Sourcebook of self-help protocols in mental health. New York:
Springer.
L'Abate, L., (in preparation). Competence socialization in intimate relationships: Research,
theory, and practice.
L'Abate, L. & Baggett, M. S. (1997). The self in the family: A classification of personality,
psychopathology, and criminality. New York: Wiley.
L’Abate, L., & De Giacomo, P. (2003). Intimate relationships and how to improve them:
Integration of theoretical models with prevention and psychotherapy applications.
Westport, CT: Praeger.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

L'Abate, L., L'Abate, B. L., & Maino, E. (2005). A review of 25 years of part-time
professional practice: Workbooks and length of psychotherapy. American Journal of
Family Therapy, 32, 19-31.
L'Abate, L., & Weinstein, S. E. (19987). Structured enrichment programs for couples and
families. New York: Brunner/Mazel.
L'Abate, L., & Young, L. (1987). Casebook of structured enrichment programs for couples
and families. New York: Brunner/Mazel.
McMahan, O., & L'Abate, L. (2001). Programmed distance writing with seminarian couples.
In L. L'Abate (Ed.), Distance writing and computer-assisted interventions in psychiatry
and mental health (pp. 137-156). Westport, CT: Ablex.
Parke, R. D. (2004). Development in the family. Annual Review of Psychology, 55, 365-399.
Serbin, L. A., & Karp, J. (2004). The intergenerational transfer of psychosocial risk:
Mediators of vulnerability and resilience. Annual Review of Psychology, 55, 333-365.
Stevens, F., & L'Abate L. (1989). Validity and reliability of a theory-derived measure of
intimacy. American Journal of Family Therapy, 17, 359-368.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 In: The Quick Theory Reference Guide ISBN: 978-1-60021-624-4
Editor: Karin Jordan, pp. 493-499 © 2008 Nova Science Publishers, Inc.

Chapter 33

MEDICAL FAMILY THERAPY

Colleen M. Peterson and Kathleen Briggs

Medical Family Therapy emerged from the recognition of the significant interplay
between biological, psychological, and social factors in medical illness. Part of this
recognition stems from the fact that so many people present with psychosomatic and other
mental heath symptoms to their primary care physicians. With approximately 25 – 30% of
primary care patients presenting with depression, anxiety, substance abuse and other
psychological disorders (Ormel, VoKorff, Ustin, Pini, Korton & Oldehinkel, 1994), 78% of
patients with a diagnosable mental health condition seeking care from primary care
physicians (Miranda, Hohnmann & Attkisson, 1994), and many patients presenting with
somatic issues, it is critical that physicians be able to distinguish between treatable medical
illness and psychological/psychosomatic issues. Medical family therapists, working
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collaboratively with physicians and medical care providers, are a valuable asset to this
ferreting out process. Medical family therapists help educate medical providers about
psychosocial issues, how to assess for such issues, as well as allow medical providers to focus
on the medical issues by providing psychological services to those in need.
The “biopsychosocial model,” which examines a person’s biological, psychological and
social realms, has become increasingly accepted and utilized by mental health and medical
professionals alike. Medical family therapy is a framework through which therapists assist
patients with medical, mental health, and relationship concerns for themselves and their
family members. Medical family therapy is commonly used in tertiary care settings where
specific chronic and terminal illnesses are treated. In these settings, patients and their families
receive assistance in dealing with the unique challenges of chronic disorders such as heart
disease, diabetes, high blood pressure, cancer, etc. Medical family therapy emphasizes the
importance of the therapist having illness-specific knowledge in order to facilitate working
with the patients and their families. With this illness-specific knowledge, the therapist is able
to focus on the immediate concerns, rather than spending valuable time learning about the
illness from the patient and engaging in the time consuming assessment procedures typically
associated with the more general therapy process; illness-specific knowledge allows the
therapist to get right to the point in working with patients and their families.

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 494 Colleen M. Peterson and Kathleen Briggs

Medical family therapy was developed and articulated by family therapists working in
medical settings. Key authors and contributors in this area include Susan McDaniel, Jeri
Hepworth, William Doherty, Tom Campbell, and David Seaburn.

KEY CONCEPTS
Medical family therapy is a metaframework that draws on systems theory and the
biopsychosocial model (Engel, 1980). The biopsychosocial model emphases the
interrelatedness of biological, psychological, and social aspects of human existence and how
they play out in areas of health and disease (Ruddy & McDaniel, 2003). It applies systems
theory to human functioning, recognizing that all these areas impact one another
simultaneously, and that intervention affects many levels of the human experience (Ruddy &
McDaniel, 2003).
Although not a theory or model, collaboration is an important element of medical family
therapy. This collaboration is essential for therapists working with medical providers. Not
only must the therapist establish collaborative working relationships with the medical
providers, s/he must also learn about the medical setting, with its own culture, language,
expectations and traditions. Using his/her knowledge of the medical context, the medical
family therapist must learn to facilitate and negotiate communication between himself/herself
and the medical community, as well as between the patients and the medical providers.

HEALTHY VS. UNHEALTHY/DYSFUNCTIONAL FUNCTIONING

With the systemic biopsychosocial lens, the medical family therapist doesn’t necessarily
view things from the perspective of healthy vs. unhealthy functioning, but rather from the
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

continuation of adaptation. A medical family therapist sees chronic illness as a challenge to

the patient and his or her family and looks at how well the patient and family are adapting to
the illness. As a result, the therapist focuses on the stressors/challenges associated with the
illness and the adaptations necessary to cope with it. Some of the stressors that require
adaptation include individual/family role changes, caregiver burden, financial hardship due to
loss of employment and medical expenses, accommodation to treatment regimens, and
communication surrounding the illness (Ruddy & McDaniel, 2003). In addition, the patient
and family must face and deal with multiple losses such as changes in lifestyle, functioning,
intimacy, and the possibility of the death of a loved one. Because various illnesses present
different impacts and challenges, it is important that therapist understand the stressors specific
to the illness and for the family in order to help patients and their families adapt to them.
The biopsychosocial model recognizes the mind-body connection, and subsequently
addresses the biological, psychological, and social issues as interconnected systems of the
body. This model draws a distinction between the actual pathological processes that cause
disease and the patient’s perception of his/her health and the effects on it, called the illness.
Rather than operating solely from a biomedical model, which emphasizes the disease, disease
processes and treatment, the biopsychosocial model incorporates the psychosocial aspects as

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Medical Family Therapy 495

well, recognizing how each aspect interacts with the other and affects patients and their
families.

THE CHANGE PROCESS

Within the medical family therapy approach, therapists work with patients and their
families to promote adaptation to illness. This is done through psychoeducation and
facilitating adaptation. When it comes to psychoeducation, therapists can educate patients and
families regarding the specific illness – what they can expect and how it typically impacts
individuals and family members. Psychoeducation can be accomplished through support
groups, bibliotherapy, and interaction with medical providers, as well as individual and
family therapy. Psychoeducation empowers patients and family members with information
and sense of agency. It teaches them about their illness, coping strategies and how they can
enhance their quality of life (McDaniel, Hepworth & Doherty, 1992).
The therapeutic process validates the patient’s and his/her family members’ experience
with the illness. Therapy, as well as support group experiences, normalize the experience with
illness and provide an atmosphere that is safe and conducive to exploring, discussing and
learning about the illness and its effects, and possible ways to deal with and adapt to it.
Support groups in particular, give patients and family members the sense that they are not
alone and provide hope, by seeing and learning from others that they too can deal with the
challenges posed by the illness.

THE THERAPEUTIC PROCESS

Assessment and Diagnosis

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With the medical family therapy approach, the purpose of assessment is to ascertain the
impact/effects of the illness on the patient and his/her family members, how the patient/family
members are coping with/adapting to the stressors, and potential factors needing attention to
facilitate adaptation. Additionally, the therapist examines the recursive effect between the
family’s psychological well being, coping choices, and social support and the impact on the
patient. The therapist’s illness-specific knowledge becomes central to this process to guide
him/her in asking questions about the disease, its impact, and how it is being dealt with. The
primary assessment tool used by the medical family therapist is interviewing/discussion. The
therapist is assessing the illness stressors and coping skills, and which stressors require
additional coping skills to facilitate adaptation.

Treatment

Medical family therapists work with the patient and family members to set goals for their
work together. This is done by identifying the impact of the illness on the patient and family
members, how they are adapting to the illness, and then determining what coping skills could

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 496 Colleen M. Peterson and Kathleen Briggs

facilitate more effective adaptive responses. Treatment in medical family therapy includes the
joining, working and termination phases just as other family therapy models do.

Joining

When joining with patients and their families, it is important for medical family therapists
to use the medical language and terminology associated with the specific illness. A working
knowledge of the diagnostic and treatment regimens associated with the illness (i.e. the drugs
being prescribed and their effects and side effects) is essential for the therapist’s
understanding of the patient’s and family members’ experience. By demonstrating a strong
working knowledge of the illness, its etiology, treatment, and effects, medical family
therapists can foster a sense of confidence and trust in the patient and family members. Often
the ordeal of dealing with an illness can be tiresome and overwhelming. Having a therapist
who is well-versed in the illness and subsequent treatment gives the patient and family
confidence that the therapist understands their situation and will really be able to help them.
The joining techniques associated with other therapy models apply to medical family therapy
as well – establishing rapport, assessing the situation, establishing goals.
Once the medical family therapist has established a working relationship with the patient
and his/her family, s/he moves into the work phase of treatment. This phase involves a
detailed exploration of how the illness is impacting the patient and his/her family, how they
are adapting to the illness, and how adaptation to the illness can be facilitated. In the work
phase of treatment the therapist uses his/her knowledge of the illness, its treatment, and
common challenges with them, to guide the exploration of issues and potential solutions.
Termination of treatment occurs when therapy goals have been completed and the
patient/family have addressed the stressors and coping mechanisms associated with the
illness.
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Techniques

Techniques used to promote family adaptation to illness are summarized as follows

(Ruddy & McDaniel, 2003; Rolland, 1994):

• Heighten awareness of shifting family roles – pragmatic and emotional. In adapting

to the illness, family roles and interaction patterns shift. The changing roles include
things like routine daily tasks (e.g. the transportation of children to events) and more
subtle things like the management of emotions or communication in the family.
Medical family therapists assist with shifting roles by normalizing the effects of
illness, by making the changes in roles overt, and facilitating a discussion of the
changes and how the family wants to address them. This sometimes includes a
discussion of the extent to which the ill person has taken on the “illness role.” During
this discussion, the therapist helps the patient address what responsibilities he/she
has, the extent to which the illness will allow him/her to carry them out, and what
shifts need to made in those responsibilities.

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 Medical Family Therapy 497

• Facilitate major family lifestyle changes – dietary changes, smoking cessation, etc.
Sometimes the illness requires families to make major lifestyle changes. These
lifestyle changes, such as dietary changes or smoking cessation, can be sore spots
between family members, and also between the family and medical providers.
Facilitating discussion of such changes helps patient and family understand and
accept the changes, increasing motivation to change and the potential success in
making the changes. The discussion typically includes normalizing the difficulty of
such changes and the impact of not making those changes (on family members, as
well as on the illness itself).
• Increase communication within and outside the family, regarding the illness. The
medical family therapist needs to help the family communicate about the illness, both
amongst themselves, and also with others, in order utilize resources to deal with the
stress related to the illness. By opening up communication and having family
members talk about how the illness is impacting each of them individually, the
therapist increases empathy and support between family members. It also encourages
family members to work together to cope with the illness and its impact. When
family members reach out to people outside their immediate circle, particularly those
in similar circumstances, it normalizes the experience, reduces feelings of frustration,
and provides information about how others have dealt with the illness and associated
stress.
• Help family members accept what they cannot control and focus energies on what
they can control. When families feel like they do not have any control over the
situation, this often contributes to a sense of helplessness. By helping identify the
things that they cannot control, the medical family therapist helps families with a
reality check, accept those things, and move on. Once this is done, families tend to
have realistic expectations and it helps them to better cope with the situation by
focusing on what they can do.
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• Find meaning in the illness. Medical family therapists can help families accept the
situation and make peace with it. This is done by exploring with family members
how the illness has changed their lives in positive ways. For example, family
members often realize that the illness has had a positive impact on how they relate to
and work with each other.
• Facilitate grieving of inevitable losses – of function, of dreams, of life. Therapists
can help patients and their families grieve the losses associated with the illness.
These range from the loss of self-sufficiency to the loss of life imposed by the illness.
Dealing with the potential loss of life is often difficult because the patient and/or
family members want to protect one another from mortality. As difficult as these
discussions may be, they are crucial to helping patients and their family members
make critical end of life decisions and improve quality of life. Often having these
difficult conversations makes it easier on survivors after their loved ones have died.
• Increase productive collaboration among patients, families, and health-care team.
Medical family therapists can help families develop productive collaborative
relationships with the medical providers by helping them recognize any biases they
may have, coaching them on how to get their needs met and questions answered, and
addressing any parallel processes between themselves and their interactions with the
medical community. Many times family members realize that the way they interact
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 498 Colleen M. Peterson and Kathleen Briggs

amongst themselves does not work with their medical providers. The therapist can
help improve the communication and collaboration between family members and the
medical care providers.
• Explore and facilitate hope. The medical family therapist recognizes the important
role that hope plays in patients and family members coping with illness. Hope is
essential to the well-being and quality of life for patients and family members.
• Explore and facilitate quality of life. Medical family therapists explore issues and
help patients and their families maximize quality of life. For example, the therapist
would explore the relational, emotional, and spiritual aspects of living associated
with quality of life. During this exploration the medical family therapist focuses on
helping the patient and family identify those areas that bring meaning and enjoyment,
and how they can bring more of them into their lives. This might include looking at
how they spend their time together as a couple or family and determining what they
can do to improve that time together. It might also include discussing limitations
imposed by the illness and alternative means to maintain the quality interactions that
they desire. For example, the illness may seriously impact a patient’s stamina or
his/her ability to stand, walk or engage in activities that s/he participated in with
family members. Through exploring this situation, the therapist might help the
patient and family identify other ways to allow this activity to continue, such as
utilizing a wheelchair.

Techniques from various marriage and family therapy models can be used beneficially in
medical family therapy. For instance, families dealing with illness often benefit from
narrative family therapy techniques, which allow their stories to be heard and also allow for
externalizing the problem, and unify family members in fighting the illness. In addition,
techniques such as genograms facilitate exploration of family patterns at hand – patterns of
health concerns, dealing with medical providers, communication patterns, etc.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

STRENGTHS AND LIMITATIONS

Strengths

Perhaps the greatest strength of the medical family therapy model is the broad and
inclusive recognition of the interplay between biological, psychological, and social factors
when dealing with illness. In addition, the biopsychosocial model takes the biomedical model
to the next level by incorporating psychological and social aspects into consideration. On a
pragmatic level, medical family therapy provides an avenue of treatment for patients and their
family members to deal with the emotional and relational aspects of illness. Not only is this
beneficial to the patients and their families, but also to the medical providers whose time is
limited by medical system constraints and whose training often does not include emotional or
relational issues.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Medical Family Therapy 499

Limitations

Because medical family therapy’s biopsychosocial focus is so inclusive of factors that

influence human existence, there aren’t really limitations per se. The limitations related to this
model, however, play out in the context within which it is practiced. With the cost of medical
services, oversight of HMOs and other third party payors, one of the major challenges of
medical family therapy is funding for the services. Although advances have been made
substantiating the validity and value add of medical family therapy, some insurance will not
reimburse for such services. As a result some medical settings do not provide these valuable
services and for some the lack of resources does not allow them to utilize the services.

SUMMARY
With the call for increased recognition of the mind-body interplay and society’s emphasis
on health and well-being, medical family therapy provides a needed bridge between the
medical world and the world of individuals and families dealing with illness. With all of the
medical advances, including technology and pharmacology, and an aging population with
longer life expectancies, the likelihood of illness affecting individuals and their families
increases significantly. Medical family therapy, with its biopsychosocial model, offers a
viable avenue for helping patients and families facing illness deal with the challenges, gain
new coping skills, and adapt to the impact of illness. It offers hope that although illness
presents challenges, those challenges can be faced and overcome in ways that preserve
dignity and foster quality of life.

REFERENCES
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Engel, G. L. (1980). The clinical application of the biopsychosocial model. American Journal
of Psychiatry, 137, 535-544.
McDaniel, S. H., Hepworth, J., & Doherty, W. J. (1992). Medical family therapy: A
biopsychosocial approach to families with health problems. New York: Basic Books.
Miranda, J., Hohnmann, A. A. & Attkisson, C. A. (1994). Epidemiology of mental health
disorders in primary care. San Francisco, CA: Jossey-Bass.
Ormel, L., VoKorff, M., Ustin, T., Pini S., Korton, A., & Oldehinkel, T. (1994). Common
mental disorders and disability across cultures: Results from the WHO collaborative
study on psychological problems in general health care. Journal of the American Medical
Association, 272, 1741-1748.
Rolland, J. (1994). Families, illness and disability: An integrative treatment model. New
York: Basic Books.
Ruddy, N. B., & McDaniel, S. H. (2003). Medical Family Therapy, in T.L. Sexton, G. R.
Weeks, & M. S. Robbins (Eds.), Handbook of Family Therapy (pp. 365-379). New York:
Brunner-Routledge.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 In: The Quick Theory Reference Guide ISBN: 978-1-60021-624-4
Editor: Karin Jordan, pp. 501-510 © 2008 Nova Science Publishers, Inc.

Chapter 34

FEMINIST FAMILY THEORY AND THERAPY

Toni Schindler Zimmerman and Angie Besel

Beginning in the 1950s, Marriage and Family Therapy has attempted to view behavior
from a systems perspective and be inclusive of all family members. Over time, however,
fundamental issues of equality in the family system became an area of concern for feminist
therapists. In an effort to make the field more inclusive of power issues in systems, Feminist
Family Therapy added to systems thinking the critical element of creating a therapeutic
environment based on acceptance, equality, and empowerment of gender and culture.

DEFINITIONS
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Feminist family therapy is an orientation that can be applied to all schools of therapy by
paying particular attention to the fundamental values and principles of feminist ideology
(Simola, 1992). Feminist family therapists encourage both male and female clients to free
themselves from outdated and ineffective sex role constraints derived from an oppressive
social structure (Danoski, Penn, Carlson, & Hecker, 1998). Furthermore, assisting clients in
examining how constrained gender roles and stereotyping frequently interfere with individual
growth and relationship satisfaction is central to the role of a feminist family therapist.
Feminist family therapy is not a specific set of techniques or interventions. Rather, it is driven
by the belief that raising awareness of power differentials in our personal and public lives and
assisting clients in reducing these damaging power differentials in their own lives, is
fundamental to relationship success and healthy functioning.

HISTORY
Systems theory, the primary theory in the field of family therapy, has ignored gender in
the family as a major organizing principle. Systems theory assumes that people are
interchangeable, thereby ignoring the power differentials between men and women, and

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 502 Toni Schindler Zimmerman and Angie Besel

ignoring the impact of influences outside of the family (Avis, 1988; Hare-Musten, 1989;
McGoldrick, Anderson, & Walsh, 1989; Silverstein, 2003; Simola, 1992; Walsh &
Scheinkman, 1989; Walters, 1990).
Historically, family therapy emerged during the 1950’s, a politically conservative era.
During this time, a leading assertion was that a gendered division of power and labor was
natural and governed by a set of innate or natural laws. This framework included the belief
that the private sphere was the woman’s domain and it was her responsibility to create a
haven for her family (particularly her husband) from the public (male) sphere (Goodrich,
Rampage, Ellman, & Halstead, 1988). This historical context contributed to the sexism
inherent in family therapy and the invisibleness of gender in systems thinking. Additionally,
the majority of early family therapists were white men, leaving the voices of females and
persons of color out of the development of the field (McGoldrick et al., 1989; Silverstein,
2003).
This power differential omission in family therapy theory, practice, and training has
resulted in therapy that is detrimental to women (Avis, 1988; Goodrich et al., 1988). Feminist
family therapy scholars have scrutinized the basic concepts of systems theory. This
examination has focused on several areas. First, on family therapy’s failure to address gender
as a primary variable in society and family life as well as, viewing family dynamics without
considering the social context. Other issues include blaming mothers for family relational
problems, a common occurrence in therapy, and the reinforcement of traditional and outdated
gender roles. Feminist family scholars also assert that a neutral stance in family therapy
ignores power imbalances (e.g. domestic violence), and reinforces traditional patriarchal
family structures and behaviors. This examination has led to a full integration of these critical
issues throughout the field of family therapy.

THEORY DESCRIPTION
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One of the most unique features of feminist family therapy is that it is not a theory
defined and constricted by specific techniques, but is instead an overarching conceptual lens
through which any other family theory can be viewed (Braverman, 1988; Haddock,
Zimmerman, & MacPhee, 2000; Walters, 1990; Wright & Fish, 1997). Feminist family
therapy is essentially a meta perspective which can inform and guide therapists who are
working from any of the major family therapy theories. Feminist family therapy is not only a
therapeutic perspective but is also a socially and politically active stance that works to raise
awareness of gender and power differentials present in all aspects of our lives (Braverman;
Brown, 2002; Danoski et al., 1998; Haddock et al. Avis, 1988; Hare-Mustin, 1989; Miller &
Wieling, 2002; Haddock et al., 2000; Walters, 1990; Wright & Fish, 1997).
Gender and power dynamics are a result of socialization from the family and the larger
society. This socialization occurs through everyday, ordinary events. Therefore, it can occur
on a subconscious level, resulting in an innate sexism which reinforces men’s power and
maintains women’s powerlessness, resulting in many of women’s social, economic, and
psychological difficulties (Avis, 1988). For this reason, feminist family therapists actively
strive to notice and address gender and power issues in couple and family therapy (Brown,
2002; Haddock et al., 2000; Haddock & Zimmerman, 2001; Kune-Karrer & Foy, 2003;

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 Feminist Family Theory and Therapy 503

Turner & Avis, 2003). They also emphasize that individual and family needs are important
but one should not be sacrificed for the other (Wright & Fish, 199). Furthermore, feminist
family therapists work towards empowering couples and encouraging the development of
egalitarian relationships in all areas of the couple’s lives from mundane housework, to the
joys and responsibilities of parenting, to major decision making.
Finally, feminist family therapy believes that not only is it important to eliminate gender
based oppression, but other types of oppression as well, thereby encouraging cultural
sensitivity and examining the impact that gender has on other social dimensions such as race,
class, and sexual orientation (Brown, 2002; Haddock et al., 2000; Ziemba, 2001).

NATURE OF PERSONS/FAMILIES
Feminist family theory holds that human nature is determined not by biology but by
culture and society. This idea is extremely important for the validity of the theory because
without it one could argue that men and women are biologically unequal and therefore
equality is impossible and undesirable. However, because there are some biological
differences between men and women it is important for us to differentiate between sex and
gender. Sex refers to the anatomical differences between men and women, but makes no
value judgments about these differences or assigns particular tasks to those with a particular
anatomy (Goodrich et al., 1988; Haddock & Zimmerman, 2001; Hare-Musten, 1989).
Gender is a socially constructed notion that prescribes certain roles and tasks to each
gender (Goodrich et al, 2003.; Haddock & Zimmerman, 2001; Hare-Musten, 1989). The
problem with these gender roles and power structures is that they are oppressive and limiting,
especially for women and society is structured to “oppress women and uplift men” (Goodrich
et al., p. 1; Goodrich, 2003; Hare-Musten, 1989). For example, occupations such as teacher
and nurse, which are still primarily female, pay less than occupations that are traditionally
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

male such as business and engineering.

These culturally determined gender roles state that people of a particular sex need to
participate in activities “appropriate” for members of their sex (Goodrich et al.1988;
McGoldrick et al., 1989). For example, in our culture some of the assumptions about male
and female roles are the beliefs that men are privileged and therefore deserve the right to
control women, women are responsible for all problems in their relationships, and women
believe that men are necessary for their happiness and welfare (Goodrich et al.). While there
are a few sex differences, there is evidence to suggest that the actual differences between the
sexes are minimal and we perceive greater differences between the sexes because of society’s
emphasis on difference rather than similarity (Hare-Musten, 1989).
The societal belief that men and women are dramatically different from one another and
not equal can be seen in the popularity of self-help books like Men are from Mars, Women
are from Venus (Zimmerman, Haddock, McGeorge, 2001). When couples, individuals, and
families work to resist gender-stereotyped inequities, they are moving away from popularly
held notions about gender. However, more and more people are moving in this direction and
the family therapy research suggests their relationships are better for it (Gottman, 1999). Men
and women are not from different planets, they are more alike than different and when it

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Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 504 Toni Schindler Zimmerman and Angie Besel

comes to relationships the more equal they are (e.g. treating each other as equal partners) the
better the relationship seems to be (Gottman, 1999; Rabin, 1996).
Society also has long held notions about what constitutes a “normal” family. Generally,
the nuclear family is considered the ideal family and other family structures are seen as
“deviant” (Brown, 2002). This idea is rejected by feminist family theory because of society’s
claim that the concept of “family” is determined by nature, not by the social context in which
the family exists (Goodrich et al., 1988; McGoldrick et al., 1989). Additionally, many
feminists want to alter the idea of the nuclear family as “normal” because it is an inaccurate
representation of most families today who are not nuclear families but nevertheless function
very well (Goodrich et al, 1988; Walsh,2003).

THEORETICAL UNDERPINNINGS
Feminist family therapy is the result of two major schools of thought: feminism and
systems theory. Within feminism there are three separate styles that are united by their belief
in the fundamental oppression of women (Avis, 1988). The first style is liberal feminism.
This style emphasizes equality through equal rights and equal opportunities and believes that
society is responsible for the existence of sexism. Most feminist family therapists identify
primarily with liberal feminism. The second style of feminism is socialist/Marxist. This style
holds that human nature is determined by society and not biology. Additionally, this style
considers capitalism and patriarchy to be reciprocal systems that are reinforce sexism. The
third style is radical feminism. This style emphasizes the connection between the oppression
in the public and private spheres and perceives sexism as the result of men exercising control
over women (Avis, 1988; Danoski et al., 1998). Even though these styles obviously have
some great differences, they still share the basic premises of feminism.
The second major theory influencing feminist family therapy is systems theory. Systems
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

theory is the primary theory from which family therapists operate (Goodrich et al., 1988). The
basis of this theory is that the family is a system and what occurs in one part of the system
equally affects the rest of the system. A person’s behavior cannot be fully understood outside
the context of the family system. However, this theory neglects to acknowledge that not all
family members have equal power and influence in the family. Three major concepts in
systems theory that feminist family therapists find problematic are complementarily,
circularity, and neutrality. Complementarity is the assumption that inequalities are temporary
and will eventually shift. Circularity is the belief that people are caught in re-occurring
behavior patterns that are mutually instigated and reinforced. Neutrality refers to the stance
that the therapist should hold so no member of the family feels sided with or against
(Goodrich et al, 1988). These concepts are problematic because they draw the focus away
from power differences and gender roles that influence the functioning of the family (Hare-
Mustin, 1989).

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Feminist Family Theory and Therapy 505

HEALTHY/UNHEALTHY FUNCTIONING
Healthy and unhealthy functioning of an individual can only be fully understood in the
context of their family system (Simola, 1992). The basis of healthy functioning in feminist
family theory is equality. Rigid gender roles and power differentials are oppressive and
harmful to men (e.g. discouraging a full range of emotions including crying), but especially to
women (e.g. domestic violence). Such roles are harmful to families because they limit the
members’ desires, behaviors, and expectations and this may lead to resentment between
couples and feel oppressive to individuals (Goodrich et al., 1988). For instance, a male who
does not express his emotions or spend time with his children or a woman who does not assert
her desires or feels overly burdened by domestic life may feel personally oppressed, sad, and
unfulfilled.
On the other hand, the essence of healthy functioning is equality. To fully achieve this, it
is important to value aspects of feminine and masculine roles in a balanced, flexible way.
(Wright & Fish, 1997). There are many benefits to egalitarian relationships including high
relationship satisfaction, physical health benefits, and a deep and profound friendship with
your significant partner (Gottman, 1999; Rabin, 1996).

CHANGE PROCESS
Feminist family therapy asserts that for change to happen it is best if it occurs on three
levels: an individual or family level, a therapeutic level, and a societal level. On an individual
and familial level, it is important to change gender expectations because of the negative
consequences for men and women who form relationships based on power differences and
inequalities.
Second, family therapists need to understand the impact of the interactions of all systems
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

(society, religion, etc.) on the family, not the family system alone (McGoldrick et al., 1989).
One way therapists elicit change, particularly in families and individuals, is through the
therapeutic environment. It is important for the therapist to interact with clients in ways that
are validating and empowering in order to help clients alter their behaviors, values, and
feelings. These behaviors are helpful because clients learn not only from the therapist’s
instructions, but also through the way the therapist interacts with them (Goodrich et al.,
1988).
Change on the societal level is imperative because society maintains the importance of
following prescribed gender roles (Danoski et al., 1998; Simola, 1992). For change to occur
there must be a growing validation of women and womanly traits, and the acceptance of the
view that all women, including mothers, are deserving of equality. It is also important to
demystify the idea that a particular gender division of labor is desirable (Hare-Mustin, 1989;
Goodrich et al., 1988; McGoldrick et al., 1989). Additionally, changes are needed in men’s
commitment to the world of competition at the expense of human connectedness (McGoldrick
et al.).
However, change is not and will not be easy. Many traditional gender values are deeply
embedded in our culture. Even when individuals and families change, the newly integrated
values are difficult to maintain because they contradict societal norms. Nonetheless, for

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 506 Toni Schindler Zimmerman and Angie Besel

change to occur, it needs to begin somewhere. The family is an ideal location for beginning
this change because it is the primary means of culture transmission. Families teach, reinforce,
and uphold the power structure and gender roles of a society (Goodrich, 2003; Goodrich et
al., 1988; McGoldrick et al., 1989).
Feminist family therapists encourage change by explicitly addressing gender issues,
asking questions, and giving assignments in order to indicate the importance of sharing power
(Goodrich et al., 1988). In particular, therapists challenge family members to integrate
expressive and instrumental roles in men and women and to take responsibility for their
behaviors and the associated consequences (Wright & Fish, 1997). Additionally, it is
important for therapists to challenge rigid gender roles and how they are limiting (Wright &
Fish, 1997). Finally, while encouraging families to change is important, feminist family
therapists also emphasize the value of actively working toward societal change (Simola,
1992).

THERAPEUTIC PROCESS

Assessment and Diagnosis

To recognize and intervene in power differentials with clients, a therapist must first be
able to recognize them in society (e.g. media, government, pay and labor inequities) and in
their own lives. It is essential for therapists to be aware of their own gender-based values and
beliefs in order to be conscious of which values they are subtly or directly reinforcing (Avis,
1988; Goodrich et al.). For instance, when therapists remain silent about power differentials
in therapy, they are communicating implicit support.
It is critical for a feminist family therapist to model human behavior that is not
constrained by gender stereotypes. For instance, a male therapist might be conscious of not
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

dominating a female client and a female therapist might be careful not to defer to the male
client. As issues and problems are presented in therapy, a feminist family therapist views
interactions from a gender analysis perspective. For instance, if a couple is discussing
parenting problems, the therapist would be cognizant of the tendency for mothers to be
blamed for children and family relationship problems and the tendency to accept that fathers
are less involved in household labor and emotional work. Gender and power arrangements are
explored to determine whether they are contributing to the family’s difficulties (Brown,
2002). If gender and power are determined to be contributing to family and/or individual
problems, the family will be encouraged to explore alternative ways of relating and behaving
that are based on equality and fairness. A therapist might assess where a couple falls on the
continuum from traditional, gender-aware, polarized, and in-balance in order to help them
move towards power sharing (Kune-Karrer & Foy, 2003). Generally, this assessment is done
directly by asking questions about how the couple makes decisions, who does what in terms
of domestic labor, as well as simply observing clients behaviors in order to assess who holds
more power. For example, noticing who interrupts whom, whom defers to whom, or who
takes primary responsibility for relationship problems can provide the therapist with a great
deal of information about the power structure in the couple or family.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Feminist Family Theory and Therapy 507

Treatment

Treatment goals often increasing a client’s understanding of power differentials in society

as well as in the client’s personal life. Talking about how families are embedded in the larger
sociological context in which power differentials are condoned is helpful for clients because it
normalizes how their own power differentials developed (Wright & Fish, 1997). The
foundational understanding and awareness that society is organized by gender power
differentials (e.g. unequal pay, few women in government positions, and violence against
women by men) is helpful in therapy. Once clients begin to recognize this in society, they
often report “seeing it everywhere” (e.g. commercials, movies, magazines, talk shows).
This societal awareness often, although not always, precedes an awareness of how power
differentials are operating in the client’s lives in terms of gender expectations, privilege, and
responsibilities. Clients can set goals for themselves to reduce and/or eliminate these power
differentials by using a tool such as the power equity guide (Haddock, Zimmerman, McPhee,
2000) to determine strengths and areas for growth in multiple areas of their lives (e.g.
decision making, housework, relationship maintenance, and sexuality).
Alternatively, clients can simply, with the assistance of the therapist, explore how they
can break cycles of rigid gender based behavior that are undermining personal and family
satisfaction. An example of this would be if a couple determined that the mother felt overly
responsible for their children’s schedule (e.g. soccer, guitar, school projects and homework).
The couple might use behavioral techniques to share parenting responsibilities more equally.
Each parent might take three areas of the child’s schedule and commit to having primary
responsibility over these areas to more fairly share the burden and joys of these tasks.
Offering alternatives to the narrow definitions of male and female expectations is at the heart
of feminist family therapy (Goodrich et al., 1988). Essential to feminist family therapy goal
setting is assisting couples in the attainment of ongoing intimacy and friendship by reducing
or eliminating the power differential in their relationship (Haddock et al., 2000; Haddock &
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Zimmerman). Research indicates that shared power and deep friendship are key variable to
successful partnerships (Gottman, 1999; Schwartz, 1994; Rabin, 1996). Therefore, the
attainment of equality is a primary goal.
In order to create a model of shared power, goal setting occurs collaboratively with
clients and the therapist rather than relying on an expert hierarchal stance. The therapist
works to create an environment that is respectful of expressions of each family member’s
views and beliefs (Brown, 2002; Goodrich et al., 1988).

Techniques

In feminist family therapy, the process of therapy is as important as homework

assignments and interventions. For example, a therapist encouraging a woman to be assertive
and independent might suggest a homework assignment of interviewing assertive women or
asking for what you need at work or at home, but would then conduct therapy sessions in a
way that invites the client to be assertive, thus reducing the hierarchy between therapist and
client.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 508 Toni Schindler Zimmerman and Angie Besel

A therapist will generally focus on client strengths, avoid labels, develop collaborate with
clients to give them more control over their own therapy, and will encourage social analysis
to increase awareness of the personal and societal costs of stereotypical
A feminist family therapist can use any technique from any type of therapy as long as it is
not sexist or oppressive (Goodrich et al., 1988). Feminist family therapy can be viewed as a
meta theory which informs all family therapy theories and theories in other helping
professions as well.

STRENGTHS AND LIMITATIONS

Strengths

The primary strength of feminist family therapy is that it has challenged prevalent family
therapy theories. . Feminist family therapists have challenged many assumptions about
families, including the idea that the only healthy family is a nuclear family. (Avis, 1988). The
contributions and strengths of feminist family therapy are far reaching and make an impact on
all family therapy theories.
An additional important contribution and strength of feminist family therapy is the
emphasis on individual and family well-being rather than encouraging female subordination
of personal needs for family happiness. The needs and desires of all family members is
considered equally important and (Brown, 2002; Wright & Fish, 1997).

Limitations

A limitation of feminist family therapy, particularly in the early years of its development
is its incorrect assumption that women of different races and cultures experience oppression
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

in the same way (Avis, 1988; Ziemba, 2001). Primarily concerned with white middle-class
women’s oppression, feminist family therapy neglected the special issues faced by women of
color, LGBT women, third world women, and women of a different class (Avis; Miller &
Wieling, 2002; Silverstein, 2003; Ziemba). Concern with oppression based in race, class,
sexual orientation, and other marginalized groups, has become a major part of feminist family
therapy. This literature has examined power imbalances in economics, law, divorce,
employment, relationship responsibilities, childcare, household responsibilities, and violence
across diverse populations (Wright & Fish, 1997). This wide lens approach certainly
encourages the field to view families within its historical and structural context (Simola,
1992).
The name “feminist family therapy” in itself can also be a limitation because it conjures
up many misconceptions and stereotypes (Danoski et al., 1998; Haddock et al., 2000). It is a
struggle to use the label “feminist,” which for some may be synonymous with anti-male, anti-
god, superiority of women, or hatred of men. These misconceptions, primarily generated by
the media (e.g. Rush Limbaugh) do not represent the vast majority of feminist family
therapists. this makes it necessary for feminists to be explicitly clear about what they stand for
(Goodrich, 2003; Silverstein, 2003). This label may also make it difficult for men to see how
and where they have a place in feminism (Danoski et al.). Therapists must be sure to help

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Feminist Family Theory and Therapy 509

men, particularly white men, see that equal rights and privileges for all people leads to
healthier relationships and more productive societies. Furthermore, research indicates that
shared power among couples not only improves the well being and satisfaction of women but
also of men (Gottman, 1999; Schwartz, 1994; Rabin, 1996). After understanding what
feminism means and why its principles are effective for healthy relationships, many men and
women can call themselves feminists.

REFERENCES
Avis, J. M. (1988). Deepening Awareness: A private study guide to feminism and family
therapy. In L. Braverman (Ed.), A guide to feminist family therapy (pp. 15-46). New
York, NY: Harrington Park Press.
Braverman, L. (1988). Feminism and family therapy: Friends or foes. In L. Braverman (Ed.),
A Guide to Feminist Family Therapy (pp. 5-14). New York, NY: Harrington Park Press.
Brown, S. (2002). We are, therefore I am: A multisystems approach with families in poverty.
The Family Journal: Couples and Therapy for Couples and Families, 10, 405-409.
Danoski, M.E., Penn, C.D., Carlson, T.D., & Hecker, L.L. (1998). What’s in a name? A study
of family therapists’ use and acceptance of the feminist perspective. The American
Journal of Family Therapy, 26, 95-104.
Goodrich, T. J., Rampage, C., Ellman, B., & Halstead, K. (1988). Feminist family therapy: A
casebook. New York, NY: W.W. Norton & Company.
Goodrich , T. J. (2003). A feminist family therapist’s work is never done. In L. B. Silverstein
& T. J. Goodrich (Eds.), Feminist family therapy: Empowerment in social context (p. 3-
15). Washington, DC: American Psychological Association.
Gottman, J.M. (1999). The marriage clinic: A scientifically based marital therapy. New
York, Crown.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Gottman, J. M. & Silver, , N. (1999). Seven principles for making marriage work. New York,
Crown.
Haddock, S.A., Zimmerman, T.S., & MacPhee, D. (2000). The power equity guide: Attending
to gender in family therapy. Journal of Marital and Family Therapy, 26, 153-170.
Haddock, S.A.& Zimmerman, T.S. (2001). The power equity guide: An activity to assist
couples in negotiating a fair and equitable relationship. Journal of Clinical Activities,
Assignments & Handouts in Psychotherapy Practice, 1(2), 1-15.
Hare-Mustin, R. T. (1989). The problem of gender in family therapy theory. In M.
McGoldrick, C. M. Anderson, & F. Walsh (Eds.), Women in families: A framework for
family therapy (pp. 61-78). New York: W.W. Norton & Company.
Kune-Karrer, B. M. & Foy, C. W. (2003). The gender metaframework. In L. B. Silverstein &
T. J. Goodrich (Eds.), Feminist family therapy: Empowerment in social context (p. 351-
363). Washington, DC: American Psychological Association
McGoldrick, M., Anderson, C. M., & Walsh, F. (1989). Women in families and in family
therapy. In M. McGoldrick, C. M. Anderson, & F. Walsh (Eds.), Women in families: A
framework for family therapy (p. 3-15). New York: W.W. Norton & Company.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
 510 Toni Schindler Zimmerman and Angie Besel

Miller, M.M. & Wieling, E. (2002). Points of connection and disconnection: A look at
feminist and post modernism in family therapy. Journal of Feminist Family Therapy,
14(2), 1-19.
Rabin, C. (1996). Equal partners, good friends: Empowering couples through therapy. New
York: Routledge.
Silverstein, L. B. (2003). Classic texts and early critiques. In L. B. Silverstein & T. J.
Goodrich (Eds.), Feminist family therapy: Empowerment in social context (p. 17-35).
Washington, DC: American Psychological Association.
Simola, S. K. (1992). Differences among sexist, nonsexist, and feminist family therapies.
Professional Psychology: Research and Practice, 23(5), 397-403.
Schwartz, P. (1994). Love between equal: How peer marriage really works. New York, Free
Press.
Turner, J. & Avis, J. M. (2003). Naming injustice, engendering hope: Tensions in feminist
family therapy training. In L. B. Silverstein & T. J. Goodrich (Eds.), Feminist Family
Therapy: Empowerment in Social Context (p. 365-378). Washington, DC: American
Psychological Association.
Walsh, F. (2003). Normal family process, third edition. New York: Guilford.
Walsh, F. & Scheinkman, M. (1989). (Fe)male: The hidden gender dimension in models of
family therapy. In M. McGoldrick, C. M. Anderson, & F. Walsh (Eds.), Women in
families: A framework for family therapy (p. 16-41). New York: W.W. Norton &
Company.
Walters, M. (1990). A feminist perspective in family therapy. In M. P. Mirkin (Ed.), The
social and political contexts of family therapy (p. 51-67). Needham Heights, MA: Allyn
and Bacon.
Wright, C. I. & Fish, L. S. (1997). Feminist family therapy: The battle against subtle sexism.
In N. V. Benokraitis (Ed.), Subtle sexism: current practice and prospects for change (pp.
201-215). Thousand Oaks, CA: SAGE Publications.
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Ziemba, S. J. (2001). Therapy with families in poverty: Application of feminist family

therapy principles. Journal of Feminist Family Therapy, 12, 205-237.
Zimmerman, T.S. Haddock, S.A. & McGeorge, C.R. (2001). Mars and venus; Unequal
planets. Journal of Marital and Family Therapy, 27 (1), 55-68.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
 INDEX

afternoon, 431
age, 12, 62, 77, 79, 106, 119, 127, 130, 144, 170,
A 177, 210, 211, 212, 213, 215, 229, 303, 430, 443,
449, 458, 472, 481, 482, 485
Aaron Beck, 23, 127, 165
agent, 203, 243, 288, 356, 422
abdomen, 430, 439
aggression, 8, 12, 13, 106, 262, 265, 283, 364, 374,
abortion, 413
376, 457, 484, 489
academic performance, 341
aggressive behavior, 16, 123
access, 17, 100, 102, 172, 173, 178, 191, 204, 217,
aging, 61, 499
253, 286, 319, 327, 337, 389, 417, 468
aging population, 499
accessibility, 361
airports, 480
accommodation, 88, 337, 342, 494
alcohol, 112, 130, 154, 231, 364, 411
accountability, 336, 338
alcohol abuse, 364
accounting, 490
alcohol dependence, 154, 231
acculturation, 9, 392
alcoholism, 412
accuracy, 42, 70, 296, 355, 455
alertness, 453
achievement, 35, 38, 118, 170, 257
algorithm, 465
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

activation, 86, 143, 291

alienation, 55, 201, 483
acupuncture, 160
alternative(s), 27, 49, 62, 80, 89, 90, 91, 97, 101,
adaptability, 255, 389
103, 147, 168, 172, 188, 191, 294, 295, 333, 338,
adaptation, 10, 209, 331, 332, 334, 335, 345, 494,
375, 391, 392, 405, 406, 412, 414, 447, 450, 451,
495, 496
454, 455, 456, 466, 498, 506, 507
adaptive functioning, 288
alternative behaviors, 392
addiction, 130, 231, 337, 360
alters, 36
adenoids, 161
altruism, 302, 355, 462
ADHD, 342, 438, 449, 450, 453, 457, 459
ambiguity, 189, 192, 193, 254, 260, 336
adjustment, 24, 25, 69, 71, 72, 77, 87, 88, 89, 91, 95,
ambivalence, 189, 193, 337
98, 154, 371, 381, 382
American Indian(s), 398
administration, 475, 490, 491
American Psychiatric Association, xviii, 194, 232,
adolescence, 12, 23
236, 385, 481, 491
adolescents, 125, 251, 331, 344, 345, 346, 355, 417
American Psychological Association, xv, xviii, 63,
adulthood, 10, 23, 210, 218, 228
78, 79, 123, 167, 169, 179, 180, 181, 195, 207,
adults, 55, 76, 119, 123, 210, 218, 224, 258, 306,
297, 298, 329, 397, 472, 509, 510
320, 335, 468, 489
anal stage, 11
advertising, 158, 160, 161
anatomy, 44, 503
advocacy, 362, 366, 369, 377
anger, 96, 114, 133, 216, 239, 240, 288, 305, 334,
affective disorder, 362
407, 409, 410, 414, 438, 469, 484, 489
affective states, 219
anger management, 469
Africa, 153, 265

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 512 Index

animals, 51, 107, 110, 132, 138 attacks, 305

ankles, 407 attention, xi, xix, 13, 15, 17, 40, 52, 61, 89, 95, 100,
annihilation, 84 104, 108, 112, 141, 153, 160, 177, 179, 183, 188,
antagonism, 366 189, 190, 191, 192, 199, 206, 215, 216, 240, 248,
anthropology, 19, 52, 459 266, 273, 286, 289, 290, 291, 292, 295, 300, 322,
antidepressant(s), 119 328, 331, 338, 340, 342, 373, 391, 392, 395, 409,
antipsychotic, 362, 379, 381, 382 421, 432, 438, 441, 442, 445, 448, 451, 456, 464,
antipsychotic drugs, 379 495, 501
antisocial acts, 138 Attention Deficit Disorder, 461
antisocial behavior, 346 attitudes, 16, 24, 27, 51, 54, 57, 67, 73, 76, 151, 152,
antisocial personality, 292 153, 191, 198, 199, 219, 288, 317, 334, 342, 365,
antisocial personality disorder, 292 368, 425, 483, 485
anus, 11 attractiveness, 12
anxiety, 10, 12, 13, 14, 20, 21, 38, 48, 49, 53, 54, 57, attribution, 146, 344, 419
58, 62, 71, 77, 101, 110, 111, 112, 116, 117, 122, aura, 281
124, 127, 130, 131, 137, 144, 147, 150, 152, 154, Aurelius, Marcus, 127
157, 210, 219, 221, 240, 243, 245, 247, 248, 258, Australia, 166, 282, 367, 459, 460
259, 260, 269, 273, 280, 293, 297, 303, 333, 334, authenticity, 56, 113, 192, 277, 395
337, 357, 359, 363, 484, 489, 493 authority, 74, 75, 192, 260, 280, 313, 349, 352, 358,
anxiety disorder, 154, 297 450, 452
apathy, 371 autobiographical memory, 287
appraisals, 287, 302 autogenic training, 117
archeology, 44 automation, 86
argument, 302, 448, 465 autonomy, 2, 68, 242, 247, 251, 254, 259, 264, 270,
Aristotle, 41, 47, 263, 264 312, 333, 336, 389, 470
arousal, 101, 290, 292, 334 availability, 14, 103, 378, 394, 483
arrest, 134 avoidance, 40, 91, 98, 99, 112, 143, 146, 147, 148,
articulation, 392, 421 153, 257, 294, 312, 481, 484
aspiration, 33
assertiveness, 112, 113, 117, 120
assessment, 17, 26, 27, 37, 38, 55, 61, 71, 72, 76, 77, B
93, 94, 95, 96, 107, 109, 113, 114, 115, 118, 154,
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

background information, 189

171, 174, 175, 181, 188, 189, 190, 204, 206, 214,
Bacon, Francis, 1
220, 222, 232, 235, 236, 244, 245, 257, 274, 291,
baggage, 246
292, 311, 321, 322, 327, 333, 335, 337, 339, 340,
Bandura, Albert, 107, 127
341, 342, 350, 354, 355, 362, 365, 367, 368, 385,
barriers, 92, 149, 304, 305, 317, 335, 337, 341
390, 391, 392, 393, 394, 398, 424, 449, 450, 466,
basic needs, 52
467, 468, 471, 473, 489, 493, 495, 506
behavior modification, 122, 124
assessment procedures, 114, 493
behavior therapy, 23, 29, 107, 108, 109, 110, 111,
assessment tools, 55, 118, 232, 341
112, 113, 114, 115, 116, 118, 119, 120, 121, 122,
assets, 276, 368, 394, 395
123, 124, 125, 127, 128, 139, 141, 142, 143, 144,
assignment, 76, 205, 372, 404, 405, 409, 413, 414,
145, 149, 151, 152, 153, 384, 385
477, 478, 483, 484, 485, 486, 507
behavioral aspects, 132
assimilation, 41, 266
behavioral assessment, 365, 367, 368
assumptions, 1, 3, 10, 21, 24, 27, 55, 58, 59, 60, 65,
behavioral change, 29, 353, 390, 470
66, 73, 74, 76, 81, 83, 84, 88, 94, 101, 103, 144,
behavioral disorders, 153
205, 272, 311, 332, 334, 342, 418, 427, 433, 439,
behavioral models, 154
457, 475, 479, 481, 483, 503, 508
behavioral problems, 131, 331, 335
asymmetry, 16
behavioral sciences, 152
attachment, 8, 13, 14, 148, 183, 210, 218, 219, 220,
behavioral theory, 151
221, 222, 228, 288, 292, 293, 318, 333, 341, 347,
behaviorism, 2, 83, 89, 108, 124, 127, 479
361, 461, 463, 467, 469, 487
belief systems, 38, 183, 257
attachment theory, 8, 183

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
 Index 513

beliefs, 1, 2, 5, 24, 25, 29, 33, 49, 52, 54, 57, 67, bulimia nervosa, 123, 125
103, 109, 113, 132, 133, 139, 141, 143, 161, 170, burn, 413, 425, 451
171, 172, 178, 183, 185, 186, 189, 191, 194, 201, burning, 429
210, 228, 237, 238, 239, 244, 254, 256, 288, 289, burnout, 150, 153
313, 314, 319, 323, 324, 326, 328, 338, 344, 363,
369, 388, 396, 399, 454, 469, 503, 506, 507
bending, 427, 428, 430 C
benefits, 90, 124, 233, 259, 295, 368, 375, 379, 384,
California, xvii, xix, 211, 265, 366
396, 505
Camus, Albert , 47
benign, 256
cancer, 240, 311, 437, 493
bias, 11, 58, 94, 168, 169, 180
candidates, 138
biological processes, 9
capitalism, 504
biopsychosocial model, 493, 494, 498, 499
cardinal principle, 183, 269
bi-polar disorder, 461
career development, 4
birth, 24, 25, 26, 29, 199, 205, 210, 241, 254, 300,
caregivers, 209, 220, 241, 341, 363, 366
458
caregiving, 331, 336, 341
births, 351
Carl Rogers, 1, 63, 64, 74, 76, 78, 79, 80, 81, 100,
blame, 138, 216, 235, 312, 316, 319, 338, 353, 359,
300, 308, 425
395, 486
Carl Whitaker’s theory, 237
blind spot, 364
carrier, 418
blocks, 246, 343, 374, 408, 464, 467
case study, 124
blood, 115, 161, 202, 493
cast, 42, 66, 142, 240
blood pressure, 115, 493
casting, 326
body image, 187
castration, 12
bonding, 229, 254, 288, 294
CAT scan, 161
bonds, 440, 467
catalyst, 41, 253, 255, 271, 279, 281
borderline personality disorder, 296, 297
catalytic effect, 44
boredom, 86, 253
categorization, 387
borrowing, 177
category a, 354
bounds, 291
catharsis, 17, 469
bowel, 11
cats, 110
Bowen Family Systems theory, 237
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

causal attribution, 467

Bowen, Murray, 2, 237
causality, 2, 145, 388, 391
boys, 19, 179, 408
causation, 84, 389
Boszormenyi-Nagy, Ivan, 237, 249
central nervous system, 307
brain, 145, 156, 158, 160, 161, 162, 164, 248, 266,
cerebral cortex, 253
297, 369
certainty, 47
brain chemistry, 145, 369
certificate, xv
brain functioning, 248
changing environment, 91
brainstorming, 327
chaos, 186, 211, 321, 334, 346
breakdown, 255
chemotherapy, 384
breakfast, 406
Chicago, 79, 80, 105, 123, 153, 207, 309, 443, 459
breathing, 96, 101, 117, 191, 315, 326, 430, 431,
chickens, 312
439, 441
child abuse, 425
breeding, 363
child development, 308, 344
Britain, 218
child rearing, 107
brothers, 214, 312
childbearing, 364
Buber, Martin, 47, 58, 88, 99, 264, 267, 282
childcare, 508
Buddha, 127, 183, 399
childhood, 10, 14, 15, 19, 24, 26, 129, 131, 138, 161,
Buddhism, 128, 130, 138, 153
168, 205, 212, 213, 264, 306, 346, 347
buffer, 215, 216
childhood sexual abuse, 168
building blocks, 374
children, xvii, 11, 12, 55, 119, 123, 124, 125, 145,
bulimia, 123, 124, 125
151, 152, 159, 162, 163, 172, 197, 204, 206, 210,

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
 514 Index

211, 212, 213, 215, 227, 230, 233, 234, 235, 238, collaboration, 252, 294, 295, 342, 372, 390, 393,
239, 240, 241, 258, 270, 300, 302, 303, 306, 307, 423, 429, 431, 439, 465, 466, 494, 497
331, 332, 333, 334, 335, 336, 341, 343, 344, 346, Collaborative Therapy, 417, 418, 419, 420, 422, 424,
347, 352, 355, 359, 396, 398, 399, 404, 405, 406, 425, 426
407, 409, 412, 417, 438, 449, 450, 453, 459, 460, collective unconscious, 31, 33, 36
468, 496, 505, 506, 507 Columbia University, 106
China, xvi, 367 commercials, 507
Christianity, 44, 128 communication, 40, 65, 66, 70, 75, 78, 81, 118, 132,
chronic disorders, 493 183, 184, 186, 192, 193, 199, 203, 205, 210, 222,
chronic illness, 332, 382, 494 228, 246, 251, 260, 264, 272, 273, 293, 306, 307,
chronic pain, 150, 154 315, 316, 321, 322, 324, 328, 334, 342, 343, 344,
civil war, 259 349, 350, 352, 363, 365, 367, 368, 369, 370, 371,
classes, xvii, 104, 288, 362, 394 372, 373, 374, 375, 377, 378, 382, 387, 389, 392,
classical conditioning, 107, 110, 111, 116, 142 396, 419, 423, 451, 457, 461, 463, 469, 487, 488,
classification, 103, 221, 475, 482, 492 490, 494, 496, 497, 498
cleaning, 157 communication skills, 344, 367, 371, 372, 373, 374,
clinical approach, 18, 142 375, 377, 382, 396, 463, 469
clinical assessment, 339 community, xiii, 7, 9, 24, 26, 63, 66, 73, 74, 90, 104,
clinical disorders, 121 181, 197, 198, 200, 204, 235, 264, 267, 270, 300,
clinical judgment, 94, 95, 180 307, 318, 332, 335, 337, 340, 342, 350, 355, 362,
clinical presentation, 29, 148 374, 380, 382, 383, 384, 385, 388, 393, 418, 419,
clinical psychology, xv, xvii, xviii, 123, 143, 144, 420, 421, 422, 426, 429, 441, 494, 497
149, 150, 267, 473 community service, 350
clinical symptoms, 123, 345 community support, 385
clinical trials, 344, 379 compassion, 99, 113, 138, 192, 244, 279, 295, 304,
clinicians, xiii, 31, 43, 103, 112, 125, 141, 142, 144, 318, 319, 398, 411, 484
145, 146, 151, 175, 369, 492 compatibility, 177
close relationships, 223, 398 compensation, 40
closure, 257, 269 competence, 259, 275, 276, 279, 280, 281, 328, 342,
clustering, 2 346, 347, 392, 420, 475, 480, 491
coaches, 245, 246, 247, 372, 411 competency, 179, 232, 335, 339, 342, 425, 469
codes, 232 competition, 159, 172, 322, 441, 490, 505
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

coercion, 392, 430 compilation, 190

cognition, xvi, 9, 84, 94, 103, 111, 128, 141, 142, complement, 62, 88
144, 145, 146, 147, 153, 154, 178, 221, 273, 297, complex interactions, 84, 173
462, 465, 467 complexity, xi, 60, 86, 92, 93, 98, 102, 103, 243,
cognitive abilities, 93 249, 304, 340, 420, 447
cognitive behavior therapy (CBT), 141 compliance, 121, 148, 344, 372, 379, 381, 413
cognitive function, 238, 378 complications, 138
cognitive perspective, 472 components, 41, 70, 143, 147, 177, 197, 203, 220,
cognitive process, 4, 103, 142, 396 227, 237, 287, 367, 371, 395, 479
cognitive processing, 396 composition, 344
cognitive psychology, 142 comprehension, 364, 370
cognitive science, 142, 195 compulsion, 15
cognitive set, 103 computers, 488
cognitive therapists, 143 concentration, 49, 116, 188, 304
cognitive therapy, 23, 29, 107, 141, 142, 143, 145, conception, 83, 84, 144, 251, 300, 301, 363
154, 195 conceptual model, 21
coherence, 187, 287, 288, 289, 334, 463 conceptualization, 13, 154, 192, 200, 230, 342
cohesion, 254, 389 concordance, 366
cohesiveness, 203, 470 concrete, 14, 47, 56, 94, 115, 149, 223, 331, 341,
cohort, 42, 144, 381 343, 390, 392, 393, 396, 404, 453, 456
colitis, 111 conditioned response, 110

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Index 515

conditioning, 84, 107, 108, 109, 110, 111, 112, 113, cooking, 406
116, 129, 142, 299, 468 coping strategies, 175, 378, 393, 495
conduct disorder, 457 correlation, 95
conductor, 372 correlations, 245
confessions, 258 cortex, 253
confidence, 24, 189, 190, 247, 275, 279, 290, 299, costs, 144, 363, 381, 508
305, 392, 397, 496 cough, 434
confidentiality, 93, 192, 215, 363, 364 counsel, 156, 158, 159, 161, 162, 163, 164, 203, 204
configuration, 88, 93, 229, 344 counseling, ix, xi, xii, xv, xvii, xviii, 1, 3, 4, 6, 47,
conflict, 2, 9, 11, 12, 13, 14, 24, 43, 50, 63, 65, 87, 58, 74, 78, 79, 80, 81, 104, 115, 122, 156, 161,
90, 92, 93, 97, 120, 187, 201, 205, 213, 214, 215, 162, 163, 164, 165, 167, 168, 169, 171, 176, 177,
240, 244, 254, 255, 257, 266, 268, 269, 273, 287, 178, 179, 180, 194, 195, 197, 198, 199, 203, 204,
289, 293, 305, 312, 318, 323, 325, 331, 334, 336, 207, 217, 261, 282, 321, 350, 352, 363, 396, 398,
337, 343, 382, 389, 392, 408, 457, 462, 464, 467, 400, 402, 404, 407, 414, 415, 445, 450, 452, 457,
469, 484 460
conflict resolution, 63, 205, 214, 392, 469 counterbalance, 102
conformity, 142, 202, 272, 312 counterconditioning, 110
confrontation, 16, 17, 97, 255, 258, 266, 274 country of origin, 51
Confucius, 127 couples, xvi, 5, 29, 96, 214, 215, 216, 217, 227, 233,
confusion, 19, 43, 186, 213, 235, 269, 276, 351, 353, 240, 241, 243, 244, 245, 246, 248, 267, 268, 269,
382 277, 281, 283, 292, 304, 312, 313, 317, 320, 328,
congruence, 64, 67, 69, 72, 73, 77, 78, 289, 303, 304, 344, 350, 385, 400, 401, 406, 407, 410, 415, 417,
306, 371 461, 463, 467, 470, 471, 472, 473, 488, 489, 491,
connectivity, 34, 37 492, 503, 505, 507, 509, 510
conscious awareness, 17, 34, 287, 350 creative potential, 266, 268
consciousness, 31, 32, 33, 36, 64, 80, 86, 168, 171, creative process, 38, 43
178, 185, 189, 253, 269, 289, 296, 301, 313, 454 creativity, xvi, 84, 88, 89, 100, 102, 104, 189, 193,
consensus, 275, 280, 368 251, 312, 315, 317, 350, 359
consent, 112, 189, 489 credentials, 66
conservation, 91 credibility, 306, 337
constraints, 319, 320, 322, 328, 367, 390, 392, 393, credit, 23, 234, 265, 356, 411
466, 498, 501 creep, 430
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

construction, 151, 185, 221, 243, 295, 346, 387, 391, criminal behavior, 270, 358
399, 418, 419, 425, 458 criminality, 351, 484, 492
consultants, 105, 455 critical thinking, 193
consulting, 38, 98, 455 criticism, 19, 74, 134, 300, 301, 366, 368
consumers, 176, 464, 466, 470 crying, 439, 505
contact time, 333 cues, 91, 190
Contextual Family Therapy, 227, 237, 245, 248 cultural beliefs, 289
contiguity, 111 cultural differences, 32, 268
contingency, 394 cultural norms, 168
continuity, 39, 103, 141, 185, 364, 379 cultural values, 167, 169, 173, 178, 179, 337
contradictory experiences, 305 culture, 9, 31, 50, 51, 76, 95, 120, 143, 170, 173,
control, 2, 10, 11, 13, 15, 24, 32, 34, 43, 60, 61, 65, 193, 206, 230, 283, 287, 303, 304, 351, 359, 400,
68, 71, 107, 108, 119, 145, 146, 148, 150, 153, 402, 419, 420, 447, 448, 449, 466, 470, 471, 494,
154, 159, 160, 162, 163, 185, 186, 187, 192, 199, 501, 503, 505
210, 215, 258, 288, 290, 299, 303, 321, 334, 336, curing, 156
337, 338, 342, 354, 358, 378, 384, 410, 411, 412, curiosity, 190, 271, 279, 296, 319, 340, 356, 395,
447, 448, 464, 482, 484, 486, 497, 503, 504, 508 423, 451
control group, 119 current limit, 179
controlled studies, 142, 365 curriculum, 104
convergence, 87 cycles, 186, 190, 340, 341, 350, 374, 470, 507
conviction, 27, 388, 436 Czech Republic, xiv

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
 516 Index

developmental psychology, 19
D developmental psychopathology, 332
developmental theories, 8
daily living, 363, 364, 366
deviation, 260
dairy, 312
diabetes, 493
danger, 98, 278, 287, 307, 359, 438, 452
Diagnostic and Statistical Manual of Mental
data collection, 341, 394
Disorders, 114, 175, 232
data gathering, 339
Diagnostic Statistical Manual, 8, 14, 491
dating, 321, 389
Dicks, 209, 210, 211, 212, 224
de Beauvoir, Simone, 47
didactic teaching, 132
death(s), 13, 18, 19, 23, 47, 48, 50, 51, 53, 55, 58,
diet, 121, 158
146, 161, 210, 211, 244, 254, 293, 311, 351, 379,
differential diagnosis, 302
412, 457, 494
differentiation, 13, 35, 40, 68, 85, 232, 239, 240,
debts, 239, 241, 242, 244, 245, 248, 259
242, 243, 244, 245, 247, 257, 476, 483
decision making, 199, 238, 368, 470, 503, 507
dignity, 113, 118, 124, 139, 499
decisions, 58, 96, 199, 205, 238, 239, 242, 243, 245,
direct observation, 115, 205
323, 368, 428, 447, 465, 497, 506
directionality, 69
deconstruction, 418
directives, 39, 349, 350, 356, 357, 358
defense, 8, 12, 13, 14, 15, 20, 44, 147, 220, 221, 223,
disability, 152, 308, 374, 375, 499
224, 318, 396, 405
disappointment, 86, 428
defense mechanisms, 8, 13, 14, 20, 220, 221, 223,
disaster, 54
396
discipline, 19, 44, 104, 128, 130, 138, 332
defensiveness, 302, 317, 395
disclosure, 39, 178, 197, 203, 256, 273, 276, 277,
deficiency, 482
292, 307, 450
deficit, 112, 371, 420, 438, 450
discomfort, 162, 231, 428, 429, 433, 442, 453
definition, 3, 6, 16, 89, 109, 149, 155, 156, 158, 235,
discontinuity, 141
263, 266, 338, 352, 404, 466, 484
discourse, 57, 67, 70
deinstitutionalization, 362, 381, 383
discrimination, 99, 167, 175
delinquency, 332, 360
disequilibrium, 184
delinquent adolescents, 251
disinhibition, 482
delivery, 165, 367, 413, 466
disorder, 2, 112, 115, 119, 121, 125, 186, 187, 232,
delusions, 162, 363, 369
292, 296, 345, 360, 364, 365, 368, 369, 370, 374,
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

demand, 11, 86, 134, 210, 306, 334, 335, 350

375, 377, 378, 382, 438, 461, 470
demand characteristic, 334
dissatisfaction, 269
democracy, 199
dissociation, 8
denial, 13, 77, 271, 368, 422, 448
distortions, 184
Denmark, xvi
distress, 116, 152, 174, 186, 240, 290, 302, 303, 307,
Department of Justice, 360
317, 334, 336, 337, 367, 390
dependent variable, 145, 482, 483
distribution, 10, 469
deposits, 34
divergence, 169
depression, xvi, 38, 125, 130, 131, 137, 143, 147,
divergent thinking, 36
150, 151, 152, 153, 154, 157, 158, 210, 240, 248,
diversity, xviii, xix, 19, 169, 170, 171, 180, 328, 462
293, 296, 297, 298, 332, 358, 359, 363, 484, 489,
division, 502, 505
493
division of labor, 505
derivatives, 17
divorce, 68, 84, 159, 240, 270, 406, 411, 412, 414,
desensitization, 107, 108, 116, 118, 119, 124, 129
457, 473, 508
desire(s), 9, 11, 12, 13, 16, 40, 55, 129, 130, 131,
doctors, 155, 160, 429
174, 241, 264, 270, 318, 345, 363, 364, 366, 374,
domestic labor, 506
393, 452, 454, 461, 498, 505, 508
domestic violence, 328, 425, 502, 505
destruction, 89, 90, 92
dominance, 312
determinism, 84, 122
Donald Meichenbaum, 127
devaluation, 168, 172, 175
doors, 438
developmental disabilities, 307
dream, xv, 33, 40, 71, 95, 454
developmental process, 97, 184, 193

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
 Index 517

dreaming, 44 ego strength, 190

Dreikurs, Rudolf, 197 Einstein, Albert, 1
drinking water, 157 elaboration, 186, 340
drive theory, 87 email, 321
drug abuse, 358, 360, 471 emotion, xvi, 25, 33, 127, 128, 132, 144, 146, 152,
drug abusers, 358 190, 244, 285, 286, 287, 288, 289, 290, 291, 292,
drug therapy, 378, 381 294, 295, 296, 297, 317, 331, 332, 334, 337, 338,
drug treatment, 379 346, 370, 384, 397, 467, 469, 479
drug use, 112, 351 Emotion focused therapy (EFT), 285
drugs, 112, 156, 157, 158, 160, 162, 164, 240, 258, emotion regulation, 331, 332, 334, 338
307, 351, 370, 378, 379, 411, 496 emotional connections, 334, 337
DSM, xviii, 8, 14, 17, 114, 123, 156, 157, 158, 162, emotional disorder, 122, 139
164, 189, 232, 355, 476, 481, 484 emotional distress, 307
DSM-IV, xviii, 114, 123, 156, 157, 158, 162, 164, emotional experience, 16, 27, 36, 188, 238, 285, 286,
189, 232, 355, 476, 481, 484 288, 289, 290, 291, 293, 294, 295, 296, 317
dualism, 88 emotional health, 32
duplication, 40 emotional reactions, 288, 289, 296, 394
durability, 375 emotional responses, 287, 288, 289, 291, 294, 295
duration, 3, 4, 5, 56, 261, 334, 368 emotional stability, 334
duties, 353 emotional state, 128, 285, 291, 334, 336
DVD, 165 emotionality, 192, 290
dysphoria, 367 emotions, xvi, 1, 3, 28, 33, 37, 55, 57, 61, 114, 137,
Dysthmic Disorder, 461 144, 186, 188, 222, 228, 230, 238, 239, 242, 243,
244, 251, 253, 255, 256, 260, 273, 276, 277, 285,
288, 290, 291, 294, 297, 298, 317, 334, 337, 338,
E 343, 344, 357, 371, 395, 399, 401, 496, 505
empathy, 41, 42, 67, 77, 100, 113, 118, 148, 192,
early warning, 364
220, 221, 222, 257, 291, 294, 296, 300, 303, 304,
earth, 159, 161, 377
305, 306, 323, 351, 395, 497
Eastern Religions, 31
employment, 28, 74, 365, 494, 508
eating, 86, 110, 119, 130, 374, 412, 425, 457
empowerment, 66, 116, 176, 181, 188, 365, 501
eating disorders, 119, 123, 425
encounter groups, 63, 66, 80, 81
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

eating disturbances, 457

encouragement, xii, 28, 190, 198, 200, 203, 205,
echoing, 306
271, 322, 451
ecology, 6, 332, 345
endurance, 155, 389, 390
economic status, 170, 177, 344, 449
energy, 2, 9, 10, 14, 35, 36, 85, 86, 92, 100, 190,
economics, 392, 459, 508
209, 244, 269, 272, 279, 280, 315, 316, 317, 318,
ecosystem, 335
432, 454
Ecosystemic Structural Family Therapy (ESFT), 331
engagement, 7, 31, 37, 85, 188, 243, 260, 293, 340,
Edmund Husserl, 47, 269
344, 366, 378, 379, 390, 422, 462
education, 5, 26, 29, 63, 66, 76, 77, 78, 80, 81, 94,
England, xiv, xviii, 46, 77, 78, 79, 80, 81, 181, 262,
102, 107, 117, 121, 152, 155, 157, 158, 159, 164,
360, 367, 384, 472
180, 194, 197, 204, 252, 253, 344, 365, 367, 369,
Enlightenment, 128
370, 377, 382, 383, 384, 385, 392, 417, 425, 443,
enthusiasm, 425, 433
463, 468
entropy, 2
Education, xv, 78, 157, 181, 365, 367, 382
enuresis, 376
educational objective, 382
environment, 10, 13, 15, 16, 17, 39, 41, 43, 51, 77,
educational process, 377, 382
83, 84, 86, 87, 88, 89, 91, 93, 95, 96, 98, 99, 109,
educational programs, 365, 377
113, 114, 116, 171, 174, 185, 198, 199, 221, 222,
educators, xiii
225, 232, 243, 254, 258, 266, 269, 273, 279, 280,
egg, 34
286, 287, 289, 291, 292, 294, 300, 301, 307, 322,
eggs, 312
327, 336, 337, 344, 354, 372, 378, 382, 388, 391,
ego, 8, 10, 12, 13, 14, 17, 33, 34, 35, 36, 38, 39, 40,
420, 448, 449, 461, 501, 505, 507
190, 209, 218, 219, 221, 224, 272, 480

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
 518 Index

environmental conditions, 84, 90, 93, 101

environmental context, 174
F
environmental influences, 84
fabric, 249
environmental resources, 87
facial expression, 190, 287, 371
environmental stimuli, 388
facilitators, 395
Epictetus, 127, 129, 139
failure, 41, 50, 74, 78, 92, 130, 168, 187, 240, 301,
Epicurus, 127, 130
317, 337, 374, 457, 502
epidemic, 161
fairness, 227, 228, 229, 233, 239, 241, 242, 246, 248,
epilepsy, 153
303, 318, 462, 506
epistemology, 1, 184, 433, 458
faith, 35, 89, 128, 129, 192, 205, 299, 357, 406
equality, 57, 122, 199, 205, 207, 355, 501, 503, 504,
false belief, 363, 369
505, 506, 507
family conflict, 354
equilibrium, 5, 191, 231
family development, 218, 219, 221, 254, 332, 334,
equipment, 307
347
equity, xix, 507, 509
family environment, 344, 461
ethics, 233, 458
family functioning, 237, 239, 344
ethnic groups, 172, 179, 359
family history, 223, 257
ethnic minority, 396
family interactions, 201, 220, 269, 318, 349, 353,
ethnicity, 170, 177, 344, 392, 449
372
ethnocentrism, 178
family life, 66, 72, 76, 201, 209, 254, 271, 331, 345,
etiology, 214, 252, 302, 361, 382, 393, 496
350, 351, 360, 381, 464, 497, 502
EU, 72
family relationships, 210, 219, 272, 338, 378, 412
Europe, 7, 66, 100, 265, 299
family structures, 502, 504
European refugees, 267
family system, xiii, 2, 13, 120, 197, 201, 204, 211,
evening, 406, 408, 409, 413
218, 219, 220, 221, 223, 224, 231, 242, 244, 247,
event-related potential, 151
259, 264, 265, 268, 270, 272, 277, 278, 280, 281,
evidence, 34, 36, 74, 75, 133, 141, 142, 146, 147,
315, 319, 320, 331, 333, 340, 342, 350, 351, 352,
148, 149, 150, 152, 154, 161, 175, 183, 186, 279,
354, 355, 382, 392, 461, 463, 464, 466, 501, 504,
297, 337, 344, 351, 365, 392, 414, 424, 450, 456,
505
468, 486, 490, 503
family units, 378
evil, 35, 36, 68, 138
family violence, 274, 457, 467
evolution, 31, 37, 43, 69, 106, 108, 123, 139, 186,
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

family structure, 5, 332, 333, 336, 341, 344, 355,

346
463, 502, 504
exaggeration, 101
famine, 52
exchange relationship, 478
fat, 121
exclusion, 174, 202, 240, 289, 368, 479
fatigue, 157, 187
excuse, 277, 372, 410
fear, 35, 39, 98, 102, 116, 123, 137, 146, 255, 258,
execution, 273
279, 287, 288, 290, 317, 318, 326, 334, 428, 432
executive function, 337
fears, 58, 216, 248, 273, 275, 337, 486, 489
executive functioning, 337
federal government, 429
exercise, 44, 121, 134, 155, 157, 158, 189, 459
feedback, 2, 5, 117, 164, 202, 215, 245, 334, 340,
existentialism, 83, 266, 479
464, 470
expertise, xii, xiii, 27, 203, 295, 418, 419, 421, 422,
feet, 67, 448
424, 425, 456
females, 11, 12, 178, 502
exposure, 41, 116, 119, 149, 238, 334, 336, 337, 343
feminism, 504, 508, 509
external environment, 41, 336
feminist, 123, 167, 168, 169, 170, 171, 172, 175,
externalization, 489
176, 177, 179, 180, 181, 501, 502, 503, 504, 505,
extinction, 112, 146
506, 507, 508, 509, 510
extrapolation, 63
fever, 368
extraversion, 480
fibers, 249
extroversion, 41
fibromyalgia, 157, 161
eyes, 13, 59, 134, 192, 311, 326, 368, 409, 431, 432
fidelity, 228
field theory, 83, 84, 85, 88

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
 Index 519

films, 64, 433

financial support, 363, 366
G
Finland, xvi, 46
gambling, 411
first dimension, 228
garbage, 257, 283
first generation, 211, 469
gay men, 360
fitness, 51, 155
gender, xix, 32, 33, 50, 51, 168, 169, 170, 172, 173,
fixation, 8, 11, 14
174, 175, 177, 178, 179, 180, 199, 201, 205, 216,
flex, 457
303, 400, 449, 470, 471, 481, 482, 485, 501, 502,
flexibility, 68, 89, 147, 149, 172, 193, 244, 254, 259,
503, 504, 505, 506, 507, 509, 510
344
gender equity, xix
flight, 10
gender role, 501, 502, 503, 504, 505, 506
float, 402
gene, 97, 490
floating, 279
general knowledge, 33
flooding, 243
general practitioner, 428
fluctuations, 187, 188
generalization, 111, 142, 372, 375, 383
fluid, 85, 90, 97, 100, 144, 187, 193, 269, 288, 289,
generalized anxiety disorder, 154
418, 419
generation, 34, 42, 43, 141, 142, 144, 145, 150, 151,
focus groups, 164
201, 211, 228, 230, 247, 259, 271, 367, 387, 388,
focusing, xix, 4, 5, 28, 52, 61, 94, 96, 98, 101, 107,
412, 463, 469
108, 109, 115, 116, 119, 161, 171, 188, 211, 215,
generativity, 423
216, 219, 221, 223, 240, 249, 251, 252, 260, 268,
genes, 159
270, 294, 296, 313, 314, 316, 327, 342, 395, 469,
genetic endowment, 108
497
genetics, 238, 286, 364, 370
folklore, 40
Geneva, xv
food, 13, 110, 114, 121, 129, 210, 212, 404, 421, 478
genital stage, 10, 12
food intake, 121
Georgia, xiv, xvi, 252
foreign language, 40
Germany, xvi, 66, 367
forgiveness, 138, 217, 236, 243, 410
Gestalt, xii, xv, xix, 79, 83, 84, 85, 86, 87, 88, 89,
fragility, 406
90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100, 101,
fragmentation, 332, 334
102, 103, 104, 105, 106, 128, 132, 139, 150, 200,
free association, 7, 38, 192
260, 263, 264, 265, 266, 267, 268, 269, 270, 271,
free energy, 100
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

272, 273, 274, 275, 276, 277, 278, 279, 280, 281,
free will, 109, 132
282, 283, 285, 291, 297, 479
freedom, 25, 32, 41, 48, 53, 66, 84, 87, 102, 104,
Gestalt psychology, 263, 265, 282
109, 118, 124, 139, 155, 159, 187, 193, 199, 203,
gestalten, 83, 90, 91, 92, 98, 100
227, 259, 286, 293, 403, 404, 415, 420, 425
gestures, 423
freedom of choice, 203
gift, xiii, 440
Freud, Sigmund, 1, 3, 7, 21, 127, 299
girls, 19, 179
Freudian theory, 7, 20
glass, 438
friction, 366
Glasser, William, xix, 127, 155, 163, 165, 166, 316
friendship, 199, 227, 379, 422, 505, 507
glucose, 149
Fromm, Erich, 127
goal setting, 18, 56, 115, 118, 149, 337, 369, 378,
frustration, 15, 130, 137, 210, 363, 364, 366, 497
424, 463, 464, 471, 507
fuel, 202
goal-directed behavior, 396
fugue, 8
goals, 1, 18, 25, 27, 28, 34, 35, 44, 55, 56, 72, 76, 84,
fulfillment, 15, 16, 52, 221
92, 96, 97, 115, 121, 129, 131, 144, 149, 150,
funding, 429, 499
153, 176, 190, 197, 198, 199, 200, 201, 202, 203,
furniture, 93
204, 205, 206, 214, 220, 233, 244, 245, 246, 274,
fusion, 148
275, 281, 287, 290, 293, 322, 338, 341, 342, 343,
futures, 389, 395, 419, 421
365, 367, 368, 372, 377, 378, 379, 382, 389, 390,
391, 392, 393, 395, 399, 462, 464, 465, 466, 467,
468, 470, 485, 495, 496, 507
goal-setting, 95, 96, 97, 356

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
 520 Index

God, 34, 399 health, ix, xiii, xvi, xvii, 4, 5, 7, 18, 25, 26, 31, 32,
gold, 433 34, 39, 43, 51, 52, 61, 75, 76, 88, 89, 90, 120,
good behavior, 372 121, 129, 142, 153, 155, 156, 157, 158, 159, 160,
Goodman, Paul, 83, 263, 267, 278, 281 161, 162, 163, 164, 165, 167, 168, 173, 176, 180,
government, 312, 328, 429, 506, 507 186, 200, 227, 228, 232, 235, 245, 254, 270, 274,
grades, 68 280, 288, 300, 302, 311, 313, 320, 328, 341, 361,
grading, 303 362, 363, 364, 365, 367, 377, 378, 379, 381, 382,
graduate students, ix 383, 384, 385, 388, 389, 396, 447, 461, 462, 475,
grains, 433 487, 488, 492, 493, 494, 497, 498, 499, 505
gravity, 101 health care, 43, 121, 158, 162, 165, 499
grief, 86, 328, 363, 457 health education, 158, 159
grounding, 47 health information, 158
group interactions, 276, 280 health problems, 61, 142, 499
group therapy, xv, 23, 28, 29, 76, 81, 214, 215, 279, health services, 164, 367, 383, 385
394, 417 Heart, 317
group work, 104 heart disease, 493
groups, xiii, xv, 3, 29, 41, 63, 66, 80, 81, 104, 106, heart failure, 240
117, 119, 130, 132, 163, 164, 165, 167, 168, 169, heart rate, 115, 123
170, 171, 172, 173, 174, 175, 176, 178, 179, 180, hedonism, 130
243, 246, 268, 312, 313, 320, 328, 359, 365, 367, Heidegger, Martin, 47
369, 370, 378, 395, 396, 401, 495, 508 height, 265, 281, 316, 469
growth, 3, 4, 29, 35, 39, 65, 66, 67, 68, 81, 86, 89, helplessness, 276, 354, 382, 390, 497
91, 93, 96, 99, 106, 121, 139, 173, 183, 189, 193, heredity, 51, 199, 230
194, 197, 201, 205, 218, 219, 220, 221, 251, 252, heterosexuals, 170
253, 254, 256, 257, 258, 261, 263, 266, 267, 268, high blood pressure, 493
270, 272, 277, 280, 282, 283, 287, 297, 312, 313, high school, 406
318, 320, 322, 327, 328, 333, 335, 336, 338, 341, higher education, 5
342, 343, 361, 390, 394, 470, 471, 501, 507 higher quality, 245
guessing, 205 high-risk populations, 358
guidance, 1, 23, 44, 104, 266, 308, 322, 336, 363, hip, 66, 255, 383, 430
379 Hiroshima, 299
guidelines, 179, 187, 199, 202, 205, 372, 378 HIV, xv
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

guilt, 13, 49, 53, 233, 353, 357, 363, 382 holism, 88, 197, 263
guilty, 49 homeostasis, 5, 334
guns, 307 homework, 102, 109, 117, 127, 133, 149, 190, 192,
gynecologist, 251 205, 206, 338, 353, 356, 372, 373, 375, 383, 394,
407, 484, 486, 491, 507
homicide, 240
H honesty, 205, 234, 276
hopelessness, 276, 337
hallucinations, 152, 363, 369
hospitalization, 43, 361, 362, 381
hands, 160, 408, 423, 430, 431, 434, 435, 439, 440
hospitals, 68, 361, 362
happiness, 26, 52, 120, 130, 139, 302, 402, 503, 508
host, 206
harassment, 168, 175
hostility, 484, 489
harm, xv, 29, 35, 120, 138, 147, 160, 164, 235, 441,
hotels, 411, 480
452
House, 45, 224, 282, 398
harmful effects, 180
household tasks, 368
harmony, 29, 120, 441
households, 370, 377, 380
Harvard, xiv, 106, 124, 217, 224, 345, 346, 416, 458,
housing, 363, 365, 366, 375
472
Hubble, 313, 317, 323, 327, 329, 416, 464, 472
hate, 256, 436
human actions, 198
healing, xvi, 34, 35, 36, 37, 41, 42, 43, 65, 89, 106,
human activity, 185
160, 194, 245, 246, 259, 269, 275, 318, 390, 410,
412, 488

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
 Index 521

human behavior, 1, 2, 5, 84, 87, 108, 110, 112, 152, in transition, 123
199, 418, 506 in vivo, 108, 116, 129, 343, 373
human brain, 297 incarceration, 214
human condition, 141, 151, 299, 300 inclusion, 17, 98, 99, 101, 202, 302
human development, 4, 7, 19, 20, 32, 34, 61, 63, 102, independence, 58, 172, 210, 239, 435
105, 173, 192, 251, 345 independent variable, 482, 483
human dignity, 113 Indians, 398
human experience, 25, 34, 57, 83, 86, 88, 141, 144, indication, 68, 160, 240
184, 186, 265, 297, 388, 389, 390, 494 indicators, 40, 120, 294
human nature, 9, 10, 26, 32, 50, 51, 85, 109, 238, indices, 379
266, 286, 332, 358, 503, 504 indigenous, 301
human psychology, 8, 19 individual development, 173, 462
human values, 36 individual differences, 332, 333
humanism, 224, 479 individual personality, 467
humanistic psychology, 23, 65, 263, 265, 282 individualism, 2, 100, 106, 418
humanity, 31, 36, 44, 245, 389 individuality, 18, 33, 48, 235
humility, 12 induction, 109, 372
husband, xii, 133, 134, 159, 217, 233, 267, 324, 325, industry, 300, 475
326, 355, 402, 403, 404, 405, 406, 407, 409, 410, inertia, 371
411, 413, 414, 415, 429, 438, 502 infants, 145, 146, 290
hyperactivity, 438 inferiority, 24, 198, 199, 200
hypertension, 120 infinite, 177, 421
hypnosis, 8, 349, 350, 360, 416 information processing, 145, 479
hypothesis, 25, 64, 65, 66, 320, 340, 356, 357, 389 informed consent, 112, 189
hypothesis test, 64 infrastructure, 253
inheritance, 364
inhibition, 108, 125
I initiation, 17
injury, 150
id, 8, 10, 12, 17, 209, 224
injustice, 510
identification, 92, 93, 176, 221, 241, 266, 292, 308
insecurity, 290
identity, 34, 51, 100, 170, 171, 175, 176, 177, 178,
insight, 3, 16, 26, 27, 29, 32, 36, 95, 120, 131, 132,
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

179, 180, 185, 203, 254, 292, 333, 453, 456, 480,
142, 203, 205, 206, 216, 217, 219, 221, 222, 238,
483
239, 242, 252, 253, 269, 274, 277, 280, 285, 349,
ideology, 301, 361, 501
353, 362, 469, 479
idiosyncratic, 89
insomnia, 120
illusion, 50, 92
inspiration, 50, 389, 439
illusions, 31
instability, 240
imagery, 117, 134, 137, 139, 326
instinct, 13, 34
images, 14, 28, 33, 40, 190, 191, 210, 216, 332, 413
institutions, 167, 168, 170, 251, 428
imagination, 28, 38, 40, 101, 116, 359, 389, 454
instruction, 357, 382
imbalances, 176, 278, 502, 508
instructors, 164
imitation, 107, 112
instruments, 114, 189, 253, 368, 380, 467, 488, 489
immediate gratification, 13
insurance, 38, 232, 355, 499
immediate situation, 288
integration, 9, 10, 34, 41, 45, 64, 65, 69, 71, 77, 84,
immigration, 170, 177
85, 90, 92, 93, 108, 129, 177, 180, 198, 207, 224,
immunization, 157
257, 266, 285, 286, 287, 289, 318, 360, 410, 463,
impairments, 240, 255, 363, 382
502
implementation, 180, 337, 338, 339, 345, 362, 375,
integrity, 9, 16, 33, 90, 215, 234, 255, 304, 334, 410,
376
411
impotence, 256
intellect, 317
impulsive, 479
intellectual development, 194
impulsivity, 342
in situ, 109, 117, 216, 239, 242, 274, 428

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
 522 Index

intensity, 34, 144, 190, 214, 231, 243, 244, 274, 278, intrusions, 343
289, 290, 334, 343, 378, 390, 454, 487, 488 intuition, 41
intentionality, xi, 269 inversion, 272
intentions, 96, 192, 203, 217, 272, 454, 458, 485 investment, 8, 148, 257
interaction(s), 2, 10, 37, 44, 51, 52, 57, 84, 85, 86, Ireland, 78
83, 95, 97, 11, 171, 173, 185, 197, 198, 201, 202, irritability, 111, 363, 368, 374
203, 204, 209, 211, 219, 220, 221, 222, 224, 227, isolation, 12, 51, 58, 85, 187, 198, 291, 325, 388
229, 230, 232, 235, 237, 238, 242, 243, 245, 247, Italy, xvi, 431
248, 260, 261, 262, 266, 272, 276, 278, 305, 308,
318, 321, 322, 331, 332, 333, 334, 335, 337, 340,
341, 342, 343, 349, 353, 354, 356, 368, 371, 372,
387, 390, 392, 446, 463, 495, 496, 497, 498, 505,
506 J
interactivity, 303
James, William, 65, 88, 183, 300
interdependence, 169, 172, 201, 239, 293, 302
Japan, xvi
internal organization, 334
jobs, 305
internal processes, 1, 467
Jordan, xii, xiii, xvi, 1, 107, 209, 251, 263
internalization, 18, 359, 489
judgment, 31, 34, 36, 37, 53, 90, 104, 200, 290, 317,
internalizing, 448
424, 480
international relations, 312
Jung, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42,
internet, 378
43, 44, 45, 46, 138
Internet, 488
justice, xi, 227, 228, 229, 230, 233, 234, 241, 242,
interpersonal communication, 65
246, 248, 318, 358, 398, 462
interpersonal conflict, 95, 318, 337, 343, 389
juveniles, 483
interpersonal conflicts, 95
interpersonal contact, 118, 366
interpersonal interactions, 321 K
interpersonal relations, 66, 76, 77, 79, 81, 187, 199,
209, 219, 223, 255, 293, 309, 383 Kant, 183, 184
interpersonal relationships, 76, 77, 79, 187, 199, 209, Karen Horney, 19, 23, 127, 129
219, 223, 309 Karl Jaspers, 47, 50, 278
interpersonal skills, 81 Keynes, 62
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

interpretation, 16, 17, 20, 48, 55, 71, 74, 192, 198, Kierkegaard, 47, 48, 50, 62, 65
219, 220, 244, 353, 381 killing, 411
interrelatedness, 389, 494 knees, 436, 441
interrelationships, 2, 145, 188, 340, 389 knots, 305
intervention, 4, 26, 29, 84, 87, 103, 117, 143, 145, Korea, xvi, xix
147, 153, 176, 184, 224, 233, 234, 236, 240, 245,
249, 261, 270, 275, 277, 278, 293, 294, 295, 296,
297, 312, 323, 337, 339, 346, 349, 353, 356, 358, L
359, 365, 368, 369, 375, 377, 385, 394, 397, 404,
407, 408, 413, 414, 431, 432, 461, 462, 463, 465, labeling, 175, 354, 355, 402, 453
466, 467, 468, 469, 470, 471, 487, 491, 494 labor, 257, 260, 502, 505, 506
intervention strategies, 4, 84, 103, 234, 270, 462, landscapes, 167, 170, 454
465, 468, 471 language, xvi, 19, 25, 26, 28, 32, 37, 38, 40, 51, 89,
interview, 17, 18, 114, 137, 189, 197, 262, 274, 292, 132, 145, 146, 147, 148, 152, 153, 173, 184, 185,
311, 368, 398, 399, 489 190, 191, 230, 232, 235, 238, 251, 286, 290, 300,
intimacy, 51, 228, 229, 230, 233, 247, 254, 266, 268, 322, 328, 345, 347, 372, 394, 396, 399, 403, 408,
270, 302, 304, 328, 334, 336, 404, 482, 492, 494, 418, 419, 420, 424, 426, 428, 432, 433, 439, 440,
507 441, 446, 447, 448, 450, 455, 457, 463, 464, 494,
intrinsic motivation, 183 496
introspection, 188, 305 language skills, 396
introversion, 40, 480 Lao-Tsu, 127
latency, 10, 12
Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
 Index 523

laughing, 439 literature, 31, 36, 44, 61, 103, 116, 169, 199, 235,
laughter, 40, 436 261, 267, 328, 479, 480, 485, 508
laws, 1, 174, 232, 335, 405, 476, 502 local authorities, 429
Lazarus, Arnold, 107, 108, 132 local community, 374, 429
lead, 2, 9, 11, 12, 35, 39, 40, 57, 60, 61, 76, 88, 89, location, 9, 170, 177, 178, 181, 408, 413, 449, 506
90, 91, 105, 112, 127, 130, 148, 149, 156, 157, locus, 65, 148
158, 163, 164, 174, 187, 191, 202, 203, 210, 219, London, xiv, xviii, 21, 45, 46, 62, 77, 79, 81, 106,
221, 235, 238, 239, 241, 243, 245, 246, 269, 270, 139, 166, 218, 224, 225, 308, 309, 360, 366, 383,
290, 316, 318, 341, 350, 359, 381, 389, 401, 406, 399, 425, 443, 458, 472, 473
411, 422, 446, 467, 479, 485, 488, 505 loneliness, 86, 427, 435
leadership, 63, 66, 79, 175, 320, 322, 343, 377, 464, Los Angeles, xv, xvii, xix, 265, 399
484 love, 12, 14, 33, 36, 41, 44, 51, 129, 130, 131, 159,
learning, xiii, 12, 16, 33, 39, 41, 44, 51, 66, 76, 78, 165, 199, 227, 228, 229, 230, 233, 234, 256, 270,
81, 89, 90, 102, 107, 109, 110, 111, 112, 113, 304, 307, 313, 315, 317, 318, 325, 388, 398, 408,
115, 116, 118, 121, 122, 132, 142, 146, 150, 161, 411, 481, 482, 487
164, 169, 190, 192, 194, 204, 242, 244, 248, 267, low fat diet, 121
297, 307, 312, 325, 333, 334, 338, 342, 361, 365, loyalty, 215, 241, 246, 259, 270, 271, 336
367, 370, 371, 372, 375, 377, 382, 383, 385, 391, lying, 410
423, 425, 426, 493, 495
learning disabilities, 372
learning environment, 382 M
learning process, 204, 377, 383
magazines, 507
learning styles, 342
mainstream psychology, 263
legal issues, 391
males, 11, 178
leisure, 381, 485
management, 37, 66, 79, 109, 121, 152, 163, 230,
lending, 234, 282
236, 270, 278, 334, 361, 364, 365, 366, 367, 368,
lens, 102, 230, 231, 237, 269, 278, 318, 350, 351,
370, 373, 376, 377, 378, 380, 381, 382, 383, 384,
358, 447, 466, 494, 502, 508
385, 441, 469, 480, 496
Lesbian,, 167, 180
mandates, 355
liberation, 399, 447
mania, 157
libido, 8, 12, 20
manipulation, 202, 312
life cycle, 215, 254, 257, 334, 345, 350, 351, 352,
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

manners, 417, 430

355, 360
mapping, 31, 247, 451, 453
life experiences, 24, 28, 176, 178, 257, 387, 481
marital partners, 254
life quality, 187
marriage, ix, xi, xiii, xiv, xv, xvii, xix, 2, 3, 5, 68,
life span, 58, 132, 178, 184
159, 213, 214, 216, 237, 252, 254, 301, 312, 317,
life style, 24, 26, 27, 199, 201, 203
329, 355, 403, 404, 406, 407, 410, 411, 413, 414,
lifecycle, 255
498, 509, 510
lifespan, 183, 185
married couples, 304
lifestyle, 24, 25, 26, 27, 29, 205, 206, 494, 497
Mars, 503, 510
lifestyle changes, 497
Maryland, xv
lifetime, 33, 108, 245, 265
mastery, 17, 43, 57, 288, 334, 370
likelihood, 337, 395, 450, 499
mathematics, 2, 7, 194
limitation, 19, 59, 61, 73, 74, 75, 180, 235, 261, 279,
maturation, 257
280, 315, 328, 345, 359, 471, 490, 508
Maya, xii
linguistics, 19
meanings, 3, 16, 70, 184, 185, 186, 191, 192, 205,
links, 94, 103, 357
242, 266, 285, 288, 289, 290, 295, 304, 323, 388,
liquids, 13
390, 391, 395, 397, 418, 419, 420, 421, 429, 440,
listening, 22, 39, 40, 44, 57, 59, 60, 159, 161, 246,
441, 450, 469, 475
248, 272, 274, 276, 337, 338, 367, 371, 393, 423,
measurement, 142, 189
431, 438, 450, 453
measures, 1, 115, 142, 149, 150, 198, 302, 308, 344,
literacy, 370
467, 483
media, 34, 370, 487, 506, 508

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
 524 Index

mediation, 473 models, xi, xii, 2, 9, 17, 18, 28, 83, 102, 116, 138,
mediational analyses, 143 151, 154, 157, 165, 170, 178, 180, 205, 236, 237,
medical care, 377, 493, 498 242, 246, 248, 257, 276, 277, 282, 324, 332, 337,
medication, 104, 121, 157, 160, 162, 193, 341, 364, 343, 344, 346, 347, 351, 360, 370, 387, 394, 397,
365, 366, 377, 381, 382, 383 472, 475, 478, 479, 480, 481, 482, 483, 485, 486,
medication compliance, 121, 381 487, 488, 490, 491, 492, 496, 498, 510
medicine, 19, 107, 115, 161, 370, 398, 475 modernism, 510
membership, 198, 218 modules, 376, 377
memory, 20, 33, 85, 111, 184, 224, 286, 287 money, 130, 134, 164, 223, 410, 411, 413, 482
men, 168, 170, 172, 173, 174, 178, 179, 360, 437, monograph, 127
470, 501, 502, 503, 504, 505, 506, 507, 508 monopoly, 421
mental disorder, 20, 194, 236, 328, 361, 362, 363, mood, 103, 114, 248, 257, 260, 364, 365, 374
364, 365, 366, 367, 368, 369, 370, 374, 375, 376, mood disorder, 365
377, 381, 382, 383, 499 mood states, 103
mental health, ix, xiii, xvi, xvii, 4, 5, 7, 18, 26, 31, mood swings, 364, 374
39, 43, 61, 75, 76, 90, 129, 155, 156, 157, 158, moral code, 24, 232
159, 160, 161, 162, 163, 164, 165, 167, 168, 180, moral judgment, 36
186, 200, 232, 235, 300, 302, 309, 311, 361, 362, morale, 365
363, 364, 365, 367, 377, 378, 379, 381, 382, 383, morality, 8, 61
384, 385, 396, 461, 475, 487, 488, 492, 493, 499 morals, 185, 209
mental health professionals, xiii, 362, 363, 364, 367, morbidity, 384
377, 379, 383, 396 morning, 406
mental illness, 81, 155, 156, 160, 161, 163, 164, 165, mortality, 48, 53, 58, 497
181, 270, 300, 302, 332, 337, 362, 363, 364, 369, mothers, 210, 502, 505, 506
370, 374, 383, 384 motion, 236, 244, 249, 341, 353
mental life, 9 motivation, 13, 19, 39, 56, 57, 85, 183, 214, 287,
mental processes, 114 290, 303, 339, 355, 368, 371, 391, 393, 410, 414,
mental retardation, 76 479, 497
mental state, 302 motives, 64, 80, 264, 414, 415
mentally ill persons, 362, 382 movement, 50, 65, 85, 88, 93, 96, 101, 105, 142,
Merleau-Ponty, 47, 61, 62, 442 168, 171, 178, 186, 191, 194, 201, 202, 242, 263,
messages, 34, 40, 168, 174, 175, 178, 203, 319 264, 265, 267, 276, 311, 426, 427
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

meta analysis, 119 MRI, xviii, 161, 360

meta-analysis, 119, 120, 123, 125, 154 multicultural education, 180
metamorphosis, 350 multidimensional, 87, 154
metaphor, 36, 67, 258, 259, 276, 316, 351, 353, 354, multiperspectival, 83
355, 356, 357, 359, 446, 454 multiple factors, 83, 84, 94
metapsychology, 21 Multiple Impact Therapy (MIT, 417
middle class, 74, 120 murder, 484
migration, 391 muscle relaxation, 108
military, 264, 475 muscles, 117, 428, 430, 441
Milton H. Erickson, 401, 416 mushrooms, 428
mind-body, 494, 499 music, 102, 411
Minnesota, 63, 489 Muslim, 138
minorities, 167, 170, 179, 396, 398 mutual inquiry, 423
minority, 149, 171, 331, 365, 396 mutual respect, 276, 342
minority groups, 396 mutuality, 18, 32
misconceptions, 24, 283, 508
misunderstanding, 263
MIT, 417, 426, 443 N
modeling, 107, 109, 113, 116, 118, 122, 160, 239,
naming, 354
241, 257, 278, 280, 312
narcissism, 8, 14
narcotics, 112

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Index 525

narratives, 26, 286, 419, 445, 469 nurses, 5, 156, 157, 377, 429
nation, 79, 80 nursing, 5
natural disasters, 52 nurturance, 322, 336
natural environment, 109, 113, 114
natural laws, 502
Nebraska, xvi, 80 O
negative consequences, 120, 505
obedience, 312
negative coping, 342
obesity, 121, 125
negative emotions, 137, 186, 337, 343
objective reality, 418
negative reinforcement, 107, 110
objectivity, 2, 94, 279
negative relation, 487
obligation, 49, 228, 302
negativity, 338, 480
observable behavior, 114
neglect, 381
observational learning, 111
negotiating, 159, 335, 466, 486, 509
observations, 66, 67, 68, 78, 94, 114, 191, 214, 222,
negotiation, 86, 115, 201, 202, 469, 482, 486
260, 278, 279, 280, 281, 322, 413, 430
neon, 432
obsessive-compulsive disorder, 119, 121
nervous system, 10, 307
occupational therapy, 104
network, 76, 339, 341, 352
OCD, 119
networking, 254, 377
offenders, 120, 358
neurobiology, 347
Oklahoma, xv
neuroleptic drugs, 378, 379
omission, 502
neurological disease, 156
one dimension, 381
neurologist, 266
openness, 55, 59, 150, 188, 254, 276, 302, 377, 395
neuropsychiatry, 9
openness to experience, 188, 302
neuroscience, 8, 19, 109
operant conditioning, 107, 110, 111, 116
neuroses, 122, 129, 300
oppression, 167, 168, 169, 171, 172, 173, 174, 176,
neutral stimulus, 110, 111
178, 179, 180, 367, 392, 503, 504, 508
New England, xiv, 384
optimism, 11, 24, 26, 299, 361, 387, 394
New Jersey, 21, 45, 194, 195
oral stage, 11
New South Wales, 282
organ, 85, 287, 318
New York, xv, xix, 6, 20, 21, 44, 45, 46, 62, 77, 78,
organism, 10, 67, 68, 69, 71, 77, 83, 84, 86, 87, 88,
79, 80, 81, 105, 106, 122, 123, 124, 134, 139,
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

89, 95, 106, 108, 269, 282, 301, 309

151, 152, 153, 154, 166, 180, 181, 194, 195, 207,
organization(s), xix, 2, 8, 10, 14, 92, 105, 164, 184,
223, 224, 236, 249, 261, 262, 264, 267, 282, 283,
185, 205, 229, 268, 287, 334, 336, 341, 355, 362,
297, 298, 308, 309, 329, 345, 346, 347, 360, 384,
369, 392, 475
385, 397, 398, 399, 400, 415, 416, 425, 426, 443,
organizational development, 105, 267
458, 459, 460, 471, 472, 473, 491, 492, 499, 509,
orientation, 94, 95, 96, 102, 170, 174, 176, 177, 265,
510
266, 301, 314, 323, 327, 328, 331, 335, 437, 448,
New Zealand, 445, 458
449, 501, 503, 508
Newton, 1
otherness, 85
Newtonian physics, 88
oversight, 499
next generation, 228, 412
ownership, 53, 271, 356, 422, 423, 425
nickel, 146
Nietzsche, 38, 45, 47, 49, 50, 53, 62, 264, 271, 283
noise, 436, 437 P
nonverbal communication, 203, 306
normal development, 15 Pacific, xv, xix, 6, 46, 122, 124, 125, 236, 329, 360,
normative behavior, 120 400, 426, 458, 459, 491
North America, xv, 29, 100, 207 pacing, 187, 397
Norway, xiv, 428, 432, 443 pain, 5, 8, 26, 38, 40, 42, 43, 111, 146, 147, 149,
novelty, 86, 89, 90, 92, 447 150, 152, 154, 155, 157, 159, 164, 209, 231, 248,
nuclear family, 13, 206, 239, 247, 504, 508 270, 274, 276, 289, 293, 294, 312, 323, 324, 325,
nucleus, 40 326, 376, 389, 391, 392, 430, 438

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
 526 Index

pairing, 112, 116 personal identity, 185

pancreatic cancer, 311 personal life, 507
panic disorder, 116, 119 personal relations, 421
paradigm shift, 2, 84, 88, 211 personal relationship, 421
paradox, 91, 325, 349, 352, 354, 358, 359 personal responsibility, 232, 265, 266, 447, 453, 487
parental relationships, 24 personal values, 404, 421, 470
parenting, xix, 104, 199, 336, 341, 342, 344, 345, personality, 10, 11, 12, 13, 23, 26, 33, 34, 35, 40, 41,
352, 407, 469, 503, 506, 507 45, 47, 51, 64, 65, 66, 68, 69, 70, 71, 72, 76, 77,
parents, 11, 12, 26, 50, 117, 159, 162, 197, 204, 205, 79, 80, 85, 86, 90, 95, 103, 104, 105, 106, 108,
210, 212, 213, 214, 215, 216, 234, 240, 241, 242, 129, 173, 198, 199, 201, 204, 210, 224, 232, 242,
243, 244, 246, 247, 248, 258, 302, 303, 306, 307, 263, 264, 266, 271, 272, 274, 277, 278, 281, 282,
312, 319, 320, 324, 331, 333, 336, 339, 341, 342, 283, 287, 292, 297, 298, 309, 358, 365, 394, 396,
343, 344, 351, 352, 355, 359, 368, 379, 404, 405, 397, 440, 462, 466, 467, 471, 473, 475, 477, 479,
407, 413, 414, 450 481, 482, 484, 488, 491, 492
particles, 88 personality characteristics, 70
partnership, 118, 278, 280, 337, 339, 342, 366, 424 personality disorder, 105, 129, 292, 297, 358, 365,
partnerships, 507 471, 479, 481, 482
passive, 52, 61, 99, 117, 128, 272, 280, 333, 402, Personality disorders, 25
450 personality inventories, 232
passive-aggressive, 280, 402 personality traits, 13, 394
pathogenic, 17, 485 personality type, 40, 466
pathology, 1, 4, 32, 50, 55, 77, 95, 103, 155, 156, Person-Centered Approach, 63, 64, 299, 301, 302
157, 158, 160, 161, 164, 168, 171, 172, 174, 175, personhood, 133, 228, 322
186, 235, 244, 274, 313, 328, 387, 418, 441, 462, pessimism, 11, 276
464 phallic stage, 11, 12, 13
pathways, 462, 466 pharmacokinetics, 378
pattern recognition, 95, 220 pharmacological treatment, 121
patterning, 185 pharmacology, 499
Pavlov, Ivan, 110, 299 pharmacotherapy, 121, 362
Pavlovian, 107 phenomenology, 45, 61, 80, 94, 96, 100, 102, 263,
pedagogy, 180 269, 479
peer relationship, 206 philosophers, 47, 50, 127, 130, 138, 183
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

peer support, 365 phobia, 112, 124

peers, 26, 340, 470 physical environment, 51
penis, 19 physical health, 155, 156, 158, 228, 505
Perls, Fritz, 83, 128, 264, 265, 266, 271, 276, 278, physical sciences, 88
279, 281, 282 Physicians, 160
Perls, Laura, 83, 87, 88, 263, 264, 265, 267, 283 physics, 2, 7, 88
People of Color, 167, 170 physiological factors, 109
perception(s), 3, 24, 41, 77, 85, 86, 87, 88, 89, 97, physiology, 7
128, 170, 171, 177, 183, 184, 185, 189, 198, 201, pitch, 436
203, 205, 230, 231, 239, 244, 258, 260, 266, 276, pith, 300
278, 280, 286, 287, 289, 291, 303, 305, 316, 319, placebo, 119, 160
321, 323, 326, 332, 338, 341, 360, 365, 368, 369, planets, 503, 510
382, 388, 389, 390, 391, 401, 403, 448, 457, 494 planned action, 353
perfectionism, 293 planning, 38, 103, 234, 335, 339, 341, 362, 363, 394,
performance, 78, 127, 133, 341, 366, 382, 446, 483 398, 412
permeability, 333, 336 plants, 68, 312
permit, 90, 370 Plato, 41, 47, 257
personal communication, 75, 183, 184, 186, 193, pleasure, 8, 11, 28, 130, 209, 323
264, 451, 457, 490 pleasure principle, 8, 11, 209
personal goals, 201, 465 police, 111
personal histories, 124 politeness, 441

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
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 Index 527

politics, 52, 63, 180, 457, 458 problem solving, 146, 205, 324, 334, 344, 365, 367,
poor, 24, 25, 142, 149, 257, 272, 273, 278, 303, 361, 368, 369, 370, 374, 375, 377, 382, 383, 389, 461,
379 463, 486
population, 96, 104, 151, 193, 331, 344, 359, 365, problem-solving skills, 365, 369, 370, 374, 375, 382,
499 383
portfolio, 300 processing deficits, 375
Portugal, xiv procreation, 301, 480
positive behaviors, 394 producers, 478
positive feedback, 117 production, 483
positive mental health, 309 productivity, 39, 131, 315, 317, 318
positive regard, 64, 67, 69, 70, 71, 72, 73, 75, 76, 77, profession(s), 4, 5, 122, 241, 419, 452, 508
78, 80, 81, 256, 294, 357 prognosis, 361, 363, 364
positive reinforcement, 379 program, xv, xvii, xviii, 66, 138, 158, 159, 163, 164,
positive relation, 378 267, 360, 365, 369, 370, 372, 379, 381, 385, 482,
positive relationship, 378 485
post traumatic stress disorder, 105 projective test, 39
postmodernism, 418, 419 promote, 29, 36, 40, 197, 205, 260, 278, 288, 295,
post-traumatic stress disorder, 365 297, 322, 325, 334, 335, 361, 369, 370, 377, 392,
posture, 117, 150, 342, 343, 424 394, 409, 469, 470, 471, 475, 492, 495, 496
potatoes, 67, 158 proposition, 129, 198
poverty, 270, 509, 510 protective factors, 362
power, 11, 25, 28, 35, 43, 80, 100, 159, 160, 170, protocol(s) 37, 42, 84, 117, 149, 475, 487, 488, 489,
172, 175, 176, 177, 178, 181, 187, 191, 199, 201, 491, 492
202, 205, 219, 252, 253, 264, 268, 270, 272, 276, prototype, 366, 481
278, 279, 280, 291, 303, 312, 326, 333, 337, 338, provocation, 274, 277, 406
341, 343, 355, 368, 388, 399, 405, 411, 446, 447, Prozac, 166
449, 452, 458, 469, 488, 501, 502, 503, 504, 505, psyche, 10, 33, 34, 35, 45, 209, 262
506, 507, 508, 509 psychiatric illness, 364
power relations, 175 psychiatric patients, 385
power sharing, 506 psychiatrist(s), xix, 3, 4, 5, 50, 128, 155, 156, 157,
pragmatism, 88, 144, 432, 479 158, 160, 161, 162, 164, 217, 237, 252, 363, 364,
predictability, 86, 272, 487 377, 379, 429, 431
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

prediction, 144 psychic energy, 209

preference, 450, 451 psychoanalysis, xiv, 7, 8, 9, 16, 19, 20, 21, 22, 31,
preferential treatment, xi 34, 42, 45, 83, 89, 107, 127, 128, 129, 209, 218,
prejudice, 128, 150 222, 224, 263, 299, 479, 490
preparedness, 10 psychoeducational intervention, 491
president, xv, xix, 211, 217 psychological adaptations, 10
pressure, 10, 13, 115, 163, 273 psychological development, 10, 184
prevention, 125, 152, 154, 204, 370, 380, 384, 475, psychological distress, 302, 390
480, 482, 483, 484, 487, 490, 491, 492 psychological functions, 10
preventive approach, 487 psychological health, 25, 32, 34, 289, 388
primacy, 26 psychological instruments, 189
primary caregivers, 241 psychological phenomena, 151
priming, 151 psychological problems, 2, 499
privacy, 363, 480 psychological processes, 1, 24, 142
private practice, xiv, xv, xvii, xviii, xix, 252, 265, psychologist, xvi, xviii, 63, 64, 108, 128, 197, 211,
267, 268 252, 268, 420, 425, 429, 445, 454, 492
probability, 116, 176, 185, 304 psychology, xi, xiv, xv, xvi, xvii, xviii, 1, 2, 5, 7, 8,
probe, 449 17, 19, 20, 23, 29, 31, 32, 33, 34, 35, 44, 45, 46,
problem behavior, 113, 115, 220 47, 52, 65, 83, 88, 104, 106, 107, 109, 122, 123,
problem drinking, 125 142, 143, 144, 149, 150, 151, 180, 181, 197, 198,
199, 200, 207, 209, 223, 238, 251, 263, 264, 265,

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
 528 Index

267, 269, 282, 283, 299, 300, 308, 309, 402, 420, 419, 421, 427, 433, 439, 445, 451, 479, 480, 485,
426, 466, 472, 473, 491 497
psychopathology, 14, 24, 25, 32, 103, 112, 142, 147, reasoning, 34, 132, 142, 163, 260, 285
149, 154, 181, 200, 206, 224, 269, 302, 332, 345, recall, 85, 415
462, 464, 492 reception, 272
psychopharmacology, 145 reciprocity, 18, 202
psychophysiology, 252 recognition, 39, 41, 95, 197, 220, 233, 266, 306, 442,
psychoses, 79, 157, 224, 240 451, 493, 498, 499
psychosis, 35, 248, 292, 297, 378 recollection, 26
psychosocial functioning, 344, 365, 388 reconciliation, 44
psychosocial stress, 391 reconditioning, 120
psychosomatic, 105, 493 reconstruction, 396, 397
psychotic symptoms, 379, 380 recovery, xviii, 42, 121, 365, 399
public awareness, 362 recreation, 363, 366, 368
public domain, 51 Red Cross, 486
public health, 90, 157, 158, 164, 384 redistribution, 233
public safety, 90 reduction, xv, 11, 43, 71, 124, 149, 150, 313, 338,
publishers, 299 370, 379
punishment, 15, 110, 116, 312 redundancy, 54
refining, 56
reflection, 38, 54, 59, 73, 77, 191, 193, 204, 267,
Q 279, 287, 289, 290, 295, 304, 305, 326, 432, 457
refugees, 267, 428
qualifications, 104
regression, 8
qualitative research, 75, 425
regulation, 40, 87, 89, 91, 102, 105, 192, 288, 289,
quality of life, 28, 245, 371, 382, 383, 495, 497, 498,
331, 332, 334, 338, 342, 343, 482, 491
499
rehabilitation, 78, 194, 361, 362, 364, 366, 369, 370,
quality of service, 366
375, 377, 379, 381, 382, 383, 385, 492
quantitative research, 76
rehabilitation program, 379, 382
questioning, 53, 54, 59, 133, 189, 222, 260, 326,
reinforcement, 107, 108, 109, 110, 112, 113, 117,
340, 391, 392, 418, 421, 423, 432, 438
379, 394, 463, 502
questionnaire, 450, 481, 484, 490
reinforcement contingencies, 463
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

questionnaires, 341, 368, 481

reinforcers, 110, 368
rejection, 12, 51, 91, 100, 315, 316, 328, 359
R relapses, 15, 357, 369
relational theory, 475, 492
race, 51, 170, 177, 344, 449, 503, 508 relationship maintenance, 507
racism, 169, 178 relationship satisfaction, 398, 501, 505
radical behaviorism, 108 relatives, 246, 333, 361, 362, 363, 364, 365, 366,
range, xii, 3, 25, 51, 86, 87, 89, 90, 100, 111, 130, 367, 368, 369, 370, 371, 372, 373, 374, 375, 376,
167, 172, 174, 177, 179, 190, 206, 259, 289, 333, 377, 381, 382, 383, 384, 385
334, 336, 338, 341, 345, 350, 359, 366, 449, 469, relaxation, 108, 110, 116, 117, 120, 121, 122, 123,
470, 471, 489, 497, 505 469
rape, xviii, 168, 169, 174 relevance, 94, 151, 418, 421, 424, 463, 470
ratings, 119, 380 reliability, 114, 227, 233, 492
Rational Emotive Behavior Therapy (REBT), 127 religion, 40, 44, 52, 138, 194, 312, 415, 485, 505
reactivity, 123, 239, 245, 258, 334, 337 religious traditions, 145
reading, 102, 130, 160, 194, 256, 307, 402, 456, 457 remission, 314, 323, 365, 380, 381
reality, xii, 1, 8, 16, 17, 20, 22, 43, 44, 46, 48, 49, 53, Rene Descartes, 1
54, 58, 83, 88, 100, 113, 128, 161, 162, 163, 183, repair, 248
184, 185, 189, 193, 198, 203, 210, 218, 224, 253, reparation, 358
258, 266, 286, 327, 364, 387, 388, 390, 401, 418, replication, 124, 261
repression, 8, 12, 15, 219, 271

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
 Index 529

reproduction, 68 schema, 198

reputation, 263 schizophrenia, 32, 80, 252, 361, 362, 363, 264, 365,
research design, 431 366, 369, 370, 375, 376, 377, 378, 379, 380, 381,
resentment, 306, 505 382, 383, 384, 385
residues, 210 schizophrenic patients, 378, 380
resilience, 291, 302, 400, 473, 492 school, xi, 7, 73, 79, 80, 81, 129, 131, 155, 159, 163,
resistance, xiii, 15, 16, 17, 98, 99, 101, 150, 187, 204, 206, 235, 240, 269, 276, 307, 314, 321, 335,
193, 211, 215, 268, 271, 272, 279, 280, 283, 318, 339, 340, 350, 352, 355, 370, 402, 404, 405, 406,
349, 422, 448, 464 407, 441, 454, 456, 457, 460, 467, 470, 479, 480,
resolution, 17, 18, 40, 63, 85, 87, 89, 205, 214, 217, 485, 501, 504, 507
261, 269, 333, 343, 347, 392, 463, 469 science, 44, 80, 128, 139, 141, 142, 143, 145, 147,
resources, xii, 42, 56, 67, 87, 88, 104, 172, 173, 178, 150, 152, 158, 160, 248, 265, 283, 299, 308, 462,
192, 195, 231, 235, 257, 260, 289, 291, 295, 296, 471, 472
313, 314, 317, 319, 321, 322, 323, 324, 327, 328, scientific knowledge, 32
335, 339, 363, 364, 367, 368, 369, 388, 390, 391, scientific method, 9, 64, 75
392, 393, 395, 397, 465, 482, 497, 499 scientific theory, 77
responsiveness, 359, 371, 472 scores, 138, 483
restructuring, 168, 187, 291 search, 45, 49, 55, 56, 68, 188, 283, 308, 359, 387,
retardation, 76 389, 406, 432, 434
retention, 344 searching, 40, 247, 252, 429
retirement, 144 second generation, 142, 145
retirement age, 144 securities, 48
returns, 240 security, 25, 52, 325, 333, 336, 337, 390
Revolutionary, 63 seed, 34
rewards, 112, 117, 209 seeds, 148, 312, 421
rhetoric, 66, 81 seizures, 150
rhythm, 275 selecting, 112, 368
rhythms, 188 selective attention, 395
rickets, 23 self esteem, 302
rigidity, 68, 90, 91, 257, 270 self help, 117
rings, 11 self-actualization, 67, 69, 75, 78
risk, 91, 93, 98, 130, 134, 152, 192, 211, 216, 273, self-assessment, 388, 390
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

278, 295, 304, 331, 344, 350, 358, 359, 369, 385, self-awareness, 16, 33, 91, 94, 188, 189, 260, 265,
421, 458, 467, 492 481
role playing, 137 self-concept, 24, 66, 67, 68, 69, 77, 185, 187
role-playing, 192 self-discipline, 138
Rome, 129 self-discovery, 273
routines, 275, 337 self-efficacy, 28, 107, 111, 122, 390, 447
rust, 234, 312 self-esteem, 28, 38, 187, 188, 293, 302, 480
self-fulfilling prophesy, 396
self-identity, 171
S self-image, 12
self-improvement, 392
sabotage, 130, 354, 486
self-knowledge, 9
sacrifice, 33, 392
self-monitoring, 117, 368
sadness, 52, 130, 288, 334
self-organization, 186, 286, 287
safety, 41, 51, 86, 90, 172, 191, 192, 279, 287, 290,
self-organizing, 183, 184
291, 295, 304, 318, 410, 411, 415
self-perceptions, 319
sample, 452, 454
self-reflection, 54, 187, 191, 193
satisfaction, 18, 52, 74, 86, 90, 95, 212, 214, 269,
self-regard, 71, 72, 77
368, 394, 398, 406, 501, 505, 507, 509
self-regulation, 40, 87, 89, 91, 102, 105, 342, 482,
savings, 411
491
scaling, 392
self-reports, 43
scheduling, 117

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
 530 Index

self-understanding, 16, 29, 67, 120, 189, 287 190, 191, 192, 203, 205, 236, 268, 269, 273, 276,
self-worth, 315 297, 323, 324, 325, 326, 327, 329, 333, 337, 341,
semantic networks, 151 344, 357, 364, 365, 367, 369, 370, 371, 372, 373,
semantic priming, 151 374, 375, 376, 377, 382, 383, 384, 389, 392, 393,
semantics, 459 396, 399, 401, 450, 452, 463, 469, 495, 499
sensation, 7, 41, 84, 85, 286, 295 skills training, xvii, 120, 122, 365, 369, 376, 377,
sensations, 85, 102, 144, 287, 288 383, 384, 463, 469
sensing, 269 skin, 439
sensitivity, 113, 144, 147, 204, 503 Skinner, B. F., 1, 107, 108, 109, 110, 121, 124, 128,
sensory experience, 94, 96 129, 139, 299, 309
separateness, 18, 259, 392 Skinner box, 110
separation, 65, 218, 219, 260, 264, 365 slaves, 288
sequencing, 337, 340, 454 smoke, 121
series, 2, 10, 50, 97, 221, 290, 346, 372, 431, 472 smoking, 114, 125, 150, 157, 158, 497
service provider, 335, 377 smoking cessation, 497
severity, 118, 345, 363, 461 soccer, 507
sex, xv, 12, 13, 23, 129, 134, 180, 217, 344, 358, social adjustment, 89, 370, 381, 382
360, 404, 405, 501, 503 social behavior, 202
sex differences, 503 social change, 167, 168, 169, 171, 173, 174, 176,
sex offenders, 358 179, 180
sex role, 501 social class, 51, 362
sexism, 167, 168, 169, 178, 179, 180, 502, 504, 510 social construct, 332, 346, 388, 391, 399, 418, 419,
sexual abuse, 168, 351, 358, 399, 410 426, 433, 443, 447, 458
sexual behavior, 174 social constructivism, 332
sexual harassment, 168, 175 social context, 24, 52, 80, 171, 174, 176, 340, 461,
sexual orientation, 170, 174, 177, 344, 449, 503, 508 502, 504, 509, 510
sexuality, 10, 12, 19, 61, 507 social development, 205
shame, 106, 134, 290, 353, 395, 428 social environment, 171, 173, 174, 175, 178
shape, 25, 90, 104, 144, 148, 302, 367, 372, 396, social exchange, 468
447, 449, 454, 456 social factors, 493, 498
shaping, 44, 65, 97, 103, 149, 333, 452, 462, 463 social group, 170, 178
shares, 24, 36, 160, 189, 260, 275, 286, 325, 353, social identity, 171, 175, 176, 177, 178
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

364 social impairment, 240

sharing, 98, 169, 178, 270, 278, 307, 317, 325, 377, social influence, 113
411, 414, 445, 467, 486, 488, 506 social influences, 113
shelter, 129, 410, 478 social institutions, 167
shock, 110, 146 social justice, 358, 398
shy, 55, 101, 206 social learning, 110, 111, 116, 385
shyness, 12 social learning theory, 110, 111, 116
sibling, 2, 24, 228, 351, 412, 457 social life, 131
siblings, 205, 206, 213, 214, 228, 242, 243, 246, 248, social network, 339
254, 302, 303, 333, 351, 374 social phobia, 117
Siddharta, 127 social problems, 28, 172, 198
side effects, 248, 362, 363, 496 social psychology, 109, 122, 198
sign(s), 49, 89, 99, 244, 279, 364, 366, 368, 407, social relations, 209, 303
411, 451, 464 social relationships, 209
signaling, 342 social responsibility, 315
signals, 424 social rules, 8, 12, 13
similarity, 92, 146, 483, 503 social sciences, 102, 299
sine wave, 269 Social Security, 368, 375
skill acquisition, 116 social services, 369, 382
skills, xiii, xvii, 3, 4, 28, 81, 98, 99, 109, 110, 112, social situations, 117, 356
116, 120, 122, 123, 146, 149, 169, 172, 175, 188, social skills, xvii, 120, 365, 377, 383, 384

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
 Index 531

social skills training, xvii, 120, 365, 377, 383, 384 365, 367, 377, 378, 393, 401, 461, 462, 463, 464,
social structure, 9, 171, 501 465, 466, 467, 468, 469, 471, 495
social support, 314, 323, 369, 370, 377, 495 stream of consciousness, 189
social withdrawal, 363, 376 strength, 43, 52, 60, 61, 80, 145, 155, 179, 190, 193,
social workers, xiii, 3, 4, 5, 156, 377, 429, 452 203, 261, 271, 275, 277, 279, 280, 337, 344, 358,
socialization, 167, 170, 171, 173, 174, 175, 178, 368, 424, 429, 435, 451, 457, 462, 487, 498, 508
475, 477, 491, 492, 502 stress, 105, 121, 128, 150, 152, 179, 187, 201, 219,
society, 11, 12, 13, 14, 24, 29, 32, 36, 51, 62, 68, 71, 230, 236, 239, 242, 243, 254, 256, 258, 304, 334,
77, 87, 90, 168, 170, 172, 173, 176, 177, 178, 337, 361, 362, 363, 365, 366, 369, 370, 372, 374,
198, 232, 299, 318, 365, 413, 446, 449, 499, 502, 375, 377, 378, 379, 380, 382, 383, 388, 391, 485,
503, 504, 505, 506, 507 497
socioeconomic conditions, 93 stressors, 186, 324, 374, 391, 494, 495, 496
Socrates, 47, 127, 183 stretching, 430, 457
soil, 67, 449 strong force, 36
Solution-Oriented, xii, 401, 402, 406, 409, 411, 412, Structural Family Therapy (SFT), 331, 332, 333,
413, 414, 415, 416 337, 344, 387, 388, 389, 391, 392, 393, 394, 395,
sorting, 290, 368 396, 397
sounds, 111, 325, 405 structuring, 73, 185, 204, 399
South Africa, 124, 150, 153, 265 students, ix, xii, xiii, xvii, 29, 43, 50, 65, 66, 75, 235,
Spain, 367 264, 267, 281, 424, 456, 490
specialization, 4 subgroups, 259
species, 108, 301 subjective experience, 94, 210, 212, 286
specific knowledge, 493, 495 subjectivity, 48, 308, 391
specificity, 19, 145, 152, 490 subscribers, 164
spectrum, 344 substance abuse, 150, 153, 214, 270, 331, 332, 397,
speech, 415 425, 493
speed, 148, 428 substance use, 391
spirituality, 31, 145, 148, 152, 283, 392, 398, 400, success rate, 358
449 suffering, xvi, 9, 26, 32, 49, 157, 160, 248, 303, 307,
spontaneity, xvii, 273, 276 357, 363, 369, 383, 389, 397, 399, 412, 461
sports, 131 sugar, 160
stability, 5, 52, 192, 227, 240, 245, 257, 334, 412 suicide, 80, 431, 484
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

stabilization, 104, 334, 379 summaries, 39

stages, 8, 10, 11, 12, 13, 14, 17, 28, 171, 210, 214, summer, 431
215, 219, 231, 234, 243, 244, 254, 256, 292, 295, superego, 8, 10, 15, 209, 480
307, 320, 321, 338, 339, 351, 464, 479, 481 superiority, 198, 379, 508
stakeholders, 464 supervision, xvii, xix, 220, 222, 251, 267, 374, 415,
standards, 53, 89, 90, 103, 170, 446, 447 425
stars, 460 supervisor, xvi, 203, 211, 415
stereotypes, 178, 180, 243, 246, 399, 506, 508 supply, 142, 157, 232
stereotyping, 169, 175, 180, 399, 501 suppression, 35, 144, 146, 154
stigma, 150, 362 surplus, 480, 485
stillbirth, 413 surprise, 159, 162, 379, 409, 411, 430
stimulus, 44, 74, 110, 111, 146, 151, 153 survival, 52, 108, 159, 201, 319, 369, 478
stimulus generalization, 111 survivors, 174, 416, 497
stock, 55 sweat, 408
stomach, 111, 439 Sweden, 153
strain, 363, 378 switching, 485
strategic management, 441 symbiosis, 224, 483
strategies, 1, 4, 24, 25, 28, 84, 86, 103, 104, 114, symbiotic, 41
122, 143, 151, 174, 175, 176, 181, 191, 199, 207, Symbolic Experiential Family Therapy (S-EFT), 251
230, 234, 270, 278, 334, 340, 344, 350, 361, 364, symbolic meanings, 192
symbolic systems, 186

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
 532 Index

symbols, 40, 45, 190, 253 therapeutic approaches, 56, 64, 71, 168, 180, 446,
symptom, 2, 8, 9, 14, 15, 18, 26, 35, 38, 74, 77, 111, 461, 488
115, 120, 123, 147, 149, 152, 156, 157, 158, 160, therapeutic change, 79, 112, 174, 277, 300
161, 162, 164, 174, 175, 200, 203, 205, 221, 232, therapeutic encounter, 92, 100, 273, 279, 282
240, 61, 162, 164, 174, 175, 200, 203, 254, 257, therapeutic goal, 28, 34, 38, 392
258, 259, 279, 302, 313, 319, 328, 340, 341, 344, therapeutic interventions, 291, 320
345, 350, 351, 352, 354, 355, 357, 358, 359, 363, therapeutic practice, xiv, 271
364, 365, 367, 369, 370, 374, 378, 379, 380, 381, therapeutic process, 16, 17, 44, 55, 67, 69, 70, 72,
382, 413, 450, 455, 464, 470, 488, 489, 493 73, 103, 113, 204, 206, 291, 315, 321, 327, 328,
symptomology, 233 352, 354, 449, 495
synthesis, 36, 79, 92, 202, 332, 383, 473 therapeutic relationship, 9, 16, 17, 25, 27, 28, 29, 32,
systematic desensitization, 107, 108, 118, 119 36, 37, 41, 46, 55, 58, 60, 69, 70, 72, 80, 88, 92,
systems, xii, xiii, 2, 5, 13, 23, 29, 38, 84, 85, 87, 88, 93, 98, 99, 100, 113, 118, 121, 172, 176, 177,
89, 90, 96, 97, 102, 103, 104, 127, 128, 132, 150, 178, 189, 192, 194, 234, 246, 256, 300, 303, 327,
175, 183, 184, 186, 197, 200, 201, 211, 218, 219, 338, 354, 359, 396, 452, 460
220, 223, 224, 235, 236, 238, 242, 247, 254, 257, therapy methods, 137
259, 264, 265, 268, 269, 272, 277, 280, 281, 300, thermodynamics, 7
301, 313, 315, 319, 320, 328, 332, 333, 334, 335, thinking, ix, 1, 2, 7, 8, 9, 10, 13, 18, 19, 23, 36, 41,
337, 342, 345, 347, 349, 350, 355, 365, 385, 387, 47, 48, 53, 55, 59, 66, 87, 103, 104, 106, 111,
388, 390, 391, 419, 425, 426, 463, 466, 467, 469, 112, 127, 128, 129, 130, 131, 132, 134, 137, 142,
472, 494, 501, 502, 504, 505 143, 148, 151, 156, 159, 163, 183, 186, 190, 193,
195, 199, 204, 209, 218, 223, 231, 234, 235, 237,
238, 239, 241, 242, 243, 245, 252, 265, 278, 299,
T 344, 345, 369, 382, 390, 396, 398, 404, 406, 409,
420, 428, 433, 437, 443, 445, 449, 452, 453, 457,
tactics, 280, 355
469, 501, 502
talent, 408
threat, 287, 312
Taoism, 263
threats, 430
target behavior, 118
threshold, 334, 374
targets, 142, 209, 464
Tillich, Paul 47
teachers, ix, 138, 159, 160, 163, 164, 165, 197, 450,
time frame, 17, 379
456
time periods, 116
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

teaching, xiv, xvi, xix, 29, 132, 163, 164, 194, 248,
timing, 11, 365, 421
267, 268, 297, 365, 374, 375, 376, 378, 382, 383,
toddlers, 210, 212
399, 459
toilet training, 11
teaching experience, xiv
tonsils, 161
teaching process, 378
toxicity, 344
technology, 76, 77, 147, 149, 299, 499
toys, 307
teenagers, 358
tracking, 95, 103, 105, 392, 454, 463, 464
teens, 127, 355
tradition, 16, 18, 19, 47, 79, 104, 291, 415, 418, 422,
teeth, 144, 430
466
telephone, 404
trainees, xi, 61
television, 161, 206, 401, 407
training, xiii, xiv, xv, xviii, xix, 3, 5, 11, 29, 31, 61,
temperament, 321
66, 73, 78, 79, 87, 94, 102, 104, 105, 112, 117,
temperature, 368
120, 122, 123, 127, 128, 138, 146, 154, 163, 164,
Tennessee, 252
165, 180, 195, 206, 218, 237, 238, 251, 264, 267,
tension, 10, 11, 66, 71, 87, 156, 201, 209, 239, 295,
268, 306, 329, 332, 357, 360, 365, 369, 371, 375,
337, 363, 369, 374, 382, 429, 430, 447
376, 377, 379, 450, 463, 469, 498, 502, 510
tenure, xiv, xv, 380
training programs, xv, 29, 66
terminal illness, 493
traits, 10, 11, 12, 13, 35, 86, 131, 168, 172, 319, 333,
territory, 318, 390, 449, 458
394, 480, 505
Texas, xiv, 417, 426, 443
trajectory, 98
textbooks, ix, 457, 473
tranquilizers, 370
theoretical assumptions, 81, 475, 479, 483

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
 Index 533

transactions, 16, 211, 271, 274, 355 199, 201, 202, 205, 206, 237, 256, 275, 276, 277,
transcendence, 9, 16, 389, 400 278, 279, 287, 303, 304, 337, 344, 391, 396, 397,
transference, 15, 16, 17, 18, 22, 36, 37, 41, 45, 219, 404, 415, 421, 454, 457, 462, 470, 485, 501, 505,
221, 222, 260 506
transformation, 9, 10, 36, 54, 289, 291, 294, 418, variabl(e), 39, 89, 94, 141, 145, 146, 303, 353, 379,
419, 422, 469 392, 479, 481, 482, 485, 502, 507
transformations, 93, 177 variance, 150
transition, 45, 98, 99, 123, 177, 252, 257, 259, 351, variation, 272, 333, 334, 377
413 vegetables, 409
transitions, 218, 254, 255, 340, 391 vein, 16, 395
translation, 101, 145, 370 venue, 305
transmission, 5, 506 Venus, 503
transparency, 457 veterans, 266, 472
transportation, 381, 496 victimization, 168
trauma, 8, 17, 266, 296, 328, 337, 399, 412 victims, 260, 319, 333, 358, 483
treatment methods, 109 videotape, 207
treatment programs, 332, 380 violence, 123, 168, 172, 181, 274, 307, 328, 351,
trend, 15, 19, 209, 335, 401 360, 363, 407, 410, 425, 457, 467, 502, 505, 507,
trial, 122, 151, 152, 153, 257, 260 508
triangulation, 255, 337 Virginia, xvii, xviii, 268, 307, 311, 312, 314, 327,
tribes, 79, 80 328, 329
truancy, 339 vision, xii, 249, 364, 390, 395, 450
trust, 36, 37, 41, 57, 67, 77, 95, 96, 98, 99, 102, 105, vocabulary, 32, 203
118, 188, 190, 210, 215, 222, 227, 228, 229, 230, vocational rehabilitation, 375, 377
233, 234, 236, 243, 277, 303, 304, 306, 307, 317, vocational training, 379
318, 357, 411, 412, 496 voice, 100, 101, 106, 117, 172, 190, 258, 287, 296,
trustworthiness, 229, 233, 246, 248 311, 317, 322, 326, 371, 406, 409, 421, 435, 436
vulnerability, 227, 293, 335, 361, 362, 374, 383, 487,
492
U vulnerable people, 14
Vygotsky, 418, 426, 439, 441, 442, 443
UK, 50, 166, 297
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

uncertainty, 422, 423, 425, 447

unconditional positive regard, 64, 67, 69, 70, 71, 72, W
73, 75, 76, 77, 78, 81, 357
unhappiness, 158 waking, 40
United States, xvii, 21, 65, 168, 197, 211, 218, 265, Wales, 282
267, 349, 350, 362, 365, 367, 398 war, 8, 49, 68, 211, 240, 259
universality, 81, 485 warts, 59
universe, 67, 86 watches, 201
universities, xix, 299, 490 watershed, 81
updating, 355 weakness, 52, 100, 279, 369
UPR, 72 wealth, 33, 51, 102
weapons, 256
wear, 405
V web, 83, 84, 88, 242, 399
welfare, 503
vacuum, 84, 378, 478
well-being, 52, 53, 60, 176, 186, 188, 191, 276, 287,
validation, 232, 295, 315, 337, 361, 491, 505
314, 385, 389, 390, 498, 499, 508
validity, 88, 100, 114, 289, 291, 311, 488, 490, 499,
wellness, 4
503
Wertheimer, Max, 88
values, 9, 24, 26, 28, 29, 35, 36, 43, 49, 53, 54, 57,
Western Europe, 100
71, 77, 102, 120, 145, 147, 148, 149, 150, 167,
WHO, 499
168, 169, 172, 173, 176, 177, 178, 179, 185, 189,
wind, 39, 42, 133

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.
 534 Index

wine, 438 worldview, 54, 55, 189, 190, 395

winter, 405 worry, 154, 290
Wisconsin, xv, xviii, 74, 80, 81, 252, 312 writing, xvii, xix, 43, 44, 48, 252, 388, 410, 412,
withdrawal, 84, 86, 89, 99, 199, 238, 240, 244, 269, 413, 414, 442, 487, 488, 489, 491, 492
303, 363, 364, 374, 376, 379 Wundt, Wilhelm, 7
wives, 159
Wolpe, Joseph, 107, 128
women, xviii, xix, 134, 137, 157, 167, 168, 169, 170, Y
171, 172, 173, 174, 175, 176, 178, 179, 180, 181,
yield, 232, 389
404, 410, 437, 470, 501, 502, 503, 504, 505, 506,
507, 508
workers, xiii, 3, 4, 5, 156, 235, 374, 377, 429, 452, Z
485
workplace, 175 zeitgeist, 2, 121
World War, 251
World War I, 251
World War II, 251
Copyright © 2007. Nova Science Publishers, Incorporated. All rights reserved.

Jordan, Karin. The Quick Theory Reference Guide: A Resource for Expert and Novice Mental Health Professionals : A Resource of Expert and Novice
Mental Health Professionals, edited by Karin Jordan, Nova Science Publishers, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/georgefox/detail.action?docID=3021112
Created from georgefox on 2022-09-20 00:11:55.