Counselling Psychology

PSY 350

Course Instructor: Rucha Sarwate

School of Arts and Sciences

Monsoon 2024 - 25
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Course PSY350 Counselling Semester Monsoon Semester 2024
Psychology

Faculty Name(s) Rucha Sarwate Contact [email protected]

School SAS Credits 3

GER Category: Not Applicable Teaching Pedagogy P/NP Course: Can not be taken as P/NP
Enable:NO

Schedule
Section 1 01:00 pm to 02:30 pm Mon 01-08-24 to 26-11-24

01:00 pm to 02:30 pm Fri 01-08-24 to 26-11-24

Prerequisite PSY 101 Introduction to Psychology/PSY101 Introduction to Psychology

OR
PSY161 Personality and Individual Differences & PSY252 Health Psychology & PSY272
Industrial and Organisational Psychology & PSY280 Abnormal Psychology
OR
PSY280 Abnormal Psychology & PSY252 Health Psychology
OR
PSY101 is mandatory, the student needs to have completed any one of the three pre-requisites
in OR (either Health Psychology or Personality and individual differences or Abnormal
Psychology

Antirequisite Not Applicable

Corequisite Not Applicable

Course Description Counselling psychology is offered as a major elective course for students who intend to major
in Psychology. It is designed to provide the student with an overview of counseling psychology
as a profession. The course primarily focuses on orienting the student towards the
fundamental skills, theoretical approaches to counseling and its applications across various
settings. The course also intends to foster the understanding of the signi cance of personal
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awareness in the effective and ethical application of counseling skills.
This course explores the basics of counselling, counselling process, and the different method
and techniques in classical and contemporary therapies. We will examine the major schools of
therapies: Psychoanalytic, Humanistic, Behavioural, Cognitive and Eclectic therapies with the
aim of developing a sound theoretical background in psychotherapies. Along with discussing
the various theories of psychotherapy, this course offers an understanding in application of
counseling skills across different elds like family and couple counseling, and career
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counseling, etc. The intensive focus of course will be on the development of individual
counseling skills through readings, group discussions, reviews of videotaped interviews and
other experiential exercises.
Course Objectives The course aims to:
1. To introduce students to the nature and processes of counselling.
2. To familiarize students with the basic counselling skills
3. To teach the students about different theoretical approaches of counseling as well as the
speci c psychotherapeutic skills

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4. To introduce students to various settings associated with the counseling profession.

Learning Outcomes On completion of this course students will be able to:

1. De ne the eld of counseling psychology and identify the various functions of a counselor.

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2. Demonstrate the understanding of the guiding ethical principles followed in counseling
practice.
3. Demonstrate the understanding of the counseling process and the importance of a
therapeutic alliance.
4. Demonstrate basic active listening skills and describe the theoretical frameworks and
concepts in counselling psychology
5. Explain and demonstrate the various techniques used in diverse counseling models
6. Differentiate between various applied settings in diverse counseling practices.

Pedagogy 1. Lectures
2. Class discussions
3. Experiential exercises such as review of videotaped interviews
4. Case studies
5. Role-plays
6. Group assignments

Expectation From Students are expected to come prepared with the prescribed readings for the session.
Students Students should actively participate in classroom discussions and activities.

Assessment/Evaluation Mid-Semester Examination:

Mid term exam - 20%
End Semester Examination:
End term exam - 30%
Other Components:
Quiz - 20%
Group Assignment and Presentation - 25%
Class participation (Including attendance) - 5%

Attendance Policy As per Ahmedabad University Policy.

Project / Assignment
Details Group project on creating awareness towards mental health 10th and 14th October (25 marks):
Poster presentations, small plays, plan activities, presentation on strategies to take care of
mental health etc

Course Material Reference Book

Introduction to counseling: An art and science perspective., Nystul, M. S., SAGE
Publications, Year: 2015,
Counselling in India: Re ections on the process. Springer, Singapore., Sriram, S. (Ed.).,
fl
Springer, Singapore, Year: 2016,
Ethical issues in counselling and psychotherapy practice: Walking the line., Bhola, P., &
Raguram, A. (Eds.). (2016)., Springer, Year: 2016,
Additional Information 1. Class participation (5 marks)

2. Group project on creating awareness towards mental health 10th and 14th October (25
marks): Poster presentations, small plays, plan activities, presentation on strategies to take
care of mental health.

3. 4 Monthly quizzes (Aggregates: 20 marks)

4. Mid- term – exam: short notes (20 marks)

5. Final Essay Exam on entire course (30 marks)

Total = 100 marks

 Session Plan

N TOPIC TITLE TOPIC & SUBTOPIC DETAILS READINGS,CASES,ETC ACTIVITIES IMPORT

O. . ANT
DATES

0 Topic Title Topic & Subtopic Details Readings, Cases, etc. Activities

1 Introduction Introduction to counseling. 1. Nystul, M. S.

and (2015). Introduction
professional to counseling: An art
foundations of and science
counseling perspective. Sage
Publications. (pp. 1-
15)

2 Self-awareness of the counselor: 1. Gladding S.T. Self-inventory:

Professional and personal (2018) Counselling: A Identify your beliefs
characteristics Comprehensive (Self of a counselor)
Profession (8 th Ed).
(pp. 1-14)

3 Counseling Overview of counseling process 1. Gladding S.T. Audio-visual material

process and (2018) Counselling: A
foundational Comprehensive
skills: Stages Profession (8th Ed).
of counseling (pp. 92-97)

4 Questioning skills: Types of 1. Berman, P. S., & Audio-visual material

questions, areas of questions Shopland, S. N.
(2004). Interviewing
and diagnostic
exercises for clinical
and counseling skills
building. (pp.7-12)

5 Maintaining positive therapeutic Sutton, J., & Stewart, Audio-visual material

relationship W. (2017). Learning
To Counsel: How to
develop the skills,
insight and
knowledge to counsel
others . (pp. 82-98)

6 Counselor skills in the working Gladding S.T. (2018) Role-play

stage of counseling: Counselling: A
Understanding and action Comprehensive
Profession (8th Ed).
(pp. 115-130)

7 Closing counseling relationship: Gladding S.T. (2018)

Counselling: A
Comprehensive
Profession (8th Ed).
(pp. 132-145)
8 Ethical Issues in counseling 1. Corey, G. Case presentation
practice: Mandatory, aspirational (2016). Theory and and discussion
and positive ethics. practice of
counseling and
psychotherapy,
Enhanced . Cengage
Learning. (pp. 38-42)

9 Psychoanalytic Broad overview of psychoanalytic Corey, G. (2016).

therapies therapies Theory and practice
of counseling and
psychotherapy,
Enhanced . Cengage
Learning. (pp.58- 72)

10 Psychoanalytic therapies (contd.) Corey, G. (2016). Audio-visual material

Theory and practice
of counseling and
psychotherapy,
Enhanced . Cengage
Learning. (pp. 38-42

11 Humanistic Introduction to humanistic Seligman, L. W., &

Psychotherapie psychotherapy: Role of Reichenberg, L. W.
s phenomenology. (2013). Theories of
counseling and
psychotherapy:
Systems, strategies,
and skills . (pp. 136-
138)

12 Gestalt therapy: Important Seligman, L. W., & Role-play: Gestalt

theoretical concepts, key Reichenberg, L. W. chair work
techniques, current status and (2013). Theories of
evaluation counseling and
psychotherapy:
Systems, strategies,
and skills . (pp. 201-
223)

13 Thought- Overview of thought focused Corey, G. (2016). Disputing Irrational

focused therapies Theory and practice beliefs using ABCDE
therapies of counseling and format
psychotherapy. (pp.
270-280)

14 Cognitive therapy: Aaron Beck: Seligman, L. W., & Activity : Automatic

Development of cognitive therapy, Reichenberg, L. W. thought record sheet
Important theoretical concepts, (2013). Theories of
key techniques, application and counseling and
current status, evaluation psychotherapy:
Systems, strategies,
and skills . (pp. 292-
311)

15 Re ection and Review

fl
16 Mid-semester exam
17 Behavioral Basic assumptions & various Corey, G. (2016).
therapies forms of behaviour therapies: Theory and practice
of counseling and
psychotherapy. (pp.
231-267)

18 Third- Mindfulness-based cognitive Feltham, C., Hanley, Mindful listening

generation of therapy: Development of MBCT, T., & Winter, L. A.
behavioral Important theoretical concepts, (Eds.). (2017). The
therapies key techniques, application and SAGE handbook of
current status, evaluation counselling and
psychotherapy (pp.
515-523)

19 Integrative Nature of eclectic and integrative Seligman, L. W., &

therapies therapies Reichenberg, L. W.
(2013). Theories of
counseling and
psychotherapy:
Systems, strategies,
and skills . (pp. 429-
435)

20 Applications of Couple and family counseling: Gladding S.T. (2018).

counseling Counselling: A
Comprehensive
Profession (8th Ed).
Dorling Kindersley
(India) Pvt Ltd. of
Pearson Education.
(pp. 314-332)

21 Couple and family counseling Gladding S.T. (2018). Case presentation

(Contd.) Counselling: A and discussion
Comprehensive
Profession (8th Ed).
Dorling Kindersley
(India) Pvt Ltd. of
Pearson Education.
(pp. 314-332)

22 Child and adolescent counseling Nystul, M. S. (2015). Audio-visual material

Introduction to
counseling: An art
and science
perspective . Sage
Publications. (pp.
280-313)

23 School counseling: 1. Tammana, S.

(2016). The role of a
school counsellor. In
Counselling in India
(pp. 163-181).
Springer, Singapore.
24 Middle school counseling: Gladding S.T. (2018).
Emphasis, activities, prevention, Counselling: A
and remediation Comprehensive
Profession (8th Ed).
Dorling Kindersley
(India) Pvt Ltd. of
Pearson Education.
(pp346-357.)

25 Carrier counseling over the life- Gladding S.T. (2018).

span Counselling: A
Comprehensive
Profession (8th Ed).
Dorling Kindersley
(India) Pvt Ltd. of
Pearson Education.
(pp. 288-313)

26 Crisis Suicide and self-harm Feltham, C., Hanley,

intervention T., & Winter, L. A.
(Eds.). (2017). The
SAGE handbook of
counselling and
psychotherapy. Sage.
(pp. 991-999)

27 Intersections in Counseling health psychology Berman, M. I., &

counseling James, L. C. (2012).
Counseling health
psychology. In
Altmaier, E. M., &
Hansen, J. I. C.
(Eds.). The Oxford
handbook of
counseling
psychology . Oxford
University Press.

28 Counseling health psychology Feltham, C., Hanley,

(contd.) T., & Winter, L. A.
(Eds.). (2017). The
SAGE handbook of
counselling and
psychotherapy. Sage.

29 Revision and Re ection

fl
30 End-semester exam
 PA R T O N E
    

An Overview of Counseling and

the Counseling Process

Part One provides a conceptual framework for understanding counseling and the
counseling process. The following five chapters are covered in Part One:

Chapter 1 An overview of counseling

Chapter 2 Professional preparation and ethical and legal issues
Chapter 3 The counseling process
Chapter 4 Assessment and diagnosis
Chapter 5 Counseling research and evaluation

1
    
CHAPTER 1
An Overview of Counseling

CHAPTER OVERVIEW
This chapter provides several models that can be used to conceptualize counseling. Highlights of
the chapter include
䊏 The art and science of counseling and 䊏 Personal qualities of effective helpers
psychotherapy 䊏 The helping profession
䊏 Counseling as storytelling 䊏 Counseling from a historical perspective
䊏 Counseling versus psychotherapy 䊏 Future trends in counseling
䊏 Formal versus informal helping

WELCOME TO THE FIELD OF COUNSELING

The field of counseling can be of interest to you even if you do not want to become a professional
counselor. It offers tools for understanding, connecting, and helping that can be used to promote
self-awareness and self-improvement and to enhance all aspects of life, including interpersonal
relations, coping with stress, and problem solving.
Counseling as a career can be exciting and rewarding, and there are many reasons for
becoming a counselor. You may think that helping a client work through a crisis or develop a
more effective and meaningful lifestyle will be personally gratifying. Perhaps you find people
interesting, or you are curious about how the mind functions, or even fascinated by abnormal
conditions such as schizophrenia. You may view the challenge of working in a relatively new pro-
fession as appealing. Counseling offers numerous opportunities for its practitioners to make a
significant contribution to the profession. You can develop new approaches to counseling or
become involved in professional issues such as licensure. There are many ways to involve yourself
in the counseling profession, and this book tries to help you identify some facet of counseling you
would like to explore.

2
 Chapter 1 • An Overview of Counseling 3

WHAT IS COUNSELING?
No simple answer addresses the question “What is counseling?” Counseling can more appropriately
be understood as a dynamic process associated with an emerging profession. It involves a profession-
ally trained counselor assisting a client with particular concerns. In this process, the counselor can
use a variety of counseling strategies, such as individual, group, or family counseling, to assist the
client to bring about beneficial changes and generate a variety of outcomes—facilitating behavior
change, enhancing coping skills, promoting decision making, and improving relationships.
This chapter presents several conceptual models for understanding the different facets of
counseling. Counseling is described first as an art and a science, then from the perspective of narra-
tive psychology or storytelling. The chapter also differentiates counseling from psychotherapy and
formal from informal helping, describes the personal qualities of effective helpers, identifies mem-
bers of the helping profession, and provides information on past and future trends in counseling.

The Art and Science of Counseling and Psychotherapy

Counseling is essentially both an art and a science. The art-and-science model promoted
throughout the book suggests that counseling is an attempt to balance the subjective and objec-
tive dimensions of the counseling process. From this perspective, the counselor, like an artist, can
sensitively reach into the world of the client yet on some level maintain a sense of professional
and scientific objectivity.
The theoretical origins of the art and science of counseling and psychotherapy can be traced to
the scientist-practitioner model set forth in Boulder, Colorado, in 1949. The scientist-practitioner, or
Boulder, model (Raimy, 1950) suggests that science should provide a foundation for clinical practice.
The Boulder model continues to have a major influence over the structure of university programs for
the education of those in the helping profession (Baker & Benjamin, 2000; Peterson, 2000). However,
Beutler, Williams, Wakefield, and Entwistle (1995) noted that practitioners have become increasingly
dissatisfied with traditional research methodologies and have become interested in alternative
approaches to research that are more directly linked to everyday clinical practice. Single-case research
design (see Chapter 5), for example, is receiving attention as a viable tool for helping counselors
bridge the gap between research and practice (Murray, 2009; Sharpley, 2007).
The art-and-science model of counseling and psychotherapy represents an extension of the
scientist-practitioner model. From this perspective, the science of counseling generates a base of
knowledge that promotes competency and efficacy in counseling. The art of counseling involves
using this knowledge base to develop skills that can be applied sensitively to clients in a multicul-
tural society. The art of counseling relates to the subjective dimension, and the science of counsel-
ing reflects the objective dimension. The focus of counseling can shift back and forth between
these two dimensions as one proceeds through the counseling process. For example, during the
initial sessions, the counselor may function more like an artist, using listening skills to understand
the client. Later, the focus might shift to the science dimension as the counselor uses psychologi-
cal tests to obtain an objective understanding of the client. Together, the art and science can create
a balanced approach to counseling. A more detailed description of these two dimensions follows.

THE ART OF COUNSELING. To a large degree, counseling is an art. To call counseling an art
suggests it is a flexible, creative process whereby the counselor adjusts the approach to the unique
and emerging needs of the client. The first Personal Note that follows provides an illustration of
how a counselor can be flexible and creative in working with a client.
4 Part 1 • An Overview of Counseling and the Counseling Process

A Personal Note

As a psychologist working for the Public Health Service on a Navajo Indian Reservation, I was asked to
work with an autistic child as part of my consultation with the public schools. School personnel
had placed the young girl in a classroom for the mentally retarded, not knowing she was autistic. The
child was referred to me for counseling and self-concept development. When she came into my office,
I had some puppets ready to use with her. These puppets were part of a self-concept program called
Developing an Understanding of Self and Others (DUSO) (Dinkmeyer & Dinkmeyer, 1982). I soon real-
ized that she seemed oblivious to me and the puppets. My counseling plans appeared to be useless.
I wanted to make contact with the child and find a way to reach into her world and develop a spe-
cial relationship with her. I decided to let her be the guide, and I would follow. She walked over and threw
the puppets into a neat pile. If she missed the pile, she threw the puppet until it landed right on top of the
others. She was very good at throwing puppets into a pile, and she seemed to enjoy doing it. I had iden-
tified one of her assets—something she felt good about, something she felt secure with. It was an exten-
sion of her world, her way of doing things. It made sense to her.
I wanted to become part of her world by reaching into it. I walked over and put my arms around
her pile of puppets, becoming a puppet-basketball net. She continued to throw her puppets on the pile
and through my net. For the next 20 minutes, the child threw the puppets into a pile. When she ran out
of puppets, she would gather them up and start over, throwing them into a new pile. I would move the
“net” as necessary. During this time, she never made eye contact with me or said a word. I became dis-
couraged and walked back to my seat. As I did, I noticed that her eyes followed my movement. At that
instant, I knew I had made contact. I had found a way into her world.
Over the next year, she let me further into her world. For the most part, she was the guide and I the
follower—a guest in her home. As the relationship grew stronger, she became willing to explore my
world. Through our relationship, I helped her reach out into the world of others. For example, I helped
her with language development and encouraged her to move away from her ritualistic behavioral pat-
terns. (A more detailed description of this case can be found by referring to Nystul, 1986.)

Another aspect of the art of counseling is the giving of oneself in counseling. This concept,
derived from humanistic psychology, emphasizes the importance of counselors being authentic
and human in their approach. Counselors can give of themselves on many levels. They can give
concern and support as they empathize with their client, or, at a more intense level, engage in an
existential encounter, which involves the process of self-transcendence. In this experience, the
counselor moves beyond the self and feels at one with the client (Nystul, 1987a). The experience
can help a client overcome feelings of aloneness and alienation.
Giving of oneself in counseling may be especially appropriate in situations that involve work-
ing with neglected and abused children. These children may be wards of a court, without parents or
significant others. They may feel unloved and lost, lacking a reason to live. In these cases, the coun-
selor may attempt to communicate compassion, kindness, tenderness, and perhaps even love. The
second Personal Note that follows illustrates the concept of giving of oneself in counseling.
Counselors must use safeguards when expressing intense feelings to a client. They must
clearly establish their role as a counselor and not a parent. They must avoid becoming overly
involved to the point where they lose professional objectivity. Counselors must also be aware that
excessive concern or worry about a child could lead to burnout. Giving of oneself in counseling is
a very delicate process. It can be enriching and rewarding for the counselor and the child, but it
can also be exhausting. Communicating intense emotion may not be practical for some coun-
selors. For others, it is an art that must be developed over time.
 Chapter 1 • An Overview of Counseling 5

A Personal Note

A 5-year-old child was abandoned by her parents and placed in a residential facility for neglected and
abused children. On one occasion, the caretakers of the institution became concerned when the child
stayed up all night crying and vomiting. They brought her to a hospital the next morning. A pediatrician
found nothing physically wrong with the child and referred her to me for mental health services.
After introducing myself to the child, I asked her how she was feeling. She sat down, put her face
between her legs, and began to cry. It was the most deep-sorrowful sobbing I had ever heard. I leaned for-
ward and gently touched her head, trying to comfort her. I could feel her pain. She looked up at me and
appeared frightened and alone. I reached over and held her hand and told her I wanted to help her feel
better. My heart reached out to her. I looked at her and said I thought she was a beautiful person, and
I wanted to work with her every day. She nodded in agreement. I worked with her in play therapy for
several weeks. During that time, her depression gradually lifted.

THE SCIENCE OF COUNSELING. The science of counseling provides a balance to the art of
counseling by creating an objective dimension to the counseling process. Claiborn (1987) noted
that science is an important aspect of counselors’ identity in that the scientific perspective differ-
entiates professional counselors from nonprofessional helpers. He suggested that counselors
should strive to be counselors-as-scientists (i.e., someone who functions as a counselor and
thinks as a scientist). Thinking as a scientist requires the counselor to have the skills to formulate
objective observations and inferences, test hypotheses, and build theories (Claiborn, 1987).
Claiborn also suggested that the scientist-practitioner model, set forth by Pepinsky and Pepinsky
(1954), could provide useful guidelines for contemporary counselors. This model conceptualizes
science and practice as integrated, mutually dependent, and overlapping activities. The interrela-
tionship of theory, research, and practice illustrates the complementary nature of science and
practice. A counseling theory, for example, can be tested in practice and can then, in turn, be eval-
uated by research.
The science aspect of counseling also encourages counselors to develop skills that can pro-
mote professional objectivity in the counseling process. These skills include observation, infer-
ence, hypothesis testing, and theory building, which Claiborn (1987) suggested are necessary for
counselors to think as scientists. The use of psychological tests, a systematic approach to diagno-
sis, and research methods to establish counseling accountability and efficacy are other aspects of
the scientific model. We should not view these as separate entities of counseling. Instead, coun-
selors should integrate these skills and strategies into their overall role and function.

Counseling as Storytelling
Counseling as storytelling is an emerging conceptual model. Howard (1991) and Sexton and
Whiston (1994) suggested that narrative (or storytelling) methods for understanding human
behavior have become increasingly popular in psychology. For example, identity development
can represent life-story construction, and psychopathology can be related to dysfunctional life
stories and can involve story repair (Howard, 1991).
Narrative psychology and its application to counseling as a form of storytelling are related to
two emerging and complementary trends in counseling—the theories associated with postmod-
ernism and with brief-solution-focused counseling approaches (additional information regarding
these trends are provided throughout the text). Narrative approaches to counseling attempt to
6 Part 1 • An Overview of Counseling and the Counseling Process

simplify and demystify counseling by focusing on the client’s own language as opposed to psycho-
logical jargon (Eron & Lund, 1993). The role of the counselor is to engage in a collaborative, non-
impositional relationship with the client (Eron & Lund, 1993). In this process, the counselor and
client work together to create new narratives (or alternative stories) as a means of enhancing the
client’s well-being.
Howard (1991) provides a detailed description of the role of storytelling in counseling:

In the course of telling the story of his or her problem, the client provides the thera-
pist with a rough idea of his or her orientation toward life, his or her plans, goals,
ambitions, and some idea of the events and pressures surrounding the particular
presenting problem. Over time, the therapist must decide whether this problem rep-
resents a minor deviation from an otherwise healthy life story. Is this a normal, devel-
opmentally appropriate adjustment issue? Or does the therapist detect signs of more
thoroughgoing problems in the client’s life story? Will therapy play a minor, support-
ive role to an individual experiencing a low point in his or her life course? If so, the
orientation and major themes of the life will be largely unchanged in the therapy
experience. But if the trajectory of the life story is problematic in some fundamental
way, then more serious, long-term story repair (or rebiographing) might be indicated.
So, from this perspective, part of the work between client and therapist can be seen as
life-story elaboration, adjustments, or repair. (p. 194)

Meichenbaum and Fitzpatrick (1992) provide additional information on storytelling in terms of

how people cope with stress:
• People organize information in terms of stories about themselves.
• Negative, stressful life events affect people’s belief systems, thereby altering the nature of
their stories.
• How people rescript their stories (i.e., engage in narrative repair) will influence how well
they cope with stress.
• The literature is beginning to identify what are adaptive and maladaptive narratives and
how stress-inoculation training can be used to help clients construct adaptive narratives to
stressful life events.
Counseling as storytelling is an intriguing concept that appears to offer much promise for
understanding counseling. As Russell and Lucariello (1992) have noted, there is a great need for
empirical research to investigate the impact of storytelling on the counseling process. The follow-
ing Personal Note provides an illustration of the role of storytelling in counseling.

Counseling and Psychotherapy

In order to understand what counseling is, it is important to understand key terms and concepts
such as counseling and psychotherapy. The counseling literature has not made a clear distinction
between these concepts (Corsini & Wedding, 2000), perhaps because the two processes are more
similar than different. We can probably best understand their relationship within a continuum,
with counseling at one end and psychotherapy at the other. A counselor may actually do both
counseling and psychotherapy in one session. The two processes can therefore blend.
We can identify some subtle differences between these two processes. The main difference
is that counseling addresses the conscious mental state, whereas psychotherapy also ventures into
 Chapter 1 • An Overview of Counseling 7

A Personal Note

It seems as if everyone has a story to tell if one is willing to listen. I remember a mailman (whom I did
not even know) who stopped me when I was walking around in my backyard. He was visibly angry and
proceeded to tell me how a policeman had blocked his way on the road while he was giving a ticket. The
mailman said, “I asked him to let me by, so I could do my job. But he wouldn’t, so I went by anyway driv-
ing onto the shoulder. Good grief, some people only think of themselves.”
As he talked on, I thought this is a story that this man must tell someone, anyone, to ventilate and
to feel understood. I can think of many other examples (such as some plane and bus trips I’ve had) where
people have expressed their desire to tell their stories. I have also been in need of telling my own stories
from time to time.
Lately I have become more aware of the role of storytelling in counseling. It has been my experi-
ence that most clients have stories to tell. Many of these clients have told their stories to others (such as
friends or family members) with disappointing results. In counseling, the clients’ stories will hopefully be
shown the respect and care they deserve.
One example of a client’s story that stands out for me is one of pain, struggle, and courage. Pat was a
40-year-old Anglo single parent of four children. She had been in a serious car accident a year before I had my
first counseling session with her. Much of our first sessions involved Pat sharing her story of the accident and
her anger at the drunk driver who hit her and the lack of support she was feeling from her insurance company.
Pat’s story was also one of struggling for her physical and emotional survival. She had to endure
numerous operations for her physical injuries, was unable to go back to work due to physical limitations,
and had multiple psychological problems that included insomnia, depression, and anxiety. It was there-
fore necessary to work closely with a psychiatrist to include medication in conjunction with counseling
in her treatment program.
Fortunately, Pat had a very strong support system, including friends and family members who
helped her feel safe and encouraged, which helped her overcome some of her feelings of anxiety and
depression. Gradually, Pat was able to work her way out of her sadness and depression and see some hope
and possibilities for a better tomorrow. As she struggled to gain control of her life, she appeared to be
engaging in a process of narrative repair, replacing words of gloom with feelings of hope.

the client’s unconscious processes—providing insight to a client. Several other differences exist
between counseling and psychotherapy in terms of focus, clients’ problems, goals, treatment, and
setting. These differences are shown in Table 1.1.
As depicted in Table 1.1, the focus of counseling tends to be developmental in nature,
whereas psychotherapy has a remediative emphasis. Counseling attempts to empower clients
with tools they can use to meet the normal developmental challenges of progressing through the
lifespan. Counseling is therefore preventative in nature and growth facilitating. Psychotherapy,
on the other hand, is directed at helping clients overcome the pain and suffering associated with
existing problems, such as anxiety and depression. Counseling is used with clients whose prob-
lems do not stem from a serious mental disorder, such as a major depression. Instead, it is more
appropriate for clients who have “problems of living,” such as parent–child conflicts or marital
difficulties. The goals of counseling tend to focus on resolving immediate concerns, such as, help-
ing clients work through a relationship difficulty or make a career decision.
Treatment programs in counseling vary according to the client’s concern. For example,
counseling might involve a parent education program to help parents learn how to establish a
positive relationship with their child. Other counseling strategies might help a client work
through marital difficulties. Counseling approaches are usually short-term, involving one session
8 Part 1 • An Overview of Counseling and the Counseling Process

TABLE 1.1 Comparison of Counseling and Psychotherapy

Counseling Psychotherapy

Focus Developmental—fosters coping skills to Remediative—aims at helping clients overcome

facilitate development and prevent existing problems, such as anxiety and
problems. depression.
Clients’ Clients tend to have “problems of living,” Clients’ problems are more complex and may
Problems such as relationship difficulties, or need require formal diagnostic procedures to
assistance with specific problems, such determine whether there is a mental disorder.
as career choice.
Goals The focus is on short-term goals The focus is on short- and long-term goals.
(resolution of immediate concerns). Long-term goals can involve processes such as
helping the client overcome a particular mental
disorder.
Treatment The treatment program can include Psychotherapeutic approaches are complex. They
Approaches preventative approaches and various utilize strategies that relate to conscious and
counseling strategies to assist with the unconscious processes.
client’s concerns.
Setting Counseling services can be provided in a Psychotherapy is typically offered in settings such
variety of settings, such as schools, as private practice, mental health centers, and
churches, and mental health clinics. hospitals.

each week for 3 to 12 weeks, and counseling services may take place in a variety of settings, such
as schools, churches, and mental health clinics.
Psychotherapy is a process that can be used to assist a client who is experiencing more com-
plex problems, such as a mental disorder, and can involve both short- and long-term goals. The
short-term goals may focus on problems similar to those addressed in counseling, for example,
dealing with marital problems. Long-term goals relate to more deep-seated or involved problems,
such as depression or schizophrenia. Psychotherapy is complex and requires expertise in several
areas, such as personality theory and abnormal psychology. It relates to both conscious and uncon-
scious processes; for example, the process may involve hypnosis, projective tests, and dream analy-
sis techniques to examine unconscious processes. Psychotherapeutic approaches are usually long-
term, involving sessions once each week for 3 to 6 months and sometimes even longer. Typical
settings for psychotherapy are private practice, mental health centers, and hospitals.

Differentiating Formal from Informal Helping

Another way to answer the question “What is counseling?” is to differentiate counseling from the
informal helping that can take place between friends. Some individuals who have had no formal
training in counseling can provide valuable assistance. These informal helpers usually have some
of the personal qualities associated with effective counselors, such as being caring, nonjudgmen-
tal, and able to utilize listening skills. However, professional counselors may differ from informal
helpers in a number of ways.
First, counselors can maintain a degree of objectivity because they are not directly involved in
the client’s life. Though there are exceptions, informal helpers usually have a personal relationship
 Chapter 1 • An Overview of Counseling 9

with the individual, so the assistance they provide is likely to reflect a personal bias. A related fact is
that counselors usually do not have a preconceived idea of how a client should behave. Having no
previous experience with the counselor, the client is free to try new modes of behaving and relating.
This often does not occur with informal helpers, who may expect the person they are trying to help
to act in a certain way. The person being helped might easily fall into the habits established in the
relationship, which can create a restrictive environment.
Second, counselors are guided by a code of ethics, the American Counseling Association
(ACA) Code of Ethics and Standards of Practice (2005), which is designed to protect the rights of
clients. For example, the information that a client presents to a counselor must be held in confi-
dence, except in extreme circumstances, such as when the client plans to do serious harm to self
or others. Knowing this, a client might feel more free to share thoughts and feelings with a profes-
sional counselor than with an informal helper.
Third, formal counseling can be an intense and emotionally exhausting experience. After
establishing rapport, the counselor may find it necessary to confront the client with painful
issues. Informal helpers may avoid confrontation to avoid jeopardizing the friendship. They often
play a more supportive and reassuring role, at times even attempting to rescue the person they are
helping. In doing so, the helper, despite good intentions, does not communicate the all-important
belief that the client is a capable person. In this way, the helper may deprive the individual of an
opportunity to get in touch with feelings.
A final difference lies in the repertoire of counseling strategies and techniques available to
professional counselors and their ability to systematically utilize these strategies and techniques
to promote client growth. For example, a client may have a phobia about heights. The counselor
may use a behavioral technique called systematic desensitization, which helps the client replace
an anxiety response to heights with a relaxation response. Some clients may not be able to stand
up for their rights or state their opinions and could therefore benefit from assertiveness training.
Other clients may have marriage or family problems; the professional counselor may draw upon
various marriage and family therapies to assist these clients. Lacking formal counselor training,
informal helpers are unfamiliar with and thereby unable to utilize these strategies. Instead, they
typically rely on advice-giving as their main method of helping.

Personal Qualities of Effective Helpers

The following helping formula developed by Brammer (1999) provides yet another conceptual
model for answering the question “What is counseling?”

Personality Helping Growth-Facilitating Specific

⫹ ⫽ → Outcomes
of the Helper Skills Conditions

This formula suggests that taking the personality of the helper and adding some helping skills like
counseling techniques can generate growth-facilitating conditions. A feeling of mutual trust,
respect, and freedom between the counselor and client characterize these conditions (Brammer,
2002), and when they exist, desirable outcomes tend to emerge from the counseling process.
The helping formula emphasizes the importance of the personality of the helper (Brammer,
2002). Evidence is emerging that suggests the personal characteristics of the counselor play a critical
role in the efficacy of counseling (Corey, Corey, & Callanan, 2007; Herman, 1993). As early as 1969,
Combs et al. (1969) suggested that the central technique of counseling is to use the “self as an instru-
ment” of change. In other words, counselors use their personality to create a presence that conveys
10 Part 1 • An Overview of Counseling and the Counseling Process

encouragement for, belief in, and support of the client. Rogers (1981) also commented on the impor-
tance of the counselor’s personal qualities. He noted that the client’s perception of the counselor’s atti-
tude is more important than the counselor’s theories and methods. Rogers’s point underscores the fact
that clients are interested in and influenced by the personal style of the counselor.
A number of attempts have been made to identify the personal characteristics that pro-
mote positive outcomes in counseling. Strong (1968) suggested that counselors be perceived as
expert, attractive, and trustworthy. Corey, Corey, and Callanan (2003) contend that effective
counselors present a positive model for their clients by being actively involved in their own self-
development, expanding their self-awareness as they look honestly at their lives and the choices
associated with personal growth and development. Beutler, Machado, and Neufeldt (1994)
found some empirical support for other counselor characteristics, such as emotional well-being,
self-disclosure, and optimism.
It would not be realistic to imply that an effective counselor must be a certain type of person.
At the same time, the literature does suggest certain basic qualities tend to be important to the
counseling process. I have incorporated these basic qualities into what I believe are the 14 personal
characteristics of an effective counselor.
1. Encouraging. Being encouraging may be the most important quality of an effective
counselor. Encouragement helps clients learn to believe in their potential for growth and develop-
ment. A number of Adlerian counselors have written about the power of encouragement (e.g.,
Dinkmeyer & Losoncy, 1980).
2. Artistic. As mentioned, effective counselors tend to be sensitive and responsive to their
clients. Being artistic implies being creative and flexible and adjusting counseling techniques to
the unique needs of the client. Just as true artists give something of themselves to each thing they
create, counselors must give of themselves to the counseling process. Effective counselors cannot
insist on maintaining an emotional distance from the client if such a distance inhibits client
growth. If necessary, counselors must allow themselves to experience the client’s world directly
and be personally affected by the counseling process, as they bring their humanness and vulnera-
bility to the moment. Counselors who allow themselves to be human may also promote authen-
ticity and genuineness in the counseling process.
3. Emotionally stable. An emotionally unbalanced counselor will probably do more harm
than good for the client. Unfortunately, some counselors enter the counseling profession in order
to work through their own serious mental problems. These counselors may attempt to meet their
own needs at the expense of their clients. Langs (1985) goes so far as to suggest that a substantial
number of clients spend much of their energy adjusting to the mood swings of their counselor. In
some instances, clients might even believe they have to provide temporary counseling for the
counselor (Langs, 1985). Role reversals of this type are obviously not in the best interest of the
client. An inconsistent counselor will not only waste valuable time but create confusion and inse-
curity within the client.
4. Empathic and caring. Effective counselors care about people and have the desire to
help those in need. They are sensitive to the emotional states of others and can communicate an
understanding of their struggles with life. Clients experience a sense of support and kindness
from these counselors. This can help the client have the courage to face life realistically and
explore new directions and possibilities.
5. Self-aware. Being self-aware enables counselors to become aware of their limitations.
Self-awareness can also help counselors monitor their needs so that they can gratify those needs in
 Chapter 1 • An Overview of Counseling 11

a manner that does not interfere with the counseling process. Self-awareness requires an ongoing
effort by the counselor. The various ways counselors can promote their self-awareness include
using meditation techniques and taking time for personal reflection.
Self-awareness appears to be related to a number of other concepts related to the “self,” such
as self-acceptance, self-esteem, and self-realization. In this regard, as people become more aware
of themselves, they are in a better position to accept themselves. Self-acceptance can then lead to
enhancement of one’s self-image or self-esteem, which in turn can free a person to move toward
self-realization.
6. Self-acceptance. Self-acceptance suggests that counselors are comfortable with them-
selves. Although ideally they will be working on enhancing their personal growth and develop-
ment, the discrepancy between the real self and the ideal self would not be so great as to cause
undue anxiety.
7. Positive self-esteem. Positive self-esteem can help counselors cope with their personal
and professional lives and maintain the emotional stability that is central to their job. Also, coun-
selors who do not feel positive about themselves may look for the negative in their clients. Even
worse, such counselors may attempt to degrade the client to enhance their own self-image.
8. Self-realization. Self-realization is the process of actualizing one’s potential. It repre-
sents a journey into personal growth and discovery. Effective helpers reach out in new directions
and explore new horizons. As they do, they realize that growth requires commitment, risk, and
suffering. In this process, they model for their clients that one must stretch to grow. Counselors
welcome life experiences and learn from them. They develop a broad outlook on life that can help
their clients put their problems in perspective. Counselors’ enthusiasm for life can create energy
and optimism that can energize and create hope for a client.
9. Self-disclosure. Effective counselors are constructively open with their thoughts and
feelings. When counselors model openness, they encourage their clients to be open. The resulting
candidness can be critical to the counseling process.
10. Courageous. Although it is important for clients to perceive their counselors as
competent, counselors are not perfect and they should not be viewed as perfect. Instead, they
should try to model the courage to be imperfect (Nystul, 1979c). Counselors with the courage
to communicate their weaknesses as well as their strengths are disclosing an authentic picture
of themselves. They are also presenting a realistic view of the human condition and can help
clients avoid self-defeating, perfectionist tendencies. Another facet of the courage to be imper-
fect is the willingness of counselors to seek out counseling services for themselves if the need
arises. Counselors should not feel that they are so “complete” or “perfect” they have no need for
counseling or they may develop a condescending attitude about counseling that could result in
their regarding their clients as “inferior.” Obtaining counseling can also help counselors under-
stand what it feels like to be in the role of client, contributing to a better understanding of the
counseling process.
11. Patient. Being patient can be valuable in the counseling process. Helping someone
change is a complex process and requires significant effort. Clients may make some progress and
then regress to old habits. Counselors must be patient and recognize the goal of achieving overall
positive therapeutic movement.
12. Nonjudgmental. Counselors must be careful not to impose their values or beliefs on
the client, even though they may wish at times to expose clients to new ideas. Being nonjudgmen-
tal communicates respect for clients and allows them to actualize their unique potential.
12 Part 1 • An Overview of Counseling and the Counseling Process

13. Tolerance for ambiguity. Ambiguity can be associated with the art of counseling. For
example, the counselor never knows for sure what the best technique is to use with a client or
exactly what was accomplished during a session. Although the science of counseling can
contribute to the objective understanding of the counseling process, counselors must be able to
tolerate some ambiguity.
14. Spirituality. Spirituality recognizes the value of addressing the spiritual–religious
dimension in the helping process. Characteristics of spirituality include being sensitive to
religious–spiritual issues in oneself and others (such as concepts of morality and the soul) and
being able to function from and relate to the spiritual world as distinct from the material world.

The Helping Profession

Counseling can also be understood within the general context of the helping profession. The
term helping profession encompasses several professional disciplines, including psychology, coun-
seling, and psychiatry, each of which is distinguished by its unique training programs and result-
ing specialties. Many individuals from these various groups provide similar services, such as
counseling and psychotherapy.
Members of the helping profession often work together on multidisciplinary teams. For
example, school counselors and school psychologists join forces to provide counseling services in
school settings. Psychiatrists, psychiatric nurses, psychiatric social workers, psychologists, and
mental health counselors blend their specialized skills to provide a comprehensive treatment plan
in mental health settings. An overview of the degree requirements, specialized skills, and work
settings for the members of the helping profession is provided in Table 1.2.

COUNSELING: PAST, PRESENT, AND FUTURE

The counseling profession has undergone a dynamic evolution. This section describes some of
the key individuals and events and attempts to predict some future trends in counseling.

Counseling from a Historical Perspective

Kottler and Brown (2000) have traced the origins of counseling to noted individuals in our ances-
tral past who provided insights into the human condition that continue to influence the evolu-
tion of counseling and modern clinical practice.
• Hippocrates (400 B.C.) developed a classification system for mental illness and personality
types.
• Socrates (400 B.C.) posited that self-awareness was the purest state of knowledge.
• Plato (350 B.C.) described human behavior as an internal state.
• Aristotle (350 B.C.) provided a psychological perspective of emotions, including anger.
• St. Augustine (A.D. 400) suggested that introspection was necessary to control emotions.
• Leonardo da Vinci (1500) described the human condition in terms of art and science.
• Shakespeare (1600) created psychologically complex characters in his literary works.
• Phillippe Pinel (1800) described abnormal conditions in terms of neurosis and psychosis.
• Anton Mesmer (1800) used hypnosis to treat psychological conditions.
• Charles Darwin (1850) proposed that individual differences are shaped by evolutionary
events relating to the survival of the species.
• Søren Kierkegaard (1850) related existential thought to personal meaning in life.
 TABLE 1.2 Types of Professional Helpers

Type of Helper Licensure and Degree Requirements Skills and Responsibilities Work Setting

Mental health Master’s degree in counseling or related field. Use of counseling and Community mental health centers,
counselor Most states require licensure. psychotherapeutic strategies. hospitals, and private practice.
Marriage, child, Usually a master’s degree in marriage, Marriage, child, and family counseling. Private practice.
and family child, and family counseling or related
counselors field. An increasing number of states
require licensure.
Psychiatric Usually a master’s degree in social Counseling and psychotherapy, usually from Most work in hospitals and social
social worker work. Most states require licensure. a family perspective; knowledge about service agencies. Some have their own
psychiatric service; ability to assist with private practice.
social services (food, shelter, child abuse
and neglect, foster and nursing care).
Pastoral Master’s degree in counseling or Counseling and psychotherapy from a Churches or agencies with church
counselor related field. Some states require religious perspective. Some focus on affiliation.
certification or licensure. issues pertaining to marriage and the
family (e.g., marital enrichment).
Clinical and Psy.D., Ph.D., or Ed.D. (doctor of psychology, Counseling and psychotherapy, psychological University counseling centers,
counseling philosophy, or education). All states require testing, and mental health specialist. Some community mental health centers,
psychologist licensure or certification. states grant prescription privileges. hospitals, and private practice.
Psychiatrist M.D. (medical degree) and 3–4 years Treatment of serious mental disorders, Hospitals, community mental health
specialized training in psychiatry in a full usually involving the use of medications; centers, and private practice.
residency program. All states require some counseling and psychotherapy; and
licensure. consultation. Supervision of other mental
health workers is usually involved.
Psychiatric nurse R.N. (registered nurse degree). All states Assist in the psychiatric treatment of mental Hospitals and community mental
require licensure. disorders by monitoring medication and health centers.
providing counseling and psychotherapy.
School counselor Many states require a master’s degree in Personal and career counseling and Elementary, middle, and high schools.
counseling. All states require certification consultation with school staff
or licensure in school counseling. and parents.
School Many states require at least a master’s Psychological testing, counseling, Elementary, middle, and high schools.
psychologist degree in school psychology or a related and consulting.
field. All states require certification or
licensure as a school psychologist.

13
14 Part 1 • An Overview of Counseling and the Counseling Process

A number of other prominent individuals have made unique and lasting contributions to
the counseling profession. The pioneering work of Freud, Adler, and Jung (see Chapter 7) can be
credited with establishing the foundation for modern clinical practice. These three men, col-
leagues in Vienna in the early 1900s, each went on to develop a unique school of counseling and
psychotherapy. Freud developed psychoanalysis, which emphasizes the role of sexuality in per-
sonality development. Adler developed his own school of psychology called individual
psychology, which emphasizes the importance of social interest in mental health. Jung is credited
with originating the school of psychology called analytic psychology. Jung’s work was influenced
by various disciplines, including theology, philosophy, and anthropology. His theory is probably
best known for its recognition of a collective unconscious, which suggests that all people share
some common memories.
Numerous other schools of counseling have emerged since the pioneering work of Freud, Adler,
and Jung. Perhaps more than any other theorist, Rogers has influenced the development of contempo-
rary counseling approaches. His person-centered approach was founded on a belief in the dignity and
worth of the individual (Rogers, 1981) and has gained wide support among individuals in the helping
profession. Rogers was particularly influential in the development of the third force, or humanistic,
school of counseling and psychotherapy. Becoming increasingly popular are the cognitive-behavioral
theories of counseling, such as those developed by Albert Ellis (1994) and Aaron Beck (1993). These
approaches have been welcomed by managed care health organizations because they tend to focus on
relief of symptoms (such as anxiety or depression) and can be accomplished in a time-limited format.
Recent trends in counseling are reflected in the postmodern theories of constructivism
(Mahoney, 1995a) and social constructionism (Gergen, 1994b), brief-solution-focused approaches
to counseling (de Shazer, 1994), and empirically supported treatments (Norcross & Hill, 2003).
Postmodern theories have created an opportunity for a paradigm shift in counseling by their recog-
nition of the roles cognition, language, and narratives play in defining truth, knowledge, and reality.
Similarly, brief-solution-focused approaches have also created potential for a paradigm shift through
their focus on strengths and solutions as opposed to problems, weakness, and pathology.

KEY HISTORIC EVENTS. Several events have been important in the history and evolution of
counseling. Among these are the vocational guidance movement, the standardized testing move-
ment, the mental health movement, and key legislative acts.
The vocational guidance movement had its inception in the efforts of Frank Parsons, a
Boston educator who started the Vocational Bureau in 1908. Parsons contended that an individ-
ual who took the time to choose a vocation, as opposed to a job, would be more likely to experi-
ence success and work satisfaction (Brown & Brooks, 2002). Career counseling, which focuses on
helping clients explore their unique potential in relation to the world of work, evolved from the
vocational movement.
The standardized testing movement can be traced to Sir Francis Galton, an English biologist,
and his study of heredity. Galton developed simple tests to differentiate characteristics of geneti-
cally related and unrelated people (Anastasi & Urbina, 1997). Many others have made significant
contributions to the testing movement. James Cattel set forth the concept of mental testing in 1890
(Anastasi & Urbani, 1997), and Alfred Binet developed the first intelligence scale in 1905.
World Wars I and II played important roles in the testing movement. The army’s need to classify
new recruits for training programs resulted in the development of mass intelligence and ability testing.
Examples are World War I’s Army Alpha and Army Beta tests and World War II’s Army General
Classification test. After World War II, the use of tests proliferated throughout American society and
soon became an integral part of the public school system. Tests were also used in a variety of other
 Chapter 1 • An Overview of Counseling 15

settings, including mental health services and employment agencies. During the 1960s, the testing
movement declined to some extent when it became apparent that many standardized tests reflected a
cultural bias (Minton & Schneider, 1981). Since that time, an increased sensitivity to multicultural
issues appears to have developed in terms of the construction and use of tests.
The mental health movement arose as a result of several forces. In 1908, Clifford Beers
wrote A Mind That Found Itself, describing the horrors of his 3 years as a patient in a mental
hospital. Beers’s efforts resulted in an increased public awareness of the issues relating to mental
disorders. Beers later formed the Society for Mental Hygiene, which promoted comprehensive
treatment programs for the mentally ill (Baruth & Robinson, 1987).
Another major factor in the mental health movement was the development in 1952 of
medications that could treat serious disorders such as schizophrenia (Rosenhan & Seligman,
1995). Today, it is uncommon for psychiatric patients to remain in a hospital for more than a
couple of weeks. Although medications do not cure mental disorders, they often can control
symptoms to the degree that a person can function in society. Unfortunately, it has been difficult
to develop effective follow-up programs for psychiatric patients after their discharge, which has
resulted in an alarming number of mentally disturbed people wandering the streets as homeless
“street people.” Several studies have estimated that 25–50% of homeless people are mentally ill
(Frazier, 1985; Ball & Harassy, 1984). Many mental health professionals are attempting to develop
more effective follow-up and outreach services for the chronically mentally ill.
Key legislative acts have also contributed to the evolution of the counseling profession, in
particular, the National Defense Education Act (NDEA) of 1958. This act, designed to improve
the teaching of science in public schools, was motivated by a popular belief that the United States
was lagging behind Russia’s achievements in science, which developed after Americans learned of
the Soviet Union’s success in launching the first space satellite, Sputnik. The NDEA had a major
impact on the counseling profession by providing funds to train school counselors, resulting in a
marked increase in the number of counselors employed in U.S. schools.

Present Trends
This section attempts to predict what directions counseling may take in the future. It covers
trends in research, ethics, multicultural counseling, managed mental health services, empirically
supported treatment, brief-solution-focused counseling, mental disorders, postmodernism, spir-
ituality, cybercounseling, technology, and problematic-impaired students.

RESEARCH. Gelso and Fassinger (1990) have provided a comprehensive review of the counsel-
ing research conducted during the 1980s. They noted that the decade was characterized by
increased interest in alternative research methodologies that incorporate more field-based and
fewer laboratory-based designs. They suggested that the interest in alternative research designs
would continue, along with “a trend toward the use of more refined methodological strategies
and, in particular, advanced statistical procedures” (p. 374).
The scientist-practitioner model of counseling, which emphasizes the importance of clini-
cians integrating research into their clinical practice (Stricker & Trierweiler, 1995), seems to be
increasingly unpopular. This separation of science from practice does not appear to have arisen
from a lack of interest by practitioners, but rather from the opinion that current research tends to
be of little use or relevance to the day-to-day practice of counselors (Edelson, 1994; Havens,
1994). Maling and Howard (1994) suggest that the statistical abstractions associated with quanti-
tative research are of little use to counselors who are struggling with the individualized issues of
PART I
Professional Foundations
of Counseling

Chapter 1 Personal and Professional Aspects of Counseling

Chapter 2 Ethical and Legal Aspects of Counseling
Chapter 3 Counseling in a Multicultural Society
Chapter 4 Counseling with Diverse Populations

1
 1 Personal and Professional Aspects
of Counseling

Chapter Overview
From reading this chapter
you will learn about:
■ The consensus definition of
counseling adopted by 29
diverse counseling
associations
■ The important personality
factors and background
qualities of counselors
■ The professional aspects of
being a counselor,
including credentialing
■ The attribution and
systematic framework of
counseling RATOCA/Fotolia
■ Engaging in professional
counselor-related activities
There is a quietness that comes
As you read consider: in the awareness of presenting names
■ What has motivated you to and recalling places
enter the profession of in the history of persons
counseling who come seeking help.
■ What qualities you need to
Confusion and direction are a part of the process
where in trying to sort out tracks
cultivate in order to be
that parallel into life
successful as a counselor
a person’s past is traveled.
■ The many facets of
Counseling is a complex riddle
credentialing and the where the mind’s lines are joined
differences in the types of with scrambling and precision
credentials available to make sense out of nonsense,
a tedious process
like piecing fragments of a puzzle together
until a picture is formed.
Reprinted from “In the Midst of the Puzzles and Counseling Journey,” by S. T.
Gladding, 1978, Personnel and Guidance Journal, 57, p. 148. © S. T. Gladding.

2
 Chapter 1 • Personal and Professional Aspects of Counseling 3

Counseling is a noble and altruistic profession. It emphasizes growth as well as remediation

over the course of a life span in various areas of life: childhood, adolescence, adulthood, and
older adulthood. Counselors specialize in helping individuals, couples, groups, families, and
social systems that are experiencing situational, developmental, and long- or short-term
problems. Counseling’s focus on development, prevention, wellness, and treatment makes it
attractive to those seeking healthy life-stage transitions and productive lives.
However, counseling has not always been an encompassing and comprehensive profession.
It has evolved over the years from diverse disciplines “including but not limited to anthropol-
ogy, education, ethics, history, law, medical sciences, philosophy, psychology, and sociology”
(Smith, 2001, p. 570). (See Appendix A for a history of counseling.) Some people associate
counseling with educational institutions or equate the word “guidance” with counseling because
they are unaware of counseling’s evolution. As a consequence, outdated ideas linger in their
minds in contrast to reality. They misunderstand the essence of the profession and those who
work in it. Even among counselors themselves, those who fail to keep up in their professional
development may become confused as to exactly what counseling is, where it has been, and
how it is moving forward. As C. H. Patterson, a pioneer in counseling, once observed, some
writers in counseling journals seem “ignorant of the history of the counseling profession . . .
[and thus] go over the same ground covered in publications of the 1950s and 1960s”
(Goodyear & Watkins, 1983, p. 594).

DEFINITION OF COUNSELING
There have always been “counselors”—people who listen to others and help them resolve diffi-
culties—but the word “counselor” has been misused over the years by connecting it with descrip-
tive adjectives to promote products. Thus, one hears of carpet counselors, color coordination
counselors, pest control counselors, financial counselors, camp counselors, and so on. These
counselors are mostly glorified salespersons, advice givers, and supervisors of children or ser-
vices. They are to professional counseling what furniture doctors are to medicine.
Counseling as a profession grew out of the progressive guidance movement of the early
1900s. Its emphasis was on prevention and purposefulness—on helping individuals of all ages
and stages avoid making bad choices in life while finding meaning, direction, and fulfillment in
what they did. Today professional counseling encompasses within its practice clinicians who
still focus on the avoidance of problems and the promotion of growth, but the profession is much
more than that. The focus is on wellness, development, mindfulness, meaningfulness, mattering,
and growth, as well as the remediation of mental disorders, for individuals, groups, couples, and
families across the life span. To understand what counseling is now, it is important first to under-
stand how counseling is similar to and different from concepts such as guidance and psycho-
therapy.

Guidance
Guidance focuses on helping people make important choices that affect their lives, such as
choosing a preferred lifestyle. Although the decision-making aspect of guidance has long played
an important role in the counseling process, the concept itself, as a word in counseling, “has gone
the way of ‘consumption’ in medicine” (Tyler, 1986, p. 153). It has more historical significance
than present-day usage. Nevertheless, it sometimes distinguishes a way of helping that differs
from the more encompassing word “counseling.”
4 Part I • Professional Foundations of Counseling

One distinction between guidance and counseling is that guidance focuses on helping indi-
viduals choose what they value most, whereas counseling helps them make changes. Much of
the early work in guidance occurred in schools and career centers where an adult would help a
student make decisions, such as deciding on a course of study or a vocation. That relationship
was between unequals and was beneficial in helping the less experienced person find direction in
life. Similarly, children have long received “guidance” from parents, religious leaders, and
coaches. In the process they have gained an understanding of themselves and their world. This
type of guidance will never become passé. No matter what the age or stage of life, a person often
needs help in making choices. But guidance is only one part of the overall services provided by
professional counseling.

Psychotherapy
Traditionally, psychotherapy (or therapy) has focused on serious problems associated with
intrapsychic disorders (such as delusions or hallucinations), internal conflicts, and personality
issues (such as dependency or inadequacy in working with others). It has dealt with the establish-
ment or “recovery of adequacy” (Casey, 1996, p. 175). As such, psychotherapy, especially ana-
lytically based therapy, has emphasized (a) the past more than the present, (b) insight more than
change, (c) the detachment of the therapist, and (d) the therapist’s role as an expert. In addition,
psychotherapy has historically involved a long-term relationship (20 to 40 sessions over a
period of 6 months to 2 years) that concentrated on reconstructive change as opposed to a more
short-term relationship (8 to 12 sessions spread over a period of less than 6 months).
Psychotherapy has also been more of a process associated with inpatient settings—some of
which are residential, such as mental hospitals—as opposed to outpatient settings—some of
which are nonresidential, such as community agencies.
However, in more modern times, the distinction between psychotherapy and counseling
has blurred, and professionals who provide clinical services often determine whether clients
receive counseling or psychotherapy. Some counseling theories, such as psychoanalysis, are
commonly referred to as therapies as well and can be used in multiple settings. Therefore, the
similarities in the counseling and psychotherapy processes often overlap.

Counseling
The term counseling eluded definition for years. However, in 2010, a consensus definition of
counseling was agreed upon by 29 counseling associations including the American Counseling
Association (ACA) and all but two of its then 19 divisions, along with the American Association
of State Counseling Boards (AASCB), the Council for the Accreditation of Counseling and
Related Educational Programs (CACREP), the National Board for Certified Counselors (NBCC),
the Council of Rehabilitation Education (CORE), the Commission of Rehabilitation Counselor
Certification (CRCC), and Chi Sigma Iota (counseling honor society international). It was
achieved through a process called 20/20 where these groups met over a 3-year period in person
and through Internet exchanges to create a broad, concise, and inclusive description of the pro-
cess. According to the 20/20: A Vision for the Future of Counseling consortium, counseling is
defined as follows:

Counseling is a professional relationship that empowers diverse individuals, families,

and groups to accomplish mental health, wellness, education, and career goals.
(www.counseling.org/20-20/index.aspx)
 Chapter 1 • Personal and Professional Aspects of Counseling 5

This definition contains a number of implicit and explicit points that are important for
counselors as well as consumers to realize.
• Counseling deals with wellness, personal growth, career, education, and empowerment
concerns. In other words, counselors work in areas that involve a plethora of issues
including those that are personal and those that are interpersonal. These areas include con-
cerns related to finding meaning, adjustment, and fulfillment in mental and physical health,
and the achievement of goals in such settings as work and school. Counselors are concerned
with social justice and advocate for the oppressed and powerless as a part of the process.
• Counseling is conducted with persons individually, in groups, and in families. Clients
seen by counselors live and work in a wide variety of settings and in all strata of society.
Their problems may require short-term or long-term interventions that focus on just one
person or with multiple individuals who are related or not related to one another.
• Counseling is diverse and multicultural. Counselors see clients with varied cultural
backgrounds and at different ages and stages of life. Those from minority and majority
cultures are helped in a variety of ways depending on their needs, which may include
addressing larger societal issues, such as discrimination or prejudice.
• Counseling is a dynamic process. Counselors not only focus on their clients’ goals, but
they also help clients accomplish them. This dynamic process comes through using a range
of theories and methods. Thus, counseling involves making choices as well as changes.
Counseling is lively and engaging. In most cases, “counseling is a rehearsal for action”
(Casey, 1996, p. 176) either internally with thoughts and feelings or externally with behavior.
In addition to defining counseling in general, the ACA has defined a professional counsel-
ing specialty, which is an area (within counseling) that is “narrowly focused, requiring advanced
knowledge in the field” of counseling (www.counseling.org). Among the specialties within
counseling are those dealing with educational settings such as schools or colleges and those per-
taining to situations in life such as marriage, mental health, rehabilitation, aging, assessment,
addiction, and careers. According to the ACA, becoming a specialist is founded on the premise
that “all professional counselors must first meet the requirements for the general practice of pro-
fessional counseling” (www.counseling.org).

PERSONAL REFLECTION
What special talents do you have? How did they develop from your overall definition of yourself as
a person? How do you see your personal circumstances paralleling the general definition of counsel-
ing and counseling specialties?

Individuals aspire to become counselors for many reasons. For the most part, “it attracts
caring, warm, friendly and sensitive people” (Myrick, 1997, p. 4). However, some motivators,
like the people involved, are healthier than others, just as some counselor education programs,
theories, and systems of counseling are stronger than others. It is important that persons who
wish to be counselors examine themselves before committing their lives to the profession.
Whether they choose counseling as a career or not, people can be helped by studying counseling.
By doing so they may gain insight into their thoughts, feelings, and actions; learn how to relate
better to others; and understand how the counseling process works. They may also further
develop their moral reasoning, critical thinking, and empathetic abilities.
6 Part I • Professional Foundations of Counseling

The effectiveness of a counselor and of counseling depends on numerous variables,

including
• the personality and background of the counselor;
• the formal education of the counselor; and
• the ability of the counselor to engage in professional counseling-related activities,
such as continuing education, supervision, advocacy, and the building of a portfolio.
Counselors and the counseling process have a dynamic effect on others. If counseling is not
beneficial, it is most likely harmful (Carkhuff, 1969; Ellis, 1984; Mays & Franks, 1980). Thus,
personal and professional factors that influence the counseling profession must be examined.

THE PERSONALITY AND BACKGROUND OF THE COUNSELOR

A counselor’s personality is at times a crucial ingredient in counseling. Counselors should pos-
sess personal qualities of maturity, empathy, and warmth. They should be humane in spirit and
not easily upset or frustrated. Unfortunately, such is not always the case, and some people aspire
to be in the profession of counseling for the wrong reasons.

Negative Motivators for Becoming a Counselor

Not everyone who wants to be a counselor or applies to a counselor education program should
enter the field. The reason has to do with the motivation behind the pursuit of the profession and the
incongruent personality match between the would-be counselor and the demands of counseling.
A number of students “attracted to professional counseling … appear to have serious per-
sonality and adjustment problems” such as narcissism or unresolved developmental issues
(Witmer & Young, 1996, p. 142). Most are screened out or decide to pursue other careers before
they finish a counselor preparation program. However, before matriculating into graduate coun-
seling programs, candidates should explore their reasons for doing so. According to Guy (1987),
dysfunctional motivators for becoming a counselor include the following:
• Emotional distress—individuals who have unresolved personal traumas
• Vicarious coping—persons who live their lives through others rather than have meaning-
ful lives of their own
• Loneliness and isolation—individuals who do not have friends and seek them through
counseling experiences
• A desire for power—people who feel frightened and impotent in their lives and seek to
control others
• A need for love—individuals who are narcissistic and grandiose and believe that all prob-
lems are resolved through the expression of love and tenderness
• Vicarious rebellion—persons who have unresolved anger and act out their thoughts and
feelings through their clients’ defiant behaviors
Fortunately, most people who eventually become counselors and remain in the profession
have healthy reasons for pursuing the profession, and a number even consider it to be a “calling”
(Foster, 1996). Counselors and counselors-in-training should always assess themselves in regard
to who they are and what they are doing. Such questions may include those that examine their
development histories, their best and worst qualities, and personal/professional goals and objec-
tives (Faiver, Eisengart, & Colonna, 2004).
 Chapter 1 • Personal and Professional Aspects of Counseling 7

CASE EXAMPLE
Roberta’s Rotation
Roberta had been a business student pursuing an MBA. However, she found dealing with facts
and figures boring. So she quit. “What now?” she wondered. After a few months of floundering,
she went to see a career specialist. In examining her interests, she found she liked working with
people. “That’s it!” she said excitedly. “I’ll become a counselor! That way I can ‘assist’ all those
overwrought and overeducated business types who are bored to death with their jobs. And all I’ll
have to do is listen and, of course, give them advice. Sweet!”
Would you want Roberta in your counseling program? Why? What else do you think she
should consider?

Personal Qualities of an Effective Counselor

Among the functional and positive factors that motivate individuals to pursue careers in
counseling and make them well suited for the profession are the following qualities as delineated
by Foster (1996) and Guy (1987). Although this list is not exhaustive, it highlights aspects of
one’s personal life that make a person best suited to function as a counselor. (You can evaluate
how you rate yourself on these qualities by taking the “Effective Counselor Self Examination” on
the next page.)
• Curiosity and inquisitiveness—a natural interest in people
• Ability to listen—the ability to find listening stimulating
• Comfort with conversation—enjoyment of verbal exchanges
• Empathy and understanding—the ability to put oneself in another’s place, even if that
person is totally different from you
• Emotional insightfulness—comfort dealing with a wide range of feelings, from anger to joy
• Introspection—the ability to see or feel from within
• Capacity for self-denial—the ability to set aside personal needs to listen and take care of
others’ needs first
• Tolerance of intimacy—the ability to sustain emotional closeness
• Comfort with power—the acceptance of power with a certain degree of detachment
• Ability to laugh—the capability of seeing the bittersweet quality of life events and the
humor in them
In addition to personal qualities associated with entering the counseling profession, a num-
ber of personal characteristics are associated with being an effective counselor over time (Welfel
& Patterson, 2005). They include stability, harmony, constancy, and purposefulness. Overall, the
potency of counseling is related to counselors’ personal togetherness (Carkhuff & Berenson,
1967; Gladding, 2009; Kottler, 2010). The personhood or personality of counselors is as impor-
tant, if not more crucial in bringing about client change, than their mastery of knowledge, skills, or
techniques (McAuliffe & Lovell, 2006; Rogers, 1961). Education cannot change a person’s basic
characteristics. Effective counselors are growing as persons and are helping others do the same
both personally and globally. In other words, effective counselors are sensitive to themselves and
others. They monitor their own biases, listen, ask for clarification, and explore racial and cultural
differences in an open and positive way (Ford, Harris, & Schuerger, 1993). In addition, effective
8 Part I • Professional Foundations of Counseling

counselors practice what Wicks and Buck (2014) call “alonetime”—an intentional practice of
devoting periods in their lives to silence and solitude and reflectivity. These are times when they
improve self-awareness, renew self-care, and practice gratitude. They need to be planned and do
not have to be long but can be as simple as taking a walk, waiting in line, or preparing for sleep.

Effective Counselor Self Examination

Answer the following questions as you see yourself in regard
to the peer group with whom you most identify. What do
the results tell you about yourself?

somewhat a quality
not like me like me like me I aspire to
1 2 3 4

Intellectually Curious

Capacity for Self Denial

Self-Aware

Sense of Humor

Able to Listen

Empathic

Emotionally Insightful

Introspective

Comfortable with Conversation

Comfortable with Power

Tolerant of Intimacy

Related to this sensitive and growth-enhancing quality of effective counselors is their

appropriate use of themselves as instruments in the counseling process (Brammer & MacDonald,
2003; Combs, 1982). Effective counselors are able to be spontaneous, creative, and empathetic
(Gladding, 2016a). “There is a certain art to the choice and timing of counseling interventions”
(Wilcox-Matthew, Ottens, & Minor, 1997, p. 288). Effective counselors choose and time their
moves intuitively and according to what research has verified works best. It is helpful if counsel-
ors’ lives have been tempered by multiple life experiences that have enabled them to realize
some of what their clients are going through and therefore to be both aware and appropriate.
 Chapter 1 • Personal and Professional Aspects of Counseling 9

The ability to work from a perspective of resolved emotional experience that has sensitized
a person to self and others in a helpful way is what Rollo May characterizes as being a wounded
healer (May, Remen, Young, & Berland, 1985). It is a paradoxical phenomenon. Individuals
who have been hurt and have been able to transcend their pain and gain insight into themselves
and the world can be helpful to others who struggle to overcome emotional problems (Miller,
Wagner, Britton, & Gridley, 1998). They have been where their clients are now. Thus, “counsel-
ors who have experienced painful life events and have adjusted positively can usually connect
and be authentic with clients in distress” (Foster, 1996, p. 21).
Effective counselors are also people who have successfully integrated scientific knowl-
edge and skills into their lives. They have achieved a balance of interpersonal and technical
competence (Cormier, Nurius, & Osborn, 2017). Qualities of effective counselors over time
other than those already mentioned include the following:
• Intellectual competence—the desire and ability to learn as well as think fast and creatively
• Energy—the ability to be active in sessions and sustain that activity even when one sees a
number of clients in a row
• Flexibility—the ability to adapt what one does to meet clients’ needs
• Support—the capacity to encourage clients in making their own decisions while helping to
engender hope
• Goodwill—the desire to work on behalf of clients in a constructive way that ethically pro-
motes independence
• Self-awareness—a knowledge of self, including attitudes, values, and feelings and the
ability to recognize how and what factors affect oneself (Hansen, 2009).
According to Holland (1997), specific personality types are attracted to and work best in
certain vocational environments. The environment in which counselors work well is primarily
social and problem oriented. It calls for skill in interpersonal relationships and creativity. The act
of creativity requires courage (Cohen, 2000; May, 1975) and involves a selling of new ideas and
ways of working that promote intrapersonal as well as interpersonal relations. The more aligned
counselors’ personalities are to their environments, the more effective and satisfied they will be.

PERSONAL REFLECTION
Take the O’Net Inventory Profiler (www.onetcenter.org/IP.html?p=3). Compare your highest interest
scores with those found in different occupations, including counseling. What does this information
reveal to you about how well you might fit into the environment of a helping profession? How does
your score relate to the Wiggins and Weslander study that follows? What are the drawbacks to mak-
ing a career decision based on a single inventory?

In an enlightening and classic study, Wiggins and Weslander (1979) found empirical sup-
port for Holland’s hypothesis. They studied the personality traits and rated the job performance
of 320 counselors in four states. In general, those counselors who were rated “highly effective”
scored highest on the social (social, service oriented) and artistic (creative, imaginative) scales of
John Holland’s Vocational Preference Inventory. Counselors who were rated “ineffective” gen-
erally scored highest on the realistic (concrete, technical) and conventional (organized, practical)
scales. Other factors, such as gender, age, and level of education, were not found to be statisti-
cally significant in predicting effectiveness. The result of this research and other studies like it
10 Part I • Professional Foundations of Counseling

affirms that the personality of counselors is related to their effectiveness in the profession.
Nevertheless, the relationship of persons and environments is complex: Individuals with many
different personality types manage to find places within the broad field of counseling and make
significant contributions to the profession.

CASE EXAMPLE
Pass the Pain, Please
Patricia grew up in a comfortable environment. She went to private schools, was extensively
tutored, toasted by her parents’ associates, and was on the path to succeeding her father as CEO
of a large corporation when she realized she wanted to work with people in a therapeutic way.
She applied to a number of counseling programs and was accepted. However, she decided that
before she entered a program she would take a year to work with poor people in a developing
country so she could “suffer” some and become more empathetic.
What do you think of her idea? Do you think her plan would help her?

Maintaining Effectiveness as a Counselor

Counselors gain confidence through experience, successes, and earning respect from others for
what they do (Moss, Gibson, & Dollarhide, 2014). Nevertheless, persons who become counsel-
ors experience the same difficulties as everyone else and are challenged to deal with these situa-
tions effectively. Among the personal events counselors must deal with are aging, illness, death,
marriage, getting a mortgage, parenting, job changes, divorce, loneliness, success, and a host of
other common, developmental, and unexpected problems and occurrences that fill the lives of
ordinary people. Some of these life events, such as marrying for the first time late in life or expe-
riencing the death of a child, are considered developmentally “off time,” or out of sequence and
even tragic (Skovholt & McCarthy, 1988). Other events consist of unintended but fortuitous
chance encounters, such as meeting a person with whom one develops a lifelong friendship
(Bandura, 1982; Krumboltz & Levin, 2004).
Both traumatic and fortunate experiences are problematic because of the stress they natu-
rally create. A critical issue is how counselors handle these life events. As Roehlke (1988) points
out, Carl Jung’s idea of synchronicity, “which he [Jung] defined as two simultaneous events that
occur coincidentally [and that] result in a meaningful connection,” is perhaps the most produc-
tive way for counselors to perceive and deal with unexpected life experiences (p. 133).
Besides finding meaning in potentially problematic areas, other strategies counselors use
for coping with crisis situations include remaining objective, accepting and confronting situa-
tions, asserting their own wishes, participating in a wellness lifestyle, and grieving (Shallcross,
2011b; Witmer & Young, 1996). Counselors who have healthy personal lives and learn from
both their mistakes and their successes are more likely than others to grow personally and thera-
peutically and be able to concentrate fully and sensitively on clients’ problems. Therefore, coun-
selors, and those who wish to enter the profession, need to adapt to losses as well as gains in life
and remain relatively free from destructive triangling patterns with persons, especially parents,
in their families of origin (McGoldrick, Gerson, & Petry, 2008). Such a stance enables them to
foster and maintain intimate yet autonomous relationships in the present as desired (Gaushell &
Lawson, 1994).
 Chapter 1 • Personal and Professional Aspects of Counseling 11

Other ways effective counselors maintain their health and well-being include taking preven-
tive measures to avoid problematic behaviors, such as compassion fatigue and burnout (Grosch &
Olsen, 1994; Merriman, 2015; Morkides, 2009). Compassion fatigue is indifference and apathy to
those who are suffering, as a result of frequent or overexposure to people in need. It is characterized
as an inability to react sympathetically or empathetically to a crisis or need situation. Burnout con-
sists of three components: emotional and physical exhaustion, cynicism, and decreased perceived
efficacy (Lambert & Lawson, 2013). Those who have burnout describe it as a state of being emo-
tionally or physically drained to the point that one cannot perform functions meaningfully. Burnout
may exist simultaneously with compassion fatigue. There are a number of reasons why profes-
sional counselors become burned out, some of which overlap with compassion fatigue (Sang Min,
Seong Ho, Kissinger, & Ogle, 2010). One of the main reasons involved in both is too much work
and not enough downtime, hobbies, distractions, or other activities outside of counseling. When
such a state of living occurs, counselors may not just lose concern, compassion, and feeling for oth-
ers but they may also develop a negative self-concept and a negative job attitude. They often feel
physically exhausted and emotionally spent as well. Burnout and compassion fatigue are the most
common negative personal consequences of working as a counselor. It is estimated that approxi-
mately 39% of school and clinical mental health counselors experience a high to moderate amount
of symptoms associated with these maladies during their careers (Emerson & Markos, 1996).
To avoid compassion fatigue and burnout, counselors need to modify environmental as
well as individual and interpersonal factors associated with these conditions (Wilkerson &
Bellini, 2006). For example, counselors need to step out of their professional roles and develop
interests outside counseling. They must avoid taking their work home, either mentally or physi-
cally. They also must take responsibility for rejuvenating their professional selves through such
small but significant steps as refurbishing their offices every few years; purging, condensing,
and creating new files; evaluating new materials; and contributing to the counseling profession
through writing or presenting material with which they are comfortable (McCormick, 1998).
Furthermore, they must invest time in becoming individuated by developing their personalities
and sense of self outside of work, through reflective practices connected with their cognitive and
affective functioning (Rosin, 2015). Other ways in which counselors can avoid or treat com-
passion fatigue and burnout include the following:
• Associate with healthy individuals
• Work with committed colleagues and organizations that have a sense of mission
• Be reasonably committed to a theory of counseling
• Use stress-reduction exercises
• Modify environmental stressors
• Engage in self-assessment (i.e., identify stressors and relaxers)
• Periodically examine and clarify counseling roles, expectations, and beliefs (i.e., work
smarter, not necessarily longer)
• Obtain personal therapy
• Set aside free and private time (i.e., balance one’s lifestyle)
• Maintain an attitude of detached concern when working with clients
• Retain an attitude of hope
In summing up previous research about the personalities, qualities, and interests of coun-
selors, Auvenshine and Noffsinger (1984) concluded, “Effective counselors must be emotionally
mature, stable, and objective. They must have self-awareness and be secure in that awareness,
incorporating their own strengths and weaknesses realistically” (p. 151).
12 Part I • Professional Foundations of Counseling

PERSONAL REFLECTION
What do you do that invigorates or refreshes you or that you enjoy? What other activities or hobbies
would you like to include in your life? What keeps you from doing so? How might you get around
any real or potential barriers?

PROFESSIONAL ASPECTS OF COUNSELING

Levels of Helping
There are three levels of helping relationships: nonprofessional, paraprofessional, and professional
(Table 1.1). To practice at a certain level requires that helpers acquire the skills necessary for the task.
The first level of helping involves nonprofessional helpers. These helpers may be friends,
colleagues, untrained volunteers, or supervisors who try to assist those in need in whatever ways
they can. Nonprofessional helpers possess varying degrees of wisdom and skill. No specific educa-
tional requirements are involved, and the level of helping varies greatly among people in this group.
A second and higher level of helping encompasses what is known as generalist human
services workers. These individuals are usually human services workers who have received
some formal training in human relations skills but work as part of a team rather than as individu-
als. People on this level often work as mental health technicians, child care workers, probation
personnel, and youth counselors. When properly trained and supervised, generalist human ser-
vices workers such as residence hall assistants can have a major impact on facilitating positive
relationships that promote mental health throughout a social environment (Waldo, 1989).
Finally, there are professional helpers. These persons are educated to provide assistance
on both a preventive and a remedial level. People in this group include counselors, psycholo-
gists, psychiatrists, social workers, psychiatric nurses, and marriage and family therapists.
Workers on this level have a specialized advanced degree and have had supervised internships to
help them prepare to deal with a plethora of situations.
In regard to the education of helpers on the last two levels, Robinson and Kinnier (1988)
found that self-instructional and traditional classroom training were equally effective at teaching
skills. However, it is the practice of helping skills that is most important.

Professional Helping Specialties

Each helping profession has its own educational and practice requirements. Counselors need to
know the educational backgrounds of other professions in order to use their services, communi-
cate with them in an informed manner, and collaborate with them on matters of mutual concern.

TABLE 1.1 Three Levels of Helping

Category Individuals Involved Helping Skills
Nonprofessionals Friends, untrained volunteers Vary greatly, no formal training in
helping skills
Generalist human service Probation personnel, mental Have basic skills, often work as part
workers health technicians, etc. of a team
Professional helpers Counselors, psychologists, Advanced skilled training; both
social workers, etc. preventive and remedial
 Chapter 1 • Personal and Professional Aspects of Counseling 13

TABLE 1.2 Three Helping Professions Related to Counseling

Profession Degree Emphases
Psychiatry MD Major psychological disorders; biopsychological focus; may
prescribe medications; clients called patients
Psychology PhD, EdD, PsyD Clinical, counseling, and school specialties; counseling
psychology
Shares a long history with counselor education but is
distinct
Social Work BA, MSW, DSW, PhD Negotiates social systems and advocates for change;
provides social services

Three helping professions with which counselors frequently interact are psychiatrists, psy-
chologists, and social workers (Table 1.2).
Psychiatrists earn a medical degree (MD) and complete a residency in psychiatry. They are
specialists in working with people who have major psychological disorders. They are schooled in
the biomedical model, “which focuses on the physical processes thought to underlay mental and
emotional disorders” (MacCluskie & Ingersoll, 2001, p. 8). Frequently, they prescribe medica-
tions and then evaluate the results, especially in agencies such as mental health clinics. Generally,
psychiatrists take almost an exclusively biopsychological approach in treatment, and as a group
they are not as heavily engaged in counseling activities as many other helping professionals. They
must pass both national and state examinations to practice. Their clients are called patients.
Psychologists earn one of the following advanced degrees in psychology: a doctor of phi-
losophy (PhD), a doctor of education (EdD), or a doctor of psychology (PsyD). Their course-
work and internships may be concentrated in clinical, counseling, or school-related areas. All
states license psychologists, but the requirements for licensure differ from state to state. Most
clinically oriented psychologists are listed in the National Register of Health Service Providers,
which has uniform standards for inclusion. Graduates of counseling psychology programs fol-
low a curriculum that includes courses in scientific and professional ethics and standards,
research design and methodology, statistics and psychological measurement, biological bases of
behavior, cognitive–affective bases of behavior, social bases of behavior, individual behavior,
and courses in specialty areas. Counseling psychology and counselor education share many
common roots, concerns, and significant persons in their histories but they differ too (Elmore,
1984; Evans & Gladding, 2010). While once close as disciplines, they differ now to the point
that professionals who earn degrees in these distinct areas are no longer considered equals.
Social workers usually earn a master’s of social work degree (MSW), although some uni-
versities award a bachelor’s degree in social work. There is also advanced training at the doctoral
level. Regardless of their educational background, social workers on all levels have completed
internships in social agency settings. Social workers vary in regard to how they function. Some
administer government programs for the underprivileged and disenfranchised. Others engage in
counseling activities. “Social work differentiates itself from counseling, psychology, and psy-
chiatry in that its mission includes mandates to negotiate social systems and advocate for change,
to understand clients’ habitats (physical and social settings within cultural contexts) and niches
(statuses and roles in community) and to provide social services” (MacCluskie & Ingersoll,
2001, p. 13). The National Association of Social Workers (NASW) offers credentials for mem-
bers who demonstrate advanced clinical and educational competencies.
14 Part I • Professional Foundations of Counseling

The Education of Professional Counselors

Few, if any, people have the ability to work effectively as counselors without formal education
in human development and counseling (Kurpius, 1986b). The level of education needed is
directly related to the intensity, expertise, and emphasis of work in which one engages.
Professional counselors obtain either a master’s or a doctorate in counseling from a counselor
education program and complete internships in specialty areas such as school counseling; reha-
bilitation counseling; mental health counseling; career counseling; gerontological counseling;
addiction counseling; or marriage, couple, and family counseling. They are usually certified by
the National Board of Certified Counselors (NBCC) (the primary national agency that certi-
fies counselors) as a National Certified Counselor (NCC) (the entry level of national creden-
tialing). Often they are credentialed on a specialist level, such as school, mental health, or
addiction. In addition, they are licensed to practice by individual states.
An accredited counselor education program is one recognized at either the master’s or
doctoral level. The accrediting body for counselor education programs is the Council for
Accreditation of Counseling and Related Educational Programs (CACREP). This indepen-
dent body evolved from the efforts of the Association for Counselor Education and Supervision
(ACES) and the American Counseling Association (ACA) to establish standards and guidelines
for counseling independent of the National Council for Accreditation of Teacher Education
(NCATE), which is the primary accreditation agency for teacher education programs.
On the master’s level, CACREP accredits programs in career counseling; clinical mental
health counseling; school counseling; marital, couple, and family counseling/therapy; college
counseling and student affairs (Bobby, 2013). Graduates from accredited master’s programs have
an advantage over graduates from nonaccredited programs in (a) obtaining admittance to accred-
ited counselor education doctoral programs, (b) meeting the educational requirements for coun-
selor licensure and certification, and (c) obtaining employment as a counselor (Urofsky, 2013).
Although accreditation standards are periodically changing, the following broad standards
must be met in an accredited counselor education master’s degree program (CACREP, 2016):

• The entry-level program must be a minimum of 2 full academic years in length, with a
minimum of 48 semester hours required of all students. The entry-level program in mental
health counseling must be 60 semester hours long, and the entry-level program in mar-
riage, couple, and family counseling must also be 60 semester hours.
• Curricular experiences and demonstrated knowledge and skill competence is required of
all students in each of eight common core areas of counseling: (a) human growth and
development, (b) social and cultural foundations, (c) helping relationships, (d) groups,
(e) lifestyles and career development, (f) appraisal, (g) research and evaluation, and
(h) professional orientation.
• Clinical experiences are required under the direction of supervisors with specific qualifica-
tions. The student must complete 100 clock hours of a supervised practicum with 1 hour
per week of individual supervision and 1.5 hours per week of group supervision with other
students in similar practice.
• The program must require that each student complete 600 clock hours of a supervised
internship, which is to begin only after successful completion of the student’s practicum.
• Three full-time faculty members must be assigned to the academic unit in counselor education.

CACREP accredits programs on the doctoral level too in counselor education and supervi-
sion (EdD and PhD). In 2016 there were 68 doctoral programs in counselor education accredited
 5 Building Counseling Relationships

Chapter Overview
From this chapter you will
learn about:
■ Factors that influence the
counseling process such as
the seriousness of a
problem
■ The importance of initiative
and structure in counseling
■ How the physical setting of
an office and client
qualities can influence a
counseling sesssion
■ Types of counseling
interviews
■ Helpful and nonhelpful Lane V. Erickson/Shutterstock

ways of responding to
clients and the importance
Your words splash heavily upon my mind
of goals in directing
like early cold October rain
counseling
falling on my roof at dusk.
As you read consider: The patterns change like an autumn storm
■ What you would put in a from violently rumbling thundering sounds
professional disclosure to clear, soft steady streams of expression.
statement Through it all I look at you
■
soaked in past fears and turmoil;
How you would like to
Then patiently I watch with you in the darkness
decorate a counseling office
for the breaking of black clouds
■ Your tendencies now in that linger in your turbulent mind
responding to others And the dawning of your smile
■ What goals you might feel that comes in the light of new beginnings.
most comfortable in
Reprinted from “Autumn Storm,” by S. T. Gladding, 1975, Personnel and Guidance
helping a client achieve Journal, 54, p. 149. © Samuel T. Gladding.

92
 Chapter 5 • Building Counseling Relationships 93

The process of counseling develops in definable stages with recognizable transitions. The
first stage involves building a relationship and focuses on engaging clients to explore
issues that directly affect them. Two struggles take place at this time (Napier & Whitaker,
1978). One is the battle for structure, which involves issues of administrative control
(e.g., scheduling, fees, participation in sessions). The other is the battle for initiative,
which concerns the motivation for change and client responsibility. It is essential that
counselors win the first battle and clients win the second. If there are failures at these
points, the counseling effort will be prematurely terminated, and the counselor and client
may feel worse for the experience.
Other factors that influence the progress and direction of counseling are the physical
setting, the client’s background, the counselor’s skill, and the quality of the relationship
established. They will be examined here as well as the nature of the first interview and the
exploration stage of counseling. Carkhuff (1969, 2000) and Daniel and Ivey (2007) have
demonstrated that some counseling responses cut across theoretical and cultural lines in
helping build a counselor–client relationship. These responses are sometimes known as
microskills and include atheoretical and social-learning behaviors such as attending,
encouraging, reflecting, and listening. When mastered, these abilities allow counselors to
be with their clients more fully, “act in a culturally appropriate manner, and find positives
in life experience” (Weinrach, 1987, p. 533). Thus, part of this chapter will focus on
microskills.

FACTORS THAT INFLUENCE THE COUNSELING PROCESS

A number of factors affect the counseling process for better or worse. Those covered here are the
seriousness of the concern presented, structure, initiative, physical setting, client qualities, and
counselor qualities.

Seriousness of the Presenting Problem

Counseling is impacted by the seriousness of clients’ presenting problem. Evidence has sug-
gested a relationship between the initial self-reported disturbance level and the treatment course.
“Thus, clients reporting higher initial distress take more sessions to reach clinically significant
improvement than clients reporting lower levels of distress” (Leibert, 2006, p. 109). For instance,
clients who come to counseling with unfinished business (unexpressed feelings—such as
resentment, hate, pain, hurt, anxiety, guilt, and grief—and events and memories that linger in the
background and clamor for completion) will, as a rule, take longer to treat than clients who have
just experienced a difficulty (Corey, 2016).
Research suggests that the largest gains in improvement occur early in treatment but that
seriously disturbed individuals benefit from longer term treatment. Furthermore, some condi-
tions such as schizophrenia and clients who exhibit antisocial personality disorders are least
likely to show improvement through traditional talk therapies.
Overall, clients who are in better shape at the onset of treatment seem to improve the
most, in the least amount of time, and with the best long-term results. Research, as summa-
rized by Leibert (2006), has found “50% of clients diagnosed with anxiety or depression had
improved by Sessions 8–13” and “85% of clients improved after 1 year of weekly treat-
ment” (p. 109).
94 Part II • Counseling Processes and Theories

Structure
Clients and counselors sometimes have different perceptions about the purpose and nature
of counseling. Clients often do not know what to expect from the process or how to act.
Seeing a counselor is a last resort for many individuals. They are likely to have already
sought help from more familiar sources, such as friends, family members, ministers, or
teachers (Hinson & Swanson, 1993). Therefore, many clients enter counseling reluctantly
and hesitantly. This uncertainty can inhibit the counseling process unless some structure is
provided (Ritchie, 1986). Structure in counseling is defined as “a joint understanding
between the counselor and client regarding the characteristics, conditions, procedures, and
parameters of counseling” (Day & Sparacio, 1980, p. 246). Structure helps clarify the coun-
selor–client relationship and give it direction; protect the rights, roles, and obligations of
both counselors and clients; and ensure the success of counseling (Brammer, Abrego, &
Shostrom, 1993).
Practical guidelines are part of building structure. They include time limits (such as
a 50-minute session), action limits (for the prevention of destructive behavior), role limits
(what will be expected of each participant), and procedural limits (in which the client is
given the responsibility to work on specific goals or needs) (Brammer & MacDonald, 2003).
Guidelines also provide information on fee schedules and other important concerns of cli-
ents. In general, structure promotes the development of counseling by providing a frame-
work in which the process can take place. “It is therapeutic in and of itself” (Day & Sparacio,
1980, p. 246).
Structure is provided throughout all stages of counseling but is especially important at the
beginning. Dorn (1984) states that “clients usually seek counseling because they are in a static
behavior state” (p. 342). That is, clients feel stuck and unable to change their behavior. To help
clients gain new directions in their lives, counselors provide constructive guidelines. Their deci-
sions on how to establish this structure are based on their theoretical orientation to counseling,
the personalities of their clients, and the major problem areas with which they will deal. Too
much structure can be just as detrimental as not enough (Welfel & Patterson, 2005). Therefore,
counselors need to stay flexible and continually negotiate the nature of the structure with
their clients.
The importance of structure is most obvious when clients arrive for counseling with
unrealistic expectations (Welfel & Patterson, 2005). Counselors need to move quickly to
establish structure at such times. One way is for counselors to provide information about the
counseling process and themselves with professional disclosure statements that include
details about the nature of counseling, expectations, responsibilities, methods, and ethics of
counseling (Figure 5.1).

PERSONAL REFLECTION
When have you found structure helpful in your life? What did it provide for you that would not have
been there otherwise?
 Chapter 5 • Building Counseling Relationships 95

Professional Disclosure Statement

Samuel T. Gladding, Ph.D.—Licensed Professional Counselor
I am glad you have selected me as your counselor. In considering our professional relationship,
Ihave written this document to describe my background and my clinical approach.

Professional Background
I hold a Master of Arts degree in counseling from Wake Forest University, a Master of Arts
degree in religion from Yale Divinity School, and a Ph.D. from the UNC-Greensboro in family
relations with cognates in counseling and psychology. In addition, I did a post doctorate at
UNCG (18 semester hours) in psychology. I have worked in a public mental health center
(Rockingham County, North Carolina) and in a private clinical practice (Birmingham, Alabama).
Ihave also taught counseling at the graduate level in Connecticut (Fairfield University), in
Alabama (University of Alabama at Birmingham), and in North Carolina (Wake Forest University).
I am a Licensed Professional Counselor (#636) in the state of North Carolina, a National
Certified Counselor (#334), and a Certified Clinical Mental Health Counselor (#351).

Counseling Services Offered

As a licensed professional counselor with a specialty in mental health, I am interested in the
growth, development, and wellness of the whole person. I respect the uniqueness of each per-
son and his/her life journey where applicable. My responsibility is to facilitate and empower your
use of thoughts, feelings, and behaviors to achieve healing and wholeness in your life.
I have offered outpatient, fee-based counseling services since 1971, although not sequentially.
Ihave worked with individuals, couples, families, and groups in areas such as depression, anxiety,
grief, abuse, career exploration, situational adjustments, life development, and crises.
Counseling presents you with the opportunity to invest in your personal, emotional, cognitive,
behavioral, and spiritual well-being and growth in the context of a helping relationship. Your goals
for seeking counseling, which I will explore and update with you frequently, will give direction to our
work together and will influence the therapeutic approaches that I will use. My style of counseling
is based on person-centered, gestalt, existential, family systems, and cognitive-behavioral theories.
Although some counseling changes may be easy and rapid, others are slow and deliberate. These
latter changes will require considerable proactive commitment on your part. This commitment
may involve work outside of our sessions such as reading, reflecting, journaling, and working on
cognitive-behavioral assignments.
At the outset I will listen carefully to your story and take a history to learn the specific initial
therapy goals that emerge. I will work closely with you to evaluate and fine-tune together these
goals as the process unfolds. At any session each of us may evaluate how the process is unfolding
and where we may need to make revisions. At the end of the counseling process, you will be
provided with an evaluation form to reflect on our work together. Coming to know yourself
in greater depth and make changes can be inspiring as well as painful. You may experience a
myriad of thoughts and feelings during this process, including but not limited to, frustration,
sadness, anxiety, guilt, and anger. I will typically make a diagnosis regarding your situation,
which will become a part of your record.

Professional Ethics
For our relationship to be respectful and effective, confidentiality is a must. I will not discuss the
content of our work outside of our sessions. State law and the ethical principles of my professional
organizations (the American Counseling Association, the National Board for Certified Counselors,

FIGURE 5.1 Professional disclosure statement (continued)

96 Part II • Counseling Processes and Theories

and the North Carolina Board of Licensed Professional Counselors) mandate confidentiality except
under two circumstances: (1) when I believe you intend to harm yourself or another person, or
(2) when I believe a child or elderly person has been or will be abused or neglected. In rare cir-
cumstances, a court of law can mandate me to release information on you. Otherwise, I will not
disclose anything about your history, diagnosis, or progress. I will not even acknowledge our
professional relationship without your full knowledge and a signed Release of Information Form.
Such a form must be signed to release information to your insurance carrier as well.
Ethical and legal standards mandate that even though our relationship might be intense and
intimate in many ways, it must remain professional rather than social. You will be served best if
our sessions and relationship concentrate exclusively on your concerns. Thus, I will not attend
social events, receive gifts, or relate to you in any way other than in the professional context of
our sessions.

Length of Sessions
My services will be rendered in a professional manner consistent with the accepted clinical
standards of the American Counseling Association, National Board for Certified Counselors,
and the North Carolina Board of Licensed Professional Counselors. Sessions will last fifty
(50)minutes. We shall schedule sessions by mutual agreement. Often persons prefer to main-
tain a standard appointment time. A twenty-four (24)-hour notice is required for cancellation
unless there is a sickness or emergency. Without these exceptions, payment for missed sessions
is required. Every effort will be made to start and stop sessions on time. Each of us has the
responsibility of being prompt.

Fees and Methods of Payment

The fee for initial intake sessions is $115.00 with each subsequent session being $95.00. Sessions
are payable by personal check or in cash at the beginning of each appointment. Our office will
provide you with a super bill for your records or to submit to your insurance carrier. Some insur-
ance companies will pay for counseling services; others will not. Please remember that you and
not your insurance company are responsible for paying in full the fees agreed upon.

Complaint Procedure
If you have difficulty with any aspect of our work, please inform me immediately so that we
can discuss how we might work better together. This discussion is an important aspect of our
continuous evaluation of this process.
Should you feel treated unfairly or unethically by me or another counselor, you may make a
formal complaint to the following licensure board and associations.

North Carolina Board of Licensed Professional Counselors

PO Box 2105
Raleigh, NC 27619-1005
919-661-0820
National Board for Certified Counselors
3 Terrace Way
Greensboro, NC 27403
336-547-0607

FIGURE 5.1 Professional disclosure statement (continued)

 Chapter 5 • Building Counseling Relationships 97

American Counseling Association

5999 Stevenson Avenue
Alexandria, VA 22304
1-800-347-6647
Please sign and date both copies of this form. A copy for your records will be returned to you.
I shall keep a copy in my confidential records.

Signature of Client/Parent/Guardian Date

Signature of Counselor Date

FIGURE 5.1 (continued )

Initiative
Initiative can be thought of as the motivation to change. Most counselors and counseling theories
assume that clients will be cooperative. Indeed, many clients come to counseling on a voluntary
or self-referred basis. They experience tension and concern about themselves or others, but they
are willing to work hard in counseling sessions. Other clients, however, are more reserved about
participating in counseling. Vriend and Dyer (1973) estimate that the majority of clients who visit
counselors are reluctant to some degree. When counselors meet clients who seem to lack initia-
tive, they often do not know what to do with them, much less how to go about counseling.
Therefore, some counselors are impatient, irritated, and may ultimately give up trying to work
with such persons. The result is not only termination of the relationship but also scapegoating—
blaming a person when the problem was not entirely his or her fault. Many counselors end up
blaming themselves or their clients if counseling is not successful. Such recriminations need not
occur if counselors understand the dynamics involved in working with difficult clients. Part of
this understanding involves assuming the role of an involuntary client and imagining how it
would feel to come for counseling. A role-reversal exercise can promote counselor empathy and
is an excellent technique to use at such times.
A reluctant client is one who has been referred by a third party and is frequently “unmoti-
vated to seek help” (Ritchie, 1986, p. 516). Many schoolchildren and court-referred clients are
reluctant. They do not wish to be in counseling, let alone talk about themselves. Many reluctant
clients terminate counseling prematurely and report dissatisfaction with the process.

CASE EXAMPLE
Rachel the Reluctant
Rachel was caught smoking marijuana in the girl’s bathroom at her high school. The school
had a zero tolerance policy on drugs and immediately suspended Rachel until she received
counseling. Rachel was furious, but made an appointment with a counselor that the school
recommended. Her first words to the counselor were, “You can make me come but you can’t
make me talk.”
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TABLE 5.1 Reluctant vs. Resistant Client Behaviors

Reluctant Reluctant and Resistant Resistant
A client who seems to lack Both reluctant and resistant A client who is unwilling,
initiative. clients avoid getting involved unready, or opposed to
A client referred by a third in the counseling process change.
party who is frequently immediately. A client who does not wish to
unmotivated to seek help. Both reluctant and resistant go through the emotional
A client who seems to know clients do not want to come to pain, change in perspective, or
nothing about counseling and counseling initially. enhanced awareness that
therefore is hesitant to do or counseling demands.
say anything for fear of what A client who clings to the
might happen. certainty of present behavior,
A client who has heard even when such action is
misrepresentations about counterproductive and
counseling from others and dysfunctional.
therefore decided the best A client who refuses to make
strategy for dealing with decisions, is superficial in
counseling is to be superficial dealing with problems, or who
in his or her dealings with the will take any action to resolve
counselor. a problems such as doing
anything a counselor says.
 Chapter 5 • Building Counseling Relationships 99

Counselors can help clients win the battle for initiative and achieve success in counseling
in several ways. One is to anticipate the anger, frustration, and defensiveness that some clients
display. Counselors who realize that a percentage of their clients are reluctant or resistant can
work with these individuals because they are not surprised by them or their behaviors.
A second way to deal with a lack of initiative is to show acceptance, patience, and under-
standing as well as a general nonjudgmental attitude. This stance promotes trust, which is the
basis of an interpersonal relationship. Nonjudgmental behavior also helps clients better under-
stand their thoughts and feelings about counseling. Thus, acceptance opens clients to others,
themselves, and the counseling process.
A third way to win the battle for initiative is for counselors to use persuasion (Kerr,
Claiborn, & Dixon, 1982; Senour, 1982). All counselors have some influence on clients, and
vice versa (Dorn, 1984; Strong, 1982). How a counselor responds to the client, directly or indi-
rectly, can make a significant difference in whether clients take the initiative in working to
produce change. Roloff and Miller (1980) mention two direct persuasion techniques employed
in counseling: the “foot in the door” and the “door in the face.” In the first technique, the
counselor asks the client to comply with a minor request and then later follows with a larger
request. For example, an initial request might be “Would you keep a journal of your thoughts
and feelings for this week” followed the next week by “I’d like you to keep a journal of your
thoughts and feelings from now on.” In the second technique, the counselor asks the client to do
a seemingly impossible task and then follows by requesting the client to do a more reasonable
task. For instance, the initial request might be “I’d like you to talk briefly to 100 people a day
between now and our next session” followed, after the client’s refusal, by “Since that assign-
ment seems to be more than you are comfortable in handling, I’d like you to say hello to just
three new people each day.”

PERSONAL REFLECTION
When have you seen a situation where a person either got a foot in the door or used the door in the
face technique? How do you think you might use either of these procedures?

A fourth way a counselor can assist clients in gaining initiative is through confrontation.
In this procedure the counselor simply points out to the client exactly what the client is doing,
such as being inconsistent. For example, a parent might be disciplining children for misbehaving
sometimes and then letting them act out at other times. In such situations, the client must take
responsibility for responding to the confrontation. The three primary ways of responding are
denying the behavior, accepting all or part of the confrontation as true, or developing a middle
position that synthesizes the first two (Young, 2017). Doing something differently or gaining a
new perception on a problem can be a beneficial result of confrontation, especially if what has
previously been tried has not worked.
Counselors can also use language, especially metaphors, to soften resistance or reluctance
(Grothe, 2008). “Metaphors can be used to teach and reduce threat levels by providing stories, by
painting images, by offering fresh insights, by challenging rigid thinking, by permitting toler-
ance for new beliefs, and by overcoming the tension often present between a counselor and the
resistant [or reluctant] client” (James & Hazler, 1998, p. 122). For instance, in addressing a client
who keeps repeating the same mistake, the counselor might say, “What does a fighter do when
he gets badly beaten up every time he fights?” (p. 127).
100 Part II • Counseling Processes and Theories

The sixth way counselors can help reluctant and resistant clients, indeed all clients, and
strengthen the counseling relationship is through “mattering,” the perception that as human beings
we are important and significant to the world around us and to others in our lives (Rayle, 2006).
Research shows that mattering to others directly affects individuals’ lives and relationships.
Finally, Sack (1988) recommends the use of pragmatic techniques, such as silence (or
pause), reflection (or empathy), questioning, describing, assessing, pretending, and sharing the
counselor’s perspective, as ways to overcome client resistance. These techniques are especially
helpful with individuals who respond to counselor initiatives with “I don’t know.” Depending on
one’s theoretical orientation, resistance can also be declared officially dead (deShazer, 1984).
From such a perspective, change is inevitable and clients are seen as cooperative. The reason
change has not occurred is that the counselor has yet to find a way to help stuck clients initiate a
sufficient push to escape patterns that have been troubling them. (See Figure 5.2 for ways coun-
selors can help clients win the battle for initiative.)

The Physical Setting

Counseling can occur almost anywhere, but some physical settings promote the process better
than others. Among the most important factors that help or hurt the process is the place where
the counseling occurs. Most counseling occurs in a room, although Benjamin (1987) tells of
counseling in a tent. He says that there is no universal quality that a room should have “except
[that] it should not be overwhelming, noisy, or distracting” (p. 3). Shertzer and Stone (1980)
implicitly agree: “The room should be comfortable and attractive” (p. 252). Erdman and
Lampe (1996) believe that certain features of a counseling office will improve its general
appearance and probably facilitate counseling by not distracting the client. These features
include soft lighting; quiet colors; an absence of clutter; harmonious, comfortable furniture;
and diverse cultural artifacts. They go on to recommend that when working with families who
have children or with children apart from families, counselors need to have furniture that is
child size.
In an extensive review of the research on the physical environment and counseling, Pressly
and Heesacker (2001, p. 156) looked at eight common architectural characteristics of space

1. Anticipate the anger, frustration, and defensiveness that some clients display.
2. Show acceptance, patience, and understanding as well as a general nonjudgmental
attitude.
3. Use persuasion—the foot in the door or the door in the face technique.
4. Use confrontation—point out to the client exactly what the client is doing, such as being
inconsistent.
5. Use metaphors and similes—comparisons of people or actions in one situation to another,
for example, “your life has reached a dead end” or “you seem to be like a car that has
plenty of gas but that is not in drive.”
6. Use “mattering”—the perception that as human beings we are important and significant to
the world around us and to others in our lives.
7. Use pragmatic techniques, such as silence (or pause), reflection (or empathy), questioning,
describing, assessing, pretending, and sharing the counselor’s perspective.

FIGURE 5.2 Ways of helping clients win the battle for initiative
 Chapter 5 • Building Counseling Relationships 101

and their potential impact on counseling sessions. The factors they reviewed and their findings
are as follows:
1. Accessories (i.e., artwork, objects, plants)—“people prefer texturally complex images of
natural settings, rather than posters of people, urban life, and abstract compositions”; peo-
ple feel “more comfortable in offices that are clean and have plants and artwork”
2. Color (i.e., hue, value, intensity)—“bright colors are associated with positive emotions
and dark colors are linked with negative emotions”
3. Furniture and room design (i.e., form, line, color, texture, scale)—“clients prefer interme-
diate distance in counseling and … more protective furniture layouts … than do counselors”
4. Lighting (i.e., artificial, natural)—“general communication tends to occur in bright
environments, whereas more intimate conversation tends to occur in softer light”; “full-
spectrum lighting helps to decrease depression symptomatology” (In an experiment with
80 undergraduates in Japan, Miwa and Hanyu [2006] found that dim lighting yields more
pleasant and relaxed feelings, more favorable impressions of the counselor, and more self-
disclosure than bright lighting.)
5. Smell (i.e., plants, ambient fragrances, general odors)—“unpleasant smells elicit
unhappy memories, whereas pleasant smells trigger happy memories”; “inhaled food and
fruit fragrances have resulted in self-reported depressive symptoms”
6. Sound (i.e., loudness, frequency)—“sound may enhance or detract from task perfor-
mance”; “music may enhance the healing process and affect muscle tone, blood pressure,
heart rate, and the experience of pain”
7. Texture (i.e., floors, walls, ceilings, furniture)—“counselors should consider using soft,
textured surfaces to absorb sound and to increase clients’ feelings of privacy”
8. Thermal conditions (i.e., temperature, relative humidity, air velocity)—“most individu-
als feel comfortable in temperatures ranging from 69 to 80 degrees [Fahrenheit] and 30%
to 60% relative humidity”
The distance between counselor and client (the spatial features of the environment or
proxemics) can also affect the counseling relationship and has been studied. Individuals differ
about the level of comfort experienced in interactions with others. Among other things, comfort
level is influenced by cultural background, gender, and the nature of the relationship. A distance
of 30 to 39 inches has been found to be the average range of comfort between counselors and
clients of both genders in the United States (Haase, 1970). This optimum distance may vary
because of room size and furniture arrangement (Haase & DiMattia, 1976).
The arrangement of furniture depends on the counselor. Some counselors prefer to sit
behind a desk during sessions, but most do not. The reason desks are generally eschewed by
counselors is that a desk can be a physical and symbolic barrier against the development of a
close relationship. Benjamin (1987) suggests that counselors include two chairs and a nearby
table in the setting. The chairs should be set at a 90-degree angle from each other so that clients
can look either at their counselors or straight ahead. The table can be used for many purposes,
such as a place to keep a box of tissues. Benjamin’s ideas are strictly his own; each counselor
must find a physical arrangement that is comfortable for him or her. See Figure 5.3 for an ideal
physical setting for individual counseling sessions.
Regardless of the arrangement within the room, counselors should not be interrupted when
conducting sessions. All phone calls, including cell phone calls, should be held. If necessary, coun-
selors should put “do not disturb” signs on the door to keep others from entering. Auditory and visual
privacy are mandated by professional codes of ethics and ensure maximum client self-disclosure.
102 Part II • Counseling Processes and Theories

FIGURE 5.3 An ideal physical setting for individual counseling

Client Qualities
Counseling relationships start with first impressions. The way that counselor and client perceive
each other is vital to the establishment of a productive relationship. Warnath (1977) points out
that “clients come in all shapes and sizes, personality characteristics, and degrees of attractive-
ness” (p. 85). Some clients are more likely to be successful in counseling than others. The most
successful candidates for traditional approaches tend to be YAVIS: young, attractive, verbal,
intelligent, and successful (Schofield, 1964). Less successful candidates are seen as HOUNDs
(homely, old, unintelligent, nonverbal, and disadvantaged) or DUDs (dumb, unintelligent, and
disadvantaged) (Allen, 1977). These acronyms are cruel (Lichtenberg, 1986), but counselors are
influenced by the appearance and sophistication of the people with whom they work. Counselors
most enjoy working with clients who they think have the potential to change.
A number of stereotypes have been built around the physical attractiveness of individu-
als, and these stereotypes generalize to clients. The physically attractive are perceived as
healthiest and are responded to more positively than others. Goldstein (1973), for instance,
found that clients who were seen by their counselors as most attractive talked more and were
more spontaneous when compared with other clients. Most likely, counselors were more
encouraging to and engaged with the attractive clients. Therefore, aging clients and those with
physical disabilities may face invisible but powerful barriers in certain counseling situations.
Ponzo (1985) suggests that counselors become aware of the importance of physical attractive-
ness in their own lives and monitor their behavioral reactions when working with attractive
clients. Otherwise, stereotypes and unfounded assumptions may “lead to self-fulfilling prophe-
cies” (p. 485).
The nonverbal behaviors of clients are also very important. Clients constantly send coun-
selors unspoken messages about how they think or feel. Children are especially prone to use
 Chapter 5 • Building Counseling Relationships 103

nonverbal means to convey their thoughts and feelings. Mehrabian (1971) and associates found
that expressed like and dislike between individuals could be explained as follows:

Total liking equals 7% verbal liking plus 38% vocal liking plus 55% facial liking. The impact
of facial expression is greatest, then the impact of the tone of voice (or vocal expression), and
finally that of the words. If the facial expression is inconsistent with the words, the degree of
liking conveyed by the facial expression will dominate and determine the impact of the total
message. (p. 43)

Thus, a client who reports that all is going well but who looks down at the ground and
frowns while doing so is probably indicating just the opposite. A counselor must consider a cli-
ent’s body gestures, eye contact, facial expression, and vocal quality to be as important as verbal
communication in a counseling relationship. It is also crucial to consider the cultural background
of the person whose body language is being evaluated and interpret nonverbal messages cau-
tiously (Sielski, 1979).

Counselor Qualities
The personal and professional qualities of counselors are very important in facilitating any help-
ing relationship. Okun and Kantrowitz (2015) note that it is hard to separate the helper’s person-
ality characteristics from his or her levels and styles of functioning, as both are interrelated. They
then list five important characteristics that helpers should possess: self-awareness, honesty, con-
gruence, ability to communicate, and knowledge.
Counselors who continually develop their self-awareness skills are in touch with their val-
ues, thoughts, and feelings. They are likely to have a clear perception of their own and their cli-
ents’ needs and accurately assess both. Such awareness can help them be honest with themselves
and others. They are able to be more congruent and build trust simultaneously. Counselors who
possess this type of knowledge are more likely to communicate clearly and accurately.
Three other characteristics that make counselors initially more influential are perceived
expertness, attractiveness, and trustworthiness (Strong, 1968). Expertness is the degree to which
counselors are perceived as knowledgeable and informed about their specialty. Counselors who
display evidential cues in their offices, such as certificates and diplomas, are usually perceived as
more credible than those who do not and, as a result, are likely to be effective (Loesch, 1984; Siegal
& Sell, 1978). Clients want to work with counselors who appear to know the profession well.
Attractiveness is a function of perceived similarity between clients and counselors as
well as physical features. Counselors can make themselves attractive by speaking in clear, sim-
ple, jargon-free sentences and offering appropriate self-disclosure (Watkins & Schneider,
1989). The manner in which counselors greet clients and maintain eye contact can also increase
the attractiveness rating. Counselors who use nonverbal cues in responding to clients, such as
head nodding and eye contact, are seen as more attractive than those who do not (Claiborn,
1979; LaCross, 1975). The attire of counselors also makes a difference (Hubble & Gelso,
1978). Clothes should be clean, neat, and professional looking but not attract undue attention.
Physical features make a difference, too, in that under controlled conditions, research suggests
individuals are more willing to self-disclose to an attractive counselor than to an unattractive
one (Harris & Busby, 1998).
Trustworthiness is related to the sincerity and consistency of counselors. Those who are
genuinely concerned about their clients show it over time by establishing a close relationship.
“There is and can be no such thing as instant intimacy” or trustworthiness (Patterson, 1985,
104 Part II • Counseling Processes and Theories

p. 124). Rather, both are generated through patterns of behavior that demonstrate care and
concern. Most clients are neither completely distrusting nor given to blind trust. However, as
Fong and Cox (1983) note, many clients test the trustworthiness of the counselor by requesting
information, telling a secret, asking a favor, inconveniencing the counselor, deprecating them-
selves, or questioning the motives and dedication of the counselor. It is essential, therefore, that
counselors respond to the question of trust rather than the verbal content of clients in order to
facilitate the counseling relationship.
Many beginning counselors make the mistake of dealing with surface issues instead of real
concerns. For example, if a client asks a counselor, “Can I tell you anything?” a novice counselor
might respond, “What do you mean by anything?” An experienced counselor might say, “It
sounds as if you are uncertain about whether you can really trust me and this relationship. Tell
me more.” Trust with children, like adults, is built by listening first and allowing children the
freedom to express themselves openly on a verbal or nonverbal level before the counselor
responds (Erdman & Lampe, 1996).

CASE EXAMPLE
Brigit’s Breakdown
Brigit was 48, bucktoothed, pock-faced, undereducated, and largely avoided by most people. To
make matters worse, she was introverted and lonely. Her best friend on the weekend was her
television. Therefore, when her sister suggested she try counseling, she agreed and thought,
“I have nothing to lose.” However, she encountered problems from the beginning. Brigit’s coun-
selor, Channel, acted as if Brigit’s bad looks were contagious and seemed to distance herself
from Brigit and blame her for not being more extraverted. Brigit became furious and decided to
do something about the situation.
During the second session, Brigit pointed out specific behaviors Channel was doing that
made her feel rejected. Channel was embarrassed and admitted engaging in all the actions Brigit
confronted her with, but then continued to criticize Brigit in a subtle fashion.
What else might Brigit do with this situation? What would you suggest Channel do to help
correct her mistakes and make the counseling session productive?

TYPES OF INITIAL INTERVIEWS

The counseling process begins with the initial session. Levine (1983) points out that authorities
in the profession have observed that “the goals of counseling change over time and change
according to the intimacy and effectiveness of the counseling relationship” (p. 431). How much
change happens or whether there is a second session is usually determined by the results of the
first session.
In the first session, both counselors and clients work to decide whether they want to or
can continue the relationship. Counselors should quickly assess whether they are capable of
handling and managing clients’ problems through being honest, open, and appropriately con-
frontive (Okun & Kantrowitz, 2015). However, clients must ask themselves whether they
feel comfortable with and trust the counselor before they can enter the relationship
wholeheartedly.
 Chapter 5 • Building Counseling Relationships 105

Client- versus Counselor-Initiated Interviews

Benjamin (1987) distinguishes between two types of first interviews: those initiated by clients
and those initiated by counselors. When the initial interview is requested by a client, the coun-
selor is often unsure of the client’s purpose. This uncertainty may create anxiety in the counselor,
especially if background information is not gathered before the session. Benjamin (1987) recom-
mends that counselors work to overcome these feelings by listening as hard as possible to what
clients have to say. In such situations, as with counseling in general, listening “requires a sub-
mersion of the self and immersion in the other” (Nichols, 1998, p. 1). There is no formula for
beginning the session. The helping interview is as much an art as a science, and every counselor
must work out a style based on experience, stimulation, and reflection. The counselor is probably
prudent not to inquire initially about any problem the client may have because the client may not
have a problem in the traditional sense of the word and may just be seeking information. Thus,
inquiring as to “what brought you here to see me?” may be an open and safe query for counselors
to begin with.
When the first session is requested by the counselor, Benjamin (1987) believes that the
counselor should immediately state his or her reason for wanting to see the client. In the case
of a school counselor, for instance, a session might be requested so that the counselor can
introduce himself or herself to a student. If the counselor does not immediately give a reason
for requesting the session, the client is kept guessing, tension is created, and rapport is
often lost.
Welfel and Patterson (2005) think that all clients enter counseling with some anxiety and
resistance regardless of prior preparation. Benjamin (1987) hypothesizes that most counselors
are also a bit frightened and uncertain when conducting a first interview. Uncertain feelings in
clients and counselors may result in behaviors such as seduction or aggression (Watkins, 1983).
Counselors can prevent such occurrences by exchanging information with clients. Manthei
(1983) advocates that counselors’ presentations about themselves and their functioning be multi-
modal: visual, auditory, written, spoken, and descriptive. Although such presentations may be
difficult, they pay off by creating good counselor–client relationships. Overall, early exchanges
of information increase the likelihood that clients and counselors will make meaningful choices
and participate more fully in the counseling process.

Information-Oriented First Interview

Cormier (2015) points out that the initial counseling interview can fulfill two functions: (a) It can
be an intake interview to collect needed information about the client, or (b) it can signal the
beginning of a relationship. Each type of interview is appropriate and certain tasks are common
to both, though the skills emphasized in each differ.
If the purpose of the first interview is to gather information, the structure of the session
will be counselor focused: The counselor wants the client to talk about certain subjects. The
counselor will respond to the client predominantly through the use of probes, accents, closed
questions, and requests for clarification (Cormier, 2015). These responses are aimed at eliciting
facts.
The probe is a question that usually begins with who, what, where, or how. It requires
more than a one- or two-word response—for example, “What do you plan to do about getting
a job?” Few probes ever begin with the word why, which usually connotes disapproval, places
a client on the defensive (e.g., “Why are you doing that?”), and is often unanswerable
(Benjamin, 1987).
106 Part II • Counseling Processes and Theories

An accent is highlighting the last few words of the client. For example:
Client: The situation I’m in now is driving me crazy!
Counselor: Driving you crazy?
A closed question is one that requires a specific and limited response, such as yes or no. It
often begins with the words is, do, or are:
Counselor: Do you enjoy meeting other people?
Client: Yes.
The closed question is quite effective in eliciting large amounts of information in a short
period of time. However, it does not encourage elaboration that might also be helpful.
In contrast to the closed question is the open question, which typically begins with what,
how, or could and allows the client more latitude to respond. Examples are “How does this
affect you?” “Could you give me more information?” and “Tell me more about it.” The major
difference between a closed and open question “is whether or not the question encourages more
client talk” (Galvin & Ivey, 1981, p. 539). It is the difference between a multiple-choice inquiry
that checks the facts and an essay in which a deeper level of understanding and explanation is
encouraged.
Finally, a request for clarification is a response counselors use to be sure they understand
what clients are saying. These requests require clients to repeat or elaborate on material just cov-
ered. For example, a counselor might say, “Please help me understand this relationship” or “I
don’t see the connection here.”
Counselors wish to obtain several facts in an information-oriented first interview. They
often assume this information may be used as a part of a psychological, vocational, or psychoso-
cial assessment. Counselors employed by medical, mental health, correctional, rehabilitation,
and social agencies are particularly likely to conduct these types of interviews. Cormier (2015)
outlines some of the data counselors gather in these initial sessions (Figure 5.4).

Relationship-Oriented First Interview

Interviews that focus on feelings or relationship dynamics differ markedly from information-
oriented first sessions. They concentrate more on the client’s attitudes and emotions. Common
counselor responses include restatement, reflection of feeling, summary of feelings, request for
clarification, and acknowledgment of nonverbal behavior (Cormier, 2015).
A restatement is a simple mirror response to a client that lets the client know the counselor
is actively listening. Used alone, it is relatively sterile and ineffective:
Client: I’m not sure if I’ll ever find a suitable partner. My job keeps me on the
road and isolated.
Counselor: You don’t know if you will ever find a spouse because of the nature of
your job.
Reflection of feeling is similar to a restatement, but it deals with verbal and nonverbal
expression. Reflections may be on several levels; some convey more empathy than others. An
example is this counselor response to a client who is silently sobbing over the loss of a parent:
“You’re still really feeling the pain.”
Summary of feelings is the act of paraphrasing a number of feelings that the client has
conveyed. For example, a counselor might say to a client, “John, if I understand you correctly,
 Chapter 5 • Building Counseling Relationships 107

I. Identifying data
A. Client’s name, address, telephone number through which client can be reached. This information is
important in the event the counselor needs to contact the client between sessions. The client’s
address also gives some hint about the conditions under which the client lives (e.g., large apartment
complex, student dormitory, private home, etc.).
B. Age, sex, marital status, occupation (or school class and year). Again, this is information that can be
important. It lets you know when the client is still legally a minor and provides a basis for under-
standing information that will come out in later sessions.

II. Presenting problems, both primary and secondary

It is best when these are presented in exactly the way the client reported them. If the problem has
behavioral components, these should be recorded as well. Questions that help reveal this type of
information include
A. How much does the problem interfere with the client’s everyday functioning?
B. How does the problem manifest itself? What are the thoughts, feelings, and so on that are
associated with it? What observable behavior is associated with it?
C. How often does the problem arise? How long has the problem existed?
D. Can the client identify a pattern of events that surround the problem? When does it occur? With
whom? What happens before and after its occurrence?
E. What caused the client to decide to enter counseling at this time?

III. Client’s current life setting

How does the client spend a typical day or week? What social and religious activities, recreational
activities, and so on are present? What is the nature of the client’s vocational and/or educational
situation?

IV. Family history

A. Father’s and mother’s ages, occupations, descriptions of their personalities, relationships of each to
the other and each to the client and other siblings.
B. Names, ages, and order of brothers and sisters; relationship between client and siblings.
C. Is there any history of mental disturbance in the family?
D. Descriptions of family stability, including number of jobs held, number of family moves, and so on.
(This information provides insights in later sessions when issues related to client stability and/or
relationships emerge.)

V. Personal history
A. Medical history: any unusual or relevant illness or injury from prenatal period to present.
B. Educational history: academic progress through grade school, high school, and post-high school.
This includes extracurricular interests and relationships with peers.
C. Military service record.
D. Vocational history: Where has the client worked, at what types of jobs, for what duration, and what
were the relationships with fellow workers?
E. Sexual and marital history: Where did the client receive sexual information? What was the client’s
dating history? Any engagements and/or marriages? Other serious emotional involvements prior to
the present? Reasons that previous relationships terminated? What was the courtship like with
present spouse? What were the reasons (spouse’s characteristics, personal thoughts) that led to
marriage? What has been the relationship with spouse since marriage? Are there any children?

FIGURE 5.4 An information-oriented first interview

108 Part II • Counseling Processes and Theories

F. What experience has the client had with counseling, and what were the client’s reactions?
G. What are the client’s personal goals in life?

VI. Description of the client during the interview

Here you might want to indicate the client’s physical appearance, including dress, posture, gestures,
facial expressions, voice quality, tensions; how the client seemed to relate to you in the session; client’s
readiness of response, motivation, warmth, distance, passivity, etc. Did there appear to be any
perceptual or sensory functions that intruded upon the interaction? (Document with your observations.)
What was the general level of information, vocabulary, judgment, and abstraction abilities displayed by
the client? What was the stream of thought, regularity, and rate of talking? Were the client’s remarks
logical? Connected to one another?

VII. Summary and recommendations

In this section you will want to acknowledge any connections that appear to exist between the client’s
statement of a problem and other information collected in this session. What type of counselor do you
think would best fit this client? If you are to be this client’s counselor, which of your characteristics
might be particularly helpful? Which might be particularly unhelpful? How realistic are the client’s goals
for counseling? How long do you think counseling might continue?

FIGURE 5.4 (continued ) Source: From ‘’Counseling Strategies and Interventions 7e (pp. 66–68)” by L. S. Cormier and H. Hackney
© 2008. Reprinted by permission of Allyn & Bacon. Pearson Education, Inc.

you are feeling depressed over the death of your father and discouraged that your friends have
not helped you work through your grief. In addition, you feel your work is boring and that your
wife is emotionally distant from you.”
Acknowledgment of nonverbal behavior differs from the previous examples. For
instance, acknowledgment comes when the counselor says to a client, “I notice that your arms
are folded across your chest and you’re looking at the floor.” This type of response does not
interpret the meaning of the behavior.

CONDUCTING THE INITIAL INTERVIEW

There is no one place to begin an initial interview, but experts recommend that counselors start
by trying to make their clients feel comfortable (Cormier, 2015). Counselors should set aside
their own agendas and focus on the person of the client, including listening to the client’s story
and presenting issues (Myers, 2000; Wilcox-Matthew, Ottens, & Minor, 1997). This type of
behavior, in which there is a genuine interest in and acceptance of a client, is known as rapport.
Ivey, Ivey, and Zalaquett (2014) state that the two most important microskills for rap-
port building are basic attending behavior and client-observation skills. A counselor needs to
tune in to what the client is thinking and feeling and how he or she is behaving. In this process,
“counselor sensitivity to client-generated metaphors may help to convey understanding of the
client’s unique way of knowing and at the same time contribute to the development of a shared
language and collaborative bond between the client and counselor” (Lyddon, Clay, & Sparks,
2001, p. 270). For instance, a client may describe herself as being treated by others as “yester-
day’s leftovers.” This metaphor gives both the client and counselor information about the think-
ing and behavior going on in the client as she seeks to be seen “as the blue plate special.”
 Chapter 5 • Building Counseling Relationships 109

Regardless, establishing and maintaining rapport is vital for the disclosure of information, the
initiation of change, and the ultimate success of counseling.
Inviting clients to focus on reasons for seeking help is one way in which counselors may
initiate rapport. Such noncoercive invitations to talk are called door openers and contrast with
judgmental or evaluative responses known as door closers (Bolton, 1979). Appropriate door
openers include inquiries and observations such as “What brings you to see me?” “What would
you like to talk about?” and “You look as if you are in a lot of pain. Tell me about it.” These
unstructured, open-ended invitations allow clients to take the initiative (Cormier, 2015; Young,
2017). In such situations, clients are most likely to talk about priority topics.
The amount of talking that clients engage in and the insight and benefits derived from the
initial interview can be enhanced by the counselor who appropriately conveys empathy, encour-
agement, support, caring, attentiveness, acceptance, and genuineness. Of all of these qualities,
empathy is the most important.

Empathy
Rogers (1961) describes empathy as the counselor’s ability to “enter the client’s phenomenal
world, to experience the client’s world as if it were your own without ever losing the ‘as if’ qual-
ity” (p. 284). Empathy involves two specific skills: perception and communication (Welfel &
Patterson, 2005).
Effective counselors perceive the cultural frame of reference from which their clients oper-
ate, including their clients’ perceptual and cognitive processes (Weinrach, 1987). This type of
sensitivity, if it bridges the cultural gap between counselors and clients, is known as culturally
sensitive empathy and is a quality counselors may cultivate and acquire (Chung & Bemak,
2002). Nevertheless, counselors who can accurately perceive what it is like to be their client but
cannot communicate that experience are limited since no one knows of their awareness. The
ability to communicate clearly plays a vital role in any counseling relationship (Okun &
Kantrowitz, 2015).
In the initial interview, counselors must be able to convey primary empathy (Welfel &
Patterson, 2005). Primary empathy is the ability to respond in such a way that it is apparent to
both client and counselor that the counselor has understood the client’s major themes. It is
embraced by almost all theories because it is helpful in identifying client issues and has been
shown to be positively related to positive client outcomes (Neukrug, Bayne, Dean-Nganga, &
Pusateri, 2013). Primary empathy is conveyed through nonverbal communication and various ver-
bal responses. For example, the counselor, leaning forward and speaking in a soft, understanding
voice, may say to the client, “I hear that your life has been defined by a series of serious losses.”
Advanced empathy is a process of helping clients explore themes, issues, and emotions
new to their awareness (Welfel & Patterson, 2005). This second level of empathy is usually inap-
propriate for an initial interview because it examines too much material too quickly. Clients must
be developmentally ready for counseling to be beneficial. Therefore, advanced empathy is used
in the working stage of counseling.

PERSONAL REFLECTION
It has been said that a counselor who cannot convey empathy is like a tree in a forest that falls with
no one around. What do you think of that analogy? What other analogies do you think are appro-
priate to describe this phenomenon?
110 Part II • Counseling Processes and Theories

Verbal and Nonverbal Behavior

Whatever its form, empathy may be fostered by attentiveness (the amount of verbal and nonverbal
behavior shown to the client). Verbal behaviors include communications that show a desire to com-
prehend or discuss what is important to the client (Cormier, Nurius, & Osborn, 2017). These
behaviors (which include probing, requesting clarification, restating, and summarizing feelings)
indicate that the counselor is focusing on the person of the client. Equally important are the coun-
selor’s nonverbal behaviors. According to Mehrabian (1970), physically attending behaviors such
as smiling, leaning forward, making eye contact, gesturing, and nodding one’s head are effective
nonverbal ways of conveying to clients that the counselor is interested in and open to them.
Egan (2014) summarizes five nonverbal skills involved in initial attending. They are best
remembered in the acronym SOLER.

The Meaning of the Letters in SOLER

S = face the client squarely

Facing a client squarely can be understood literally or metaphorically depending on the
situation. The important thing is that the counselor shows involvement and interest in the client.
O = adopt an open posture
Do not cross arms and legs. Be nondefensive.
L = lean toward the client
Leaning too far forward and being too close may be frightening, whereas leaning too far
away indicates disinterest. The counselor needs to find a middle distance that is comfortable
for both parties.
E = eye contact
Good eye contact with most clients is a sign that the counselor is attuned to the client. For
other clients, less eye contact (or even no eye contact) is appropriate.
R = relax
A counselor needs to be and look relaxed as well as comfortable.

Okun and Kantrowitz (2015) list supportive verbal and nonverbal behavioral aids that
counselors often display throughout counseling. Among the supportive verbal responses are
using understandable words, summarizing, being nonjudgmental and respectful, and occasion-
ally using humor to reduce tension. Among the nonverbal responses are such behaviors as occa-
sionally smiling, talking at a moderate rate, and using occasional hand gestures.
One of the last nonverbal behaviors on Okun and Kantrowitz’s list, occasional touching,
is politically sensitive and somewhat controversial. Although Willison and Masson (1986), in
agreement with Okun and Kantrowitz, point out that human touch may be therapeutic in counsel-
ing, Alyn (1988) emphasizes that “the wide range of individual motivations for, interpretations
of, and responses to touch make it an extremely unclear and possibly a dangerous means of com-
munication in therapy” (p. 433). As a general counseling principle, Young (2017) suggests that
touch should be appropriately employed, applied briefly and sparingly, and used to communicate
concern. Applying the “Touch Test,” which simply asks, “Would you do this with a stranger?”
 Chapter 5 • Building Counseling Relationships 111

is one way to implement Young’s suggestions (Del Prete, 1998, p. 63). Thus, counselors who use
touch in their work should do so cautiously and with the understanding that what they are doing
can have adverse effects. This same critical scrutiny is suggested when using any verbal or non-
verbal technique.

Nonhelpful Interview Behavior

When building a relationship, counselors must also realize what they should not do. Otherwise,
nonhelpful behaviors may be included in their counseling repertoire. Welfel and Patterson (2005)
list four major actions that usually block counselor–client communication and should
be generally avoided: advice giving, lecturing, excessive questioning, and storytelling by the
counselor.
Advice giving is the most controversial of these four behaviors. Knowles (1979) found
that 70% to 90% of all responses from volunteer helpers on a crisis line consisted of giving
advice. When a counselor gives advice, especially in the first session, it may in effect deny a
client the chance to work through personal thoughts and feelings about a subject and ulti-
mately curtail his or her ability to make difficult decisions. A response meant to be helpful
ends up being hurtful by disempowering the client. For example, if a client is advised to
break off a relationship he or she is ambivalent about, the client is denied the opportunity to
struggle, become aware, and work through the thoughts and feelings that initially led to the
ambivalence.
Sack (1985) suggests that advice giving need not always be destructive. He notes that there
are emergency situations (as in crisis counseling) when, for the client’s immediate welfare and
safety, some direct action must be taken, which includes giving advice. He cautions counselors,
however, to listen carefully to make sure the client is really asking for advice or simply being
reflective through self-questions. There is a big difference between “What should I do?” and
“I wonder what I should do.” In addition, Sack advocates the responses developed by Carkhuff
(1969) as ways in which counselors can answer direct requests for advice. In this model, coun-
selors respond using one of seven approaches: respect, empathy, genuineness, concreteness, self-
disclosure, confrontation, and immediacy. Sack (1985) concludes that counselors must examine
their roles in counseling to “free themselves of the limitations and pitfalls of giving advice and
move toward employing a variety of responses that can more appropriately address their clients’
needs” (p. 131).
Lecturing, or preaching, is really a disguised form of advice giving (Welfel &
Patterson, 2005). It sets up a power struggle between the counselor and client that neither
individual can win. For example, if a sexually active girl is told “Don’t get involved with
boys anymore,” she may do just the opposite to assert her independence. In such a case, both
the counselor and client fail in their desire to change behaviors. Counselors are probably
lecturing when they say more than three consecutive sentences in a row to their clients.
Instead of lecturing, counselors can be effective by following the client’s lead (Evans, Hearn,
Uhlemann, & Ivey, 2011).

PERSONAL REFLECTION
When have you found advice helpful? When have you found it harmful? What were the results of
each?
112 Part II • Counseling Processes and Theories

Excessive questioning is a common mistake of many counselors. Verbal interaction with

clients needs to include statements, observations, and encouragers as well as questions. When
excessive questioning is used, clients feel as though they are being interrogated rather than coun-
seled. In such situations, they have little chance to take the initiative and may become guarded.
Children may especially respond in this way or make a game out of answering a question, wait-
ing for the next one, answering it, waiting, and so on (Erdman & Lampe, 1996). Counseling
relationships are more productive when counselors avoid asking more than two questions in a
row and keep their questions open rather than closed.
Storytelling by the counselor is the final nonhelpful behavior. There are a few prominent
professionals who can use stories to benefit clients. Milton Erickson, a legendary pioneer in fam-
ily counseling, was one. His stories were always metaphorically tailored to his clients’ situations.
They were beneficial because they directed clients to think about their own situations in light of
the stories he told. Most counselors, however, should stay away from storytelling because the
story usually focuses attention on the counselor instead of the client and distracts from problem
solving.
Okun and Kantrowitz (2015) list other nonhelpful verbal and nonverbal behaviors. Some
of these behaviors, such as yawning or acting rushed, clearly show the counselor’s disinterest.
Others, such as interrupting, blaming, and directing, are dismissive or disempowering, which is
just the opposite of what counseling should be.

• Acting rushed
• Advice giving
• Being dismissive
• Blaming
• Excessive questioning
• Interrupting
• Lecturing
• Storytelling
• Yawning

Nonhelpful and Nonverbal Behaviors in Counseling

EXPLORATION AND THE IDENTIFICATION OF GOALS

In the final part of building a counseling relationship, the counselor helps the client explore spe-
cific areas and begin to identify goals that the client wants to achieve. Hill (2014) emphasizes
that establishing goals is crucial in providing direction and expectation at any stage of counsel-
ing. Egan (2014) observes that exploring and ultimately identifying goals often occur when a
client is given the opportunity to talk about situations or to tell personal stories. The counselor
reinforces the client’s focus on self by providing structure, actively listening (hearing both con-
tent and feelings), and helping identify and clarify goals.
Rule (1982) states that goals “are the energizing fabric of daily living” but are often elu-
sive (p. 195). He describes some goals as unfocused, unrealistic, and uncoordinated. Unfocused
goals are not identified, too broad, or not prioritized. Sometimes counselors and clients may
 Chapter 5 • Building Counseling Relationships 113

leave unfocused goals alone because the time and expense of chasing them is not as productive
as changing unwanted behaviors. In most cases, however, it is helpful to identify a client’s goals,
put them into a workable form, and decide which goals to pursue first.
Unrealistic goals, as defined by either counselor or client, include happiness, perfection,
progress, being number one, and self-actualization. They have merit but are not easily obtained or
sustained. For example, the client who has worked hard and is happy about being promoted will
soon have to settle into the duties of the new job and the reality of future job progress. Unrealistic
goals may best be dealt with by putting them into the context of broader life goals. Then the coun-
selor may encourage the client to devise exploratory and homework strategies for dealing with them.
Uncoordinated goals, according to Rule (1982), are generally divided “into two groups:
those probably really uncoordinated and those seemingly uncoordinated” (p. 196). Goals in the
first group may be incompatible with one another or with the personality of the client. A person
who seeks counseling but really does not wish to work on changing exemplifies an individual with
incompatible goals. These clients are often labeled resistant. Into the second group, Rule places
the goals of clients who appear to have uncoordinated goals but really do not. These individuals
may be afraid to take personal responsibility and engage any helper in a “yes, but . . .” dialogue.
Dyer and Vriend (1977) emphasize seven specific criteria for judging effective goals in
counseling:
1. Goals are mutually agreed on by client and counselor. Without mutuality, neither
party will invest much energy in working on the goals.
2. Goals are specific. If goals are too broad, they will never be met.
3. Goals are relevant to self-defeating behavior. There are many possible goals for cli-
ents to work on, but only those that are relevant to changing self-defeating action should be
pursued.
4. Goals are achievement and success oriented. Counseling goals need to be realistic and
have both intrinsic and extrinsic payoffs for clients.
5. Goals are quantifiable and measurable. It is important that both client and counselor
know when goals are achieved. When goals are defined quantitatively, achievement is
most easily recognized.
6. Goals are behavioral and observable. This criterion relates to the previous one: An
effective goal is one that can be seen when achieved.
7. Goals are understandable and can be restated clearly. It is vital that client and coun-
selor communicate clearly about goals. One way to assess how well this process is achieved
is through restating goals in one’s own words.

CASE EXAMPLE
Crossing the Goal Line
Timothy has lived with an overlay of depression all his life. Now that he is in college, he has
decided to do something about it. When he visited the College Counseling Center, his counselor,
LaShonda, suggested that he set goals on how he was going to handle his depression. Timothy
listed the following:
1. Exercise every morning before class.
2. Eat healthy food.
3. Get engaged in at least one campus activity, such as playing an intramural sport.
114 Part II • Counseling Processes and Theories

4. Keep a journal of my thoughts and feelings and when they come.

5. Come to counseling for a month.
What do you think of Timothy’s goals? Are they realistic? What else do you think he
should do (if anything)?
Egan (2014) cautions that in the exploratory and goal-setting stage of counseling, several
problems may inhibit the building of a solid counselor–client relationship. The most notable
include moving too fast, moving too slowly, fear of intensity, client rambling, and excessive
time and energy devoted to probing the past. Counselors who are forewarned about such poten-
tial problems are in a much better position to address them effectively. It is vital that counselors
work with clients to build a mutually satisfying relationship from the start. When this process
occurs, a more active working stage of counseling begins.

Summary and Conclusion

Building a relationship, the first stage in counseling, seemingly unmotivated. Clients are likely to work
is a continuous process. It begins by having the best with counselors they perceive as trustworthy,
counselor win the battle for structure and the client attractive, and knowledgeable.
win the battle for initiative. In such situations, both Regardless of the external circumstances and
parties are winners. The client wins by becoming the initial perceptions, a counselor who attends to
more informed about the nature of counseling and the verbal and nonverbal expressions of a client is
learning what to expect. The counselor wins by cre- more likely to establish rapport. The counselor’s
ating an atmosphere in which the client is comfort- conveying of empathy and the use of other helpful
able about sharing thoughts and feelings. microskills such as the use of the SOLER model
Counseling may occur in any setting, but some may further enhance the relationship. When coun-
circumstances are more likely than others to promote selors are attuned to their own values and feelings,
its development. Counselors need to be aware of the they are able to become even more effective. The
physical setting in which the counseling takes place. initial counseling interview can be counselor or cli-
Clients may adjust to any room, but certain qualities ent initiated and can center on the gathering of
about an environment, such as the seating arrange- information or on relationship dynamics. In any sit-
ment, make counseling more conducive. Other, less uation, it is vital for the counselor to explore with
apparent qualities also affect the building of a rela- the client the reasons for coming to counseling and
tionship. For example, the perception that clients and what might be realistic outcomes. Such disclosures
counselors have about one another is important. can encourage clients to define goals and facilitate
Attractive clients who are young, verbal, intelligent, the setting of a mutually agreed-on agenda in coun-
and social may be treated in a more positive way seling. When this step is accomplished, the work of
than clients who are older, less intelligent, and reaching goals begins.

MyCounselingLab® for Introduction to Counseling

Try the Topic 3 Assignments: Characteristics of the Effective Counselor.
 Helping the Client Explore the Problem (Part 1) 83

So when you are CHAPTER 5 to facilitate exploration of the client’s issues, we start by
listening to examining primary empathy (the capacity to step into the
somebody,
completely,
Helping the Client Explore the client’s shoes and step out again; to accurately perceive the
attentively, then client’s internal world through the client’s eyes). Empathy
you are listening
Problem (Part 1) hinges on the quality of active listening. Empathy will not
not only to the thrive in an atmosphere of imperfect listening. The client will
words, but also intuitively know if we are listening by the quality of our
to the feeling of responses and by how precisely we respond.
what is being
conveyed,to the
whole of it, not
part of it.
JIDDU
H aving examined various topics related to establishing a
climate of safety and trust designed to enable
counselling to start off on a good footing in the previous
Empathic responding
Communicating empathy is a central to active listening –
KRISHNAMURTI, hearing what the client says from their internal frame of
AUTHOR
chapter, the next two chapters concentrate on the
reference, and responding in such a way that the client knows
fundamentals of counselling – what the counsellor does to
and feels that the counsellor is striving to understand their
facilitate the counselling process.
difficulties accurately. It is crucial to remember that empathy is
In this chapter the spotlight is placed on basic skills used by
about distinguishing and acknowledging the client’s frame of
counsellors to facilitate exploration of the client’s problem:
reference, not conveying our own.
primary level empathy, active listening, attending, appropriate
use of silences, paraphrasing, reflecting feelings, and open and
closed questions. Examples of the skills in action are presented Primary level empathy in action
to augment learning, and pitfalls that can hinder client– (Client and counsellor talking.)
counsellor communication are also given prominence. 1. Client: I keep telling myself not to move too quickly
Essentially, the core skills for a blossoming client experience with Jenny. She’s so quiet, and when she does
are characterised by good listening skills on the part of the say anything, it’s usually how nervous she is.
counsellor. To get a feel for the listening skills used by the It’s obvious to me that when I say anything to
counsellor to facilitate exploration of the problem see Figure 5.1. her she gets fidgety and anxious, then I wish I
Counsellor uses the skills of hadn’t opened my mouth. It’s like a
checkmate. If I move I push her away, and if I
Primary Active Paraphrasing Using Summarising Focusing Concreteness don’t move, nothing will happen between us,
level listening content and open and I’ll lose her anyway.
empathy and reflecting questions
attending feelings (Facts and feelings identified by counsellor:
Aim: To facilitate exploration of the problem
anxious, Catch-22, cautious, frustrated,
protective, regret.)
Counsellor: George, you feel both protective of Jenny
Figure 5.1 The listening skills used by the counsellor to facilitate exploration of the problem.
because you want to respect her pace, yet you
also feel on edge because you’re afraid that the
Primary level empathy relationship is not going anywhere.
To introduce you to the basic skills counsellors need to acquire
2. Client: I’m enjoying the work, and get on really well
with my colleagues, but I am struggling to

82
84 Learning to Counsel Helping the Client Explore the Problem (Part 1) 85

keep up with the long hours. I can’t sleep – 1. Not paying attention – wandering off at a tangent,
keep waking up at 4.30am, have lost my daydreaming, clock-watching, preoccupation with other
appetite, and am getting a lot of headaches. things/other client concerns.
(Facts and feelings identified by counsellor: 2. Listening only for the facts and not hearing the client’s
enthusiastic, stressed, exhausted, falling apart.) feelings.
Counsellor: While on the one hand you like your job, and 3. Pretend-listening – faking listening, acting interested while
have a good relationship with your co-workers, planning what to say next.
on the other you are feeling the pressure from 4. Selective listening – tuning in to elements of the client’s
having to put in such long hours, which is story that interest you and filtering out the rest.
making it difficult for you keep afloat and is 5. Listening but not hearing the meaning – missing the point,
taking a considerable toll on your overall well- losing the gist.
being. 6. Mental rehearsal – calculating how to respond before the
client has finished talking.
7. Interrupting the client in mid-sentence – breaking the
Knowing if empathy has been achieved
client’s train of thought.
Client responses such as ‘You’ve got it in one’, ‘That’s it 8. Second-guessing what the client is going to say next –
exactly’, ‘You’ve hit the nail right on the head’, or ‘That’s it in predicting the client’s next statement.
a nutshell’ generally indicate that the counsellor has accurately 9. Appeasing the client to maintain harmony by agreeing with
perceived the situation from the client’s frame of reference. what she has said rather than sensitively drawing attention
to identified cognitive distortions or negative thought
Active listening patterns that could be preventing the client from moving
Active listening is a powerful tool for improving understanding. forward.
It enhances mutual trust and respect; it demonstrates interest in 10. Side-stepping difficult material – avoiding emotionally-
the client and illustrates that you are keen to hear about, and laden experiences, memories, or words.
grasp, the client’s situation. The tools of active listening
include, but are not limited to, attending, listening with an Other obstacles to listening
open mind, listening for meaning, listening beyond the words
Active listening can also be affected by a range of other factors.
to hear the client’s feelings, listening to the whole person, and
Figure 5.2 provides examples of ‘internal blocks’ to listening,
observing the client’s verbal and non-verbal signals for signs of followed by Figure 5.3 which gives examples of ‘external blocks’
possible conflict. Active listening is an art that requires much to listening.
more than simply listening – it entails energetic use of our
senses: our ears to hear, our eyes to see, and our sense of smell,
touch, and taste to perceive the full picture. Perfecting the art Listening with the third ear
of active listening implies constantly sharpening your tools. Theodor Reik (1888–1969), a prominent psychoanalyst, and
author of Listening with the Third Ear: The Inner Experience of
a Psychoanalyst (1948) coined the term ‘listening with the third
Examples of poor listening
ear’ to emphasise the quality of psychotherapy, where active
Good listening can be affected by numerous factors – here are listening goes beyond the five senses. The ‘third ear’ hears what
ten examples of poor listening that could encumber effective is said, as well as hearing what is not being expressed (the
client–counsellor interaction:
86 Learning to Counsel Helping the Client Explore the Problem (Part 1) 87

emotions behind the words – the sensations – the silent

Listening blocks (internal) language expressed by the body, the client’s internal
experience).
The listener wishes to ‘do well’ and Prejudice. Any ‘ism’s’, eg racism,
constantly watches himself for a sexism. Listener stereotypes the client
glowing performance. and fails to listen for differences. Principles for third ear listening
X Have a reason or purpose for listening.
The listener gets irritated by
X Suspend judgment.
The listener’s own thoughts are
something the client says, and gets triggered off by something the client X Resist distractions.
caught up with her own emotions. has said. X Wait before responding.
X Repeat verbatim.
The listener is afraid to listen, The listener concentrates too much X Rephrase the message accurately.
because of the responsibility on the problem rather than listening X Identify important themes.
involved, e.g. coping with the to the client’s feelings about the
X Reflect content and search for meaning.
client’s distress. problem.
X Be ready to respond.

The listener’s attitude. For example,

The listener is tired, especially if the Contrasting good and poor listening
disapproves of the client’s tattoos,
client talks in a monotonous tone.
body piercings, clothes or accent.
With good listening, we communicate interest in the client,
show respect for the client’s thoughts, feelings and actions (i.e.
The listener listens to his own unconditionally accept the client even though we may not
The listener wants to rearrange the
expectations of what the client’s
client’s life to her own expectations. concur with their beliefs, values or behaviour), and validate the
problem is.
client as a person of worth.
Figure 5.2 Examples of ‘internal blocks’ to listening. Listening demonstrates, it does not tell. Listening catches
on. Just as non-constructive anger is typically greeted with
antagonism, good listening cultivates enhanced listening.
Listening is a beneficial activity and the person who
Listening blocks (external)
consistently listens with understanding is the person who is
most likely to be listened to.
Telephone ringing Noise outside the room Amenable listening can bring about changes in attitudes and
the way we behave toward others and ourselves. When we
genuinely feel heard, we tend to respond in a more emotionally
Listener fidgeting Listener looking at watch
mature way, become more trusting, more open, more
accepting, more independent. We listen to ourselves with more
Someone knocking on the door Listener sighing, yawning care, and can express our thoughts and feelings more clearly,
free from fear of being judged, criticised, or erecting barriers to
protect ourselves. We can shed our masks of pretence, discover
Room too hot or cold Distractions – books, papers
our real selves, and allow ourselves to become at one with who
we truly are.
Listener not concentrating on what
Insufficient organised time to listen
the speaker is saying

Figure 5.3 Examples of ‘external blocks’ to listening.

88 Learning to Counsel Helping the Client Explore the Problem (Part 1) 89

Good listening feeds on itself – what we give out invariably or would like to see them, this is control and direction, and is
flows back. more for our needs than for theirs. The less we need to
evaluate, influence, control and direct, the more we enable
ourselves to listen with understanding.
In contrast, poor listening has many unpleasant by- X When we respond to the demand for decisions, actions,
products. It can keep us stuck it a state of limbo, embarrassed
judgments and evaluations, or agree with someone against
to speak out, afraid to come out of our shell, ashamed to show
someone else, we are in danger of losing our objectivity.
who we really are, battened down emotionally, firmly anchored X When we shoulder responsibility for other people, we
in the victim position, hurting inside, fearful of criticism, or
remove from them the right to be active participants in the
shackled to painful unresolved issues or long-held hidden and
problem-solving process. Active involvement releases energy,
toxic secrets.
it does not drain it from the other person. Active
Poor listening is pervasive – it keeps us emotionally participation is a process of thinking with people, instead of
impoverished, vulnerable, and fearful of trusting, reaching thinking for, or about them.
X Judgment – critical or favourable – is generally patronising.
out, rejection and intimacy.
X Platitudes and clichés demonstrate either disinterest or a
verbal poverty.
X Verbal reassurances are insulting, for they demean the
Responding as a part of listening problem.
Passive listening, without responding, is deadening and
demeaning. We should never assume that we have really
Conveying non-acceptance
understood until we can communicate that understanding to
the full satisfaction of the client. Effective listening hinges on Demonstrating unconditional acceptance of the client is crucial
constant clarification to establish true understanding. to the client’s personal growth. Non-acceptance is characterised
by:
Effective listeners: X Advising, giving solutions – ‘Why don’t you. . .?’
1. Put the talker at ease. X Evaluating, blaming – ‘You are definitely wrong. . . ’
2. Limit their own talking. X Interpreting, analysing – ‘What you need is. . . ’
3. Are attentive. X Lecturing, informing – ‘Here are the facts. . .’
4. Remove distractions. X Name-calling, shaming – ‘You are stupid. . .’
5. Get inside the talker’s frame of reference. X Ordering, directing – ‘You have to. . . ’
6. Are patient and don’t interrupt. X Praising, agreeing – ‘You are definitely right. . .’
7. Watch for ‘feeling’ words. X Preaching, moralising – ‘You ought to. . .’
8. Listen to the paralinguistics (utterances, manner of X Questioning, probing – ‘Why did you . . .?’
speaking, pitch, volume, intonation). X Sympathising, supporting – ‘You’ll be OK. . .’
9. Are aware of their own biases. X Warning, threatening – ‘You had better not. . .’
10. Are aware of body language. X Withdrawing, avoiding – ‘Let’s forget it. . .’

Knowing what to avoid Staying in tune with the client

When we try to get people to see themselves as we see them, Remaining on the same wavelength as clients involves:
90 Learning to Counsel Helping the Client Explore the Problem (Part 1) 91

X Entering the client’s frame of reference (the client’s internal Attending

world). The greatest gift you can give another is the purity of your
X Listening for total meaning which is the content and the attention.
feelings. Both require hearing and responding to. In some Richard Moss (teacher and author)
instances the content is far less important than the feeling,
for the words are but vehicles. We must try to remain Attending demonstrates that we are physically and emotionally
sensitive to the total meaning the message has to the client: available to the client. It involves giving the client our
– What is the client trying to convey? undivided attention – listening to the facts, and feelings, and
– What does this mean to the client? paying attention to the client’s body language.
– How does the client see this situation? Attending involves:
X Note all cues; not all communication is verbal. Truly X body: eye contact, facial expression, limbs relaxed;
sensitive listening notes: X thoughts: uncluttered and focused, totally engaged in
– body posture; listening;
– breathing changes; X attitude: open and available;
– eye movements; X feelings: secure, calm, confident.
– facial expression;
– hand movements; Gerard Egan (2007, pp75–7) coined the acronym SOLER to
– hesitancies; encapsulate the non-verbal skills required to stay tuned in to
– inflection; the client. See Figure 5.4 for examples of SOLER contact.
– mumbled words;

S O L E R
– stressed words.

Summary
Listening is far from the passive state which some people think
Sitting at a Open posture. Leaning Effective eye Remaining
it is. Active listening – as presented here – is a skill of great
comfortable Arms and legs forward from contact relatively
sophistication, which is available to all who would attempt to
angle and uncrossed. time to time. without relaxed.
acquire and practise it. Words are vehicles for feelings, and
distance. Looking staring.
feelings are the cement which holds together the bricks of a
genuinely
relationship. So it is essential to respond to both words
interested.
(content) and feelings.
Listening
Responding is giving feedback, but not feedback which
attentively.
merely repeats what the person says – that is parroting, which
is unconstructive.
Constructive feedback is two-pronged. Positive feedback, Figure 5.4 Examples of SOLER contact.
sincerely given, can be a priceless gift to building the client’s
self-esteem and acknowledging the client’s achievements and Minimal encouragers
progress. Alternatively, while negative feedback may feel
Minimal encouragers are single words, brief phrases, or sounds
uncomfortable to give, if imparted sensitively and caringly, it
that demonstrate to the client that you are fully attending. They
has potential to facilitate the client’s personal growth.
92 Learning to Counsel Helping the Client Explore the Problem (Part 1) 93

are designed to encourage the client to say more, and to reveal that follows perfectly illustrate the authors’ differing beliefs on
to the client you are listening, interested, and open to hearing the value of silence in counselling.
additional information. Here are some examples of attending
responses:
Use of silences (Jan’s view)
X Oh . . .
X And? In some instances, remaining quiet can be a valuable minimal
X Go on . . . encourager as it provides time and space for the client to think,
X Uh-huh feel and express. However, while some clients are comfortable
X Umm-hmmm with silences, others can feel threatened or intimidated by
X I’m listening . . . them. Thus counsellors need to be extremely cautious about
X And after that . . . allowing long silences, particularly in the early stages of
X Tell me more . . . counselling when the client may be feeling fragile, vulnerable,
X But . . .? and exposed.
X Then? Tense silences can be very distressing, particularly for many
trauma survivors, who could have spent years locked in a world
of silence, and who may view the silent counsellor as
Attending means total concentration. We can look as if we are
threatening, authoritarian, all powerful, remote – even abusive.
attending, but our thoughts can be a thousand miles away. We
may fool ourselves, but the other person will be intuitively
aware that we have left to go on another journey. At some of Reading the silence
the more dramatic moments of our life, just having another Read the client’s silence with your eyes and instincts – listen to
person with us helps us to feel in control, when otherwise we its intensity – is it a golden silence? Does the client appear
might collapse. relaxed, calm, and contemplative? Or is it a vociferous silence
In relationships, ask yourself: (sends shivers up and down your spine?). Does the client
X Am I truly present and in emotional contact? appear to be anxious, fidgety, or looking as if she can’t wait to
X Does my non-verbal behaviour reinforce my attitudes? leave? Trust your gut reaction. If you sense that the client is
X How am I being distracted from giving my full attention? struggling with the silence, consider actively intervening to end
X What am I doing to handle these distractions? the silence and put the client at ease or to prevent the client
from ‘suffering in silence’.
Silence as a minimal encourager While the positive value of tolerating silences may be
emphasised in some counselling traditions as sacrosanct to
Just as each client’s life experiences, feelings and beliefs are
allow time for the ‘penny to drop’, it needs to be borne in
unique, so it is with counsellors – we each bring our lived
mind that silences are only effective if the client feels
experiences, training and casework experiences into the
comfortable with them. Leaving a client ‘stuck in a threatening
counselling arena. Diversity of experiences and divergent
silence’ is not only dispassionate, it may well drive the client to
standpoints are healthy – they bring fresh perspectives, voices
abandon counselling holding the belief that counselling is more
of experience that can be shared, and varied points of view to
harmful than helpful.
consider. While collaborative book writing on a subject close to
the authors’ hearts can prove both interesting and stimulating it
can inevitably raise a disparity of opinion. The real-life view
94 Learning to Counsel Helping the Client Explore the Problem (Part 1) 95

Use of silences (William’s view) 4. Ellen: ‘I felt so low when my Charlie died, but now. . .’
On the one hand, we have to be careful that we don’t interpret William: ‘But now?’
silences wrongly; for example as resistance, because they may Ellen: ‘Well now I have met a kind and caring man
be a necessary process in helping the client integrate what has who wants me to move in with him, but . . .’
been said and perhaps to gain some insight or to understand William: ‘But?’
some deep emotion. Don’t give the impression of being caught Ellen: ‘But I know my Charlie wouldn’t approve – don’t
up in an express train. On the other hand, take note of the get me wrong – he wouldn’t want me to be
client who must always rush in and say something. Counsellors unhappy.’
who are never silent deprive themselves and their clients of the William: ‘Tell me a bit more.’
opportunity to listen to the deeper meanings that lie beyond 5. Danny: ‘I keep losing my temper – that’s the problem.’
words. When silence is thought to be resistance or blocking, Jan: ‘Uh-huh.’
the counsellor may use a prompt, for example, by repeating Danny: ‘It’s got me into trouble – I nearly got sent to
something previously said, or by drawing attention to the prison.’
nature of the silence. Counsellors may have to work hard on Jan: ‘Sent to prison.’
their ability to tolerate silence – what could be a constructive
silence is easily ruined by too quick an intervention. Some
silences are as deep as communing with another spirit. Paraphrasing
Paraphrasing refers to reflecting back the client’s
communication in your own words. Paraphrasing can bring
Attending responses in action with our five fictitious clients clarification. It means reflecting the content, mirroring the
1. Pat: ‘It’s really embarrassing to talk about what he literal meaning of the communication.
did.’ Sometimes paraphrasing is necessary; at others, reflecting
Jan: ‘Embarrassing?’ feelings is more appropriate. In every communication, words
Pat: ‘Yes, you see, I think it was partly my fault. . .’ are vehicles for feelings, so it is essential to hear and respond
Jan: ‘Please go on.’ to both content and feeling.
2. Paul: ‘I’ve tried getting another job and have sent off When listening, we focus initially upon the content. In
six application forms. . . ’ doing so, we want to be sure that we have all the details of the
William: ‘And?’ client’s experiences. Otherwise we will not be able to help the
Paul: ‘And I’ve heard absolutely nothing, it’s so . . .’ client to understand them.
William: ‘So?’
A paraphrased response will capture the main points
Paul: ‘Disheartening. I almost feel like giving up.’
communicated.
3. Hayley: ‘I keep cutting and burning myself.’
Jan: ‘Go on.’
Hayley: ‘I feel so ashamed and disgusted with myself. . .’
Focusing on content
Jan: (Leans forward towards Hayley and remains
WHO? WHAT? WHY? WHEN? WHERE? HOW?
silent.)
I keep six honest serving-men
Hayley: Bursts into tears and says, ‘I really hate myself, (They taught me all I knew);
and I can’t take much more.’ Their names are What and Why and When
Jan: ‘Can’t take much more?’ And How and Where and Who.
(Just So Stories ‘The Elephant’s Child’, Rudyard Kipling, 1902)
96 Learning to Counsel Helping the Client Explore the Problem (Part 1) 97

If we can supply answers to the above questions, we can be X So, to paraphrase then . . .
sure that we have the basic ingredients of the client’s X From listening to you, would it be correct to say that . . .
experience. X So, in effect, what you are saying is . . .
Useful formats for responding to content are:
X ‘You’re saying ____________________________________ ’
Paraphrasing in action
or
X ‘In other words ___________________________________’ (Client and counsellor talking.)
or 1. Client: I used to . . . enjoy going out and having . . .
X ‘It sounds as if ___________________________________ ’ fun. Now I have to really force myself, and I, I
. . . don’t enjoy myself any more. All the time
However, if we’re not careful, such responses can sound stilted I just have a, a . . . feeling of (longer pause)
and stereotyped. Try to retain freshness. sadness. I’m not really part of the group any
more.
(The key words and phrases here are: going
Paraphrasing is not parroting out; fun; force; sadness, not part of.)
A paraphrase is a brief response, in the hearer’s own words, Counsellor: In the past, Andrew, you had a great time
that captures the main points of the content of what the other socialising. Right now, however, you’ve lost
person has said. It may condense or expand what has been your drive, and don’t get much pleasure from
said. In general conversation, many assumptions are made going out and meeting people. For a lot of the
about what has been said. Counselling is not an ‘ordinary’ time you feel down and flat and not really part
conversation. of what’s going on around you.

Effective paraphrasing is part of effective listening which 2. Client: I don’t expect Sam to help with all the
ensures understanding. household chores, but he knows very well I
need time to study for my nursing finals. I
can’t spend all my spare time cooking and
Words carry feelings, so not only is it necessary to understand cleaning and waiting on him hand and foot.
the client’s words, we must also try to understand why (The key words and phrases here are: expect,
particular words, in preference to others, are used. chores, time, exams, hand and foot.)
If clients have been expressing their thoughts with difficulty, Counsellor: Susan, you would like Sam to support you
then is a good time to paraphrase. Letting clients hear the more, and take his share of the work around
meaning as understood by someone else may help them to the house, so that you can find more time to
clarify more precisely what they do mean. Paraphrasing may study instead of running after him. You would
echo feeling words without responding to them. Here are some like a bit more sharing.
examples of paraphrasing responses:
X What I seem to be hearing is . . .
To conclude our discussion on paraphrasing we continue our
X So what you are saying is . . .
dialogue with our five fictitious clients:
X So it’s as though . . .
X In other words, what you’re saying is . . .
1. Counsellor: Pat, ‘So what you are saying is that you think you
X What appears to be coming across is . . .
might be partly to blame for what happened . . .’
X From what you have told me it seems as if . . .
98 Learning to Counsel

2. Counsellor: ‘Paul, it sounds as if not getting any replies to

your job applications so far is making your
wonder whether it’s worth bothering applying for
any more . . .’
3. Counsellor: ‘Hayley, from what you have told me it seems as
though you are having a difficult time right now,
and things are getting too much for you . . .’
4. Counsellor: ‘Ellen, what you seem to be saying is that you
think you would be letting Charlie down in some
way if you accepted this man’s offer . . . ’
5. Counsellor: ‘Danny, from my understanding, your anger is
landing you in trouble, and the magistrates’ court
is concerned that if you don’t learn to manage it
constructively you’ll end up in serious trouble . ..’

Reflecting feelings
Being in touch with, and connected to, our feelings and
emotions is crucial to physical and psychological well-being,
and many clients seek counselling to help them identify and
work through distressing and difficult emotions – indeed,
helping clients to recognise and process painful emotions is a
key task for most counsellors.
Reflecting concentrates on the feelings within a statement.
Paraphrasing and reflecting are invariably linked. In practice, it
may be artificial to try to separate them. Reflecting feelings
accurately depends on empathic understanding.
In listening to someone who is talking about a problem,
neither pity nor sympathy are constructive. Both are highly
subjective. Reflecting involves both listening and understanding
and communicating that understanding. If our understanding
remains locked up within us, we contribute little to the
communication.
The ability to accurately reflect feelings involve viewing the
world from the other person’s frame of reference; thoughts,
feelings and behaviours. Effective responding indicates a basic
acceptance of people.
Reflecting does not act as a communication ‘stopper’ on the
flow of talk, on emotions, or make people feel inadequate,
Working in and Closing a Counseling
Relationship 6
Chapter Overview
From this chapter you will
learn about:
■ The Johari window

conceptualization of a client
development in counseling
■ Counselor skills in the

understanding, action, and

closing phases of counseling
■ Transference,

countertransference, and
the real relationship
■ The importance of closing

a counseling relationship
and types of closing, such
as counselor initiated, client
initiated, mutually agreed
Photographee.eu/Fotolia on, and premature
■ Issues in ending counseling

either on a session or case

I listen and you tell me how basis and the importance of
the feelings rage and toss within you. follow-up and referral
A mother died, a child deserted,
As you read consider:
and you, that child, have not forgotten ■ How you conceptualize
what it is to be alone. change occurring in
I nod my head, your words continue counseling
rich in anger from early memories, ■ Your ability to smoothly
Feelings that you tap with care incorporate new skills into
after years of shaky storage. your interpersonal
As you drink their bitter flavor, relationships
which you declined to taste at seven, ■ When you have transferred

I mentally wince while watching you thoughts and feelings onto

open your life to the dark overflow someone else and when you
of pain that has grown strong with age. have had a genuine and deep
relationship with someone
From “Memory Traces,” by S. T. Gladding, 1977, North Carolina Personnel and ■ Your ease or difficulty (for
Guidance Journal, 6, p. 50. © S. T. Gladding.
example, resistance) in
closing a relationship and
your reaction to premature
endings of events
■ How well you follow up with

people and how you do so

116 Part II • Counseling Processes and Theories

The successful outcome of any counseling effort depends on a working alliance between
counselor and client (Kottler, Sexton, & Whiston, 1994; Okun & Kantrowitz, 2015). A
working alliance is a conscious and purposeful aspect of a counseling relationship and
includes affective or bonding elements such as “liking, respect, and trust,” along with a
collaborative spirit between counselor and client in “establishing tasks and goals of treatment”
(Fitzpatrick & Irannejad, 2008, p. 438). Building this relationship is a developmental process
that involves exploring the situation that has motivated the client to seek help. “Research with
adults has shown that to establish effective alliances, counselors need to constantly assess
clients’ commitment and deal with obstacles that impinge on this commitment” (p. 438).
Establishing a working alliance with adolescents is more difficult yet because many of them do
not seek counseling on a voluntary basis and do not think they need therapeutic services.
Regardless of age or stage in life, clients arrive in counseling with certain areas of their
lives open or understood and other areas hidden or suppressed. The Johari window, shown in
Figure 6.1, is a conceptual device used to represent the way in which most individuals enter the
counseling relationship (Luft, 1970). This simple diagram depicts what clients know about
themselves and what others know about them. Usually, clients have limited or distorted infor-
mation about how others see them, and they have substantial hidden areas of themselves that
they avoid exposing. They live a rather constricted life that is freely known to themselves and
others but is not fulfilling, and they are often unaware (as are others) of their potential.
Successful counseling helps clients relax enough to tell their stories and discover informa-
tion located in the blind areas of themselves, two regions about which they have been unaware
(Quadrants III and IV). Once they obtain a better understanding of these areas (either verbally or
nonverbally), informed clients can decide how to proceed in expanding what is known to them-
selves and to others (Quadrant I). If they are successful in their work, they extend the dimensions
of this area of free activity as represented in the Johari window while shrinking the dimensions
of the more restrictive areas. Quadrant II (known to self but hidden from others) may expand a
lot or a little depending on the sensitivity of the information within it (Figure 6.2).
It may appear that the counseling process described in this text and represented in the
Johari window is linear, but such is not the case (Moursund & Kenny, 2002). Counseling is
multifaceted, with various factors impacting each other continuously. Therefore, procedures

Known to Self Not Known to Self

I. III.

Known to Blind Area—Blind to

Area of Free Activity
Others self, seen by others

II. IV.
Avoided or Hidden Area of Unknown
Not Known
Area—Self hidden from Activity
to Others
others

FIGURE 6.1 The Johari window of the client

Sources: From Luft, J. The Johari window of the client. In J. Luft, Of human interaction. Copyright © 1969 by Joseph
Luft. Reprinted with permission of the author.
 Chapter 6 • Working in and Closing a Counseling Relationship 117

Relationship Initiated Close Relationship

I II

I II

III IV

III IV

FIGURE 6.2 Johari window as modified through the relationship with the counselor
Source: From Luft, J. Group processes: An introduction to group dynamics. In J. Luft, Of human interaction (3rd ed.,
p. 14). Palo Alto, CA: National Press Books / Mayfield Publishing Co. © 1984. Reprinted by permission of Joseph Luft.

overlap considerably, and progress is uneven (Egan, 2014). Because of the unevenness of coun-
seling and times of regression, some skills and techniques are used repeatedly. Yet as counsel-
ing progresses, new and different practices and procedures are regularly incorporated. Likewise
when a counseling session or a counseling experience is closing, skills particular to the situa-
tion are employed along with those that may have been used previously.
In this chapter, common practices associated with the working and closing phases of
counseling are explored. They involve a number of counselor skills, including changing percep-
tions, leading, multifocused responding, accurate empathy, self-disclosure, immediacy,
confrontation, contracting, rehearsal, referral, ending, and follow-up.

COUNSELOR SKILLS IN THE WORKING STAGE OF COUNSELING:

UNDERSTANDING AND ACTION
Counselors must be active in helping clients change and develop. After rapport has been estab-
lished, counselors need to employ skills that result in clients’ viewing their lives differently
(altering perceptions) and thinking, feeling, and behaving accordingly.

Changing Perceptions
Clients often come to counseling as a last resort, when they perceive that the situation is not only
serious but hopeless (Watzlawick, 1983). People think their perceptions and interpretations are
accurate. When they communicate their view of reality to others, it is commonly accepted as
factual (Cavanagh & Levitov, 2002). This phenomenon, called functional fixity, means seeing
things in only one way or from one perspective or being fixated on the idea that this particular
situation or attribute is the issue (Cormier, Nurius, & Osborn, 2017).
For example, a middle-aged man is concerned about taking care of his elderly mother. He real-
izes that personal attention to this task will take him away from his family and put a strain on them
and him. Furthermore, he is aware that his energy will be drained from his business and he might not
receive the promotion he wants. He is torn between caring for two families and sees his situation as
118 Part II • Counseling Processes and Theories

problematic. Appropriate and realistic counseling objectives would include finding community and
family resources the man could use to help take care of his mother, his family, and himself. In the
process, the man would discover what he needs to do to relieve himself of sole responsibility in this
case and uncover concrete ways he can increase his work efficiency but not his stress. The focus on
taking care of self and others, as well as using community and family resources, gives the man a dif-
ferent perspective about his situation and may help him deal with it in a healthy manner.
Counselors can help clients change distorted or unrealistic objectives by offering them the
opportunity to explore thoughts and desires within a safe, accepting, and nonjudgmental envi-
ronment. Goals are refined or altered using cognitive, behavioral, or cognitive–behavioral strate-
gies, such as
• redefining the problem,
• altering behavior in certain situations, or
• perceiving the problem in a more manageable and less stressful way and acting accord-
ingly (Okun & Kantrowitz, 2015).
By paying attention to both verbal (i.e., language) and nonverbal (i.e., behaviors) metaphors,
counselors can help clients become more aware of where they are and where they wish to be
(Lyddon, Clay, & Sparks, 2001). They can also enhance counselor–client relationships and inter-
vention strategies as well as improve their own competence in moving beyond jargon and fixed
interpretations that may be less than accurate (Robert & Kelly, 2010; Sommer, Ward, & Scofield,
2010). Basically, metaphors (including similes) provide insight for clients and counselors and
ways of conceptualizing the counseling process in a productive way, such as “life is a journey”
(i.e., it takes time and effort) or “counseling is like baking a cake” (i.e., it requires a blending of
the right ingredients) (Tay, 2012).
Perceptions commonly change through the process of reframing, a technique that offers
the client another probable and positive viewpoint or perspective on a situation. Such a changed
point of view gives a client a different way of responding (Young, 2017). Effective counselors
consistently reframe life experiences for both themselves and their clients. For instance, a per-
son’s rude behavior may be explained as the result of pressure from trying to complete a task
quickly rather than dislike for the impolitely treated person.
Reframing is used in almost all forms of counseling. For example, in family counseling
reframing helps families change their focus from viewing one member of the family as the source
of all their problems (i.e., the scapegoat) to seeing the whole family as responsible. In cases
concerning individuals, Cormier and colleagues (2017) point out that reframing can reduce resis-
tance and mobilize the clients’ energy to do something differently by changing their perception
of the problem. In short, reframing helps clients become more aware of situational factors asso-
ciated with behavior. It shifts the focus from a simplistic attribution of traits, such as “I’m worth-
less,” to a more complex and accurate view, such as “I have some days when things don’t go
very well and I put myself down.” Through reframing, clients see themselves and their environ-
ments with greater accuracy and insight.

PERSONAL REFLECTION
When our third child was born, my wife, Claire, looked up at me and said, “The honeymoon is not
over. There are just more people on it!”
When have you or someone close to you reframed a situation or circumstance? How did it
influence your perception of the situation or circumstance?
 Chapter 6 • Working in and Closing a Counseling Relationship 119

Leading
Changing client perceptions requires persuasive skill and direction from the counselor. Such
input is known as leading. The term was coined by Francis Robinson (1950) to describe certain
deliberate behaviors counselors engage in for the benefit of their clients. Leads vary in length,
and some are more appropriate at one stage of counseling than another. Robinson used the anal-
ogy of a football quarterback and receiver to describe a lead. A good quarterback anticipates
where the receiver will be on the field and throws the ball to that spot.
The same kind of analogy of quarterbacks and receivers is true for counselors and clients.
Counselors anticipate where their clients are and where they are likely to go. They then respond
accordingly. If they misjudge and the lead is either too far ahead (i.e., too persuasive or direct) or
not far enough (too uninvolved and nondirect), the counseling relationship suffers.
Welfel and Patterson (2005) list a number of leads that counselors can use with their cli-
ents (Figure 6.3). Some, such as silence, acceptance, and paraphrasing, are most appropriate at
the beginning of the counseling process. Others, such as persuasion, are directive and more
appropriate in the understanding and action phases.
The type of lead counselors use is determined in part by the theoretical approach they
embrace and the current phase of counseling. Minimal leads (sometimes referred to as minimal
encouragers) such as “hmmm,” “yes,” or “I hear you” are best used in the building phase of a
relationship because they are low risk. Maximum leads, such as confrontation, are more chal-
lenging and should be employed only after a solid relationship has been established.

Multifocused Responding
People have preferences for the way they process information through their senses. Counselors can
enhance their effectiveness by remembering that individuals receive input from their worlds differ-
ently and that preferred styles influence perceptions and behaviors. Some clients experience the
world visually: They see what is happening. Others are primarily auditory: They listen to their envi-
ronments. Still others are kinesthetic: They feel situations as though physically in touch with them.
Regardless, Ivey, Ivey, and Zalaquett (2014) and Lazarus (2008) think that tuning in to clients’
major modes of perceiving and learning is crucial to bringing about change. Because many clients
have multiple ways of knowing the world, counselors should vary their responses and incorporate
words that reflect an understanding of clients’ worlds. For example, the counselor might say to a
multimodal sensory person, “I see your point and hear your concern. I feel that you are really upset.”
The importance of responding in a client’s own language can be powerful. Counselors
need to distinguish between the predominantly affective, behavioral, and cognitive nature of
speech. Affective responses focus on a client’s feelings, behavioral responses attend to actions,
and cognitive responses center on thought. Thus, counselors working with affectively oriented
individuals select words accordingly.

Accurate Empathy
There is near-universal agreement among practitioners and theorists that the use of empathy is
one of the most vital elements in counseling, one that transcends counseling stages (Gladstein,
1983; Hackney, 1978; Rogers, 1975). In Chapter 5, two types of empathy were briefly noted.
The basic type is called primary empathy; the second level is known as advanced empathy
(Carkhuff, 1969). Accurate empathy on both levels is achieved when counselors see clients’
worlds from the clients’ point of view and are able to communicate this understanding back
120 Part II • Counseling Processes and Theories

Least leading response

Silence When the counselor makes no verbal response at all, the client will
ordinarily feel some pressure to continue and will choose how to
continue with minimum input from the counselor.
Acceptance The counselor simply acknowledges the client’s previous statement with
a response such as “yes” or “uhuh.” The client is verbally encouraged to
continue, but without content stimulus from the counselor.
Restatement (paraphrase) The counselor restates the client’s verbalization, including both content
and affect, using nearly the same wording. The client is prompted to
reexamine what has been said.
Clarification The counselor states the meaning of the client’s statement in his or her
own words, seeking to clarify the client’s meaning. Sometimes elements
of several of the client’s statements are brought into a single response.
The counselor’s ability to perceive accurately and communicate correctly
is important, and the client must test the “fit” of the counselor’s lead.
Approval (affirmation) The counselor affirms the correctness of information or encourages the
client’s efforts at self-determination: “That’s good new information,” or
“You seem to be gaining more control.” The client may follow up with
further exploration as he or she sees fit.
General leads The counselor directs the client to talk more about a specific subject with
statements such as “Tell me what you mean,” or “Please say some more
about that.” The client is expected to follow the counselor’s suggestion.
Interpretation The counselor uses psychodiagnostic principles to suggest sources of
the client’s stress or explanations for the client’s motivation and
behavior. The counselor’s statements are presented as hypotheses, and
the client is confronted with potentially new ways of seeing self.
Rejection (persuasion) The counselor tries to reverse the client’s behavior or perceptions by
actively advising different behavior or suggesting different interpretations
of life events than those presented by the client.
Reassurance The counselor states that, in his or her judgment, the client’s concern is
not unusual and that people with similar problems have succeeded in
overcoming them. The client may feel that the reassurance is supportive
but may also feel that his or her problem is discounted by the counselor
as unimportant.
Introducing new The counselor moves away from the client’s last statement and
information or a new idea prompts the client to consider new material.

Most leading response

FIGURE 6.3 Continuum of leads

Source: From Patterson, L. E., & Eisenberg, S. The counseling process (3rd ed., pp. 126–127). © 1983 Houghton Mifflin. Reprinted by
permission of S. Eisenberg. All rights reserved.
 Chapter 6 • Working in and Closing a Counseling Relationship 121

(Egan, 2014). Two factors that make empathy possible are (a) realizing that “an infinite number
of feelings” does not exist and (b) having a feeling of personal security so that “you can let your-
self go into the world of this other person and still know that you can return to your own world.
Everything you are feeling is ‘as if’” (Rogers, 1987, pp. 45–46).
Primary empathy, when it is accurate, involves communicating a basic understanding of what
the client is feeling and the experiences and behaviors underlying these feelings. It helps establish the
counseling relationship, gather data, and clarify problems. For example, a client might say, “I’m
really feeling like I can’t do anything for myself.” The counselor replies, “You’re feeling helpless.”
Advanced empathy, when it is accurate, reflects not only what clients state overtly but
also what they imply or state incompletely. For example, a counselor notes that a client says,
“And I hope everything will work out” while looking off into space. The counselor responds,
“For if it doesn’t, I’m not sure what I will do next.”
As shown in Figure 6.4 empathy involves three elements: perceptiveness, know-how,
and assertiveness (Egan, 2014).
Several levels of responses reflect different aspects of counselor empathy. A scale formu-
lated by Carkhuff (1969), called Empathic Understanding in Interpersonal Process, is a measure
of these levels. Each of the five levels either adds to or subtracts from the meaning and feeling
tone of a client’s statement.
1. The verbal and behavioral expressions of the counselor either do not attend to or detract
significantly from the verbal and behavioral expressions of the client. (minus 2)
2. Although the counselor responds to the expressed feelings of the client, he or she does so
in a way that subtracts noticeable affect from the communications of the client. (minus 1)
3. The expressions of the counselor in response to the expressions of the client are essentially
interchangeable. (neutral 0)
4. The responses of the counselor add noticeably to the expressions of the client in a way that
expresses feelings a level deeper than the client was able to express. (plus 1)
5. The counselor’s responses add significantly to the feeling and meaning of the expressions
of the client in a way that accurately expresses feeling levels below what the client is able
to express. (plus 2)
Responses at the first two levels are not considered empathic; in fact, they inhibit the cre-
ation of an empathic environment. For example, if a client reveals that she is heartbroken over the
loss of a lover, a counselor operating on either of the first two levels might reply, “Well, you want
your former love to be happy, don’t you?” Such a response misses the pain the client is feeling.

Empathy

Perceptiveness Know-how Assertiveness

FIGURE 6.4 The three elements of empathy

Source: Based on Egan, 2014. Pearson Education, Inc.
122 Part II • Counseling Processes and Theories

At level 3 on the Carkhuff scale, a counselor’s response is rated as “interchangeable” with

that of a client. Such a response may well come in the form of a paraphrase such as follows:

Client: “I am really feeling anxious.”

Counselor: “You are really feeling nervous.”

On levels 4 and 5, a counselor either “adds noticeably” or “adds significantly” to what a

client has said. This ability to go beyond what clients say distinguishes counseling from conver-
sation or other less helpful forms of behavior (Carkhuff, 1972). The following interchange is an
example of a higher level empathetic response:

Client: I have been running around from activity to activity. I am so tired I feel like
I could drop.
Counselor: Your life has been a merry-go-round of activity, and you’d like to slow
it down before you collapse. You’d like to be more in charge of your own life.

Means (1973) elaborates on levels 4 and 5 to show how counselors can add noticeably and
significantly to their clients’ perceptions of an emotional experience, an environmental stimulus,
a behavior pattern, a self-evaluation, a self-expectation, and beliefs about self. Clients’ state-
ments are extremely varied, and counselors must therefore be flexible in responding to them.
Whether a counselor’s response is empathetic is determined by the reaction of clients (Turock,
1978). Regardless, in the understanding and action phases of counseling, it is important that
counselors integrate the two levels of empathy they use in responding to clients seeking help.

CASE EXAMPLE
Edwina Attempts Empathy
Edwina still considered herself a novice, although she had worked as a counselor for 2 years. She
seemed to have an especially hard time conveying empathy on any level. One day a client,
Andre, who was agonizing over the death of a recent relationship, made an appointment with
Edwina. In the session he became tearful.
“I just feel like a hollow tree,” he said. “The shell of the tree is standing but inside there is
an emptiness. The outside of me does not reveal my interior feeling.”
Edwina replied: “It’s as if you were a robot. On the outside you look fine, but inside you
lack all the necessary elements of life.”
What do you think of Edwina’s response? Is it empathetic? If so, on what level? If not,
why not? What might you say to Andre?

Self-Disclosure
Self-disclosure is a complex, multifaceted phenomenon that has generated more than 200 stud-
ies (Watkins, 1990a). It may be succinctly defined as “a conscious, intentional technique in
which clinicians share information about their lives outside the counseling relationship” (Simone,
McCarthy, & Skay, 1998, p. 174). Sidney Jourard (1958, 1964, 1968) did the original work in
this area. For him, self-disclosure referred to making oneself known to another person by
 Chapter 6 • Working in and Closing a Counseling Relationship 123

revealing personal information. Jourard discovered that self-disclosure helped establish trust and
facilitated the counseling relationship. He labeled reciprocal self-disclosure the dyadic effect.
Client self-disclosure is necessary for successful counseling to occur. Yet it is not always
necessary for counselors to be self-disclosing. “Each counselor-client relationship must be eval-
uated individually in regard to disclosure,” and when it occurs, care must be taken to match dis-
closure “to the client’s needs” (Hendrick, 1988, p. 423).
Clients are more likely to trust counselors who disclose personal information (up to a
point) and are prone to make reciprocal disclosures (Curtis, 1981; Kottler et al., 1994).
Adolescents especially seem to be more comfortable with counselors who are “fairly unguarded
and personally available” (Simone et al., 1998, p. 174). Counselors employ self-disclosure on
a formal basis at the initial interview by giving clients written statements about the counselor
and the counseling process (a professional disclosure statement). They also use self-disclosure
spontaneously in counseling sessions to reveal pertinent personal facts to their clients.
Spontaneous self-disclosure is important in facilitating client movement (Watkins, 1990a).
According to Egan (2014), counselor self-disclosure serves two principal functions: mod-
eling and developing a new perspective. Clients learn to be more open by observing counselors
who are open. Counselor self-disclosure can help clients see that counselors are not free of prob-
lems or devoid of feelings (Hackney & Cormier, 2013). Thus, while hearing about select aspects
of counselors’ personal lives, clients may examine aspects of their own lives, such as stubborn-
ness or fear, and realize that some difficulties or experiences are universal and manageable. Egan
(2014) stresses that counselor self-disclosure
• should be brief and focused,
• should not add to the clients’ problems, and
• should not be used frequently.
The process is not linear, and more self-disclosure is not necessarily better. Before self-disclos-
ing, counselors should ask themselves such questions as “Have I thought through why I am dis-
closing?” “Are there other more effective and less risky ways to reach the same goal?” and “Is
my timing right?” (Simone et al., 1998, pp. 181–182).
Kline (1986) observes that clients perceive self-disclosure as risky and may be hesitant to
take such a risk. Hesitancy may take the form of refusing to discuss issues, changing the subject,
being silent, and talking excessively. Counselors can help clients overcome these fears by not
only modeling and inviting self-disclosure but also exploring negative feelings that clients have
about the counseling process, contracting with clients to talk about a certain subject area, and
confronting clients with the avoidance of a specific issue.

CASE EXAMPLE
Della Discloses
Della’s client, Candace, was reluctant to talk. She had been mandated to see Della because she
was acting out sexually, and her mother could not handle her without some help. Della had tried
everything she knew to invite Candace to talk. Finally, she self-disclosed by saying to Candace:
“When I was 18, I could not stand my mother or any older adult. I thought they were all full of
rules against what I wanted to do. I wonder if you might be feeling that way, too?”
Do you believe Della’s self-disclosure to Candace might be helpful? Why or why not?
124 Part II • Counseling Processes and Theories

Immediacy
“Immediacy . . . is one of the most important skills” in counseling (Wheeler & D’Andrea, 2004,
p. 117). It “focuses on the here and now and the therapeutic relationship” from the perspective of
how both the client and the counselor feel (p. 117). At its core, immediacy involves a counsel-
or’s and a client’s understanding and communicating at the moment what is going on between
them in the helping relationship, particularly feelings, impressions, and expectations (Kasper,
Hill, & Kivlighan, 2008).
There are basically two kinds of immediacy:
1. Overall relationship immediacy—“How are you and I doing?”
2. “Immediacy that focuses on some particular event in a session—‘What’s going on
between you and me right now?’” (Egan, 2014, p. 266)
As a rule, immediacy is difficult and demanding. It requires more courage or assertiveness than
almost any other interpersonal communication skill. Turock (1980) lists three fears many coun-
selors have about immediacy. First, they may be afraid that clients will misinterpret their mes-
sages. Immediacy requires counselors to make a tentative guess or interpretation of what their
clients are thinking or feeling, and a wrong guess can cause counselors to lose credibility with
their clients.
Second, immediacy may produce an unexpected outcome. Many counseling skills, such as
reflection, have predictable outcomes; immediacy does not. Its use may break down a familiar
pattern between counselors and clients. In the process, relationships may suffer.
Third, immediacy may influence clients’ decisions to terminate counseling sessions
because they can no longer control or manipulate relationships. Some clients play games, such as
“ain’t it awful,” and expect their counselors to respond accordingly (Berne, 1964). When clients
receive an unexpected payoff, they may decide not to stay in the relationship. Egan (2014) states
that immediacy is best used in the following situations:
• In a directionless relationship where it seems no progress is being made
• Where there is tension between the client and counselor
• Where there is a question of trust
• When there is considerable social distance between counselor and client, such as in
diversity
• Where there is client dependency
Other situations where immediacy may be needed or helpful include those
• Where there is counterdependency
• When there is an attraction between counselor and client

Hope
Clients do best in counseling when hope is engendered in the process. Hope is the feeling that
something desirable, such as the achievement of a goal, is possible. Hope has multiple benefits,
including increasing a client’s motivation to work on a problem. It has been linked to academic
success, athletic performance, psychological adjustment, and physical health (Pedrotti, Edwards,
& Lopez, 2008). “Because hope is understood to play a foundational role in client change, prac-
titioners … should become knowledgeable about research on hope as an important aspect of
counseling practice” (Larsen & Stege, 2012, p. 52).
 Chapter 6 • Working in and Closing a Counseling Relationship 125

Humor
Humor involves giving an incongruent or unexpected response to a question or situation to the
amusement of those involved. It makes people laugh, and healthy humor requires both sensitiv-
ity and timing on the part of the counselor. Humor in counseling should never be aimed at
demeaning anyone (Gladding, 1995; Gladding & Wallace, 2016). Instead, it should be used to
build bridges between counselors and clients. If used properly, it is “a clinical tool that has many
therapeutic applications” (Ness, 1989, p. 35). Humor can circumvent clients’ resistance, build
rapport, dispel tension, help clients distance themselves from psychological pain, and aid in the
increase of a client’s self-efficacy (Goldin et al., 2006; Vereen, Butler, Williams, Darg, &
Downing, 2006). “Ha-ha” often leads to an awareness of “ah-ha” and a clearer perception of a
situation (i.e., insight). For instance, when a counselor is working with a client who is unsure
whether he or she wants to be in counseling, the counselor might initiate the following exchange:

Counselor: Joan, how many counselors does it take to change a lightbulb?

Client: (hesitantly) I’m not sure.
Counselor: Just one, but the lightbulb has got to really want to be changed.
Client: (smiling) I guess I’m a lightbulb that’s undecided.
Counselor: It’s OK to be undecided. We can work on that. Our sessions will probably be
more fruitful, however, if you can turn on to what you’d like to see different
in your life and what it is we could jointly work on.

Overall, humor can contribute to creative thinking; promote attachment; help keep things in
perspective; and make it easier to explore difficult, awkward, or nonsensical aspects of life
(Bergman, 1985; Goldin et al., 2006; Nelson, 2008). However, “counselors must remember that to
use humor effectively they must understand what is humorous and under what circumstances it is
humorous” (Erdman & Lampe, 1996, p. 376). Therefore, they need to realize before attempting
humor in a counseling situation that both clients and counselors must be comfortable with it as an
activity, that there should be a purpose to it, that trust and respect must have been established before
humor is used, and that humor should be tailored or customized to a particular client’s specific
cultural orientation and uniqueness (Maples et al., 2001). Counselors can use humor to challenge a
client’s beliefs, magnify irrational beliefs to absurdity, or even to make a paradoxical intervention
(Goldin & Bordan, 1999). When handled right, humor can open up counselor–client relationships.

PERSONAL REFLECTION
I have a counselor friend who was completely different in almost every way from a client he saw. Instead
of saying to the client something like “We really appear to be different,” he lightheartedly said, “If I
didn’t know better, I would say you must be the other half of me since we never seem to agree or see
things the same way.” What do you think of that as a humorous response (on a scale from 1 to 10)? What
might you say in such a situation that would be more humorous (unless you rated the response a 10)?

Confrontation
Confrontation, like immediacy, is often misunderstood. Uninformed counselors sometimes think
confrontation involves an attack on clients, a kind of “in your face” approach that is berating.
Instead, confrontation is invitational and a dialogue (Strong & Zeman, 2010). Confrontation
126 Part II • Counseling Processes and Theories

challenges a client to examine, modify, or control an aspect of behavior that is currently nonex-
istent or improperly used. Sometimes confrontation involves giving metacommunication feed-
back at variance with what the client wants or expects. This type of response may be inconsistent
with a client’s perception of self or circumstances (Wilcox-Matthew, Ottens, & Minor, 1997).
Confrontation can help “people see more clearly what is happening, what the consequences
are, and how they can assume responsibility for taking action to change in ways that can lead to a
more effective life and better and fairer relationships with others” (Tamminen & Smaby, 1981,
p. 42). A good, responsible, caring, and appropriate confrontation produces growth and encour-
ages an honest examination of self. Sometimes it may actually be detrimental to clients if counsel-
ors fails to confront. Avoiding confrontation of clients’ behaviors is known as the MUM effect
and results in the counselors being less effective than they might be (Rosen & Tesser, 1970).
However, there are certain boundaries to confrontation (Leaman, 1978). Counselors need
to be sure that the relationships with their clients are strong enough to sustain a confrontation.
Counselors also must time a confrontation appropriately and remain true to the motives that led
to the act of confronting. It is more productive in the long run to confront clients’ strengths than
their weaknesses (Berenson & Mitchell, 1974). Counselors should challenge clients to use
resources they are failing to employ.
Regardless of whether confrontation involves strengths or weaknesses, counselors use a
“you said … but look” structure to implement the confrontation process (Hackney & Cormier,
2013). For example, in the first part of the confrontation, a counselor might say, “You said you
wanted to get out more and meet people.” In the second part, the counselor highlights the dis-
crepancy or contradiction in the client’s words and actions—for instance, “But you are now
watching television 4 to 6 hours a night.”

Contracting
There are two aspects of contracting: One focuses on the processes involved in reaching a goal;
the other concentrates on the final outcome. In goal setting, counselors operate from a theoretical
base that directs their actions. In response, clients learn to change their ways of thinking, feeling,
and behaving to obtain goals. It is natural for counselors and clients to engage in contractual
behavior. Goodyear and Bradley (1980) point out that all interpersonal relationships are contrac-
tual, but some are more explicit than others are. Because the median number of counseling ses-
sions may be as few as five to six, it is useful and time saving for counselors and clients to work
on goals through a contract system. Such a system lets both parties participate in determining
direction in counseling and evaluating change. It helps them be more specific.
Other advantages to using contracts in counseling are as follows:
• First, a contract provides a written record of goals the counselor and client have agreed to
pursue and the course of action to be taken.
• Second, the formal nature of a contract and its time limits may act as motivators for a client
who tends to procrastinate.
• Third, if the contract is broken down into definable sections, a client may get a clear feel-
ing that problems can be solved.
• Fourth, a contract puts the responsibility for any change on the client and thereby has the
potential to empower the client and make him or her more responsive to the environment
and more responsible for his or her behaviors.
• Finally, the contract system, by specifically outlining the number of sessions to be held,
ensures that clients will return to counseling regularly (Thomas & Ezell, 1972).
 Chapter 6 • Working in and Closing a Counseling Relationship 127

There are several approaches to setting up contracts. Goodyear and Bradley (1980) offer
recommendations for promoting maximum effectiveness of contracts:
• It is essential that counselors indicate to their clients that the purpose of counseling is to
work. It is important to begin by asking the client, “What would you like to work on?” as
opposed to “What would you like to talk about?”
• It is vital that the contract for counseling concern change in the client rather than a person
not present at the sessions. The counselor acts as a consultant when the client wishes to
examine the behavior of another person, but work of this type is limited.
• The counselor must insist on setting up contracts that avoid the inclusion of client con
words such as try or maybe—or any words that are not specific. Such words usually
result in the client’s failing to achieve a goal.
• The counselor must be wary of client goals that are directed toward pleasing others and
include words such as should or must. Such statements embody externally driven goals.
For instance, a client who sets an initial goal that includes the statement “I should please
my spouse more” may do so only temporarily because the goal is not internally driven. To
avoid this kind of contract goal, the counselor needs to ask what the client really wants.
• It is vital to define concretely what clients wish to achieve through counseling. There is a
great deal of difference between clients who state that they wish to be happy and clients
who explain that they want to lose 10 pounds or talk to at least three new people a day. The
latter goals are more concrete and thus more achievable.
• Counselors must insist that contracts focus on change. Clients may wish to understand
why they do something, but insight alone rarely produces action. Therefore, counselors
must emphasize contracts that promote change in clients’ behaviors, thoughts, or feelings.

Another briefer way to think of what to include in a contract is to use the acronym SAFE,
where the S stands for specificity (i.e., treatment goals), A for awareness (i.e., knowledge of
procedures, goals, and side effects of counseling), F for fairness (i.e., the relationship is bal-
anced and both client and counselor have enough information to work), and E for efficacy (i.e.,
making sure the client is empowered in the areas of choice and decision making) (Moursund &
Kenny, 2002).
Even though contracts are an important part of helping clients define, understand, and
work on specific aspects of their lives, a contract system does have disadvantages. Okun and
Kantrowitz (2015) stress that contracts need to be open to renegotiation by both parties. This
process is often time-consuming and personally taxing. Thomas and Ezell (1972) list several
other weaknesses of a contract system.

• First, counselors cannot hold clients to a contract. The agreement has no external rewards
or punishments that counselors can use to force clients to fulfill the agreement.
• Second, some clients’ problems may not lend themselves to the contract system. For
example, clients who want to make new friends may contract to visit places where there
is a good opportunity to encounter the types of people with whom they wish to be associ-
ated. There is no way, however, that a contract can ensure that clients will make new
friends.
• Third, a contractual way of dealing with problems focuses on outward behavior. Even if
the contract is fulfilled successfully, clients may not achieve insight or altered perception.
• Finally, the initial appeal of a contract is limited. Clients who are motivated to change and
who find the idea fresh and appealing may become bored with such a system in time.
128 Part II • Counseling Processes and Theories

In determining the formality of the contract, counselors must consider clients’ background
and motivational levels, the nature of the presenting problems, and what resources are available
to clients to ensure the successful completion of the contract. Goodyear and Bradley (1980) sug-
gest that counselors ask how clients might sabotage the contract. This question helps make cli-
ents aware of any resistance they harbor to fulfillment of the agreement.

Rehearsal
Once a contract is set up, counselors can help clients maximize the chance of fulfilling it by get-
ting them to rehearse or practice designated behavior. Clients can rehearse in two ways: overtly
and covertly (Cormier et al., 2017). Overt rehearsal requires clients to verbalize or act out what
they are going to do. For example, if a woman is going to ask a man out for a date, she will want
to rehearse what she is going to say and how she is going to act beforehand. Covert rehearsal is
imagining or reflecting on the desired goal. For instance, students giving a speech can first imag-
ine the conditions under which they will perform and then reflect about how to organize the
subject matter that they will present.
Sometimes a client needs a counselor coaching during the rehearsal period. Coaching may
take the form of providing temporary aids to help the client remember what to do next (Bandura,
1976) or it may simply involve giving feedback to the client on how he or she is doing. Feedback
means helping the client recognize and correct any problem areas that he or she has in mastering
a behavior. Feedback works well as long as it is not overdone (Geis & Chapman, 1971). To
maximize its effectiveness, feedback should be given both orally and in writing.
Counselors can also assign clients homework (sometimes called “empowering assign-
ments” or “between-session tasks”) to help them practice the skills learned in counseling ses-
sions and generalize such skills to relevant areas of their lives. Homework involves additional
work on a particular skill outside the counseling session and has numerous advantages, such as
• keeping clients focused on relevant behavior between sessions,
• helping them to see clearly the kind of progress they are making,
• motivating clients to change behaviors,
• helping them to evaluate and modify their activities,
• making clients more responsible for self-control, and
• celebrating a breakthrough achieved in counseling (Hay & Kinnier, 1998; Hutchins &
Vaught, 1997).
Cognitive–behavioral counselors are most likely to emphasize homework assignments.
For instance, counselors with this theoretical background may have clients use workbooks to
augment cognitive–behavioral in-session work. Workbooks require active participation and
provide a tangible record of what clients have done. Two excellent cognitive–behavioral work-
book exercises geared toward children are Vernon’s (2006) “Decisions and Consequences,” in
her book Thinking, Feeling and Behaving, which focuses on cause and effect by having the
counselor do such things as drop an egg into a bowl, and Kendall and Hedtke’s (2006) Coping
Cat Workbook, which concentrates on the connections between thoughts and feelings by having
children engage in such activities as viewing life from a cat’s perspective.
However, counselors from all theoretical perspectives can use homework if they wish to
help clients help themselves. For homework to be most effective, it needs to be specifically tied
to some measurable behavior change (Okun & Kantrowitz, 2015). It must also be relevant to
clients’ situations if it is to be meaningful and helpful (Young, 2017). Clients need to complete
homework assignments if they are to benefit from using a homework method.
 Chapter 6 • Working in and Closing a Counseling Relationship 129

“The kinds of homework that can be assigned are limited only by the creativity of the
counselor and the client” (Hay & Kinnier, 1998, p. 126). Types of homework that are frequently
given include those that are paradoxical (an attempt to create the opposite effect), behavioral
(practicing a new skill), risk taking (doing something that is feared), thinking (mulling over
select thoughts), written (keeping a log or journal), bibliotherapeutic (reading, listening, or
viewing literature), and not doing anything (taking a break from one’s usual habits).

CASE EXAMPLE
Conrad Undermines the Contract
Conrad went to see a counselor because he was socially inept. He did not pick up on nonverbal
cues, and he was not able to sustain a conversation for any length of time. Conrad’s counselor,
Penelope, worked up a contract for him. First, he was to watch television without the sound and
try to identify emotional expressions. Second, he was to ask three people each day in the park
how they were doing and talk with them as long as he could.
Conrad fulfilled his contract for the first week but then gave it up. He said it was “too
hard.”
If you were Penelope, what would you do to help Conrad get back on a contract?

TRANSFERENCE AND COUNTERTRANSFERENCE

Counselor skills that help promote development during the counseling process are essential if the
counselor is to avoid circular counseling, in which the same ground is covered over and over
again. There is an equally important aspect of counseling, however, that influences the quality of
the outcome: the relationship between counselor and client. The ability of the counselor and cli-
ent to work effectively with each other is influenced largely by the relationship they develop.
Counseling can be an intensely emotional experience. In a few instances, counselors and clients
genuinely dislike each other or have incompatible personalities. Usually, however, they can and
must work through transference and countertransference phenomena that result from the thoughts
and emotions they think, feel, and express to one another. Although some counseling theories
emphasize transference and countertransference more than others, these two concepts occur to
some extent in almost all counseling relationships.

Transference
Transference is the client’s projection of past or present feelings, attitudes, or desires onto the
counselor (Brammer, Abrego, & Shostrom, 1993; Brammer & MacDonald, 2003). It can be used
in two ways. Initially, transference reactions help counselors understand clients better. A second
way to use transference is to employ it as a way of resolving the client’s problems (Teyber,
2000). Transference as a concept comes from the literature of psychoanalysis. It originally
emphasized the transference of earlier life emotions onto a therapist, where they would be
worked through. Today, transference is not restricted to psychoanalytic therapy, and it may be
based on current as well as past experiences (Corey, Corey, Corey, & Callanan, 2015).
All counselors have what Gelso and Carter (1985) describe as a transference pull, an
image generated through the use of personality and a particular theoretical approach. A client
reacts to the image of the counselor in terms of the client’s personal background and current
130 Part II • Counseling Processes and Theories

conditions. The way the counselor sits, speaks, gestures, or looks may trigger a client reaction.
An example of such an occurrence is a client saying to a counselor, “You sound just like my
mother.” The statement in and of itself may be observational. But if the client starts behaving as
if the counselor were the client’s mother, transference has occurred.
Five patterns of transference behavior frequently appear in counseling: The client may
perceive the counselor as ideal, seer, nurturer, frustrator, or nonentity (Watkins, 1983b, p. 207).
The counselor may at first enjoy transference phenomena that hold him or her in a positive
light. Such enjoyment soon wears thin. To overcome the effects associated with transference
experiences, Watkins advocates focusing on the client’s needs and expectations as well as estab-
lishing trust.
Cavanagh and Levitov (2002) note that transference can be either direct or indirect. Direct
transference is well represented by the example of the client who thinks of the counselor as his
or her mother. Indirect transference is harder to recognize. It is usually revealed in client state-
ments or actions that are not obviously directly related to the counselor (e.g., “Talk is cheap and
ineffective” or “I think counseling is the experience I’ve always wanted”).
Regardless of its degree of directness, transference is either negative or positive. Negative
transference is when the client accuses the counselor of neglecting or acting negatively toward
him or her. Although painful to handle initially, negative transference must be worked through
for the counseling relationship to get back to reality and ultimately be productive. It has a direct
impact on the quality of the relationship. Positive transference, especially a mild form such as
client admiration for the counselor, may not be readily acknowledged because it appears at first
to add something to the relationship (Watkins, 1983b). Indirect or mild forms of positive trans-
ference are least harmful to the work of the counselor and client.
Cavanagh and Levitov (2002) hold that both negative and positive transference are forms
of resistance. As long as the client keeps the attention of the counselor on transference issues,
little progress is made in setting or achieving goals. To resolve transference issues, the counselor
may work directly and interpersonally rather than analytically. For example, if the client com-
plains that a counselor cares only about being admired, the counselor can respond, “I agree that
some counselors may have this need, and it is not very helpful. On the other hand, we have been
focusing on your goals. Let’s go back to them. If the needs of counselors, as you observe them,
become relevant to your goals, we will explore that issue.”
Corey and associates (2015) see a therapeutic value in working through transference.
They believe that the counselor–client relationship improves once the client resolves dis-
torted perceptions about the counselor. If the situation is handled sensitively, the improved
relationship is reflected in the client’s increased trust and confidence in the counselor.
Furthermore, by resolving feelings of transference, a client may gain insight into the past and
become free to act differently in the present and future.

Countertransference
Countertransference refers to the counselor’s projected emotional reaction to or behavior
toward the client (Fauth & Hayes, 2006; Hansen, Rossberg, & Cramer, 1994). This reaction may
be irrational, interpersonally stressful, and neurotic—emanating from the counselor’s own unre-
solved issues. Furthermore, countertransference is often “harmful to, threatening, challenging,
and/or taxing” to the counselor’s coping resources (Fauth & Hayes, 2006, p. 431). Thus, manag-
ing countertransference successfully is related to better therapy outcomes (Hayes, Gelso, &
Hummel, 2011). Two examples of countertransference are a counselor manifesting behaviors
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PERSONAL REFLECTION
When have you met people you immediately seemed to like or dislike? How did you treat them?
How did you feel when you interacted with them? How is that like countertransference? How is it
different?

THE REAL RELATIONSHIP

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132 Part II • Counseling Processes and Theories

According to Gelso (2011), there are specific propositions about the nature of a real rela-
tionship. One is that the relationship increases and deepens during the counseling process.
Another is that counselors and clients have different expectations and actualizations of what a
real relationship is like. Counseling is a dynamic, interactional process, and the strength of rela-
tionships between counselors and clients varies over time.
Study of the real relationship has headed in a promising direction toward the social con-
struction perspective—that is, “the process by which people come to describe, explain, or oth-
erwise account for the world (including themselves) in which they live” (Sexton & Whiston,
1994, p. 60). Realness and growth, although not precisely defined at present, appear to be an
important part of counseling relationships that will continue to attract attention and be important
and especially emerge in the working phase of counseling.

Closing a Counseling Relationship

Closing a counseling relationship refers to the decision to end it. Sometimes this is called termi-
nation. The decision may be made unilaterally or mutually after the working stage of counseling
has waned. Regardless, closing is probably the least researched, most neglected aspect of coun-
seling. Many theorists and counselors assume that closing will occur naturally and leave both
clients and counselors pleased and satisfied with the results. Goodyear (1981) states that “it is
almost as though we operate from a myth that closing is a process from which the counselor
remains aloof and to which the client alone is responsive” (p. 347).
However, the closing of a counseling relationship has an impact on all involved, and it is
often complex, difficult, and awkwardly done (Bulkeley, 2009). Closing may well produce
mixed feelings on the part of both the counselor and the client (Kottler, Sexton, & Whiston,
1994). For example, a client may be both appreciative and regretful about a particular counseling
experience. Unless it is handled properly, closing has the power to harm as well as heal.
Closing is a multidimensional process that can take any of several forms. For example,
closing may involve individual sessions as well as the entire counseling relationship. Closing
also includes strategies and issues related to resistance in closing, premature closing, counselor-
initiated closing, and the importance of terminating a relationship on a positive note. The related
areas of follow-up, referral, and recycling in counseling relate to closing, too.

FUNCTION OF CLOSING A COUNSELING RELATIONSHIP

Historically, addressing the process of closing a counseling relationship directly has been
avoided for a couple of reasons. Ward (1984) has suggested two of the most prominent. First,
ending is associated with loss, a traditionally taboo subject in all parts of society, especially
counseling, which is generally viewed as emphasizing growth and development unrelated to
endings. Second, closing is not directly related to the microskills that facilitate counseling
relationships. Therefore, closing is not a process usually highlighted in counseling. Its signifi-
cance has begun to emerge, however, because of societal trends, such as the aging of the
American population (Erber, 2013), the wide acceptance of the concept of life stages (Sheehy,
1976), an increased attention to death as a part of the life span (Kubler-Ross, 1969), and the fact
that loss may be associated with re-creation, transcendence, greater self-understanding, and new
discoveries such as posttraumatic growth (i.e., positive life changes that come about as a result
of suffering or struggling with natural or human-made traumatic events, such as hurricanes and
wars) (Calhoun & Tedeschi, 2006; Hayes, 1993).
 Chapter 6 • Working in and Closing a Counseling Relationship 133

Closing serves several important functions. First, closing signals that something is fin-
ished. Life is a series of hellos and good-byes (Meier & Davis, 2011). Hellos begin at birth, and
good-byes end at death. Between the two, individuals enter into and leave a succession of expe-
riences, including jobs and relationships. Growth and adjustment depend on an ability to make
the most of these experiences and learn from them. To begin something new, a former experi-
ence must be completed and resolved. Closing is the opportunity to end a learning experience
properly, whether on a personal or professional level (Hulse-Killacky, 1993). In counseling,
closing is more than an act signifying the end of therapy; it is also a motivator (Yalom &
Leszcz, 2005).
Both client and counselor are motivated by the knowledge that the counseling experience
is limited in time (Young, 2017). This awareness is similar to that of young adults who realize
that they cannot remain promising persons forever. Such a realization may spur individuals on to
hard work while there is still time to do something significant. Some counselors, such as those
associated with strategic, systemic, and solution-focused family therapy, purposely limit the
number of counseling sessions so that clients and counselors are more aware of time constraints
and make the most of sessions (Gladding, 2015b).
Second, closing is a means of maintaining changes already achieved and generalizing
problem-solving skills acquired in counseling. Successful counseling results in significant
changes in the way the client thinks, feels, or acts. These changes are rehearsed in counseling,
but they must be practiced in the real world. Closing provides an opportunity for such practice.
The client can always go back to the counselor for any needed follow-up, but closing is the natu-
ral point for the practice of independence to begin. It is a potentially empowering experience for
clients and enables them to address the present in an entirely new or modified way. At closing,
the opportunity to put “insights into actions” is created (Gladding, 1990a, p. 130). In other words,
what seems like an exit becomes an entrance.
Third, closing serves as a reminder that the client has matured (Vickio, 1990). Besides
offering clients new skills or different ways of thinking about themselves, effective counseling
closing marks a time in the clients’ lives when they are less absorbed by and preoccupied with
personal problems and more able to deal with outside people and events. This ability to handle
external situations may result in more interdependent relationships that are mutually supportive
and consequently lead toward a “more independent and satisfying life” (Burke, 1989, p. 47).
Having achieved a successful resolution to a problem, a client now has new insights and abilities
that are stored in memory and may be recalled and used on occasions.

PERSONAL REFLECTION
Think about times you have voluntarily ended events or relationships. What did closing feel like for
you? What did you learn from the experience? What value do you see in concluding an experience?

TIMING OF CLOSING
When to terminate a relationship is a question that has no definite answer. However, closing
should be planned and deliberate. If the relationship is ended too soon, clients may lose the
ground they gained in counseling and regress to earlier behaviors. However, if closing is never
addressed, clients can become dependent on the counselor and fail to resolve difficulties and
134 Part II • Counseling Processes and Theories

grow as persons. There are several pragmatic considerations in the timing of closing (Cormier,
2015; Young, 2017).

• Have clients achieved behavioral, cognitive, or affective contract goals? When both
clients and counselors have a clear idea about whether particular goals have been reached,
the timing of closing is easier to figure out. The key to this consideration is setting up a
mutually agreed-on contract before counseling begins.
• Can clients concretely show where they have made progress in what they wanted to
accomplish? In this situation, specific progress may be the basis for making a decision.
• Is the counseling relationship helpful? If either the client or the counselor senses that
what is occurring in the counseling sessions is not helpful, closing is appropriate.
• Has the context of the initial counseling arrangement changed? In cases where there
is a move or a prolonged illness, closing (as well as a referral) should be considered.
Overall, there is no one right time to terminate a counseling relationship. The “when” of
closing must be figured out in accordance with the uniqueness of the situation and overall ethical
and professional guidelines.

ISSUES IN CLOSING
Closing of Individual Sessions
Closing is an issue during individual counseling sessions. Initial sessions should have clearly
defined time limits (Brammer & MacDonald, 2003; Cormier, 2015). A range of 45 to 50 minutes
is generally considered adequate for an individual counseling session. It usually takes a coun-
selor 5 to 10 minutes to adjust to the client and the client’s concerns. Counseling sessions that
terminate too quickly may be as unproductive as ones that last too long.
Benjamin (1987) proposes two important factors in closing an interview. First, both client
and counselor should be aware that the session is ending. Second, no new material should be
introduced or discussed during this ending. If the client introduces new material, the counselor
needs to work to make it the anticipated focus of the next session.
A counselor can close an interview effectively in several ways. One is simply to make
a brief statement indicating that time is up (Cormier, 2015). For example, he or she might say,
“It looks like our time is up for today.” The simpler the statement, the better. If a client is dis-
cussing a number of subjects in an open-ended manner near the end of a session, the counselor
should remind the client that there are only 5 or 10 minutes left. For example, the counselor can
say: “Lily, it looks like we only have a few minutes left in our session. Would you like to sum-
marize what you have learned today and tell me what you would like to focus on next time?” The
client can then focus attention on important matters in the present as well as those that need to be
addressed in the future. As an alternative or in addition to the direct statement, counselors can
use nonverbal gestures to indicate that the session is ending. These include looking at their watch
or standing up. Nonverbal gestures are probably best used with verbal indicators. Each rein-
forces the other.
As indicated toward the end of the interview, it is usually helpful to summarize what has
happened in the session. Either the counselor or the client may initiate this summation. A good
summary ties together the main points of the session and should be brief, to the point, and without
interpretation. If both the counselor and client summarize, they may gain insight into what each
has gotten out of the session. Such a process provides a means for clearing up misunderstandings.
 Chapter 6 • Working in and Closing a Counseling Relationship 135

An important part of terminating any individual session is setting up the next appointment.
Clients and counselors need to know when they will meet again to continue the work in progress.
It is easier and more efficient to set up a next appointment at the end of a session than to do it
later by phone.

CASE EXAMPLE
Tina Terminates a Session
Tina grew impatient with her client, Macheta, as Macheta seemed to drone on and on about the
misery in her life. Tina was sympathetic and empathetic, but only up to a point. Then she became
annoyed and realized she was not doing the kind of work as a counselor that was helpful to her
or to her client. Therefore, even though only 35 out of 50 minutes had passed since they began,
Tina decided to end the session. She told Macheta that she was having a difficult time following
her, and she asked if Macheta would summarize what she was trying to convey. Macheta was
startled but when she thought about it, she was able to convey the essence of the session in only
a few sentences.
What do you think of Tina’s tactic? What else might she have done to make the session
with Macheta more productive?

Closing of a Counseling Relationship

Counseling relationships vary in length and purpose. It is vital to the health and well-being of
everyone that the subject of closing be brought up early so that counselor and client can make the
most of their time together (Cavanagh & Levitov, 2002). Individuals need time to prepare for an
ending. There may be some sadness, even if a relationship ends in a positive way. Thus, closing
should not necessarily be presented as the zenith of the counseling experience. It is better to play
down the importance of a closing rather than play it up.
The counselor and client must agree on when closing of the relationship is appropriate
and helpful (Young, 2017). Generally, they give each other verbal messages about a readi-
ness to terminate. For example, a client may say, “I really think I’ve made a lot of progress
over the past few months.” Or a counselor may state, “You appear to be well on your way to
no longer needing my services.” Such statements suggest the beginning of the end of the
counseling relationship. They usually imply recognition of growth or resolution. A number
of other behaviors may also signal the end of counseling. These include a decrease in the
intensity of work; more humor; consistent reports of improved abilities to cope; verbal com-
mitments to the future; and less denial, withdrawal, anger, mourning, or dependence
(Shulman, 2016).
Cormier (2015) believes that, in a relationship that has lasted more than 3 months, the
final 3 or 4 weeks should be spent discussing the impact of closing. For instance, counselors
may inquire how their clients will cope without the support of the relationship. Counselors
may also ask clients to talk about the meaning of the counseling relationship and how they will
use what they have learned in the future. Shulman (2016) suggests that, as a general rule of
thumb, one-sixth of the time spent in a counseling relationship should be devoted to focusing
on closing.
136 Part II • Counseling Processes and Theories

Maholick and Turner (1979) discuss specific areas of concern when deciding whether to
terminate counseling. They include:
• An examination of whether the client’s initial problem or symptoms have been reduced or
eliminated
• A determination of whether the stress-producing feelings that led to counseling have been
eliminated
• An assessment of the client’s coping ability and understanding of self and others
• A determination of whether the client can relate better to others and is able to love and be
loved
• An examination of whether the client has acquired abilities to plan and work productively
• An evaluation of whether the client can better play and enjoy life
These areas are not equally important for all clients, but it is essential that, before the clos-
ing of counseling, clients feel confident to live effectively without the relationship (Ward, 1984;
Young, 2017).
There are at least two other ways to facilitate the ending of a counselor–client relation-
ship. One involves the use of fading. Dixon and Glover (1984) define fading as “a gradual
decrease in the unnatural structures developed to create desired changes” (p. 165). In other
words, clients gradually stop receiving reinforcement from counselors for behaving in certain
ways, and appointments are spread out. A desired goal of all counseling is to help clients become
less dependent on the counselor and the counseling sessions and more dependent on themselves
and interdependent with others. From counseling, clients should also learn the positive reinforce-
ment of natural contingencies. To promote fading, counseling sessions can be simply shortened
(e.g., from 50 to 30 minutes) as well as spaced further apart (e.g., from every week to every 2
weeks) (Cormier, Nurius, & Osborn, 2017; MacCluskie & Ingersoll, 2001).
Another way to promote closing is to help clients develop successful problem-solving
skills. Clients, like everyone else, are constantly faced with problems. If counselors can help
their clients learn more effective ways to cope with these difficulties, clients will no longer need
the counseling relationship. This is a process of generalization from counseling experience to
life. At its best, this process includes an emphasis on education and prevention as well as deci-
sion-making skills for everyday life and crisis situations.

PERSONAL REFLECTION
When has education, either formal or self-taught, helped you stop doing something (e.g., smoking,
biting your nails, displaying a nervous twitch, talking excessively)? How do you relate doing some-
thing new to closing?

RESISTANCE TO CLOSING
Resistance to closing may come from either the counselor or the client. Welfel and Patterson
(2005) note that resistance is especially likely when the counseling relationship has lasted for a
long time or has involved a high level of intimacy. Other factors that may promote resistance
include the pain of earlier losses, loneliness, unresolved grief, need gratification, fear of rejec-
tion, and fear of having to be self-reliant. Some of these factors are more prevalent with clients,
whereas others are more likely to characterize counselors.
 Chapter 6 • Working in and Closing a Counseling Relationship 137

Client Resistance
Clients resist closing in many ways. Two easily recognized expressions of resistance are (a)
asking for more time at the end of a session and (b) asking for more appointments once a
goal has been reached. Another more troublesome form of client resistance is the development
of new problems that were not part of an original concern, such as depression or anxiety. The
manifestation of these symptoms makes closing more difficult; in such situations, a client may
convince the counselor that only he or she can help. Thus, the counselor may feel obligated to
continue working with the person for either personal or ethical reasons.
Regardless of the strategy employed, the closing process is best carried out gradually.
Sessions can become less frequent over time, and client skills, abilities, and resources can be
highlighted simultaneously. Sometimes when clients are especially hesitant to terminate, the
counselor can “prescribe” a limited number of future sessions or concentrate with clients on
how they will set themselves up for relapse (Anderson & Stewart, 1983). These procedures
make the covert more overt and help counselors and clients identify what issues are involved in
leaving.
Vickio (1990) has developed a unique way of implementing a concrete strategy for college
students who are dealing with loss and closing. In The Goodbye Brochure, he describes what it
means to say good-bye and why good-byes should be carried out. He then discusses five Ds for
successfully dealing with departure and loss and an equal number of Ds for unsuccessfully deal-
ing with them (p. 576).

Successfully Dealing with Loss

1. Determine ways to make your transition a gradual process.
2. Discover the significance that different activities have had in your life.
3. Describe this significance to others.
4. Delight in what you have gained and in what lies ahead of you.
5. Define areas of continuity in your life.

Unsuccessfully Dealing with Loss

1. Deny the loss.
2. Distort your experience by overglorifying it.
3. Denigrate your activities and relationships.
4. Distract yourself from thinking about departure.
5. Detach yourself abruptly from your activities and relationships.
Lerner and Lerner (1983) believe that client resistance often results from a fear of
change. If clients come to value a counseling relationship, they may fear that they cannot
function well without it. For example, people who have grown up in unstable or chaotic envi-
ronments involving the abuse of alcohol or an adversarial divorce may be especially prone to
hold on to the stability of counseling and the relationship with the counselor. It is vital that
the counselor recognize the special needs of these individuals and the difficulties they have in
coping with loneliness and intimacy. It is even more critical that the counselor take steps to
help such clients help themselves by exploring with them the advantages of working in other
therapeutic settings, such as support or self-help groups. For such clients, counseling is poten-
tially addictive. If they are to function in healthy ways, they must find alternative sources of
support.
138 Part II • Counseling Processes and Theories

Counselor Resistance
Although the ultimate goal in counseling is for counselors to become obsolete and unnecessary
to their clients, some counselors are reluctant to say good-bye at the appropriate time (Nystul,
2016). Clients who have special or unusual needs or those who are very productive may be espe-
cially attractive to counselors. Goodyear (1981) lists eight conditions in which closing may be
particularly difficult for counselors:
1. When closing signals the end of a significant relationship
2. When closing arouses the counselor’s anxieties about the client’s ability to function inde-
pendently
3. When closing arouses guilt in the counselor about not having been more effective with the
client
4. When the counselor’s professional self-concept is threatened by the client who leaves
abruptly and angrily
5. When closing signals the end of a learning experience for the counselor (e.g., the counselor
may have been relying on the client to learn more about the dynamics of a disorder or a
particular culture)
6. When closing signals the end of a particularly exciting experience of living vicariously
through the adventures of the client
7. When closing becomes a symbolic recapitulation of other (especially unresolved) fare-
wells in the counselor’s life
8. When closing arouses in the counselor conflicts about his or her own individuation (p. 348)
It is important that counselors recognize any difficulties they have in letting go of certain
clients. A counselor may seek consultation with colleagues in dealing with this problem or
undergo counseling to resolve the problem. The latter option is quite valuable if the counselor
has a personal history of detachment, isolation, and excessive fear of intimacy. Guy (1987)
reports that some persons who enter the helping professions possess just such characteristics.

PERSONAL REFLECTION
Almost everyone has a situation in his or her life that ended too soon or that was less than ideal. You
may want to explore some of those times in your own life.
Could acknowledging those feelings or behaviors help you in working with a client you may
not want to terminate? How?

PREMATURE CLOSING
The question of whether clients terminate counseling prematurely is not one that can usually be
measured by the number of sessions the client has completed. Rather, premature closing often
has to do with how well clients believe they have achieved personal goals and how well they are
functioning generally. A substantial minority of individuals reported terminating prematurely
because of treatment dissatisfaction. Clients with weaker therapeutic alliance are more likely to
drop out of counseling than those who bond well with their counselor (Sharf, Primavera, &
Diener, 2010). Early termination seems to be more prevalent with lower income and less well-
educated clients who may not understand many of the subtleties of counseling (Westmacott &
 Chapter 6 • Working in and Closing a Counseling Relationship 139

Hunsley, 2010). Younger clients, those with greater dysfunctionality, and people of color are
more likely to drop out of counseling as well (Lampropoulos, Schneider, & Spengler, 2009).
Regardless of socioeconomic class and other background factors, some clients show little, if
any, commitment or motivation to change their present circumstances and request that counseling
be terminated after the first session. Such a request is more likely to happen if these clients see an
intake counselor first and are then transferred to another treatment counselor (Nielsen et al., 2009).
Other clients express the desire to terminate early after realizing the work necessary for change.
Regardless of how clients express a wish for premature closing, it is likely to trigger
thoughts and feelings within the counselor that must be dealt with. Hansen, Warner, and Smith
(1980) suggest that the topic of premature closing be discussed openly between a counselor and
client if the client expresses a desire to terminate before specified goals have been met or if the
counselor suspects that premature closing may occur. With discussion, thoughts and feelings of
both the client and counselor can be examined and a premature ending prevented.
Sometimes a client fails to keep an appointment and does not call to reschedule. In such
cases, the counselor should attempt to reach the client by phone or mail. Sending a letter to a cli-
ent allows him or her more “space” in which to consider the decision of whether to continue
counseling or not (MacCluskie & Ingersoll, 2001). A model for a “no show” letter is as follows.

Dear ______________:

I have missed you at our last scheduled session. I would like very much for us to continue
to work together, yet the choice about whether to counsel is yours. If you do wish to
reschedule, could you please do so in the next 30 days? Otherwise, I will close your
chart and assume you are not interested in services at this time.

Sincerely,
Mary Counselor (p. 179)

If the counselor finds that the client wishes to quit, an exit interview may be set up. Ward
(1984) reports four possible benefits from such an interview:
1. An exit interview may help the client resolve any negative feelings resulting from the
counseling experience.
2. An exit interview serves as a way to invite the client to continue in counseling if he or she
so wishes.
3. Another form of treatment or a different counselor can be considered in an exit interview
if the client so desires.
4. An exit interview may increase the chance that the next time the client needs help, he or
she will seek counseling.
In premature closing, a counselor often makes one of two mistakes. One is to blame
either himself or herself or the client for what is happening. A counselor is more likely to
140 Part II • Counseling Processes and Theories

blame the client. In either case, someone is berated, and the problem is compounded. It may be
more productive for the counselor to think of the situation as one in which no one is at fault.
This strategy is premised on the idea that some matches between clients and counselors do not
work.
A second mistake on the counselor’s part is to act in a cavalier manner about the situation.
An example is the counselor who says, “It’s too bad this client has chosen not to continue coun-
seling, but I’ve got others.” To avoid making either mistake, counselors need to find out why a
client terminated prematurely. Possible reasons include the following:
• To see whether the counselor really cares
• To try to elicit positive feelings from the counselor
• To punish or try to hurt the counselor
• To eliminate anxiety
• To show the counselor that the client has found a cure elsewhere
• To express to the counselor that the client does not feel understood
Counselors need to understand that regardless of what they do, some clients terminate
counseling prematurely. This realization allows counselors to feel that they do not have to be
perfect and frees them to be more authentic in the therapeutic relationship. It also enables them
to acknowledge overtly that, no matter how talented and skillful they are, some clients find other
counselors more helpful. Ideally, counselors are aware of the anatomy of closing. With such
knowledge, they become empowered to deal realistically with closing situations.
Not all people who seek counseling are equally ready to work in such a relationship, and
the readiness level may vary as the relationship continues. Some clients need to terminate prema-
turely for good reasons, and their action does not necessarily reflect on the counselor’s compe-
tence. Counselors can control only a limited number of variables in a counseling relationship.
The following list includes several of the variables most likely to be effective in preventing
premature closing (Young, 2017):
• Appointments. The less time between appointments and the more regularly they are
scheduled, the better.
• Orientation to counseling. The more clients know about the process of counseling, the
more likely they are to stay with it.
• Consistency of counselor. Clients do not like to be processed from counselor to coun-
selor. Therefore, the counselor who does the initial intake should continue the counseling.
• Reminders to motivate client attendance. Cards, telephone calls, texts, or e-mail can
be effective reminders. Because of the sensitivity of counseling, however, a counselor
should always have the client’s permission to send an appointment reminder.

COUNSELOR-INITIATED CLOSING
Counselor-initiated closing is the opposite of premature closing. A counselor sometimes needs
to end relationships with some or all clients. Reasons include illness, working through counter-
transference, relocation to another area, the end of an internship or practicum experience, an
extended trip, or the realization that client needs could be better served by someone else. Other
reasons for terminating a client relationship are associated with a counselor feeling endangered,
or the client not paying agreed upon fees. These are what Cavanagh and Levitov (2002) classify
as “good reasons” for the counselor to terminate.
 Chapter 6 • Working in and Closing a Counseling Relationship 141

There are also poor reasons for counselor-initiated terminations. They include a coun-
selor’s feelings of anger, boredom, or anxiety. If counselors end a relationship because of such
feelings, clients may feel rejected and even worse than they did in the beginning. It is one thing
for a person to handle rejection from peers; it is another to handle rejection from a counselor.
Although a counselor may have some negative feelings about a client, it is possible to acknowl-
edge and work through those feelings without behaving in a detrimental way.
Both London (1982) and Seligman (1984) present models for helping clients deal with the
temporary absence of the counselor. These researchers stress that clients and counselors should
prepare as far in advance as possible for temporary closing by openly discussing the impending
event and working through any strong feelings about the issue of separation. Clients may actu-
ally experience benefits from counselor-initiated closing by realizing that the counselor is human
and replaceable. They may also come to understand that people have choices about how to deal
with interpersonal relationships. Furthermore, they may explore previous feelings and major life
decisions, learning more clearly that new behaviors carry over into other life experiences
(London, 1982). Refocusing may also occur during the closing process and help clients see
issues on which to work more clearly.
Seligman (1984) recommends a more structured way of preparing clients for counselor-
initiated closing than London does, but both models can be effective. It is important in any situ-
ation like this to make sure clients have the names and numbers of a few other counselors to
contact in case of an emergency.
There is also the matter of permanent counselor-initiated closing. In today’s mobile
society “more frequently than before, it is counselors who leave, certain they will not return”
(Pearson, 1998, p. 55). In such cases, closing is more painful for clients and presents quite a chal-
lenge for counselors. The timing expected in the counseling process is off.
In permanent counselor-initiated closing, it is still vital to review clients’ progress, end the
relationship at a specific time, and make postcounseling plans. A number of other tasks must be
accomplished; among these are counselors working through their own feelings about closing,
such as sadness, grief, anger, and fear. Furthermore, counselors need to put clients’ losses in
perspective and plan accordingly how each client will deal with the loss. Counselors must take
care of their physical needs, too, and seek professional and personal support where necessary.
In the process of their own closing preparations, counselors should be open with clients
about where they are going, what they will be doing, or other reasons for ending the relationship.
They should make such announcements in a timely manner and allow clients to respond. They
should also allow enough time for the client to process the ending—30 days at least if possible
(Herlihy & Corey, 2015). “Advanced empathy is a powerful means for helping clients express
and work through the range of their emotions” (Pearson, 1998, p. 61). Arranging for transfers or
referrals to other counselors is critical if clients’ needs are such. It is crucial that the client not
feel abandoned. Finally, there is the matter of saying good-bye and ending the relationship. This
process may be facilitated through the use of immediacy and/or rituals.

CASE EXAMPLE
Miguel Moves
Miguel enjoyed his work as a counselor at family services. He was enthusiastic, energetic, and
carried a full case load. However, when his wife received a promotion at work that required a
move to another city, he realized he had to end his present counseling practice. Most troubling
142 Part II • Counseling Processes and Theories

was the fact that he had only a month to do so, and as a child Miguel had had some trauma
regarding loss. Thus, Miguel was not sure exactly what to do and how. He wanted to be profes-
sional and helpful to his clients, but he also wanted to take care of himself.
How would you prioritize the actions Miguel needs to take first in regard to his clients?
Would a letter letting them know that he is leaving be unprofessional or crass? How would you
suggest Miguel take care of himself?

ENDING ON A POSITIVE NOTE

The process of closing, like counseling itself, involves a series of checkpoints that counselors
and clients can consult to evaluate the progress they are making and determine their readiness to
move to another stage. It is important that closing be mutually agreed on, if at all possible, so that
all involved can move on in ways deemed most productive. Nevertheless, this is not always pos-
sible. Welfel and Patterson (2005, pp. 124–125) present four guidelines a counselor can use to
end an intense counseling relationship in a positive way:
1. “Be aware of the client’s needs and desires and allow the client time to express
them.” At the end of a counseling relationship, the client may need time to express grat-
itude for the help received. Counselors should accept such expressions “without minimiz-
ing the value of their work.”
2. “Review the major events of the counseling experience and bring the review into the
present.” The focus of this process is to help a client see where he or she is now as com-
pared with the beginning of counseling and realize more fully the growth that has been
accomplished. The procedure includes a review of significant past moments and turning
points in the relationship with a focus on personalizing the summary.
3. “Supportively acknowledge the changes the client has made.” At this point, the coun-
selor lets the client know that he or she recognizes the progress that has been achieved and
actively encourages the client to maintain it. “When a client has chosen not to implement
action plans” for issues that emerged in counseling, “the process of closing should also
include an inventory of such issues and a discussion of the option of future counseling.”
4. “Request follow-up contact.” Counseling relationships eventually end, but the caring,
concern, and respect counselors have for clients are not terminated at the final session.
Clients need to know that counselors continue to be interested in what is happening in their
lives. It is an additional incentive for clients to maintain the changes that counseling has
produced.

ISSUES RELATED TO CLOSING: FOLLOW-UP AND REFERRAL

Follow-Up
Follow-up entails checking to see how the client is doing, with respect to whatever the problem
was, sometime after closing has occurred (Okun & Kantrowitz, 2015). In essence, it is a positive
monitoring process that encourages client growth (Egan, 2014). Follow-up is a step that some
counselors neglect. It is important because it reinforces the gains clients have made in counseling
and helps both the counselor and the client reevaluate the experience. It also emphasizes the
counselor’s genuine care and concern for the client.
 Chapter 6 • Working in and Closing a Counseling Relationship 143

Follow-up can be conducted on either a short- or long-term basis. Short-term follow-up is

usually conducted 3 to 6 months after a counseling relationship terminates. Long-term follow-
up is conducted at least 6 months after closing.
Follow-up may take many forms, but there are four main ways in which it is usually con-
ducted (Cormier et al., 2017). The first is to invite the client in for a session to discuss any
progress he or she has continued to make in achieving desired goals. A second way is through a
telephone call to the client. A call allows the client to report to the counselor, although only
verbal interaction is possible. A third way is for the counselor to send the client a letter asking
about the client’s current status. A fourth and more impersonal way is for the counselor to mail
or e-mail the client a questionnaire dealing with his or her current levels of functioning. Many
public agencies use this type of follow-up as a way of showing accountability. Such procedures
do not preclude the use of more personal follow-up procedures by individual counselors.
Although time-consuming, a personal follow-up is probably the most effective way of evaluat-
ing past counseling experiences. It helps assure clients that they are cared about as individuals.
Sometimes, regardless of the type of follow-up used, it is helpful if the client monitors his
or her own progress through the use of graphs or charts. Then, when relating information to the
counselor, the client can do so in a more concrete and objective way. If counselor and client
agree at the end of the last session on a follow-up time, this type of self-monitoring may be espe-
cially meaningful and give the client concrete proof of progress and clearer insights.

CASE EXAMPLE
Follow-Up Flo
Flo was an excellent counselor, but she had one major fault: She never followed up with her
clients. As far as she was concerned, they were doing fine unless proven otherwise. In her
20 years of counseling, Flo had had only a handful of clients ever return for more therapy.
Therefore, Flo hypothesized that she had been able to see and help more people because she was
not spending time interacting with those who were better.
Could Flo’s philosophy be right? If not, why not? Would you adopt it?

Referral and Recycling

Counselors are not able to help everyone who seeks assistance. When a counselor realizes that a
situation is unproductive, it is important to know whether to terminate the relationship or make a
referral. A referral involves arranging other assistance for a client when the initial arrangement
is not or cannot be helpful (Okun & Kantrowitz, 2015). There are many reasons for referring,
including the following (Goldstein, 1971):
• The client has a problem the counselor does not know how to handle.
• The counselor is inexperienced in a particular area (e.g., substance abuse or mental disor-
ders) and does not have the necessary skill to help the client.
• The counselor knows of a nearby expert who would be more helpful to the client.
• The counselor and client have incompatible personalities.
• The relationship between counselor and client is stuck in an initial phase of counseling.
144 Part II • Counseling Processes and Theories

Referrals Involve a How, a When, and a Who. The how involves knowing how to call on a
helping resource and handle the client to maximize the chances that he or she will follow through
with the referral process. A client may resist a referral if the client feels rejected by the coun-
selor. Welfel and Patterson (2005) suggest that a counselor spend at least one session with the
client in preparation for the referral. Some clients will need several sessions.
The when of making a referral involves timing. The longer a client works with a coun-
selor, the more reluctant the client may be to see someone else. Thus, timing is crucial. If a
counselor suspects an impasse with a certain client, he or she should refer that client as soon
as possible. However, if the counselor has worked with the client for a while, he or she should
be sensitive about giving the client enough time to get used to the idea of working with some-
one else.
The who of making a referral involves the person to whom you are sending a client. The
interpersonal ability of that professional may be as important initially as his or her skills if the
referral is going to work well. A good question to ask oneself when making a referral is whether
the new counselor is someone you would feel comfortable sending a family member to see
(MacCluskie & Ingersoll, 2001).
Recycling is an alternative when the counselor thinks the counseling process has not yet
worked but can be made to do so. It means reexamining all phases of the therapeutic process.
Perhaps the goals were not properly defined or an inappropriate strategy was chosen. Whatever
the case, by reexamining the counseling process, counselor and client can decide how or whether
to revise and reinvest in the counseling process. Counseling, like other experiences, is not always
successful on the first attempt. Recycling gives both counselor and client a second chance to
achieve what each wants: positive change.

Summary and Conclusion

This chapter has emphasized the understanding, ways of relating, the less damage they are likely to
action phases of counseling, as well as closure—that do in their relationships with significant others and
is, termination. Working in a counseling relationship the more self-insight they are likely to achieve. A
occurs after clients and counselors have established a successful resolution of these issues promotes real-
rapport and explored possible goals toward which to ness, and at the root of growth and goal attainment is
work. Action is facilitated by mutual interaction the ability to experience the world realistically.
between the individuals involved. The counselor can Closing is an important but often neglected
help the client by appropriate leads, challenges to per- and misunderstood phase of counseling. The sub-
ception, multifocused responding, accurate empathy, jects of loss and ending are usually given less
self-disclosure, immediacy, confrontation, contracts, emphasis in counseling than those of growth and
and rehearsal. These skills are focused on the client, development. Thus, the subject of closing is fre-
but they also help the counselor gain self-insight. quently either ignored or taken for granted. Yet, suc-
Client and counselor must work through trans- cessful closing is vital to the health and well-being
ference and countertransference in their counseling of both counselors and clients. It is a phase of coun-
relationship. Some clients and counselors will seling that can determine the success of all previous
encounter less transference and countertransference phases and must be handled with skill.
than others, but it is important that each recognize This chapter has emphasized the procedures
when he or she is engaged in such modes of commu- involved in terminating an individual counseling
nication. The more aware people are about these session as well as an extended counseling
 Chapter 6 • Working in and Closing a Counseling Relationship 145

relationship. These processes can be generalized to resistance is related to unresolved feelings of grief
ending group or family counseling sessions. Both and separation. When a client has such feelings, he
clients and counselors must be prepared for these or she may choose to terminate the relationship
endings. One way to facilitate this preparation is prematurely. A counselor may also initiate closing
through the use of structure and verbal and nonver- but must do so for good reasons. Regardless of
bal signals. Clients must learn problem-solving skills who initiates closing, it is vital that all involved
before a counseling relationship is over so that they know what is happening and prepare accordingly.
can depend on themselves rather than their counsel- If possible, it is best to end counseling on a posi-
ors when they face difficult life situations. Neverthe- tive note. Once closing is completed, it is helpful
less, it is important that a client be given permission to conduct some type of follow-up within a year.
to contact the counselor again if needed. An open Sometimes, referrals or recycling procedures are
policy does much to alleviate anxiety. indicated to ensure that the client receives the type
At times the counselor, client, or both resist of help needed.
terminating the relationship. Many times this

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38 C HAP TE R THR EE

Introduction
This chapter introduces some of the ethical principles and issues that will be LO1
a basic part of your professional practice. I hope to stimulate your thinking about
the importance of ethical practice so you will have a sound foundation for making
ethical decisions. Topics addressed include balancing clients’ needs against your
own needs, ways of making good ethical decisions, educating clients about their
rights, parameters of confidentiality, ethical concerns in counseling diverse client
populations, ethical issues involving diagnosis, evidence-based practice, and dealing
with multiple relationships and managing boundaries.
Students sometimes think of ethics merely as a list of rules and prohibitions
that result in sanctions and malpractice actions if practitioners do not follow them.
You will learn that being an ethical practitioners is far more complex than a set of
rules. Mandatory ethics involves a level of ethical functioning at the minimum level
of professional practice. In contrast, aspirational ethics focuses on doing what is in
the best interests of clients. Functioning at the aspirational level involves the high-
est standards of thinking and conduct. Aspirational practice requires counselors to
do more than simply meet the letter of the ethics code. It entails understanding the
spirit of the code and the principles on which the code is based. Fear-based ethics does
not constitute sound ethical practice. Ethics is more than a list of things to avoid
for fear of punishment. Strive to work toward concern-based ethics, and think about
how you can become the best practitioner possible (Corey, Corey, Corey, & Callanan,
2015). Positive ethics is an approach taken by practitioners who want to do their
best for clients rather than simply meet minimum standards to stay out of trouble
(Knapp & VandeCreek, 2006).
Visit CengageBrain.com or watch the DVD for the video program on Chapter 3, Theory and
Practice of Counseling and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you view the
brief lecture for each chapter prior to reading the chapter.

Putting Clients’ Needs Before Your Own

As counselors we cannot always keep our personal needs completely separate from
our relationships with clients. Ethically, it is essential that we become aware of our
own needs, areas of unfinished business, potential personal problems, and espe-
cially our sources of countertransference. We need to realize how such factors could
interfere with effectively and ethically serving our clients.
Our professional relationships with our clients exist for their benefit. A use-
ful question to frequently ask yourself is this: “Whose needs are being met in this
relationship, my client’s or my own?” It takes considerable professional maturity to
make an honest appraisal of how your behavior affects your clients. It is not unethi-
cal for us to meet our personal needs through our professional work, but it is essen-
tial that these needs be kept in perspective. An ethical problem exists when we meet
our needs, in either obvious or subtle ways, at the expense of our clients’ needs. It is
crucial that we avoid exploiting or harming clients.
We all have certain blind spots and distortions of reality. As helping profession-
als, we must actively work toward expanding our self-awareness and learn to recognize
 ET H I C AL I S S U ES I N C O U N S EL I N G PRAC T ICE 39

our areas of prejudice and vulnerability. If we are aware of our personal problems and
are willing to work through them, there is less chance that we will project them onto
clients. If certain problem areas surface and old conflicts become reactivated, we have
an ethical obligation to do whatever it takes to avoid harming our clients.
We must also examine other, less obviously harmful personal needs that can
get in the way of creating growth-producing relationships, such as the need for con-
trol and power; the inordinate need to be nurturing; the need to change others in
the direction of our own values; the need for feeling adequate, particularly when it
becomes overly important that the client confirm our competence; and the need
to be respected and appreciated. It is crucial that we do not meet our needs at the
expense of our clients. For an expanded discussion of this topic, see M. Corey and
Corey (2016, chap. 1).

Ethical Decision Making

The ready-made answers to ethical dilemmas provided by professional LO2
organizations typically contain only broad guidelines for responsible practice. In
practice, you will have to apply the ethics codes of your profession to the many
practical problems you face. Professionals are expected to exercise prudent judg-
ment when it comes to interpreting and applying ethical principles to specific situ-
ations. Although you are responsible for making ethical decisions, you do not have
to do so alone. Learn about the resources available to you. Consult with colleagues,
keep yourself informed about laws affecting your practice, keep up to date in your
specialty field, stay abreast of developments in ethical practice, reflect on the impact
your values have on your practice, and be willing to engage in honest self-examina-
tion. You should also be aware of the consequences of practicing in ways that are
not sanctioned by organizations of which you are a member or the state in which
you are licensed to practice.

The Role of Ethics Codes as a Catalyst for Improving Practice

Professional codes of ethics serve a number of purposes. They educate counseling
practitioners and the general public about the responsibilities of the profession.
They provide a basis for accountability, and protect clients from unethical practices.
Perhaps most important, ethics codes provide a basis for reflecting on and improv-
ing your professional practice. Self-monitoring is a better route for professionals to
take than being policed by an outside agency (Herlihy & Corey, 2015a).
From my perspective, an unfortunate recent trend is for ethics codes to increas-
ingly take on legalistic, rule-based dimensions. Being an ethical practitioner involves
far more than following a list of rules. Practitioners anxious to avoid any litigation
may gear their practices mainly toward fulfilling legal minimums. If we are too con-
cerned with being sued, it is unlikely that we will be very creative or effective in our
work. It makes sense to be aware of the legal aspects of practice and to know and
practice risk-management strategies, but we should not lose sight of what is best for
our clients. One of the best ways to prevent being sued for malpractice is to demon-
strate respect for clients, keep client welfare as a central concern, and practice within
the framework of professional codes.
40 C HAP TE R THR EE

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

Some Steps in Making Ethical Decisions

Most models for ethical decision making focus on the application of principles to
ethical dilemmas. My colleagues and I have identified a series of procedural steps
to help you think through ethical problems when using these principles (see Corey,
Corey, Corey, & Callanan, 2015):
ŠIdentify the problem or dilemma. Gather information that will shed
light on the nature of the problem. This will help you decide whether
the problem is mainly ethical, legal, professional, clinical, or moral.
ŠIdentify the potential issues. Evaluate the rights, responsibilities, and
welfare of all those who are involved in the situation.
ŠLook at the relevant ethics codes for general guidance on the matter.
Consider whether your own values and ethics are consistent with or in
conflict with the relevant guidelines.
ŠConsider the applicable laws and regulations, and determine how they
may have a bearing on an ethical dilemma.
ŠSeek consultation from more than one source to obtain various per-
spectives on the dilemma, and document in the client’s record the
suggestions you received from this consultation.
ŠBrainstorm various possible courses of action. Continue discussing
options with other professionals. Include the client in this process of
considering options for action. Again, document the nature of this
discussion with your client.
ŠEnumerate the consequences of various decisions, and reflect on the
implications of each course of action for your client.
ŠDecide on what appears to be the best possible course of action.
Once the course of action has been implemented, follow up to evalu-
ate the outcomes and to determine whether further action is neces-
sary. Document the reasons for the actions you took as well as your
evaluation measures.
In reasoning through any ethical dilemma, there is rarely just one course of action
to follow, and practitioners may make different decisions. The more subtle the
ethical dilemma, the more complex and demanding the decision-making process.
Professional maturity implies that you are open to questioning and discussing
your quandaries with colleagues. In seeking consultation, it is generally possible to
protect the identity of your client and still get useful input that is critical to making
sound ethical decisions. Because ethics codes do not make decisions for you, it is a
good practice to demonstrate a willingness to explore various aspects of a problem,
 ET H I C AL I S S U ES I N C O U N S EL I N G PRAC T ICE 41

raise questions, discuss ethical concerns with others, and continually clarify your
values and examine your motivations. To the degree that it is possible, include the
client in all phases of the ethical decision-making process. Again, it is essential to
document how you included your client as well as the steps you took to ensure
ethical practice.

The Right of Informed Consent

Regardless of your theoretical framework, informed consent is an ethical LO3
and legal requirement that is an integral part of the therapeutic process. It also
establishes a basic foundation for creating a working alliance and a collabora-
tive partnership between the client and the therapist. Informed consent involves
the right of clients to be informed about their therapy and to make autonomous
decisions pertaining to it. Providing clients with information they need to make
informed choices tends to promote the active cooperation of clients in their coun-
seling plan. By educating your clients about their rights and responsibilities, you are
both empowering them and building a trusting relationship with them. Seen in this
light, informed consent is something far broader than simply making sure clients
sign the appropriate forms. It is a positive approach that helps clients become active
partners and true collaborators in their therapy.
Some aspects of the informed consent process include the general goals of coun-
seling, the responsibilities of the counselor toward the client, the responsibilities of
clients, limitations of and exceptions to confidentiality, legal and ethical parameters
that could define the relationship, the qualifications and background of the prac-
titioner, the fees involved, the services the client can expect, and the approximate
length of the therapeutic process. Further areas might include the benefits of coun-
seling, the risks involved, and the possibility that the client’s case will be discussed
with the therapist’s colleagues or supervisors.
There are a host of ways to violate a client’s privacy through the inappropriate
use of various forms of modern-day technology. Most of us have become accustomed
to relying on technology, and we need to give careful thought to the subtle ways cli-
ent privacy can be compromised. As a part of the informed consent process, it is
wise to discuss the potential privacy problems of using a wide range of technology
and to take preventive measures to protect both you and your clients. For example,
clients and counselors should carefully consider privacy issues before agreeing to
send e-mail messages to clients’ workplace or home. A good policy is to limit e-mail
exchanges to basic information such as appointment times.
Educating the client begins with the initial counseling session, and this process
will continue for the duration of counseling. The challenge of fulfilling the spirit of
informed consent is to strike a balance between giving clients too much information
and giving them too little. For example, it is too late to tell minors that you intend
to consult with their parents after they have disclosed that they are considering an
abortion. Young clients have a right to know about the limitations of confidentiality
before they make such highly personal disclosures. Clients can be overwhelmed, how-
ever, if counselors go into too much detail initially about the interventions they are
likely to make. It takes both intuition and skill for practitioners to strike a balance.
42 C HAP TE R THR EE

Informed consent in counseling can be provided in written form, orally, or some

combination of both. If it is done orally, therapists must make an entry in the client’s
clinical record documenting the nature and extent of informed consent (Nagy, 2011).
It is a good idea to provide basic information about the therapy process in writing,
as well as to discuss with clients topics that will enable them to get the maximum
benefit from their counseling experience. Written information protects both clients
and therapists and enables clients to think about the information and bring up ques-
tions at the following session. For a more complete discussion of informed consent
and client rights, see Issues and Ethics in the Helping Professions (Corey, Corey, Corey, &
Callanan, 2015, chap. 5), The Counselor and the Law: A Guide to Legal and Ethical Practice
(Wheeler & Bertram, 2015, chap. 2), Ethical, Legal, and Professional Issues in Counseling
(Remley & Herlihy, 2016), and Essential Ethics for Psychologists (Nagy, 2011, chap. 5).

Dimensions of Confidentiality
Confidentiality and privileged communication are two related but some- LO4
what different concepts. Both of these concepts are rooted in a client’s right to pri-
vacy. Confidentiality is an ethical concept, and in most states it is the legal duty of
therapists not to disclose information about a client. Privileged communication
is a legal concept that protects clients from having their confidential communications
revealed in court without their permission (Herlihy & Corey, 2015a). All states have
enacted into law some form of psychotherapist–client privilege, but the specifics
of this privilege vary from state to state. These laws ensure that disclosures clients
make in therapy will be protected from exposure by therapists in legal proceedings.
Generally speaking, the legal concept of privileged communication does not apply
to group counseling, couples counseling, family therapy, child and adolescent ther-
apy, or whenever there are more than two people in the room.
Confidentiality is central to developing a trusting and productive client–thera-
pist relationship. Because no genuine therapy can occur unless clients trust in the
privacy of their revelations to their therapists, professionals have the responsibility
to define the degree of confidentiality that can be promised. Counselors have an
ethical and legal responsibility to discuss the nature and purpose of confidentiality
with their clients early in the counseling process. In addition, clients have a right to
know that their therapist may be discussing certain details of the relationship with
a supervisor or a colleague.

Ethical Concerns with the Use of Technology

Issues pertaining to confidentiality and privacy can become more com- LO5
plicated when technology is involved. Section H of the ACA Code of Ethics (2014)
contains a new set of standards with regard to the use of technology, relationships
established through computer-mediated communication, and social media as a
delivery platform. Major subsections address competency to provide services and
the laws associated with distance counseling, components of informed consent and
security (confidentiality and its limitations), client verification, the distance coun-
seling relationship (access, accessibility, and professional boundaries), maintenance
of records, accessibility of websites, and the use of social media (Jencius, 2015).
 CHAPTER 7
Overview of Emotion-Focused
Treatment Systems

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Dimensions of Humanistic Treatment Systems Gestalt Therapy

Humanism Constructivist Approaches: Narrative,
Self-Actualizing Tendency Solution-Focused, and Feminist Ttherapy
Phenomenological Perspective The Importance of Emotions in Counseling and
Holistic Psychotherapy
Active Dimensions of Emotions and Sensations
Focus on Emotions Multicultural Factors and Emotions
An Introduction to Theoretical Models of Gender and Emotions
Humanistic Psychotherapies Age and Emotions
Carl Rogers and Person-Centered Counseling Culture and Emotions
Existential Psychotherapy Summary

In the preface to this book, you leamed about the BETA model, which reflects the four important
areas of focus in counseling and psychotherapy(background, emotions, droughts, actions) and pro-
vides the structure of tMs text. Part 2 focused on treatment approaches that emphasize the impor-
tance of background. Although those approaches do not ignore clients' emotions, they are viewed
primarily as a route to identifying long-standing pattems stemming h.om early attachments.
Part 3 of ellis book focuses on treatment approaches that emphasize emotions. 'll)is introduc-
tory chapter provides an overview of humanistic, or emotion-focused,psychotherapies as well as a
survey of emotions and their characteristics. The information in this chapter will introduce you to
136
 Chapter 7 Overview of Emotion-Focused Treatment Systems 137

some of the skills that are essential in helping clients identify and understand their emotions and
also team how to self-soothe and how to manage their emotions.
More than anyone else, Carl Rogers is associated with theories of counseling and psycho-
therapy that emphasize emotions. As much a way of being as a treatment approach, Rogers's
person-centered counseling was built on a strong humanistic base. Humanism views people as
capable and autonomous, with the ability to resolve their difficulties, realize their potential, and
change their lives in positive ways. The person-centered clinician seeks to build a relationship
with clients that wi]] promote a deeper self-understanding, enable them to become more authentic
and actualized, and empower them to use their strengths and flourish.
Humanistic therapies changed the way psychotherapyhad been conducted. Up until that time,
psychoanalysis, with its focus on the unconscious, and behavioral therapy, which focused on stimu-
lus and response, were the only methods in widespread practice. In both methodologies, the thera-
pist was traditionally seen as the expert. Carl Rogers revolutionized psychology and focused on the
client as the expert on his or her own life. Rogers(1961) wrote: "It is the client who knows what
hurts, what directions to go, what problems are crucial, what experiences have been deeply buried"
(PP. ll 12)

DI IENSIONS OF HUI IANISTIC TREATMENT SYSTEMS

The humanistic treatment systems presented in Part 3 not only pay particular attention to emotions
and sensations but also are experiential; they view as important what people have observed, encoun-
tered, and experienced. These approaches are phenomenological because of the importance they
ascribe to how people view themselves and their world. Now we look at each of the core concepts
of humanistic therapy in more detail.

Humanism
Theories that focus on emotions rather than background or cognitions, including client-centered,
existential, Gestalt, and emotion-focused therapy, are considered to be humanistic. They share the
following common beliefs:
The person should be viewed holistically.
Each person has an innate self-actualization tendency.
Humans have free will and are able to make choices.
Because humans have free will and choice, they also have responsibility for those choices.
Humanistic theories emphasize the positive natum of human beings, which "far overshadows
any emphasis on dysfunction or psychopathology"(Seeman, 2008, p. 39). Since Rogers's time,
research on the impact of stress and emotions on health, the development of positive psychology,
and the growth of Eastem-influencedand transpersonal theories have all focused on optimal func-
tioning. Compared to Freud's complicated theory of drives and &e unconscious, humanistic dieo-
ries seem rather simple. Humanists generally assume only one drive--the hate need to self
actualize
C

Self-Actualizing Tendency
Implicit in all humanistic 6eories is a strong belief in the dignity and worth of each individual.
Practitioners believe that people must be appreciated and accepted for themselves, not shaped to fit
a mold. They believe that people have a right to their own thoughts and opinions, should be free to
construct their own lives, and are fundamentally good and mistworthy. They believe in the human
138 Part 3 Treailnent Systems Emphasizing Emotions and Sensations

potential--in the inherent tendency of people to develop in positive ways that enhance and main-
tain themselves as well as humanity(Cain, 2008). Carl Rogers was one of the founders of the
human potential movement and the creator of the encounter group model, which encourages group
actualization.
Self-actualization is a calling to be, or to become, the best person that we can be. Emotion-
focused and humanistic therapies are by their nature more open to spiritual and transpersonal expe-
riences. A client is considered to be a "spiritual being on a spiritual path, even though they may not
be aware of it yet"(Rowan, 1998, p. 45).

Phenomenological Perspective
Humanistic therapies also share a phenomenological way of viewing the world. There is no objec-
tive reality, rather each person has his or her unique perception of the world. That perception deter-
mines the person's beliefs, behaviors, emotions, and relationships. "The organism reacts to the field
as it is experienced and perceived. This perceptual field is, for the individual, reality"(Rogers,
1951, P. 483).
Humanistic therapists believe in basic equality in the client-clinician relationship. No longer
is the person coming for treatment referred to as a "patient," a medical tami used in psychoanaly-
sis. Instead they are client and clinician, a team, working together to help the client with their
problems, not seejdng a cure. Carl Rogers first made this very important move away from medical
temlinology, and toward empowering the person to work toward finding his or her own solutions
to life ' s problems.

Holistic
Most of the humanistic psychotherapies consider the whole person. Just as Me mind cannot be con-
templated without the brain, neither can the person be helped without considering cognitive, emo-
tional, physical, and spiritual issues. Gestalt therapy and focusing techniques are the most focused
on bodily sensations and what Gendlin(1996) refers to as "felt sense." Most humanistic therapists
value emotions and experience over thought processes. The theories that will be discussed in Part 3
of this book integrate mind, body, and spirit. Some theories, especially Gestalt and postmodem
theories, also look at the individual within the broader context of society, culture, and other figure/
ground perspectives.

Active
Compared with psychodynamic approaches, humanistic psychotherapies are active. Therapists take
an active interest in their clients. They are responsive, auaientic, and real, engaging with the client
and being affected by the universal truths of Me client's story. Gestalt is the most active of the
humanistic therapies, transactional analysis the most directive, and Rogers's client-centered therapy
the least active or directive. Overall, there is a shared "felt sense" in the humanistic therapies Mat is
spontaneous--vital--energetic--contactual--present--improvising--active--embodied--per-
sonal--concrete--open--and sensuous"(Totton, 2010, p. 20).

Focus on Emotions
Theories that focus on emotions consider emotion to be crucial to the experiencing and understand-
ing of the self. Emotions can be both innately adaptive(helping the client to make sense of and
respond to the environment) or maladaptive(Damasio, 1994). The goal of working win) emotion
in therapy is to help clients become more proficient at accessing, identifying, understanding, and
Person-Centered
Therapy 7
LEARNING OBJECTIVES

1. Examine the evolution of person- 7. Examine the application of the

centered therapy over time. person-centered approach to crisis
2. Describe the main thrust of intervention.
emotion-focused therapy. 8. Understand the unique
3. Differentiate the contributions characteristics of person-centered
of Carl Rogers and Abraham expressive arts and how it is based
Maslow to humanistic on person-centered philosophy.
psychology. 9. Examine the key concepts
4. Understand the role of the and principles of motivational
therapist’s attitudes in the therapy interviewing and the stages
process. of change.
5. Describe the ways that empathy, 10. Recognize the contributions
unconditional positive regard, and shortcomings of the
and genuineness are fundamental person-centered approach to
to the process and outcome understanding and working with
of therapy. clients from diverse cultures.
6. Identify the personal characteristics 11. Identify the contributions and
of therapists that are essential for limitations of the person-centered
clients’ progress. approach.

163
164 C HAP TE R SEVEN

CARL ROGERS (1902–1987), a major psychology. He was a courageous pioneer

spokesperson for humanistic psychol- who “was about 50 years ahead of his
ogy, led a life that reflected the ideas he time and has been waiting for us to catch
developed for half a century. He showed up” (Elkins, 2009, p. 20). Often called the
a questioning stance, a deep openness “father of psychotherapy research,” Rogers
to change, and the courage to forge into was the first to study the counseling pro-
unknown territory both as a person and as cess in depth by analyzing the transcripts

Roger Ressmeyer/Corbis
a professional. In writing about his early of actual therapy sessions, and he was
years, Rogers (1961) recalled his fam- the first clinician to conduct major stud-
ily atmosphere as characterized by close ies on psychotherapy using quantitative
and warm relationships but also by strict methods. He was the first to formulate a
religious standards. Play was discouraged, Carl Rogers comprehensive theory of personality and
and the virtues of the Protestant ethic psychotherapy grounded in empirical
were extolled. His boyhood was somewhat lonely, and research, and he contributed to developing a theory
he pursued scholarly interests instead of social ones. of psychotherapy that focused on the strengths and
Rogers was an introverted person, and he spent a lot of resources of individuals. He was not afraid to take
time reading and engaging in imaginative activity and a strong position and challenged the status quo
reflection. During his college years his interests and throughout his professional career.
academic major changed from agriculture to history, During the last 15 years of his life, Rogers applied
then to religion, and finally to clinical psychology. the person-centered approach to world peace by train-
Rogers held academic positions in various fields, ing policymakers, leaders, and groups in conflict.
including education, social work, counseling, psycho- Perhaps his greatest passion was directed toward the
therapy, group therapy, peace, and interpersonal rela- reduction of interracial tensions and the effort to
tions, and he earned recognition around the world for achieve world peace, for which he was nominated for
originating and developing the humanistic movement the Nobel Peace Prize.
in psychotherapy. His foundational ideas, especially For a detailed video presentation of the life and
the central role of the client–therapist relationship as a works of Carl Rogers, see Carl Rogers: A Daughter’s
means to growth and change, have been incorporated Tribute (N. Rogers, 2002), which is described at the
in many other theoretical approaches. Rogers’s ideas end of this chapter. For an in-depth look at this
continue to have far-reaching effects on the field of psy- remarkable man and his work, see Carl Rogers: The
chotherapy (Cain, 2010). Quiet Revolutionary (Rogers & Russell, 2002) and
It is difficult to overestimate the significance of The Life and Work of Carl Rogers (Kirschenbaum,
Rogers’s contributions to clinical and counseling 2009).

NATALIE ROGERS (b. 1928) is a pioneer theory by helping individuals access their
in the field of person-centered expres- feelings through creative expressions.
sive arts therapy. She expanded on her N. Rogers has developed the concept of
father’s (Carl Rogers) theory of cre- the Creative Connection®—a process
ativity by using the expressive arts to whereby the client or group member is
enhance personal growth for individuals invited to access inner feelings through
and groups. Person-centered expres- an uninterrupted sequence of movement,
sive arts therapy employs a variety of sound, visual art, and journal writing. As
forms—movement, painting, sculpting, the client moves through this process,
Fiona Chang

music, writing, and improvisation—in a hidden or unconscious aspects of self are

supportive setting to facilitate growth discovered, and these insights are shared
and healing. It extends person-centered Natalie Rogers with the therapist.
 PERS O N - C EN T ERED T H ERAPY 165

N. Rogers’s work evolved from what she felt was Today, at 87 years of age, N. Rogers continues to
lacking in her father’s theory. As a woman growing up in find ways to bring meaning to her personal and pro-
an era when females were meant to be accommodating fessional life. During the past 10 years she taught and
to men, she eventually discovered her underlying anger facilitated workshops in the United States, England,
at being a second-class citizen. Her art was one vehi- Hong Kong, Latin America, Russia, and South Korea.
cle to express and gain insight into this injustice. She She continues to participate in teaching the six-week
also expressed her anger at her father because he was expressive arts certificate program at Sofia University
unknowingly a part of the patriarchal system. He was in northern California. See the resources section at
surprised but open to learning. After hearing about the the end of this chapter if you are interested in train-
role he and other men played in holding women back, ing in the person-centered approach to expressive arts
he changed many of his ways of being and writing. therapy.

Introduction
Of all the pioneers who have founded a therapeutic approach, for me Carl Rogers
stands out as one of the most influential figures in revolutionizing the direction of
counseling theory and practice. Rogers has become known as a “quiet revolution-
ary” who both contributed to theory development and whose influence continues
to shape counseling practice today (see Cain, 2010; Kirschenbaum, 2009; Rogers &
Russell, 2002).
The person-centered approach shares many concepts and values with the exis-
tential perspective presented in Chapter 6. Rogers’s basic assumptions are that peo-
ple are essentially trustworthy, that they have a vast potential for understanding
themselves and resolving their own problems without direct intervention on the
therapist’s part, and that they are capable of self-directed growth if they are involved
in a specific kind of therapeutic relationship. From the beginning, Rogers empha-
sized the attitudes and personal characteristics of the therapist and the quality of the
client–therapist relationship as the prime determinants of the outcome of the thera-
peutic process. He consistently relegated to a secondary position matters such as
the therapist’s knowledge of theory and techniques. This belief in the client’s capac-
ity for self-healing is in contrast with many theories that view the therapist’s tech-
niques as the most powerful agents that lead to change (Bohart & Tallman, 2010).
Clearly, Rogers revolutionized the field of psychotherapy by proposing a theory that
centered on the client as the primary agent for constructive self-change (Bohart &
Tallman, 2010; Bozarth, Zimring, & Tausch, 2002; Elkins, 2016).
Contemporary person-centered therapy is the result of an evolutionary pro-
cess that continues to remain open to change and refinement (see Cain, 2010;
Cain & Seeman, 2002). Rogers did not present the person-centered theory as a
fixed and completed approach to therapy. He hoped that others would view his
theory as a set of tentative principles relating to how the therapy process devel-
ops, not as dogma. Rogers expected his model to evolve and was open and recep-
tive to change.

Visit CengageBrain.com or watch the DVD for the video program on Chapter 7, Theory and
Practice of Counseling and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you view the
brief lecture for each chapter prior to reading the chapter.
166 C HAP TE R SEVEN

Four Periods of Development of the Approach

In tracing the major turning points in Rogers’s approach, Zimring and LO1
Raskin (1992) and Bozarth, Zimring, and Tausch (2002) have identified four periods
of development. In the first period, during the 1940s, Rogers developed what was
known as nondirective counseling, which provided a powerful and revolutionary alter-
native to the directive and interpretive approaches to therapy then being practiced.
While he was a professor at Ohio State University, Rogers (1942) published Counsel-
ing and Psychotherapy: Newer Concepts in Practice, which described the philosophy and
practice of nondirective counseling. Rogers’s theory emphasized the counselor’s
creation of a permissive and nondirective climate. When he challenged the basic
assumption that “the counselor knows best,” he realized this radical idea would
affect the power dynamics and politics of the counseling profession, and indeed it
caused a great furor (Elkins, 2009).
Rogers also challenged the validity of commonly accepted therapeutic proce-
dures such as advice, suggestion, direction, persuasion, teaching, diagnosis, and
interpretation. Based on his conviction that diagnostic concepts and procedures
were inadequate, prejudicial, and often misused, Rogers omitted them from his
approach. Nondirective counselors avoided sharing a great deal about themselves
with clients and instead focused mainly on reflecting and clarifying the clients’ ver-
bal communications and intended meanings.
In the second period, during the 1950s, Rogers (1951) renamed his approach
client-centered therapy, which reflected his emphasis on the client rather than on non-
directive methods. In addition, he started the Counseling Center at the University
of Chicago. This period was characterized by a shift from clarification of feelings to
a focus on the phenomenological world of the client. Rogers assumed that the best
vantage point for understanding how people behave was from their own internal
frame of reference. He focused more explicitly on the actualizing tendency as the
basic motivational force that leads to client change.
The third period, which began in the late 1950s and extended into the 1970s,
addressed the necessary and sufficient conditions of therapy. Rogers (1957) set forth
a hypothesis that resulted in three decades of research. A significant publication was
On Becoming a Person (C. Rogers, 1961), which addressed the nature of “becoming
the self that one truly is,” an idea he borrowed from Kierkegaard. Rogers published
this work during the time that he held joint appointments in the departments of
psychology and psychiatry at the University of Wisconsin. In this book he described
the process of “becoming one’s experience,” which is characterized by an openness
to experience, a trust in one’s experience, an internal locus of evaluation, and the
willingness to be in process. During the 1950s and 1960s, Rogers and his associates
continued to test the underlying hypotheses of the client-centered approach by con-
ducting extensive research on both the process and the outcomes of psychotherapy.
He was interested in how people best progress in psychotherapy, and he studied
the qualities of the client–therapist relationship as a catalyst leading to personality
change.
Rogers and his associates at the University of Chicago conducted research to
identify the ingredients in psychotherapy that account for therapeutic change. The
client-centered approach emphasized the role of the therapist as a facilitator of
 PERS O N - C EN T ERED T H ERAPY 167

growth and honored the inherent power of the client. Research findings consistently
supported this approach, confirming that therapeutic change is due to personal and
interpersonal factors rather than to specific techniques for curing specific disorders
(Elkins, 2016). On the basis of this research, the approach was further refined and
expanded (C. Rogers, 1961). For example, client-centered philosophy was applied to
education and was called student-centered teaching (C. Rogers & Freiberg, 1994). The
approach was also applied to encounter groups (C. Rogers, 1970).
The fourth phase, during the 1980s and the 1990s, was marked by considerable
expansion to education, couples and families, industry, groups, conflict resolution,
politics, and the search for world peace. Because of Rogers’s ever-widening scope of
influence, including his interest in how people obtain, possess, share, or surrender
power and control over others and themselves, his theory became known as the per-
son-centered approach. This shift in terms reflected the broadening application of the
approach. Although the person-centered approach has been applied mainly to indi-
vidual and group counseling, important areas of further application include educa-
tion, family life, leadership and administration, organizational development, health
care, cross-cultural and interracial activity, and international relations. During the
1980s Rogers directed his efforts toward applying the person-centered approach to
politics, especially to efforts related to the achievement of world peace.
In a comprehensive review of the research on person-centered therapy over a
period of 60 years, Bozarth, Zimring, and Tausch (2002) concluded the following:
ŠIn the earliest years of the approach, the client rather than the therapist
determined the direction and goals of therapy and the therapist’s role
was to help the client clarify feelings. This style of nondirective therapy
was associated with increased understanding, greater self-exploration,
and improved self-concepts.
ŠLater a shift from clarification of feelings to a focus on the client’s lived
experiences took place.
ŠAs person-centered therapy developed further, research centered on
the core conditions assumed to be both necessary and sufficient for
successful therapy. The attitude of the therapist—an empathic under-
standing of the client’s world and the ability to communicate a non-
judgmental stance to the client—along with the therapist’s genuineness
were found to be basic to a successful therapy outcome.
ŠThe main source of successful psychotherapy is the client. The therapist’s
attention to the client’s frame of reference fosters the client’s utilization
of inner and outer resources.

Emotion-Focused Therapy
Emotion-focused therapy (EFT) emerged as a person-centered “approach LO2
informed by understanding the role of emotion in human functioning and psycho-
therapeutic change” (Greenberg, 2014, p. 15). Leslie Greenberg, a prominent figure
in the development of this integrative approach, states that EFT is designed to help
clients increase their awareness of their emotions and make productive use of them.
Like person-centered therapists, emotion-focused therapists establish a therapeutic
168 C HAP TE R SEVEN

relationship based on the core therapeutic conditions. Once the therapeutic alliance
is created, however, the EFT practitioner actively works with emotions using a range
of experiential techniques to strengthen the self, regulate affect, and create new mean-
ing. New narratives can be created that disrupt maladaptive past emotional schemas,
which provides opportunities for positive emotional experiencing (McDonald, 2015).
EFT strategies focus on two major tasks: (1) help clients with too little emotion
access their emotions, and (2) help clients who experience too much emotion con-
tain their emotions (Greenberg, 2014). Many traditional therapies emphasize con-
scious understanding and cognitive and behavioral change, but they often neglect
the foundational role of emotional change. A main goal of EFT is to help individuals
access and process emotions to construct new ways of being. This approach has a
good deal to offer with respect to teaching us about the role of emotion in per-
sonal change and how emotional change can be a primary pathway to cognitive and
behavioral change (Greenberg, 2014).
EFT emphasizes the importance of awareness, acceptance, and understanding
the visceral experience of emotion. Greenberg (2014) believes that our emotions
cannot be change merely by talking about them, understanding their origins, or by
modifying our beliefs. Clients are encouraged to identify, experience, accept, express,
explore, transform, and manage their emotions. The act of experiencing feelings and
replacing old feelings with new positive feelings offers a corrective emotional expe-
rience. “One changes emotions by accepting and experiencing them, by opposing
them with different emotions to transform them, and by reflecting on them to cre-
ate new narrative meaning” (p. 18).
Both psychoanalytic and cognitive behavioral approaches are increasingly focus-
ing on emotions and are rapidly assimilating many aspects of EFT. Gestalt therapy
has always emphasized experiencing and exploring emotions. McDonald (2015)
reports that a strength of EFT is that it is an empirically validated brief therapeutic
approach with demonstrated effectiveness in treating anxiety, intimate partner vio-
lence, eating disorders, and trauma. EFT is being applied to counseling individuals,
groups, couples, families, and in working in diverse cultural contexts.
The theory and practice of EFT are only briefly discussed in this chapter. For an
in-depth discussion of the principles and techniques involved in the practice of EFT,
see Greenberg (2011), Emotion-Focused Therapy.

Existentialism and Humanism

In the 1960s and 1970s there was a growing interest among counselors in a “third
force” in therapy as an alternative to the psychoanalytic and behavioral approaches.
Under this heading fall existential therapy (Chapter 6), person-centered therapy
(Chapter 7), Gestalt therapy (Chapter 8), and certain other experiential and rela-
tionship-oriented approaches.
The connections between the terms existentialism and humanism have tended
to be confusing for students and theorists alike. The two viewpoints have much in
common, yet there also are significant philosophical differences between them. They
share a respect for the client’s subjective experience, the uniqueness and individual-
ity of each client, and a trust in the capacity of the client to make positive and con-
structive conscious choices. They have in common an emphasis on concepts such as
 PERS O N - C EN T ERED T H ERAPY 169

freedom, choice, values, personal responsibility, autonomy, purpose, and meaning.

Both approaches place little value on the role of techniques in the therapeutic pro-
cess and emphasize instead the importance of genuine encounter.
They differ in that existentialists take the position that we are faced with the
anxiety of choosing to create an identity in a world that lacks intrinsic meaning.
Existentialists tend to acknowledge the stark realities of human experience, and
their writings often focus on death, anxiety, meaninglessness, and isolation. The
humanists, in contrast, take the somewhat less anxiety-evoking and more optimistic
view that each of us has a natural potential that we can actualize and through which
we can find meaning. Many contemporary existential therapists refer to themselves
as existential-humanistic practitioners, indicating that their roots are in existential
philosophy but that they have incorporated many aspects of North American
humanistic psychotherapies (Cain, 2002a; Schneider & Krug, 2010).
As will become evident in this chapter, the existential and person-centered
approaches have parallel concepts with regard to the client–therapist relationship
being at the core of therapy. The phenomenological emphasis that is basic to the exis-
tentialist approach is also fundamental to person-centered theory. Both approaches
focus on the client’s perceptions and call for the therapist to be fully present with the
client so that it is possible to understand the client’s subjective world, and they both
emphasize the client’s capacity for self-awareness and self-healing. The therapist aims
to provide the client with a safe, responsive, and caring relationship to facilitate self-
exploration, growth, and healing (Watson, Goldman, & Greenberg, 2011).

Abraham Maslow’s Contributions to Humanistic Psychology

Abraham Maslow (1970) was a pioneer in the development of humanistic LO3
psychology and was influential in furthering the understanding of self-actualizing
individuals. Many of Carl Rogers’s ideas, especially on the positive aspects of being
human and the fully functioning person, are influenced by Maslow’s basic philoso-
phy. Maslow criticized Freudian psychology for what he saw as its preoccupation
with the sick and dark side of human nature. Maslow believed too much research
was being conducted on anxiety, hostility, and neuroses and too little into joy, cre-
ativity, and self-fulfillment. Self-actualization was the central theme of the work
of Abraham Maslow (1968, 1970, 1971). The positive psychology movement that
recently has come into prominence shares many concepts on the healthy side of
human existence with the humanistic approach.
Maslow studied what he called “self-actualizing people” and found that they dif-
fered in important ways from so-called normal individuals. The core characteristics of
self-actualizing people are self-awareness, freedom, basic honesty and caring, and trust
and autonomy. Other characteristics of self-actualizing individuals include a capacity
to welcome uncertainty in their lives, acceptance of themselves and others, spontane-
ity and creativity, a need for privacy and solitude, autonomy, a capacity for deep and
intense interpersonal relationships, a genuine caring for others, an inner-directedness
(as opposed to the tendency to live by others’ expectations), the absence of artificial
dichotomies within themselves (such as work/play, love/hate, and weak/strong), and
a sense of humor (Maslow, 1970). All of these personal characteristics are compatible
with the person-centered philosophy.
170 C HAP TE R SEVEN

Maslow postulated a hierarchy of needs as a source of motivation, with the most

basic needs being physiological needs. If we are hungry and thirsty, our attention is
riveted on meeting these basic needs. Next are the safety needs, which include a sense
of security and stability. Once our physical and safety needs are fulfilled, we become
concerned with meeting our needs for belonging and love, followed by our need for
esteem, both from self and others. We are able to strive toward self-actualization
only after these four basic needs are met. The key factor determining which need is
dominant at a given time is the degree to which those below it are satisfied.

The Vision of Humanistic Philosophy The underlying vision of humanistic

philosophy is captured by the metaphor of how an acorn, if provided with the
appropriate conditions, will “automatically” grow in positive ways, pushed
naturally toward its actualization as an oak. In contrast, for many existentialists
there is nothing that we “are,” no internal “nature” we can count on. We are faced
at every moment with a choice about what to make of this condition. Maslow’s
emphasis on the healthy side of being human and the emphasis on joy, creativity,
and self-fulfillment are part of the person-centered philosophy. The humanistic
philosophy on which the person-centered approach rests is expressed in attitudes
and behaviors that create a growth-producing climate. According to Rogers (1986b),
when this philosophy is lived, it helps people develop their capacities and stimulates
constructive change in others. Individuals are empowered, and they are able to use
this power for personal and social transformation.

Key Concepts
View of Human Nature
A common theme originating in Rogers’s early writing and continuing to permeate
all of his works is a basic sense of trust in the client’s ability to move forward in a
constructive manner if conditions fostering growth are present. His professional
experience taught him that if one is able to get to the core of an individual, one finds
a trustworthy, positive center (C. Rogers, 1987a). In keeping with the philosophy
of humanistic psychology, Rogers firmly maintained that people are trustworthy,
resourceful, capable of self-understanding and self-direction, able to make construc-
tive changes, and able to live effective and productive lives. When therapists are able
to experience and communicate their realness, support, caring, and nonjudgmental
understanding, significant changes in the client are most likely to occur.
Rogers maintained that three therapist attributes create a growth-promoting
climate in which individuals can move forward and become what they are capable
of becoming: (1) congruence (genuineness, or realness), (2) unconditional positive regard
(acceptance and caring), and (3) accurate empathic understanding (an ability to deeply
grasp the subjective world of another person). According to Rogers, if therapists
communicate these attitudes, those being helped will become less defensive and
more open to themselves and their world, and they will behave in prosocial and con-
structive ways.
The actualizing tendency is a directional process of striving toward realization,
fulfillment, autonomy, and self-determination. This natural inclination of humans
 PERS O N - C EN T ERED T H ERAPY 171

is based on Maslow’s (1970) studies of self-actualizing people, and it has significant

implications for the practice of therapy. Because of the belief that the individual has an
inherent capacity to move away from maladjustment and toward psychological health
and growth, the therapist places the primary responsibility on the client. The person-
centered approach rejects the role of the therapist as the authority who knows best
and of the passive client who depends on the therapist’s expertise. Therapy is rooted in
the client’s capacity for awareness and self-directed change in attitudes and behavior.
The person-centered approach emphasizes clients’ abilities to engage their own
resources to act in their world with others. Clients can move forward in constructive
directions and successfully deal with obstacles (both from within themselves and
outside of themselves) that are blocking their growth. By promoting self-awareness
and self-reflection, clients learn to exercise choice. Humanistic therapists emphasize
a discovery-oriented approach in which clients are the experts on their own inner
experience (Watson et al., 2011), and they encourage clients to make changes that
will lead to living fully and authentically, with the realization that this kind of exis-
tence demands a continuing struggle.

The Therapeutic Process

Therapeutic Goals
Rogers did not believe the goal of therapy was merely to solve problems. Rather, the
goal is to assist clients in achieving a greater degree of independence and integra-
tion so they can better cope with problems as they identify them. Before clients are
able to work toward that goal, they must first get behind the masks they wear, which
they develop through the process of socialization. Clients come to recognize that
they have lost contact with themselves by using facades. In a climate of safety in the
therapeutic session, they also come to realize that there are more authentic ways of
being. The therapist does not choose specific goals for the client. The cornerstone
of person-centered theory is the view that clients in a relationship with a facilitating
therapist have the capacity to define and clarify their own goals. Person-centered
therapists are in agreement on the matter of not setting goals for what clients need
to change, yet they differ on the matter of how to best help clients achieve their own
goals and to find their own answers (Bohart & Watson, 2011).

Therapist’s Function and Role

The role of person-centered therapists is rooted in their ways of being and LO4
attitudes, not in techniques designed to get the client to “do something.” Research
on person-centered therapy indicates that the attitude of therapists, rather than
their knowledge, theories, or techniques, facilitate personality change in clients
(C. Rogers, 1961). Basically, therapists use themselves as an instrument of change by
encountering clients on a person-to-person level. In examining the human elements
of psychotherapy, Elkins (2016) concludes that the human dimensions are more
powerful determinants of therapeutic effectiveness than theories or techniques. It is
the therapist’s attitude and belief in the inner resources of the client that creates the
therapeutic climate for growth (Bozarth et al., 2002).
172 C HAP TE R SEVEN

Person-centered theory holds that the therapist’s function is to be present and

accessible to clients and to focus on their immediate experience. First and foremost,
the therapist must be willing to be real in the relationship with clients. By being
congruent, accepting, and empathic, the therapist is a catalyst for change. Instead of
viewing clients in preconceived diagnostic categories, the therapist meets them on
a moment-to-moment experiential basis and enters their world. Through the thera-
pist’s attitude of genuine caring, respect, acceptance, support, and understanding,
clients are able to loosen their defenses and rigid perceptions and move to a higher
level of personal functioning. When these therapist attitudes are present, clients
then have the necessary freedom to explore areas of their life that were either denied
to awareness or distorted.

Client’s Experience in Therapy

Therapeutic change depends on clients’ perceptions both of their own experience
in therapy and of the counselor’s basic attitudes. If the counselor creates a climate
conducive to self-exploration, clients have the opportunity to explore the full range
of their experience, which includes their feelings, beliefs, behavior, and worldview.
What follows is a general sketch of clients’ experiences in therapy.
Clients come to the counselor in a state of incongruence; that is, a discrepancy
exists between their self-perception and their experience in reality. For example, Leon,
a college student, may see himself as a future physician, yet his below-average grades
could exclude him from medical school. The discrepancy between how Leon sees
himself (self-concept) or how he would like to view himself (ideal self-concept) and
the reality of his poor academic performance may result in anxiety and personal vul-
nerability, which can provide the necessary motivation to enter therapy. Leon must
perceive that a problem exists or, at least, that he is uncomfortable enough with his
present psychological adjustment to want to explore possibilities for change.
One reason clients seek therapy is a feeling of basic helplessness, powerlessness,
and an inability to make decisions or effectively direct their own lives. They may
hope to find “the way” through the guidance of the therapist. Within the person-
centered framework, however, clients soon learn that they can be responsible for
themselves in the relationship and that they can learn to be more free by using the
relationship to gain greater self-understanding.
As counseling progresses, clients are able to explore a wider range of beliefs and
feelings. They can express their fears, anxiety, guilt, shame, hatred, anger, and other
emotions that they had deemed too negative to accept and incorporate into their
self-structure. With therapy, people distort less and move to a greater acceptance
and integration of conflicting and confusing feelings. They increasingly discover
aspects within themselves that had been kept hidden. As clients feel understood
and accepted, they become less defensive and become more open to their experience.
Because they feel safer and are less vulnerable, they become more realistic, perceive
others with greater accuracy, and become better able to understand and accept oth-
ers. Individuals in therapy come to appreciate themselves more as they are, and their
behavior shows more flexibility and creativity. They become less concerned about
meeting others’ expectations, and thus begin to behave in ways that are truer to
themselves. These individuals direct their own lives instead of looking outside of
 PERS O N - C EN T ERED T H ERAPY 173

themselves for answers. They move in the direction of being more in contact with
what they are experiencing at the present moment, less bound by the past, less deter-
mined, freer to make decisions, and increasingly trusting in themselves to manage
their own lives. In short, their experience in therapy is like throwing off the self-
imposed shackles that had kept them in a psychological prison. With increased free-
dom, they tend to become more mature psychologically and move toward increased
self-actualization.
Person-centered therapy is grounded on the assumption that clients create their
own self-growth and are active self-healers (Bohart & Tallman, 1999, 2010; Bohart &
Wade, 2013; Bohart & Watson, 2011). The therapy relationship provides a support-
ive structure within which clients’ self-healing capacities are activated. What clients
value most is being understood and accepted, which results in creating a safe place
to explore feelings, thoughts, behaviors, and experiences; clients also value support
for trying out new behaviors (Bohart & Tallman, 2010).

Relationship Between Therapist and Client

Rogers (1957) based his hypothesis of the “necessary and sufficient condi- LO5
tions for therapeutic personality change” on the quality of the relationship: “If I can
provide a certain type of relationship, the other person will discover within himself
or herself the capacity to use that relationship for growth and change, and personal
development will occur” (C. Rogers, 1961, p. 33). Rogers (1967) hypothesized fur-
ther that “significant positive personality change does not occur except in a rela-
tionship” (p. 73). Rogers’s hypothesis was formulated on the basis of many years of
his professional experience, and it remains basically unchanged to this day.
1. Two persons are in psychological contact.
2. The first, whom we shall term the client, is in a state of incongruence,
being vulnerable or anxious.
3. The second person, whom we term the therapist, is congruent (real or
genuine) in the relationship, and this congruence is perceived by the
client.
4. The therapist experiences unconditional positive regard for the
client.
5. The therapist experiences an empathic understanding of the client’s
internal frame of reference and endeavors to communicate this experi-
ence to the client.
6. The communication to the client of the therapist’s empathic under-
standing and unconditional positive regard is to a minimal degree
achieved. (as cited in Cain 2002a, p. 20)
Rogers hypothesized that no other conditions were necessary. If the therapeutic
core conditions exist over some period of time, constructive personality change
will occur. The core conditions do not vary according to client type. Further, they
are both necessary and sufficient for therapeutic change to occur.
From Rogers’s perspective, the client–therapist relationship is characterized by
equality. Therapists do not keep their knowledge a secret or attempt to mystify the
therapeutic process. The process of change in the client depends to a large degree
174 C HAP TE R SEVEN

on the quality of this equal relationship. As clients experience the therapist listen-
ing in an accepting way to them, they gradually learn how to listen acceptingly to
themselves. As they find the therapist caring for and valuing them (even the aspects
that have been hidden and regarded as negative), clients begin to develop worth and
value in themselves. As they experience the realness of the therapist, clients drop
many of their pretenses and become real with both themselves and the therapist.
This humanistic approach is perhaps best characterized as a way of being and as a
shared journey in which therapist and client reveal their humanness and participate in
a growth experience. The therapist can be a relational guide on this journey because
he or she is usually more psychologically experienced in this role than the client.
Therapists are invested in broadening their own life experiences and are willing to
do what it takes to deepen their self-knowledge.
Rogers admitted that his theory was strikingly provocative and radical. His for-
mulation has generated considerable controversy, for he maintained that many con-
ditions other therapists commonly regard as necessary for effective psychotherapy
were nonessential. The core therapist conditions of congruence, unconditional posi-
tive regard, and accurate empathic understanding subsequently have been embraced
by many therapeutic schools as essential in facilitating therapeutic change. These
core qualities of therapists, along with the therapist’s presence, work holistically to
create a safe environment for learning (Cain, 2010). Regardless of theoretical orien-
tation, most therapists strive to listen fully and empathically to clients, especially
during the initial stages of therapy. We now turn to a detailed discussion of how
these core conditions are an integral part of the therapeutic relationship.

Congruence, or Genuineness Congruence implies that therapists are real; that

is, they are genuine, integrated, and authentic during the therapy hour. They are
without a false front, their inner experience and outer expression of that experience
match, and they can openly express feelings, thoughts, reactions, and attitudes that
are present in the relationship with the client. This communication is done with
careful reflection and considered judgment on the therapist’s part (Kolden, Klein,
Wang, & Austin, 2011).
Through authenticity the therapist serves as a model of a human being strug-
gling toward greater realness. Being congruent might necessitate expressing a
range of feelings including anger, frustration, liking, concern, and annoyance. This
does not mean that therapists should impulsively share all their reactions, for self-
disclosure must be appropriate, well timed, and have a constructive therapeutic
intent. Counselors can try too hard to be genuine; sharing because they think it
will be good for the client, without being genuinely moved to express something
regarded as personal, can be incongruent. Person-centered therapy stresses that
counseling will be inhibited if the counselor feels one way about the client but acts
in a different way. For example, if the practitioner dislikes or disapproves of the cli-
ent but feigns acceptance, therapy will be impaired. Cain (2010) stresses that thera-
pists need to be attuned to the emerging needs of the client and to respond in ways
that are in the best interests of the individual. If therapists keep this in mind, they
are likely to make sound therapeutic decisions most of the time.
Rogers’s concept of congruence does not imply that only a fully self-actualized
therapist can be effective in counseling. Because therapists are human, they cannot
 PERS O N - C EN T ERED T H ERAPY 175

be expected to be fully authentic. Congruence exists on a continuum from highly

congruent to very incongruent. This is true of all three characteristics.

Unconditional Positive Regard and Acceptance The second attitude therapists

need to communicate is deep and genuine caring for the client as a person.
Unconditional positive regard can best be achieved through empathic identifica-
tion with the client (Farber & Doolin, 2011). The caring is nonpossessive and is
not contaminated by evaluation or judgment of the client’s feelings, thoughts,
and behavior as good or bad. Therapists value and warmly accept clients without
placing stipulations on their acceptance. It is not an attitude of “I’ll accept you
when . . . ”; rather, it is one of “I’ll accept you as you are.” Therapists communicate
through their behavior that they value their clients as they are and that clients are
free to have feelings and experiences.
According to Rogers’s (1977) research, the greater the degree of caring, prizing,
accepting, and valuing of the client in a nonpossessive way, the greater the chance
that therapy will be successful. He also makes it clear that it is not possible for thera-
pists to genuinely feel acceptance and unconditional caring at all times. However, if
therapists have little respect for their clients, or an active dislike or disgust, it is not
likely that the therapeutic work will be fruitful. If therapists’ caring stems from their
own need to be liked and appreciated, constructive change in the client is inhibited.
This notion of positive regard has implications for all therapists, regardless of their
theoretical orientation (Farber & Doolin, 2011).

Accurate Empathic Understanding One of the main tasks of the therapist is

to understand clients’ experience and feelings sensitively and accurately as they
are revealed in the moment-to-moment interaction during the therapy session.
The therapist strives to sense clients’ subjective experience, particularly in the here
and now. The aim is to encourage clients to get closer to themselves, to feel more
deeply and intensely, and to recognize and resolve the incongruity that exists
within them.
Empathy is a deep and subjective understanding of the client with the client.
Empathy is not sympathy, or feeling sorry for a client. Therapists are able to share
the client’s subjective world by drawing from their own experiences that may be
similar to the client’s feelings. Yet therapists must not lose their own separateness.
Rogers asserts that when therapists can grasp the client’s private world as the client
sees and feels it—without losing the separateness of their own identity—constructive
change is likely to occur. Empathy, particularly emotionally focused empathy, helps
clients (1) pay attention to and value their experiencing, (2) process their experience
both cognitively and bodily, (3) view prior experiences in new ways, and (4) increase
their confidence in making choices and in pursuing a course of action (Cain, 2010).
Clark (2010) describes an integral model of empathy in the counseling process
that is based on three ways of knowing: (1) subjective empathy enables practitioners to
experience what it is like to be the client; (2) interpersonal empathy pertains to under-
standing a client’s internal frame of reference and conveying a sense of the private
meanings to the person; and (3) objective empathy relies on knowledge sources outside
of a client’s frame of reference. By using a multiple-perspective model of empathy,
counselors have a broader way to understand clients.
176 C HAP TE R SEVEN

Accurate empathy is the cornerstone of the person-centered approach, and it

is a necessary ingredient of any effective therapy (Cain, 2010). Accurate empathic
understanding implies that the therapist will sense clients’ feelings as if they were
his or her own without becoming lost in those feelings. It is a way for therapists to
hear the meanings expressed by their clients that often lie at the edge of their aware-
ness. A primary means of determining whether an individual experiences a thera-
pist’s empathy is to secure feedback from the client (Norcross, 2010).
According to Watson (2002), full empathy entails understanding the meaning
and feeling of a client’s experiencing. It is like grasping “what it is like to be you.”
Empathy is an active ingredient of change that facilitates clients’ cognitive processes
and emotional self-regulation. Watson’s comprehensive review of the research litera-
ture on therapeutic empathy has consistently demonstrated that therapist empathy
is the most potent predictor of client progress in therapy. Empathy is an essential
component of successful therapy in every therapeutic modality.
Clients’ perceptions of feeling understood by their therapists relate favorably to
outcome. Empathic therapists strive to discover the meaning of the client’s experi-
ence, understand the overall goals of the client, and tailor their responses to the
particular client. Effective empathy is grounded in authentic caring for the client
(Elliott, Bohart, Watson, & Greenberg, 2011).

Application: Therapeutic Techniques and Procedures

Early Emphasis on Reflection of Feelings
Rogers’s original emphasis was on grasping the world of the client and reflecting
this understanding. As his view of psychotherapy developed, however, his focus
shifted away from an absolutist, nondirective stance and emphasized the therapist’s
relationship with the client. Many followers of Rogers simply imitated his reflec-
tive style, and client-centered therapy has often been identified primarily with the
technique of reflection despite Rogers’s contention that the therapist’s relational
attitudes and fundamental ways of being with the client constitute the heart of the
change process. Rogers and other contributors to the development of the person-
centered approach have been critical of the stereotypic view that this approach is
basically a simple restatement of what the client just said.

Evolution of Person-Centered Methods

Contemporary person-centered therapy is the result of an evolutionary pro- LO6
cess of more than 70 years, and it continues to remain open to change and refine-
ment. One of Rogers’s main contributions to the counseling field is the notion that
the quality of the therapeutic relationship, as opposed to administering techniques,
is the primary agent of growth in the client. The therapist’s ability to establish a
strong connection with clients is the critical factor determining successful counsel-
ing outcomes.
No techniques are basic to the practice of person-centered therapy; “being with”
clients and entering imaginatively into their world of perceptions and feelings is
sufficient for facilitating a process of change. Person-centered therapists are not
 PERS O N - C EN T ERED T H ERAPY 177

prohibited from suggesting techniques, but how these suggestions are presented is
crucial. Some clients do better with more direction, whereas others do better in a
nondirective climate (Cain, 2010). What is essential for clients’ progress is the thera-
pist’s presence—being completely attentive to and immersed in the client as well as
in the client’s expressed concerns (Cain, 2010). Qualities and skills such as listening,
accepting, respecting, understanding, and responding must be honest expressions
by the therapist. Techniques may be suggested when doing so fosters the process of
client and therapist being together in an empathic way. Techniques are not attempts
at “doing anything” to a client (Bohart & Watson, 2011).
Rogers expected person-centered therapy to continue to evolve and supported
others in breaking new ground. One of the main ways in which person-centered
therapy has evolved is the diversity, innovation, and individualization in practice.
There is no longer one way of practicing person-centered therapy (Cain, 2010), and
there has been increased latitude for therapists to share their reactions, to confront
clients in a caring way, and to participate more actively and fully in the therapeutic
process (Bozarth et al., 2002). Immediacy, or addressing what is going on between
the client and therapist, is highly valued in this approach. This development encour-
ages the use of a wider variety of methods and allows for considerable diversity in
personal style among person-centered therapists. The shift toward genuineness
enables person-centered therapists both to practice in more flexible and integrative
ways that suit their personalities and to have greater flexibility in tailoring the coun-
seling relationship to suit different clients (Bohart & Watson, 2011).
Cain (2010, 2013) believes it is essential for therapists to adapt their therapeutic
style to accommodate the unique needs of each client. Person-centered therapists
have the freedom to use a variety of responses and methods to assist their clients;
a guiding question therapists need to ask is, “Does it fit?” Cain contends that, ide-
ally, therapists will continually monitor whether what they are doing fits, especially
whether their therapeutic style is compatible with their clients’ way of viewing and
understanding their problems. For an illustration of how Dr. David Cain works
with the case of Ruth in a person-centered style, see Case Approach to Counseling and
Psychotherapy (Corey, 2013, chap. 5).
Today, those who practice a person-centered approach work in diverse ways that
reflect both advances in theory and practice and a plethora of personal styles. This is
appropriate and fortunate, for none of us can emulate the style of Carl Rogers and
still be true to ourselves. If we strive to model our style after Rogers, and if that style
does not fit for us, we are not being ourselves and we are not being fully congruent.

The Role of Assessment

Assessment is frequently viewed as a prerequisite to the treatment process. Many
mental health agencies use a variety of assessment procedures, including diagnostic
screening, identification of clients’ strengths and liabilities, and various tests. Person-
centered therapists generally do not find traditional assessment and diagnosis to be
useful because these procedures encourage an external and expert perspective on the
client (Bohart & Watson, 2011). What matters is not how the counselor assesses the
client but the client’s self-assessment. From a person-centered perspective, the best
source of knowledge about the client is the individual client. Rogers saw therapy as
178 C HAP TE R SEVEN

co-assessment, whereby the therapist and the client engage in a continuous process
of self-understanding.
Assessment seems to be gaining in importance in short-term treatments in most
counseling agencies, and it is imperative that clients be involved in a collaborative
process in making decisions that are central to their therapy. Today it may not be a
question of whether to incorporate assessment into therapeutic practice but of how
to involve clients as fully as possible in their assessment and treatment process.

Application of the Philosophy of the Person-Centered Approach

The person-centered approach has been applied to working with individuals, groups,
and families. Bozrath, Zimring, and Tausch (2002) cite studies done through the
1990s that revealed the effectiveness of person-centered therapy with a wide range
of client problems including anxiety disorders, alcoholism, psychosomatic prob-
lems, agoraphobia, interpersonal difficulties, depression, cancer, and personality
disorders. Person-centered therapy has been shown to be as viable as the more goal-
oriented therapies. Furthermore, outcome research conducted in the 1990s revealed
that effective therapy is based on the client–therapist relationship in combination
with the inner and external resources of the client (Duncan, Miller, Wampold, &
Hubble, 2010).
The person-centered approach has been applied extensively in training both pro-
fessionals and paraprofessionals who work with people in a variety of settings. This
approach emphasizes staying with clients as opposed to getting ahead of them with
interpretations. People without advanced psychological education are able to ben-
efit by translating the therapeutic conditions of genuineness, empathic understand-
ing, and unconditional positive regard into both their personal and professional
lives. Learning to listen to oneself with acceptance is a valuable life skill that enables
individuals to be their own therapists. The basic concepts are straightforward and
easy to comprehend, and they encourage locating power in the person rather than
fostering an authoritarian structure in which control and power are denied to the
person. These core skills also provide an essential foundation for virtually all of the
other therapy systems covered in this book. If counselors are lacking in these rela-
tionship and communication skills, they will not be effective in carrying out a treat-
ment program for their clients.
The person-centered approach demands a great deal of the therapist. An effective
person-centered therapist must be an astute listener who is grounded, centered, gen-
uine, respectful, caring, present, focused, patient, and accepting in a way that involves
maturity. Without a person-centered way of being, mere application of skills is likely
to be hollow. Natalie Rogers (2011) points out that the person-centered approach is
a way of being that is easy to understand intellectually but is very difficult to put into
practice. She continues to find the core conditions of genuineness, positive regard,
and empathy most important in developing trust, safety, and growth in a group.

Application to Crisis Intervention

The person-centered approach is especially applicable in crisis intervention LO7
such as an unwanted pregnancy, an illness, a disastrous event, or the loss of a loved
one. People in the helping professions (nursing, medicine, education, the ministry)
 PERS O N - C EN T ERED T H ERAPY 179

are often first on the scene in a variety of crises, and they can do much if the basic
attitudes described in this chapter are present. When people are in crisis, one of
the first steps is to give them an opportunity to fully express themselves. Sensitive
listening, hearing, and understanding are essential at this point. Being heard and
understood helps ground people in crises, helps to calm them in the midst of tur-
moil, and enables them to think more clearly and make better decisions. Although
a person’s crisis is not likely to be resolved by one or two contacts with a helper,
such contacts can pave the way for being open to receiving help later. If the person
in crisis does not feel understood and accepted, he or she may lose hope of “return-
ing to normal” and may not seek help in the future. Genuine support, caring, and
nonpossessive warmth can go a long way in building bridges that can motivate
people to do something to work through and resolve a crisis. Communicating a
deep sense of understanding should always precede other more problem-solving
interventions.
In crisis situations person-centered therapists may need to provide more struc-
ture and direction than would be the case for clients who are not experiencing a cri-
sis. Suggestions, guidance, and even direction may be called for if clients are not able
to function effectively. For example, it may be necessary to take action to hospitalize
a suicidal client to protect this person from self-harm.

Application to Group Counseling

The person-centered approach emphasizes the unique role of the group counselor
as a facilitator rather than a leader. The primary function of the facilitator is to
create a safe and healing climate—a place where the group members can interact in
honest and meaningful ways. In this climate members become more appreciative
and trusting of themselves as they are and are able to move toward self-direction
and empowerment. The facilitator’s way of being can create a productive climate
within a group:

Facilitators cannot make participants trust the group process. Facilitators earn
trust by being respectful, caring, and even loving. Being an effective group facilita-
tor has much to do with one’s “way of being.” No method or technique can evoke
trust unless the facilitator herself has a capacity to be fully present, considerate,
caring, authentic, and responsive. This includes the ability to challenge people
constructively. (N. Rogers, 2011, p. 57)

With the presence of the facilitator and the support of other members, participants
realize that they do not have to experience the struggles of change alone and that
groups as collective entities have their own source of transformation.
Carl Rogers (1970) clearly believed that groups tend to move forward if the
facilitator exhibits a deep sense of trust in the members and refrains from using
techniques or exercises to get a group moving. Facilitators should avoid making
interpretive comments or group process observations because such comments are
apt to make the group self-conscious and slow the process down. Group process
observations should come from members, a view that is consistent with Rogers’s
philosophy of placing the responsibility for the direction of the group on the mem-
bers. Instead of leading the members toward specific goals, the group facilitator
180 C HAP TE R SEVEN

assists members in developing attitudes and behaviors of genuineness, acceptance,

and empathy, which enables the members to interact with each other in therapeutic
ways to find their own sense of direction as a group.
Regardless of a group leader’s theoretical orientation, the core conditions that
have been described here are highly applicable to any leader’s style of group facilita-
tion. Only when the leader is able to create a person-centered climate will movement
take place within a group. All of the theories discussed in this book depend on the
quality of the therapeutic relationship as a foundation. As you will see, the cognitive
behavioral approaches to group work also emphasize creating a working alliance
and collaborative relationships. Indeed, most effective approaches to group work
share key elements of a person-centered philosophy. For a more detailed treatment
of person-centered group counseling, see Corey (2016, chap. 10). Also see Natalie
Rogers’s book (2011), The Creative Connection for Groups: Person-Centered Expressive Arts
for Healing and Social Change.

Person-Centered Expressive Arts Therapy*

Natalie Rogers (1993, 2011) expanded on her father’s (C. Rogers, 1961) the- LO8
ory of creativity using the expressive arts to enhance personal growth for individuals
and groups. N. Rogers’s approach, known as expressive arts therapy, extends the
person-centered approach to spontaneous creative expression, which symbolizes
deep and sometimes inaccessible feelings and emotional states. Counselors trained
in person-centered expressive arts offer their clients the opportunity to create move-
ment, visual art, journal writing, sound, and music to express their feelings and gain
insight from these activities.

Principles of Expressive Arts Therapy

Expressive arts therapy uses various artistic forms—movement, drawing, painting,
sculpting, music, writing, and improvisation—toward the end of growth, healing,
and self-discovery. This is a multimodal approach integrating mind, body, emo-
tions, and inner spiritual resources. Methods of expressive arts therapy are based
on humanistic principles but give fuller form to Carl Rogers’s notions of creativity.
These principles include the following (N. Rogers, 1993):
ŠAll people have an innate ability to be creative.
ŠThe creative process is transformative and healing. The healing aspects
involve activities such as meditation, movement, art, music, and journal
writing.
ŠPersonal growth and higher states of consciousness are achieved
through self-awareness, self-understanding, and insight.

*Much of the material in this section is based on key ideas that are more fully developed in The Creative
Connection: Expressive Arts as Healing (N. Rogers, 1993) and The Creative Connection for Groups: Person-Centered
Expressive Arts for Healing and Social Change (N. Rogers, 2011). This section was written in close collaboration
with Natalie Rogers.
 PERS O N - C EN T ERED T H ERAPY 181

ŠSelf-awareness, understanding, and insight are achieved by delving into

our feelings of grief, anger, pain, fear, joy, and ecstasy.
ŠOur feelings and emotions are an energy source that can be channeled
into the expressive arts to be released and transformed.
ŠThe expressive arts lead us into the unconscious, thereby enabling us to
express previously unknown facets of ourselves and bring to light new
information and awareness.
ŠOne art form stimulates and nurtures the other, bringing us to an inner
core or essence that is our life energy.
ŠA connection exists between our life force—our inner core, or soul—and
the essence of all beings.
ŠAs we journey inward to discover our essence or wholeness, we discover
our relatedness to the outer world, and the inner and outer become one.
The various art modes interrelate in what Natalie Rogers calls the “creative connec-
tion.” When we move, it affects how we write or paint. When we write or paint, it
affects how we feel and think.
Natalie Rogers’s approach is based on a person-centered theory of individual
and group process. The same conditions that Carl Rogers and his colleagues found
basic to fostering a facilitative client–counselor relationship also help support cre-
ativity. Personal growth takes place in a safe, supportive environment created by
counselors or facilitators who are genuine, warm, empathic, open, honest, congru-
ent, and caring—qualities that are best learned by first being experienced. Taking
time to reflect on and evaluate these experiences allows for personal integration at
many levels—intellectual, emotional, physical, and spiritual.

Creativity and Offering Stimulating Experiences

According to Natalie Rogers, this deep faith in the individual’s innate drive to
become fully oneself is basic to the work in person-centered expressive arts. Indi-
viduals have a tremendous capacity for self-healing through creativity if given the
proper environment. When one feels appreciated, trusted, and given support to use
individuality to develop a plan, create a project, write a paper, or to be authentic, the
challenge is exciting, stimulating, and gives a sense of personal expansion. N. Rogers
believes the tendency to actualize and become one’s full potential, including innate
creativity, is undervalued, discounted, and frequently squashed in our society. Tra-
ditional educational institutions tend to promote conformity rather than original
thinking and the creative process.
Person-centered expressive arts therapy utilizes the arts for spontaneous cre-
ative expression that symbolizes deep and sometimes inaccessible feelings and
emotional states. The conditions that foster creativity require acceptance of the
individual, a nonjudgmental setting, empathy, psychological freedom, and avail-
ability of stimulating and challenging experiences. With this type of environment
in place, the facilitative internal conditions of the client are encouraged and
inspired. The client experiences a nondefensive openness and an internal locus of
evaluation that receives but is not overly concerned with the reactions of others.
N. Rogers (1993) believes that we cheat ourselves out of a fulfilling and joyous source
182 C HAP TE R SEVEN

of creativity if we cling to the idea that an artist is the only one who can enter the
realm of creativity. Art is not only for the few who develop a talent or master a
medium. We all can use various art forms to facilitate self-expression and personal
growth.

Motivational Interviewing
Motivational Interviewing (MI) is a humanistic, client-centered, psycho- LO9
social, and modestly directive counseling approach developed by William R. Miller
and Stephen Rollnick in the early 1980s. The clinical and research applications of
this evidenced-based practice have received increased attention in recent years, and
MI has been shown to be effective as a relatively brief intervention (Corbett, 2016;
Dean, 2015). Motivational interviewing is based on humanistic principles, has many
basic similarities with person-centered therapy, and expands the traditional person-
centered approach.
Motivational interviewing was initially designed as a brief intervention for prob-
lem drinking, but more recently this approach has been applied to a wide range of
clinical problems including substance abuse, compulsive gambling, eating disorders,
anxiety disorders, depression, suicidality, chronic disease management, and health
behavior change practices (Arkowitz & Miller, 2008; Arkowitz & Westra, 2009). MI
stresses client self-responsibility and promotes an invitational style for working
cooperatively with clients to generate alternative solutions to behavioral problems.
MI provides multiple ways to address the impasses clients often experience during
the change process. Both MI and person-centered practitioners believe in the client’s
abilities, strengths, resources, and competencies. The underlying assumption is that
clients want to be healthy and desire positive change.

The MI Spirit
MI is rooted in the philosophy of person-centered therapy, but with a “twist.” Unlike
the nondirective and unstructured person-centered approach, MI is deliberately
directive while staying within the client’s frame of reference. The primary goal is to
reduce client ambivalence about change and increase the client’s own motivation
for change. Miller and Rollnick (2013) believe that “MI is about arranging conver-
sations so that people talk themselves into change, based on their own values and
interests” (p. 4). It is essential that therapists function within the spirit of MI—that
is, within the relational context of therapy—rather than simply applying the strate-
gies of the approach. The attitudes and skills in MI are based on a person-centered
philosophy and include using open-ended questions, employing reflective listening,
creating a safe climate, affirming and supporting the client, expressing empathy,
responding to resistance in a nonconfrontational manner, guiding a discussion of
ambivalence, summarizing and linking at the end of sessions, and eliciting and rein-
forcing “change talk” (Dean, 2015). MI therapists avoid arguing with clients and
reframe resistance as a healthy response. MI therapists do not view clients as oppo-
nents to be defeated but as allies who play a major role in their present and future
success. Practitioners assist clients in becoming their own advocates for change and
the primary agents of change in their lives.
 PERS O N - C EN T ERED T H ERAPY 183

In both person-centered therapy and MI, the counselor provides the condi-
tions for growth and change by communicating attitudes of accurate empathy and
unconditional positive regard. In MI, the therapeutic relationship is as important
in achieving successful outcomes as the specific theoretical model or school of psy-
chotherapy from which the therapist operates (Miller & Rollnick, 2013). Both MI
and person-centered therapy are based on the premise that individuals have within
themselves the capacity to generate an intrinsic motivation to change. Responsibil-
ity for change rests with clients, not with the counselor, and therapist and client
share a sense of hope and optimism that change is possible. Once clients believe that
they have the capacity to change and heal, new possibilities open up for them.

The Basic Principles of Motivational Interviewing

Miller and Rollnick (2013) formulated five basic principles of MI:
1. Therapists strive to experience the world from the client’s perspec-
tive without judgment or criticism. MI emphasizes reflective listening,
which is a way for practitioners to better understand the subjective
world of clients. Expressing empathy is foundational in creating a safe
climate for clients to explore their ambivalence for change. When cli-
ents are slow to change, they likely have compelling reasons to remain
as they are as well as having reasons to change.
2. MI is designed to evoke and explore both discrepancies and ambiva-
lence. Counselors reflect discrepancies between the behaviors and
values of clients to increase the motivation to change. Counselors pay
particular attention to clients’ arguments for changing compared
to their arguments for not changing. Therapists elicit and reinforce
change talk by employing specific strategies to strengthen discus-
sion about change. Clinicians encourage clients to determine whether
change will occur, and if so, what kinds of changes will occur and
when.
3. Reluctance to change is viewed as an expected part of the therapeu-
tic process. Although individuals may see advantages to making life
changes, they also may have many concerns and fears about changing.
People who seek therapy are often ambivalent about change, and their
motivation may ebb and flow during the course of therapy. MI thera-
pists assume a respectful view of resistance and work therapeutically
with any reluctance or caution on the part of clients. MI practitioners
avoid disagreeing with, arguing with, or persuading clients because this
only entrenches resistance. Instead, therapists roll with the resistance,
which tends to reduce clients’ defensiveness (Corbett, 2016).
4. Practitioners support clients’ self-efficacy, mainly by encouraging them
to use their own resources to take necessary actions that can lead to
success in changing. MI clinicians strive to enhance client agency about
change and emphasize the right and inherent ability of clients to for-
mulate their own personal goals and to make their own decisions. MI
focuses on present and future conditions and empowers clients to find
ways to achieve their goals.
184 C HAP TE R SEVEN

5. When clients show signs of readiness to change through decreased

resistance to change and increased talk about change, a critical phase
of MI begins. In this stage, clients may express a desire and ability
to change, show an interest in questions about change, experiment
with making changes between sessions, and envision a future picture
of how their life will be different once the desired changes have been
made. At this time therapists shift their focus toward strengthen-
ing clients’ commitments to change and helping them implement a
change plan.

The Stages of Change

The stages of change model assumes that people progress through a series of five
identifiable stages in the counseling process. In the precontemplation stage, there is
no intention of changing a behavior pattern in the near future. In the contemplation
stage, people are aware of a problem and are considering overcoming it, but they
have not yet made a commitment to take action to bring about the change. In the
preparation stage, individuals intend to take action immediately and report some
small behavioral changes. In the action stage, individuals are taking steps to modify
their behavior to solve their problems. During the maintenance stage, people work to
consolidate their gains and prevent relapse.
People do not pass neatly through these five stages in linear fashion, and a
client’s readiness can fluctuate throughout the change process. If change is ini-
tially unsuccessful, individuals may return to an earlier stage (Prochaska &
Norcross, 2014). MI therapists strive to match specific interventions with whatever
stage of change clients are experiencing. If there is a mismatch between process
and stage, movement through the stage will be impeded and is likely to be mani-
fested in reluctant behavior. When clients demonstrate any form of reluctance or
resistance, this could be due to a therapist’s misjudgment of a client’s readiness
to change.
Motivational interviewing is but one example of how therapeutic strategies
have been developed based on the foundational principles and philosophy of the
person-centered approach. Indeed, most of the therapeutic models illustrate how
the core therapeutic conditions are necessary aspects leading to client change.
Where many therapeutic approaches, including motivational interviewing, diverge
from traditional person-centered therapy is the assumption that the therapeutic
factors are both necessary and sufficient in bringing about change. Many other mod-
els employ specific intervention strategies to address specific concerns clients bring
to therapy.

Person-Centered Therapy From a Multicultural Perspective

Strengths From a Diversity Perspective
One of the strengths of the person-centered approach is its impact on the LO10
field of human relations with diverse cultural groups. Person-centered philosophy
and practice can now be studied in several European countries, South America,
 PERS O N - C EN T ERED T H ERAPY 185

and Japan. Here are some examples of ways in which this approach has been incor-
porated in various countries and cultures:
ŠIn several European countries person-centered concepts have had a sig-
nificant impact on the practice of counseling as well as on education,
cross-cultural communication, and reduction of racial and political
tensions. In the 1980s Carl Rogers (1987b) elaborated on a theory of
reducing tension among antagonistic groups that he began developing
in 1948.
ŠIn the 1970s Rogers and his associates began conducting workshops
promoting cross-cultural communication. Well into the 1980s he led
large workshops in many parts of the world. International encounter
groups have provided participants with multicultural experiences.
ŠJapan, Australia, South America, Mexico, and the United Kingdom have
all been receptive to person-centered concepts and have adapted these
practices to fit their cultures.
ŠShortly before his death, Rogers conducted intensive workshops with
professionals in the former Soviet Union.
There is no doubt that Carl Rogers has had a global impact. His work has reached
more than 30 countries, and his writings have been translated into 12 languages. The
emphasis on core conditions makes the person-centered approach useful in under-
standing diverse worldviews. The underlying philosophy of person-centered therapy
is grounded on the importance of hearing the deeper messages of a client. Empathy,
being present, and respecting the values of clients are essential attitudes and skills in
counseling culturally diverse clients. Although person-centered therapists are aware
of diversity factors, they do not make initial assumptions about individuals (Cain,
2010, 2013). Therapists realize that each client’s journey is unique and take steps to
tailor their methods to fit the individual.
Several writers consider person-centered therapy as being ideally suited to clients
in a diverse world. Bohart and Watson (2011) claim that the person-centered philos-
ophy is particularly appropriate for working with diverse client populations because
the counselor does not assume the role of expert who is going to impose a “right
way of being” on the client. Instead, the therapist is a “fellow explorer” who attempts
to understand the client’s phenomenological world in an interested, accepting, and
open way and checks with the client to confirm that the therapist’s perceptions are
accurate. Motivational interviewing, which is based on the philosophy of person-
centered therapy, is a culturally sensitive approach that can be effective across popu-
lation domains, including gender, age, ethnicity, and sexual orientation (Levensky,
Kersh, Cavasos, & Brooks, 2008).

Shortcomings From a Diversity Perspective

Although the person-centered approach has made significant contributions to
counseling people from diverse social, political, and cultural backgrounds, there
are some shortcomings to practicing exclusively within this framework. Many cli-
ents who come to community mental health clinics or who are involved in outpa-
tient treatment want more structure than this approach provides. Some clients seek
186 C HAP TE R SEVEN

professional help to deal with a crisis, to alleviate emotional problems, or to learn

coping skills in dealing with everyday problems. These clients often expect coun-
selors to provide guidance or give advice and can be put off by this unstructured
approach.
A second shortcoming of the person-centered approach is that it is difficult to
translate the core therapeutic conditions into actual practice in certain cultures.
Communication of these core conditions must be consistent with the client’s cul-
tural framework. Consider, for example, the expression of therapist congruence and
empathy. Clients accustomed to indirect communication may not be comfortable
with direct expressions of empathy or self-disclosure on the therapist’s part.
A third shortcoming in applying the person-centered approach with clients
from diverse cultures pertains to the fact that this approach extols the value of an
internal locus of evaluation. The humanistic foundation of person-centered therapy
emphasizes dimensions such as self-awareness, freedom, autonomy, self-acceptance,
inner-directedness, and self-actualization. Cain (2010) points out that “persons
from collectivistic cultures are oriented less toward self-actualization and more
toward intimacy, connection, and harmony with others and toward what is best for
the community and the common good” (p. 143). The focus on development of indi-
vidual autonomy and personal growth may be viewed as being selfish in a culture
that stresses the common good.
Consider Lupe, a Latina client who values the interests of her family over her
self-interests. From a person-centered perspective she could be viewed as being in
danger of “losing her own identity” by being primarily concerned with her role in
taking care of others in the family. Rather than pushing her to make her personal
wants a priority, the counselor will explore Lupe’s cultural values and her level of
commitment to these values in working with her. It would be inappropriate for the
counselor to communicate a vision of the kind of woman she should be. (This topic
is discussed more extensively in Chapter 12.)
Despite these shortcomings, the person-centered approach offers many oppor-
tunities for working with clients from diverse cultures. There is great diversity
among any group of people, and there is room for a variety of therapeutic styles.
Counseling a culturally different client may require more activity and structuring
than is usually the case in a person-centered framework, but the potential positive
impact of a counselor who responds empathically to a culturally different client can-
not be overestimated.

Person-Centered Therapy Applied to the Case of Stan

S tan’s autobiography indicates that he has a sense

of what he wants for his life. As a person-centered
therapist, I rely on his self-report of the way he views
and seems to have sufficient anxiety to work toward
these desired changes. I have faith in Stan’s ability to
find his own way, and I trust that he has the necessary
himself rather than on a formal assessment and diag- resources for reaching his therapy goals. I encourage
nosis. My concern is with understanding him from his Stan to speak freely about the discrepancy between
internal frame of reference. Stan has stated goals that the person he sees himself as being and the person
are meaningful for him. He is motivated to change he would like to become; about his feelings of being
 PERS O N - C EN T ERED T H ERAPY 187

a failure, being inadequate; about his fears and uncer- caring and faith he experiences from me in our rela-
tainties; and about his hopelessness at times. I attempt tionship, Stan is able to increase his own faith and
to create an atmosphere of freedom and security that confidence in himself.
will encourage Stan to explore the threatening aspects My empathy assists Stan in hearing himself and
of his self-concept. accessing himself at a deeper level. Stan gradually
Stan has a low evaluation of his self-worth. becomes more sensitive to his own internal messages
Although he finds it difficult to believe that others and less dependent on confirmation from others
really like him, he wants to feel loved. He says, “I hope around him. As a result of the therapeutic venture,
I can learn to love at least a few people, most of all, Stan discovers that there is someone in his life whom
women.” He wants to feel equal to others and not have he can depend on—himself.
to apologize for his existence, yet most of the time he
feels inferior. By creating a supportive, trusting, and Questions for Reflection
encouraging atmosphere, I can help Stan learn to be Š How would you respond to Stan’s deep feelings
more accepting of himself, with both his strengths of self-doubt? Could you enter his frame of refer-
and limitations. He has the opportunity to openly ence and respond in an empathic manner that lets
express his fears of women, of not being able to work Stan know you hear his pain and struggle without
with people, and of feeling inadequate and stupid. He needing to give advice or suggestions?
can explore how he feels judged by his parents and Š How would you describe Stan’s deeper struggles?
by authorities. He has an opportunity to express his What sense do you have of his world?
guilt—that is, his feelings that he has not lived up to Š To what extent do you think that the relation-
his parents’ expectations and that he has let them and ship you would develop with Stan would help
himself down. He can also relate his feelings of hurt him move forward in a positive direction? What,
over not having ever felt loved and wanted. He can if anything, might get in your way—either with
express the loneliness and isolation that he so often him or in yourself—in establishing a therapeutic
feels, as well as the need to numb these feelings with relationship?
alcohol or drugs. Visit CengageBrain.com or watch the DVD for
Stan is no longer totally alone, for he is taking the video program Theory and Practice of Counseling
the risk of letting me into his private world of feel- and Psychotherapy: The Case of Stan and Lecturettes,
ings. Stan gradually gets a sharper focus on his Session 5 (person-centered therapy), for a demon-
experiencing and is able to clarify his own feelings and stration of my approach to counseling Stan from
attitudes. He sees that he has the capacity to make his this perspective. This session focuses on exploring
own decisions. In short, our therapeutic relationship the immediacy of our relationship and assisting
frees him from his self-defeating ways. Because of the Stan in finding his own way.

Person-Centered Therapy Applied to the Case of Gwen*

G wen arrives for this session moving quite slowly.

She reports having been in pain for the past few
days. I asked her to describe the pain in her body, and
Therapist: Tell me more about this feeling.
Gwen: I don’t mean sit down and die, I mean sit
down and take a break from life for a while. I
she explains that it is a full body achiness.
have just been feeling down and stressed.
Gwen: I can’t sleep through the night, and I feel tired
all day long. I try to push through the achiness, but To gain a better understanding of how Gwen’s
sometimes I just want to sit down and not get up. pain has affected her week, I administer a brief rating

*Dr. Kellie Kirksey writes about her ways of thinking and practicing from a person-centered perspective and applying this model to Gwen.
188 C HAP TE R SEVEN

scale at the beginning of this session. The Outcome would like to find some way of dealing with
Rating Scale (ORS) is a short questionnaire developed them and find more peace in your life.
by Scott D. Miller that assesses how well a person has Gwen: Yes, but I don’t know where to begin. I can’t
been doing (individually, interpersonally, socially, and seem to find time for relaxation.
overall well-being) during the last week. I explain that
Therapist: It sounds like you feel unsure about
the ORS will give us a quick look at her current level
where to start and whether you’ll find time for
of functioning and feeling. The ORS can also help
yourself at all. I am wondering when you feel
Gwen see which particular areas of her life hold the
somewhat relaxed.
most stress for her. Gwen marks the form quickly,
Gwen: I feel best when I’m caught up with all my
and the results indicate that personal well-being and
projects at work and have some time for myself.
interpersonal relationships are her most significant
I like it when I have crossed some things off my
areas of challenge. This assessment provides a starting
list of things to do. I used to reward myself with
point for discussing how our therapeutic relationship
a spa day when I finished a big project. I haven’t
is contributing to her overall well-being.
done that in ages.
Therapist: Gwen, I hope that information is helpful Therapist: As you talk about this time, I can see
for you. Where would you like to start today? how excited you are about crossing things off
Gwen: I need to work on the personal well-being your list and having time for yourself. That’s
issues. I just want to unwind and relax a little when you really feel good about yourself—when
before I go back into my busy day. I get so tired you’re accomplishing things yet you realize you
of running around so much. I seem to live in need to take care of yourself too.
an “overwhelm” mode. I am ready to retire that Gwen: Before I became the caregiver for my mom, I
way of living. I could use some balance in my life. used to get to the gym about three days a week.
I know that’s why I have been feeling so achy. I loved doing dancing and yoga! It really made
It’s the stress I have been carrying. I can feel the a difference in my stress level. Working out just
tension. fell by the wayside as my life got busier.
Therapist: Would you like to say more about the Therapist: That must be exhausting; you take care
sense of “overwhelm” you mentioned? of your mom, husband, grown kids, colleagues,
Gwen: I am always juggling between getting my and everyone else. Yet I hear that you are not
own house in order and putting out fires with taking care of yourself. How satisfied are you
my mom’s health team or insurance. I work about meeting your own needs right now?
hard at my job, and then I come home and need
Gwen: Not at all. I have totally abandoned myself. I
to get my own house in order. I am stretched
am feeling worn down.
in too many directions, and at the end of the
Therapist: Tell me more about being worn down.
day I still feel like I am on call and can’t turn
my mind off. I lay down at night and feel all my Gwen: I guess saying I am worn down is a bit extreme
responsibilities whirling around in my mind. [Gwen is smiling]. My body is definitely telling me
Sometimes I just cover my head and hope to slow down and focus on me for a change.
that everything will go away and I can at least Therapist: So one side is telling you that you can’t
have some peace at night. I know nothing will keep up this pace and you need to take care of
disappear from my list until I take it off and yourself, and the other side is saying, “Gwen,
that I have to make an effort to find space for you need to handle everything that’s being
relaxation in my life. thrown at you.”
Therapist: Hearing you explain what “overwhelm Gwen: That sounds right. It’s been a while since I
mode” looks like for you gets my heart rate up actually paid attention to myself. I feel sad saying
[immediacy]. Although you know that many that out loud. I know I want to do something
of your responsibilities will not diminish, you different. Even if it’s a small something!
 PERS O N - C EN T ERED T H ERAPY 189

Therapist: You are disappointed in yourself for not and the SRS is a good way to get Gwen’s feedback on
recognizing that you need a break, and yet you her own progress and her perception of the value of the
seem determined to make some small change therapy session. As a therapist, I invite this feedback
now. Can you identify what you might begin to and see it as a useful way of getting Gwen’s perspective.
do differently? In collaboration with Gwen, I strive to make adjust-
Gwen: I want to make myself a priority. I can ments in my work with her based on her feedback.
start taking my breaks at work again and use Gwen then says a few words about how she is feeling.
that time to take care of me. I used to do some Gwen: I am definitely not as tense as I was when I
stretching at my desk and walk around the first came in. I needed to get some things off of
building. It was actually fun: we would do a my chest. I would have liked more suggestions
pedometer challenge at work. It was good. I from you on what I need to do next. I know you
don’t know why I let all of that go. I just started don’t have the magic answer, but sometimes that’s
putting everyone and everything in front of me. just what I want.
We even have a lunch time dance class I could go
Therapist: Thanks for your honest feedback. The
to. I forgot how happy doing those little things
goal is for you to be the director of this session
used to make me feel.
and of your life. As you lead the way, your own
Therapist: It sounds like you regret that some of answers will surface to assist you in resolving
those activities aren’t in you life. What would some of your challenges. In today’s session you
it look like to make yourself a priority in some clearly identified areas of stress, and then you
small way? reconnected with activities that brought you
Gwen: I guess I could find 15 minutes to do peace and relaxation in the past. You were able
something for myself. I could even go get my hair to find your answers within yourself.
done. Maybe a break in my regular routine would
be helpful. It’s been forever since I treated myself. Person-centered therapy is a collaborative journey
driven by what the client brings into the session. I fol-
Therapist: With you changing your lifestyle, I want
lowed the lead provided by Gwen of what was troubling
to make sure you do it safely. I suggest you ask
her and attempted to work within the framework of
your primary care physician about a physical
what she said she wanted. At each step along the way,
examination to determine any possible reasons
I show empathy and compassion for her challenges as
for the pain and physical symptoms you are
she works to rebuild self-trust and reconnect to her
experiencing.
own sense of personal power and value.
Gwen: That is a good idea, and I will follow up on
that suggestion.
Questions for Reflection
Therapist: Before you leave, I want to give you
Š What are your thoughts about soliciting client
the Session Rating Scale (SRS). All you have to
do is rate today’s session based on four items: feedback using rating scales such as the ORS and
our relationship, goals and topics, therapeutic the SRS?
Š Gwen wants more suggestions from her therapist.
approach, and overall view of our time today.
It’s similar to the form you filled out at the If you were her therapist, how would you intervene
beginning of session. with her when she wants more direction from you?
Š How does person-centered therapy fit with who
Gwen takes a moment to fill out the form and you are as a person? Would you be comfortable
passes it back with marks reflecting that she felt heard in mostly identifying the client’s underlying mes-
and that we talked about what she wanted to discuss. sages as the therapist did in this session?
She also marked that there was something missing Š Frequently person-centered therapists identify con-
from the session, which gave us an opportunity to flicts or the competing sides of an issue. Where did
identify what might be missing for her. Using the ORS the therapist do this in her dialogue with Gwen?
190 C HAP TE R SEVEN

Summary and Evaluation

Summary
Person-centered therapy is based on a philosophy of human nature that postulates
an innate striving for self-actualization. Carl Rogers’s view of human nature is phe-
nomenological; that is, we structure ourselves according to our perceptions of real-
ity. We are motivated to actualize ourselves in the reality that we perceive.
Rogers’s theory rests on the assumption that clients can understand the factors
in their lives that are causing them to be distressed. They also have the capacity for
self-direction and constructive personal change. Change will occur if a congruent
therapist makes psychological contact with a client in a state of anxiety or incongru-
ence. It is essential for the therapist to establish a relationship the client perceives
as genuine, accepting, and understanding. Therapeutic counseling is based on an
I/Thou, or person-to-person, relationship in the safety and acceptance of which cli-
ents drop their defenses and come to accept and integrate aspects that they have
denied or distorted. The person-centered approach emphasizes this personal rela-
tionship between client and therapist; the therapist’s attitudes are more critical than
are knowledge, theory, or techniques employed. In the context of this relationship,
clients unleash their growth potential and become more of the person they are capa-
ble of becoming. An abundance of research supports the notion that the human
elements of psychotherapy (client factors, therapist effects, and the therapeutic alli-
ance) are far more important than models and techniques in the effectiveness and
outcomes of therapy (Elkins, 2016).
This approach places primary responsibility for the direction of therapy on
the client. In the therapeutic context, individuals have the opportunity to decide
for themselves and come to terms with their own personal power. The underlying
assumption is that no one knows the client better than the client; in short, the cli-
ent is viewed as an expert on his or her own life (Cain, 2010). The general goals of
therapy are becoming more open to experience, achieving self-trust, developing an
internal source of evaluation, and being willing to continue growing. Specific goals
are not suggested for clients; rather, clients choose their own values and goals. Cur-
rent applications of the theory emphasize more active participation by the therapist
than was the case earlier. Counselors are now encouraged to be fully involved as
persons in the therapeutic relationship. More latitude is allowed for therapists to
express their reactions and feelings as they are appropriate to what is occurring in
therapy. Person-centered practitioners are willing to be transparent about persistent
feelings that exist in their relationships with clients (Watson et al., 2011). It is the
therapist’s job to adapt and accommodate in a manner that works best for each
client, which means being flexible in the application of methods in the counseling
process (Cain, 2010).

Contributions of the Person-Centered Approach

When Carl Rogers founded nondirective counseling more than 70 years LO11
ago, there were very few other therapeutic models. The longevity of this approach is
certainly a factor to consider in assessing its influence. Rogers had, and his theory
continues to have, a major impact on the field of counseling and psychotherapy.
 PERS O N - C EN T ERED T H ERAPY 191

When he introduced his revolutionary ideas in the 1940s, he provided a powerful

and radical alternative to psychoanalysis and to the directive approaches then prac-
ticed. Rogers was a pioneer in shifting the therapeutic focus from an emphasis on
technique and reliance on therapist authority to that of the power of the therapeu-
tic relationship.
Kirschenbaum (2009) contends that the scope and influence of Rogers’s work
has continued well beyond his death; the person-centered approach is alive, well, and
expanding. Today there is not one version of person-centered therapy, but a number
of continuously evolving person-centered psychotherapies (Cain, 2010). Although
few psychotherapists claim to have an exclusive person-centered theoretical orienta-
tion, the philosophy and principles of this approach permeate the practice of most
therapists. Other schools of therapy are increasingly recognizing the centrality of
the therapeutic relationship as a route to therapeutic change.
Person-centered therapy is strongly represented in Europe, and there is continu-
ing interest in this approach in both South America and the Far East. The person-
centered approach has established a firm foothold in British universities, and some
of the most in-depth training of person-centered counselors is taking place in the
United Kingdom today (N. Rogers, 2011).
As we have seen, Natalie Rogers has made a significant contribution to the
application of the person-centered approach by incorporating the expressive arts
as a medium to facilitate healing and social change, primarily in a group setting.
She has been instrumental in the evolution of the person-centered approach using
nonverbal methods to enable individuals to heal and to develop. Many individuals
who have difficulty expressing themselves verbally can find new possibilities for self-
expression through nonverbal channels and through the expressive arts (N. Rogers,
2011). Cain (2010) believes “Natalie Rogers’s expressive arts therapy represents a
major innovation in practice and helped open the way for other person-centered
therapists to expand the variety and range of practice” (p. 60).

Emphasis on Research One of Carl Rogers’s contributions to the field of

psychotherapy was his willingness to state his concepts as testable hypotheses and
to submit them to research. He literally opened the field to research. He was truly a
pioneer in his insistence on subjecting the transcripts of therapy sessions to critical
examination and applying research technology to counselor–client dialogues.
According to Cain (2010), an enormous body of research, conducted over a period of
70 years, supports the effectiveness of the person-centered approach. This research
is ongoing in many parts of the world and continues to expand and refine our
understanding of what constitutes effective psychotherapy. Cain (2010) concludes,
“person centered therapy is as vital and effective as it has ever been and continues to
develop in ways that will make it increasingly so in the years to come” (p. 169).
Even his critics give Rogers credit for having conducted and inspired others to
conduct extensive studies of counseling process and outcome. Rogers presented a
challenge to psychology to design new models of scientific investigation capable of
dealing with the inner, subjective experiences of the person. His theories of therapy
and personality change have had a tremendous heuristic effect, and though much
controversy surrounds this approach, his work has challenged practitioners and
theoreticians to examine their own therapeutic styles and beliefs.
192 C HAP TE R SEVEN

Limitations and Criticisms of the Person-Centered Approach

Although I applaud person-centered therapists for their willingness to subject their
hypotheses and procedures to empirical scrutiny, some researchers have been criti-
cal of the methodological errors contained in some of these studies. Accusations of
scientific shortcomings involve using control subjects who are not candidates for
therapy, failing to use an untreated control group, failing to account for placebo
effects, reliance on self-reports as a major way to assess the outcomes of therapy, and
using inappropriate statistical procedures. In all fairness, these accusations apply to
the research on many other therapeutic approaches as well.
There is a similar limitation shared by both the person-centered and existential
(experiential) approaches. Neither of these therapeutic modalities emphasizes the
role of techniques aimed at bringing about change in clients’ behavior. Proponents
of psychotherapy manuals, or manualized treatment methods for specific disorders,
find serious limitations in the experiential approaches due to their lack of attention
to proven techniques and strategies. Those who call for accountability as defined by
evidence-based practices within the field of mental health also are quite critical of
the experiential approaches.
I do not believe manualized treatment methods can be considered the gold stan-
dard in psychotherapy, however. There is good research demonstrating that tech-
niques account for only 15% of client outcome (see Duncan et al., 2010), whereas
contextual factors have powerful effects on what happens in therapy (Elkins, 2009,
2012, 2016). Research points to relational and client factors as the main predictors of
effective therapy. Furthermore, the evaluation of evidence-based practices has been
broadened to include best available research; the expertise of the clinician; and cli-
ent characteristics, culture, and preferences (see Norcross, Hogan, & Koocher, 2008).
A potential limitation of the person-centered approach is that some students-
in-training and practitioners with this orientation may have a tendency to be very
supportive of clients without being challenging. Out of their misunderstanding of
the basic concepts of the approach, some have limited the range of their responses
and counseling styles mainly to reflections and empathic listening. Although there
is value in accurately and deeply hearing a client and in reflecting and communicat-
ing understanding, counseling entails more than this. I believe that the therapeutic
core conditions are necessary for therapy to succeed, yet I do not see them as being
sufficient conditions for change for all clients at all times. From my perspective, these
basic attitudes are the foundation on which counselors must then build the skills of
therapeutic intervention. Motivational interviewing rests on the therapeutic core
conditions, for example, but MI employs a range of strategies that enables clients to
develop action plans leading to change.
A related challenge for counselors using this approach is to truly support clients in
finding their own way. Counselors sometimes experience difficulty in allowing clients to
decide their own specific goals in therapy. It is easy to give lip service to the concept of cli-
ents’ finding their own way, but it takes considerable respect for clients and faith on the
therapist’s part to encourage clients to listen to themselves and follow their own direc-
tions, particularly when they make choices that are not what the therapist hoped for.
More than any other quality, the therapist’s genuineness determines the power
of the therapeutic relationship. If therapists submerge their unique identity and style
 PERS O N - C EN T ERED T H ERAPY 193

in a passive and nondirective manner, they are not likely to affect clients in powerful
ways. Therapist authenticity and congruence are so vital to this approach that those
who practice within this framework must feel natural in doing so and must find a
way to express their own reactions to clients. If not, a real possibility is that person-
centered therapy will be reduced to a bland, safe, and ineffectual approach.

Self-Reflection and Discussion Questions

1. To what degree do you believe clients have the ability to understand
and resolve their own problems without a great deal of advice or sug-
gestions from a therapist?
2. This therapy approach places considerable importance on congruence
(realness or genuineness) on the part of the therapist. How confident
are you that you will be able to be genuine in your interaction with your
clients?
3. The therapeutic relationship is given prominence in this theory. What
kind of relationship do you hope to create with your clients? Identify
the characteristics you deem most important.
4. Empathy is a core ingredient in person-centered therapy. What do you
think you can do to increase your ability to develop empathy toward a
client who you perceive of as being difficult?
5. How would it be for you to practice by relying on a minimum of tech-
niques and instead staying tuned into a client’s moment-by-moment
experience?

Where to Go From Here

In the DVD for Integrative Counseling: The Case of Ruth and Lecturettes, you will see a con-
crete illustration of how I view the therapeutic relationship as the foundation for our
work together. Refer especially to Session 1 (“Beginning of Counseling”), Session 2
(“The Therapeutic Relationship”), and Session 3 (“Establishing Therapeutic Goals”)
for a demonstration of how I apply principles from the person-centered approach to
my work with Ruth.

Free Podcasts for ACA Members

You can download ACA Podcasts (prerecorded interviews) by going to www.counseling
.org; click on the Resource button and then select the Podcast Series. For Chapter 7,
Carl Rogers and the Person-Centered Approach, look for Podcast 7 by Dr. Howard
Kirschenbaum.

Other Resources
The American Psychological Association offers the following DVDs in their Psycho-
therapy Video Series:
Greenberg, L. S. (2010). Emotion-Focused Therapy Over Time
Cain, D. J. (2010). Person-Centered Therapy Over Time
194 C HAP TE R SEVEN

Psychotherapy.net is a comprehensive resource for students and professionals

that offers videos and interviews featuring Natalie Rogers, Rollo May, and more.
New articles, interviews, blogs, therapy cartoons, and videos are published monthly.
DVDs relevant to this chapter are available at www.psychotherapy.net and include
the following:
Rogers, N. (1997). Person-Centered Expressive Arts Therapy
May, R. (2007). Rollo May on Existential Psychotherapy
The Association for the Development of the Person-Centered Approach (ADPCA)
is an interdisciplinary and international organization that consists of a network of
individuals who support the development and application of the person-centered
approach. Membership includes a subscription to the Person-Centered Journal, the
association’s newsletter, a membership directory, and information about the annual
meeting. ADPCA also provides information about continuing education and super-
vision and training in the person-centered approach. For information about the
Person-Centered Journal, contact the editor (Jon Rose).
Association for the Development of the Person-Centered Approach, Inc.
www.adpca.org
The Association for Humanistic Psychology (AHP) is devoted to promoting per-
sonal integrity, creative learning, and active responsibility in embracing the chal-
lenges of being human in these times. Information about the Journal of Humanistic
Psychology is available from the Association for Humanistic Psychology or at the pub-
lisher’s website.
Association for Humanistic Psychology
www.ahpweb.org
Division 32 of APA, Society for Humanistic Psychology, represents a constella-
tion of “humanistic psychologies” that includes the earlier Rogerian, transpersonal,
and existential orientations as well as recently developing perspectives. Division 32
seeks to contribute to psychotherapy, education, theory, research, epistemological
diversity, cultural diversity, organization, management, social responsibility, and
change. The division has been at the forefront in the development of qualitative
research methodologies. The Society for Humanistic Psychology offers journal
access to The Humanistic Psychologist. Information about membership, conferences,
and journals is available from the website of Division 32.
Society for Humanistic Psychology
www.societyforhumanisticpsychology.com/
The Carl Rogers CD-ROM is a visually beautiful and lasting archive of the life
and works of the founder of humanistic psychology. It includes excerpts from his 16
books, over 120 photographs spanning his lifetime, and award-winning video foot-
age of two encounter groups and Carl’s early counseling sessions. It is an essential
resource for students, teachers, libraries, and universities. It is a profound tribute to
one of the most important thinkers, influential psychologists, and peace activists of
the 20th century. Developed for Natalie Rogers, PhD, by Mindgarden Media, Inc.
 PERS O N - C EN T ERED T H ERAPY 195

Carl Rogers: A Daughter’s Tribute

www.nrogers.com
The Center for Studies of the Person (CSP) offers workshops, training seminars,
experiential small groups, residential workshops, and sharing of learning in com-
munity meetings.
Center for Studies of the Person
www.centerfortheperson.org
For training in expressive art therapy, join Natalie Rogers, Sue Ann Herron, and
Terri Goslin-Jones in their course, “Expressive Arts for Healing and Social Change:
A Person-Centered Approach” at Sofia University. This 16-unit certificate program
requires six weeks of study spread over two years at a retreat center north of San Fran-
cisco. The expressive arts within a person-centered counseling framework program
includes counseling demonstrations, practice counseling sessions, readings, discus-
sions, papers, and a creative project to teach experiential and theoretical methods.
Training in the Person-Centered Approach to Expressive Arts
www.nrogers.com

Sofia University
www.sofia.edu/

Recommended Supplementary Readings

On Becoming a Person (C. Rogers, 1961) is one of the The Life and Work of Carl Rogers (Kirschenbaum,
best primary sources for further reading on person- 2009) is a definitive biography of Carl Rogers that
centered therapy. This classic book is a collection of follows his life from his early childhood through his
Rogers’s articles on the process of psychotherapy, its death. This book illustrates the legacy of Carl Rog-
outcomes, the therapeutic relationship, education, ers and shows his enormous influence on the field of
family life, communication, and the nature of the counseling and psychotherapy.
healthy person. Person-Centered Psychotherapies (Cain, 2010) con-
A Way of Being (C. Rogers, 1980) contains a series of tains a clear discussion of person-centered theory,
writings on Rogers’s personal experiences and per- the therapeutic process, evaluation of the approach,
spectives, as well as chapters on the foundations and and future developments.
applications of the person-centered approach. Humanistic Psychology: A Clinical Manifesto (Elkins,
The Creative Connection: Expressive Arts as Healing 2009) offers an insightful critique of the medical
(N. Rogers, 1993) is a practical, spirited book lav- model of psychotherapy and the myth of empirically
ishly illustrated with color and action photos and supported treatments. The author calls for a rela-
filled with fresh ideas to stimulate creativity, self- tionship-based approach to psychotherapy that can
expression, healing, and transformation. Natalie provide both individual and social transformation.
Rogers combines the philosophy of her father with
the expressive arts to enhance communication
between client and therapist.
 #

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The People Who Developed Transactional Analysis

Gestalt Tbherapy Theoretical Concepts and Development of
The Development of Gestalt Therapy Transactional Analysis
Important Theoretical Concepts Treatment Using Transactional Analysis
View of Humankind Application of Transactional Analysis
Who[eness, integration, Application and Current Use of Gestalt Therapy
and Balance Application to Diagnostic Groups
Awareness Application to Multicultural Groups
'Die Nature of Growth Disorders Application to Other Groups
Treatment Using Gestalt Therapy Current I.Jse of Gestalt Therapy
Goals Evaluation of Gestalt Therapy
How People Change Limitations
Therapeutic Alliance Strengths and Contributions
Experiments Skill Development: Gestalt Chairwork
Use of Language Case lllusuation
Dreams Exercises
Fantasy Large-Group Exercises
Role-Play Using Empty Chair Methods Small-Group Exercises
Tbe Body as a Vehicle of Communication Individual Exercises
The Use of Gestalt Therapy in Groups Summary
The Hot Seat Recommended Readings
Making the Rounds Additional Sources of Infomiation

201
202 Part 3 Treatment Systems Emphasizing Emotions and Sensations

What distinguishes Gestalt therapy from other humanistic approaches is its emphasis on the Gesra/r,
which Laura Perle(1992) defined as "a structured entity that is more than and different from its
parts. It is the foreground figure that stands out hom its ground, it 'exists'"(p. 52). According to
Gestalt therapists, people experience psychological difhculties because they have become cut off
from important parts of themselves such as their emotions, bodies, or contacts with others. The
purpose of Gestalt therapy is to help people become aware of these neglected and disowned pacts
and restore wholeness, integration, and balance.
Gestalt therapy was developed primarily by Fritz Perls, with contributions from his wife
Laura Peels. Erving and Miriam Polster also contributed important enhancements to Gestalt ther-
apy. Widely used during the 1960s and 1970s, it has evolved and matured into a widely used treat-
ment methodology and has influenced adler approaches to treatment.

THE PEOPLE WHO DEVELOPED GESTALT THERAPY

Frederick Perle, known as Fritz Peres, was bom in 1893, the middle child and only son of a middle-
class Jewish family living in Berlin, Gemiany. Although Peels was not always a motivated student,
he succeeded in receiving an MD degree with a specialization in psychiatry(Peels, 1969b). Interested
in becoming a practicing psychoanalyst, Peels moved to Vienna, home of Sigmund Freud, where he
met many of the leaders in his field. Perls studied with Karen Homey and was psychoanalyzed by
both Homey and Wilhelm Reich. Reich's emphasis on the use of facial, bodily, and linguistic cues
to promote understanding and personal growth had a powerful influence on Perle and on the con-
cepts and strategies of Gestalt therapy(Wulf, 1998).
Perle also was strongly influenced by several other experiences. During World War 1, he
served as a medical corpsman, a powerful personal experience. After the war, he worked with neu-
rologist Kurt Goldstein at the Frankflnt Neurological Institute, a treatment facility for people with
brain injuries. Both experiences led Perls to reflect on the workings of the human mind, on Gestalt
psychology, and on better ways to help people (Simkin, 1975; Wheeler, 1991). Even early in his
career as a psychoanalyst, he was becoming disenchanted with psychoanalysis as well as with
behaviorism.
'lbe versatile and extroverted Peels also worked as an actor in the 1920s. He later reported that
his experiences in the theater gave him an understanding of and appreciation for nonverbal com-
munication, an essential aspect of Gestalt therapy. In 1930, Fritz Perls married Laura Posner, a
concert pianist and dancer(Serlin, 1992). Whereas Fritz Perle emphasized independence and con-
frontation, Laura Perle advocated support and connections. She studied existentialism with Martin
Buber and Paul Tillich and drew on this background as she became involved in developing Gestalt
therapy
When Hitler came into power, the couple left Europe, relocating Hast in Holland and then in
South Africa, where Fritz Perle served as a captain in the South African Medical Coils. During hs
years in South Africa, he out]ined his theory of personality integration, which cater became Gestalt
therapy(Simkin, 1975). In"1 946, the couple immigrated to the United States, where Fritz Peels pub-
lished Gesfa/f Therapy. frcifemelzf a/zd Grawfh in rhe Hama/z Persona/iQ(Perls, Hefferline, &
Goodman, 1951). ]n 1952, he established the Gestalt Institute of America.
The most important impetus for the growth of Gestalt therapy was Fritz Peels's work between
1962 and 1969 at the Esalen Institute in Big Sur, Califomia. He became best known there for his use
of the "hot seat" in his workshops and soon was regarded as an innovative and charismatic advocate
of the human potential movement.
Perls's personality enhanced the popularity and success of Gestalt therapy. An outspoken free
spirit, unafraid to challenge and reject established traditions and procedures, both Perls and his
 Chapter 10 ' Gestalt Therapy 203

work were in tune with the 1 960s, when many people sought more fulfillment in their lives and new
ways to live. As he stated, "'lbe meaning of life is that it is to be lived; and it is not to be traded and
conceptualized and squeezed into a pattern of systems. We realize that manipulation and control are
not the ultimate job of life" (Perls, 1969a, p. 3).
Fritz Perle died in 1970, when the popularity of Gestalt therapy was at its peak. Many clini-
cians abandoned traditional systems of treatment in favor of this exciting approach, while others
incorporated elements of Gestalt therapy into already-established treatment approaches. After her
husband's death, Laura Perle continued their work on Gestalt therapy until her death in 1990.
Others continue to develop and refine Gestalt therapy. Particularly important were Erving and
Miriam Polster. Both served for many years as codirectors of the Gestalt Training Center in San
Diego, expanded on Perle's ideas, and emphasized the importance of theory to increase the credibil-
ity of this treatment system (Polster & Polster, 1973). Others, including Yontef ( 1993, 201 2), Evans
and Gilbert (2005), and Lichtenberg (2012), have contributed to the maturation of Gestalt therapy
during the past 60 years (Finlay & Evans, 2009).

THE DEVELOPMENT OF GESTALT THERAPY

Like many other treatment approaches, Gestalt therapy has its roots in Europe. A group of Gestalt
psychologists in Berlin, including Max Wertheimer, KuH Koffka, and Wolfgang Kahler, laid the
groundwork for Gestalt therapy with their studies of perception and integration of parts into percep-
tual wholes. These theorists believed that understanding knowledge in "units of whores, Gestalten" is
more useful to the expansion of knowledge than dissecting the parts(Wulf, 1998, p. 86). In other
words, they believed that the whole is greater than the sum of die parts. They also viewed people as
having a natural tendency toward closure and equilibrium, which leads to thinking in temps of whales
rather than parts- For a comprehensive discussion of the history of Gestalt, see Hergenhahn(2009).
Although Gestalt psychologists provided the name and a basic premise for Gestalt therapy
Peres drew on many sources of knowledge in developing his treatment system, including Kurt
Lewin's field theory, existentialism, and Eastem thought (Sapriel, 201 2). The ideas of Sigmund
Freud, Karen Homey, Wilhelm Reich, and Otto Rank also helped to shape Gestalt therapy.
In addition, Jacob Moreno's psychodrama, along with Peels's own experiences as an actor, are
reflected in the development of Gestalt therapy. Psychodrama encourages people to work out per-
sonal difficulties by creating dramatizations of problematic situations such as a family Hight. With the
help of a therapist, members of the audience assume family and other roles and give the protagonist
an opportunity to relive and change paint ul experiences. Feedback aom observers both enhances the
impact of the process and affords observers vicarious benefits. Peres's techniques, including the
empty chair, role-plays, group feedback, and perhaps even the hot seat, were influenced by Moreno's
ideas, as was Perle's emphasis on spontaneity, creativity, and enactment(gulf, 1998).
During Perls's lifetime, the highly charged techniques associated with his approach received
attention because of their use at Esa]en, their powerful impact, and their application to encounter
groups, widely used during the 1960s and early 1970s. Since then, Gestalt therapy has become less
sensational and more solid. Practitioners of mindfulness meditation will recognize concepts of
BuddlHst thought woven throughout Gestalt theory. Fritz and Laura Perle aust became familiar with
Zen Buddhism through their friend Paul Weisz who was a doctor and .a serious student of Zen
(Clarkson & Mackewn, 1993). Weitz trained in Gestalt theory with Fritz Peres and introduced him
to Eastem ideas, which Perls wholeheartedly incorporated into his work. Buddhist theories such as
the paradoxical notion of change, the polarity of life, and present moment awareness are core con-
cepts of Gestalt. Clinging and aversion, Buddhist concepts that are considered hindrances to mind-
fulness meditation, correspond with Gestalt concepts, as do self-acceptance and maintaining a
204 Part 3 Treatment Systems Emphasizing Emotions and Sensations

nonjudgmental approach to life, free of "shoulda" and "oughts" (Kim, 201 1). Perle believed his
exercises offered a Zen-like experience for Westemers. He later studied Zen Buddhism in Kyoto,
Japan. He was also influenced by Alan Watts, philosopher and author of 77ze Wisdom of/Pzsecwrf(y,
1951 ; and T%e Way ooze/z, 1957.

l IPORTANT THEORETICAL CONCEPTS

Although Peels often used distinctive tem)inology, his theoretical concepts are in many ways
consistent with person-centered and existential approaches. However, Perls and his associates
did add their own ideas, which distinguish Gestalt therapy from other treatment systems. In
addition, the strategies used in Gestalt therapy represent a considerable departure from existen-
tial and person-centered treatment approaches, which make minimal use of specific intervention
strategies.

View of Humankind
Like other humanists, Peels had an optimistic and empowering view of people and placed great
importance on self-actualization: "Every individual, every plant, every animal has only one inbom
goal--to actualize itself as it is"(Perle, 1969a, p. 33). He believed that people were basically good
and had the capacity to cope with their lives successfully, although he recognized that they some-
times needed help. According to Perle, healthy people engaged productively in the tasks of survival
and maintenance and intuitively moved toward self-preservation and growth. Gestalt therapy helps
people develop awareness, inner strength, and self-sufficiency. These qualities enable them to rec-
ognize that the resources they need for positive growth and change are within themselves rather
than in a partner, title, career, or clinician.

Wholeness, Integration. and Balance

As its name implies, Gestalt therapy is a holistic approach that emphasizes the importance of inte-
gration and balance in people's lives. People cannot be separated from their environment nor can
they be divided into parts (such as body and mind) (Murdock, 2009). Perls (1969a) said of the
human organism, "We have not a liver or a heart. We are liver and heart and brain and yet, even this
is wrong--we are nof a summation of parts but a coordi/ rio/z of the whole. We do not have a body,
we are a body, we are somebody"(p. 6).
To some extent, this po]arization and denial of parts of the self stem from a drive toward
homeostasis. People have difficulty dealing with ambiguity or disequilibrium and prefer stability
and cohesiveness. This may lead them to stay "stuck" in an unsatisfying marriage because they fear
the altemative, or to exclude from awareness the parts of themselves that seem incongruent or cause
discomfort, in a misguided effort to force equilibrium.

INTEGRATING POIARITIES People's need for homeostasis also can lead them to view themselves
and their world in temps of po/ariries or extremes. The world may seem easier to understand if we
categorize people as either good or bad. However, these polarities generally reflect intemal or inter-
personal conflicts. To truly achieve wholeness, people must become aware of and integrate their
polarities, especially the polarities of the mind and the body. IJnless we accomplish that, the
neglected or rejected side of the polarity is likely to build barriers against our efforts toward growth.
For example, people who believe they must always be independent may deny the part of themselves
that craves connection and intimacy, whereas people who believe that their intellwt is their greatest
gift may cut themselves off from their emotions and sensations.
 Chapter 10 ' Gestalt Therapy 205
FIELD THEORY: INTEGRATING FIGURE AND GROUND Although people strive for homeostasis,
our lives and our world are always in flux, always changing. People constantly experience disequi-
librium and then naturally try to restore balance. We are hungry, so we eat. We are tired, so we nap.
We shift priorities based on the nature and importance of the rising needs to be met.
Perle incorporated Lewin's field theory, which was popular in physics, into the concept of the
.Pgure/groff/zd to clarify this constant flux. The metaphor of driving a car illustrates how we must
live our lives in the here and now, using our bestjudgment and knowledge to react to the constantly
changing needs on the road. We cannot possibly control every experience on the road, nor can we
get in a car with a predetemiined goal of driving 70 miles an hour until we reach our destihadon.
Rather, certain elements come into the foreground, depending on the environment. The figures that
emerge require different levels of focus and attention. 'l'he self is the fluid part of this environmental
field, and the one that is always shifting and changing. 'lllis shift in the figure/ground is a process
that attends to the immediate needs of the organism. Not to change results in stagnation and the
sense of being "stuck.
This process--shifting back and forth between figure and foreground--is the crux of psycho-
therapy. According to Per]s, the basis of the Gesta]t approach is the paradoxical situation that the
organism has a two-part existence: both the awareness of what is happening in the present moment,
and the relationship that this is in contrast with. Foreground implies background and vice versa.
According to Perle, recognizing these splits and activating both is the goal of psychotherapy.
Through awareness, boundaries become fluid, disappear, and then reappear. Similar to our car anal-
ogy, something is always receding into the background or moving into the foreground.
The therapist can use his or her perspective as part of the field as a tool in therapy. Through
the use of Gestalt techniques such as the empty chair and the two-chair technique, the therapist
helps the client become aware of the background--foreground, to recognize the duality, and to con-
clude that things are not "either/or," but "both/and." This both/and way of thinking results in a
paradigm shift for the client that reduces judgmentalness, increases compassion, and eventually
brings about change(Neff, Kirkpatrick, & Rude, 2007).
More significant figure/ground shifts lead to sudden and often important changes in our
understanding of events and experiences. For example, after dating for 10 months, Kristen arrived
about 45 minutes late to pick up her boyfnend Luke for a party at his supervisor's house. Before she
could explain that an accident had caused her delay, Luke became enraged and hit Kristen in the
face. He had become angry with her before and had come close to hitting her, but Kristen had over-
looked those signs of Luke's violent behavior; she had grown up in an environment in which anger
and shouting were acceptable and even desirable expressions of feeling. However, when Luke actu-
ally hit her, she saw those early waning signs in a new light, integrating figure and ground. She
recognized that Luke presented a danger to her and that they did not have a healthy relationship.

EGO BOUNDARY Just as the figure/ground relationship changes, so does the ego boundary. Perle
(1969a) described the ega bou/z(&zW as "the organism's definition in relation to its environment
t!)is nlationship is experienced both by what is inside the skin and what is outside the skin, but it is not
a nixed thing"(p. 7). The two polarides of the fluid ego boundary aPe identification and alienation.
Identification, as with our parents, our babes, and our jobs, brings those aspects of our lives into our
ego boundaries, whereas alienation, for example, from other people or parts of ourselves, leads us to
put those aspects outside our ego boundaries. According to Perls, "So dle whole idea of good and bad,
right and wrong, is always a matter of boundary, of which side of the fence lam on"(p. 9).
Gestalt therapy, like the other approaches discussed in Part 3, is p/zerzomenoZoglca/. It recog-
nizes plat people's perceptions of a situation can vary widely; that even within a person, perceptions
can change; and that our perceptions greatly influence our thoughts, emotions, and behaviors. Perle
206 Part 3 Treatment Systems Emphasizing Emotions and Sensations

first introduced Hie[d theory in his semina] work(Per]s et a]., 195 1) and was consistent with scion
dfic writings at the time, including Einstein's theory of relativity(O'Neill, 2012; Perle & Philippson
2012). Current use of the unified field perspective in Gestalt therapy considers the self as an interac
tive part of the larger environmental 6leld. The person exists in a larger field, and cannot be under-
stood outside of that context(Perle et al., 195 1).

HOMEOSTASIS VERSUS FLUX Peels used a great many terms, including figure/ground, ego
boundary, and polarities, to refer to the constant state of flux that people experience. These con-
structs all pose threats to our homeostasis. Clearly, people cannot achieve a state of fixed homeosta-
sis and then freeze the action. Our lives are always changing. However, through awareness of and
identiHlcation with all aspects of ourselves, we can deal successfully with flux and still have a
sense of integration and wholeness. Homeostasis can be explained by the organism's need "to
complete all unfinished situations in the sequence of the survival importance"(Perle & Philippson,
2012, P. 169).

0 Awareness
For Gestalt therapists, awareness is an essential element of emotional health: "Awareness per se--
by and of itself---can be curative. Because with full awareness you become aware of this organismic
self-regulation, you can let the organism take over without interfering, without intemipting; we can
rely on the wisdom of the organism"(Perle, 1969a, p. 17). Awareness is both a hallmark of the
healthy person and a goal of treatment.
Several possible causes have been identified for people's limited awareness. Preoccupation is
one of the foremost. We may be so caught up with our pasts, our fantasies, our perceived flaws or
strengths, that we lose sight of the whole picture and become unaware. Another reason for lack of
awareness is low self-esteem: "The less confident we are in ourselves, the less we are in touch with
ourse[ves and the wor]d, the more we want to contro]"(Per]s, 1969a, p. 2]). Low self-esteem makes
it difficult for people to trust themselves, to allow their natural health and strength to propel them
toward growth and self-actualization. Rather, people with low selfesteem typically set out to con-
trol themselves and others in an effort to realize an idealized self-image rather than to truly become
actualized. The result is often exactly the opposite of what is intended.
Awareness is facilitated in Gestalt therapy by the use of experiments, a here-and-now focus,
and process statements. Because it is not enough for clients to merely talk about their feelings--
talking leads to intellectualization---Gestalt therapists do not practice reflective listening. Rather,
they focus on their clients' nonverbal language--the way they sit, their tone of voice, or a tapping
Ringer. By attending to these and other body movements, the therapist requires clients to go deeper,
to reexperience their emotions in the here-and-now environment of the therapy session, and to
understand the physical as well as verbal meaning of what they are prqecting.

ENVIRONMENTAL CONTACT TO PROMOTE GROWTH People engage in many shorts to achieve

awareness, and contact with the environment is one of the most important. Contact is made through
seven functions: looking, listening, touching, talking, moving, smelling, and tasting(Polster &
Polster, 1973, pp. 129--138). Contact is necessary for growth; when we make contact with other
people or aspects of our world, we must react and change. The experience of contact teaches us
about ourselves and our environment and helps us to feela part of our world, while defining more
clearly who we are. People who avoid closeness with others and live isolated and circumscribed
lives may believe that they are protecting themselves, but, in reality, they are preventing their
growth and actualization.
 Chapter 10 ' Gestalt Therapy 207

Peres( 1969a) identiHled five levels or stages of contact and growth

l Thephony paler, People play games, assume roles, react in stereotyped and inauthentic ways,
and are insincere.
2 Thephobic ZaWer. People avoid pain, hide their real selves to prevent rejection, act out of fear,
and feel vulnerable and helpless.
3 The inzpasse &zyer, Having passed through the aust twolayers, people feel confused, stuck,
and powerless; they seek help from others.
4 The ImpZoslve &zyer. People become aware that they have limited themselves and begin to
experiment with change, to deal with unfinished business, to lower defenses, and to move
toward greater integration. People connect with their possibilities and give up old layers. This
implosion tums into an explosion in the fifa layer.
5 The explosive layer. People experience reintegration and wholeness, become their audientic
selves, gain access to great energy, feel and express emotions, and become more actualized.

Treatment often involves helping people progress through the layers, peeling away each one like
the skin of an onion to expose the next healthier layer of the adult personality. In this way, people
truly become their authentic, actualized selves, capable of full contact with the environment, other
people, and themselves.

HERE AND NOW Another way to increase awareness is to live in and be conscious of the present
moment rather than remaining tied to the past or trying to control the future. According to Perle
(1969a), "Nothing exists except the here and now. . . . The past is no more. The future is not yet. .
You should live in the here and now"(p. 44). When we are centered in the present, we are more
likely to be congruent--to have our minds, our bodies, and our emotions integrated. When we are
not fully in the present, we may be fragmented. Our emotions may be stuck in past hurts and our
thoughts may wander to future anticipations while we talk with people in the present. When we are
not centered in the present, we give confusing messages to others, have a poorly integrated sense of
ourselves, and have difblculty making contact because we are not fully present.
Gestalt therapy takes place in the here and now. The therapist reacts in a genuine, empathic, and
Uansparent way to the client's material. ellis transparency may include disclosures rom the therapist,
but any disclosure must be made in the best interest of the client. Finlay and Evans(2009) caution that
the use of the here and now is not a technique to be selected for use with the client, but a way of being
that Bflects the l-thou relationship found in aU humanistic therapies(Buber, 1970; Yontef, 1993).
More will be said about the l-thou relationship in the discussion of the therapeutic alliance.

RESPONSIBILITY Like the other humanistic theorists, Gestalt therapists place importance on
accepting responsibility for our own lives rather than giving that power away or blaming and resent-
ing others for our disappointments. Gestalt therapists believe that people must make their own
choices rather than allowing others to choose for them.
Perle's focus, in keeping with the climate of the 1960s, was on the individual; but contempo-
rary Gestalt therapists have modified the concept of responsibility. Now it refers not only to taking
care of ourselves but also to recognizing that from birth we rely on the presence of interdependent
relationships. To maintain a healthy balance between interconnectedness and independence, we
must have awareness and self-acceptance, which lies at the core of the healthy person.

The Nature of Growth Disorders

Although Peels sometimes used the temp ne roses to describe emotional problems, he believed that
these difficulties should more accurately be refened to as "growth disorders"(Perle, 1969a, p. 30).
208 PaR 3 Treatment Systems Emphasizing Emotions and Sensations

ibis term is used in connection with people who deny or reject aspects of themselves and their
environment, are not living in the present, are not making fulfilling contact with others, lack aware-
ness, and are not becoming actualized. Rather than changing or growing, they have become stuck.
Change is an inevitable part of life, and diose who do not change stagnate.
Avoidance and resistance, what Perle refened to as creative adjustment, keep people trapped
in this unhealthy state. They avoid dealing with uncomfortable feelings, remain unaware, and cir-
cumscribe their lives to minimize flux or change. They make extensive use of ego defenses such as
prqection of disowned aspects of themselves onto others, distraction, failure to set boundaries
between themselves and others, and ina.ojections and withdrawal from their surroundings. Wholeness,
integrity, freedom of choice, and actualization are sacrificed to the illusion of safety and homeosta-
sis. Such people do not allow themselves to be aware of, anticipate, and cope successfully and flex-
ibly with the changes in their lives. Rather, they persist in unsuccessful defensive maneuvers to
avoid change. Paradoxically, as Perle observed, even stagnation indicates that movement has
occured and there is hope. Ironically, it can result in greater tumioil and discomfort than those who
are aware of and use their own powerful resources to manage their lives.
People who are not developing in healthy ways often have a great deal of unfinished business.
According to Perle(1969a), "Our life is basically practically nothing but an infinite number of
unHlnished situations--incomplete Gestalts. No sooner have we finished one situation than another
comes up"(p. 15). Healthy people may be disconcerted by the constant unHlnished business in their
lives but liam to use their resources to deal with it effectively. People who do not adapt to life's
changes develop growth disorders. ellis malfunction or breakdown in the process of living is not a
medical problem, but rather "one possibility of existence"(Levine, 2012, p. 9). Because they are
alienated from many aspects of their environments and themselves, they cannot deal effectively
with the demands of their lives, so they accumulate more and more unfinished business. Their
energy is sapped by their unproductive efforts to cope, leaving them depleted of the resources they
need to live dieir lives successfully. People who are overwhelmed by unfinished business typically
feel stuck or blocked and may experience physical symptoms. Their current issues tend to mirror
unresolved past issues and are never finished because they are not addressed in the here and now.
Gestalt therapists serve as facilitators of growth and self-regulation, not as change agents. One of
the major goals of Gestalt therapy is to help people become aware of their backlog of unfinished
business and bring it to closure--finish it so that they are able to live more fully in the present.

TREATI LENT USING GESTALT THERAPY

Unlike person-centeredcounseling and existential therapy, Gestalt therapy includes a rich array of
strategies that facilitate Ueatment. 'obese strategies have been developed to fllrther what Peres et al.
(195 1) identified as the four major emphases in Gestalt work:
l To pay atkntion to expedience and become awad of and concentraB on the actual pnsent situation
2. To maintain and promote the integrity and interrelationships of social, cultural, historical,
physical, emotional, and other important factors
3 To experiment
4 To encourage creativity.

Goals
Many of the treatment objectives of Gestalt therapy are similar to those of person-centered and
existential therapy. However, others are unique to this approach. The most important goals of
Gestalt therapy are:
 Chapter 10 ' Gestalt Therapy 209

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According to Perle(1969a), "The difference between Gestalt therapy and most other types of
psychotherapy is essentially that we do lzof analyze. We iPzregrare" (p. 70). The ultimate aim of
Gestalt therapy is to promote the natural growth of the human organism and enable people to live
aware and actualized lives--not just to solve problems or promote adaptation but also to help cli-
ents feel more fulHllled and whole.

How People Change

Gestalt clinicians believe that awareness is the primary vehicle of change. If people can gain aware-
ness of their unfinished business(the areas in which they are blocked and alienated) and their own
strengths and resources, they can grow and become more actualized. Particularly important is
awareness gained through the body since, according to Gestalt theory, most people overemphasize
intellectual awareness and ignore messages from the body and the senses.

e Therapeutic Alliance
Like the existential therapists discussed in the previous chapter, Gestalt therapists seek to create an
l-thou relationship in contrast to the l-it relationship, which is the type of everyday relationship
flat moves us forward throughout the day but does not involve deep meaning. 'lbe l-thou relation-
ship is a willingness to U.uly know the other person as he or she is, as well as the willingness to be
transparent and to be fully known. Although l-it ways of relating are not to be shunned(because
they make up the bulk of our communications), Crocker(2005) noted that they miss the depth of
our humanity. She writes: "Being constantly open to the revelation of 'lthou, whenever and from
wherever it comes--even while busy in the workings of l-it--and being willing to reveal oneself as
Thou to an other's lwhen the opportunity presents itself:--that is being faithful to oneself as a per-
son. For Buber, the unique individuality of the Other is revealed and received, and from this mutual
process rises true community and thus d)e fulHlllment of life"(p. 72).
Gestalt clinicians strive to be genuine and aware of their own feelings, experiences, and per-
ceptions. They build relationships with clients in which both client and clinician are free from judg-
ment, narcissism, or expectations; are respectful and accepting of the other; are open; and are fully
210 Part 3 Treatment Systems Emphasizing Emotions and Sensations

present in the here and now(Buber, 1970; Finlay & Evans, 2009). They do not urge or persuade
people to change or tell people how they should be. Radler, they establish a climate that promotes
trust, awareness, and a willingness to experiment with new ways of thinking, feeling, and acting.
Clinicians and clients enter into a partnership in which both are committed to and active in the treat-
ment process. However, clients take responsibility for their own development and decide for them-
selves how they will use the infomlation that emerges in their sessions.
This bringing into awareness is often referred to as the paradoxical principle of change.
:Change occurs when one becomes what he is, not when he vies to become what he is not"(Beisser,
1970, p. 77). It is only through ownership and integration of previously disavowed aspects of the
self that change becomes possible. When a clinician observes that a client's attention is wandering,
that conflicts are emerging, or that a person seems fragmented or out of contact, the clinician calls
attention to these phenomena in the "here and now" of the session. The clinician makes this obser-
vation without interpretation orjudgment, but simply to provide infomiation that is likely to refocus
attention, create awareness of blocks, and help people maintain contact with their present activities
and experiences. Instead of trying to figure out their clients, Gestalt therapists focus on listening and
helping clients find their own way.
Experience in Me here and now is the process used to increase awareness. Awareness occurs
in the present experiential moment, so even though the client may be addressing a past experience,
the focus in therapy is on the "present moment where the past is embedded and therefore alive and
obvious"(Melnick & Nevis, 2005, p. 105). It is only through this web of relational interconnections
that we know ourselves(Finlay & Evans, 2009).

Experiments
One task of Gestalt therapists is suggesting experiments or leaming experiences for their clients. These
are individually tailored to each client in order to accomplish a purpose relevant to that person, usually
to promote awareness and bring problems and unfinished business into die present where they can be
resolved. These experiments should not be dneatening or negative; instead, they should be positive
and growth promoting. Presentation of suggested experiments should always be mspectful, inviting,
and canfully timed. Although confrontation may be used to encourage involvement, clients are never
demeaned and can always choose whether or not to involve themselves in the experiments.
Experiments might take the foml of enactments, role-plays, homework, or activities for cli-
ents to accomplish between sessions (Polster & Polster, 1 973). For example, a Gestalt therapist
suggested to a withdrawn and guarded woman who wanted to have closer relationships with people
that she tella friend something about herself that would surprise and please the trend. Spending
time thinking about what she would tell die friend promoted the woman's self-awareness, and the
eventual sharing increased the closeness between the woman and her Blend.

Use of Language
Language plays an important part in Gestalt therapy By choosing their words carefully, clinicians
create an environment that encourages change.

EMPHASIS ON STATEMENTS Although questions are part of Gestalt therapy, clinicians typically
prefer statements. obey are more likely to say, "I am experiencing a loss of contact between us,
than "Where has your attention gone?" The immediacy and direct person-to-person contact of a
statement promotes a collaborative client-clinician relationship. Questions, on the other hand, are
reminiscent of a teacher-student relationship in which the power differential may undem)ine the
process. Talking with someone rather than af someone is critical in building a connection.
 Chapter 10 ' Gestalt Therapy 211

"WHAT" AND "HOW" QUESTIONS When Gestalt therapists do ask questions, they usually begin
them with "what," "how," or sometimes "where," but rarely with "why." Questions such as "What
are you experiencing when you stamp your foot?" and "How does it feel when you stamp your
foot?" are more likely to keep the client in the present moment and promote integration than are
questions such as "Why are you stamping your foot?" "Why" questions typically lead to a focus on
past experiences, as we]] as blocks and manifestations of resistance.

"l" STATEMENTS Gestalt therapists encourage people to own and focus on their own feelings and
experiences rather than talk about other people(they) or events(it). Statements beginning with "l"
such as "] fee] angry" and "]n the dream, ]am ]ost" encourage ownership and responsibility as we]]
as integration. Statements such as "My mother made me angry" and "My dream was about being
lost" take the focus off the client and the present moment and promote fragmentation and extemal-
izing of responsibility.

THE PRESENT TENSE Even when clients talk about past events, Gestalt clinicians encourage them
to focus on their present experience of the events--to bring events into the room and into the
moment. For example, rather than focusing on a client's perceptions of how his father abandoned
him when he was a child, the therapist might suggest that the client describe how that early aban-
donment affects his feelings and behaviors in the therapy session. This fosters awareness as well as
a true connection with the clients' experience of the events.

ENCOURAGING RESPONSIBILITY Gestalt therapists encourage people to take responsibility for

themselves, their words, their emotions, their thoughts, and their behaviors in order to facilitate
integration. Language can help further that goal. For example, the clinician might suggest that peo-
ple temporarily begin all their sentences with the phrase "I take responsibility for . . ." to help them
recognize and accept their feelings. They might also apply to themselves statements they have made
about others to facilitate awareness of their projections. 'l'he woman who says, "My sister only
thinks of herself," might be asked to say, "I think only of myself," and then talk about what feelings
this brings up for her.
Anodier way to encourage people to take responsibility for themselves is for clinicians to help
them make the implicit explicit. For example, a woman assured her husband that she would be
happy to accompany him to church as he requested. However, each Sunday she told him that she
had work to do so she could not go to church. Her therapist encouraged her to make her feelings
explicit by stating, "I really don't want to go to church with you; Ifeel uncomfoRable and out of
place there because it is not the religion lwas brought up to believe.

Dreams
Dreams occupy an important place in Gestalt therapy. Perls viewed dreams as the royal road to
integration rather than the royal road to the unconscious, as Freud had viewed them. Perle believed
that the parts of a dream represent projections or aspects of the dreamer. Awareness comes from
assuming the various roles or parts of the dream and enacting the dream as though it is happening in
the present.
For example, a man had a dream about a rabbit, which was being chased across a field by a fox,
escaping into a burrow. Freud, of course, would focus on dle unconscious meaning of the conflict
between the fox and the rabbit and the possibly sexual significance of die burrow. Perle, on the other
hand, would encourage the man to assume the roles of each of the salient parts of the dream. One at
a time, the client would enact the roles of the fHghtened rabbit, the menacing fox, the open fteld, and
212 PaH 3 Treatment Systems Emphasizing Emotions and Sensations

the protective burrow, speaking the thoughts and feelings that arose for him in each role. For exam-
ple. he might say, "I am that rabbit, running scared, ahaid that lwill be swallowed up. lam always
running for cover, safe just in the nick of dme, but knowing that Imight not make it the next time.'
This approach to understanding dreams puts the client in chwge of the process. It also allows peo-
ple to take responsibility for their drams, see their dreams as part of themselves, incnase integmtion,
and become aware of thoughts and emotions reflected in the dream that they might otherwise disown.
Many concise examples of dmamwork can be found in Perls's book Gesfa/f 77ze/upy Verbatim(1969a).

Fantasy
Fantasies, like dreams, can help people become more seK.aware. Clinicians might use guided imaged
to take people on ajoumey into their imaginations. Clients might be encouraged to imagine themselves
walking dlrough a beautiful meadow with a ramshackle house, looking around to see who is with them,
and deciding what to do in that situation. Clinicians might make the fantasy more productive by asking
questions to promote exploration and suggesting actions the person might take in the fantasy.
As with dreams, Gestalt therapists assume that the parts of the fantasy represent prqections or
aspects of the person. When the fantasy is. completed, clinicians encourage people to process the
experience by becoming the parts of the fantasy, speaking as though alley are each part. This tech-
nique, as with the exploration of dreams, often helps people become more aware of and in contact
with their feelings and more able to express their emotions.
Fantasies also can be used to bring closure to unHlnished business. For example, a woman
who had undergone surgery was left with some angry feelings about her surgeon and the need to
have her surgery redone. When she called to express her feelings to the physician, he failed to retum
her telephone calls. To help her reach closure, her clinician led her on a guided fantasy in which she
expressed her feelings to the physician and affimied her ability to take care of herself and have the
unsatisfactory surgery corrected.

e, Role-Play Using Empty Chair Methods

Role-play, in various fomts, is an essential tool of Gestalt therapists. Although Perls was influenced
by Moreno's psychodrama, Gestalt therapy rarely uses other people to play roles, in part because
that might encourage fragmentation. Rather, an empty chair is more often used to represent a role.

THE TWO-CHAIR METHOD FOR ADDRESSING AN INNER CONFLICT This common type of role-
play is intended to help people become aware of and resolve inner conflicts, develop clarity, and
gain insight into a]] aspects of a problem (Strumpfel & Goldman, 2002). It can also help people
become aware of their self-judgments, how they respond to their self-judgments, and help them to
develop compassion for themselves (Barnard & Curry, 2012). Two chairs are used, representing
two parts of the person that are in conflict, perhaps the intellect and the body or love and anger.
Resolving conflicts involving anger, accompanied by emotions such as shame, grief, and sadness,
seems especially therapeutic. The client spends time sitting in each Chair and talking from the per-
spective represented by that chair.
Underlying this exercise is the Gestalt concept of the top dog and the underdog. Peres believed
that "we constantly harass ourselves with . . . the top dog/underdog game where part of ourselves
attempts to lecture, urge, and threaten the other part into 'good behavior'"(Fagan & Shepherd,
1970, p. 4). The top dog, a sort of superego or conscience, makes judgments and tells the underdog
how it should feel, think, or act. The underdog tends to be meek and apologetic but does not really
uy to change. Although the top dog may seem more powerfu], the underdog really has control by
refusing to change or cooperate despite feelings of guilt. In addition to having both a top dog and
 Chapter 10 ' Gestalt Therapy 213

underdog within them, people may cast another person into the role of top dog while they assume
the role of the guilty but ineffectual underdog. Some clients seek such a relationship with their clini-
cians, creating a hierarchical and nonproductive relationship.
When the two-chair method is used to address an inner conflict or split, the dialogue generally
begins with the top dog or dominant part of the person expressing strong criticism of the other part,
which is likely to become def'ensive and vulnerable. As the dialogue continues, the clinician encour-
ages the critic to become even harsher while prompting die underdog to express its pain and sad-
ness. Recollections, misunderstandings, and previously unspoken and unacknowledged feelings
may surface at this point. This, in tum, creates what Peres has described as an "ah-ha" experience:
the shock of recognition in which people gain new emotional awareness and understanding. The
goal of this exercise is to avoid an impasse and enable the two parts to achieve resolution; the critic
becomes more tolerant and accepting, while the underdog gains self-confidence and a direct means
of self-expression. People become more able to own and integrate both parts of themselves.
The polarity of the top dog versus the underdog is one of the most well known of the Gestalt
polarities. As the name suggests, the top dog polarity is our underlying need to be right, to be in
charge, and to appear to be "one up" on other people; at the opposite pole, the underdog is the incli-
nation to be the victim, to act lazy, stupid, or passive, in order to avoid the responsibility of being
Ae top dog. Although each of us swings between these two polarities, the healthy person finds bal-
ance, whereas the unhealthy person clings to one of the polar extremes in an effort to avoid emo-
tional pain. This is true with all of the polarities, whether it is connection/separation, strength/
vulnerability, or others (Prochaska & Norcross, 2009). If people stay in the either/or mode of the
polaiities and fail to accept Mat they are also the opposite of what they pretend to be, they will not
experience the entirety of life, the full Gestalt. Tbe ful! Gestalt takes a botlyand approach to life.

THE EMPTY ClIAIR METHOD FOR ADDRESSING UNFINISHED BUSINESS According to Strumpfel
and Goldman(2002), ". . . signiHlcant unmet needs represent unclosed gestalts that have not fully
receded from awareness"(p. 196). The empty chair dialogue is a way of addressing and resolving in
he imagination close unclosed gestalts. The empty chair might represent another person, a trou-
bling and confusing part of a person's dream or fantasy, or a physical symptom the client is experi-
encing such as a headache.
Clients visualize in the empty chair a person(or symptom or part of a dream) wiki whom they
have important unfinished business. 'obey then express their thoughts and feelings to Uat person, in
an effort to complete a process that had been interrupted. The goal of this experience is a resolution
in which clients develop greater understanding and acceptance of the other person or issue, as well
as growth in their own self-conHldence.
Sujata, a woman who was bom in India, had unfinished business with her father. Constantly
trying to eam his approval, she proudly called him with each professional and academic achieve-
ment. His usual response was to ignore her infomiation or ask when she was going to produce
another grandchild for him. When she finally earned her doctorate after many years of hard work
and received the same reply from her father, she became discouraged and devalued her accomplish-
ments. Tllrough an empty chair dialogue with her father, she came to understand the influence of his
cultural background and the messages he had received from his parents. This led her to become
more tolerant ahd accepting of his values while maintaining pride in her own accomplishments.

The Body as a Vehicle of Communication

Gestalt therapy seeks to give people a sense of wholeness, enabling them to access and be aware of
their thoughts, emotions, and physical sensations. Many people have fairly good awareness of their
214 Part 3 Treatment Systems Emphasizing Emotions and Sensations

thoughts and emotions. However, they ignore or cut themselves off from their bodily sensations.
Consequently, Gestalt therapists pay particular attention to the messages of the body.
The following strategies are especially useful in focusing attention on the body:
lae#fgica#on; Clinicians remain alert to bodily messages. If they notice that a part of a per-
son's body is in a reactive state, such as fingers tapping on a table or a leg strenuously swing-
ing, they call attention to the movements and ask about their message. A clinician might say,
:l notice that your leg began swinging when we started to talk about your relationship with
your sister. What is your leg saying?" or "Become your leg and give your leg a voice. What is
your leg feeling?"
Z,acadizg emofb s ilz fhe body: Another strategy is helping people locate their emotions in
the body so that they can more fully experience their feelings. A clinician might say, "You
have told me that you feel rage toward your sister. Show me where you are experiencing this
rage." Once the client locates the rage, perhaps in her stomach, the clinician can explore the
client ' s physical sensations, enabling her to more fully connect with and express her feelings.
RqpedHolz a d eiraggerafiolz; When they observe body movements or symptoms, clinicians
often encourage clients to repeat and exaggerate them. For example, a clinician might say, "I
notice you are tapping your foot. lwould like you to exaggerate the tapping, do it as hard as
you can, and then talk about what feelings come up-" The techniques of exaggeration or rep-
etition a]so can be applied to a tone of voice or a meaningfu] phrase that the person uses. 'Fills
intervention focuses attention on where energy is located and can succeed in releasing blocked
awareness and energy.

THE USE OF GESTALT THERAPY IN GROUPS

[nitia[[y, Gesta]t therapy usua]]y took the fomi of individual therapy practiced in a group. Today,
individual therapy is the primary mode of treatment, but use of this approach in a group setting
overs many benefits. Gestalt therapy groups focus on both interpersonal dynamics and the dynam-
ics of the group system. Feedback and support from both the clinician and the group members can
accelerate the process of awareness and empowemlent. Members also can lean vicariously from
each other. The use of Gestalt therapy in a group setting has led to the development of several useful
techniques.

The Hot Seat

Fritz Perls's work in Big Sur at the Esalen Institute emphasized the use of the hot seat in a group
setting. This powerful technique brought him considerable attention, and it was widely adopted by
encounter groups during the 1960s and 1970s. The hot seat is a chair, placed in the middle of the
group, usually with a box of tissues nearby since sitting in the hot seat often evokes strong emo-
tions. Group members volunteer, one at a time, to spend 5 to 10 minutes in the hot seat, becoming
the center of the group's attention. When people are in the hot seat, they are encouraged to express
and stay with their feelings. Feedback from the group on their body language and verbal messages
promotes their awareness of themselves and their feelings.

Making the Rounds

When making the rounds, people in the hot seat speak to each member of the group, perhaps identi
fying something they want from that person or something in him or her that reminds them of them.
selves. Altematively, group members might take tums giving people in the hot seat feedback
 Chapter 10 ' Gestalt Therapy 215
perhaps on their strengths, in an effort to empower them. Like many of the adler experiments used
in Gestalt therapy, this is a powerful technique that is likely to have an enduring impact on people.
As in all Gestalt therapy, figure/ground dynamics, Hleld theory, and intersubjectivityare con-
sidered in Gestalt group therapy(Gaffney, 2012). Gestalt group work can also be applied to clinical
supervision (Gaffney, 2008).

TRANSACTIONAL ANALYSIS
Developed by Eric Beme, transactional analysis(TA) has its roots in psychoanalysis but today is
often integrated with Gestalt therapy and psychodrama. TA de-emphasizes the unconscious and
instead focuses on responsibility, emotional health, and social relationships (Tonton, 2010).
However, Beme, who originally trained as a psychoanalyst, also stressed the importance of early
childhood development and of parental messages. Like Alfred Adler, Beme believed that people
fomi life scripts in childhood that guide their lives. Beme sought to reduce the complexity and
increase the relevance of psychoanalytic concepts. His book Tralzsacfiona/ .Alza/yfls in
Psyc'horherapy(1961)was soon followed by Games People P/ay(1964), a bestseller that led to
widespread interest in TA. Beme died in 1970, having published eight books and 64 articles.

Theoretical Concepts and Development of Transactional Analysis

Although not as popular as it once was, TA continues to be used, either alone or in combination
with Gestalt or omer treatment systems. The following infomiation is provided for readers who
want to liam more about this approach.

HUMAN DEVELOPMENT AND EGO STATES Beme suggested that people evolve through devel-
opmental stages. Although Freud's and Erikson's influences are evident, Berne put his own stamp
on the stages through his concept of the three ego states: child, adult, and parent.
The c/zi/d ego sfafe contains early experiences, emotions, intuitions, inquisitiveness, and the
capacity for baal joy and shame. The child ego state may talk in superlatives, focus on the
self, and manifest such nonverbal behaviors as tears, whining, giggling, and squinning.
The adu/f ego ifafe is like a computer; it is obUecdve and rational, emphasizes logic over emo-
tion, processes infomlation, integrates messages from the other ego states, and solves problems.
'ellis ego state is sa:aighdorward, gives opinions, and asks questions. It cannot erase material in
the parent or child ego states, but it can integrate or minimize the input from those states.
Theparelzf ego sfafe has two parts: the nurturing parent, which provides support, afHmation,
and caring but can be overprotective; and the critical parent, which makes judgments, disap-
proves and criticizes, and sets standards. The critical parent grows out of the rules, repri-
mands, praise, and rewards that children receive hom parents, teachers, and other authority
figures and reflects their conceptions of right and wrong(Hams, 1967). The parent ego state
tends to use words such as a/ways, /lever, and fhozz/d and focuses on yozt("You need to clean
your room" or "You aren't doing a goodjob"). Nonverbal signs include pointing, sighing, and
a raised voice. The parent ego state may provide clear guidelines or give mixed messages.

Ideally, the three major ego states(child, adult, and parent) are in balance in the personality.
However, if a person relies too heavily on one or two of the ego states, or if one ego state contami-
nates or insides on another, the person is likely to develop difnlculties, especially in relationships.
For example, the person who has too little adult is likely to be illogical, whereas the person with too
much adult will probably be uninteresting. Similarly, the person with too little flee child is likely to
216 Part 3 Treatment Systems Emphasizing Emotions and Sensations

be constricted and rigid, whereas the person with too much free child may be inesponsible. A strum
rural analysis can assess ego state balance.

TRANSACTIONS Transactions are the basic units of behavior. They involve an exchange of verbal
or nonverbal messages between two people. TA describes three types of transactions characterized
by the source of the transaction, its target, and the replying ego state:

1. Conzplemeizfaly /ru#sacda#. The target and the replying ego states are the same, and the reply
is directed to the source ego state. Complementary h.ansactions are likely to lead to interactions
and relationships that are clear, open, and rewarding. People say what they mean and can
understand what other people are saying. Any disagreements are evident and can be addressed.
Example A (Figure 10.1)
Pare/zf rsource ego srafe) to ch;/d (larger ego sfafeJ.- Please pick up your toys
Chi/d rreplyfng ego stare) to parent rfarger of repZ}).' All right, lwill.

P = Parent; A = Adult; C = Child

Example A: Complementary Transaction

FIGURE 10.1 Complementary Transaction

2. Crossed ZramsacfloH. The target ego state and the replying ego state differ. In crossed transac-
tions, the responses people receive usually are different from what they anticipated, and they
may feel ignored and misunderstood
Example B ( Figure 10.2)
Ad /r to adu/r (larger ego i/afe).- It's cold out. Do you want to get your coat?
Chi/d rrepZyi/zg ego sra/e) to pare/zr: Don't tell me what to dol

Example B: Crossed Transaction

FIGURE l0.2 Crossed Transaction

 Chapter 10 ' Gestalt Therapy 217

Example C (Figure 10.3)

Pare/zf to chl/d rfarger ego sfafe). Your desk is a mess. Aren't you ever going to clear off that
junk pile?
.4dzf/f prep/}//zg ego sure) to aduZf.' You know, Idealized the other day that my desk really has
become a mess. I'm planning to clear it off as soon as Ifinish Mis project.

e
Example C

8- -a
FIGURE l0.3 Example C

3. Uberfor traHsacfioms. These transactions take place on two levels of communication simulta-
neously: an overt or social ]eve] and a covert or psycho]ogica] ]eve]. They invo]ve more than
one ego state as a source or target of a communication. Ulterior transactions are the most
problematic: The overt communication is incongruent with the covert communication, and
neither person really knows what is in the mind of the other. A continuing pattem of ulterior
transactions is likely to lead to a dysfunctional relationship or one that is temlinated.

Example D(Person lto Person 2, after Person 2 am'ives home late; Figure 10.4)
Adu/f to ad J/ (overt message).' is it acer ] ip.w. a]ready? ]don't](now where the time went
tonight.
ParCEl ro c/zi/d (covert message): lwant you to know Inoticed that you came in after your
curfew. Don't expect an extended curfew this weekends

Example D: Ulterior Transactions

©!.©
8 --€-©
FIGURE l0.4 Ulterior Transaction
© '©
Example E(Person 2 to Person 1; Figure 10.5)
Adu/f fa adz4lf (oven message): Yes, it is after 11. Excuse me; Inked to read my e-mail.
Chf/d fa parelzf (cove message); There she goes again, ready to give me a hard time because
I came in a few minutes late. I'll go into my room so she won't bother me.
218 Part 3 Treatment Systems Emphasizing Emotions and Sensations

© ''\ (1..!.

a
\\ \

FIGURE l0.5 Example E

'B
The overt transactions in these last examples appear to be complementarytransactions from
adult to adult. However, the covert transactions are actually from parent to child and from child
back to parent, as the thoughts behind the words reflect.

STROKES AND INJUNCTIONS Children's emotional and ego state development is largely deter-
mined by the messages and responses they receive from their caregivers. Beme identified two types of
messages. S/rakes an positive messages and aK best when they are unconditional, whereas Inyzz/lcrfons
(negative strokes) express disapproval and dislike and include criticisms and prohibitions. Positive and
negative strokes may be verba](such as words of praise or criticism) or nonverba](suchas a hug, a slap,
or a lack of eye contact). According to Beme(1961), strokes am the basic motivation for human interac-
tion; and even negative strokes are prefened to no strokes---that is, being ignored and discounted.

BASIC LIFE POSITIONS According to Harris(1967), people develop basic life positions that reflect
the value they perceive in themselves and others. These positions can be identified by the age of 5
(Harris & Brockbank, 2011) and are revealed in people's thoughts, feelings, and behaviors. Harris
(1967) described four possible life positions:
1. /'m ol OK; you 're OXI. ellis position is appropriate for young children who perceive them-
selves as weak and helpless and seek strokes from others who appear powerful and in control.
However, if this position persists, it can cause difficulties. In this position, people typically
feel guilty, depressed, powerless, and inferior to others, although they long for acceptance and
appreciation. They may have a constricted flee child or a rigid adapted child, always follow-
ing the rules in hope of acceptance. On the other hand, they may act out, viewing themselves
as unworthy of positive strokes and preferring negative strokes to none.
2. /'m OX; yoa 're Bof OXI. This position also might characterize people who received few posi-
tive strokes. However, they survived through self-stroking. They grow up believing that they
must rely totally on themselves. They treat others in angry and punitive ways and have a sense
of entitlement and grandiosity. They blame others for their difHiculdes and have little empathy
or caring for others. They may engage in criminal behavior or abuse of others.
3. /'m of OJq yow 're aof OKI. This is the most negative of the four positions. As children, peo-
ple in this position typically were deprived of strokes. Consequently, they become hopeless
and even suicidal, seeing no value in dlemselves or others.
4. /'m OX yo 're OK in this position, people feel good about themselves and others. While
they need stmkes, they can be caring and reciprocate those strokes. Harris viewed this as the
healthiest of the four positions. 'obese people focus on win--win situations and have a good
balance among their ego states.
 Chapter 10 ' Gestalt 'lberapy 219

SCRIPTS According to TA, people develop scripts that guide them through life. 'lbese scripts are
shaped primarily by the intemalized strokes and injunctions that they received as children and
reflect dieir life positions. Scripts lead people to envision their lives a certain way. If life scripts are
based on outdated or erroneous infomiation, faulty life scripts such as psychosis, substance abuse,
or suicide can result(Totton, 2010). TA believes these faulty life scripts were created by people and
can, therefore, be changed.

Treatment Using Transactional Analysis

The goal of TA is not insight into Me unconscious but autonomy. According to Beme(1964), this is
comprised of awareness, spontaneity, and intimacy. In addition, TA helps people move into an "l'm
OK; you're OK" position, achieve balance among their ego states, and make healthy use of their
time
In TA, clinicians assume a flexible role, adapting to the needs of dle clients, while always
conducting sessions &om the adult ego state(Harris & Brockbank, 2011). Collaboration between
clients and clinicians is important. Both participate actively and share responsibility for the treat-
ment. Clinicians provide education on the language and concepts of TA and guide the therapeutic
process. Clients are expected to be open, responsible for themselves, and willing to take risks to
make positive changes. Clinicians are alert to the possibility that the ways in which clients commu-
nicate with them may reflect childhood patterns. Carefully used reparenting is sometimes part of
TA; clinicians take on a reparative role, providing strokes to compensate for a lack of strokes in the
client's childhood.
Contracts me an important component in TA(Muller & Tudor, 2002). They clarify the nature
of the treatment process and aftm the roles and responsibilities of clinicians and clients. TA was
one of the 6nst approaches to use such an agreement to establish a collaborative and effective cli-
ent-clinician relationship.
According to Harris(1967), people are prompted to change when they are hurting or bored or
discover that they can change. The goal is to obtain a clear picture of the following in each client:

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By analyzing and understanding this infomiation, people become more aware of their pattems and
why those pattems developed. This, in tum, frees people to modify patterns and choose healthier
ways of relating to others. It enables them to fomia more positive picture of themselves and of the
people in their lives: "l'm OK; you're OK."

Application of Transactional Analysis

Although it is lacking in an overall theory, as a.tool, TA can be easily combined with other experi-
ential therapies. Tonton(2010) noted that 'TA is inventive, imaginative, observant, eloquent, and
flm"(p. 15) and is easily applied and relevant to the problems people bring to treatment. The com-
bination of TA and Gestalt therapy is particularly efTmtive, with TA emphasizing the cognitive and
analytical aspects of the person and Gestalt drawing in die a#ective parts. Transactional analysis
220 Paa 3 Treatment Systems Emphasizing Emotions and Sensations

has also been integrated with brief psychoanalytic therapy(Mothersole, 2002) and short-term cog-
nitive thempy(Hargaden & Sills, 2002).
TA's combination of systemic and intrapsychic thinking helps couples to differentiate and
has been found to be helpful in working with both high-conflict and conflict-avoidant couples. The
games people play and transactional lingo is so easy to comprehend that it is also being used to help
children and adolescents develop a new way of looking at problems, and for improving the parent--
child relationship (Tudor, 2008; Zadeh, Jenkins, & Pepper, 20 10).
Harris and Brockbank (20 1 1) promote the use of TA in supervision to help supervisees recog-
nize their own ego states, both in their interactions with clients and in supervision. Ideally, the
supervisor relates to supervisees adult to adult, providing feedback in a straightforward and sup-
portive manner. More infomlation on supervision, training programs, family and couples work, and
integrating TA with other finns of treatment is available from the International Tr ansactional
Analysis Association(http://www.itaaworld.org).

APPLICATION AND CURRENT USE OF GESTALT THERAPY

Current trends in Gestalt therapy integrate relational themes, emotion focus, and attachment
theory and the use of experiments in a relational therapy. Clients explore topics of identity,
trauma, childhood abuse, and other developmental bruises that may have shaped their early
years (Finlay & Evans, 2009). Gestalt therapists focus on the relationship and use much more
caring confrontations than was the norm in the 1970s. They help clients to understand the sub-
jective interconnectedness of everything, while also helping them to take responsibility for
their own feelings and actions. Topics such as male identity, women's aggression, and ruptures
in the therapeutic alliance may all be fodder for discussion in the here and now of the therapy
session. For example, the therapist and client might discuss the client's feelings of shame and
guilt that resulted from her parent's overly strict socialization process, how that shame is erupt-
ing in her current relationship with her husband, what triggers it, and how it impacts the ther-
apy session.
Several meta-analytical analyses of Gestalt effectiveness studies found evidence supporting
the use of Gestalt therapy in the treatment of affmtive disorders, personality disorders, and sub-
stance use disorders(Strumpfel, 2006; Smimpfel& Martin, 2004). In addition, research suggests
that the positive treatment results from Gestalt therapy are enduring.

Application to Diagnostic Groups

Case studies in the literature show Gestalt therapy being adapted for treatment of a wide range of
problems that impact emotion regulation including sexual trauma, narcissistic self-hatred, shame,
and aggression(Bloom & Brownell, 2011). Clinicians who work with children and adolescents will
find Gestalt play therapy, as developed by Virginia Oaklander(1994, 1997), to be a highly experi-
ential, existential "here-and-now" philosophy for work with children(Blom, 2006). As mentioned
earlier, Gestalt family therapy combines a systemic perspective with field theory and provides an
integrative and holistic model for couples counseling (O'Neill, 201 2).
Gestalt therapy may be helpful to people with eating disorders including anorexia nervosa
and bulimia nervosa(Angemlann,1998),people with substance use disorders(Clemmens, 2005),
and for people who channel emotional concems into their babes. Such people might be diagnosed
with somatofoml disorders(often called psychosomatic illnesses) in which they report physical
complaints that have no medical basis. Several relatively large-scale research studies have been
 Chapter 10 ' Gestalt Therapy 221

conducted using Gestalt therapy with clients such as these. Results show reductions in both physical
and psychosocial symptoms(Strumpfel& Goldman, 2002).

Application to Multicultural Groups

Because Gestalt therapy views the individual holistically, it is by definition an inclusive approach.
People cannot be understood in isolation, but only within the broader perspective of their historical
and social backgrounds. Thus Gestalt innately attends to "cultural difference, historical background,
and social perspectives"(Mackewn, 1997, p. 51).
When working with people from a variety of cultures, therapists must be careful to select
culturally appropriate interventions that respect non--Western European communication styles.
Traditional Asian or Native American clients may view direct and confrontational forms of
therapy such as Gestalt to be lacking in respect and sensitivity (Duran, 2006). Similarly clients
from cultures that value restraint of strong emotions, unassertiveness, or filial piety, as do
many Asian cultures, are likely to feel uncomfortable or intimidated if the counselor uses role-
plays, behavioral rehearsal, or the Gestalt empty chair technique (Sue & Sue, 2008). Rather
than taking a universal perspective or a one-size-fits-all approach, Sue and Sue recommend
therapists show respect for the client's cultural background and adapt their techniques, inter-
ventions, energy level, and tone of voice to match the client's. Recognizing when Gestalt tech-
niques such as the empty chair or the hot seat should not be used is equally as important as
knowing when to use them.
For example, when working with Asian American clients, using the empty chair technique
can be appropriate if the client is struggling to have a conversation with parents about moving out
of the family home to be independent and suppressing one's own desires and wishes as an expres-
sion of respect and sensitivity to elderly authoritative figures. In comparison, the empty chair tech-
nique may not be suitable for the same client with a higher level of psychological distress when
exploring and confronting feelings from a traumatic incident such as a history of childhood sexual
trauma, causing a strong emotional reaction that is unproductive and hamiful.
Gestalt therapy seems particularly appropriate for treatment with people who have disabili-
ties. It could promote their responsibility for themselves, their self-awareness, and the integration of
their mind and body(Livneh & Sherwood, 1991).
Gestalt therapy is likely to help people who are dealing with issues of grief and of death and
dying because of its emphasis on living life to its fullest in the present. For example, this approach
has been used to treat homosexual men diagnosed with HIV/AIDS who were experiencing symp-
toms of depression(Mulder et al., 1994).
Enns ( 1987) suggested integrating Gestalt and feminist therapy (discussed in Chapter 1 1),
believing that the Gestalt approach could empower women, promote their self-awareness and estab-
lishment of healthy interpersonal boundaries, and facilitate the expression of denied or suppressed
emotions. Gestalt therapy also seems likely to help men who are dealing with gender issues, feel-
ings of powerlessness, and impaired awareness of themselves and their emotions.

Application to Other Groups

Gestalt therapy has been used with low-achieving adolescents and high school students (Strumpfel &
Goldman, 2002); to help middle school students deal with the suicide of a classmate(Alexander
& Harman, 1988); and to help pregnant women prepare for the birth of their childKn. Gestalt therapy's
present orientation, as well as its use of powerful exercises, can quickly bring all aspwts of an issue
222 Part 3 Treatment Systems Emphasizing Emotions and Sensations

into awareness and encourage closum as well as growth. Used skillfully, and adapted to the needs of a
particular client or group, the range of this approach is almost unlimited.

Current Use of Gestalt Therapy

Bowman(2012) speaks of the growth of Gestalt therapy during the past 20 years as nothing short of
a Renaissance. He attributes ellis resurgence in Gestalt popularity to the fact that Gestalt therapists
have become even more aware of the importance of the client-clinician relationship and strive to
establish a true l--thou collaborative relationship rather than adopting the charismatic and powerful
role modeled by Fritz Perls. At the same time, they have de-emphasized pathology and reduced reli-
ance on techniques.
Gestalt therapy is flexible enough to be easily integrated with a broad range of other treatment
systems. The empty chair and two-chair dialogues of Gestalt therapy as well as other strategies also
have been integrated into new process-experiential therapies discussed earlier in Chapter 8. The
Gestalt approach to dreamwork, as well as the use of role-plays, continues to play a prominent part
in treatment.
Gestalt therapy is actively evolving through the work of many practitioners and at more than 60
Gestalt therapy institutes around the world(Wagner-Moon, 2004). Although Fritz Peels was the
embaliment of Gestalt therapy during his lifetime, his ideas have attmcted many followers and live on.

EVALUATION OF GESTALT THERAPY

Like other treatment approaches, Gestalt therapy has both strengths and limitations. Because of its
powerful nature, clinicians need to be particularly aware of its limitations and appropriate use.

Limitations
Gestalt techniques are not for everybody. 'lthey can be powerful motivators for change, or have
limited applicability, especially with people who have severe cognitive disorders or impulse control
disorders--acting out, delinquency, and explosive disorders --or with people who have sociopathic
or psychotic symptoms(Saltzman, 1989). Gestalt techniques may even cause hama if not used care-
fully(Wagner-Moore, 2004). Other criticisms of the therapy include that it focuses too much on felt
bodily sensations and not enough on cognitions, and that getting in touch with intemal polarities to
relieve emotional problems sounds too much like blaming the victim. Due to its emphasis on self-
regulation, people who come from collectivist cultural backgrounds and those who are uncomfort-
able putting themselves Hast may have difficulty with the "l-ness" instead of "we-ness" of Gestalt
therapy (Prochaska & Norcross, 2009, p. 1 97).
Polster and Polster(1993) addressed other possible shortcomings, expressing concem about
the risk of oversimplification as well as of neglecting important past concems in the service of pro-
moting immediacy. They also speculated that some clinicians might be more concemed with repli-
cating the charismatic style of Fritz Perls than minding their own way to use this approach and really
understanding its underlying theory and philosophy. Gestalt therapy also runs the risk of overem-
phasizing emotions and ignoring cognitions, which most clinicians now view as important detemii-
nants of emotions and vehicles for modifying feelings.
In addition, Gestalt therapy tends to evoke strong emotional reactions. In one group ther-
apy session, a woman in the hot seat became so anxious that she lost control of her bladder.
which led her to experience shame and social withdrawal. Thus, just as this approach has the
power to do good, it also has the power to do harm. lts strategies are appealing and may seem
 Chapter 10 ' Gestalt Therapy 223

deceptively simple, but in reality they require a skilled and experienced clinician who can deter-
mine their appropriate use, guide people through the treatment process, and protect them. This is
more likely to happen if clinicians do not take on the powerful role embodied by Fritz Peres but,
instead, temper that role with support, education, exploration of cognitions, and recognition of
the importance of culture and background(Stoehr, 2009). In addition, combining Gestalt strate-
gies with those from other approaches, including process-experiential and cognitive-behavioral
therapy, reduces the risk of overemphasizing emotions and creates a more supportive treatment
environment.

Strengths and Contributions

Despite these limitations, Gestalt therapy has many strengths. Studies on the impact of the empty
chair and two-chair experiences have been particularly positive. In one study, when compared to
empathic responses, the two-chair technique resulted in greater depth of experience and greater
awareness than the empathic techniques(Greenberg,Elliott, & Lietaer, 1994; Strumpfe1, 2006).
The two-chair technique has also been empirically validated for reducing marital conflict, indeci-
sion, conflict splits, and other interpersonal difHlculties(Suumpfel& Martin, 2004; Wagner-Moore,
2004). When reseuch compares Gestalt therapy to cognitive-behavioral therapy, the two have
comparable positive outcomes. In two large studies of Gestalt therapy, 73%u of the clients showed "a
strong to mid-range improvement in the symptoms and problems that led them to seek therapy; only
5qu suffered a worsening in their symptoms. . . . Ninety percent of all clients reported that they had
teamed strategies in Gestalt therapy with which to successfully combat any reappearing symptoms"
(Smimpfel& Goldman, 2002, p. 204). One comparison of cognitive, Gestalt, and supportive, self-
directed psychologies for depression found dial all treatments were effective, and that Gestalt ther-
apy tends to work best with clients who have low resistance, are overly socialized, and are
intemalizing(Beutler, Consoli, & Lane, 2005).
The flexibility of Gestalt therapy is one of its strengths, making it naturally integrative. It
has been successfully combined with other treatment approaches including transactional analysis,
cognitive--behavioral therapy, person-centered therapy, mindfulness meditation, and brief ther-
apy. A manualized approach to Gestalt therapy has been developed and is used for research as
well as practice.
Gestalt therapy is a philosophy of life, growth, and change and also provides specific ways
to help people realize that growth. It respects the individual and adapts o.eatment to the needs of
each person. lts emphasis on process and the client-clinician relationship is consistent with cur-
rent understandings of how counseling and psychotherapy effect change. Gestalt therapy is a
compassionate approach that can empower people and enable them to have more joy and fulfill-
ment in their lives.
Gestalt therapy has made many contributions to counseling and psychotherapy. The concepts
of field theory, of immediacy and wholeness, and the importance of mind-body integration are
particularly important and have been assimilated into other theoretical systems(Woldt & Toman,
2005). Similarly, many innovative strategies, including the empty chair, die emphasis on nonverbal
messages, Perls's approach to processing dreams, and "l" statements, have achieved wide accept-
ance. Chair work has been so well accepted that many forget its Gestalt origins. The Gestalt
approach to dreamwork has become an often-used and powerful altemative to psychoanalytic dream
interpretation. In addition, the work of Gestalt therapists, along with that of the person-centered and
existential theorists, established the importance of phenomenological, experiential, and humanistic
approaches to Ueatment as well as the realization that the therapeutic alliance is probably the most
important element in successful therapy.
270 C HAP TE R T EN

Introduction
As you saw in Chapter 9, traditional behavior therapy has broadened and LO1
largely moved in the direction of cognitive behavior therapy. Several of the more
prominent cognitive behavioral approaches are featured in this chapter, including
Albert Ellis’s rational emotive behavior therapy (REBT), Aaron T. Beck and Judith
Beck’s cognitive therapy (CT), Christine Padesky’s strengths-based CBT (SB-CBT),
and Donald Meichenbaum’s cognitive behavior therapy. These approaches all fall
under the general umbrella of cognitive behavior therapies (CBT).
All of the cognitive behavioral approaches share the same basic characteristics
and assumptions as traditional behavior therapy (see Chapter 9). Although the
approaches are quite diverse, they do share these attributes: (1) a collaborative rela-
tionship between client and therapist, (2) the premise that psychological distress
is often maintained by cognitive processes, (3) a focus on changing cognitions to
produce desired changes in affect and behavior, (4) a present-centered, time-limited
focus, (5) an active and directive stance by the therapist, and (6) an educational
treatment focusing on specific and structured target problems (A. Beck & Weishaar,
2014). In addition, both cognitive therapy and the cognitive behavioral therapies
are based on a structured psychoeducational model, make use of homework, place
responsibility on the client to assume an active role both during and outside ther-
apy sessions, emphasize developing a strong therapeutic alliance, and draw from
a variety of cognitive and behavioral strategies to bring about change. Therapists
help clients examine how they understand themselves and their world and suggest
ways clients can experiment with new ways of behaving (Dienes, Torres-Harding,
Reinecke, Freeman, & Sauer, 2011).
To a large degree, both cognitive therapy and cognitive behavior therapy are based
on the assumption that beliefs, behaviors, emotions, and physical reactions are all
reciprocally linked. Changes in one area lead to changes in the other areas. A change
in beliefs is not the only target of therapy, but enduring changes usually require a
change in beliefs. CBT therapists apply behavioral techniques such as operant condi-
tioning, modeling, and behavioral rehearsal to the more subjective processes of think-
ing and internal dialogue. In addition, therapists help clients actively test their beliefs
in therapy, on paper, and through behavioral experiments. Cognitive therapy and the
cognitive behavioral approaches include a variety of behavioral strategies (discussed in
Chapter 9) as well as cognitive strategies as a part of their integrative repertoire.

Visit CengageBrain.com or watch the DVD video program on Chapter 10, Theory and Practice
of Counseling and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you view the brief
lecture for each chapter prior to reading the chapter.

Albert Ellis’s Rational Emotive Behavior Therapy

Introduction
Rational emotive behavior therapy (REBT) was the first of the cognitive behav-
ior therapies, and today it continues to be a major cognitive behavioral approach.
REBT has a great deal in common with the therapies that are oriented toward
 C O G N I T I V E B EH AV I O R T H ERAP Y 271

ALBERT ELLIS (1913–2007) was born in adolescence he was extremely shy around
Pittsburgh but escaped to the wilds of young women. At age 19 he forced him-
New York at the age of 4 and lived there self to talk to 100 different women in the
(except for a year in New Jersey) for the Bronx Botanical Gardens over a period of

Photo Courtesy of Albert Ellis Institute

rest of his life. He was hospitalized nine one month. Although he never managed
times as a child, mainly with nephritis, to get a date from these brief encounters,
and developed renal glycosuria at the he does report that he desensitized himself
age of 19 and diabetes at the age of 40. to his fear of rejection by women. By apply-
Despite his many physical challenges, ing rational and behavioral methods, he
he lived an unusually robust, active, and managed to conquer some of his strongest
energetic life until his death at age 93. emotional blocks (A. Ellis, 1994, 1997).
As he put it, “I am busy spreading the Albert Ellis People who heard Ellis lecture often
gospel according to St. Albert.” commented on his abrasive, humorous,
Realizing that he could counsel people skillfully and flamboyant style. In his workshops it seemed
and that he greatly enjoyed doing so, Ellis decided to that he took delight in giving vent to his eccentric
become a psychologist. Believing psychoanalysis to be side, such as peppering his speech with four-letter
the deepest form of psychotherapy, Ellis was analyzed words. He greatly enjoyed his work and teaching
and supervised by a training analyst. He then practiced REBT, which was his passion and primary commit-
psychoanalytically oriented psychotherapy, but even- ment in life. He gave workshops wherever he went
tually he became disillusioned with the slow progress in his travels and had proclaimed, “I wouldn’t go to
of his clients. He observed that they improved more the Taj Mahal unless they asked me to do a work-
quickly once they changed their ways of thinking shop there!”
about themselves and their problems. Early in 1955 Ellis married Australian psychologist Debbie
he developed an approach to psychotherapy he called Joffe in November 2004, whom he has called “the
rational therapy and later rational emotive therapy, greatest love of my life” (A. Ellis, 2008). They shared
and which is now known as rational emotive behavior the same life goals and ideals, and they worked as
therapy (REBT). Ellis has rightly been referred to as a team presenting workshops. If you are interested
the grandfather of cognitive behavior therapy. in learning more about the life and work of Albert
To some extent Ellis developed his approach as Ellis, I recommend two of his books: Rational Emo-
a method of dealing with his own problems during tive Behavior Therapy: It Works for Me—It Can Work for
his youth. At one point in his life, for example, he had You (A. Ellis, 2004a) and All Out! An Autobiography
exaggerated fears of speaking in public. During his (A. Ellis, 2010).

cognition and behavior as it also emphasizes thinking, assessing, deciding, analyz-

ing, and doing. A basic assumption of REBT is that people contribute to their own
psychological problems, as well as to specific symptoms, by the rigid and extreme
beliefs they hold about events and situations. REBT is based on the assumption
that cognitions, emotions, and behaviors interact significantly and have a reciprocal
cause-and-effect relationship. REBT has consistently emphasized all three of these
modalities and their interactions, thus qualifying it as a holistic and integrative
approach (A. Ellis & Ellis, 2011, 2014; D. Ellis, 2014).
Although REBT is generally conceded to be the parent of today’s cognitive
behavioral approaches, it was preceded by earlier schools of thought. Ellis gave credit
to Alfred Adler as an influential precursor of REBT, and Karen Horney’s (1950) ideas
on the “tyranny of the shoulds” are apparent in the conceptual framework of REBT.
Ellis also acknowledged his debt to some of the Eastern philosophies and the ancient
Greeks, especially the Stoic philosopher Epictetus, who said around 2,000 years ago:
272 C HAP TE R T EN

“People are disturbed not by events, but by the views which they take of them”
(as cited in A. Ellis, 2001a, p. 16). Ellis’s reformulation of Epictetus’s dictum can be
stated as, “People disturb themselves as a result of the rigid and extreme beliefs they
hold about events more than the events themselves.”
REBT’s basic hypothesis is that our emotions are mainly created from our
beliefs, which influence the evaluations and interpretations we make and fuel
the reactions we have to life situations. Through the therapeutic process, cli-
ents are taught skills that give them the tools to identify and dispute irrational
beliefs that have been acquired and self-constructed and are now maintained by
self-indoctrination. They learn how to replace such detrimental ways of think-
ing with effective and rational cognitions, and as a result they change their
emotional experience and their reactions to situations. The therapeutic process
allows clients to apply REBT principles for change not only to a particular pre-
senting problem but also to many other problems in life or future problems they
might encounter.
A large part of the therapy is seen as an educational process. The therapist func-
tions in many ways like teacher, collaborating with the client on homework assign-
ments and introducing strategies for constructive thinking. The client is the learner
who then practices these new skills in everyday life.

Key Concepts
View of Emotional Disturbance
REBT is based on the premise that we learn irrational beliefs from significant others
during childhood and then re-create these irrational beliefs throughout our life-
time. We actively reinforce our self-defeating beliefs through the processes of auto-
suggestion and self-repetition, and we then behave in ways that are consistent with
these beliefs. Hence, it is largely our own repetition of early-indoctrinated irrational
beliefs, rather than a parent’s repetition, that keeps dysfunctional attitudes alive
and operative within us.
Ellis asserted that blame can be at the core of many emotional disturbances. If
we want to become psychologically healthy, we had better stop blaming ourselves
and others and learn to fully and unconditionally accept ourselves despite our
imperfections. Ellis (A. Ellis & Blau, 1998; A. Ellis & Harper, 1997; A. Ellis & Ellis,
2011) hypothesizes that we have strong tendencies to transform our desires and
preferences into dogmatic “shoulds,” “musts,” “oughts,” demands, and commands.
When we are feeling disturbed, it is a good idea to look to our hidden dogmatic
“musts” and absolutist “shoulds.” Such demands create disruptive feelings and dys-
functional behaviors (A. Ellis, 2001a, 2004a).
Here are three basics musts (or irrational beliefs) we internalize that inevitably lead
to self-defeat (A. Ellis & Ellis, 2011):
1. “I must do well and be loved and approved by others.”
2. “Other people must treat me fairly, kindly, and well.”
3. “The world and my living conditions must be comfortable, gratifying,
and just, providing me with all that I want in life.”
 C O G N I T I V E B EH AV I O R T H ERAP Y 273

We have a strong tendency to make and keep ourselves emotionally disturbed by

internalizing and perpetuating self-defeating beliefs such as these, which is one
reason it is a real challenge to achieve and maintain good psychological health
(A. Ellis, 2001a, 2001b).

A-B-C Framework
The A-B-C framework is central to REBT theory and practice. This model LO2
provides a useful tool for understanding the client’s feelings, thoughts, events, and
behavior (A. Ellis & Ellis, 2011). A is the existence of an activating event or adversity, or
an inference about an event by an individual. C is the emotional and behavioral conse-
quence or reaction of the individual; the reaction can be either healthy or unhealthy. A
(the activating event) does not cause C (the emotional consequence). Instead, B, which
is the person’s belief about A, largely creates C, the emotional reaction.
If a person experiences depression after a divorce, for example, it may not be
the divorce itself that causes the depressive reaction, nor his inference that he has
failed, but the person’s beliefs about his divorce or about his failure (D. Ellis, 2014).
Ellis maintains that the beliefs about the rejection and failure (at point B) are what
mainly cause the depression (at point C)—not the actual event of the divorce or the
person’s inference of failure (at point A). Believing that human beings are largely
responsible for creating their own emotional reactions and disturbances, and show-
ing people how they can change their irrational beliefs that directly “cause” their
disturbed emotional consequences, is at the heart of REBT (A. Ellis & Ellis, 2011; A.
Ellis & Harper, 1997).
After A, B, and C comes D (disputing). Essentially, D encompasses methods that
help clients challenge their irrational beliefs. There are three components of this dis-
puting process: detecting, debating, and discriminating. Clients learn to discriminate
irrational (self-defeating) beliefs from rational (self-helping) beliefs (A. Ellis & Ellis,
2011). Once they can detect irrational beliefs, particularly absolutistic “shoulds” and
“musts,” “awfulizing,” and “self-downing,” clients debate dysfunctional beliefs by
logically, empirically, and pragmatically questioning them. Clients are asked to vig-
orously argue themselves out of believing and acting on irrational beliefs. Although
REBT uses many other cognitive, emotive, and behavioral methods to help clients
minimize their irrational beliefs, it emphasizes the process of vigorously disputing
(D) such beliefs both during therapy sessions and in everyday life. Following that,
clients are encouraged to develop E, a new effective philosophy, which also has a
practical side. A new and effective belief system consists of replacing unhealthy irra-
tional thoughts with healthy rational ones. “Homework” can enhance and maintain
these therapeutic gains and personal insights.

The Therapeutic Process

Therapeutic Goals
The many roads taken in rational emotive behavior therapy lead toward the destina-
tion of clients minimizing their emotional disturbances and self-defeating behav-
iors by acquiring a more realistic, workable, and compassionate philosophy of life.
274 C HAP TE R T EN

The therapeutic process of REBT involves a collaborative effort between therapist

and client to choose realistic and life-enhancing therapeutic goals. The therapist’s
task is to help clients differentiate between realistic and unrealistic goals and also
between self-defeating and life-enhancing goals. A basic aim is to teach clients how
to change their dysfunctional emotions and behaviors into healthy ones. According
to Ellis and Ellis (2011) another goal of REBT is to assist clients in the process of
achieving unconditional self-acceptance (USA), unconditional other-acceptance (UOA), and
unconditional life-acceptance (ULA). As clients become more able to accept themselves,
they are more likely to unconditionally accept others and to accept life as it is. A
famous saying of Ellis (A. Ellis & Ellis, 2011) is: “Life has inevitable suffering as well
as pleasure. By realistically thinking, feeling, and acting to enjoy what you can, and
unangrily and unwhiningly accepting painful aspects that cannot be changed, you
open yourself to much joy” (p. 48).

Therapist’s Function and Role

The therapist has specific tasks, and the first step is to show clients how they have
incorporated many irrational absolute “shoulds,” “oughts,” and “musts” into their
thinking. The therapist disputes clients’ irrational beliefs and encourages clients to
engage in activities that will counter their self-defeating beliefs by replacing their
rigid “musts” with preferences.
A second step in the therapeutic process is to demonstrate how clients are keep-
ing their emotional disturbances active by continuing to think illogically and unre-
alistically. In other words, when clients keep reindoctrinating themselves, they create
their own psychological problems. Ellis reminds us that we are responsible for our
own emotional destiny (A. Ellis, 2004b, 2010).
To get beyond mere recognition of irrational thoughts, the therapist takes a
third step—helping clients change their thinking and minimize their irrational ideas.
Although it may be unlikely that we can entirely eliminate the tendency to think irra-
tionally, we can make ongoing efforts to reduce the frequency of such thinking. The
therapist encourages clients to identify the irrational beliefs they have unquestion-
ingly accepted, demonstrates how they are continuing to indoctrinate themselves
with these beliefs, and reminds them that change is possible with persistent effort.
The fourth step in the therapeutic process is to strongly encourage clients to
develop a rational philosophy of life so that in the future they can avoid hurting
themselves again by believing other irrational beliefs. Tackling only specific prob-
lems or symptoms can give no assurance that new disabling fears will not emerge.
It is desirable, then, for the therapist to dispute the core irrational thinking and to
teach clients how to substitute rational beliefs and healthy behaviors for irrational
beliefs and self-defeating behaviors.

Client’s Experience in Therapy

The therapeutic process largely focuses on clients’ experiences in the present. Like
the person-centered and existential approaches to therapy, REBT emphasizes here-
and-now experiences and clients’ present ability to change the patterns of think-
ing and emoting that they constructed earlier. The therapist may not devote much
time to exploring clients’ early history and making connections between their past
 C O G N I T I V E B EH AV I O R T H ERAP Y 275

and present behavior unless doing so will aid the therapeutic process. REBT differs
from many other therapeutic approaches in that it does not place much value on
free association, working with dreams, or dealing with transference phenomena.
Ellis and Ellis (2014) maintain that transference is not encouraged, and when it
does occur, the therapist is likely to confront it because it is generally based on the
client’s dire need to be liked and approved of by the therapist. Any unhealthy needi-
ness clients display can be counterproductive and foster dependence on approval
from the therapist.
Clients are encouraged to actively work outside therapy sessions. By carrying out
behavioral homework assignments, clients become increasingly proficient at mini-
mizing irrational thinking and disturbances in feeling and behaving. Homework
is carefully designed and agreed upon and is aimed at getting clients to carry out
productive actions that contribute to emotional and attitudinal change. These
assignments are checked in later sessions, and clients continue to focus on learning
effective ways to dispute self-defeating thinking. Toward the end of therapy, clients
review their progress, make plans, and identify strategies to prevent, or cope with,
any new challenges as they arise.

Relationship Between Therapist and Client

Because REBT is a cognitive and directive behavioral process, a warm relation-
ship between therapist and client is not required, but it may enhance the process
for some. At the very least, a respectful relationship is recommended. As with the
person-centered therapy of Rogers, REBT practitioners strive to unconditionally
accept all clients and to teach them to unconditionally accept others and them-
selves. The therapist takes the mystery out of the therapeutic process, teaching
clients about the cognitive hypothesis of disturbance and helping clients under-
stand how they are continuing to sabotage themselves and what they can do to
change. Insight alone does not typically lead to psychotherapeutic change, action
is also required. The therapist frequently acknowledges any progress clients have
made due to their own efforts. REBT practitioners accept their clients (and them-
selves!) as imperfect beings who can be helped through a variety of techniques
including teaching, bibliotherapy, and behavior modification (A. Ellis & Ellis,
2011, 2014; D. Ellis, 2014).

Application: Therapeutic Techniques and Procedures

The Practice of Rational Emotive Behavior Therapy
Rational emotive behavior therapists are multimodal and integrative. REBT prac-
titioners use a number of different modalities (cognitive, emotive, behavioral, and
interpersonal) to dispel self-defeating cognitions and to teach people how to acquire
a rational approach to living. Therapists are encouraged to be flexible and creative
in their use of methods, making sure to tailor the techniques to the unique needs of
each client (A. Ellis & Ellis, 2011; D. Ellis, 2014).
For a concrete illustration of how Dr. Ellis works with the client Ruth drawing
from cognitive, emotive, and behavioral techniques, see Case Approach to Counseling
276 C HAP TE R T EN

and Psychotherapy (Corey, 2013, chap. 8). What follows is a brief summary of the
major cognitive, emotive, and behavioral techniques Ellis describes (A. Ellis, 2004a;
A. Ellis & Crawford, 2000; A. Ellis & Ellis, 2011).

Cognitive Methods REBT practitioners usually incorporate a persuasive LO3

cognitive methodology in the therapeutic process. They demonstrate to clients, often
in a quick and direct manner, what it is that they are continuing to tell themselves.
Then they teach clients how to challenge these self-statements so that they no longer
believe them, encouraging them to acquire a philosophy based on facts. REBT relies
heavily on thinking, disputing, debating, challenging, interpreting, explaining, and
teaching. The most efficient way to bring about lasting emotional and behavioral
change is for clients to change their way of thinking (A. Ellis & Ellis, 2011, 2014).
Here are some cognitive techniques available to the therapist.

ŠDisputing irrational beliefs. The most common cognitive method of REBT

consists of the therapist actively disputing clients’ irrational beliefs and
teaching them how to do this challenging on their own. Clients dispute
a particular “must,” absolute “should,” or “ought” until they no longer
hold that irrational belief, or at least until it is diminished in strength.
Here are some examples of questions or statements clients learn to tell
themselves when they dispute their irrational ideas: “Why must people
treat me fairly?” “How do I become a total flop if I don’t succeed at
important tasks I try?” “If I don’t get the job I want, it may be disap-
pointing, but I can certainly stand it.” “If life doesn’t always go the way
I would like it to, it isn’t awful, just inconvenient.”
ŠDoing cognitive homework. REBT clients are expected to make lists of their
problems, look for their absolutist beliefs, and dispute these beliefs.
Clients are encouraged to record and think about how their beliefs
contribute to their personal problems and are asked to work hard at
uprooting these self-defeating cognitions. Homework assignments are a
way of tracking down and attending to the “shoulds” and “musts” that
are part of their internalized self-messages. In this way, clients gradu-
ally learn to lessen anxiety and to challenge basic irrational thinking.
They often fill out the REBT Self-Help Form, which is reproduced in
the Student Manual for Theory and Practice of Counseling and Psychotherapy
(Corey, 2017). Their comments on this form can focus therapy sessions
as they critically evaluate the disputation of their beliefs. Clients may be
encouraged to put themselves in risk-taking situations that will allow
them to challenge self-limiting beliefs. For example, a client with a tal-
ent for acting who is afraid to act in front of an audience because of fear
of failure may be asked to take a small part in a stage play. Work in the
therapy session can be designed so that out-of-session tasks are feasible
and the client has the skills to complete these tasks. Making changes
tends to be hard work. Doing work outside sessions is of real value in
revising clients’ thinking, feeling, and behaving.
ŠBibliotherapy. REBT, and other CBT approaches, can utilize biblio-
therapy as an adjunctive form of treatment. There are advantages of
 C O G N I T I V E B EH AV I O R T H ERAP Y 277

bibliotherapy, such as cost-effectiveness, widespread availability, and the

potential of reaching a broad spectrum of populations. Bibliotherapeu-
tic approaches have empirical support for a range of clinical problems,
including the treatment of depression and many anxiety disorders
(Jacobs, 2008). Because therapy is seen as an educational process, clients
are encouraged to read REBT self-help books such as Rational Emotive
Behavior Therapy: It Works for Me—It Can Work for You (A. Ellis, 2004a) and
other books by Ellis (1999, 2000, 2001a, 2001b, 2005, 2010; A. Ellis &
Ellis, 2011).
ŠChanging one’s language. REBT rests on the premise that imprecise lan-
guage is one of the causes of distorted thinking processes. Clients
learn that “musts,” “oughts,” and absolute “shoulds” can be replaced
by preferences. Instead of saying “It would be absolutely awful if …” they
learn to say “It would be inconvenient if …” Clients who use language
patterns that reflect helplessness and self-condemnation can learn to
employ new self-statements, which help them think and behave differ-
ently. As a consequence, they also begin to feel differently.
ŠPsychoeducational methods. REBT programs introduce clients to various edu-
cational materials such as books, DVDs, and articles. Therapists educate
clients about the nature of their problems and how treatment is likely to
proceed. They ask clients how particular concepts apply to them. Clients
are more likely to cooperate with a treatment program if they understand
how the therapy process works and if they understand why particular
techniques are being used (Ledley, Marx, & Heimberg, 2010).

Emotive Techniques REBT practitioners use a variety of emotive procedures,

including unconditional acceptance, rational emotive role playing, modeling,
rational emotive imagery, and shame-attacking exercises. These emotive techniques
tend to be vivid and evocative in nature, and their purpose is to dispute clients’
irrational beliefs. These strategies are used both during the therapy sessions and
as homework assignments in daily life. Their purpose is not simply to provide a
cathartic experience but to help clients change some of their thoughts, emotions,
and behaviors (A. Ellis, 2001b; A. Ellis & Ellis, 2011). Let’s look at some of these
evocative and emotive therapeutic techniques in more detail.
ŠRational emotive imagery. This is a form of intense mental practice
designed to establish new emotional patterns in place of disrup-
tive ones by thinking in healthy ways (see A. Ellis, 2001a, 2001b).
In rational emotive imagery (REI), clients are asked to vividly
imagine one of the worst things that might happen to them and to
describe their disturbing feelings. Clients are shown how to train
themselves to develop healthy emotions, and as their feelings about
adversities change, they stand a better chance of changing their
behavior in the situation. This technique can be usefully applied to
interpersonal and other situations that are problematic for the indi-
vidual. Clients who practice rational emotive imagery several times
a week for a few weeks may reach the point where they no longer
278 C HAP TE R T EN

feel upset over these negative events (A. Ellis, 2001a; A. Ellis & Ellis,
2011; D. Ellis, 2014).
ŠHumor. Ellis contends that emotional disturbances often result from
taking oneself too seriously. He wrote hundreds of “Rational Humor-
ous Songs” (A. Ellis, 2005) and often led attendees at his workshops
in singing them. One appealing aspect of REBT is that it fosters the
development of a better sense of humor and helps put life into healthy
perspective (A. Ellis 2004a, 2010). Humor has both cognitive and
emotional benefits in bringing about change. Humor shows the absur-
dity of certain ideas that clients steadfastly maintain, and it teaches
clients to laugh—not at themselves but at their self-defeating ways of
thinking.
ŠRole playing. Role playing has emotive, cognitive, and behavioral com-
ponents. The therapist may interrupt to show clients what they are
telling themselves to create their disturbances and what they can do to
change unhealthy feelings to healthy ones. Clients can rehearse certain
roles to bring out what they feel in a situation. For example, Dawson
may put off applying to a graduate school because he is afraid he won’t
be accepted. Just the thought of not being accepted to the school of
his choice brings out intense feelings of shame for “being stupid.” The
focus is on working through underlying irrational beliefs related to his
unpleasant feelings. Dawson role-plays an interview with the dean of
graduate students, notes his anxiety and the specific beliefs leading to
it, and challenges his conviction that he absolutely must be accepted
and that not gaining such acceptance means that he is a stupid and
incompetent person.
ŠShame-attacking exercises. Ellis developed exercises to help people reduce
shame and anxiety over behaving in certain ways. He asserts that we
can stubbornly refuse to feel ashamed by telling ourselves that it is
not catastrophic if someone thinks we are foolish. Practicing shame-
attacking exercises can reduce, minimize, and prevent feelings of
shame, guilt, anxiety, and depression (A. Ellis, 1999, 2000, 2001a,
2001b, 2005, 2010; A. Ellis & Ellis, 2011, 2014). The exercises are aimed
at increasing self-acceptance and mature responsibility, as well as
helping clients see that much of what they think of as being shameful
has to do with the way they define reality for themselves. Clients may
take the risk of doing something that they are ordinarily afraid to do
because of what others might think. Through homework practice, cli-
ents eventually learn that they can choose not to let others’ reactions
or possible disapproval stop them from doing the things they would
like to do. For example, clients may wear “loud” clothes designed to
attract attention, sing loudly, ask a silly question at a lecture, or ask
for a left-handed monkey wrench in a grocery store. By carrying out
such assignments, clients are likely to find out that other people are
not really that interested in their behavior. Note that these exercises do
not involve illegal activities or acts that will be harmful to oneself, to
others, or that will unduly alarm other people!
 C O G N I T I V E B EH AV I O R T H ERAP Y 279

Behavioral Techniques REBT practitioners use most of the standard behavior

therapy procedures, especially operant conditioning, self-management principles,
systematic desensitization, relaxation techniques, and modeling. Behavioral homework
assignments carried out in real-life situations are particularly important. These
assignments are done systematically and are recorded and analyzed. Homework gives
clients opportunities to practice new skills outside of the therapy session, which may
be even more valuable for clients than work done during the therapy hour (Ledley et al.,
2010). Doing homework may involve in-vivo desensitization (A. Ellis & Ellis, 2011) and
live exposure in daily life situations. Clients actually do new and difficult things, and in
this way they put their insights to use in the form of concrete action. Acting differently
helps them incorporate functional beliefs.

Applications of REBT as a Brief Therapy

Ellis originally developed REBT to try to make psychotherapy more efficient than
other systems of therapy. He maintained that the best and most effective therapy
quickly teaches clients how to tackle present as well as future problems. REBT is
well suited as a brief form of therapy, whether it is applied to individuals, groups,
couples, or families. Clients learn self-therapy techniques that they can continue to
apply through their own ongoing work and practice (A. Ellis & Ellis, 2011).

Application to Group Counseling

Cognitive behavior therapy (CBT) groups are among the most popular treatments
in clinics and community agency settings. One of the most common CBT group
approaches is based on REBT principles and techniques. REBT practitioners employ
an active role in encouraging members to commit themselves to practicing what
they are learning in the group sessions in everyday life. What goes on during the
group is valuable, but therapists know that consistent work between group sessions
and after a group ends is crucial. The group context provides members with tools
they can use to become self-reliant and to accept themselves, and others, uncondi-
tionally as they encounter new problems in daily living.
In group therapy, members are taught how to apply REBT principles to one
another. Ellis recommends that some clients experience group therapy as well
as individual therapy. Group members (1) learn how their beliefs influence what
they feel and what they do, (2) explore ways to change self-defeating thoughts in
various concrete situations, and (3) learn to minimize symptoms through a pro-
found change in their philosophy. Ellis and Ellis (2011, 2014) contend that group
REBT is frequently the treatment of choice because it affords many opportunities
to practice assertiveness skills, to take risks by practicing different behaviors, to
challenge self-defeating thinking, to learn from the experiences of others, and to
interact therapeutically and socially with each other in after-group sessions. All of
the cognitive, emotive, and behavioral techniques described earlier are applicable to
group counseling as are the techniques covered in Chapter 9 on behavior therapy.
Behavioral homework and skills training are just two useful methods for a group
format. For a more detailed discussion of REBT applied to group counseling, see
Corey (2016, chap. 14).
280 C HAP TE R T EN

AARON TEMKIN BECK (b. 1921) was is the founder of cognitive therapy (CT),

Courtesy of Beck Institute for Cognitive Behavior Therapy,

born in Providence, Rhode Island. His one of the most influential and empirically
childhood, although happy, was inter- validated approaches to psychotherapy. He
rupted by a life-threatening illness when has won nearly every national and interna-
he was 8 years old. As a consequence, tional prize for his scientific contributions
he experienced blood injury fears, fear to psychotherapy and suicide research and
of suffocation, and anxiety about his was even short-listed for the Nobel Prize in
health. Beck used his personal problems medicine.

Bala Cynwyd, PA.

as a basis for understanding others and Beck joined the Department of Psy-
for developing his cognitive theory. chiatry of the University of Pennsylvania
A graduate of Brown University and in 1954, where he currently holds the posi-
Yale School of Medicine, Beck initially was Aaron T. Beck tion of University Professor (Emeritus) of
trained as a neurologist, but he switched Psychiatry. Beck has successfully applied
to psychiatry during his residency. Beck attempted to cognitive therapy to depression, generalized anxiety
validate Freud’s theory of depression, but the results of and panic disorders, suicide, alcoholism and drug
his research did not support Freud’s motivational model abuse, eating disorders, marital and relationship prob-
and the explanation of depression as “anger turned lems, psychotic disorders, and personality disorders.
inward.” Beck set out to develop a model for depression He has developed assessment scales for depression,
that fit with his empirical findings, and for many years suicide risk, anxiety, self-concept, and personality.
Beck endured isolation from and rejection by most of He is the founder of the Beck Institute, which is
his colleagues in the psychiatric community. Through a research and training center directed by one of his
his research, Beck developed a cognitive theory of depres- four children, Dr. Judith Beck. He has nine grand-
sion, which represented a new and comprehensive con- children and five great-grandchildren and has been
ceptualization. He found the cognitions of depressed married for more than 60 years. To his credit, Aaron
individuals were characterized by errors in interpretation Beck has focused on developing the cognitive therapy
that he called “cognitive distortions.” For Beck, negative skills of tens of thousands of clinicians throughout
thoughts reflect underlying dysfunctional beliefs and the world. In turn, many of them have established
assumptions. When these beliefs are triggered by situ- their own cognitive therapy centers. Beck has a vision
ational events, a depressive pattern is put in motion. Beck for the cognitive therapy community that is global,
believes clients can assume an active role in modifying inclusive, collaborative, empowering, and benevolent.
their dysfunctional thinking and thereby gain relief from He continues to remain active in writing and research
a range of psychiatric conditions. His continuous research and has published 24 books and more than 600 arti-
in the areas of psychopathology and the utility of cogni- cles and book chapters. For more on the life of Aaron
tive therapy eventually earned him a place of prominence T. Beck, see Aaron T. Beck (Weishaar, 1993) or “Aaron
in the scientific community in the United States. Beck T. Beck: Mind, Man and Mentor” (Padesky, 2004).

JUDITH S. BECK (b. 1954) was born Her ability to break down complex sub-
Courtesy of Beck Institute for Cognitive Behavior

in Philadelphia, the second of four jects into easily understandable ideas, so

children. Both her parents were quite critical in the education of children with
notable in their fields: her father, as learning differences, is characteristic of
“the father of cognitive therapy,” and all her work.
Therapy, Bala Cynwyd, PA.

her mother, as the first female judge Beck later returned to graduate
on the appellate court of the Common- school, studied education and psychol-
wealth of Pennsylvania. From an early ogy, and completed a postdoctoral fel-
age, Beck wanted to be an educator, and lowship at the Center for Cognitive
she began her professional career teach- Behavior Therapy at the University of
ing children with learning disabilities. Judith S. Beck Pennsylvania. In 1994 she and her father
 W

CHAPTER 14

Aaron Beck and Cognitive Therapy

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Aaron Beck Evaluation of Cognitive Therapy

The Development of Cognitive Therapy Limitations
Important Theoretical Concepts Sh.engths and Contributions
Development of Cognitive Distortions Skill Development: Analyzing and Modifying
Principles of Cognitive Therapy Cognitions
Levels of Cognitions Eliciting Actions, Emotions, and 'lbhoughts
Treatment Using Cognitive Therapy Assessing the Validity of the Cognitions
Goals Identifying a Core Cognition
Therapeutic Alliance Categorizing the Cognitive Distortions
Case Formulation Disputing and Replacing Cognitions
Eliciting and Rating Cognitions Relating 'lboughts and Feelings and
Detemlining the Validity of Cognitions Modifying Actions
Labeling the Distortion Review of Steps in Analyzing and Modifbring
Assessment of Mood Cagnitions
Strategies for Modifying Cognitions Case Illustration
Temlination and Relapse Prevention Exercises
Application and Cunent Use of Cognitive Large-Group Exercises
Therapy Small-Group Exercises
App[ication to Diagnostic(groups Individual Exercises
Application to Multicultural Groups Su------ary
Application to Other Groups Recommended Readings
Current Use of Cognitive Therapy Additional Sources of Infomiation

292
 Chapter 14 Aaron Beck and Cognitive Therapy 293

Cognitive therapy had its beginnings in the 1 960s and has grown in importance in the past 50 years
to become one of the leading approaches to counseling and psychotherapy in use today. Cognitive
therapy was initially created by Aaron Beck to provide a structured treatment of depression.
As we have seen, cognitive therapy and Ellis's rational emotive behavior therapy evolved
around the same time. Both theories focus on cognitions--the automatic thoughts that everyone
has--and how these cognitions, and the meaning people give to them, can be either helpful or
hamtful. Helping people to recognize and change dysfunctional or unhealthy ways of thinking so
they can lead happier lives is the goal of both theoretical orientations. But there are some differ-
ences as well. The difference between rational emotive behavior therapy and Beck's cognitive
therapy is one of emphasis. Ellis was very directive and frequently focused on decatastrophizing.
Beck's style was less colorful, and his interest was focused more on Handing what worked to alle-
viate dysfunction. Beck and his colleagues fueled the growth of cognitive therapy through the use
of empirical research to validate its effectiveness, first with depression, and later with most of the
other major Axis I disorders (Kellogg & Young, 2008). Recent research indicates that cognitive
therapy and schema therapy are also effective in the treatment of borderline and other personality
disorders, with substance abuse, for pain management, and in the treatment of sexual disorders
(Hofmann, 2012).
Cognitive therapy is a well-organized, powerful, usually short-tami approach that has proven
its effectiveness. As the health care industry has moved toward evidence-based practice, cognitive
therapy has become even more widespread. Forty-Hive percent of respondents to an American
Psychological Association survey considered themselves to be cognitive-behavioral in their theo-
retical orientation, making it the most popular of any treaMient modality(Stewart & Chambless,
2007). Cognitive-behavioral therapy is also the most ftequentjy taught treatment methodology in
U.S. graduate schools(Norcross, 20 11; Pxychorherapy NeMorker. 2007).
It is important to note that while cognitive therapies today maintain the underlying structure
of Ellis's and Beck's work, most practitioners now integrate beha\doral techniques and other fomls
of therapy that make it a more active approach. We will liam more about these newer treatment
models in Part 5 of this book, which focuses on actions. But now we tum to the history of the devel-
opment of Beck's cognitive theory.

AARON BECK
Aaron T. Beck, the man behind the development of cognitive therapy, was bom in New England in
1921. He was the fifth and youngest child of Harry Beck and Elizabeth Temkin Beck, Russian
Jewish immigrants to the IJnited States(Weishau, 1 993). Two of the five children bom to this fam-
ily died in infancy, apparently contributing to emotional problems in Beck's mother. He perceived
her as depressed, unpredictable, and overprotective--very diHerent &om his calm father.
Beck himself had many difficulties during childhood. He was often ill, missing many days
of school. As a result, he had to repeat a grade, leading him to develop negative views of his intel-
lectual abilities. In addition, his illnesses left him with many apprehensions, including a blood/
injury phobia and fears of public speaking and of suffocation. Beck used reasoning to alleviate
his anxieties and apparently was successful since he studied surgery as part of his medical train-
ing and gave many presentations throughout his life. A connection seems probable between his
early experiences with anxiety and depression and his subsequent work, focused on treating those
symptoms.
Beck graduated from Brown University and Yale Medical School, where he studied psychia-
try. Although he was trained in psychoanalysis, he had little faith in that approach, even early in his
career. At the I.Jniversity of Pennsylvania Medical School, Beck, an assistant professor of psychiatry,
294 Part 4 ' Treatment Systems Emphasizing Thoughts

engaged in research designed to substantiate psychoanalytic principles. Instead, his work led him to
develop cognitive therapy, which has since been the focus of his teaching, research, writing, and
clinical work. He has spent most of his professional career at the University of Pennsylvania, where
he established die Beck Institute for Cognitive Therapy and Research.

THE DEVELOP LENT OF COGNITIVE THERAPY

According to Judith Beck(2011), the roots of her father's cognitive therapy lie in the ideas of the
Stoic philosophers of ancient Greece and Rome. Epictetus's belief that people are disturbed not by
things but by the view they take of them is particularly relevant. George Kelly's (1955) personal
constructs psychology is a modem precursor of cognitive therapy. Kelly was one of the nast theo-
rists to recognize the role of beliefs in controlling and changing thoughts, emotions, and actions. He
suggested that people each have a set of personal constructs that enables Aem to make sense of and
categorize people and experiences. These constructs operate like scientific hypotheses, paving the
way for people to make predictions about reality. When their predictions are not bome out or when
people recognize that their personal constructs are hamdul, they may seek altemative constructs
(Hergenhahn & Olson, 2007).
Aaron Beck's carefu]]y designed research and professional writing led to the current wide-
spread use of cognitive therapy. Beck drew on the ideas of George Kelly, Alfred Adler, and Karen
Homey as he sought efficient and effective ways to help people. Working at the University of
Pennsylvania in the 1960s, Beck and his colleagues initially sought to develop a stmctured, short-
teml, present-oriented, problem-solving approach to the treatment of depression(Beck, 1995). The
book, Cognlrive Therapy of Depression(Beck, Rush, Shaw, & Emery, 1979), described the results
of this work, which had a powerful impact on the field of psychotherapy. It o#ered a clear and structured
approach to the treatment of depression, the symptom clinicians most often see in both inpatient and
outpatient mental health settings. Beck and his colleagues provided evidence Aat cognitive therapy
was more effective in treating depression than the antidepressant medications of that time.
Beck has acknowledged a strong debt to Albert Ellis's work (Weishaar, 1993). At the same
time, Beck's personal style, as well as the development of his theory, differs from Ellis's. Beck
enhanced the importance of his system of cognitive therapy through research, clinical applica-
tion, and writing. In demonstrations and videotapes, he appears reserved and thoughtful, a
researcher at least as much as a clinician. His books, articles, and inventories, including recent
titles such as Cagrzirlve T%erapy od A/zxleQ Z)isorders (Clark & Beck, 2011), Schizophrenlcz.'
Cogrzirive Theory, Research and Therapy (Beck, Rector, Stolar, & Grant, 2008), and "The
Empirical Status of Cognitive--Behavioral Therapy: A Review of Meta-Analyses" (Butler,
Chapman, Fomlan, & Beck, 2006), continue to expand the application of cognitive therapy and
validate its effectiveness.
Beck published his first outcome study in 1977. Since that time, he has published more than
500 articles, authored or coaudiored 25 books, and lectured Uiroughout the world. He is the only
psychiauist to receive research awards from both the American Psychological Association and the
American Psychiatric Association. Beck is listed as "one of the Hive most influential psychothera-
pists of all time"(American Psyc/zo/ogfsr, 1989).
Many others should be mentioned for their conuibutions to cognitive therapy. Aaron Beck's
daughter, Judith S. Beck, has been collaborating with him for many years. Now director of the
Beck Institute for Cognitive Therapy and Research and professor at the University of Pennsylvania,
she continues the development of cognitive therapy, most recently with the publication of the sec-
ond edition of her book Cognlrlve Be/taylor Therapy: The Basics and Beyond(2011), which pro-
vides a solid overview of what is probably the most widely researched fomi of therapy. In addition,
 Chapter 14 ' Aaron Beck and Cognitive Therapy 295

er therapists.such as Donald Meichenbaum ( 1994), who was among the first to combine cogni-
tive therapy with behavioral interventions, and Beck's colleagues (Beck, Freeman, & Davis. 2006;
Scott & Freeman, 2010), and others have expanded the model of cognitive therapy during the past
JU years
Cognitive therapy has provided a solid foundation on which postmodem constructivist inter-
ventions have been built. More willbe said about these newer approaches in the coming chapters.

l IPORTANT THEORETICAL CONCEPTS

Judith Beck(2011) has summarized cognitive therapy: "In a nutshell, the cognfrlve mode/ proposes
that dysfunctional thinking(which influences the patient's mood and behavior) is common to all
psychological disturbances. When people lean to evaluate their thinking in a more realistic and
adaptive way, they experience improvement in their emotional state and in their behavior"(p. 3)
The purpose of cognitive therapy is to teach people to identify, evaluate, and modif5r their own dys-
functional thoughts and beliefs. ' '

Development of Cognitive Distortions

Cognitive therapists believe that many factors contribute to the development of dysfunctional cog-
nitions, including people's biology and genetic predispositions, life experiences, and their accumu-
lation of knowledge and leaming. Distorted cognitions begin to take shape in childhood and are
reflected in people's fundamental beliefs; this makes people more susceptible to problems. In con-
sidering a stress-vulnerability model, as more stress occurs, the more the person's automatic
thoughts are at the mercy of underlying dysfunctional beliefs and schemas. Because the processing
of thoughts is already biased, distorted cognitions result (Scott & Freeman, 20 1 0).
Cognitive therapists value the importance of making an accurate diagnosis. An extensive
intake interview is used to give clinicians a good understanding of their clients' history, devel-
opment, and background. Cognitive theory suggests that each mental disorder is characterized
by relatively predictable types of underlying cognitive distortions. For example, feelings of
depression typically stem from thoughts of loss. An accurate diagnosis can therefore facilitate
identification of those distortions and ways to change them. It also can guide clinicians' infor-
mation gathering so that they can better understand their clients. For example, discussion of
childhood experiences probably is important in treatment of people with personality disorders,
read discussion of traumatic experiences is essentia] for people diagnosed with post-traumatic
stress disorder (PTSD). However, discussion of past experiences is less likely to be important in
treatment of people with disorders that are mild, brief, transient, and recent, such as adjust-
ment disorders.
Although cognitive theorists focus primarily on thoughts, they take a holistic view of peo-
ple and believe that learning about and understanding their feelings and behaviors also is impor-
tant. Particularly important--and related to positive outcome--is understanding the emotional
responses people have to their faulty cognitions and the impact of those cognitions on mood
(Leahy, Tirch, & Napolitano, 201 1). Having a comprehensive understanding of people is particu-
larly useful in helping clinicians develop interventions that target all three areas of functioning:
thinking, feeling, and acting.
According to cognitive theory, psychologically healthy people are aware of their cognitions.
They can systematically test their own hypotheses and, if they find they have dysfunctional and
unwananted assumptions, can replace them with healthier, more accurate, and more helpful beliefs
that lead to more positive emotions and behaviors.
296 PaH 4 Treatment Systems Emphasizing Thoughts

Principles of Cognitive Therapy

The following important principles characterize the practice of cognitive therapy (Beck, 1995
201 1; Beck et al., 2006):

cognid% tlia8py k based m tln finding &ai chm8es in tllinking lead b chmgo$ h fbcling uxl acting.
Trwtment sequins a sound and mllaborative dnmpeutic alliance.
TKRulleN is generally shah tami, problem Reused, and goal (dented..
Cognitive dierapy i$ an active and suuchuud ippromh to trwMont.h '
It fmuns on tbe pnwnt, although Mtontion is paid to tbe paH when indicated-

Cognidve therapy ages a broad range 6f saakgies md interventions to tied people Walu#te and

]hducdve nasaning and Sacrdie qi#s6lining an paticululy importbM smtc$w

Tills is a psych(ndinationd model &at pfomlotw an(Hon81 health md invents nlap9e by bacMng
people to identiq, evaluate. and i130dify Gear own cognitions.
Task asdgiuxnlh follow-up, md clint feed)uk an important in aiswing dK success of dns approach.

Levels of Cognitions
Cognitions can be categorized according to four levels: automatic thoughts, intemlediate beliefs,
core beliefs, and schemas. In cognitive therapy, treatment typically begins with automatic thoughts
and then proceeds to identification, evaluation, and modification of intemlediate and core beliefs
and finally to revision of schemas.
Aufomafic rhoug/zrs are the stream of cognitions that constantly flow through our minds. As
we go through our day, situation-specific thoughts spontaneously arise in reaction to our expen-
ences: "I don't think I'll ever be able to get all that work done," "I think I'll eat a healthy lunch
today," "I don't think I should call my father yet," "l'm going to help Bill with his homework
tonight," "That man makes me think of my brother," and on and on. When people pay attention to
their droughts, they become more accessible and people can articulate and evaluate them.
Automatic thoughts mediate between a situation and an emotion. Consider the following
example:
S&aaHoa; Michael teams that his sister has been in town but did not caH him.
It/khaeJ's awfomafic faoughf; She finds me unlikable and doesn't want to be with me.
ll#ichaeJ's emo#oiz: Sadness.
What caused the emotion, sadness. was not the situation itself but the man's automatic cognition,
reflecting the meaning he made of the situation. IJnderstanding people's automatic thoughts is
important in helping them change their emotions.
/n/e/medlare bell(:fs often reflect extreme and absolute noes and attitudes that shape people's
automatic thoughts. In the previous example, Michael's intermediate beliefs might include "A sister
should call her family when she is in town" and "Being ignored by your sister is a terrible thing.
Care be/if:fs are central ideas about ourselves that underlie many of our automatic cognltions
and usually are reflected in our intemlediate beliefs. Core beliefs can be described as "global, rigid,
and overgeneralized"(Beck, 2011, p. 34). They typically stem from childhood experiences, are not
necessarily tme, and can be identified and modified. Core beliefs reflect our views of the world,
other people, ourselves, and the future. They may be positive and helpful such as "I am likable," "I
am a capable person," and "The world is full of interesting and exciting oppomnlities and people.
However, they also can be negative, such as "People only care about themselves," "The world is a
 Chapter 14 Aaron Beck and Cognitive Therapy 297

dangerous place," and "I make a mess of everything." Most negative core beliefs can be categorized
as /ze/p/ess core be/il:fs such as "I am weak" and "I am a failure" or as zln/oval/e core be/f({fs such
as "I am not good enough" and "I am bound to be abandoned" (Beck, 201 1, p. 233). In this exam-
ple, Michael seems to have unlovable core beliefs.
As clinicians get to know and understand a client and hear a series of automatic thoughts, they
can fomlulate hypotheses about that client's core beliefs. At an appropriate time, clinicians can
share this hypothesis with the client for confirmation or disconnumation, along with infomiation on
the nature and development of core beliefs. Clients are encouraged to view their core beliefs as
ideas rather than truths and to collaborate with the clinician to evaluate and, if indicated, change
their core beliefs.
Sc/lamas have been defined as a "hypothesized mental structure that organizes infomlation:
that encompass the core beliefs (Beck, 2011 , p. 33). They go beyond core beliefs, in breadth and
depth, and include thoughts, emotions, and actions. Schemas have content as well as structural
qualities such as breadth, flexibility, and prominence.
Beck viewed schemas as "specinlc rules that govem infomlation processing and behavior '
(Beck et al., 2006, p. 8). Schemas lead us to have expectations about experiences, events, and roles
and to amplify those with infomiation contained in our schemas. Schemas can act as mental Hllters.
aHecting the way we perceive reality. Schemas are idiosyncratic and habitua] ways of viewing our-
selves, the world, and the future. Schemas can be personal, familial, cultural, religious, gender
related, or occupational in origin and application (Beck et al., 2006). Examples of maladaptive
schemas include dependence/incompetence and deprivation.
Schemas may be activated by a particular stimulus or lie domlant until triggered. For example, a
person may have a danger schema that gives the message "'lbe world is a dangerous place. Avoid any
possible danger." 'ellis schema is usually latent but can be activated by threats to that person's safety.
When a schema has been activated, it readily incorporates any confimling infomlation and
tends to neglect contradictory information. For example, when people view themselves as incompe-
tent, they accept negative infomiation they receive about themselves and overlook or dispute any-
thing positive. Turkey and Brewer(2003) found that schemas influence retention and distortion of
memories. We are more likely to recall observations that are consistent or inconsistent with our
schemas, compared to observations that are irrelevant to our schemas; inaccuracies in recollections
are particularly likely to be schema consistent.
The distinctions among automatic cognitions, intemiediate beliefs, core beliefs, and schemas
can be confusing. Consider the following example, illustrating each of these. After several disap-
pointing relationships, Joshua has developed a rewarding relationship with Sharon; after living
together for 2 years, Sharon suggests mamage and Joshua agrees. He has the following thoughts:

Aafomm#c fhoughfs: lean't be the sort of husband Sharon wants and our marriage will end.
/ lermedbfe beZliqfs; A good husband must be willing to sacrifice his own needs for those of
his wife and children. Maniage is a difHlcult endeavor at which few succeed.
Core bell(f' lam not able to love another person and have little to offer in my relationships.
Schemaflam inadequate and am destined to fail, no matter how hud Itty. This makes me
feel discouraged about my upcoming marriage; Ifeel disaster and shame hanging over my
head. What's the point of tiling iflknow lwill fail at whatever Ido.

Because of this maladaptive schema, Joshua will probably focus on infomlation that conHimls his
beliefs and ignore or explain away disconfimling infomlation. He will enter marriage with a nega-
tive attitude, accompanied by ineffective behaviors that will contribute to the destruction of his
marriage and the substantiation of his beliefs.
Schemas become amenable to analysis and modification after people have experienced some
change as a result of assessing and altering their automatic thoughts, intemlediate beliefs, and core
298 Pan 4 Treatment Systems Emphasizing Thoughts

beliefs. Beck viewed schema work as the heart of the herapeutic process(Beck et al., 2006). More
will be said about working with schemas later.
Cognitive therapy operates at several levels, seeking to elicit and change people's symptoms
as well as their automatic thoughts, intemiediate beliefs, core cognitions, and underlying schemas.
Once healthy thinking has been restored, clinicians help people to develop the skills they need to
monitor, assess, and respond to their own cognitions as well as lead their lives more successfully

TREATI LENT USING COGNITIVE THERAPY

Treatment via cognitive therapy usually is time limited, for example, 6 to 14 sessions long for rela-
tively straightforward problems(Beck, 2011). Sessions are carefully planned and structured to max-
imize their impact and efntciency. People complete inventories and intake questionnaires before
beginning treatment. Clinicians review these before the first session in order to be well prepared.
Each session has clear goals and an agenda. Judith Beck(2011, p. 60) recommends the fol-
lowing 10 procedures for an initial session:

l& Obtain tbe4GliEol'B fbodbuk on:tbe SBSBion. t .;:;

Throughout the session, clinicians promote development of the therapeutic alliance and build trust,
rapport, and collaboration while encouraging realistic hope and optimism.
Subsequent sessions follow a similar structure. They typically begin with an assessment of
the person's mood, focusing particularly on changes. Next, the foundation for the session is estab-
lished by making a transition from the previous session to the current one; clinicians ask about cli-
ents' learning from and reactions to the previous session and obtain an overview of the clients
week, highlighting any important happenings. This facilitates establishment of an agenda for the
session, which always includes reviewing homework. The central part of the session addresses
items on that agenda, with clinicians eliciting and assessing thoughts as well as emotions and actions
related to the identified issues. Each session concludes with new homework, a summary of the ses-
sion, and feedback from clients on the session and the process of treatment. Ending the session on a
positive note promotes optimism and motivation.
Cognitive therapists make sure to explain to clients the nature and purpose of the sessions:
structure. Clients generally find that structure reassuring. They know what to expect and are opti-
mistic that this plan will help them as it has helped others. Of course, an agenda may be modified if
needed, perhaps if a crisis has occurred, but any changes are planned when the agenda is detemiined
at the outset of each session.

Goals
Cognitive therapists carefully specify ' goals for their treatment, and they draw on a rich array of inter-
ventions to achieve 6em. The overall goal of cognitive therapy is to help lnople recognize and collect
 Chapter 14 Aaron Beck and Cognitive Therapy 299

errors in their infomiation-processingsystems. To accomplish this, clinicians help people identify

both their unmediate (automatic) and underlying(intemlediate, con, schema) thoughts and beliefs as
well as associated emotions and behaviors; evaluate the validity of these Uloughts; and modify them if
indicated. Throughout treatment, people leam to use this process independendy and also to develop
the skills and attitudes alley need to think more realisticaHy and lead more awarding lives.
Clinicians and clients collaborate on determining specific goals. Once identified, goals are
written down, with copies made for both client and clinician. Goals are referred to regularly to
assess progress. Having clear, specific, and measurable goals is an important component of cogni-
tive therapy and increases the likelihood that clients and clinicians will collaborate to achieve a
shared objective.

1> Therapeutic Alliance

Cognitive behavioral therapy requires a sound therapeutic alliance" (Beck, 201 1 , p. 7). The cogni-
tive therapist is active, collaborative, goal oriented, and problem f ocused.
Cognitive therapists strive to be nonjudgmental and help clients to develop the skins they need
to make their own judgments and choices. As mentioned earlier, cognitive therapists use Socratic
questioning to lead clients through what Scott and Freeman(2010) refer to as "guided discovery
(p. 35). By asking questions that clients can answer, focusing the clients' attention on infomiation that
is relevant but they may not be aware of, and moving from the concrete to the abstract. die client is
guided toward new thoughts and ideas from which they can fomlulate their own conclusions.
The four stages of guided discovery are:
1. Socratic questioning to elicit the client's concems
2. Active listening for clarification, inconsistencies, and emotional reactions
3. Summarization to provide feedback and enhance clariHlcation
4. Synthesis or analytical questions that pull all of the infomlation together, along with the
client's original concem, and pose an analytical question (Scott & Freeman, 2010).
The therapeutic re]ationship is crucial to the success of this approach, and cognitive thera-
pists maintain a great deal of role flexibility. Problems that arise within the therapeutic relation-
ship need to be explored. Judith Beck (201 1) suggests asking clients for feedback at the end of
the session or any time a client's aHect appears to become negative during the session. Especially
when working with difHlcult clients, therapists need to identify when such problems occur, con-
ceptualize the reason it occurred, and work toward correcting the problem to prevent a rupture in
the therapeutic alliance.

Oi Case Formulation
Before cognitive therapists move forward with interventions designed to modify cognidons, they
take the time to develop a case formulation, reflecting in-depth understanding of the client.
According to Persons( 1989), a complete case fom)ujation includes six elements:

1. 1.ist of pmblems and concems @

,+ #i*2. Hypo&asfbau @p,uadedyiHB moaliadsm (aizbelief a'ldaha)

3. Relationship of this Inlief to cinlent pmbleins
'L Fbreq#&a@!©j$Ktjjg@g@©kw
5. Uh&f:duidin8 of ba,;lc8rou-H ible$mt n dwelopn;ht dwiliodyinB hbefs
300 Part 4 ' Treatment Systems Emphasizing Thoughts

A thorough case formulation enables clinicians to develop treatment plans that are likely to be
successful. When planning treatment, cognitive clinicians identify the best points for initialinter-
vention, treatment strategies that are likely to be helpful, and ways to reduce anxiety and other
obstacles to progress. Treatment usually focuses first on overt automatic cognitions related to cli-
ents' presenting problems and, as progress is made, shifts to identification and assessment of under-
lying core beliefs and schemas.

Eliciting and Rating Cognitions

Judith Beck (201 1) suggests a basic question to elicit people's thoughts: "What was going through
your mind just then?" (p. 83). Once one thought is presented, it often leads to production of other
thoughts. Especially important are thoughts that appear repeatedly in conjunction with a variety of
experiences and have a negative impact on the person. Beck uses what she calls a dysfunctional
thought record to facilitate identification and modification of such thoughts(p. 95). This record
includes six items:

1. . '1b sitnMw illqt dGiUd tb Bicni#n 4nd.h.#coanpw)ringphydca! responses

3. Alltotna&c dlwgUs aad extent qf belief b close thou8bB rated oa a 0$ © IQ0% scale

and intensity lathes. and new Bctims.

The first four items are completed initially, as in the following example:
l The school called to tell me that my son had been seen breaking into the school over the
weekend. He was accused of vandalizing the computer room. Ifelt a knot in my stomach; I
fe[t eight-headed and tense a]] over.
2 ibis happened on Monday moming about 8:30 A.M.
3 I am a failure as a parent: 95% belief rating. My son is a hopeless criminal, and it's my fault:
90%n belief rating.
4 Anxious: 95% intensity; sad: 85% intensity.

Determining the Validity of Cognitions

Once the cognitions have been elicited and placed in context, people can assess their validity.
Especially important is clinicians' use of guided discovery(also called Socradc dialogue) via skill-
ful questioning a I experiments to help people test the reality of their thoughts. These are powerful
techniques tha . 'lst be used with care. Tbherapists should never act as though they know better than
the client, should bot debate or argue with clients, and should remain neutral on whether a thought
is distorted. The clinician ' s role is to help clients find the truth.
The following dialogue illustrates the use of questioning to help the client in the previous
example assess the logic and validity of her thoughts:
Cli,iNiCiAN: One thought you had was that your son was a hopeless criminal. What led you
to have that thought?
CuKNr: Well, it sounds like he committed a crime.
CLINICIAN: Yes, he may have. Does he have a history of criminal behavior?
 Chapter 14 ' Aaron Beck and Cognitive Therapy 301

CLIENT No, not at all. He's always been very well behaved.
CLINICIAN So this is the aust time he has been suspected of breaking the law?
CLIENT: Yes
CtINiCiAN: And what is your definition of a hopeless criminal?
CLIENT I guess it's someone who repeatedly breaks the law, who can't be rehabilitated
CLINICIAN: And does that sound like your son?
CLIENT No. 1guess loverreacted when lsaid he was a hopeless criminal
CLINICIAN: And what about your thought that you are to blame for his behavior. What led
you to think that?
CLIENT I'm his parent. Aren't lthe biggest influence in his life?
CLINICIAN Yes, your role is certainly an important one. How might you have encouraged
him to become a criminal?
CLIENT: I don't know what you mean
CLiNiCiAN: I wonder if you have engaged in criminal behavior yourself.
CLIENT: No, of course not.
CLINICIAN: Perhaps you condoned criminal behavior or didn't tly to teach him the differ-
ence between right and wrong?
CLIENT No, just the opposite. Ihave very strong values, and lalways tried to transmit
them to my son. When he misbehaved, lwould talk to him about what was
wrong with his behavior and teach him how to act differently.
CLINICIAN I'm confused then, about how you might have caused his criminal behavior.
CLIENT I guess lwas just feeling bad and wanted to Hind an explanation. But kan see
that lcertainly never taught him to break the law
Experiments designed to test hypotheses stemming atom faulty thinking are another important
approach to helping people evaluate the reality of their cognitions. In the previous example, the client
might use her statements "My son is a hopeless criminal" and "I am to blame for my son's criminal
behavior" as hypotheses. Clinician and client then develop experiments or ways to test these hypothe-
ses. The client might talk with her son about the reasons for his behavior, confer with school personnel
about this incident as well as about her son's usual behavior at school, and nad about criminal behavior.
A third approach is to use the three-question technique, a fomi of the Socratic method Mat
helps clients to revise negative blinking. The therapist asks dle client:(1) What evidence is there for
the belief?(2) How else could the situation be interpreted?(3) if it is true, what would the implica-
tions be? Each of the three questions helps the client to delve deeper into the distorted belief, recog-
nize the distortion, and adopt more objective thinking.
In our example, the boy might have been erroneously accused of breaking into the school.
Even if he had committed the crime, mitigating factors might have played a part, such as his being
forced or coerced to engage in d)e break-in.
Following are additional approaches that cognitive therapists use to help people evaluate the
validity of their cognitions:

. A'!king dems hoV iinobK pet$m +ihaii obey o;l$e&iiiaold &iA:bl,.;w ta sltbatiM
:lu:: n died &&dWvMd s©'#lh& :Md&h$e h tl&'th.jugi&t&}.&vbi
Uii8g hinnor atemggdaMn h take m id& ni& mbeliie: 1: ' :f- ' j s
302 Part 4 Treatment Systems Emphasizing Thoughts

}@!$@ki:pli@eima@l!@$i $$$$w: $ii !eb iii

g6$$ agNgi$i e$@ltn%#$8i691$fiilb+13PI g@$ $$g$igbm'&®e dli i@ith &i l$8xy e;@id6d

Rgde6hhgi$jwtt! @ii@ ai$#6$@&i ll&a# $1$1 mejat! ei&6Mihlgd+@gg

Decentering, or IKlping people see tlKy an ECK {lK cause ofdle pinblem ar tln Center of attention.

Labeling the Distortion

Evaluation of distoHed cognitions can be facilitated by categorizing and labeling the distortions.
This helps people see more clearly the nature of their unrealistic thinking, reminds them fiat other
people have had similar distorted cognitions, and gives them a tool for assessing subsequent
thoughts. Many lists of cognitive distortions have been published(Beck, 1976; Bums, }999). Here
these categories are illustrated with statements made by the previous client:

A/Z-ar-aofhllzg orpohrlzed f&f kiizg; Viewing a situation in semis of extremes rather than on
a continuum. "Either my son is innocent, or he is a hopeless criminal."
OpergelzeraZlzafio ; Drawing sweeping conclusions that are not justified by the evidence. "I
am a failure as a parent because my son was arrested."
il#eHMJ.#Zrer (seZecHve absaucfD ): Focusing selectively on negative details and failing to
see the broad picture. "I know my son has been a good student and has not caused any prob-
lems in the past, but alllcan think about is that he broke the law.
Z)isgziaZIOing f&epos#fvei Paying attention only to negative infonnation.."What good are all
my efforts to be a good mother if this is the result?"
/ inpiizg to coizcZztsio s (arblb'azy iilferemces,); Drawing hasty and unwarranted conclu-
sions. "My son must be guilty. Someone saw him hanging around the school late that night.:
Mbgiz /bafion/miHimizalbn; Making too much of the negative, devaluing positive infomta-
tion. "My son stole a candy bar from another child when he was four. He was destined to
become a criminal.:
Emofiona/ reasa#fitg: Believing that something is true because it feels that way; paying no
attention to contradictory evidence. "I just feel like d)is is my fault, and no one can convince
me it isn't.
f$howZd" alls "mast)' s femeizfs; Having definite and inflexible ideas about how we and oth-
ers should behave and how life should be. "I should never have let Kevin get his driver's license.
I should have made sure Imet all his fiends. lshould have been a better modier to him.:
Z.abeZfizg a#d mishbellng: Attaching an extreme, broad, and unjustified label to someone.
Kevin is a hopeless criminal.
PenoHaZlzaHo#; Assuming inordinate Ksponsibility for events or others' behaviors. "My son
and Ihad an argument about his curfew three days before the school break-in. Iflhadn't
yelled at him, this probably never would have happened."
Cafasfraphfziizg: Predicting a negative outcome without considering other possibilities. "I
just know Kevin will be sent to prison for this.:
A/liza readliag; Attributing negative thoughts and reactions to others without checking if they
are present. "My husband will never forgive Kevin for this. He'll disown him.'
Tun e/ pisblz; Focusing only on the negative aspects of a situation. "I can't do anything right
as a parent. There lwas, eating dinner, while my son was breaking into the school. How could
I not have known what was going on?"
 Chapter 14 Aaron Beck and Cognitive Therapy 303

Becoming familiar with these categories of cognitive distortions can help people identify,
understand, and dispute their own cognitive distortions. In addition, reviewing this list can reassure
clients that having cognitive distortions is common and that dysfunctional thinking can be changed.
This reassurance can reduce self-blame and facilitate efforts to fomlulate healdiier and more valid
cognitions.

Assessment of Mood
Assessing mood is an important part of cognitive therapy for many reasons. Troubling emotions are
often the reason people seek treatment. Upsetting emotions are likely to be close to the surface and
presented early in treatment. Those feelings can point the way to distorted cognitions. In addition,
monitoring the nature and intensity ratings of people's emotions can provide evidence of progress,
while improvement in mood can enhance clients' motivation and optimism. Cognitive therapy was
initially developed for the treatment of depression and anxiety and considerable research demon-
strates the eHectiveness of this approach in treating those emotional symptoms.
Cognitive therapists use structured approaches to assess emotions, as they do to assess
thoughts. One of Aaron Beck's major contributions to psychotherapy is the development of brief,
concise inventohes that provide a quick measure of the nature and intensity of emotions that are
most likely to be troubling to people. These inventories include the Beck Depression Inventory
(BD]), the Beck Anxiety Inventory (BAI), the Beck Hopelessness Inventory, and the Beck Scale for
Suicidal Ideation. Published by Psychological Corporation, these inventories each take only a few
minutes to complete. Any or a]] of these might be administered to obtain an emotional baseline
before a person begins treatment. If elevated scores are obtained on an inventory, administration of
that inventory every few sessions enables client and clinician to track and quantify changes in emo-
tions. An even more rapid assessment of emotion can be obtained using an informa10 to 100 scale
of severity or intensity of a specinlc mood such as anger, jealousy, or sadness. Clients can rate them-
selves on these scales at the beginning of each session.

QP Strategies for codifying Cognitions

Clinicians work closely with clients to restructure their cognitions and help them find words to
express their new cognitions accurately, realistically, and in ways that are compatible with their
emotions. This process involves helping people deepen their beliefs in their revised cognitions and
make those cognitions part of themselves.
Once again, cognitive therapists draw on a wealth of strategies to accomplish these goals.
Although many of these techniques are primarily cognitive in nature, others are behavioral and will
be addressed fllrther in Part 5. Following are some of the strategies that enhance the work of cogni-
tive therapists:

. C/za//ePtging also/lite sfafeme/zfs. Clients ofhn use absolutes such as "never" and "always
when telling their stories. "My husband is never home for dinner" or "My boss is always late." By
challenging the absolute nature of these statements(i.e., "Never? in the past month, your husband
has never been home for dinner?" or "Always is pretty definitive"), the clinician gives the client an
opportunity to retract the absolute statement and clarify the behavior more accurately.
.'lcrlviO xc/zedu/fng encourages people to plan and try out new behaviors and ways of
thinking as well as to remain active despite feelings of sadness or apprehension. Leaming a new and
interesting skill and having a good time can contribute to improved moods and clever thinking.
. Reaffrfb rf/zg b/ame. Clients often tum intemally and blame themselves whenever some-
thing goes wrong in their lives. This false attribution of blame can start a cascade of negative
304 Part 4 Treatment Systems Emphasizing Thoughts

emotions and behaviors. Through the use of Socratic dialogue and asking questions that get to the
heart of the problem, clinicians can h61p clients look at the situation more clearly, as illustrated in
this brief dialogue:
CLIENT: A pipe burst at my parent's house while they were on vacation and now the
whole condo is flooded. It ' s all my fault.
CLINICIAN: Were you watching your parent ' s house while they were gone?
CLIENT: No, 1haven't been there in years. They live in Florida, but lshould have had
the water tumed off before Mey left.
CLiNiCiAN: Did they ask you tum off the water?
CLIENT: No
Cog/zifive rehearse/ is a strategy inwhich people mentally rehearse a new behavior and
hen create a cognitive model of themselves successfully perfomiing that behavior. Some athletes
use this technique to improve their skills in their span. A woman maivied to a verbally abusive
husband used this approach to rehearse asserting herself to her husband, making it easier for her to
stand up to him when he spoke to her in a demeaning way. A variation is for people to imagine
themselves as someone they admire and then tackle a challenging situation as if they were that
person
Diversions or disfracffoni also can help people reduce their negative thinking. A woman
who was diagnosed with a life-threatening illness had a good prognosis but still experienced con-
stant thoughts of death. To distract herself from these troubling thoughts, she mentally cataloged
each item in her extensive wardrobe, beginning the mental list anew each time the negative thoughts
retumed
U e

Se# /aZk is a technique in which people repeat to themselves many times a day positive and
encouraging phrases that they have identified as helpful, such as "Don't let fear conti.ol you. You
can do it." in essence, they are giving themselves a pep talk.
Al#i/maffons are closely related to self-talk. An af6imiation is a sort of slogan that is posi-
tive and reinforcing. People can post these in prominent places such as the refrigerator or keep them
in a three-ring binder of index cards where they can review them frequently and be reminded to
shift their thinking. An adolescent girl chose as her affirmation "Someday you will realize your
great potential." Keeping those words in mind helped her deal e#ectively with challenges.
Keeps/zg dfarfes of events, realistic and distorted cognitions, emotions, and efforts to make
positive changes can increase people's awareness of their inner and outer experiences. These writ-
ten records can provide important material for discussion in sessions and serve as a way to track
both progress and difficulties.
.I,ef/er wrifl/zg provides another avenue for exploring and expressing thoughts and feelings.
The woman whose son was accused of breaking into his school(discussed previously) might ben-
efit from drafhng a letter to her son expressing her reactions to his behavior. The letter need not be
mailed but can be used as the focus of a session.
Sys£ei2zaric assessPwnf of a/remarives(cost/bene6ltanalysis) is an approach that can help
people make wise decisions or choices. They 6xst list their options, along with the pros and cons of
each one. Then they assign numbers on a scale oflto 10, showing the importance of each advan-
tage and disadvantage. Finally, they total the numbers assigned to the pros and cons of each option.
A man considering a career change used this approach to help him decide whether to remain in his
secure, well-paying position in computer technology or pursue his lifelong goal of becoming a
counselor; die numerical totals strongly reflected a preference for becoming a counselor, whereas
the list of cons pointed out obstacles to this goal.
 Chapter ]4 ' Aaron Beck and Cognitive Therapy 305

Re/abe/ing or renaming experiences or perceptions can help people think di#erently about
them. For example, a woman who had few dating experiences at age 35 stopped thinking of herself
as a failure and instead viewed herself as a late bloomer.
. Ro/e-p/aping can enable people to actualize some of the new thoughts they have about
themselves. For example, a man who had developed a more positive view of his abilities role-
played sharing his accomplishmentswith his fnends, asking his supervisor for a raise, and inviting
a colleague to join him for lunch.
When ro/e'p/ayf/zg a dfa/ogzze bef t/ee/z oZd and flew rhoz£g/zrs, clients can use two chairs
(as described in Chapter 10) to represent both dleir old and their new thoughts. Moving from one
chair to another, they engage in a dialogue between the two groups of thoughts. This can help peo-
ple clarify changes in their thinking and solidify their rational thoughts.
. Z)isle/zciitg involves projecting into the future to put a problem in perspective and diminish
its importance. A woman realized that getting a B in a college course would mean little to her in lO
years
Bib/lorherapy, or the use of books in the counseling process, can help a person modify his
or her thinking. Reading books about other people who have coped well with experiences similar to
the client's, can be cathartic, providing emotional release, new ways of thinking and interacting,
and help clients to solve problems.
One example of bibliotherapy involved the treatment of a 12-year-old boy who had lost his
mother. The boy was sad, especially when he came home from school and she was not there. In
therapy, after the female therapist conducted an assessment and recognized the client's need for
catharsis, she gave him a copy of Tear Soup, a picture book about grief and loss in which a woman
is cooking soup(tear soup) that helps her express her underlying feelings of grief. The boy began to
identify with the person who was making the soup, and Qe recognition hat it was okay to grieve.
Other types of bibliotherapy include interactive bibiiotherapy in which a workbook is used to help
the client address the ongoing issue. Erford and colleagues(2010) provide the following recom-
mendations in the use of bibliotherapy:(1) Therapists should only use books they have read;(2) the
client's specific reality should be kept in mind during the process;(3) reading level and interest
should be taken into account; and(4) not all clients will enjoy reading or have Uie time to complete
the book. Movies and videos can also be used as a form of bibliotherapy.
Graded fast aislgnmen/s are activities that clients complete between sessions. Starting
with easy assignments that guarantee success, clinicians gradually increase the difficulty of the
tasks, so that people continue to learn from them and feels sense of mastery and accomplishment.

Termination and Relapse Prevention

Like the other phases of cognitive therapy, the concluding phase is carefully planned and structured
to help people successfully apply what they have teamed tluough treatment. Sessions afe scheduled
less #equently, typically shifting to every other week, then to once a month, then to every 3 months
for at least a year(Beck, 2011). This gives people the opportunity to test their skills and cope with
any setbacks while maintaining contact with their clinicians.
Nomializing setbacks and stwssing the importance of ongoing teaming can enable people to
cope with future disappointments successfully. Life skills such as assertiveness, decision making, cop-
ing strategies, and communication skills, which have probably been taught d)roughout the treaMlent
process, am reviewed and solidified. ProgKss also is mviewed, will every ebert made to help clients
accept credit for and take pride in their accomplishments. Clinicians address any concems that clients
have about termination and elicit feedback about the treatment process. Finally, clients and clinicians
collaborate in developing goals and plans for clients to continue their progress on heir own.
306 Part 4 ' Treatment Systems Emphasizing Thoughts

APPLICATION AND CURRENT USE OF COGNITIVE THERAPY

Cognitive therapy has established itself as a major treatment approach. Because Aaron Beck and his
co[[eagues, as we]] as other cognitive therapists, have encouraged and engaged in extensive research
on the impact of this approach, its effectiveness has been more clearly demonstrated in more than
500 outcome studies (Beck, 201 1). Cognitive therapy is elective in a variety of populations and
with an ever expanding range of applications.

Application to Diagnostic Groups

Originally developed f or the treatment of depression, cognitive therapy has since been found to be
effective for most of the major Axis Idisorders, particularly mood disorders, anxiety disorders, and
PTSD (Dobson, 2010). A recent study found sustained improvement at 5-year follow-up for the
treatment of social phobias (Mortberg, Clark, & Bergerot, 20 1 1). Cognitive therapy has been used
successfully to treat insomnia and alcohol abuse, to alleviate stress and wordy, to reduce suicidal
thoughts, and for pain management (Dobson, 2010; Hofmann, 201 2).
Because of its focus on changing cognitions, this type of therapy can provide an effective
adjunct to medica] treatment for disorders that are associated with high levels of stress, anxiety, or
depression. Clients with inferti]ity. epi]epsy, erectile dysfunction, and breast cancer have a]] reported
benefiting from adjunctive cognitive therapy to reduce negative cognitions. Cognitive treatment helps
people manage chronic pain(Otis, 2007), lowers anxiety in gay clients recently diagnosed with HIV
(Spiegler, 2008), helps people manage behavioral issues elated to epilepsy, and increases relaxation
and improves sleep in clients with restless leg syndrome(Homyak et al., 2008).
Beck and colleagues (2008) combined neurobiology with psychology to show how a cogni-
tive approach can be used to understand and beat schizophrenia. Delusions, hallucinations, negative
symptoms, and fomlal thought disorder are conceptualized in terms of cognitive theory. Growing
research in the area of severe mental disorders, such as bipolar disorder and schizophrenia, has
found cognitive therapy to be an elective adjunct to medication in the treatment of delusions and
hallucinations. Interventions include helping clients to recognize nonpsychotic misinteipretations
and cha]]enge their upsetting interpretations, behavioral experiments to help clients check out delu-
sional misinterpretations, and treatment to reduce symptoms of depression and anxiety and reduce
suicidal risk. Cognitive therapy has also been shown to improve insight and treatment adherence for
people with schizophrenia(Kingdon, Rathod, leiden, & Turkington, 2008). Cognitive therapy has
become so popular, and its e#ectiveness so widespread, that manuals and workbooks are available
for most Axis land Axis ll disorders.

Application to Multicultural Groups

Because cognitive therapy is respectful, addresses present concems, and does not require disclosure
of emotions and experiences that may feel very personal, this approach appeals to people from a
wide variety of ages and backgrounds. It is especially useful in treating people for whom sharing
thoughts is more comfortable and acceptable than sharing emotions. For example, the respectful
stance of the cognitive clinician, as well as the emphasis on thoughts inherent in this approach,
seems well suited for people from Asian backgrounds who omen are reluctant to share deeply per-
sonal experiences and emotions with people who are not close family or friends.
However, if there is a research gap to be found anywhere in the cognitive therapy literature, it
is in the area of cultural diversity. Certain groups are simply underrepresented in the treatment out-
come literature. While a growing number of those seeking treatment in the United States are from
an increasing[y diverse array of cu]tura] backgrounds, religions, sexual preferences, disabilities, and
 Chapter. 14 ' Aaron Beck and Cognitive Therapy 307

socioeconomic status, the providers of mental health services seem to be less diverse. In fact, the
American Psychological Association reports that 94%u of APA members are of European American
background(Pantalone, lwamasa, & Manel1, 2010).
What should a therapist do? "Do CBT as you know it," according to Pantalone and colleagues
(201 0, p. 454). Logic, as well as empirical research in general, suggests the value of using cognitive
therapy with people from diverse cultures. Of course, cognitive therapists must use culturally com-
petent skills and communication styles, and not make assumptions about what is in the person's
best interest. A collaborative approach that considers the client to be the expert on his or her own
problems would be consistent with the cognitive therapy paradigm. In one study, Kubany et al.
(2004) found that, in an adapted version of cognitive therapy used to treat "battered women" with
PTSD, "white and ethnic minority women beneHlted equally" (p. 3) from treatment.
There is some evidence that cognitive therapy is an effective treatment approach for people of
al] ages. Cognitive therapy can be adapted in work with elderly adults to accommodate age-related
cognitive decline (Gallagher-Thompson, Steffen, & Thompson, 2008). It is effective with play ther-
apy, and in improving self-esteem in children(Seller, 2008), and for childhood disorders such as
ADHD, conduct disorder, oppositional defiant disorder, adolescent mood and anxiety disorders,
eating disorders, and childhood trauma(Crawley, Podell, Beidas, Braswell, & Kendall, 2010; Hoch,
2009; Reinecke, Dattilio, & Freeman, 2006). Although components of each group will be specific
to the age-range and the disorder, common elements usuajjy include an education and problem-
solving component, cognitive restructuring, education about affect, relaxation training, practice or
role-playing, reinforcement, and some method to encourage transportability of lessons leaned to
other aspects of the child ' s life.
The following example provides an outline for a 10-session cognitive group therapy interven
lion for middle-school students with symptoms of PTSD (Stein et al., 2003, p. 605):
Session ]: Introductions, explanation of treatment using stories, infomiation on types of
stress and trauma

Sessio 2; Education about healthy responses to stress and trauma, relaxation training
Sessfolz 3: Introduction to cognitive therapy, explanation of the connection between thoughts
and feelings, measuring fear, fighting off negative thoughts
Session 4; More about staving off negative thoughts
Session 5: Coping strategies, construction of a fear hierarchy
SessfoB 6: Exposure to troubling memories through imagination, drawing, and writing
Session 7; Continuation of exposure-based treatment
Session 8: Social problem solving
SessloPZ 9: Practice using social problem solving via the hot seat
Sessioiz /O: Psychoeducation about relapse prevention and "graduation.
An increasing number of books, treatment manuals, meta-analyses, and research studies illus-
trate the populations and varieties of topics that can benefit from a cognitive group approach
(Crawley et al., 2010).

Application to Other Groups

Increasing use has been made of cognitive therapy with psychiatric inpatients, in partial hospitaliza-
tion programs, and dirough computer-assisted delivery methods. These modalities enable cognitive
therapists to reach more people and to use cognitive therapy for preventive purposes.
308 Part 4 ' Treatment Systems Emphasizing 'lboughts

A 4-year study on the effectiveness of cognitive-behavioral therapy with psychiatric inpa-

tients showed that a manualized treahnent approach to group therapy, as an adjunct to medication
and omer treatments, resulted in fewer readmissions for clients with schzophrenia and bipolar dis-
order(Velcro et al., 2008). Cognitive therapy has also been used successfully as an adjunct treat-
ment in partial hospitalization settings(Witt-Browder,2000).
Cognitive family therapy can also provide much-needed assistance. A study by Pavuluri
(2004) illusuates die integration of medication management, cognitive therapy, behavior therapy,
and family-focused therapy(FFT), along with psychoeducation to treat 34 children diagnosed wiki
bipolar disorder. Interventions focused on increasing coping skills and empathy in family members,
decreasing stress and expression of negative emotions, and improving family problem solving and
communication. Treatment also included collaboration with the children's teachers and psychoedu-
cation on bipolar disorders. Outcome measures found significant reductions in symptoms such as
attention difficulties, aggression, mania, psychosis, depression, and sleep disturbance, along with
improved overall functioning.
Psychoeducation, based on cognitive therapy, can be conducted with people experiencing
problems or mental disorders, with people at risk, and with a general population. Cognitive psych-
oeducation presents die concept that thoughts underlie feelings and actions and describes strategies
that people can use to monitor, assess, dispute, and modify their thoughts. ]nfomiation on behavio-
ral strategies further enhances the process.

Current Use of Cognitive Therapy

Although the fundamentals of Beck's cognitive therapy have changed little in the past 40 years
since it first gained attention, cognitive therapy continues to evolve. Two relatively new uses of
cognitive therapy that have provided greater depth and usefulness are schema therapy and emo-
tion schema therapy. Of course, behavioral therapy is the treatment method most commonly inte-
grated with cognitive therapy to create cognitive-behavioral therapy(CBT). But this treatment
modality is so extensive, it is the subject of its own chapter. Much more will be said about CBT
in Chapter 16.

SCHEMA THERAPY Schema therapy, developed by Jeffrey Young (1990/1999), goes beyond
Beck's cognitive therapy and integrates interpersonal, attachment, and experiential techniques to
achieve change at the emotional level. The approach goes deeper than most cognitive therapies, to
recognize that core schemas have developed in childhood that can have lifelong implications.
Schema therapy can be seamlessly integrated wiki CBT for Axis ll or other disorders such as sub-
stance abuse, mood and anxiety disorders, or eating disorders(Rafaeli, Bemstein, & Young, 2011).
The approach offers a bridge between regular CBT or brief fomis of treatment and longer interven-
tions that attempt to get at the root of more ingrained problems.
As discussed earlier, schema therapy was originally developed to work with clients with char-
acter disorders and those with chronic problems for whom focused interventions were not working.
By looking at early childhood adaptive pattems, schema therapy helps clients understand how
actions in the present bigger self-defeating emotional pattems from childhood. "Early maladaptive
schemas are self-defeating emotional pattems that begin early in our development and repeat
throughout life"(Young, Klosko, & Weishaar, 2006, p. 7).
Schema therapy helps clients to recognize their maladaptive pattems that fall within five
schema domains:

1. Z)fscoizizecdo a d re#ecHolz: Abandonment, defectiveness/shame, social isolation, emo

tional deprivation, mistrust/abuse
 Chapter 14 ' Aaron Beck and Cognitive Therapy 309

2 llnpaired autonom) and performance:

a. Dependence/incompetence
b. Vulnerability(to hama or illness)
c. Enmeshment
d. Failure
3 /nzpafred Zimlfs; Entitlement/grandiosity, lacldng self-control or discipline
4 Offer direc#edpzess; Approval- or recognition-seeking, subjugation, self-sacrificing
5 Oven'iBiZa ce a d IhibfHan; Negativity, emotional inhibition, punitiveness, unrelenting
standards/criticalness

When a schema is activated, a person responds in one of three ways:(1) overcompensation,(2)

avoidance, or(3) surrender to the schema as if it were true(Ohanian & Rashed, 2012). All dIrGe of
these responses could lead to problems in coping with life and relationships. For example, Suzanne
is a divorced woman who has an attachment schema that causes her to fear abandonment. Her attach-
ment schema is activated one Friday night when a man she has been seeing for 3 months does not
show up at the restaurant at the agreed-upon time. When activated, Suzanne responds wide emotions:
anger Mat he does not respect her enough to be on time, sadness that he might not be Me right man
for her, and fear that she will always be alone. She responds by leaving the restaurant in a huff, avoid-
ing his calls, and not responding to his text messages. Suzanne's method of coping(avoidance) was
leamed in childhood when she would avoid her mother's anger and wrath by leaving the house and
going to the neighbor's. But the childhood method of coping does not work so well now that Suzanne
is an adult. In this case, by actively avoiding the man's attempts {o reach her, she prevented him from
explaining that he had been in a car accident and was unable to keep the date. By resorting to her
childhood pattem of avoidance, Suzanne unconsciously contributed to the creation of the very situa-
tion that she feared most--an end of the relationship and the result that she is alone once again.
The goal of schema therapy is to help people achieve and maintain a healthy adult mode of
functioning(Ohanian & Rashad, 2012). The assessment phase may include the use of experiential
exercises and schema inventories such as the yoztng Schema Qzies/ionnafre(Young, 2005), the
Xo /zg Cornpeniaaon /nve/brow(Young, 2003a), Me yow/tg Paremffng /rzvenroW(Shefnleld et al.,
2005; Young, 2003b), and the Schema it/ode /nvenfoW(Young et al., 2007). T'he therapist's own
responses to the client also provide valuable infomiation.
Interventions in schema therapy include the use of cognitive and experiential techniques,
helping clients recognize and change self-defeating pattems, and the use of the power of the thera-
peutic alliance in an intervention known as limited reparenting(Kellogg & Young, 2008; Rafaeli et
al., 2011). By recognizing Aat people develop maladaptive schemas because core needs were not
met in childhood, the therapist works to create a therapeutic environment in which the client ' s needs
can be met. Therapists also use empathic confrontation to challenge clients' maladaptive schemas
(Edwards & Amtz, 2012).
People have a variety of schemas fiat they use in diHerent situations, including emotional, deci-
sional, relational, and physical schemas(Beck et al., 2006). Recent neurobiological Ksearch reinforces
that a great deal of mental processing occurs at the unconscious or implicit level(Uhlmann, Pizarro, &
Bloom, 2008). Temperament, biological predisposition, and life experience conuibute to the develop-
ment of coping styles. When working with schemas, the therapist must take care to balance empathic
attunement with caring con&ontation. The goal is to help clients develop and sustain a healthy adult
schema so they have greater amounts of flexibility and freedom, and, ultimately, am happier.
Schema therapy has been found to be elective in treating people with borderline personality
disorder(Farrell, Shaw, & Webber, 2009; Giesen-Bloo et al., 2006; Nadort et al., 2009), people with
Klational problems(Rafaeli et al., 2011), and people who an duaUy diagnosed with a co-occumng
310 Paa 4 Treatment Systems Emphasizing Thoughts

personality disorder and an Axis Idisorder such as an anxiety, mood, or substance use disorder.
Schema therapy can be brief, but is generally longer in duration, depending on the client's needs. It
also diners from cognitive therapy in that it explores childhood origins of psychological problems.

INTEGRATION WITH OTHER TREATMENT APPROACHES Cognitive therapy has increasingly been
combined with other approaches to create a powerful integrated treatment system. Clinicians cur-
rently practicing cognitive therapy also seem more cognizant of the importance of addressing emo-
tions. Emotional schema therapy (EST), recently developed by Leahy and colleagues (201 1), is an
integrative approach that combines schema therapy and cognitive restructuring with a focus on
emotion regulation. EST recognizes that emotion regulation is often a necessary precursor to being
able to accomplish cognitive work with clients, and is built on the following principles:
Emotions are universal and adaptive
Presuppositional beliefs and schemas about emotion lead to emotiona! expression that is
either appropriate or escalated, much as anxiety is escalated in a panic attack.
Schemas about emotion can include fear of expressing emotion, shame-based emotion
catash'ophizing, and feeling that one's emotions are unique, permanent, or out of control.
Strong emotions are viewed as intolerable feelings to be avoided, thus many people tum to
drugs, a]coho], binge eating, and other impulse control disorders in an attempt to reduce
strong emotions.
Emotional understanding, expression. and validation help to nomlalize, universalize, and
reduce shame, guilt, and fear associated with lack of emotional control (Leahy et al., 201 1).

EST interventions incorporate psychoeducation about emotions, as well as emotional valida-

tion and regulation techniques such as mindfulness, self-compassion (loving kindness), and stress
reduction. No research is currently available on the effectiveness of EST, but the combination of
cognitive and affective interventions has been associated with positive outcomes. More research is
necessary on this promising approach.
Cognitive therapy is also being used as a culturally sensitive method to help people with
trauma. Hinton and colleagues(2012) have adapted cognitive therapy to help traumatized refugees
and ethnic minorities. Their approach describes 1 2 components of culturally sensitive treatment for
refugees who have been traumatized and out]ines a model to improve emotional and cognitive flex-
ibility in this population.

EVALUATION OF COGNITIVE THERAPY

Although cognitive therapy has a great deal to offer, it also has ]imitations. Keeping these in mind
can help clinicians maximize the effectiveness of this approach.
Limitations
Cognitive therapy is, of course, not for everyone. It is a structured approach that requires people to
assume an active and collaborative role in their treatment and to complete suggested tasks between
sessions. In addition, cognitive therapy stresses present-oriented, relatively brief treatment. The
goal of cognitive therapy is improved ability to think clearly and cope with life's challenges.
People seeking unstructured, long-temp treatment that focuses on development of insight and
expo(x:anon of background may view ellis therapy as ill suited to their needs. In addition, people who aK
Kluctant to participate ftdly in their own tnatment, an intellectually limited, or are unmotivated to make
changes may not be good candidates. Canfbl screening of clients as well as discussion about the natuK
of cognitive therapy can help clinicians detemline if a cHent is an appropriate candidate for treatment.
 Chapter 14 ' Aaron Beck and Cognitive Therapy 311

Cognitive therapy also is demanding of clinicians. Clinicians must be organized, comfortable

with structure, and willing to use inventories and forms to elicit and assess clients' concems and
progress. They must be knowledgeable about human development, leaning theory, behavior ther-
apy, and diagnosis, and be able to skillfully use a broad range of interventions. Planning and effort
are integral to the success of cognitive therapy. Both clients and clinicians should be aware of the
commitment required by this approach.
Other potential limitations can result from therapist shortcomings. At its inception, some clini-
cians erroneously viewed cognitive therapy as a rapid solution to immediate concems; they neglected
to develop a strong therapeutic alliance, downplayed die importance of empad)y, and even became
critical and judgmental of what the clinicians perceived as people's dysfunctional thoughts. These
views reflect a misunderstanding of cognitive therapy and would not be reflected in effective treat-
ment. Readers should keep in mind that cognitive therapy has more depth and complexity than may be
evident initially and care should be taken to fully understand this powerful approach.

Strengths and Contributions

Cognitive therapy has many strengths. Because this approach is eHecdve at amelionating the most com-
mon concems presented for tnannent--depressionand anxiety--it is useful with a broad range of disor-
ders and c]ients. ]t is we]] received by most people because it is clear and logical and is not inuusive.
Cognitive thempy does not require people to share intimate detaUs of their past or focus extensively on
their emotions. It is an empowering and nonthreatening approach. As we have seen, cognitive dlerapy
draws on a broad allay of interventions and can be integrated with many other Ueatment approaches.
The clear and carefully planned structure of cognitive therapy facilitates both teaching and
research on this treatment system. lts time-limited nature makes it efHlcient and appealing, while its
use of long-temp follow-up provides a safeguard against relapse. lts emphasis on building a collabo-
rative client-clinician alliance, providing assignments between sessions, giving Me client credit for
progress, reinforcing positive changes, and teaching skills is empowering. This approach is designed
not just to resolve immediate problems but to enable people to manage their lives successfully.
Although mastery of cognitive therapy is not as simple as it seems, with training and experi-
ence most clinicians can easily lean and use it effectively. All clinicians should be familiar with the
powerful and important concepts of cognitive therapy.
Cognitive therapy has made important contributions to counseling and psychotherapy. Aaron
Beck's work, in particular, has emphasized the importance of research and evidence of effective-
ness. This has led to increased research throughout the helping professions as wellas development
of treatment manuals designed to provide some unifomlity to treatment and facilitate assessment of
efficacy. Cognitive therapy's use of case fomlulations and Ueatment planning is compatible with
today's emphasis on goal setting and accountability in treatment and has established a standard that
other treatment systems are expected to follow.
The field of cognitive assessment is mom han 30 years old. During that time, Beck and others
have promoted the development and use of many helpful inventories that illuminate cognitive proc-
esses, anxiety and mood disorders, phobias, schemas, and other constructs that had previously been
difficult to measure. Beck's depression and anxiety inventories, and Young's schema questionnaires
mentioned earlier, arejust a few of the self-report questionnaires that have become 6e most hequently
used tools for cognitive assessment available today(Dunkley, Blankstein, & Segal, 2010).
Perhaps the most important conuibution of cognitive therapy is the message that analysis and
modification of distorted cognitions are important ways to help people change. Although emotions,
actions, and background should never be ignored in treatment, helping people develop more realis-
tic cognitions is an elective and efficient way to help them reach their goals.
Behavior Therapy
9
LEARNING OBJECTIVES

1. Identify the key figures associated 7. Describe the key concepts of

with the development of behavior EMDR, its main applications, and
therapy. the effectiveness of this approach.
2. Differentiate the four 8. Describe the basic elements of
developmental areas of behavior social skills training.
therapy: classical conditioning, 9. Understand and explain the main
operant conditioning, social steps involved in self-management
cognitive theory, and cognitive programs.
behavior therapy.
10. Identify the key concepts of the
3. Evaluate the central characteristics four major approaches of the
and assumptions that unite the mindfulness and acceptance-
diverse field of behavior therapy. based behavior therapies.
4. Understand how the function and 11. Examine the application of
role of the therapist affects the behavioral principles and
therapy process. techniques to brief interventions
5. Describe the role of the client– and to group counseling.
therapist relationship in the 12. Understand the advantages and
behavioral approaches. shortcomings of behavior therapy
6. Identify the diverse array of in working with culturally diverse
behavioral techniques and clients.
procedures and how they fit 13. Discuss the evaluation of
within the evidence-based practice contemporary behavior therapy.
movement.

231
232 C HAP TE R NINE

B. F. SKINNER (1904–1990) reported given to environmental factors that can

that he was brought up in a warm, stable be directly observed and changed. He
family environment.* As he was grow- was extremely interested in the concept
ing up, Skinner was greatly interested of reinforcement, which he applied to
in building all sorts of things, an inter- his own life. For example, after working
est that followed him throughout his for many hours, he would go into his
professional life. He received his PhD in constructed cocoon (like a tent), put on
psychology from Harvard University in headphones, and listen to classical music
1931 and eventually returned to Harvard (Frank Dattilio, personal communica-

AP Images
after teaching in several universities. He tion, September 24, 2010).
had two daughters, one of whom is an Most of Skinner’s work was of an
educational psychologist and the other B. F. Skinner experimental nature in the laboratory,
an artist. but others have applied his ideas to teach-
Skinner was a prominent spokesperson for ing, managing human problems, and social plan-
behaviorism and can be considered the father of the ning. Science and Human Behavior (Skinner, 1953) best
behavioral approach to psychology. Skinner cham- illustrates how Skinner thought behavioral concepts
pioned radical behaviorism, which places primary could be applied to every domain of human behav-
emphasis on the effects of environment on behavior. ior. In Walden II (1948) Skinner describes a utopian
Skinner was also a determinist; he did not believe that community in which his ideas, derived from the lab-
humans had free choice. He acknowledged that feel- oratory, are applied to social issues. His 1971 book,
ings and thoughts exist, but he denied that they caused Beyond Freedom and Dignity, addressed the need for
our actions. Instead, he stressed the cause-and-effect drastic changes if our society was to survive. Skinner
links between objective, observable environmental believed that science and technology held the promise
conditions and behavior. Skinner maintained that for a better future.
too much attention had been given to internal states
of mind and motives, which cannot be observed and *This biography is based largely on Nye’s (2000) discussion of
changed directly, and that too little focus had been B. F. Skinner’s radical behaviorism.

ALBERT BANDURA (b. 1925) was born Bandura 1971a, 1971b; Bandura & Wal-
in a small town in northern Alberta, ters, 1963). In his research programs at
Courtesy, Dr. Albert Bandura, StanfordUniversity,

Canada; he was the youngest of six chil- Stanford University, Bandura and his
dren in a family of Eastern European colleagues explored social learning the-
descent.* Bandura spent his elemen- ory and the prominent role of observa-
tary and high school years in the one tional learning and social modeling in
school in town, which was short of human motivation, thought, and action.
teachers and resources. These meager By the mid-1980s Bandura had renamed
educational resources proved to be an his theoretical approach social cogni-
Palo Alto, CA

asset rather than a liability as Bandura tive theory, which shed light on how we
early on learned the skills of self-direct- function as self-organizing, proactive,
edness, which would later become one Albert Bandura self-reflective, and self-regulating beings
of his research themes. He earned his (see Bandura, 1986). This notion that we
PhD in clinical psychology from the University of are not simply reactive organisms shaped by environ-
Iowa in 1952, and a year later he joined the faculty mental forces or driven by inner impulses represented
at Stanford University. Bandura and his colleagues a dramatic shift in the development of behavior ther-
did pioneering work in the area of social model- apy. Bandura broadened the scope of behavior ther-
ing and demonstrated that modeling is a powerful apy by exploring the inner cognitive-affective forces
process that explains diverse forms of learning (see that motivate human behavior.
 B EH AV I O R T H ERAP Y 233

There are some existential qualities inherent in affect their lives; and (4) how stress reactions and
Bandura’s social cognitive theory. Bandura has pro- depressions are caused. Bandura has created one of
duced a wealth of empirical evidence that demon- the few mega-theories that still thrive in the 21st
strates the life choices we have in all aspects of our century. He has shown that people need a sense of
lives. In Self-Efficacy: The Exercise of Control (Bandura, self-efficacy and resilience to create a successful life
1997), Bandura shows the comprehensive applica- and to meet the inevitable obstacles and adversities
tions of his theory of self-efficacy to areas such as they encounter.
human development, psychology, psychiatry, educa- Bandura has written nine books, many of which
tion, medicine and health, athletics, business, social have been translated into various languages. In 2004
and political change, and international affairs. he received the Outstanding Lifetime Contribution
Bandura has concentrated on four areas of to Psychology Award from the American Psychologi-
research: (1) the power of psychological modeling cal Association. He still makes time for hiking, opera,
in shaping thought, emotion, and action; (2) the being with his family, and wine tasting in the Napa
mechanisms of human agency, or the ways peo- and Sonoma valleys.
ple influence their own motivation and behavior
through choice; (3) people’s perceptions of their *This biography is based largely on Panjares’s (2004) discussion of
efficacy to exercise influence over the events that Bandura’s life and work.

Introduction
Behavior therapy practitioners focus on directly observable behavior, current
determinants of behavior, learning experiences that promote change, tailoring
treatment strategies to individual clients, and rigorous assessment and evalua-
tion. Behavior therapy has been used to treat a wide range of psychological disor-
ders with specific client populations. Anxiety disorders, depression, posttraumatic
stress disorder, substance abuse, eating and weight disorders, sexual problems,
pain management, and hypertension have all been successfully treated using this
approach (Wilson, 2011). Behavioral procedures are used in the fields of develop-
mental disabilities, mental illness, education and special education, community
psychology, clinical psychology, rehabilitation, business, self-management, sports
psychology, health-related behaviors, medicine, and gerontology (Miltenberger,
2012; Wilson, 2011).

Historical Background
The behavioral approach had its origin in the 1950s and early 1960s, and it LO1
was a radical departure from the dominant psychoanalytic perspective. The behav-
ior therapy movement differed from other therapeutic approaches in its application
of principles of classical and operant conditioning (which will be explained shortly)
to the treatment of a variety of problem behaviors. Today, it is difficult to find a con-
sensus on the definition of behavior therapy because the field has grown, become
more complex, and is marked by a diversity of views. Contemporary behavior ther-
apy is no longer limited to treatments based on traditional learning theory (Antony
& Roemer, 2011b), and it increasingly overlaps with other theoretical approaches
(Antony, 2014). Behavior therapists now use a variety of evidence-based techniques
in their practices, including cognitive therapy, social skills training, relaxation
234 C HAP TE R NINE

training, and mindfulness strategies—all discussed in this chapter. The following

historical sketch of behavior therapy is largely based on Spiegler (2016).
Traditional behavior therapy arose simultaneously in the United States, South
Africa, and Great Britain in the 1950s. In spite of harsh criticism and resistance from
psychoanalytic psychotherapists, the approach has survived. Its focus was on dem-
onstrating that behavioral conditioning techniques were effective and were a viable
alternative to psychoanalytic therapy.
In the 1960s Albert Bandura developed social learning theory, which combined
classical and operant conditioning with observational learning. Bandura made
cognition a legitimate focus for behavior therapy. During the 1960s a number of
cognitive behavioral approaches sprang up, which focus on cognitive representations of
the environment rather than on characteristics of the objective environment.
Contemporary behavior therapy emerged as a major force in psychology during
the 1970s, and it had a significant impact on education, psychology, psychotherapy,
psychiatry, and social work. Behavioral techniques were expanded to provide solu-
tions for business, industry, and child-rearing problems as well. Behavior therapy
techniques were viewed as the treatment of choice for many psychological problems.
The 1980s were characterized by a search for new horizons in concepts and methods
that went beyond traditional learning theory. Behavior therapists continued to subject
their methods to empirical scrutiny and to consider the impact of the practice of therapy
on both their clients and the larger society. Increased attention was given to the role of
emotions in therapeutic change, as well as to the role of biological factors in psychologi-
cal disorders. Two of the most significant developments in the field were (1) the contin-
ued emergence of cognitive behavior therapy as a major force and (2) the application of
behavioral techniques to the prevention and treatment of health-related disorders.
By the late 1990s the Association for Behavioral and Cognitive Therapies (ABCT)
(formerly known as the Association for Advancement of Behavior Therapy) claimed
a membership of about 4,500. Currently, ABCT includes approximately 6,000 men-
tal health professionals and students who are interested in empirically based behav-
ior therapy or cognitive behavior therapy. This name change and description reveals
the current thinking of integrating behavioral and cognitive therapies.
By the early 2000s, the behavioral tradition had broadened considerably, which
involved enlarging the scope of research and practice. This newest development,
sometimes known as the “third generation” or “third wave” of behavior therapy,
includes dialectical behavior therapy (DBT), mindfulness-based stress reduction
(MBSR), mindfulness-based cognitive therapy (MBCT), and acceptance and com-
mitment therapy (ACT). Behavior therapies are among the most widely used treat-
ment interventions for psychological and behavioral problems today (Antony, 2014).
Visit CengageBrain.com or watch the DVD for the video program on Chapter 9, Theory and
Practice of Counseling and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you view the
brief lecture for each chapter prior to reading the chapter.

Four Areas of Development

Contemporary behavior therapy can be understood by considering four LO2
major areas of development: (1) classical conditioning, (2) operant conditioning,
(3) social-cognitive theory, and (4) cognitive behavior therapy.
 B EH AV I O R T H ERAP Y 235

Classical conditioning (respondent conditioning) refers to what happens prior

to learning that creates a response through pairing. A key figure in this area is Ivan
Pavlov who illustrated classical conditioning through experiments with dogs. Plac-
ing food in a dog’s mouth leads to salivation, which is respondent behavior. When
food is repeatedly presented with some originally neutral stimulus (something that
does not elicit a particular response), such as the sound of a bell, the dog will eventu-
ally salivate to the sound of the bell alone. However, if a bell is sounded repeatedly
but not paired again with food, the salivation response will eventually diminish and
become extinct. An example of a procedure that is based on the classical condition-
ing model is Joseph Wolpe’s systematic desensitization, which is described later in
this chapter. This technique illustrates how principles of learning derived from the
experimental laboratory can be applied clinically. Desensitization can be applied to
people who, through classical conditioning, developed an intense fear of flying after
having a frightening experience while flying.
Technically one can develop an intense fear of flying without having a frighten-
ing experience personally. For example, someone may see visual images of a plane
crashing off the coast of Brazil and develop a fear of flying even though that person
has never flown anywhere. Some researchers hold a different view and believe that
fear of flying may be due primarily to claustrophobia (Frank Dattilio, personal com-
munication, September 24, 2010).
Most of the significant responses we make in everyday life are examples of oper-
ant behaviors, such as reading, writing, driving a car, and eating with utensils. Oper-
ant conditioning involves a type of learning in which behaviors are influenced
mainly by the consequences that follow them. If the environmental changes brought
about by the behavior are reinforcing—that is, if they provide some reward to the
organism or eliminate aversive stimuli—the chances are increased that the behavior
will occur again. If the environmental changes produce no reinforcement or pro-
duce aversive stimuli, the chances are lessened that the behavior will recur. Posi-
tive and negative reinforcement, punishment, and extinction techniques, described
later in this chapter, illustrate how operant conditioning in applied settings can be
instrumental in developing prosocial and adaptive behaviors. Operant techniques
are used by behavioral practitioners in parent education programs and with weight
management programs.
The behaviorists of both the classical and operant conditioning models
excluded any reference to mediational concepts, such as the role of thinking pro-
cesses, attitudes, and values. This focus is perhaps due to a reaction against the
insight-oriented psychodynamic approaches. The social learning approach (or the
social-cognitive approach) developed by Albert Bandura and Richard Walters (1963) is
interactional, interdisciplinary, and multimodal (Bandura, 1977, 1982). Social-cognitive
theory involves a triadic reciprocal interaction among the environment, personal fac-
tors (beliefs, preferences, expectations, self-perceptions, and interpretations), and
individual behavior. In the social-cognitive approach, the environmental events on
behavior are mainly determined by cognitive processes governing how environmen-
tal influences are perceived by an individual and how these events are interpreted. A
basic assumption is that people are capable of self-directed behavior change and that
the person is the agent of change. For Bandura (1982, 1997), self-efficacy is the indi-
vidual’s belief or expectation that he or she can master a situation and bring about
236 C HAP TE R NINE

desired change. An example of social learning is ways people can develop effective
social skills after they are in contact with other people who effectively model inter-
personal skills.
Cognitive behavior therapy (CBT) represents the mainstream of contempo-
rary behavior therapy and is a popular theoretical orientation among psychologists.
Cognitive behavioral therapy operates on the assumption that what people believe
influences how they act and feel. Since the early 1970s, the behavioral movement
has conceded a legitimate place to thinking, even to the extent of giving cognitive
factors a central role in understanding and treating emotional and behavioral prob-
lems. By the mid-1970s, cognitive behavior therapy had replaced behavior therapy as the
accepted designation, and the field began emphasizing the interaction among affec-
tive, behavioral, and cognitive dimensions.
Contemporary behavior therapy has much in common with cognitive behavior
therapy in which the mechanism of change is both cognitive (modifying thoughts
to change behaviors) and behavioral (altering external factors that lead to behavior
change; Follette & Callaghan, 2011). Social skills training, cognitive therapy, stress
management training, mindfulness, and acceptance-based practices all represent
the cognitive behavioral tradition. This chapter goes beyond the traditional behav-
ioral perspective and deals mainly with applied aspects of this model. Chapter 10 is
devoted to the cognitive behavioral approaches, which focus on changing clients’
cognitions (thoughts and beliefs) that maintain psychological problems.

Key Concepts
Current Trend in Behavior Therapy
Contemporary behavior therapy is grounded on a scientific view of human behavior
that accommodates a systematic and structured approach to counseling. The cur-
rent trend in behavior therapy is toward developing procedures that give control to
clients and thus increase their range of freedom. Behavior therapy aims to increase
people’s skills so that they have more options for responding. By overcoming debili-
tating behaviors that restrict choices, people are freer to select from possibilities
that were not available to them earlier, which increases individual freedom.

Basic Characteristics and Assumptions

Seven key characteristics define behavior therapy and its assumptions. One LO3
defining characteristic is that behavior therapy is based on the principles and pro-
cedures of the scientific method. Experimentally derived principles of learning
are systematically applied to help people change their maladaptive behaviors. The
distinguishing characteristic of behavioral practitioners is their systematic adher-
ence to precision and to empirical evaluation. Behavior therapists state treatment
goals in concrete objective terms to make replication of their interventions possible.
Treatment goals are agreed upon by the client and the therapist. Throughout the
course of therapy, the therapist assesses problem behaviors and the conditions that
are maintaining them. Evaluation methods are used to discern the effectiveness
 B EH AV I O R T H ERAP Y 237

of both assessment and treatment procedures. Therapeutic techniques employed

must have demonstrated effectiveness. In short, behavioral concepts and proce-
dures are stated explicitly, tested empirically within a conceptual framework, and
revised continually.
Behavior is not limited to overt actions a person engages in that we can observe,
however; behavior also includes internal processes such as cognitions, images,
beliefs, and emotions. The key characteristic of a behavior is that it is something
that can be operationally defined.
Behavior therapy deals with the client’s current problems and the factors influ-
encing them today rather than analyzing possible historical determinants. Empha-
sis is on specific factors that influence present functioning and what factors can be
used to modify performance. Behavior therapists look to the current environmental
events that maintain problem behaviors and help clients produce behavior change
by changing environmental events, through a process called functional assessment, or
what Wolpe (1990) referred to as a “behavioral analysis.” Behavior therapy recog-
nizes the importance of the individual, the individual’s environment, and the inter-
action between the person and the environment in facilitating change.
Clients involved in behavior therapy are expected to assume an active role by
engaging in specific actions to deal with their problems. Rather than simply talking
about their condition, clients are required to do something to bring about change.
Clients monitor their behaviors both during and outside the therapy sessions, learn
and practice coping skills, and role-play new behavior. Therapeutic tasks that clients
carry out in daily life, or homework assignments, are a basic part of this approach.
Behavior therapy is an action-oriented and an educational approach, and learning is
viewed as being at the core of therapy. Clients learn new and adaptive behaviors to
replace old and maladaptive behaviors.
This approach assumes that change can take place without insight into under-
lying dynamics and without understanding the origins of a psychological problem.
Behavior therapists operate on the premise that changes in behavior can occur prior
to or simultaneously with understanding of oneself, and that behavioral changes
may well lead to an increased level of self-understanding. Although it is true that
insight and understanding about the contingencies that exacerbate one’s problems
can supply motivation to change, knowing that one has a problem and knowing how
to change it are two different things (Martell, 2007).
Assessment is an ongoing process of observation and self-monitoring that
focuses on the current determinants of behavior, including identifying the prob-
lem and evaluating the change. Assessment informs the treatment process and
involves attending to the culture of clients as part of their social environments,
including social support networks relating to target behaviors. Critical to behav-
ioral approaches is the careful assessment and evaluation of the interventions used
to determine whether the behavior change resulted from the procedure.
Behavioral treatment interventions are individually tailored to specific prob-
lems experienced by the client. Several therapy techniques may be used to treat an
individual client’s problems. An important question that serves as a guide for this
choice is, “What treatment, by whom, is the most effective for this individual with that
specific problem and under which set of circumstances?” (Paul, 1967, p. 111).
238 C HAP TE R NINE

The Therapeutic Process

Therapeutic Goals
Goals occupy a place of central importance in behavior therapy. The general goals
of behavior therapy are to increase personal choice and to create new conditions for
learning. The client, with the help of the therapist, defines specific treatment goals
at the outset of the therapeutic process. Although assessment and treatment occur
together, a formal assessment takes place prior to treatment to determine behaviors
that are targets of change. Continual assessment throughout therapy determines
the degree to which identified goals are being met. It is important to devise a way to
measure progress toward goals based on empirical validation.
Contemporary behavior therapy stresses clients’ active role in formulating spe-
cific measurable goals. Goals must be clear, concrete, understood, and agreed on by
the client and the counselor. The counselor and client discuss the behaviors associ-
ated with the goals, the circumstances required for change, the nature of subgoals,
and a plan of action to work toward these goals. This process of determining thera-
peutic goals entails a negotiation between client and counselor that results in a con-
tract that guides the course of therapy. Behavior therapists and clients alter goals
throughout the therapeutic process as needed.

Therapist’s Function and Role

Behavior therapists conduct a thorough functional assessment (or behav- LO4
ioral analysis) to identify the maintaining conditions by systematically gather-
ing information about situational antecedents (A), the dimensions of the problem
behavior (B), and the consequences (C) of the problem. This is known as the ABC
model, and the goal of a functional assessment of a client’s behavior is to under-
stand the ABC sequence. This model of behavior suggests that behavior (B) is influ-
enced by some particular events that precede it, called antecedents (A), and by certain
events that follow it, called consequences (C). Antecedent events cue or elicit a cer-
tain behavior. For example, with a client who has trouble going to sleep, listening to
a relaxation tape may serve as a cue for sleep induction. Turning off the lights
and removing the television from the bedroom may elicit sleep behaviors as well.
Consequences are events that maintain a behavior in some way, either by increas-
ing or decreasing it. For example, a client may be more likely to return to counseling
after the counselor offers verbal praise or encouragement for having come in or for
having completed some homework. A client may be less likely to return if the coun-
selor is consistently late to sessions. In doing a behavioral assessment interview,
the therapist’s task is to identify the particular antecedent and consequent events
that influence, or are functionally related to, an individual’s behavior (Cormier,
Nurius, & Osborn, 2013).
Behaviorally oriented practitioners tend to be active and directive and to func-
tion as consultants and problem solvers. They rely heavily on empirical evidence
about the efficacy of the techniques they apply to particular problems. Behavioral
practitioners must have skills in selecting and applying treatment methods. They pay
close attention to the clues given by clients, and they are willing to follow their clini-
cal hunches. Behavior therapists use some techniques common to other approaches,
 B EH AV I O R T H ERAP Y 239

such as summarizing, reflection, clarification, and open-ended questioning. Behav-

ior therapists are directive and often offer suggestions (Antony, 2014), but they may
perform these other functions as well (Miltenberger, 2012; Speigler, 2016):
ŠThe therapist strives to understand the function of client behaviors,
including how certain behaviors originated and how they are sustained.
With this understanding, the therapist formulates initial treatment
goals and designs and implements a treatment plan to accomplish
these goals.
ŠThe behavioral clinician uses strategies that have research support for
use with a particular kind of problem. These evidence-based strategies
promote generalization and maintenance of behavior change. A num-
ber of these strategies are described later in this chapter.
ŠThe clinician evaluates the success of the change plan by measuring
progress toward the goals throughout the duration of treatment. Out-
come measures are given to the client at the beginning of treatment
(called a baseline) and collected again periodically during and after
treatment to determine whether the strategy and treatment plan are
working. If not, adjustments are made in the strategies being used.
ŠFollow-up assessments are conducted to evaluate whether the changes
are durable over time. Clients learn how to identify and cope with
potential setbacks and acquire behavioral and cognitive coping skills to
maintain changes and to prevent relapses.
Let’s examine how a behavior therapist might perform these functions. A cli-
ent comes to therapy to reduce her anxiety, which is preventing her from leaving the
house. The therapist is likely to begin with a specific analysis of the nature of her
anxiety. The therapist will ask how she experiences the anxiety of leaving her house,
including what she actually does in these situations. Systematically, the therapist gath-
ers information about this anxiety. When did the problem begin? In what situations
does it arise? What does she do at these times? What are her feelings and thoughts in
these situations? Who is present when she experiences anxiety? What does she do to
reduce the anxiety? How do her present fears interfere with living effectively? After this
assessment, specific behavioral goals are developed, and strategies such as relaxation
training, systematic desensitization, and exposure therapy are designed to help the
client reduce her anxiety to a manageable level. The therapist will get a commitment
from the client to work toward the specified goals, and the two of them will evaluate
the client’s progress toward meeting these goals throughout the duration of therapy.
For a description of applying a behavioral approach to the assessment and treat-
ment of an individual client, see Dr. Sherry Cormier’s behavioral interventions with
Ruth in Case Approach to Counseling and Psychotherapy (Corey, 2013, chap. 7).

Client’s Experience in Therapy

One of the unique contributions of behavior therapy is that it provides the therapist
with a well-defined system of procedures to employ. Both therapist and client have
clearly defined roles, and the importance of client awareness and participation in
the therapeutic process is stressed. Behavior therapy is characterized by an active
240 C HAP TE R NINE

role for both therapist and client. A large part of the therapist’s role is to teach
concrete skills through the provision of instructions, modeling, and performance
feedback. The client engages in behavioral rehearsal with feedback until skills are
well learned and generally receives active homework assignments (such as self-
monitoring of problem behaviors) to complete between therapy sessions. Behavior
clinicians emphasize that changes clients make in therapy need to be translated into
their daily lives.
It is important for clients to be motivated to change, and they are expected to
cooperate in carrying out therapeutic activities, both during therapy sessions and in
everyday life. If clients are not involved in this way, the chances are slim that therapy
will be successful. Motivational interviewing (see Chapter 7), which honors the cli-
ent’s resistance in such a way that his or her motivation to change is increased over
time, is a behavioral strategy that has considerable empirical support (Miller & Roll-
nick, 2013).
Clients are encouraged to experiment for the purpose of enlarging their reper-
toire of adaptive behaviors. Counseling is not complete unless actions follow verbal-
izations. Behavioral practitioners make the assumption that it is only when the
transfer of changes is made from the sessions to everyday life that the effects of
therapy can be considered successful. Clients are as aware as the therapist is regard-
ing when the goals have been accomplished and when it is appropriate to terminate
treatment. It is clear that clients are expected to do more than merely gather insights;
they need to be willing to make changes and to continue implementing new behav-
ior once formal treatment has ended.

Relationship Between Therapist and Client

Behavioral practitioners have increasingly recognized the role of the thera- LO5
peutic relationship and therapist behavior as critical factors related to the process
and outcome of treatment. As you will recall, the experiential therapies (existential
therapy, person-centered therapy, and Gestalt therapy) place primary emphasis on
the nature of the engagement between counselor and client. Today most behavioral
practitioners stress the value of establishing a collaborative working relationship
with clients but contend that warmth, empathy, authenticity, permissiveness, and
acceptance are necessary, but not sufficient, for behavior change to occur. The client–
therapist relationship is a foundation on which behavioral strategies are built to
help clients change in the direction they wish.

Application: Therapeutic Techniques and Procedures

A strength of the behavioral approaches is the development of specific thera- LO6
peutic procedures that must be shown to be effective through objective means. The
results of behavioral interventions become clear because therapists receive continual
direct feedback from their clients. A hallmark of the behavioral approaches is that
the therapeutic techniques are empirically supported and evidence-based practice is
highly valued. Behavior therapy has been shown to be effective with many different
populations and for a wide array of disorders. Behavioral techniques can easily be
incorporated in other approaches as well.
 B EH AV I O R T H ERAP Y 241

The therapeutic procedures used by behavior therapists are specifically designed

for a particular client rather than being randomly selected from a “bag of techniques.”
Therapists are often quite creative in their interventions. In the following sections I
describe a range of behavioral techniques available to the practitioner: applied behav-
ioral analysis, relaxation training, systematic desensitization, exposure therapies, eye
movement desensitization and reprocessing, social skills training, self-management
programs, multimodal therapy, and mindfulness and acceptance-based approaches.
These techniques do not encompass the full spectrum of behavioral procedures, but
they do represent a sample of the approaches used in the practice of contemporary
behavior therapy.

Applied Behavioral Analysis: Operant Conditioning Techniques

This section describes a few key principles of operant conditioning: positive rein-
forcement, negative reinforcement, extinction, positive punishment, and negative
punishment. For a detailed treatment of the wide range of operant conditioning
methods that are part of contemporary behavior modification, I recommend Milt-
enberger (2012) and Speigler (2016).
The most important contribution of applied behavior analysis is that it offers a
functional approach to understanding clients’ problems and addresses these prob-
lems by changing antecedents and consequences (the ABC model). Behaviorists
believe we respond in predictable ways because of the gains we experience (positive
reinforcement) or because of the need to escape or avoid unpleasant consequences
(negative reinforcement). Once clients’ goals have been assessed, specific behaviors
are targeted. The goal of reinforcement, whether positive or negative, is to increase
the target behavior. Positive reinforcement involves the addition of something of
value to the individual (such as praise, attention, money, or food) as a consequence
of certain behavior. The stimulus that follows the behavior is the positive reinforcer.
For example, a child earns excellent grades and is praised for studying by her parents.
If she values this praise, it is likely that she will have an investment in studying in the
future. When the goal of a program is to decrease or eliminate undesirable behav-
iors, positive reinforcement is often used to increase the frequency of more desirable
behaviors, which replace undesirable behaviors. In the above example, the parental
praise functions as the positive reinforcer and makes it more likely that the child
will maintain or even increase the frequency of studying and earning good grades.
Note that if a child did not value parental praise, this would not serve as a reinforcer.
The reinforcer is not defined by the form or substance that it takes but rather by the
function it serves: namely, to maintain or increase the frequency of a desired behavior.
Negative reinforcement involves the escape from or the avoidance of aversive
(unpleasant) stimuli. The individual is motivated to exhibit a desired behavior to
avoid the unpleasant condition. For example, a friend of mine does not appreciate
waking up to the shrill sound of an alarm clock. She has trained herself to wake up
a few minutes before the alarm sounds to avoid the aversive stimulus of the alarm
buzzer.
Another operant method of changing behavior is extinction, which refers to
withholding reinforcement from a previously reinforced response. In applied set-
tings, extinction can be used for behaviors that have been maintained by positive
242 C HAP TE R NINE

reinforcement or negative reinforcement. For example, in the case of children who

display temper tantrums, parents often reinforce this behavior by the attention they
give to it. An approach to dealing with problematic behavior is to eliminate the con-
nection between a certain behavior (tantrums) and positive reinforcement (atten-
tion). In this example, if the parent ignores the child’s tantrum-related behaviors,
these behaviors will decrease or be eliminated through the extinction process. It should
be noted that extinction might well have negative side effects, such as anger and
aggression. Also note that during the extinction process unwanted behaviors may
increase temporarily before they begin to decrease. Extinction can reduce or elimi-
nate certain behaviors, but extinction does not replace those responses that have
been extinguished.
Another way behavior is controlled is through punishment, sometimes referred
to as aversive control, in which the consequences of a certain behavior result in a
decrease of that behavior. The goal of reinforcement is to increase target behavior, but
the goal of punishment is to decrease target behavior. Miltenberger (2012) describes
two kinds of punishment that may occur as a consequence of behavior: positive
punishment and negative punishment. In positive punishment an aversive stimu-
lus is added after the behavior to decrease the frequency of a behavior (such as a time-
out procedure with a child who is displaying misbehavior).
In negative punishment a reinforcing stimulus is removed following the behav-
ior to decrease the frequency of a target behavior (such as deducting money from a
worker’s salary for missing time at work, or taking television time away from a child
for misbehavior). In both kinds of punishment, the behavior is less likely to occur in
the future. These four operant procedures form the basis of behavior therapy pro-
grams for parent skills training and are also used in the self-management proce-
dures that are discussed later in this chapter.
Some behavioral practitioners are opposed to using aversive control or punish-
ment and recommended substituting positive reinforcement. The key principle in
the applied behavior analysis approach is to use the least aversive means possible
to change behavior, and positive reinforcement is known to be the most powerful
change agent. It is essential that reinforcement be used as a way to develop appropri-
ate behaviors that replace the behaviors that are suppressed.

Progressive Muscle Relaxation

Progressive muscle relaxation has become increasingly popular as a method of
teaching people to cope with the stresses produced by daily living. It is aimed at
achieving muscle and mental relaxation and is easily learned. After clients learn the
basics of relaxation procedures, it is essential that they practice these exercises daily
to obtain maximum results.
Jacobson (1938) is credited with initially developing the progressive muscle relax-
ation procedure. It has since been refined and modified, and relaxation procedures
are frequently used in combination with a number of other behavioral techniques.
Progressive muscle relaxation involves several components. Clients are given a set of
instructions that teaches them to relax. They assume a passive and relaxed position
in a quiet environment while alternately contracting and relaxing muscles. This pro-
gressive muscle relaxation is explicitly taught to the client by the therapist. Deep and
 B EH AV I O R T H ERAP Y 243

regular breathing also is associated with producing relaxation. At the same time cli-
ents learn to mentally “let go,” perhaps by focusing on pleasant thoughts or images.
Clients are instructed to actually feel and experience the tension building up, to notice
their muscles getting tighter and study this tension, and to hold and fully experience
the tension. It is useful for clients to experience the difference between a tense and a
relaxed state. The client is then taught how to relax all the muscles while visualizing
the various parts of the body, with emphasis on the facial muscles. The arm muscles
are relaxed first, followed by the head, the neck and shoulders, the back, abdomen,
and thorax, and then the lower limbs. Relaxation becomes a well-learned response,
which can become a habitual pattern if practiced daily for about 25 minutes each day.
Relaxation procedures have been applied to a variety of clinical problems, either
as a separate technique or in conjunction with related methods. The most common
use has been with problems related to stress and anxiety, which are often mani-
fested in psychosomatic symptoms. Relaxation training has benefits in areas such
as preparing patients for surgery, teaching clients how to cope with chronic pain,
and reducing the frequency of migraine attacks (Ferguson & Sgambati, 2008). Some
other ailments for which progressive muscle relaxation is helpful include asthma,
headache, hypertension, insomnia, irritable bowel syndrome, and panic disorder
(Cormier et al., 2013).
For an exercise of the phases of the progressive muscle relaxation procedure that
you can apply to yourself, see Student Manual for Theory and Practice of Counseling and
Psychotherapy (Corey, 2017). For a more detailed discussion of progressive muscle
relaxation, see Ferguson and Sgambati (2008).

Systematic Desensitization
Systematic desensitization, which is based on the principle of classical condition-
ing, is a basic behavioral procedure developed by Joseph Wolpe, one of the pioneers
of behavior therapy. Clients imagine successively more anxiety-arousing situations
at the same time that they engage in a behavior that competes with anxiety. Grad-
ually, or systematically, clients become less sensitive (desensitized) to the anxiety-
arousing situation. This procedure can be considered a form of exposure therapy
because clients are required to expose themselves to anxiety-arousing images as a
way to reduce anxiety.
Systematic desensitization is an empirically researched behavior therapy pro-
cedure that is time consuming, yet it is clearly effective and efficient in reducing
maladaptive anxiety and treating anxiety-related disorders, particularly in the area
of specific phobias (Cormier et al., 2013; Spiegler, 2016). Before implementing the
desensitization procedure, the therapist conducts an initial interview to identify spe-
cific information about the anxiety and to gather relevant background information
about the client. This interview, which may last several sessions, gives the therapist
a good understanding of who the client is. The therapist questions the client about
the particular circumstances that elicit the conditioned fears. For instance, under
what circumstances does the client feel anxious? If the client is anxious in social
situations, does the anxiety vary with the number of people present? Is the client
more anxious with women or men? The client is asked to begin a self-monitoring
process consisting of observing and recording situations during the week that elicit
244 C HAP TE R NINE

anxiety responses. Some therapists also administer a questionnaire to gather addi-

tional data about situations leading to anxiety.
If the decision is made to use the desensitization procedure, the therapist gives
the client a rationale for the procedure and briefly describes what is involved. A three-
step process is carried out in the desensitization process: (1) relaxation training, (2)
development of a graduated anxiety hierarchy, and (3) systematic desensitization
through presentation of hierarchy items while the client is in a deeply relaxed state
(Head & Gross, 2008).
The first step is progressive muscle relaxation, which were described earlier. The
therapist uses a quiet, soft, and pleasant voice to teach progressive muscular relax-
ation. The client is asked to create imagery of previously relaxing situations, such
as sitting by a lake or wandering through a beautiful field. It is important that the
client reach a state of calm and peacefulness. The client is instructed to practice
relaxation both as a part of the desensitization procedure and also outside the ses-
sion on a daily basis.
The therapist then works with the client to develop an anxiety hierarchy for each
of the identified areas. Stimuli that elicit anxiety in a particular area are analyzed,
such as rejection, jealousy, criticism, disapproval, or any phobia. The therapist con-
structs a ranked list of situations that elicit increasing degrees of anxiety or avoid-
ance. The hierarchy is arranged in order from the most anxiety-provoking situation
the client can imagine down to the situation that evokes the least anxiety. If it has
been determined that the client has anxiety related to fear of rejection, for exam-
ple, the highest anxiety-producing situation might be rejection by the spouse, next,
rejection by a close friend, and then rejection by a coworker. The least disturbing
situation might be a stranger’s indifference toward the client at a party.
Desensitization does not begin until several sessions after the initial interview has
been completed. Enough time is allowed for clients to learn relaxation in therapy
sessions, to practice it at home, and to construct their anxiety hierarchy. The desen-
sitization process begins with the client reaching complete relaxation with eyes
closed. A neutral scene is presented, and the client is asked to imagine it. If the client
remains relaxed, he or she is asked to imagine the least anxiety-arousing scene on
the hierarchy of situations that has been developed. The therapist moves progres-
sively up the hierarchy until the client signals that he or she is experiencing anxiety,
at which time the scene is terminated. Relaxation is then induced again, and the
scene is reintroduced again until little anxiety is experienced to it. Treatment ends
when the client is able to remain in a relaxed state while imagining the scene that
was formerly the most disturbing and anxiety-producing. The core of systematic
desensitization is repeated exposure in the imagination to anxiety-evoking situa-
tions without experiencing any negative consequences.
Homework and follow-up are essential components of successful desensiti-
zation. Clients are encouraged to practice selected relaxation procedures daily, at
which time they visualize scenes completed in the previous session. Gradually, they
can expose themselves to daily-life situations as a further way to manage their anxi-
eties. Clients tend to benefit the most when they have a variety of ways to cope with
anxiety-arousing situations that they can continue to use once therapy has ended
(Head & Gross, 2008).
 B EH AV I O R T H ERAP Y 245

Systematic desensitization is among the most empirically supported therapy

methods available, especially for the treatment of anxiety. Not only does systematic
desensitization have a good track record in dealing with fears, it also has been used
to treat a variety of conditions including anger, asthmatic attacks, insomnia, motion
sickness, nightmares, and sleepwalking (Spiegler, 2016). Systematic desensitization
is often acceptable to clients because they are gradually and symbolically exposed to
anxiety-evoking situations. For a more detailed discussion of systematic desensitiza-
tion, see Head and Gross (2008), Speigler (2016), and Cormier et al. (2013).

In Vivo Exposure and Flooding

Exposure therapies are designed to treat fears and other negative emotional responses
by introducing clients, under carefully controlled conditions, to the situations that
contributed to such problems. Exposure is a key process in treating a wide range
of problems associated with fear and anxiety. Exposure therapy involves systematic
confrontation with a feared stimulus, either through imagination or in vivo (live).
Imaginal exposure can be used prior to implementing in vivo exposure when a
client’s fears are so severe that the client is unable to participate in live exposure
(Hazlett-Stevens & Craske, 2008). Whatever route is used, exposure involves con-
tact by clients with what they find fearful. Desensitization is one type of exposure
therapy, but there are others. Two variations of traditional systematic desensitiza-
tion are in vivo exposure and flooding.

In Vivo Exposure In vivo exposure involves client exposure to the actual anxiety-
evoking events rather than simply imagining these situations. Live exposure has been
a cornerstone of behavior therapy for decades. Hazlett-Stevens and Craske (2008)
describe the key elements of the process of in vivo exposure. Typically, treatment
begins with a functional analysis of objects or situations a person avoids or fears.
Together, the therapist and the client generate a hierarchy of situations for the client
to encounter in ascending order of difficulty. In vivo exposure involves repeated
systematic exposure to fear items, beginning from the bottom of the hierarchy.
Clients engage in a brief, graduated series of exposures to feared events. As is the case
with systematic desensitization, clients learn responses incompatible with anxiety,
such as responses involving muscle relaxation. Clients are encouraged eventually to
experience their full fear response during exposure without engaging in avoidance.
Between therapy sessions, clients carry out self-directed exposure exercises. Clients’
progress with home practice is reviewed, and the therapist provides feedback on
how the client could deal with any difficulties encountered.
In some cases the therapist may accompany clients as they encounter feared sit-
uations. For example, a therapist could go with clients in an elevator if they had pho-
bias of using elevators. Of course, when this kind of out-of-office procedure is used,
matters of safety and appropriate ethical boundaries are always considered. People
who have extreme fears of certain animals could be exposed to these animals in real
life in a safe setting with a therapist. Self-managed in vivo exposure—a procedure in
which clients expose themselves to anxiety-evoking events on their own—is an alter-
native when it is not practical for a therapist to be with clients in real-life situations.
246 C HAP TE R NINE

Flooding Another form of exposure therapy is flooding, which refers to either in

vivo or imaginal exposure to anxiety-evoking stimuli for a prolonged period of time.
As is characteristic of all exposure therapies, even though the client experiences
anxiety during the exposure, the feared consequences do not occur.
In vivo flooding consists of intense and prolonged exposure to the actual anx-
iety-producing stimuli. Remaining exposed to feared stimuli for a prolonged period
without engaging in any anxiety-reducing behaviors allows the anxiety to decrease
on its own. Generally, highly fearful clients tend to curb their anxiety through the
use of maladaptive behaviors. In flooding, clients are prevented from engaging in
their usual maladaptive responses to anxiety-arousing situations. In vivo flooding
tends to reduce anxiety rapidly.
Imaginal flooding is based on similar principles and follows the same proce-
dures except the exposure occurs in the client’s imagination instead of in daily life.
An advantage of using imaginal flooding over in vivo flooding is that there are no
restrictions on the nature of the anxiety-arousing situations that can be treated. In
vivo exposure to actual traumatic events (airplane crash, rape, fire, flood) is often
not possible nor is it appropriate for both ethical and practical reasons. Imagi-
nal flooding can re-create the circumstances of the trauma in a way that does not
bring about adverse consequences to the client. Survivors of an airplane crash,
for example, may suffer from a range of debilitating symptoms. They are likely to
have nightmares and flashbacks to the disaster; they may avoid travel by air or have
anxiety about travel by any means; and they probably have a variety of distressing
symptoms such as guilt, anxiety, and depression. In vivo and imaginal exposure,
as well as flooding, are frequently used in the behavioral treatment for anxiety-
related disorders, specific phobia, social phobia, panic disorder, obsessive-compul-
sive disorder, posttraumatic stress disorder, and agoraphobia (Hazlett-Stevens &
Craske, 2008).
Because of the discomfort associated with prolonged and intense exposure,
some clients may not elect these exposure treatments. It is important for the
behavior therapist to work with the client to create motivation and readiness for
exposure. From an ethical perspective, clients should have adequate information
about prolonged and intense exposure therapy before agreeing to participate. It
is important that they understand that anxiety will be induced as a way to reduce
it. Clients need to make informed decisions after considering the pros and cons
of subjecting themselves to temporarily stressful aspects of treatment. Clients
should be informed that they can terminate exposure if they experience a high
level of anxiety.
The repeated success of exposure therapy in treating various disorders has
resulted in exposure being used as a part of most behavioral treatments for anxiety
disorders. Spiegler (2016) notes that exposure therapies are among the most potent
behavioral procedures available for anxiety-related disorders, and they can have
long-lasting effects. However, he adds, using exposure as a single treatment proce-
dure is not always sufficient. In cases involving severe and multifaceted disorders,
more than one behavioral intervention is often required. This is especially true with
posttraumatic stress disorders. Increasingly, imaginal and in vivo exposure are being
used in combination, which fits with the trend in behavior therapy to use treatment
packages as a way to enhance the effectiveness of therapy.
 B EH AV I O R T H ERAP Y 247

Eye Movement Desensitization and Reprocessing

Eye movement desensitization and reprocessing (EMDR) is a form of LO7
exposure therapy that entails assessment and preparation, imaginal flooding, and
cognitive restructuring in the treatment of individuals with traumatic memories.
According to Shapiro and Solomon (2015), “EMDR is an integrative psychothera-
peutic approach that conceptualizes current mental health problems as emanating
from past experiences that have been maladaptively stored neurophysiologically as
unprocessed memories” (p. 303). The treatment involves the use of rapid, rhythmic
eye movements and other bilateral stimulation to treat clients who have experienced
traumatic stress. “EMDR comprises eight phases and a three-pronged methodology
to identify and process (1) memories of past adverse life experiences that underlie
present problems, (2) current situations that elicit disturbance, and (3) needed skills
that will provide positive memory templates to guide the client’s future behavior”
(p. 389). Developed by Francine Shapiro (2001), this therapeutic procedure draws
from a wide range of behavioral interventions. Designed to assist clients in dealing
with posttraumatic stress disorders, EMDR has been applied to a variety of popula-
tions including children, couples, sexual abuse victims, combat veterans, victims of
crime, rape survivors, accident victims, and individuals dealing with anxiety, panic,
depression, grief, addictions, and phobias.
Shapiro (2001) emphasizes the importance of the safety and welfare of the cli-
ent when using this approach. EMDR may appear simple to some, but the ethical
use of the procedure demands training and clinical supervision, as is true of using
exposure therapies in general. Because of the powerful reactions from clients, it is
essential that practitioners know how to safely and effectively manage these occur-
rences. Therapists should not use this procedure unless they receive proper training
and supervision from an authorized EMDR instructor. A more complete discussion
of this behavioral procedure can be found in Shapiro (2001, 2002a).
There is some controversy over whether the eye movements themselves create
change or whether cognitive techniques paired with eye movements act as change
agents. The role of lateral eye movements has yet to be clearly demonstrated, and
some evidence indicates that the eye movement component may not be integral
to the treatment (Prochaska & Norcross, 2014; Speigler, 2016). In a review of con-
trolled studies of EMDR in the treatment of trauma, Shapiro (2002b) reports that
EMDR clearly outperforms no treatment and achieves similar or superior results to
other methods of treating trauma. Shapiro and Solomon (2015) state that extensive
research has validated EMDR and randomized trials have confirmed that EMDR
is both effective and efficient. Twelve sessions with combat veterans resulted in the
elimination of PTSD diagnosis in more than 77% of the cases. When it comes to
the overall effectiveness of EMDR, Prochaska and Norcross (2014) note that “in
its 25-year history, EMDR has garnered more controlled research than any other
method used to treat trauma” (p. 210). In writing about the future of EMDR, Pro-
chaska and Norcross make several predictions: increasing numbers of practitioners
will receive training in EMDR; outcome research will shed light on EMDR’s effec-
tiveness compared to other current therapies for trauma; and further research and
practice will provide a sense of its effectiveness with disorders beyond posttraumatic
stress disorder.
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Social Skills Training

Social skills training is a broad category that deals with an individual’s abil- LO8
ity to interact effectively with others in various social situations; it is used to help
clients develop and achieve skills in interpersonal competence. Social skills involve
being able to communicate with others in a way that is both appropriate and effec-
tive. Individuals who experience psychosocial problems that are partly caused by
interpersonal difficulties are good candidates for social skills training. Typically,
social skills training involves various behavioral techniques such as psychoeduca-
tion, modeling, behavior rehearsal, and feedback (Antony & Roemer, 2011b). Social
skills training is effective in treating psychosocial problems by increasing clients’
interpersonal skills (Kress & Henry, 2015; Segrin, 2008). Some of the desirable
aspects of social skills training are that it has a very broad base of applicability and
that it can easily be tailored to suit the particular needs of individual clients.
Key elements of social skills training include assessment, direct instruction and
coaching, modeling, role playing, and homework assignments (Segrin 2008). Clients
learn information that they can apply to various interpersonal situations, and skills
are modeled for them so they can actually see how skills can be used. A key step
involves clients putting into action the information they are acquiring. Individu-
als actively practice desired behaviors through role playing. Feedback and reinforce-
ment assist clients in conceptualizing and using a new set of social skills that enables
them to communicate more effectively. If clients are able to correct their problem-
atic behaviors in practice situations, they can then apply these new skills in daily life
(Kress & Henry, 2015). A follow-up phase is critical for clients in establishing a range
of effective behaviors that can be applied to many social situations.
A few examples of evidence-based applications of social skills training include
alcohol/substance abuse, attention-deficit/hyperactivity disorder, bullying, social
anxiety, emotional and behavioral problems in children, behavioral treatment for
couples, and depression (Antony & Roemer, 2011b; Segrin, 2008). A popular varia-
tion of social skills training is anger management training, which is designed for indi-
viduals who have trouble with aggressive behavior.

Self-Management Programs and Self-Directed Behavior

For some time there has been a trend toward “giving psychology away.” This LO9
involves psychologists being willing to share their knowledge so that “consumers”
can increasingly lead self-directed lives and not be dependent on experts to deal with
their problems. Psychologists who share this perspective are primarily concerned
with teaching people the skills they will need to manage their own lives effectively.
An advantage of self-management techniques is that treatment can be extended
to consumers in ways that cannot be done with traditional approaches to therapy.
Another advantage is that costs are minimal. Because clients have a direct role in
their own treatment, techniques aimed at self-change tend to increase involvement
and commitment to their treatment.
The basic idea of self-management assessments and interventions is that change
can be brought about by teaching people to use coping skills in problematic situa-
tions. Self-management strategies include teaching clients how to select realistic
goals, how to translate these goals into target behaviors, how to create an action
 B EH AV I O R T H ERAP Y 249

plan for change, and ways to self-monitor and evaluate their actions (Kress & Henry
2015). Generalization and maintenance of the outcomes are enhanced by encourag-
ing clients to accept the responsibility for carrying out these strategies in daily life.
In self-management programs people make decisions concerning specific behav-
iors they want to control or change. People frequently discover that a major reason
they do not attain their goals is the lack of certain skills or unrealistic expectations
of change. Hope can be a therapeutic factor that leads to change, but unrealistic
hope can pave the way for a pattern of failures in a self-change program. A self-
directed approach can provide the guidelines for change and a realistic plan that will
lead to change.
If you want to succeed in such a program, a careful analysis of the context of
the behavior pattern is essential, and you must be willing to follow some basic steps
such as these provided by Watson and Tharp (2014):
1. Selecting goals. Goals should be established one at a time, and they
should be measurable, attainable, positive, and significant for you. It is
essential that expectations be realistic.
2. Translating goals into target behaviors. Identify behaviors targeted for
change. Once targets for change are selected, anticipate obstacles and
think of ways to negotiate them.
3. Self-monitoring. Deliberately and systematically observe your own
behavior, and keep a behavioral diary in which you record your actions,
thoughts, and feelings along with comments about the relevant ante-
cedent cues and consequences. This diary can help you identify what
you need to change.
4. Working out a plan for change. A good plan involves substituting new
thoughts and behaviors for ineffective thoughts and behaviors. Devise an
action program to bring about actual changes that are in line with your
goals. Various plans for the same goal can be designed, each of which
can be effective. Some type of self-reinforcement system is necessary in
this plan because reinforcement is the cornerstone of modern behavior
therapy. Discover and select reinforcers to use until the new behaviors
have been implemented in everyday life. Practice the new behaviors you
want to acquire or refine, and take steps to ensure that the gains made
will be maintained.
5. Evaluating an action plan. Evaluate the plan for change to determine
whether goals are being achieved, and adjust and revise the plan as
other ways to meet goals are learned. Be willing to adjust your plan as
conditions change. Evaluation is an ongoing process rather than a one-
time occurrence, and self-change is a lifelong practice.
Self-management strategies have been successfully applied to many popula-
tions and problems, a few of which include coping with panic attacks, reducing
perfectionism, helping children to cope with fear of the dark, increasing creative
productivity, managing anxiety in social situations, encouraging speaking in front
of a class, increasing exercise, reducing conflict with coworkers, improving study
habits, control of smoking, and dealing with depression (Watson & Tharp, 2014).
Research on self-management has been conducted in a wide variety of health
250 C HAP TE R NINE

problems, a few of which include arthritis, asthma, cancer, cardiac disease, sub-
stance abuse, diabetes, headaches, vision loss, depression, nutrition, and self-health
care (Cormier et al., 2013).

Multimodal Therapy: Clinical Behavior Therapy

Multimodal therapy is a comprehensive, systematic, holistic approach to behav-
ior therapy developed by the late Arnold Lazarus (1989,1997, 2005, 2008a), a key
pioneer in clinical behavior therapy. Multimodal therapy is grounded in social cog-
nitive learning theory. The assessment process is multimodal, yet the treatment is
cognitive behavioral and draws upon empirically supported methods. It is an open
system that encourages technical eclecticism in that it applies diverse behavioral tech-
niques from a variety of theories to a wide range of problems. Whenever possible,
multimodal therapists strive to incorporate empirically supported and evidence-
based treatments in their practice (Lazarus & Lazarus, 2015). This approach serves
as a major link between some behavioral principles and the cognitive behavioral
approach that has largely replaced traditional behavioral therapy.
Multimodal therapists borrow techniques from many other therapy systems,
but Lazarus and Lazarus (2015) point out that these techniques are never used in
a shotgun manner: “a rag-tag combination of techniques without a sound ratio-
nale will likely result only in syncretistic confusion” (p. 682). Multimodal therapists
take great pains to determine precisely what relationship and what treatment strate-
gies will work best with each client and under which particular circumstances. The
underlying assumption of this approach is that because individuals are troubled
by a variety of specific problems it is appropriate that a multitude of treatment
strategies be used in bringing about change. Therapeutic flexibility and versatility,
along with breadth over depth, are highly valued, and multimodal therapists are
constantly adjusting their procedures to achieve the client’s goals. Therapists need
to decide when and how to be challenging or supportive and how to adapt their rela-
tionship style to the needs of the client. The therapeutic relationship is the soil that
enables techniques to take root, and multimodal therapists recognize that a good
working alliance is a cornerstone in the foundation of effective therapeutic prac-
tice (Lazarus & Lazarus, 2015). Multimodal therapists tend to be very active during
therapist sessions, functioning as trainers, educators, consultants, coaches, and role
models. They provide information, instruction, and feedback as well as modeling
assertive behaviors. They offer suggestions, positive reinforcements, and are appro-
priately self-disclosing.
For an illustration of how Dr. Lazarus applies the BASIC I.D. assessment model
to the case of Ruth, along with examples of various techniques he uses, see Case
Approach to Counseling and Psychotherapy (Corey, 2013, chap. 7).

Mindfulness and Acceptance-Based Approaches

The third generation (or “third wave”) of behavior therapy emphasizes con- LO10
siderations that were considered off limits for behavior therapists until recently,
including mindfulness, acceptance, the therapeutic relationship, spirituality, val-
ues, meditation, being in the present moment, and emotional expression (Hayes,
Follette, & Linehan, 2004; Herbert & Forman, 2011). Third-generation behavior
 B EH AV I O R T H ERAP Y 251

therapies center around five interrelated core themes: (1) an expanded view of psy-
chological health, (2) a broad view of acceptable outcomes in therapy, (3) accep-
tance, (4) mindfulness, and (5) creating a life worth living (Speigler, 2016).
Mindfulness is “the awareness that emerges through having attention on pur-
pose, in the present moment, and nonjudgmentally, to the unfolding of experience
moment by moment” (Kabat-Zinn, 2003, p. 145). In mindfulness practice, clients
train themselves to intentionally focus on their “present experience with accep-
tance” (Siegel, 2010, p. 27) and develop an attitude of curiosity and compassion
toward present experience.
Mindfulness shows promise across a broad range of clinical problems, includ-
ing the treatment of depression, anxiety disorders, relationship problems, substance
abuse, and psychophysiological disorders (Germer, Siegel, & Fulton, 2013). It is
useful in treating posttraumatic stress disorder among military veterans. Through
mindfulness exercises, veterans may be better able to observe repetitive negative
thinking and prevent extensive engagement with maladaptive ruminative pro-
cesses (Vujanovic, Niles, Pietrefesa, Schmertz, & Potter, 2011). Many therapeutic
approaches are incorporating mindfulness and meditation, as well as other contem-
plative practices, in the counseling process, and this trend seems likely to continue
(Worthington, 2011).
Acceptance is a process involving receiving one’s present experience without
judgment or preference, but with curiosity and kindness, and striving for full aware-
ness of the present moment (Germer, 2013). Acceptance is an alternative way of
responding to our internal experience. By replacing judgment, criticism, and avoid-
ance with acceptance, the likely result is increased adaptive functioning (Antony &
Roemer, 2011b). Mindfulness and acceptance approaches are also good avenues for
the integration of spirituality in the counseling process.
For an extensive discussion of mindfulness and acceptance, see Acceptance and
Mindfulness in Cognitive Behavior Therapy: Understanding and Applying the New Therapies
(Herbert & Forman, 2011).
Recent developments in the cognitive behavioral tradition include four major
approaches: (1) dialectical behavior therapy, which has become a recognized treatment
for borderline personality disorder (Linehan, 1993a, 1993b, 2015); (2) mindfulness-
based stress reduction, an 8- to 10-week group program that applies mindfulness
techniques to coping with stress and promoting physical and psychological health
(Kabat-Zinn, 1990, 2003); (3) mindfulness-based cognitive therapy, aimed primarily at
treating depression (Segal, Williams, & Teasdale, 2013); and (4) acceptance and commit-
ment therapy, which encourages clients to accept unpleasant sensations rather than
attempting to control or change them (Hayes, Strosahl, & Houts, 2005; Hayes, Stro-
sahl, & Wilson, 2011). All four of these approaches use mindfulness strategies that
have been subjected to empirical scrutiny, a hallmark of the behavioral tradition.

Dialectical Behavior Therapy (DBT) Dialectical behavior therapy was originally

developed to treat chronically suicidal individuals diagnosed with borderline
personality disorder (BPD), and it is now recognized as a major psychological
treatment for this population. Formulated by Linehan (1993a, 1993b, 2015), who
was motivated to alleviate emotional suffering for those miserable enough to
consider suicide, DBT has been proven effective in treating a wide range of disorders,
252 C HAP TE R NINE

including substance dependence, depression, posttraumatic stress disorder (PTSD),

eating disorders, suicidal behavior, and nonsuicidal self-injury (Linehan, 2015).
DBT is a promising blend of behavioral and psychoanalytic techniques for treat-
ing borderline personality disorders. Like analytic therapy, DBT emphasizes the
importance of the psychotherapeutic relationship, validation of the client, the etio-
logic importance of the client having experienced an “invalidating environment” as
a child, and confrontation of resistance. DBT treatment includes both acceptance-
and change-oriented strategies. Mindfulness procedures are taught to develop an
attitude of acceptance (Fishman, Rego, & Muller, 2011; Kuo & Fitzpatrick, 2015).
The treatment program is geared toward helping clients make changes in their
behavior and environment while communicating acceptance of their current state
(Kuo & Fitzpatrick, 2015; Robins & Rosenthal, 2011). To help clients who have par-
ticular problems with emotional regulation, DBT teaches clients to recognize and
accept the existence of simultaneous, opposing forces. By acknowledging this fun-
damental dialectic relationship—such as not wanting to engage in a certain behav-
ior, yet knowing they have to engage in the behavior if they want to achieve a desired
goal—clients can learn to integrate the opposing notions of acceptance and change,
and the therapist can teach clients how to regulate their emotions and behaviors.
DBT skills training is not a “quick fix” approach. It generally involves a mini-
mum of one year of treatment and includes both individual therapy and skills train-
ing done in a group. DBT is an empirically supported intervention that employs
behavioral and cognitive behavioral techniques, including a form of exposure ther-
apy in which the client learns to tolerate painful emotions without enacting self-
destructive behaviors. DBT draws upon Zen teachings and practices to integrate
mindfulness and acceptance-based techniques in therapy (Kuo & Fitzpatrick, 2015).
Some of the Zen Buddhist principles and practices include being aware of the pres-
ent moment, seeing reality without distortion, accepting reality without judgment,
letting go of attachments that result in suffering, developing a greater degree of
acceptance of self and others, and entering fully into present activities without sepa-
rating oneself from ongoing events and interactions (Robins & Rosenthal, 2011).
DBT promotes a structured, predictable therapeutic environment. The goals are
tailored to each individual. Therapists assist clients in using whatever skills they
possess or are learning to navigate crises more effectively and to address problem
behaviors (Robins & Rosenthal, 2011). Skills are taught in four modules: mindful-
ness, interpersonal effectiveness, emotional regulation, and distress tolerance (Kuo
& Fitzpatrick, 2015).
Mindfulness is a fundamental skill in DBT that teaches individuals to be aware
of and accept the world as it is and to respond to each moment effectively. Through
mindfulness, clients learn to embrace and tolerate the intense emotions they experi-
ence when facing distressing situations. Interpersonal effectiveness teaches clients to ask
for what they need and how to say “no” while maintaining self-respect and relation-
ships with others. This skill entails increasing the chances that a client’s goals will
be met, while at the same time not damaging the relationship. Emotional regulation
includes identifying emotions, identifying obstacles to changing emotions, reduc-
ing vulnerability, and increasing positive emotions. Clients learn the benefits of
regulating emotions such as anger, depression, and anxiety. Distress tolerance is aimed
at helping individuals to calmly recognizing emotions associated with negative
 B EH AV I O R T H ERAP Y 253

situations without becoming overwhelmed by these situations. Clients learn how to

tolerate pain or discomfort skillfully.
DBT helps individuals acquire, strengthen, and generalize the skills they learn in
therapy to their daily environments (Kuo & Fitzpatrick, 2015). Because DBT places
heavy emphasis on didactic instruction and teaching mindfulness skills, therapists
must obtain training to become competent in applying these skills and be able to
model specific strategies and attitudes for clients. Therapists who want to employ
mindfulness strategies must also have personal understanding of these interven-
tions to be able to effectively use them with clients.
For a more detailed review of DBT, see DBT Skills Training Manual (Linehan,
2015), which includes instructions for orienting clients to DBT and explains how
to use many skills in DBT. Another useful resource for a more detailed discussion of
DBT is Robins and Rosenthal (2011).

Mindfulness-Based Stress Reduction (MBSR) Jon Kabat-Zinn, at the University

of Massachusetts, developed MBSR in 1979 to see if it was possible to create a
training program to relieve medical patients of stress, pain, illness, and other forms
of suffering. The eight-week structured group program involves training people
in mindfulness meditation, and today instructors are often not mental health
clinicians. Originally designed to help people increase their responsibility for their
own well-being and to actively develop inner resources for treating their physical
health concerns (Kabat-Zinn, 2003), MBSR is not a form of psychotherapy per se,
but it can be an adjunct to therapy.
The essence of mindfulness-based stress reduction (MBSR) consists of the
notion that much of our distress and suffering results from continually wanting
things to be different from how they actually are (Salmon, Sephton, & Dreeben,
2011). MBSR assists people in learning how to live more fully in the present rather
than ruminating about the past or being overly concerned about the future. MBSR
does not actively teach cognitive modification techniques, nor does it label certain
cognitions as “dysfunctional,” because this is not consistent with the nonjudgmen-
tal attitude one strives to cultivate in mindfulness practice.
The approach adopted in the MBSR program is to develop the capacity for sus-
tained directed attention through formal and informal meditation practice. There
is a heavy emphasis on experiential learning and the process of client self-discovery
(Dimidjian & Linehan, 2008). In formal practice, skills taught include sitting medi-
tation and mindful yoga, which are aimed at cultivating mindfulness. The program
includes a body scan meditation, which helps clients to observe all the sensations in
their body. Clients are encouraged to bring mindfulness into all of their daily activi-
ties, and this informal practice includes being mindful when standing, walking, eat-
ing, and doing chores. Those who are involved in the program are encouraged to
practice formal mindfulness meditation for 45 minutes daily.
The MBSR program is designed to teach participants to relate to external and
internal sources of stress in constructive ways, and an ongoing commitment to culti-
vate and practice its principles in each moment is required. Acquiring a mindful way of
being is not a simple behavioral technique but is more like an art form that individu-
als develop over time as they deepen their focus through disciplined practice. Kabat-
Zinn (2003) makes it clear that mindfulness is not about getting anywhere or fixing
254 C HAP TE R NINE

anything: “It is an invitation to allow oneself to be where one already is and to know
the inner and outer landscape of the direct experience in each moment” (p. 148).
MBSR programs are offered in hospitals, clinics, schools, workplaces, corporate
offices, law schools, prisons, and inner-city health centers (Kabat-Zinn, 2003). MBSR
has many clinical applications, and it is expected that the approach will evolve to
address a range of negative psychological states, such as anxiety, stress, and depres-
sion. This approach has many applications in the area of health and wellness and in
promoting healthy lifestyle changes. Numerous research reviews and meta-analyses
indicate that mindfulness, acceptance, and compassion-based treatments are effec-
tive in promoting physical and psychological health (Germer, 2013). One of these
studies suggests that MBSR training may lead to changes in the brain that result in
people being able to better cope with negative emotional reactions under stress (as
cited in Kabat-Zinn, 2003).
Kabat-Zinn’s (1990, 1994) books offer a comprehensive treatment of MBSR, and
they did a great deal to popularize the program he developed. An excellent resource
for a more detailed treatment of MBSR is Salmon, Sephton, and Dreeben (2011).

Mindfulness-Based Cognitive Therapy (MBCT) This program is a comprehensive

integration of the principles and skills of mindfulness applied to the treatment of
depression (Segal et al., 2013). MBCT is an eight-week group treatment program of
two-hour weekly sessions adapted from Kabat-Zinn’s (1990, 2003) mindfulness-based
stress reduction program. The program integrates techniques from MBSR with teaching
cognitive behavioral skills to clients. The primary aim is to change clients’ awareness of
and relation to their negative thoughts. Participants are taught how to respond in skillful
and intentional ways to their automatic negative thought patterns (Hammond, 2015).
Segal, Williams, and Teasdale (2013) describe kindness and self-compassion as
essential components of MBCT. Mindfulness is a way of developing self-compassion,
which is a form of self-care when facing difficult situations. Mindfulness practices
focus on moment-to-moment experiencing and assist clients in developing an atti-
tude of open awareness and acceptance of what is rather than being self-critical. When
we acknowledge our shortcomings without critical judgment, we can begin to treat
ourselves with kindness. We can intentionally activate goodwill toward ourselves and
others while experiencing emotions such as anger, anxiety, and depression. Research
has shown that self-compassion is positively associated with emotional well-being and
decreased levels of anxiety and depression (Morgan, Morgan, & Germer, 2013; Neff,
2012). Other research findings on the association between self-compassion and emo-
tional well-being have been reported by Neff (2012):
ŠSelf-compassionate people recognize when they are suffering, yet they
are kind toward themselves in these moments.
ŠSelf-compassion is associated with greater wisdom and emotional
intelligence.
ŠSelf-compassion is associated with feelings of life satisfaction and con-
nection to others.
ŠSelf-compassionate individuals tend to experience increased happiness,
optimism, curiosity, and positive emotions.
ŠSelf-compassion engenders compassion toward others.
 B EH AV I O R T H ERAP Y 255

Morgan, Morgan, and Germer (2013) report that there is ample evidence that
mindfulness meditation enhances the ability to pay attention in a concentrated and
sustained manner. Being able to attend to present experiencing is a route to devel-
oping compassion toward oneself and expressing compassion toward others. Mind-
fulness is something that is caught more than something that is taught. The attitude
and behavior of the instructor/facilitator of the MBCT group are critical in helping
participants acquire an accepting way of being and discarding self-critical and judg-
mental habits.
Segal, Williams, and Teasdale (2013) describe the essence of eight sessions in the
MBCT program:
ŠTherapy begins by identifying negative automatic thinking of people
experiencing depression and by introducing some basic mindfulness
practices.
ŠIn the second session, participants learn about the reactions they have
to life experiences and learn more about mindfulness practices. Clients
learn the importance of kindness and self-compassion, both to self and
to others.
ŠThe third session is focused on gathering the scattered mind; partici-
pants learn breathing techniques and focus their attention on their
present experiencing. Clients learn how to anchor thoughts with a
focus on the breath while allowing experience to unfold.
ŠIn session four, the emphasis is on learning to experience the moment
without becoming attached to outcomes; participants practice sitting
meditation and mindful walking.
ŠThe fifth session teaches participants how to accept their experiencing
without holding on; participants learn the value of allowing and letting be.
ŠSession six is used to describe thoughts as “merely thoughts”; clients
learn that they do not have to act on their thoughts. They can tell them-
selves, “I am not my thoughts” and “Thoughts are not facts.”
ŠIn session seven, participants learn how to take care of themselves and
to develop an action plan to deal with the threat of relapse.
ŠSession eight focuses on maintaining and extending new learning; clients
learn how to generalize their mindfulness practices to daily life.
MBCT emphasizes experiential learning, in-session practice, learning from feed-
back, completing homework assignments, and applying what is learned in the pro-
gram to challenging situations encountered outside of the sessions. The brevity of
MBCT makes this approach an efficient and cost-effective treatment. For a more
detailed review of MBCT, see Mindfulness-Based Cognitive Therapy for Depression (Segal
et al., 2013).

Acceptance and Commitment Therapy (ACT) Another mindfulness-based

approach is acceptance and commitment therapy (Hayes et al., 2005, 2011). ACT is a
unique empirically based psychological intervention that uses acceptance and
mindfulness strategies, together with commitment and behavior change strategies,
to increase psychological flexibility. ACT involves fully accepting present experience
and mindfully letting go of obstacles. In this approach “acceptance is not merely
256 C HAP TE R NINE

tolerance—rather it is the active nonjudgmental embracing of experience in the

here and now” (Hayes, 2004, p. 32). Acceptance is a stance or posture from which
to conduct therapy and from which a client can conduct life that provides an
alternative to contemporary forms of cognitive behavioral therapy. In contrast to the
cognitive behavioral approaches discussed in Chapter 10, in which dysfunctional
thoughts are identified and challenged, in ACT there is little emphasis on changing
the content of a client’s thoughts. Hayes has found that confronting maladaptive
cognitions strengthens rather than reduces these cognitions. Instead, the emphasis
is on acceptance (nonjudgmental awareness) of cognitions. The goal is for individuals
to become aware of and examine their thoughts. Clients learn how to change their
relationship to their thoughts. They learn how to accept yet not identify with
thoughts and feelings they may have been trying to deny.
Values are a basic part of the therapeutic process, and the work of ACT depends
on what an individual wants and values. Client and therapist work together to identify
personal values in areas such as work, relationships, spirituality, and well-being (Bat-
ten & Cairrochi, 2015). ACT practitioners might ask clients, “What do you want your
life to stand for?” Therapy involves assisting clients to choose values they want to live
by, designing specific goals, and taking steps to achieve their goals (Speigler, 2016).
A commitment to action is essential, and clients are asked to make mindful
decisions about what they are willing to do to live a valued and meaningful life. Con-
crete homework and behavioral exercises as two ways clients can commit to action.
For example, one form of homework asks clients to write down life goals or things
they value in various aspects of their lives. Clients learn to allow experience to come
and go while they pursue a meaningful life.
ACT is an effective form of therapy that continues to influence the practice
of behavior therapy. Germer (2013) suggests “mindfulness appears to be drawing
clinical theory, research, and practice closer together, and helping to integrate the
private and professional lives of therapists” (p. 13). ACT emphasizes common pro-
cesses across clinical disorders, which makes it easier to learn basic treatment skills.
Practitioners can then implement basic principles in diverse and creative ways. ACT
has been empirically shown to be effective in the treatment of a variety of disorders,
including substance abuse, depression, anxiety, phobias, posttraumatic stress disor-
der, and chronic pain (Batten & Cairrochi, 2015).
For an in-depth discussion of the role of mindfulness in psychotherapeutic
practice, four highly recommended books are Acceptance and Mindfulness in Cognitive
Behavior Therapy: Understanding and Applying the New Therapies (Herbert & Forman,
2011), Mindfulness and Acceptance: Expanding the Cognitive-Behavioral Tradition (Hayes et
al., 2004), Mindfulness and Psychotherapy (Germer et al., 2013), and Wisdom and Compas-
sion in Psychotherapy: Deepening Mindfulness in Clinical Practice, (Germer & Siegel, 2012).

Application to Group Counseling

Behavioral group therapy incorporates classical behavior therapy treatment LO11
principles rooted in classical conditioning, operant conditioning, and social learn-
ing theory. The focus of a behavioral group is on teaching, modeling, and applying
scientific principles to target specific behaviors for change (Kress & Henry, 2015).
 B EH AV I O R T H ERAP Y 257

Group-based behavioral approaches emphasize teaching clients self-management

skills and a range of new coping behaviors, as well as how to restructure their
thoughts. Clients can learn to use these techniques to control their lives, deal effec-
tively with present and future problems, and function well after they complete their
group experience. Many groups are designed primarily to increase the client’s degree
of control and freedom in specific aspects of daily life.
Group leaders who function within a behavioral framework may develop tech-
niques from various theoretical viewpoints. Behavioral practitioners make use of a
brief, active, directive, structured, collaborative, psychoeducational model of therapy
that relies on empirical validation of its concepts and techniques. The leader follows
the progress of group members through the ongoing collection of data before, dur-
ing, and after all interventions. Such an approach provides both the group leader and
the members with continuous feedback about therapeutic progress. Today, many
groups in community agencies demand this kind of accountability.
Behavioral group therapy has some unique characteristics that set it apart
from most of the other group approaches. A distinguishing characteristic of
behavioral practitioners is their systematic adherence to specification and mea-
surement. The specific unique characteristics of behavioral group therapy include
(1) conducting a behavioral assessment, (2) precisely spelling out collaborative
treatment goals, (3) formulating a specific treatment procedure appropriate to
a particular problem, and (4) objectively evaluating the outcomes of therapy.
Behavior therapists tend to utilize short-term, time-limited interventions aimed
at efficiently and effectively solving problems and assisting members in develop-
ing new skills.
Behavioral group leaders assume the role of teacher and encourage members to
learn and practice skills in the group that they can apply to everyday living. Group
leaders typically assume an active, directive, and supportive role in the group and
apply their knowledge of behavioral principles and skills to the resolution of prob-
lems. They model active participation and collaboration by their involvement with
members in creating an agenda, designing homework, and teaching skills and new
behaviors. Leaders carefully observe and assess behavior to determine the conditions
that are related to certain problems and the conditions that will facilitate change.
Members in behavioral groups identify specific skills that they lack or would like to
enhance. Assertiveness and social skills training fit well into a group format. Relax-
ation procedures, behavioral rehearsal, modeling, coaching, meditation, and mind-
fulness techniques are often incorporated in behavioral groups. The experience of
being mindful is expanded in the group setting where people meditate and are still
in the presence of others. Most of the other techniques described earlier in this chap-
ter can be applied to group work.
Today, most behavior therapy groups blend cognitive and behavioral concepts
and techniques, with few having a strictly behavioral focus (Kress & Henry, 2015).
There are many different types of groups with a behavioral twist, or groups that
blend both behavioral and cognitive methods for specific populations. Structured
groups, with a psychoeducational focus, are especially popular in various settings
today. At least four general approaches can be applied to the practice of behavioral
groups: (1) social skills training groups, (2) psychoeducational groups with specific
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themes, (3) stress management groups, and (4) mindfulness and acceptance-based
behavior therapy in groups.
For a more detailed discussion of cognitive behavioral approaches to groups, see
Corey (2016, chap. 13).

Behavior Therapy From a Multicultural Perspective

Strengths From a Diversity Perspective
Behavior therapy has some clear advantages over many other theories in LO12
counseling culturally diverse clients. Because of their cultural and ethnic back-
grounds, some clients hold values that are contrary to the free expression of feelings
and the sharing of personal concerns. Behavioral counseling does not generally place
emphasis on experiencing catharsis. Rather, it stresses changing specific behaviors
and developing problem-solving skills. Some potential strengths of the behavioral
approaches in working with diverse client populations include its specificity, task
orientation, focus on objectivity, focus on cognition and behavior, action orienta-
tion, dealing with the present more than the past, emphasis on brief interventions,
teaching coping strategies, and problem-solving orientation. The attention given to
transfer of learning and the principles and strategies for maintaining new behavior
in daily life are crucial. Clients who are looking for action plans and specific behav-
ioral change are likely to cooperate with this approach because they can see that it
offers them concrete methods for dealing with their problems of living.
Behavior therapy focuses on environmental conditions that contribute to a cli-
ent’s problems. Social and political influences can play a significant role in the lives
of people of color through discriminatory practices and economic problems, and
the behavioral approach takes into consideration the social and cultural dimensions
of the client’s life. Behavior therapy is based on an experimental analysis of behavior
in the client’s own social environment and gives special attention to a number of
specific conditions: the client’s cultural conception of problem behaviors, establish-
ing specific therapeutic goals, arranging conditions to increase the client’s expecta-
tion of successful therapeutic outcomes, and employing appropriate social influence
agents (Tanaka-Matsumi, Higginbotham, & Chang, 2002). The foundation of ethi-
cal practice involves a therapist’s familiarity with the client’s culture, as well as the
competent application of this knowledge in formulating assessment, diagnostic,
and treatment strategies.
The behavioral approach has moved beyond treating clients for a specific symp-
tom or behavioral problem. Instead, it stresses a thorough assessment of the person’s
life circumstances to ascertain not only what conditions give rise to the client’s prob-
lems but also whether the target behavior is amenable to change and whether such a
change is likely to lead to a significant improvement in the client’s total life situation.
In designing a change program for clients from diverse backgrounds, effective
behavioral practitioners conduct a functional analysis of the problem situation. This
assessment includes the cultural context in which the problem behavior occurs, the con-
sequences both to the client and to the client’s sociocultural environment, the resources
within the environment that can promote change, and the impact that change is likely
to have on others in the client’s social surroundings. Assessment methods should be
 B EH AV I O R T H ERAP Y 259

chosen with the client’s cultural background in mind (Spiegler, 2016; Tanaka-Matsumi
et al., 2002). Counselors must be knowledgeable as well as open and sensitive to issues
such as these: What is considered normal and abnormal behavior in the client’s culture?
What are the client’s culturally based conceptions of his or her problems? What is the
potential role of spirituality or religion in the client’s life? What kind of information
about the client is essential in making an accurate assessment?

Shortcomings From a Diversity Perspective

Although behavior therapy is sensitive to differences among clients in a broad sense,
behavior therapists need to become more responsive to specific issues pertaining to
all forms of diversity. Because race, gender, ethnicity, and sexual orientation are crit-
ical variables that influence the process and outcome of therapy, it is essential that
behavior therapists pay careful attention to these factors and address social justice
issues as they arise in a client’s therapy.
Some behavioral counselors may focus on using a variety of techniques in narrowly
treating specific behavioral problems. Instead of viewing clients in the context of their
sociocultural environment, these practitioners concentrate too much on problems
within the individual. In doing so they may overlook significant issues in the lives of cli-
ents. Such practitioners are not likely to bring about beneficial changes for their clients.
The fact that behavioral interventions often work well raises an interesting issue
in multicultural counseling. When clients make significant personal changes, it is
very likely that others in their environment will react to them differently. Before
deciding too quickly on goals for therapy, the counselor and client need to discuss
the complexity inherent in change. It is essential for therapists to conduct a thor-
ough assessment of the interpersonal and cultural dimensions of the problem. Cli-
ents should be helped in assessing the possible consequences of some of their newly
acquired social skills. Once goals are determined and therapy is under way, clients
should have opportunities to talk about the problems they encounter as they bring
new skills and behaviors into their home and work settings.

Behavior Therapy Applied to the Case of Stan

I n Stan’s case many specific and interrelated prob-

lems can be identified through an assessment pro-
cess. Behaviorally, he is defensive, avoids eye contact,
thoughts and beliefs, is governed by categorical imper-
atives (“shoulds,” “oughts,” “musts”), engages in fatal-
istic thinking, and compares himself negatively with
speaks hesitantly, uses alcohol excessively, has a poor others. In the interpersonal area, Stan is unassertive, has
sleep pattern, and displays various avoidance behaviors an unsatisfactory relationship with his parents, has
in social and interpersonal situations. In the emotional few friends, is afraid of contact with women and fears
area, Stan has a number of specific problems, some of intimacy, and feels socially inferior.
which include anxiety, panic attacks, depression, fear After completing this assessment, I focus on help-
of criticism and rejection, feeling worthless and stu- ing Stan define the specific areas where he would like
pid, and feeling isolated and alienated. He experiences to make changes. Before developing a treatment plan,
a range of physiological complaints such as dizziness, I assist Stan in understanding the purposes of his
heart palpitations, and headaches. Cognitively, he wor- behavior. I then educate Stan about how the therapy
ries about death and dying, has many self-defeating sessions (and his work outside of the sessions) can
260 C HAP TE R NINE

help him reach his goals. Early during treatment I help Stan begins repeated, systematic exposure to items
Stan translate some of his general goals into concrete that he finds frightening, beginning at the bottom of
and measurable ones. When Stan says, “I want to feel the fear hierarchy. He continues with repeated expo-
better about myself,” I help him define more specific sure to the next fear hierarchy item when exposure to
goals. When he says, “I want to get rid of my inferior- the previous item generates only mild fear. Part of the
ity complex,” I reply: “What exactly do you mean by process involves exposure exercises for practice in vari-
this? What are some situations in which you feel infe- ous situations away from the therapy office.
rior? What do you actually do that leads to feelings of The goal of therapy is to help Stan modify the
inferiority?” Stan’s concrete aims include his desire behavior that results in his feelings of guilt and anxi-
to function without drugs or alcohol. I suggest that ety. By learning more appropriate coping behaviors,
he keep a record of when he drinks and what events eliminating unrealistic anxiety and guilt, and acquiring
lead to drinking. My hope is that Stan will establish more adaptive responses, Stan’s presenting symptoms
goals that are based on positive markers, not negative decrease, and he reports a greater degree of satisfaction.
goals. Instead of focusing on what Stan would like to
get rid of, I am more interested in what he would like Questions for Reflection
to acquire and develop. Š How would you collaboratively work with Stan in
Stan indicates that he does not want to feel apolo- identifying specific behavioral goals to give a direc-
getic for his existence. I introduce behavioral skills tion to your therapy?
training because he has trouble talking with his boss Š What behavioral techniques might be most appro-
and coworkers. I demonstrate specific skills that he priate in helping Stan with his problems?
can use in approaching them more directly and confi- Š Stan indicates that he does not want to feel apolo-
dently. This procedure includes modeling, role playing, getic for his existence. How might you help him
and behavior rehearsal. He then tries more effective translate this wish into a specific behavioral goal?
behaviors with me as I play the role of the boss. I give What behavioral techniques might you draw on in
him feedback on how strong or apologetic he seemed. helping him in this area?
Imaginal exposure and systematic desensitization Š What homework assignments are you likely to
are appropriate in working with Stan’s fear of failing. suggest for Stan?
Before using these procedures, I explain the procedure
to Stan and get his informed consent. Stan first learns Visit CengageBrain.com or watch the DVD
relaxation procedures during the sessions and then for the video program Theory and Practice of
practices them daily at home. Next, he lists his specific Counseling and Psychotherapy: The Case of Stan and
fears relating to failure, and he then generates a hierar- Lecturettes, Session 7 (behavior therapy), for a
chy of fear items. Stan identifies his greatest fear as fear demonstration of my approach to counseling
of dating and interacting with women. The least fear- Stan from this perspective. This session involves
ful situation he identifies is being with a female stu- collaboratively working on homework and
dent for whom he does not feel an attraction. I first do behavior rehearsals to experiment with assertive
some systematic desensitization on Stan’s hierarchy. behavior.

Behavior Therapy Applied to the Case of Gwen*

I n daily life, Gwen has a tendency to try to get every-

thing done without enlisting the support of others.
In our previous session, she decided on a goal of ask-
We engaged in behavioral rehearsals in which Gwen
practiced asking someone for support. Gwen found
this difficult, but she hesitantly said she was willing
ing for support from others both at home and at work. to try out these new behaviors. Her homework was to

*Dr. Kellie Kirksey writes about her ways of thinking and practicing from a behavior therapy perspective and applying this model to Gwen.
 B EH AV I O R T H ERAP Y 261

ask for help both at work and at home. Gwen is late Assessment is a large part of behavioral therapy, and
for our session, and when she arrives she looks tired reviewing homework assignments helps us to see if our
and defeated. approach is effective. Although Gwen was aware of her
pattern of silence at home, she was not able to modify
Gwen: Sorry I am late. I left work early to take my her behavior and express her feelings to her husband.
mother to the doctor, and the appointment ran I decide to introduce Gwen to the concept of
longer than I expected. mindfulness to help her stop the automatic behaviors
Therapist: I am pleased you were able to make it, that have kept her feeling stressed and overwhelmed.
but our session will be shorter. Last week you Gwen has difficulty being in the present moment, and
talked about feeling disconnected from your she could profit from slowing down and engaging
husband. We agreed that asking him for assis- in self-care activities. Mindfulness practice can bring
tance and sharing your daily life with him might increased peace and calm into her life and quiet the
help you communicate with each other. What constant chatter in her mind. I want to give Gwen
have you done this week to get support and share some simple tools she can use and practice at home.
more at home?
Therapist: Gwen, take a moment to sit quietly. Let
Gwen: I expressed to colleagues that I needed help your thoughts flow away and concentrate your
when completing some tasks at work, but I fell attention on the present moment. How are you
back into the same pattern of silence when at home feeling? [She begins to notice bodily sensations] Gwen
with Ron. please bring your awareness to the top of your head
Therapist: Tell me more about falling back into the and slowly begin to scan your entire body for any
same pattern of silence. sensations of tension or tightness. What are you
Gwen: I wanted to ask Ron to help with my mom, noticing?
but ultimately I feel like she is my mom and my Gwen: I am aware of tightness in my chest. It feels like
responsibility. He sees what I am doing and could a ball of stress.
offer to pitch in. Therapist: Focus all of your attention on the sensa-
Therapist: You seemed eager to express your need for tion in your chest. As you consciously tell yourself
support to Ron, but then something stopped you. to relax, simply notice the sensations without judg-
What do you think caused you to stop? [Using the ing them. How are you feeling?
A-B-C model] Gwen: It’s a little strange, but I feel more at ease than
Gwen: I hate to ask. It is my responsibility. I think I when I first walked in the door.
am the only one who can do it. I would feel like I Therapist: Do you think you can practice this mind-
was putting a burden on Ron’s shoulders if I asked fulness at home this week and focus on what you
for help. want to bring into your life?
Therapist: You must feel an overwhelming amount of Gwen: I do want to communicate better with my
pressure being solely responsible for so much. husband and be able to ask him for support. I feel
Gwen: Yes, it is hard to make sense of it all. much more relaxed here now, and I would like to
Therapist: Let me see if I understand. It sounds try to feel that at home too. Calming myself and
as though taking care of your mom is your sole staying in the moment is a new experience for me.
responsibility and not Ron’s [antecedent]. You Therapist: You have a good start on learning how
do not want to feel like a burden to Ron, so mindfulness feels; let’s see how much progress you
you stop yourself from asking for support can make at home as you practice this week.
[behavior]. Gwen: OK, I feel less stressed when I slow down and
Gwen: Yes, when I get home I want to talk, but I do try to relax in the moment. I am going to practice
not want to become a burden on someone I love. this every day during the week. [Goal-setting is an
So I just withdraw into myself [consequence]. important part of behavior therapy]
262 C HAP TE R NINE

I encourage Gwen to practice paying attention to Questions for Reflection

her behaviors and to consider using mindfulness Š What could be the consequence(s) if Gwen does
practice as a way of refocusing on what she wants not change her behavior?
to bring into her life. It is my hope that her mind- Š What kind of homework might you suggest to
fulness practice will lead to an overall reduction in Gwen?
stress and increased presence and connection in her Š What kind of mindfulness practices would you
life. like to incorporate into your daily life?

Summary and Evaluation

Summary
Behavior therapy is diverse with respect not only to basic concepts but also LO13
to techniques that can be applied in coping with specific problems with a wide range
of clients. The behavioral movement includes four major areas of development:
classical conditioning, operant conditioning, social-cognitive theory, and increas-
ing attention to the cognitive factors influencing behavior (see Chapter 10). Third-
generation behavior therapies are recent developments in the field, and they include
mindfulness and acceptance-based behavior therapies. A unique characteristic of
all forms of behavior therapy is its strict reliance on the principles of the scientific
method. Concepts and procedures are stated explicitly, tested empirically, and
revised continually. Treatment and assessment are interrelated and occur simulta-
neously. Research is considered to be a basic aspect of the approach, and therapeutic
techniques are continually refined.
A cornerstone of behavior therapy is identifying specific goals at the outset of
the therapeutic process. In helping clients achieve their goals, behavior therapists
typically assume an active and directive role. Although the client generally deter-
mines what behavior will be changed, the therapist typically determines how this
behavior can best be modified. In designing a treatment plan, behavior therapists
employ techniques and procedures from a wide variety of therapeutic systems and
apply them to the unique needs of each client.
Contemporary behavior therapy places emphasis on the interplay between the
individual and the environment. Behavioral strategies can be used to attain both
individual goals and societal goals. Because cognitive factors have a place in the
practice of behavior therapy, techniques from this approach can be used to attain
humanistic ends. It is clear that bridges can connect humanistic and behavioral
therapies, especially with the current focus of attention on self-management and
the incorporation of mindfulness and acceptance-based approaches into behav-
ioral practice. Mindfulness practices rely on experiential learning and client dis-
covery rather than on didactic instruction. Mindfulness is a way of being that takes
ongoing effort to develop and refine (Kabat-Zinn, 2003). Self-compassion is a foun-
dational part of the new wave of behavior therapies and is linked to an increased
 B EH AV I O R T H ERAP Y 263

sense of well-being. These newer approaches represent a blend of Eastern practices

and Western methodology. Contemporary behavior therapy has broadened from
a narrow focus on dealing with simple problems to addressing complex aspects of
personal functioning.

Contributions of Behavior Therapy

Behavior therapy challenges us to reconsider our global approach to counseling. Some
may assume they know what a client means by the statement, “I feel unloved; life
has no meaning.” A humanist might nod in acceptance to such a statement, but the
behaviorist may respond with: “Who specifically do you feel is not loving you?” “What
is going on in your life to make you think it has no meaning?” “What are some specific
things you might be doing that contribute to the state you are in?” “What would you
most like to change?” A key strength of behavior therapy is its precision in specifying
goals, target behaviors, and procedures. The specificity of the behavioral approaches
helps clients translate unclear goals into concrete plans of action, and it helps both
the counselor and the client to keep these plans clearly in focus. Ledley, Marx, and
Heimberg (2010) state that therapists can help clients learn about the contingencies
that maintain their problematic thoughts and behaviors and then teach them ways
to make the changes they want. Techniques such as role playing, relaxation proce-
dures, behavioral rehearsal, coaching, guided practice, modeling, feedback, learning
by successive approximations, mindfulness skills, and homework assignments can be
included in any therapist’s repertoire, regardless of theoretical orientation.
An advantage behavior therapists have is the wide variety of specific behavioral
techniques at their disposal. Because behavior therapy stresses doing, as opposed
to merely talking about problems and gathering insights, practitioners use many
behavioral strategies to assist clients in formulating a plan of action for changing
behavior. The basic therapeutic conditions stressed by person-centered therapists—
active listening, accurate empathy, positive regard, genuineness, respect, acceptance,
and immediacy—need to be integrated in a behavioral framework.
A major contribution of behavior therapy is its emphasis on research into and
assessment of treatment outcomes. It is up to practitioners to demonstrate that
therapy is working. If progress is not being made, therapists look carefully at the
original analysis and treatment plan. Of all the therapies presented in this book, this
approach and its techniques have been subjected to the most empirical research.
Behavioral practitioners are put to the test of identifying specific interventions that
have been demonstrated to be effective.
Evidence-based therapies (EBT) are a hallmark of both behavior therapy and
cognitive behavior therapy. To their credit, behavior therapists are willing to exam-
ine the effectiveness of their procedures in terms of the generalizability, meaningful-
ness, and durability of change. Most studies show that behavior therapy methods
are more effective than no treatment. Moreover, a number of behavioral and cogni-
tive behavioral procedures are currently the best treatment strategies available for
depression, obsessive-compulsive disorder, panic disorder, social phobia, hypochon-
driasis, generalized anxiety disorder, posttraumatic stress disorder, eating disorders,
264 C HAP TE R NINE

borderline personality disorder, bipolar disorder, and childhood disorders (Hollon

& DiGiuseppe, 2011).
The new generation of mindfulness and acceptance-based therapies has shifted
behavior therapy from treating simple and discrete problems to a more complex and
complete psychotherapy that is based in behavioral principles (Prochaska & Nor-
cross, 2014). Prochaska and Norcross confidently predict an increase and expansion
of the third-wave therapies in the next decade and state that these approaches will
likely “become firmly established within the ever-expanding, evidence-based context
of cognitive-behavioral therapy” (p. 314).
A strength of the behavioral approaches is the emphasis on ethical accountabil-
ity. Behavior therapy is ethically neutral in that it does not dictate whose behavior
or what behavior should be changed. At least in cases of voluntary counseling, the
behavioral practitioner only specifies how to change those behaviors the client tar-
gets for change. Clients have a good deal of control and freedom in deciding what
the goals of therapy will be. A collaborative therapist–client relationship is an essen-
tial aspect of behavior therapy. Because clients are active in selecting goals and pro-
cedures in the therapy process and are applying what they are learning in therapy
to daily life, the chance that they will become the target of unethical behavior is
decreased (Speigler, 2016).

Limitations and Criticisms of Behavior Therapy

Behavior therapy has been criticized for a variety of reasons. Let’s examine four
common criticisms and misconceptions people often have about behavior therapy,
together with my reactions.

Behavior therapy may change behaviors, but it does not change feelings. Some
critics argue that feelings must change before behavior can change. Behavioral
practitioners hold that empirical evidence has not shown that feelings must be
changed first, and behavioral clinicians do in actual practice deal with feelings as
an overall part of the treatment process. A general criticism of both the behavioral
and the cognitive approaches is that clients are not encouraged to experience their
emotions. In concentrating on how clients are behaving or thinking, some behavior
therapists tend to play down the working through of emotional issues. Generally,
I favor initially focusing on what clients are feeling and then working with the
behavioral and cognitive dimensions. When clients’ feelings are engaged, this seems
to me to be a good point of departure. I can still tie a discussion of what clients are
feeling with how this is affecting their behavior, and I can later inquire about their
cognitions.

Behavior therapy does not provide insight. If this assertion is indeed true,
behavior therapists would probably respond that insight is not a necessary requisite
for behavior change. Follette and Callaghan (2011) state that contemporary behavior
therapists tend to be leery of the role of insight in favor of alterable, controllable,
causal variables. It is possible for therapy to proceed without a client knowing how
change is taking place. Although change may be taking place, clients often cannot
explain precisely why. Furthermore, insights may result after clients make a change
 B EH AV I O R T H ERAP Y 265

in behavior. Behavioral shifts often lead to a change in understanding or to insight,

which may lead to emotional changes as well.

Behavior therapy treats symptoms rather than causes. The psychoanalytic

assumption is that early traumatic events are at the root of present dysfunction.
Behavior therapists may acknowledge that deviant responses have historical origins,
but they contend that history is less important in the maintenance of current
problems than environmental events such as antecedents and consequences. However,
behavior therapists emphasize changing current environmental circumstances to
change behavior.
Related to this criticism is the notion that unless historical causes of present
behavior are therapeutically explored new symptoms will soon take the place of
those that were “cured.” Behaviorists rebut this assertion on both theoretical and
empirical grounds. They contend that behavior therapy directly changes the main-
taining conditions of problem behaviors (symptoms), thereby indirectly changing
the problem behaviors. Furthermore, they assert that there is no empirical evidence
that symptom substitution occurs after behavior therapy has successfully elimi-
nated unwanted behavior because they have changed the conditions that give rise to
those behaviors (Spiegler, 2016).

Behavior therapy involves control and social influence by the therapist. All
therapists have a power relationship with the client and thus therapy involves
social influence; the ethical issue relates to the therapist’s degree of awareness of
this influence and how it is addressed in therapy. Behavior therapy recognizes the
importance of making the social influence process explicit, and it emphasizes client-
oriented behavioral goals. Therapy progress is continually assessed and treatment is
modified to ensure that the client’s goals are being met.
Behavior therapists address ethical issues by stating that therapy is basically a
psychoeducational process. At the outset of behavior therapy, clients learn about the
nature of counseling, the procedures that may be employed, and the benefits and
risks. Clients are given information about the specific therapy procedures appropri-
ate for their particular problems. To some extent, they also participate in the choice
of techniques that will be used in dealing with their problems. With this informa-
tion clients become informed, genuine partners in the therapeutic venture.

The literature in the field of behavior therapy is so extensive and diverse that it is
not possible in one brief survey chapter to present a comprehensive, in-depth discus-
sion of behavioral concepts and techniques. Examining some of the suggested read-
ings at the end of this chapter will further your knowledge of this complex approach.

Self-Reflection and Discussion Questions

1. Behavior therapists use a brief, active, directive, collaborative, present-
focused, didactic, psychoeducational model of therapy that relies on
empirical validation of its concepts and techniques. What do you see as
the main strengths and limitations of this focus?
266 C HAP TE R NINE

2. What are some unique characteristics common to all of the behavioral

therapies? How do you see these therapies as being able to apply to a
setting in which you might work?
3. The third-generation behavioral approaches involve mindfulness and
acceptance-based concepts. What aspects of these concepts would you
most want to incorporate in your work with clients?
4. How can you apply mindfulness techniques in your daily life? What
value do you place on becoming more mindful?
5. What are some of the behavioral interventions that you can see yourself
applying to your personal life? What specific behavioral techniques do
you most want to incorporate into your counseling practice?

Where to Go From Here

Visit CengageBrain,com or watch the DVD program Integrative Counseling: The Case
of Ruth and Lecturettes, Session 8 (“Behavioral Focus in Counseling”), in which I dem-
onstrate a behavioral way to assist Ruth in developing an exercise program. It is
crucial that Ruth makes her own decisions about specific behavioral goals she wants
to pursue. This applies to my attempts to work with her in developing methods of
relaxation, increasing her self-efficacy, and designing an exercise plan.

Other Resources
DVDs offered by the American Psychological Association that are relevant to this
chapter include the following:
Antony, M. M. (2009). Behavioral Therapy Over Time (APA Psychotherapy
Video Series)
Hayes, S. C. (2011). Acceptance and Commitment Therapy (Systems of Psycho-
therapy Video Series)
Psychotherapy.net is a comprehensive resource for students and professionals
that offers videos and interviews on behavior therapy. New video and editorial con-
tent is made available monthly. DVDs relevant to this chapter are available at www
.psychotherapy.net and include the following:
Stuart, R. (1998). Behavioral Couples Therapy (Couples Therapy With the
Experts Series)
If you have an interest in further training in behavior therapy, the Association
for Behavioral and Cognitive Therapies (ABCT) is an excellent resource. ABCT (for-
merly AABT) is a membership organization of more than 4,500 mental health pro-
fessionals and students who are interested in behavior therapy, cognitive behavior
therapy, behavioral assessment, and applied behavioral analysis. Members receive
discounts on all ABCT publications, some of which are:
ŠDirectory of Graduate Training in Behavior Therapy and Experimental-Clinical
Psychology is an excellent source for students and job seekers who want
information on programs with an emphasis on behavioral training.
 B EH AV I O R T H ERAP Y 267

ŠDirectory of Psychology Internships: Programs Offering Behavioral Training

describes training programs having a behavioral component.
ŠBehavior Therapy is an international quarterly journal focusing on origi-
nal experimental and clinical research, theory, and practice.
ŠCognitive and Behavioral Practice is a quarterly journal that features clini-
cally oriented articles.
Full and associate memberships are $199 and include one journal subscription
(to either Behavior Therapy or Cognitive and Behavioral Practice) and a subscription to
the Behavior Therapist (a newsletter with feature articles, training updates, and asso-
ciation news). Membership also includes reduced registration and continuing edu-
cation course fees for ABCT’s annual convention held in November, which features
workshops, master clinician programs, symposia, and other educational presenta-
tions. Student memberships are $49.
Association for Behavioral and Cognitive Therapies
www.abct.org

Mindfulness and Acceptance-Based Approaches

If you are interested in finding out more about mindfulness and acceptance-based
programs and resources for the newer therapies, explore some of these websites:
Institute for Meditation and Psychotherapy
www.meditationandpsychotherapy.org

Mindfulness-Based Stress Reduction

www.umassmed.edu/cfm

Dialectical Behavior Therapy

www.behavioraltech.com

Acceptance and Commitment Therapy

www.acceptanceandcommitmenttherapy.com

Self-Compassion Resources
www.self-compassion.org

Recommended Supplementary Readings

Behavior Therapy (Antony & Roemer, 2011a) offers and clearly written textbook dealing with training
a useful and updated overview of behavior therapy. experiences and skill development. This book offers
Contemporary Behavior Therapy (Spiegler, 2016) is a practitioners a wealth of material on a variety of
comprehensive discussion of basic principles and topics, such as assessment procedures, selection of
applications of the behavior therapies. It is an excel- goals, development of appropriate treatment pro-
lent text that is based on research. grams, and methods of evaluating outcomes.

Interviewing and Change Strategies for Helpers (Corm- Mindfulness and Psychotherapy (Germer, Siegel, & Ful-
ier, Nurius, & Osborn, 2013) is a comprehensive ton, 2013) is a practical introduction to mindfulness
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 M

CHAPTER 19

Integrative Therapies

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Reasons for the Growth of Eclectic and Integrated Emerging Integrated and Eclectic Treatment
Approaches Systems
The Challenges of Eclectic and Integrated TransMeoretical Model of Change
Approaches Other Stages-of-Change and Matching
The Benefits of Eclectic and Integrated Approaches Models
The Nature of Eclectic and Integrated Approaches Hill's Three-Stage Integrated Model
Types of Eclectic and Integrated Approaches Common Factors Models
Integrating Treatment Systems Skill Development: Tem)ination of Treatment
Chamcteristics of Sound Eclectic and Case lllusuation
Integrated Approaches Exercises
Fomiulating an Integrative Treatment System Large-Group Exercises
Integrative Psychodynamic--Behavior Therapy Small-Group Exercises
Muldmodal Therapy Individual Exercises
Theory and Practice of Multimodal Therapy Summary
Therapeutic Alliance Recommended Readings
Application and Cunent Status Additional Sources of Infomiation
Evaluation

The most popular treatment methodologies of most mental health professionals are integrated or
eclectic methods. In fact, nearly 34%n of counseling psychologists, 26qo of social workers, and 23qo
of counselors describe their primary theoretical orientation as eclectic or integrative(Prochaska &
Norcross, 2009). These percentages have been increasing over the years, and the trend seems likely

429
430 Part 6 ' Other Tmatment Approaches

to continue. Even c]inicians who adhere to one theoretica] orientation commonly incorporate into
their work interventions from other treatment approaches. However, it should be stressed that before
a clinician can integrate treatment approaches, they must first be grounded in a theory and knowl-
edgeable about the different approaches to treatment overall.
Parts 2 through 5 of this book focused on theories of counseling and psychotherapy reflect-
ing four major emphases--background, emotions, thoughts, and actions--and reviewed treat-
ment strategies and skills associated with each. Knowledge of an array of theoretical approaches
is necessary so that clinicians can detemline which treatment approach is best for them and for
each of their clients and to afford clinicians an array of useful interventions. Although this knowl-
edge is integral to the professional development of every effective clinician, many counselors and
psychologists today do not align themselves strongly with one particular approach. Instead, they
draw on a variety of theories and interventions in developing a treatment plan that seems likely to
help a given person.

REASONS FOR THE GROWTH OF ECLECTIC

AND INTEGRATED APPROACHES
Many factors account for this trend toward integrative and eclectic treatment. Chief among them is
the fact that no single theory has yet been found that can clearly capture the entire range of human
experiences across the life span. In light of the diversity of people seeking treatment--who vary
according to many dimensions including culture, ethnicity, gender, sexual orientation. intelligence.
abilities, interpersonal skills, life experiences, self-awareness, support systems, and symptoms--
strictly adhering to one specific model of counseling or psychotherapy may greatly reduce
therapeutic options. At the same time, evidence increasingly indicates that matching clients who
have a preferred treatment modality or type of therapist with that preference reduces the dropout
rate and is more likely to result in improvements in therapeutic outcomes (Swift, Callahan, &
Vo[[mer, 20] 1).
Not so surprisingly, Miller, Duncan, and Hubble (2002) found that as a therapist's years of
experience increased, they were less likely to strictly follow just one theoretical approach. Perhaps
this is because c]inica] expertise has been found to be necessary for finding and combining the best
research-based practices that match specific client needs (APA Presidential Task Force on Evidence-
Based Practice, 2006).
In addition, no one theoretical model has proven itself superior to the rest despite efforts
to identify such a theory. Luborsky, Singer, and Luborsky (1975) reviewed the comparative lit-
erature on psychotherapy and concluded that the result was a dodo bird verdict. (The dodo bird,
in .4/fce 's ,4dvenr res in Wonder/and, stated that since everyone had won the race, all must have
prizes.) Despite extensive research since 1 975, the dodo bird verdict still stands. According to
Hansen (2002), ". . . meta-analysis of counseling outcome studies clearly shows that no one
approach has emerged as the correct or most helpful . . . it seems that all well-established
approaches promote healing" (p. 3 1 5). In fact, research suggests that what the therapist does is
as empirically validated as the type of treatment that is used (Duncan, Miller, Wampold, &
Hubble, 20] 0).
At the same time, research has demonstrated that some treatment approaches are more effec-
tive than others with particular problems, diagnoses, or types of people. For example, cognitive
therapy and interpersonal psychotherapy are particularly powerful in the treatment of major depres-
sive disorder(Nathan & Gorman, 2002), whereas reality therapy has been widely used in treating
conduct disorders. In addition, recent research indicates that psychotherapy is more enduring than
medication management(Holton, Stewart, & Struck, 2006).
 Chapter 19 ' Integrative Therapies 431

The following 12 factors have combined during the past 30 years to move clinicians in the
direction of preferring integrative and eclectic approaches over adherence to one specific treatment
system(Prochaska & Norcross, 2009):
1. The large and growing number of approaches to treatment; more than 500 treatment systems
have been identi6led
2. Tbhe increasing diversity and complexity of clients and their concems
3. The inability of any one treatment system to successfully address all clients and all problems
4. The growing importance of solution-focused brief approaches that encourage clinicians to
draw on and combine interventions from various systems of therapy to find the most effective
and ef6lcient suategy for each treatment situation
5. The avai]abi]ity of n'awning opportunities, as we]] as case studies and other infomiative litera-
ture. that give clinicians the opportunity to study, observe, and gain experience in a wide
variety of treatment approaches
6. '1be requirement of some state and national credentialing bodies that clinicians obtain post-
graduate continuing education units; this encourages continued professional growth and
development of new skills and ideas
7. Increasing pressure from managed care organizations, govemmental agencies, consumers,
and others for clinicians to detemline the most effective and efficient Ueatment approach for
each client, to plan and document their work, and to maintain accountability
8. The growing body of compelling research demonstrating which treatment approaches are
most likely to be successful in the treatment of particular people, disorders, or problems
(Seligman & Reichenberg, 2012)
9. The increasing availability of manuals, providing detailed and empirically validated treat-
ment plans for specific mental disorders
10. The development of organizations such as the Society for the Exploration of Psychotherapy
Integration that focus on studying and promoting treatment integration
[[. The emergence of models providing b]ueprints or guide]ines for ]ogica] and therapeutically
sound integration of Ueatment approaches
12. Clinicians' increasing awareness that common factors among treatment approaches, such as
the nature of the therapeutic alliance, are at least as important in detemlining treatment suc-
cess as are specific strategies.

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

THE CHALLENGES OF ECLECTIC AND INTEGRATED APPROACHES

Choosing to adopt an eclectic or integrated theoretical orientation is challenging and probably
demands more of clinicians than does adherence to one specific theory. If clinicians decide, for
example, that they will specialize in cognitive therapy, they should develop expertise in that
approach and know when it is and is not likely to be helpful so that they can refer to others those
clients who are unlikely to benefit from cognitive therapy. Because they have limited the scope of
their work, these clinicians do not have to develop expertise in other treatment approaches, although
they should be familiar with other approaches.
However, clinicians who view their primary theoretical orientation as eclectic or integrated
need expertise in a range of treatment systems so they can draw on those approaches in creating
effective treatment plans. Of course, clinicians who have an eclectic or integrated orientation also
set limits on the scope of their practice; no clinician could have sufficient knowledge and expertise
432 Part 6 ' Other Treatment Approaches

in the entire range of therapeutic approaches to treat all clients and all problems. Clinicians should
define the scope of their practice according to the nature of their clientele, the problems or mental
disorders they treat, and the strategies they employ. Nevertheless, clinicians who prefer eclectic or
integrated treatment approaches still have a professional role that is more comprehensive and chal-
lenging than that of clinicians with a specific theoretical orientation.
In addition, clinicians advocating an eclectic or integrated treatment approach must carefully
think through their treatment of each client to ensure that the disparate parts of treatment comprise
a seamless whole in which each intervention is chosen deliberately to accomplish a purpose.
Treatment must notjust be an amalgam of "tricks of the trade" but, rather, should reflect coherence.
relevance, and planning and be solidly grounded in both theory and empirical research. As Schwartz
and Waldo(2003) stated, "The danger of creating a 'hodge-podge ' of apples and oranges can be
avoided if the theories are compatible, carefully integrated, and if they reflect the basic characteris-
tics of mental health counseling" (pp. IO1--102).

THE BENEFITS OF ECLECTIC AND INTEGRATED APPROACHES

Integrated and eclectic theoretical approaches have benefits as well as challenges. They bring flex-
ibility to the treatment process, enabling clinicians to tailor their work to specific clients and con-
cems in an effort to find a good fit between treatment and client.
This is especially important when clinicians treat people from diverse cultural backgrounds
who may respond better to modified or integrated approaches than they do to standardized ones. For
example, people from Asian backgrounds may respond best to treatment approaches that are struc-
tured in nature but that also recognize the importance of the family and society. Clinicians can
demonstrate multicultural competence by creating integrated treatment plans that reflect sensitivity
to clients' culture and context.
Because they have greater flexibility in their work, clinicians espousing an integrated or
eclectic approach probably can work with a broader range of people and problems than those who
afElliate themselves with a single treatment system. Of course, all clinicians must practice within
their areas of expertise or obtain supervision or training to expand their skills.
In addition, integrated and eclectic approaches allow clinicians to adapt standard treatment
approaches to their own beliefs about human growth and development as well as to their natural
style and personality.
Finally, integrated and eclectic approaches facilitate clinician efforts to assume a scientist-
practitioner role and to combine theoretica] information, empirical research, and practical experi-
ence. Basing their work on treatment approaches that have proven their value through research.
clinicians can expand on that foundation by incorporating into their work ideas that have face valid-
ity as well as strategies that they have used successfully with other clients.

THE NATURE OF ECLECTIC AND INTEGRATED APPROACHES

When clinicians first began to describe their theoretical orientations as ec/eerie. the term lacked a
clear meaning; it simply suggested that clinicians drew on more than one approach to treatment.
Although some clinicians who characterized their work as eclectic were gifted therapists and
astute theoreticians with a clear rationale for combining interventions in their work, others lacked
a thoughtful and systematic approach to treatment. Eysenck(1970) denounced what he referred to
as "lazy eclecticism"(p. 140), the use of a grab bag of interventions combined without an overrid-
ing logic. Without a logic or structure, ec]ecticism can lead to treatment that is haphazard and
 Chapter 19 ' Integrative Therapies 433

inconsistent, lacking in direction and coherence. This has been referred to as sy/zcrefism. Such an
approach reflects a lack of knowledge and professionalism and is incompatible with current
emphases on accountability and treatment planning in counseling and psychotherapy.

Types of Eclectic and Integrated Approaches

Four types of eclecticism have been identified:
1. ,4fheoreHcaZ ecZecffcfsm is characterized by combining interventions without an overriding
theory of change or development. Unless an intuitive or underlying logic prevails, clinicians
whose work reflects atheoretical eclecticism run the risk of syncretism--providing treatment
that is without direction, including elements that are disparate and perhaps incompatible.
Such an approach probably will be confusing to clients, may lead them to question the clini
dan's competence (as well as their own), can interfere with client cooperation and motiva-
tion, and may well lead to treatment failure.
2. Common/actors ecZecficlsm hypothesized that certain elements of treatment, notably a theta
peutic alliance that communicates support, empathy, and unconditional positive regard. are
primarily responsible for promoting client growth and change (Norcross & Wampold, 201 1).
Specific interventions are linked to these common factors rather than to a specific theory. In
Part I you leamed about commonalities in successful treatment.
3. Technical eclec#clsm provides a framework for combining interventions from different treat-
ment systems without necessarily subscribing to the theories or philosophies associated with
those interventions. In general, counselors who practice technical eclecticism seek out the
most effective techniques available for their client ' s specific problems. Technical eclecticism
can be thought of as an organized collection of interventions, rather than an integration of
ideas. The selection of interventions should have an empirical basis, reflecting research on the
effectiveness of various interventions in successfully addressing clients' concems. However.
technical eclecticism lacks a coherent model for human development and growth. Lazarus's
multimodal therapy exemplifies this type of eclecticism.
4. Theoredca/ llzfegrado offers conceptual guidelines for combining two or more treatment
approaches to provide a clearer understanding of clients and more effective ways to help
them. A theoretical integration usually provides clinicians with a framework for understand-
ing how people grow and change and guidelines for developing treatment plans that reflect
that understanding. Integrated treatment approaches often include a multistage, systematic
approach to treaHlent as well as infomlation on assessing client strengths and difHjculties and
matching treatment to client. Clinicians have guidelines to help them answer the seminal
question "W/zaf treatment, by whom, is the most elective for r/zlx individual with f/zaf specific
problem, and under what set of circumstances?" (Paul, 1967, p. 109). In a true theoretical
integration, the whole is greater than the sum of its parts The combination of approaches
blends well and fomns a new theory or treatment system that builds on and improves each of
the individua] approaches to form a better product. Treatment is theory focused rather than
technique driven. Hill ' s three-stage integration model, discussed later in this chapter, is an
example of theoretical integration.

INTEGRATING TREATMENT SYSTEMS

Although most clinicians do not adhere to a systematic approach to theoretical integration, they
probably have fomlulated their own logic for combining compatible theories. The most common
combinations of theories, in descending order of frequency, include ( 1) cognitive and behavioral
434 Part 6 ' Other Treatment Approaches

ueatment systems, (2) humanistic and cognitive approaches, and (3) psychoanalytic and cognitive
approaches (Prochaska & Norcross, 2009). The presence of cognitive therapy in all three combina-
tions is noteworthy, suggesting the flexibility of that approach and its importance in treatment.

Characteristics of Sound Eclectic and Integrated Approaches

Certain hallmarks distinguish conceptually sound integrated and eclectic approaches from eclecti
asm that is haphazard and ill conceived. Sound eclecticism has the following characteristics:
::l:g:gi:az:! :::

Evident of building ox tbe stli:ngths of eM8ting Uioaria

An undeiiying theory of human bdnviar and devcl{)pnnnt

A philosophy or theory of change
Logic, guidelines, and procedures for adapting the.appfaach to # pMculM person or problem
Strategies and interventions, related to Qc undulying theories, that facilitatechange
Inclusion of the commonalities of elective tieabiwnt. swh u support, positive ngard, empathy, and

FORMULATING AN INTEGRATIVE TREATMENT SYSTEM

When clinicians fomlulate an integrative treatment system, they must address many questions
including the following:

1. What model of human development underlies the theory?

2. How does this treatment approach suggest that change is best facilitated7
3. What infomiation should be obtained in an intake interview?
4. 'Rrhat conception does this approach have of the influence of the past on the present, and how
should past experiences and difHculties be addressed in treatment?
5. How important is insight in promoting change, and how much attention should be paid in
treatment to improving insight?
6. How important is exploration of emotions in promoting change, and how much attention
should be paid in treatment to helping people identify, express, and modify their emotions?
7. How important is identification and modification of dysfunctional cognitions in promoting
change, and how much attention should be paid in treatment to helping people alter their cog-
nitions?
8. How important is identification and modification of self-destructive and unhelpful behaviors
in promoting change, and how much attention should be paid in treatment to helping people
alter their behaviors?
9. What sorts of people and problems are likely to respond well to this approach?
lO. In what treatment settings and contexts is this approach likely to be successfU?
11. How well does this approach address issues of diversity, and what is the appropriate use of
this approach with people from multicultural backgrounds?
12. What is the place of diagnosis and treatment planning in this approach?
13. What are the overall goals of treatment?
14. What types of therapeutic alliances and client-clinician interactions are most likelv to be oro.
ductive?
15. What clinical skills are especially important for those who adopt this approach?
16. What interventions and strategies are compatible with this treatment system?
 Chapter 19 ' Integrative Therapies 435

17. How should this approach be adapted for use with individuals? Families? Groupso
18. How long is treatment likely to last '?
19. How is effectiveness measured, and what detemiines when Ueatment is finished?
20. Has this treatment system been adequately substantiated by empirical research? if not, what
information is needed to support the value of this approach?
Some of the shortcomings of eclectic and integrated approaches can be overcome by adopting
a sound and systematic rationale for developing treatment plans. As Lazarus and Beutler ( 1993)
stated, "Procedures are not selected haphazardly, but their selection is specifically dependent on a
logical decisional process that takes into account the client, setting, problem, and the nature of the
counselor's skills" (p. 384).
This chapter reviews some established or promising approaches that demonstrate ways to
provide integrated treatment by design rather than default. Two models receive particular atten-
tion: cyclical psychodynamic-behavior therapy developed by Paul Wachtel. and multimodal ther-
apy developed by Amold Lazarus. These two approaches differ considerably, although both are
well-developed treatment systems with demonstrated success. We also give some attention to
other integrated and eclectic treatment systems, including the transtheoretical model of change
developed by Prochaska and his colleagues, Hill's three-stage integrated model of helping, and
common factors models.

INTEGRATIVE PSYCHODYNAI llC-BEHAVIOR THERAPY

The aust person to truly integrate two separate theoretical orientations was Paul Wachtel( 977),
1

who combined psychodynamic therapy with behavioral therapy to create cyclical psychodynamic
behavior therapy. As its name implies, the treatment approach integrates the insight achieved
through psychodynamic therapy with app]ied behaviora] interventions, with the goa] of providing a
more powerful intervention than either treatment modality alone
Wachtel's groundbreaking work, is considered to be an example of technical eclecticism
(Sharf, 2012). Tt broadened the field by providing a primacy and secondary approach to treatment
while also emphasizing the need to adapt treatment to the client's worldview, to consider both
social and psycho]ogica] dimensions, and to empower the c]ient (Wachte], 2008; Wachtel, Kruk, &
Mckinney, 2005).
Stricker and Gold (20 1 1 ) consider Wachtel's theory to be "the most comprehensive and influ-
ential integrative theory of personality" (p. 343). Wachtel and others found much support for the
theory of a cyc]ica] nature of personality dynamics. The temp "vicious cycles" comes to mind, in
which people continue to repeat pattems of behavior, or even make reality consistent with their
expecladons of what will happen. Research has shown that people induce in others the behavior
they expect from them (Gilbert & Jones, 1986). Such self-fulfilling prophesies, also known as fun-
damental attribution errors or expectancy biases, can keep a person stuck in a continuing pattem
despite his or her greatest efforts to overcome them.
Wachtel suggests that early experiences trigger cycles or pattems of behavior that are main-
tained by present attitudes or inclinations. He believes that an integration of psychodynamic and
behavioral approaches provides a dynamic treatment in which insight leads to behavioral change
and behavioral change leads to insight in a cyclical pattem.
The opposite is also true. For example, a person who leans toward depression may actually
elicit and contribute to relationships that maintain that negativity. Even while protesting that they
want to change, they may actually surround themselves with people who reinforce negative behav-
iors and increase the sense of victimization. A similar dynamic occurs when we solicit an opinion
 14 Couple and Family Counseling

Chapter Overview
From this chapter you will
learn about:
■ Family life, the family life

cycle, and the changing

forms of families
■ The nature of couple and

family counseling
■ The process of couple and

family counseling
As you read consider:
■ How you might treat

different family types and

why
■ The research associated
Stockbyte/Getty Images
with the various forms of
family counseling
■ The difference between At thirty-five, with wife and child
working with families and a Ph.D.
groups or individuals and hopes as bright as a full moon
on a warm August night,
He took a role as a healing man
blending it with imagination,
necessary change and common sense
To make more than an image on an eye lens
of a small figure running quickly up steps;
Quietly he traveled
like one who holds a candle to darkness
and questions its power
So that with heavy years, long walks,
shared love, and additional births
He became as a seasoned actor,
who, forgetting his lines in the silence,
stepped upstage and without prompting
lived them.
Reprinted from “Without Applause,” by S. T. Gladding, 1974, Personnel and Guidance
Journal, 52, p. 586. © S. T. Gladding.
314
 Chapter 14 • Couple and Family Counseling 315

This chapter examines the genesis and development of couple and family counseling along with an
overview of couple and family counseling organizations and research. It also describes the family
life cycle and addresses how family counseling differs from individual and group counseling. The
process of couple and family counseling from beginning to closure is looked at as well.
Couple relationships and family life are rooted in antiquity. Whether arranged by a family or
the couple themselves, men and women, and in more recent time same-sex partners, have paired
together in unions sanctioned by religion and/or society for economic, societal, and procreation
reasons for millennia. The terms couple and family have distinct connotations in different societ-
ies. Marriage is generally seen as a socially or religiously sanctioned union between two adults
for economic, social, and/or procreational reasons. The term couple is more informal and
broader. It simply denotes two people in a relationship together. They may be married or not,
intimate or not. Nevertheless, they are seen as linked together, that is, “bonded” in one or more
ways. A family, on the other hand, consists of “those persons who are biologically and/or psy-
chologically related … [through] historical, emotional, or economic bonds … and who perceive
themselves as a part of a household” (Gladding, 2015b, p. 6). These definitions of marriage, cou-
ple, and family allow for maximum flexibility and can encompass a wide variety of forms.
Couple and family counseling is a popular pursuit of counselors. There are at least three
reasons why. First is the realization that persons are directly affected by how their couple rela-
tionship or families function (Goldenberg & Goldenberg, 2002). For instance, in family life, cha-
otic families frequently produce offspring who have difficulty relating to others because of a lack
of order or even knowledge of what to do, whereas enmeshed families have children who often
have difficulty leaving home because they are overdependent on parents or other family members.
A second reason couple and family counseling is attractive is a financial consideration.
Problems can often be addressed more economically when a couple or family is seen
together. Finally, the encompassing nature of couple and family counseling work makes it
intrinsically appealing. There are multiple factors to be aware of and to address. Counselors
who are engaged in helping marital units, couples, and families must constantly be active men-
tally and even sometimes physically. The process itself can be exciting as well as rewarding
when change takes place. Couple and family counseling attracts many clinicians who wish to
work on complex, multifaceted levels in the most effective way possible.

THE CHANGING FORMS OF FAMILY LIFE

The strong interest in couple and family counseling today is partly due to the rapid change in
American family life since World War II. In 1950, two types of families, which still exist, domi-
nated American cultural life:
• the nuclear family, a core unit of husband, wife, and their children; and
• the multigenerational family, households that include at least three generations, such as a
child/children, parent(s), and grandparent(s). This type of family sometimes includes
unmarried relatives, such as aunts and uncles.
After the war, a rising divorce rate made two more family types prevalent:
• the single-parent family, which includes one parent, either biological or adoptive, who is
solely responsible for the care of self and a child/children; and
• the blended (i.e., remarried, step) family, a household created when two people marry and
at least one of them has been previously married and has a child/children.
316 Part IV • Counseling Specialties

In addition, changes in societal norms and demographics since the 1950s have fostered the
development and recognition of several other family forms besides those already mentioned,
specifically,
• the dual-career family, in which both marital partners are engaged in work that is
developmental in sequence and to which they have a high commitment;
• the childless family, which consists of couples who consciously decide not to have
children or who remain childless as a result of chance or biological factors;
• the aging family, in which the head or heads of the household are age 65 or above;
• the gay/lesbian family, which is made up of same-sex couples with or without a child/children
from either a previous union or as a result of artificial insemination or adoption; and
• the multicultural family, in which individuals from two different cultures unite and form
a household that may or may not have children.
Couples and families in the 21st century are quite varied. Those who choose to enter such
relationships face a host of economic, social, and developmental challenges that demand their atten-
tion daily. They also find a number of rewards in such unions including physical, financial, and
psychological support. The drawbacks and impacts of couple and family life are great and some-
times complicated. Professional counselors who work with couples and families must be attuned to
a host of difficulties as well as possibilities. They must be ready to deal with extremely intricate and
unsettling changes that developmentally or situationally may face these units (Napier, 1988).

PERSONAL REFLECTION
What type of family did you grow up in? What were its strengths? What were its weaknesses? What
type of family listed previously would you prefer, if you could choose? Why?

THE BEGINNINGS OF COUPLE AND FAMILY COUNSELING

The profession of couple and family counseling is relatively new (Framo, 1996). Its substantial
beginnings are traced to the 1940s and early 1950s, but its real growth occurred in the late 1970s
and the 1980s (Nichols, 1993). It is interesting to note that the rise in popularity of couple and
family counseling closely followed dramatic changes in the form, composition, structure, and
emphasis of the American family noted earlier in this chapter (Markowitz, 1994). In this section,
trends and personalities that influenced the development of the field will be noted, including
some contemporary leaders.

Trends
At the end of World War II, the United States experienced an unsettling readjustment from war to
peace that manifested itself in three trends that had an impact on the family, other than a rise in dif-
ferent types of family forms (Walsh, 1993). One was a sharp rise in the divorce rate, which took
place almost simultaneously with the baby boom beginning in 1946. Whereas divorce had been
fairly uncommon up to that point, it rose dramatically thereafter and did not level out until the
1990s. The impact of this phenomenon was unsettling. Today, a large percentage (around 50%) of
couples who marry eventually dissolve their unions (Maples & Abney, 2006; Whitehead, 1997).
However, new Census data show the divorce rate for most age groups has been dropping
 Chapter 14 • Couple and Family Counseling 317

(Kreider & Ellis, 2011). The reason for the drop in divorce rates in recent years can be attributed to
a number of factors, such as education, but perhaps the most significant one is that couples in the
United States are waiting longer to get married and are therefore more mature when they do marry.
A second trend that influenced the rise of couple and family counseling was the changing
role of women. After World War II, more women sought employment outside the home. Many
women became the breadwinners of their families as well as the bread makers. The women’s
rights movement of the 1960s also fostered the development of new opportunities for women.
Thus, traditions and expectations fell and/or were expanded for women. The results were unset-
tling, as any major social change is, and both men and women in families and marriages needed
help in making adequate adjustments. In 2015, 51% of women in the United States were unmar-
ried and most women, including those who were married, worked outside the home.
The expansion of the life span was the third event that had an impact on family life and
made couple and family counseling more relevant to the American public. Couples found them-
selves living with the same partners longer than at any previous time in history (Maples &
Abney, 2006). Many were not sure exactly how to relate to their spouses, partners, or children
over time because there were few previous models.
Thus, the need to work with couples and individuals who were affected by these changes
brought researchers, practitioners, and theorists together. They set the stage for an entirely new
way of conceptualizing and working with married people, couples, and families.

Couple and Family Therapy Pioneers and Contemporary Leaders

A number of helping specialists advanced the field of couple and family counseling after World
War II and up to the present—more than can be mentioned here. Some, like Nathan Ackerman
and Virginia Satir, did it using the persuasive nature of their personalities. Others, such as
Salvador Minuchin, John Gottman, and Sue Johnson, became important and notable because of
the research they conducted.
The work of Nathan Ackerman (1958), a New York City psychoanalyst, was especially
critical in focusing the attention of a well-established form of therapy, psychoanalysis, on fami-
lies. Before Ackerman, psychoanalysts had purposely excluded family members from the treat-
ment of individual clients for fear that family involvement would be disruptive. Ackerman
applied psychoanalytic practices to the treatment of families and made family therapy respected
in the profession of psychiatry.
Two other pioneers that emerged on a national level about the time of Ackerman were
experiential in nature: Virginia Satir and Carl Whitaker. Both of these individuals had engaging
personalities and a presence that commanded attention. Satir was an especially clear writer and
presenter, whereas Whitaker was a maverick whose unorthodox style and creativity, such as fall-
ing asleep during a session and having a dream, provoked considerable thought and discussion in
the marriage and family field and in the couples and families with whom he worked.
Jay Haley was probably the dominant figure of the early family therapists, however. Haley
culled ideas from Milton Erickson, blended them with his own thoughts, and through persistence
kept early family counselors in touch with one another and with developing ideas in the field.
Haley also had a major role in developing strategic family therapy and influencing structural
family therapy.
Other pioneers worked in teams as researchers conducting exploratory studies in the
area of family dynamics and the etiology of schizophrenia. Among the teams were the
Gregory Bateson group (Bateson, Jackson, Haley, & Weakland, 1956) in Palo Alto,
318 Part IV • Counseling Specialties

California, and the Murray Bowen and Lyman Wynne groups (Bowen, 1960; Wynne,
Ryckoff, Day, & Hirsch, 1958) at the National Institute of Mental Health (NIMH). They
observed how couples and families functioned when a family member was diagnosed as
schizophrenic. The Bateson group came up with a number of interesting concepts, such as the
double bind, where a person receives two contradictory messages at the same time and,
unable to follow both, develops physical and psychological symptoms as a way to lessen ten-
sion and escape. Bowen went on to develop his own systemic form of treatment based on
multigenerational considerations and originate a now widely popular clinical tool, the geno-
gram (a three-generational visual representation of one’s family tree depicted in geometric
figures, lines, and words).
The group movement, especially in the 1960s, also had an impact on the emergence of
couple and family counseling. Some practitioners, such as John Bell (e.g., Bell, 1975, 1976),
even started treating families as a group and began the practice of couple/family group counsel-
ing (Ohlsen, 1979, 1982). Foreign-born therapists have had a major influence on marriage, cou-
ple, and family therapy since the 1960s. These include Salvador Minuchin, the originator of
Structural Family Therapy; Mara Selvini Palazzoli, a creator of a form of strategic family ther-
apy known as the Milan Approach; as well as (more recently) Michael White and David Epston,
the founders of Narrative Therapy.
Most recently there has been a Midwestern influx into the field led by Steve deShazer and
Bill O’Hanlon, who developed brief therapeutic therapies that emphasize solutions and possi-
bilities. In addition, Monica McGoldrick (McGoldrick, Giordano, & Garcia-Preto, 2005) has
emphasized the importance of multicultural factors and cultural background in treating couples
and families. Included in the idea of culture today are inherited cultures (e.g., ethnicity, nation-
ality, religion, groupings such as baby boomers) and acquired cultures (learned habits, such as
those of being a counselor) (Markowitz, 1994). Betty Carter and a host of others have also
focused on an awakening in the couple and family counseling field to gender-sensitive issues,
such as the overriding importance of power structures. Finally, exemplary researchers, such as
John Gottman and Neil Jacobson, have helped practitioners understand better the dynamics
within couples and families, especially factors related to domestic violence and higher function-
ing marriage relationships (Peterson, 2002).

ASSOCIATIONS, EDUCATION, AND RESEARCH

Associations
Four major professional associations attract marriage, couple, and family clinicians.
• The largest and oldest, which was established in 1942, is the American Association for
Marriage and Family Therapy (AAMFT).
• The second group, the International Association of Marriage and Family Counselors
(IAMFC), a division within the American Counseling Association (ACA), was chartered
in 1986.
• The third association, Division 43 (Family Psychology), a division within the American
Psychological Association (APA), was formed in 1984 and comprises psychologists who
work with couples and families.
• The fourth association is the American Family Therapy Association (AFTA), formed in
1977. It is identified as an academy of advanced professionals interested in the exchange
of ideas.
 Chapter 14 • Couple and Family Counseling 319

Education
Both the AAMFT and IAMFC have established guidelines for training professionals in working
with couples and families. AAMFT standards are drawn up and administered by the Commission
on Accreditation for Marriage and Family Therapy Education (CAMFTE); those for IAMFC are
handled through the Council for Accreditation of Counseling and Related Educational Programs
(CACREP). A minimum of a 60-semester-hour master’s degree is required for becoming a mar-
riage, couple, and family counselor through a CACREP-accredited program. The exact content
and sequencing of courses will vary from program to program but the courses in Table 14.1 are
almost always included.

Research
Regardless of professional affiliation and curriculum background, professionals are attracted to
couple and family counseling largely due to a societal need for the specialty and its growing
research base. Gurman and Kniskern (1981) reported that approximately 50% of all problems
brought to counselors are related to marriage and family issues. Unemployment, poor school
performance, spouse abuse, depression, rebellion, and self-concept issues are just a few of the
many situations that can be dealt with from this perspective. Individual development dovetails
with family and career issues (Cavanaugh & Blanchard-Fields, 2015; Okun, 1984). Each one
impacts the resolution of the other in a systemic manner. Bratcher (1982) comments on the inter-
relatedness of career and family development, recommending the use of family systems theory
for experienced counselors working with individuals seeking career counseling.

TABLE 14.1 Example of Coursework Areas Required for a Master’s Degree in AAMFT-
Accredited and CACREP-Accredited Programs
CACREP Curriculum AAMFT Curriculum
Human Growth and Development Introduction to Family/Child Development
Social and Cultural Foundations Marital and Family Systems
Helping Relationships
Groups Dysfunctions in Marriage/Family
Lifestyle and Career Development Advanced Child Development
Appraisal/Assessment Assessment in Marital/Family
Research and Evaluation Research Methods Child/Family
Professional Orientation Professional Issues Family
Theoretical Foundation MFT Theories of MFT
Techniques/Treatment MFT Marriage/Family Pre-Practicum
Clinical Practicum/Internship Clinical Practicum
Substance Abuse Treatment Human Sexual Behavior
Human Sexuality Thesis
Electives Electives
Source: From “The Training of Marriage and Family Counselors/Therapists: A ‘Systemic’ Controversy among
Disciplines,” by Michael Baltimore, 1993, Alabama Counseling Association Journal, 19, p. 40. Copyright 1993,
Alabama Counseling Association. Reprinted with permission.
320 Part IV • Counseling Specialties

Research studies summarized by Doherty and Simmons (1996), Gurman and Kniskern
(1981), Haber (1983), Pinsof and Wynne (1995), and Wohlman and Stricker (1983) report a
number of interesting findings:
• First, family counseling interventions are at least as effective as individual interven-
tions for most client complaints and lead to significantly greater durability of change.
• Second, some forms of family counseling (e.g., using structural-strategic family ther-
apy with substance abusers) are more effective in treating problems than other coun-
seling approaches.
• Third, the presence of both parents, especially noncompliant fathers, in family coun-
seling situations greatly improves the chances for success. Similarly, the effectiveness
of marriage counseling when both partners meet conjointly with the counselor is
nearly twice that of counselors working with just one spouse.
• Fourth, when marriage and family counseling services are not offered to couples con-
jointly or to families systemically, the results of the intervention may be negative and
problems may worsen.
• Finally, there is high client satisfaction from those who receive marital, couple, and
family counseling services, with more than 97% rating the services they received from
good to excellent. Overall, the basic argument for employing marriage and family counsel-
ing is its proven efficiency. This form of treatment is logical, fast, satisfactory, and
economical.

CASE EXAMPLE
Shasta Seeks a Marriage Counselor
Shasta grew up in a single-parent family that was often strapped for money. Therefore Shasta
learned to hoard food and to hide any valuables she might obtain. Later, she married Marcus who
was financially quite successful. Still, she hoarded and hid items around the house to the point
that it caused tension in the relationship.
Shasta finally realized she needed help and sought out a marriage and family counselor.
Do you think such a counselor could help her resolve her problem? If so, how? If not, why not?

FAMILY LIFE AND THE FAMILY LIFE CYCLE

Family life and the growth and developments that take place within it are at the heart of mar-
riage, couple, and family counseling. The family life cycle is the name given to the stages a fam-
ily goes through as it evolves over the years. These stages sometimes parallel and complement
those in the individual life cycle, but often they are unique because of the number of people
involved and the diversity of tasks to be accomplished. Becvar and Becvar (2013) outline a nine-
stage cycle that begins with the unattached adult and continues through retirement (Table 14.2).
Some families and family members are more “on time” in achieving stage-critical tasks
that go with the family life cycle and their own personal cycle of growth. In such cases, a better
sense of well-being is achieved (McGoldrick, Garcia-Preto, & Carter, 2016). Other families,
such as those that are dysfunctional, never achieve stage-critical tasks, for instance, substance
 Chapter 14 • Couple and Family Counseling 321

TABLE 14.2 Stages of the Family Life Cycle

Stage Emotion Stage-Critical Tasks
1. Unattached adult Accepting parent- a. Differentiation from family of origin
offspring separation b. Development of peer relations
c. Initiation of career
2. Newly married Commitment to the a. Formation of marital system
marriage b. Making room for spouse with family and friends
c. Adjusting career demands
3. Childbearing Accepting new members a. Adjusting marriage to make room for child
into the system b. Taking on parenting roles
4. Preschool-age child Accepting the new a. Adjusting family to the needs of specific child(ren)
personality b. Coping with energy drain and lack of privacy
c. Taking time out to be a couple
5. School-age child Allowing child to a. Extending family/society interactions
establish relationships b. Encouraging the child’s educational progress
outside the family c. Dealing with increased activities and time demands
6. Teenage child Increasing flexibility of a. Shifting the balance in the parent-child relationship
family boundaries to b. Refocusing on mid-life career and marital issues
allow independence c. Dealing with increasing concerns for older generation
7. Launching center Accepting exits from a. Releasing adult children into work, college, marriage
and entries into the b. Maintaining supportive home base
family c. Accepting occasional returns of adult children
8. Middle-age adult Letting go of children a. Rebuilding the marriage
and facing each other b. Welcoming children’s spouses, grandchildren into family
c. Dealing with aging of one’s own parents
9. Retirement Accepting retirement a. Maintaining individual and couple functioning
and old age b. Supporting middle generation
c. Coping with death of parents, spouse
d. Closing or adapting family home
Source: From Family Therapy: A Systematic Integration (pp. 128–129), by Dorothy Stroh Becvar and Raphael J. Becvar. © 1993 by
Allyn & Bacon. All rights reserved. Reprinted with permission.

abuse families. In these families substance abuse behavior is promoted or enabled. Thus, chil-
dren “from homes in which parents are chemically dependent or abuse alcohol or other drugs
(CDs) are at risk for a wide range of developmental problems” (Buelow, 1995, p. 327). Many
families that abuse alcohol, for example, tend to be isolated and children within them conse-
quently suffer from a lack of positive role models. As children get older, they seem to be particu-
larly affected for the worse from growing up in these families.
Substance abuse is used by these young people as a way to relieve stress, reduce anxiety,
and structure time (Robinson, 1995). It is also an attempt by young adults to protect and stabilize
dysfunctional families by keeping their attention off overall dynamics and on predictable prob-
lematic behaviors (Stanton & Todd, 1982). Substance abuse may serve as a substitute for sex as
322 Part IV • Counseling Specialties

well and promote pseudo-individuation (a false sense of self). These complex and interrelated
factors make it difficult to help families caught up in substance abuse patterns to change behav-
iors without an intensive social action approach designed to change dysfunctional systems (Lee
& Walz, 1998; Margolis & Zweben, 2011).
Families often organize themselves around substance abuse in a systemic way and enable
family members to drink excessively (Bateson, 1971; Steinglass, 1979). In the alcoholic family
system, there is an overresponsible–underresponsible phenomenon, with the overresponsible
person(s) being a so-called codependent (Berenson, 1992). “An essential characteristic of some-
one who is codependent is that they continually invest their self-esteem in the ability to control
and influence behavior and feelings in others as well as in themselves, even when faced with
adverse consequences such as feelings of inadequacy after failure” (Springer, Britt, & Schlenker,
1998, p. 141). In such a situation, it is easier and more productive to work with the overfunction-
ing person(s) and modify that phenomenon than to try to get the underfunctioning person(s) to
change.
Regardless of functionality, all families have to deal with family cohesion (emotional
bonding) and family adaptability (ability to be flexible and change). These two dimensions
each have four levels, represented by Olson (1986) in the circumplex model of marital and
family systems (Figure 14.1). “The two dimensions are curvilinear in that families that appar-
ently are very high or very low on both dimensions seem dysfunctional, whereas families that are
balanced seem to function more adequately” (Maynard & Olson, 1987, p. 502). For instance, a
family that is high in cohesion is enmeshed (extremely close sometimes to the point of not being
well differentiated). If the same family is also high in adaptability they will also be chaotic (dis-
organized). This combination results in a family that is chaotically enmeshed, very close but not
able to function effectively, with the result being that they are unbalanced. In examining the
circumplex model, ideals for family functioning are close to the center with less functional ways
of working closest to the outside. In reality, even the most dysfunctional families execute well at
times and vice versa. Also, families move around on the circumplex model during their life
cycles. For instance, the death of a family member may send a family that is flexibly separated
into one that is rigidly disengaged as individuals drift apart and grieve separately.
Families that are most successful, functional, happy, and strong are not only balanced but also
• committed to one another,
• appreciate each other,
• spend time together (both qualitatively and quantitatively),
• have good communication patterns,
• have a high degree of religious/spiritual orientation, and
• are able to deal with crisis in a positive manner (Gladding, 2015b; Stinnett, 1998; Stinnett
& DeFrain, 1985).
According to Wilcoxon (1985), couple and family counselors need to be aware of the dif-
ferent stages within the family while staying attuned to the developmental tasks of individual
members. When counselors are sensitive to individual family members and the family as a
whole, they are able to realize that some individual manifestations, such as depression (Stevenson,
2007), career indecisiveness (Kinnier, Brigman, & Noble, 1990), and substance abuse (Edwards,
2012), are related to family structure and functioning. Consequently, they are able to be more
inclusive in their treatment plans.
When evaluating family patterns and the mental health of everyone involved, it is
crucial that an assessment be based on the form and developmental stage of the family
 Chapter 14 • Couple and Family Counseling 323

Low COHESION High

REVISED
PERCENTAGE Disengaged Separated Connected Enmeshed
SCORE 0 10 20 30 40 50 60 70 80 90 100
100
Chaotically Chaotically
disengaged enmeshed
Chaotic 90 Chaotically Chaotically
separated connected

80
High

70

Flexible Flexibly Flexibly Flexibly Flexibly

60 disengaged separated connected enmeshed
ADAPTABILITY

50

40 Structurally Structurally Structurally Structurally

Structured disengaged separated connected enmeshed

30
Low

20
Rigidly Rigidly
Rigid separated connected
10
Rigidly Rigidly
disengaged enmeshed
0

Balanced Midrange Unbalanced

FIGURE 14.1 The circumplex model

Source: From Prepare/Enrich, Inc., David H. Olson, president, Minneapolis, MN. © 1979 (rev. 1986). Reprinted with
permission. PREPARE/ENRICH, 2660 Arthur St., Roseville, MN 55113. https://www.prepare-enrich.com.

constellation. To facilitate this process, McGoldrick and colleagues (2016) propose sets of
developmental tasks for traditional and nontraditional families, such as those headed by sin-
gle parents or blended families. It is important to note that nontraditional families are not
pathological because of their differences; they are merely on a different schedule of growth
and development.
Today, more than 4 in 10 American adults have at least one step relative in their family—
either a stepparent, a step or half sibling, or a stepchild. People with step relatives are just as
likely as others to say that family is the most important element of their life. Seven in 10 adults
who have at least one step relative say they are very satisfied with their family life. Those who
do not have any step relatives register slightly higher levels of family satisfaction (78% very
satisfied) (Parker, 2011).
Bowen (1978) suggests terms such as “enmeshment” and “triangulation” to describe fam-
ily dysfunctionality regardless of the family form. (Enmeshment refers to family environments
324 Part IV • Counseling Specialties

in which members are overly dependent on each other or are undifferentiated. Triangulation
describes family fusion situations in which the other members of the triangle pull a person in two
different directions.) Counselors who effectively work with couples and families have guidelines
for determining how, where, when, or whether to intervene in the family process. They do not
fail to act (e.g., neglect to engage everyone in the therapeutic process), nor do they overreact
(perhaps place too much emphasis on verbal expression).

PERSONAL REFLECTION
Who were you closest to in your family of origin? Who were you most distant from? What factors or
events brought you together? What factors or events distanced you from one another?

COUPLE/FAMILY COUNSELING VERSUS INDIVIDUAL/GROUP

COUNSELING
There are similarities and differences in the approaches to couple or family counseling and indi-
vidual or group counseling (Gladding, 2015b; Hines, 1988; Trotzer, 1988). A major similarity
centers on theories. Some theories used in individual or group counseling (e.g., person-centered,
Adlerian, reality therapy, behavioral) are used with couples and families (Horne, 2000). Other
approaches (e.g., structural, strategic, solution-focused family therapy) are unique to couple and
family counseling and are systemic in nature. Counselors must learn about these additional theo-
ries as well as new applications of previous theories to become skilled at working with couples
or families.
Couple or family counseling and individual counseling share a number of assumptions.
For instance, both recognize the importance the family plays in the individual’s life, both focus
on problem behaviors and conflicts between the individual and the environment, and both are
developmental. A difference is that individual counseling usually treats the person outside his
or her family, whereas couple or family counseling generally includes the involvement of oth-
ers, usually family members. Further, couple and family counseling works at resolving issues
within the family as a way of helping individual members better cope with the environment
(Nichols, 2013).
Couple and family counseling sessions are similar to group counseling sessions in orga-
nization, basic dynamics, and stage development. Furthermore, both types of counseling have
an interpersonal emphasis. However, the family is not like a typical group, although knowl-
edge of the group process may be useful. For example, family members are not equal in status
and power. In addition, families may perpetuate myths, whereas groups are initially more
objective in dealing with events. More emotional baggage is also carried among family mem-
bers than members of another type of group because the arrangement in a family is not limited
in time and is related to sex roles and affective bonds that have a long history (Becvar, 1982).
Although the family may be a group, it is not well suited to work that takes place only through
group theory.
Finally, the emphasis of couple and family counseling is generally on dynamics as opposed
to linear causality as in much individual and some group counseling. In other words, the dynam-
ics behind couple and family counseling generally differ from the other two types of counseling.
In making the transition from an individual perspective to a family orientation, Resnikoff (1981)
 Chapter 14 • Couple and Family Counseling 325

stresses specific questions that counselors should ask themselves to understand family function-
ing and dynamics. By asking the right questions, the counselor becomes more attuned to the
family as a client and how best to work with it.
• What is the outward appearance of the family?
• What repetitive, nonproductive sequences are noticeable; that is, what is the family’s
dance?
• What is the basic feeling state in the family, and who carries it?
• What individual roles reinforce family resistance, and what are the most prevalent family
defenses?
• How are family members differentiated from one another, and what are the subgroup
boundaries?
• What part of the life cycle is the family experiencing, and what are its problem-solving
methods?
Whether working with families or with couples, counselors ask many of these same
questions.

OVERVIEW OF COUPLE AND FAMILY COUNSELING

Couple Counseling
Early pioneers in couple counseling focused on the couple relationship rather than just the indi-
viduals involved. The new emphasis meant that three entities were considered in such relation-
ships: two individuals and one couple. Thus, from its beginning couple counselors set a precedent
for seeing couples together in conjoint sessions, a practice that continues today.
Couples seek relationship counseling for a wide variety of reasons, including finances,
children, fidelity, communication, and compatibility (Long & Young, 2007). Almost any situa-
tion can serve as the impetus to seek help. Regardless of who initiates the request, it is crucial
that the counselor see both members of the couple from the beginning if at all possible. Whitaker
(1977) notes that if a counselor is not able to structure the situation in this way, he or she will
probably not help the couple and may do harm. Trying to treat one partner alone for even one or
two sessions increases the other’s resistance to counseling and his or her anxiety. Moreover, if
one member of a couple tries to change without the other’s knowledge or support, conflict is
bound to ensue.
If both partners decide to enter couple counseling, the counselor may take a variety of
approaches. Seven of the main counseling theories used are object relational, behavioral, cogni-
tive–behavioral, Bowen systems (i.e., transgenerational), structural, emotionally focused, and
narrative (Gurman, Lebow, & Snyder, 2015). All of these theoretical perspectives have their
strengths. The two strongest, however, are the emotionally focused approach of Susan Johnson
and the behavioral approach of John Gottman. The reason is that both are heavily research based.

Family Counseling
Families enter counseling for a number of reasons. Usually, there is an identified patient (IP)—
an individual who is seen as the cause of trouble within the family structure—whom family
members use as their ticket of entry. Most family counseling practitioners do not view one mem-
ber of a family as the problem but instead work with the whole family system. Occasionally,
family therapy is done from an individual perspective but with the hope that changes in the
326 Part IV • Counseling Specialties

person will have a ripple effect (an influence generated from the center outward) and positively
impact a family (Nichols, 1988).
Family counseling has expanded rapidly since the mid-1970s and encompasses many
aspects of couples counseling. Although a few family counselors, such as behaviorist, narrative,
or solution-focused therapists, are primarily linear and work on a cause-and-effect or a construc-
tivist perspective, most are not. Rather, the majority of counselors operate from a general sys-
tems framework and conceptualize the family as an open system that evolves over the family life
cycle in a sociocultural context. Functional families follow rules and are flexible in meeting the
demands of family members and outside agencies. Family systems counselors stress the idea of
circular causality. They also emphasize the following concepts:
• Nonsummativity. The family is greater than the sum of its parts. It is necessary to exam-
ine the patterns within a family rather than the actions of any specific member alone.
• Equifinality. The same origin may lead to different outcomes, and the same outcome
may result from different origins. Thus, the family that experiences a natural disaster may
become stronger or weaker as a result. Likewise, healthy families may have quite dissimi-
lar backgrounds. Therefore, treatment focuses on interactional family patterns rather than
particular conditions or events.
• Communication. All behavior is seen as communicative. It is important to attend to the
two functions of interpersonal messages: content (factual information) and relationship
(how the message is to be understood). The what of a message is conveyed by how it is
delivered.
• Family rules. A family’s functioning is based on explicit and implicit rules. Family
rules provide expectations about roles and actions that govern family life. Most families
operate on a small set of predictable rules, a pattern known as the redundancy principle.
To help families change dysfunctional ways of working, family counselors have to help
them define or expand the rules under which they operate.
• Morphogenesis. The ability of the family to modify its functioning to meet the changing
demands of internal and external factors is known as morphogenesis. Morphogenesis usu-
ally requires a second-order change (the ability to make an entirely new response) rather
than a first-order change (continuing to do more of the same things that have worked
previously) (Watzlawick, Weakland, & Fisch, 1974). Instead of just talking, family mem-
bers may need to try new ways of behaving.
• Homeostasis. Like biological organisms, families have a tendency to remain in a steady,
stable state of equilibrium unless otherwise forced to change. When a family member
unbalances the family through his or her actions, other members quickly try to rectify the
situation through negative feedback. The model of functioning can be compared to a fur-
nace, which comes on when a house falls below a set temperature and cuts off once the
temperature is reached. Sometimes homeostasis can be advantageous in helping a family
achieve life-cycle goals, but often it prevents the family from moving on to another stage
in its development.
Counselors who operate from a family systems approach work according to the concepts
just listed. For instance, if family rules are covert and cause confusion, the counselor helps the
family make these regulations overt and clear. All members of the family are engaged in the
process so that communication channels are opened. Often, a genogram is constructed to help
family members and the counselor detect intergenerational patterns of family functioning that
have an impact on the present (McGoldrick, 2011; McGoldrick, Gerson, & Petry, 2008).
 Chapter 14 • Couple and Family Counseling 327

For a genogram, three generations of the family should be drawn. (See Chapter 8 for an
example of a genogram). Names, dates of birth, marriage, separation, and divorce should be indi-
cated, along with basic information such as current age and occupation. A genogram can also be
used in a multicultural context to assess the worldview and cultural factors that often influence
family members’ behaviors (Thomas, 1998). Overall, “the genogram appears to provide an effec-
tive and personally meaningful strategy to facilitate systems thinking,” especially by new client
families and counselors who are just beginning to work with families (Pistole, 1997b, p. 339).

THE PROCESS OF COUPLE AND FAMILY COUNSELING

The process of couple and family counseling is based on several premises. One is that persons
conducting the counseling are psychologically healthy and understand their own families of ori-
gin well. When such is the case, counselors are able to clearly focus on their client families and
not contaminate sessions with material from their own family life that they have not resolved.
A second premise of working with families is that counselors will not overemphasize or
underemphasize possible aspects or interventions in the therapeutic process (Gladding, 2015b).
In other words, counselors will balance what they do. Such a process means not being overly
concerned about making family members happy but at the same time engaging members in a
personable way.
A third component of conducting couple and family counseling is for the counselor to win
the battle for structure (i.e., establish the parameters under which counseling is conducted)
while letting the family win the battle for initiative (i.e., motivation to make needed changes)
(Napier & Whitaker, 1978). The battle for structure is won when counselors inform clients about
ways they will work with them, including important but mundane facts about how often they will
meet, for how long, and who is to be involved. A good part of structure can be included in a
professional disclosure statement that the counselor has the couple or family read and sign before
counseling begins. Initiative in the therapeutic process must come from couples and families
themselves; however, once counselors listen and outline what they see as possibilities, couple or
family members often pull together toward common goals.
Fourth, couple and family counselors need to be able to see the couple or family difficul-
ties in the context in which they are occurring. Thus, the counselor needs to be developmentally
sophisticated on multiple levels of life and have some life experiences including resolving toxic
or adversarial conditions in less than ideal conditions. Such skills and insights bring to counsel-
ors an understanding of how couples and families become either more together or apart when
faced with different life stages, cultural norms, or situational circumstances.

Presession Planning
Before a couple or family is seen for counseling, several matters should be addressed. One is the
expectation(s) the caller has for an initial session or for treatment in general. The person who
calls gives a rationale for seeking therapy that may or may not be the reason anyone else in the
couple or family relationship has for wanting or not wanting counseling. Nevertheless, the coun-
selor must listen carefully and obtain essential clinical information—such as a concise descrip-
tion of the problem—and factual information—such as the caller’s name, address, and phone
number. In gathering this information, the counselor should listen for what is conveyed as well
as what is not said. In doing so, the counselor can begin to hypothesize about issues that are
prevalent in certain family life stages and cultural traditions as they may relate to the caller’s
328 Part IV • Counseling Specialties

family. For example, a family with adolescents may expect to have boundary problems; how-
ever, the way they are handled in a traditional Italian American family versus a traditional British
American family may be quite different. Regardless, by the end of the initial phone call, an
appointment should be scheduled.

Initial Session(s)
Research indicates that the first few sessions are the most critical in regard to whether counselors
have success therapeutically with couples and families (Odell & Quinn, 1998). Therefore, get-
ting off to a good start is essential. One way a good beginning can be fostered is for the counselor
to establish rapport with each person attending and the couple or family unit as a whole. This
type of bonding, in which trust, a working relationship, and a shared agenda evolve, is known as
a therapeutic alliance. It can be created through a number of means such as
• Maintenance—as the counselor confirms or supports a couple’s or family member’s
position;
• Tracking—when a counselor, through a series of clarifying questions, tracks or follows a
sequence of events; and
• Mimesis—when a counselor adopts a couple’s or family’s style or tempo of communica-
tion, such as being jovial with a lighthearted couple or family or serious with a couple or
family that is somber.
In establishing a therapeutic alliance, it is important for the counselor to engage the couple
or family and its members enough to gain a perspective on how individuals view the presenting
problem, person, or situation. This perspective is called a frame. The counselor may challenge
the frame of the couple or family members to gain a clearer perspective of what is happening in
the relationship or to give the couple or family another option by which they can perceive their
situation (i.e., reframe).

PERSONAL REFLECTION
How would you frame how your family of origin functioned when you were growing up? How do
you think another member of your family would have framed it? How might it be reframed? For
example, “family members were always moving about but were connected like a spinning top” ver-
sus “family members were always doing a variety of activities like members of a marching band, in
harmony but different.”

In the initial session or sessions, the counselor is also an observer. He or she looks for a
phenomenon called the couple or family dance, which is the way a couple or family typically
interacts on either a verbal or nonverbal level (Napier & Whitaker, 1978). If the counselor misses
this interaction at first, he or she need not worry, for the pattern will repeat itself. It is important
in observing the family dance to see whether some member or members of the family are being
scapegoated (i.e., blamed for the family’s problems). For instance, a family may accuse its teen-
age son of being a lazy troublemaker because the adolescent sleeps late whenever possible and
gets into mischief when he is out on the town with his friends. Although it may be true that the
son has some problems, it is more likely that he is not the main cause of the family’s problems.
Thus, again, the counselor will need to probe and even challenge the family members’ percep-
tions of where difficulties are located such as a lack of boundaries, vague or dysfunctional com-
munication, a failure to support one another, and so on.
 Chapter 14 • Couple and Family Counseling 329

One way of broadly defining or clarifying what is happening in the couple or family is to ask
circular questions—that is, questions that focus attention on couple or family connections and
highlight differences among members. For instance, in a family the father might be asked how his
daughter responds when verbally attacked by his wife and how other members of the family react
as well, including himself. Such a strategy helps counselors and the families they work with see
more of the dynamics involved in family life and may well take pressure off the person who has
been seen as the problem. This type of questioning may also help the counselor and family see if
triangulation is taking place (i.e., the drawing in of a third person or party into a dyadic conflict,
such as the mother enlisting the father’s support whenever she has an argument with the daughter).
In addition to these aspects of engaging the couple or family, it is crucial that the counselor
develop the capacity to draw some initial conclusions in regard to the way the couple or family
behaves (e.g., in a family, who talks to whom and who sits next to whom). In this way the coun-
selor can gauge the dimensions of boundaries (i.e., those that allow closeness and caregiving
versus ones that may be intrusive, such as a parent speaking for a child who is capable of speak-
ing for himself or herself) (Worden, 2003). Intimacy and power can also be determined in this
way. Essentially, through observation and engagement of the couple or family in conversation,
the counselor becomes attuned to the dynamics within the couple or family, which in the long
run are usually as important as, if not more important than, the content of conversations that
occur within the counseling process.
Overall, a first session(s) usually is one in which a counselor evaluates how the couple or
family is functioning and what may need to be done to help the relationship run more smoothly.
Tentative goals are set as well, and a return appointment is made.

CASE EXAMPLE
Cleo Takes the Intake Call
Cleo had worked at family services for some time, but the call she received from a distraught mother
at 2 a.m. confirmed the importance of listening to details. Helena, the mother, who was sobbing, told
Cleo that she would like to make an appointment for her family because of abuses occurring within
it. Cleo carefully probed and found out there was no immediate danger, but still something felt
wrong. She then took the names and addresses of family members and their relationship to one
another as well as other details. Finally, she said to Helena, “I can see your family in my office at 9
a.m. tomorrow morning,” to which Helena responded, “I hope you can straighten them out for me.”
Cleo then realized what was happening. Helena was not planning to come to the session
but instead was going to send her family to the therapist to be “fixed.”
What would be your response to Helena at this point? What would you hope to accomplish
by responding to her in this way? What difficulties might arise if the referring members of a fam-
ily did not come to a session?

The Middle Phase of Couple and Family Counseling

The middle phase of couple and family counseling consists of those sessions between the initial
session(s) and termination. This part of treatment is where the couple or family will most likely
make needed changes in themselves, if they change at all.
330 Part IV • Counseling Specialties

During this time, couples or families and the counselor explore new behaviors and take
chances. Couples and families that are not sure if they wish to change will often make only
superficial alterations in what they do. This type of change is known as a first-order change. An
example is parents setting a curfew back by an hour without any real discussion about it or the
importance of a teenage daughter accepting responsibility for her actions. Second-order change,
where structured rules are altered, is quite different and is the type of change that is hoped for in
a couple or family undergoing therapy. An example of second-order change is a rigid, authoritar-
ian family becoming more democratic by adopting new rules regarding family interactions after
everyone has had a chance to make suggestions and give input in regard to them during a family
meeting (Watzlawick et al., 1974).
In fostering change within the couple or family, the counselor stays active mentally, ver-
bally, and behaviorally (Friedlander, Wildman, Heatherington, & Skowron, 1994). The coun-
selor also makes sure the couple or family goes beyond merely understanding what they need to
do because cognitive knowledge alone seldom produces change. In addition, during the middle
phase of counseling, the counselor links the couple or family with appropriate outside agencies,
if possible. For example, in working with a family that has one or more members who are abus-
ers of alcohol, the counselor makes sure they find out information about Alcoholics Anonymous
(AA) (an organization of individuals who help one another stay sober), Al-Anon (a self-help
organization for adult relatives and friends of people with drinking problems), and/or Alateen
(a similar program to Al-Anon but for younger people, usually ages 12 to 19).
Throughout the middle phase of treatment, there is a continuous focus on the process of
what is happening within the couple or family. In many cases, couples and families make the
easiest changes first. Consequently, counselors must press the couple or family for greater
change if treatment is going to have any significance for them in a lasting way. The press is
manifested in concentrating on cognitions, as well as their affective responses and behaviors
(Worden, 2003). Sometimes this action is done in a straightforward manner, whereas at other
times it is accomplished through injecting humor into the therapeutic process, a right that a
counselor has to earn through first showing care and developing trust. An example of using
humor in treatment to promote change can be seen in the following mother and daughter
interaction:

Mother to Daughter: I will just die if you repeat that behavior again.
Daughter to Mother: You will not. You’re just trying to make me feel guilty.
Counselor: Sounds like this plan has worked before.
Daughter: It has. But she never dies and I just get mad and frustrated.
Mother: I tell you, if you do it one more time, I will die!
Counselor to Mother: So your daughter is pretty powerful. She can end your life
with an action?
Mother (Dramatically): Yes.
Counselor to Daughter: And you have said before that you love your mother.
Daughter: I do. But I’m tired of her reactions to what I do. They are just
so overdone.
Counselor to Daughter: But your mother says you are powerful and could kill her.
Since you love her, I know you wouldn’t do that. However,
since you have so much power I wonder if you would ever
consider paralyzing one of her arms with a lesser behavior?
Mother: What?!
 Chapter 14 • Couple and Family Counseling 331

Daughter (Laughing): Well, it might get her to stop harping at me and give us a
chance to talk.
Counselor (to Mother Maybe that chance is now and no one has to suffer
and Daughter): physically if we do it right.

The counselor in this case addressed a pressing issue of power and drama in a serious but some-
what humorous way that got the attention of the two individuals most involved in the struggle, broke
a dysfunctional pattern, and set up an opportunity for real dialogue and new interactions to emerge.
In addition to the previous ways of working, the counselor must look for evidence of sta-
bility of change such as a couple or family accommodating more to one another through subtle
as well as obvious means. For instance, seating patterns, the names family members call each
other, or even the tone individuals use when addressing one another are all signs that somewhat
permanent change has occurred in the couple or family if they differ greatly from where they
were when the therapeutic process began. In the case of a couple or family that is changing, the
tone of addressing one another might go from harsh to inviting.

PERSONAL REFLECTION
Many people today carry cell phones. What do you notice about their ring tones? Are some more
appealing than others? Could the same kind of linkage be made in regard to the tones family mem-
bers use with each other? How would you react if your ring tone always conveyed a harsh sound?

In the middle phase of couple and family counseling, it is crucial that the counselor not get
ahead of the couple or family members. Should that happen, therapeutic progress will end because
the couple or family will not be invested. Therefore, staying on task and on target requires the
counselor to keep balanced and push only so far. A way to help couples and families stay engaged
and make progress is to give them homework (i.e., tasks to complete outside the counseling ses-
sions such as setting aside time for a conversation) and psychoeducational assignments (i.e.,
reading a book or viewing a video) to complete together so that they are literally learning more and
interacting together. For example, the family might watch some episodes from the comedy televi-
sion show The Addams Family of the 1960s or the 2015s comedy hit Modern Family. They could
then come back and talk about how they are like and unlike in regard to the family they viewed.
Such a way of working gives family members even more in common than would otherwise be the
case, may draw them closer psychologically, and helps them clarify who they are and what they do.

Termination/Closure
Termination can be considered to be a misnomer in couple or family counseling since “from a
family systems perspective, the therapist-family therapeutic system has reached an end point, but
the family system certainly continues” (Worden, 2003, p. 187). Regardless, termination (includ-
ing follow-up) is the final phase of treatment in working with couples and families.
The couple or family, the counselor, or both may initiate termination. There is no one person
who should start the process or one single way that closure should be conducted. However, termina-
tion should not be sudden and should not be seen as the highlight of counseling (Gladding, 2015b).
Rather, termination is designed to provide a counselor and a couple or family with closure. It should
be a means to assess whether couple or family goals have been reached.
Thus, in beginning termination, the counselor and couple or family should ask themselves
why they are entering this phase. One reason may be that enough progress has been made that
332 Part IV • Counseling Specialties

the couple or family is now able to function on its own better than ever before. Likewise, every-
one involved may agree that the couple or family has accomplished what it set out to do and that
to continue would not be a wise investment in time and effort.
Whatever the reason for terminating, the counselor should make sure that the work the
couple or family has done is summarized and celebrated (if appropriate) so that the couple or fam-
ily leaves counseling more aware and feeling stronger in realizing what they accomplished. In
addition to summarization, another aspect of termination is deciding on long-term goals, such as
creating a calm household where members are open to one another. This projective process gives
couple and family members something to think about and plan out (sometimes with the counsel-
or’s input). A part of many termination sessions involves predicting setbacks as well, so that
couples and families do not become too upset when they fail to achieve their goals as planned.
A final part of termination is follow-up (i.e., checking up on the couple or family following
treatment after a period of time). Follow-up conveys care and lets couples and families know that
they can return to counseling to finish anything they began there or to work on other issues. Client
couples and families often do better when they have follow-up because they become aware that
their progress is being monitored both within and outside the context in which they live.

Summary and Conclusion

American families have changed over the years those who work with couples and families need to
from a few dominant forms to a great many variet- know the life cycle of families in order to assess
ies. These changes were brought about by a number whether a marriage or family problem is develop-
of forces within society such as the women’s move- mental or situational. Couple and family counselors
ment, global and regional wars, and federal legisla- also need to be aware of systems theories and the
tion. With these changes has come a greater need ways that couples and families work systemically.
for working with married and unmarried couples as The field of couple counseling is sometimes
well as families. The profession of couple and fam- incorporated into family counseling models, but pro-
ily counseling has grown rapidly since the 1950s fessionals in this specialty need to be aware of the
for a number of reasons, including theory develop- theories and processes that are used in each area.
ment and proven research effectiveness. It has pros- They must also realize how individual or group theo-
pered also because it has had strong advocates and ries may complement or detract from work with
has generated a number of unique and effective families. Finally, couple and family counselors need
approaches for a variety of couple and family forms. to be well schooled in the stages that family counsel-
Professionals who enter the couple and family ing entails—preplanning, initial session(s), the mid-
counseling field align with at least four associations, dle phase, and termination—and the general
depending on their background and philosophy. Most techniques and emphasis within each.
counselors join the International Association for Overall, working with couples and families is
Marriage and Family Counseling (IAMFC) because a dynamic and exciting way of helping people.
of its affiliation with the ACA, but some affiliate Because of its complexity and the intricacies of the
with the American Association for Marriage and process, it is not for everyone but it is an entity that
Family Therapy (AAMFT), the largest marriage and many counselors seem to enjoy and from which
family therapy association. Regardless of affiliation, many people in society benefit.

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CHAPTER 11
Child and Adolescent Counseling

The young . . . are full of passion, which excludes fear; and of hope,
which inspires confidence.
—ARISTOTLE, RHETORIC BOOK II

CHAPTER OVERVIEW
This chapter provides an overview of child and adolescent counseling. Highlights of the chapter
include
䊏 The art and science of child and adolescent resolution, and guidelines for child and
counseling adolescent counseling)
䊏 Children and adolescents from a historical 䊏 Special problems of children and
perspective adolescents (child abuse and neglect,
䊏 Developmental theories depression, and antisocial behavior)
䊏 Diversity and postmodern issues in child
䊏 Emerging developmental theories (optimal
development, attachment theory, resiliency, and adolescent counseling
and emotional intelligence)
䊏 Special approaches to child and adolescent
counseling (play therapy, conflict

Child and adolescent counseling is an emerging specialty within the counseling profession. Some
of the most promising advances in counseling and psychology are occurring in this field. These
are reflected in our understanding and treatment of common problems that children and adoles-
cents experience, including child abuse and neglect, child/adolescent depression, and antisocial
behavior. In this chapter, information is presented on these types of problems as well as other
conceptual and treatment issues.

THE ART AND SCIENCE OF CHILD AND ADOLESCENT COUNSELING

Child and adolescent counseling, like all aspects of counseling, is an art and a science. Discovering
the private world of children and adolescents is an art. The challenge when working with children
is finding ways to communicate that are not restricted by language and cognitive development.
280
 Chapter 11 • Child and Adolescent Counseling 281

When working with adolescents the challenges include keeping lines of communication open and
maintaining trust. Possible strategies that can be used to transcend these potential barriers include
play therapy, conflict resolution, parent education, family therapy, consultation with teachers and
parents, and ecological–environmental approaches directed at enhancing the world of children
and adolescents.
One way of conceptualizing the art of child and adolescent counseling is “reaching
in–reaching out” (Nystul, 1986); that is, the counselor attempts to enter the child’s or adolescent’s
internal frame of reference—the world that makes sense to them and that they feel safe in. As
trust and respect are established, the child or adolescent may then feel encouraged to reach out
into the world of others. They may, for example, move toward success-oriented rather than
failure-oriented activities in school. Throughout this process, the counselor communicates a
wide range of emotions, such as caring, compassion, and perhaps even anger, to provide the
structure and emotional support necessary for optimal development.
The science of child and adolescent counseling is grounded in developmental theory,
research, and practice, which recognize that counseling across the lifespan must be cognizant of
the physical, cognitive, and psychosocial aspects of development and their impact on the counsel-
ing process. From a developmental perspective, children and adolescents need assistance
in acquiring the coping skills necessary to master the various tasks necessary to move forward in
their development. Counseling strategies can be directed at helping children and adolescents
acquire these coping skills by fostering resiliency, positive attachment relationships, emotional
and intellectual intelligence, and other qualities that promote optimal development. Recent
research on diversity issues and postmodernism must also be addressed when formulating coun-
seling strategies with children and adolescents.

CHILDREN AND ADOLESCENTS FROM A HISTORICAL PERSPECTIVE

Children
The concept of childhood as a distinct developmental stage is relatively new (LeVine & Sallee,
1992). In the past, children were viewed as miniature adults and were forced to work alongside
adults in the fields and factories and to fight in wars. Children had no special privileges and
lacked the protection of child labor laws or the advantages of formal education. They were to be
“seen and not heard” and used in whatever way their parents dictated (LeVine & Sallee, 1992).
Children were often lucky to survive long enough to become adults. Until the 19th century,
parents had the right to kill a newborn child who was deformed, sickly, retarded, or even the
“wrong” sex (Radbill, 1980). If children survived that possibility, there was still a very good
chance they would die of illness or accident. In the 1600s, 59% of children in London died before
they were 5 years old, and 64% died before they turned 10 (LeVine & Sallee, 1992). The following
story illustrates how a 7-year-old girl was viewed and treated in 1713 (Kanner, 1962).

This 7-year-old girl, the offspring of an aristocratic family, whose father remarried after
an unhappy first matrimony, offended her “noble and god-fearing” stepmother by her
peculiar behavior. Worst of all, she would not join in the prayers and was panic-strick-
en when taken to the black-robed preacher in the dark and gloomy chapel. She avoided
contact with people by hiding in closets or running away from home. The local physi-
cian had nothing to offer beyond declaring that she might be insane. She was placed in
the custody of a minister known for his rigid orthodoxy. The minister, who saw in her
282 Part 3 • Special Approaches and Settings

ways the machinations of a “baneful and infernal” power, used a number of would-be
therapeutic devices. He laid her on a bench and beat her with cat-o’-nine-tails. He
locked her in a dark pantry. He subjected her to a period of starvation. He clothed her
with a frock of burlap. Under these circumstances, the child did not last long. She died
after a few months, and everybody felt relieved. The minister was amply rewarded for
his efforts by Emerentia’s parents. (p. 97)

LeVine and Sallee (1992) cited the following events as contributing to the recognition of
childhood as a distinct stage of development. In 1744, Pestalozzi published what was the first sci-
entific record of the development of a young child. In the late 19th century, two books were pub-
lished that served as models for observational and experimental approaches for analyzing child
development: Charles Darwin’s Biographical Sketch of an Infant in 1877 and Wilhelm Preyer’s The
Mind of a Child in late 1892. It was also during the latter part of the 19th century that G. Stanley
Hall at Clark University studied the physical and mental capabilities of children. Then, in the
early 1900s, child-guidance clinics were founded to provide counseling and guidance services to
children. In 1910, the Stanford-Binet IQ tests were published, and in 1917, John B. Watson con-
ducted his now-famous “Little Albert” experiments, which demonstrated that a child could be
conditioned to cry at the sight of a furry object.
Although childhood has come a long way from the dark ages of the past, there are still signs
that being a child is not easy. Children are faced with a wide array of sociocultural conditions that
often have an adverse effect on their development (Wagner, 1994). For example, 25% of children
under 5 years of age are living in poverty, and the number of children born into a single-parent
home has increased from 4% to 25% between 1950 and 1988 (Wagner, 1994). Parents are spend-
ing an increasing amount of time at work, significantly reducing their involvement in child
rearing (Committee for Economic Development, 1991). The void left by a lack of parental
involvement is being filled by several negative activities, including television viewing, where pro-
grams are often laden with sex and violence (3- to 4-year-olds watch an average of 2 or more
hours a day [Sroufe & Cooper, 1996]); escaping into substance abuse; and attempting to meet the
basic needs of love, belonging, and self-esteem through gang involvement.

Adolescents
It was not until the 20th century that adolescence was considered a separate stage of development
(Sroufe & Cooper, 1996). Before that time (and in some underdeveloped countries today), puberty
marked the transition from childhood to adulthood. G. Stanley Hall (1904) was one of the first
to recognize adolescence as a distinct stage of development, which he characterized as a conflict-
ridden period resulting from rapid and profound physical changes set off by the onset of puberty.
Hall’s characterization has been modified by the contemporary views of adolescence as not
normally a period of “storm and stress” but a time of relatively healthy development (Sroufe &
Cooper, 1996; Wagner, 1996). Current estimates suggest that 80% of adolescents manage very
well in terms of their overall psychological functioning, with the remaining 20% having signifi-
cant behavioral difficulties requiring some form of clinical intervention (Weiner, 1992). More
specifically, 20% pass through adolescence with virtually no recognized mental disorders, 20%
have mental disorders, and the remaining 60% have mild psychological problems that do not sig-
nificantly interfere with daily functioning (Weiner, 1992).
Although adolescence is not typically the stormy period claimed by Hall, evidence suggests
it is a time of increasingly high risk for problems that adversely affect healthy development, such
 Chapter 11 • Child and Adolescent Counseling 283

as substance abuse, teenage pregnancy, depression, and violence (Takanishi, 1993; Wagner, 1996).
Approximately 25% of U.S. adolescents face serious risk and 25% face moderate risk for health-
and safety-related problems—problems that appear to be growing at an alarming rate (Takanishi,
1993). For example, more U.S. children and adolescents are experimenting with alcohol and illegal
drugs than ever before, and at a younger age (15 and younger); depression affects between 7% and
33% of adolescents; suicide rates tripled between 1968 and 1985 for 10- to 14-year-olds and dou-
bled during that time period for 15- to 19-year-olds; homicide rates have escalated, especially for
African-American males between 15 and 19 years of age, increasing by 111% between 1985 and
1990; and pregnancy rates have increased 23% between 1973 and 1987 for 10- to 14-year-olds
(Takanishi, 1993). With all the challenges facing adolescents, the resurgence of interest in the coun-
seling profession in the field of adolescent counseling is not surprising (see, for example, the spe-
cial issues on adolescence in The American Psychologist, 48(2), 1993, and The Counseling
Psychologist, 24(3), 1996).
With approximately 12% of individuals under the age of 18 having a serious emotional or
behavioral disorder and only a minority receiving adequate mental health services, Collins and
Collins (1994) have suggested that the current mental health delivery system for children and
adolescents is inadequate and that it is necessary to develop a community-based system of care.
This community system should be an ecological one, that is, a unified attempt of all community
organizations and agencies to promote family strength and optimal development.

DEVELOPMENTAL THEORIES
Counseling children and adolescents is significantly different from working with adults. Unlike
adults, children and adolescents are undergoing constant changes in their physical, cognitive, and
psychosocial abilities. A child or adolescent may therefore express certain symptoms at one stage
of development and entirely different symptoms at another stage (LeVine & Sallee, 1992). For
example, a child at age 3 may resort to temper tantrums when under stress. The same child at age
13 may turn to drugs as a means of dealing with stress (LeVine & Sallee, 1992).
It is therefore important to work with children from a developmental perspective. This
section provides an overview of developmental theories relating to cognitive, moral, and psy-
chosocial development as well as issues that relate to psychopathology; and the classic theories
of personality (summarized in Table 11.1). A more detailed description of developmental char-
acteristics (physical, cognitive, and social–emotional) and associated counseling and consulta-
tion strategies in early childhood through adolescence can be found in Stern and Newland
(1994) and Vernon (1995).

Cognitive Theories
Many theories have attempted to explain how cognitive development occurs throughout the
lifespan (Piaget, 1952; Brunner, 1973). Among these, Jean Piaget’s theory has received significant
attention in literature. Piaget (1952) divided cognitive development into four distinct stages: sen-
sorimotor (birth to 2 years of age); preoperational (2 to 6 years of age); concrete operational
(ages 7 to 11); and formal operational (age 12 through adulthood). According to Piaget, the cog-
nitive development of children and adolescents becomes more sophisticated as they progress
from one stage to the next. For example, children are usually unable to understand cause and
effect during the preoperational stage (2 to 6 years old) and therefore concepts such as divorce or
death may therefore be difficult for them to understand. They may become confused and even
284 Part 3 • Special Approaches and Settings

TABLE 11.1 Developmental Theories

Developmental
Theories Founder Key Concepts Implications for Counseling

Cognitive theory Jean Piaget, Divided cognitive development into Counselors should adjust
David Elkind four distinct stages: sensorimotor the counseling approach to the
(birth to age 2), preoperational (age 2 child’s or adolescent’s level of
to 7), concrete operations (age 7 to cognitive functioning.
11), and formal operations (begins
after age 11).
Theory of moral Lawrence Identified three levels of moral An understanding of moral
development Kohlberg, development beginning with an reasoning can be useful to
Carol egocentric view regarding morality promote self-control.
Gilligan (i.e., a child controls behavior out
of a fear of punishment).
Psychosocial Erik Erikson Identified seven psychosocial stages Counselors can help clients
development and their associated developmental obtain the coping skills necessary
theory tasks (e.g., from birth to 1 year of to master developmental tasks so
age the central task is trust). they can move forward in their
development.
Developmental Alan Kazdin, Study of child and adolescent Provides a framework for
psychopathology Maria psychopathology in the context of understanding child and
Kovacs, and maturational and developmental adolescent psychopathology as
others processes. distinct from adult
psychopathology and aids in
accurate assessment, diagnosis,
and treatment.
The classic Sigmund The theories of personality posited by Provide useful information for
theories Freud, Alfred the classic theorists emphasize the counselors to understand the
Adler, and role of early life experiences on child dynamics of behavior before
Carl Jung and adolescent development. they begin to use counseling
techniques to promote
behavior change.

blame themselves. It is therefore important for counselors to be aware of a child’s and adoles-
cent’s level of cognitive development during the counseling process.
Cognitive development can also play an important role in how children respond to
questions. The cognitive style of children aged 7 to 11 tends to be concrete in nature (concrete
operational stage). The children therefore tend to respond well to questions that ask for spe-
cific information (probing questions), such as “Do you like school?” Open-ended statements
such as “How are you doing?” can be difficult for children and often result in limited
responses, such as “Fine.” Adolescents typically function at the formal operational stage and
have the ability to think abstractly, which enables them to generate more robust responses to
open-ended questions. Most of the other listening skills discussed in Chapter 3 can be used
with children and adolescents (e.g., reflection of feeling, paraphrasing, clarifying, minimal
encouragers, summarizing, and so forth).
 Chapter 11 • Child and Adolescent Counseling 285

David Elkind (1984) extended Piaget’s theory of cognitive development to include infor-
mation on adolescent egocentrism. According to Elkind, adolescent thinking tends to be quite
self-centered or egocentric in nature and can result in several tendencies that can impede com-
munication and psychological functioning. For example, since adolescents tend to see things
from their point of view, they are inclined to argue with opposing positions (especially those of
adults). Two other characteristics associated with adolescent egocentricism are the imaginary
audience and personal fable. Imaginary audience relates to the adolescent tendency to be self-
conscious. For example, when adolescents play tennis, they may think everyone’s eyes are on
them, leading to frequent bouts of giggles and other expressions of embarrassment. Personal
fable involves adolescents feeling invulnerable because they believe that what they do is so spe-
cial and no harm will come to them. Adolescents may feel that pregnancy is impossible because
they are so in love, and their love is so perfect that nothing bad can happen.
Counseling implications of adolescent egocentricism include being aware of this tendency
and guarding against it by not overreacting (e.g., getting angry at an adolescent’s self-centered
point of view). Counselors can also try to be patient and help adolescents discover the value of
appreciating different points of view as a means of enhancing communication. Group counseling
with adolescents may be particularly useful in this process. Counselors may also wish to use real-
ity testing to help adolescents overcome the tendency to be self-conscious and feeling invulnera-
ble. This can involve objectively examining various activities (such as engaging in sex) to help
them develop a realistic understanding of the consequences of their behavior.

Theories of Moral Development

Counselors are facing an increasing number of children and adolescents who are out of control
and engaging in various acts of misbehavior (McMahon & Forehand, 1988). Theories of moral
development can provide a better understanding of children and adolescents who misbehave in
terms of their moral reasoning.
Piaget (1965) and later Lawrence Kohlberg (1963, 1973, 1981) both developed theories of
moral development, with Kohlberg’s theory, which is based on Piaget’s work, being widely
accepted in the literature. In Kohlberg’s theory, moral development is divided into three levels,
with each level containing two stages. These levels and stages are hierarchical, requiring a person
to move through them one at a time without skipping any.
According to Kohlberg, children functioning at Level 1 have an egocentric point of view
regarding morality. They control their behavior out of fear of punishment. Individuals at Level 2
of moral development control their behavior and abide by laws out of concern over how others
will view them as a person and also how they will view themselves. At Level 3, people control their
behavior and abide by laws on the basis of a rational decision to contribute to the good of society.
Individuals who have reached the age of 11 or 12 are often capable of functioning at Level 3.
Carol Gilligan (1982, 1987, 1990) contends that Kohlberg’s theory does not take into account
gender issues associated with moral development. According to Gilligan (1982, 1987), Kohlberg’s
theory is based primarily on the way men perceive morality, as a set of values and moral principles
that can be applied to all situations regardless of the social context and that are concerned with what
is fair and equitable. Gilligan contends that female moral reasoning is more concerned with caring
for the needs of others than with equity and is also directly related to the social context, in that one’s
moral reasoning is influenced by how one will be viewed by significant others.
Parr and Ostrovsky (1991) have described how theories of moral development can be used
as guides to counseling children and adolescents. For example, a behavior modification technique
286 Part 3 • Special Approaches and Settings

such as a token economy may be useful with first graders since their moral decision making is
strongly influenced by obeying rules and the fear of being punished. The same approach may not
be as effective with adolescents since they may be more concerned with social issues, such as how
their behavior conforms to shared norms and how their decisions will be perceived by their peer
group. Group counseling can provide teens with a social milieu to work through their concerns
and facilitate moral decision making.

Psychosocial Theories
Psychosocial development is another important issue in counseling children and adolescents.
Erik Erikson’s (1963, 1968) theory identified seven psychosocial stages, from birth to death. Each
stage involves a particular task that must be accomplished before the individual can proceed
effectively to the next developmental task. From birth to age 1, for example, the central task is to
experience a sense of trust from the environment. Without that experience, an infant will develop
a mistrustful attitude. To accomplish each task, the individual must master its various associated
coping skills. To promote positive psychosocial development, counselors can help children and
adolescents acquire these coping skills (Blocher, 1987; Stern & Newland, 1994). Chapter 14 pro-
vides a more detailed description of the role of developmental tasks in the counseling process.

Developmental Psychopathology
Recently, the counseling field has attempted to view psychopathology from a developmental
perspective (Bergman & Magnusson, 1997; Kazdin, 1993; Sroufe, 1997; Wakefield, 1997).
Developmental psychopathology is “the study of clinical dysfunction in the context of matura-
tional and developmental processes” (Kazdin, 1989, p. 180). Developmental psychopathology
attempts to address three issues: (a) how the developing organism mediates the development
of mental disorders; (b) the impact of mental disorders on age-appropriate abilities; and
(c) whether mental disorders develop continually or in stages (Kovacs, 1989).
According to Alan Kazdin (1989), the greatest advance in developmental psychopathology
occurred with the publication of the Diagnostic and Statistical Manual for Mental Disorders
(DSM-III) and later DSM-III-R (American Psychiatric Association, 1980, 1987). Kazdin (1989)
noted, “It represented a quantum leap in the attention accorded disorders of infancy, childhood,
and adolescence” (p. 183). The DSM recognized the variations from childhood to adulthood in
the nature and course of psychopathology. For example, the DSM-IV notes that it is common for
a depressed child to experience problems that are usually not found with adult depression. Some
of these are somatic, or bodily, complaints; psychomotor agitation; and mood-congruent halluci-
nations. Comorbidity (two or more diagnoses) is also common in children and adolescents
(Sroufe, 1997). Such multiple diagnoses can obscure or mask a psychological problem, making
an accurate assessment difficult. For example, if a child has a substance abuse problem, an
oppositional–defiant disorder, and an anxiety disorder, the clinician may focus on the drug and
oppositional problems and could miss the anxiety problem.
A great deal of research and theoretical development is occurring in the field of develop-
mental psychopathology. A wide range of topics have been explored, among them are the role of
nature and nurture (Rutter et al., 1997); transition and turning points (Rutter, 1996); and emo-
tions (Cicchetti, Ackerman, & Izard, 1995). From their investigation of the role of emotional
regulation in developmental psychopathology, Cicchetti et al. (1995) contended that the primary
function of emotional regulation is to initiate, organize, and motivate adaptive behavior, thereby
preventing abnormal conditions and responses.
 Chapter 11 • Child and Adolescent Counseling 287

However, research specifically directed at the developmental psychopathology of adoles-

cence has not received much emphasis. Developmental psychopathology has tended to focus on
children and overlook adolescence (Kardin, 1993) because adolescence had been viewed as a
transitional period between childhood and adulthood that was in constant change due to biolog-
ical flux, making it difficult to identify clear mental health patterns. This point of view is chang-
ing as the unique developmental characteristics of adolescence have become recognized and
accepted as an important domain for scientific investigation (Kazdin, 1993).
In terms of refining the process of assessment and diagnosis in child and adolescent coun-
seling, advances in the study of developmental psychopathology hold promise. Additional
research is required to determine how different developmental levels may influence symptom
expression and treatment (Kazdin, 1989).

The Classic Theories

The classic personality theories of Sigmund Freud, Alfred Adler, and Carl Jung (see Chapter 7)
can also provide useful information for understanding children and adolescents. These theories
all emphasize the role of early life experiences in child and adolescent development. Freud, one of
the first to look at stages of development in children and adolescents, viewed them from a psy-
chosexual perspective: the oral, anal, phallic, latency, and genital stages. According to Freud’s the-
ory, traumatic experiences during any of these stages can fixate development at that level, and
adults can spend the rest of their lives attempting to resolve the needs unmet in childhood or
adolescence. For example, if children do not have opportunities to fulfill their oral needs, they
may continually attempt to meet those needs in later life and in the process develop an orally fix-
ated personality. Such tendencies can be positive, such as becoming an orator, or negative, such as
nail biting.
Adler, his colleague Rudolf Dreikurs, and others of the Adlerian school offered much
insight into child and adolescent development. They developed numerous psychological con-
structs that can be used to understand and counsel children and adolescents, including birth
order, the family constellation, lifestyle, goals of misbehavior, encouragement, and the use of con-
sequences as a disciplinary technique.
Jungian psychology adds another valuable dimension to the conceptualization of child and
adolescent development. Jung’s concepts of holism and balance, for example, have been inte-
grated in Jungian forms of play therapy, which is described later in this chapter.

Emerging Developmental Trends

There has been a major shift in orientation in the field of counseling from pathology to well-
ness. The recognition that strength is required to overcome adversity has come to play a central
role in virtually all aspects of counseling, from holistic health, which suggests that clients
develop a wellness orientation, to brief-solution-focused counseling, which encourages clients
to use what has worked before (exceptions to the problem) to overcome current difficulties.
Given this ongoing emphasis on strengths, it is not surprising that developmental theories and
concepts are beginning to take on a strengths perspective. This section reviews four emerging
developmental trends that have a strengths perspective (optimal development, resiliency,
attachment theory, and emotional intelligence) (see Table 11.2). Because resiliency, secure
attachment, and emotional intelligence facilitate optimal development, these trends appear to
be interrelated.
288 Part 3 • Special Approaches and Settings

TABLE 11.2 Emerging Developmental Trends

Developmental Theories Implications for

and Concepts Founder Key Concepts Counselors

Optimal development No one individual: A view of human Optimal development

contributors include development that can help counselors
Carl Rogers, Abraham focuses on positive, take a strengths
Maslow, and William healthy development as perspective by focusing
Wagner opposed to a pathological on what people can do
view of development rather than what they
cannot do. This
perspective promotes a
positive, self-fulfilling
prophecy.
Resiliency No one individual; A research trend that is Resiliency characteristics
Emmy Werner’s attempting to identify can provide useful
research stands out coping mechanisms that survival responses
provide a buffer to to stress, which in
harmful stress and turn can promote
obstacles to development optimal development.
Counselors can promote
resiliency characteristics
in their approach
with clients.
Attachment theory Mary Ainsworth, A study of the relationship An understanding of a
John Bowlby, and between the emotional client’s present and past
others bond between a parent attachment relationships
and child and that child’s can provide useful
psychosocial development insights into how to
over the lifespan move toward optimal
psychosocial
development.
Emotional intelligence John Mayer and A study of the role that Counselors can promote
Peter Salovey social emotions play in emotional intelligence in
psychological functioning clients by helping them
gain a better
understanding of how
emotions foster optimal
development.
Counselors can also help
clients enhance their
emotional intelligence
through such activities
as social-skills training in
groups.
 Chapter 11 • Child and Adolescent Counseling 289

OPTIMAL DEVELOPMENT. The roots of optimal development lie in the work of humanistic
psychologists like Carl Rogers (1951) and Abraham Maslow (1968), who proposed a model of
human growth and development based on inherent self-actualizing tendencies. Rogers believed
that a person will move toward self-actualization (optimal development) if the right conditions
are established. More recently, Wagner (1996) has presented optimal development as a develop-
mental perspective that emphasizes health and wellness over pathology. Wagner (1996) notes that
what constitutes optimal development varies to some degree contextually in terms of culture and
so forth. Wagner goes on to review the literature to identify biophysical, cognitive, and psychoso-
cial competencies that appear to characterize optimal development in adolescence. These
research findings are summarized as follows:
• Biophysical. “Upon reaching the age of 18, an adolescent will be alive and healthy, physical-
ly mature, and engaged in health-enhancing behaviors, including proper diet and regular
exercise” (Wagner, 1996, p. 364).
• Cognitive. “Upon reaching the age of 18, adolescents will engage in efficient and purpo-
sively idiosyncratic thinking of a more hypothetical, multidimensional, future-oriented
and relative nature that is based on prior life experiences, including the completion or near
completion of at least 12 years of formal education” (Wagner, 1996, p. 368).
• Psychosocial functioning. “Upon reaching the age of 18, adolescents will be emotionally
aware, feel secure and self-confident, be determined and optimistic about the future, and
possess the resilience needed to overcome adversity” (Wagner, 1996, p. 371).
Several authors have proposed a person–environmental fit model of development that can
be used to understand how optimal development occurs (Chu & Powers, 1995; Eccles et al.,
1993). According to this model, a person moves forward toward optimal development when there
is a good fit between his or her needs and the social environment. Synchrony occurs when the
social environment is responsive to the individual in terms of promoting personal independence,
self-determination, and decision making. In addition, synchrony plays a key role in promoting
important competencies in children and adolescents, such as attachment, autonomy, and social
competency (Chu & Powers, 1995).
When the fit between the social environment and the individual is strained, the person can
become discouraged and lack motivation for positive involvement (Eccles et al., 1993). This can lead
to disruptions in the developmental process, such as excessive rebelliousness during adolescence,
dropping out of school, and drug abuse. The person–environmental fit model can provide a possible
explanation for why early and middle adolescence might be particularly problematic for adolescents.
Once an adolescent goes to middle school, parents tend to renegotiate rules relating to autonomy and
control (e.g., how late the teen can stay out) (Chu & Powers, 1995). At the same time, it is not uncom-
mon for middle school teachers to also place a high premium on discipline and control. When the
adolescent no longer feels a sense of empowerment, he or she can feel discouraged and lack motiva-
tion for involvement in family life or school, resulting in a variety of serious problems.
Optimal development can be facilitated in children and adolescents by building strengths in
resiliency, coping, and problem solving (Van Slyck, Stern, & Zak-Place, 1996). Preventative pro-
grams that focus on conflict resolution are effective interventions for fostering these strengths,
especially for adolescents since they are prone to problems that stem from interpersonal conflicts.
Some guidelines for promoting synchrony in child- or adolescent-adult relationships are main-
taining flexibility and openness to change and sensitivity and activeness in terms of encouraging
problem solving and decision making (Chu & Powers, 1995). These characteristics also seem to be
valuable in promoting strengths associated with optimal development in children.
290 Part 3 • Special Approaches and Settings

RESILIENCY. Resiliency is a term that has been used to describe why some at-risk children and
adolescents thrive, whereas others experience disruptions in their development. It can be defined
as a tendency to overcome adverse conditions as a result of having growth-facilitating character-
istics that promote optimal development. Research investigations have attempted to understand
the dynamics of resilience. Perhaps the most significant study on resiliency was one conducted by
Werner and her colleagues (Werner, 1992; Werner & Smith, 1982, 1992) that attempted to identi-
fy resiliency characteristics for 200 at-risk children in Hawaii over a 32-year period. These chil-
dren had experienced at least four risk factors, such as family dysfunction, parental alcoholism,
and poverty. Surprisingly, one out of three of these at-risk children grew into competent, happy,
productive young adults.
In an overview of the literature on resilience in terms of its characteristics and implications
for counseling and development, Rak and Patterson (1996) identified some of these resiliency
characteristics: a positive self-concept, an optimistic outlook, good interpersonal skills resulting in
positive social experiences, good problem-solving and decision-making skills, a well-developed
sense of personal autonomy, an environmental support system (within or outside of the family),
and a significant other who can provide adequate mentoring. Adams’s (1997) qualitative study
involving interviews with 10 individuals 85 years or older suggested that resiliency is related to a
wide array of health factors (e.g., emotional, physical, spiritual, social, and internal).
Resiliency research poses a new way of conceptualizing counseling and development. It
has revealed that resiliency characteristics act as a buffer to help children and adolescents cope
with stress so they can move toward optimal development (Rak & Patterson, 1996). From a
strengths perspective, counselors can foster resiliency characteristics in their clients, thereby
promoting survival responses and maximizing developmental opportunities. The field of
resiliency research appears to offer opportunities for counselors to utilize a strengths perspective
in counseling.

ATTACHMENT THEORY. Attachment theory was originally developed by Mary Ainsworth and
associates (Ainsworth, Blehar, Waters, & Wall, 1978), John Bowlby (1969/1982), and others as an
investigation into the emotional bond between parents and child and the implications that bond
has for psychosocial development throughout the lifespan. Ainsworth et al. (1978) devised an
experiment called the Strange Situation that investigated attachment patterns of 1-year-olds.
An overview of the experiment (Feldman, 2008) follows:
A mother enters a room with an infant. She sits down and lets her child freely explore the
room. A stranger enters the room and converses with the mother and infant. The mother then
leaves the infant alone in the room with the stranger. The mother returns and greets and comforts
the infant, and the stranger departs. The mother then leaves the infant alone in the room. The
stranger goes back into the room. The experiment concludes with the mother returning and the
stranger exiting the room.
Based on the Strange Situation experiment, Ainsworth suggested there were three patterns
of attachment: secure, avoidant, and ambivalent. Feldman’s (2008) description of these three
attachment patterns follows.

Secure attachment occurs with the majority of children in North America. Securely
attached infants have a special-nurturing relationship with their caregivers. The caregiver is
sensitive to the infant’s needs, promoting feelings of safety and security. These infants are
able to explore their environment independently. They become upset when their caregiver
leaves and seek contact when the caregiver returns.
 Chapter 11 • Child and Adolescent Counseling 291

Avoidant attachment occurs with approximately 20% of infants. Avoidant attachment is

characterized by infants who appear to avoid contact with their caregiver and seem indif-
ferent to their caregiver. They do not get upset when separated from the caregiver or seek
out the caregiver when the caregiver returns.
Ambivalent attachment occurs with about 10 to 15% of infants. Ambivalent attachment is
associated with infants who display both positive and negative feelings towards their care-
giver. They tend to stay close to their caregiver, undermining their ability to engage in inde-
pendent exploratory behavior. When separated from the caregiver, these infants become
very upset. When reunited, they display mixed emotional responses towards the caregiver
(e.g., fluctuating between affection and anger).

A fourth attachment pattern relating to Ainsworth’s work has been identified (Feldman,
2008). Disorganized/disoriented attachment occurs with 5 to 10% of infants. These infants appear
to have the most insecure attachment patterns. Disorganized/disoriented attachment is charac-
terized by inconsistent, confused, and contradictory emotional and behavioral responses to the
caregiver. For example, after a period of separation, an infant may seek out the caregiver but
avoid eye contact. Emotional expressions with the caregiver can fluctuate dramatically for no
apparent reason (e.g., one moment appearing calm and then engaging in a crying tantrum).
The first three to four years of life, can be considered the sensitive period for establishing a
secure attachment. A sensitive period is “a point in development when organisms are particularly
susceptible to certain kinds of stimuli in their environments, but the absence of those stimuli does
not always produce irreversible consequences” (Feldman, 2008, p. 12). When a child has significant
problems formulating a secure attachment, serious psychological impairment can result. In
extreme cases (often involving child abuse or neglect), a reactive attachment disorder may occur,
undermining a child’s ability to formulate meaningful relationships with others (Feldman, 2008).
Ainsworth (1989, 1991) and Bowlby (1988a, 1988b) advocate for what is known as a
continuity theory regarding attachment. According to this theory, the nature of the attachment in
early life influences development throughout the lifespan. Much research has tested this hypoth-
esis and has also investigated the relationship between attachment styles and affect regulation and
social competence in adults (Lopez, 1995), producing some evidence in support of the continuity
hypothesis (Lopez, 1995). For example, securely attached infants and children tend to become
adults who have secure attachment styles (Brennan, Shaver, & Tobey, 1991; Carnelley,
Pietromonaco, & Jaffe, 1994) and also become parents who are able to establish secure attach-
ments with their family members (Ricks, 1985). The true test of the continuity hypothesis will
require longitudinal studies that investigate the relationship between early attachment and devel-
opment throughout the lifespan (Lopez, 1995).
A compelling body of research suggests there is a relationship between adult attachment
styles and adult affect regulation and social competence (Lopez, 1995). For example, securely
attached adults tend to have superior communication and problem-solving skills (Pistole, 1993;
Shaver & Brennan, 1992), higher levels of marital adjustment (Kobak & Hazan, 1991), and the
ability to provide more emotional support to distressed partners and solicit emotional support
when they need it (Simpson, Rholes, & Nelligan, 1992).
There are several commonalities between attachment theory and Adler’s individual
psychology (Peluso, Peluso, White, & Kern, 2004). Two key theoretical constructs in Adlerian psy-
chology are lifestyle analysis and social interest. Lifestyle refers to a person’s basic orientation to
life. Social interest relates to inborn tendencies to cooperate and work with others (which is
believed to increase with mental health and wellness). Attachment and lifestyle are similar in
292 Part 3 • Special Approaches and Settings

terms of their emphasis on early family relationships. Being securely attached can contribute to a
person’s being self–confident and having an active lifestyle. Attachment and social interest are
also similar constructs, for both suggest that the ability to establish meaningful social relation-
ships is influenced by the nature of early parent–child relationships. Securely attached individu-
als are better able to establish and maintain meaningful social relationships.
One intriguing area for the application of attachment theory is in career development.
Securely attached individuals tend to have adaptive characteristics that promote success in career
exploration and decision making (Blustein, Prezioso, & Schultheiss, 1995). Some of these charac-
teristics are enhanced ego identity development (Rice, 1990), enhanced adult work behavior
(Hazan & Shaver, 1990), and enhanced exploratory behavior (Hazan & Shaver, 1990).
Attachment theory is a view of a healthy personality in terms of relational issues in devel-
opment (Lopez, 1995) and therefore provides a strengths perspective for counseling. Concrete
strategies for applying attachment theory in counseling practice are beginning to emerge, and
several instruments have been developed to assess the nature and scope of a person’s attachment
style (for adolescent and adult attachment instruments, see Lyddon, Bradford, & Nelson, 1993,
and Bradford & Lyddon, 1994). Krause and Haverkamp (1996) have suggested that it may be pro-
ductive to assess adults’ current attachment relationships with their parents to gain insights into
adult or child–older parent relationships. Clients who appear to have problematic histories or
current problems with attachments may wish to address attachment issues in counseling to free
the way for optimal development (Blustein et al., 1995).

EMOTIONAL INTELLIGENCE. Mayer and Salovey are credited with developing the concept of
emotional intelligence (Mayer, Dipaolo, & Salovey, 1990; Mayer & Salovey, 1997; Salovey &
Mayer, 1990). Based on their scientific description of emotional intelligence (or EI), Mayer
(1999, 2001) contends that it is a unitary ability that can be measured reliably and is related to
but independent of standard intelligence. Emotional intelligence is a form of alternative intel-
ligence that can be traced to Thorndike’s (1920) work on social intelligence (Mayer, Salovey,
& Caruso, 2000), which essentially explores how people make judgments regarding others and
examines the accuracy of those judgments (Mayer & Geher, 1996). Emotional intelligence has
evolved into a more complex construct, defined as “an ability to recognize the meanings of
emotions and their relationships, and to reason and problem-solve on the basis of them.
Emotional intelligence is involved with the capacity to perceive emotions, assimilate emotion-
related feelings, understand the information of those emotions, and manage them” (Mayer,
Caruso, & Salovey, 1999, p. 267).
Goleman’s (1997) best-selling book Emotional Intelligence presented a popularized ver-
sion of emotional intelligence theory. The book refers to emotional intelligence as EQ, as
opposed to the intellectual quotient (IQ), and provides information on the practical applica-
tions of emotional intelligence to everyday life, suggesting that emotional intelligence may be
more important in determining personal success than intellectual intelligence. According to
Goleman, IQ may get you hired, but it is EQ skills that are primarily responsible for promo-
tions and other job-related successes. Goleman notes that self-awareness may be the corner-
stone of emotional intelligence since it is necessary for a wide range of prosocial behaviors such
as self-control. Other key characteristics that have been linked to success are empathy and
interpersonal skills (Goleman, 1997), optimism (Seligman, 1991), practical intelligence or
common sense (Sternberg, Wagner, Williams, & Horvath, 1995), and delay of gratification
(Mischel, Shoda, & Rodriguez, 1989; Shoda, Mischel, & Peake, 1990). Optimistic responses
to setbacks have been associated with job-related success, such as increased sales in the life
 Chapter 11 • Child and Adolescent Counseling 293

insurance profession (Seligman, 1991), and practical intelligence or common sense is a better
predictor of success in employment than intellectual intelligence (Sternberg et al., 1995).
Mischel et al.’s (1989) “marshmallow” study on delay of gratification is another example of
the effects of emotional intelligence on psychological functioning. In this study, 4-year-olds were
told they could have one marshmallow now or two when the researcher returned from an errand.
Those who waited for two marshmallows utilized a variety of delay-of-gratification coping skills,
such as singing, playing games, and so forth. The researchers then conducted a longitudinal study
that extended from childhood into adolescence (Mischel et al., 1989; Shoda et al., 1990). They
found that the 4-year-olds who waited for two marshmallows were rated as more intelligent, bet-
ter able to concentrate, and more goal-oriented than those who preferred instant gratification. In
addition, children who could delay gratification went on to become adolescents who tended to
have significantly higher SAT scores (Shoda et al., 1990).
Much of what is being studied in the field of emotional intelligence is also being explored in
the emerging field of evolutionary psychology (Gibbs, 1995). Evolutionary psychology, which is
based on the work of Charles Darwin, explores all aspects of development in terms of survival of the
human species (Daly & Wilson, 1983; Wright, 1994). From an evolutionary perspective, human emo-
tions like anger may trigger a fight-or-flight response (Goleman, 1997), empathy can act as a buffer to
cruelty (Goleman, 1997), and facial beauty and attractiveness can be related to reproductive capacity
(Johnston & Oliver-Rodriguez, 1997). The research in evolutionary psychology appears promising in
terms of understanding human development, including the realm of emotional intelligence.
Emotional intelligence provides a strengths perspective for counselors by recognizing the
vital role that social emotions play in human functioning. For example, counselors can help
clients use the power of encouragement to foster self-efficacy. In addition, preventative programs
in schools can promote strengths in emotional literacy to overcome the negative tendencies of
violence, loneliness, and despair (Goleman, 1997). School counselors have an ideal setting in
which to promote emotional intelligence through classroom presentations, counseling (especially
group), and consultation with parents and teachers.

TREATMENT ISSUES
This section addresses treatment issues in child and adolescent counseling. It begins by describ-
ing some of the commonly used assessment procedures. The chapter then provides information
on treatment in terms of research findings and a description of special counseling approaches
with children and adolescents.

Assessment Procedures
Child and adolescent counseling encompasses the full range of standardized and nonstandard-
ized assessment procedures described in Chapter 4. Two additional child and adolescent assess-
ment procedures are the use of drawings as an assessment tool, a procedure clinicians have used
for some time, and the use of clinical interviews with children, adolescents, and parents.
Although clinical interviews have been used with adults for many years, their use with children
and adolescents is more recent (Edelbrock & Costello, 1988) and represents a major advance in
the assessment of childhood and adolescent disorders (Kazdin, 1989).

DRAWINGS. Drawings can be used in both standardized and nonstandardized assessment

procedures. One standardized test is the Goodenough-Harris Drawing Test (Harris, 1963).
This test requires children and adolescents to make a picture of a man or woman (depending
294 Part 3 • Special Approaches and Settings

on the sex of the child) and a picture of themselves. Another commonly used standardized test
is the House-Tree-Person Test (Buck, 1949), in which children and adolescents first draw a
house, then a tree, and last a person. More recent is the Kinetic Drawing System for Family and
School (Knoff & Prout, 1985), in which children and adolescents draw one picture of their
family and another that relates to school. This test assesses important relationships at home
and school.
Drawings by children and adolescents can also be used in a nonstandardized way to obtain an
estimate of a child or adolescent’s cognitive and psychosocial development and level of maturity
(Stabler, 1984). The following five factors that are important in assessing drawings (Stabler, 1984):
1. Proportion or form. Do figures in the drawings have appropriate proportion or form?
2. Detail. What is the degree of detail in the drawing (are there ears, eyes, mouth, and a nose
on the face)?
3. Movement or action. Is there movement or action depicted in the drawing, such as hav-
ing the appearance of a three-dimensional person?
4. Theme. Is there a theme or story conveyed in the picture, such as two people in love or
Superman stopping a villain?
5. Gender identity. Is there evidence that the child or adolescent has a clear concept of gen-
der identity?
There are also guidelines for assessing drawings in terms of cognitive functioning and overall
maturity for children and adolescents in three age groups: aged 5 to 7, 8 to 9, and 10 to 12
(Stabler, 1984). For example, children from age 5 to 7 tend to be able to draw pictures that are
more or less proportional; have limited detail; some evidence of gender identity emerging;
rather poor movement or action; and typically no theme. Figure 11.1 illustrates a typical draw-
ing by a 6-year-old and a 12-year-old.
Three types of drawings are particularly useful in the assessment process: free draw-
ings, where children are encouraged to draw whatever they like; self-portraits; and family
drawings, in which children draw themselves with their family (Stabler, 1984). These draw-
ings enable the counselor to make hypotheses about what to explore with a child. For exam-
ple, a free drawing may have themes that represent children’s concerns, so a child who
repeatedly draws a house with a child by a mother and father in the home could suggest the
child is concerned with issues relating to home and family life. A self-portrait with no arms
or legs could indicate a sense of lack of control over the environment. Children who draw a
self-portrait without a mouth may think that others do not value their views. A family draw-
ing with a significant distance between the child and other family members could suggest a
feeling of isolation or alienation.

CLINICAL INTERVIEWS. The clinical interview has become an increasingly popular tool for
assisting with assessment and diagnosis (see Chapter 4 for a description of the clinical interview).
The clinical interview does not replace other forms of assessment, but it can be viewed as an
adjunct to the process of assessment and diagnosis. In this role, the clinical interview has been
shown to increase diagnostic reliability (Robins, Helzer, Croughan, & Ratcliff, 1981). Although
clinical interviews have been used with adults for some time, their development and use with
children and adolescents have occurred primarily during the last 20 years, corresponding to the
increased differentiation of mental disorders in children and adolescents.
There are several advantages and disadvantages of clinical interviews compared to other
child and adolescent assessment procedures, such as observation and psychological tests
 Chapter 11 • Child and Adolescent Counseling 295

12-Year-Old
6-Year-Old

FIGURE 11.1 Typical Drawing by a 6-Year-Old Child and 12-Year-Old Adolescent.

Source: From Children’s Drawings (pp. 5, 8) by B. Stabler, 1984, Chapel Hill, NC: Health Sciences
Consortium. Copyright 1984 by Health Sciences Consortium. Reprinted by permission.

(Edelbrock & Costello, 1988). The advantages include enabling the counselor to establish
rapport, clarify misunderstandings, and obtain self-report data from parents, children,
and adolescents. The primary disadvantages relate to questionable levels of validity and relia-
bility owing to the newness of these instruments and the consequent lack of time for empiri-
cal evaluation.

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296 Part 3 • Special Approaches and Settings

Many clinical interview instruments for children and adolescents are currently available. The
commonly used clinical interviews vary in terms of structure, and the more structured interviews
require less training to administer (Edelbrock & Costello, 1988). The following are three examples:
1. The Diagnostic Interview for Children and Adolescents (Herjanic & Reich, 1982). This
is a highly structured diagnostic interview that can be used with children 6 years of age or older.
It covers a broad range of childhood symptoms in terms of frequency and duration. There is also
a version for parents, which solicits pertinent developmental and family history.
2. The Interview Schedule for Children (Kovacs, 1982). This is a semistructured interview
for children ages 8 to 17. It is symptom-oriented and focuses primarily on depression, although it
also assesses other diagnostic criteria. A separate interview can be conducted with parents, chil-
dren, and adolescents.
3. The Diagnostic Interview Schedule for Children (Costello, Edelbrock, Kalas, Kessler, &
Klaric, 1982). This is a highly structured interview for children and adolescents ages 6 to 18. It
provides information on a wide range of symptoms and behaviors in terms of onset, duration,
and severity. A parallel version can be used with parents and children or adolescents.

Child and Adolescent Counseling Goals

One way to conceptualize counseling goals in child and adolescent counseling is from a develop-
mental perspective. The developmental perspective can be applied to clients of all ages. It can be
especially useful in child and adolescent counseling (such as in school counseling) where devel-
opmental issues are continuously addressed. The developmental perspective differentiates
between two types of counseling goals: universal–primary goals and secondary goals. Universal-
primary goals address developmental issues; secondary counseling goals relate to specific
problems, such as procrastinating and not turning in schoolwork on time.
Universal–primary goals promote optimal development through the enhancement of devel-
opmental competencies such as self-esteem, attachment, resiliency, emotional intelligence, self-
awareness, self-control, self-efficacy, intrinsic motivation, and internal locus of control. They are
considered primary counseling goals because they relate to the child’s or adolescent’s overall growth
and development. In addition, universal–primary goals may promote developmental competencies
necessary to successfully address secondary counseling goals to which they may be directly or indi-
rectly related. For example, promoting intrinsic motivation and self-control are universal–primary
goals that may be directly related to overcoming problems with procrastination. Promoting self-
awareness may be a developmental goal that is indirectly related to the procrastination problem but
could be important to the child’s or adolescent’s overall growth and development.
It is important to consider both universal–primary and secondary counseling goals when
assessing progress in counseling. From a developmental perspective, success should be measured
both in terms of whether problems have been resolved (secondary goals) and how clients are pro-
gressing relative to their overall growth and development (primary-universal goals). Counselors
and clients should be encouraged if progress is being made with either universal–primary or sec-
ondary counseling goals.

Child and Adolescent Counseling Research

Overviews (Weisz, Weiss, & Donenberg, 1992; Kazdin, 1993) of a number of meta-analyses on
child and adolescent counseling (e.g., Hazelrigg, Cooper, & Borduin, 1987; Kazdin, Bass, Ayers, &
Rodgers, 1990) report strong support for the efficacy of child and adolescent counseling. For
 Chapter 11 • Child and Adolescent Counseling 297

example, the effects of child and adolescent counseling are superior to no treatment, the degree of
positive change is comparable to adult counseling, there is little variation in efficacy of treatment
modalities such as behavioral versus nonbehavioral, and treatment outcomes are similar for
internalized problems such as depression and externalized problems such as aggression (Kazdin,
1993). Research also suggests that a developmental perspective is critical in identifying appropri-
ate counseling interventions for children and adolescents. For example, behavioral approaches
such as behavior modification have been useful in treating children (Kazdin, 1993), and adoles-
cents (owing to their ability to think abstractly) are able to utilize cognitive–behavioral
approaches better than children (Durlak, Fuhrman, & Lampman, 1991).
Kazdin (1993) also notes that there is strong support for preventative programs with chil-
dren and adolescents (Goldston, Yager, Heinicke, & Pynoos, 1990; Weissberg, Caplan, &
Harwood, 1991). Programs that provide support to a family during a child’s formative years
appear to prevent problems, such as a child engaging in antisocial behavior later in childhood and
adolescence. Research also suggests that school-based programs appear to be effective in prevent-
ing a wide array of problems, such as substance use and abuse and school dropout. Kazdin (1993)
proposes that the success of preventative programs depends to some degree on the ability to not
only change attitudes but also to change behavior. Schultz and Nystul (1980) found in an earlier
study on parent education that the internalization and transfer from an attitude to a behavior
requires some form of action, such as role-play.

Special Counseling Approaches for Children and Adolescents

Most counseling approaches used with children and adolescents (such as behavioral and
cognitive–behavioral) are adaptations of strategies used with adults (Tuma, 1989). Play therapy
and conflict resolution are two counseling approaches that have been specifically designed for
working with children and adolescents. This section is an overview of these unique methods and
provides guidelines for child and adolescent counseling.

PLAY THERAPY. Play represents an important developmental tool for children and adolescents.
It is a natural form of communication (Campbell, 1993) and an expression of creativity linked to
learning, coping, and self-realization (Rogers & Sharapan, 1993). Through play, children and ado-
lescents are able to enhance cognitive, physical, and psychosocial development (Papalia & Olds,
2001). For example, playing hide-and-seek involves deciding where and how to hide (cognitive);
mobility, such as running and squatting (physical); and cooperating with others (psychosocial).
Sports like basketball and baseball become favored forms of play for adolescents and adults and
continue to provide opportunities to enhance development.
Play therapy is a counseling strategy that has been used primarily with children for a variety of
purposes: to build relationships, conduct assessment, promote communication, provide psychologi-
cal healing, and foster growth (Orton, 1997). Play therapy involves play media such as sand play, art,
and music to learn skills and work through problems so children can progress in their development.
Sand play, an emerging form of play therapy (Carmichael, 1994), involves the use of two 20-by-30-by-
4-inch trays (one with wet sand and one with dry sand) and numerous objects that represent every-
day life (people, fences, animals, and so forth). Children are encouraged to use the objects to express
themselves in fantasy play. The three stages of play therapy (including what one would expect in sand
play) are chaos, struggle, and resolution (Allan & Brown, 1993). During the initial stage (chaos), chil-
dren tend to express negative feelings such as anger and confusion and project those feelings onto
their play activities. As play therapy progresses, the therapist encourages children to utilize play as a
298 Part 3 • Special Approaches and Settings

means of working through their struggles. The last phase of play therapy is characterized by creative
expressions that are more positive in nature (such as cooperation), reflecting resolution of conflicts.
The historical roots of play therapy can be traced to two major schools of counseling,
Freudian and Rogerian. Anna Freud (1928), the daughter of Sigmund Freud, was perhaps the first
to use play therapy with children, and Melanie Klein (1960) further developed the psychoanalytic
school of play therapy. These clinicians incorporated the major principles of psychoanalysis into
their approach, for example, strengthening the ego to minimize endopsychic conflicts and utilizing
the transference relationship to help children overcome traumatic experiences. The psychoanalytic
counselor conceptualizes play in a manner similar to free association. From this perspective, play
allows children to express themselves freely and spontaneously. The counselor’s role in this process
is passive and interpretive. For example, if a child painted a picture with dark objects, the counselor
might ask, “Are you feeling sad or gloomy today?”
The theoretical foundation of Virginia Axline’s (1970) school of play therapy can be traced to
Carl Rogers’s person-centered school of counseling; it is therefore a humanistic–phenomenological
approach. The counselor conveys a warm and accepting attitude toward the child and encourages
the child to freely explore the different play materials (Axline, 1964, 1974). The role of the counselor
is similar to that in person-centered counseling. As the child plays, the counselor attempts to convey
empathic understanding by reflecting what he or she senses the child is experiencing. A more
detailed description of Axline’s approach can be found in Dibs: In Search of Self (Axline, 1964).
Contemporary forms of play therapy are based on a number of theoretical orientations,
such as Rogerian (Landreth, 1993), Jungian (Allan & Brown, 1993), and Adlerian (Kottman &
Johnson, 1993; Nystul, 1980a). Current trends in Rogerian child-centered play therapy reflect
the earlier model developed by Axline and are being used to treat a wide range of problems—
regressive behavior, depression, abuse, and socially inappropriate behavior (Landreth, 1993).
Jungian play therapy involves an application of the major Jungian principles (see Chapter 7).
Jungian play therapy uses the therapeutic alliance to help the child work through unconscious
struggles and conflicts reflected in play (Allan & Brown, 1993). A central goal is to help the child
create a balance between the inner world of feelings, drives, and impulses and the demands of the
outer world as reflected in school, peers, and family. Another major goal in Jungian play therapy
is to strengthen the child’s ego so it can become an effective mediator between the child’s inner
and outer world. In fact, Jungians have found sand play to be particularly useful as a means of
strengthening the child’s ego to create a balance between the child’s inner and outer world
(Carmichael, 1994).
Adlerian play therapy is based on the work of Adler (1930) and of Dreikurs and associates
(Dreikurs & Soltz, 1964). It is used to foster a positive counseling relationship, help parents and
teachers gain a better understanding of children, enable children to gain insight and self-awareness,
and provide skills and experiences necessary for children to work through conflict and enhance
their development (Kottman & Johnson, 1993; Nystul, 1980a). Consultation with parents and
teachers can be an important adjunct to Adlerian play therapy (Kottman & Johnson, 1993; Nystul,
1987b). Counselors can use Adlerian/Dreikursian concepts to help parents and teachers develop
tools to better understand and work with children. Some of the more widely used concepts are the
goals of misbehavior, the birth-order factor in personality development, encouragement versus
praise, and consequences versus punishment. Programs such as systematic training for effective
parenting (STEP) by Dinkmeyer and McKay (1997) provide an excellent summary of these ideas as
well as structured activities for applying them.
The following Personal Note provides an example of how I developed my own approach to
play therapy.
 Chapter 11 • Child and Adolescent Counseling 299

A Personal Note

I have developed my own approach to play therapy (Nystul, 1980a). It is grounded in Adlerian/Dreikursian
psychology and also integrates the four phases of multimodality creative arts therapy described in Chapter 8:
set the stage, set an example, set yourself at ease, and obtain a phenomenological understanding of the child.
My approach to play therapy is based on the following seven assumptions:
1. The counselor attempts to establish a feeling of mutual respect with the child.
2. The counselor uses encouragement whenever possible.
3. The counselor attempts to understand the child by exploring the child’s private logic.
4. The counselor tries to redirect the child’s teleological movement to increase the child’s motivation
for change.
5. The session starts with 15 to 30 minutes of self-concept development and ends with 15 to 30 min-
utes of multimodality creative arts therapy.
6. The counselor uses logical and natural consequences to establish realistic limits.
7. The counselor recognizes the importance of parent and teacher involvement as an adjunct to play
therapy.
Over the years, I have found play therapy to be a very effective way to work with children. I believe
play is a natural medium for communicating with them. Play allows children an opportunity to relax and
be themselves as they work through issues that concern them.

GUIDELINES FOR PLAY THERAPY. The following guidelines may be useful when implement-
ing a play-therapy program.
Play therapy can be conducted individually or in small groups of two or three children.
The play-therapy room should be approximately 15 by 15 feet. It should be big enough for
two adults and four children, but small enough to promote a sense of closeness between the
counselor and the child. If the room is too large, for example, the child may wander off. The
counselor should ensure privacy. No one should be permitted to come into the play-therapy
room while a session is in progress. Interruptions can be a major distraction from the coun-
seling process.

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300 Part 3 • Special Approaches and Settings

Different play materials, such as play houses, puppets, babies, and other family members,
should be on hand. Art supplies like molding clay and watercolors and musical instruments like
bongo drums and a tambourine are also useful.
The counselor should establish limits with the child during the first session regarding time
and behavior. In terms of time, the session length can vary according to the time available but
should not exceed 1 hour. The length of time should be determined before the first session and
adhered to as much as possible. Regarding behavior, the counselor should restrain a child who
acts in an aggressive, hostile manner. It may even be necessary to discontinue the play-therapy
session if the child persists in being hostile. When a child abuses a toy, the counselor can use a
logical consequence. For example, a counselor might say, “It looks like you’re not ready to use
the drum today. I’ll put it up for now. Some other time, you can try to use it the way it is sup-
posed to be used.”
In communicating, counselors should use a friendly, kind voice, especially if they sense a
child feels insecure; not talk down to a child in terms of tone of voice; and use an appropriate
vocabulary level so that the child will understand their words. Although it may be necessary to be
firm with a child, it is probably counterproductive to be stern. Counselors should let themselves
laugh and have fun with the child, and they should talk from a positive perspective, using encour-
agement whenever possible.
Play therapy offers a means to reach into the world of the child and help the child reach out
to the world of others. It can be used to treat a wide range of problems and concerns. For exam-
ple, play therapy can be used to help autistic children learn language and other skills necessary to
overcome some autistic tendencies (Nystul, 1986a). Play therapy can provide an important
dimension to comprehensive developmental counseling programs by helping children overcome
tendencies toward reluctance and resistance, fostering problem solving and so forth (Campbell,
1993). Play therapy has cross-cultural potential by creating a universal language through play and
involvement in the creative arts (Cochran, 1996). It can help overcome language barriers and
other sources of resistance in order to foster school success in children and adolescents (Cochran,
1996). A meta-analysis of 15 research reports on play therapy shows that play therapy is superior
to nontreatment and promotes general adaptation and intellectual skills (Reams & Friedrich,
1983). Additional research seems warranted to gain a clearer understanding of how play therapy
can be used with children.

CONFLICT RESOLUTION. Specially designed youth-oriented conflict-resolution procedures can

be used with children (Stern & Newland, 1994) and adolescents (Van Slyck et al., 1996). As noted
in Chapter 14, conflict resolution is particularly useful in middle school counseling, where prob-
lems tend to be related to interpersonal conflict. Youth-oriented conflict resolution, which is used
in both school and mental health counseling, has its own unique theories, techniques, and train-
ing requirements (Van Slyck et al., 1996).
An overview of the field is as follows (Van Slyck et al., 1996). Youth-oriented conflict res-
olution is considered distinct from adult conflict resolution in that the youth takes an active role
in the process by learning how to manage his or her own conflicts; adults tend to take a more
passive role by bringing in a mediator to resolve the conflict (such as in divorce mediation). The
overall goal of youth-oriented conflict resolution is to foster problem-solving skills, coping
skills, and resiliency characteristics that can be used to overcome conflict and foster optimal
development.
Youth-oriented conflict-resolution programs can be both preventative and remedial
in nature. Preventative programs are directed at helping young people learn how to apply
 Chapter 11 • Child and Adolescent Counseling 301

conflict-resolution theory and skills to foster a life with minimal adverse conflicts and stress.
Large and small group guidance activities on conflict resolution as well as adaptations in
the school curriculum can play a major role in implementing preventative programs.
Remedial conflict resolution relates to overcoming currently existing conflicts. This can
involve the use of peer counseling (e.g., peer mediation) or direct intervention by teachers,
staff, and counselors. Regardless of the level of intervention (prevention or remedial), the
focus is on helping young people use problem-solving skills to successfully mediate and nego-
tiate problems of living.
Several steps of Dysinger’s (1993) youth conflict-resolution model have been incorporated
into the following framework for conflict-resolution problem solving:

1. Take a positive approach. It begins by encouraging young people to approach conflict

resolution from a win-win perspective. Ground rules are established that promote a positive,
strengths perspective rather than an adversarial approach (e.g., no name-calling or threatening).
2. Listen and respond appropriately. It involves helping the conflicting parties learn to use
listening skills to understand opposing points of view and to respond constructively. Ground
rules include no interrupting while others are talking (so that the parties can be in the role of lis-
tener and learner) and respond from a position of caring.
3. Become aware of choices and responsibility. Youths are encouraged to become aware of
the choices they have made and the responsibility they must assume in relation to the conflict.
Ground rules include no blaming or whining. Use of personal pronouns can be encouraged to
help young people take responsibility for their behavior.
4. Create solutions that promote friendship. This step identifies a new approach, which
can be used to overcome the conflict. The nature of the new approach will vary with the situation
and people involved. For some, assurance that the other person will not engage in a certain
behavior will be enough, for others, simply understanding the other person’s point of view can
resolve the conflict.
5. Follow up. Follow-up involves checking to see whether the conflict has been resolved
and encouraging the youths to engage in conflict-resolution problem solving if the problem con-
tinues. Through cooperation and caring, friendships can be enhanced and conflicts and stress can
be minimized.

Guidelines for Child and Adolescent Counseling

The following guidelines can be integrated into one’s personal approach to counseling children
and adolescents.

MAINTAIN A LINE OF COMMUNICATION. Parents, teachers, and counselors can get discour-
aged when counseling children and adolescents. Parents can contribute to communication
problems by utilizing a rigid parenting style such as using ultimatums like “While under my
roof, you do as I say, or else.” Children and adolescents may create special challenges for adults
as they act out rebellious stages, say and do hurtful things, and find ways to annoy others. When
this occurs, it is important for concerned adults to maintain a line of communication with the
child or adolescent.
The following Personal Note provides examples of clinical issues associated with maintain-
ing a line of communication.
302 Part 3 • Special Approaches and Settings

A Personal Note

I will always remember what a woman who specialized in working with adolescents told me. She said the
most important thing in counseling adolescents is to always maintain a line of communication. It is very
easy to lose that connection with adolescents due to their rebelliousness, parental rigidity, and so forth.
Without communication, problems cannot be resolved and bad situations only get worse.
I have found that several theoretical perspectives can be used to maintain a line of communication
with children and adolescents. For example, Glasser (1980) suggests counselors convey to their clients
that they will never give up on them regardless of what they do. Children and adolescents often test their
counselors by escalating their misbehavior to see if their counselors really mean it. My theory of emo-
tional balancing (described in Chapter 3, Nystul, 2002a, b) provides another tool for maintaining a line
of communication. According to this theory, a person can maintain meaningful communication and
emotional balance by avoiding emotional disengagement and emotional enmeshment.

USE INTERVENTIONS GROUNDED IN THEORY. Theory provides a conceptual framework for

understanding and addressing clinical issues. The following Personal Note describes why I have
found theory to play a key role in child and adolescent counseling.

A Personal Note

Once when I went to an Adlerian conference, I attended a presentation by Professor James Croake.
During the presentation, he said that having a solid grounding in theory could be very beneficial in help-
ing relationships, and it should be emphasized over technique. I could not agree with him more. I have
found that theories (such as theories of personality and theories of child development) promote under-
standing of why the child is misbehaving and so on, and understanding tends to promote interest and
compassion, which in turn can foster positive outcomes such as problem resolution.
Interventions grounded in theory are also useful to those in the role of consultant. As a school psy-
chologist, I am often asked by teachers what they should do about a student’s misbehavior. My consulta-
tion usually focuses on helping them understand the dynamics of the child’s or adolescent’s misbehavior.
In this process, we explore the application of simple, practical theories such as Glasser’s (1969) concept
of success versus failure identity and Dreikurs’s concepts of goals of misbehavior and encouragement
versus praise (Dreikurs & Soltz, 1964). These theories are great because they have stood the test of time.

INCORPORATE PARENTING CONCEPTS IN ONE’S APPROACH. Parenting programs like

Dinkmeyer and McKay’s (1997) systematic training for effective parenting (STEP) can be impor-
tant adjuncts to child and adolescent counseling. Parenting concepts and ideas can be used to
address child/adolescent problems and enhance family relationships (Nystul, 1980b, 1982b, 1984,
1987b). Parenting programs such as STEP do not require licensed professionals and are often led
by interested parents.
In some instances, more in-depth parenting interventions are required. In these cases,
counselors can utilize parenting programs as an adjunct to child and adolescent counseling.
Parent management training (PMT) is the most popular parenting program used by counselors
to assist parents (Friedlander & Tuason, 2000). PMT is a psychoeducational intervention that
involves helping parents learn parenting procedures to address a number of child and adolescent
problems, such as oppositional and conduct disorders, attention-deficit hyperactivity disorder,
and delinquency (Estrada & Pinsoff, 1995). PMT has also been used to enhance overall family
 Chapter 11 • Child and Adolescent Counseling 303

functioning by reducing family conflict and increasing family cohesion and expression (Sayger,
Horne, & Glaser, 1993). Positive gains associated with PMT can be significantly reduced when
parents are depressed or experiencing high levels of stress (Webster-Stratton, 1990) or families
are disadvantaged or isolated (Estrada & Pinsof, 1995).

EMPHASIZE CHOICE AND RESPONSIBILITY. Glasser (1998) emphasizes the role of choice and
responsibility in promoting mental health. Choice and responsibility can be especially useful in
child and adolescent counseling strategies to promote optimal development. Parents, teachers,
and others can help children and adolescents become aware of their choices and assume respon-
sibility for those choices, resulting in personal and relational benefits. Personal growth resulting
from choice-responsibility can include self-efficacy, self-control, self-esteem, and internal locus
of control. Relational benefits can include minimizing conflict between the adult and child or
adolescent (because the parent is focusing on the child’s or adolescent’s choices rather than
getting sidetracked into issues such as power and control).

UTILIZE THE REACHING IN–REACHING OUT MODEL. The reaching in–reaching out approach
can be useful in child and adolescent counseling (Nystul, 1986). Reaching in–reaching out involves
counselors finding a way into the world of the client and then helping the client reach out to the
world of others. The more rigid and ritualistic clients are, the more resistant they can be and there-
fore the more important it is to meet them on their terms. When clients are met on their terms,
they tend to feel safe, thereby lowering their resistance to being with their counselor. As clients let
counselors into their world, the resultant existential encounter can be enhanced by enjoyable expe-
riences such as “having fun” with puppets, music, or other creative play modalities.
“Having fun” can set the stage for the “reaching out” phase of counseling by increasing the
client’s motivation for working with the counselor. The “reaching-out” phase involves a “transfor-
mation of the self ” reflected in a shift in the client’s private logic to increased social interest and
willingness to cooperate with the counselor (e.g., “I want to listen and cooperate with my coun-
selor because he can be fun.”). Once the “transformation of the self ” has occurred, counselors can
help clients reach out to the world of others by directly addressing their problems (such as help-
ing an autistic child learn language skills). Counselors can then work with other concerned adults
like parents and teachers to help them effectively relate to children and adolescents by applying
the reaching in–reaching out approach.
The following Personal Note (first described in Chapter 1 in a Personal Note relating to the
art of counseling) illustrates how to reach into a child’s world. The case involved a first-grade girl
who had been placed in a class for the mentally retarded. As it turned out, she was misdiagnosed
and was not retarded but autistic.

A Personal Note

When I first saw her I was not aware that she was autistic. I had brought puppets that I was going to use
to present self-concept material and other activities. Her idea of using the puppets was to throw them all
in a pile and redo a throw if it didn’t land right on the other puppets (that type of ritualistic behavior is
common with autistic children). As I attempted to reach into her world (a world she felt safe with and
understood), I became a “puppet basketball net.” I circled my arms around her pile of puppets and yelled
“two points” when she threw one in my circle. Over time, she felt safe with me and began to welcome my

(Continued)
304 Part 3 • Special Approaches and Settings

company. I used this interest to encourage her to reach out to the world of others by fostering her
language development and eventually finding ways to help her break out of some of the rigidity of her
autistic world.
Over the years I have reflected on this case and have come to believe that, to some degree, all coun-
seling is a reaching in–reaching out process. Initially in counseling, I find ways to reach into my client’s
world. With children it can be through play therapy; with adults perhaps creative arts therapy or listen-
ing skills to discover the personal meaning of their stories. After a while, we establish a positive counsel-
ing relationship that provides the basis for encouraging my clients to reach out in new directions, expand
their horizons, and foster their optimal development.

SPECIAL PROBLEMS OF CHILDREN AND ADOLESCENTS

This section is an overview of some of the special problems experienced by children and adoles-
cents: child abuse and neglect, depression, and antisocial behavior. For each type of problem,
information is presented on incidence, assessment, causes, effects, and treatment.

Child Abuse and Neglect

Children have been abused and neglected throughout history, but it was not until the early
1960s that child abuse and neglect became recognized as social problems that require compre-
hensive treatment (Wolfe, 1988). This section reviews some of the issues associated with child
abuse and neglect.

INCIDENCE. The incidence of child abuse and neglect continues to increase at an alarming rate
in the United States, with current estimates as high as 2 million children a year (Papalia & Olds,
2001). Psychological abuse may be the most prevalent and destructive form of child abuse
(Dworetzky, 1996). Many children have also been sexually abused (Papalia & Olds, 2001). The in-
cidence of sexual abuse in the United States is also staggering. Current estimates suggest that one
in every four girls and one in every seven to ten boys will have a sexual experience with an adult
before reaching 18 years of age (England & Thompson, 1988).

ASSESSMENT. Early identification and treatment of child abuse and neglect are critical to min-
imizing negative effects on the child. The following are warning signs of the various forms of
child abuse and neglect (Salkind, 1994):
• Physical abuse. Signs of bruises, burns, and broken bones
• Child neglect. Poor health and hygiene and excessive school absenteeism
• Sexual abuse. Use of sexually explicit terminology, nightmares, genital injury, and sexually
transmitted disease
• Psychological (emotional) abuse. Depression, self-deprecation, somatic (bodily) com-
plaints such as headaches or stomachaches, and fear of adults
The assessment of child abuse and neglect is a multistage process (Wolfe, 1988). It usually
begins with impressionistic data from the reporting and referral source. That stage is followed by
a refinement of information during interviews with parents and the child (Wolfe, 1988). Much of
the initial information regarding the functioning of the parent and child can be obtained in a
semistructured interview with the parent (Wolfe, 1988). The Parent Interview and Assessment
 Chapter 11 • Child and Adolescent Counseling 305

Guide can be used to structure the interview and provide information on family background,
marital relationship, areas of stress and support, and symptomatology (Wolfe, 1988). Several
instruments can be used to survey the attitudes of parents on topics relating to marriage and the
family. The Child Abuse Potential Inventory (Milner, 1986) identifies familial patterns associated
with child abuse. The Childhood Level of Living Scale (Polansky, Chalmers, Buttenwieser, &
Williams, 1981) measures the degree of positive and negative influences in the home and is par-
ticularly useful for assessing neglect (Wolfe, 1988).

CAUSES. Research shows that child abuse results from a complex interaction of events. Wolfe
(1988) summarizes the research by noting that child abuse is a special type of aggression result-
ing from proximal and distal events.
Proximal events are those that precipitate abuse. A proximal event can involve a child’s
behavior or an adult conflict that triggers the abuse. Common child behaviors that can trigger
child abuse are aggression, unspecified misbehavior, lying, and stealing (Kadushin & Martin,
1981). Marital problems and violence are also associated with child abuse (Straus, Gelles, &
Steinmetz, 1980). Distal events are those that are indirectly associated with child abuse. These fac-
tors include low socioeconomic status and poverty, restricted educational and occupational
opportunities, unstable family environment, excessive heat, overcrowding, ambient noise level,
and unemployment (Wolfe, 1988).
Other research has attempted to identify characteristics of abusive parents as a means of
understanding the causes of child abuse. Abusive parents tend to have been abused as children,
have difficulty coping with stress, suffer from substance abuse problems, be immature and hold
unrealistic expectations of children, and have children with special needs that require extra
time and energy (Talbutt, 1986). A typical profile of parents at high risk for child abuse
describes them as tending to be young, poorly educated, single, living in poverty, and socially
isolated, and feeling little support from a significant other (Sroufe & Cooper, 1996). Abusive
mothers tend to have a negative attitude toward their pregnancy (Sroufe & Cooper, 1996).
Compared to nonabusive parents, they tend to have less understanding of what is involved in
caring for an infant, are less prone to plan for pregnancy, do not attend childbirth classes, do
not have special living quarters for the baby to sleep, and have unrealistic expectations about
raising an infant.

EFFECTS. Physical neglect that results from not meeting a child’s basic needs like food and shel-
ter tends to produce a lack of competency in dealing with the tasks of daily living, such as person-
al hygiene. Physical abuse and emotional unavailability often result in behavioral and emotional
problems, such as avoidance of intimacy in relationships, aggressiveness with peers, and blunted
emotions (Sroufe & Cooper, 1996). Psychologically abused children can develop neurotic traits,
conduct disorders, negative self-image, and distorted relations with others (Craig, 2002; Hart &
Brassard, 1987).
Sexual abuse can have traumatic and enduring effects. Children who have been victimized
by sexual abuse often suffer significant psychological distress; with 48% meeting the DSM-IV-TR
criteria for posttraumatic stress disorder (PTSD) (Putman, 2009). A number of symptoms are
associated with child sexual abuse and PTSD (Putman, 2009):
• Fear reactions and phobic avoidance of males;
• Reenactment of the traumatic event via nightmares, traumatic play, flashbacks, and intru-
sive thoughts;
306 Part 3 • Special Approaches and Settings

• Dissociation or altered state of consciousness (can include amnesia, sleepwalking, and

trancelike states) contributing to loss of memory and loss of personal identity;
• Avoidance of stimuli associated with trauma via cognitive suppression and behavioral
avoidance, undermining overall functioning;
• Emotional detachment characterized by blunted affect;
• Negative sense of self (self-blame and reduction in self-efficacy) and the future; and
• Heightened state of arousal including sleep problems, exaggerated startle response, trouble
concentrating, and aggression.

Putman (2009) noted it is common for children who have been victimized by sexual abuse
to have suicide ideations and multiple DSM disorders. DSM disorders that commonly occur with
PTSD include: attention deficit hyperactivity disorder (ADHD), mood disorders (e.g., major
depression), and anxiety disorders (e.g., social phobias). Putman suggests that it is important
to obtain an accurate diagnosis, screen for possible suicidal risks, and address these clinical issues
as necessary.
There are several ways in which sexual abuse can damage a child (O’Brien, 1983):

• Psychological effects. Sexual experiences can be confusing for children because they are
unable to understand the strong emotional feelings associated with sex.
• Low self-esteem. Children may blame themselves for permitting the sexual contact or may
feel dirty or ashamed as a result of the experience.
• Exploitation. Sexually abused children may feel used and develop a hostile, suspicious atti-
tude toward others.
• Vulnerability. Because children are dependent on adults, they are vulnerable to and
trusting of adults. When that trust is broken, children may develop a negative attitude
toward vulnerability, making it difficult for them to develop trust and intimacy in their
relationships.
• Distorted view of sexuality. It is common for sexually abused children to develop a very
negative or perverted attitude toward sex. As they grow up, they may avoid sex or become
sexually promiscuous.
• Violation of the child’s privacy. After an incestuous relationship is discovered, the abused
child must cooperate with the authorities. This violation of the child’s privacy can be very
traumatic and anxiety-provoking.
• Distorted moral development. Sexual abuse often occurs between the ages of 9 and 11
when a child’s moral development is being formulated. Children can become quite con-
fused about what is right and wrong when an adult is allowed to violate them sexually.

The following Personal Note illustrates how difficult it can be for a child to deal consciously
with the trauma of sexual abuse.

A Personal Note

When I was a psychologist at a hospital, I worked with several girls who had babies as a result of incestuous
relationships with their fathers. These girls tended to use denial as a means of coping with what had happened.
For example, I met a 14-year-old girl the day before she had her baby. She insisted that she was not
even pregnant. After she had the baby, she said that the baby was not hers. This patient required extensive
counseling and psychotherapy to develop a realistic approach to her situation.
 Chapter 11 • Child and Adolescent Counseling 307

TREATMENT. The most hopeful treatment for abusive parents involves “resocialization” tasks,
which help parents overcome isolation and foster interpersonal relations and support (Brockman,
1987). These efforts can include encouraging parents to join Parents Anonymous or other self-
help groups. Several preventative programs can also be promoted in schools (Brockman, 1987),
including adult education, interpersonal training for students, courses on sexuality and parenting
in high school, and guest speakers for students from organizations like Parents Anonymous.
Thompson and Wilcox (1995), on the other hand, note that little empirical evidence supports
the social-isolation theory of child abuse, citing numerous examples of parents who are provided
social support and who continue to engage in child abuse because of many other stressors (such as
substance abuse problems). They contend that child abuse and neglect is a cross-disciplinary
problem that should be addressed by research and intervention teams composed of people from
disciplines like psychology, social work, and sociology because such teams can gain a more compre-
hensive understanding of the causes and treatment strategies associated with child mistreatment.
Treatment efforts can also be directed at the abused child. Group counseling can be espe-
cially effective in working with abused and neglected children (Damon & Waterman, 1986) and
adolescents (Hazzard, King, & Webb, 1986) to foster self-esteem, overcome problems with trust,
correct distorted cognitions, and enhance self-control skills (Kitchur & Bell, 1989). Play therapy
has also been used extensively with abused children (White & Allers, 1994). A review of this liter-
ature shows a pattern of unique behaviors that emerged in conducting play therapy, with abused
children. Some of these behaviors include developmental immaturity; repetitive and compulsive
behavior; opposition and aggression; withdrawal and passivity; self-depreciation and self-
destructive behavior; hypervigilance; sexual behavior; and dissociation (an unconscious denial of
abuse). The nature of play is also unique; abused children are not very imaginative in their play,
and their play does not seem to elevate their anxiety.
Special treatment considerations relating to sexual abuse involve a three-stage model called
the resolution model (Orenchuk-Tomiuk, Matthey, & Christensen, 1990). The three stages are
(a) the noncommittal or oppositional stage, (b) the middle stage, and (c) the resolution stage.
The model differentiates among treatment issues for the child, the nonoffending parent, and the
offending parent at each stage, as follows:

The child feels responsible for the abuse during the noncommittal or oppositional stage,
feels angry and experiences symptoms associated with posttraumatic stress disorder during
the middle stage, and no longer feels responsible for the sexual abuse nor experiences prob-
lematic symptoms during the resolution stage.
The nonoffending parent denies the occurrence of sexual abuse, blames the child for dis-
closure, and defends the offender during the noncommittal or oppositional stage, believes
the abuse has taken place and begins to become an ally for the child during the middle
stage, and becomes a positive ally for the child and works through guilt associated with not
protecting the child during the resolution stage.
The offender refuses to accept responsibility for abuse and/or denies its occurrence during
the noncommittal or oppositional stage, is able to admit to the abuse but may blame the
child during the middle stage, and assumes responsibility for the abuse and establishes a
more positive parental role during the resolution stage.

The resolution model recommends that individual and group counseling can be useful during the
noncommittal or oppositional stage. Couples and family counseling should not be used until the
middle or resolution stages and should involve the child only if the child is ready.
308 Part 3 • Special Approaches and Settings

Some guidelines that counselors can use with children who have been sexually abused are
that counselors should take on the role of advocate for sexually abused children; help them over-
come feelings of guilt and shame, emphasizing that the abuse was not their fault and that it will
stop; use open-ended questions when assessing for sexual abuse and thus avoid leading questions;
and take their accusations seriously since children tend not to lie about sexual abuse, and psycho-
logical harm can occur if they are not taken seriously (England & Thompson, 1988).
Additional counseling strategies that can be used to treat PTSD associated with sexual abuse
are art and play therapy, which can facilitate expressions of trauma associated with sexual abuse.
Cognitive–behavioral therapy is believed to be the most effective approach for treating PTSD
symptoms. For example, cognitive–behavioral strategies can be directed at overcoming cognitive
confusion and intrusive memories of the abuse; group counseling, can also be included in the
treatment plan to promote coping skills, problem-solving strategies, and peer support and encour-
agement (Putman, 2009).

Depression
The recognition of childhood and adolescent depression is a relatively recent occurrence
(Petersen et al., 1993; Wagner, 1994, 1996). This section reviews some of the major issues associ-
ated with depression in children and adolescents.

INCIDENCE. Research investigations suggest that children are as capable of experiencing clini-
cal depression as adults (Alper, 1986; Kovacs, 1989). Serious depression has been found in infants
(Field et al., 1988; Spitz, 1946), preschool and school-age children (Digdon & Gotlib, 1985;
Kazdin, 1988; Kovacs, 1989), and adolescents (Petersen et al., 1993; Rice & Meyer, 1994; Wagner,
1996). One in eight adolescents (ages 10–19) experience depression (Dixon, Scheidegger, &
McWhirter, 2009). The average duration of a major depression in children and adolescents is 7 to
9 months, and a dysthymic depression lasts an average of 3 or more years (Kovacs, 1989).
Manic disorders in their classic form are rare and hard to diagnose accurately in children
and adolescents (Strober et al., 1989). An overview of bipolar disorder in children reveals that
children experience much higher rates of bipolar disorder than previously believed (Hammen &
Rudolph, 2003). The disorder was apparently underdiagnosed because children do not present
with the traditional symptoms of bipolar disorder experienced in adults. For example, children
can cycle from their manic-depressive states in one day (versus adults, who spend days in each
state). In addition, children do not experience the euphoria and grandiosity states common in
adults with bipolar disorder. The difficulty with diagnosing bipolar disorder in children is asso-
ciated with a wide array of psychological symptoms, including rapid mood shifts often charac-
terized by intense irritability, aggression, and rage; destructive, social, and academic problems;
and psychosis, delusions, and suicidal thoughts and behaviors (Hammen & Rudolph, 2003).
Bipolar disorder in children typically is comorbid with other mental disorders, such as attention
deficit hyperactivity disorder (ADHD), anxiety disorders, oppositional–defiant disorder, and
substance abuse.

ASSESSMENT. As noted earlier in this chapter, developmental psychopathology provides a

framework for understanding how mental disorders such as depression vary over the lifespan
(including during childhood and adolescence). Some major symptoms associated with child-
hood depression include the following (Sakolske & Janzen, 1987). Changes in mood and affect
are the most obvious indications. Examples include children who were relatively happy and had
 Chapter 11 • Child and Adolescent Counseling 309

positive self-images suddenly saying they are sad, miserable, and no good. Another indication is
that depressed children tend to show disinterest in activities that were previously enjoyable, such
as hobbies and sports. They may also lose interest in friends and family members. Other symp-
toms include physical complaints such as headaches and abdominal discomfort; sleep distur-
bances including nightmares; changes in appetite; impaired cognitive processes such as difficulty
concentrating; and problems in school, work, and interpersonal relationships. Depressed adoles-
cents typically show signs of unhappiness and have a number of fears and worries, such as a fear
of not being loved or not having friends, and worry about their appearance and relationships
(Petersen et al., 1993). In addition, it is estimated that adolescents experience major depression at
a much higher rate than children (Petersen et al., 1993).
To be diagnosed with major depression, a person (regardless of age) must meet the estab-
lished criteria. For example, the DSM-IV-TR (American Psychiatric Association, 2000) includes
such factors as depressed mood, decreased ability to experience pleasure, weight loss (or failure to
thrive in children), loss of energy, thoughts of death, and so forth. The DSM also notes that “cer-
tain symptoms such as somatic complaints, irritability, and social withdrawal are particularly
common in children, whereas psychomotor retardation, hypersomnia, and delusions are less
common in prepuberty than in adolescence and adulthood” (American Psychiatric Association,
2000, p. 354).
Multiple diagnoses (comorbidity) are common with depressed children and adolescents.
Depression under these circumstances is sometimes referred to by clinicians as a “masked depres-
sion” since the symptoms of depression are obscured by the additional diagnosis (Kovacs, 1989).
The DSM-IV-TR notes that major depression in children normally does occur with other mental
disorders—anxiety disorders, disruptive behavioral disorders, and attention deficit disorders.
Comorbidity in adolescents is often associated with mental disorders like eating disorders, sub-
stance abuse disorders, and disruptive behavioral disorders (American Psychiatric Association,
2000). Bipolar disorder is particularly difficult to diagnose in children, because it typically occurs
in conjunction with severe symptoms such as psychosis and mental disorders such as ADHD and
anxiety disorders (Hammen & Rudolph, 2003). ADHD poses a significant challenge to the diag-
nostic process, because it potentially masks bipolar disorder.
Several instruments have been designed specifically to assess childhood and adolescent
depression. For example, diagnostic interviews have been developed to assess child and adoles-
cent mental disorders (Edelbrock & Costello, 1988). Most other instruments are directed at chil-
dren, the most widely used being the Children’s Depression Inventory (Kovacs, 1981), which was
developed from the Beck Depression Inventory. It assesses the cognitive, affective, and behavioral
signs of depression. Other instruments include the Short Children’s Depression Inventory
(Carlson & Cantwell, 1979), the Children’s Depression Scale (Lang & Tisher, 1978), and the
Schedule for Affective Disorders and Schizophrenia for School-Age Children (Chambers, Puig-
Antich, & Tabrizi, 1978). All of these instruments are described in Kazdin (1988).

CAUSES. Several factors have been associated with childhood depression, including parents who
have high standards and do not express positive affect to their child (Cole & Rehm, 1986); children
who have negative cognitive schemata characterized by self-deprecation, hopelessness, and despair
(Hammer & Zupan, 1984); and social-skill and problem-solving deficits (Altmann & Gotlib,
1988). The underlying etiology of bipolar disorder in children is primarily associated with genetics
(Hammen & Rudolph, 2003). The ecological perspective for conceptualizing mental health prob-
lems of children recognizes the effects of the “povertization of childhood” (Wagner, 1994). Wagner
noted that 25% of children aged 5 or younger are living in poverty, and a great number of these
310 Part 3 • Special Approaches and Settings

children are born to single mothers. This “povertization” has been associated with impeding the
development of children and having a devastating effect on their well-being (Wagner, 1994).
Major causes of adolescent depression (many of which also seem relevant to childhood
depression) include pessimistic–negative cognitions; genetic predisposition (a parent with a his-
tory of depression); and social–systemic factors such as excessive environmental stress, problems
with home (including family and marital discord), school, and peer group (Petersen et al., 1993).
It is interesting to note that one of the best predictors of adult depression is impaired peer-group
relations during adolescence. The importance of social networking and mental health was
revealed in research that found adolescents who perceived they mattered to others were less prone
to develop anxiety or depression (with mattering to others and anxiety and depression having an
inverse correlation) (Dixon et al., 2009).
From an existential perspective, Frankl’s (1963) logotherapy seems ideally suited to address-
ing adolescent depression, because adolescence can be a challenging period of development as
youths struggle with issues of self-awareness; personal identity; peer pressure; and experimentation
with alcohol, drugs, and sexuality (Blair, 2004). As adolescents attempt to define their existence, they
can experience an existential vacuum or a lack of meaning in life associated with not living up to
one’s potential. Adolescents who struggle with identity issues, as they attempt to define themselves
and give their life meaning, can experience symptoms of depression such as sadness and despair
(Blair, 2004). Problems regarding the emergence of the “self ” can result from the conflicting
demands from the adolescents’ peer group and the expectations of their parents.

EFFECTS. Depression in childhood and adolescence can have serious consequences: impaired
cognition (Kovacs, Gatsonis, Marsh, & Richards, 1988; Petersen et al., 1993); problems with social
and educational progress (Kovacs et al., 1988; Petersen et al., 1993); and suicidal tendencies
(Garland & Zigler, 1993; Kovacs, 1989). Bipolar disorder in children is associated with suicidal
tendencies and impairment in social relationships, academic achievement, self-control, and abil-
ity to maintain contact with reality (Hammen & Rudolph, 2003). Even if a person does not
become depressed as a child, childhood experiences can make an individual prone to depression
as an adult. Children who experience the death of their mother before they are 11 years of age are
more prone than other children to develop depression as adults (Brown & Harris, 1978).

TREATMENT. Treatment considerations for depression and bipolar disorders vary when work-
ing with children and adolescents. Antidepressant medication can be considered in the treatment
of depression, although there are mixed reports regarding its efficacy for children (Puig-Antich et
al., 1987) and some concern that antidepressants can cause an increased risk for suicide in chil-
dren and adolescents. Several counseling approaches are available for treating childhood depres-
sion. Among them, cognitive approaches have been particularly effective (Reynolds & Coats,
1986). Another approach to treatment is parent education to help parents learn skills for promot-
ing a positive environment in the family. Play therapy is another option, which enables children
to work through traumatic experiences and enhance their social skills and self-image.
An overview of existential strategies, based on Frankl’s (1963) logotherapy, which can be
used to treat adolescent depression, can be summarized as follows (Blair, 2004):

• Counselors should build a relationship of respect and trust by emotionally connecting with
clients and maintaining a nonjudgmental position.
• Counselors should help clients understand the purpose behind the depression (e.g., it can
create motivation for self-exploration and change).
 Chapter 11 • Child and Adolescent Counseling 311

• Counselors should assist clients in identifying what is missing in their lives (i.e., what is
necessary to reach their full potential).
• Counselors should address the clients’ strengths, talents, and interests that they can use to
achieve necessary change.
• Counselors should facilitate clients’ search for meaning by emphasizing that they have
choices, are free to make choices, and must ultimately take responsibility for their choices.
Dixon et al. (2009) suggested that since adolescent anxiety and depression have been
related to perceived mattering to others, counselors can explore how adolescents perceive their
relationships with others. In this process, counselors can explore perceptions regarding peer
group, friends, and family to enhance social support systems, personal meaning, and mental
health. McCarthy, Downes, & Sherman (2008) conducted qualitative research that involved inter-
viewing young adults who had been diagnosed and treated for major depression when they were
adolescents. Themes that emerged from the study included:
• simply talking about depression helped;
• counseling brought relief from the depression and was viewed as more helpful than
medication;
• friends often provided important support; and
• parents played critical roles (e.g., were co-partners in the recovery process).
Bipolar disorders in children and adolescents require special treatment considerations. The
most important treatment issue is an accurate diagnosis. In fact, some clinicians contend that
early detection and treatment of bipolar disorder in children can lessen the effects of the disorder
and that misdiagnosis can make the course of the disorder worse (Hammen & Rudolph, 2003).
However, accurate diagnosis of bipolar disorder in children can be a daunting task since, as noted
earlier, it is often comorbid with other disorders such as ADHD and a wide range of psychologi-
cal features like extreme mood changes and rage.
Medication can play a major role in the treatment of bipolar disorder. Establishing an effec-
tive treatment regime can be challenging, however, since medications used to treat one disorder can
undermine the treatment of a coexisting disorder. For example, antidepressant medications may
trigger hypomania and the rapid cycling associated with bipolar disorder, and psychostimulants
used to treat ADHD can have an adverse effect on both depression and mania (Hammen &
Rudolph, 2003).

Suicide
Child and adolescent suicide is a special problem that has far-reaching consequences extending
beyond the victim to the family, community, and society. It is a complex phenomenon that has
been linked to factors such as depression. This section reviews some of the trends in research on
suicide among children and adolescents based on Capuzzi and Nystul (1986) and Goldman and
Beardslee (1999).

INCIDENCE. Suicide rates for children and adolescents have increased dramatically since 1950.
For example, adolescents committed 2.7 suicides per 100,000 in 1950; 5.2 per 100,000 in 1960;
and 13.8 per 100,000 in 1994. The suicide rate for children is approximately one-tenth of that for
adolescents. Among children, suicide is the fifth leading cause of death; it is the third leading
cause of death among adolescents. Of particular concern is the fact that children’s suicide rates
have recently doubled.
312 Part 3 • Special Approaches and Settings

The disparity of suicide rates between children and adolescents has been attributed to a
number of factors. Children have less ability to plan and carry out a successful suicide than ado-
lescents, in part due to their lower level of cognitive functioning and the fact that they have less
access to lethal weapons. Children also have fewer problems with feelings of hopelessness and
helplessness that are often associated with suicide. They tend to live in the present and therefore
do not believe that feelings of hopelessness and helplessness will be ongoing. In addition, chil-
dren tend to be more comfortable with feelings of helplessness because childhood is character-
ized by high levels of dependence for survival. Lower suicide rates among children can also be
attributed to parents monitoring them more closely than adolescents.
Incidences of suicide vary according to gender, sexual orientation, and culture. Females
think about and attempt suicide at significantly higher rates than males (4:1 and 3:1, respec-
tively), yet males commit 5 times as many successful suicides as females. In part this may be due
to males using more violent suicidal methods, such as lethal weapons, and females tending to use
pills, which may allow for successful medical interventions. Sexual orientation has also been asso-
ciated with increased risk of suicide. The rate of successful suicide is much higher for gay and les-
bian adolescents than for the general population. In these instances, a lack of acceptance of sexual
orientation by friends, family, and society may have undermined identity formation during ado-
lescence. Culture has also been associated with different rates of childhood and adolescent sui-
cide. Native Americans have the highest rates of adolescent suicide, followed by Anglos, and then
African Americans. Native-American youth suicide rates appear to be higher in tribes that place a
lower emphasis on traditional values.

ASSESSMENT. The pathway to child and adolescent suicide involves a complex set of factors.
Increased vulnerability is associated with psychopathology, such as depression and substance
abuse; stress from problems of living (e.g., teen pregnancy); family factors, such as family dys-
function, violence, and abuse; a lack of coping and problem-solving skills; and an insufficient
social–emotional support system. The MMPI (means, motive, plan, and intent) acronym can also
be used to assess for suicide. For example, an adolescent who insists he wants to kill himself be-
cause of a recent breakup would have high intent and motive. If he had a loaded gun in his car, he
would also have the means and plan and would be considered a high risk for suicide.

CAUSES. Suicide can be understood from a number of perspectives. The biochemical model is
based on the chemical imbalance associated with depression and resultant increased risk for suicide.
The psychological perspective focuses on feelings such as hopelessness and despair and how a child
or adolescent can view suicide as a way out of his or her problems. Developmental theory suggests
that a child or adolescent can commit suicide as a response to conflict over identity formation.

EFFECTS. The effects of suicide transcend the victim, affecting the victim’s family, school, com-
munity, and society. Loved ones are left to contend with a wide array of feelings, such as anger
and guilt. It is also common for friends and family members to spend considerable time and
energy wondering why the act was committed and whether there was anything they could have
done to prevent the suicide.

TREATMENT. Suicide prevention plays a central role in treatment. Children and adolescents
must be assessed and monitored for suicidal ideations and actions, and parents and school officials
are an important part of this process. Any child who appears sad or depressed should be referred
to the school counselor for assessment of possible suicide. Schools can take other preventive
 Chapter 11 • Child and Adolescent Counseling 313

actions, such as promoting resiliency characteristics to enhance coping mechanisms for stress.
Once a child or adolescent is identified as suicidal, suicide contracts can be used that require a par-
ent and/or child/adolescent to notify a mental health worker if the child/adolescent becomes
actively suicidal. Hospitalization and treatment should be considered when a child/adolescent
becomes a high risk for suicide. Once children/adolescents are stabilized in terms of their suicidal
ideations, counseling can focus on identifying underlying causal factors associated with their
suicidal tendencies. Treatment can then be directed at resolving these issues to enhance overall
psychological functioning.

Antisocial Behavior
Antisocial behavior in children and adolescents includes acts that violate major social rules—
among them, violence and aggression, bullying, lying, stealing, and truancy (Kazdin, Bass, Siegel,
& Thomas, 1989). This section reviews some of the issues associated with antisocial behavior.

INCIDENCE. Some researchers suggest that children and adolescents are being raised in a “cul-
ture of violence” as reflected in increasingly high rates of domestic violence, hate crimes, and
other antisocial activities (Weinhold, 2007, p. 186). The incidence of children engaging in antiso-
cial behavior is high and one-third to one-half of all mental health clinical referrals involve such
behavior (Kazdin et al., 1989). Rates of antisocial behavior in the form of delinquency are also
high, with 6% of serious crimes in the United States such as rape, murder, assault, and robbery
being committed by youths under 15 and 16% committed by adolescents 15 to 18 years of age
(Berger & Thompson, 2000). Worldwide, a person is more likely to be arrested during adoles-
cence and young adulthood than at any other time.
Incidents of school shootings are increasing. Although there can be multiple factors associ-
ated with violence, bullying is receiving attention as a contributing factor in school violence.
Bullying is unprovoked and repeated aggressive behavior that causes distress to its victim and
verbal or physical behavior that disturbs someone who is less powerful (Goldstein, 1999; Nansel
et al., 2001). Incidences of bullying vary with age and setting and appear to peak in middle school
and junior high (Goldstein, 1999). Bullying appears to be widespread, affecting one in three stu-
dents between sixth and tenth grade (Nansel et al., 2001). Children and adolescents who were
bullied may later retaliate with violence (Wartik, 2001). Two of the Columbine High School
shooters and the Santee, California, shooter were believed to have been victims of bullying.

ASSESSMENT. Children or adolescents who engage in a well-established pattern of antisocial

behavior for at least 6 months tend to receive a DSM-IV-TR diagnosis of either conduct disorder
or oppositional–defiant disorder. Conduct disorder is the more serious mental disorder and
involves individuals who have violated the rights of others or rules of society. Most behaviors asso-
ciated with conduct disorder involve “direct confrontation or disruption of the environment” and
are basically the same type of behavior that Patterson (1982) and Loeber and Schmaling (1985)
have labeled “overt antisocial behavior” (McMahon & Forehand, 1988, p. 107). The main feature of
oppositional defiant disorder “is a recurrent pattern of negativistic, defiant, disobedient, and hos-
tile behavior toward authority figures that persists for at least 6 months and is characterized by the
frequent occurrence of at least four of the following behaviors: losing temper, arguing with adults,
actively defying or refusing to comply with the requests or rules of adults, deliberately doing things
that will annoy other people, blaming others for his or her own mistakes or misbehavior, being
touchy or easily annoyed by others, being angry and resentful, or being spiteful or vindictive”
(American Psychiatric Association, 2000, p. 100).
 Professional School Counseling 15
Chapter Overview
From this chapter you will
learn about:
■ The American School

Counseling Association
(ASCA) national model
■ Elementary school

counseling—emphasis and
role, activities, prevention,
and remediation
■ Middle school counseling—

emphasis and role, activities,

prevention, and remediation
■ Secondary school

counseling—emphasis and
role, activities, prevention,
Scott Cunningham/Pearson Education, Inc.
and remediation
■ 21st-century school

I skip down the hall like a boy of seven counseling

before the last bell of school As you read consider:
and the first day of summer, ■ What the daily life of a
My ivy-league tie flying through the stagnant air
school counselor is like in
that I break into small breezes as I bobbingly pass.
an elementary, middle, and
At my side, within fingertip touch,
secondary school
a first grade child with a large cowlick
■ What the rewards and
roughly traces my every step
filling in spaces with moves of his own drawbacks are in working
on the custodian’s just waxed floor. with children, parents,
“Draw me a man” teachers, and administrators
I ask as we stop, in schools
■ How you could thrive and
And with no thought of crayons and paper
he shyly comes with open arms be productive as a school
to quietly take me in with a hug. counselor regardless of the
setting
From “Portraits,” by S. T. Gladding, 1974, Personnel and Guidance Journal, 53, p. 110. ■ The need for school
© Samuel T. Gladding.
counselors in the future and
how the role of the school
counselor will change
333
334 Part IV • Counseling Specialties

The field of school counseling involves a wide range of ages, developmental stages, background
experiences, and types of problems (Baker & Gerler, 2008; Cobia & Henderson, 2007; Erford,
2015b). In the United States almost four million children begin their formal education each year,
while millions more continue their schooling. Within this population, some children are
developmentally ready, eager, and able, whereas others are disadvantaged because of physical,
mental, cultural, or socioeconomic factors (Bemak & Chung, 2008). Yet a third group carries the
burden of traumas, such as various forms of abuse, through no fault of their own (Fontes, 2002;
Richardson & Norman, 1997).
Like children in other countries, American schoolchildren face a barrage of complex
events and processes that have temporary and permanent impacts on them. Alcohol and other
drug abuse, changing family patterns, poor self-esteem, hopelessness, poverty, AIDS, racial and
ethnic tensions, crime and violence, teenage pregnancy, sexism, and the explosion of knowl-
edge have a negative influence on these children regardless of their age or environment (Keys
& Bemak, 1997; McGowan, 1995). It is little wonder then that it is estimated that 13–20% of
children will struggle with a mental health disorder each year (DeKruyf, Auger, & Trice-Black,
2013), and 1 in 10 children has a serious emotional disturbance that significantly impairs his or
her functioning at school, at home, and in the community (Mellin, 2009). That is where school
counselors come in.
Years of research have concluded that, in school environments, “counseling interven-
tions have a substantial impact on students’ educational and personal development” (Borders
& Drury, 1992, p. 495). Indeed, outcome research has indicated that school counselors make
a positive difference in children’s lives and in educational environments (Gysbers, 2011;
Whiston & Sexton, 1998). Counseling interventions tend to be particularly effective in
increasing students’ problem-solving behaviors and reducing disciplinary referrals (Whiston,
Wendi Lee, Rahardja, & Eder, 2011). School counselors contribute “to student academic
achievement through school counseling programs that address the personal/social, career,
and academic development of all students” (Barna & Brott, 2011, p. 243). For instance, the
Student Success Skills (SSS) program, delivered by school counselors, has been found to
augment curricular-focused teaching practices with learning and relationship-building activi-
ties that improve learning skills and academic achievement (Lemberger, Selig, Bowers, &
Rogers, 2015).
Overall, school counselors and comprehensive guidance and counseling programs help
children and adolescents become better adjusted academically and developmentally while
• feeling safer,
• having better relationships with teachers and peers,
• believing their education is relevant to their future,
• having fewer problems in school, and
• earning higher grades (Lapan, Gysbers, & Petroski, 2001).
In a nutshell, research demonstrates that effective counseling services in schools can act as
a protective factor that minimizes the adverse effect of risk factors that may be in students’
environment (Lapan, Wells, Petersen, & McCann, 2014). A good part of the reason is that the
student becomes connected with the school. Unfortunately, counseling services are not as avail-
able as they should be. In 2014–2015, the U.S. student-to-counselor ratio was 457:1, far above
the American Counseling Association’s recommended maximum average student-to-counselor
ratio of 250:1. The lower figure is recommended to ensure that students have adequate access
to counseling services.
 Chapter 15 • Professional School Counseling 335

This chapter examines the roles of professional school counselors in general and the
unique and overlapping roles they have at the elementary, middle, and secondary levels. It
addresses the special situational and developmental aspects of dealing with each school-age
population and the importance of being sensitive to children’s cultural backgrounds and differ-
ing worldviews (Baker & Gerler, 2008; Lee, 2001). Particular attention is given to prevention
and treatment issues associated with children in schools and to the American School Counselor
Association (ASCA) National Model.

THE ASCA NATIONAL MODEL

Historically, professional school counseling grew out of vocational guidance and character
development initiatives. However, school counseling is now widely considered to be a compre-
hensive, developmental, programmatic component of K–12 public education (Falco, Bauman,
Sumnicht, & Engelstad, 2011). Because of some identity problems and perceptions both within
and outside the profession, school counselors have sometimes been misunderstood and even
called “guidance counselors!” In such cases school counselors have struggled to prove their
worth to superintendents, principals, teachers, students, and parents who are ill-informed as to
what they do (Guerra, 1998). In order to overcome this confusion and to focus on what activities
school counselors should be engaged in, the American School Counselor Association (ASCA;
801 N. Fairfax Street, Suite 310, Alexandria, VA 22314) has published a national model for
school counseling (ASCA, 2012). It defines what a school counselor is and clarifies the roles of
school counselors for the profession and for the public.
Noncounseling and inappropriate duties for school counselors according to the ASCA
National Model include but are not limited to registering and scheduling all new students, cleri-
cal record keeping, assisting with duties in the principal’s office, performing disciplinary actions,
and teaching classes when teachers are absent. Appropriate and counseling-related duties include
collaborating with teachers to present proactive, prevention-based guidance curriculum lessons,
working with the principal to identify and resolve student issues, and counseling with students
who have excessive tardiness, absenteeism, or disciplinary problems. To show the difference
school counselors make, Bemak, Williams, and Chung (2015) stress that there are four critical
domains of accountability for them to keep track of. These are grades, attendance, disciplinary
referrals, and suspension. These factors are kept track of by schools and can be generalized
across primary and secondary levels, geography, region, location, and culture. They “demon-
strate counseling accountability and provide a critical tool for school counselors to show evi-
dence that their work helps improve academic performance and success” (p. 109).
At its core, the ASCA National Model “encourages school counselors to think in terms of
the expected results of what students should know and be able to do as a result of implementing
a standards-based comprehensive school counseling program” (Dahir & Stone, 2009, p. 12). It
does this through an interlocking lineage of four components (Scarborough & Culbreth, 2008):
• foundation (beliefs and philosophy, mission),
• delivery system (guidance curriculum, individual student planning, responsive ser-
vices, systems support),
• management systems (agreements, advisory council, use of data, action plans, use of
time, use of calendar), and
• accountability (results reports, school counselor performance standards, program
audit).
336 Part IV • Counseling Specialties

The ASCA National Model supports the mission of schools by promoting three main
areas in the delivery system. They can be conceptualized as follows:
• academic achievement,
• career planning, and
• personal and social development.
The ASCA National Model recommends that school counselors collaborate with parents,
students, teachers, and support staff to focus on the development of all students—not just those
who are high achievers or at high risk. Furthermore, this national model recommends that 80%
of school counselors’ time be spent in direct contact with students. Inappropriate duties assigned
to school counselors should be jettisoned in favor of appropriate responsibilities.

ASCA National Model

Personal and
Social
Development

Academic Career
Achievement Planning

Overall, the ASCA National Model embodies what is known as strength-based school
counseling (SBSC) (Galassi, Griffin, & Akos, 2008). In SBSC the emphasis is on promoting
evidence-based interventions and practices that are proactive on the individual, group, and
school levels. Activities in SBSC include a focus on student strengths, advocacy for students
who lack resources, and the forming of partnerships with other professionals and families of
children. This approach differs from deficit-based counseling, where the focus is on fixing a
problem.

School Counselors at Various Levels

School counselors on all levels are considered to be the “heart” of a school (McMahon, Mason,
Daluga-Guenther, & Ruiz, 2014, p. 469). During the course of a day they may move from being
active on the microlevel (working with individuals), to the mesolevel (working with large stu-
dent groups), to the macrolevel (collaborating with stakeholders on large policy issues). Within
the field of school counseling, the professional literature focuses on three distinct school-age
populations: elementary school children (Grades K–5), middle school children (Grades
6–8), and secondary school children (Grades 9–12). Each of these populations has particular
concerns and universal needs. How needs are addressed depends on many variables, including
school level of employment (i.e., elementary, middle, high), years of experience as a school
counselor, number of students per caseload, amount of time spent in non-guidance-related activ-
ities, professional identity and development, as well as the organizational culture in the school
(Scarborough & Culbreth, 2008). However, at the very heart of school counseling on any level is
the enhancement of student personal/social development (Van Veisor, 2009).
 Chapter 15 • Professional School Counseling 337

PERSONAL REFLECTION
What do you remember most about the school counselors you had growing up? What duties did
they perform? Was there a difference in their focus at various levels? How do you think the ASCA
National Model might have helped them and your school(s)?

ELEMENTARY SCHOOL COUNSELING

Elementary school counseling is a relatively recent development. The first book on this subject
was published in the 1950s, and the discipline was virtually nonexistent before 1965 (Dinkmeyer,
1973a, 1989). In fact, fewer than 10 universities offered coursework in elementary school coun-
seling in 1964 (Muro, 1981).
The development of elementary school counseling was slow for three reasons (Peters,
1980; Schmidt, 2014). First, many people believed that elementary school teachers should serve
as counselors for their students because they worked with them all day and were in an ideal posi-
tion to identify specific problems. Second, counseling at the time was primarily concerned with
vocational development, which is not a major focus of elementary school children. Finally, many
people did not recognize a need for counseling on the elementary school level. Psychologists and
social workers were employed by some secondary schools to diagnose emotional and learning
problems in older children and offer advice in difficult family situations, but full-time counseling
on the elementary level was not considered.
Although the first elementary school counselors were employed in the late 1950s, elemen-
tary school counseling did not gain momentum until the 1960s (Faust, 1968). In 1964, Congress
passed the National Defense Education Act (NDEA) Title V-A, and counseling services were
extended to include elementary school children (Herr, 2002). Two years later, the Joint
Committee on the Elementary School Counselor (a cooperative effort between the Association
for Counselor Education and Supervision [ACES] and ASCA) issued a report defining the roles
and functions of the elementary school counselor, which emphasized counseling, consultation,
and coordination (ACES-ASCA, 1966). Government grants to establish training institutes for
elementary school counselors were authorized in 1968; by 1972, more than 10,000 elementary
school counselors were employed (Dinkmeyer, 1973a).
During the 1970s, the number of counselors entering the elementary school counseling
specialty leveled off and then fell temporarily due to declining school enrollments and economic
problems (Baker & Gerler, 2008). In the late 1980s, however, accrediting agencies and state
departments of public instruction began mandating that schools provide counseling services on
the elementary level, and a surge in demand for elementary school counselors ensued. This
renewed interest in the specialty was a result of publications such as A Nation at Risk, which was
released by the National Commission on Excellence in Education (Schmidt, 2014). Although it
does not refer to elementary school counseling, the report emphasizes accountability and effec-
tiveness within schools at all levels.

Emphases and Roles

Elementary school counselors are a vanguard in the mental health movement at educational set-
tings (Gysbers & Henderson, 2012). No other profession has ever been organized to work with
338 Part IV • Counseling Specialties

individuals from a purely preventive and developmental perspective. Among the tasks that
elementary school counselors regularly perform are the following:
• implement effective school counseling core curriculum lessons,
• provide individual and small-group counseling,
• assist students in identifying their skills and abilities,
• work with special populations,
• develop students’ career awareness,
• coordinate school, community, and business resources,
• consult with teachers and other professionals,
• communicate and exchange information with parents/guardians, and
• participate in school improvement and interdisciplinary teams (ASCA, 2012).
A study in California of the perceived, actual, and ideal roles of elementary school coun-
selors found that the majority of counselors who were surveyed spent a large portion of their
time in counseling, consultation, and parental-help activities (Furlong, Atkinson, & Janoff,
1979). Their actual and ideal roles were nearly identical. Schmidt and Osborne (1982) found
similar results in a study of North Carolina elementary school counselors, whose top activities
were counseling with individuals and groups and consulting with teachers. Morse and Russell
(1988) also found preferences involving consultation, counseling, and group work when they
analyzed the roles of Pacific Northwest elementary school counselors in K–5 settings. Three of
the five highest ranked actual roles of these counselors involved consultation activities, whereas
two of the five included individual counseling with students. These counselors ranked four of
their top five ideal activities as those that involved working with groups of students. Indeed, it
appears that elementary school counselors desire to spend time in group activities with children.
The lowest ranked and most inappropriate tasks that other school personnel try to assign
elementary school counselors include substitute teaching, monitoring lunchrooms or play-
grounds, and acting as school disciplinarian or student records clerk. The emphases that elemen-
tary school counselors place on such noncounseling services have important consequences for
them and the children and schools they serve. If counselors are used in such ways, they lose their
effectiveness and everyone suffers.

CASE EXAMPLE
Pat and the Promotion
Pat was an elementary school counselor and loved his job even though at times it was stressful and
he was economically stretched. One day his principal, Daniel, came by to see him and announced
he was considering retirement. During the conversation Daniel mentioned that he thought Pat
would make a great principal. To get Pat ready for taking on such a responsibility and to make him
an attractive candidate, Daniel suggested shifting some of his administrative duties to Pat. “It
won’t take much time,” he said, “and it is important. Besides, you’ll make a lot more money.”
Put yourself in Pat’s shoes. How would you respond and why?

In an important and well-investigated article on the effectiveness of elementary school

counseling, Gerler (1985) reviewed research reports published in Elementary School Guidance
and Counseling from 1974 to 1984. He focused on studies designed to help children from
 Chapter 15 • Professional School Counseling 339

behavioral, affective, social, and mental image/sensory awareness perspectives to combat such
negatives such as aggression, depression, hyperactivity, and stress that hinder student success in
school and in life. Gerler found strong evidence that elementary school counseling programs
“can positively influence the affective, behavioral, and inter-personal domains of children’s lives
and, as a result, can affect children’s achievement positively” (p. 45). In a more recent article
Barna and Brott (2013) found elementary school counselors “can support academic achievement
by connecting their comprehensive programs to increasing academic competence” (p. 97). One
valuable framework focused on “academic enablers, which were identified as interpersonal
skills, motivation, engagement, and study skill” (p. 97). In a classic earlier article, Keat (1990)
detailed how elementary school counselors can use a multimodal approach called HELPING
(an acronym for health; emotions; learning; personal relationships; imagery; need to know;
and guidance of actions, behaviors, and consequences) to help children grow and develop.
The fact that elementary school counselors have, can, and do make a difference in the lives
of the children they serve is a strong rationale for keeping and increasing their services. That is
one reason ASCA initiated its model. It is easier to handle difficulties during the younger years
than at later times (Dahir & Stone, 2012; Henderson & Thompson 2016). Elementary school
counselors who have vision (for example, that children can be problem solvers) and follow
through (such as Claudia Vangstad in Oregon) can transform the culture of a school (Littrell &
Peterson, 2001). In Vangstad’s case, she used 10 core values (Table 15.1) to build an exemplary

TABLE 15.1 A Comparison of the Old and New School Culture

Old School Culture
1. Adult-driven
2. Punishment
3. Externally imposed discipline
4. Focus on problems
5. Competitive, non-collaborative
6. Unit expected to change: the individual
7. Peer isolation
8. Problems approached by adults using discipline, threats, paddle, and behavior modification
9. Children try to solve problems by swearing, hitting, and threats
10. Children not empowered to change themselves and to help others change
New School Culture
1. Student-driven
2. Learning new skills
3. Self-imposed discipline
4. Focus on problem solving
5. Cooperative, collaborative
6. Unit expected to change: the individual, the group, and the community
7. Peer support
8. Problems resolved by adults using dialogue, positive interactions, cooperation,
and a problem-solving model
9. Children try to solve problems by the problem-solving model and peer support
10. Children are empowered to change themselves and to help others change
340 Part IV • Counseling Specialties

elementary school counseling program and helped transform a school culture. She utilized her
power as a person and a counselor in the interest of creatively conceiving a program that others
could and did buy into.

Activities
Elementary school counselors engage in a number of activities. Some of these are prescribed by
law, such as the reporting of child abuse. “In the United States, all 50 states and the District of
Columbia have laws that require schools and their agents [such as school counselors] to report
suspicions or allegations of child abuse and neglect to a local agency mandated to protect chil-
dren” (Barrett-Kruse, Martinez, & Carll, 1998, p. 57). Most activities of elementary school coun-
selors are not so legally mandated, however, and include a plethora of preventive and remedial
activities. Prevention is preferred because of its psychological payoff in time invested and
results.

PREVENTION. Elementary school counseling programs strive to create a positive school envi-
ronment for students. They emphasize the four Cs: counseling services, coordination of activ-
ities, consultation with others, and curriculum development. The last activity, curriculum
development, is both developmental and educational. It focuses on formulating “guidance classes
[on] life skills and in preventing … difficulties” that might otherwise occur (Bailey, Deery,
Gehrke, Perry, & Whitledge, 1989 p. 9). The ASCA National Model (American School Counselor
Association [ASCA], 2012) suggests that elementary school counselors spend up to half of their
time delivering classroom guidance. Providing school counseling core curriculum lessons “are
an efficient way for school counselors to inform students about school-wide opportunities (e.g.,
counseling department services), distribute information (e.g., educational resources, postsecond-
ary opportunities), and address student needs (e.g., preparing for school transitions, learning
skills to eliminate bullying)” (Akos, Cockman, & Strickland, 2007, p. 455).
At their best, classroom guidance lessons are proactive and focus on prevention (e.g.,
school violence) as well as promotion (e.g., a positive body image). As an example of proactive
classroom guidance, Magnuson (1996) developed a lesson for fourth graders that compared the
web that Charlotte, the spider, spins for physical nutrition in the book Charlotte’s Web (White,
1952) with the webs that human beings spin for personal nurturing. Just as Charlotte needed a
variety of insects to stay healthy, the lesson stressed that people need to attract a variety of
friends and support to live life to the fullest. The lesson ended with children not only discussing
the parallels between Charlotte and themselves but also drawing a “personal web” filled with
significant and important persons in their lives.
A first priority for elementary school counselors is making themselves known and estab-
lishing links with others. School personnel are not usually viewed by young children as the first
source of help. Therefore, elementary school counselors need to publicize who they are, what
they do, and how and when they can help. This process is usually handled best through orienta-
tion programs, classroom visits, or both. The important point is to let children, parents, teachers,
and administrators know what counseling and guidance services are available and how they are
a vital part of the total school environment.
For instance, in situations in which very young children (3- to 5-year-olds) are part of the
school environment, elementary school counselors can make themselves known by offering spe-
cial assistance to these children and their families, such as monitoring developmental aspects of
the children’s lives (Hohenshil & Hohenshil, 1989). Many children in this age range face a
 Chapter 15 • Professional School Counseling 341

multitude of detrimental conditions including poverty, family/community violence, and neglect

(Carnegie Task Force on Meeting the Needs of Young Children, 1994). The efforts of elemen-
tary school counselors with these children may include offering prosocial classroom guidance
lessons centered around socialization skills (Paisley & Hubbard, 1994; Smead, 1995).
Furthermore, elementary school counselors can consult with teachers and other mental health
professionals to be sure that efforts at helping these young children are maximized.
It is especially important to work with parents and the community when children, regard-
less of age, are at risk for developing either low self-concepts or antisocial attitudes (Capuzzi &
Gross, 2014). Having lunch with parents where they work, even at odd hours, is one way for
counselors to reach out and support families in the education of their children (Evans & Hines,
1997). Family counseling interventions by school counselors is another way to focus on three
primary subsystems: the family, the school, and the subsystem formed by the family and
school interactions (Lewis, 1996). Elementary school counselors (and for that matter middle
and secondary school counselors) avoid assuming that most student problems are a result of
dysfunctional families and instead focus on constructively addressing all three subsystems as
needed.
Yet a third way of combating potential destructiveness is known as multiple concurrent
actions. In this approach, counselors access more than one set of services within the community
at a time—for example, social services and learning disabilities specialists. This type of coordi-
nated action between school and community agencies is collaborative and integrative, and it
requires energy and commitment on the part of the counselor (Keys, Bemak, Carpenter, &
King-Sears, 1998).
Simultaneous with publicizing their services and establishing relationships with others in
the community, elementary school counselors must be active in their schools in a variety of
ways, especially in guidance activities. Myrick (2011) recommends a proactive, developmental,
comprehensive approach to guidance programs: two to three large classroom meetings each
week and twice as many small-group sessions. These activities focus on structured learning,
such as understanding oneself, decision making, problem solving, establishing healthy girl-boy
relations, and how to get along with teachers and make friends (Coppock, 1993; Snyder & Daly,
1993). Classroom guidance should also address conflict resolution and peer mediation in which
students learn peaceful and constructive ways of settling differences and preventing violence
(Carruthers, Sweeney, Kmitta, & Harris, 1996).
Other preventive services offered by elementary school counselors include setting up peer
mediation programs and consultation/education activities. Peer mediators are specially selected
and trained students who serve the school and the counselor in positive and unique ways. They
may help students get to know one another, create an atmosphere of sharing and acceptance,
provide opportunities for other students to resolve personal difficulties, and enhance the
problem-solving skills of the students (Garner, Martin, & Martin, 1989). Peer mediators assist
elementary school counselors in reaching a number of individuals they might otherwise miss.
Peer mediators also may enhance the overall cooperative atmosphere in a school (Cohen,
2005; Joynt, 1993). The effectiveness of peer mediation on the elementary school level can be
seen in preventing and reducing school-wide violence. For example, Schellenberg, Parks-
Savage, and Rehfuss (2007) found in a 3-year longitudinal study that a school-wide peer media-
tion program reduced out-of-school suspensions and resulted in “significant mediator knowledge
gains pertaining to conflict, conflict resolution, and mediation” (p. 475). In another similar type
of situation, Scarborough (1997) found that she could foster the social, emotional, and cognitive
skills of fifth graders through a peer helper program she called the Serve Our School (SOS)
342 Part IV • Counseling Specialties

Club. Students in the club served as assistants working with school staff as they carried out their
responsibilities. Members also provided cross-age tutoring. Everyone benefited and learned.
By implementing consultation/education sessions for teachers, administrators, and parents,
counselors address common concerns and teach new ways of handling old problems by getting
many people committed to working in a cooperative manner (Dougherty, 1986). For example, help-
ing establish culturally compatible classrooms in which student diversity is recognized, appreci-
ated, and used is a service elementary school counselors can provide constituents (Herring & White,
1995; Lee, 2001). Promoting communication skills between teachers and students is another crucial
cooperative service elementary school counselors can set up (Hawes, 1989). Yet a third cooperative
service that elementary school counselors can provide is a class on parenting skills that emphasizes
effective communication procedures and behavior management (Ritchie & Partin, 1994).
Skilled elementary school counselors can even use their counseling role in a preventive
way. For instance, by meeting regularly in individual sessions with at-risk children (those most
likely to develop problems because of their backgrounds or present behaviors), counselors can
assess how well these children are functioning and what interventions, if any, might be helpful to
them or significant others (Capuzzi & Gross, 2014; Webb, 1992).
Bullying behavior may be another place where preventive interventions can take place.
“Bullying is a subset of aggression with three components: (a) intent to harm, (b) repetition, and
(c) a power imbalance between the bully and the target or victim. Bullying is distinguished from
conflict by unequal power between the persons involved” (Bauman, 2008, p. 363). Although
bullying is usually thought of “as one person threatening or actually physically assaulting another
person for no apparent reason,” it can include “name-calling, teasing, writing hurtful statements,
intentional exclusion, stealing, and defacing personal property” (Beale & Scott, 2001, p. 300).
Elementary school children are twice as likely to be bullied as secondary school children, with
grades 5–8 consistently found to be the grades where bullying is most likely to take place
(Janson, Carney, Hazler, & Insoo, 2009). Contrary to expectations, most bullying occurs in
schools such as on playgrounds, in hallways, and in bathrooms, where there is a minimum of
adult supervision. Surprisingly, bystanders experienced significant traumatic reactions as a result
of witnessing common forms of repetitive abuse between their peers, thus signaling another rea-
son not to let such behavior continue (Janson et al., 2009).
Regardless, bullying behavior can be addressed in a preventive fashion through a number
of means. Probably the most effective is for the elementary school counselor to take a leadership
role as an advocate in antibullying efforts for a school. In such a role, the counselor can serve as
a catalyst, a consultant, and a change agent (Goodman-Scott, Doyle, & Brott, 2013). An impor-
tant step in this process is the forming of a steering committee (composed of teachers, adminis-
trators, and students) that works as a team to combat bullying.
Other techniques used to prevent bullying can be found in several forms. One is a peer-
performed psychoeducational drama that “allows students to indirectly experience many of the
negative consequences of bullying in an impersonal, non-threatening way” (Beale & Scott, 2001,
p. 302). Providing positive adult role models for children to emulate may be helpful too as a
preventive measure along with systemically addressing negative influences such as parental
physical discipline, negative peer models, lack of adult supervision, and neighborhood safety
concerns (Espelage, Bosworth, & Simon, 2000).
Besides obvious problems, such as bullying, preventive counseling services are needed for
less obvious groups and behaviors. For example, gifted and talented students may need special
help from a prevention perspective in developing their unique talents. For the gifted, high
intelligence is both an asset and a burden. It separates them in numerous ways from their peers
 Chapter 15 • Professional School Counseling 343

and often means they need support from school counselors in meeting unforeseen challenges that
intelligence alone will not solve (Peterson, 2015). Although this subgroup of students usually
appears to function well, in reality these individuals may have some concerns, such as under-
achieving, overextending, and handling stress (Colangelo & Wood, 2015; Greene, 2006). They
may also display signs of unhealthy perfectionism, anxiety, depression, and suicidality (Cross &
Cross, 2015). Helping them learn to manage stress, plan ahead, and not be overcritical of them-
selves or their abilities are just some of the ways elementary school counselors can help these
talented students stay balanced and develop healthy self-concepts.
In working with children and the topic of divorce, elementary school counselors can do
much good on the preventive level (Crosbie-Burnett & Newcomer, 1989). Preventively, they can
address divorce as a topic in classroom guidance classes. Such classes should be informationally
humane in intent and aimed at alleviating much of the negative stereotyping and myths that sur-
round divorce. Elementary school counselors can use small groups to concentrate on specific
children’s needs regarding divorce as well, thereby preventing further problems. Groups for
children experiencing divorce have been found effective in reducing dysfunctional behaviors,
especially if both the custodial and noncustodial parents are involved (Frieman, 1994).
Small-group counseling programs on the elementary level can also help students increase
learning behaviors and narrow the gap between poor students, students of color, and students
who have material and psychological advantages (Steen & Kaffenberger, 2007). Integrating aca-
demic interventions and group counseling improves students’ behaviors (e.g., asking questions,
completing assignments, and staying on task) related to school achievement. At the same time, it
can address personal/social concerns as well, such as “changing families, friendships, and/or
anger management” (p. 516).
Overall, elementary school counselors can work with others in the school to design and
implement a comprehensive prevention program, the best known of which is the school-wide
positive behavioral support (SWPBS) program (Curtis, Van Horne, Robertson, & Karvonen,
2010). The SWPBS is composed of “five basic components: (a) a leadership team; (b) a brief,
overriding school-wide philosophy; (c) specific behavioral guidelines for each area of the school
(e.g., playground, buses, cafeteria); (d) individual classroom guidelines; and (e) specific strate-
gies for students who need extra attention. Another key component of SWPBS is collecting and
monitoring data to determine where further action is needed. This way, if problems persist on the
buses or in the restrooms, for instance, the leadership team can target strategies for those two
specific areas” (Curtis et al., 2010).
A specific form of SWPBS is to use a positive behavior support approach on a school-
wide basis (Sherrod, Getch, & Ziomek-Daigle, 2009). In this type of approach, school counsel-
ors help school administrators define, teach, and acknowledge expected behaviors while applying
clear consequences to inappropriate behaviors in specific areas of the school, such as the hall-
ways and in classrooms. Individualized plans used to address the specific problem behaviors of
the students who have chronic behavior problems and those at risk of developing behavior prob-
lems are used as well. Basically, this approach is systematic. Because it is so comprehensive, it
has proven more effective than “tough love” approaches such as suspension and expulsion.

PERSONAL REFLECTION
As you have read, elementary school counselors work hard at providing preventive mental health
services. How do you think they might present their work to the public, especially since many indi-
viduals are skeptical of prevention programs?
344 Part IV • Counseling Specialties

REMEDIATION. Remediation is the act of trying to make a situation right or to correct it. The
word implies that something is wrong and that it will take work to implement correction. In ele-
mentary school counseling, a number of activities come under the remediation heading. One
example is children’s self-esteem.
Children’s self-esteem is related to their self-concept, how they perceive themselves in a
variety of areas, academically, physically, socially, and so forth (McWhirter, McWhirter,
McWhirter, & McWhirter, 2013). Self-esteem results from the comparison of oneself to others in
a peer group. Although it may be situational or characterological, self-esteem is basically how
well individuals like what they see—how people evaluate themselves (Street & Isaacs, 1998). It
is always evolving (Duys & Hobson, 2004). To enhance self-esteem is an arduous process. For
such a task, counselors need an understanding of developmental theory, such as that of Robert
Kegan. Such a theory can help them conceptualize the evolution of self-esteem, especially since
Kegan incorporates cognitive, moral, and psychosocial development into his assumptions about
the evolution of self-esteem. Pragmatically, counselors must focus on helping low-self-esteem
children, who are at risk for failure, improve in the following areas: critical school academic
competencies, self-concept, communication skills, coping ability, and control. McWhirter,
McWhirter, McWhirter, and McWhirter (1994) call these the “Five Cs of Competency” (p. 188).
Counselors can enhance self-esteem in these areas by skill building, such as improving social
skills, problem-solving skills, and coping skills (Street & Isaacs, 1998). In working in remedia-
tion, elementary school counselors must rely on their individual and group counseling skills, as
well as their social action abilities, in making environmental changes and modifications.
One way of determining what needs to be remediated and at what level is to use a needs
assessment. Needs assessments are structured surveys that focus on the systematic appraisal of
the types, depths, and scope of problems in particular populations (Cook, 1989; Rossi, Lipsey &
Freeman, 2004). Needs assessments may be purchased commercially, borrowed and modified
from others, or originated by an institution’s staff. In school settings, counselors can gain a great
deal of useful information if they regularly take the time to survey students, teachers, parents, and
support personnel. This knowledge helps them address specific problems. Typically, concerns
uncovered through needs assessments fall into four main areas: school, family relations, rela-
tionships with others, and the self (Berube & Berube, 1997; Dinkmeyer & Caldwell, 1970).

Example of Needs Assessment: Evaluation of Self

Please circle the number of your concern about the following statements as they pertain
to you.
Not Concerned Somewhat Concerned Concerned Very Concerned
1 2 3 4

1. My ability to relate well to other students. 1 2 3 4

2. My ability to learn. 1 2 3 4
3. My ability to keep quiet or still in class. 1 2 3 4
4. My looks and appearance. 1 2 3 4
5. My eating habits. 1 2 3 4

A second way of determining what needs to be remediated is through evidence-based or

data-based decision making where the school counselor uses institutional data about student
 Chapter 15 • Professional School Counseling 345

performance and behavior to identify problems that need to be addressed (Carey & Dimmitt,
2008). The collection of such information is followed up using multidisciplinary teams to iden-
tify and implement research-based interventions. The interventions and programs are evaluated
to demonstrate their effectiveness. The result of this three-step process is better outcomes for
students and enhanced professional status for the counselor.

Three-Step Process of Evidence-Based or Data-Based Decision Making

1. Collect institutional data to identify or describe problems that need to be addressed.

2. Use multidisciplinary evidence-based teams led by the school counselor to implement
research-based interventions.
3. Evaluate interventions used to assess their effectiveness.

In remediation sessions, young children often respond best to counseling strategies built
around techniques that require active participation. Play therapy, bibliotherapy, and the use of
games are three strategic interventions that help counselors establish rapport with young children
and facilitate their self-understanding.
Play therapy is a specialized way of working with children that requires skill and training.
It, along with art therapy, is “less limited by cultural differences” between counselors and clients
“than are other forms of interventions” (Cochran, 1996, p. 287). Therefore, this form of counsel-
ing is covered more and more frequently in counselor education programs (Landreth, 2012).
Basically, children express emotions by manipulating play media such as toys. “In what might
be called ‘play reconstruction,’ children symbolically reenact traumatic or puzzling experi-
ences by repeating a significant pattern in play” (Chesley, Gillett, & Wagner, 2008, p. 401).
When counselors participate with children in the play process—that is, communicate by
acknowledging children’s thoughts and feelings—they establish rapport and a helping relation-
ship (Campbell, 1993b; Trice-Black, Bailey, & Riechel, 2013). By expressing their feelings in a
natural way, children are more able to recognize and constructively deal with volatile affect
(Henderson & Thompson, 2016; Janson et al., 2009). A number of approaches can be used in
play therapy, but Jungian and person-centered are two of the most popular.
When conducting play sessions with children, it is ideal to have a well-equipped playroom.
However, most schools do not, so counselors usually need a tote bag in which to store their mate-
rials. Play materials fall into one of three broad categories: real-life toys, acting-out or
aggressive toys, and toys for creative expression or release (Landreth, 2012). Items frequently
include puppets, masks, drawing materials, and clay. Sand play has been effective in working
with children who have low self-esteem, poor academic progress, high anxiety, and mild depres-
sion (Allan & Brown, 1993; Carmichael, 1994). In some situations, counselors may work with
parents to continue play therapy sessions at home (Guerney, 1983); in other cases, counselors
may hold counseling sessions for students who are involved in play therapy. Child-centered
group play therapy is a culturally sensitive counseling approach that Baggerly and Parker (2005)
have found effective with African American boys. This approach honors the African world-
view: emotional vitality, interdependence, collective survival, and harmonious blending
(Parham, White, & Ajamu, 2000) and builds self-confidence. It helps African American boys
“develop an internal strength to buffer racism” (Baggerly & Parker, 2005, p. 393).
Bibliotherapy can be used, too, in activities with elementary school children (Borders &
Paisley, 1992; Gladding & Gladding, 1991; Lucas & Soares, 2013). Bibliotherapy is “the use of
346 Part IV • Counseling Specialties

books [or media] as aids to help children gain insight into their problems and find appropriate
solutions” (Hollander, 1989, pp. 184–185). For example, books and videos that emphasize diver-
sity, such as Babe, Pocahontas, The Lion King, or The Little Mermaid, may be used to promote
acceptance and tolerance (Richardson & Norman, 1997). These counseling tools are especially
helpful if counselors summarize stories for children, openly discuss characters’ feelings, explore
consequences of a character’s action, and sometimes draw conclusions.
School counselors who work directly with children who have been abused may also choose
to use bibliotherapy because of the way media promote nonthreatening relationships. A number
of books can be used therapeutically with children who have been sexually abused. Two of the
best are I Can’t Talk About It, a book about how a young girl deals with her father touching her
private parts, and My Body Is Private, a book about a young girl’s awareness of her body and her
discussion with her mother about keeping one’s body private.
Games are yet a third way to work with elementary school children in counseling. Games
“offer a safe, relatively non-threatening connection to children’s problems” (Friedberg, 1996, p.
17). They are also familiar to children and valued by them. What’s more, games are considered
fun and enhance the counseling relationship. For example, playing with a Nerf ball may relax a
nervous child and lead to the child revealing some troublesome behaviors.
A number of games have been professionally developed to deal with such common ele-
mentary school child problems as assertiveness, anger, self-control, anxiety, and depression
(Berg, 1986, 1989, 1990a, 1990b, 1990c; Erford, 2008). In addition, counselors can make up
games, the best of which are simple, flexible, and connected with the difficulties the child is
experiencing (Friedberg, 1996).

MIDDLE SCHOOL COUNSELING

Emphasis on middle school counseling is an even more recent phenomenon than elementary
school counseling. It came into prominence in the 1970s as a hybrid way to offer services for
students who did not fit the emphases given by either elementary school or high school counsel-
ors (Cole, 1988). That may be why school counseling articles that focus specifically on middle
school populations have been the least frequently published in mainstream periodicals such as
Professional School Counseling (Falco et al., 2011).
The idea of a special curriculum and environment for preadolescents and early adolescents
was first implemented as a junior high concept—an attempt to group younger adolescents (ages
12–14 and grades 7–9) from older adolescents. However, middle schools typically enroll chil-
dren between the ages of 10 and 14 and encompass grades 6 through 9. Children at this age and
grade level are often referred to as transescents (Cole, 1988) or bubblegummers (Thornburg,
1978). “In addition to experiencing the normal problems that exist in the family, school, and
community, middle school boys and girls adjust to changes in the body, pressure from peers,
demands by the school for excellence, conflicting attitudes of parents, and other problems with
establishing self-identity” (Matthews & Burnett, 1989, p. 122). There is little homogeneity about
them, and their most common characteristic is unlikeness.
According to Dougherty (1986), we know less about this age group than any other. Part of
the reason is that few middle school counselors conduct research or publish their findings about
this population (St. Clair, 1989). Yet the Gesell Institute of Child Development and other child
study centers offer a description of cognitive, physical, and emotional factors that can be
expected during this time (Johnson & Kottman, 1992). Furthermore, there has been a concerted
effort in recent years by counselor educators and practitioners to present relevant research on
 Chapter 15 • Professional School Counseling 347

early adolescent development and middle school counseling (e.g., Hughey & Akos, 2005). Too
few counselors avail themselves of these data.
On a general level, however, most middle school counselors are aware of the major physi-
cal, intellectual, and social developmental tasks that middle school children must accomplish.
Thornburg (1986) outlines them:
• Becoming aware of increased physical changes
• Organizing knowledge and concepts into problem-solving strategies
• Making the transition from concrete to abstract symbols
• Learning new social and sex roles
• Identifying with stereotypical role models
• Developing friendships
• Gaining a sense of independence
• Developing a sense of responsibility (pp. 170–171)

CASE EXAMPLE
Marge and Middle School Research
Marge wanted to know she was making a difference in the lives of middle schoolers as their
counselor. Therefore, she thought she would set up a research study. She was not sure where to
begin, but she thought a before and after design would be helpful.
She distributed a survey at the beginning of the school year asking students to check off
problems or concerns they had. At the end of the year, she did the same thing and compared
results. To her surprise and delight, some problems were checked fewer times. To her dismay,
some were checked more often.
What did Marge do right in regard to her research with middle schoolers? What did she do
wrong? What could she do, if anything, to fix the flaws in her approach?

Elkind (1986) notes that, in addition to developmental tasks, middle graders also must deal
successfully with three basic stress situations. A Type A stress situation is one that is foresee-
able and avoidable, such as not walking in a dangerous area at night. A Type B stress situation
is neither foreseeable nor avoidable, such as an unexpected death. A Type C stress situation is
foreseeable but not avoidable, such as going to the dentist.
Overall, middle school children tend to experience more anxiety than either elementary
or high school students. Therefore, they are at risk for not achieving or successfully resolving
developmental tasks (Schmidt, 2014). Middle school counselors can be most helpful during
times of stress because they can provide opportunities for children to experience themselves
and their worlds in different and creative ways (Schmidt, 2010). Counselors can also help
middle schoolers foster a sense of uniqueness as well as identify with universal common con-
cerns. In such a process, counselors help middle schoolers overcome their restlessness and
moodiness and counter influences by peers and the popular culture that suggest violence or
other destructive behaviors are an acceptable solution to complex, perplexing problems
(Peterson & O’Neal, 1998).
348 Part IV • Counseling Specialties

Emphases and Roles

Schools often neglect the physical and social development of the child while stimulating intel-
lectual growth (Van Veisor, 2009). Middle school counseling and guidance, like elementary
school counseling and guidance, seeks to correct this imbalance by focusing on the child’s total
development. The emphasis is holistic: Counselors stress not only growth and development but
also the process of transition involved in leaving childhood and entering adolescence (Cobia &
Henderson, 2007; Schmidt, 2014). Their activities include
• working with students individually and in groups;
• working with teachers and administrators;
• working in the community with education agencies, social services, and businesses; and
• partnering with parents to address unique needs of specific children (Campbell & Dahir,
1997).
These roles may be fulfilled more easily if counselors develop capacities and programs in
certain ways. The necessary capacities, according to Thornburg (1986), include general informa-
tion about developmental characteristics of middle schoolers and specific tasks students are
expected to achieve. In addition, middle school counselors must understand the specific child
with whom they are interacting and his or her perspective on a problem. Finally, middle school
counselors need to know how to help students make decisions so that students can help them-
selves in the future.
The ideal role of middle school counselors includes providing individual counseling,
group experiences, peer support systems, teacher consultation, student assessment, parent
consultation, and evaluation of guidance services (Schmidt, 2010, 2014). In a survey of
Kansas principals and counselors, Bonebrake and Borgers (1984) found that participants
agreed on not only the ideal role of the middle school counselor but also a counselor’s lowest
priorities: serving as principal, supervising lunchroom discipline, and teaching nonguidance
classes. This survey is encouraging because it shows the close agreement between principals
and counselors concerning ideal roles. After all, principals usually “determine the role and
function of counselors within the school” (Ribak-Rosenthal, 1994, p. 158). Yet outside the
school, various groups have different perceptions and priorities about the purpose of middle
school counselors. To ease the tension that may arise from such evaluations, Bonebrake and
Borgers (1984) recommend that counselors document their functions and run “a visible,
well-defined, and carefully evaluated program” (p. 198). Middle school counselors also need
to be in constant communication with their various publics about what they do and when.
Publicity as well as delivery of services is as crucial at this level as it is in elementary schools
(Ribak-Rosenthal, 1994).

Activities
Working with middle school children requires both a preventive and a remedial approach. It is
similar to dealing with elementary school children except that counselors must penetrate more
barriers if they are to be truly helpful in a holistic way.

PREVENTION. One of the most promising prevention programs for middle schoolers is the
Succeeding in School approach (Gerler & Anderson, 1986). Composed of ten 50-minute class-
room guidance units, this program is geared toward helping children become comfortable with
themselves, their teachers, and their schools (Gerler, 1987). Furthermore, the approach is
 Chapter 15 • Professional School Counseling 349

“designed to help students focus on behaviors, attitudes, and human relations skills that lead to
improved academic success” (Baker & Gerler, 2008, p. 22). Each lesson plan focuses on a pro-
social aspect of personal and institutional living, such as identifying with successful people,
being comfortable in school, cooperating with peers and teachers, and recognizing the bright
side of life events (Gerler, Drew, & Mohr, 1990). Succeeding in School is now online and can be
accessed through the website http://genesislight.com/succeedinginschool/. Its interactive
program activities allow for students to complete pre- and postprogram measures of school
success online.
A complement to the Succeeding in School program is Rosemarie Smead’s (1995) group
counseling activities for children and adolescents. These activities develop skills for living.
Because her exercises for small groups can be used in various ways, middle school counselors
have flexibility in helping students deal with sensitive areas such as anger, grief, stress,
divorce, assertiveness, and friendship. As Akos, Hamm, Mack, and Dunaway (2007) have
pointed out, group work is particularly appropriate for working with middle schoolers because
they “naturally coalesce into peer groups” (p. 53). For instance, Rose and Steen (2014) set up
a group intervention based on the Achieving Success Everyday (ASE) model. The eight ses-
sions, once-a-week meetings focused on exposing students to the characteristics of resiliency.
The goal was to increase students’ academic achievement (grades) and personal functioning
(e.g., positive learning behaviors). The results showed that overall students achieved a 16%
increase in their GPA and a greater awareness of their personal-social functioning following
the intervention.
In addition to classroom guidance and group work, middle school counselors (like elemen-
tary school counselors) can use individual counseling, peer counseling, and consultation activi-
ties to foster problem prevention (Henderson & Thompson, 2016). One theoretical approach that
helps in this process is Developmental Counseling and Therapy (DCT) (Ivey, Ivey, Myers, &
Sweeney, 2005). DCT incorporates developmental concepts from individual theories such as
those by Kohlberg, Gilligan, Kegan, and Erikson, along with family theories and multicultural
theories (Myers, Shoffner, & Briggs, 2002). It provides a systematic way for counselors to relate
to middle schoolers in their preferred developmental orientation—sensorimotor, concrete, for-
mal operations, and dialetic/systemic. Most middle schoolers will relate on the first two levels,
with the third occasionally coming into play.
Another preventive type of program is peer mentoring. In this arrangement, an older stu-
dent, usually high school age, is paired with a younger student, typically a seventh grader or
younger (Karcher, 2008). The older student both accepts and teaches the younger student through
a cooperative learning arrangement and both students learn and benefit from the experience. Noll
(1997) reports that in a cross-age mentoring program she set up to help younger students with
learning disabilities acquire social skills, the arrangement worked well. The younger students
made significant gains in their social development, and the older students achieved an increase in
their “ability to relate better to parents, an increase in self-esteem, better conflict resolution
skills, and enhanced organization skills” (p. 241).

PERSONAL REFLECTION
Think of your middle school experience and what you learned from peers. How do you think a peer
mentor could have helped you (assuming you did not have one)? How do you think being a peer
mentor is helpful (whether you were one or not)?
350 Part IV • Counseling Specialties

Middle school counselors may also set up teacher-advisor programs (TAPs), which are
based on the premises that “guidance is everybody’s responsibility, that there are not enough
trained counselors to handle all of a school’s guidance needs, and that teacher-based guidance is
an important supplement to school counseling” (Galassi & Gulledge, 1997, p. 56). Through such
programs, teachers become more involved with counselors and with the nonacademic lives of
their students. The beneficiaries of these programs are middle schoolers and the schools in which
they study.

REMEDIATION. One of the best ways to work remedially with middle school students is to
combine it with a preventive approach. According to Stamm and Nissman (1979), the activi-
ties of middle school counselors are best viewed as services that revolve around “a Human
Development Center (HDC) that deals with sensitive human beings (students, teachers, par-
ents, and the community as a whole)” (p. 52). They recommend developing a rapport with
these persons and coordinating middle school counseling and guidance services with others to
provide the most productive program possible. Stamm and Nissman outline eight service areas
that they believe are vital to a comprehensive middle school counseling and guidance pro-
gram. Their model is based on service clusters. It is comprehensive like the ASCA National
Model and is aimed at providing services to all students (although not necessarily by the
school counselor).
Each service cluster is linked with the others. However, middle school counselors cannot
perform all the recommended functions alone, so they must delegate responsibility and solicit
the help of other school personnel, parents, and community volunteers. A counselor’s job, then,
entails coordinating service activities as well as delivering direct services when able.
The communication service cluster is primarily concerned with public relations. It is the
counselor’s outreach arm and is critical for informing the general public about what the school
counseling program is doing. Curriculum service, however, concentrates on facilitating course
placements and academic adjustment. Middle school counselors need to help teachers “psy-
chologize” the curriculum so that students can deal with significant issues in their lives, such as
peer relationships and values (Beane, 1986). If the curriculum is not relevant to children at this
age, they often divert their energy to nonproductive activities. The assessment service cluster
provides testing and evaluation services and is often linked to the career resource cluster,
which focuses on the student’s future goals and vocation.
The counseling service cluster and the crisis center cluster are also closely connected.
Counseling services are provided on an individual, peer, and group level and are offered during
off-school and in-school hours. Sometimes counseling activities are aimed at self-counseling,
which is “when people (including middle graders) think the ideas that they believe, then react to
those ideas with logical emotional reactions and logical physical behaviors” (Maultsby, 1986, p.
207). Rational self-counseling is one research-based way to help students help themselves deal
effectively with their emotions. At other times, peer facilitators help middle schoolers make
friends and learn about their environments and schoolwork (Bowman, 1986; Sprinthall, Hall, &
Gerler, 1992).
There is also someone designated in the Stamm and Nissman model as a crisis person dur-
ing the school day. This individual deals with emergencies and, with the help of the counselor,
finds an appropriate way to assist the child who is experiencing sudden distress. On an individual
level, a crisis and the resulting distress may be connected with loss or internal or external pres-
sures that result in a child acting out or withdrawing. On a group level, a crisis and the resulting
distress may involve “cases of trauma that affect large numbers of students such as homicide,
 Chapter 15 • Professional School Counseling 351

suicide, accidental death, or severe accident” (Lockhart & Keys, 1998, p. 4). (It is vital that ele-
mentary and secondary school counselors have a crisis plan as well as a crisis person or better
yet, a crisis team, in their school counseling programs.)
The community contact cluster focuses on working with parents and other interested
people to open the lines of communication between the school and other agencies. The profes-
sional growth cluster provides programs for school staff and paraprofessionals. This last task is
critical to the counselor’s success. If the total school environment is to be positively affected,
middle school counselors must help “teachers develop skills related to enhancing the students’
self-concept and self-esteem” (Beane, 1986, p. 192).

SECONDARY SCHOOL COUNSELING

“There are few situations in life more difficult to cope with than an adolescent son or daughter
during their attempt to liberate themselves” (Freud, 1958, p. 278). Liberation variables among
adolescents include “relating to parents with new independence, relating to friends with new
intimacy, and relating to oneself with new understanding” (Coll, Thobro, & Hass, 2004, p. 41).
Mattering (the internal perception that an individual is recognized as important to those people
who are significant in his or her life and matters to them) is a crucial element in liberating oneself
as well as forming a positive identity (Dixon, Scheidegger, & McWhirter, 2009). It is negatively
correlated with anxiety and depression.
Although most adolescents make it through this period of their lives by addressing these
variables and the tasks that go with them in a healthy way, some experience great difficulty.
Secondary school counselors must deal with this thorny population and the problems unique to
it. They may take some comfort in the fact that some problems in adolescence are more cyclical
than others. For example, “delinquent behaviors are rare in early adolescence, almost universal
by midadolescence (ages 15 to 17), and decrease thereafter” (McCarthy, Brack, Lambert, Brack,
& Orr, 1996, p. 277). However, many other concerns connected with this population are situa-
tional and unpredictable.
Secondary school counseling and guidance began in the early 1900s when its primary
emphasis was on guidance activities that would help build better citizens (Gysbers & Guidance
Program Field Writers, 1990). Frank Parsons influenced the early growth of the profession,
although John Brewer really pushed for the establishment of secondary school guidance in the
1930s (Aubrey, 1979). Brewer believed that both guidance and education meant assisting young
people in living. His ideas did not gain wide acceptance at the time, but under the name life skills
training they have become increasingly popular, and there is much more emphasis on this type
of training and character education today.
The growth of secondary school counseling was particularly dramatic during the 1960s.
Counselor employment in this specialty more than tripled from about 12,000 in 1958–1959
to more than 40,000 in 1969–1970 (Shertzer & Stone, 1981). According to the Occupational
Outlook Handbook, an estimated 63,000 people worked as public school counselors during
2000, with a ratio of 3 to 1 in favor of secondary school counselors over elementary school
counselors. Several thousand more counselors worked in private schools. Furthermore, the
number of employment opportunities for school counselors began increasing in the late
1980s as many counselors who had trained in NDEA institutes began to retire and more
states mandated better counseling services in the schools at all levels (Baker & Gerler, 2008).
Today, there are an estimated 100,000 counselors in schools, many of them working on the
secondary level.
352 Part IV • Counseling Specialties

Emphases and Roles

Counselors in high school environments concentrate on the following tasks:
• Providing direct counseling services individually, in groups, and to the school as a whole
• Providing educational and support services to parents
• Offering consultation and in-service programs to teachers and staff
• Delivering classroom guidance
• Facilitating referrals to outside agencies
• Networking to postsecondary schools and businesses
• Advising academically (Campbell & Dahir, 1997)
Aubrey (1979) argues that a real conflict exists for secondary school counselors, who are
faced with two needs: (a) engaging in student counseling and (b) doing academic and administra-
tive tasks, such as scheduling, which school administrative personnel often require. He contends
that school counselors, especially on the high school level, frequently get bogged down in nonpro-
fessional activities. Brown (1989) states that dysfunctional counselors are frequently misunder-
stood or misdirected by their principals, are poorly educated, lack a plan of action, are not engaged
in public relations, and violate ethical standards. To combat attempts to cast them into inappropri-
ate roles, secondary school counselors need to develop and publicize what they do and how they
do it, not only to students but to teachers, principals, and administrators as well (Guerra, 1998).
They can do this by “writing monthly newsletters, posting the counselor’s schedule, distributing
the American School Counselor Association (ASCA) role statement, developing a guidance ser-
vice handbook, making presentations at faculty meetings,” and pointing out to others the cost
efficiency of allowing counselors to do their jobs correctly (Ribak-Rosenthal, 1994, p. 163).
Peer (1985) elicited the opinions of state directors of guidance and counseling and others in
regard to views about the role of secondary school counselors. He found mixed opinions. Those
who held secondary school programs in highest regard were principals, superintendents, students,
college and university personnel, other secondary school counselors, and counselor educators.
Teachers, parents, community leaders, and business leaders were less positive. State directors
overwhelmingly reported that secondary school counselors are “probably” or “definitely” heavily
involved in nonprofessional activities. If this is true, it is understandable why secondary school
counselors have come under heavy criticism from people outside the school environment.
The Peer survey also discovered that secondary school counselors are not seen as being
actively involved in group counseling or group guidance, not serving as consultants, and not
making an impact on the majority of students. Overall, programs at this level are not viewed as
favorably as those in elementary schools in the same district. On a positive note, however,
respondents perceived secondary counselors as avoiding disciplinarian roles, well qualified, and
helpful to individual students, especially those bound for college. Significantly, respondents
thought counselors could effect changes in counseling programs.
Ways of improving the perception and behavior of the secondary school counselor include
an emphasis on roles that meet real needs. For instance, school counselors must be facilitators of
healthy learning environments, which should include facilitating problem solving within regular
classrooms, developing professional growth groups, and improving staff communications. All
these roles give counselors maximum exposure among groups who have traditionally held them
in low esteem. By functioning as facilitators in student–adult interactions and adult–adult trans-
actions, counselors provide the means for a productive exchange between divergent and often
isolated groups of people.
 Chapter 15 • Professional School Counseling 353

An important function for any school counselor is the constant remodeling of the coun-
seling program (Gysbers, 2011; Gysbers & Henderson, 2012). A systematic plan is crucial to
this process. It includes not only implementation of services but also evaluation of these activi-
ties. Some stress can be expected in setting up and restructuring guidance and counseling activi-
ties within the school, but a great deal of satisfaction also results. Secondary school counselors
must be in constant touch with their constituents if they are to keep their services and roles
appropriate and current.

Activities
The activities of secondary school counselors can be divided into several areas. In addition to
evaluating their own activities, they are involved in prevention, remediation and intervention,
and cooperation and facilitation. These categories are not mutually exclusive, and there are a
multitude of concerns under each heading.

PREVENTION. Secondary school counselors, like elementary and middle school counselors,
stress preventive services. These efforts “need to be comprehensive, multifaceted, and inte-
grated” (Keys & Bemak, 1997, p. 257). The reason is that adolescent problems outside the class-
room and school problems are interrelated (McCarthy et al., 1996). Therefore, to address one
situation and neglect the other usually will not work. One way to address both simultaneously is
through school bonding, that is, connecting students to their schools and the people and organi-
zations within. School bonding is also known as school connectedness, school engagement, and
school attachment. The reason school bonding, especially during the senior year, is so powerful
is because of its developmental quality to engage students with one another socially and other-
wise. It increases students’ abilities “to overcome life’s challenges and meet academic success”
(Bryan et al., 2012).
There are multiple ways to build primary prevention programs besides school bonding.
One way is for secondary school counselors to become familiar with current popular songs
(Ostlund & Kinnier, 1997). By listening attentively to the lyrics of these songs, secondary school
counselors become “more knowledgeable about adolescent subcultures and may be better able to
help many teenagers cope with typical adolescent problems” (pp. 87–88). They immediately
establish rapport by knowing the words and/or tunes to popular songs, and thus when they speak
or make suggestions they are listened to more.
A second additional way for counselors to practice prevention is to run groups (Paisley &
Milsom, 2007). Thematic groups, which “bring together students experiencing similar prob-
lems and allow counselors to make effective use of their time and skills,” are particularly impor-
tant (Zinck & Littrell, 2000, p. 51). Research indicates that group counseling has been especially
effective in addressing and/or preventing adolescent problems in a number of areas. For instance,
a 10-week group for at-risk adolescent girls was found to foster effective, positive, and lasting
change (Zinck & Littrell, 2000).
A third additional way for counselors to be proactive in secondary school environments is
occasionally to teach prevention-based curriculum offerings in classes. Anxieties about
school and tests, study skills, interpersonal relationships, self-control, and career planning may
be dealt with in this way. Such an approach has two major advantages: Less time needs to be
devoted to remediation and intervention activities, and the counselor maintains a positive high
profile with teachers and students. As an adjunct or an integrated part of curriculum offerings,
counselors can have class members participate in an interactive bibliotherapy process in
354 Part IV • Counseling Specialties

which they read either fiction or nonfiction books on specific subjects and discuss their reac-
tions with the counselor. (This process may be individualized in personal counseling as well.)
Books dealing with illness and death, family relations, self-destructive behaviors, identity,
abuse, race and prejudice, and sex and sexuality are readily available. Christenbury, Beale, and
Patch (1996) suggest several of them. Other works are easily attainable through Books for You
(Christenbury, 1995).
Through primary prevention, whether on a global or limited scale, students become more
self-reliant and less dominated by their peer group. They also become less egocentric, more
attuned to principles as guidelines in making decisions, and more empathetic. Relationships
between the teacher and counselor and the student and counselor are enhanced in this process, too.

CASE EXAMPLE
Leslie’s Lessons through Songs
Leslie realized that students in her high school listened to music all day. They not only listened,
but they also talked about lyrics, and occasionally a student would saunter down the halls sing-
ing. Therefore, Leslie decided to use music and lyrics in her guidance lessons and to promote
interpersonal skills.
She created the “Song Olympics” where students had to either fill in original lyrics or make
up prosocial lyrics. Everyone was enthused, but the activity soon became very competitive.
How might Leslie modify the activity to make it more of a learning experience for everyone?

Five examples of problem areas in which prevention can make a major difference are
bullying, substance abuse, adolescent suicide/homicide, prevention of HIV infection, and
abusive relationships.
According to the Josephson Institute of Ethics 2010 survey of 43,000 high school students,
half admitted they bullied someone in the past year, and nearly as many, 47%, said they were
bullied, teased, or taunted in a way that seriously upset them (charactercounts.org). “Bullying
can be face to face or through electronic media such as texting, e-mailing, social networking or
postings on the Internet” (Pinjala & Pierce, 2010, p. 32). This latter type of bullying, known as
cyberbullying, is particularly troublesome because it can be done in an anonymous and constant
way with no place for the target of this abuse to hide. “Effective prevention programs strive to
create a sense of shared ownership and responsibility of bully prevention among targets, bullies,
bystanders, school staff, caregivers and the community. Together, standardized and clear poli-
cies and procedures must be created and implemented” (p. 35).
“A small proportion of students who experiment and regularly use substances will go on to
develop more severe substance abuse problems that significantly affect their lives” (Burrow-
Sanchez & Lopez, 2009, p. 72). Programs for preventing substance abuse work best when they
are started early in students’ lives, based on social influence models, tailored to the age and stage
of different student groups, and involve students, parents, teachers, and community members in
the planning process (Mohai, 1991). A specific effective model is one in which counselors work
with potentially susceptible at-risk students in a multidimensional way (Gloria & Kurpius
Robinson, 2000). In general, multidimensional approaches increase self-esteem, reduce negative
peer influence, and provide drug information. Student assistance programs (SAPs) set up by
 Chapter 15 • Professional School Counseling 355

counselors in schools are also effective (Moore & Forster, 1993). SAP teams are composed of
school personnel from a variety of backgrounds and function in ways similar to multidisciplinary
special education teams in schools. They may be specific or general in nature but are aimed at
being informative and helping students to cope with their problems (Rainey, Hensley, &
Crutchfield, 1997).
Suicide and homicide prevention programs follow broad-based approaches that stress the
seriousness of such violence and alternatives. Suicide is estimated to be attempted by 8% of
American adolescents each year and is the third leading cause of death among them. It is the
second leading cause of death among Canadian youth (ages 15 to 19 years) (Everall, Altrows, &
Paulson, 2006). There is a suicide attempt by an adolescent almost every minute, making approx-
imately 775,000 attempts annually (Carson, Butcher, & Mineka, 2000). Although more girls
attempt suicides than boys, boys are more successful in carrying them out. Boys also tend to be
the almost exclusive perpetrators of adolescent homicides. The number of youth homicides,
especially those involving multiple deaths in schools, has increased dramatically in recent years,
too. The word “Columbine” is tragically linked to mass killings in school settings.
Because antisocial behaviors like suicide and homicide are multidetermined phenomena, a
variety of interventions are needed to prevent them (Dykeman, Daehlin, Doyle, & Flamer, 1996).
Some ways to prevent suicides and homicides are to help students, parents, and school personnel
become aware of their danger signs and alert counselors and other mental health helpers to the
professional and legal standards that deal with breaking confidentiality (Peach & Reddick, 1991;
Remley & Sparkman, 1993; Sheeley & Herlihy, 1989). Involving school peers, families, and
significant others in the community is also vital (Cashwell & Vacc, 1996; Ritchie, 1989). It is
important that suicide and homicide prevention programs in schools be proactive rather than
reactive as well as systematically designed. One approach to such aggression is a concept known
as wraparound programs (Cautilli & Skinner, 1996). These programs have multiple services
provided by a team of many mental health professionals, including counselors, who work
together to provide direct assistance to the youth at risk of violence as well as his or her family
and community/school personnel who come in contact with the youth.
A common factor among suicidal and homicidal youth is feelings of depression and anger.
Therefore, preventive programs, such as support or psychoeducational groups, that deal with
improving self-esteem, social competence, and coping with loss and rejection are important.
Such programs help youth use their intelligence wisely in a wide range of situations and assist
them in developing resilience: “an adaptive process whereby the individual willingly makes use
of internal and external resources to overcome adversity or threats to development” (Everall et
al., 2006). Likewise, programs aimed at preventing copycat and cluster suicides and at providing
community awareness are vital (Popenhagen & Qualley, 1998). Individual identification of
youth at risk for either suicide or homicide is crucial, too. Youth intervention programs tailored
to the needs and circumstances of potential suicide victims and homicide perpetrators are essen-
tial. A plan of action for dealing with suicide and homicide potential should be as broad-based as
possible (Capuzzi, 2009).
When working to prevent HIV, counselors may or may not persuade students to change
their sexual activity. However, they can help them avoid contracting HIV and other sexually
transmitted diseases by employing both an informational and skills-based intervention system
(Stevens-Smith & Remley, 1994). For instance, the school counselor can make sure students
know how HIV is spread and what behaviors, such as sharing intravenous needles and unpro-
tected casual sex, put them into greatest danger (Keeling, 1993). In addition, counselors can
offer students opportunities for interpersonal skill building by simulating situations that are
356 Part IV • Counseling Specialties

potentially hazardous. They can also support teenagers who decide to try new and positive
behaviors such as changing their habits or environments. Support groups, workshops for parents
and administrators, and peer education programs can also be used. Peer education is one of the
strongest means of dissuading adolescents from engaging in destructive behaviors and helping
them focus on productive action (Wittmer & Adorno, 2000).
Finally, interpersonal violence (i.e., abusive relationships) can be prevented through
school counselor interventions (Becky & Farren, 1997; Bemak & Keys, 2000). In such pro-
grams, counselors work with students in groups to emphasize to them that slapping, pushing, and
emotionally threatening language are not a normal or necessary part of interpersonal relation-
ships. Furthermore, they focus on teaching students violence-prevention strategies such as anger
management, assertiveness, and responsible verbal and nonverbal communication. “Dating
Safely” is one model available in a programmed format that is easy to follow.
Overall, as these examples show, school counselors are in a strong position because of
their skills, training, and knowledge “to be leaders in the development of … school- and commu-
nity-based intervention” programs (Stevens-Smith & Remley, 1994, p. 182). They can help stu-
dents master coping skills, that is, “an ability to adapt to stress and adversity” (Compass,
Connor-Smith, Saltzman, Thomsen, & Wadsworth, 2001, p. 87). This mastery can take place
through either active or passive means, such as through consequential thinking or simply observ-
ing (Balkin & Roland, 2007).

REMEDIATION. Secondary school counselors initiate remediation and intervention programs

to help students with specific problems that are not amenable to prevention techniques. Some
common mental disorders of childhood and adolescence manifest themselves clearly at this time,
such as problems centering around adjustment, behavior, anxiety, substance abuse, and eating
(Geroski, Rodgers, & Breen, 1997). The identification, assessment, referral, and in some cases
treatment of these disorders found in the Diagnostic and Statistical Manual of Mental Disorders
are among the most valuable services a secondary school counselor, or any school counselor, can
render (often in consultation with other mental health providers). Because of time and resources,
secondary school counselors usually do not deal directly in treating severe mental disorders but
rather focus on other specific problematic behaviors that occur in their settings. Four of the
most prevalent of these problems are depression, parental divorce, teenage parenting, and
substance abuse.
Depression is related in adolescence to negative life stress (Benson & Deeter, 1992;
Mondimore & Kelly, 2016). Forrest (1983) states that about 15% of all schoolchildren may be
depressed because of external stressors and inadequate individual response abilities. He lists
common emotional, physical, intellectual, and behavioral indicators of depression. Furthermore,
he emphasizes the need for school counselors to use a variety of approaches in dealing with the
problem. Among the most prominent are using Lazarus’s multimodal model; teaching the stu-
dent how to develop self-esteem; helping the student become aware of depression and the stress
factors that influence it; and teaching relaxation procedures, new coping skills, and ways of
modifying negative self-messages. All these approaches require a significant investment of time
and energy.
Approximately one million children experience parental divorces each year, and it is
estimated that 45% of all American children can expect their families to break up before they
reach the age of 18 (Whitehead, 1997). Secondary school counselors can help children, parents,
and teachers adjust to divorce through both direct and indirect services. Interventions that directly
address the problems of divorce include individual and group counseling services within the
 Chapter 15 • Professional School Counseling 357

school for the children. Structured, short-term group work can make a positive impact in helping
secondary school students sort out and resolve their feelings about the divorce experience
(Smead, 1995). More indirect services can also be implemented, such as consulting with teachers
and parents about the children’s feelings. Teachers and parents need information about what to
expect from children of divorce and what useful interventions they might employ in the process
of helping. Likewise, children may need resources in coping and school counselors can help by
giving them information both directly and indirectly, for example, readings on the subject.
Teenage parenting is filled with emotional issues for both society and teens. When par-
enting results from an out-of-wedlock pregnancy, feelings run high. The challenge for school
counselors is to develop outreach strategies for working with members of this population. In
addition, counselors must address personal and career concerns of young parents and make nec-
essary referrals. Usually the process is accomplished best through collaborative efforts between
school counselors and community mental health workers (Kiselica & Pfaller, 1993). One essen-
tial task is to prevent teenage parents from having a second child. Another crucial aspect is keep-
ing unwed mothers (and fathers) in school and increasing their success in academic, personal,
and interpersonal arenas (DeRidder, 1993).
Experimentation with various substances, from alcohol to hard drugs, is typical for teens.
“Approximately 34% of 10th-grade students and 45% of 12th-grade students report the use of
alcohol …, and almost 18% of 10th-grade students and 22% of 12th-grade students report using
an illicit substance” (Burrow-Sanchez, Jenson, & Clark, 2008, p. 238). Unfortunately, some ado-
lescents develop substance abuse problems that substantially affect their lives. These problems
are often paired with other mental health difficulties such as depression, ADHD, conduct disor-
ders, anxiety disorders, bipolar disorders, and academic failure, which make them hard to treat.
Thus, successfully intervening with students who abuse substances is a challenge for secondary
school counselors because there are so many complexities to the problem. Treatment is even
more difficult because most teens are reluctant to talk openly about substance abuse with adults.
Treatment can vary but may include individual interventions, such as a counselor trained
to deal with substance abuse and motivational interviewing, as well as group interventions, such
as psychoeducational groups and support (or aftercare) groups if the student has received com-
munity-based help. The process is time consuming, but results have been positive when these
strategies have been implemented.

COOPERATION AND FACILITATION. Cooperation and facilitation involve the counselor in a

variety of community and school activities beyond that of caregiver. Counselors who are not
aware of or involved in community and school groups are not as effective as they could other-
wise be. Part of a counselor’s responsibility is becoming involved with others in ways outside
direct counseling services (Lee & Walz, 1998). Thus, secondary school counselors often have to
take the initiative in working with teachers and other school personnel. By becoming more
involved with teachers, administrators, and sponsors of extracurricular activities, counselors
integrate their views into the total life of schools and “help create the kind of school environ-
ments that stimulate growth and learning” (Glosoff & Koprowicz, 1990, p. 10).
In a very practical article on the role of the school counselor as service coordinator, DeVoe
and McClam (1982) stress the importance of counselors’ being accountable for performing three
roles. The first role is information retriever. Here, the counselor either collects information or
works with other professionals to collect information about particularly complex situations, such
as the abused and drug-dependent pregnant teenager. The second role is related to service
coordination. The counselor determines whether he or she has the expertise to meet particular
 13 Career Counseling over the Life Span

Chapter Overview
From reading this chapter
you will learn about:
■ The importance of career

counseling and the scope of

career counseling
■ Major career counseling

theories and techniques,

(e.g., developmental,
social–cognitive)
■ Career counseling with
diverse populations, (e.g.,
children, adolescents,
adults, women, GLBTs,
and cultural minorities)
As you read consider: Scott Cunningham/Pearson Education, Inc.

■ How career counseling is

similar to and different Far in the back of his mind he harbors thoughts
from personal counseling like small boats in a quiet cove
■ What career theory or ready to set sail at a moment’s notice.
theories appeal to you most I, seated on his starboard side,
and why listen for the winds of change
■ The challenges of career ready to lift anchor with him
counseling with and explore the choppy waves of life ahead.
populations you are not as Counseling requires a special patience
familiar with and what you best known to seamen and navigators—
can do to help make courses are only charted for times
yourself more prepared when the tide is high and the breezes steady.
Reprinted from “Harbor Thoughts,” by S. T. Gladding, 1985, Journal of Humanistic
Education and Development, 23, p. 68. © 1985 by Samuel T. Gladding.

288
 Chapter 13 • Career Counseling over the Life Span 289

The counseling profession began charting its course when Frank Parsons (1909) outlined a
process for choosing a career and initiated the vocational guidance movement. According to
Parsons, it is better to choose a vocation than merely to hunt for a job. Since his ideas first
came into prominence, a voluminous amount of research and theory has been generated in the
field of career development and counseling.
Choosing a career is more than simply deciding what one will do to earn a living. Occupa-
tions influence a person’s whole way of life, including physical and mental health. “There are
interconnections between work roles and other life roles” (Imbimbo, 1994, p. 50). Thus,
income, stress, social identity, meaning, education, clothes, hobbies, interests, friends, lifestyle,
place of residence, and even personality characteristics are tied to one’s work life (Herr,
Cramer, & Niles, 2004). Qualitative research indicates that individuals who appear most happy
in their work are committed to following their interests, exhibit a breadth of personal compe-
tencies and strengths, and function in work environments that are characterized by freedom,
challenge, meaning, and a positive social atmosphere (Henderson, 2000).
Yet despite the evidence of the importance of a person’s work, systematically exploring
and choosing careers often does not happen. Nearly one in five American workers reports get-
ting his or her current job by chance, and more than 60% of workers in the United States would
investigate job choices more thoroughly if they could plan their work lives again (Hoyt, 1989).
Therefore, it is important that individuals obtain career information early and enter the job mar-
ket with knowledge and flexibility in regard to their plans.
The process of selecting a career is unique to each individual. It is influenced by a variety
of factors. For instance, personality styles, developmental stages, and life roles come into play
(Drummond & Ryan, 1995). Happenstance and serendipity (Guindon & Hanna, 2002), family
background (Chope, 2006), gender (Watt & Eccles, 2008), giftedness (Maxwell, 2007), and age
(Canaff, 1997) may also influence the selection of a career. In addition, the global economy at
the time one decides on a career is a factor (Andersen & Vandehey, 2012). In the industrial age,
punctuality, obedience, and rote work performance were the skills needed to be successful; in
the present technological-service economy, the emphasis is on “competitive teamwork, cus-
tomer satisfaction, continual learning, and innovation” (Staley & Carey, 1997, p. 379). In addi-
tion, “the new job market in an unsettled economy calls for viewing careers not as a lifetime
commitment to one employer but as a recurring selling of services and skills to a series of
employers who need projects completed” (Savickas, 2012, p. 13).
Because an enormous amount of literature on careers is available, this chapter can provide
only an overview of the area. It will concentrate on career development and counseling from a
holistic, life-span perspective (as first proposed by Norman Gysbers). In the process, theories
and tasks appropriate for working with a variety of clients will be examined.

THE IMPORTANCE OF CAREER COUNSELING

Despite its long history and the formulation of many models, career counseling has not enjoyed
the same degree of prestige that other forms of counseling or psychotherapy have. This is unfor-
tunate for both the counseling profession and the many people who need these services. Surveys
of high school juniors and seniors and college undergraduates show that one of the counseling
services they most prefer is career counseling. Brown (1985) also posits that career counseling
may be a viable intervention for some clients who have emotional problems related to nonsup-
portive, stress-producing environments. The contribution of career counseling to personal and
290 Part IV • Counseling Specialties

relational growth and development is well documented (Krumboltz, 1994; Schultheiss, 2003). In
fact, Herr and colleagues (2004) contend that a variety of life difficulties and mental problems
ensue when one’s career or work life is unsatisfactory.
Crites (1981, pp. 14–15) lists important aspects of career counseling, which include the
following:
1. “The need for career counseling is greater than the need for psychotherapy.” Career
counseling deals with the inner and outer world of individuals, whereas most other coun-
seling approaches deal only with internal events.
2. “Career counseling can be therapeutic.” A positive correlation exists between career
and personal adjustment (Crites, 1969; Hinkelman & Luzzo, 2007; Krumboltz, 1994;
Super, 1957). Clients who successfully cope with career decisions may gain skill and con-
fidence in the ability to tackle other problem areas. They may invest more energy into
resolving noncareer problems because they have clarified career objectives. Although
Brown (1985) provides a set of assessment strategies that are useful in determining whether
a client needs personal or career counseling first, Krumboltz (1994) asserts that career and
personal counseling are inextricably intertwined and often must be treated together.
Indeed, research data refute the perspective “that career help seekers are different from
non-career help seekers” (Dollarhide, 1997, p. 180). For example, people who lose jobs
and fear they will never find other positions have both a career problem and a personal
anxiety problem. It is imperative to treat such people in a holistic manner by offering infor-
mation on the intellectual aspects of finding a career and working with them to face and
overcome their emotional concerns about seeking a new job or direction in life.
3. “Career counseling is more difficult than psychotherapy.” Crites states that, to be an
effective career counselor, a person must deal with both personal and work variables and
know how the two interact. “Being knowledgeable and proficient in career counseling
requires that counselors draw from a variety of both personality and career development
theories and techniques and that they continuously be able to gather and provide current
information about the world of work” (Imbimbo, 1994, p. 51). The same is not equally true
for counseling, which often focuses on the inner world of the client.

PERSONAL REFLECTION
How did you become interested in the career you are pursuing? Did you receive any career counsel-
ing? If so, was it helpful? If not, what use might you have made of career counseling?

CAREER COUNSELING ASSOCIATIONS AND CREDENTIALS

The National Career Development Association, or NCDA (formerly the National Vocational
Guidance Association, or NVGA; http://ncda.org/), and the National Employment
Counselors Association, or NECA (http://geocities.com/employmentcounseling/neca.html),
are the two divisions within the American Counseling Association (ACA) primarily devoted
to career development and counseling. The NCDA, the oldest division within the ACA, traces
its roots back to 1913 (Sheeley, 1978, 1988; Stephens, 1988). The association comprises pro-
fessionals in business and industry, rehabilitation agencies, government, private practice, and
educational settings who affiliate with the NCDA’s special-interest groups, such as Work and
 Chapter 13 • Career Counseling over the Life Span 291

Mental Health, Substance Abuse in the Workplace, and Employee Assistance Programs
(Parker, 1994; Smith, Engels, & Bonk, 1985). The NECA’s membership is also diverse but
more focused. Until 1966, it was an interest group of the NCDA (Meyer, Helwig, Gjernes, &
Chickering, 1985). Both divisions publish quarterly journals: the Career Development
Quarterly (formerly the Vocational Guidance Quarterly) and the Journal of Employment
Counseling, respectively.

THE SCOPE OF CAREER COUNSELING AND CAREERS

Career counseling is a hybrid discipline, often misunderstood and not always fully appreciated
by many helping professionals, businesspeople, the public, or the government (Hoyt, 2005). The
NCDA defines career counseling as a “process of assisting individuals in the development of a
life-career with a focus on the definition of the worker role and how that role interacts with other
life roles” (p. 2).
Throughout its history, career counseling has been known by a number of different names,
including vocational guidance, occupational counseling, and vocational counseling. Crites
(1981) emphasizes that the word career is more modern and inclusive than the word vocation.
Career is also broader than the word occupation, which Herr and colleagues (2004) define as a
group of similar jobs found in different industries or organizations. A job is merely an activity
undertaken for economic returns (Fox, 1994).
Career counselors clearly must consider many factors when helping persons make career
decisions. Among these factors are avocational interests, age or stage in life, maturity, gender,
familial obligations, and civic roles (Shallcross, 2009a). Some of these factors are represented in
various ways. For example, the integration and interaction of work and leisure in one’s career
over the life span according to McDaniels (1984) is expressed in the formula C = W + L, where
C equals career; W, work; and L, leisure (Gale, 1998, p. 206).
All theories of counseling are potentially applicable and useful in working with individu-
als on career choices, but people gain understanding and insight about themselves and how they
fit into the world of work through educational means as well as counseling relationships. Well-
informed persons may need fewer counseling services than others and respond more positively
to this form of helping.
Among the many functions that career counselors perform are:
• administering and interpreting tests and inventories;
• conducting personal counseling sessions;
• developing individualized career plans;
• helping clients integrate vocational and avocational life roles;
• facilitating decision-making skills; and
• providing support for persons experiencing job stress, job loss, or career transitions.

CAREER INFORMATION
The NCDA (then the NVGA) has defined career information as “information related to the
world of work that can be useful in the process of career development, including educational,
occupational, and psychosocial information related to working, e.g., availability of training, the
nature of work, and status of workers in different occupations” (Sears, 1982, p. 139). A more
modern term for career information is career data, meaning a collection of facts about
292 Part IV • Counseling Specialties

occupational and educational opportunities (Niles & Harris-Bowlsbey, 2013). Data become
information only when they are understood by clients and used to inform decision making, that
is, to assist them to choose one alternative over another
As has been discussed in previous chapters, the word guidance is usually reserved for
activities that are primarily educational. Career guidance involves all activities that seek to dis-
seminate information about present or future vocations in such a way that individuals become
more knowledgeable and aware about who they are in relation to the world of work. Guidance
activities can take the form of
• career fairs (inviting practitioners in a number of fields to explain their jobs),
• library assignments,
• outside interviews,
• computer-assisted information experiences,
• career shadowing (following someone around on his or her daily work routine),
• didactic lectures, and
• experiential exercises such as role-playing.
Career guidance and the dissemination of career information is traditionally pictured as
an educational activity. However, this process is often conducted outside a classroom
environment—for example, at governmental agencies, industries, libraries, and homes or
with a private practitioner (Harris-Bowlsbey, 1992). According to C. H. Patterson, career
guidance is “for people who are pretty normal and have no emotional problems that would
interfere with developing a rational approach to making a vocational or career choice”
(Freeman, 1990, p. 292). Many government and educational agencies (such as the National
Career Information System [NCIS] in Eugene, Oregon) computerize information about occu-
pations and disseminate it through libraries. Overall, the ways of becoming informed about
careers are extensive.
Not all ways of learning are as effective as others are, however, and those who fail to
personalize career information to specific situations often have difficulty making vocational
decisions. The result may be unrealistic aspirations, goals beyond a person’s capabilities
(Salomone & McKenna, 1982). Therefore, it is vital to provide qualitative and quantitative
information to individuals who are deciding about careers, including the nature of the career
decision process, such as mentioning that “career decidedness develops over time” and “the
decision-making process is complex, not simple” (Krieshok, 1998). Knowledge of career
information and the processes associated with it does not guarantee self-exploration in career
development, but good career decisions cannot be made without these data. A lack of enough
information or up-to-date information is one reason that individuals fail to make decisions or
make unwise choices.
Several publications are considered classic references for finding in-depth and current
information on careers and trends. They include the government-published Dictionary of
Occupational Titles (DOT), which has now been transformed into the Occupational Information
Network (O*Net) and put online (www.doleta.gov/programs/onet) by the U.S. Department of
Labor as a replacement for the DOT. O*Net is a comprehensive database that provides informa-
tion about approximately 975 occupations, worker skills, and job training requirements. It is
updated regularly. Likewise, the Occupational Outlook Handbook (www.bls.gov/oco/home.
htm) and other major publications of the Department of Labor have been put on the Web. Career
counselors can also make use of applied technology outside the government, especially the use
of electronic career searches.
 Chapter 13 • Career Counseling over the Life Span 293

CASE EXAMPLE
Muggsy Bogues and Basketball
On a good day Muggsy Bogues stood 5 foot 3 inches tall and weighed 136 pounds. Yet he went
on to play college basketball and then to play 14 years in the National Basketball Association
(NBA). He was an exceptional passer, a ball stealer, and one of the fastest men on the court. He
came from an impoverished background and yet attained fame and fortune at the end of the 20th
century.
How does a case like that of Muggsy Bogues reflect on the value of career counseling?
(Would any career counselor have advised him in high school or college to try to play profes-
sional basketball?)

A number of computer-based career planning systems (CBCPSs) and computer-

assisted career guidance systems (CACGS) offer career information and help individuals sort
through their values and interests or find job information. One of the beauties of computer-based
and computer-assisted career planning and guidance systems is their accessibility: They are
available in many settings and with diverse people across cultures and the life span (Niles &
Harris-Bowlsbey, 2013; Sampson & Bloom, 2001). Some of the top programs include SIGI3
(System of Interactive Guidance and Information, with “3” indicating a refinement of the sys-
tem), DISCOVER, and the Kuder Career Planning System (Maples & Luzzo, 2005).
SIGI3 (www.valparint.com/sigi.htm; Katz, 1975, 1993) contains five components with a
focal point on
1. self-assessment (Values),
2. identification of occupational alternatives (Locate),
3. review of occupational information (Compare),
4. review of information on preparation programs (Planning), and
5. making tentative occupational choices (Strategy).
By using SIGI3, searchers are able to clarify their values, locate and identify occupational
options, compare choices, learn planning skills, and develop rational career decision-making
skills.
DISCOVER (www.act.org; ACT, 1998) contains nine modules:
1. Beginning the career journey
2. Learning about the world of work
3. Learning about yourself
4. Finding occupations
5. Learning about occupations
6. Making educational choices
7. Planning next steps
8. Planning your career
9. Making transitions
Most users of DISCOVER proceed through the modules in a sequential order, but the
modules may be accessed on demand depending on need.
294 Part IV • Counseling Specialties

The Kuder Career Planning System (www.kuder.com) offers a comprehensive solution

for career planners at all stages of career development. It includes, among other things, the Kuder
Online Career Portfolio and Research-Based Assessments. The Online Career Portfolio pro-
vides lifelong career planning that allows individuals to store personal and academic informa-
tion, search and save educational and occupational data, build resumes, and access assessment
progress and results from any Internet connection. The Research-Based Assessments, which
are available in either English or Spanish, help system users discover their interests, skills, and
work values and how those characteristics relate to the world of work.
Ways of enhancing computer-based career planning systems and computer-assisted career
guidance systems are constantly being implemented, including interactive programs (Niles &
Harris-Bowlsbey, 2013; Zunker, 2016). No matter how sophisticated the programs, however, it is
wise to have trained career counselors available to assist those individuals who may make use of
this technology but still have questions about its applicability to their lives (Walker-Staggs, 2000).
In addition to these instruments, there are career choices curriculums developed by the
National Occupational Information Coordinating Committee (NOICC) that can be used in
educational settings such as high schools to provide career information that is relevant to stu-
dents in English, math, and social science classes.
Furthermore, some self-help books, such as Bolles’s (2012) What Color Is Your Parachute?
and Kay’s (2006) Life’s a Bitch and Then You Change Careers: 9 Steps to Get Out of Your Funk
and On to Your Future, are still available in print form. These books outline practical steps most
individuals, from late adolescence on, can follow to define personal values and successfully
complete career-seeking tasks, such as writing a resume. These texts also provide a wealth of
information on how to locate positions of specific interest.

CAREER DEVELOPMENT THEORIES AND COUNSELING

Career development theories try to explain why individuals choose careers. They also deal with
the career adjustments people make over time. Modern theories, which are broad and compre-
hensive in regard to individual and occupational development, began appearing in the literature
in the 1950s (Gysbers, Heppner, & Johnstone, 2014). The theories described here (i.e., trait-and-
factor, developmental, social–cognitive, constructivist) and the counseling procedures that go
with them are among the most prominent and widely used in the field of career counseling.

Trait-and-Factor Theory
The origin of trait-and-factor theory can be traced back to Frank Parsons. It stresses that the
traits of clients should first be assessed and then systematically matched with factors inherent in
various occupations. Its most widespread influence occurred during the Great Depression when
E. G. Williamson (1939) championed its use. It was out of favor during the 1950s and 1960s but
has resurfaced in a more modern form, which is best characterized as “structural” and is reflected
in the work of researchers such as John Holland (1997). The trait-and-factor approach has always
stressed the uniqueness of persons. Original advocates of the theory assumed that a person’s
abilities and traits could be measured objectively and quantified. Personal motivation was con-
sidered relatively stable. Thus, satisfaction in a particular occupation depended on a proper fit
between one’s abilities and the job requirements.
In its modern form, trait-and-factor theory stresses the interpersonal nature of careers and asso-
ciated lifestyles as well as the performance requirements of a work position. Holland (1997) identifies
 Chapter 13 • Career Counseling over the Life Span 295

REALISTIC INVESTIGATIVE
Skilled, concrete, technical, Scientific, abstract, analytical
mechanical (e.g., engineer, (e.g., researcher, computer
mechanic, farmer) programmer, lab technician)

CONVENTIONAL ARTISTIC
Organized, practical, Creative, imaginative,
conforming (e.g., aesthetic (e.g., musician,
accountant, teller, clerk) painter, writer)

ENTERPRISING SOCIAL
Persuasive, outgoing, verbal Educational, service oriented,
(e.g., sales, management, sociable (e.g., counselor,
entrepreneur) teacher, nurse)
FIGURE 13.1 Holland’s six categories of personality and occupation
Source: Reproduced by special permission of the Publisher, Psychological Assessment Resources, Inc., 16204 North
Florida Avenue, Lutz, FL 33549, from Making Vocational Choices, Third Edition, Copyright 1973, 1985, 1992, 1997 by
PAR, Inc. All rights reserved.

six categories in which personality types and occupational environments can be classified: real-
istic, investigative, artistic, social, enterprising, and conventional (RIASEC) (Figure 13.1).
Ranked according to prestige, investigative (I) occupations rank highest, followed by enterprising
(E), artistic (A), and social (S) occupations, which have roughly the same level of prestige. The low-
est levels of prestige are realistic (R) and conventional (C) occupations (Gottfredson, 1981).
In an analysis of census data using the Holland codes, Reardon, Bullock, and Meyer (2007)
confirmed that the distribution across Holland’s types is asymmetrical. They found that from
1960 to 2000 “the Realistic area had the largest number of individuals employed and that the
Artistic area had the fewest number employed” (p. 266). The gap between the number of people
employed in the Realistic and Enterprising areas shrank during the five decades to where in 2000
there were approximately equal numbers of people employed in both areas. Interestingly, the
Investigative area more than doubled during this time whereas the other four areas remained
relatively stable. Regardless of age, between 75% and 85% of male workers were employed in
the Realistic and Enterprising areas; women were more varied and concentrated in the
Conventional, Realistic, Social, and (more recently) Enterprising areas.
Personal satisfaction in a work setting depends on a number of factors, but among the most
important are the degree of congruence between personality type, work environment, and social
class (Gade, Fuqua, & Hurlburt, 1988; Holland & Gottfredson, 1976; Savickas, 2012; Trusty,
Robinson, Plata, & Ng, 2000). Also as a general rule, with notable exceptions, “women value
language-related tasks more, and men value mathematics-related tasks more” (Trusty et al.,
2000, p. 470). Some nonpsychological factors, such as economic or cultural influences, account
for why many professional and nonprofessional workers accept and keep their jobs (Brown,
2012; Salomone & Sheehan, 1985).
Nevertheless, as Holland emphasizes, it is vital for persons to have adequate knowledge of
themselves and occupational requirements to make informed career decisions. According to
Holland, a three-letter code represents a client’s overall personality, which can be matched with
a type of work environment. Three-letter codes tend to remain relatively stable over the life span
beginning as early as high school (Miller, 2002). A profile of SAE would suggest a person is
296 Part IV • Counseling Specialties

most similar to a social type, then an artistic type, and finally an enterprising type. However, it is
the interaction of letter codes that influences the makeup of the person and his or her fit in an
occupational environment. Miller (1998) suggests that, instead of using the three highest scores
on Holland’s hexagon for such a purpose, the top two, middle two, and lowest two scores should
be paired and presented to give the client a fuller picture of his or her personality profile and
similarity to others in a given career. Given the first criteria, Donald Super’s profile would be
S/I/R, whereas John Holland’s would be A/E/IRS. The second criteria would yield a profile for
Super of SI/RA/EC, with Holland’s profile being AE/IR/SC (Weinrach, 1996).
Trait-and-factor career counseling is sometimes inappropriately caricatured as “three inter-
views and a cloud of dust.” The first interview session is spent getting to know a client’s background
and assigning tests. The client then takes a battery of tests and returns for the second interview to
have the counselor interpret the results of the tests. In the third session, the client reviews career
choices in light of the data presented and is sent out by the counselor to find further information on
specific careers. Williamson (1972) originally implemented this theory to help clients learn self-
management skills. But as Crites (1969, 1981) notes, trait-and-factor career counselors may ignore
the psychological realities of decision making and fail to promote self-help skills in their clients.
Such counselors may overemphasize test information, which clients either forget or distort.

CASE STUDY
Hannah and the Hammer
Hannah loved tools from the time she was a little girl. Now as an 11th grader, she wondered
whether she should go to a liberal arts college or a trade school. She saw advantages to both. Her
dad was a carpenter and her mother a teacher. They simply told her they would help her regard-
less of what she decided to do. Her Holland profile was a bit unusual: SR/CA/IE. She was
ambivalent.
What advice might you give to Hannah about her upcoming decision if you were a trait-
and-factor career counselor?

Developmental Theories
Two of the most widely known career theories are those associated with Donald Super and Eli
Ginzberg. They are both based on personal development. The original developmental theory
proposed by Ginzberg and associates (Ginzberg, Ginsburg, Axelrad, & Herma, 1951) has had
considerable influence and has been revised (Ginzberg, 1972). However, Super’s theory is
examined in detail here because more extensive work has been done with it and it has overshad-
owed other developmental approaches to career counseling.
Compared with other theoretical propositions, developmental theories are generally more
inclusive, more concerned with longitudinal expression of career behavior, and more inclined to
highlight the importance of self-concept. Super (1957, 1990) believed that making a career
choice is “linked with implementing one’s vocational self-concept” (Hinkelman & Luzzo, 2007,
p. 143). People’s views of themselves are reflected in what they do. He suggested that vocational
development unfolds in five stages, each of which contains a developmental task to be com-
pleted (Table 13.1). The first stage is growth (from birth to age 14). During this stage, with its
substages of fantasy (ages 4–10), interest (ages 11–12), and capacity (ages 13–14), children form
 TABLE 13.1 Super’s Stages
Growth Exploration Establishment Maintenance Decline
Birth to Age 14 Ages 14 to 24 Ages 24 to 44 Ages 44 to 64 Ages 64 and Beyond
Self-concept develops Self-examination, role Having found an appropriate field, Having made a place As physical and mental
through identification tryouts, and occupational an effort is made to establish a in the world of work, powers decline, work
with key figures in family exploration take place in permanent place in it. Thereafter the concern is how to activity changes and in
and school; needs and school, leisure activities, and changes that occur are changes of hold on to it. Little due course ceases.
fantasy are dominant part-time work. position, job, or employer, not of new ground is broken, New roles must be
early in this stage; occupation. continuation of developed: first,
interest and capacity established pattern. selective participant
become more important Concerned about and then observer.
with increasing social maintaining present Individual must find
participation and reality status while being other sources of
testing; learn behaviors forced by competition satisfaction to replace
associated with self- from younger workers those lost through
help, social interaction, in the advancement retirement.
self-direction, industry, stage.
goal setting, persistence.
Substages Substages Substages Substages
Fantasy (4–10) Needs are Tentative (15–17) Needs, Trial—Commitment and Deceleration (65–70)
dominant; role-playing interests, capacities, values Stabilization (25–30) Settling The pace of work
in fantasy is important. and opportunities are all down. Securing a permanent place slackens, duties are
Interest (11–12) Likes are considered; tentative in the chosen occupation. May shifted, or the nature
the major determinant choices are made and tried prove unsatisfactory, resulting in of work is changed to
of aspirations and out in fantasy, discussion, one or two changes before the life suit declining
activities. courses, work, and so on. work is found or before it becomes capacities. Many find
Capacity (13–14) Possible appropriate fields clear that the life work will be a part-time jobs to
Abilities are given more and levels of work are succession of unrelated jobs. replace their full-time
weight and job identified. Advancement (31–44) Effort is put occupations.
requirements (including forth to stabilize, to make a secure Retirement (71 on)
training) are considered. place in the world of work. For Variation on complete
most persons these are the creative cessation of work or
years. Seniority is acquired; shift to part-time,
clientele are developed; superior volunteer, or leisure
performance is demonstrated; activities.
qualifications are improved.
297 (Continued)
298 TABLE 13.1 Super’s Stages (Continued)
Growth Exploration Establishment Maintenance Decline
Task—Crystallizing a
Tasks Vocational Preference Tasks Tasks Tasks
Developing a picture Transition (18–21) Reality Finding opportunity to do desired Accepting one’s Developing
of the kind of person considerations are given work. limitations. nonoccupational roles.
one is. more weight as the person Learning to relate to others. Identifying new Finding a good
Developing an enters the labor market or Consolidation and advancement. problems to work on. retirement spot.
orientation to the world professional training and Developing new skills. Doing things one has
Making occupational position
of work and an attempts to implement a always wanted to do.
secure. Focusing on essential
understanding of the self-concept. Generalized
Settling down in a permanent activities. Reducing working
meaning of work. choice is converted to
position. Preservation of hours.
specific choice.
achieved status and
gains.
Task—Specifying a
Vocational Preference
Trial—Little Commitment
(22–24) A seemingly
appropriate occupation
having been found, a first
job is located and is tried
out as a potential life work.
Commitment is still
provisional, and if the job is
not appropriate, the person
may reinstitute the process
of crystallizing, specifying,
and implementing a
preference. Implementing a
vocational preference.
Developing a realistic self-
concept. Learning more
about more opportunities.
Source: From Edwin L. Herr, Stanley H. Cramer, and Spencer Niles, Career Guidance and Counseling Through the Life Span: Systematic Approaches, 6/e. Published by
Allyn and Bacon, Boston, MA. Copyright © 2004 by Pearson Education. Reprinted by permission of the publisher. Pearson Education, Inc.
 Chapter 13 • Career Counseling over the Life Span 299

a mental picture of themselves in relation to others. Support affirming the multiple dimensions
of this stage in Super’s theory has been substantiated (Palladino Schultheiss, Palma, & Manzi,
2005). During the process of growth, children become oriented to the world of work in many
ways (e.g., exploration, information, interests, etc.).
The second stage, exploration (ages 14–24), has three substages: tentative (ages 14–17),
transition (ages 18–21), and trial (ages 22–24). The major task of this stage is a general explora-
tion of the world of work and the specification of a career preference.
The third stage is known as establishment (ages 24–44). Its two substages, trial (ages
24–30) and advancement (ages 31–44), constitute the major task of becoming established in a
preferred and appropriate field of work. Once established, persons can concentrate on advance-
ment until they tire of their job or reach the top of the profession.
The fourth stage, maintenance (ages 44–64), has the major task of preserving what one
has already achieved. The final stage, decline or disengagement (age 65 to death), is a time for
disengagement from work and alignment with other sources of satisfaction. It has two substages:
deceleration (ages 65–70) and retirement (age 71 to death).
The major contributions of developmental career counseling are its emphases on the
importance of the life span in career decision making and on career decisions that are influenced
by other processes and events in a person’s life. This “life pattern paradigm for career counseling
encourages counselors to consider a client’s aptitudes and interests in a matrix of life experi-
ences, not just in comparison to some normative group” (Savickas, 1989, p. 127).
The developmental approach can be conceptualized as career-pattern counseling (Super,
1954a). Although this method has been criticized for its historical and descriptive emphases,
these features, along with the conceptual depth of the theory, have also been considered strengths
(Herr, 1997). Overall, developmental career counseling as conceptualized by Super has a num-
ber of applications. “For example, it has been used as the framework for career development
programs for children and adolescents” (Brown, 2012, p. 54). In addition, the comprehensive
rainbow theory that Super conceptualized toward the end of his life continues to attract research
interest (Super, 1990; Super, Thompson, & Lindeman, 1988) (Figure 13.2). Finally, the theory
has been used not only as the basis for career counseling but also for attempts at understanding
the development of career maturity. One of the drawbacks to Super’s approach, however, is its
applicability to groups other than those with a Eurocentric background, such as Asian Americans
who subscribe to more collaborative social values.

PERSONAL REFLECTION
How does Super’s developmental career theory fit with your own experience? Do you see any pat-
terns in your own professional development over time?

Social–Cognitive Career Theory

Social–cognitive career theory (SCCT) was first published in 1994 and has had a tremendous
impact on research regarding career choice. It stems from the initial work of Albert Bandura and
his emphasis on the triadic reciprocal model of causality, which assumes that personal attributes,
the environment, and overt behavior operate with each other in an interlocking bidirectional way
(Niles & Harris-Bowlsbey, 2013). The most important part of this triad is self-efficacy—that is,
“a person’s beliefs regarding her or his ability to successfully perform a particular task” (Maples
& Luzzo, 2005, p. 275).
300 Part IV • Counseling Specialties

SITUATIONAL DETERMINANTS:
HISTORICAL AND
SOCIOECONOMIC
Maintenance
40 45
35 Homemaker 50

30 55
Establishment
Worker 60
25
Citizen
65
20 Leisurite
Decline
Student 70
15

Exploration Child
75
10

Growth PERSONAL DETERMINANTS: 80

5 PSYCHOLOGICAL AND
BIOLOGICAL
LIFE STAGES AND AGES AGES AND LIFE STAGES

FIGURE 13.2 Super’s rainbow theory: Six life roles in schematic life space
Source: From Super, D. E. (1980). A life-span, life-space approach to career development. Journal of Vocational Behavior, 16, 282–298.
© 1980. Published by Academic Press. Reprinted by permission. Elsevier Ltd.

Among other central propositions of SCCT are the following:

1. “The interaction between people and their environments is highly dynamic” (i.e., they
influence each other)
2. “Career-related behavior is influenced by four aspects of the person: behavior, self-
efficacy, outcome expectations, and goals in addition to genetically determined character-
istics”
3. “Self-efficacy beliefs and expectations of outcomes interact directly to influence interest
development”
4. In addition to expectations of outcome, factors such as “gender, race, physical health, dis-
abilities, and environmental variables influence self-efficacy development”
5. “Actual career choice and implementation are influenced by a number of direct and indirect
variables other than self-efficacy, expectations, and goals” (e.g., discrimination, economic
variables, and chance happenings)
6. “All things being equal, people with the highest levels of ability and the strongest self-
efficacy beliefs perform at the highest level” (Brown, 2012, p. 69).
One other important assumption of SCCT is that “self-efficacy and interests are linked”
and interests “can be developed or strengthened using modeling, encouragement, and most
powerfully, by performance enactment. Therefore, groups of clients, such as women [and
cultural minorities] who may have little opportunity to engage in certain activities because
of sex-typing [or discrimination], can benefit from the application of this theory” (Brown,
2012, p. 70).
 Chapter 13 • Career Counseling over the Life Span 301

Social–cognitive career theory can be used in a number of settings. For instance, it can be
used with rural Appalachian youth to help them develop, change, and go after career interests
(Ali & Saunders, 2006). It can also be used with first-generation college students who need
information that will counteract incorrect beliefs they may have (Gibbons & Shoffner, 2004).
Overall, SCCT-based interventions can be used with diverse groups. “An additional strength of
SCCT is that it addresses both intra-individual and contextual variables in career development”
(Niles & Harris-Bowlsbey, 2013, p. 91).
Krumboltz (1979, 1996) has formulated an equally comprehensive but less developmental
social–cognitive approach to career development. He takes the position that four factors influ-
ence a person’s career choice:
• genetic endowment,
• conditions and events in the environment,
• learning experiences, and
• task-approach skills (e.g., values, work habits).
According to Krumboltz, career decisions are controlled by both internal and external pro-
cesses. There is continuous learning that results in what Krumboltz labels
• self-observation generalizations, an overt or covert self-statement of evaluation that may
or may not be true;
• task-approach skills, an effort by people to project their self-observation generalizations
into the future in order to predict future events; and
• actions, implementations of behaviors, such as applying for a job.
Overall, a strength of Krumboltz’s theory is that it views people as having some control
over events they find reinforcing. Whereas individuals and the world change, persons can learn
to take advantage of learning opportunities and make career decisions accordingly. “In sum-
mary, Krumboltz outlines a dynamic approach to career counseling that can be applied to males
and females, as well as to racial and ethnic minorities who have individualistic perspectives”
(Brown, 2012, p. 68).

Constructivist Career Theory

Constructivist career theory is based on meaning-making. People create this meaning in their
lives. It is an interactive process. As clients talk, career counselors communicate with them about
their understanding of the client’s own worlds. It is through clients’ understanding of their role(s)
in their worlds that they, the clients, can understand what factors affect them in their decision mak-
ing, what people and values are most important to them, and what they need in order to achieve
their goals (Savickas, 2005). For instance, Fred talks to his career counselor about superheroes in
his life and how he has always wanted to be one. He is thinking about joining the armed forces or
the police force instead of going to a university. His values are to work with others and save lives.
In constructivist career theory, careers do not unfold. Rather, they are developed as indi-
viduals “make choices that express their self-concepts and substantiate their goals in the social
reality of work roles” (p. 43). The theory is subjective in asserting that individuals construct their
careers by imposing meaning on their vocational behaviors and occupational experiences. It is
the patterning of experiences, not the sum of them, which produces meaningful stories. In telling
their stories, individuals highlight narrative truths by which they live and aspire to live. It is the
implementation of self-concepts that is at the heart of this approach. Purpose, rather than traits,
302 Part IV • Counseling Specialties

as in trait-factor theory, compose life themes that in turn explain and control behaviors, “sustain
identity coherence, and foresee future actions” (p.44).
In constructionist career theory, Holland’s hexagon of personality and work environment
types (RIASEC) is utilized as a bridge in the process of helping individuals transition between
career content and career process. Likewise Super’s developmental model provides an outline of
an occupational maxicycle that is structured and valid for some. What usually happens, though,
is that individuals go through minicycles in their careers and adapt to environments that, if they
are successful, allow them to implement their self-concepts in occupational roles.
Savickas and the constructionists focus with clients on the why of a career. In other words,
what does a person find attractive about becoming or acquiring skills in a certain area? The rea-
sons are traced back to childhood, such as the heroes the person had as a child and the television
characters and magazines the person found most attractive. The what and the how are also con-
sidered by constructionist career counseling as they seek to be comprehensive as well as relevant
in the twenty-first century (Vess & Lara, 2016). Overall, the constructionist theory emphasizes
flexibility, employability, commitment, emotional intelligence, and lifelong learning (Savickas,
2012). The perspective is a “fundamental reordering of career counseling theory that envisions
career intervention from a different perspective and elaborates it from new premises about self
and identity” (p. 14).

PERSONAL REFLECTION
How does your study of counseling fit with your self-concept? Be as specific as you can.

CAREER COUNSELING WITH DIVERSE POPULATIONS

Career counseling and education are conducted with a wide variety of individuals in diverse set-
tings. Brown (1985, 2012) observes that career counseling typically is offered in college coun-
seling centers, rehabilitation facilities, employment offices, and public schools. He thinks it
could be applied with great advantage in many other places as well, including mental health
centers and private practice offices. Jesser (1983) agrees, asserting that there is a need to provide
career information and counseling to potential users, such as people who are unemployed, learn-
ing disabled, in prison, and those released from mental hospitals who seek to reenter the job
market. Reimbursement is a drawback to offering career counseling outside its traditional popu-
lations and settings. Career concerns are not covered in the DSM, and most health care coverage
excludes this service from reimbursement.
This lack of coverage is unfortunate because many people have difficulties making career
decisions. These difficulties are related to three factors present both prior to and during the
decision-making process. These factors are:
• lack of readiness,
• lack of information, and
• inconsistent information.
Because the concept of careers encompasses the life span, counselors who specialize in
this area find themselves working with a full age range of clients, from young children to octo-
genarians. Consequently, many different approaches and techniques have been developed for
working effectively with select groups.
 Chapter 13 • Career Counseling over the Life Span 303

Career Counseling with Children

The process of career development begins in the preschool years and becomes more direct in
elementary schools. Herr and colleagues (2004) cite numerous studies to show that during the
first 6 years of school, many children develop a relatively stable self-perception and make a ten-
tative commitment to a vocation. These processes are observed whether career counseling and
guidance activities are offered or not. Nevertheless, it is beneficial for children, especially those
who live in areas with limited employment opportunities, to have a broad, systematic program of
career counseling and guidance in the schools. Such programs should focus on awareness rather
than firm decision making. They should provide as many experiential activities as possible and
should help children realize that they have career choices. As children progress in the elementary
school grades, they should receive more detailed information about careers and become
acquainted with career opportunities that might transcend socioeconomic levels and gender
(Bobo, Hildreth, & Durodoye, 1998).
Jesser (1983) suggests that levels of career awareness in elementary school children may
be raised through activities such as field trips to local industries, bakeries, manufacturing plants,
or banks. For example, “because pizza is an immediate attention getter with elementary school
children, a field trip to a pizza restaurant can provide an entertaining learning experience” (Beale
& Nugent, 1996, p. 294). When such trips are carefully preplanned, implemented, and followed
up with appropriate classroom learning exercises (e.g., class discussions), children become
aware of a wider spectrum of related occupations, the value of work, and the importance of
teams in carrying out tasks. For instance, for a pizza parlor to run efficiently there have to be
dishwashers, cashiers, managers, and servers as well as pizza makers.
Dishwasher
Pizza maker

Taste Waitress staff

tester

Public
relations

Cashier

Manager

Clean-up crew

Other ways of expanding children’s awareness of careers are through “inviting parents into
the elementary classroom and encouraging parents to invite students into their work environ-
ments” (Wahl & Blackhurst, 2000, p. 372). Such a process capitalizes on parents’ influence as
role models and may be especially helpful for children whose parents are unemployed or under-
employed. To break down children’s stereotypes connected with careers, persons who hold non-
traditional occupations may be invited to speak. Reading stories about or seeing videos about
persons and their typical activities on jobs may likewise be helpful. For example, the Children’s
Dictionary of Occupations (Paramore, Hopke, & Drier, 2004) and other publications like it that
contain student activity packages are excellent sources of accurate information.
304 Part IV • Counseling Specialties

Splete (1982b) outlines a comprehensive program for working with children that includes
parent education and classroom discussions jointly planned by the teacher and counselor. He
emphasizes that there are three key career development areas at the elementary school level: self-
awareness (i.e., one’s uniqueness), career awareness and exploration, and decision making. Well-
designed career guidance and counseling programs that are implemented at an early age and
coordinated with programs across all levels of the educational system can go a long way toward
dispelling irrational and decision-hindering career development myths, such as “a career decision
is an event that should occur at a specific point in time” (Lewis & Gilhousen, 1981, p. 297).

PERSONAL REFLECTION
Think about careers that you aspired to during childhood (before the age of 12). List as many as you
can think of but at least five. How similar are they to each other according to John Holland’s code?
How similar are they to the profession of counseling?

Career Counseling with Adolescents

In working with adolescents in regard to career matters, the American School Counselor
Association (ASCA) National Model (2012) emphasizes that school counselors should provide
career counseling on a school-wide basis. This service should involve others, both inside and
outside the school, in its delivery.
Cole (1982) stresses that in middle school, career guidance activities should include the
exploration of work opportunities and students’ evaluation of their own strengths and weak-
nesses in regard to possible future careers. Assets that students should become aware of and
begin to evaluate include talents and skills, general intelligence, motivation level, friends, fam-
ily, life experience, appearance, and health (Campbell, 1974). “Applied arts curriculum such as
industrial arts (applied technology), home economics (family life education) and computer lit-
eracy classes … offer ideal opportunities for integrated career education. Libraries and/or career
centers may have special middle level computerized career information delivery systems
(CIDS) for student use” (National Occupational Information Coordinating Committee [NOICC],
1994, p. 9). The four components common to most CIDS are assessment, occupational search,
occupational information, and educational information (Gysbers et al., 2014). Overall, “career
exploration is an important complement to the intellectual and social development” of middle
school students (Craig, Contreras, & Peterson, 2000, p. 24).
At the senior high school, career guidance and counseling activities are related to students’
maturity. Some students know themselves better than others. Regardless, many high school stu-
dents benefit from using self-knowledge as a beginning point for exploring careers (Roudebush,
2011). The greatest challenge and need for career development programs occur on this level,
especially in the area of acquiring basic skills (Bynner, 1997). In general, career counseling at
the high school level has three emphases: stimulating career development, providing treatment,
and aiding placement. More specifically, counselors provide students with reassurance, informa-
tion, emotional support, reality testing, planning strategies, attitude clarification, and work expe-
riences, depending on a student’s needs and level of functioning (Herr et al., 2004).
Several techniques have proven quite effective in helping adolescents crystallize ideas
about careers. Some are mainly cognitive whereas others are more experiential and comprehen-
sive. Among the cognitive techniques is the use of guided fantasies, such as imagining a typical
day in the future, an awards ceremony, a midcareer change, or retirement (Morgan & Skovholt,
 Chapter 13 • Career Counseling over the Life Span 305

1977). Another cognitive technique involves the providing of fundamental information about
career entry and development. For example, a career day or a career fair “featuring employers
and professionals from a variety of occupations allows students to make a realistic comparison
of each occupation’s primary duties, day-to-day activities, and training needs” (Wahl &
Blackhurst, 2000, p. 372). Completing an occupational family tree to find out how present inter-
ests compare with the careers of family members is a final cognitive approach that may be useful
(Dickson & Parmerlee, 1980).
Aunt Ann – financial
analysis Uncle Fred – physician
Sister – accountant
Cousin Ralph – physician

Paternal Brother –
Grandfather – farmer Cousin physician
Jane – banker
Mother – teacher
Paternal
Grandmother – cashier Father – banker

My Occupational Tree

More experiential and comprehensive techniques include offering youth apprenticeships.

These apprenticeships are a popular approach that provides work-based learning for adolescents.
Apprenticeships also help students who are not college-bound make a smooth transition from
high school to the primary work environment. Although apprenticeships hold much promise,
they pose several challenges for career counselors such as

(a) helping clients learn adaptive skills that will enable them to change with change, (b) helping
clients find ways to acquire the kinds of work [identified in government reports], and
(c) helping clients to develop a personally meaningful set of work values that will enable them
to humanize the workplace for themselves and thus receive the personal satisfaction that comes
from true work. (Hoyt, 1994, p. 222)

In addition to helping youth in school, career counselors must make special efforts to help
high school students who leave school before graduation (Rumberger, 1987). These young peo-
ple are at risk of unemployment or underemployment for the rest of their lives. Educational and
experiential programs, such as Mann’s (1986) four Cs (cash, care, computers, and coali-
tions), can help at-risk students become involved in career exploration and development.
According to Bloch (1988, 1989), successful educational counseling programs for students at
risk of dropping out should follow six guidelines:
1. They make a connection between a student’s present and future status (i.e., cash—
students are paid for attending).
2. They individualize programs and communicate caring.
306 Part IV • Counseling Specialties

3. They form successful coalitions with community institutions and businesses.

4. They integrate sequencing of career development activities.
5. They offer age- and stage-appropriate career development activities.
6. They use a wide variety of media and career development resources, including
computers.

Career Counseling with College Students

“Committing to a career choice is one of the main psychosocial tasks that college students face”
(Osborn, Howard, & Leierer, 2007, p. 365). Approximately half of all college students experi-
ence career-related problems (Herr et al., 2004). Part of the reason is that despite appearances
“most college students are rarely the informed consumers that they are assumed to be” (Laker,
2002, p. 61). Therefore, college students need and value career counseling services, such as
undergraduate career exploration courses (Osborn et al., 2007). Even students who have already
decided on their college majors and careers seek such services both to validate their choices and
seek additional information. As Erikson (1963) stated: “it is primarily the inability to settle on an
occupational identity which disturbs young people” (p. 252).
In responding to student needs, comprehensive career guidance and counseling programs in
institutions of higher education attempt to provide a number of services. Among these services are
• helping with the selection of a major field of study;
• offering self-assessment and self-analysis through psychological testing;
• helping students understand the world of work;
• facilitating access to employment opportunities through career fairs, internships, and cam-
pus interviews;
• teaching decision-making skills; and
• meeting the needs of special populations (Herr et al., 2004).
College counseling centers can also offer group career counseling. Such a service has been
found to make a significantly greater increase in career decision-making abilities for students
participating in a group than for those not participating (Rowell, Mobley, Kemer, & Giordano,
2014). Part of the reason was group members’ added processing of external as well as internal
information (Pyle, 2007).
Besides offering these options, students need “life-career developmental counseling,”
too (Engels, Jacobs, & Kern, 2000). This broader approach seeks to help people plan for future
careers while “balancing and integrating life-work roles and responsibilities” in an appropriate
way, for example, being a worker and a family member, parent, and citizen” (p. 192). Anticipating
problems related to work, intimate relationships, and responsibilities is an important career-
related counseling service counselors can offer college students. Counselors can often be the
bridge that connects college students to school and work (Murphy, Blustein, Bohlig, & Platt,
2010). By sharing information pertinent to their intended career field and knowledge about the
emerging adulthood transition, counselors can help prepare these students for their first work
experience and beyond (Kennedy, 2008a). Such knowledge can help prevent work–family con-
flicts (WFC) that might otherwise arise and negatively affect a person’s behavior, emotions, and
health (Frone, 2003).
Despite all of the services institutions of higher education offer, some college students sabo-
tage their career decisions by adopting maladaptive perfectionism and dysfunctional career think-
ing. Interventions addressing these maladies in career decision making can enhance students’
 Chapter 13 • Career Counseling over the Life Span 307

confidence and help them be more realistic (Andrews, Bullock-Yowell, Dahlen, & Nicholson,
2014). One way this is done is through the creation of realistic job previews (RJPs) of a specific
job. The process involves contacting and interviewing people with knowledge about the careers
that the students are considering. RJPs ultimately benefit potential job seekers in an occupation by
both decreasing employee turnover and by increasing employee satisfaction (Laker, 2002).
Students should supplement these types of interviews by completing computer-based career plan-
ning systems (CBCPSs) such as DISCOVER. The reason is that the completion of such systems
is active, immediate, empowering, and rewarded with a printed result that promotes self-efficacy
and the likelihood that individuals will complete other career-exploratory behaviors (Maples &
Luzzo, 2005).
Despite preparation, economic factors, such as a recession, can impact the initial career
decision of college graduates. Thus while many college graduates in 2008 were whisked off to
high-paying jobs in consulting and finance, the graduates of the barren years of 2009 and 2010
were not. The result was that more young people were employed in public service positions,
such as government and nonprofits. Applications for AmeriCorps positions nearly tripled to
258,829 in 2010 from 91,399 in 2008 and the number of applicants for Teach for America
climbed 32% during the same time to a record 46,359 (Rampell, 2010).

Career Counseling with Adults

Career interest patterns tend to be more stable after college than during college. Emerging adults
(young adults from 18 up to age 30) are especially in need of relationship support and space to
develop autonomy and competence as they transition from college to career (Murphy et al.,
2010). However, many older adults continue to need and seek career counseling even into late
adulthood (adults 65 years and older) (AARP, www.aarp.org; Swanson & Hansen, 1988).
Indeed, adults experience cyclical periods of stability and transition throughout their lives, and
career change is a developmental as well as situational expectation at the adult stage of life
(Kerka, 1991).
Developmentally, some adults have a midlife career change that occurs as they enter their
40s and what Erik Erikson described as a stage of generativity versus stagnation. At this time,
adults may change careers as they become more introspective and seek to put more meaning in
their lives. Situationally, adults may seek career changes after a trauma such as a death, layoff, or
divorce (Marino, 1996).
Adults may have particularly difficult times with their careers and career decisions when
they find “themselves unhappy in their work yet feel appropriately ambivalent about switching
directions” (Lowman, 1993, p. 549). In such situations they may create illogical or troublesome
career beliefs that become self-fulfilling and self-defeating (J. Krumboltz, 1992). An example of
such a belief is “I’ll never find a job I really like.” It is crucial in such cases to help people
change their ways of thinking and become more realistic.
There are two dominant ways of working with adults in career counseling: the differ-
ential approach and the developmental approach. The differential approach stresses that “the
typology of persons and environments is more useful than any life stage strategies for coping
with career problems” (Holland & Gottfredson, 1976, p. 23). It avoids age-related stereotypes,
gender and minority group issues, and the scientific and practical difficulties of dealing with life-
span problems. “At any age, the level and quality of a person’s vocational coping is a function of
the interaction of personality type and type of environment plus the consistency and differentia-
tion of each” (Holland & Gottfredson, 1976, p. 23).
308 Part IV • Counseling Specialties

According to this view, a career counselor who is aware of typological formulations such
as Holland’s can predict the characteristic ways a given person may cope with career problems.
For example, a person with a well-defined social/artistic personality (typical of many individu-
als employed as counselors) would be expected to have high educational and vocational aspira-
tions, to have good decision-making ability, to have a strong and lifelong interest in learning, to
have moderate personal competency, and to have a marked interest in creative and high-level
performance rather than in leadership (Holland, 1997). A person with such a profile would also
have a tendency to remold or leave an environment in the face of adversity. A major advantage
of working from this approach is the ease with which it explains career shifts at any age. People
who shift careers, at any point in life, seek to find more consistency between personality and
environment.
The developmental approach examines a greater number of individual and environ-
mental variables. “The experiences people have with events, situations and other people play
a large part in determining their identities (i.e., what they believe and value, how they respond
to others, and what their own self images are)” (Gladstein & Apfel, 1987, p. 181).
Developmental life-span career theory proposes that adults are always in the process of
evaluating themselves in regard to how they are affected by outside environmental influences
(e.g., spouse, family, friends) and how they impact these variables. Okun (1984) and Gladstein
and Apfel (1987) believe the interplay of other people and events strongly influences career
decisions in adulthood.
Gladstein and Apfel’s (1987) approach to adult career counseling focuses on a combina-
tion of six elements: developmental, comprehensive, self-in-group, longitudinal, mutual com-
mitment, and multimethodological. These elements work together in the process of change at
this stage of life. This model, which has been implemented on a practical level at the University
of Rochester Adult Counseling Center, considers the person’s total identity over time. In a
related model, Chusmir (1990) stresses the interaction of multiple factors in the process that men
undergo when choosing nontraditional careers (careers in which people of one gender are not
usually employed). Whether or not careers are nontraditional, the fact is that many forces enter
into career decisions.

CASE EXAMPLE
Dick Becomes Differentiated
Dick had struggled with holding a job for years. He moved from one position to another as a
cook, a sanitation engineer, a security officer, and a landscaper. Not being satisfied with any of
his work, at 29 he went to see Susan, a career counselor.
Susan gave Dick several inventories, including those on O*Net. She noted from Dick’s
results that he had a predominant artistic and social theme, which was just the opposite of the
realistic and conventional jobs he had been dissatisfied with. Susan then explored with Dick
what he could do at various levels of education with this predominant theme and, through the use
of the Occupational Outlook Handbook, what job growth was expected in each area.
Dick decided to enroll in a local community college and further his education so that he
could pursue a career in the entertainment industry. He was pleased. As he said to Susan in leav-
ing: “This type of career just feels right for me.”
 Chapter 13 • Career Counseling over the Life Span 309

Career Counseling with Women and Ethnic Minorities

“Many of the assumptions inherent in traditional theories of career development fall short in
their application to women and ethnic minorities” (Luzzo & McWhirter, 2001, p. 61). Women
and ethnic minorities historically have received less adequate career counseling than European
American males have and have faced more barriers in pursuit of their careers (Brown, 2002).
The reason has often involved stereotypical beliefs and practices connected with these two
groups (Herr et al., 2004). For example, society has generally assumed that women will have
discontinuous career patterns to accommodate their families’ needs. Likewise, ethnic minorities
have often been viewed as interested in only a limited number of occupations. The growing
social activism among women and ethnic minority groups, combined with a growing body of
research, are helping challenge constraining negative forces and create models of career counsel-
ing for these populations (Peterson & Gonzalez, 2000). That is why, among other reasons, career
counselors should promote social justice in the workplace.

WOMEN. Gender-based career patterns for women have changed for several reasons. For one
thing, more than 70 percent of women in the United States now work for wages (Greenstone &
Looney, 2011). Furthermore, “children are being exposed to greater and more varied career
choices. Additionally, women have moved into careers previously reserved for men, thereby
creating a broader range in the role models they provide girls” (Bobo et al., 1998, pp. 40–41).
Since 1970, there has been a dramatic rise in research on and interest in the career develop-
ment of women (King & Knight, 2011; Luzzo & McWhirter, 2001; Whitmarsh, Brown, Cooper,
Hawkins-Rodgers, & Wentworth, 2007). “Research on women’s career development has identi-
fied both internal and external barriers associated with women’s career development, document-
ing that the process of career decision making and maintaining a career are more complex and
restricted for women than for men” (Sullivan & Mahalik, 2000, p. 54). One aspect of the com-
plexity of career development for women is what is known as the work–family conflict, where
there is a clash between work responsibilities such as working late and family responsibilities
such as picking up children at day care (Slan-Jerusalim & Chen, 2009). This conflict may result
in role overload (competing and sometimes conflicting demands for multiple roles expected of
a person, such as breadwinner, breadmaker, parent, community service worker) (Pearson, 2008).
In such a situation there is little to no time left over for leisure, which has an impact on a person’s
sense of “psychological health and overall well-being” (p. 57). Complicating matters even fur-
ther, many theories of career development cannot be appropriately applied to women because
they were formulated for men or are incomplete (Cook, Heppner, & O’Brien, 2002; Gottfredson,
2005; Jackson & Scharman, 2002).
Therefore, in working with women, counselors need to realize they are often entering new
territory and must watch out for and resist occupational sex-role stereotyping, even at the ele-
mentary school level (McMahon & Patton, 1997). Common stereotypes include viewing women
as primarily mothers (nurturing), children (dependent), iron maidens (hard driving), and sex
objects (Gysbers et al., 2014), or mistakenly assuming that, as a group, females prefer social,
artistic, and conventional occupations as opposed to realistic, investigative, and enterprising
occupations (Tomlinson & Evans-Hughes, 1991).
In addition, there is the “glass ceiling” phenomenon in which women are seen as able to
rise only so far in a corporation because they are not viewed as being able to perform top-level
executive duties. When these myths are accepted, girls and women are not challenged to explore
their abilities and possibilities and, as a result, some women fail to develop their abilities or gifts
310 Part IV • Counseling Specialties

to the fullest. Consequently, they never work; develop a low or moderate commitment to work;
or focus on “safe,” traditional, female-dominated occupations such as teaching, clerical work,
nursing, or social services (Betz & Fitzgerald, 1987; Brown, 2002; Walsh & Heppner, 2006).
Some other barriers outside these myths also must be considered in career counseling for
women. For instance, a company culture may revolve around the expectation of working far
more hours than may be described in a job description, in attending certain events, or being “one
of the guys.” Thus, women must overcome these realities, as well as the myths that surround
them, in order to achieve career goals (Luzzo & McWhirter, 2001). Counselors may advise them
that they may more readily find a job that is not in a female-dominated occupational field by
socially contacting men rather than women (Mencken & Winfield, 2000). Overcoming barriers
and misperceptions and finding balance is an essential part of the counseling process.
To understand how women may combine a career and a family, Jackson and Scharman
(2002) studied a national sample of “26 women identified as having creatively constructed their
careers to maximize time with their families” (p. 181). Eight different themes emerged as to how
these women managed to construct family-friendly careers. Their strategies ranged from “peaceful
trade-offs” to “partner career flexibility.” However, “each participant found satisfying solutions to
combining career and family that did not require an either/or choice” (p. 184). Overall, these
women demonstrated remarkable self-efficacy (i.e., confidence in themselves to cope with or man-
age complex or difficult situations). This ability is becoming an increasingly important factor in the
career development of women. Career self-efficacy is one that can be increased through working
with women in groups to address factors that compose it, such as performance accomplishments,
vicarious experiences, emotional arousal, and verbal persuasion (Sullivan & Mahalik, 2000).
Another helpful career counseling strategy in working with women, especially if they are
depressed and indecisive about a career, is to offer “career plus life counseling, meaning that in
counseling they [the women] focus on personal and relationship issues in addition to explicit
career issues” (Lucas, Skokowski, & Ancis, 2000, p. 325). An ecological perspective, where
career counselors work with women on career development issues in the context and complexity
of the environment in which they live, is increasingly gaining recognition as a way of helping
women become more empowered and shape their futures (Cook et al., 2002).
An area that warrants counselors’ attention in career counseling with women in the future
is demographics and trends. The labor market has shifted from goods-producing to service-
producing industries (Van Buren, Kelly, & Hall, 1993). Service jobs are those such as sales clerk
and computer operator. When young women take these jobs when they are qualified to pursue
higher paying, nontraditional careers in skilled trades, they become more subjected to economic
forces such as poverty, social welfare, and dependence on men that are not in their or society’s
best interest. Therefore, there is “an urgent need for career counseling interventions” offered
through live or video modeling “that will persuade young women to consider the economic ben-
efits of nontraditional career choices” or choices that are in line with their real interests (Van
Buren et al., 1993, p. 101). Interestingly, more women are beginning to pursue their career inter-
ests and in recent years have been turning to enterprising occupations where they may earn more
and be more in charge of their lives (Reardon et al., 2007).

PERSONAL REFLECTION
From all you have read in this chapter, as well as your own observations, why is it important to have
different theories and approaches for career counseling with women? Do you think some theories
and approaches apply equally to both sexes?
 Chapter 13 • Career Counseling over the Life Span 311

CULTURAL MINORITIES. “Career counseling must incorporate different variables and different
processes to be effective for clients from different cultural contexts” (Fouad & Byars-Winston,
2005, p. 223). Yet cultural minorities are so diverse that it is almost impossible to focus on all the
factors that career counselors must deal with in working with them individually or collectively.
Many cultural minorities have difficulty obtaining meaningful employment because of
employers’ discrimination practices, lack of marketable skills, and limited access to informal
networks that lead to good jobs (Leong, 1995; Turner & Conkel, 2010). Therefore, many racial/
ethnic minorities are “concentrated in lower level positions and unskilled occupations” (Fouad &
Byars-Winston, 2005, p. 223). In addition, the interest patterns of cultural minorities (as a group)
have tended not to necessarily fall within Holland’s (1997) circular RIASEC ordering in the
same way European Americans have, thus presenting challenges for many career counselors in
regard to helping them (Osipow & Fitzgerald, 1996). Whereas about 27% of adults in the United
States express a need for assistance in finding information about work, the rate is much higher
among specific minority populations: African Americans, 44%; Asian/Pacific Islanders, 36%;
and Hispanics/Latinos, 35% (National Career Development Association [NCDA], 1990).
Counselors must remember that cultural minorities have special needs in regard to establishing
themselves in careers. Thus, counselors need to be sensitive to such issues and at the same time help
individuals overcome artificial and real barriers that prohibit them from maximizing their potential.
For instance, compared to White students, Black college students are more attracted to future income
and future status when making a career choice (Daire, LaMothe, & Fuller, 2007). Likewise, some
Black youths who have lived in poverty all their lives are characterized as vocationally handicapped
because “they have few positive work-related experiences, limited educational opportunities, and
frequently lack positive work role models” (Dunn & Veltman, 1989, pp. 156–157). Structured pro-
grams for these individuals use positive role models and experiences to affirm cultural or ethnic
heritage and abilities, thus working to address and overcome traditional restrictions (Drummond &
Ryan, 1995; Locke & Faubert, 1993). In the process, counselors help these youths, as they do others,
to distinguish between barriers over which they have control and responsibility for transcending
those which they may not have the capacity to overcome (Albert & Luzzo, 1999).
Career awareness programs for Chinese American and Korean American parents have also
proven beneficial (Evanoski & Tse, 1989). In these Asian cultures, parents traditionally make
career decisions for their children, regardless of the children’s interests. By staging neighbor-
hood workshops to introduce parents to American career opportunities, a greater variety of
choices is opened to all concerned. The success of such workshops is due to bilingual role mod-
els and career guidance materials written in the participants’ language.
Finally, when working with inner city youth in the area of careers, counselors need to real-
ize that traditional theories of career development may not work well. In essence many of these
theories are middle class and are not a good fit for the environment in which these young people
grow up because inner city youth face the challenge of overcoming the effects of poverty, minor-
ity status, and lack of opportunity. To gain adaptive advantages in the current and future labor
markets, young people need to acquire an integrated set of vocational development skills (Turner
& Conkel, 2010, p. 463).
Career development gains can be increased by using the Integrative Contextual Model
of Career Development (ICM). ICM is a career model, drawn from different theoretical per-
spectives, that includes the skills of self- and career-exploration; person-environment fit; goal
setting; social, prosocial, and work readiness skills; self-regulated learning; and the utilization of
social support. Although this approach still needs more empirical research, it has been found to
be effective with middle school students.
312 Part IV • Counseling Specialties

Career Counseling with Gays, Lesbians, Bisexuals, and Transgenders

Special diverse groups not often considered in career counseling are lesbians, gays, bisexuals,
and transgenders (LGBT). These individuals face unique concerns as well as many that are com-
mon to other groups. Of special concern to many LGBT individuals is whether to be overt or
covert in disclosing their sexual orientation at work (Chojnacki & Gelberg, 1994). Persons with
minority sexual orientations face personal and professional developmental concerns, including
discrimination, if they openly acknowledge their beliefs and practices (Degges-White &
Shoffner, 2002; O’Ryan & McFarland, 2010). This may be especially true if gay members of this
population are in male-dominated occupations, which tend to be more homophobic than other
occupational groups (Jome, Surething, & Taylor, 2005). To overcome the difficulties they face,
O’Ryan & McFarland (2010) found that dual-career lesbian and gay couples use three primary
strategies: planfulness, creating positive social networks, and shifting from marginalization to
consolidation and integration.
Although traditional career-counseling methods are usually appropriate with individuals
of all sexual orientations, special attention should be given to helping LGBT individuals assess
the fit between their lifestyle preferences and specific work environments. Sexual orientation
cannot be ignored as an important variable in career counseling if the process is to be construc-
tive (Croteau & Thiel, 1993; Degges-White & Shoffner, 2002).
In working with members of this population, career counselors must evaluate both
their and the surrounding community’s stereotyping of LGBT individuals. In such an
appraisal, they must gauge personal, professional, and environmental bias toward people
who are not heterosexual. In addition, they need to use gender-free language and become
familiar with support networks that are within their communities for members of these
groups. Furthermore, they need to become informed about overt and covert discrimination in
the workplace, such as blackmail, ostracism, harassment, exclusion, and termination. The
“lavender ceiling” also needs to be discussed with gays, lesbians, bisexuals, and transgen-
ders. This barrier to advancement in a career is the equivalent to the glass ceiling for women,
where a career plateaus early due to discreet prejudice by upper management against persons
because of beliefs about them related to their sexuality (Friskopp & Silverstein, 1995;
Zunker, 2016).

CASE EXAMPLE
David and His Career Decision
David struggled. He was a gay African American man who was just finishing college and had no
idea what to do with his life. He was accepted in his neighborhood but he wondered about how
well he would be accepted in a work environment. He was particularly interested in business and
the culinary arts. His Holland code was AS/ER/CI.
After working with a career counselor at his college, David decided to set up a catering
service. He was a good cook and had a flare for organization as well as a disciplined style with
his money. He thought by starting such a business; he could be successful, meet people, and
avoid blatant prejudice outside his neighborhood. His career counselor was not as sure as David
that his choice was a good one.
What do you think about David’s career choice? What other options might he have?
 Chapter 13 • Career Counseling over the Life Span 313

Summary and Conclusion

This chapter has covered information on various ethnicity, and the social milieu, combine to influence
aspects of career counseling including its importance career decisions. Developments around the world,
and the associations within counseling, such as the especially in technology, are impacting the field of
NCDA and NECA, which are particularly concerned careers as well. “The information age continues to
with its development. Major theories of career coun- alter the number of job openings as well as the way
seling—trait-and-factor, developmental, social– in which a wide variety of jobs are done” (Walls &
cognitive, and constructivist—were reviewed. Career Fullmer, 1996, p. 154). As advancing technology
counseling with particular populations—especially creates new or modifies old kinds of jobs, previously
individuals at different developmental ages and stages valued skills and entire occupations may diminish or
in life, women, cultural minorities, and those with dis- vanish. Therefore, career counseling is becoming
tinct sexual orientation—were examined, too. ever more important, and counselors who are going
Overall, multiple factors, including inner to be relevant to their clients must be knowledgeable
needs and drives and external circumstances such as about procedures and practices in this field across
the economy, gender, educational attainment, the life span.

MyCounselingLab® for Introduction to Counseling

Try the Topic 2 Assignments: Career/Individual/Development Counseling.
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