Counseling Theories and Case Conceptualization [1 ed.] 9780826182913, 9780826182920, 9780826182968, 9780826182937, 9780826182944, 9780826182951, 9780826183392

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Counseling Theories and Case Conceptualization A PRACTICE-BASED APPROACH

EDITORS

Stephen V. Flynn Joshua J. Castleberry

COUNSELING THEORIES AND CASE CONCEPTUALIZATION

Stephen V. Flynn, PhD, LPC, LMFT-S, NCC, ACS, is a professor of counselor education‌‌‌‌‌‌, a research fellow, the founding director of the Marriage and Family Therapy program, and the Play Therapy program coordinator at Plymouth State University in Plymouth, New Hampshire. Dr. Flynn earned his MA degree from Rowan University and his PhD from the University of Northern Colorado. He teaches counseling; couple, marriage, and family; child and adolescent; and research and writing courses for the Counselor Education, Marriage and Family Therapy, and Educational Leadership graduate programs at Plymouth State University. He is a licensed professional counselor (Colorado), a licensed marriage and family therapist (LMFT; Colorado, New Hampshire), a national certified counselor, an approved clinical supervisor, an American Association for Marriage and Family Therapy (AAMFT) clinical fellow, and an AAMFT approved supervisor. Dr. Flynn has diverse clinical experiences in a wide range of applied settings, including inpatient psychiatric care; ED multidisciplinary teams; agencies; residential treatment programs serving youth and families; wraparound services for youth and families; chemical dependency intensive outpatient programs; university counseling centers; as a private practice provider of individual, couple, and family counseling; and as the founding director of a university-based counseling and school psychological service center. Joshua J. Castleberry, PhD, NCC, is an assistant professor of counselor education‌‌‌‌‌‌ at Kent State University in Kent, Ohio. He earned his MS, EdS, and PhD degrees from Georgia State University. Dr. Castleberry teaches courses on counseling theories, case conceptualization, foundations of addiction, and psychopathology for graduate programs in Counselor Education and Supervision. He is also a regional epidemiologist for the Ohio Substance Abuse Monitoring (OSAM) team under the Ohio Department of Mental Health and Addiction Services (OMHAS), where he tracks drug trends in Southeastern Ohio. With a primary clinical focus on addiction, trauma, and crisis counseling, Dr. Castleberry has extensive experience as an addiction counselor, working with chemically dependent clients and advocating for counseling services to at-risk homeless populations. His research interests include clinical factors in populations experiencing poverty and issues related to self-development within a self-determination theoretical lens. Dr. Castleberry brings an extensive background in statistical modeling, data visualization, and analytical thinking to his research, as well as several years of experience working in nonprofit management and leadership. He is committed to advancing the counseling profession through his teaching, research, and clinical work.

COUNSELING THEORIES AND CASE CONCEPTUALIZATION A PRACTICE-BASED APPROACH Editors Stephen V. Flynn, PhD, LPC, LMFT-S, NCC, ACS Joshua J. Castleberry, PhD, NCC

Copyright © 2024 Springer Publishing Company, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Springer Publishing Company, LLC, or authorization through payment of the appropriate fees to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400, fax 978-646-8600, [email protected] or at www.copyright.com. Springer Publishing Company, LLC 11 West 42nd Street, New York, NY 10036 www.springerpub.com connect.springerpub.com Acquisitions Editor: Mindy Okura-Marszycki Production Editor: Rachel Haines Compositor: Pajeflow ISBN: 978-0-8261-8291-3 ebook ISBN: 978-0-8261-8292-0 DOI: 10.1891/9780826182920 SUPPLEMENTS: A robust set of instructor resources designed to supplement this text is available. Qualifying instructors may request access by emailing [email protected]. Instructor Materials: LMS Common Cartridge (All Instructor Resources and Instructions for Use) ISBN: 978-0-8261-8296-8 Instructor Manual ISBN: 978-0-8261-8293-7 Instructor Test Bank ISBN: 978-0-8261-8294-4 Instructor PowerPoints ISBN: 978-0-8261-8295-1 Student Materials: Video Transcripts ISBN: 978-0-8261-8339-2 23 24 25 26 27 / 5 4 3 2 1 Stephen V. Flynn: https://orcid.org/0000-0002-4806-1860 Joshua J. Castleberry: https://orcid.org/0000-0002-4041-3526 The author and the publisher of this Work have made every effort to use sources believed to be reliable to provide information that is accurate and compatible with the standards generally accepted at the time of publication. Because medical science is continually advancing, our knowledge base continues to expand. Therefore, as new information becomes available, changes in procedures become necessary. We recommend that the reader always consult current research and specific institutional policies before performing any clinical procedure or delivering any medication. The author and publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance on, the information contained in this book. The publisher has no responsibility for the persistence or accuracy of URLs for external or third-party Internet websites referred to in this publication and does not guarantee that any content on such websites is, or will remain, accurate or appropriate. Library of Congress Cataloging-in-Publication Data Names: Flynn, Stephen V., editor. | Castleberry, Joshua J., editor. Title: Counseling theories and case conceptualization : a practice-based approach / editors, Stephen V. Flynn, Joshua J. Castleberry. Description: New York, NY : Springer Publishing Company, LLC. [2024] | Includes bibliographical references and index. Identifiers: LCCN 2023029357 (print) | LCCN 2023029358 (ebook) | ISBN 9780826182913 (paperback) | ISBN 9780826182920 (ebook) Subjects: LCSH: Counseling—Textbooks. Classification: LCC BF636.6 .C6766 2024 (print) | LCC BF636.6 (ebook) | DDC 158.3—dc23/eng/20230726 LC record available at https://lccn.loc.gov/2023029357 LC ebook record available at https://lccn.loc.gov/2023029358 Contact [email protected] to receive discount rates on bulk purchases. Publisher’s Note: New and used products purchased from third-party sellers are not guaranteed for quality, authenticity, or access to any included digital components. Printed in the United States of America.

Stephen V. Flynn I dedicate this book to my spouse, Meredith, and our children, Corrina, Anelie, and Eliza, whose love inspires an endless amount of passion and creativity. Joshua J. Castleberry To Leigh, Eli, and Hannah—the three most important people in my life. Thank you for your unwavering love and support, which inspire me every day. This book is dedicated to you with all my heart.

CON TENTS Contributors  xv List of Videos   xvii Foreword  Nicole R. Hill  xix Preface  xxi Acknowledgments  xxvii Springer Publishing Resources   xxix

SECTION I. INTRODUCTION AND SOCIAL JUSTICE–ORIENTED THEORIES 1. Introduction to Theory and Case Conceptualization   3 Stephen V. Flynn and Joshua J. Castleberry Learning Objectives  3 Introduction to Theory and Case Conceptualization   3 Accreditation  6 The Theories of Counseling   10 Models of Case Conceptualization   13 Theoretical Models  15 Common Factor Models and Implications   19 Unitary Theory, Integration, Eclecticism, and Pluralism   22 Theoretical Multiculturalism, Intersectionality, and Social Justice   23 Theory Fit With Telebehavioral Interventions   24 Fitting the Person With the Approach   25 Dialectic Centered on Counseling Theory and Practitioner Humility   28 The Case of Mark Stockton   29 Summary  30 Student Exercises  31 Resources  32 References  33

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viii  |  CONTENTS 2. Multicultural Counseling Theory   34 Sherritta Hughes Learning Objectives  34 Introduction  34 Leaders and Legacies of Multicultural Counseling Theory   35 Metatheoretical Nature of Multicultural Counseling Theory   42 Modalities Used Within a Multicultural Counseling Framework   45 Intersecting Layers of Multicultural Counseling Theory: Three Frameworks   52 Recognizing and Eliminating Oppression, Inequality, and Marginalization   55 Descriptions of the Roles of Client and Counselor   56 Specific Theoretical Techniques Used in Multicultural Counseling Theory   57 Relevant Theory-Based Scholarship and Research   60 Detailed Case Conceptualization Pragmatics and Transcripts   64 Descriptions of How to Engage in Social Activism   70 Limitations  70 Summary  71 Voices From the Field   71 Student Exercises  72 Resources  75 References  76 3. Feminist Approaches   77 Amanda C. La Guardia Learning Objectives  77 Introduction  77 History, Leaders, and Legacies of Feminist Theory   77 Feminist Worldview  89 Approaches and Interventions   92 Process of Assessment   95 Detailed Case Conceptualization Pragmatics and Transcript   96 Summary  99 Voices From the Field   99 Student Exercises  100 Resources  100 References  101

SECTION II. TRADITIONAL AND RELATIONAL PSYCHOANALYTIC THEORIES 4. Traditional Psychoanalytic Approaches   105 Elyssa B. Smith, Andrea McGrath, Joshua Mangin, and Nicole Altenberg Learning Objectives  105 Introduction  105 Leaders and Legacies of Traditional Psychoanalytic Theory   105 Personality Development  108 Origins and Nature of Mental Health Concerns   109 Emotional and Psychological Well-Being   112

CONTENTS

Roles of Client and Counselor   112 Nature of Human Development   114 Process of Change   115 Clinical Assessment  116 Techniques  118 Multicultural, Intersectional, and Social Justice Issues   121 Scholarship and Research   123 Detailed Case Conceptualization Pragmatics and Transcript   124 Theoretical Limitations  126 Summary  127 Voices From the Field   127 Student Exercises  128 Resources  128 References  129 5. Relational Approaches to Psychoanalytic Treatment   131 Sherrie Bruner and Julianna Williams Learning Objectives  131 Introduction  131 Leaders and Legacies of Relational Approaches to Psychoanalytic Theory   131 Conceptualization of Personality   133 Conceptualization of Well-Being   138 Roles of Client and Counselor   138 Nature of Human Development   139 Process of Change   141 Clinical Assessment  143 Specific Theoretical Techniques   143 Multicultural, Intersectional, and Social Justice Issues   146 Research Trends  147 Detailed Case Conceptualization Pragmatics and Transcript   148 Theoretical Limitations  153 Summary  153 Voices From the Field   153 Student Exercises  154 Resources  154 References  155

SECTION III. PERSON-CENTERED, EXPERIENTIAL, AND EXISTENTIAL THEORIES 6. Person-Centered Counseling and Related Experiential Approaches   159 Elizabeth K. Norris, Tyler Wilkinson, and Jeff D. Cook Learning Objectives  159 Introduction  159 Leaders and Legacies of Person-Centered and Related Experiential Theories   159 Origin and Nature of Mental Health Concerns   162 Emotional and Psychological Well-Being   166

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x  |  CONTENTS Roles of the Client and Counselor   168 The Nature of Human Development   171 Process of Change   173 The Process of Maintaining Progress   176 Process of Clinical Assessment   177 Specific Theoretical Techniques   179 Theoretical Multicultural, Intersectional, and Social Justice Issues   181 Relevant Theory-Based Scholarship and Research Trends   182 Detailed Case Conceptualization Pragmatics and Transcript   183 Theoretical Limitations  184 Summary  185 Voices From the Field   185 Student Exercises  185 Resources  186 References  187 7. Existential-Humanistic Approaches   188 Joel Givens, Phillip L. Waalkes, and Paul H. Smith Learning Objectives  188 Introduction  188 Leaders and Legacies of Existential and Humanistic Theories   189 Origin and Nature of Mental Health Concerns   193 What Constitutes Emotional and Psychological Well-Being   195 Descriptions of the Roles of Client and Counselor   196 The Nature of Human Development   197 The Theory’s Process of Change   197 Description of How Progress Is Maintained   198 Process of Clinical Assessment   199 Specific Theoretical Techniques   200 Theoretical Multicultural, Intersectional, and Social Justice Issues   200 Relevant Theory-Based Scholarship and Research Trends   203 Detailed Case Conceptualization Pragmatics and Transcript   204 Theoretical Limitations  207 Summary  208 Voices From the Field   208 Student Exercises  209 Resources  210 References  211

SECTION IV. BEHAVIORAL AND COGNITIVE THEORIES 8. Behavioral Approaches   215 Lynne Guillot Miller Learning Objectives  215 Introduction  215 Leaders and Legacies of Behavioral Theory   216 Key Tenets of Behavioral Approaches   218 The Origin and Nature of Mental Health Concerns   220

CONTENTS

Emotional and Psychological Well-Being   222 The Roles of the Client and Counselor   223 The Nature of Human Development   225 Process of Change   225 Maintenance of Progress   227 Process of Assessment   228 Theoretical Techniques  230 Multicultural, Intersectional, and Social Justice Issues   234 Scholarship and Research Trends   235 Detailed Case Conceptualization Pragmatics and Transcript   236 Theoretical Limitations  238 Summary  239 Voices From the Field   240 Student Exercises  240 Resources  241 References  242 9. Cognitive Approaches   243 Dodie Limberg, Alexander M. Fields, Donya Wallace, Rawle D. Sookwah, and Sabrina M. Johnson Learning Objectives  243 Introduction  243 Leaders and Legacies of Cognitive Theory   243 Origin and Nature of Mental Health Concerns   244 Emotional and Psychological Well-Being   245 The Roles of the Counselor and Client   247 The Nature of Human Development   249 Process of Change   250 How Progress Is Maintained   252 Clinical Assessment  253 Theoretical Techniques in Cognitive Approaches   255 Multicultural, Intersectional, and Social Justice Issues   259 Theory-Based Scholarship and Research Trends   261 Detailed Case Conceptualization Pragmatics and Transcript   261 Theoretical Limitations  264 Summary  264 Voices From the Field   264 Student Exercises  265 Resources  266 References  267

SECTION V. SYSTEMIC AND POSTMODERN THEORIES 10. Systemic Approaches   271 Tiffany Nielson and Timothy J. Hakenwerth Learning Objectives  271 Introduction  271

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xii  |  CONTENTS Leaders and Legacies of Systemic Theory   271 The Origin and Nature of Mental Health Concerns and Human Development   275 What Constitutes Emotional and Psychological Well-Being   279 Roles of the Client and Counselor   281 Process of Change   282 Maintaining Progress  285 Process of Clinical Assessment   286 Specific Theoretical Techniques   288 Multicultural, Intersectional, and Social Justice Issues   292 Relevant Theory-Based Scholarship and Research Trends   293 Detailed Case Conceptualization Pragmatics and Transcript   295 Theoretical Limitations  298 Summary  299 Voices From the Field   300 Student Exercises  300 Resources  302 References  303 11. Postmodern Approaches   304 Michelle S. Hinkle and Caroline Perjessy Learning Objectives  304 Introduction  304 Leaders and Legacies of Postmodern Theory   306 The Origin and Nature of Mental Health Concerns   308 What Constitutes Emotional and Psychological Well-Being   310 Descriptions of the Roles of Client and Counselor   311 Process of Change   313 Description of How Progress Is Maintained   315 Process of Clinical Assessment   316 Specific Therapeutic Techniques   317 Multicultural, Intersectional, and Social Justice Issues   321 Relevant Theory-Based Scholarship and Research Trends   322 Detailed Case Conceptualization Pragmatics and Transcript   323 Theoretical Limitations  326 Summary  327 Voices From the Field   327 Student Exercises  328 Resources  328 References  329

SECTION VI. INTEGRATIVE AND BRIEF COUNSELING THEORIES 12. Integrative Approaches   333 W. Bradley McKibben and Seneka R. Gainer Learning Objectives  333 Introduction  333 Leaders and Legacies of Integrative Theory   334

CONTENTS

Origin and Nature of Mental Health Concerns   336 Emotional and Psychological Well-Being   339 Roles of the Client and Counselor   340 Nature of Human Development   342 Process of Change   343 How Progress Is Maintained   344 Process of Clinical Assessment   345 Theoretical Techniques  348 Multicultural, Intersectional, and Social Justice Issues   350 Scholarship and Research Trends   351 Detailed Case Conceptualization Pragmatics and Transcript   353 Theoretical Limitations  356 Summary  357 Voices From the Field   357 Student Exercises  358 Resources  359 References  360 13. Brief Counseling Approaches   361 Derek X. Seward and Brittany A. Williams Learning Objectives  361 Introduction  361 Leaders and Legacies of Brief Counseling Theory   362 The Origin and Nature of Mental Health Concerns   365 Emotional and Psychological Well-Being   366 Roles of Client and Counselor   368 The Nature of Human Development   369 Process of Change   369 Maintenance of Progress   373 Process of Clinical Assessment   375 Specific Theoretical Techniques   376 Multicultural, Intersectional, and Social Justice Issues   379 Theory-Based Research Trends   381 Detailed Case Conceptualization Pragmatics and Transcript   381 Theoretical Limitations  384 Summary  384 Voices From the Field   385 Student Exercises  385 Resources  386 References  387 Index  389

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CON TRI BU TORS Nicole Altenberg, Student in Psychology and Women’s, Gender, and Sexuality Studies, University of Mary Washington, Fredericksburg, Virginia Sherrie Bruner, PhD, Clinical Assistant Professor, Educational Psychology and Counseling, University of Tennessee–Knoxville, Knoxville, Tennessee Joshua J. Castleberry, PhD, NCC, Assistant Professor, Counselor Education Department, Kent State University, Kent, Ohio Jeff D. Cook, PhD, Associate Professor, Clinical Mental Health Counseling Program Chair, Division of Counseling, Denver Seminary, Littleton, Colorado Alexander M. Fields, Doctoral Candidate, Department of Educational Studies, University of South Carolina, Columbia, South Carolina Stephen V. Flynn, PhD, LPC, LMFT-S, NCC, ACS, Professor, Counselor Education and Supervision, Plymouth State University, Plymouth, New Hampshire Seneka R. Gainer, PhD, Assistant Professor, Department of Clinical Mental Health Counseling, Jacksonville University, Jacksonville, Florida Joel Givens, PhD, LPC, Assistant Professor, Purdue University Fort Wayne, Fort Wayne, Indiana Timothy J. Hakenwerth, PhD, LPC, NCC, Assistant Professor, Department of Counseling and Social Work, University of Illinois Springfield, Springfield, Illinois Michelle S. Hinkle, PhD, Professor, Department of Special Education, Professional Counseling, and Disability Studies, William Paterson University of New Jersey, Wayne, New Jersey Sherritta Hughes, PhD, LPC, NCC, ACS, Program Director, Assistant Professor, Department of Psychology and Counseling, Georgian Court University, Lakewood, New Jersey Sabrina M. Johnson, Education Specialist, Doctoral Candidate, Department of Educational Studies, University of South Carolina, Columbia, South Carolina xv

xvi  |  Cont ributo r s Amanda C. La Guardia, PhD, LPCC-S, NCC, Associate Professor, University of Cincinnati, Cincinnati, Ohio Dodie Limberg, PhD, Associate Professor, Department of Educational Studies, University of South Carolina, Columbia, South Carolina Joshua Mangin, MS, LCPC-C, NCC, Doctoral Student in the Leadership Program, University of Southern Maine, Portland, Maine Andrea McGrath, PhD, LIMHP, LPC, Assistant Professor, Master of Arts in Counseling, Doane University–Lincoln Campus, Lincoln, Nebraska W. Bradley McKibben, PhD, Associate Professor, Department of Clinical Mental Health Counseling, Jacksonville University, Jacksonville, Florida Lynne Guillot Miller, PhD, Associate Professor, Counselor Education and Supervision Program, Kent State University, Kent, Ohio Tiffany Nielson, PhD, LPC, Associate Professor, Department of Counseling and Social Work, University of Illinois Springfield, Springfield, Illinois Elizabeth K. Norris, PhD, Denver Seminary, Assistant Professor, Counseling Division, Denver Seminary, Littleton, Colorado Caroline Perjessy, PhD, Clinical Faculty, Southern New Hampshire University, Hooksett, New Hampshire Rawle D. Sookwah, LPC, NCC, Psychotherapist and Counselor Educator, University of South Carolina, Counselor Education and Supervision, Columbia, South Carolina Derek X. Seward, PhD, Associate Professor, Department of Counseling and Human Services, Syracuse University, Syracuse, New York Elyssa B. Smith, PhD, LPC, RPT, NCC, ACS, Assistant Professor of Counseling, Stockton University, Galloway, New Jersey Paul H. Smith, PhD, LPC, NCC, ACS, Assistant Professor, University of North Georgia, Dahlonega, Georgia Phillip L. Waalkes, PhD, NCC, ACS, Assistant Professor, University of Missouri–St. Louis, St. Louis, Missouri Donya Wallace, PhD, NCC, LPC/S (SC), Assistant Professor, Palo Alto University, Palo Alto, California Tyler Wilkinson, PhD, Associate Professor and Program Coordinator PhD in Counselor Education and Supervision, Department of Counseling, College of Professional Advancement, Mercer University, Macon, Georgia Brittany A. Williams, PhD, Assistant Teaching Professor, Department of Counseling and Human Services, Syracuse University, Syracuse, New York Julianna Williams, MA, Ed, Counselor Education Doctoral Candidate, Educational Psychology and Counseling, University of Tennessee–Knoxville, Knoxville, Tennessee

LI S T O F VI D EOS Organized by chapter, the Voices From the Field videos are available to support readers. Chapters with this feature also include a recorded video interview where participants explore multicultural, social justice, equity, diversity, and intersectionality issues. These videos provide diverse real-world perspectives and applications to contextualize the topics and theories discussed in each chapter. Access the 12 videos with the QR codes. Chapter 2. Multicultural Counseling Theory Taqueena Quintana interviewed by Sherritta Hughes

Chapter 3. Feminist Approaches Patricia Robertson interviewed by Amanda C. La Guardia

Chapter 4. Traditional Psychoanalytic Approaches Sarah Spiegelhoff interviewed by Elyssa B. Smith

Chapter 5. Relational Approaches to Psychoanalytic Treatment Evan Sorenson interviewed by Sherrie Bruner

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OF VIDEOS

Chapter 6. Person-Centered Counseling and Related Experiential Approaches Edward Ewe interviewed by Jeff D. Cook

Chapter 7. Existential-Humanistic Approaches Alfredo F. Palacios interviewed by Joel Givens

Chapter 8. Behavioral Approaches Christina Lloyd interviewed by Lynne Guillot Miller

Chapter 9. Cognitive Approaches LaNita Jefferson interviewed by Alexander M. Fields

Chapter 10. Systemic Approaches Shawn Parmanand interviewed by Timothy J. Hakenwerth

Chapter 11. Postmodern Approaches Josephine Rodriguez interviewed by Caroline Perjessy

Chapter 12. Integrative Approaches Tyra Roy interviewed by W. Bradley McKibben

Chapter 13. Brief Counseling Approaches Bradford Hill interviewed by Brittany A. Williams

FO REW ORD Therapeutic impact as a counselor is grounded in our capacity to be authentic, congruent, empathic, and resourceful while cultivating respect for the complexity of the human experience and honoring the diversity of that experience. Developing as an emerging counselor requires the expansion of one’s worldview and purposeful nurturing of multiple perspectives that serve as the cognitive foundations for advanced empathy. Across my career as a counselor educator and supervisor, a dynamic, complex, and scholarly grappling with counseling theories has been the nexus of counselor development. Active learning, understanding, exploring, examining, critiquing, and applying counseling theories, both contemporary and historical, shape the trajectory of professional and dispositional competence. A lack of intentionality related to the theoretical factors of counseling translates into a counseling practice that is undeveloped, is not guided by research and coherency, and does not optimize client potentiality. The criticality of purposeful and complex application of counseling theories to the development of counselor identity and competence is what makes this edition of Counseling Theories and Case Conceptualizations: A Practice-Based Approach, a much-needed companion for emerging counselors. Dr. Flynn’s framing of theories as a “philosophical map” to healing and transformation resonates with the ways in which theories expand our understanding of the human experience, conceptualize the interpersonal dynamics impacting well-being, and chart a course for growth and development. Counseling is a catalyst for transformation and growth, and theories dynamically create a foundation, framework, and trajectory to inform the collective work of the counselor and client. Dr. Flynn’s work invites us on a journey that harnesses the power of our history, captures the challenges of our current professional work, and challenges us to apply complex constructs from an intersectional and social justice–oriented approach. We, as readers and cocreators of the case conceptualizations, are transformed through this work as we purposefully create a series of maps on the complexity of psychological well-being and human change processes. The power of theories to transform is captured in a quote by Anaïs Nin who stated, “Each friend represents a world in us, a world possibly not born until they arrive, and it is only by this meeting that a new world is born.” Though the quote references friendship, I believe that the complexity of conceptualization and cultivation of competencies for emerging counselors are similarly constructed through the engagement of counseling theories provided across these 13 chapters in this text. Each set of theoretical approaches, with accompanying case conceptualization analysis, introduces emerging counselors to a xix

xx  |  Foreword “world” of counseling legacy and contemporary practice, thereby evoking “new worlds” within the individual counselor as they develop their theoretical complexity and therapeutic framework. The profession of counseling amplifies the intersectionality of identity, values, and actions. The guiding beliefs of valuing our profession and having pride in our work must be coupled with action. Alfred Adler stated, “Trust only movement. Life happens at the level of events, not of words. Trust movement.” For me, this quote emphasizes the need to be professionally engaged and consistently evolving and to couple our words and values with action. One of the aspects of this textbook that I most appreciate is that Dr. Flynn embraces action as a scholar by integrating the most relevant and impactful theoretical practices, tackling developing trends such as telebehavioral health, and challenging us, as readers, to apply complex theoretical constructs from an intersectional, culturally responsive, and social justice paradigm. This is not a reimagining of the traditional counseling theories textbooks from 10 years ago but rather an act of evolution and engagement captured in the immediate assertion of social justice–oriented theories. Professional excellence is not static, but rather, it is dynamic. As a profession, as emerging counselors, and as scholars, we cannot be complacent. We must always consider how to further promote our development by having a purposeful level of reflexivity related to our professional identity and professional development. Dr. Flynn’s work embraces this mindset of striving for excellence by creating a comprehensive text that is contextualized, intersectional, and transformative in a way that manifests what is required of us as emerging counselors to be authentic, skilled, complex, and scholarly in our approach to the practice of counseling within the diverse communities we serve. As you explore the text and accompanying Voices From the Field, I am excited to have you grapple with theoretical constructs in the context of our professional legacy, our therapeutic opportunities, and our ongoing assertion of the need for counseling theories and practices to be inclusive, intersectional, and socially just.

Nicole R. Hill Interim Provost and Vice President for Academic Affairs Professor, Counselor Education Shippensburg University

PREFACE Have a dialogue between the two opposing parts and you will find that they always start out ­fighting each other until we come to an appreciation of difference. … a oneness and integration of the two opposing forces. Then the civil war is finished, and your energies are ready for your struggle with the world. —Frederick (Fritz) Perls

The first edition of Counseling Theories and Case Conceptualization: A Practice-Based Approach symbolizes a comprehensive theoretical journey emphasizing the legacies, philosophy, science, and practice of counseling. Understanding the complexities of contemporary and classic theories of counseling and case conceptualization, the multiple contextual levels of diversity, intersectionality, and identity that individuals embody, and the skills and interventions necessary to produce positive outcomes, are paramount to the success and rigor of the counseling profession. This textbook represents a deep exploration of counseling theory; case conceptualization; and multicultural, intersectional, and social justice factors along with the relevant areas related to theory-congruent professional practice, assessment, intervention, and skill. Our profession’s unique theoretical history, leaders, legacies, waves of philosophical and political change, and practice-based skills are thoroughly examined throughout this text. Counseling Theories and Case Conceptualization: A Practice-Based Approach provides clinicians with the information needed to fully understand how counseling theories make meaning of mental health issues, human development, client and counselor therapeutic roles, counseling skills, and assessments, allowing them to provide high-quality service to their future clients.

GOALS OF THIS TEXTBOOK The main goal of this textbook is to guide emerging counselors in the exploration of theories and case conceptualization models that provide a philosophical map centered on how to help clients heal and change. Additional objectives are centered on informing students enrolled in masters and advanced doctoral degree programs about (a) atheoretical and theory-specific case conceptualization; (b) how each theoretical tradition addresses

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xxii  |  Preface multicultural, intersectional, and social justice issues; (c) how to understand and apply theory-congruent assessment instruments; (d) the major techniques related to classic and contemporary theories of counseling; (e) common skill-based and conceptualization factors related to working with individuals affected by racism, discrimination, hatred, and inequity; (f) the chapter content relevance to the Council for Accreditation of Counseling and Related Educational Programs (CACREP, 2016, 2024) standards; (g) the use of sole, integrative, eclectic, and pluralistic theoretical frameworks; (h) a detailed description of the legacy of the theory founders and major contributors; (i) contemporary theory-based research; (j) the use of diverse Voices From the Field to further enhance the multicultural and social justice aspects of each theoretical grouping; and (k) a review of the common factor approaches to counseling. Through providing clear and in-depth information on contemporary theoretical approaches as well as time-honored traditions, Counseling Theories and Case Conceptualization: A Practice-Based Approach provides a thorough review of the philosophies, professional practice standards, and conceptualization skills associated with major theoretical groups. Specifically, each chapter reviews the following theoretical elements: the legacy of the theory founder(s); new and emerging theoretical efforts; the origin and nature of mental health concerns; what constitutes emotional and psychological well-being; descriptions of the roles of the client and counselor; the nature of human development; the theory’s process of change; description of how progress is maintained; process of clinical assessment; specific theoretical techniques; theoretical multicultural, intersectional, and social justice issues; relevant theory-based scholarship and research trends; detailed theoretical case conceptualization pragmatics; theoretical limitations; and a transcript of a session of a counselor using well-established theory-based skills with a fictitious client. While this is a 13-chapter textbook, 36 theories of counseling are thoroughly reviewed. This textbook has chapters dedicated to approaches that are often not included in books related to counseling theory and professional practice. For example, there are entire chapters dedicated to multicultural counseling theory (MCT), feminist theoretical approaches, integrative traditions, and brief counseling theories.

INSTRUCTOR RESOURCES Counseling Theories and Case Conceptualization: A Practice-Based Approach is accompanied by an Instructor Manual and other comprehensive instructor resources, which include PowerPoint slides and a Test Bank. Structurally, all chapters have learning objectives, student exercises, a summary, helpful books, website links, video links, and a reference section that indicates the most influential resources within each chapter. Each theory-based chapter includes a video interview entitled Voices From the Field. These are digitally recorded interviews with practitioners who have expertise in the explicated theory. Voices From the Field participants identify with a marginalized community and/or a community of color and/or have clinical experience working with these important populations. This textbook has an easily accessible chapter flow that lends itself nicely to graduate school courses. Educators can direct student’s attention to the chapter-based learning exercises, chapter transcripts, and skill examples and encourage further student learning with the suggested Web links and readings. Lastly, throughout the textbook, the reader is provided clear, detailed, and contextually accurate examples of a variety of theory-based skills and interventions.

Pref ace

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INTENDED AUDIENCE The intended audiences of this textbook are counseling masters and doctoral degree programs. While the target audience of this book is masters- and doctoral-level counselor education programs, it has a secondary audience of masters- and doctoral-level social work, psychology, marriage and family therapy, and addictions programs. Following are five potential courses in which this textbook could be adopted: ■ ■ ■ ■ ■

Theories of Counseling Counseling Theories and Personality Counseling Theories and Case Conceptualization Counseling Theory and Practice Advanced Counseling Theory

Mid- and late-career professionals who have some experience with counseling theory will also find this book useful for understanding various contemporary theories; conceptualization models; nuanced multicultural, intersectional, and social justice content; and professional practice-based issues and skills.

ORGANIZATION OF THE CONTENT Counseling Theories and Case Conceptualization: A Practice-Based Approach is an introduction as well as an in-depth, detailed synopsis of the theory and practice of counseling. This 13-chapter textbook includes information on counseling theoretical groupings; the history of counseling theory and practice; atheoretical and theoretical models of case conceptualization; innovations and growing trends in telebehavioral health; the evolving nature of multiculturalism, intersectionality, and social justice issues; the key components relevant to contemporary common factor models; the elements necessary for the incorporation of a unitary, integrative, eclectic, and plural approach to counseling; the process of picking a theoretical approach; a dialectic centered on counseling theory and practitioner humility; and an introduction to the case of Mark Stockton (Chapter 1); an in-depth theoretical and skill-based review of models of MCT including multicultural and social justice counseling competence, the counselor advocate–scholar model, and the theory of multicultural counseling (MC; Chapter 2); feminism and feminist approaches to counseling (Chapter 3); traditional psychoanalytic approaches to counseling including psychoanalysis, Jungian psychology, and object relations (Chapter 4); relational approaches to psychoanalytic treatment including individual psychology, feminist psychology, and self-­psychology (Chapter 5); person-centered counseling and related experiential approaches including person-­centered counseling, the process experiential approach, and emotionally focused therapy (Chapter 6); existential-humanistic approaches to counseling including Yalom’s existential psychology, logotherapy, and gestalt therapy (Chapter 7); behavioral approaches to counseling including classical conditioning, operant conditioning, and dialectical behavior therapy (DBT; Chapter 8); cognitive approaches to counseling including cognitive therapy, social cognitive theory, and acceptance and commitment therapy (ACT; Chapter 9); systemic approaches to counseling including transgenerational family therapy, the human validation process, and structural family therapy (Chapter 10); postmodern approaches to counseling including solution-focused therapy, narrative therapy, and social constructivist therapy (Chapter 11); integrative approaches to counseling including integrative psychotherapy, the transtheoretical model (TTM) of behavior change, and multimodal therapy (MMT; Chapter 12); and brief counseling approaches including Adlerian brief therapy (ABT), solution-focused brief counseling and therapy, and brief eclectic psychotherapy (BEP; Chapter 13).

xxiv  |  Preface Included with this textbook are digitally based video recordings entitled Voices From the Field. The reader is provided recorded digital interviews of practitioners who represent a wide range of diversity and intersectionality, who have expertise in one of the theories reviewed, and who have pertinent clinical experiences in applied settings. The 13 clinicians representing various contextual backgrounds and intersectional identities have shared their perspectives and experiences on how best to help marginalized communities who have experienced various barriers including (but not limited to) hatred, inequity, bias, discrimination, racism, microaggressions, and macroaggressions and their unique experiences related to using a particular theoretical approach to counseling. The participants fold into their discussions many examples of foundational and advanced skills, pertinent readings, conceptualization, and, of course, theory. To help organize the distinct yet interrelated sections of this textbook, the chapters are organized into six sections, including (a) Section I: Introduction and Social Justice–Oriented Theories; (b) Section II: Traditional and Relational Psychoanalytic Theories; (c) Section III: Person-Centered, Experiential, and Existential Theories; (d) Section IV: Behavioral and Cognitive Theories; (e) Section V: Systemic and Postmodern Theories; and (f) Section VI: Integrative and Brief Counseling Theories.

Section I: Introduction and Social Justice–Oriented Theories The first three chapters of this textbook prepare emerging counselors with relevant information on the essential counseling theoretical and case conceptualization groupings; key theoretical leaders and legacies in the counseling profession; telebehavioral health information; descriptions of multiculturalism, intersectionality, and social justice tenets; the key ingredients necessary for adopting a unitary, integrative, eclectic, and pluralistic approach to counseling; information describing the process for selecting a theoretical orientation; common factors approaches; a dialectic centered on counseling theory and practitioner humility; an introduction and two theory-based transcripts centered on the case of Mark Stockton; an in-depth theoretical and skill-based review of models of MCT (multicultural and social justice counseling competence, the counselor advocate–scholar model, and the theory of MC); and feminism and feminist approaches to counseling. In short, this section sets the stage for the remainder of the textbook by providing emerging counselors with a thorough theory-based introduction to the text and delivering a comprehensive exploration of multicultural, intersectionality, social justice, and feminist theories; contemporary issues; research; history; and skill-based descriptions and examples.

Section II: Traditional and Relational Psychoanalytic Theories Chapters 4 and 5 provide a thorough scholarly, philosophical, and clinical journey into traditional and relational psychoanalytic theories. The specific theories explored include, but are not limited to, psychoanalysis, Jungian psychology, object relations therapy, individual psychology, feminist psychology, and self-psychology. These chapters deeply explore the legacy of the theory founders; new and emerging theoretical efforts; how these theories conceptualize personality; the origin and nature of mental health concerns; what constitutes emotional and psychological well-being; descriptions of the roles of the client and counselor; the nature of human development; the theory’s process of change; description of how progress is maintained; process of clinical assessment; specific theoretical techniques; theoretical multicultural, intersectional, and social justice issues; relevant theory-based scholarship and research trends; detailed theoretical case conceptualization pragmatics; theoretical limitations; and session transcripts showcasing a counselor who uses various theory-based skills.

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Section III: Person-Centered, Experiential, and Existential Theories Chapters 6 and 7 provide a thorough scholarly, philosophical, and clinical journey into person-centered, experiential, and existential theories. The specific theories explored include, but are not limited to, person-centered counseling, the process experiential approach, emotionally focused therapy, Yalom’s existential psychology, logotherapy, and gestalt therapy. These chapters deeply explore the legacy of the theory founders; new and emerging theoretical efforts; the origin and nature of mental health concerns; what constitutes emotional and psychological well-being; descriptions of the roles of the client and counselor; the nature of human development; the theory’s process of change; description of how progress is maintained; process of clinical assessment; specific theoretical techniques; theoretical multicultural, intersectional, and social justice issues; relevant theory-based scholarship and research trends; detailed theoretical case conceptualization pragmatics; theoretical limitations; and session transcripts showcasing a counselor who uses various theory-based skills.

Section IV: Behavioral and Cognitive Theories Chapters 8 and 9 provide a thorough scholarly, philosophical, and clinical journey into behavioral and cognitive theories. The specific theories explored include, but are not limited to, classical conditioning, operant conditioning, DBT, cognitive therapy, social cognitive theory, and ACT. These chapters deeply explore the legacy of the theory founders; new and emerging theoretical efforts; what constitutes emotional and psychological well-being; descriptions of the roles of the client and counselor; the nature of human development; the theory’s process of change; description of how progress is maintained; process of clinical assessment; specific theoretical techniques; theoretical multicultural, intersectional, and social justice issues; relevant theory-based scholarship and research trends; detailed theoretical case conceptualization pragmatics; theoretical limitations; and session transcripts showcasing a counselor who uses various theory-based skills.

Section V: Systemic and Postmodern Theories Chapters 10 and 11 provide a thorough scholarly, philosophical, and clinical journey into systemic and postmodern counseling theories. The specific theories explored include, but are not limited to, transgenerational family therapy, the human validation process, structural family therapy, solution-focused therapy, narrative therapy, and social constructivist therapy. These chapters deeply explore the legacy of the theory founders; new and emerging theoretical efforts; the origin and nature of mental health concerns; what constitutes emotional and psychological well-being; descriptions of the roles of the client and counselor; the nature of human development; the theory’s process of change; description of how progress is maintained; process of clinical assessment; specific theoretical techniques; theoretical multicultural, intersectional, and social justice issues; relevant theory-based scholarship and research trends; detailed theoretical case conceptualization pragmatics; theoretical limitations; and session transcripts showcasing a counselor who uses various theory-based skills.

Section VI: Integrative and Brief Counseling Theories Chapters 12 and 13 provide a thorough scholarly, philosophical, and clinical journey into integrative and brief counseling theories. The specific theories explored include, but are not limited to, integrative psychotherapy, the TTM of behavior change, MMT, ABT, solution-focused brief counseling and therapy, and BEP. These chapters deeply explore the legacy of the theory founders; new and emerging theoretical efforts; the origin and nature of mental

xxvi  |  Preface health concerns; what constitutes emotional and psychological well-being; descriptions of the roles of the client and counselor; the nature of human development; the theory’s process of change; description of how progress is maintained; process of clinical assessment; specific theoretical techniques; theoretical multicultural, intersectional, and social justice issues; relevant theory-based scholarship and research trends; detailed theoretical case conceptualization pragmatics; theoretical limitations; and session transcripts showcasing a counselor who uses various theory-based skills. Stephen V. Flynn

ACK NOW L ED GME N T S This textbook and our process have benefited tremendously from many individuals and their contributions. We begin by thanking Springer Acquisitions Editors, Mindy Okura-Marszycki and Rhonda Dearborn, for their coordination, guidance, and support throughout the project. In addition, we would like to give a special thank you to Springer Senior Assistant Editor, Kirsten Elmer, for her expertise and management throughout the publication, writing, and editing process. We would also like to thank the entire Springer staff for their encouragement and support of the counseling theory and case conceptualization topic area. We wish to acknowledge and express our gratitude to the scholars who contributed their time, expertise, and talent to the completion of their respective book chapters and for advancing the topic area of counseling theory and case conceptualization. We would also like to recognize the following reviewers for their helpful feedback during the book development process: Leigh Green, West Texas A & M; Kathryn J. Raley, Regis University; Bianca Augustine, Upper Iowa University; Anita McCormick, Texas A & M University; Sara Martino, Stockton University; and Michael S. Ternes, Louisiana Tech University. We would like to extend our deepest gratitude to the following 13 individuals who graciously provided their thoughts and experiences within the digital video recordings entitled Voices From the Field: Alfredo F. Palacios, Bradford Hill, Christina Lloyd, Edward Ewe, Evan Sorenson, Jeff D. Cook, Josephine Rodriguez, LaNita Jefferson, Patricia Robertson, Sarah Spiegelhoff, Shawn Parmanand, Taqueena Quintana, and Tyra Roy.

STEPHEN V. FLYNN I would like to acknowledge a number of family members who were important in helping me with the writing and editing of this textbook. None of this would have been possible without my supportive spouse, Meredith Flynn. In addition, I am eternally grateful to my bright, energetic, and delightful children Corrina Flynn, Anelie Flynn, and Eliza Flynn for providing a tremendous amount of inspiration and motivation to complete the first edition of this textbook. I would like to thank my mother, Joyce Flynn, for her unconditional support during this project and in all aspects of my life. And a very special thanks to my sisters Suzy Ueberroth and Janet Flatley for their unconditional love and support. Lastly, I would like to thank Plymouth State University graduate student Ruby Nash her contributions to this project. xxvii

xxviii  |  Ackno wled gm ents

JOSHUA J. CASTLEBERRY I would like to take a moment to express my deepest gratitude to my wife, Leigh, who has been an unwavering pillar of support throughout the writing of this book. Her faith has set an example for me, and her encouragement has given me the strength to persevere through the challenging times. I am grateful to my children Eli and Hannah for their love and support during this process. Our time spent climbing and training together have been a much-needed respite, allowing me to recharge and refocus. Their unwavering encouragement and motivation have kept me grounded and determined. I feel incredibly fortunate to have such a loving and supportive family, who have stood by me every step of the way. Without them, this project would not have been possible.

SPRINGER PUBLISHING RESOURCES

Resources available to all purchasers of this text include the following: ■

Videos of Voices From the Field ● Interviews with content experts who represent a wide range of diversity and intersectionality ● To access the Voices From the Field videos, see the List of Videos on page xvii.

■

Video Transcripts

Instructor Resources A robust set of instructor resources designed to supplement this text is available. Qualifying instructors may request access by emailing [email protected].

Available resources include: ■

LMS Common Cartridge With All Instructor Resources and Instructions for Use

■

Instructor Manual ● Chapter overview ● Learning objectives ● Class activities

■

Test Bank

■

Instructor Chapter PowerPoints

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SECTION I

INTRODUCTION AND SOCIAL JUSTICE– ORIENTED THEORIES

1

INTRODUCTION TO THEORY AND CASE CONCEPTUALIZATION Stephen V. Flynn and Joshua J. Castleberry

LEARNING OBJECTIVES After reading this chapter, you will be able to: ■ Describe the core counseling theoretical groupings ■ Recognize the history of counseling theory and practice ■ Provide details regarding atheoretical and theoretical case conceptualization ■ Explain trends in telebehavioral health ■ Identify the nuances of multiculturalism, intersectionality, diversity, and context in professional practice ■ Describe the incorporation of a unitary, integrative, eclectic, and plural approach to counseling ■ Recognize the process of picking a theoretical approach

INTRODUCTION TO THEORY AND CASE CONCEPTUALIZATION Within this textbook, we showcase essential counseling theoretical groupings. The word essential is provided to inform readers that these theories have stood the test of time and sit on a solid foundation of research and practice. The word groupings is meant to describe an umbrella that houses many theoretical traditions. Within these theoretical groupings, all chapters deeply explore at least three relevant theories. The presented theories provide early-, mid-, and late-career professionals with a clinical foundation of theoretical case conceptualization, theory-driven multicultural/intersectional and social justice issues, empirically based practice, a wide range of professional and contemporary issues, and a bedrock of research. We have deliberately combined the presentation of theoretical traditions that have their origins in the early years of psychotherapy with contemporary theories that have been developed relatively recently and/or have had an enormous impact on the counseling profession as a multicultural and/or social justice school of thought. The time-honored theories included in this text include traditional and relational psychoanalytic theory, person-­ centered and related experiential theory, existential-humanistic theory, behavioral theory, cognitive theory, and systemic theory. These theoretical groupings have been thoroughly updated and revised over the years. Consequently, they continue to remain relevant today. Essential counseling theoretical groupings that have been developed relatively recently and/or symbolize a multicultural and social justice theoretical approaches include multicultural counseling theory (MCT), feminist theory, postmodern theory, integrative theory, and brief counseling theory. According to the SAGE Encyclopedia of Theory in Counseling and Psychotherapy, there are well over 300 approaches to counseling (Neukrug, 2015). While this number seems vast,

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having reviewed this important resource, it is our belief that many theoretical schools of thought are only partially completed methods or provide a small deviation to an existing theoretical approach. Within this textbook, we assume that most counseling theories can be grouped into one of 12 distinguishable types. While we believe the theoretical groupings in this textbook have been adequately siphoned down, Neukrug (2015) produced evidence that suggests all approaches to counseling can be traced back to one of six major theoretical categories: psychoanalytic, behavioral, cognitive, humanistic, constructionist, and systemic. Within the current edition of this textbook, we do make a point to provide readers with clear and distinct theories of counseling (e.g., traditional psychoanalytic theory, MCT, postmodern theory); however, it should be noted that research indicates most practicing helping professionals consider themselves to be integrative or eclectic (Tasca et al., 2015). While we understand and respect our present clinical reality, we see a tremendous amount of value in presenting distinct theoretical groupings of counseling. The benefits include, but are not limited to, (a) understanding the origins of particular theories; (b) considering how particular groups of theories conceptualize human development, mental illness, and well-being; (c) understanding where unique skills and interventions were initially developed and how they were intended to be used; and (d) comprehending how various theoretical movements have influenced the counseling profession. While this is a textbook designed for counseling professionals, throughout this text, the terms counselor, helping professional, therapist, clinician, and practitioner are frequently used for readability purposes or to adjust the scope of dialogue. This textbook uses counseling, therapy, and psychotherapy interchangeably to describe the act of professional therapeutic service. Lastly, when general references to gender are suggested, we deliberately apply the term they and avoid the binary terms he and she. In professional practice, clients often choose to work with a counselor and to enter a therapeutic relationship due to some issue or concern that is affecting their lives. Clients desire relief from these issues and choose to engage in counseling to help reduce or eliminate their problems. However, counselors do not enter these therapeutic relationships as blank slates or function as behavioral software programmed to help anyone with any issues. Counselors have their own life experiences, biases, and expectations and have been socialized within a particular context that includes unique familial factors, cultural norms, religion/spirituality, and other environmental factors. The key questions‌‌‌‌‌‌‌ that come up for counselors include the following: (a) How do I present myself in a way that optimally blends my professional and personal self? (b) How do I know what to do when entering a counseling space with a particular client, couple, group, network, and/or family? (c) What information is relevant/ irrelevant to treatment? (d) What theoretical model should I be operating from? These questions are common areas of reflective practice (Reiter, 2014). Questions like those previously stated are partly answered through the process of developing a theoretical and conceptual framework, which include basic clinical competencies that serve as a linchpin to all professional practice (Betan & Binder, 2010). They are also the foundation for (a) how counselors view what’s taking place in a counseling session; (b) a counselor’s understanding for the personal process taking place within every client they work with; (c) comprehending the interpersonal dynamics between client and counselor; and (d) what is needed to cocreate a sense of helping, healing, and change. These internal processes cocreate a model that supports counselor clinical practice with various populations and presenting issues. For early-career professionals entering the counseling profession, their personal beliefs and opinions about helping often coalesces around an established academic theoretical model. As counselors become more advanced, they will often start to move beyond the strict confines of an established therapeutic model and begin to create their own theory of helping, healing, and change (Reiter, 2014). Whether you are an early-, mid-, or late-career professional, the development of a

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theory of professional practice is important for the well-being of clients, to the counselor’s own sense of identity, and to fully integrate one’s professional and personal self in a meaningful and holistic manner.

The Importance of Theory and Case Conceptualization Oxford Languages (n.d.) defines theory as “a supposition or a system of ideas intended to explain something, especially one based on general principles independent of the thing to be explained.” Depending on the context theory is used, it can arouse a variety of reactions. Consider your initial response to the following scientific and psychological theories: Darwin’s theory of evolution, Einstein’s theory of relativity, Copernicus’s theory of the solar system, and Freud’s theory of the unconscious mind. For most, these frameworks are unified and verified explanations used to describe data and findings in a particular area of science or psychology. Now consider the following uses of theory: “If my theory is correct, I will live to be 100 years of age” or “Theoretically speaking, you can understand everything about a person through analyzing their dreams, age, and gender.” Instead of a verified scientific explanation, these are colloquial guesses and do not typically generate a tremendous amount of confidence. They can also inhibit the importance of theory. Counseling professionals who question the importance of theory might suggest training programs sidestep teaching theoretical courses all together and focus on educating counselors-in-training on researched-based common factors (Wampold, 2015). While some counseling professionals may suggest this course of action, theory helps counselors make meaning of every aspect of treatment including, but not limited to, diversity and intersectionality, clients’ presenting issues, case conceptualization, assessment, diagnosis, treatment planning, treatment method, and care coordination. Theory also impacts what information counselors find clinically relevant and irrelevant. The theoretical process of making sense of and filtering out information allows counselors to provide effective treatment and avoid being overwhelmed by an enormous amount of client information. Without a theoretical conceptualization of various psychological phenomena (e.g., culture, pathology, human development, well-­ being, role of counselor/client), counselors would be lost. Counseling theory aims to add meaning to the underpinnings of human thoughts, emotions, drives, and behaviors. It also serves as a road map for counselors to provide emotional, cognitive, and behavioral treatments to individuals who are seeking to make fundamental changes within themselves and their lives. According to Corsini and Wedding (1989)‌‌‌‌‌‌‌, counseling is best conceptualized as an art built on science. Counseling is not a mechanical vocation; often, what goes on in the counseling room is a process of personal discovery, self-expression, and processing emotions and thoughts. Counselors seek to journey with their clients into the depths of their subjective thoughts and feelings and, through this process, a counselor’s own subjective experiences become essential to the work. In this sense, the degree to which a counselor introspects and explores their own thoughts, emotions, and behaviors, the more likely they are to be able to dive into the depths of their clients’ experiences, deeply empathize with their pain, and to help clients see things from multiple perspectives. Counseling theories guide therapeutic work at all levels from highly data-driven behavioral approaches to art-based counseling methods. In some cases, empirically based brief counseling is vital to helping a client achieve their goals in a timely manner. However, for a major life change to occur and/or to influence client personality, traditions that offer a combination of subjective and objective practices are often preferrable. Counseling theories are essential to the counselor’s ability to organize client content, make sense of complex processes, and effectively pair interventions with client goals. When clients enter a counseling relationship, they are usually required to provide a tremendous amount of personal information during the initial phase of treatment, which is collected through a variety of methods: (a) a thorough intake assessment, (b) psychosocial

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background information, (c) information related to mental status, (d) treatment plan information and goals, (e) psychopharmacological information, (f) client conceptualization of the current problem(s), and (g) details related to past providers and experiences in counseling. The bombardment of client information can leave the counselor overwhelmed and confused if they do not have an overarching theory to make sense of it all. It is not enough that a counseling theory provides organization and hypothesis about a client’s concerns; it must also provide skills and techniques designed to help clients achieve their therapeutic goals. First, however, counselors must find a way to bridge the gap between their client and their preferred theory of counseling. This is a function of case conceptualization. Case conceptualization is the method for understanding, explaining, and guiding the treatment process (Sperry & Sperry, 2020). It is the foundation of a coherent treatment strategy that is centered on planning and focusing treatment on meeting a client’s unique goals. A detailed case conceptualization provides counselors with a bridge between client and theory, a cognitive process to determine the usefulness of various counseling interventions, and the organizational-level (e.g., agency, hospital) accountability for effective clinical practice (Prieto & Scheel, 2002). Lastly, whether the counselor works in a clinical or school setting, organizations that offer counseling services almost always have a team centered on assisting clients and students with therapeutic and educational services (e.g., treatment team, 504 plan accommodation team, individualized education program [IEP] team). These teams depend on an accurate and thorough conceptualization of the clients/students’ presenting issues‌‌‌‌‌‌‌ to ensure effective treatment, teamwork, and communication. This textbook is centered on the theories and models that guide counselors in their service to clients. The theories presented are more than a set of ideas or systemic approaches to change; they are about understanding others. Counselors come from a long line of those attempting to understand the human condition. Spanning across continents‌‌‌‌‌‌‌ and through centuries, this textbook reviews the works of scholars who have pursued theories and therapies that speak to people’s intrapsychic dynamics and behavioral, emotional, cognitive, and relational needs. While we employ a vocation that is simultaneously an art and a science, contained by ethics and values, counseling is ultimately about helping, healing, and change. As you journey through this textbook, reflect on where you align your thoughts and feelings about the human condition and consider which theories you connect with. In the end, we hope your findings can provide the blueprints for how you can best serve, understand, and collaborate with those fellow travelers you find sitting across from you in session. As Irvin Yalom (2002) eloquently stated: Instead, I prefer to think of my patients and myself as fellow travelers, a term that abolishes distinctions between “them” (the afflicted) and “us” (the healers) […] We are all in this together and there is no therapist and no person immune to the inherent tragedies of existence. (p. 8)

ACCREDITATION Accredited academic institutions are required to attain appropriate and acceptable levels of training quality for emerging helping professionals. Graduate programs accredited through the Council for Accreditation of Counseling and Related Educational Programs (CACREP) emphasize theory and case conceptualization practices in the training of counselors. CACREP accreditation is the training standard for counselors that has been recognized by the National Academy of Medicine, the Veterans Administration, and the Council for Higher Education Accreditation (CHEA). In most states, a CACREPapproved education meets the curriculum required for counseling licensure. Accredited

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programs engage in a continuous review process to meet and maintain counseling theory standards, ethics, faculty identity, curriculum, and licensure expectations set by the profession (Flynn, 2023). Throughout this textbook, accreditation standards are considered in the context of counseling theory, case conceptualization, social and cultural diversity, and professional practice. At the time of this writing, the two authors of this chapter serve as faculty members in CACREP-accredited counseling programs housed within two separate state universities. At any point in time, there is a current set of CACREP standards being implemented while a newer version of the standards is in the process of being created. Presently, the 2016 CACREP standards are required for all CACREP programs, while the 2024 CACREP standards are in development. Therefore, the present textbook covers both the 2016 and 2024 CACREP standards. Please see Table 1.1 for a breakdown of the CACREP 2024 standards and standard location within the textbook. The following theory/professional practice-based 2016 CACREP standards are frequently addressed within this textbook: 2.F.3.c. theories of normal and abnormal personality development (Chapters 1–13); 2.F.3.f. systemic and environmental factors that affect human development, functioning, and behavior (Chapters 1–13); 2.F.5.a. theories and models of counseling (Chapters 1–13); 2.F.5.b. a systems approach to conceptualizing clients (Chapter 10); 2.F.5.f. counselor characteristics and behaviors that influence the counseling process (Chapters 1–13); 2.F.5.g. essential interviewing, counseling, and case conceptualization skills (Chapters 1–13); 2.F.5.j. evidence-based counseling strategies and techniques for prevention and intervention (Chapters 1–13); 5.C.1.b. theories and models related to clinical mental health counseling (Chapters 1–13); and 5.C.3.b. techniques and interventions for prevention and treatment of a broad range of mental health issues (Chapters 2–13). Although researchers have suggested that a proper understanding of theory, treatment planning, and diagnosis can and should be achieved through education, supervision, and training, case conceptualization has increasingly been seen as the most effective way to teach their integration (Cline et al., 2022; Meier, 1999; Osborn et al., 2004). CACREP (2016) currently requires case conceptualization skills (CACREP 2.F.5.g). CACREP further requires more specified knowledge of case conceptualization within the specialty areas of addiction counseling (CACREP 5.A.1.d); clinical mental health counseling (CACREP 5.C.1.c); clinical rehabilitation counseling (CACREP 5.D.1.d); and marriage, couple, and family counseling (CACREP 5.F.1.e). Theory congruent case conceptualization is reviewed and applied in every chapter of this textbook. Race, ethnicity, gender, gender identity, sexual orientation, religion, culture, racism, homophobia, sexism, racial macro- and microaggressions, and xenophobia are just some of the important social justice-/diversity-based discussions taking place around the world. Within the United States, we are presently experiencing one of the largest human rights movements in history. Due in part to the systemic and institutional racism in the United States and the recent incidents of police brutality and shootings of Black people including, but not limited to, Trayvon Martin (1995–2012), Michael Brown (1996–2014), Eric Garner (1970–2014), Breonna Taylor (1993–2020), and George Floyd (1973–2020), the #BlackLivesMatter (BLM) movement has gained enormous momentum over recent years. The BLM movement is centered on stopping racially motivated violence against Black people. Similarly, due to a somewhat recent escalation in anti-Asian American and Pacific Islander (AAPI) sentiment, a rise in Asian hate crimes, and American leadership scapegoating Asian communities in the COVID-19 pandemic, there has been a dramatic increase in race-related politics and social attention given to ensuring human rights and social justice for all Asian Americans. Lastly, the #MeToo movement is a contemporary feminist movement that began in 2006 and became much more culturally prominent in 2017 when women started coming forward via news and social media with stories of harassment and

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Table 1.1. 2024 CACREP Accreditation Standards and Location CACREP 2024 Standard

Where the Standards Are Met Within the Textbook

Section 3.1.a: history and philosophy of the counseling profession and its specialized practice areas

Chapters 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13

Section 3.2.d: the role and process of the professional counselor advocating on behalf of and with individuals receiving counseling services to address systemic, institutional, architectural, attitudinal, disability, and social barriers that impede access, equity, and success

Chapters 1, 2, and 3

Section 3.1.k: self-care, self-awareness, and self-evaluation strategies for ethical and effective practice

Chapters 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13

Section 3.2.a: theories and models of multicultural counseling, social justice, and advocacy

Chapters 2 and 3

Section 3.2.b: the influence of heritage, attitudes, values, beliefs, understandings, within-group difference, and acculturative experiences on individuals’ worldviews

Chapters 2 and 3

Section 3.2.e: the effects of stereotypes, overt and covert discrimination, racism, power, oppression, privilege, marginalization, and violence on counselors and clients

Chapters 2 and 3

Section 3.2.f: the effects of various sociocultural influences on mental and physical health and wellness, including public policies, social movements, and cultural values

Chapters 2 and 3

Section 3.2.i: strategies for identifying and eliminating barriers, prejudices, and intentional and unintentional oppression and discrimination

Chapters 2 and 3

Section 3.5.a: theories and models of counseling, including relevance to clients from diverse cultural backgrounds

Chapters 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13

Section 3.5.c: case conceptualization skills using a variety of models and approaches

Chapters 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13

Section 3.5.e: application of technology related to counseling

Chapter 1

Section 3.5.g: culturally sustaining and responsive strategies for establishing and maintaining counseling relationships across service delivery modalities

Chapters 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13

Section 3.5.h: counselor characteristics, behaviors, and strategies that facilitate effective counseling relationships

Chapters 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13

Section 3.5.i: interviewing, attending, and listening skills in the counseling process

Chapters 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13 (continued)

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Table 1.1. 2024 CACREP Accreditation Standards and Location (continued) CACREP 2024 Standard

Where the Standards Are Met Within the Textbook

Section 3.5.j: counseling strategies and techniques used to facilitate the client change process

Chapters 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13

Section 3.5.k: strategies for adapting and accommodating the counseling process to client culture, context, abilities, and preferences

Chapters 1 and 2

Section 3.5.o: evidence-based counseling strategies and techniques for prevention and intervention

Chapters 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13

Section 3.5.v: processes for developing a personal model of counseling

Chapter 1

Section 3.7.h: use of assessments in academic/educational, career, personal, and social development

Chapters 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13

Section 3.7.i: use of environmental assessments and systematic behavioral observations

Chapters 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13

Note: All accreditation information within the table was taken from the Council for Accreditation of Counseling and Related Educational Programs (CACREP 2024) standards. https://www.cacrep.org/wp-content/­ uploads/2022/10/Draft-4-2024-CACREP-Standards.pdf

sexual assault committed by men. By saying “me too,” a survivor of harassment, sexual assault, and/or rape stands in solidarity with other women who have experienced similar atrocities. The #MeToo movement has made a big cultural impact around raising awareness, accountability, and empowerment regarding sexual misconduct perpetrated against women. In addition to creating a community centered on safety, empathy, and hope, the #MeToo movement made a very positive impact in the United States through increasing the reporting of sex crimes by 10% in its first 6 months and increasing the number of arrests for sexual assault crimes (Meyers, 2018‌‌‌‌‌‌‌‌‌). This textbook deliberately focuses on theory-based multiculturalism, intersectionality, and social justice within every chapter. While we intentionally weave these elements in, much of the textbook content is centered on theory, case conceptualization, and professional practice. For those interested in a comprehensive review of culture, diversity, multiculturalism, intersectionality, racism, and discrimination, please consider reviewing Sue et al.’s (2019) textbook entitled Counseling the Culturally Diverse: Theory and Practice. From a CACREP perspective, the following 2016 social and cultural diversity standards are frequently reviewed throughout this edition of the textbook: 2.F.2.a. multicultural and pluralistic characteristics within and among diverse groups nationally and internationally (Chapter 2); 2.F.2.b. theories and models of multicultural counseling, cultural identity development, and social justice and advocacy (Chapters 2 and 3); 2.F.2.c. multicultural counseling competencies (Chapters 1–13); 2.F.2.d. the impact of heritage, attitudes, beliefs, understandings, and acculturative experiences on an individual’s views of others (Chapters 2–13); 2.F.2.e. the effects of power and privilege for counselors and clients (Chapters 2 and 3); 2.F.2.f. help-seeking behaviors of diverse clients (Chapter 1–13); and 2.F.2.h. strategies for identifying and eliminating barriers, prejudices, and processes of intentional and unintentional oppression and discrimination (Chapters 2 and 3).

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THE THEORIES OF COUNSELING You may be wondering, “Do most people acknowledge that empathic conversations with a professional counselor create a sense of healing?” The answer is “yes.” Because counseling professionals use empirically validated skills and interventions that have been proven through research to address specific mental health concerns, counseling is considered a legitimate form of healing. Counselors are agents of helping, healing, and change; however, they are far more effective when they are operating from a theory. Counseling theories are intellectual models used for understanding human behavior and they are at the core of counselor preparation. These theoretical formulations are centered on the notion that mental health concerns can be healed through the art and science of counseling. Skills and interventions are often embedded within a theory and most theories are part of a larger theoretical grouping. For example, the empty chair technique is an in-session experiment originally developed in Gestalt therapy. Gestalt therapy is an experiential therapeutic approach that is often grouped under the humanistic counseling theories umbrella. These theoretical groupings are centered on certain ways of understanding human behavior, thought, emotion, and/or interpersonal dynamics, and include multicultural counseling theories, feminist theories, traditional psychoanalytic theories, relational approaches to psychoanalytic treatment, person-centered counseling and related experiential theories, existential-humanistic theories, behavioral theories, cognitive theories, systemic theories, postmodern theories, integrative theories, and brief counseling theories. While these theoretical camps are important intellectual models, they are pragmatically used as a foundation for creating skills and interventions that help clients understand, enhance, and/or change maladaptive behaviors, feelings, cognitions, and interpersonal challenges. Counseling theories tend to be affected by fads, trends, and novelties that garner much attention and enthusiasm; however, after a period of high interest, many of these fads seem to vanish from the therapeutic world. The counseling theories with long-standing tradition often become part of the foundation of client conceptualization and counselor skill-based training. We believe the theories presented within this textbook have withstood the test of time and are deeply connected to counselor preparation and research. The theoretical groups within this textbook are truly distinct and relevant, demonstrate unique methods for helping others, and symbolize unique pathways for understanding human behavior. Furthermore, the distinct‌‌‌‌‌‌‌ and unique nature of each theoretical camp is bridged by similarities including, but not limited to, the importance of multiculturalism, intersectionality, and social justice and the centrality of the therapeutic relationship, client/counselor context, assessment, and skill acquisition, which have been the cornerstone of professional counseling for decades. Table 1.2 provides a breakdown of the chapter titles, leaders and legacies reviewed in each chapter, and the essence of the theoretical camp being explored.

The History of Counseling While it has been suggested that the roots of the practice‌‌‌‌‌‌‌ of counseling can be traced back to incantations provided by the Enlightenment Era priests from Mesopotamia, Persia, and Egypt (Hackney & Cormier, 2009‌‌‌‌‌‌‌‌‌), the origins of contemporary professional counseling theory‌‌‌‌‌‌‌ are centered on the contributions of professional pioneers Frank Parsons (1854–1908) and Carl Rogers (1902–1987). While the impact of Parsons and Rogers were enormous, additional noteworthy influences include, but are not limited to, Sigmund Freud (1856–1939), Alfred Adler (1870–1937), Otto Rank (1884–1939), Fritz Perls (1893–1970), Abraham Maslow (1908–1970), Virginia Satir (1916–1988), and Carl Whitaker (1912–1995). Please note, while Parsons and Rogers often get the nod as being the pioneers of professional counseling, Sigmund Freud, the founder of psychoanalysis and modern psychotherapy, is the pioneer

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Table 1.2. Chapters, Leaders and Legacies, and the Essence of the Theoretical Grouping Chapter and Title

Leaders and Legacies

Essence of the Theoretical Group

Chapter 2. Multicultural Counseling Theory

Clemmont Vontress Derald Wing Sue Janet Helms Manivong J. Ratts Paul B. Pederson Patricia Arredondo Thelma Daley

The essence of multicultural counseling includes contextually understanding the nuances of counseling with individuals who are culturally different (race, ethnicity, socioeconomic, etc.).

Chapter 3. Feminist Approaches

Mary Wollstonecraft Simone de Beauvoir Carol Gilligan bell hooks Judith Butler

The essence of feminist theory includes the notion that the personal is political, honoring the value within the messages of marginalized people, and the importance of demystifying power structures.

Chapter 4. Traditional Psychoanalytic Approaches

Sigmund Freud Josef Breuer Carl G. Jung Donald Winnicott

The essence of traditional psychoanalytic theory includes therapeutically working with individuals so they can develop self-understanding and insight and resolve the unconscious conflicts within their minds.

Chapter 5. Relational Approaches to Psychoanalytic Treatment

Karen Horney Heinz Kohut Alfred Adler

The essence of the relational approaches to psychoanalysis includes the notion that all individuals are embedded within social relationships, and the counselor and client are both participants within the analytic process.

Chapter 6. Person-Centered and Related Experiential Approaches

Carl Rogers Otto Rank Abraham Maslow Leslie Greenberg Sue Johnson

The essence of person-centered and related experiential theories includes the notion that humans are relational in nature, behaviors and cognitions are attempting to meet relational needs, and emotions are healed by emotions.

Chapter 7. Existential-Humanistic Approaches

Irvin Yalom Viktor Frankl Fritz Perls Rollo May

The essence of the existential-­ humanistic theories includes approaching clients with a sense of wonder, curiosity, and genuineness as they face the mysteries of life and the difficult realities of existence.

Chapter 8. Behavioral Approaches

Ivan Pavlov John B. Watson Rosalie Rayner Edward Thorndike Joseph Wolpe Mary Cover Jones B. F. Skinner

The essence of behavioral theory includes the understanding that all client behavior is learned, has a purpose, and is modifiable using skills and interventions grounded in empirical support. (continued)

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Table 1.2. Chapters, Leaders and Legacies, and the Essence of the Theoretical Grouping (continued) Chapter and Title

Leaders and Legacies

Essence of the Theoretical Group

Chapter 9. Cognitive Approaches

Albert Ellis Aaron Beck Albert Bandura Martin Seligman Donald Meichenbaum Steven Hayes

The essence of cognitive theories is the understanding that client issues result from the lack of attunement between thoughts, feelings, and behavior and the interplay of these factors is enhanced when more adaptive thought patterns are adopted.

Chapter 10. Systemic Approaches

Gregory Bateson Murray Bowen Virginia Satir John Weakland Paul Watzlawick Salvador Minuchin Donald Jackson Cloe Madanes Jay Haley

The essence of systemic theories includes the notion that the issues ­clients bring into counseling reflect their context and familial/relational behavior, and counselors cocreate ­client change through understanding and influencing the circularity of interactions, subjective nature of experiences, relational behavior, and communication patterns.

Chapter 11. Postmodern Approaches

David Epston Michael White George Kelly Insoo Kim Berg Steve de Shazer

The essence of postmodern theories includes the philosophy that issues explored in counseling often reflect one way of viewing multiple possible realities, during counseling the counselor and client co-construct knowledge, and all therapeutic results are based on a perception of perspectives that individuals apply their own ­meaning to.

Chapter 12. Integrative Approaches

Aaron Lazarus John C. Norcross James Prochaska

The essence of integrative theories includes the understanding that c ­ lients present with different issues, needs, and preferences. Consequently, counselors assimilate and draw from a variety of therapeutic models and ­techniques to best serve their clientele.

Chapter 13. Brief Counseling Approaches

James Bitter William Nicoll Berthold Gersons Insoo Kim Berg Steve de Shazer

The essence of brief counseling theories is for the counselor to provide a planned and time-limited approach to understanding the issues that led the client to come to counseling and d ­ elivering direct and parsimonious interventions that lead to a sense of c ­ lient relief and clinical goal achievement.

who ultimately set the stage for Parsons, Rogers, and all other modern approaches to counseling (Flynn & Sangganjanavanich, 2014‌‌‌‌‌‌‌‌‌). Frank Parsons’s impact was so prominent that he has been referenced as the “Father of Vocational Guidance” (Blocher, 2000; Limberg et al., 2022). He was passionate about fighting for the rights and needs of individuals who were exploited by industrial monopolies. He was very interested in how people chose their vocation (i.e., career), and his theory of vocational development postulated the importance of harmony between a worker’s strengths, limitations,

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abilities, aptitudes, and resources in selecting a suitable job. His textbook Choosing a Vocation provided important information on how to help people arrive at a wise career selection through expert counsel (Parsons, 1909‌‌‌‌‌‌‌‌‌). Among his many achievements, Parsons authored 14 books and created the first counseling agency that served as an antecedent to the emergence of vocational guidance in U.S. schools (i.e., school counseling; Limberg et al., 2022). American psychologist Carl Rogers (1902–1987) is not only a pioneer of the counseling profession but is also one of the founders of the entire humanistic movement. His achievements and impact in the development of counseling theory and practice are so great that his work has become the roots of the entire counseling profession. His two groundbreaking books include On Becoming a Person: A Therapist’s View of Psychotherapy (Rogers, 1961) and A Way of Being (Rogers, 1980). While humanistic psychology can be traced back to the Middle Ages when the philosophy of humanism was created, the second half of the 20th century is the time period most relevant to present-day counseling theory. Today, humanism is still very much evident theoretically (e.g., person-centered therapy and theory), through clinical practice (e.g., invitational and attending counseling skills), and within the research world (e.g., The Journal of Humanistic Counseling; Flynn, 2023). Humanistic theoretical approaches emphasize a sense of acceptance and unconditional positive regard, highlight the importance of everybody’s worth, embrace the holistic nature of the human condition, demonstrate an anti-reductionistic outlook, value free will and agency, accept emotions, uphold the importance of context and subjectivity, and still consider the development of a safe and meaningful empathic relationship as the principle of effective clinical practice (Bohart, 2003; Flynn, 2023; Raskin & Rogers, 1989‌‌‌‌‌‌‌‌‌). Carl Rogers’s person-­ centered approach was heavily influenced by the fundamental principle of nondirectiveness. In fact, Rogers’s therapeutic approach was once called nondirective psychotherapy. Rogers essentially created a therapeutic atmosphere centered on permissiveness, genuineness, nonjudgment, and not using assessments or clinical interventions. Bohart (2003) and Rogers (1963) described the skills of acceptance and clarification as the only “interventions” used to help individuals become fully functioning beings. This anti-interventionist framework is key to why his approach is considered nondirective. While contemporary counselors learn a variety of theoretical models, the influence of the person-centered approach remains evident within counselor preparation and scholarly literature. For example, most practitioners continue to believe the overall importance of the following counseling factors and dispositions: the therapeutic relationship, empathy, the accurate reflection of feelings, congruence, and genuineness.

MODELS OF CASE CONCEPTUALIZATION According to Sperry and Sperry (2020b) “…a case conceptualization is a process and cognitive map for understanding and explaining a client’s presenting issues and for guiding the counseling process” (para. 3). Having a solid case conceptualization format is a basic counseling proficiency and has been described as the most salient counseling competency outside of the development of the therapeutic relationship (Sperry & Sperry, 2020b). Case conceptualization serves as a foundation for client assessment, clinician’s use of skills and techniques, client diagnosis, psychopharmacological referral, and treatment planning (e.g., goals, objectives, target behaviors, interventions). The primary purpose is to build a bridge between counselor and client through theory, resulting in a well-developed and coherent narrative. How does one do this? Various models can be used with almost any developed counseling theory to help the clinician through the complex and challenging case conceptualization process. Models are organized around multiple elements of client data to create a treatment blueprint for future sessions. Specifically, a case conceptualization narrative will identify the precipitating causes (i.e., events) of a client’s presentation (i.e., symptoms), the patterns that activate and maintain the client’s problems, how social and cultural factors

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impact the client presentation, and the strategies for intervention planning (John & Segal, 2015; Sperry & Sperry, 2020a). How a case conceptualization model is chosen is influenced by a variety of factors, including, but not limited to, the counselor’s theoretical orientation, client presenting problem(s), empirically based assessment(s), agency/hospital policies, and the treatment goal(s). The general nature of effective case conceptualization involves (a) gathering client background information and engaging in a thorough clinical interview to arrive at a comprehensive diagnosis; (b) deciding what type of counseling (e.g., family counseling, crisis counseling, individual counseling) and/or services (e.g., outpatient services, inpatient hospitalization, substance detox, appointment with a psychiatrist) are needed; (c) collecting the history of current symptoms and how they have been maintained (e.g., “When did your anxious thoughts and feelings first start?”); (d) cocreating a cultural and intersectional formulation of the presenting issue(s) (e.g., race, ethnicity, gender, socioeconomic status [SES], religion, age, ability); and (e) developing a nuanced treatment plan (Sperry & Sperry, 2020a). Here we will provide a brief overview of the two atheoretical models of case conceptualization.

The Biopsychosocial Model of Case Conceptualization Arguably, the most common method of case conceptualization is the biopsychosocial model. This model is mainly atheoretical, involving the client’s vulnerabilities and protective factors relevant to their biological, psychological, and sociocultural predispositions. Because of its biological basis, this method has been used across many allied healthcare professions and has considerable appeal to those practicing in medical contexts. Within the biopsychosocial model of case conceptualization, the client’s concerns and presentation are considered a product of hierarchically organized biological, psychological, and sociocultural factors. It is a multilevel, multisystem framework for client functioning. Biological predispositions account for risk of and resilience to mental illness. These biological predispositions begin in prenatal development and continue through adulthood but are exhibited primarily in early development. Their causes include genetics, pre- or post-natal trauma, disease, or birth complications. Relevant psychological factors to consider may include personality style, coping capacities, past mental health histories, and developmental history. Finally, sociocultural risk factors are considered as they may influence both biological and psychological factors, further protecting from or activating the development of psychopathology. Counselors must also be mindful of client’s social history, context, external stressors, identities, marginalization, sociopolitical power and access, relationships, and other sociocultural variables impacting the client’s symptoms and function. In short, these three factors (i.e., biopsychosocial) work together to activate a client’s vulnerabilities and strengths. In this model, the counselor views the manifestation of the client’s symptoms as an attempt to cope with stressors activated through their vulnerabilities. Ultimately, biopsychosocial case conceptualization focuses treatment on assuaging client symptoms and increasing functioning through an integrative treatment approach (Borrell-Carrió, Sunchman, & Epstein, 2004).

The Eight P’s A second popular atheoretical model of case conceptualization is Sperry and Sperry’s (2020b) eight P’s. This model is ideal for counselors who are seeking a brief, quick to understand, and comprehensive atheoretical client conceptualization model. The format is centered on the nature and origin of the client’s presenting issue and treatment. The step-by-step format includes (a) presentation (i.e., clinical symptoms, traits, and interpersonal issues), (b) predisposition (i.e., biological, social, psychological, and cultural considerations), (c) precipitants (i.e., issues that served as an antecedent or cause or simply coincided with the onset of

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clinical symptomology), (d) protective factors and strengths (e.g., coping skills, attachment style, and client strengths), (e) pattern (i.e., predictable maladaptive patterns of coping, feeling, thinking, and behaving), (f) perpetuants (i.e., how maladaptive patterns are reinforced and confirmed within a client’s environment), (g) plan (i.e., treatment plan, objectives, goals, and interventions), and (h) prognosis (i.e., prediction of client ability and readiness to change). This model clearly describes issues related to the client’s presenting problem. In fact, four of the P’s (i.e., predisposition, precipitants, pattern, and perpetuants) are centered on the presenting concerns. The substantial amount of clinical information gathered will assist counselors with writing their treatment plan and providing a well-researched diagnosis based on current mental status, family development and social history, personal mental health and physical health history, and client resources and strengths.

THEORETICAL MODELS Most models of case conceptualization are theoretically based. One of the most practiced psychotherapies today is cognitive behavior therapy (CBT). While there are a variety of forms and formats of CBT, cognitive behavioral (CB) case conceptualization unites the various iterations of the approach. As part of the integrative counseling theoretical grouping, intricately combining cognitions and behaviors in a manner that best supports clients is the central focus of the CBT case conceptualization model. However, in addition to cognitions and behaviors, CB case conceptualization includes factors like the client’s cultural identification, their intersectional identity, their acculturation status (if relevant), and the explanation of the cause of the client’s presenting issue (Easden & Kazantzis, 2018). CB case conceptualization centers on analyzing antecedents and responses to a problem and the client’s resulting cognitive, emotional, and behavioral experiences (Padesky & Mooney, 1990). This format of conceptualization is similar to behavioral functional analysis (Haynes & O’Brien, 2000) and Ellis’s (1962)‌‌ A-B-C framework. You will review functional analysis in Chapter 8, and rational emotive behavior therapy (REBT) in Chapter 9 of this text. A case conceptualization framework is not stagnant; it is an iterative and evolving process. Prior to entering the counseling profession or graduate school, soon-to-be counselors have their own way of understanding and informally assessing people, mental health issues, and environmental factors. This initial framework was largely developed through life experiences, socialization, culture, family, and one’s own personal development process. After entering graduate school, counseling students are intentionally provided academically oriented theoretical models and atheoretical models of case conceptualization, which are fluid and evolving. When new research and information emerges in the professional stratosphere, it is absorbed into the traditional methods, and case conceptualization models change. The next section briefly describes the models of case conceptualization presented within this textbook.

Multicultural Counseling Theory MCT was developed and influenced by many individuals, including, but not limited to, Paul B. Pederson (1936–2017), Derald Wing Sue, Manivong J. Ratts, Patricia Arredondo, Thelma Daley, and Courtland Lee. MCT emphasizes understanding race, ethnicity, sexuality, gender, religion, SES, and any other nuances that influence a client. Central themes in the MCT model include (a) advocating for a call to action, (b) attaining multicultural competency, (c) using well-vetted MCT counseling interventions and techniques, (d) developing ethnic and racial identity, (e) embracing spirituality, (f) understanding sexual orientation development, (g) and engaging in social justice and advocacy. When practicing from an MCT perspective, presenting issues are linked to understanding, coping, and attaining resiliency despite the barriers brought forth by issues such as systemic oppression, racism,

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inequity, and marginalization. To create a strong therapeutic alliance, counselors practicing from an MCT theoretical perspective do not shy away from conversations pertaining to race, ethnicity, and culture, especially as it relates to differences between the counselor and client(s) (Hughes, 2023).

Feminist Theory Feminist theory has many leaders, legacies, and contributors. The key figures within the feminist movement include, but are not limited to, Mary Wollstonecraft (1759–1797), Simone de Beauvoir (1908–1986), Carol Gilligan, bell hooks (1952–2021), and Judith Butler. The essence of feminist theory is the belief that the personal is political, there is value within the messages of marginalized communities, and demystifying power structures is important. Feminist case conceptualization incorporates a sense of egalitarianism, multiculturalism, social justice, advocacy, and a dedication to empathizing and collaborating with individuals, groups, families, and couples. When conceptualizing client issues, feminists carefully balance listening and affirming the voices of clients; understanding the various contextual issues in a client’s life; assessing the roles, groups, and relationships impacting a client; and actively observing, challenging, and resisting the continuation of oppression and subjugation. To lift clientele out of the grips of oppression, feminist counselors create a therapeutic environment that supports open communication, sharing beliefs and ideas, and ask clients to collaborate on a shared meaning-making therapeutic experience (La Guardia, 2023).

Traditional Psychoanalytic Theory The founder of psychoanalytic theory was Sigmund Freud (1856–1939). Three additional key contributors to psychoanalytic theory include Josef Breuer (1842–1925), Carl G. Jung (1875–1961), and Donald Winnicott (1896–1971). The core of traditional psychoanalytic theoretical case conceptualization is helping individuals, couples, families, and groups develop a sense of self-understanding, begin lifelong habits of introspection, and resolve unconscious conflicts that interfere in their everyday life. The practice of psychoanalysis continues to explore the nature of the unconscious mind, the salience of childhood experiences on the development of one’s personality, and the evolving nature of the collaborative and empathic therapeutic alliance. Contemporary psychoanalysis has moved away from the counselor acting as if they were a blank slate for the use of client projection to the counselor serving as a more relational and collaborative participant in the session within a close therapeutic alliance. Counselors practicing from a psychoanalytic perspective engage in active listening to uncover client conflicts through collaboration, explore the origins of interpersonal conflict, and identify pertinent client unconscious material (Smith, McGrath, Mangin, & Altenberg, 2023).

Relational Approaches to Psychoanalytic Treatment Relational approaches to psychoanalytic treatment have been influenced by several psychology pioneers, including, but not limited to, Alfred Adler (1870–1937), Karen Horney (1885– 1952), and Heinz Kohut (1913–1981). The essence of case conceptualization from a relational approach includes many aspects of traditional psychoanalysis along with the conception that all individuals are connected through interpersonal relationships. Factors like client countertransference disclosures are used collaboratively, instead of hierarchically, to explore the many relational scenarios that are being enacted between the counselor and client. This relational conceptualization is also woven into the therapeutic relationship as both the counselor and client are participants within the analytic process. This change is significant when

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compared to the traditional psychoanalytic conceptualization that describes the counselor as a blank slate who can detach themselves and analyze aspects of the client’s psyche with neutrality (Bruner & Williams, 2023).

Person-Centered Counseling and Related Experiential Theories Person-centered counseling and related experiential approaches are a theoretical grouping that is part of an even larger theoretical camp known as “humanism” or “humanistic therapeutic approaches.” This larger humanistic grouping also includes the existential counseling traditions. The key figures within this theoretical grouping include, but are not limited to, Otto Rank (1884–1939), Carl Rogers (1902–1987), Abraham Maslow (1908–1970), Leslie Greenberg, and Susan Johnson. Case conceptualization from this theoretical perspective is centered on the importance of moment-to-moment personal functioning; the human actualizing tendency; creativity; the relational nature of humans; the importance of understanding diversity, multiculturalism, and intersectionality; and that belief that hurt emotions are best healed by emotions. Lastly, all person-centered counseling and related experiential approaches view emotions, behavior, cognition, and mental illness as being deeply influenced by context (Norris et al., 2023).

Existential-Humanistic Theories Existential and humanistic counseling theories are a long-standing therapeutic tradition. This theoretical group embraces existential philosophy dating back to Socratic, Renaissance, Romantic, and Asiatic eras. The key existential counseling leaders include, but are not limited to, Irvin Yalom, Fritz Perls (1893–1997), Viktor Frankl (1905–1997), and Rollo May (1909–1994). From a case conceptualization perspective, existential-humanistic counselors approach client situations with a sense of wonder, genuineness, and curiosity. Within this conceptualization, they consider the whole client in their entirety (i.e., past, present, conscious, unconscious, environment, culture, etc.). Existential-humanistic counselors journey with clients as they struggle with attempting to create meaning from the realities of existence. As counselors conceptualize each client’s unique struggle and meaning-making experience, they consider a variety of factors including freedom, responsibility, reflection, destiny, death, isolation, meaninglessness, and context (Givens et al., 2023).

Behavioral Theory Since the late 1800s, behavioral counseling approaches have encompassed a wide array of theories, leaders, scholars, and techniques. The key behavioral leaders include, but are not limited to, Ivan Pavlov (1849–1936), John B. Watson (1878–1958), Rosalie Rayner (1898–1935), Edward Thorndike (1874–1949), Joseph Wolpe (1874–1949), Mary Cover Jones (1897–1987), and B. F. Skinner (1904–1990). Behavioral counseling is centered on the following concepts: (a) Client behavior is the focal point of all treatment, (b) all client behavior is learned and can be unlearned, and (c) healing comes from using empirically based skills and interventions to modify variables in a client’s environment. Behaviorally oriented case conceptualization pulls from many theories including classical conditioning, operant conditioning, CBT, reciprocal inhibition, applied behavior analysis, behavior modification, and dialectical behavior therapy (DBT). Conceptually speaking, behaviorists believe maladaptive behaviors can be changed to become more adaptive. Through focusing on current observable behaviors, instead of internal processes, personality, or the past, behaviorists are able to determine the antecedents, behaviors, and consequences that maintain and influence both adaptive and maladaptive behaviors. Personality is reflected in client behavior, individual learning history, and patterns of reinforcement. Through applying scientific methodology, behaviorists

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carefully conceptualize ways to modify the client’s environment to reduce or eliminate maladaptive behaviors (Guillot Miller, 2023).

Cognitive Theory The cognitive approach to counseling has received considerable attention over the past 50 years. The key leaders/scholars that have contributed to the cognitive school of thought include, but are not limited to, Albert Ellis (1913–2007), Aaron Beck (1921–2021), Albert Bandura (1925–2021), Martin Seligman, Donald Meichenbaum, and Steven Hayes. The core theoretical tenant underlying cognitive theory is the notion that client concerns often result from a lack of attunement between thoughts, feelings, and behaviors. All cognitive theories aim to replace faulty and/or dysfunctional cognitions with more adaptive ones. Faulty and/or dysfunctional cognitions are often conceptualized as cognitive distortions and/or irrational beliefs. The case conceptualization process involves a thorough analysis of the client’s immediate thoughts that frequently emerge in their mind (i.e., automatic thoughts); intermediate beliefs that underly the automatic thoughts (i.e., assumptions); and core beliefs about self, others, and the world (i.e., schemas). Using empirically based interventions, counselors practicing from a cognitive theoretical perspective will work with clients to create awareness around these cognitions, help clients recognize how the maladaptive cognitions are impacting their daily functioning, and collaborate on restructuring client cognitions with more adaptive and healthy thoughts (Flynn, 2023; Limberg et al., 2023).

Systemic Theory Systemic theories reflect a field grounded in psychology, mathematics, anthropology, science, and hypnosis. The key systemic theorists include, but are not limited to, Gregory Bateson (1904–1980), Murray Bowen (1913–1990), Virginia Satir (1916–1988), John Weakland (1919–1995), Donald Jackson (1920–1968), Paul Watzlawick (1921–2007), Salvador Minuchin (1921–2017), Cloe Madanes, and Jay Haley (1923–2007). Systemic counseling represents a theoretical paradigm shift centered on the notion that structural, system, and rule-based adjustments create a deeper and more sustainable change when compared with individually oriented interventions and/or theories. The core of systemic theory is centered on the notion that the issues clients bring into counseling reflect their context and familial/ relational behavior. Counselors cocreate systemic client change through understanding and influencing the circularity of interactions, subjective nature of experiences, relational nature of behavior, and client communication patterns. From a case conceptualization perspective, systemic theory is heavily influenced by cybernetics, social constructivism/constructionism, attachment, and postmodern theories and therapies. Counselors operating in this framework do not believe clients have a stable collection of intrapersonal/interpersonal traits that appear fixed across time and location. Instead, clients are viewed as being in relation to their context, and individual traits are theorized as being fluid, relative, and reflecting circumstance, environment, and situation (Flynn, 2023; Nielson, 2023).

Postmodern Theory Postmodern counseling theories are influenced by multiple theories including humanism, systems theory, feminism, constructivism, social constructivism, and social constructionism. Individuals who have deeply influenced postmodern approaches to counseling include, but are not limited to, George Kelly (1905–1967), Insoo Kim Berg (1934–2007), Steve de Shazer (1940–2005), David Epston, and Michael White (1948–2008). The emergence of the postmodern theoretical grouping is ushered in a sense of creativity and humility to the counseling relationship as clinicians and clients began to freely view issues from multiple perspectives

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and resisted feeling restricted to one or two modern narratives. This also reduced the somewhat hierarchical nature of a counseling relationship. A central tenant of all postmodern theories is the salience of an individual’s perception of the world. One’s view of reality is heavily influenced by language, culture, and personhood. In addition, instead of receiving expert-based recommendations, clients are encouraged to make personal meaning around their experiences. The core of postmodern case conceptualization is appreciation for viewing multiple possible clinical realities, co-construction of knowledge and reality through counseling, and participating in the clinical meaning-making process through communication (Hinkle & Perjessy, 2023).

Integrative Theory Integrative approaches to counseling are centered on synthesizing the theoretical tenants and clinical skills of multiple theoretical traditions. The key pioneers who have made a significant contribution to this theoretical grouping include, but are not limited to, Arnold Lazarus (1932–2013), John C. Norcross, and James Prochaska. Counselors assimilate and draw from a variety of theoretical models and interventions to effectively serve the diverse needs of their clients. The consequence of this assimilation is increased clinical effectiveness with a wider range in presenting issues and the ability to provide high-quality service to diverse client populations. Counselors practicing from an integrative perspective never rely on one single approach to describe mental illness, wellness, or human development. In short, humans are unique and complex so there is no one set of skills or theories that objectively and clearly describe client issues and concerns. Lastly, almost any type of empirically based intervention may be used when considered therapeutically appropriate (McKibben & Gainer, 2023).

Brief Counseling Theory Two common ingredients in all brief counseling theories are the ideas that (a) change and/ or healing can occur in the moment and (b) brief counseling is an efficient way to engage in treatment. Notable leaders of this form of treatment include, but are not limited to, James Bitter, William Nicoll, Berthold Gersons, Insoo Kim Berg, and Steve de Shazer. The central feature of brief counseling is for the counselor to provide a planned, time-limited approach to issues that led the client to enter counseling and efficient services that lead to client healing and goal achievement. In general, the brief counseling format aims to make the most out of each session and use empirically based methods to bring about fast and predictable change. The common ingredients that cut across all brief counseling modalities are the importance of the therapeutic alliance, measurable goals and objectives, clear descriptions of client and counselor roles, strength-based focus, and a focus on the current issues (i.e., here and now). These elements are key to brief counseling case conceptualization. Clients who tend to succeed in this form of counseling believe most change takes place after counseling, have clear treatment goals, desire efficient short-term help, and actively engage in out-of-session work (Seward & Williams, 2023).

COMMON FACTOR MODELS AND IMPLICATIONS It is well established that counseling can effectively treat mental health disorders and help clients overcome barriers to their development (Cristea et al., 2017; Mohr et al., 2014). Most of the theories presented have been subjected to scientific analysis and verification. It is important to note that describing the tenants of a theory or the empirical evidence supporting a therapy’s effectiveness in treating a mental health disorder does not demonstrate the nature of the theory in clinical practice (Kazdin, 2007). A theory, like counseling itself, is

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a complex activity. Our experience is that most counseling theory textbooks do not do an adequate job of demonstrating how theories work. Common questions that go unaddressed include the following: (a) Which processes within the theory carry the effects? (b) What combination of mechanisms are necessary, and which can be removed? (c) How effective are counseling interventions and skills? These are difficult questions to answer. As a result, little is known about the processes of change among many theories and therapies (Cuijpers et al., 2019). Despite these difficulties, all counseling theory must be built upon a scientific foundation, which means counselors need to ensure what they are doing produces positive therapeutic results. While the art and science of psychotherapy looks much different today, all present-day theory has been molded and influenced by leading psychological thinkers and scholars of their age. In truth, the therapeutic world has a unique and interesting history. From the ceremonious and dramatic proffering of mesmerism (i.e., internal magnetic forces affecting mental illness; Franz Anton Mesmer [1734–1815]) and the wholly discredited pseudoscience of phrenology (i.e., study of bumps, size, and shape of cranium as an indication of mental functioning; Franz Joseph Gall [1758–1828]) of the 18th and 19th century, to the late 19th and 20th century, psychological theories proffered by the likes of Josef Breuer (1842–1925), Sigmund Freud (1856–1939), John B. Watson (1878–1958), and Carl Rogers (1902–1987; Bankart, 1997‌). Today, our field promotes the comprehension of therapeutic common factors, empirical validation, and research-based exploration of what approach to counseling works with a particular population and/or mental health issue. As time has progressed, so has the nature of psychotherapy science and its standards for rigor. In 1936, Saul Rosenzweig (1907–2004) first commented that all psychotherapies are effective due to common factors (i.e., personal characteristics of the counselor, client resources, and therapeutic relationship). He used the analogy to the Caucus race in Lewis Caroll’s Alice’s Adventures in Wonderland. In Caroll’s story, all the animals are soaked by the tears of giant-sized Alice. To dry off, they all decide to have a race. The dodo bird was left behind to officiate and decide the winner, ruling “Everybody has won, and all must have prizes” (Carroll, 2015, p. 34). Therefore, if the effectiveness of all psychotherapies is due to common factors present, then all have won, and all must have prizes. As such, Rosenzweig’s hypothesis was termed the dodo bird effect. Since Rosenzweig first introduced the idea of general equivalence across all psychotherapies, the dodo bird effect has been heavily researched and hotly debated (Budd & Hughes. 2009; Wampold & Imel, 2015). Common factors have been defined as the “ingredients or elements that exist in all forms of psychotherapy” (Hubble et al., 2010, p. 28). It is important to clarify that common factor models are not theoretical models per se; they are more accurately described as a framework for understanding how theories of counseling function. In short, counseling theoretical models serve as frameworks that house common factors. Since Rosenzweig proposed the effect of therapy was due to common factors, researchers have attempted to identify, organize, and operationalize all aspects of counseling that were common to all theoretical models (Castonguay, 1993; Frank & Frank, 1993; Wampold, 2015‌‌‌‌‌‌‌‌‌). In an attempt to clarify the concepts of common factors, Castonguay (1993) provided three meanings to understand the nonspecific and common factors of counseling. The first was the factors that are not specific to any theory (e.g., insight, corrective experiences, emotional expression, and increased sense of mastery). The second was centered on the elements of the therapeutic relationship (i.e., working alliance). Lastly, the third was based on influenced outcomes but were not therapeutic activities (i.e., client expectancies and engagement in treatment). These findings provided clarity for theorists and those contributing to the integration movement of psychotherapy. Lambert and colleagues (1992) engaged in groundbreaking research into the common curative factors in counseling. Their findings included (a) extratherapeutic factors (40% of successful outcome variance); (b) counseling relationship factors (30% of successful outcome

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variance); (c) expectancy, hope, and placebo factors (15% of successful outcome variance); and (d) model and technique factors (15% of successful outcome variance). According to Lambert (1992), extratherapeutic factors are the most important to the client and their environment when it comes to fostering change. They affect all counseling theories because they are salient to whether the client has resources to engage in the recommended process of change. Personal client factors could be the ability to engage in personal introspection, openness to confronting fears, or the ability to differentiate thoughts from behaviors and feelings. Client environmental factors include the ability to make therapeutic contact with family members or the openness of a spouse to engaging in treatment. According to Lambert’s (1992) research, the second most influential component relating to client change is the therapeutic relationship, which should come as no surprise to any practicing counselor. The art and science of the therapeutic relationship is at the heart of professional counseling. There are two key elements to this common curative factor: the client’s experience of the counselor and the counselor’s experience of the client. If both areas are positive, the therapeutic experience will likely be fruitful. This is because all theory, skills, and interventions are enacted within the realm of the therapeutic relationship. If one or both areas is negative, then the impact of any therapeutic intervention will likely be diminished (Duncan et al., 1997; Lambert, 1992). Expectancy, hope, and placebo factors account for the third highest level of change (Lambert, 1992). When clients have expectations or hope that counseling will provide positive results, it often does. In short, because clients think counseling will help, it often proves to be at least somewhat beneficial. Counselors can also enhance client positive treatment outcomes and anticipation of change through exuding a sense of confidence in their approach, having a well-thought-out case conceptualization, and offering acknowledgment of the struggles the client has endured. In this way, positive therapeutic outcomes certainly favor the informed mind. The last common curative factor according to Lambert (1992) is the power of theory-based techniques, which stems not only from the use of the chosen techniques but also the counselor’s belief in their effectiveness. A counselor’s understanding of a therapeutic model, along with their comfort and ability in delivering model-based techniques, is proven to impact client change (Duncan et al., 1997; Lambert, 1992). If we reframe this a bit, it sounds very akin to the power of suggestion (i.e., guiding the thoughts, feelings, and behaviors of others through suggestions) and/or the placebo effect (i.e., psychological improvement centered in believing a treatment will work). Lambert was not the only scholar who defined common factors in effective counseling. Frank and Frank (1993) outlined four common factors they found that collectively shape a theoretical model highlighting mechanisms of change in therapy. Frank and Frank described these common factors as the functioning relationship between the client and counselor, a treatment plan rationale, procedures delivered in a structured manner, and the importance of establishing a healing environment. These factors were organized into a psychotherapy model known as the contextual model (Wampold, 2015), which outlined three pathways to produce benefits in therapy: (a) the counselor–client relationship, (b) expectations set through discussion and treatment between the counselor and client, and (c) the client enacting health-promoting behaviors. Additional information on the common factor models and their integration into theory will be presented in Chapter 12. The discussion of common factors and their subsequent models has continued beyond the high-impact work of Frank and Frank, Wampold, Lambert, and others with new schools of thought and techniques continuing to develop. For the counselor in training, be mindful of the risks and rewards of these common factor claims. While evidence strongly suggests the importance of common factors in counseling, these models ultimately represent an atheoretical collection of commonalities (Wampold, 2015). This is partly why the counseling profession emphasizes use of self, personhood of the counselor, and verbal and nonverbal

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therapeutic behavior. Whatever the model or theory a counselor ascribes to, an equipped and skillful counselor is at the center of both theory and practice.

UNITARY THEORY, INTEGRATION, ECLECTICISM, AND PLURALISM Developing a personal counseling theory is often a lifelong process. It is important for ‌‌‌‌‌‌‌beginning counselors to understand that at its core, counseling is a practice‌‌‌‌‌‌‌; that a counselor’s evolution is constant and lengthy; and that personal growth is also paramount to this journey. When one is physically and psychologically well and frequently engaging others around the trials, tribulations, and successes associated with the human condition, growth is inevitable. Part of this professional and personal growth is the development of a theoretical orientation. The classic model for developing a counseling theoretical orientation is to invest in a unitary theoretical model (i.e., one counseling theory). There are an enormous number of potential theories for counselors to choose from; however, as previously stated, most of the theories can be boiled down to six salient clusters, including (a) psychoanalytic, (b) behavioral, (c) humanistic, (d) systemic, and (e) constructionist (Neukrug, 2015).

Integration While a sole theory may be appealing to some, research (Tasca et al., 2015) suggests that very few contemporary practitioners rely on a unitary theory of practice. When practitioners want to blend two or more theories together in a manner that incorporates technical, conceptual, and theoretical domains, they are engaging in integration (Benito, 2018). Integration is centered on synthesizing multiple approaches to develop an optimal theoretical and skill-based framework for helping clients. To successfully integrate, clinicians may ask themselves the following questions: “How well do these theories complement each other?” “Is there a sense of coherence and cohesiveness involved in the integration?” “Are these theories so contradictory that they cannot integrate?” “Are these theories empirically based and validated?” While successful integration takes careful planning, time, research, and strategy, some of the most efficacious theories are integrative in practice (e.g., common factors, CBT, DBT, acceptance and commitment therapy [ACT], emotionally focused therapy [EFT]). Integrative theoretical camps include, but are not limited to, theoretical integration (i.e., using tenants from various theories), common factors (i.e., therapeutic factors that jointly help clients), assimilative integration (i.e., a technique is absorbed into a theoretical orientation), and technical eclecticism (i.e., methodically incorporating treatment and theory; Benito, 2018).

Eclecticism Eclecticism can be described as method of technique selection. Specifically, an eclectic clinician attempts to provide the techniques, regardless of where they theoretically originated from, that they believe best suites the client’s presenting problem ‌‌‌‌‌‌‌. Essentially, an eclectic clinician attempts to use the most efficacious approach, method, or integration of methods that they believe can best help their clients. While clinicians can experience a great deal of personal freedom while using this approach, the interventions and skills used should be based on empirical evidence (i.e., not based on the clinician’s whim). Furthermore, eclecticism is misunderstood and misused when clinicians base their technique selection on the personal interest and comfort rather than fully understanding a technique’s procedure, the theory that supports the technique, the rationale for selecting the technique given the clinical context, the empirical evidence supporting the use of the technique, and the compatibility of the intervention with what the counselor has been using to up to this point (Benito, 2018; Lebow, 1997).

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Pluralism Pluralism is the most social constructivist form of theoretical integration. From a pluralistic perspective, there is no correct method, theory, or technique to use when conducting counseling. Furthermore, the pluralistic process is centered on a mutual decision-­making approach between the counselor and client. Specifically, pluralism encourages conjoint decision-making regarding technique selection. The rationale for this type of counseling theory integration is based on the notion that there are many ways to help someone, and given the level of diversity among clientele, clinicians should be able to choose whatever they believe fits the client’s culture, style, needs, and preferences (Cooper & McLeod, 2006; Cooper & Dryden, 2016).

THEORETICAL MULTICULTURALISM, INTERSECTIONALITY, AND SOCIAL JUSTICE A main emphasis within this textbook is social justice, context, multiculturalism, and intersectionality. When the first author envisioned this textbook, he deliberately required an emphasis on these factors throughout every chapter. As a profession, counseling has fully embraced this mind-set within our skills, interventions, theories, and standards (e.g., ethical codes, accreditation standards, research, professional practice). You may be wondering, “Why it is so important to infuse this information into a theory textbook?” Great question. To start, according to the American Counseling Association (ACA), when counselors use a multicultural lens while working with individuals, they gain an understanding of their client’s identity, culture, ethnicity, race, social class, religious affiliation, sexuality, and SES (Garcia & McDowell, 2010). These contextual issues influence a client’s experience of the world, and understanding this context is central to holistically treating a client. Consequently, a central component of a student’s professional development should be to infuse an understanding of these factors in every counseling theory they explore. While there are various definitions, at its heart, multiculturalism is the respectful coexistence of different cultural groups that have myriad contextual factors that create different levels of cultural privilege, power, and oppression (Garcia & McDowell, 2010). You may be wondering how a counselor can fully comprehend an individual’s cultural background with so many different and unique contextual factors. Theoretically, there are a large number of interacting and overlapping variables at play whenever you meet a person. The blending of these personal experiences creates an intersection of identity (Crenshaw, 1991‌‌‌‌‌‌‌‌‌). A theory-based understanding of these issues gives counselors an idea of what clients experience within their daily lives, the dynamics involved in various relationships, and an awareness of the unique tapestry of personal equity, privilege, and equality within a client’s culture. Counselors adopt an intersectional framework to gain an accurate understanding of a client’s internal world, to accurately conceptualize a client’s unique needs, and to individually tailor a client’s treatment. While theory, cultural issues, and research may help counselors glean an understanding of the issues at play in a client’s life, there is no onesize-fits-all when it comes to conceptualizing client multiculturalism and intersectionality. A major component of understanding an individual’s situation is through developing an empathic therapeutic alliance where a client feels safe to disclose their own distinct situation and experiences. Some client experiences may coincide with patterns identified in multicultural and intersectional literature, while other factors will be unique to the individual(s) engaging in treatment (Flynn, 2023). While awareness and care for multiculturalism and intersectionality is essential to client care, social justice fuels these levels of awareness with intentional action. According to ACA’s Counselors for Social Justice Division,

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Social justice in counseling represents a multifaceted approach in which counselors strive to simultaneously promote human development and the common good through addressing challenges related to both individual and distributive justice. This approach includes empowerment of individuals and groups as well as active confrontation of injustice and inequality in society, both as they impact clientele and in their systemic contexts…. (Counselors for Social Justice, 2009) Embedded within the social justice theory and literature is an ethic toward cultural participation. It is important to comprehend, challenge, and rebuild social entities and systems that perpetuate power imbalances, injustice, and inequity. Through meaningful advocacy and public political participation, counselors create accessible resources for marginalized communities (Flynn, 2023; Seedall et al., 2013).

THEORY FIT WITH TELEBEHAVIORAL INTERVENTIONS The 2020 global pandemic (i.e., COVID-19) sparked a need to urgently increase the use of telebehavioral health in clinical practice. COVID-19 greatly increased the need for therapeutic digital technology; however, prior to the global pandemic, most areas in the United States had a large list of practitioners offering telebehavioral health services. While there are many potential negative issues associated with telebehavioral health services (e.g., disruption in service, miscommunication due to visual or auditory glitches, lack of privacy, disruptive background noise, etc.), there are also many potential benefits that help those in need. From a positive perspective, telebehavioral health has allowed (a) individuals who live in remote/underserved areas a chance to engage in treatment, (b) clients to work with nonlocal clinicians who possess much-needed expertise, (c) clients to engage in treatment while not spending additional money on traveling expenses (e.g., gas), and (d) clients to maintain a sense of privacy due to approved providers being located outside of one’s local community. In addition to the client benefits, counselors who serve clients through telebehavioral health can experience the following: (a) greater flexibility in where they offer counseling, (b) an enormous reduction in overhead costs, (c) the ability to reach clients who live at a distance, and (d) the security in not risking their personal health and safety during counseling (e.g., contracting COVID-19; Hecker & Edward, 2014). Telebehavioral health can be applied to every counseling modality (e.g., individual, group, family, couple, network, etc.) and every counseling theory. Due to the gradual increase in telebehavioral health options, mass convergence during the pandemic, and popular demand for online therapeutic platforms, there have been a number of Health Insurance Portability and Accountability Act (HIPAA)-compliant options for counselors to utilize, including, but not limited to, Doxy.me, Zoom for Healthcare, GoTo Meeting, and Webex for Healthcare (www.gethealthie.com/blog/the-5-best-hipaa-compliant-telehealthtools). While each online platform provides unique features that attempt to aid counselors in the practice of telehealth, there are still challenges when serving particular populations (e.g., children, elderly) or when using different modalities (e.g., couple, family, group counseling) in online sessions. Fortunately, some companies and online platforms seek to assist counselors with their telehealth sessions. One noteworthy example is the organization Therapist Aid (www.therapistaid.com), which provides practitioners with a website and a number of free/inexpensive evidence-based therapeutic tools that can help engage with children in a telehealth format: Focus Fish helps children manage symptoms of attention deficit hyperactivity disorder (ADHD; www.therapistaid.com/interactive-­ therapy-tool/ focus-fish), The Little Lion Who Lost Someone is a tool centered on health grieving (www. therapistaid.com/interactive-therapy-tool/lion-grief), Worry Bugs is an online tool centered on teaching children about anxiety and worry (www.therapistaid.com/interactive-therapy-tool/worry-bugs), and Angry Monsters provides children with games and activities

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for understanding and handling anger (www.therapistaid.com/interactive-therapy-tool/ anger-monsters). While the application of telebehavioral health appears to provide a tremendous amount of innovation and potential, counseling professionals must understand the ethics, standards, and security matters related to engaging in teletherapy. In addition to understanding the standards of care within the ACA’s Code of Ethics (see Section H Distance Counseling, Technology, and Social Media), counselors should understand and frequently review HIPAA and the Health Information Technology for Economic and Clinical Health Act (HITECH) to ensure they are engaging in ethical telebehavioral health practice. While reviewing all ethical information related to telebehavioral health is beyond the scope of this chapter, understanding requirements like the use of two-way encryption, state jurisdiction and scope of practice, and standards of protected healthcare information is key. Table 1.3 reviews the relevant ACA (2014) profession-based ethical standards and professional practice stipulations.

FITTING THE PERSON WITH THE APPROACH When first entering the counseling profession, emerging counselors are often amazed and overwhelmed by the wide array of counseling theories at their disposal. Given the number of theories to choose from, you may be wondering, “What factors influence a counselor’s choice in theoretical orientation?” or “When inundated with a number of potential theoretical orientations, how does a counselor choose a preferrable theoretical orientation?” As you can imagine, there are many potential answers to questions like these. Specifically, many factors could play into their decision-making process including, but not limited to, personal belief system, religious beliefs, family influence, cognitive style, and life events (Petko et al., 2016). Furthermore, preferences in counseling theory often evolve over the course of one’s career (Freeman et al., 2007‌‌‌‌‌‌‌‌‌). When initially learning about the various approaches to counseling, students may find themselves more interested and attracted to a particular theory or theoretical school of thought. A salient question they may ask themselves is, “What theory best fits my view of human nature, development, and motivation?” Some approaches may support one’s thoughts and preferences more than others. Consequently, counselors tend to gravitate toward their theoretical interest and comfort area, which may land on a particular unitary theory or morph into an integrated, eclectic, technically eclectic, or pluralistic theoretical approach. While it is our experience that most counseling trainees gravitate toward theories that please and interest them, researchers, instructors, and supervisors often encourage counselors to consider what approach best serves the client. For example, if a new clinician develops a clinical specialization that helps individuals who struggle with traits associated with cluster B personality disorders (e.g., antisocial personality disorder, borderline personality disorder, histrionic personality disorder, and narcissistic personality disorder), they will likely augment their preferrable theory of choice with evidence-based treatments (e.g., DBT, CBT, trauma-informed counseling) aimed at helping their population of interest. As counseling students begin to absorb information from various theoretical schools, some may find a unitary theoretical orientation preferrable, while others may feel that the strict adherence to one theoretical framework is not sufficient enough or is too limiting. The use and integration of multiple theoretical orientations reflects many of the common factor approaches (e.g., the contextual model; Wampold & Imel, 2015), technical eclectic models (e.g., the multimodal model; Lazarus, 1967), and various theoretical integration approaches (e.g., CBT, DBT). Developing a theoretical orientation is an important aspect of professional development and identity that takes considerable time, reflection, and introspection (Skovholt & Rønnestad, 1995). Evidence suggests it is helpful to learn basic counseling skills prior to choosing a theoretical orientation (Corey, 2013; Young, 2016). Petko et al. (2016) ­discovered that solely reading about a theoretical orientation is not a sufficient method

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Table 1.3. Professional Counseling and Telebehavioral Health Ethical Standards Section Code

Standard

H. Introduction

Counselors actively attempt to understand the evolving nature of the profession with regard to distance counseling, technology, and social media and how such resources may be used to better serve their clients…and make every attempt to protect confidentiality and meet any legal and ethical requirements for the use of such resources.

H.1.b. Laws and Statutes

Counselors…understand that they may be subject to laws and regulations of both the counselor’s practicing location and the client’s place of residence. Counselors ensure that their clients are aware of pertinent legal rights and limitations governing the practice of counseling across state lines or international boundaries.

H.2.a. Informed Consent and Disclosure

…the following issues, unique to the use of distance counseling, technology, and/ or social media, are addressed in the informed consent process: • distance counseling credentials, physical location of practice, and contact information • risks and benefits of engaging in the use of distance counseling, technology, and/or social media • possibility of technology failure and alternate methods of service delivery • anticipated response time • emergency procedures to follow when the counselor is not available • time zone differences • cultural and/or language differences that may affect delivery of services

H.2.b. Confidentiality Maintained by the Counselor

Counselors acknowledge the limitations of maintaining the confidentiality of electronic records and transmissions.

H.2.c. Acknowledgment of Limitations

Counselors inform clients about the inherent limits of confidentiality when using technology.

H.2.d. Security

Counselors use current encryption standards within their websites and/or technology-based communications that meet applicable legal requirements. Counselors take reasonable precautions to ensure the confidentiality of information transmitted through any electronic means.

H.3. Client Verification

Counselors who engage in the use of distance counseling, technology, and/ or social media to interact with clients take steps to verify the client’s identity at the beginning and throughout the therapeutic process. Verification can include, but is not limited to, using code words, numbers, graphics, or other nondescript identifiers.

H.4.a. Benefits and Limitations

Counselors inform clients of the benefits and limitations of using technology applications in the provision of counseling services.

H.4.b. Professional Boundaries in Distance Counseling

Counselors discuss and establish professional boundaries with clients regarding the appropriate use and/or application of technology and the limitations of its use within the counseling relationship (e.g., lack of confidentiality, times when not appropriate to use). (continued)

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Table 1.3. Professional Counseling and Telebehavioral Health Ethical Standards (continued) Section Code

Standard

H.4.c. Technology-Assisted Services

When providing technology-assisted services, counselors make reasonable efforts to determine that clients are intellectually, emotionally, physically, linguistically, and functionally capable of using the application and that the application is appropriate for the needs of the client.

H.4.d. Effectiveness of Services

When distance counseling services are deemed ineffective by the counselor or client, counselors consider delivering services face-to-face. If the counselor is not able to provide face-to-face services (e.g., lives in another state), the counselor assists the client in identifying appropriate services.

H.4.e. Access

Counselors provide information to clients regarding reasonable access to pertinent applications when providing technology-­ assisted services.

H.4.f. Communication Differences in Electronic Media

Counselors consider the differences between face-to-face and electronic communication (nonverbal and verbal cues) and how these may affect the counseling process. Counselors educate clients on how to prevent and address potential misunderstandings arising from the lack of visual cues and voice intonations when communicating electronically.

H.5.a. Records

Counselors maintain electronic records in accordance with relevant laws and statutes. Counselors inform clients on how records are maintained electronically.

H.5.b. Client Rights

Counselors who offer distance counseling services and/ or m ­ aintain a professional website provide electronic links to r­ elevant licensure and professional certification boards to p ­ rotect consumer and client rights and address ethical concerns.

H.5.c. Electronic Links

Counselors regularly ensure that electronic links are working and are professionally appropriate.

H.5.d. Multicultural and Disability Considerations

Counselors who maintain websites provide accessibility to ­persons with disabilities. They provide translation capabilities for clients who have a different primary language, when feasible. Counselors acknowledge the imperfect nature of such translations and accessibilities.

H.6.a. Virtual Professional Presence

In cases where counselors wish to maintain a professional and personal presence for social media use, separate ­professional and personal web pages and profiles are created to clearly ­distinguish between the two kinds of virtual presence.

H.6.b. Social Media as Part of Informed Consent

Counselors clearly explain to their clients, as part of the informed consent procedure, the benefits, limitations, and boundaries of the use of social media.

H.6.c. Client Virtual Presence

Counselors respect the privacy of their clients’ presence on social media unless given consent to view such information.

H.6.d. Use of Public Social Media

Counselors take precautions to avoid disclosing confidential information through public social media.

Note: All information within the table was taken from American Counseling Association’s Code of Ethics (2014).

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to fully understanding the approach. These authors found that counseling students are more able to fully comprehend a theoretical orientation if they view theoretical skills in action (i.e., practice example). The review of practice examples also assists ­counselors-in-training in understanding how a theory and the associated skills can be woven into the counselor’s personal style of helping. A graduate counseling theories class is probably the first place a counselor might experience a discussion of a theory and practice example. During a theories class, counselors deeply benefit from the instructor scaffolding examples of theory-based techniques into their discussion and relevant skills presented in a textbook. As you, the reader, peruse through the various chapters of this textbook, you will notice that each chapter provides a significant number of clinical examples, discussion of theoretically congruent case conceptualization, and a detailed transcript demonstrating how to use a particular theory’s techniques. This is to help bring the various theories to life and to take the ­macro-based theoretical information down to the micro-based skill level.

DIALECTIC CENTERED ON COUNSELING THEORY AND PRACTITIONER HUMILITY Ambiguity is inherent in the counseling process and within the vast array of theoretical approaches available to clinicians. Counseling students and practicing counselors alike take into consideration a wide range of theories and approaches to therapy. The initial exposure to this multitude of approaches often leaves them confused and overwhelmed (Fowler, 1992; Hanna et al., 1996). It is important to be mindful about how to think about this multiverse of theoretical options. Dialectic-centered counseling theory helps counselors see beyond the labels and language of a theory. Dialectical thinking, as it relates to counseling, is defined as the ability to conceptualize contradictory client and clinical issues from multiple perspectives with a goal of arriving at a clear and reasonable understanding. Through dialectic thinking, counselors seek a deeper understanding by acknowledging how opposites interplay (Hanna et al., 1996). We believe that dialectic thinking can greatly enhance one’s use and understanding of theory by (a) increasing counselor reflectivity, (b) decreasing unhelpful dichotomous cognitive processes, (c) encouraging a sense of acceptance and appreciation for client issues, (d) increasing counselor’s level of self-understanding and acceptance, (d)  increasing levels of genuineness and authenticity within the counseling relationship, (e) increasing a sense of therapeutic creativity, and (f) helping counselors consider how they can blend academic theoretical models with their personal way of helping others. Dialectic thinking transforms clear contradictions by engaging two opposing ends of a continuum (Todd & Abrams, 2011). Rappaport (1981) describes dialectic thinking as the tension of needing to pay attention to two opposing views of thought. By holding or struggling with apparent contradictions, the counselor can move along a continuum of thought. For counselors, this can manifest in many ways. For example, within their investigation exploring White student dialectics, Todd and Abrams (2011) discovered distinct thought processes and associated dialectic tension among White participants who reflected on their race. Specifically, they discovered an association between a belief that one’s race should not matter and a tendency to minimize racism. In other words, those who minimized the importance of race also minimized the existence of racism. Todd and Abrams also discovered that participants who endorsed these beliefs and acknowledged some forms of racism existed would experience tension resulting in anger and frustration. Participants who had previously engaged in introspection regarding their own race demonstrated a greater sense of openness and engaged in deeper connections in multiracial relationships. Similarly, Flynn and Black (2011, 2013) qualitatively researched an important dialectic topic involving the tension between altruism and self-interest within the counseling profession. Participants described the destructive nature of this philosophical false dichotomy. Specifically, an overadherence to altruism (i.e., selflessness) increased counselor burnout and impairment

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and increased unhelpful counselor thought processes and role selection (e.g., martyr, victim, enabler). They also discovered that an overadherence to self-interest (i.e., selfishness) increased boundary violations, the use of unethical practice standards, and hurtful behavior toward colleagues and created unhelpful processes and role selection (e.g., abuser, overly ambitious, domineering). This dialectic-based scholarly journey concluded with identifying the importance of the interaction and interdependence of altruism and self-interest in every human interaction. These scholarly works serve as dialectic examples that highlight the importance of counselors engaging in reflectivity and accepting ambiguity. They also challenged the counseling profession to develop practitioners who have a solid understanding themselves and their client’s internal/external world (Miller & Rollnick, 2004). Indeed, building tolerance and acceptance of the tension inherent in the ambiguity of counseling is essential to a counselor’s personal and professional development. Counselors who tolerate or embrace ambiguity when faced with different perspectives, approaches, or interpretations may find the pursuit of counseling theory and practice desirable and stimulating. Being able to self-reflect and think through the challenges that dialectic thoughts inspire ultimately helps counselors develop a more integrated and accurate view of the self and others. Davis et al.‌‌‌‌‌‌‌ (2016) described the accuracy of a counselor’s view of self and their ability to be interpersonally other-oriented and humble. Humility is an important trait to have as a counselor and it is connected to the quality of the therapeutic relationships (Davis et al., 2013‌‌‌‌‌‌‌‌‌; Weatherford & Spokane, 2013). Clients are regularly assessing the quality of the therapeutic relationship. If a counselor unintentionally behaves in a way that ruptures the relationship, a lack of humility will likely cause continued deterioration in the working alliance. A counselor who is low in humility would be reluctant to revisit decisions or introspect, which further entrenches them in their existing beliefs and choices. This limited sense of humility and introspection has a negative effect on the therapeutic relationship with clients as well as impedes the counseling learning process. In short, they are ultimately leading to poorer counseling outcomes. Therefore, dialectic thinking centered on counseling and humility is a critical concept that is deeply tied to understanding counseling theory.

THE CASE OF MARK STOCKTON Throughout this textbook, the case of Mark Stockton will be conceptualized through a variety of theories. Additionally, authors will showcase theory-based skills and techniques in repeating chapter-based counseling session transcripts. The following is an overview of the case of Mark Stockton. Mark Stockton identifies as a 42-year-old, Black, cisgender male who works as a project manager for a general contracting company. His immediate family consists of two daughters Elle, 12, and Carla, 10; mother, Gloria, 71; father, Dennis, 72; brother Rob, 45; and sister, Alicia, 36. Approximately 1 year ago, Mark’s spouse, Candace (Hispanic, cisgender woman, age 40), filed for divorce. Since that time, Candace has been somewhat estranged from the family. She makes infrequent contact with the two daughters, and Mark reports she has a new boyfriend who has three children of his own. Mark is seeking counseling for anxiety, sadness, and anger that occurred following his divorce. In addition, Mark has expressed feeling lonely and guilty for wanting to start dating again because it “takes me away from my daughters.” Mark describes his anxiety as a lifelong struggle that he has handled on his own. He indicates that he has never sought counseling or taken medications for his anxiety. After his recent divorce, he decided to engage in counseling, and he is presently reconsidering his position on pharmacological treatment. Mark’s anxiety manifests in the following ways: constantly feeling wound-up, difficulty concentrating, irritability, and frequently feeling worried about a variety of issues. In the past, Mark had used regular exercise to help soothe

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his feelings of anxiety. He claims this has helped tremendously. Mark enjoys running, lifting weights, and frequently uses a rowing machine he keeps in his garage. Mark mentions that he finds some happiness in his work; however, he states that he feels he has hit a ceiling in terms of his potential for professional growth in the company. Mark says that the only meaningful thing in his life are his daughters. Elle is the older sibling and Mark identifies her as a natural-born leader, bright, and a bit of a know-it-all. Mark describes Carla as his “heart” and describes her as caring, athletic, and very stubborn. Aside from the occasional argument and taking each other’s clothes without permission, Elle and Carla appear to get along well. They do not typically discuss the disappearance of their mom (Candace). Mark states that Candace was very close with both daughters, and he has assumed that following the divorce they would both be living full time with her. When Candace calls or visits, they both get very excited. Mark mentions that Candace’s infrequent visits, communication, and dedication to her new partner’s family causes him a lot of sadness and anger. When asked about his recent divorce with Candace, Mark states that it was somewhat surprising and is the most painful experience he has ever had to endure. Mark claims that he is still in love with Candace and feels confused as to why she suddenly stopped loving him. When further probed, Mark admits to a few financial mishandlings, an IRS investigation, and states that Candace felt very worried about his ability to handle financial matters. Mark indicates that within the relationship, he did not include Candace in many of his decisions. He shares that when his handling of the family finances went poorly, Candace became very upset. Gloria, Mark’s mother, frequently comes over the house to help take care of Elle and Carla and assists Mark with household chores. While Mark states having gratitude for his mother’s assistance, he feels very guilty about the depth of her involvement with the family. Additionally, Mark frequently witnesses his mother falling asleep on the living room couch during the daytime hours and feels they are not on the same page when it comes to child discipline. Specifically, he believes his mom employs an “old-fashioned” parenting style that involves harsh comments toward the children and the occasional use of corporal punishment. While Gloria’s involvement and influence on the family has been a hard adjustment for everyone, Mark feels uncomfortable confronting her due to his need for her assistance and fear that if he confronts her, she will stop helping him.

SUMMARY In this chapter, you were introduced to the core counseling theoretical groupings; the history of counseling theory and practice; the atheoretical and theoretical models of case conceptualization; the innovations and growing trends in telebehavioral health; the evolving nature multiculturalism, intersectionality, and social justice; the key components relevant to contemporary common factor models; the elements necessary for the incorporation of a unitary, integrative, eclectic, and plural approach to counseling; the process of picking a theoretical approach; and a dialectic centered on counseling theory and practitioner humility. This chapter serves as a guide for the remainder of the textbook. As you continue your professional journey into various counseling theoretical groupings, you will notice that relevant topics are scaffolded on this initial chapter of knowledge. Specifically, theory-based factors and tenants, case conceptualization models, and counselor skill and interventions are repeatedly introduced and explored throughout this textbook. Additionally, the case of Mark Stockton was introduced within this chapter. This case will be reviewed throughout the textbook in the form of chapter-based transcripts that showcase the unique theoretical conceptualizations and skills pertinent to each chapter. We wish you well in your future work as professional counselors and we hope you will contribute, in your own way, to the therapeutic world.

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STUDENT EXERCISES ‌‌‌‌‌ Exercise 1: Scaling Beliefs About Counseling

Directions: On a sheet of paper, draw five horizontal lines. Each of the following points provides two beliefs. On each end of your horizontal line, write the two beliefs. Next, mark how close you are to each belief. Take a moment and reflect on your position and why you placed yourself where you did on the continuum. ■

Counseling is more art or science? Art       ‌‌‌‌‌ Science

■

Do people make changes by changing their thoughts or changing their behaviors? Thoughts        Behaviors

■

Are people driven by their past or motivated by the prospect of their future? Past        Future

■

Is an individual’s distress a result of environmental or internal influences? Environmental        Internal

■

Which is more effective, telebehavioral health counseling or in-person counseling? Telebehavioral        In-person

Note: This activity can be performed in class by having the students identify their positions as a large group. One option is to have students move to different sides of the room indicating which beliefs they hold and then ask students to share why they chose the sides they did.

Exercise 2: Unitary Versus Eclectic Theoretical Orientation

Directions: On a sheet of paper, draw a line down the center. Take a few minutes and provide evidence on one side of the line that would support a unitary theory of practice. Then on the other, provide evidence that would support an eclectic theory of practice. Following this exercise, connect with a peer and process each of your findings.

Exercise 3: Build a Counselor

Directions: Identify the characteristics that you would look for in a counselor. What characteristics would motivate you to achieve your therapeutic goals? What dispositions would be a red flag for you? Reflect on which characteristics would be the most helpful and which would be the most harmful. Consider the following points: ■ ■ ■ ■ ■ ■ ■

The counseling office/space Their grooming, demeanor, and how they dress The physical/psychological health of the counselor Age Years in the profession Type of licensure they possess The ability to engage in occasional superficial chatty behavior

Exercise 4: Learning Plan

Directions: In groups of two or three, come up with five things you would need to become comfortable using a theory in counseling, including but not limited to the following mechanisms: ■ ■

Reading professional literature relative to the theory Reading case studies and written skill demonstrations

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Observing videos of counselors practicing from the theoretical orientation Hiring and working with an experienced supervisor who uses the theory Attending professional conferences/presentations centered on the use of the theory

After determining your criteria, discuss how you and your peer’s responses are similar and different. Lastly, write a brief action plan to pursue one of the things identified as needed to become comfortable using a theory in counseling.

Exercise 5: Discussion and Reflection

Directions: Go to your university’s online EBSCO Database and find Academic Search Premier. Search and find an article focused on a counseling theoretical orientation of interest. Review the article in its entirety and answer the following questions: ■ ■ ■ ■

How does the article showcase the theoretical orientation? What aspects of this theoretical orientation do you identify with? What elements from different theories would you add to your emerging theoretical orientation? Reflect and discuss with a peer what theory you chose and the essence of the article.

RESOURCES Helpful Links ■ ■ ■ ■ ■ ■ ■

American Counseling Association: www.counseling.org/ Multicultural Counseling Development: www.multiculturalcounselingdevelopment.org/ International Integrative Psychotherapy Association: www.integrativeassociation.com Relationship Factors in Counseling and Psychotherapy: https://johnsommersflanagan. com/category/counseling-and-psychotherapy-theory-and-practice/ Core Counseling Courses: https://counseling.education/ Introduction to Telehealth for Behaviorial Health Care: https://telehealth.hhs.gov/ providers/telehealth-for-behavioral-health/ Telebehavioral Health Information and Counselors in Health Care: www.­counseling.org/ knowledge-center/mental-health-resources/trauma-disaster/telehealth-informationand-counselors-in-health-care

Helpful Books ■ ■ ■ ■ ■ ■ ■

Capuzzi, D., & Stauffer, M. D. (2016). Counseling and psychotherapy: Theories and ­interventions. John Wiley & Sons. Hart, J. (2012). Modern eclectic therapy: A functional orientation to counseling and psychotherapy: Including a twelve-month manual for therapists. Springer Science & Business Media. Magnavita, J. J., & Anchin, J. C. (2013). Unifying psychotherapy: Principles, methods, and ­evidence from clinical science. Springer Publishing Company. Myers, J. E., & Sweeney, T. J. (Eds.). (2005). Counseling for wellness: Theory, research, and practice. American Counseling Association. Ratts, M. J., & Pedersen, P. B. (2014). Counseling for multiculturalism and social justice: Integration, theory, and application. John Wiley & Sons. Robertson, H. C., & CASAC, C. (2020). Telemental health and distance counseling: A counselor’s guide to decisions, resources, and practice. Springer Publishing Company. Sperry, L., & Sperry, J. (2020). Case conceptualization: Mastering this competency with ease and confidence. Routledge.

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Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work. Routledge.

Helpful Videos ■ ■ ■ ■ ■

Counseling and Psychotherapy Theories in Context and Practice: www.psychotherapy .net/video/counseling-psychotherapy-theories Bruce Wampold on What Actually Makes Us Good Therapists: www.psychotherapy.net/ interview/bruce-wampold-psychotherapy-effectiveness Integrative Counseling: www.psychotherapy.net/video/jeffrey-kottler-integrativecounseling Multicultural Competence in Counseling & Psychotherapy: www.psychotherapy.net/ video/multicultural-competence-psychotherapy-sue The Future of Telebehavioral Health and Digital Mental Health Services: www.youtube .com/watch?v=edZbQ2vKL4M

A robust set of instructor resources designed to supplement this text is available. Qualifying instructors may request access by emailing [email protected].

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Hinkle, M. S., Perjessy, C. (2023). Postmodern approaches. In S. V. Flynn & J. S. Castleberry (Eds.), Counseling theories: Theory and case conceptualization. Springer Publishing. Hughes, S. (2023). Multicultural counseling theory. In S. V. Flynn & J. J. Castleberry (Eds.), Counseling theories: Theory and case conceptualization. Springer Publishing. John, S., & Segal, D. L. (2015). Case conceptualization. The Encyclopedia of Clinical Psychology, 1–4. https:// doi.org/10.1002/9781118625392.wbecp106 Kazdin, A. E. (2007). Mediators and mechanisms of change in psychotherapy research. Annual Review of Clinical Psychology, 3, 1–27. https://doi.org/10.1146/annurev.clinpsy.3.022806.091432 La Guardia A.C. (2023). Feminist approaches. In S. V. Flynn & J. J. Castleberry (Eds.), Counseling theories: Theory and case conceptualization. Springer Publishing. Lambert, M. J. (1992). Psychotherapy outcome research: Implications for integrative and eclectical therapists. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (pp. 94–129). Basic Books. Lazarus, A. A. (1967). In support of technical eclecticism. Psychological Reports, 21(2), 415–416. https://doi. org/10.2466/pr0.1967.21.2.415 Lebow, J. (1997). The integrative revolution in couple and family therapy. Family Process, 36(1), 1–17. https://doi.org/10.1111/j.1545-5300.1997.00001.x Limberg, D., Guest, J. D., & Gonzales, S. (2022). History of research in the social sciences. In S. V. Flynn (Ed.), Research design for the behavioral sciences: An applied approach. Springer Publishing. Limberg, D., Fields, A. M., Wallace, D., Ragoonath, R., & Johnson, S. M. (2023). Cognitive approaches. In S. V. Flynn & J. J. Castleberry (Eds.), Counseling theories: Theory and case conceptualization. Springer Publishing. McKibben, W. B., & Gainer, S. R. (2023). Integrative approaches. In S. V. Flynn & J. J. Castleberry (Eds.), Counseling theories: Theory and case conceptualization. Springer Publishing. Meier, S. T. (1999). Training the practitioner-scientist: Bridging case conceptualization, assessment, and intervention. The Counseling Psychologist, 27(6), 846–869. https://doi.org/10.1177/0011000099276008 Meyers, L. (2018, August 31). Talking about #MeToo. Counseling Today. https://ct.counseling .org/2018/ 08/talking-about-metoo/ Miller, W. R., & Rollnick, S. (2004). Talking oneself into change: Motivational interviewing, stages of change, and therapeutic process. Journal of Cognitive Psychotherapy, 18(4), 299–308. https://doi. org/10.1891/jcop.18.4.299.64003 Mohr, D. C., Ho, J., Hart, T. L., Baron, K. G., Berendsen, M., Beckner, V., Cai, X., Cuijpers, P., Spring, B., & Kinsinger, S. W. (2014). Control condition design and implementation features in controlled trials: a meta-analysis of trials evaluating psychotherapy for depression. Translational Behavioral Medicine, 4(4), 407–423. https://doi.org/10.1007/s13142-014-0262-3 Neukrug, E. (2015). The world of the counselor: An introduction to the counseling profession. Brooks/Cole. Nielson, T., & Hakenewerth, T. J. (2023). Systemic approaches. In S. V. Flynn & J. J. Castleberry (Eds.), Counseling theories: Theory and case conceptualization. Springer Publishing. Norris, E. K., Wilkinson, T., & Cook, J. D. (2023). Person-centered counseling and related experiential approaches. In S. V. Flynn & J. S. Castleberry (Eds.), Counseling theories: Theory and case conceptualization. Springer Publishing. Osborn, C. J., Dean, E. P., & Petruzzi, M. L. (2004). Use of simulated multidisciplinary treatment teams and client actors to teach case conceptualization and treatment planning skills. Counselor Education and Supervision, 44(2), 121–134. https://doi.org/10.1002/j.1556-6978.2004.tb01865.x Padesky, C. A., & Mooney, K. A. (1990). Clinical tip: Presenting the cognitive model to clients. International Cognitive Therapy Newsletter, 6, 1. Parsons, F. (1909). Choosing a vocation. Houghton Mifflin Co. Petko J. T., Kendrick, E., & Young, M.E. (2016). Selecting a theory of counseling: What influences a counseling student to choose? Universal Journal of Psychology, 4(6), 285–291. doi: 10.13189/ujp.2016.040606. Prieto, L. R., & Scheel, K. R. (2002). Using case documentation to strengthen counselor trainees’ case conceptualization skills. Journal of Counseling & Development, 80(1), 11–21. https://doi. org/10.1002/j.1556-6678.2002.tb00161.x Rappaport, J. (1981). In praise of paradox: A social policy of empowerment over prevention. American Journal of Community Psychology, 9(1), 1–25. https://doi.org/10.1007/BF00896357 Raskin, N. J., & Rogers, C. R. (1989). Person-centered therapy. In R. J. Corsini & D. Wedding (Eds.), Current psychotherapies (pp. 155–194). F. E. Peacock Publishers. Reiter M. D. (2014). Case conceptualization in family therapy. Pearson.

Rogers, C. R. (1963). The concept of the fully functioning person. Psychotherapy: Theory, Research & Practice, 1(1), 17–26. https://doi.org/10.1037/h0088567 Seedall, R. B., Holtrop, K., & Parra-Cardona, J. R. (2013). Diversity, social justice, and intersectionality trends in C/MFT: A content analysis of three family therapy journals, 2004–2011. Journal of Marital and Family Therapy, 40(2), 139–151. https://doi.org/10.1111/jmft.12015 Seward, D., Williams, B. (2023). Brief counseling approaches. In S. V. Flynn & J. J. Castleberry (Eds.), Counseling theories: Theory and case conceptualization. Springer Publishing. Skovholt, T. M., & Rønnestad, M. H. (1995). The evolving professional self: Stages and themes in therapist and coun­selor development. Wiley. Smith, E. B., McGrath, A., Mangin, J. & Altenberg, N. (2023). Psychoanalytic approaches. In S. V. Flynn & J. J. Castleberry (Eds.), Counseling theories: Theory and case conceptualization. Springer Publishing. Sperry, J., & Sperry, L. (2020a, December 7). Case conceptualization: Key to highly e­ ffective counseling. Counseling Today, 63(6). https://ct.counseling.org/2020/12/case-conceptualization-key-to-highlyeffective-counseling/ Sperry, L., & Sperry, J. (2020b). Case conceptualization: Mastering this competency with ease and confidence. Routledge. https://www.routledge.com/Case-Conceptualization-Mastering-This-Competencywith-Ease-and-Confidence/Sperry-Sperry/p/book/9780367256654‌‌‌‌‌‌‌‌‌ Tasca, G. A., Sylvestre, J., Balfour, L., Chyurlia, L., Evans, J., Fortin-Langelier, B., Francis, K., Gandhi, J., Huehn, L., Hunsley, J., Joyce, A. S., Kinley, J., Koszycki, D., Leszcz, M., Lybanon-Daigle, V., Mercer, D., Ogrodniczuk, J. S., Presniak, M., Ravitz, P., … Wilson, B. (2015). What clinicians want: Findings from a psychotherapy practice research network survey. Psychotherapy, 52(1), 1–11. https://doi. org/10.1037/a0038252 Todd, N. R., & Abrams, E. M. (2011). White dialectics: A new framework for theory, research, and practice with White students. The Counseling Psychologist, 39(3), 353–395. https://doi. org/10.1177/0011000010377665 Wampold, B. E. (2015). How important are the common factors in psychotherapy? An update. World Psychiatry, 14(3), 270–277. https://doi.org/10.1002/wps.20238 Weatherford, R. D., & Spokane, A. R. (2013). The relationship between personality dispositions, multicultural exposure, and multicultural case conceptualization ability. Training and Education in Professional Psychology, 7(3), 215–1224. https://doi.org/10.1037/a0033543 Yalom, I. D. (2002). The gift of therapy. Reflections on being a therapist. London: Judy Piatkus Ltd. Young, M. E. (2016). Learning the art of helping: Building blocks and techniques (6th ed.). Merrill.

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MULTICULTURAL COUNSELING THEORY Sherritta Hughes

LEARNING OBJECTIVES After reading this chapter, you will be able to: ■ Define concepts that reflect structure, application, and understanding of ­multicultural counseling theory (MCT) ■ Discuss theoretical principles and tenets of MCT ■ Demonstrate grounding knowledge of MCT used in the therapeutic process ■ Distinguish the elements of MCT clinical case analysis and conceptualization ■ Formulate a comprehensive understanding of historic and contemporary ­contributing figures in MCT

INTRODUCTION There are four forces of counseling and psychotherapy: psychoanalysis, behaviorism, ­humanism-existentialism, and multicultural counseling theory (MCT). MCT is centered on theoretical approaches to human growth and development within the context of cultural impact on counseling and psychotherapies (Daniels, 2007; Pedersen, 2016; Ratts, 2009). This form of counseling reflects contemporary insights, theories, and therapeutic practices that contribute to understanding client needs, issues, and concerns. MCT is rooted in understanding inequalities that influence the counseling process and the cultural level disparities that are experienced by communities of color in the form of exclusion, oppression, discrimination, and marginalization. As a force, multicultural counseling or cross-cultural counseling (Pedersen et al., 2016) is considered as salient, in terms of theoretical impact, compared to the first three forces. Not only is‌it an independent and established theoretical grouping, but also it is an interrelated extension of psychoanalysis, behaviorism, and humanism-existentialism. In addition to MCT being the fourth force in counseling and psychotherapies, it functions in several other contexts within the profession. It is incorporated into the ethical codes of conduct for counselors (American Counseling Association [ACA], 2014); in a section of standards used in counselor training programs (Council for Accreditation of Counseling and Related Educational Programs [CACREP], 2016, 2024); and across several sets of counselor competencies (Arredondo, 2005), including career counseling, rehabilitation, and school counseling, as well as counseling people who are sexual minorities and in relation to spirituality and religious practices. While the fourth force has a tremendous amount of multidimensionality and is context diverse, this chapter will cover its application relative to the professional practice of counseling. As a counseling paradigm, MCT is dynamic and continuously evolving to address the increasing diversity among clients, the profession, and counselor practitioners. It views

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clients as pluralistic social and cultural beings and encourages counselors to enhance their understanding of themselves and their clients’ diverse social and cultural backgrounds. MCT also acknowledges that we all exist and are influenced by our surrounding environmental systems and context. A comprehensive worldview can help individuals navigate life experiences, interpret problems, and build relationships with themselves and others (Crethar et al., 2008). MCT aims to provide a client-centered, culturally nuanced approach to therapy. It emphasizes the importance of considering a client’s values, beliefs, and life experiences in the therapeutic process rather than just focusing on their problem. This approach is intentional, as MCT was developed initially as a response to the limitations of traditional theories that tend to operate from an ethnocentric perspective, assuming that the norms and practices of one’s cultural group are universal and applicable to others. MCT aims to‌challenge and move beyond these limitations by considering each individual client’s unique and diverse experiences and perspectives. MCT was designed to address the sociopolitical factors that impact clients and create a safe space for addressing assumptions about human behavior. MCT’s therapeutic interventions were developed using emic and etic approaches, which offer a comprehensive understanding of race, ethnicity, and other intersecting identities. An etic approach explores culture from a universal perspective, while an emic approach explores culture from a specific and unique view of cultural groups (Choudhuri et al., 2012). This combination of etic and emic approaches helps counselors address clients holistically and provides culturally sensitive and appropriate counseling tailored to people’s individual needs and experiences. To effectively apply the concepts of MCT with the case study of Mark, counselors are advised to take the following steps: (a) conduct a thorough review of relevant multidisciplinary literature on the topic, (b) ask questions related to the topic during the counseling sessions, and (c) build a theoretical understanding that supports Mark’s lived experiences and worldview. These steps will help develop cultural trust and build a cross-cultural therapeutic relationship with Mark. It is important to‌note that the application of these steps will be complex in Mark’s case due to the multiple cultural contexts involved, such as his biracial children, his marriage with a person with a different racial identity, his cultural upbringing, and possibly his conflicting worldviews in his marriage and mental health. This chapter begins with a definition and description of multicultural counseling. The reader is provided historical and contemporary insights into the foundations and theoretical fundamentals of multicultural counseling. After the definition and description, the chapter provides an in-depth review of leaders and legacies who have made and continue to make significant contributions to this evolving school of thought. As a disclaimer, there are many notable contributors of multicultural counseling. Hence, the list provided in this chapter is partial and not exhaustive. Please review the reference list at the end of the chapter to learn about other notable contributors to multicultural counseling. Next, there is an offering of key concepts for use in understanding and applying applications of multicultural counseling. At the conclusion of the chapter, there are five reflective exercises based on MCT in practice and a selection of resources for lifelong learning. Finally, throughout this chapter, there are points of reflection that demonstrate MCT in action with Mark, our hypothetical client whom the case study across the chapters is based upon.

LEADERS AND LEGACIES OF MULTICULTURAL COUNSELING THEORY There are many contributors who have shaped MCT. Because there is no leading author or field that has molded our collective understanding of multiculturalism, intersectionality, and social justice issues, MCT authors come from a broad range of professions and their scholarly works are represented in multidisciplinary literature and research. You, the reader,

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may be aware of some of these individuals and unfamiliar with others. It is important to recognize the names of major contributors who may or may not have been included in mainstream peer-reviewed scholarship in the counseling profession. Because of wide-­ranging professional identities, capturing the salient contributors and the location of their scholarly works to provide an adequate introductory list of MCT leaders and legacies section was challenging. The names promoted within this chapter consistently surfaced in mainstream peer-reviewed scholarship, were recommended by elders in the counseling profession, and were identified as major contributors to the MCT literature. Lastly, individuals who emerged as legacies in MCT often published on the topics of the MCT movement, race and ethnicity, pluralistic identity, cross-cultural counseling, oppression, marginalized client exclusion, and discrimination.

Clemmont Vontress Dr. Clemmont Vontress was an existential counselor, global scholar, pioneer, and one of the leaders of MCT. Born in Kentucky, Vontress earned his PhD at Indiana University with minors in sociology and psychology, and practiced counseling at Crispus Attucks High School in Indiana. He taught at Howard University and then at George Washington University, where he earned the emeritus status and retired from academia. Though he died on April 10, 2021, he was and remains a pivotal counselor theorist who wrote extensively on what it means to be human, cross-cultural counseling competency, the intrapersonal and interpersonal experiences of Black men, and existential theory. Vontress was an active member of ACA and served on the Board of Directors (1969–1971), the editorial board of the Personnel and Guidance Journal (1969–1972), and the American Personnel and Guidance Association (APGA) Human Rights Commission (1971–1975). He is considered a pioneer in cross-cultural counseling (Charura, 2013; Jackson, 1987; Moodley, 2010; Pedersen, 2016; Phillips, 2021). In a memoriam column on the ACA website, Vontress is called the “father of cross-cultural counseling” (Phillips, 2021). In Table 2.1, select works of Vontress are provided to highlight just a few of his major contributions that have been published for the counseling profession. A large portion of the earliest literature in the multicultural counseling movement was centered on encouraging the profession to account for culture in the therapeutic process. Vontress was a true scholar–practitioner, contributing to this body of academic literature (Vontress, 1968, 1969, 1979, 1991, 2004) while also actively working in the counseling field and educating the next generation of counselors in the classroom. He passionately urged counselors to improve their therapeutic ability “to be effective in counseling culturally different clients, whether they are American minorities or foreign visitors” (Vontress, 1979, p. 117). Morris L. Jackson (1987), in an interview with Vontress, noted that he had already published over 100 articles topical to the address of culture in practice. In a groundbreaking publication, Vontress (1969) wrote a paper titled Cultural Differences: Implications for Counseling, which urged the profession to reshape the language of cultural diversity in terms of the deficit approach that had been (and continued to be) used to describe communities of color. He stated in this article a breakdown of counselor implications for therapeutic work with several marginalized groups he called “cultural minorities” of that era: American Indians, the Appalachians, Spanish heritage groups, and the Negro. The common thread among these four marginalized communities was “their suspicion of, and reserve toward, the dominant cultural group and its representatives” (Vontress, 1969, p. 273). Vontress suggested that it is the counselor’s responsibility to “break through cultural barriers” (p. 273) by finding meaningful relationship building therapeutic tools. To showcase this important responsibility, Vontress studied and applied a unique existential counseling approach in his clinical practice (Jackson, 1987; Moodley, 2010; Phillips, 2021; Vontress, 1979).

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Table 2.1. Selected Publications by Dr. Clemmont Vontress, Existentialist and Father of Cross-Cultural Counseling Title of Publication

Reference for Further Reading

Reactions to the Multicultural Counseling Competencies Debate

Vontress, C. E., & Jackson, M. L. (2004). Reactions to the multicultural counseling ­competencies debate. Journal of Mental Health Counseling, 26(1), 74–80.

Cross-Cultural Counseling: An Existential Approach

Vontress, C. E. (1979). Cross-cultural ­counseling: An existential approach. Personnel & Guidance Journal, 58(2), 117. https://doi. org/10.1002/j.2164-4918.1979.tb00363.x

Cultural Differences: Implications for Counseling

Vontress, C. E. (1969). Cultural differences: Implications for counseling. The Journal of Negro Education, 38(3), 266–275. https://doi. org/10.2307/2294010

Existential Anxiety: Implications for Counseling

Vontress, C. E. (1986). Existential anxiety: Implications for counseling. American Mental Health Counselors Association Journal, 8(2), 100–109.

An Existential Approach to Cross-Cultural Counseling

Vontress, C. E. (1988). An existential approach to cross-cultural counseling. Journal of Multicultural Counseling and Development, 16(2), 73–83.

Note: This table compiles several pivotal works of Dr. Clemmont E. Vontress. In the left column are the titles and in the right column are the references for easier access to these readings.

In Cross-Cultural Counseling: An Existential Approach (1979) and An Existential Approach to Cross-Cultural Counseling (1988), Vontress shared a series of fundamentals important for awareness of cultural differences between the counselor and the client grounded in his work as an existential theorist. In each of these articles, Vontress declared that “despite the large [amount of] literature on the subject, counseling members of ethnic groups different from that of the counseling remains problematic” (Vontress, 1979, p. 117). This argument persists today in the counseling field, though the profession has grown in diversity among licensed professional counselors and client populations.

Derald Wing Sue Dr. Derald Wing Sue has been described as a cultural icon and prolific scholar in multicultural counseling, Asian American psychology, and sociopolitical issues (Parham, 2011). Sue is an integral expert who has provided theoretical grounding of clinical applications of MCT and is considered one of the primary pioneers who defined the movement of multiculturalism (Jackson, 1995). As a multicultural counseling theorist, practitioner–scholar, trainer, lecturer, and leader in the profession of counseling, Sue’s legacy cannot be captured in the space allotted for this chapter. This summary of Sue’s legacy in MCT aims to outline a few of his contributions. Sue is currently a professor of counseling and psychology at Teachers College, Columbia University, and an active member of the National Institute for Multicultural Competence (NIMC). He has held many leadership positions across the state of California, from the California School of Professional Psychology, Alliant University in San Francisco, California State University, and the Berkeley Counseling Center (Parham, 2011). Sue is responsible for an expansive list of literature that includes groundbreaking scholarship. He was ranked number one out of 50 scholars listed in Legends of the Field: Influential

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Scholars in Multicultural Counseling‌, a publication devoted to giving credit to the most influential scholars in multicultural counseling (Ponterotto et al., 2012). His literary contributions include, but are not limited to, Counseling the Culturally Different (Sue, 1981), Multicultural Competencies and Standards: A Call to the Profession (Sue et al., 1992), Barriers to Effective CrossCultural Counseling (Sue, 1977), and A Theory of Multicultural Counseling and Therapy (Sue et al., 1996). These publications, among others, are considered high-impact exemplars. Each of these publications has improved awareness among clinicians who sought to expand therapeutic processes with clients who are racially and culturally diverse and minoritized. Sue teaches that as society grows toward being more multiethnic, multiracial, and multilingual, there is a need in the counseling and mental health profession to address issues of race, culture, and ethnicity. Sue’s multicultural counseling textbooks are the most widely selected learning resources in both counseling and psychology training programs. A few of Sue’s notable publications are listed in Table 2.2.

Janet Helms Dr. Janet Helms has built a legacy on racial and ethnic identity development (Choudhuri et al., 2012; Jernigan, 2012). Much of her work is original and a continuation of Dr. William Cross’s Nigrescence, who is a living legacy scholar in Black identity development. Helms graduated from the University of Missouri–Kansas City with an undergraduate degree in mathematics and then pursued master and doctoral degrees in counseling psychology from Iowa State University. Her first field and academic position was in Pullman, Washington, where she worked in the Counseling Center and the Department of Counseling and Guidance. Helms went on to Southern Illinois University, the University of Maryland, and then Boston College. While at Southern Illinois, Helms advised some of the most prominent Table 2.2 Selected Publications by Dr. Derald Wing Sue, Pioneer of Multiculturalism Title of Publication

Reference for Further Reading

Chinese American Personality and Mental Health

Sue, S., & Sue, D. W. (1971). Chinese American personality and mental health. Amerasia Journal, 2, 36–49.

Eliminating Cultural Oppression in Counseling: Toward a General Theory

Sue, D. W. (1978). Eliminating cultural ­oppression in counseling: Toward a general theory. Journal of Counseling Psychology, 25, 419–428.

Counseling the Culturally Different

Sue, D. W. (1981). Counseling the culturally ­different. John Wiley.

Multicultural Competencies and Standards: A Call to the Profession

Sue, D. W., Arredondo, P., & McDavis, R. (1992). Multicultural competencies and standards: A call to the profession. Journal of Counseling and Development, 70, 477–486.

The Role of Culture and Cultural Techniques in Psychotherapy: A Critique and Reformulation

Sue, D. W., & Zane, N. (2009). The role of ­culture and cultural techniques in psychotherapy: A critique and reformulation. Asian American Journal of Psychology, 1, 3–14.

Counseling the Culturally Diverse: Theory and Practice

Sue, D. W., Sue, D., Neville, H. A., & Smith, L. (2019). Counseling the culturally diverse: Theory and practice (8th ed.). Wiley.

Note: The scholarship in this chart is authored by Sue and colleagues. Listed are the titles and references for that are suggested for further reading and to gain more insight into the work of Dr. Derald W. Sue as pioneer of multiculturalism and Asian American psychology issues.

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counselors and psychologists before their widespread scholarly acclaim. For example, Dr. Helms advised Dr. Thomas Parham, a past president of the Association for Multicultural Counseling and Development (AMCD). Helms and Parham collaborated on an article titled “Attitudes of Racial Identity and SelfEsteem: An Exploratory Investigation” (Parham & Helms, 1985). At Maryland and Boston College, Helms produced a considerable amount of scholarship. She also held a variety of leadership roles in social science professional associations, such as the Association of Black Psychologists (ABPsi) and served as the 2008–2009 president of the Society of Counseling Psychology, Division 17, of the American Psychological Association (APA). While at Boston College, Helms was chair of the Augustus Long Professoriate in the Department of Counseling, Development, and Educational Psychology. During her time as the Augustus Long Professor Chair, Helms was director of the Institute for the Study and Promotion of Race and Culture (ISPRC). As a result of her scholarship, Helms has received a series of awards such as the Leona Tyler Award in recognition for outstanding research. At ISPRC, Helms made many strides in uncovering what counselors and individuals undergo when developing their understanding of identity development across race and ethnicity. These empirically based theories include Black identity development, White identity development, and people of color identity development (Helms, 1990, 1995). Table 2.3 includes a list of the identity development models. Helms conducted research to offer empirical evidence on how to address “societal conflicts associated with race or culture in theory and research, mental health practice, education, business, and society at large” (Jernigan, 2012, p. 918). As a result of this research, Helms produced topical literature in counselor and counselor-related peer-reviewed journals. Maryam M. Jernigan (2012)‌referenced these topics by theme, whereby a few are noted as racial identity and cultural factors in treatment, research, and policy; race culture and trauma; and intersections of race or ethnic culture with gender and/or sexual orientation. Helms was one of the first scholars to make a distinction between race and ethnicity, explaining that racial identity concerned development that centered on “responses to the experiences of oppression in contemporary society” (Choudhuri et al., 2012, p. 76), and she knew that “race and culture were not always seen as legitimate topics of study” (Jernigan, 2012, p. 925). Because of this issue of legitimacy, Helms initially focused her studies on women’s issues, which was more accepted by academia at the time. She struggled to find publishers for her notable work, A Race Is a Nice Thing to Have (Helms, 2020). Despite this opposition, she persevered in her research agenda to study race, ethnicity, and culture (REC). Helms consistently described awareness of race and ethnicity as integral to human development. Two publications considered central to the Helms legacy of MCT are The Counseling Process Defined by Relationship Types: A Test of Helms’s Interactional Model (Carter & Helms, 1992) and Using Race and Culture in Counseling and Psychotherapy (Helms & Cook, 1999). Table 2.3 displays other groundbreaking literature that stems from Helms contributions to MCT.

Patricia Arredondo Dr. Patricia Arredondo is a living legend in the MCT movement, having made significant strides in creating multicultural counseling competency tools for application by counselors and other mental health practitioners. Arredondo is known for multicultural counseling competency work and collectively forming culturally appropriate intervention strategies and techniques (Arredondo, 1999). She is also one of the most frequently cited scholars in multicultural counseling textbooks and other literary works (Ponterotto et al., 2012). In these interventions and techniques, Arredondo and colleagues detailed competencies that were paired with an explanatory statement designed to direct counselors on proper practice. To provide an example, the competency declared “culturally skilled counselors are

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Table 2.3. SELECTED Publications of Dr. Janet Helms, a Pioneer in Racial Identity Development Part 1. Selected Publications of Dr. Janet Helms Title of Publication

Reference for Further Reading

The Counseling Process Defined by Relationship Types: A Test of Helms’s Interactional Model

Carter, R. T., & Helms, J. E. (1992). The counseling process defined by relationship types: A test of Helms’s interactional model. Journal of Multicultural Counseling and Development, 20(4), 181–201.

Toward a Theoretical Explanation of the Effects of Race on Counseling: A Black and White Model

Helms, J. E. (1984). Toward a theoretical explanation of the effects of race on counseling: A Black and White model. The Counseling Psychologist, 12(3–4), 153–165.

Using Race and Culture in Counseling and Psychotherapy: Theory and Process

Helms, J. E., & Cook, D. A. (1999). Using race and culture in counseling and psychotherapy: Theory and process. Allyn & Bacon.

Part 2. Selected Publications That Demonstrate Applications of Helms’s Racial Identity Models Title of Publication

Reference for Further Reading

Asian Americans and Racism: When Bad Things Happened to “Model Minorities”

Alvarez, A., Juang, L., & Liang, C. T. H. (2006). Asian Americans and racism: When bad things happened to “model minorities”. Cultural Diversity and Ethnicity Minority Psychology, 12(3), 477–492.

White Racial Identity: Theory, Research, and Implications for Organizational Context

Block, C., & Carter, R. T. (1998). White racial identity: Theory, research, and implications for organizational context. In A. Daly (Ed.), Workplace diversity (pp. 265–279). National Association of Social Workers Press.

Eating Disorders in African American Girls: Implications for Counselors

Talleyrand, R. (2010). Eating disorders in African American girls: Implications for counselors. Journal of Counseling & Development, 88, 319–326.

Note: This table is divided into two parts. Part 1 is a table that compiles several pivotal works of Dr. Janet E. Helms. In the left column are the titles and in the right column are the references for easier access to these readings. Part 2 of this divided table is a table that compiles several publications that demonstrate application of Helms’s racial identity models. The latter demonstrates a multidisciplinary use of Helms’s research.

aware of institutional barriers that prevent minorities from using mental health services” (Sue  et al., 1992, p. 482) and included that the counselor should be able to “identify and communicate possible alternatives that would reduce or eliminate existing barriers within their institutions and within local, state, and national decision-making bodies” (Arredondo et al., 1996, p. 69). Dr. Thomas Parham, past president of the AMCD, charged Sue, McDavis, and Arredondo with developing multicultural competencies for the profession. This team of major contributors formulated an “articulate set of guidelines, outcome-based learning statements that would add further legitimacy to the focus on culture, multiculturalism, and diversity in the counseling profession” (Arredondo et al., 1996, p. 102). Arredondo and colleagues provided instruction for what counselors could do to demonstrate multicultural counseling competency. These instructions included actions that counselors could implement to address

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client experiences within the context of their social and cultural identities. These “explicit statements” within the first editions of the multicultural counseling competencies (MCC‌s) were created to guide ACA's ethical standards, credentialing practices of CACREP and the National Board for Certified Counselors (NBCC), counselor training curriculum, continuing education for counselors, and specialty areas related to the practice of counseling (Arredondo, 1999). Arredondo also created personal dimensions of identity (PDI), a model that is explored later in this chapter. This early multicultural conceptual tool was used to consider the cultural identity of a client during intake process. Table 2.4 summarizes a few of Arredondo’s groundbreaking works that demonstrate her salience in MCT.

Paul B. Pedersen Dr. Paul B. Pedersen is a prolific theorist in MCT and has provided a wide range of topical scholarship on issues related to cultural bias, the cross-cultural movement in the counseling profession, multiculturalism as a fourth force in counseling and psychotherapies, and the theoretical constructs of MCT for application. Pedersen persistently promoted the need to address cultural identity of the client and counselor in the process of counseling. He explored the agency required to attend to cultural issues of racism and social injustice and the need to produce research on these aspects as they can impede therapeutic trust and alliance if left unexplored or ignored in the field of counseling. Pedersen called for greater centering on cultural identity as a broader facet of the client experience. In his historic article The Constructs of Complexity and Balance in Multicultural Counseling Theory and Practice (Pedersen, 1990), Pedersen described a broader view of cultural identity to include ethnographic, status, and other demographic variables. These variables are what Pedersen called “categories of culture” that consist of interrelated facets of a client’s identity. Example ethnographic variables include ethnicity, nationality, religion, and language (Pedersen, 1990). Example demographic variables are age and gender (Pedersen, Table 2.4. Selected Publications of Dr. Patricia Arredondo, Multicultural Counselor Competency Expert Title of Publication

Reference for Further Reading

Personal Dimensions of Identity Model

Arredondo, P., & Glauner, T. (1992). Personal dimensions of identity model. Empowerment Workshops.

Multicultural Counseling Competencies as Tools to Address Oppression and Racism

Arredondo, P. (1999). Multicultural counseling competencies as tools to address oppression and racism. Journal of Counseling & Development, 77, 102–110.

Expanding Multicultural Competence Through Social Justice Leadership

Arredondo, P., & Perez, P. (2003). Expanding multicultural competence through social justice leadership. The Counseling Psychologist, 31, 282–289.

Multicultural Counseling Competencies = Ethical Practice

Arredondo, P., & Toporek, R. (2004). Multicultural counseling competencies = ethical practice. Journal of Mental Health Counseling, 26(1), 44–45.

Note: In the chart are a select groundbreaking literature by counselor competency expert Dr. Patricia Arredondo. The articles and book selected are major contributions to the grounding of MCT and the profession of counseling and counselor training programs.

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1990). Example status variables are socioeconomic status (SES), educational background, and formal and/or informal memberships and affiliations (Pedersen, 1990). Pedersen posited that the heuristic nature of MCT lends itself to understanding counseling constructs that are empirically measurable (e.g., cultural mistrust, microaggression, bias, ethnocentrism, cultural humility, etc.). He advocated for the ongoing need for evidenced-based psychological treatments in multicultural counseling to reinforce its value in the profession. Pedersen and colleagues (Pedersen et al., 2016) approached MCT by exploring how counselors can best acquire the skills vital to work effectively across various cultural groups. Pederson proffered that all behaviors and thoughts are learned in specific cultural contexts and that everyone has “cultural teachers” (Pedersen et al., 2016, p. 1). These individuals teach‌people the values, norms, and ways of thinking and provide an overall influence for how cultural group members interpret the world. Pederson shaped goals for applying the multicultural perspective in the textbook Counseling Across Cultures (2016), now in its 7th edition. Table 2.5 provides selected literature featuring Paul Pederson.

METATHEORETICAL NATURE OF MULTICULTURAL COUNSELING THEORY In An Existential Approach to Cross-Cultural Counseling, Vontress defined multicultural counseling‌as “counseling in which a counselor and the client are culturally different because of socialization acquired in distinct cultural, subcultural, race, ethnic, or socioeconomic environments” in 1988 (p. 74). Multicultural counseling itself has been mentioned and explored in the literature, albeit briefly, since at least the 1950s (Jackson, 1995) and has been defined and redefined as it plays an increasing role in the practice of counseling and psychotherapy (Choudhuri et al., 2012; Sommers-Flanagan & Sommers-Flanagan, 2018; Speight, Myers, Cox, & Highlen, 1991; Vontress, 1988). Despite an evolving definition, there has still been much ambiguity in what would constitute multicultural counseling in action. As the awareness of the need for MCT grew, the counseling profession has collectively asked itself questions like how does a counselor purport to demonstrate multicultural counseling with clientele? How would this demonstration be measured? What elements would be measured to know if the intervention has a level of efficacy? From such questioning, researchers developed empirically based reliability, validity, and theoretical frameworks which are explored in the following subsection (Pedersen, 1990). Table 2.5. Selected Publications of Dr. Paul B. Pedersen, MCT Theorist and Researcher Title of Publication

Reference for Further Reading

Ten Frequent Assumptions of Cultural Bias in Counseling

Pedersen, P. B. (1987). Ten frequent assumptions of cultural bias in counseling. Journal of Multicultural Counseling & Development, 15, 16–24.

The Constructs of Complexity and Balance in Multicultural Counseling Theory and Practice

Pedersen, P. B. (1999). The constructs of complexity and balance in multicultural counseling theory and practice. Journal of Counseling & Development, 68, 550–554.

Multiculturalism as a Fourth Force

Pedersen, P. B. (Ed.) (1999). Multiculturalism as a fourth force. Brunner/Maze.

Counseling Across Cultures

Pedersen, P., Lonner, W. J., Draguns, J. G., Trimble, J. E., & Scharrón-del Río María, R. (2016). Counseling across cultures, 7th Edition. SAGE.

Note: This literature by Dr. Paul B. Pedersen are select publications that demonstrate the significant mark he has made in the shaping of MCT in terms of theory, research, and application evidenced-based methodologies.

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A host of scholar–practitioners in the profession provide literature to inform the multicultural counseling theoretical framework with principles, competencies, and evidence-based interventions (Arredondo et  al., 1996; Brown et al., 1996; D’Andrea & Daniels, 1991; Lee & Walz, 1998; Sue, 1995). Topics such as religious and spiritual issues in multicultural counseling (Smith et al., 2019), career counseling through a multicultural theory (Arthur & McMahon, 2005), poverty counseling as an intersectional issue that affects marginalized individuals (Clark et al.,  2020), and affirmative wellness counseling with older LGBTQ adults (Chaney & Whitman, 2020) all fall under this important umbrella. Since the expansion of cross-cultural counseling into the broader concept of multicultural counseling, and now MCT, clinical implications have been explored by scholar–­ practitioners. Sue proposed that MCT is a helping role and a process whereby there is a use of a pluralistic modality (Sue, 1995). This means that practitioners are encouraged to use various approaches in the therapeutic process that are not just conceptually based but empirically sound (Pedersen et al., 2016). Approaches studied in MCT aim to purposefully consider both the client and the counselor as people who have multiple cultural identities. MCT approaches have increased in their ability to help counselors intentionally consider pluralistic identities within the cross-cultural encounter (i.e., the counselor and the client). MCT is a framework for counselors that encourages the consideration of multiple modalities while creating treatment goals that align with life experiences and cultural values. The counselor uses MCT to validate the client’s social and cultural identities. Sue’s (1995) series of conceptual directives, which are aligned with the framework, are as follows: MCT counselors are to (a) recognize identities of the client, inclusive of individualist and collectivistic identities; (b) apply strategies and roles in therapy that signify advocacy of universal and cultural-specific processes; and (c) balance a recognition for subjective uniqueness with group relationships across clinical components of counseling and psychotherapy. MCT is continually broadening overtime to incorporate the growing diversity in the counseling profession, within client populations, and to account for the ever-changing cultural and sociopolitical climate across the United States and the globe. There are limitations within traditional theoretical counseling orientations that can be addressed by MCT. Whether applying MCT as a practice, current culture requires that a counselor become more aware of who they are as a cultural being. Counselors who are conscious of their personal ideals, cultural values, biases, and stereotypes gain important self-awareness that can improve the therapeutic alliance, fostering trust, particularly with marginalized clients. Counselors who ask culturally relevant questions help clients process experiences and confront realities that improve psychological well-being. Inquiries into the impact of culture increase personal reflection and lead to defining client cultural identity. Questions used as intervention tools in MCT provide opportunities for deeper exploration of counselor and client identities as individuals and as a dyad. Counselors who approach treatment with a multicultural lens reduce their unconscious bias and the likelihood of cultural oppression enacted unintentionally in session. Inquiry into and attention to the cultural identity of clients and counselors promote dismantling or at least limiting oppressive conditions, inequality, and marginalization that are all possible experiences in counseling.

Theoretical Constructs of Multicultural Counseling Theory According to Robinson and Morris (2000), systemic racism manifests in counseling through discriminatory practices intentionally and unintentionally embedded into the training and delivery of mental health. It is no longer acceptable to be a practitioner with a lack of awareness of how cultural values, belief systems, lived experiences that inform behaviors, conceptualization of presenting problems, coping skills (or lack thereof), perspectives of mental health and well-being, and risk and protective factors affect all human beings.

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Heightened awareness of systemic racism in overall mental healthcare has led to efforts to embed multicultural counseling needs into counseling profession. Conceptual and empirical studies were carried out to encourage discussions and create trainings to foster counselor development with multicultural views. MCT was formed to reduce ineffective therapeutic processes, discourage noninclusive decision-making for treatment planning, limit misdiagnoses, and deter incomplete client conceptualizations. MCT has a distinct theoretical structure that allows counselors to practice with aim, intent, and intervention. MCT encourages counselors to build the therapeutic relationship around cultural trust, acknowledgment of diversity and cultural issues as potential hindrances to a working alliance, and self-awareness. In MCT, both the client and counselor are salient to the helping relationship; their pluralistic identities inform how they will work together on behalf of the client. A cross-cultural relationship occurs in tandem with the therapeutic relationship in multicultural counseling. It reflects encounters experienced within the greater society, and it can positively or negatively affect counseling outcomes. The counselor’s level of cultural self-awareness can have an enormous effect on a client’s ability to heal or change. MCT counseling practice requires that clinicians consider social and cultural identity experiences across the life span. MCT is an interplay between the interpersonal, intrapersonal, and systemic. Socio­ political and systemic problems are often found to influence emotional function (Sue et al., 1996). Cultural identity often increases the number of systemic barriers encountered and risk levels for mental health problems. For example, concepts like acculturation and discrimination have been found to lead to depressive symptoms among Latinx populations (Cobb et al., 2017). Constructs like identity, systemic oppression, and mental health symptoms are deeply intertwined when marginalized communities seek help from the counseling profession. Each facet is deserving of clinical attention to inform intervention selection, treatment considerations, diagnosis, and case conceptualization. MCT is structured to provide counselors with tools to apply these clinical skills as they consider the whole client. The application of MCT, when framed within the associated praxis of competencies, makes it a useful tool for responsive, effective, and strategically ethical practice (Ratts et al., 2015). The multicultural competency praxis is illustrated and defined for application in the multicultural and social justice counseling competencies (MSJCC). This framework has been supported by the following tenets.

Tenets of Multicultural Counseling Theory Multicultural counseling theoretical tenets are fluid. They require flexibility to further develop and to purposefully tend to the role of culture as it continues to evolve. These tenets serve as areas of professional development for counselors-in-training. The tenets are structured with a premise and are followed by a description. Within the description are details framed within the praxis structure of the multicultural counseling and social justice competencies (MCSJCs). FIRST TENET OF MULTICULTURAL COUNSELING THEORY: DISMANTLING SYSTEMIC EXCLUSION

Client groups who were underrepresented in the development and theorizing of the first three forces have a home in the first tenet of MCT. Clients who have cultural and social identities that are minoritized and have been historically excluded from effective, responsive, and ethical counseling deserve a framework and force that represent their needs and incorporate all facets of their experience. Comstock et al. (2008) shared that “traditional [psychoanalysis, existentialism, and gestalt] theoretical models emphasize individuation, separation, and autonomy as markers of emotional maturity and psychological health” (p. 279). Harrell

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(2000) described diverse, historically oppressed cultural groups express narratives for how they cope, have different styles of resiliency, and vary in their help-­seeking behaviors. SECOND TENET OF MULTICULTURAL COUNSELING THEORY: AWARENESS OF THE LIMITATIONS OF CURRENT COUNSELOR TRAINING

The second tenet is grounded in the experiences of minoritized client groups in counseling and psychotherapy. MCTs seek to address the mental healthcare system’s historic paucity of culturally sensitive interventions and helping practices in counselor training programs. The second tenet is rooted in awareness of historic limitations of counselor training programs. Though there is plenty of evidence that culturally insensitive treatment modalities are being practiced, there has been minimal resolve in revising what counselors-in-­training are being taught until now (Robinson & Morris, 2000). Counselor education has been (a) a system taught through a Northern European frame of reference, (b) designed from a Western perspective, (c) taught predominantly by White educators focused on their own cultural values, and (d) focused on Northern European theories. THIRD TENET OF MULTICULTURAL COUNSELING THEORY: MULTICULTURAL COUNSELING IS ESSENTIAL TO TREATING THE WHOLE CLIENT

The third tenet is counselor-dependent and encourages application of MCT as a method for comprehensive treatment, either as a integrative theory with other orientations or as a stand-alone theoretical orientation. Counselors are encouraged to incorporate multicultural counseling concepts, theory, and understanding into the therapeutic process, including progress notes, intervention selection, and treatment planning. It is focused on experiential and multidisciplinary training that focuses on self- and cultural awareness, such as personal and professional development, criminal justice, psychology, ethnic and gender studies, psychiatry, among other things. Awareness of social and cultural determinants that directly and systemically impact the client is essential to MCT practice. For example, critical race theory is a concept rooted in the study of law (Crenshaw et al., 1995) and has been explored in the counseling profession as a decision-making model (Trahan & Lemberger-Truelove, 2014). Education in such concepts will influence appropriate treatment, diagnosis, prognosis, and overall case conceptualization of presenting and ongoing problems in clients’ mental health, well-being, and quality of life. EMERGING THEORETICAL EFFORTS

Social justice is considered the fifth force in counseling and psychotherapy and has a direct relationship with multicultural counseling (Singh  et al., 2020). Counselors focus on constructs of equity, oppression, access, empowerment, participation, and harmony in the therapeutic process (Crethar et al., 2008). In a groundbreaking book Handbook for Social Justice Counseling Psychology: Leadership, Vision, and Action, Toporek et al. (2006) explored the nature of this force and introduced action-oriented processes to address the mental health of clients, calling attention to inequities of daily life, fairness in accessibility of resources, and engaging in the utilization of personal rights.

MODALITIES USED WITHIN A MULTICULTURAL COUNSELING FRAMEWORK The modalities explored in this chapter are racial and cultural identity development (R/ CID), the ecological model of multicultural counseling psychology processes (EMMCPP), NTU‌therapy, multidimensional model of broaching behavior (MMBB), PDI, and relational-­ cultural theory (RCT). To learn additional modalities, please refer to the following ­multicultural-oriented counseling textbooks: Lee (2019), Pedersen et al. (2016), or Sue et al. (2019).

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Racial and Cultural Identity Development R/CID is a counseling framework developed by Atkinson, Morten, and Sue (1978; Sue & Sue, 2003). It is a five-stage developmental model that helps counselors to conceptualize and process clients’ experiences of racial and cultural identity. Outside of R/CID, there are additional racial developmental stage models (e.g., Helms, 1990, 1995), people of color racial identity theory, and Cross’s Nigrescence model of Black identity formation (1971, 1995). Thompson and Carter (1997) postulated that all racial and cultural identity models‌ have a basic premise of striving for racial self-actualization. They explain the overall process is centered on achieving a sense of self that is more internalized, integrative, and fulfilling (Choudhuri et al., 2012). Racialized identity is the root of what contributes to experiences of marginalization and oppression. A number of identity models have been formulated to explicate the developmental process. Table 2.6 showcases key identity models. The R/CID model complies with what Thompson and Carter (1997) theorized, as it directs counselors to structure questions for gathering information about the racial and cultural Table 2.6. Race, Ethnicity, and Acculturation Identity Models Name of Model

Model Applies to

Theorists Who Created the Model

Black identity formation via the theory of Nigrescence

African Americans and Black people

William Cross (1970)

Helms’s model of White racial attitudes toward people of color/White identity development and integrative model (based on R/CID and Nigrescence)

White Americans

Janet Helms (1995)

Ferdman and Gallegos model of Latino identity (in the United States)

Latinx/Latino/Hispanic Americans

Ferdman and Gallegos (2001)

Native American consciousness Model of American Indian acculturation

Indigenous Peoples of America/Native Americans

Perry G. Horse (2001) Michael Garrett and Pichette (1999)

Jean Kim’s Asian American identity development, a fivestage multidimensional model

Asian Americans

Jean Kim (2001)

Dimensions of Jewish American identity

Jewish Americans

Zak (1973)

The FMMI‌

Biracial and multiracial identity

Wijeyesinghe and Jackson (2001)

The MHID‌

Biracial and multiracial identity

Henriksen and Paladino (2009)

Ethnic identity development model

Multiethnic model: applied to African American, Latinx/ Hispanic, Asian American, and White Americans

Jean Phinney (1993)

FMMI, factor model of multiracial identity; MHID, multiple heritage identity development. Note: There are limitations of each model that lends to a need for further development and empirical ­validation. Race and ethnicity are often referred to as interchangeable concepts that are multidimensional and ­conceptualized as having a developmental process that occurs with the identity.

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background of clients. The questions concern sociohistorical and personal experiences, attitudes, belief systems, and how their racial experiences and mental health issues have been impacted by greater society. The counselor seeks to uncover how the client sees themselves in terms of race and culture. For example, how does the client perceive race? Is it in‌relation to self, others, or the greater society? The questions posed by the counselor to the client are open-ended, asking about perspectives in relation to their own racial group, experiences with other races, and within the dominant cultural group. Ideas that concern acculturation may arise, where responses of clients may be dependent on how safe the therapeutic space is and within the counseling relationship. According to West-Olatunji et al. (2007), R/CID has an “investigative” nature that allows for the counselor to better understand a clients’ level of “conformity and idealized identification with the dominant culture as well as their rejection of their own culture” (p. 42). Acculturation is the process of adapting to a new country that involves heritage-culture retention and receiving-culture acquisition (Cobb et al., 2017). It takes place consciously and unconsciously through immigration, colonization, and due to other sociopolitical changes. According to Choudhuri et al. (2012), acculturation happens across four modes: assimilation, separation, marginalization, and integration. Though the modes of acculturation are not constructs of the R/CID framework, they affect‌one’s identity development and, therefore, awareness of them contributes to effective use of R/CID. The R/CID model has five stages. The stages are conformity, dissonance, resistance/ immersion, introspection, and integrative awareness. A main assumption of this model is that people who identify in culturally diverse groups will experience these stages due to conflicts they encounter within a race-based social system. The stages are nonlinear and are based on the client’s sense of cultural devaluation or appreciation. The characteristics of racial identity development‌are similar to what Cross proffered in his Nigrescence model (1971, 1995); however, the R/CID model focuses on understanding the race-based experiences within counseling and across the life span (Vandiver et al., 2001, 2002). The stages of the R/CID are described in the following. CONFORMITY

Racially diverse clients have a greater awareness of dominant culture than that of their own racial group (i.e., culture). Should a client be in the conformity stage, the counselor may pose questions and process responses that foster insight into life experiences that have led the client to this stage. DISSONANCE

The second stage describes a conflict between clients’ “attitudes about superiority of the dominant culture and their appreciation for marginalized groups” (West-Olatunji et al., 2007, p. 43). Intra- and interpersonal experiences and perspectives may surface in the counseling process. The conflict may be difficult for the client to talk about. Questions from the counselor should revolve around interactions between the client’s racial group and the dominant racial group. RESISTANCE AND IMMERSION

The client has begun to acquire an appreciation of their own racial and cultural identity, members of their racial group, and members of other marginalized racial groups. They recognize collective struggles in society and become aware that these are not isolated events but are instead shared experiences of racial groups that have been marginalized by dominant cultural group. Social justice counseling interventions and advocacy competencies (Toporek & Daniels, 2018) are therapeutic tools that should be used with clients in this stage of R/ CID. They will help‌the counselor support the client through acknowledging the injustices happening to the client, their group, and other groups that are characteristically minoritized, racialized, and marginalized and who suffer from oppressive systems that perpetuate

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such injustices. Counselor awareness of systemic problems, present and historic, will help reduce the cultural bias held by the counselor and reduce any cultural mistrust held by the client. INTROSPECTION

The client often wants to hold membership within the dominant cultural group (e.g., White racialized cultural group, male cisgender, Christianity), possibly by masking elements of racial and cultural identity to fit into the dominant cultural group. This desire is attributed to an internal rise of conflict within the self and is possibly a reflection of the rejection of their group identity (i.e., culture, race, ethnicity, etc.). In the counseling process, the client may demonstrate introspection that emerges in the form of shame, internalized oppression, and disregard of self and other minoritized groups. INTEGRATIVE AWARENESS

In the last stage of R/CID, the individual begins to develop a sense of valuing of self and others within their cultural group. Cultural experiences unique to the client’s racial and cultural identity begin to become valued. This new appreciation may be transformational in nature because the individual gains a deep personal meaning from what is being learned about oneself and the others within their racial and/or cultural group. The R/CID stage model of racial and cultural identity is a tool for use when conducting multicultural counseling. It is important to note that Cross’s model has been refined and expanded to mirror a broader conceptualization of Black identity, which entails establishing self-concept through what he calls socialization and resocialization experiences happening across the life cycle (Choudhuri, 2012). Models like R/CID remain important to appreciate the various cultural differences between racialized cultural groups.

Ecological Model of Multicultural Counseling Psychology Processes EMMCPP is a contemporary model that was created as an integrative framework (Neville & Mobley, 2001). It integrates both ecological and multicultural factors to support counselors helping clients as they navigate the dynamics of power, oppression, and privilege that exist in their environments. The confluence of ecology and multiculturalism shapes the basis of EMMCPP to reflect a “person-environment interaction” (Neville & Mobley, 2001, p. 471). Neville and Mobley (2001) use ecological framing to demonstrate how a person has an impact on their environment and how the environment impacts the person. This interplay between client and social system is called a bidirectional impact. The EMMCPP has four subsystems: microsystem, mesosysem, exosystem, and macrosystem. The microsystem includes interpersonal interactions within the environment. Home, school, and work are examples of what exists in the microsystem. The mesosystem is composed of interactions between a person and their environment. For example, it involves the interplay between school and home. The exosystem describes relationships between the subsystems that influence a person, whether direct or indirect, and are often institutional (i.e., healthcare or law enforcement). The most outer of the four subsystems is the macrosystem, and captures societal norms, belief systems, and values (Neville & Mobley, 2001). In EMMCPP, the client has intersecting identities that influence how they interact with, adjust to, and/or change their environment. Race and facets of cultural identity are incorporated into sociocultural factors of treatment. The framework is structured to include the clients’ social composition, which in turn influences the ecosystem. All four subsystems interact and impact one another in a holistic manner. Example social compositions include race, gender, sexual identity, SES, religion, and neighborhood/home environment.

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From a clinical perspective, the EMMCPP lends itself nicely to case conceptualizations and treatment plans that address sociocultural factors in each ecological subsystem. Counselors may use the model to consider the client’s subjective experiences within the systems that they have relationship with and the interplay between these systems. Intake, diagnosis, treatment planning, and intentional creating of a safe space to speak on sociocultural factors include practice of MCSJCs and advocacy competencies (Toporek et al., 2009), while helping the client is based on the client as a system (e.g., racial and cultural identity, intersectionality).

NTU Therapy NTU is a counseling and training model used with African American populations (Foster et al., 1993; McLean & Marini, 2003; Phillips, 1990). It is based on Nguzo Saba, an Afrocentric model that has its roots in Bantu heritage of people in Central Africa and African American diaspora in the United States. According to Phillips (1990), NTU is “a concept that describes a universal, unifying force that touches on all aspects of existence” (p. 56). The NTU model is nestled within the principles of Kwanzaa. There are seven Kwanzaa principles that are practiced annually by many cultural groups in the Black community. Each principle has a day for reflection, starting on December 26 and ending on January 1. In order, the principles are Umoja (unity), Kujichagulia (self-determination), Ujima (collective work and responsibility), Nia (purpose), Kuumba (creativity), and Imani (faith). During Kwanzaa, people meet on each day to focus on one principle, create action plans, and bear witness to demonstrations of the principle. Counselors who work with Black culture and/or African Americans find NTU to be helpful in understanding the nature of identity in this social and cultural group. It is holistic, has an indigenous approach, and was developed to help clients rediscover natural alignment with who they are and are becoming. The affirmative historical foundation of NTU began in Africa, before slavery. The model is comprehensive, rich with tradition, and places importance on a racialized cultural group that has a deep-rooted history of trauma in the United States. For those interested in this model or other MCT-oriented approaches centered on working with Black/African American culture, readers should consider the text Addressing Race-Based Stress in Therapy With Black Clients: Using Multicultural and Dialectical Behavior Therapy Techniques (Johnson & Melton, 2021).

Multidimensional Model of Broaching Behavior Dr. Day-Vines is an MCT pioneer who established the model of broaching. Broaching is centered on addressing cultural and sociopolitical factors within counseling sessions and consists of the counselor demonstrating a genuine openness to discussing issues related to diversity (e.g., race, ethnicity, culture; Day-Vines et al., 2018; Day-Vines et al., 2013; Day-Vines & Holcomb-McCoy, 2013; Day-Vines et al., 2007; Erby & White, 2022). Broaching is an action-based concept that is used within cross-cultural encounters. Recently, broaching has been studied as a clinical tool for counselors to use in unpacking power differentials with trans people of color (Erby & White, 2022). Counselors invite clients to examine issues of race, culture, power, and marginalization in session. Broaching is explicit in nature in that the counselor is responsible for carving out a safe space in the therapeutic relationship so that challenging topics related to sociopolitical realities (i.e., privilege, oppression) can be openly explored in session. Initially, broaching was considered a framework to address mainly race and ethnicity; however, it has evolved into a multidimensional model that extends to other intersecting cultural dynamics and identities. In an expansion of the broaching framework, Day-Vines and Holcomb-McCoy (2013) developed a four-tier multidimensional model that has been

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used in counselor education classes. The MMBB (Day-Vines et al., 2020) has four domains that are fluid, overlapping, and interacting (Day-Vines  et al., 2020). Together, these domains offer the theoretical framework: intracounseling, intraindividual, intracounseling relative to REC (intra-REC), and intercounseling relative to REC (inter-REC; Day-Vines et al., 2020). INTRACOUNSELING

Similar to broaching, in intracounseling, the counselor opens a dialogue about the differences between the counselor and client in the areas of REC. There are two purposes of this intentional dialogue: (a) to ensure that counselor–client REC differences do not interfere with the counseling process and (b) to bring to the foreground the possibility that the counselor and/or client may be misinterpreting the REC differences between the counselor and client. A goal of this interaction is for the counselor to practice cultural humility and for the client to develop feelings of safety in the therapeutic relationship. INTRAINDIVIDUAL

The intraindividual domain is based on the perception of the counselor. It is an exploration of identity that may encroach on the client’s presenting problem (Day-Vines et al., 2020). The goal is for the counselor to avoid assigning the client a singular identity, when in fact the client may have one that is pluralistic. Achieving this goal promotes counselor behavior that is crucial to each domain, because it fosters supporting the client from a holistic perspective, primarily relative to REC. Intersectionality‌(Crenshaw, 1991) challenges the oppressive forces influencing the client’s presenting problem, such as race, gender, affectionate orientation, class, ableness, spirituality/religion customs, and so forth. In this sense, problems (or privilege) lie at the intersections of clients’ identities. Patterns of oppression emerge in this domain through in-session dialogue. INTRACOUNSELING RELATIVE TO RACE, ETHNICITY, AND CULTURE

Intra-REC encourages awareness of differences that may exist between the client and their cultural group identity (i.e., within group concerns). The intra-cultural differences that surface during treatment may concern values, beliefs, experiences with oppression, power, and privilege. A goal for this domain is for the counselor and client to communicate with transparency as opposed to circumventing REC elements. Day-Vines and colleagues (2018) developed the intra-REC domain to be in alignment with the MSJCC (Ratts et al., 2016). When there is awareness of between and within group cultural differences and similarities, there is greater insight into the client, their experience, the presenting problem, and possible solutions. Please see the MSJCC for a visual illustration of these cultural identity domains. INTERCOUNSELING RELATIVE TO RACE, ETHNICITY, AND CULTURE

The last domain, inter-REC, encourages counselors to consider the impact of systemic problems like racism and discrimination on the client. In other words, how do macrosocietal factors like racism, equity, and oppression affect clients? These systemic problems manifest at every level of society, whether explicitly or implicitly experienced. The counselor facilitates dialogue within the therapeutic relationship that acknowledges these systemic problems and empowers clients to avoid blaming themselves. This domain includes social justice advocacy, where the counselor is encouraged to incorporate interventions that diminish or eliminate the problem (Day-Vines et al., 2020). For this dialogue to be properly conducted, the counselor is encouraged to learn about the dynamics of power, oppressive systems in society, and privilege.

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Overall, the MMBB model encourages counselors to practice broaching behaviors throughout the therapeutic process. It calls for the counselor to demonstrate cultural understanding of self and others. It also serves to reflect a counselor’s cultural knowledge about REC experiences in greater society that may impact client quality of life and well-being. Finally, MMBB is what counselors use to develop cultural trust and humility within the counselor–client relationship. This serves to methodically acknowledge the dynamics that individuals from diverse RECs can experience in the counseling process.

Personal Dimensions of Identity Model The PDI model is a theoretical structure that is used to illustrate intersectional elements of individual and group identity (Arredondo, 2005). The personal identity has three interactive dimensions (A, B, and C) that provide a way to view clients individually and holistically. The aim is to provide a strategy to help counselors capture intersecting elements of personal identity that include race and ethnicity. The A dimension lists age, culture, ethnicity, gender, language, physical/mental well-­ being, race, sexual orientation, and social class. The B dimension includes educational background, geographic location, hobbies/recreation, healthcare, practices/beliefs, religion/ spirituality, military experiences, relationship status, and work experience. And lastly, the C dimension concerns what Arredondo calls historical moments/eras. THE INTERACTIONS BETWEEN THE DIMENSIONS

The A dimension includes stereotypes, assumptions, and judgments, which occur systemically in culture. These facets interact with C dimension, which details eras or events that have historical and sociopolitical salience. Both A and C dimensions are considered consequences of B dimension within the framework, which encapsulates factors that influence daily functioning: education, place of residency, and income. The PDI model lends itself to a pluralistic understanding of clients and provides a framework for interpretations of client’s presenting problems, the sociopolitical climate in which those problems present, and the therapeutic process to address each dimension.

Relational-Cultural Theory RCT is a theoretical paradigm designed by J. B. Miller (1976). It is a contemporary framework recognized in the counseling profession that serves to “accurately address the relational experiences of women and persons in other devalued cultural groups” (p. 279; Comstock et al., 2008). According to Birrell and Freyd (2006), RCT has two main assertions. The first assertion is that oppression not only happens at societal levels but also can be carried out in interpersonal relationships. The second assertion is that human violation creates a sense of brokenness in interpersonal relationships. These relational difficulties can be healed through building new healing bonds through RTC. The counselor must embrace a view of the client that is not isolationist; multiple relationships in need of repair and greater levels of connection must be considered with the ultimate goal of fostering a holistic sense of well-being that aligns with cultural worldviews of both the client and the counselor. RCT fills a gap in the psychological health of women, people of color, and marginalized men, where intersecting marginalized identities continue to experience cultural oppression and exclusion and are often excluded from traditional theories of human growth and development. Traditional theories emphasize individuation, separation, autonomy, and mastery of the self with a Eurocentric perspective. These frameworks have limited definitions of emotional maturity and antiquated standards of psychological health that still have yet to

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incorporate the contributions of scholars who identify as women or are from communities of color (Comstock et al., 2008). RCT is structured according to several tenets, a multipronged assumption, and a series of key concepts that cocreate a unique, relationally oriented MCT. The coherence among the tenets is centered on an individual’s social and cultural identities. According to RCT, the theoretical impact of the model suggests a sense of relating or relationship that a person can have with others in a cross-cultural encounter and across the life span. The tenets of RCT are reviewed in Box 2.1. According to Walker (2004) an individual’s racial, cultural, and social identities play a role in how they connect with others over the course of their life span. Comstock et al. (2008) directs counselors to examine culturally based relationships with greater awareness for intentional and/or unintentional disconnections. These disconnections often have their roots in racism, discrimination, marginalization, inequity, and hate. According to Comstock et al. (2008), “RCT is based on the assumption that the experiences of isolation, shame, humiliation, oppression, marginalization, and microaggressions are relational violations and traumas that are at the core of human suffering and threaten the survival of humankind” (p. 280). RCT includes a series of concepts that are interconnected and they are listed in Table 2.7. RCT counselors aim to purposively explore new ways to develop and maintain growth-­ producing connections with clientele to reduce harmful impact of systemic sociopolitical experiences. RCT is a comprehensive theory that integrates (a) multicultural and social justice counseling and (b) relational experiences of women, people of color, and marginalized men (Comstock et al., 2008). Relational cultural theory offers counselors a model for being inclusive and to constructively think beyond symptom reduction conceptualization.

INTERSECTING LAYERS OF MULTICULTURAL COUNSELING THEORY: THREE FRAMEWORKS This section highlights three multicultural counseling frameworks that explore social justice, along with counselor and client identity. They are (a) the MSJCC (Ratts et al., 2016), (b) the counselor advocate–scholar (CAS) model (Ratts & Greenleaf, 2018), and (c) the MCT (Atkinson & Lowe, 1995; Pedersen et al., 2016; Ponterotto et al., 1995; Sue, 2001; Sue et al., 2019). Box 2.1. Paraphrased Tenets of Relational-Cultural Theory 1. Across the life span, a person will develop and attract a series of relationships. 2. Mature participation in relationships is a resultant of reciprocity in relating. 3. Psychological growth is demonstrated when one can take part in progressing multifaceted and varied relational associations. 4. Communal empathy and empowerment are situated at the center of healthy relationship building. 5. Being genuine is a critical component to relating in healthy relationships. 6. When growing healthy relationships happens best when such efforts are collective. 7. The goal of developing healthy relationships concerns social and cultural identities, other awareness, and recognition that dynamics of relationships center on how connected a person is and feels. Source: Comstock, D. L., Hammer, T. R., Strentzsch, J., Cannon, K., Parsons, J., & Salazar, G. II. (2008). Relational-cultural theory: A framework for bridging relational, multicultural, and social justice competencies. Journal of Counseling & Development, 86(3), 279–287. https://doi.org/10.1002/j.1556-6678.2008.tb00510.x

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Table 2.7. Key Relational-Cultural Theory Concepts and Definitions Concept

Definition

Topical Research Centered on Social and Cultural Identities

Shame and humiliation

Feelings associated with minority stress and as self-conscious emotions. They reflect experiences that produce psychological distress.

Mereish, E. H., Peters, J. R., & Yen, S. (2019). Minority stress and relational mechanisms of suicide among sexual minorities: Subgroup differences in the associations between heterosexist victimization, shame, rejection sensitivity, and suicide risk. Suicide and Life-Threatening Behavior, 49(2), 547–560.

Oppression

The domination of subordinate groups in society through prejudice, discrimination, and access to political, economic, social, and cultural power

Arredondo, P. (1999). Multicultural counseling competencies as tools to address oppression and racism. Journal of Counseling & Development, 77(1), 102–108.

Marginalization

A social process where a person, group, or community is excluded across systems in society because of who they are socially and culturally. People who are marginalized have difficulty with social functioning and acceptance, potentially lacking a sense of cultural identity and self-efficacy.

Salazar, C. F., & Abrams, L. P. (2005). Conceptualizing identity development in members of marginalized groups. Journal of Professional Counseling, Practice, Theory, & Research, 33(1), 47–59.

Microaggression

An unconscious statement or action regarded as discrimination against a marginalized community. In action, it can be a continual verbal, behavioral, and environmental assaults, insults, and invalidations that occur in subtle ways that may be implicit or explicit.

Turner, J., Higgins, R., & Childs, E. (2021). Microaggression and implicit bias. The American Surgeon, 87(11), 1727–1731.

Source: Comstock, D. L., Hammer, T. R., Strentzsch, J., Cannon, K., Parsons, J., & Salazar, G. II. (2008). Relational-cultural theory: A framework for bridging relational, multicultural, and social justice competencies. Journal of Counseling & Development, 86(3), 279–287. https://doi.org/10.1002/j.1556-6678.2008.tb00510.x

Multicultural and Social Justice Counseling Competencies The MSJCC is a framework (Ratts et al., 2015) that incorporates the culture of the client and the counselor in the counseling process. It resists the assumption that the counselor is White and working with a “non-White” client (Robinson & Morris, 2000). Consequently, all counseling is considered cross-cultural counseling, signifying that the counselor and the client are cultural beings who have social and cultural characteristics that differ and impact one another and the treatment process (Pedersen, 1988). According to the MSJCC model, social and cultural characteristics such as gender, SES, religion and spirituality, affectional and sexual orientations, race, ethnicity, immigration status, and education play a role in the therapeutic encounter. The counselor is encouraged to have a significant level of awareness, knowledge, and skill that supports the client’s individual and group social and cultural identities (Sue, 1998). The complexity of addressing these identities is important because they intersect with how a person copes, develops resiliency, and interprets their problems (West-Olatunji  et al., 2007). Advocacy is woven within the competencies as an action-oriented way to support clients in social systems that are racist, marginalizing, and oppressive.

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The MSJCC model not only calls attention to various contexts of marginalization and privilege, but it also increases awareness of worldviews that are used to navigate these contexts. Worldview is a contextual reflection of culture, individual, and group identity. It is used to interpret problems, relationships, and encounters with self and greater society. These identities and worldviews are considered salient to the therapeutic process in the MSJCC model and influence the outcomes of counseling within this framework. An important factor in MSJCC is the salience of client and counselor worldviews based on life experiences. There are four guiding factors that account for these life experiences and characteristics: (a) intersections of identities, (b) oppression and mental health, (c) socioecological perspective, and (d) balancing individual counseling with social justice (Ratts et al., 2016). It is important to understand how privilege and marginalization are experienced and can impact the therapeutic encounter. In the multicultural counseling paradigm, privilege includes the systematic and unearned benefits provided to certain groups in society based on specific facets of their identity (Crethar et al., 2008). For example, those with the most privilege in the United States commonly hold the following identities: White, middle and upper class, cisgender, English-speaking, male, and able-bodied (Crethar et al., 2008). Privilege is also experienced by both client and counselor and must be acknowledged in the therapeutic process. Each is part of the sociopolitical reality of culture. In this context, privilege is unearned, which perpetuates injustices experienced by individuals who have characteristics of any marginalized group identity. Counselors bring awareness to the personal experiences clients have with privilege and oppression. Like broaching, Singh et al. (2020) encourages counselors to use social and cultural intersections of identity as prompts throughout the counseling process to focus on experiences with privilege or marginalization. When these experiences are brought up during counseling, the counselor can provide a safe space to process the client’s experiences.

Counselor Advocate–Scholar Model The CAS model was developed by Ratts and Pedersen (2014) and describes methods to dismantle systems of oppression. The CAS model is an operational framework, providing direction for counselor action and advocacy (Ratts & Greenleaf, 2018). The main premise is that issues of oppression are not easily resolved by using intrapsychic measures promoted by dominant counseling discourse (Ratts & Greenleaf, 2018). To reduce this issue, the CAS model provides practical schemas that demonstrate how counselors can operate from a social justice framework with clients (Ratts & Greenleaf, 2018). Through the CAS model, the counselor is encouraged to expand the provider role, shifting to the role of advocate and scholar (Ratts & Greenleaf, 2018). The three roles within the CAS model are depicted as three overlapping circles to produce what is called the multicultural and social justice praxis. Recall that the MSJCC is also a praxis. A praxis is defined as an objective practice that is rooted in a particular theory. The CAS praxis outlines the roles of the counselor within two of its overlapping circles; where advocate and counselor roles overlap denotes where each informs the other. The counselor role and scholar role overlap where they each serve one another in action. This overlap demonstrates the unique interrelationships of the roles. The role of counselor informs advocacy and scholarship. For example, a counselor practicing in a community may also operate in the role of advocate on behalf of the client, to fight for injustices that have been perpetuated in social systems. Such injustices fall within the -isms that are experienced by clients at group or individual levels of cultural identity and across the societal systems that impact individuals and groups. A counselor grounded in multicultural competence allows for more awareness and skillful use of therapeutic tools to intentionally address systemic problems and empower the client to relinquish unhealthy

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coping within oppressive systems in society in exchange for tools that foster social change (Ratts & Greenleaf, 2018).

Theory of Multicultural Counseling There is a need to delve into the solutions relevant to the cultural gaps that are limitations of the traditional theoretical counseling orientations. A solution to close the cultural gap is for the counselor to grow more aware of who they are as a cultural being. Counselors who are more aware of their personal ideals that concern human behavior, cultural values, biases, and stereotypes gain cultural trust with marginalized clients. Counselors further increase trust through asking culturally relevant questions that denote salience around the intersecting identities of the client. This helps clients to process content that encourages understanding of how realities inform psychological well-being and change processes. These questions increase personal reflection and are directly related to client cultural identity. Questions used as intervention tools in MCT provide opportunities for deeper contemplation on the contextual nature of counselor and client identity. In turn, the counselor will be more informed on navigating the counseling processes from a multicultural lens, reducing counselors’ unconscious bias and experiences of cultural oppression in session. Inquiry into and attention to the cultural identity of clients and counselors promote actions toward dismantling or at least limiting oppressive conditions, inequality, and marginalization that have all been experienced in counseling.

RECOGNIZING AND ELIMINATING OPPRESSION, INEQUALITY, AND MARGINALIZATION Inequities in mental healthcare for racialized minority groups are persistent, ranging from a shortage of culturally responsive services to discriminatory practices by mental health providers (Bathje et al., 2022). This has contributed to the persistence of problems in the mental healthcare system, particularly regarding cultural appropriateness and discrimination. To address these issues, scholars have proposed using MSJCC as a solution in multiple ways. There is a recurring theme in counselor literature regarding disparities in mental health treatment, with a focus on the racism faced by racialized minority clients seeking services (Buser, 2009; Robinson & Morris, 2000). However, other systemic problems beyond racism, such as oppression, inequality, and marginalization, are also being addressed due to their interrelated and often harmful effects on individuals. Before examining the frameworks used to mitigate these issues, it is crucial first to understand their interconnected nature. Oppression encompasses discrimination, racism, power dynamics, and marginalization and is defined as “the domination of subordinate groups through prejudice, discrimination, and access to political, economic, social, and cultural power” (Choudhuri et al., 2012, p. 120). The complex manifestation of discriminatory practices against individuals operating within disempowering systems results in experiences of minoritization by those with privilege and power, which is conceptualized as “advantages, favors, or immunities specifically granted through membership in a dominant group that is denied to members of subordinate groups” (Choudhuri et al., 2012, p. 120). Inequality plays a role in experiences of oppression and marginalization for those who lack privilege. It involves navigating society with limited resources compared to those with privilege while also dealing with racism and poor living conditions that can lead to decreased mental health and overall well-being (Crethar et al., 2008; Ratts & Greenleaf, 2018). In contrast, equity is defined as the fair distribution of resources, rights, and responsibilities to all members of society (Crethar et al., 2008). By gaining a deeper understanding of oppression, inequality, and marginalization, it becomes clear how these systems impact

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racialized and minority clients and how various frameworks can be used to address these issues in counseling. RCT was initially created to address the needs of women, people of color, and marginalized men seeking counseling and therapy. Due to the lack of cultural competence among mental health professionals, these individuals were often misdiagnosed and pathologized. Little attention was being paid to the systemic issues impacting their well-being and mental health. Comstock and colleagues (2008) point out that Miller, the feminist and multicultural theorist who developed RCT, aimed to challenge the limitations of traditional models that “emphasize individuation, separation, and autonomy as markers of emotional maturity and psychological health” (p. 279). In her book Toward a New Psychology of Women, Miller explained that the problems her clients reported were not aligned with traditional theories of human development and were instead related to the relationships they experienced, both inter- and intrapersonal. A contemporary solution to the systemic issues discussed in this section is to use competencies as a common therapeutic factor (Bathje et al., 2022). This approach shifts the focus from what treatment is provided to how treatment is provided, making the client’s life experiences within sociocultural systems central to the counseling process. By considering the oppression, marginalization, and discrimination experienced by the client, the therapeutic common factor framework integrates Wampold and Imel (2015) common factors and the competencies identified by Hayes et al. (2016). The competencies serve as a tool to improve the therapist–client relationship and have been shown to positively impact therapy outcomes for clients from racial and ethnic communities of color. These competencies are a critical element driving the counseling process (Bathje et al., 2022). The CAS model provides a framework for addressing the negative impact of oppression, inequality, and marginalization through advocacy. Counselors are expected to counsel their clients and advocate for them in the community. The advocacy competencies‌ endorsed by the ACA guide counselors to address and reduce systemic injustices that affect client well-being through individual, group, and system-wide interventions. These competencies encourage counselors to address injustice and empower minoritized cultural groups who experience powerlessness. The CAS model provides a platform for counselors to practice advocacy, addressing systemic injustice related to privilege and oppression in the client’s environment and within the counseling process.

DESCRIPTIONS OF THE ROLES OF CLIENT AND COUNSELOR When applying MCT clinically, the counselor plays a facilitative role in the therapeutic relationship, building trust and establishing a genuine alliance with the client. The counselor is responsible for creating a safe space for the client to explore their values, beliefs, and life experiences while acknowledging the impact of systemic and cultural factors on the client’s well-being. In this framework, the client is an active participant in the therapy process, bringing their own unique experiences and perspectives to the table. In the case of Mark, it is important for the counselor to consider his cultural identity and how it shapes his understanding of himself and the world. The counselor should also be aware of Mark’s biracial children and the cultural identities they may develop as a result. To best support Mark in his journey of self-discovery, the counselor should aim to build cultural trust and understand the role that culture plays in his life. The specific roles outlined by MCSJCs are crucial for the counselor practicing from MCT, since they serve as a guide for culturally responsive and competent practice. These competencies were first introduced by Arredondo and colleagues in 1996, have since been endorsed by the ACA, and are promoted by multicultural and social justice counseling experts. Even though this literature dates back to 1996, it is essential to note that at the time,

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the multicultural movement in the counseling and psychotherapy field was not widely accepted, received limited recognition in mainstream counseling journals, and was inadequately addressed in counselor training programs. Hence, the early work in MCT was groundbreaking and continues to play an important role in counselor preparation and fieldwork today. In MCT, the counselor has several vital roles that are essential to the success of the therapeutic relationship and the overall outcomes of the treatment process. These roles include awareness of one’s biases, acquiring knowledge, and developing culturally responsive skills. The counselor is encouraged to be aware of their implicit and explicit biases and how they may impact the therapeutic encounter. They are also expected to actively learn about the client’s identities, worldviews, and the contextual factors that play a role in the client’s life.

SPECIFIC THEORETICAL TECHNIQUES USED IN MULTICULTURAL COUNSELING THEORY MCT uses various theoretical techniques that address the intersections of diverse identities. However, some of these techniques may not fully consider all aspects of a person’s identity. To overcome this limitation, counselors must develop an MCT toolbox that includes evidence-based interventions and conceptual tools that support their multicultural and social justice competencies. By building a diverse toolbox, counselors can reduce limitations in applying theoretical techniques and enhance their ability to address a wider range of client identities and experiences. The following are three theoretical techniques and processes commonly used in MCT: 1. Affirmative intersectional counseling: This approach recognizes the intersectionality of a client’s identities and seeks to affirm and validate their experiences. 2. Liberation psychology: This framework focuses on addressing systemic oppression and promoting social justice. 3. Empowerment counseling: This approach emphasizes empowering clients to take control of their own lives and make positive changes. As you read about these theoretical techniques, consider the case of Mark. First, think about how you could use each framework to understand Mark’s presenting problem and frame questions in therapy that support his cultural perspective. Then study each technique for a more comprehensive understanding.

Affirmative Intersectional Rehabilitation Counseling Affirmative intersectional rehabilitation counseling (AIRC) is a theoretical technique used in counseling for sexual minorities who have chronic illnesses and/or disabilities (CID). It integrates competencies from the Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC), social justice, and MCT, and has been studied in rehabilitation counseling research. AIRC was developed to address the interrelated problems faced by sexual minorities with CID, including health disparities such as arthritis, obesity, poor physical health, HIV, and mental distress. The framework also addresses clients’ unique experiences with intersecting identities as sexual minorities and people with disabilities. Key concepts in AIRC include intersectionality, oppression, LGBQTIA+ identity, psychosocial experiences, CID, sexual minority identity, behavioral health-related disparities, affirmative practice, institutional discrimination, and minority stress. To better understand AIRC, readers are encouraged to research these concepts in counseling-­related literature.

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WHY AFFIRMATIVE INTERSECTIONAL REHABILITATION COUNSELING?

The intersectional identity of sexual minorities, persons with disabilities, and individuals living with CID is a unique and complex group with diverse experiences (Fassinger, 2008). According to Dispenza and colleagues (2016), this population is at higher risk for societal stigma, institutional discrimination, ableism, psychological distress, workplace violence, and stress due to oppression (Fassinger, 2008; Myer, 2003). Given the challenges faced by this minoritized group, AIRC provides a helpful framework for addressing their needs in the counseling process. However, it should be noted that this population is underrepresented in counselor-related scholarship (Dispenza et al., 2016). Expectations of the counselor when using AIRC are adopted from Smart and Smart’s (2006) CID clinical implications and are rooted in disability affirmative therapy (DAT; Olkin, 2001). A comprehensive paraphrasing of this integration is in Table 2.8. AFFIRMATIVE INTERSECTIONAL REHABILITATION COUNSELING COMPONENTS IN ACTION

The structure of AIRC is centered around affirmative intersectionality (AI). According to Dispenza et al. (2016), AI is the core of AIRC and is used to deliver rehabilitation counseling services to sexual minorities living with CID. The use of AI in the counseling process is important for several reasons. Firstly, it helps to address the forms of oppression that sexual minorities and those living with CID often experience. Secondly, AI is used to cultivate a sense of pride in clients’ identities intentionally. Finally, AI helps address cognitive, affective, and behavioral processes that arise during counseling. There are three AI approaches that focus on empowering clients to understand, identify, and challenge forms of oppression they face (Dispenza et al., 2016). Through AI in the counseling process, clients are encouraged to explore their identities and the effects of intersecting social and cultural factors on their experiences. The ultimate goal is for clients to leave the counseling process feeling more empowered and able to navigate daily challenges. It is important to note that AI is not a one-size-fits-all approach but should be tailored to each client’s unique experiences and needs. The counselor should work with the client to set therapeutic goals and objectives that align with the client’s values and priorities. Table 2.8 Comprehensive Expectations of Counselors Applying AIRC: Salient Articles and Main Takeaways Olkin, R. (2016). Disability-affirmative ­therapy. In I. Marini & M. A. Stebnicki (Eds.), The ­professional counselor's desk reference (pp. 215–223). Springer Publishing Company.

Smart, J. F., & Smart, D. W. (2006). Models of disability: Implications for the c ­ ounseling ­profession. Journal of Counseling & Development, 84, 29–40.

Be aware of what a system approach looks like in the counseling process.

Be self-aware so not to impose values and belief of others or your own onto or into the counseling process.

In the counseling process address the following: ࡟ Societal barriers ࡟ Empowerment ࡟ Coping ࡟ Disability adaptation

Acknowledge the power differential and work to disseminate it.

Make available space in the therapeutic encounter for client to share and express their experiences without your assumptions. Acknowledge that clients have multiple identities.

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Additionally, the counselor should incorporate a strength-based perspective, using the client’s strengths and resources as a foundation for growth and change in the counseling process. To effectively apply AIRC in counseling, the counselor must conduct a comprehensive intake and case conceptualization process and continuously gather subjective information from the client about their experiences of pain and systemic challenges. Additionally, the counselor should have a solid understanding of the developmental stages of the client, as age can be another aspect of identity that intersects with discriminatory, oppressive, and marginalized experiences. This knowledge will inform the counselor of appropriate interventions that align with the client’s needs.

Liberation Psychology Liberation psychology, developed by Martín-Baró (1994), is a psychological theory that draws its roots from the creator’s experiences of social action in El Salvador and Latin America. It places a strong emphasis on the concepts of oppression, resistance, and an awareness of the sociopolitical climate. Liberation psychology aims to empower individuals and communities by appreciating their heritage, history, and tradition. WHY LIBERATION PSYCHOLOGY?

Liberation psychology is a theoretical approach to counseling that focuses on addressing power dynamics and their impacts in the client’s experience and mental health (Singh et al., 2020). It considers the meso and macro levels of society, as described in Bronfenbrenner’s ecological theory, in the development of a person. The mesosystem refers to the intermediate systems that interact, such as a person’s neighborhood, home, and school. The macro level of society includes larger sociopolitical systems, such as economic systems, legal and political systems, and cultural norms, which have a bidirectional impact on the person. Through this lens, liberation psychology aims to intentionally strengthen cultural appreciation, heritage, and tradition in counseling. In the counseling field, the attention on ecological systems has been expanded to include all levels—micro, meso, and macro—to address clients’ issues. The micro level of the ecological theory focuses on the client as the central structure, with other systems nestled around it in circles. The closer the system to the center, the greater the impact on the person. By considering all levels of systems, counselors are better equipped to help clients, recognizing the importance of advocacy and action at all levels (Comas-Dias & Torres-Rivera, 2020; Singh et al., 2020). Singh and colleagues (2020) emphasize that this focus on the microsystem reflects the MCSJCs and serves as a praxis or practical application for counselor competency built from the theoretical foundations of ecological theory. LIBERATION PSYCHOLOGY IN ACTION

Liberation psychology includes four tenets that serve as principles of the theory and guide the counseling process. According to Singh and colleagues, these tenets are essential in supporting counselors in understanding and applying the MCSJ praxis. For example, the four tenets of liberation psychology established by Martín-Baró are realismo-critico, recovering historical memory, concientizacion, and deideologized reality. In the case of Mark, these tenets can be used to gain insight into various aspects of his presenting problem. For example, by exploring Mark’s interpretation of his problem, the cultural influences that have shaped his coping strategies, the strengths he has used to deal with his anxiety, and the sources of powerlessness he may feel concerning his daughters and marital status, counselors can gain a deeper understanding of Mark’s situation and develop an effective treatment plan.

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REALISMO-CRITICO

Realismo-critico empowers clients to move away from focusing on a problem to focusing on solutions to resolve the problem. MCT counselors applying liberation psychology may help Mark explore various possibilities relevant to resolving his marital situation. For instance, what does Mark ultimately want to happen that will (a) allow him to connect with his daughters, (b) find healing and acceptance in his new marital status, and (c) locate a support system that helps him develop resilience? In the case of Mark, the MCT counselor may work with him to identify possible solutions to his emotional hurt surrounding the divorce. This could involve exploring different options for resolving the situation in a way that allows him to connect with his daughters and find support systems to help him build resilience. In addition, the counselor may use realismo-critico to encourage Mark to critically evaluate the different solutions and take a realistic approach to resolve the problem. By focusing on solutions and taking action, Mark may feel more empowered and in control of his situation. CONCIENTIZACION

Concientizacion, which translates to consciousness-raising, is a crucial tenet of liberation psychology that involves empowering clients to understand the social and political influences affecting their lives and identities. Through concientizacion, clients can recognize how their experiences are shaped by systemic factors such as race, gender, SES, and more. In the case of Mark, this tenet can be applied to help him understand how societal attitudes and beliefs about fatherhood and marriage may have influenced his experiences and the challenges he is facing. By raising awareness of these systemic factors, the counselor can help Mark develop a more nuanced understanding of his situation and empower him to make changes that align with his values and goals. DEIDEOLOGIZED REALITY

Liberation psychology focuses on empowering clients to challenge and overcome oppressive experiences in their lives. The four tenets of liberation psychology (realismo-critico, recovering historical memory, concientizacion, and deideologized reality) serve as guiding principles for the counseling process and aim to help counselors address and counteract how oppression can permeate the therapeutic relationship.

RELEVANT THEORY-BASED SCHOLARSHIP AND RESEARCH The MCT theory is a multifaceted and fluid concept that encompasses a number of theories aimed at enhancing its presence in the field of counseling and psychotherapy (Arthur & McMahon, 2005; Comstock et al., 2008; Elmer et al., 2022; Hartung, 2002). These theories establish a body of empirical evidence, contributing to theory coherence. While theories are described in many ways, in this context, a theory is defined as “a general principle formulated to explain a group of related phenomena” (Chaplin, 1985, p. 467). This definition captures the broad nature of the theories discussed in the following subsections, which demonstrate the various dimensions of MCT and how it can be understood and applied in counseling and psychotherapy.

Minority Stress Minority stress refers to the unique form of stress experienced by individuals due to identity stigmatization (Myers, 2003, as cited in Elmer et al., 2022). Literature on counseling and psychotherapy has widely discussed minority stress in the context of sexual minorities (Elmer et al., 2022). However, it is important to note that the terminology sexual minorities may vary in acceptability and usage depending on the individual, group, culture, or academic field.

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In this context, the term is used as it appears in the Archives of Sexual Behavior, a reputable international peer-reviewed journal. In contrast, more recent language regarding sexual minorities is used in affirmative counseling with LGBTQIA+ individuals. This therapeutic approach views concepts such as affectional orientation and gender minorities as alternatives or supplements to sexual orientation (Gincola et al., 2017). This is because sexuality encompasses not just sexual behavior but also how individuals express their sexual selves, including practices and expressions (Choudhuri et al., 2012). When using either of these theoretical frameworks, it is crucial to practice compassion, be comfortable with discomfort, and engage in reflective practice. Reflective practice involves carefully considering one’s actions, methods, and intentions when utilizing any multicultural counseling technique.

Poverty as an Intersecting Facet of Identity Poverty is an important issue addressed in the MSJCC, the ACA advocacy competencies (Clark et al., 2020), and social justice counseling (Ratts, 2009). The relationship between poverty and social and cultural identity, particularly regarding social class and SES, is an area of growing interest. Social class is a complex construct of cultural identity that is determined by demographic factors and one’s position in the economic hierarchy of society, which includes things like prestige, power, education, and income (Liu, 2004; Smith & Brewster, 2016). Therefore, understanding and addressing poverty within a cultural context is essential to providing effective and culturally responsive counseling services. To explore poverty, the social class of a client may be investigated by examining their position in the structures of class identified by Smith and Brewster (2016). Unlike social class, SES is a quantifiable aspect of culture based on income, occupation, and education (Pope & Arthur, 2009). It does not involve belonging to a particular group (e.g., social class). Choudhuri et al. (2012) explain that the complexities of poverty are due to the interplay between social class and SES, as poverty “exists because of the unequal distribution of resources” (p. 224). Historically, this inequality has been experienced by marginalized groups such as women with children, African Americans, Latinx, and Indigenous peoples, who are often most vulnerable to poverty. These populations in the United States have consistently higher rates of poverty, leading to numerous negative impacts on the quality of life objectively and subjectively (Choudhuri et al., 2012). Poverty is also understood from an objective conceptualization, defined by a lack of economic resources necessary to meet a minimal living standard (Kang et al., 2022). According to official U.S. Census Bureau statistics, 37 million people, approximately 11.4% of the total population, were considered poor in the United States in 2020. In addition, poverty affects certain racial and ethnic groups, such as African Americans, Latinos/Latinx, and Indigenous people, at higher rates, resulting in material hardships and reduced well-being. Children who grow up in poverty-stricken households are less likely to thrive as adults. In light of these issues, poverty is considered a cause for national action and may be approached through a social justice lens. It is crucial to recognize that people living in poverty are frequently stigmatized and wrongly portrayed as unemployed in media and through societal norms. This kind of stereotype leads to discriminatory attitudes and reinforces misconceptions about poverty. However, the reality is that many people living in poverty are employed but may face difficulties in meeting their basic needs, such as having access to proper housing and healthcare, including mental health services. Poverty has been linked to poor mental health, as people experiencing poverty are at a higher risk for various psychiatric diagnoses, including acute psychiatric disorders, mood disorders, anxiety disorders, and substance use disorders (Smith & Brewster, 2016;

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Weissman et al., 2015). This makes poverty an important area for research in counseling and a focus on the MSJCC, the ACA Code of Ethics, and social justice counseling.

Empowerment Counseling Empowerment is a key component of multicultural and social justice counseling models and is also a central concept in feminist counseling. In these contexts, empowerment aims to help clients strengthen their personal power and build resilience in areas impacted by trauma and oppression. This approach is rooted in empirical research and informed by privilege, equity, oppression, and power theories. In multicultural counseling, the four main components of empowerment counseling include awareness, dialogue, psychoeducation, and processing (Crethar et al., 2008). Counselors practice these essential elements to empower their clients and promote their well-being. Empowering counseling seeks to promote psychoeducation around systemic and institutionalized oppression and how it manifests within the client’s life. This involves educating the client about the various power dynamics and intersections of privilege and oppression that impact their experiences and helping them develop a deeper understanding of their place in the larger social and cultural context. The final fundamental of empowerment counseling is processing and action, where the counselor works with the client to help them understand their experiences, feelings, and thoughts related to their experiences of oppression and how they can take action toward creating positive change in their lives and communities. The fundamentals of empowerment counseling are centered on implementing interventions designed to work with clients from a multicultural‌ and social justice‌perspective. According to Crethar et al.  (2008), these interventions aim to help clients discover their untapped potential and build the confidence to overcome institutional barriers that impact their health and overall well-being in various aspects of life. In addition, empowerment counseling aims to enhance their quality of life and promote self-actualization by providing clients with the necessary skills and support. The final fundamental of empowerment counseling is humanistic and emphasizes helping clients understand and utilize their new insights about themselves, others, and oppressive systems. The counselor works with the client to set goals that are self-actualizing, intrinsic, and free from external constraints. This aligns with the “principle of harmony,” a key component of social justice philosophy (Crethar et al., 2008, p. 273). Advocacy is a crucial aspect of empowerment counseling, as it supports the implementation of the fundamentals described previously. Counselors may use psychoeducation and consultative services to advocate for their clients. Using the Collaborative Assessment and Planning (CAP) model in conjunction with empowerment counseling is also common, as it emphasizes advocacy and addresses systemic issues of oppression impacting minoritized, racialized, and marginalized clients at both the individual and identity group levels. Empowerment counseling requires counselors to wear multiple hats, including that of a counselor, advocate, and scholar, as they work to teach clients new skills and navigate the complexities of systemic oppression.

I-CARE‌ I-CARE is a theoretical technique used in counseling those experiencing poverty. Poverty affects people of all races, genders, abilities, nationalities, and educational levels, but it has a more profound impact on marginalized groups such as women, children, minoritized racial groups, and people from diverse backgrounds (Semega et al., 2019). These groups often experience the intersections of poverty with other identities, leading to increased health issues and life problems. People experiencing poverty are also at a higher risk for mental illness, unstable employment, chronic illnesses, and higher mortality rates (Edwards, 2014). Generational poverty further perpetuates this cycle, hindering economic mobility among many marginalized cultural groups.

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Counselors must adhere to ethical guidelines when working with clients experiencing poverty, as stated in the ACA's ethical code, Standard C.5 on Nondiscrimination, which prohibits discrimination based on any aspect of a client’s identity, including SES. The multicultural and social justice competencies provide standards of practice for counselors, with a focus on theories of multicultural counseling, social justice, and advocacy (Toporek & Daniels, 2018). In addition, the competencies related to poverty concerns address social class and SES (Pedersen, 2016). The I-CARE model, created by Foss-Kelly et al. (2017), is a tool for counselors to support clients who experience the effects of poverty. This mnemonic model calls for counselors to internally reflect, cultivate the relationship, acknowledge the realities, and expand on their client’s strengths. The five themes that form the basis of the I-CARE model are training, awareness, knowledge, skills, and advocacy, and these themes reflect best practices in poverty counseling. It is important to understand the relevance of poverty in multicultural counseling, as poverty affects individuals from various races, genders, abilities, nationalities, and educational levels. For example, people experiencing poverty are at greater risk for mental illness, unstable employment, chronic illness, and higher mortality rates (Knifton & Inglis, 2020). In addition, generational poverty perpetuates a cycle of poverty and can hinder upward economic mobility for marginalized cultural groups. Counselors should be aware of their own biases and stereotypes related to poverty and strive to provide culturally responsive counseling that acknowledges the realities of their clients’ experiences with poverty. The I-CARE model can be a useful tool for counselors to practice culturally responsive approaches and expand on their clients’ strengths in the face of poverty-related challenges. Additionally, the MCSJCs and ethical standards in the counseling profession, such as the ACA’s Standard C.5 on Nondiscrimination, emphasize the importance of addressing poverty in counseling and working with clients to overcome barriers related to their SES. I-CARE IN ACTION

I-CARE is a relevant model to incorporate in the text as a tool for multicultural counseling and therapy. The mnemonic, I-CARE, acts as a framework for the poverty counseling best practices (PCBP) grounded theoretical model developed by Clark and colleagues (2020). The framework is based on the idea that a counselor should reflect on their beliefs about poverty, cultivate a relationship with the client by acknowledging their experiences with poverty, acknowledge the realities of poverty, and expand on the client’s strengths. The authors of I-CARE suggest that the four‌ themes of PCBP, which are training and awareness, knowledge, skills, and advocacy, support the counselor in using the tool effectively. Training and awareness include formal and informal training that helps the counselor to be self-aware of their social class identity, understand the client’s worldview, and be aware of their own boundaries and wellness. The knowledge theme includes subthemes on complexities and barriers of poverty experiences, privilege and oppression, intersectionality, systems theory, severe and persistent mental illness, and crisis and trauma. The skills theme includes subthemes on poverty-sensitive assessment, person-centered and relationship skills, cultural broaching, and client strengths and empowerment recognition. Finally, the advocacy theme stands alone and consists of subthemes on assisting clients with problem-solving and finding resources, increasing client access, and challenging poverty stereotypes. I-CARE, supported by PCBP, has implications for use in various settings such as community mental health, private practices, counselor education, and clinical supervision. However, due to the limited research on evidence-based therapy for clients with stratified social and racial identities that lead to life problems associated with poverty, it is recommended that counselors review the literature on mental health professionals and poverty. This literature may include concepts such as cognitive distancing, an implicit attitude directed toward people living in poverty based on negative learned beliefs.

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DETAILED CASE CONCEPTUALIZATION PRAGMATICS AND TRANSCRIPTS This section will feature two separate transcripts related to multicultural counseling. The first is related to a client named Bobbie and the second is centered on the case of Mark Stockton. See page 66 for a transcript of a first session with Bobbie‌. Her gynecologist suggested that she see someone to talk about how stressed she had become since having a baby. The client independently sought counseling by doing a search for mental health service providers through her insurance. The content of the transcript is the first half hour of a 60-minute session. It is a reflection‌of MCT etched with a brief description of the orientation; culturally relative questions; counselor skill sets of active, paraphrasing, Socratic, and open-ended questioning; culturally responsiveness that demonstrates explicitness of what type of therapeutic space it is (e.g., one that the counselor is working to gain cultural trust through use of cultural humility); and communications of what can be expected across sessions that reflects safety and freedom to talk about anything that she chooses. The client has already signed consent to participate in counseling delivered through telehealth at a private practice. Disclaimers about ethical code of when breaking confidentiality has already been communicated and agreed to by the client with the intake counselor, who conducts a formal triage with new clients. The formal triage‌process includes reviewing and signing of healthcare forms, assigning clients to counselors, and explaining details about the practice, expectations of clients, in case of emergency plans, and benefits and limitations of the therapy.

The Case of Bobbie Bobbie presented to counseling during the COVID-19 global pandemic, sharing that this was her first time seeking mental health help. Bobbie shared wanting to choose her own doctor for personal reasons and that she wanted a person of color to be her therapist and did not want an Indian person. She explained not wanting an Indian person because she herself is Indian and knows that “we are very critical of each other.” She further explained wanting a person of color because she wanted to safely talk about experiences of racism and discrimination felt on her job, which was at a prominent Ivy League university, and what it was like growing up with first-generation Indian parents. Bobbie shared that her cultural identity was important while at the same time recalled as a child wishing she were more American and like her White friends at school. However, Bobbie shared that she grew up in a community where most of the families were also Indian, resulting in most of her friends also being Indian. Bobbie shared that many of the families in her community changed their names when they came to America to fake a higher status of wealth. Her father taught her about this last name change yet told her that they were going to “make it” without doing that. She described herself as being a second-generation Indian American woman, married, and having had her first child during the pandemic. Bobbie preferred pronouns of she and her, expressing that within the past year and a half, she had been learning about cultural diversity at work and that pronouns are important now. Bobbie also expressed that she and her husband would practice gentle parenting that her mother often criticized. This was also what led to many yelling arguments between her and her mother. Bobbie expressed sentiments that the diversity equity and inclusion training had been long overdue and now seem forced because of the worsening racial climate in the United States. She shared not knowing where she fit into the training but that it seemed like a magnifying glass was now on her in a negative way. Bobbie expressed that she feels left out of being Asian because she has darker skin and is from India as opposed to northern Asian countries such as China,

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Japan, or Korea. In the first session, she shared how facets of her national identity and skin complexion had been increasingly salient because she expressed memories of her family being from the southern part of India where there was much discrimination because of their darker complexion. Bobbie also spoke about the caste system of India, feeling that it resonated with racism in America. Bobbie expressed that her parents were very strict and felt privileged to leave India for what they claimed as a better life. She also shared that her mother and father took turns returning to India to check on their families and to prepare for her grandparents to come to America to live. These returns to India would sometimes last for a year, which led to her and her brother being at home with one parent, but would visit with cousins and their parents often. Bobbie recalled that her parents followed the cultural norms and values of being in an arranged marriage and that she often felt sad because that was not the way she met her husband. She and her husband met in medical school. Bobbie shared many details of being “stretched” culturally, expressing feelings of distress and anger at her mother for not allowing her and her brother to “really be American,” which she described as shaving her legs, spending the night over friends’ houses, and having to eat Indian food that her mother prepared for her lunch daily. In explanations of what she would do to be more American, Bobbie shared that having a maid was important. She also spoke of wanting to teach her mother how to practice gentle parenting with her son because having someone outside of the family take care of her child was not up for discussion. Additionally, Bobbie shared that her mother made her own bread called “roti” and other cultural foods that children at school would make fun of when Bobbie opened up her lunch box. Bobbie shared many childhood incidents that she felt is why she has this love–hate relationship with her parents, primarily her mother. PRAGMATICS

The strategy for collecting personal information from Bobbie in this case study aligns with the principles of MCT. The language used in the case study is culturally responsive, taking into account Bobbie’s nationality and racial and ethnic identity, as well as her preferred terminology. In MCT, clients are asked to confirm understanding of concepts. How the client understands various MCT-centered language is important for the counselor to understand and be aware of. This recognition allows for interpretations to be communicated by the client and for the counselor to have awareness of clients’ perspective and worldviews that inform their interpretations and meanings of concepts. There is a chance that the client and counselor have different experiences of the concepts being used within the MCT. The strategy of data collection through MCT is flexible, whereby the pace is set by the client. It is also supportive and considerate of the client from a pluralistic identity. This is a multicultural lens, guiding the counselor's use of MCT in follow-up paraphrasing, clarifying, and empathy with the client in response to what they have shared in the session. Strategically, the counselor will want to utilize their MCT toolbox of models and interventions while using a theoretical model that supports who the client is and what they are bringing to therapy. What they are bringing into therapy constitutes life experiences that are understood to have a social and cultural embeddedness. The models and theoretical techniques introduced in this chapter are ideal for work with many diverse social and cultural client groups. The strategies within the pragmatics of applying MCT will often call for counselors to delve deeper into client identities that intersect with minority and marginalized status and demographic variables (e.g., spirituality, SES, age, affectionate orientation, etc.). These are salient identity facets, often not addressed in the counseling process as much as ethnicity and race.

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Transcript

Skill(s) Demonstrated

Counselor: Hi, my name is Dr. Sherrill Haynes. I go by Dr. H. How are you today?

Introduction and open-ended question

Client: I’m well, how are you? Thank you for seeing me. I’ve been looking for a therapist of color for weeks. I started this search a couple months ago and finally got on your calendar. Counselor: I’m well, thank you for asking and for your patience. Glad we were able to get you on the schedule. I have your name as Janri Beni, but I’d like to know if you have preferred name to be referred to. Client: Bobbie. It’s a long story, but I’ve had it for years. It’s actually just easy for people to say, so I prefer it so not to have to correct people on the pronunciation of my real name over and over. Counselor: Okay, thanks for sharing that. How often does the issues of your name come up in your life? Is that a significant theme in your life?

Open-ended and closed-ended questioning (Counselor broaches the topic of changing her name through the use of open- and closed-ended questions.)

Client: Yes. As a kid it was so frustrating with teachers, and you know how mean kids can be. So sometime around junior high school, I started telling people my name was Bobbie when I introduced myself. It felt more American, you know. Honestly, a lot of my Indian and other Asian friends did this, too. As I tell you this, I didn’t even realize that I was still holding on to a bit of that frustration and I don’t know, maybe shame, but I guess I can talk about that here. Counselor: Sure, this is a safe place to express yourself and talk about life as you want and any area of life. What you’ve been sharing right now seems to be significant to you. Feeling Bobbie is a more American name, how you and Asian peers introduced yourselves with a name that was easier to pronounce, and the frustration and shame that you express. Would you like to explore that more now? I know it’s our first session, so I want to go at a pace that you’re comfortable with. Client: Oh yeah, sounds good. But I mean I got used to it by the time I was in junior high school. That’s when I felt comfortable enough to go by Bobbie. Earlier in elementary school, I was with all Indian kids, but in third grade I went to a private school where I was the only Indian American student in my class. Those were rough times. The White students would ask what I was and other Asian kids made fun of me because I was darker in complexion, which is a big deal in my culture. I don’t know if you’ve heard about the caste system. Anyway, so I ended up being friends with these two Black or African American girls because they were so nice to me. They didn’t make a big deal about me being Indian or that I was darker. When we got to high school, we sort of drifted apart. High school was more diverse, more Indian American, Hispanics, and a few Black people were there, and it's like we naturally hung out with more people in our own racial groups. Weird, but it was a thing, not just with us, but I noticed it.

Self-disclosure, summarization, and open-ended question (Counselor discloses the safety of the counseling relationship, summarizes the various experiences Bobbie shares, and asks an open-ended question related to the client’s interest in continuing to share.)

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All the White kids hung out, the Black and Hispanic kids hung out together, and us Asians seem to hang out with our national group, like Indians with Indians or Chinese with Chinese. I hadn’t thought or talked about this in a long time, but it was like this pretty much through college. Counselor: There were a number of cultural themes in what you’re sharing about your early school years. I heard how differently you were treated by different racialized groups, how you describe yourself, and friendships. From what you shared, there were feelings connected to those relationships.

Summarization and paraphrase (Counselor summarizes the cultural themes Bobbie shares and paraphrases the feelings she felt with the various relationships.)

Client: Yes, but it wasn’t something we talked about. It felt funny at first but then became the norm. Bigger fish to fry came up for me, like dating and 9/11. I don’t want to talk about the latter just yet though. Counselor: When you’re ready. You’re doing fine, sharing in a way that is helpful for me to get to know you. Is this your first time in therapy?

Encouragement and closedended question (Counselor encourages Bobbie to go at her own pace and asks a closed-ended question regarding her experience receiving counseling.)

Client: Yes, I must sound like I’m all over the place. I didn’t know I needed this like this, because I’m usually quiet, mostly an introvert, and rather shy until I’m in lecture mode. I’m faculty but in a staff role with the medical students now. My position is a bit confusing, which is what led me to look for a therapist to talk what is going on at the university. But anyway, yes, this is my first time in therapy. I’m kind of nervous but I’m sure you can tell. I’m more so happy that I’m getting to talk to someone other than coworkers, my husband, parents, or tending to the baby. I’m going to use this as my time. Counselor: Good. Using our sessions as “me time” will hopefully be helpful to you. And yes, being nervous can be expected. I’d like to take a step back and share with you about how I orient sessions. We can talk more about how you grew up and anything that surfaces for you that you want to talk through. In my process with clients, I’m intentionally culturally responsive and wellness centered. What that means is I’ll ask specific questions about your cultural identity and how or if it relates to the problems you bring up in sessions. The wellness piece is our overall approach at the practice. Through our wellness approach, called the eight dimensions of wellness, we use it to compartmentalize life areas to process where you may be experiencing issues, where your strengths are, and just as a tool to help you and me navigate throughout session with context. I’ll ask you questions about discrimination, if you’ve experienced racism, and if there are social or cultural connections to what you bring up in session. What do you think about that? Are you understanding the approach? Client: First of all, it’s why I chose you. I wanted a person of color and a woman who could talk with me about racial-type issues and what I went through and go through on a daily basis. I never really had the guts to talk about the things that hurt me, like I don’t want me being an Indian woman to be an excuse or someone to tell me that I’m using the race or immigrant card.

Encouragement, introduction to counselor’s approach, open- and closed-ended questioning (Counselor encourages the client to follow her thoughts on using her counseling time for herself, explains the approach of counseling, and asks an open- and closed-ended question regarding the client’s understanding of the approach.)

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I was born here, making me American, but I’ve never felt with it. I mean, I couldn’t even talk about this stuff growing up. In college, it was easier to talk about because my friend group were mostly Indian and we talked about having similar experiences, though we grew up in different states. Interestingly enough, my brother and I were supposed to be grateful that we didn’t grow up poor in India. My mom was the main one who reminded us of this all the time. I do have to be honest; I did not want to see someone in my culture, someone Indian, because we judge each other so critically. I feel like I would have been talking to my parents or someone in my family. About the wellness piece, I read that you do that, and I am good with that. Yes, I did my research on you and really like the culture talk and wellness. By the way, my life area is work, even though I’m talking about growing up a little bit, but it seems connected now that I’ve been thinking about it more at home. This quarantine is something else; it’s like I have time to think, but it's stressing me out. I feel the stress in my lower back and started grinding my teeth when I sleep. I think work was an interference that was in place for me, covering up these thoughts. My husband still has to work at his job because of what he does. My stress also comes from being a new mom. But my mom and dad come over to help out a lot. Mom is an issue that I want to talk about as we go, too. Counselor: Thank you for sharing these details about your life. I’m hearing about being a new mom, that you’ve had surfacing thoughts and feelings since being home during this quarantine, about school age years, that work is significant life area for you, and your nationality. As we are in our first session, I’m gathering information that will help me to help you. So I’ll ask a series of questions that will come together to form therapy goals. Okay? Going back to what you just shared in terms of your life then and now, how else do you describe yourself culturally?

Summarization, self-­ disclosure, and open-ended question (Counselor summarizes client’s in-session disclosures, self-­ discloses why she’s gathering information, and asks an openended question centered on how the client describes herself culturally.)

The Case of Mark Mark Stockton identifies as a 42-year-old, Black, cisgender male who works as a project manager for a general contracting company. In addition to his lifelong struggle with anxiety, recently he has been battling his anger and frustration over his recent divorce; assuming the role of primary caregiver for his children, Elle (age 12) and Carla (age 10); and feeling dissatisfied with his current employer. He is attending his fourth counseling session and is continuing to explore his anger toward his ex-spouse and the course his life is now taking. The following is a transcript centered on the counselor using a broaching technique related to Mark’s divorce from Candace (ex-spouse, cisgender, Latina woman). Transcript

Skill(s) Demonstrated

Counselor: Hi, Mark. It is nice to see you. What would you like Open-ended question to work on today? (Counselor uses an open-ended question to open the session and determine what Mark is ­interested in discussing.) Client: Just still having a hard time letting go of my anger toward Candace and how easy it was for her to leave our family so suddenly and start a new one. Even though it has been 3 years since we divorced, all our hearts are still broken.

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Counselor: She broke your heart, and you feel deceived and betrayed.

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Reflection of feeling (Counselor reflects the client’s complex emotions centered on deception and betrayal.)

Client: Candace is a Latina. Specifically, her family heritage is Haitian. She’s now with a very wealthy Latino man and seems to have more pride in his family than the one she created with me. Counselor: In the past, our conversations have focused on the conflictual divorce and how Candace attempted to put the children in the middle. Now you’re discussing Candace’s heritage and that of her new partner.

Summarizing and broaching (Counselor briefly summarizes the past ­discussions related to Candace and broaches the topic of Candace’s heritage playing a factor in her recent behaviors.)

Client: I’m not so sure if it’s a very productive use of our time…just something I keep thinking about. She was so quick to drop me and our kids. She sold us out for this new life with this guy she barely knows. Meanwhile, my mom and dad have been against us breaking up the whole time. I think my father is so disappointed in me for the financial decisions I made that drove us to this point. Counselor: I sense that you feel a lot of shame and hurt around your parent’s reaction to the divorce. It also sounds like you believe there is a difference between you and Candace. From your perspective, some of this may be related to personal differences and some of this may be more centered on her family and perhaps heritage.

Reflection of feeling and broaching (Counselor reflects the shame and hurt around Mark’s parent’s reaction to the divorce and continues to broach Mark’s thoughts that this may be related to her family values or heritage.)

Client: I’m no anthropologist. It just seems like it may have more to do with her personal beliefs and what her family has instilled in her. I guess on the heritage side, she’s Hispanic and I’m Black, so I keep thinking about that…. Why was it so easy for her to leave me and our kids and suddenly have so much pride in her new family? I think she likes him more because he is Latino. I keep wondering why my family is so fixed on us staying together. Counselor: You are feeling so confused by what happened. I’m with you and want you to know that this is a safe place to discuss difficult topics. Since Candace isn’t here to discuss her side of this, maybe a good place to start is with your family and heritage. What messages does your heritage and family background tell you about marriage?

Reflection of feeling, self-­disclosure, and broaching (Counselor reflects Mark’s confusion, discloses that they are with him and that this is a safe place to explore cultural topics, and continues to broach the topic of heritage and family.)

Client: Marriage and family are sacred, holy, and forever. The more we believe in each other and God, the stronger our children will be. Although my parents occasionally fought, they always supported each other, and my mom was always so committed to us kids and my dad. She is an incredible woman. Counselor: You and your family find deep meaning in relationships, loyalty, and religion. For you, relationships are holy and meant to last forever. Client: That’s what I grew up thinking. Now I feel so cynical about it all. I could say I wish I would have picked a better spouse, but then I wouldn’t have my wonderful daughters. They are easily the best part of my life, and Candace is a big part of the reason they’re here.

Reflection of meaning (Counselor reflects Mark’s thoughts on marriage, family, and religion.)

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DESCRIPTIONS OF HOW TO ENGAGE IN SOCIAL ACTIVISM Engaging in social activism through a human rights framework is an active learning process in counseling (Singh et al., 2020). This approach involves adopting the perspectives of multiculturalism and social justice to understand and address the social issues clients are experiencing. According to Vera and Speight (2007), effective counseling occurs when attention is given to these social issues and clients are empowered to work toward resolutions rather than simply becoming victims of their circumstances. The focus is on helping clients achieve a sense of pride and empowerment rather than reinforcing negative experiences or situations. Attending to social dilemmas in counseling is essential to counselor competency as it promotes a holistic understanding of the client’s experiences. By creating a trusting space for clients to share their human condition, counselors can move toward a culturally responsive approach to whole-life healing. This shift is driven by multicultural humility and awareness that goes beyond Western culture and value systems dominant in counselor training programs. This is consistent with findings noted in counseling textbooks (e.g., Benish et al., 2011; Pedersen, 2016; Sommers-Flanigan & Sommers-Flanagan, 2018; Sue & Sue, 2003). Engaging in social activism through a human rights framework and with a multicultural and social justice lens enhances the effectiveness of counseling by addressing the social issues that clients are facing in their lives and empowering them to find solutions and achieve a greater sense of pride in themselves. According to Pedersen (2016), multicultural awareness in counseling involves acknowledging the existence of counselor and the client assumptions and bias. This recognition involves understanding that both parties bring their values, worldviews, privileges, and experiences to the counseling relationship, and these can sometimes impact the relationship in implicit or unconscious ways. When practicing social activism in counseling, it is essential to adopt a multicultural and social justice perspective and strive to understand the experiences and perspectives of diverse individuals (see Box 2.2).

LIMITATIONS Several limitations should be considered relative to the models developed under the metaphorical umbrella of multicultural counseling. One of the limitations is that MCT is often misperceived as a stand-alone theoretical orientation in counseling and psychotherapy when it is not. This is because the concept of cross-cultural counseling has evolved to include the idea that both the client and the counselor have intersecting cultural identities. Another limitation is related to the cultural activism and social justice (CAS) model, which requires that counselors be actively involved in advocacy work in the community. This may not be feasible for all counselors, especially those who are not trained or prepared to take on the roles of scholar, counselor, and advocate. The training curriculum for ­counselors-in-training often does not include education on advocacy models or provide materials based on non-Western worldviews, leading to a Eurocentric bias. Finally, a third limitation is that much of the research on MCT models and techniques is based on empirical studies. While empirical evidence is important, these studies have demonstrated little to no replication for further validation and theorizing. Additionally, there is a need for further development and testing of MCT assessment and appraisal tools to help counselors evaluate the effectiveness of the models and techniques. In conclusion, more research is needed to support the efficacy of MCT across the models, techniques, and theoretical frameworks that make up this theoretical orientation in counseling and psychotherapy.

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Box 2.2 Social Activism in Action 1. Acknowledge that there are systems in place at micro, meso, and macro levels of society that impede minoritized, racialized, marginalized, and oppressed social and cultural groups, historically and presently. 2. Increase self-knowledge and self-awareness of who you are as a social and cultural being in order to learn of personal attributes that have resulted in personal experiences of systemic problems and where you have perpetuated systemic hindrances of others based on their social and cultural identities. 3. Learn to be uncomfortable in being wrong, needing to learn, and leaning to acquire active other awareness that calls engagement with others who are socially and culturally different from you. 4. Be encouraged to intervene in the social systems upon recognition of cultural and institutional barriers that hinder quality of life and well-being attainment. 5. Reflect. 6. Consult with and learn to be social agents of change and social advocates at a level in society where you can be specific in the activism. Will it be to address community violence, access for people who have disabilities, sex trafficking, policy brutality against Black persons and other racialized groups, policy to improve workplace harassment and discrimination against LGBTQIA+ persons, etc.? 7. Commit to out-of-office social advocacy interventions with an understanding that planning and training will be needed to protect self and others. Note: This table contains seven items that suit a comprehensive introduction to social activism in action. The sources used to compile these introductory actions that counselors may take to start social activism are from the ACA endorsed advocacy competencies (Toporek et al., 2009) and social justice experts Courtland C. Lee (Lee, 2007) and Manivong J. Ratts and colleagues (Ratts et al., 2020).

SUMMARY This chapter provides a comprehensive overview of MCT. The chapter aims to provide a solid foundation for readers interested in learning about MCT and how it can be applied in a clinical setting. It highlights the importance of considering the client’s cultural identity and the impact of systemic racism, discrimination, and oppression on their lives. The chapter also explores the competency areas and theoretical-based scholarship needed for practicing MCT. It covers the history of MCT, its development, and the field’s current state. It provides a clear understanding of MCT’s key concepts and techniques and the clinical implications that arise from them. The chapter also describes the limitations of MCT and how it can be improved through further research and study. After reading the chapter, readers should understand the various techniques used in MCT and the steps that a counselor can take to apply these techniques in their work with diverse clients. This overview serves as a valuable resource for counselors looking to improve their multicultural competency and keep up with the changing diversity needs of society. The learning objectives covered in the chapter will stimulate further discussion and discourse on the essential topics of multicultural counseling and therapy. VOICES FROM THE FIELD This chapter features a digitally recorded interview entitled Voices From the Field. The interview explores multicultural, social justice, equity, diversity, and intersectionality issues from the perspective of clinicians representing a wide range of ethnic, racial, and national backgrounds. The purpose of having chapter-based authors interview individuals representing communities of color or who

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frequently serve diverse populations is to provide you, the reader, with relevant theory-based social justice and multiculturally oriented conceptualization, contemporary issues, and relevant skills.

Access the video at https://bcove.video/3RKg4aE

Dr. Taqueena Quintana is a 37-year-old Black woman from the ­northeastern region of the United States. She graduated from a CACREP-accredited doctoral counselor education program with an emphasis in school counseling. Dr. Quintana is a licensed professional counselor (District of Columbia and Georgia) and has been practicing from an integrated and multiculturally centered SolutionFocused Brief Therapy (SFBT) and narrative and cognitive behavioral therapy (CBT) theoretical orientation for the past 10 years.    

STUDENT EXERCISES Exercise 1: Johari Window

Directions: The goals of this exercise are to gain insight into what you know and do not know about yourself and which of your personal identities are known, unknown, and/ or assumed by others. The expected learning outcome is that students will be more aware of their social and cultural identities, how these identities are interrelated, and how to be able to reflect on this knowledge and how it affects counselors’ competence in forming a therapeutic relationship. The exercise takes about 60 minutes to complete and is ideal for group work and collective processing. There are four steps involved in participating in this exercise. First, create a group with peers. The second step is for each group member to create a Johari Window and fill it in. The Johari Window is illustrated in Table 2.9. Step three is for each group to discuss what they learned about themselves and one another. Step four is for each group to come back to the larger group or class and discuss the experience of working in a group, filling out the Johari Window, and the themes that surfaced in small group discussion.

Exercise 2: Reflection Questions and Answers

Directions: This is a reflection question and answer activity. The content is centered on MCT-oriented case conceptualization, treatment planning, intervention selection, and Table 2.9 Johari Window Exercise 1. Johari Window Multicultural Known to Self Counseling Theory Exercise for Counselor Cultural Self-Awareness

Not Known to Self

Known to Others

Shared

Blind

Not Known to Others

Hidden

Unknown

Note: This table illustrates the Johari Window, a classic activity to gain greater knowledge into cultural self-awareness. Sources: Pedersen, P. (1988). A handbook for developing multicultural awareness. American Association for Counseling; Sutherland, J. A. (1995). The Johari Window: A strategy for teaching therapeutic confrontation. Nurse Educator, 20(3), 22–24. https://doi.org/10.1097/00006223-199505000-00016

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progress note documentation. The goal of this activity is to increase holistic knowledge and practice counseling from an MCT approach. Answer the questions in Table 2.10 by filling in the middle (empty) column. In the far right, formulate a treatment goal that is tied to the question-and-answer columns.

Exercise 3: Power, Privilege, and Oppression

Directions: This is an exercise to assess your subjective thinking about privilege, power, and oppression through an interview process with counselor-in-training peers. The general goal of this exercise is to discover and reflect upon awareness and knowledge that may implicitly impact MCT personal and professional development. Specifically, participants will use MCT with increased advocacy competency that may be used to address oppression, power, and privilege. Table 2.10. Questions, Answers, and Practice Treatment Goals Question

Answer

Practice Treatment Goal

What are multiple stressors that impact a person from minoritized and marginalized groups? What coping mechanisms are practiced for relief from minority stress? How would you assist a person who is dealing with acculturation and adaptation? What are ways to avoid further marginalization? How will discrimination be brought up in to support development of coping skills to manage the impact in daily life? How will you manage the cross-cultural relationship? What is known about intergenerational issues affecting clients? What cross-cultural identities may impact the therapeutic relationship with your clients? How will you address gender and affectionate orientation issues with your clients? How will you address disability issues that impact client functioning in life areas? What line of questioning suits processing spirituality and religious practices and concerns? What strength-based and culturally-­ centered questions will you ask to learn of your clients’ coping strategies? How might you facilitate questioning around self, social, and cultural identity development? Source: Choudhuri, D. D., Santiago-Rivera, A. L., & Garrett, M. T. (2012). Counseling & diversity. Brooks/Cole Cengage Learning.

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If possible, you will work in pairs that are cross-cultural, meaning significantly different relative to cultural diversity. Each person will interview the other according to the interview questions in Table 2.11. In column one, from left to right, is the interview question to be posed to the interviewee. In column two, the middle column, is the response from the interviewee. The interviewer may respond to the interviewee with paraphrasing, active listening, and an other-oriented awareness approach. The third column is important because it is a space to consider first thoughts that come to mind after hearing the lived experiences of another person who is culturally different from one’s self. These thoughts are to be shared after both have been interviewed.

Exercise 4: Discussion and Reflection

Directions: Go to your university’s online EBSCO Database and find Academic Search Premier. Search and find a research article focused on MCT. Please consider reviewing Table 2.11. Interview Questions, Interviewee’s Response, Interviewer’s First Thoughts Interview Questions

Interviewee’s Response to Questions

Interviewer’s First Thoughts

Define oppression in your own words? How has it impacted your life? When have you experienced prejudice? Would you share the details of that experience, including how you felt during and afterward? Where have you learned about people from other social and cultural groups? What are those sources of learning? How have your beliefs and what you’ve learned about other social and cultural groups led you to relate with persons from these groups? In what ways has oppression impacted social and cultural groups with whom you interact? What privileges do you experience because of your social and cultural identities? How has learning about oppression and privilege improved your competence in the lives of others who experience racism and prejudice? What life area of others are you the least knowledgeable of that may decrease competency around cultural trust? What privilege and power do you have that could contribute to advocacy work on behalf of clients who have minority racialized and marginalized group identity? Note: The interview questions in this table are paraphrased from reflection questions posed by Choudhuri et al. (2012) in the chapter on oppression, power, and privilege. Source: Choudhuri, D. D., Santiago-Rivera, A. L., & Garrett, M. T. (2012). Counseling & diversity. Brooks/Cole Cengage Learning.

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an article written by one of the legacies discussed in this chapter. Review the article in its entirety and answer the following questions: ■ ■ ■ ■

How does the article showcase multicultural counseling theoretical tenants? What research methods were used to explore the topic of the article? What were five of the most significant findings of this study? Reflect and discuss with a peer how the findings of this article might impact your future work.

Exercise 5: Multicultural Counseling and Development

Directions: The AMCD is centered on developing programs specifically to improve ethnic and racial empathy and understanding. This ACA division defends human and civil rights, fosters changing attitudes, and increases understanding of cultural diversity, which is incredibly important to our field. Please do the following: ■ ■ ■ ■ ■

Visit the following link: www.multiculturalcounselingdevelopment.org/ Go to the education tab and click on AMCD Journal and you will be redirected to the Wiley AMCD homepage. Within the homepage, click on the latest issue for free access to the newest edition articles. Pick one article that interests you, download it, and read the entire article. Collaborate with two peers and discuss what you have read.

RESOURCES Helpful Links ■ ■

■

■ ■ ■ ■

A White Privilege Glasses Discussion Guide: https://www.ctschicago.edu/wpg/files/ WPG_Discussion_Guide.pdf How to become a racial equity leader via the program: Courageous Conversation. Providing training, coaching and consulting services for millions of racial equity leaders around the world: https://courageousconversation.com/ A new paradigm to understand trauma in communities of color—healing-centered engagement model: The Future of Healing: Shifting From Trauma Informed Care to Healing Centered Engagement by Shawn Ginwright, Medium: https://ginwright. medium.com/the-future-of-healing-shifting-from-trauma-informed-care-to-healing-centered-engagement-634f557ce69c bell hooks feminist theory explained: bell hooks Feminist Theory Explained, HRF: www. healthresearchfunding.org Patricia Arrendondo: www.apa.org/pi/oema/resources/ethnicity-health/psychologists/ patricia-arredondo Interview with Derald Wing Sue: www.everydayhealth.com/emotional-health/ microaggressions-what-they-are-and-why-they-can-have-macro-effects/ Clemmont E. Vontress: www.counseling.org/aca-community/in-memoriam/ in-memoriam/2021/04/19/clemmont-e.-vontress

Helpful Books ■

Choudhuri, D. D., Santiago-Rivera, A., & Garrett, M. T. (2012). Counseling & diversity. Brooks/Cole.

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Parham, T. (1997). Psychological storms: The African American struggle for identity. African American Images. Lee, C. C. (2007). Counseling for social justice (2nd ed.). American Counseling Association. Lee, C. C. (2019). Multicultural issues in counseling: New approaches to diversity (5th ed.). American Counseling Association. Linklater, R. (2014). Decolonizing trauma work: Indigenous stories and strategies. Fernwood Publishing.

Helpful Videos ■ ■ ■ ■ ■

Taiye Selasi: Don't Ask Where I'm From, Ask Where I'm a Local: www.youtube.com/ watch?v=LYCKzpXEW6E Counseling: Multicultural Clients: www.youtube.com/watch?v=3n54C6rNito&t=4s Dr. Janet Helms: 2017 Winter Roundtable Keynote Address: www.youtube.com/ watch?v=iAtIN_N7-HE Understanding the Importance of Multicultural Counseling: www.youtube.com/ watch?v=xZUgD-NbRvo Jessica Dere: Challenges and Rewards of a Culturally-Informed Approach to Mental Health: www.youtube.com/watch?v=VrYmQDiunSc

A robust set of instructor resources designed to supplement this text is available. Qualifying instructors may request access by emailing [email protected].

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Vontress, C. E., & Jackson, M. L. (2004). Reactions to the multicultural counseling competencies debate. Journal of Mental Health Counseling, 26(1), 74–80. https://doi.org/10.17744/ mehc.26.1.x8xml00jq4326uvt Vontress, C. E. (1988). An existential approach to cross-cultural counseling. Journal of Multicultural Counseling and Development, 16(2), 73–83. https://doi.org/10.1002/j.2161-1912.1988.tb00643.x Vontress, C. E. (1986). Existential anxiety: Implications for counseling. American Mental Health Counselors Association Journal, 8(2), 100–109. Vontress, C. E. (1991). Traditional healing in Africa: Implications for cross-cultural counseling. Journal of Counseling & Development, 70(1), 242–249. https://doi.org/10.1002/j.1556-6676.1991.tb01590.x Vontress, C. E. (1979). Cross-cultural counseling: An existential approach. Personnel & Guidance Journal, 58(2), 117. https://doi.org/10.1002/j.2164-4918.1979.tb00363.x Vontress, C. E. (1969). Cultural differences: Implications for counseling. The Journal of Negro Education, 38(3), 266–275. https://doi.org/10.2307/2294010 Vontress, C.E. (1968). Pseudo counselors. Clearing House, 42, 546–549. https://www.jstor.org/ stable/30180745 Vontress, C. E., Woodland, C. E., & Epp, L. (2007). Cultural dysthymia: An unrecognized disorder among African Americans? Journal of Multicultural Counseling & Development, 35(3), 130–141. https://doi. org/10.1002/j.2161-1912.2007.tb00055.x Walker, M. (2004). Walking a piece of the way: Race, power, and therapeutic movement. In M. Walker & W. B. Rosen (Eds.), How connections heal: Stories from relational-cultural therapy (pp. 35–52). The Guilford Press. Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work (2nd ed.). Routledge/Taylor & Francis Group. Weissman, J., Pratt, L. A., Miller, E. A., & Parker, J. D. (2015). Serious psychological distress among adults: United States, 2009–2013 (NCHS Data Brief No. 203). https://www.cdc.gov/nchs/data/databriefs/ db203.pdf West-Olatunji, C. A., Frazier, K. N., Guy, T. L., Smith, A. J., Clay, L., & Breaux, III, Walter. (2007). The use of the racial/cultural identity development model to understand a Vietnamese American: a research case study. Journal of Multicultural Counseling and Development, 35(1), 40+. https://link.gale.com/ apps/doc/A157745056/AONE?u=googlescholar&sid=bookmark-AONE&xid=c210d7c0

3‌‌‌ FEMINIST APPROACHES Amanda C. La Guardia

LEARNING OBJECTIVES After reading this chapter, you will be able to: ■ Discuss the historical development of feminist‌‌‌‌ theory ■ Define the major tenets associated with feminist therapies ■ Differentiate the feminist approach from other psychotherapies ■ Implement feminist theory in the conceptualization of mental health problems

INTRODUCTION Feminist counseling theory emerged from a larger philosophical framework of feminist theories that can be applied to the facilitation of change in people and also many other fields, including economics and the political sciences. As feminist theory emerged from philosophy, as many counseling theories have, the list of contributors spans generations. While feminist philosophies emerged with a focus on gender equality, feminist philosophies and their counseling theoretical counterpart have become far more expansive. Hallmarks of any relevant theory are the contributions of new generations of thinkers in the development of new frameworks that can change with culture and research that is responsive to the emergent needs tied to cultural change. Feminist theory focuses on needs related to oppression and change that promotes egalitarianism by honoring the marginalized voice. A feminist counseling process includes a focus on how expectations for behavior, defined by our culture, family, and world, may create internal limits or barriers that can contribute to distress (e.g., boys don’t cry). Feminist counseling should attend to all issues of marginalization that are often attached to intersections of sex, gender, ethnicity, affectional and sexual orientation, culture, age, ableism, and nationalism. This theory, at its core, is about helping people to value their voice, recognize its power, and use that voice to live authentically in connection with others.

HISTORY, LEADERS, AND LEGACIES OF FEMINIST THEORY Feminist theory in counseling is strongly rooted in the political movements that are associated with women’s rights, most notably beginning with the suffragists, a period often referred to as the “first wave,” of which there are three (Brown, 1994; Freedman, 2003; hooks, 2000  ). Unlike many other practice theories, feminist counseling did not evolve from the experiences of one or two people (i.e., men of European decent). This perspective is truly one that has been born from a variety of voices, contexts, and conversations over two centuries. The diverse emergence and history of feminism ‌‌‌‌ have been a source of strength and criticism for counselors who identify as conceptualizing from a feminist philosophy. Prior to the first

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wave of feminism, organized in the mid- to late-1700s and known as the women’s movement, human experience was unquestioningly rooted in the male perspective (Freedman, 2003). Men decided what was “normal” behavior, and women were decidedly “abnormal” when their behavior did not fit with what the male power structure determined was appropriate. Appropriate female behavior was thought to be less important and less evolved than the male perspective. Women were deemed and expected to be “emotional” thinkers, a state which was historically considered to be less than the “rational” male thought process. Therefore, as the field of psychology emerged, women and children were often the centers of exploration, given their “natural” shortcomings. The male experience in westernized, industrial cultures defined theories of normal development, normal psychological well-being, and normal behavior. As the feminist movement became stronger, women challenged these perspectives, and feminist theory in psychology and counseling was born. Early voices in this movement were diverse, but those voices that were recognized and organized around were often from women of racial and economic privilege, resulting in a whitewashing of feminist history spurred by racism (Brown, 2018). The philosophy of feminism has been categorized in “waves,” but really, each new development in the theory has built upon the struggles and successes of the ones that came before. Thus, the development of the philosophy has been more like a growth process (McRobbie, 2009). All of the contributions have been important, rooted in their historical period, and continue to be necessary for the theory to move forward and be influenced by the generations yet to come. Notable and influential feminist writing began with the work of Christine de Pizan, a Venetian woman who challenged misogyny in art and philosophy in the early 1400s (de Beauvoir, 1974). The first true and organized “wave” of the feminist movement followed centuries later and sought to gain political equality for women, which was mainly focused on voting, property rights, and marital decision-making. The second “wave” was primarily oriented around the middle- to upper-class white women who entered into debates about biological beliefs associated with women’s abilities and characteristics—­ basically challenging common social norms associated with beliefs like “sugar and spice and all things nice; that’s what little girls are made of!” These early pioneers believed that little girls could be made of anything; the abilities of girls and women were far broader than male-dominated culture allowed. The third “wave” started to focus the movement on the diversity of women’s experiences, all classes, races, ethnicities, and the issues women face throughout the world. Once women achieved the right to be heard, those voices inspired a deeper connection to the intersectionality of marginalization, a diversification of thinking that was affirmed beyond those voices previously concentrated within racial, ethnic, and economic privilege. A preeminent occurrence that helped move the feminist social movement into therapy was the development of consciousness raising groups in the community, which became popular in the 1950s and 1960s through today (Friedan, 1963; The Combahee River Collective, 2014). At this current point in history, the women’s political and philosophical movement is shifting into a new era of defining itself globally. Feminism is moving into a truly postmodernist perspective that encourages debate and discussion about the lives of women from a gender expansive, intersectional perspective while exploring how gender definitions across cultures influence the experiences of the individual, no matter their identity, as well as societal values (Chowdhury, 2009). In thinking about the development of feminist theory, understanding the process of its emergence through the present day is essential. The most recognized founder of the feminist political and social movement was Mary Wollstonecraft. She was a philosopher, activist, and writer living from 1759 to 1797 in England and later in France. One of her most notable and foundational works was The Vindication of the Rights of Women, which advocated for equal education, suffrage, and rights. Her work began a clear and organized women’s movement, largely in Europe, for European women. While other writings came before hers in the form of creation myths highlighting the roles of women and other related cultural discourse, none

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had as broad an impact on change as Mary’s (Wollstonecraft, 1792/2008). This success and recognition were probably due, in large part, to her social connections, coinciding historical movements challenging the monarchy fueling receptivity, and her access to education. The stage was set, and all she had to do was walk onto it and speak—which she did frequently. As with any freedom fighter, there had to be a “villain” to rail against, and this person came in the form of Edmund Burke. His writings about the structure of human nature as based around dominance over the weak, as written in Reflections on the Revolution in France (Burke & Mitchell, 2009), inspired Mary Wollstonecraft to speak out. Mary faced a lot of pain in her life, encountered oppressive forces, and decided the only thing she could do was to act against them using her strength—writing. When she made this decision, she changed her life and our history—she helped people by facing her pain and doing something useful with it. This process is a core piece of feminism to remember, the idea of taking action in order to heal. One of the inspirations behind Mary’s work, aside from the conversations she was having with the revolutionaries and dissenters she surrounded herself with, was Jean-Jacques Rousseau, a French philosopher. This connection came through her translation of Gotthilf Salzmann’s (1790) book Elements of Morality for the Use of Children, which was inspired by Rousseau’s beliefs concerning the problem of oppression. This is an important connection as much of Rousseau’s work was focused on slavery, and Mary’s work adapted those arguments to address the oppression of women. Rousseau (2004) stated in his book Discourse on the Origin of Inequality that “it would be a hard matter to prove the validity of a contract which was binding only on one side, in which one of the parties should stage everything and the other nothing, and which could turn out to the prejudice of him alone who had bound himself” (p. 43). He was writing about slavery and the idea that it limits and condemns both the master and the slave. Wollstonecraft (2008) later stated that women “may be convenient slaves, but slavery will have its constant effect, degrading the master and the abject dependent” (p. 18). Rousseau, of course, never meant for his ascertains to apply to women who he viewed to be naturally inferior or, as Aristotle put it, “the female is a female by virtue of a certain lack of qualities…we should regard the female nature as afflicted with a natural defectiveness” (as cited in de Beauvoir, 1974, p. xxii). Therefore, Wollstonecraft also argued against Rousseau and established beliefs about the nature of women in addition to refuting Burke. As a side note and point of interest, Mary Wollstonecraft was mother to Mary Shelley, who later wrote Frankenstein (1893/1994). Unfortunately, Wollstonecraft died in the birthing process, but Shelley was no doubt inspired by her mother’s work. In essence, Wollstonecraft believed strongly that women were born with the same intellectual capacity as men, that they should be afforded the same rights as men, and that societal institutions needed to change their system of hierarchy in order to accommodate this new structure based on democracy and individual choice. Others were, of course, discussing the same issues in other parts of the world, including abolitionist and writer Fredrick Douglas who stated in his 1888 essay Why I Became a Woman’s Rights Man, “War, slavery, injustice and oppression, and the idea that might makes right has been uppermost in all such governments, and the weak, for whose protection governments are ostensibly created, have had practically no rights which the strong have felt bound to respect” (as cited in Kolmar & Bartkowski, 2004, p. 99). Following Wollstonecraft, there were many speakers and writers in the women’s movement that helped attain rights for women in western industrial nations. Important works during this period included Emma Goldman’s 1910 publication of Anarchism and Other Essays, Ida B. Wells-Barnett’s publication in 1901 entitled Lynching and the Excuse for It, Anna Julia Cooper’s 1892 essay on The Status of Woman in America (Kolmar & Bartkowski, 2005), as well as Sojourner Truth’s speech at the Ohio Women’s Rights Convention in 1851 (The Sojourner Truth Project, n.d.). This process of literary and political challenge occurred prior to the First World War and peaked as the fighting encompassed government process—a

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conflict that temporarily impeded further societal change. During the period spanning both world wars, rights movements such as these were stalled (but not halted) in order to fight against the backlash of tyranny. The second wave of feminism and civil rights emerged soon after the fighting ended and world economies recovered. An important work by a French woman, Simone de Beauvoir, called The Second Sex was published first in France in 1949 and later translated to English in 1953. This important work helped to inspire a new era of activists and scholars when Simone challenged the idea that men and women were, by nature, opposites. Her contention was that when you create a system of positive and negative, one is always determined to be better or more important than the other and therefore could not be equal. “Thus humanity is male, and man defines woman not in herself but as relative to him; she is not regarded as an autonomous being” (Beauvoir & Parshley, 1953, p. xxii‌‌‌). This period of feminism was further sustained by yet another author, American Betty Friedan, who wrote The Feminine Mystique, published in 1963. Betty was inspired to campaign for women’s rights for many reasons—experiences of anti-Semitism in childhood; her work as a journalist interviewing women about their lives; and her educational experiences that facilitated her exposure to relevant literature, philosophy, and activist movements. She also had a position working with Erik Erikson, a prominent developmental psychologist. This experience served to highlight psychological inequities as she was tasked with analyzing male and female developmental behavior. Her pioneering book was grounded in these and many other life experiences and her frequent encounters with, as she termed it, “the problem that has no name.” This problem arose from the cultural message that women had to define themselves in relation to a man—wife, sex object, and mother—a partner to a man on men’s terms. Women were viewed as naturally and biologically different than men. They were supposed‌‌‌ to be nurturers, to put others before themselves, and to be caring and emotional. Because of this difference, it was believed that women should accept and flourish within service roles, and if they didn’t, then something must be wrong. No one wants to be seen as having something wrong with them, so it became a problem that was not discussed or shared, a secret that Friedan decided the world needed to know. Women were incomplete, and they needed the opportunity to find a sense of self rather than give up their identity or have it defined by others. Women needed an‌‌‌ equal voice, not a voice that was considered a subordinate, an outsider, or “other” perspective only useful inside of the home. The popular perspective that women were emotional thinkers was deeply connected with the idea that they were irrationally emotional and incapable of measured thought. This perspective consequently affected men as they were called upon to be rationally emotional—that is, acceptable rage and anger. This gender normative perspective was and has been restrictive for individuals identifying as a man or a woman. Friedan’s work was powerful and led many other women in the field of counseling and psychology to begin to voice their concerns regarding the role of prevailing theories in keeping women from finding themselves as true equals and empowering men to maintain this process. It is important to note that while Friedan’s work was groundbreaking, it was written with a primary focus on middle-class White women who were spending their lives as full-time homemakers. In 1982, Carol Gilligan (1936–) wrote In a Different Voice and thus feminist theory began to emerge on a culturally broader and recognizable scale within modern psychotherapy. The Association for Women in Psychology was eventually founded in 1969 (they had made several unsuccessful attempts to form this organization beginning in 1948) as a division of the American Psychological Association (APA) in order to address issues of sexism in psychology; however, a feminist focus was criticized as being a political movement rather than a clear psychological theory (Tiefer, 1991). Gilligan and others like her helped to ground feminism as a psychological perspective and an important philosophical approach to counseling. Gilligan, and many colleagues with whom she worked, such as Mary Belenky, were

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instrumental in challenging accepted views of development based on male-dominated stories. Gilligan (1982), like Friedan, had worked with Erik Erikson and learned “you cannot take a life out of history, that life-history and history, psychology and politics, are deeply entwined” (p. xi). In her early career, she evaluated Kohlberg’s stages of moral development, and in her interviews with young women, she often found that they made moral decisions by making a choice between selfish and selfless behavior rather than thinking about issues in terms of individual freedom and justice. Basically, Kohlberg held that those of higher moral reasoning would disobey “unjust” laws if the individual situation called for it. Gilligan held that this individualistic perspective would lead individuals, specifically women, to be viewed as less morally developed if they held responsibility for the “greater good” in their decision-making process (selflessness)—that the justice view was a W ‌‌‌estern male perspective. Females, in many cultures, were taught to be selfless and then pathologized or perceived as less than when they behaved the way there were trained but outside of male direction. Gilligan asserted that morality was relative. Morality is a process of finding a balance within sometimes conflicting responsibilities to self and others, and thus cannot be assessed objectively (meaning that one person’s truth is not and should not definitively be someone else’s truth) as it is grounded in historical context and personal experience. Feminists of this‌‌‌ time were trying to communicate that society (or more specifically, men in power) promoted a mental, informal list of all the opposing qualities believed to be integral to humanity—logic and emotion (equated with illogic), aggression and caring, leader and helper, selfish and selfless—and then placed these qualities on the people and things that seemed, at face value, to be opposite, for example, men and women. Biological sex was a physical representation of strong and weak (Lorde, 1995). Women had to be the “angel of the home” while men managed the economy and politics of the time. Feminists viewed this projected, imposed, and inaccurate message as limiting to both men and women; it was a perspective that needed to change. The message that men and women were more different from one another as a group than the individuals within those groups created a power structure that helped men to retain mastery over women (as long as men followed the rules of power). This power structure was observed within racially marginalized groups relative to White men (Hurtado, 1989). If either broke the rules, they were viewed by society and psychology to be abnormal and in need of fixing. Thus, we have a direct challenge to the way society or culture tells each gender how to behave to be “normal” and accepted—gender norms or gender normative behavior. This wave of feminism recognized it was time these gender concepts became more fluid to allow for diversity and cultural equity. The need for diversity when considering the roles and behaviors of men and women helped fuel what is commonly referred to as the third wave of feminist theory, a shift that took root in the 1990s. Feminists, such as bell hooks, cried out for reform in the movement and highlighted that many women who had fought hard for social change had stepped back once they received some power within the existing system—they stopped trying to change it because they were not benefiting from continued change. Usually, these women were middle to upper class and White. In her book‌‌‌ Feminism Is for Everybody, hooks stated that feminist theory was not being written in an understandable way and was not easy to read, and therefore, women experiencing oppression in society were not able to become involved in their own liberation. “Most people in our society do not have a basic understanding of Feminist… we must create it [accessible Feminist material] if we are to rebuild a Feminist movement that is truly for everyone” (hooks, 2000, p.112‌‌‌). In her writing, hooks attempt to make her work accessible and encourage expansion and critique authority. In many ways, the most noticeable act of defiance was her choice not to capitalize her name. She chose to de-emphasize her name in connection with her work as she wanted her thoughts and perceptions to be considered for what they were rather than connected with a symbolic authority.

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When you think about our society today, it is easy to notice the backlash that has occurred relative to the feminist movement. The power structure has shifted but is largely unchanged. Women are attempting to live new lives within a system that does not practically emphasize the value of equity but rather emphasizes strength as connected to power or privilege. A culture that values power over equity can create a sense of fear for those who traditionally experience prejudice or discrimination, especially when faced with a choice to challenge power. Thus, when some marginalized individuals attain power, they are reluctant to challenge it because they do not want to lose what they have earned or been given. This fear helps to maintain the power structure and can result in within-group discrimination (e.g., colorism; Hall, 2021). Maintenance of an unjust system perpetuated by those who have been oppressed by it is not a new concept. For example, let’s say you are from a historically marginalized group in the United States of America (e.g., African American or a trans woman‌‌‌). After working for many years, you get promoted to a managerial position in a company that you know to have issues with racism and sexism, as you have experienced both. You may decide in your newfound position that you would like to challenge that biased system; however, you worry about doing this because you realize the power that comes with your status as a manager is somewhat false. It only works to maintain what is there, not to change it. You may be thinking that if you tried to change the culture of the company you work in, you could be fired. It is easier to take what you have and try to live with it; maybe you even come to see yourself as an exception. Thus, the discrimination continues, but this time it is being channeled through someone unexpected—another person who has and does experience the same oppression as those they are helping to oppress. This process is considered to be a form of internalized oppression as first defined by Michel Foucault (1926–1984) within the field of psychotherapy in the 1970s (Foucault, 1977). Feminist philosophical thinkers and activists view internalized oppressive beliefs to be the most insidious and important issue that must be addressed in order to enact change on the individual as well as the cultural levels. The hierarchical culture we live in encourages people to get power and then use others to maintain it—White women on the shoulders of people of color; light-skinned people of color on the shoulders of those with darker skin tones; economically poor individuals using religion to oppress gay, lesbian, and trans individuals—all to feel a sense of importance and power, to feel “better than.” This is not to say the people who experience any form of privilege in society do not actively oppress others in this way or that everyone is involved in this process; this is merely an example to highlight how a power system is maintained even by those who are without the privilege to wield power. This fighting keeps everyone down and upholds the structure that is in place, influencing the wellness of individuals, families, and societies. Feminists like bell hooks believe we must address the diversity of inequity in society and the issues associated with each life experience in culture to challenge the system—to change it. This means encouraging a diverse dialogue between men and women, rich and poor; everyone must buy into the need for change and see individual and cultural value in that change. It’s no longer about what makes us different but about what makes us the same. The third wave of feminist philosophical thinking is strongly linked with post-structuralism, postmodernism, and existential beliefs about reality and existence. In considering post-structuralism as it relates to feminist counseling, the ideas of a Frenchman, Jacques Lacan, are important to consider. A self-proclaimed Freudian, Lacan challenged and added to concepts of Freudian theory, lecturing and publishing his philosophy in the 1950s until his death in 1981. His ideas on the development of self greatly influenced feminist theory and postmodernist thought. Lacan further developed the psychological premise of forming self through conflict. He furthered the belief that there is no universal truth in terms of how people define themselves and how we define life around us—experience is subjective, and therefore truth is subjective as well. Lacan’s work contributed to the development of post-structural and postmodernist perspectives. In addition to his general philosophical contributions, Lacan

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contributed to the discussion on gender and gender roles by asserting that gender was a cultural construct or perceptual illusion and not inherently related to biological sex. He believed that‌‌‌ the presence of biological differences between men and women created an illusion of a boundary, leading both men and women to define what the other was and what their role should be, as well as to create expectations for behavior. Further, Lacan, as translated by Fink (2007), asserted that “…cessation of hostilities will be the more impossible since they are in truth the same country and neither can compromise on its own superiority without detracting from the glory of the other” (p. 152). Rather than sex differences resulting from innate drives, he contended that they were simply symbols constructed by people in an attempt to understand the perceived difference. This was a new way to look at sex differences and inspired debate and further philosophical developments within the feminist therapy. Judith Butler (1956–), a self-described psychoanalytic feminist, queer theorist, and post-structuralist, wrote Gender Trouble (1990), furthering Lacan’s ideas to provide a new framework for the feminist philosophy. This work was inspired not only by Lacan but Jacques Derrida, Simone de Beauvoir, and Foucault’s beliefs regarding the internalization of oppression, among many others. She conceptualized gender as a performance that was related to contextual situations, becoming a process of self as the performance was repeated and refined overtime—a repetition of norms that is not necessarily unchangeable, as the context influences the meaning we give our performance (Derrida’s process of iterability,in this case the reiteration of a role over time). The concept of gender performance is similar to Derrida’s notion of difference, which basically states that a word can never completely communicate the meaning intended without the use of other words that differ in meaning—all of which, together, create a context for understanding (Glendinning, 2011). Butler (2009) stated that “the ‘appearance’ of gender is often mistaken as a sign of its internal or inherent truth,” attempting to communicate her belief that gender is fluid; a reflection of what an individual thinks is expected of them in combination with how they perceive themselves—a person is constantly defining their gender through comparison to what they are not in any given situation. So, for example, let’s say you are a gay man. You know that society has many stereotypes communicated by the dominant culture about how gay men are expected to behave—overtly sexual, effeminate, and emotionally reactive (Boysen et al., 2006)—but you want to be perceived as masculine/strong during an interview for a job in leadership. You know that you have some qualities that might be perceived as effeminate, and you think if you display those, you will be judged poorly. So, in an attempt to emphasize your leadership qualities relative to the expectations of the dominant culture, you choose to behave in ways that fit with stereotypical masculine behaviors, dressing and grooming yourself in a fitting way and communicating attitudes that are congruent with this performance. If you are faced with this type of situation over and over again and repeat this performance over and over again, perhaps it becomes a part of the way in which you define yourself as well as what you expect from others. Butler’s ideas about gender performance and cultural norms influenced the postmodern feminist movement in that gender was no longer seen as a process that was innately and consistently connected with biological sex but was rather something that was defined by historical context, situation, language, and the interactions of the self with others. Thus, individual social performance relative to the dominant culture is essential to explore in relation to problems of wellness.

Current Developments: Waves of Psychotherapy A common critique of feminist therapy is that it lacks a theoretical or philosophical base. Personally, I believe this to be an incorrect assessment, a belief that I hope the previous paragraphs have served to illustrate. This critique may arise from the fact that feminist theory is openly and constantly changing. It welcomes revision and diversity of voice, whereas other theoretical perspectives typically revere one or two people that have come before and are

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reluctant to take on new philosophical viewpoints. The diversity of voice that has contributed to and is contributing to feminist theory is both a source of strength and a source of confusion for many. Feminist theory is strengthened by a variety of opinions, and this valuing of diversity and change is central to the philosophy (see Table 3.1). That does not mean feminists do not disagree with each other; it just means that they expect to change through conversation, and thus feminists expect the theory to evolve and change with society. Following is a review of the major positions within the feminist philosophy that create some of the arguments you might encounter if you choose to delve into this perspective more deeply. Given the constraints of this chapter, every perspective (and there are many) cannot be adequately addressed, so know that what is provided here is just a cursory overview to help familiarize you with the major aspects of feminist thought. The summary of feminist theory relative to each school, or wave of thought, is not chronological in terms of when each wave of psychotherapy influenced feminist theory. Instead, all of these perspectives have contributed greatly to the feminist approach. Any feminist therapist may create their own combination of thought with regard to the core philosophy, which includes three major tenets‌‌‌: (1) the personal is political; (2) valuing of the marginalized voice; and (3) demystification of power. These tenets serve as the foundation of all feminist perspectives, which include radical, cultural, socialist, and liberal feminist philosophies (Enns, 1992). PSYCHOANALYSIS

A feminist psychoanalytic perspective is based on ideas associated with Freud, Jung, Lacan, and object relations theory. Karen Horney (1885–1952) is credited as one of the first theorists to discuss feminine psychology from a psychoanalytic approach. She was taught in the Freudian tradition but had several key issues with Freud’s theory, especially concerning Table 3.1 Prominent Feminist Psychological Theorists Feminist Theorist

Years of Life

Sandra Lipsitz Bem

1944–2014

Judith Butler Jean Baker Miller

1956– 1927–2006

Summary of Contribution Her research focused on gender roles and androgyny. She developed the Bem Sex Role Inventory and gender schema theory Developed theory of gender performativity and ­influenced queer feminist scholarship Contributed the relational model to relational-cultural feminist theory and established the Jean Baker Miller Training Institute

Carol Gilligan

1936–

Best known for her critique of Kohlberg’s stages of moral development and developed her own stage model

Laura Brown

UNK–‌‌‌

Focused on developing social just, culturally responsive feminist theory; explores mental health issues facing the LGBTQ+ community; and is a past president of the Society for the Psychology of Women

Lillian Comas-Diaz

UNK–

Research contributions focus on racial trauma and ethnocentrism in psychology, developing a feminist liberation model

Olivia Espín

1938–

Contributed to the development of transnational ­psychology by applying transnational feminist lenses

bell hooks

1952–2021

UNK, unknown.

A prolific feminist writer who focused on the intersectionality of race and gender within systems of oppression and founded the bell hooks institute

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the idea of "penis envy" as she felt that this observation was simply the result of cultural constraints that kept women from attaining power or privilege in society stating “…these typical motives for flight into the male role…are reinforced and supported by the actual disadvantage under which women labor in social life” (Horney, 1967, p. 69). In other words, she reframes the Freudian perspective to be one of “penis envy versus privilege envy” (P. Robertson, personal communication, December 28, 2010). Horney eventually moved to the United States from Europe. During her time in the United States, she assisted Alfred Adler (1870–1937) in forming the Neo-Freudian discipline and the American branch of the Society for Individual Psychology. Horney’s work was influenced largely by Adler’s theoretical perspectives; however, her Freudian leanings included positions from which Adler later diverged. Further, the influence of Adler’s philosophy on psychotherapy and mental health can be seen in Horney’s writings concerning the importance of social interest and holistic positions relative to the influence of culture in the formation of self (Horney, 1942). Horney was also influenced by Adler’s writings on masculine protest; thus, she has, at times, been referred to as a Neo-Adlerian. She later developed her own perspective regarding masculine protest and discussed her opinions on what she thought to be male envy of a female’s ability to give birth to and provide nurturance to children, which she dubbed “womb-envy.” This was a departure from Freud’s perspective that each sex simply envied the sexual functioning of the other, a biologically based perspective that assumed universalism of feelings that Horney did not believe existed. Horney’s contributions to feminist psychotherapy began to highlight how social boundaries and gender expectations influenced the development of both men and women and how this process could be linked to neurosis (Horney, 1945). Chodorow (1978) further influenced the psychoanalytic perspective through her work with object relations theory. She asserted that early parenting relationships served to create a core belief regarding gender roles in society. As the mother typically takes on the majority of parent–child caregiving in many cultures, this relationship is internalized to form perceptions about how the world works. Given this, she focused on the issue of father absence in child rearing and argued that father absence in conjunction with the presence of the mother would lead to further traditional sex role socialization. Of course, she did not believe that the parenting relationship was the only factor and also explored the role of outside intimate partner relationships to explain how sex roles affect women’s experiences. Radical feminist thought has multiple influences, but many of Horney’s ideas were central to the development of this specific psychoanalytic approach. Those ideas included her focus on present conflicts, development as a process of lifelong experience, gender neutrality, and the concept that women’s psychology can only be discovered once it is freed from male-dominant expectations of femininity. With regard to development, Horney (1967) believed that “interpretations which connect the present difficulties immediately with influences in childhood are scientifically only half-truths and practically useless” (p. 404–405). Radical feminists do not view female characteristics as something that should be understood in relation to male characteristics, but rather women should be defined separately so that they are not viewed as “less than” or placed into a male/female dichotomous conceptualization. Women must be discovered and understood alone and separately from men (Donovan, 2000). Radical feminists believe this perspective will help to avoid the philosophical problem of defining self in relation to others—a relationship that is not advantageous to women when compared to men within a patriarchal cultural climate. Similarly, the cultural feminist perspective is often rooted in psychoanalytic thinking. This rooting is linked to Horney’s writings on the influence of cultural expectations and social factors on development, as well as Lacan’s assertions. Cultural feminist philosopher Linda Alcoff expanded on these ideas in her 1988 essay entitled Cultural Feminism Versus Post-Structuralism: The Identity Crisis in Feminist Theory, in which she states, “In attempting to speak for women, feminism often seems to presuppose that it knows what women truly are,

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but such an assumption is fool-hard given that every source of knowledge about women has been contaminated with misogyny and sexism” (Kolmar & Bartkowski, 2005, p. 426). Cultural feminists believe that masculinity itself is a problem for women, not just the social systems that are in place, and therefore female attributes (biological and cultural) must be affirmed. This tradition was influenced by many women who advocated equal rights, not just for themselves but for all people who experienced oppression. The cultural perspective in feminist theory arose as a critique of radical feminist theory and its focus on male domination as the source of oppression. The sociological theory of intersectionality was thus developed in order to bring a voice to the many ways in which people experience oppression in society. The need for an intersectional focus was developed by Kimberlé Crenshaw in 1989 as she postulated Critical Race Theory. The idea of dichotomies (two opposing forces, one with more value than the other) came up again when bell hooks postulated that these intersections could result in varying levels of oppression due to the devaluation in meaning that some of the labels people are given carry. For instance, Black women would be more likely to experience a double source of oppression (racism and sexism), whereas white women would be more likely only to experience one source of oppression (sexism). Intersections of oppression would therefore need to be addressed within the context of White male domination. Unique experiences of oppression must be recognized in the counseling process as it would be a source of difficulty in the client’s life and could lead to internalized self-devaluation (Collins, 1986). Espín (1993) asserted that feminist theory continued to focus too heavily on the experiences of White women in order to determine the direction of the theory. Since then, she and others have worked to develop the perspective to be inclusive of all women’s experiences. Like radical feminists, they look to redefine previous psychological theories in order to include more voices, whereas many postmodernist feminist counselors believe a core based on male perspectives is itself flawed, with Lerman (1986) stating that “many psychoanalysts are extremely eager to have psychoanalysis’s glaring problems with female development rehabilitated without recognizing that the problems lie at the very heart of the theory” (p. 2). Therefore, feminist conceptualizations need to be based on women’s experiences and theorizing outside of male influence. To answer this criticism, many cultural feminists have attempted to address psychodynamic theory from a perspective that integrates intersectionality, arguing that this perspective will add a needed philosophical base from which women and other marginalized groups can be included. Most notably, Beverly Greene added to this discussion by taking the idea of intersectionality beyond present experience and discussing it within a historical, relational, and contextual framework that provides an application for Butler’s assertions of gender performance across a wider range of diverse issues (Greene, 2005). Feminist perspectives are often related to the cultural and radical schools of thought that include women of color and lesbian feminism. COGNITIVE BEHAVIORAL

As feminist theorists began to look for ways to move away from psychoanalytic traditions, some began to work on developing a cognitive behavioral (CB) approach with regard to working with women. Social learning theory seemed to fit well with the feminist philosophy as it was seen to be culturally flexible and gender-neutral. Meichenbaum’s collaborative emphasis also seemed to work well with regard to the valuing of egalitarianism in the counseling process. Worell and Remer (2003) outlined in their book a way in which a feminist counselor could conceptualize client issues from a CB perspective. Generally, however, the crux of this approach relates to a focus on language. Feminist counselors would need to address a client’s self-talk as it is associated with the societal norms and the messages typically associated with those norms. This social construction provides a way of approaching the counseling process, placing an emphasis on the connection between beliefs and actions. This is easily related to aspects of the feminist philosophy previously developed,

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and therefore, this mode of counseling is not necessarily in conflict with feminism, nor does it add any core beliefs. A criticism may come in the process by which the value of dysfunctional beliefs and moods is determined. How dysfunction is decided must be assessed from a perspective that includes gender role analysis and evaluation of the function of outside messages as they relate to internalized beliefs in order to avoid pathologizing common perspectives of women and other marginalized groups (Worell & Remer, 2003). Lipsitz Bem (1993) writes extensively on the topic of behaviorism and biological essentialism in her book The Lenses of Gender (Bem, 1993), in which she addresses the core philosophical premise of objectivism in behavioral and CB theory. Lipsitz Bem challenges‌‌‌ that even in empirical research where variables are controlled, the way in which the research is developed and constructed and results interpreted all create room for subjective reasoning. Her concern lies in the belief that science and the scientific method can somehow uncover objective universal truths about humanity—biological attributes for men and women can be found that define themselves and somehow are impervious to an external meaning-making process. She provides historical examples, such as Clarke’s 1873 Sex in Education that assumed since “the nervous system has a fixed amount of energy…energy spent on one organ reduces the amount of energy available…because education diverts a woman’s energy from the development of her reproductive organs to the development of her brain, it is harmful to a woman’s health” (p. 10). CB feminists attempt to balance the idea of objectivity with the realities of subjective experience, knowing that both are in relationship to one another, especially when attempting to understand people. Two plus two may equal four, but the meaning and value placed on that equation and its outcome is more culturally relevant than the seemingly objective result. This balance can be conceptualized within the feminist framework of valuing the common biological aspects of women as well as the culturally imposed gender norms ascribed to them. Feminists who integrate a CB perspective or apply CB techniques seek to define the “conditions under which Feminist/gender role attitudes are or are not related to Feminist-related behavioral intentions” (Bransecombe & Deaux, 1991, p. 413). However, as Fuss (1989) warns, a problem of philosophy exists between feminism and cognitive behaviorism, which must be remedied, as the “essentialist holds that the natural is repressed by the social, the constructionist maintains that the natural is produced by the social” (as cited in Kolmar & Bartkowski, 2005, p. 456). Perhaps the solution, as Fuss (1989) posits, is to risk essentialism in order to create a context in which to move forward. In essence, by broaching essentialist ideas about oppression and role expectations, a collaborative analysis of its influence on a problem can be formed. HUMANISM

The humanistic perspective is one built on the valuing of individual meaning making. Thus, it is easy to see how this perspective became central to feminist philosophy. The key components of humanistic psychology include ideas related to personal freedom, responsibility, and meaningful development, with contributions stemming from the work of Alfred Adler, Carl Rogers, Abraham Maslow, and Rollo May. Feminists who typically ascribe to or focus on the humanistic perspective sometimes refer to themselves as liberal feminists. However, it should be apparent at this point that there are many overlapping perspectives that make up the feminist philosophy as a whole. Individual feminist counselors may choose to label themselves within certain subcategories, such as liberal, radical, and so on, but the majority of feminist counselors share philosophical core beliefs related to each of these areas. Liberal feminist therapists typically attempt to work within the system currently in place in order to reform it and facilitate change. They take an inside-out approach to advocacy on a political and social level and thus translate this perspective to a psychological approach. Liberal feminism is typically seen as the least divisive of the theoretical feminist perspectives, which can be a source of strength as well as a source of criticism. Sometimes, the liberal perspective is referred to as “nonsexist” therapy due to its commitment to equal treatment

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in the counseling process and focus on gender neutrality. It is important to note that taking a perspective of equal treatment does not mean that liberal feminists ignore discrimination that may exist as a result of prevalent cultural norms—in fact, it is quite the contrary. Liberal feminists instead choose to focus on how these norms influence all clients (Marecek & Kravetz, 1977; Russell, 1984). Further, liberal feminist theory has been described as a perspective that seeks “no special privileges for women and simply demands that everyone receive equal consideration without discrimination on the basis of sex” (Rosser, 2005, p. 2). The focus is on the individual within a system, on the need for a change in male-dominant attitudes that restrict the growth and potential of women in society. A notable historical figure in liberal feminism is John Stuart Mill (1806–1873), who specifically related to his widely read essay The Subjugation of Women published in 1869 (Enns, 1992), which focused on the nature of personal liberty and utilitarianism (i.e., actions that benefit the majority). Burgess-Jackson (1995) uses the work of Mill to highlight the differences between liberal and radical feminist thought. It is believed that Mill was, in fact, a precursory radical feminist thinker. While liberal, radical, and indeed all feminists believe in the same root philosophy (that societal inequity leads to oppression, which influences personal and cultural wellness), the action that each type of feminist believes to be necessary to rectify inequity is different. Therefore, each focuses on different aspects of the philosophy in order to justify political, societal, and therapeutic action. POSTMODERNISM

The postmodernist perspective adds the final piece to the feminist philosophical puzzle as it serves to bring together each philosophical perspective discussed thus far and formulates them around advocacy and social justice. A common critique of liberal feminists is that they do not do enough to push against systemic inequities and thus may be perpetuating the core problem. Postmodernists reject positivist and individualistic ideals choosing rather to focus on the relationship between the individual and their culture—knowing they shape one another and that one cannot exist without the other. Similar to the radical and cultural perspectives, social construction is the focus of feminist conceptualization of client issues. Postmodern feminists emphasize the importance of discourse in the counseling process in order to highlight the meanings clients make juxtaposed with the daily conflicts they face—struggles with the power structure that may serve to limit them and cause problems of living. This discourse is focused on gendered meanings and how male/female definitions influence and perpetuate oppression. Individuals must evaluate these meanings in order to discover themselves. Relatedly, the socialist feminist perspective seeks to reconcile many of the issues and seeming differences between the other feminist schools of thought. Socialist feminists believe the answer to oppression isn’t rooted in either the individual or the structure but rather occurs when the two intersect in unique ways within individuals and systems. Many of the traditions previously discussed allude to this combination as a facilitator of change, but the focus of counseling typically lies in one or the other (the individual or systems). “Socialist feminism is based on the assumption that gender status is imposed and defined by social relationships, embedded in historical factors, and situated in a system that organizes social production” (Enns, 1992, p. 456). Therefore, socialis‌‌‌t feminists believe that people must reconstruct not only their internal self but also their relationships, public lives, and the system around them that serves to impose social norms. How this is done is complex due to the meaning-making process inherent in each layer (individual, others, and groups). As hooks (1989) states in her paper Feminism: A Transformational Politic, “It is necessary to remember that it is first the potential oppressor within that we must resist – the potential victim within that we must rescue – otherwise we cannot hope for an end to domination, for liberation” (p. 185). Miriam Greenspan expounded upon this idea in her work as she criticized the medical model still prevalent in psychology and mental health, citing the Diagnostic and Statistical Manual of Mental Disorders (5th ed.) to be an essential writing that fails to take into account

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the variability of women’s lives, experiences, and personal histories. She also confronted the idea of the counselor as the expert, stating that this type of therapeutic relationship would simply reflect and further reinforce power differentials already in place outside of the counseling relationship (Greenspan, 1993). In reality, the divide between feminist theoretical perspectives is one that serves to provide a discourse within the theory to assist in moving the philosophy forward so that it remains relevant. Together, they highlight the core foundations of feminist thought and provide a dialogue about how feminist counselors can address not only client issues but the societal issues that contribute to problems faced by women and men within our respective cultures. Scott (1988) summarized this best when she stated, “we need theory that will let us think in terms of pluralities and diversities rather than of the unities and universals…we need theory that will enable us to articulate alternative ways of thinking about (and thus acting upon) gender without either simply reversing the old hierarchies or confirming them” (as cited in Kolmar & Bartkowski, 2005, p. 446).

FEMINIST WORLDVIEW Now that you have a background in interdisciplinary feminist thought, it’s time to bring it all together to highlight the process of client conceptualization and its influence on technical action in session. Generally, feminist counselors believe that the personal is political. All voices and experiences should be valued, egalitarianism is crucial in the lives of our clients as well as in the counseling relationship, and change must be encouraged and personally empowered. A common criticism of current feminist philosophy comes from the fear that feminists hold the perspective that all voices should be valued, which could mean that no voice is wrong. Chesler (2005), in her book The Death of Feminism: What’s Next in the Struggle for Women’s Freedom, warns against the passivity she sometimes notices accompanying postmodern thinking—in an effort to be inclusive or politically correct, we are actually being exclusive and serving the oppressive power structure rather than challenging it. This criticism comes from the reality that, at times, feminist theory is misinterpreted and therefore put into action in a way that is not useful and does not serve the purpose for which it was created. Chesler is right in her assertions—feminist theory does take a position that certain beliefs and behaviors that oppress others are culturally useless if we are to value equality, and thus oppression should not be affirmed but rather challenged. You cannot value and affirm a culture, society, or voice that seeks to oppress and extinguish the “other.” So, even though feminists accept the notion that each of us is entitled to our own perspective and that, as a counselor, we will listen carefully to the voice and experience of each client, we are also very clear that we will resist oppression and offer an alternative voice to the often dominant voice of subjugation and culturally prescribed gender role dichotomies.

Human Nature Feminist ontology, or theory regarding the nature of our existence, is one rooted in experience and personal history. This means that feminist counselors believe that our experiences in the world, our relationships, and our roles in larger groups serve to make us who we are—how we think about ourselves and thus how we behave. Given personal meaning is developed and reinforced through personal relationships, connection must be the basis and focus of counseling. Through the therapeutic relationship, power structures can be challenged, and personal insight can be encouraged to reach a new way of relating to the world. Feminists, similar to humanistic counselors (e.g., client-centered or existential), believe that people have the agency to change and that through support and encouragement, individuals can find a new way of living that will work best for them. Further to this, it is important that the individual’s behavior be viewed within a context. It is not simply enough for

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a person to change self, but rather they must also work to change the way in which they relate to others to be congruent with self—to contribute to a greater good. For feminists, this greater good is a process by which society is restructured to value the human rights, dignity, and freedom of all people and groups, reducing harm through equity. According to Alison Jagger (1942–) in her 1983 book Feminist Politics and Human Nature, feminist philosophy, at its core, proffers the belief that human actions can alter “conditions formerly regarded as givens of natural law or human society” (as cited by Alward, 2006, para. 5). It was her contention that in order to gain control over the human process, people must become aware of their role in shaping society—humans are capable of this level of awareness and, once achieved, progress will be an ongoing struggle toward the newly defined freedom that will emerge over time as a result of prior changes. The counselor should, therefore, create an environment that encourages free discussion and open exchange of ideas and empowers a mutually beneficial meaning-making process. Humans have aspects within them that may be labeled as good or bad internally and externally, and from those extremes, each person attempts to live a life between them. In counseling, each client must feel free enough to explore both aspects of themselves in relation to whatever context is presenting the problem, determine if their meanings of good and bad fit, and then restructure those meanings, if necessary, in order to live the life they want.

Change Feminist counselors believe that change does not occur in isolation. Clients must feel supported in their journey, and this support must be present within the counseling relationship. The relationship not only provides a safe place for clients to explore themselves and their issues, but it should also serve to model the egalitarian philosophy so that the client can experience change. The purpose of change should not only serve the individual but should also seek useful change in society. This refers to the idea of consequentialism—the consequences that will result from actions. This teleology (or the idea that actions lead to a final purpose) is defined by the client together with the counselor. The client decides what actions are appropriate for them; the client then analyzes the consequences of those proposed actions with the counselor, while the counselor encourages a purpose that is useful to the client and their relationships based on client-guided goals. For instance, imagine you are working with a client who is attempting to leave a verbally and sometimes physically abusive relationship with her partner, with whom they both have a young son. The client knows that she needs to leave the relationship so that her son will no longer witness violence; she is worried about her son’s well-being. Her family has also voiced concern for her safety, so she knows she should leave for her own good as well but is worried about facing the prospect of living as a single lesbian mother in a conservative community. She feels her partner protects her from community-based discrimination and doesn’t feel that people will accept her or believe her stories regarding domestic abuse—she worries her son will be taken from her. Your client wishes that the members of her community were more informed about gay and lesbian issues. In order for change to occur, your client must not only develop a sense of self-worth, but the internal change process must be continually encouraged through positive community involvement (if at all possible), the development of support structures in and outside of counseling, and insight regarding how cultural oppression plays a role in her relationship with her partner and with herself. Change is therefore linked inextricably to action, and the results of those actions influence internal change.

Therapeutic Process Therapy is focused on the development and maintenance of an egalitarian or equal working relationship between the counselor and the client. Relationship building isn’t merely the first

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step of the process but is the core and foundation of all counseling sessions. The counseling relationship, like any other, will be challenged regularly if it is genuine and therefore must be continually assessed and fostered. Feminists do not ascribe solely to the medical model and therefore do not always value the use of diagnostic labels in every situation. However, feminist counselors do recognize that they will often find themselves working within a mental health system they would like to see change. Therefore, the use of diagnostic labels will sometimes be employed in working with managed care or attending to pervasive, seemingly biologically based concerns that require interprofessional treatment (e.g., schizophrenia). A feminist counselor will always disclose their position regarding the diagnosis, why it is appropriate, and reach a collaborative agreement (when possible) as to the use of the said diagnosis. Feminists recognize that diagnostic criteria were established through a system that values male gender role traits as “normative,” and therefore, women’s behaviors can be more prone to becoming pathologized. This does not preclude the possibility that using diagnostic criteria, at times, might help inform the work the client and the counselor do as well as normalize an experience; however, when a diagnosis is used, it will always be done with transparency. It is important that client’s experiences be evaluated, conceptualized, and treated within a broader context—not by applying externally prescribed criteria and universalized treatment initiatives based solely on symptom experience. GOALS

As the counseling relationship is egalitarian in nature, all therapeutic goals are collaboratively developed, and client guided. The process of developing goals is one based on informed consent regarding what the client should expect from counseling. Therefore, the counselor seeks to demystify what counseling is at the outset. A client may come in with preconceived notions of what counseling means—someone to give them advice, tell them what to do, and provide them with an answer that will solve their problem. This is not how feminist counselors perceive their role, so it is important that the counselor discuss perspectives on the theoretical orientation that will influence the conceptualization of client problems, expectations for the counseling relationship, and their role as a counselor. Once positionality is known, the client can make an informed decision as to whether the counseling relationship will be useful as it relates to the perceived problem. According to Susan Sturdivant (1980), feminist counselors should assess the process of sex role socialization in order to uncover sources of dissatisfaction in the client’s life. Consciousness raising groups are one way to address internalized oppression, discuss experiences of marginalization with like-minded individuals, and feel supported in the goal of challenging internal and external problems. Group counseling has been at the forefront of feminist practice and may be a good way for a client to address problems. Goals that are developed will be done so in a way that fosters an empowering approach to change and employ advocacy. Advocacy can be a process enacted on behalf of the client by the counselor in partnership with the client (in the case that the client cannot speak in a way they will be heard, for instance, when counseling a child in foster care), in the form of encouragement to assist the client in advocating for self or others, or as a community advocate. Clients are empowered to find their own voice and way of being so they can find a way to address their problems confidently. Goals are developed with the client, can be challenged and changed, and are central to all counseling sessions.

Client Experience A client working with a feminist counselor should feel informed, valued, and understood as they process their difficulties and seek change. Clients will feel challenged to explore their thoughts, beliefs, and feelings but should not feel pushed to take actions they don’t feel equipped for or pushed into actions that they do not value. The difference between

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challenging and pushing has to do with the counselor’s perspective and purpose. If I have decided that my client needs to leave her life partner because I believe this will be best for her family, then I might push this agenda without assessing my client’s readiness or interest in this goal. Voicing your perspectives, reasoning, and making suggestions can be part of a challenging discussion—pushing an agenda onto your client without regard for their lived experience is not congruent with the feminist approach to supporting change. A feminist counselor will attend to context and relationships when working with clients. A feminist counselor may have any gender identity or sex; thus, a cis man can be a pro-feminist counselor, a belief supported by Laura Brown (1994) in her 1994 book Subversive Dialogues. Suppose a cis man, or indeed any counselor-in-training, has openly evaluated and challenged their potentially patriarchal heterosexist beliefs, invites challenge from others, and has recognized and processed their unearned privilege in society. In that case, this person could then take a position congruent with the feminist philosophy. A feminist counselor attends to the gender expectations and dynamics that will emerge in the relationship with clients and is willing to address concerns both subtle and overt openly. Clients working with feminist counselors should feel as though they are a genuine part of their counselor’s life within the realm of their professional relationship, that they are cared for and truly supported. A feminist counselor will not only facilitate change but will themselves be changed through the process of engaging in dialogue with clients.

APPROACHES AND INTERVENTIONS Some of the interventions developed and used by feminist counselors may include the following: gender role analysis, power analysis, bibliotherapy, self-disclosure, consciousness raising, contextual reframing, strengths-based encouragement, as well as the empowerment of assertive behaviors. Any intervention a feminist counselor chooses to employ should be congruent with the philosophical purpose of the theory as described throughout this chapter. Techniques should (1) promote egalitarianism; (2) focus on strengths and empowerment; (3) help to highlight social inequities and how they influence meaning making; (4) assist the client in understanding the relationship between themselves, their experiences, and the contexts in which their problems occur; and (5) support the client as they trust and find value in the power of her or his own voice. Awareness of oppression, cultural and self-labeling, and the meaning one ascribes to events, roles, and beliefs is paramount (Hanna et al., 2000; McClellan et al., 2019). Techniques should be approached in a way that values the client’s voice (experiences and meaning), is transparent in purpose, and is open to adjustment based on client needs or readiness for change. Techniques developed to elucidate the application of feminist theory include gender role analysis and assertiveness training, both of which will be defined here. It is important to emphasize that techniques developed by any other theorist can be creatively altered to meet the purposes of the feminist philosophical perspective in partnership with client needs. Use of a theory to conceptualize a client’s needs and readiness for change should not preclude one from using techniques developed by other theorists that is evidenced to be of potential therapeutic benefit to the client given their symptom experience. Transparency in the application of techniques is important to the feminist therapeutic process. Clients should be informed of any intervention you plan to apply in session when that practice goes beyond typical influencing, invitational, and attending skills. Use of an intervention will require a discussion of intentionality with the client to facilitate informed consent or buy-in.

Gender Role and Power Analysis Interventions aimed at evaluating one’s role based on gender (perceived or performative) and societal expectations attached to intersecting identities that include gender (e.g., gender,

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race, sexual orientation) in relation to the dominant culture involve both role and power analysis. This analysis, or discussion, is meant to assist the client in evaluating how societal expectations may be influencing any problems they are experiencing. Specifically, power analysis should support the client in recognizing their own power within a system and how to use that power for their benefit as well as the benefit of those around them who may be experiencing similar problems. Contemplation of role expectations and personal power is an empowering process for the client and is connected to consciousness raising, advocacy, and action. To engage in these‌‌‌ discussions, the counselor must communicate accurate empathy and positive reframes in relation to personal power, challenge, and emotion-focused reflection. Ultimately, the client is the expert on their own cultural experience in society; thus, the counselor must be equally open to challenge from the client and be ready to change direction when a perception isn’t accepted by the client as a possibility. While gender role analysis includes an assessment and a psychoeducational process (Brown, 1986), the most essential component comes in discussing the client’s reactions to role expectations and how they believe those expectations could be influencing their problem. This intervention has demonstrated effectiveness in improving self-esteem and self-concept (Belgrave et al., 2000). For example, if your cis male client stated they were recently widowed and felt pressure to “find a new mother” for their children, a feminist counselor might ask how the client came to decide that his children needed a mother. The counselor might also engage the client in considering what it means to be a father. Power analysis could serve to compliment this process by assisting the client in identifying and assessing resources, strengths, and skills that could influence actions, be it social, relational, or familial.

Bibliotherapy The process of bibliotherapy can include a counselor-guided reading of a book relevant to the client’s goals or may include processing with the client their understanding of a book selected with the counselor’s input. Typically, feminist counselors will encourage a reading that they themselves have already completed or will co-read a book with the client, with agreed-upon stopping points coinciding with treatment. Both procedures have demonstrated effectiveness comparable to standard treatment, like the use of antidepressants (Hahlweg et al., 2008; Naylor et al., 2010). Selecting a book should be done openly with the client and begin as exploration. The client and counselor should explore potential books with counselor-guided parameters, which could include a topic, type (fiction or nonfiction), length, or specific books to choose from (choices for the client to consider). If the counselor does not intend to co-read, having predefined choices for the client to select from is ideal. Ultimately, the book should serve to create a new perspective from which the client can assess their problem and potential solutions and/or new ways of thinking about the issue.

Assertiveness Training Assertiveness training is described as a common intervention in a number of theories, like dialectical behavioral therapy (DBT). In feminist counseling, the purpose of assertiveness training is to empower people to use their voice to express their needs and communicate boundaries (Sieber & Cairns, 1991). The outcome should result in a client feeling a greater sense of autonomy and personal power. Typically, this technique would be applied in the later stages of counseling, following gender role and power analysis, in the action phase of change (Prochaska, 2013). This technique is often tied to consciousness raising groups (developing awareness in a connected way) and social advocacy (application of assertiveness to influence community-level change). As feminist counselors believe change is best maintained through connection and advocacy, assertiveness, or the ability to use one’s voice with a sense of personal power, is essential to long-term mental wellness. The process of

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assertiveness training occurs within the cultural context of the client; thus, the outcomes will be individually specific and guided by both a client’s cultural community and their own individual needs. This contextual approach helps to ensure that assertive responses are culturally appropriate, when cultural appropriateness is part of the goal (Sieber & Cairns, 1991). After cultural factors that might influence assertiveness have been assessed through a process of gender role analysis, responses and practice can occur within session. Role-plays with feedback, scripts, and letter writing are all useful ways to practice assertiveness and evaluation potential outcomes with the client. For this process to be empowering, decisions about the way assertiveness is communicated outside of session must be guided by the client, with challenge and reframe from the counselor when the method seems to conflict with client-stated goals.

Diversity and Ethics Inherent to feminist philosophy is a focus on diversity, social justice, and equity within the counseling relationship. Roles associated with the therapeutic process are openly defined, discussed, and agreed upon. Feminist theory has evolved beyond a focus on cis women and has expanded to address broader issues of oppression. Relational-cultural theory (RCT), as developed by Jean Baker Miller (1927–2006), has served to add to the discussion on multicultural inclusivity in the practice and philosophy of feminist theory. She proposed a focus on meaning making in relationships with others—what is expected from relationships and what meaning this process gives to self within a cultural context (Miller & Stiver, 1993). This approach was developed in an attempt to address the singular focus of early feminist theoretical perspectives, which were overwhelmingly based on the voices and experiences of privileged White women. Over time, however, the value of diversity within this theory has led to radical changes in its conceptualization and philosophy, including the addition of RCT. The focus of this approach to counseling is on evaluating and advocating against oppression in all forms, recognizing how gender norms create discrimination, finding ways to subvert that process, and bringing these perspectives to ethical practice. Feminist therapists view a wellness, strengths-based, nonexpert approach to counseling as necessary for ethical professional behavior. The integration and discussion of issues pertaining to diversity and oppression are part of the lived experiences of all and should therefore be a part of the counseling process. Enns et al. (2004) outlined the need for integrating feminist and multicultural perspectives in practice as well as in the training of counselors in order to create an ethical profession based on client welfare and self-directed discovery. Enns et al. believe any practice or training program valuing diversity should focus on (1) intersections of identity; (2) how the counselor or educator’s position of power may oppress or empower different groups of people; and (3) a willingness to tolerate ambiguity and contradiction, to process these issues openly with clients as they arise. These last two points will be important as feminist philosophy begins to take a more global role. As Chowdhury (2010) points out, feminism will be challenged by its Eurocentric and westernized roots as it moves out to join global feminist efforts. For instance, Shin (2015) calls attention to the possibility that our identity development models may, themselves, be Eurocentric and in need of decolonization. Joining and understanding women’s movements in other countries from their framework will be central to avoiding feminist colonization. As counseling and mental health initiatives become global, feminist perspectives could be useful in determining future ethical movements, especially given its support for collaborative transparency in practice. When applying‌‌‌ feminist techniques, it’s important to note that gender role analysis, power analysis, assertiveness training, and bibliotherapy tend to be the most advanced, skill-intensive processes to engage in with clients. The key skills associated with these techniques include strengths-based encouragement, self-disclosure, contextual reframing,

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empowerment, social action, and advocacy, as well as an emphasis on egalitarian communication. These basic skills are seen across counseling practice and are often included in other interventions or technical procedures, such as motivational interviewing. In order to know how well any process or technique is working, it is important to have ways of measuring client change. As a feminist counselor, finding ways to measure the quality of the counseling relationship is essential, especially when considering power dynamics inherent to the practice. While objective measures cannot provide a full picture of “the truth,” they can give us insight into our client’s world using psychological frames of reference.

PROCESS OF ASSESSMENT Any assessment used by a feminist counselor must include a discussion with the client regarding the perceived value of the assessment. Measures that evaluate the therapeutic relationship are often employed and could include the Outcome Rating Scale (ORS) and Session Rating Scale (SRS) associated with the Partners for Change Outcome Management System (PCOMS; Duncan, 2011, 2012) or the Outcome Questionnaire 45-items (OQ-45; Lambert et al., 2004). Both measures are reliable and empirically validated. They are both effective for measuring outcomes in group and individual treatment settings. However, the OQ-45 has been studied in multiple cultural contexts and languages and thus may be more reliable when working with diverse groups (e.g., Iraurgi, 2021). It is important to note that the SRS and ORS associated with the PCOMS have shown to be valid and reliable in French (Cazauvieilh et al., 2020) and have been recognized by Substance Abuse and Mental Health Services Administration (SAMHSA‌) as an evidenced-based practice assessment, and thus may have the potential to be adapted to working with culturally and linguistically diverse clients. More research is needed to validate the SRS and ORS with diverse clinical populations (Murphy et al., 2020); thus, the OQ-45 is recommended as a measure of treatment efficacy via subscales assessing symptom distress, interpersonal relationships, and social role. Partnered with the Outcome Questionnaire Therapeutic Alliance (OQ-TA ‌‌‌), which is an 11-item measure to assess the health of the therapeutic alliance, the Outcome Questionnaire 45 +Therapeutic Alliance (OQ-45+TA‌) can assist a feminist counselor in globally assessing client perspectives on their internal and external world, including the effectiveness of the relationship within the treatment room. A feminist counselor may also decide to assess a client’s perspective on gender role norms or their experiences with oppression. A number of inventories are available to address these areas. The Bem Sex Role Inventory (BSRI; Bem, 1974) is the most notable; however, it may not accurately measure the complex way in which our culture now considers masculine and feminine but may serve to highlight traditional beliefs (Choi & Fuqua, 2003). Specific to experiences of oppression, the Inventory of Microaggressions Against Black Individuals (IMABI) could assist a counselor in understanding how experiences with microaggressions have influenced general distress and perceived stress (Mercer et al., 2011). The Racial Microaggression Scale (RMAS), a 35-item measure, assesses six factors associated with microaggressions against people of color (Torres-Harding et al., 2012). Assessments such as these are important for both conceptualization and process evaluation. Research conducted by Owen et al. (2014) indicated that 53% of the 120 clients included in the study reported an experience of microaggressions from their therapists, and these experiences negatively impacted the working alliance. Further, approximately 76% of those clients reported their counselor never broached the issue. Working from a feminist theoretical framework compels the counselor to engage in self-reflection as well as process reflection with the client. Process reflections should be open, honest, and respectful of the client’s experience. The use of inventories can help to guide these discussions as it creates a common ground between the client and counselor from which both can communicate.

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DETAILED CASE CONCEPTUALIZATION PRAGMATICS AND TRANSCRIPT Mark is a 42-year-old, Black, cisgender male who works as a project manager for a general contracting company. He is divorced and lives with his two daughters. Mark is seeking counseling for anxiety, sadness, and anger that occurred following his divorce. Mark has expressed feeling lonely and guilty for wanting to start dating again because it “takes me away from my daughters.” Mark is experiencing a conflict between his perception of his role as a father and his desire to build a new romantic relationship. Mark may also be experiencing grief related to the loss of his marriage, as evidenced by his anxiety, sadness, and anger. Thus, he may be struggling with meaning making regarding the end of his marriage and cultural messages associated with divorce.

Feminist Conceptualization In order to assist Mark in achieving his personal goals and improving his distress, a feminist counselor will first focus on creating an egalitarian working alliance that creates space for Mark to explore his feeling, beliefs, and values. The personal is political; deductively, in this instance, Mark may be experiencing struggles, in part, due to cultural messages that he has learned and adopted over time that may not be useful given his current situation or are in question by Mark. Western cultural messages about marriage and divorce, defined in part by religious institutions, may be contributing to Mark’s distress as his current experience may be in violation of the moral meaning he has found comfort or pride in throughout his life. The feminist counselor would explore Mark’s beliefs about marriage, divorce, a father’s role in child rearing, and the meaning of being remarried after a divorce. Stanik and Bryant (2012) completed a study of 697 newlywed African American couples and found that a husband’s adherence to and engagement in traditional gender roles influence marriage quality for the couple, even when compared to other African American husbands/couples participating in the study. Adherence to traditional beliefs would be important to explore in order to determine their influence on Mark and his perception of his divorce, parenting, and dating after divorce. Further, Mark may struggle to communicate his feelings with others, especially negative emotions like sadness and anger, due to socialization related to intersections of emotional expression, self-protection against discrimination, and beliefs about manhood (Griffith, et al., 2015; Nelson, et al., 2012; Pierre, 2001; Smith, 2002). Exploring meaning making related to perceptions of self and others in relation to self is essential to ensure accurate conceptualization. Accurate conceptualization allows the counselor to communicate empathy accurately and make more precise decisions regarding therapeutic empowerment and challenge. Treatment will initially focus on gender role analysis and exploration of cultural values as they pertain to Mark’s perception of the presenting problem. It is important for Mark to evaluate his beliefs and how values attached to those beliefs are influencing his decisions. This challenge must occur within a collaborative, trusting working alliance and needs to be supported within Mark’s community. Supportive social connections are important to help Mark decide what path is right for him—engagement with family, men’s groups, his faith community, and his friends will allow him to honor himself and his future in a way that is connected to what is significant to him. Mark’s struggle may have caused him to disconnect from his supports for fear of judgment. Thus, the safety of these supports must also be discussed in counseling to empower Mark if he decided to reach out. Ultimately, Mark must feel empowered to engage in the goals he has for himself.

Discussion Questions 1. How might you utilize the bibliotherapy technique with Mark? What steps would you need to take to implement the intervention from a feminist framework?

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2. How do you broach the influence of cultural messages when working with Mark? Practice statements you might make to begin this discussion. 3. What role would identity development theory play in your conceptualization of Mark’s needs? How would you assess this in session without overgeneralizing or pathologizing Mark’s perception of his own experience (see Shin 2015)?

Transcript of a Counseling Session Mark is a 42-year-old, Black, cisgender male who has sought counseling to work on the conflict between his role as a father and his desire to engage in dating. He is attending his third counseling session and is continuing to explore what being a father means to him and how his values concerning that role are influencing his self-perception as well as his desire to explore a romantic partnership. Transcript

Skill(s) Demonstrated

Counselor: Hi, Mark. I’m glad you’re here with me today. In our last session, we talked a bit about how your experience growing up influenced the way you think about your own role as a father. What are the most important aspects of being a father, from your perspective?

Open-ended question (Counselor uses an open-ended question to open the session while continuing to engage in gender role analysis.)

Client: My father worked a lot to provide for us. He did a lot of hard labor and I saw the toll. He never said it, but he was tired. As I mentioned in our last session, his death was very heavy for me. He died when I was 10 from a heart attack. I think being a father means doing what is best for your family, taking care of their needs, putting them first, protecting them from harm. When my dad died, I felt exposed; he wasn’t there to teach me what I needed to know to be a man. My mom tried her best, but I still feel unsure of myself. My parents didn’t always get along, but they stuck together. I couldn’t keep my family together. Counselor: Being a father means putting the family’s needs before your own all the time, even if it runs you down. It means holding back your own struggles from your family and this communicates that you’re a strong provider. I wonder, if a man were to share his feelings with his family, to open up about how he was feeling, how might his children perceive him and what would they learn to value?

Paraphrasing, open-ended ­question/challenge (Counselor uses a brief paraphrase and then provides an open-ended Socratic question to challenge his gender role perception.)

Client: I think that’s selfish. I’m not going to tell my kids about my problems. I think they would feel worried, that I don’t have things under control. Counselor: If you were to share your concerns about dating with your children in a way they could understand, you believe they would become upset and you would feel guilty. They would learn to value their own needs above others and may grow up to share their feelings without considering their effect on the family. Client: Yes, as a man and a father, I need to show them I can take care of things, including myself. They don’t need to worry about me.

Reflecting meaning and values (Counselor uses reflection of ­meaning to accurately convey core concerns.)

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Counselor: Your children don’t worry about you. This lets you know that you’re a good father, that you’re doing a good job; yet, your desire to date seems selfish. You worry about how your children will think of you if you get remarried.

Interpretation (Counselor identifies and reflects ­patterns and goals in thinking.)

Client: I’m worried I’ll fail again, that maybe I don’t know how to be a good father. What if I can’t keep a new marriage together? What if I date someone, my children get attached, and it all falls apart again? Counselor: It is the father’s sole responsibility to keep his family together. Divorce is always a father’s failure.

Reflecting values (Counselor reflects the client’s beliefs regarding his role as a father.)

Client: No, but it feels that way to me. I don’t know why. I’m stuck. I feel ashamed. I’m angry at myself. I should be able to handle this better, but instead I’m here. Counselor: It’s hard to be here, to share your feelings and your burdens with someone else. It can make people feel vulnerable to be in an emotional space when you don’t know what the outcome will be. I’m honored to be in this space with you and appreciate your willingness to explore fatherhood with me.

Paraphrase and encouragement (Counselor paraphrases the client’s emotional experience in session and supports the client’s continued engagement in counseling.)

Client: I need to be stronger and when I start feeling this way, I feel ashamed and disappointed in myself. I don’t want to feel this way anymore, but maybe I deserve it. Counselor: You want to be strong for your children and you want to teach them what it means to be a man, to be a good father. Sharing your feelings isn’t easy. Maybe talking about your feelings, talking about how you solve hard emotional problems with your children can be a way of showing them your strength and teaching them how to grow that same strength in themselves.

Reframe (Counselor encourages client to see feeling from a different perspective to challenge client meaning effectively.)

Client: I think you’re right. I’ll have to think on that. I want to be a role model for them and I want them to be emotionally strong; I’m just not sure where the line is. What is right for me to share and what isn’t. My ex was better at that stuff. Counselor: You want to have an idea of a solution or feel more comfortable with your feelings before you engage with your children. You are open to including your children in hard decisions, but not before believe you’re in control of your feelings.

Interpretation (Counselor interpreted the client’s worry about conveying emotions within his family.)

Client: Right. I just never really learned this stuff. Maybe people learn it from their moms and my mom was so busy after my dad’s death. We never really talked about family problems beyond financial needs. Counselor: Being a good father could include sharing feelings and problem-solving with your children. It’s causing some anxiety because you’re not sure what this will look like; you’re worried you won’t be able to engage with your children emotionally and still convey strength.

Paraphrase (Counselor paraphrased the client’s perceptions of potential changes he could make related to his role as a father.)

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SUMMARY Feminist theory has a long philosophical history and has been influenced by theoretical developments within the fields of counseling, psychology, sociology, and social work. Feminist philosophies are deeply rooted in reactions to Western dominant culture propensities to oppress nondominant identities and experiences. While feminist psychological theory began with a focus on the experiences and wellness concerns of cis White women, tenets have been shaped by diverse voices, particularly over the last 30 years. The theory continues to grow toward intersectional understandings of oppression and social justice. This chapter provides a brief historical and practical overview of the theory and is meant to encourage further exploration of the principles and applications of feminist thought in counseling. While a few techniques are discussed here, other techniques include consciousness raising, which is typically a group process focused on building connections between individual experience and social injustice. The purpose of consciousness raising is to develop ways to address social problems while valuing the experiences of those affected by them in a way that fosters a sense of community. While much research has been done to evaluate the effectiveness of key feminist techniques, including the ones reviewed here, more cross-cultural research is needed to ensure appropriate application (Israeli & Santor, 2000). Feminist theory calls practitioners to explore cultural values with clients as a process of goal development and change. Feminist practitioners honor the voices, the experiences, and the needs of each client through respectful understanding that supports personal empowerment. VOICES FROM THE FIELD This chapter features a digitally recorded interview entitled Voices From the Field. The interview explores multicultural, social justice, equity, diversity, and intersectionality issues from the perspective of clinicians representing a wide range of ethnic, racial, and national backgrounds. The purpose of having chapter-based authors interview individuals representing communities of color or who frequently serve diverse populations is to provide you, the reader, with relevant ­theory-based social justice and multiculturally oriented conceptualization, contemporary issues, and relevant skills.

Access the video at https://bcove.video/3RRT1uN

Dr. Patricia Robertson was born into a loving and traditional blue-collar family. Her mother said that she was showing "signs" of feminism when she was 5 and 6 years old—challenging the patterns of patriarchy that existed in her nuclear/elementary and extended family.  She received her undergraduate degree (in religion, after studying pharmacy for years) from University of North Carolina (UNC) at Chapel Hill, her masters (in counseling) from the Western Carolina University, and her doctorate (in counselor education) from UNC at Greensboro.  She held multiple positions in higher education—­ primarily as a faculty member and administrator. She had a private practice throughout her career in academia and was grounded in feminist theory in her practice. Her living is also grounded in feminism, and most of her life, she has been a strong social justice activist—focusing her energies on issues of oppression around ethnicity, affectional orientation, gender identity, and gender. 

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STUDENT EXERCISES Exercise 1: Wellness Goal

Directions: Consider one wellness goal you have for yourself. Explore books related to this topic and select one to read. After reading the book, engage in a creative process associated with one of the characters. Draw, paint, or write a story about how you might interact with that character and the outcome of that interaction. Discuss the book and your creation with a colleague.

Exercise 2: Theoretical Integration

Directions: It is important to note that not all theoretical philosophies can or should be integrated for the purpose of conceptualization. Core beliefs must be compatible. For instance, if one theory of interest proffers the belief that psychological truths exist that are the same for everyone and another theory that believes truth is completely subjective as a concept and is reliant on perception and agreement, integration may not be useful for case conceptualization. However, theoretical integration is different from technical eclecticism or assimilative integration (how techniques are used). Thus, discuss how you might decide to use a CB technique when working from a feminist conceptual frame.

Exercise 3: Feminist Contributor

Directions: Prior to class, read more about one of the contributors to feminist theory (e.g., bell hooks). Reflect on how their life experiences may have influenced their contributions to the theory. How might your life experiences influence how you choose to contribute to the counseling profession?

Exercise 4: Feminism and Counseling Techniques

Directions: At this time, it may be useful to think about a technique you read about earlier in the book. Pick something that seems interesting to you, something you would be willing to try. For instance, if you are interested in an Adlerian technique that involves the gathering of early memories, you may be wondering how this technique could be applied when thinking about client problems from a feminist perspective. As with any technical process, outlining the use of intervention as it relates to the goals of the client can help you decide if the technique will be useful.

Exercise 5: Treatment Benefits of Feminism

Directions: Think about the client population you are most drawn to work with. What are the limitations of feminist theory in your future practice with clients? What aspects of the theory may be beneficial to consider when conceptualizing client concerns? Discuss with a colleague.

RESOURCES Helpful Links ■ ■ ■ ■ ■ ■

An Online Feminist Journal: www.academinist.org/mp/ Association for Women in Psychology: www.awpsych.org Division 35 (Society for the Psychology of Women): www.apa.org/divisions/div35 Feminist Community: www.Feminist.com Feminism and Women’s Studies: http://feminism.eserver.org NCORE (The National Conference on Race and Ethnicity in Higher Education): www.ncore.ou.edu/en/

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Psychology’s Feminist Voices: https://feministvoices.com/ Women’s Studies Resources and Feminist Empowerment: http://womenstudies.homestead.com Women’s Therapy Centre Institute: www.wtci-nyc.org/ OQ-45: www.oqmeasures.com/oq-45-2/ Enns, C. Z. (1992). Toward integrating feminist psychotherapy and feminist ­philosophy. Professional Psychology: Research and Practice, 23(6), 453–466. https://doi. org/10.1037/0735-7028.23.6.453

Helpful Books ■ ■ ■ ■ ■ ■ ■ ■ ■

Belenky, M. F., Clinchy, B. M., Goldberger, N. R., & Tarule, J. M. (1997). Women’s ways of knowing: The development of self, voice, and mind (10th Anniversary ed.). Basic Books. Butler, J. (2006). Gender trouble: Feminism and the subversion of identity. Routledge. Brown, L. (2004). Subversive dialogues: Theory in feminist therapy. Basic Books. Eckert, P. & McConnell-Ginet, S. (2003). Language and gender. Cambridge. Hill, M. & Ballou, M. (Eds.). (1997). The foundation and future of feminist therapy. Haworth Press. Kolmar, W. K. & Bartkowski, F. (2013). Feminist theory: A reader (4th ed.). McGraw-Hill. Landrine, H. (Ed.). (1995). Bringing cultural diversity to feminist psychology: Theory, research, and practice. American Psychological Association. Romero, M. & Stewart, A. (Eds.). (1999). Women’s untold stories: Breaking silence, talking back, voicing complexity. Routledge. Worell, J. & Remer, P. (2003). Feminist perspectives in therapy: Empowering diverse women (2nd ed.). Wiley.

Helpful Videos ■ ■ ■ ■ ■

Feminist Therapy with Dr. Patricia Robertson, EdD: www.youtube.com/ watch?v=YuFmc3y72Nw Alexander Street: Series VIII, Feminist Therapy Over Time: https://video.alexanderstreet.com/watch/feminist-therapy-over-time TedTalks, Modern Feminism: www.ted.com/playlists/338/talks_on_feminism Annual Feminist Theory Workshops: https://gendersexualityfeminist.duke. edu/15th-annual-feminist-theory-workshop The Need for Critical Race and Feminist Theories in Health Equity: https:// ghsm.hms.harvard.edu/ghsm-events/proseminars-social-medicine/ need-critical-race-and-feminist-theory-health-equity

A robust set of instructor resources designed to supplement this text is available. Qualifying instructors may request access by emailing [email protected].

REFERENCES Alward, E. (2006). Feminist politics and human nature: World philosophers and their works. Salem Press. Bem, S. L. (1974). The measurement of psychological androgyny. Journal of Consulting and Clinical Psychology, 42(2), 155–162. https://doi.org/10.1037/h0036215 Bem, S. L. (1993). The lenses of gender: Transforming the debate on sexual inequality. Yale University Press. http://www.jstor.org/stable/j.ctt1nq86n Belgrave, F. Z., Chase-Vaughn, G., Gray, F., Addison, J. D., & Cherry, V. R. (2000). The effectiveness of a culture and gender-specific intervention for increasing resiliency among African American preadolescent females. Journal of Black Psychology, 26(2), 133–147. https://doi. org/10.1177/0095798400026002001

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Boysen, G.A., Vogel, D.L., Madon, S., & Wester, S. R. (2006). Mental health stereotypes about gay men. Sex Roles, 54, 69–82. https://doi.org/10.1007/s11199-006-8870-0 Brown, L. S. (1986). Gender-role analysis: A neglected component of psychological assessment. Psychotherapy: Theory, Research, Practice, Training, 23(2), 243–248. https://doi.org/10.1037/h0085604 Brown, L. (1994). Subversive dialogues: Theory in feminist therapy. Basic Books. Brown, T. L. (2018). Celebrate women’s suffrage, but don’t whitewash the movement’s racism. ACLU. Retrieved from https://www.aclu.org/blog/womens-rights/celebrate-womens-suffrage-dont-whitewashmovements-racism Burgess-Jackson, K. (1995). Rape and persuasive definition. Canadian Journal of Philosophy, 25(3), 415–454. doi:10.1080/00455091.1995.10717422 Burke, E., & Mitchell, L. G. (2009). Reflections on the revolution in France (Oxford world’s classics). Oxford University Press. Butler, J. (2009). Performativity, precarity and sexual politics. Antropologia Iberoamericana, 4(3), i-xiii. http:// dx.doi.org/10.11156/aibr.040305 Cazauvieilh, C., Gana, K., Miller, S. D., et al. (2020). Validation of the French versions of two brief, clinician-friendly outcome monitoring tools: The ORS and SRS. Current Psychology, 41, 6124–6136 https://doi.org/10.1007/s12144-020-00992-x Chesler, P. (2005). The death of feminism: What’s next in the struggle for women’s freedom. Palgrave Macmillan. Chodorow, N. J. (1978). The reproduction of mothering: Psychoanalysis and the sociology of gender. University of California Press. Choi, N., & Fuqua, D. R. (2003). The structure of the Bem Sex Role Inventory: A summary report of 23 validation studies. Educational and Psychological Measurement, 63(5), 872–887. https://doi. org/10.1177/0013164403258235 Chowdhury, E.H. (2009). Locating global feminisms elsewhere braiding US women of color and ­transnational feminisms. Cultural Dynamics, 21(1), 51–78. Chowdhury, E.H. (2010). Locating global feminism elsewhere. Cultural Dynamics, 21(1), 51–78. https://doi. org/10.1177/0921374008100407 Collins, P.H. (1986). Learning from the outsider within: The sociological significance of black feminist thought. Social Problems, 33(6), s14–s32. https://doi.org/10.2307/800672 The Combahee River Collective. (2014). A black feminist statement. Women’s Studies Quarterly, 42(3/4), 271–280. http://www.jstor.org/stable/24365010 de Beauvoir, S., & Parshley, H. M. (1953). The second sex (1st American ed.). Knopf de Beauvoir, S. (1974). The second sex: The classic manifesto of the liberated woman. Random House, Inc. Donovan, J. (2000). Feminist theory: The intellectual traditions (3rd ed.). Continuum. Duncan, B. (2011). The Partners for Change Outcome Management System (PCOMS): Administration, scoring, interpreting update for the Outcome and Session Ratings Scale. Author. Duncan, B. L. (2012). The partners for change outcome management system (PCOMS): The heart and soul of change project. Canadian Psychology/Psychologie Canadienne, 53(2), 93–104. https://doi. org/10.1037/a0027762 Enns, C. Z. (1992). Toward integrating Feminist psychotherapy and Feminist philosophy. Professional Psychology: Research and Practice, 23(6), 453–466. https://doi.org/10.1037/0735-7028.23.6.453 Enns, C. Z., Sinacore, A. L., Ancis, J. R., & Phillips, J. (2004). Towards integrating feminist and multicultural pedagogies. Journal of Multicultural Counseling and Development, 32, 414–427. Espín, O. M. (1993). Feminist therapy: Not for or by White women only. The Counseling Psychologist, 21(1), 103–108. https://doi.org/10.1177/0011000093211005 Foucault, M. (1977). Discipline and punish: The birth of the prison (A. Sheridan , Trans). Vintage Books. Freedman, E. (2003). No turning back: The history of feminism and the future of women. Ballantine Books. Friedan, B. (1963). The feminine mystique. Norton & Co. Fuss, D. (1989). Essentially speaking: Feminism nature & difference. Routledge. http://www.dawsonera.com/ depp/reader/protected/external/AbstractView/S9780203699294 Gilligan, C. (1982). In a different voice: Psychological theory and women’s development. Harvard University Press. Glendinning, S. (2011). Derrida: A very short introduction. Oxford University Press. Greene, B. (2005). Psychology, diversity, and social justice: Beyond heterosexism and across the cultural divide. Counselling Psychology Quarterly, 18(4), 295–306. https://doi.org/10.1080/09515070500385770 Greenspan, M. (1993). A new approach to women and therapy (2nd ed.). Tab Books.

Griffith, D. M., Brinkley-Rubinstein, L., Bruce M. A., Thorpe, R. J., Jr., & Metzl, J. M. (2015). The interdependence of African American men’s definitions of manhood and health. Fam Community Health, 38(4), 284–296. https://doi.org/10.1097/FCH.0000000000000079. Hahlweg, K., Heinrichs, N., Kuschel, A., & Feldmann, M. (2008). Therapist-assisted, self-administered bibliotherapy to enhance parental competence: Short- and long-term effects. Behavior Modification, 32(5), 659–681. https://doi.org/10.1177/0145445508317131 Hall, R. E., & Ohio Library and Information Network. (2021). The historical globalization of colorism. Springer. Hanna, F. J., Guindon, M. H., & Talley, W. B. (2000). The power of perception: Toward a model of cultural oppression and liberation. Journal of Counseling & Development, 78(4), 430–441. https://doi. org/10.1002/j.1556-6676.2000.tb01926.x hooks, b. (1989). Feminism: A transformational politic. In D. L. Rhode (Ed.). Theoretical perspectives on sexual difference (pp. 185–193). Yale University Press. hooks, b. (2000). Feminism is for everybody: Passionate politics. South End Press. Horney, K. (1942). Self-analysis. W. W. Norton and Company, Inc. Horney, K. (1945). Our inner conflicts: A constructive theory of neurosis. W. W. Norton and Company, Inc. Horney, K. (1967). Feminine psychology. W. W. Norton & Company, Inc. Hurtado, A. (1989). Relating to privilege: Seduction and rejection in the subordination of white women and women of color. Signs: Journal of Women in Culture and Society, 14(4), 833–855. https://doi. org/10.1086/494546 Iraurgi, I., & Penas, P. (2021). Outcomes assessment in psychological treatment: Spanish adaptation of oq-45 (outcome questionnaire). Revista Latinoamericana De Psicología, 53(1), 56–63. https://doi. org/10.14349/rlp.2021.v53.7 Israeli, A. L., & Santor, D. A. (2000). Reviewing effective components of feminist therapy. Counselling Psychology Quarterly, 13(3), 233–247. https://doi.org/10.1080/095150700300091820 Kolmar, W., & Bartkowski, R. (2005). Feminist theory: A reader (2nd ed.). McGraw Hill. Lambert, M. J., Gregersen, A. T., & Burlingame, G. M. (2004). The outcome questionnaire-45. In M. E. Maruish (Ed.), The use of psychological testing for treatment planning and outcomes assessment: Instruments for adults (pp. 191–234). Lawrence Erlbaum Associates Publishers. Lerman, H. (1986). From Freud to feminist personality theory: Getting here from there. Psychology of Women Quarterly, 10, 1–18. https://doi.org/10.1111/j.1471-6402.1986.tb00733.x Lipsitz-Bem, S. (1993). The lenses of gender: Transforming the debate on sexual inequality. Yale University Press. Lorde, A. (1995). Age, race, class, and sex: Women redefining sex. In J. Arthur & A. Shapiro (Eds.), Campus wars: Multiculturalism and the politics of difference (1st ed.). Routledge. https://doi. org/10.4324/9780429038556 Marecek, J., & Kravetz, D. F. (1977). Women and mental health: A review of feminist change efforts. Psychiatry: Journal for the Study of Interpersonal Processes, 40(4), 323–329. McClellan, M. J., Montross-Thomas, L. P., Remer, P., Nakai, Y., & Monroe, A. D. (2019). Development and validation of the awareness of privilege and oppression scale–2. SAGE Open, 9(2). https://doi. org/10.1177/2158244019853906 McRobbie, A. (2009). Inside and outside the feminist academy. Australian Feminist Studies, 24(59), 123–138. https://doi.org/10.1080/08164640802680635 Mercer, S. H., Zeigler-Hill, V., Wallace, M., & Hayes, D. M. (2011). Development and initial validation of the inventory of microaggressions against Black individuals. Journal of Counseling Psychology, 58(4), 457–469. https://doi.org/10.1037/a0024937 Miller, J. B., & Stiver, I. P. (1993). A relational approach to understanding women’s lives and problems. Psychiatric Annals, 23(8), 424–431. https://psycnet.apa.org/doi/10.3928/0048-5713-19930801-07 Murphy, M. G., Rakes, S., & Harris, R. M. (2020). The psychometric properties of the Session Rating Scale: A narrative review. Journal of Evidence-Based Social Work, 17(3), 279–299. https://doi.org/10.1080/264 08066.2020.1729281 Naylor, E. V., Antonuccio, D. O., Litt, M., Johnson, G. E., Spogen, D. R., Williams, R., McCarthy, C., Lu, M. M., Fiore, D. C., & Higgins, D. L. (2010). Bibliotherapy as a treatment for depression in primary care. Journal of Clinical Psychology in Medical Settings, 17(3), 258–271. https://doi.org/10.1007/ s10880-010-9207-2 Nelson, J. A., Leerkes, E. M., O’Brien, M., Calkins, S. D., & Marcovitch, S. (2012). African American and European American mothers’ beliefs about negative emotions and emotion socialization practices. Parent Sci Pract., 12(1), 22–41. https://doi.org/10.1080/15295192.2012.638871

Owen, J., Tao, K. W., Imel, Z. E., Wampold, B. E., & Rodolfa, E. (2014). Addressing racial and ethnic microaggressions in therapy. Professional Psychology: Research and Practice, 45(4), 283–290. https://doi. org/10.1037/a0037420 Pierre, M. R., Woodland, M. H., & Mahalik, J. R. (2001). The effects of racism, African self-consciousness and psychological functioning on black masculinity: A historical and social adaptation framework. Journal of African American Men, 6, 19–39. https://doi.org/10.1007/s12111-001-1006-2 Prochaska, J. O. (2013). Transtheoretical model of behavior change. In M. D. Gellman & J. R. Turner (Eds.), Encyclopedia of behavioral medicine. Springer. https://doi.org/10.1007/978-1-4419-1005-9_70 Rosser, S. V. (2005). Through the lenses of feminist theory: Focus on women and information technology. Frontiers: A Journal of Women’s Studies, 26(1), 1–23. https://www.jstor.org/stable/4137430 Rousseau, J. J. (2004). Discourse on the origin of inequality. Dover Publications, Inc. Russell, M. (1984). Microteaching feminist counseling skills: An evaluation. Dissertation Abstracts International, 44(8–B), 2568. Salzmann, G. (1790). Elements of morality (M. Wollstonecraft, Trans). Joseph Johnson. Scott, A. (1988). Feminism and the seductiveness of the ‘real rvent.’ Feminist Review, 28(1), 88–102. https:// doi.org/10.1057/fr.1988.8 Shelley, M. (1994). Frankenstein. Dover Publications. (Original work published 1831) Shin, R. (2015). The application of critical consciousness and intersectionality as tools for decolonizing racial/ethnic identity development models in the fields of counseling and psychology. In R. Goodman & P. Gorski. (Eds.), Decolonizing “multicultural” counseling through social justice. Springer. https://doi.org/10.1007/978-1-4939-1283-4_2 Sieber, J.A., & Cairns, K.V. (1991). Feminist therapy with ethnic minority women. Canadian Journal of Counseling, 25(4), 567–580. Smith, J. E. (2002). Race, emotions, and socialization. Race, Gender & Class, 9(4), 94–110. https://www.jstor. org/stable/41675277 The Sojourner Truth Project. (n.d.). Compare the two speeches. Retrieved from https://www.thesojournertruthproject.com/compare-the-speeches Stanik C.E., &Bryant C.M. (2012). Marital quality of newlywed African American couples: Implications of egalitarian gender role dynamics. Sex Roles, 66(3–4). https://doi.org/10.1007/s11199-012-0117-7. Sturdivant, S. (1980). Therapy with women: A feminist philosophy of treatment. Springer Publishing. Tiefer, L. (1991). A brief history of the association for women in psychology (AWP): 1969–1991. http://www. awpsych.org/index.php?option=com_docman&task=doc_download&gid=18&Itemid=118 Torres-Harding, S. R., Andrade, A. L., Jr., & Romero Diaz, C. E. (2012). The Racial Microaggressions Scale (RMAS): A new scale to measure experiences of racial microaggressions in people of color. Cultural Diversity and Ethnic Minority Psychology, 18(2), 153–164. https://doi.org/10.1037/a0027658 Wollstonecraft, M. (2008). A vindication of the rights of woman. Dodo Press. (Original work publish 1792) Worell, J., & Remer, P. (2003). Feminist perspectives in therapy: Empowering diverse women (2nd ed.). John Wiley & Sons Inc.

SECTION II

TRADITIONAL AND RELATIONAL PSYCHOANALYTIC THEORIES

4

TRADITIONAL PSYCHOANALYTIC APPROACHES Elyssa B. Smith, Andrea McGrath, Joshua Mangin, and Nicole Altenberg

LEARNING OBJECTIVES After reading this chapter, you will be able to: ■ Identify the history and legacy of psychoanalytic theory and practice ■ Understand the aspects of theory congruent psychoanalytic conceptualization and clinical practice ■ Apply a psychoanalytic approach to case conceptualization and clinical practice ■ Explain the multicultural, social justice, and intersectional aspects of the psychoanalytic approach to case conceptualization and clinical practice ■ Evaluate the limitations and recent trends within psychoanalytic theory, conceptualization, and clinical practice

INTRODUCTION Psychoanalytic approaches and theories draw their roots from classical Freudian concepts. Despite Sigmund Freud’s‌‌‌‌‌‌‌‌‌‌‌‌ lasting impact, psychoanalytic theory and approaches have expanded tremendously as his followers practiced and expanded upon the origins of psychoanalytic theory. In contemporary practice, psychoanalysis has evolved and continues to evolve through developments in the role of unconscious processes in human behavior (Jungian approaches), the importance of childhood development on later personality, and the use of the therapeutic relationship (object relations). This chapter on psychoanalytic approaches provides an overview of the following information related to psychoanalytic theory and practice: (a) the legacy of the theory founder(s), including Josef Breuer (1842– 1925), Sigmund Freud (1865–1939), Carl G. Jung (1875–1961), and Donald W. Winnicott (1896–1971); (b) personality development; (c) the origin and nature of mental health concerns; (d) what constitutes emotional/psychological well-being; (e) the roles of the client and counselor; (f) the nature of human development; (g) process of change; (h) description of how progress is maintained; (i) process of clinical assessment; (j) theoretical techniques; (k) multicultural/intersectional/social justice issues; (l) relevant theory-based scholarship/ research trends; (m) detailed theoretical case conceptualization pragmatics; (n) theoretical limitations; and (o) a transcript of a psychoanalytic counseling session.

LEADERS AND LEGACIES OF TRADITIONAL PSYCHOANALYTIC THEORY Psychoanalysis forms the foundation of all counseling and psychotherapy practice. To understand the theoretical nature and approaches to psychoanalysis, it is vital to consider

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the personal, emotional, and intellectual influences in the lives of the founders of each school of thought. The following sections contain brief synopsis of the legacy of the founders of each school of thought within psychoanalysis and their major contributions to the theory. The overview begins with Josef Breuer, credited with the invention of the “cathartic method” that ultimately led Freud to the creation of psychoanalysis.

Josef Breuer (Cathartic Method; 1842–1925) Josef Breuer was born in Vienna, Austria, in 1842. His father, Leopold Breuer, was a religious teacher within the Jewish Community of Vienna. Breuer was raised by his maternal grandmother, as his mother died while he was still very young. Breuer received his education from his father until the age of 8. From age 8, he attended and graduated from the secondary school Akademisches Gymnasium of Vienna. Shortly after graduating from the school in 1858, Breuer enrolled in medical school at the University of Vienna, where he focused on internal medicine and physiological processes. Ten years later, he married Matilda Altmann. Over time, they had a total of five children together. Breuer continued in private practice studying the physiology of the ear and published several scientific papers over the span of 40 years. It was not until 1880 that he engaged in his first observation of the development of mental health issues in one of his patients, “Anna O.” Breuer experimented with the use of hypnosis in the treatment of Anna O, a young girl who experienced symptoms of paralysis and mental confusion. He found that her symptoms were temporarily relieved when he put her into a hypnotic state and invited her to speak freely about her troubles (Cranefield, 1970). As a result, Breuer began collaborating with Sigmund Freud on Studies in Hysteria (Breuer & Freud, 1895/2004). Their work detailed 13 cases using the cathartic method as a cure for symptoms of hysteria. The cathartic method centers around the idea that the source of neuroses comes from the patient holding in painful affect, causing mental distress; therefore, by engaging in verbal expression of trauma and past experiences during hypnosis, the patient experiences a sense of relief, or “catharsis.” However, Freud believed that traumatic events were the cause of hysteria based on sexual notions stemming from the patient’s childhood. Breuer deeply disagreed with this hypothesis and found it offensive, ultimately leading to the termination of their relationship and work together (Hirschmuller, 1989). CONTRIBUTIONS

Discovering the cathartic method, the idea that perception and memory are two separate psychic processes, theories regarding hallucinations, and using hypnosis in psychotherapeutic treatment

Sigmund Freud (Classical/Drive; 1865–1939) Sigmund Freud was born in the small town of Freiburg, Austria, to Amalie (Nathansohn) Freud and Jakob Freud. He was the eldest of eight children; however, his father had two sons from a former marriage and was 42 years old at the time of his birth. When he was 4 years old, his father felt that there would be more favorable opportunities for his wool merchant business in a larger city, and he moved the family to Vienna. Freud proved to be an intelligent and gifted child from an early age and was encouraged by his young mother to focus on his schoolwork and studies. Her high hopes for him paid off as Freud was first in his class during his early school. Freud learned and spoke several languages, including Greek, Latin, Hebrew, English, and French. He then taught himself Italian and Spanish and read Shakespeare at age 8. From 1866 to 1877, he attended secondary school and graduated with the highest honors (summa cum laude; Ellenberger, 1970). During the winter of 1873, Sigmund began his medical studies at the University of Vienna. Upon the completion of his medical education, Freud elected to study under the prestigious

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physiologist Ernst Wilhelm Brücke. From 1877 to 1883, Freud worked as Brücke’s assistant and was tasked to examine the biology of nervous tissue in the brain. Freud was highly influenced by Brücke’s theory that all living things are dynamic in nature and abide by the laws of physics and chemistry, and often credited Brücke as the professor who shaped him (Gay, 2006). Brücke was also responsible for introducing Freud to Josef Breuer. Breuer served as a mentor to Freud and was the first to expose him to the complexities of mental distress and hysteria illness. Freud believed that Breuer’s patient “Anna O” was his most significant patient, and the two spoke about her treatment in detail. During these discussions, Freud made it known that he was disappointed in Breuer’s lack of attention to the sexual aspects of her case, which embarrassed Breuer (Cranfield, 1970). Breuer fundamentally disagreed ‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌ with Freud’s view on sexuality and its place in neuroses, leading to the termination of their relationship and work together, although the roots of psychoanalysis developed out of Freud’s work with Breuer. The first time Freud used the term psychoanalysis was in 1896. For the next 30 years, psychoanalysis underwent both growth and development under his leadership and soon became a significant force in Europe and later in the United States (Higdon, 2012). CONTRIBUTIONS ‌‌‌‌‌‌‌‌‌‌‌‌

The idea that our childhood experiences make us who we are, the concept of free association, the importance of the therapeutic relationship, the unconscious mind, the topographic approach to mental processes, defense mechanisms, Ethos/Thanatos, libido, the dynamic model, psychosexual stages of development, and the structural theory of personality

Carl G. Jung (Jungian Psychology; 1875–1961) Carl Gustav Jung was born in 1875 in Kesswil, Switzerland, to a family of theologists and religious leaders. His paternal grandfather was a distinguished and well-known physician in Basel while eight of his uncles were pastors, and his maternal grandfather was a theologian who held a prestigious position within the Basel Swiss-reformed church. Jung had a unique, lonesome, and unhappy childhood. He spent a great deal of time alone and had trouble socializing with peers. After completing his secondary education, Jung enrolled in medical school at the University of Basel. He earned his medical degree in 1902. After completing medical school, Jung decided to work in Zürich with Eugen Bleuler on mental illness studies. Jung’s notion of the complex or cluster of emotionally charged (and largely unconscious) associations was developed due to his work with Bleuler. Jung, like several‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌ other psychoanalytic founders, was influenced by Freud’s work. From 1907 to 1912, he was one of Freud’s closest collaborators; however, he broke with Freud over the notion of the sexual basis of neuroses. Although the break in their relationship was extremely difficult for Jung, it led him to ignite a 6-year exploration into his unconscious (Jung, 1963‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌). Following this period, Jung began writing, practicing psychotherapy, teaching, and traveling to meet people from Indigenous societies. These events led Jung to create the field of analytic psychology. CONTRIBUTIONS

Individuation, introverted and extroverted personalities, archetypes, collective unconscious, the use of dreams, fantasy, and imagination to promote awareness of unconscious material, mandala, and sandtray

Donald W. Winnicott (British School of Object Relations; 1896–1971) Donald Woods Winnicott was born in Plymouth, England, in 1896. Like Freud, Winnicott was born to an older father who was 41 at the time of his birth. Winnicott was surrounded by women from an early age and described himself as having “multiple mothers.” Winnicott was sent to boarding school at age 14, where he thrived despite feeling upset about his

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father’s decision to send him away. During his time at boarding school, Winnicott was drawn to the work of Charles Darwin, which inspired and led to his decision to pursue a career as a physician. He entered medical school at Jesus College in Cambridge in 1914 and joined the British Royal Navy in 1917. Upon returning from the navy, he finished his degree at the University of London’s St. Bartholomew’s Hospital Medical College. In 1923, Winnicott began his career as a pediatrician at the Paddington Green Children’s Hospital, where he remained until 1962 (Higdon, 2012). During this time, he conducted several direct observations of the relationship between infants and mothers, which led to the basis of his idea and contributions to the object relations school of psychoanalysis (Winnicott 1965, 1975). CONTRIBUTIONS

Good enough mother, holding and containment, transitional object, and true and false self

PERSONALITY DEVELOPMENT Psychoanalytic approaches emphasize the importance of human development from birth onward and focus on the influence of early child development on the formation of adult personality and functioning.

Psychoanalytic (Classical/Drive) From a classical psychoanalytic perspective, the structure of personality contains three basic systems: the id, ego, and superego‌‌‌‌‌‌‌‌‌. The id is composed of biological drives and forces. At the same time, the superego represents the voice of conscience, and the ego is the mediation between these two extremes based on the notion of reality. The id is the structure of the psyche that encompasses an individual’s biologically based instincts/drives and desires and is related to one’s unconscious processes. At birth, the infant is based upon the id without conscious awareness. The id operates on the pleasure principle as it tries to find pleasure and avoid pain. The superego acts as the structure of morality and judgment. It determines how the ego will function and what is acceptable. Its function is to manage the id’s desires/ impulses and transform them into acceptable thoughts or behaviors with the reality principle and the morality of the superego. If the ego ‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌ is unable to adapt, the id’s impulses react in such a manner that neuroses or psychological symptoms may arise.

Jungian In his study of human personality, Jung developed a typology that focused on attitudes and functions of the psyche across various levels of consciousness. He described human personality through the typology of thinking and feeling, sensation and intuition (functions), extroversion, and introversion (attitudes; Bair, 2004). Personality types are seen as bipolar (such as extraversion and introversion), meaning only one type could be expressed at a time, but each person can express the other pole (Merikangas et al., 2011) In addition to Jung’s typology, Jung also developed an in-depth model of the human psyche. This conceptual view of personality centers on the notion of wholeness and unity, which is represented by the psyche in the form of all thoughts, feelings, and behaviors, both conscious and unconscious. As individuals develop throughout their lifetime, the s‌elf makes up both the center and totality of personality. According to this view, the human psyche contains various parts that can greatly influence the behavior and motivation of the individual (Samuel, 1994). In addition, Jung’s model of the psyche contained the personal unconscious (like Freud’s model), which consisted of unconscious memories and experiences that occurred within the individual throughout their life, and the collective unconscious, which taps into historical and cultural memories that transcend individual experiences (Stein, 2010).

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Important parts of the unconscious that are unique to Jungian psychology include the persona, the shadow, and the self‌‌‌‌‌‌‌‌‌ (Russell-Chapin et al., 1996). The persona is essentially the “masks” individuals wear in public. Commonly, the persona is used to display a socially acceptable personality. If one is not careful, it can be easy to identify with the social masks we wear, and in this case, we can forget who we are (‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌Hudson, 1978). The shadow consists of all parts of our self that are repressed and kept out of our awareness (Casement, 2003)‌‌‌‌. From Jung’s model, the traits of the best person and the worst person imaginable exist within their shadow. It is not uncommon for Jungian psychotherapy to help clients befriend their shadow side. According to ‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌Robert Johnson (1994), by becoming familiar with our shadow self‌‌‌‌‌‌‌‌‌, we can stumble upon the gold in our shadow, which is a metaphor for discovering our unique potential. This process allows our true self‌‌‌‌‌‌‌‌‌ to become expressed. The self‌‌‌‌‌‌‌‌‌ promotes harmony and wholeness of the psyche resulting in one reaching their full unique potential (Spoto, 2021).

Object Relations Object relationists are particularly interested in how an individual’s early relationship with their primary caregivers form the foundation of their personality. According to Winnicott (1965), the development of personality occurs during three overlapping stages in infancy: holding both physically and psychologically for the infant over time; mother and infant living together in which the infant moves from dependence to independence; and father, mother, and infant living in a facilitating environment. If all three are present, the infant develops an internal working model of their caregivers, which becomes the template for how the world works. Overall, these concepts integrate the intrapsychic and interpersonal dimensions of the psyche and emphasize that external relationships constantly interact with a person’s internal psychic structure (Scharff & Scharff, 1992).

ORIGINS AND NATURE OF MENTAL HEALTH CONCERNS Psychoanalytic (Classical/Drive) The concept of the unconscious mind is central to psychoanalytic theory and attempts to explain the origin of mental health concerns. Freud theorized there must be unconscious after observing patients who presented with hysterical disorders undergo hypnosis. He watched these patients discuss their repressed thoughts and memories, and eventually, their pathological symptoms subsided. The term unconscious describes the repressed, overwhelming feelings and memories (usually rooted in childhood desires, experiences, and trauma) that an individual is unaware of or is “unacceptable” to one’s mind. In contrast, the term conscious describes the part of one’s mind that an individual is aware of and accepts. Neuroses were thought to be the result of the conflict between one’s conscious and unconscious processes (Bateman et al., 2021). Another central aspect of classic psychoanalytic theory centers on the notion that many mental disorders and concerns are based upon unconscious emotions such as rage, guilt, shame, envy, and anxiety. Freud referred to this as the structural theory of emotion. Based upon the structural theory of emotion, Freud stated that emotions are understood as responses to the internal and external environment which produce an adaption function. According to the structural theory of emotion, anxiety is the basis of all negative affect. The purpose of anxiety is to alert us to some source of danger and prepares us to respond to this threat or dangerous situation. Outside of anxiety, emotions such as shame, envy, guilt, and depressive affect also serve as an adaptive response to perceived danger or threats. To cope with anxiety, the ego develops a means to manage situations. When such emotions overwhelm an individual, it often triggers defense mechanisms that push these

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negative and difficult emotions out of our awareness, keeping distressing experiences from becoming conscious (McWilliams, 2014). If used appropriately and infrequently, defense mechanisms can offer an adaptive way to manage stress and anxiety. However, when maladaptive defense mechanisms become commonplace for individuals to ward off negative and unpleasant emotions, psychological distress emerges over time leading to pathology and the development of mental health concerns (Schultz & Schultz, 2013). DEFENSE MECHANISMS

Table 4.1 provides a list of common defense mechanisms and a description of their function.

Jungian From a Jungian perspective, mental health concerns are the result of a fragmented psyche. In other words, disturbances occur when the client lacks a sense of psychological wholeness. In this state, one may feel a lack of personal meaning, disconnection from others, and limited self-knowledge (Schmidt, 2019). Fragmentation of the psyche can occur in both the personal and collective unconscious. For example, traumatic and stressful past experiences can lead to complexes (a set of schematic behaviors that tend to stem from past experiences). From a collective perspective, trauma can also be viewed through an intergenerational and historical lens. When the collective psyche is fragmented, archetypes (i.e., recurring patterns of human behavior that are seen throughout time) can impact and overtake one’s psyche (‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌Chall, 2023; Moore & Cross, 2014). It is important to note that, within Jungian psychology, there is a trend to see mental health concerns occurring for one to develop and grow as a person (‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌Pearson, 1991; Stein, 2010). In other words, fragmentation and disintegration are prerequisites for wholeness and integration.

Object Relations Early caregiver and interpersonal relationships are extremely influential in psychological health outcomes, according to object relations theories. Object relations theory dictates that the origins of mental health concerns are due to unresolved issues stemming from early primary relationships where they were unable to develop an internalized object (i.e., mental/emotional images that are mentally internalized). These issues can ‌‌‌‌‌‌‌‌‌‌‌‌‌‌ manifest themselves in several ways in clients’ lives; for example, the patient who comes in and states, “I always seem to date the same type of guy” (abusive, alcoholic, etc.), or a patient who feels a chronic sense of emptiness and lack of fulfillment in life (a lack of intimacy in relationships with others). Taken further, object relationists view psychopathology as a direct product of deprivation and environmental failure (Mitchell, 1984). According to Mitchell (1984), there are certain types of interpersonal experiences necessary for the growth of self. When these are lacking, the central features of the child remain buried, uninvoked, and frozen. In treatment, the patient enters the consulting room, presenting themselves as an empty person, missing a core. The therapist must then bring the patient to life by providing a receptive environment and assisting the patient in revealing their true self. Therefore, the therapist needs to take on the role of the early caregiver if they wish to facilitate healing and reparation. As Winnicott (1986) stated, “psychotherapy aims simply and solely to undo a psychological hitch in the individual’s emotional development, so that development may take place where it formerly could not” (p. 103). Object relations theory emphasizes two positions: the paranoid–schizoid position and the depressive position (Higdon, 2012). The paranoid–schizoid position describes the fear and anxiety around annihilation, disintegration, and abandonment. To deal with these fears, the individual tends to “split” objects and relationships into all-good or all-bad experiences. The

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Table 4.1. Defense Mechanism, Definition, and Example Defense Mechanism

Definition/Function

Example

Repression

Purposeful hiding or‌‌‌‌‌‌‌‌‌‌‌‌‌‌ intended forgetting excludes painful experiences, memories, or thoughts/feelings from conscious awareness

Traumatic events such as sexual abuse during the first 5 years of life often become repressed and unconscious.

Denial

Refusal to admit that something occurred

Hearing that a friend died in a car accident and denying that it occurred or that the friend is dead

Reaction formation

Behaving in the opposite manner

Feeling sad about a recent end to a friendship but instead acting happy about it

Rationalization

A false but personally tolerable explanation for one’s behavior often used as a way to lessen a failure or loss or soften disappointment

Doing badly on an exam and stating there was not enough time to study for it

Projection

Placing one’s own feelings onto someone else

Experiencing disappointment in a relationship and assuming that all of your friends have disappointing relationships with their significant others

Intellectualization

Avoiding painful feelings by ­removing all emotions and instead focusing only on ideas and ­quantifiable facts

The person in a marriage who asks for a divorce decides to focus on issues related to their purpose in life rather than deal with the pain and sadness they are experiencing.

Compartmentalization

Separating different parts of one’s emotional life

Viewing yourself as caring and naturing at home but a tough and cold person at work

Displacement

Relocating a feeling about one situation or person onto another situation or person

Feeling angry about a coworker due to their lack of teamwork and yelling at the dog instead

Undoing

Ritualized or repetitive behavior to create an impression of control

Two friends have an intense argument. When they meet again later that day, they both act like nothing happened and are overly nice to one another.

Fixation

Clinging/reverting back to a certain developmental phase

Oral fixations (gum chewing, excessive drinking, overeating)

Regression

Moving back to an earlier developmental phase

Holding a teddy bear when stressed like you did when you were a child

Withdraw/avoidance

Emotional or behavioral departure from painful situations

Refusing to go to dinner at your favorite restaurant because you had an argument with your ex-­boyfriend there

Sublimation

Converting a negative or socially unacceptable impulse into more acceptable outlets

Experiencing anger and the urge to express physical aggression but instead going to a gym and signing up for boxing lessons where the aggression can be channeled into fitness

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bad experiences are then projected on the object threatening the good and causing a distortion of reality. The depressive position depicts the anxiety and fears one feels for the well-being of the object. A person enters a depressive position when they can understand that the “bad” object is the same as the “good” object that provides gratification and love. This realization causes the individual to feel guilt, ambivalence, and depression. Throughout an individual’s life, they continuously go through these positions. Borderline and other psychological disorders can result from intense splitting and projection due to the misperception the individual experiences and the disjunction of objects and relationships (Winnicott, 1986).

EMOTIONAL AND PSYCHOLOGICAL WELL-BEING Throughout the psychoanalytic counseling progress, the goal of treatment is to eventually aid the patient in achieving emotional and psychological well-being. Across psychoanalytic theoretical schools of thought, emotional and psychological well-being occurs when an individual can develop self-understanding, insight, and a resolution of unconscious conflicts within themselves. This insight and resolution allow for more satisfaction in one’s life, love, and work. Additionally, emotional and psychological well-being means that the individual now has a developed understanding and a more adaptive way to deal with conflicts that surface within themselves. As a result, the individual will know themselves better and their reactions to others within relationships will feel more authentic. In turn, the individual has productive and healthy relationships with family, friends, and coworkers and can distinguish their own perspectives and views of reality (Sharf, 2016). From a classic psychoanalytic conflict/drive perspective, emotional and psychological well-being is constituted by helping the patient gain insight into id processes and use this awareness to control the ego (‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌Freud, 1923; Stiles et al., 1995). For Jungians, psychological health and well-being come from wholeness and unity in the psyche, including one’s thoughts, feelings, behaviors, and aspects of mental life (both conscious and unconscious). Such wholeness and ‌‌‌‌‌‌‌‌‌‌‌‌‌‌ integration of the parts of oneself lead an individual to a sense of fullness and help them achieve individuation. Individuation is a dynamic process in which one embodies their unique self, which Jung believed was a lifelong process (Sedgwick 2001). Finally, an object relations perspective maintains that emotional and psychological well-being is achieved through uncovering separation and individuation issues to build and improve upon a secure sense of self in relation to others.

ROLES OF CLIENT AND COUNSELOR The counselor’s role is to aid the patient in reviewing emotions, thoughts, early-life experiences, and beliefs to gain insight into their lives and their present-day problems and to evaluate the patterns they have developed over time. The counselor’s role is to aid the patient in recognizing recurring patterns among themselves and others, which helps the client/patient see how they avoid distress or how they have developed defense mechanisms as a method of coping. Once the client becomes aware of this process, gains insight, and has a corrective emotional experience, the patient can take steps to change those patterns/dynamics in relationships with others. A corrective emotional experience is essentially reexposing a client to a past experience that can now be integrated due to taking place in a safer environment.

Psychoanalytic (Classical/Drive) In the psychoanalytic situation, the unconscious thoughts and desires a client is experiencing emerge through the therapeutic relationship with the counselor. Through free association, the counselor can make meaning of these unconscious thoughts or desires they detect and form interpretations based on them. To successfully undergo psychoanalysis,

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the client must be able to recollect previously experienced memories, reflect inward upon themselves even when it is painful, speak on their free thoughts, and regress in service of the ego (Bateman et al., 2021). The counselor’s job is to be an attentive listener and make suggestions regarding the interpretations they make to the client. Responses to the interpretations are then dissected by the counselor. The counselor is also responsible for helping the client develop healthier ways of coping with stimuli that elicit immature defense mechanisms. Analyses made by the counselor may be detected through transference, which is the reenactment of infantile wishes, conflict, or deficiencies in session toward the counselor. Clinicians use transference as a mechanism to gain insight into internal conflicts inhabited by the client without them being verbally expressed. Psychoanalysts must also be aware of any type of countertransference they may be experiencing toward the client. The term countertransference‌‌‌‌‌‌‌‌‌‌‌‌‌‌ refers to the therapist’s feelings toward the patient (Bateman et al., 2021); for example, when the patient generates feelings in the therapist that helps them understand how the patient generally affects and makes others feel. Initially, Freudian analysts believed the presence of countertransference imposed a negative impact on the treatment process and limited the counselor’s ability to detect and make meanings of the unconscious thoughts the patient was experiencing. However, countertransference is no longer considered an inherently obstructive force in therapy now. When the counselor is aware of their countertransference, they can have greater empathy for the client and a better understanding of the conflicts present (Lupentiz, 2008).

Jungian The common thread across various Jungian schools of thought is that the counselor tends to take a nondirective approach. The client is seen as the expert, and the counselor is a guide to help assist the client in their unique developmental journey. At times, it is permissible for the counselor to take a more direct approach, especially providing interpretations of unconscious material. In the case of interpretations, Jungians are encouraged to remember that the client is the sole individual who has the final say in determining if the interpretations are accurate (Winborn, 2019). Within Jungian psychology, it is believed that a counselor can only take a patient as far as the counselor has been on their own individuation journey (Sedgwick, 2001). Therefore, there is much encouragement for the counselor to participate in their own therapy.

Object Relations From the object relations perspective, the counselor’s role is viewed differently than in psychoanalytic theory. Instead of searching for the client’s unconscious drives in session, the counselor’s role is to notice the client’s projections and present them to the client when the counselor believes the client is ready to receive them. Object relations theorists interpret transference as an expression of internalizations of both past (fantasy) and present (reality) object relations that cause conflict in the client’s psychic structure. Counselors can encounter countertransference in two different forms: complementary countertransference and concordant countertransference. Concordant countertransference is a term used to encompass the counselor’s empathetic thoughts and feelings associated with the client. In contrast, complementary countertransference describes the counselor’s feelings that resonate with a past or present object relationship the client has or has had previously in their life. When taking on a new client, counselors look for a sense of mutual accommodation with the prospective client in the initial intake session. Mutual accommodation refers to a harmonious connection with another person where opinions and interpretations can be communicated effectively. They also search for the client’s ability to let their emotions emerge freely, the capacity to express them in session, and the motivation for change.

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NATURE OF HUMAN DEVELOPMENT Psychoanalytic (Classical/Drive) Freud viewed the newborn’s mind as being fully encompassed by the id or instinctual pleasure-seeking drives. He theorized that development occurred through five psychosexual stages: the oral stage (0–18 months old), anal stage (18 months to 3 years old), phallic-­oedipal stage (3–6 years old), latency stage (6 years old to puberty), and genital stage (puberty through adulthood). Every stage described a time when the child’s libido was focused on a specific “erogenous zone.” Individuals go through these stages in the same order, and “fixations” occur when they experience an excessive or deficient amount of ­satisfaction in a particular stage. These stages are also associated with different personality types. The oral stage deals with one’s feelings of safety and security, whether they were nurtured sufficiently by their caregiver. An orally fixated personality is associated with needy or dependent personality characteristics and aggression. The orally fixated individual may seek oral stimulation in other ways throughout their life. Those who become fixated during the anal stage are believed to develop a controlling and stubborn personality. This is due to this stage centering around the infant gaining control of their bowel movements and autonomy over their bodies. The genitals are the erogenous zone during the phallic-oedipal stage. This is also a time when children become more competitive. Freud posits these children present with an “Oedipus (or Electra) complex” in which they exhibit jealousy and hostility toward one parent (usually the parent of the same sex) out of rage that they are taking the attention of the other parent (usually the one of the opposite sex) away from the child. Healthy development occurs when these feelings are resolved, the child identifies with the same-sex parent, and libido is shifted toward peers due to greater maturity of the ego and superego. During the latency stage, children are less driven by their libido and practice other social/life skills. The genital stage serves as the final stage, and adolescents are driven by their libido once again, this time toward their peers and potential life partners (Bateman et al., 2021).

Jungian Jung wrote about developmental issues across the life span and was particularly drawn to the notion of midlife issues and the role of spirituality in shaping an individual’s life and sense of self. A unique aspect of Jungian psychology focuses on the idea of complexes which are emotionally laden notions tied to an archetypal image. Complexes can surface at any point in an individual’s lifetime; however, they are considered especially common during midlife.

Object Relations Based on an object relations approach to psychoanalytic treatment, individuals are object-seeking and are driven based on their need to have relationships with others. Objectseeking behavior changes according to stages of development, beginning with feeding and mutual gazing and then transitioning into having common interests and shared experiences (Bateman et al., 2021). In early infancy, the child experiences “good,” pleasant, nurturing feelings when they have an attentive caregiver that consistently provides food, physical contact, and warmth. However, the child also experiences “bad” or negative feelings if these areas are deficient, causing the child to feel hungry, cold, and abandoned. An infant’s ego is unable to experience both “good” and “bad” feelings at the same time, which causes “splitting” to occur. The classic example used is the splitting of the mother’s breast into a “good” breast and a “bad” or persecutory breast that attempts to keep the “good” breast away. These good experiences

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are internalized by the infant, referred to as introjection, while bad experiences are separated and projected externally (Bateman et al., 2021). The primal “paranoid–schizoid position” occurs during the first 4 to 6 months of the infant’s life and refers to their attempt to keep the “good” breast safe from the “bad” breast. Later during the first year of an infant’s life, they reach the “depressive position” where good and bad are no longer completely split or separated. Instead, the child understands the object that they were originally fearful of is also the object they love and desire. Theorists believe that an individual will go through these two positions periodically, especially during major milestones or crisis points of development. Object relations also emphasize that familial relationships in a child’s life serve as models for relationships they will have with others. The internalization and introjection the infant experiences with a primary caregiver cause them to develop similar personality traits.

PROCESS OF CHANGE In a practical sense, the process of change occurs as the counselor aids the client in reviewing emotions, thoughts, early-life experiences, and beliefs to gain insight into their lives and present-day problems and evaluate the patterns they have developed over time. The client’s insight into recurring patterns helps the patient see how they avoid distress or how they have developed defense mechanisms as a method of coping. Once they become aware of this process and gain insight, the patient can take steps to change those patterns/dynamics in relationships with others.

Psychoanalytic (Classical/Drive) The therapeutic process is unique to each client and ideally produces a meaningful change in the client’s life. The center of change within psychoanalysis involves the client gaining awareness of their internal conflicts and why they occur from the treatment they undergo with the counselor. This tends to arise through transference in session. Change occurs in treatment through a process in which the consistency of the environment is vital, for it allows the client to explore expressing themselves to the counselor fully. Optimism, regression, and doubt in one’s improvement are both parts of an individual’s path to undergoing successful psychoanalysis. The doubt and regression that the client exhibits in session allow for interpretations of the unconscious to be made by the counselor. Once these interpretations are accepted by the client, the counselor is then able to provide more appropriate coping mechanisms to the client. Resistance occurs when the client attempts to block the counselor’s suggestions. Resistance can be conceptualized as a normal part of the therapeutic process. This can include the client terminating treatment or threatening to do so. Freudian theorists emphasize working through resistance as being a key part of the client’s improvement. Empathy from the counselor is also crucial to diminishing deficits the client has from previous experiences in their lives. Successful termination involves the client’s symptoms subsiding, and external indicators are typically present as well (e.g., an increase in positive/healthy relationships).

Jungian The focus of analysis within Jungian psychology is to work with unconscious processes and form more conscious awareness about them. As the therapy progresses over time, the patient moves toward a stronger, more individualistic, and holistic sense of self. Jungians focus highly on the process of treatment and understand that each individual works toward their unique psychological reality in a nonlinear fashion. From a Jungian perspective, regression and progression are part of life. Some clients’ symptoms may return, but rather than seeing this as a failure, it can be reframed as part of the journey of life. However,

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one way to mitigate regression and symptoms from returning is by practicing daily wholeness (Stein, 1996). Giving space to work with unconscious forces on the natural cycles of life daily will foster a healthy relationship with the unconscious and prevent fragmentation of the psyche. Daily practices should have a balance of solitary and social activities. Solitary activities can include dreamwork and creative projects. Social activities include building and maintaining healthy relationships with others as well as partaking in meaningful work.

Object Relations In object relations therapy, change is centered on the relationships the client has with others and their relationship with themselves. The counselor aids the client in advancing from the paranoid–schizoid position to the depressive position. They do this by offering suggestions/instances of the client exhibiting splitting (i.e., separating objects as good and bad and repressing the bad objects), projective identification (i.e., protecting the self by splitting off part of the ego and projecting it onto an object), and misperception with the counselor. Transference is often how these processes are presented to the counselor, and resistance can occur if the client is not receptive to the counselor’s suggestions. Once the client enters the depressive position, they view relationships as neither “all-good nor all-bad” and instead begin to conceptualize relationships more holistically. Object relations theorists have also examined the relationship between counselor and client and the unconscious interactions they have with one another as a mechanism that produces a change within a client. Resistance in this examination is characterized by the client regressing in session and viewing the counselor as a “bad object.” However, through psychoanalysis, the client will eventually grow and improve their self-image after receiving compassion through their positive relationship with the counselor.

Maintenance of Progress Across various psychoanalytic approaches, progress is maintained through consistent, ongoing sessions over time. Throughout these sessions, patients resolve unconscious material and conflicts within themselves and develop a deeper sense of self-understanding. Hence, psychoanalysis aims to bring about changes in one’s personality and character structure. Given the depth nature of this work, progress is maintained by movements in the patient’s insight and self-awareness. However, this insight must bring about changes in feelings and behaviors that lead to action and the ability of patients to better deal with the dysfunctional and repetitive patterns in their lives. From a Jungian perspective, regression and progression are part of life. Some clients’ symptoms may return, but rather than seeing this as a failure, it can be reframed as part of the journey of life. However, one way to possibly mitigate regression and symptoms from returning is by practicing daily wholeness (Stein, 1996). Giving space to work with unconscious forces that impact the natural cycles of life daily will foster a healthy relationship with the unconscious and prevent fragmentation of the psyche. Daily practices should have a balance of solitary and social activities. Solitary activities can include dreamwork and creative projects. Social activities include building and maintaining healthy relationships with others as well as partaking in meaningful work.

CLINICAL ASSESSMENT Clinical assessment within psychoanalysis varies depending on the approach and length of treatment. Psychoanalytic psychotherapists value the concept of understanding the patient and the depth of their problems across time and within the counseling process and relationship. Some approach the assessment process through a structured inventory during the first few sessions related to family and social history, while other analysts prefer to use the first

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few weeks of treatment, often known as the “trial analysis,” to assess the appropriateness of psychoanalytic psychotherapy (Cooper & Alfille, 2011). Across various psychoanalytic approaches, clinical assessment occurs over time as the counselor listens for unconscious motivations, early childhood issues, and relational patterns and applies an understanding of personality development to assess the patient’s core issues (Gabbard 2004, 2005).

Formal Psychoanalytic Assessments (Psychodynamic Diagnostic Manual and Working Alliance Inventory) PSYCHODYNAMIC DIAGNOSTIC MANUAL (PDM, PDM-2; PDM TASK FORCE, 2006)

The PDM is a diagnostic framework that covers an individual’s personality and emotional, cognitive, and social/interpersonal patterns (PDM Task Force, 2006). This diagnostic approach is not intended to replace the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Text Revision (DSM-5-TR; ‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌American Psychiatric Association, 2022) or the International Statistical Classification of Diseases and Related Health Problems, Tenth Edition (ICD-10; World Health Organization, 2004) but rather complements and adds to these models of diagnosis for case formulation and treatment (McWilliams & Shedler, 2017). However, there are several distinct philosophical differences between the PDM and DSM-5-TR. The PDM aims to further clinicians’ understandings and conceptualizations of an individual’s difficulties within the larger context of their personality functioning. PDM diagnoses are presented on a spectrum or continuum, honoring the dynamic nature of human beings and relational processes (McWilliams & Shedler, 2017). Additionally, the PDM, “in contrast to the DSM-5 alternative model, emphasizes clusters that reflect underlying themes and tensions rather than discrete trait dimensions” (McWilliams & Shedler, 2017, p. 63). Overall, the PDM postulates that mental health is more than the absence of symptoms of psychopathology (‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌McWilliams, 2011). The PDM considers subtle sources of pain that reside within an individual. For example, instead of simply providing a diagnostic label of anxiety disorder to an individual based on their symptoms, the PDM considers how the individual’s inability to perceive and respond accurately to the cues of others may be pervasively compromising their relationships and thinking and that those underlying tensions and patterns, in and of themselves, could be the source of their anxiety. In terms of practical structure and organization procedures for diagnosis, the PDM is divided into the following four major sections: (a) Classification of Adult Mental Disorders, (b) Classification of Child and Adolescent Mental Health Syndromes, (c) Classification of Infant and Early Childhood Disorders, and (d) Empirical Foundations for a Psychodynamically Based Classification System for Mental Health Disorders (Lingiardi et al., 2015, p. 97). The PDM is structured for the clinician to assess the following in all patients (outside of infants, which are assessed with a separate infancy and early childhood procedure): (a) level of personality organization and the prevalent personality style (axis P for adults and emerging personality patterns for adolescents and children), (b) level of overall mental functioning (axis M for adults and axis profile of mental functioning for adolescents and children), and (c) symptoms and syndromes and the patient’s subject experiences (axis S for adults and subjective experience for adolescents) (Lingiardi et al., 2015, p. 98). Overall, the PDM “considers each mental health issue as a constellation of signs, symptoms, or personality traits that constitute a unity of meaning” (Lingiardi et al., 2015, p. 98). As a diagnostic tool, the PDM strives to capture a holistic view of human complexity while also attending to dimensional systems and practical application in psychotherapy (Gazzillo et al., 2012). WORKING ALLIANCE INVENTORY

The Working Alliance Inventory (WAI) was developed to assess progress in therapy based on the strength and nature of the therapeutic relationship (‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌Goldberg et al., 2004). Although

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the WAI is often used for research-based purposes, many psychoanalytic practitioners find it valuable in assessing patients’ problems and the nature of the therapeutic relationship. For psychoanalytic therapists, it is vital to understand the patient’s view of the working alliance and strive for a “good enough” alliance with the patient. The WAI allows therapists to measure treatment outcomes as well as assess the patient’s perception of working alliance throughout the treatment process.

TECHNIQUES The Treatment “Frame” The foundational component of psychoanalytic theory, treatment, and approach is established through attention to and use of the treatment frame. A treatment frame includes the frequency and duration of treatment, the couch or physical arrangement of the patient, and the therapist/analysts’ use of quietness in sessions. 1. Frequency and duration: Across various psychoanalytic approaches, psychoanalysts hold sessions with patients frequently (multiple sessions per week) and over an extended time frame (typically 1–5 years). The goal of this frequent and long contact is to foster and establish depth and trust within the therapeutic relationship while facilitating the gradual presence and improvement of the patient’s central emotional conflicts, childhood anxiety, and compromise formations. 2. The couch or chair: Traditional psychoanalysts ask patients to lie on a couch with the idea of promoting the patient’s free expression of thoughts, feelings, fantasies, and unconscious material. Sessions are most frequently held in a face-to-face format with the therapist encouraging the patient to reflect upon their intrapsychic experiences. From a modern psychoanalytic perspective, analysts opt to have their patients sit upright in a chair and directly across from one another. 3. Quietness: Psychoanalysts tend to be quiet most of the time during initial sessions with patients. While remaining quiet, psychoanalytic therapists listen empathetically and closely to the patient’s associations as they work to develop a depth understanding of their thoughts and feelings. The level of the therapist’s action and ­interaction with the patient depends on the psychoanalytic therapist and their level of modernity.

Transference Transference occurs within the therapeutic relationship when prior relational experiences directly impact the client–counselor relationship. In this process, clients recreate or reenact relational patterns in their past with the counselor, projecting characteristics of significant persons onto the counselor. Directly addressing how the client is reexperiencing these relational patterns within the therapeutic relationship allows the client to gain insight into these maladaptive relational patterns and work through these relational conflicts through the therapeutic relationship. For example, a client who experienced a cold and distant parent in their upbringing may perceive the counselor as similarly cold and distant and may crave attention from the counselor, recreating a pattern. By illuminating the transference that occurs, the client can gain insight into their relational patterns and create new experiences.

Countertransference Countertransference occurs when the counselor has an emotional response or reaction to a client, often triggered by their own past experiences, conflicts, or unconscious influence. The

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danger in countertransference is that counselors may lose their sense of objectivity in working with the client, projecting their own unconscious conflicts and experiences onto the client. Counselors must be aware of their responses to the clients and interrogate themselves to gain insight and ensure that the countertransference does not harm the client. The reactions that arise during countertransference can be productive in the therapeutic process, allowing the counselor to understand the client and how to help them by investigating their emotional reactions. However, counselors must take caution to ensure that their reactions do not impede the therapeutic process by raising defensiveness and compromising objectivity. For example, a client who craves attention from the counselor might be perceived by the counselor as “needy.” The counselor might have an emotional reaction based on a past relationship with someone they perceived as needy in the same way and may feel compelled to respond to the client in a particular way.

Relational Responses: Object Relations Theory Psychoanalytic approaches view the therapeutic relationship as client-centered, with the client determining the content of the session. In traditional psychoanalysis, the counselor served as a blank slate for the client to project transference onto in the session; the counselor provided the framework for the session but maintained neutral reactions to the client and disclosed little about themselves. The counselor provides active listening and interpretation throughout the session, assisting the client in uncovering unconscious material. In more contemporary psychoanalytic approaches, the relationship between counselor and client is more relational and collaborative. Rather than providing a neutral canvas for projection, the counselor is an active participant in the session and in the relational process that unfolds. The relational psychoanalytic process involves the counselor and client working together to understand relational patterns that are occurring at the moment, identifying unconscious material, and resolving relational conflict.

Free Association: Classic/Drive Theory Free association is a tool utilized to begin accessing and exploring the unconscious. Clients are encouraged to speak freely, without planning or censoring themselves, allowing them to attend to and report on their thoughts and feelings as they happen at the moment. Free association allows the client to access unconscious thoughts, feelings, desires, and conflicts that may have been previously blocked or repressed. The counselor’s role in free association is to identify the unconscious material that emerges and build connections between the unconscious and the conscious. For example, the counselor may ask a general question about how a client’s week has been, to which the client may respond by talking about whatever has come to mind about the past week. The client may talk about stress at work and then discuss the ongoing conflict with their boss. The counselor may then assist the client in identifying how the conflict with their boss mirrors unresolved relational conflict with a parent during their development.

Dream Interpretation and Analysis: Classic/Drive Theory Dreams are viewed, in psychoanalytic approaches, as windows to the unconscious. Unconscious material appears in dreams, shrouded in symbolism or metaphor. To understand the unconscious material presented in the dream, it is necessary to interpret the dream. Dream interpretation involves translating the more literal content of the dream into its symbolic counterparts to help the patient gain understanding of the meaning of the dream. Dream analysis involves understanding the content of dreams as symbols of unconscious material, including desires, fears, needs, memories, and experiences. The role

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of the counselor in dream analysis is to elicit the content of the dream from the client and assist the client in understanding the symbolic meaning of the content and how it relates to their experiences. For example, a client may experience a dream where they show up to work to discover there is a test that they have not studied for and are not able to pass. The counselor may help the client to identify feelings of overwhelm and inadequacy at work. The counselor may then help the client to identify when they have felt similarly in the past. For example, the client may relate these feelings of inadequacy and underpreparedness to how they felt as a child when they did not do well in school and felt their parents were disappointed in them.

Interpretations of Resistance In addition to unconscious material that surfaces during free association and dream interpretation, clients often present with resistance that blocks them from accessing unconscious material. This may present as an unwillingness or inability to talk about certain experiences or emotions. From a Freudian perspective, resistance serves as a defense mechanism that protects the client from uncomfortable emotions, thoughts, or experiences but ultimately hinders the goals of therapeutic progress. The goal of the counselor is to identify and interpret resistance. Counselors may point out areas of resistance that the client is experiencing and provide an interpretation for that resistance. In doing so, the therapist assists the client in understanding and overcoming the resistance, clearing the path for unconscious exploration. In more modern psychoanalytic approaches, resistance is viewed as the way the client communicates their maturational or adaptive challenges in functioning. Resistance is respected and resolved rather than avoided, as the therapist seeks to help the client express and process these challenges through progressive communication (Fletcher, 2021). For example, a client may talk about past relationships with their mother and siblings in childhood but never brings up experiences or interactions with their father. The counselor notices this omission of the father in sessions and brings this to the client’s attention. The counselor then assists the client in exploring why they might be avoiding talking about that relationship and how that avoidance is serving them. This helps to build a path for the client to be able to speak more directly about those experiences.

Holding/Containment: Object Relations Theory Holding and containment are tools utilized to create a safe, secure, and nurturing environment within the therapeutic relationship. Initially modeled from the concept of a mother holding an infant, holding refers to creating a space where the client feels emotionally “held.” Within the holding space, clients experience the therapist’s nurturing, safety, and empathy. In addition, this secure holding allows clients to begin exploring the unconscious within a boundary space, allowing for the process of growth and maturation to unfold. Containment similarly stems from the parental relationship and refers to the ability of a caregiver to take in and hold the emotional experiences and reactions of the child, not react emotionally, and return the emotion to the child in a modified form. This containment allows the child to receive the projection back from the caregiver in a form that they can understand and integrate. In counseling, the therapist serves as the caregiver, taking in the projections and emotions of the client, providing a container, interpreting the experience, and returning it to the client in a form that they can understand. For example, a client comes into a session ranting about their boss, speaking loudly, cursing, and expressing anger toward their boss for a decision that was made at work. Rather than responding with similar anger or defensiveness (like the boss may have done), the counselor contains the experience for the

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client by taking in the emotional content and providing an interpretation. The counselor may acknowledge that the client is angry because a decision was made without his input and how that may remind him of times when he felt powerless and lacked agency in the past. Providing this container defuses the emotion of the experience and allows the client to gain an understanding of their reaction.

Sandtray and Mandalas: Jungian Theory Sandtray and mandalas are utilized primarily in Jungian approaches to create tactile representations of the client’s inner world, including the client’s conscious and unconscious representations of self. Sandtray utilizes a tray of sand and invites the client to choose various objects to place in the tray. The process of composing the sandtray may include verbalization of the objects selected or may be done independently of verbal expression. Once the client has completed the sandtray and has arranged the objects in the way they want, the client and counselor work together to analyze and interpret the final composition, identifying potential symbolism in the selection and arrangement of objects and building connections between the sandtray and the client’s inner world. For example, a client may position a figurine standing on one side of the tray and may position multiple other figures and objects on the opposite side of the tray separated by a gap in the sand. The counselor and client may work together to identify the symbolism of the client feeling isolated from others in his life. Mandalas are circular structures found in various cultures and are often utilized in meditation. In psychoanalytic approaches, the mandala is viewed as a representation of the center of self. Mandalas may be utilized in tandem with sandtray techniques. Clients may choose objects of specific color, shape, texture, or quality and arrange them in the pattern of the mandala. Like the analysis and interpretation of the sandtray, the counselor and client work together to determine the symbolism in the creation of the mandala, building connections between the physical representation of the mandala and the symbolic relation to the self.

MULTICULTURAL, INTERSECTIONAL, AND SOCIAL JUSTICE ISSUES Classical forms of psychoanalysis view the counselor as a blank slate onto which clients would project their wishes, desires, motivations, and unconscious conflict. From this perspective, the counselor was expected to provide a neutral ground free of bias and judgment. The attention to the counselor’s countertransference in response to clients was meant to safeguard the neutrality of the counselor and protect from potential biases toward the client. Psychoanalysis often receives disparagement related to reaching the needs of people across the cultural spectrum. There is a misperception that psychodynamic psychotherapy is only for the rich, those who have time to develop insight and ignore the societal impacts of class, culture, and race. With the relational turn in analysis, psychoanalytic and dynamic therapies have become more reflective of the impact of diverse group affiliations and environmental influences (Redekop, 2015). Analysts now focus on how individuals construct their own personal meanings and the enabling or disabling narratives that are a part of these constructions. Further, interpretation in the analysis is no longer viewed as all-encompassing, authoritative, and final but rather a positive way to help individuals free themselves and be open to new ways of being in the world (‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌Wetherell, 2008). A frequent criticism of classic psychoanalysis is its lack of accessibility outside of a narrow population that could afford the lengthy and costly analysis process. Due to the lengthy nature of classic psychoanalysis, it may have limited application for persons seeking shortterm care due to cost constraints or treatment preferences. Persons in crisis might be seeking

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immediate solutions to which a psychoanalytic approach is not aimed. Additionally, clients from multicultural backgrounds might not value the free association and nondirective approach that psychoanalysis provinces provide. Classic psychoanalysis centers on a predominantly Western view of development that may not resonate with clients from non-Western cultural backgrounds. Clients seeking a more relational and collaborative approach may struggle with classic psychoanalysis. Historically, psychoanalysis focused on intrapsychic conflict and neglected the role of larger contextual factors in development. The early forms of psychoanalysis were not tailored to working with multicultural populations and lacked contextual understanding of sociocultural factors. Recently, psychoanalytic therapists have placed greater attention on diverse populations and the application of psychoanalysis across broad cultural values. For example, in China, psychoanalysts consider how the group is often of more importance than the individual, which impacts the way Chinese therapists learn and practice psychoanalytic psychotherapy and the way patients experience psychoanalysis (Zhong, 2011). Another application involves consideration of how skin color can impact the transference relationship between the person of color and the therapist. Additionally, when therapists are from a community of color, this can influence and plays a role in understanding resistance in working with patients from a majority culture (Greene, 2004).

Jungian Psychology Within Western theories of counseling and psychotherapy, Jungian psychology has a long tradition of viewing mental health from a social, historical, and cultural lens. Rather than pathologize experiences that fall out of rational, empirical, and medical frameworks, Jungian psychology understands that religious, spiritual, and paranormal frameworks have deep cultural and historical significance in how clients may make sense of and understand themselves and the world around them; therefore, we should not ignore these phenomena but approach them with a balance of curiosity, fascination, and respect (‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌Pilard, 2018; Roseler & Reefschläger, 2021). However, the Jungian psychoanalytic community has much work to do regarding multicultural and social justice competencies. Unfortunately, far-right, fascist groups have frequently co-opted Jungian theory to provide a “scientific” and “psychology” explanation for the hateful ideology (Thomas & Gosnik, 2021). Within the Jungian community, there is a continued call to confront the shadow of colonial and white supremacy, which was heavily prevalent within the social milieu when Jungian psychology was being developed (‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌Martinez, 2022). Therefore, to improve multicultural and social justice competency, Jungian scholars and practitioners are called to consciously put effort into including the voices and psychological experiences of oppressed and historically marginalized groups in Jungian conceptual frameworks and, at the same time, to address and heal the personal and collective trauma caused by oppressive forces (Martinez, 2022).

Object Relations In contrast, with classic psychoanalytic approaches, object relations theory moved from focusing on the development of self to the relation of self to others, primarily caregivers. This shift marked a move toward understanding individuals within the relational context. However, despite a focus on relational context, early iterations of object relations theory focused primarily on relational caregiving norms of Western cultures and did not fully consider different values in parenting, caregiving, and relationships across diverse cultures. A strength of relational forms of psychoanalysis from a multicultural perspective is the attention to the relational experience between counselors and clients. The attention to

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transference and countertransference lends to understanding how cultural factors might impact a client’s reactions toward the counselor and may illuminate counselor biases that arise from countertransference. In more contemporary approaches, collaborative discussion of transference and countertransference and its application to cultural factors and identities may help clients and counselors understand how their identities and experiences impact the therapeutic relationship.

SCHOLARSHIP AND RESEARCH Evidence and Empirical Support Psychoanalytic approaches to counseling and psychotherapy are particularly difficult to research due to the complexity and lack of focus on symptoms and diagnosis. The long-term nature of psychoanalytic approaches poses a significant challenge when designing clinical experiments to test their effectiveness (Wallerstein, 2009). Yet, over the past 20 years, psychoanalytic researchers have made an effort to research to provide evidence of treatment effectiveness in the wake of criticisms from other theoretical camps and managed care. Psychoanalytic and psychodynamic psychotherapy is often regarded by those unfamiliar with it as lacking empirical support. However, several studies have proven the efficacy of psychodynamic psychotherapy for a range of conditions and populations with effect sizes as larger as those treatments deemed evidence-based or empirically supported (Shedler, 2010). Data from randomized control trials (RCTs) support the efficacy of psychodynamic therapy for depression, anxiety, panic, somatoform disorders, eating disorders, substance-related disorders, and personality disorders (Drisko & Simmons, 2012; Leichsenring, 2005; Milrod et al., 2007). Additionally, the meta-analysis of both shorterand longer-term psychoanalytic approaches points to significant effect sizes for patient outcomes. For example, 23 RCTs of 1,431 patients compared short-term (less than 40 hours) psychodynamic psychotherapy with controls. Findings pointed to a 0.97 overall effect size for symptom improvement, which increased to 1.51 when clients were assessed at longterm follow-up (9 months or longer, posttreatment). Such findings suggest that clients who complete psychoanalytic psychotherapeutic treatment sustain outcomes over time (Shedler, 2010). Moreover, findings from the past 30 years have pointed to evolving evidence that long-term psychodynamic therapy is more impactful than short-term psychodynamic therapy for patients with difficult-to-treat, more serve disorders (Leichsenring et al., 2013; Lindsfors et al., 2014). The evidence for the efficacy of psychoanalytic treatment for depressive disorders is particularly promising. Driessen et al. (2015) evaluated 54 studies including 3,946 patients, concluding that psychodynamic psychotherapeutic treatment led to improvements in quality of life and overall outcome measures with effect sizes ranging from 0.57 to 1.18. Such comparison data also detailed that psychodynamic psychotherapy is more effective than antidepressant medication (SSRI) treatment for depression. Additionally, the benefits of psychoanalytic therapy tend to increase over time (Driessen et al., 2015; Shedler, 2010). In other words, psychoanalytic psychotherapy enabled clients to develop insights and attain skills that continue to aid their functioning into the future. Numerous empirical investigations have determined a link between psychodynamic processes and successful outcomes in nondynamic treatment approaches, suggesting nonpsychodynamic approaches are effective in part because they use interventions and techniques central to psychodynamic theory. These techniques include focusing on and facilitating the patient’s affective experience through the therapeutic relationship and the discussion of interpersonal relations as they relate to past experiences with early caregivers (Diener et al., 2007; Høglend et al., 2008).

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DETAILED CASE CONCEPTUALIZATION PRAGMATICS AND TRANSCRIPT Mark Stockton is a 42-year-old, Black, cisgender male who works as a project manager for a general contracting company. Mark is a single father who lives with his two daughters. Mark believes that he excels at his job and enjoys the problem-solving, self-motivation, and independent nature of his work. He works as a project manager for a general contracting company. However, he struggles when he is asked to engage in interpersonal and social engagement with fellow teammates. He prefers to work alone and at times struggles with team-based projects when feelings of self-doubt and insecurity often surface. Mark is seeking counseling for anxiety and depression following a team-building game at work that caused him severe humiliation and embarrassment. When asked about his reason for entering counseling at this time, Mark reports feeling “unable to relax,” stressed and anxious most of the time, and having difficulty forming relationships with colleagues.

Discussion Questions 1. Discuss the root/origins of Mark’s anxieties, self-criticism, and interpersonal difficulties from each psychoanalytic school of thought discussed in the chapter (classical/ drive, Jungian, and object relations). 2. Identify the predominant defense mechanisms Mark uses when he experiences overwhelming feelings of shame and anxiety as a result of the team-building game at work. 3. Conceptualize and reflect upon the multicultural and intersectional aspects of Mark’s identity that play a role in his presenting concerns. Transcript

Skill(s) Demonstrated

Counselor: Hello, Mark. How have things been going lately?

Free association; open-ended question (Counselor uses free association and an open-ended prompt to allow the client to speak about what is on their mind.)

Client: Not great. I made a huge fool of myself at work this week. I am all out of sorts about it and humiliated. We were asked to play some stupid team-building game and I just couldn’t do it. Counselor: I can see why you found the situation to be not great! You feel ashamed, and it was difficult for you to play and engage in a spontaneous way.

Support and therapeutic alliance (Counselor provides support and attends to building the therapeutic alliance.)

Client: Yeah, I guess that is true. I am also both envious and jealous that embracing new experiences and forming relationships at work comes so easily to everyone else. I look around and see everyone else having fun. But for me, I don’t get it. I don’t see the purpose of it. I find it so stupid! Counselor: In your mind, playing games and having fun is purposeless and stupid. Where does your difficulty letting go and having fun come from?

Encouraging elaboration (Counselor poses a question for the ­client to elaborate upon in a deeper way. Counselor intends to discover and ­understand the patient’s personality and character traits.)

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Client: I am not really sure…. Well, I am an only child, so I never had anyone to play with. Counselor: Sounds very lonely. You felt different and alone as a child.

Support (affect) (Counselor provides support and attends to building the therapeutic alliance through the naming of emotions.)

Client: Yeah, sadly that is so true. Now that I think about it, I had pretty much a joyless childhood in general. Fun was not‌‌‌‌‌‌‌‌‌‌‌‌‌‌ a concept my parents understood. Counselor: As a child, you ‌‌‌‌‌‌‌‌‌‌‌‌‌‌ had a hard time playing and letting go. Your parents showed you how to live life for survival and purpose, not fun and play.

Addressing developmental period (Counselor points out self-defeating nature of past during development that led to current defenses, behavior, and relational patterns.)

Client: Yeah, exactly. My parents, well, they just didn’t know what a child needed. They were not unkind. But they kind of acted like life was all about survival. We never did anything unless it served a clear purpose. Counselor: I’m wondering about how your parents expressed emotions and showed love to you.

Encouraging exploration/elaboration (Counselor poses question for purposes of exploration and elaboration upon past patterns that influence present situation [defenses/conflict], emotions, and relational patterns.)

Client: Well, they didn’t, to be honest. I don’t think they knew how to do that; we never were affectionate. I can’t remember a time that my parents hugged or kissed me. Counselor: A lack of emotion was throughout your house and family growing up. And so, you decided to enter a job as a project manager because it does not require anything from you emotionally.

Interpretation (Counselor offers an understanding that is not previously within the patient’s awareness.)

Client: Wow, you are right. I never thought of that. Counselor: And yet you are envious of the ease in which others around you can have fun and live in the moment while sharing joy and emotions with one another.

Pointing out internal conflict (Counselor points out the relationship among the patient’s wishes, fears, feelings, and defenses against them.)

Client: Yeah…everyone seems to always be having a better time than me. I can remember feeling this way since I was a child. Counselor: Now you are having trouble letting go and living your life even though you desire to do so greatly.

Clarification (Counselor works to clarify elements contributing to the patient’s unhappiness and conflicts/patterns.)

Conceptualization and Treatment Plan Mark is struggling with social anxiety, depression, interpersonal discord, and a lack of meaning and purpose in his life. In the transcript, we can see that he experiences difficulty

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playing and experiencing joy. He often seeks out tasks that are rigid and do not involve interpersonal interactions or emotions. The triggering event of team building unstructured and creative activity at work left him frozen in trauma and brought up uncomfortable emotions (embarrassment, fear, anxiety). As a child, Mark missed out on the opportunity to foster creativity and play. His upbringing lacked joy and his parents were often critical of him mostly because they also were raised with their own critical parents. Over time, Mark developed defenses and anxiety in response to internal conflicts around uncomfortable emotions which are resurfacing in his present life. At present, his lack of play and creativity has created blocks in discovering meaning and living a more full, joyful life. In treatment, Mark’s counselor seeks to foster a holding space for him in the consulting room. Through interpretation, exploration, and discovery of unconscious material, Mark will develop an awareness and insight into himself. Over time and through the therapeutic relationship with his counselor, he will begin to feel and experience creativity and joy. In turn, Mark will be provided the opportunity to discover what it means for him to experience and develop a life worth living, one that brings joy and satisfaction for him in work, love, and play.

THEORETICAL LIMITATIONS Psychoanalysis, similar to any approach to counseling, has limitations which must be taken into consideration when implementing clinical treatment, assessment, and conceptualizing. The most frequent criticism of classic psychoanalysis is its lack of accessibility outside of a narrow population that could afford the lengthy and costly analysis process. Due to the lengthy nature of classic psychoanalysis, it may have limited application for persons seeking short-term care due to cost constraints or treatment preferences. Persons in crisis might be seeking immediate solutions to which a psychoanalytic approach is not aimed. Additionally, clients who have particular cultural backgrounds might not value the free association and nondirective skills associated with this approach. Classic psychoanalysis centers on a predominantly Western view of development that may not resonate with clients from non-Western cultural backgrounds. Historically, psychoanalysis focused on intrapsychic conflict and neglected the role of larger contextual factors in development. For example, more classic forms of psychoanalytic treatment can be considered deterministic and can create the impression that individuals do not have free will and instead are victims of their predetermined circumstances. The early forms of psychoanalysis were not tailored to working with multicultural populations and lacked contextual understanding of sociocultural factors. Finally, clients seeking a more relational and collaborative approach may struggle with classic psychoanalysis due to its emphasis on the counselor’s role as a neutral observer in the process. Another consideration unique to psychoanalysis is its emphasis on training, personal therapy, and supervision. Psychoanalytic training, like psychoanalytic treatment, is specific, takes several years, and can be extremely costly. Any form of psychoanalytic training requires the therapist to undergo their own psychoanalysis given that transference and resistance form the foundation of the approach. Further, since psychoanalysis is a depth form of counseling and psychotherapy, counselors must be able and willing to process aspects of the client that potentially have never been revealed or shared with anyone else in their life. Thus, if counselors attempt to implement psychoanalysis without insight into their own self of counselor issues, transference and countertransference issues become difficult to deal with and can often cause unnecessary distress for both the counselor and client. It is particularly important for psychoanalytic counselors to receive ongoing supervision to understand their own unconscious reactions to patients over time.

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SUMMARY Psychoanalysis has left a lasting impact on the current state of counseling and psychotherapy with classic Freudian concepts remaining central to modern psychoanalytic practice. Such concepts include an emphasis on the impact of childhood development on later well-being and functioning, and the role of the unconscious in human development, motivation, and personality. From a psychoanalytic theoretical perspective, mental health is influenced by these unconscious processes that, when out of awareness, lead to unhelpful and destructive behaviors. Psychoanalytic theory views emotional and psychological well-being as insight, self-knowledge, and the ability to manage internal conflicts and navigate the dynamics that arise within personal relationships. In psychoanalytic practice, change occurs through consistent sessions over longer periods of time (2–5 years). Psychoanalytic techniques are intended to bring unconsciousness to conscious awareness. The therapeutic relationship is central to psychoanalytic psychotherapy. The therapeutic relationship between client and counselor provides material for therapeutic work and treatment including resistance, countertransference, and transference concerns. During psychoanalytic psychotherapy, clinical assessment occurs over time as the counselor listens for unconscious motivations, early childhood issues, and relational patterns. Across psychoanalytic theoretical schools of thought, emotional and psychological well-being occurs when an individual can develop self-understanding, insight, and a resolution of unconscious conflicts within themselves. With an eye to multicultural, intersectional, and social justice issues, there has been a push within the psychoanalytic community to integrate more diverse perspectives into the theoretical concepts. Modern psychoanalytic models emphasize the importance of incorporating multicultural, intersectional, and social justice elements into the treatment to help establish and improve the significance of the therapeutic relationship. Further, therapeutic insights can be used with diverse clients to fuel new actions and behaviors and the concept of self within a social and cultural context. VOICES FROM THE FIELD This chapter features a digitally recorded interview entitled Voices From the Field. The interview explores multicultural, social justice, equity, diversity, and intersectionality issues from the perspective of clinicians representing a wide range of ethnic, racial, and national backgrounds. The purpose of having chapter-based authors interview individuals representing communities of color or who frequently serve diverse populations is to provide you, the reader, with relevant theory-based social justice and multiculturally oriented conceptualization, contemporary issues, and relevant skills.

Access the video at https://bcove.video/3LPkCbQ

Sarah Spiegelhoff is a 41-year-old, White, cisgender female who draws upon an integrative psychodynamic approach to counseling. She resides in the North Atlantic region of the United States. Dr. Spiegelhoff graduated from the Council for the Accreditation of Counseling and Related Educational Programs (CACREP)-accredited counselor education and supervision doctoral program and a community mental health counseling master level program. She owns a private practice and has been practicing clinical mental health counseling for 16 years. Dr. Spiegelhoff is also a visiting assistant professor of counseling at the State University of New York (SUNY), Oswego.

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STUDENT EXERCISES Exercise 1: Making the Unconscious Conscious

Directions: Based on the various schools of psychoanalytic theory and thought discussed in this chapter (classic/drive, Jungian, object relations), describe the methods each school uses to bring unconscious material to conscious awareness.

Exercise 2: The Influences That Affected Freud

Directions: In small groups, consider and describe the personal, social, intellectual, and environmental influences that most impacted Freud’s classic/drive psychoanalytic theory development.

Exercise 3: Archetypes and the Collective Unconscious

Directions: The class will split into small groups and discuss how the collective unconscious and archetypes help individuals discover aspects of the self‌‌‌‌‌‌‌‌‌.

Exercise 4: Personal Mandala

Directions: This activity involves the creation of a personal mandala. Students will first need to select their drawing materials. Suggested materials include markers, watercolors, pastels, colored pencils, and so forth. Students will also need something to create their mandala on like a piece of paper, canvas, or poster board that is the size 12×18 inches. Use a compass or anything that will help them draw a circle. They can also use anything round and solid, such as a cup or anything else to aid in the creation of nice clean circles. The core of mandala designs is the circle. It is important to note that they are not bound by any particular colors or materials, so encourage them to allow their feelings and instincts to guide them through this process. It is also recommended that they create the mandala in a space that is quiet and free from distractions. Their finished mandala will represent and reflect who they were at the time of creation. Once complete, ask each student to process the finished product by providing them with the following prompts: Note the most prevalent colors you used and the least used colors. Then write down your feelings and memories when viewing the shapes, colors, images, and designs on your mandala. The idea here is to foster a connection between your mandala and the feelings evoked within you while creating it (adapted from “Mandala Art Activity for SelfDiscovery and Healing”).‌‌‌‌‌‌‌‌‌‌‌‌‌‌

Exercise 5: Freud’s Impact

Directions: Discuss Sigmund Freud’s impact and contributions to psychotherapy and counseling. Speak specifically to the aspects of Freudian Classical/Drive Psychoanalysis that remain relevant to both psychoanalytic approaches and counseling/psychotherapy in general.

RESOURCES Helpful Links ■ ■ ■ ■ ■

Colombia University Center for Psychoanalytic Training and Research : www.psychoanalysis.columbia.edu/research/resources International Psychoanalysis website: https://internationalpsychoanalysis.net/ Accreditation Council for Psychoanalytic Education: www.acpeinc.org/ National Association for the Advancement of Psychoanalysis (NAAP): www.Naap.org The American Psychoanalytic Association (APSA): www.apsa.org . Homepage of the APSA. This site contains a brief overview of psychoanalysis as well as a section where

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you can obtain references from 34,000 entries. Listing of meetings and scientific programs are also available. McWilliams, N. (2020). The future of psychoanalysis: Preserving Jeremy Safran’s integrative vision. Psychoanalytic Psychology, 37(2), 98–107. https://doi.org/10.1037/pap0000275 Shedler, J. (2006). That was then, this is now: Psychoanalytic psychotherapy for the rest of us. http://jonathanshedler.com/writings/ Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2), 98–109. http://dx.doi.org/10.1037/a0018378.

Helpful Books ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Akhtar, Salmon. (2012). The African American experience, psychoanalytic perspectives. Rowan & Littlefield. Berzoff, Joan. (2016). Psychodynamic theories and gender. In Berzoff, J., Melano, F. & Hertz, P. (Eds.), Inside out and outside in (4th ed.). Rowan & Littlefield. Chodorow, N. J. (1989). Feminism and psychoanalytic theory. Yale University Press. Eppel, A. (2018). Short-term psychodynamic psychotherapy. Springer. Luepnitz, D. (2008). Schopenhauer's porcupines: intimacy and its dilemmas: Five stories of ­psychotherapy. Basic Books. McWilliams, N. (2004). Psychoanalytic psychotherapy: A practitioner’s guide. Guilford Press. McWilliams, N. (2020). Psychoanalytic diagnosis: Understanding personality structure in the clinical process (2nd ed.). Guilford Press. Summers, R. F., & Barber, J. P. (2010). Psychodynamic therapy: A guide to evidence-based ­practice. Guilford Press. Redekop, F. (2015). Psychoanalytic approaches for counselors. SAGE Publications. Michell, S. A., & Black, J. (2016). Freud and beyond: A history of modern psychoanalytic thought. Basic Books.

Helpful Videos ■ ■ ■ ■ ■

What Is Psychoanalysis?: www.youtube.com/watch?v=uM2FGc0wDg8 Sample Psychoanalysis Session: www.youtube.com/watch?v=tQZPd7e8lXw Black Analysts Speak (2012): https://pep-web.org/browse/document/ pepgrantvs.001.0001a Philadelphia School of Psychoanalysis (PSP) Video Series Channel: www.youtube.com/channel/UCQPGHbsdMxSs_UEcpS7vkTQ Philadelphia School of Psychoanalysis (PSP): 50th Anniversary Lecture Series: Modern Psychoanalysis: Adaptions & Advances Recordings: https://psptraining. com/50th-anniversary-lecture-series/

A robust set of instructor resources designed to supplement this text is available. Qualifying instructors may request access by emailing [email protected].

REFERENCES American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787 Bair, D. (2004). Jung: A biography. Back Bay Books. Bateman, A., Holmes, J., & Allison, E. (2021). Introduction to psychanalysis: Contemporary theory and practice (2nd ed.). Taylor & Francis. Berzoff, J., Flanagan, L. M., & Hertz, P. (Eds.). (2016). Inside out and outside in psychodynamic clinical theory and psychopathology in contemporary multicultural contexts (4th ed.). Rowman & Littlefield.

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randomized controlled trial. American Journal of Psychiatry, 170(7), 759–767. https://doi.org/10.1176/ appi.ajp.2013.12081125 Lindsfors, O., Knekt, P., Heinonen, E., & Virtala, E. (2014). Self-concept and quality of object relations as predictors of outcome in short-and-long term psychotherapy. Journal of Affective Disorders, 152–153, 202–211. https://doi.org/10.1016/j.jad.2013.09.011 Lingiardi, V., McWilliams, N., Bornstein, R. F., Gazzillo, F., & Gordon, R. M. (2015). The psychodynamic diagnostic manual version 2 (PDM-2): Assessing patients for improved clinical practice and research. Psychoanalytic Psychology, 32(1), 94. https://dx.doi.org/10.1037/a0038546 Martinez, I. (2022). The need to increase diversity in jungian communities: A personal journey. Journal of Jungian Scholarly Studies, 17, 83–91. McWilliams, N. (2011). Psychoanalytic diagnosis: Understanding personality structure in the clinical process (2nd ed.). Guilford Press. McWilliams, N. (2014). Psychodynamic therapy. In N. McWilliams, L. S. Greenberg, & A. Wenzel (Eds.), Exploring three approaches to psychotherapy (pp. 71–127). American Psychological Association. McWilliams, N., & Shedler, J. (2017). Personality syndromes P axis. In V. Lingiardi & McWilliams (Eds.), Psychodynamic diagnostic manual-2. Guilford Press. Merikangas, K. R., Jin, R., He, J. P., Kessler, R. C., Lee, S., Sampson, N. A., Viana, M. C., Andrade, L. H., Hu, C., Karam, E. G., Ladea, M., Medina-Mora, M. E., Ono, Y., Posada-Villa, J., Sagar, R., Wells, J. E., & Zarkov, Z. (2011). Prevalence and correlates of bipolar spectrum disorder in the world mental health survey initiative. Archives of general psychiatry, 68(3), 241–251. https://doi.org/10.1001/ archgenpsychiatry.2011.12 Milrod, B., Leon, A. C., Busch, F., Rudden, M., Schwalberg, M., Clarkin, J., Aronson, A., Singer, M., Turchin, W., Klass, E. T., Graf, E., Teres, J. J., & Shear, M. K. (2007). A randomized control trial of psychoanalytic psychotherapy for panic disorder. American Journal of Psychiatry, 164(2), 265–272. https://doi. org/10.1176/ajp.2007.164.2.265 Mitchell, S. A. (1984). Object relations theories and the developmental tilt. Contemporary Psychoanalysis, 20(4), 473–499. https://doi.org/10.1080/00107530.1984.10745749 PDM Task Force. (2006). Psychodynamic diagnostic manual. Alliance of Psychoanalytic Organizations. Pearson, C. S. (1991). Awakening the heroes within: Twelve archetypes to help us find ourselves and transform our world. HarperCollins. Pilard, N. (2018). C. G. Jung and intuition: From the mindscape of the paranormal to the heart of psychology. The Journal of Analytical Psychology, 63(1), 65–84. https://doi.org/10.1111/1468-5922.12380 Redekop, F. (2015). Psychoanalytic approaches for counselors. SAGE Publications. Schmidt, M. (2019). Beauty, ugliness and the sublime. Journal of Analytical Psychology, 64(1), 73–93. https:// doi.org/10.1111/1468-5922.12468 Sedgwick, D. (2001). Introduction to Jungian psychotherapy: The therapeutic relationship. Routledge. Scharff, J. S., & Scharff, D. E. (1992). Scharff notes: A primer of object relations therapy. Jason Aronson. Schultz, D. P., & Schultz, S. E. (2013). Theories of personality (10th ed.). Wadsworth Cengage Learning. Sharf, R. S. (2016). Theories of psychotherapy & counseling: Concepts and cases (6th ed.). Cengage Learning. Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2), 98–109. https://doi.org/10.1037/a0018378 Spoto, A. (2021). Experiencing whole type: Living into the archetypal self. Journal of Analytical Psychology, 66(5), 1094–1118. https://doi.org/10.1111/1468-5922.12731 Stein, M. (1996). Practicing wholeness: Analytical psychology and Jungian thought. Continuum. Stein, M. (2010). Jungian psychoanalysis: Working in the spirit of C. G. Jung. Open Court. Steinhardt, L. (1998).‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌ Sand, water, and universal form in sandplay and art therapy. Art Therapy, 15(4), 252–260. https://doi.org/10.1080/07421656.1989.10759334 Thomas, C., & Gosink, E. (2021). At the intersection of eco-crises, eco-anxiety, and political turbulence: A primer on twenty-first-century ecofascism. Perspectives on Global Development & Technology, 20(1/2), 30–54. Wallerstein, R. S. (2009). What kind of research in psychoanalytic science? The International Journal of Psychoanalysis, 90(1), 109–133. https://doi.org/10.1111/j.1745-8315.2008.00107.x Weinrib, E. L. (2012). Images of the self: The sandplay therapy process. Temenos Press. Wetherell M. (2008). Subjectivity or psycho-discursive practices? Investigating complex intersectional identities. Subjectivity, 22, 73–81. Wiener, J. (2015). The analytic setting today: Using the couch or the chair? Journal of Analytical Psychology, 60(4), 462–476. https://doi.org/10.1111/1468-5922.12164

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RELATIONAL APPROACHES TO PSYCHOANALYTIC TREATMENT Sherrie Bruner and Julianna Williams

LEARNING OBJECTIVES After reading this chapter, you will be able to: ■ Articulate how the lives of Alfred Adler, Karen Horney, and Heinz Kohut influenced their departure from traditional Freudian thought and the development of post-Freudian psychoanalytic theories ■ Identify how each theory conceptualizes mental health, intervenes to promote wellness, and assesses the impact of treatment ■ Critique the strengths and limitations of each theory from a culturally informed perspective ■ Identify culturally competent services that serve a wide range of clients representing diverse cultural backgrounds and worldviews ■ Apply the approaches to diverse settings to inform the development and wellness within diverse client populations

INTRODUCTION This chapter provides an overview of psychoanalytic approaches that build on the seminal work of Sigmund Freud (1886–1939). Alfred Adler (1870–1937) recognized the impact of environment on an individual’s development and worked to incorporate a broader understanding of what influences people. Karen Horney’s (1885–1952) feminist psychology de-emphasized male conceptualizations of normality and incorporated the impact of relationships on mental health and well-being. Heinz Kohut (1913–1981) moved away from Sigmund Freud’s emphasis on sex as the driving force of the unconscious mind and placed responsibility on the parents to develop a child’s sense of self. Each of these theories is covered in more detail with attention to their founders, basic theoretical tenets, cultural awareness, and developing directions.

LEADERS AND LEGACIES OF RELATIONAL APPROACHES TO PSYCHOANALYTIC THEORY The founders of each relational psychoanalytic approach share a common beginning within traditional Freudian psychoanalytic schools. Their stories are important to understand why they departed from Freud. For each of them, their life stories highlighted the importance of relationship and encouraged them to look beyond an individual’s internal experience while developing their conceptualizations of human behavior. Each of the theories in this chapter takes a slightly different approach and you can see the impact of each of the founder’s early-life experiences on the ways they frame personality, wellness, and change.

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Alfred Adler Alfred Adler, the founder of individual psychology, was an Austrian-born son of two Jewish parents. Born in 1870, Alfred was the second of seven children whose early life was impacted by personal and familial tragedy. He suffered from the loss of a younger brother, Rudolf Adler, at a young age. As a child, he was frail, suffering from rickets, vocal cord problems, and pneumonia that left him often unable to play with his peers. During a particularly bad bout of pneumonia, a doctor once told his parents there was no hope he would survive. He was also run over not once but twice by cars in his early childhood. Finally, Adler’s childhood was defined by a contentious relationship with his mother, who favored his older brother. Alfred’s older brother was able to do all the things Alfred could not. Alfred’s experience of an unhappy childhood shaped his desire to enter the medical profession and become a doctor specializing in childhood mental and physical health (Ansbacher & Ansbacher, 1956; Rasmussen, 2011). Adler’s theoretical approach posits that striving for a sense of belonging is foundational to the human experience (Ansbacher & Ansbacher, 1956; Rasmussen, 2011). The loss of childhood belonging that comes from playing with peers may have been a central reason for his emphasis on belonging in his theory. Similarly, his musings about constantly trailing behind his brother perhaps also explain his emphasis on striving to overcome feelings of inferiority. Like many theorists, Adler’s own experiences likely significantly influenced the way he thought about people.

Karen Horney Karen Horney was born in Germany in 1885 to strict parents who were frequently irritable. Early in life, Horney experienced disruptions in her relationship with her parents and with her older brother, with whom she was very close. Horney experienced significant depression as a child and ultimately spent considerable energy on her studies to compensate for the other, less stable, areas of her life. She attended medical school at a time when few women were able to become doctors. Horney married and experienced authoritative and controlling behavior from her husband who she eventually left after experiencing a serious depressive episode. She moved to the United States, where she developed her own theory of neurosis (Horney, 1942, 1950). After Horney’s death, others described her work as feminist because she was a woman developing a psychological theory that conceptualized the experiences of women. The book entitled Feminine Psychology (Horney, 1967) was a collection of 14 papers Horney wrote relating to a variety of topics including her theory of neurosis.

Heinz Kohut Heinz Kohut was an only child born in Vienna, Austria, to a Jewish family. Both of Kohut’s parents were business professionals. His parents were quite busy, and without siblings, Kohut was left to spend much of his time alone. Adding to this isolation was his mother’s decision to keep him out of school for the first 4 years of his schooling. As Kohut grew, he struggled to understand his own sexuality and some speculate that his eventual asexual presentation may have been a suppression of his fluid sexuality (Strozier, 2007). Kohut was originally trained under traditional psychoanalytic principles, and like the other founders of unique branches of psychoanalysis, Kohut departed from Freud in some ways but remained loyal to many traditional psychoanalytic ideas. Within the psychoanalytic community in Chicago, where Kohut fled during the Nazi invasion of Austria, Kohut was highly regarded for his creativity. While Kohut remained loyal to Freud’s classic drive theory, he believed that the emergence of unconscious drives was less pathological than

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Freud proposed. Self-psychology follows many tenets of psychoanalysis, but the ways in which Kohut departed were considered quite radical at the time (Mishne, 1994). Once Kohut sufficiently differentiated his ideas from other branches of psychoanalysis, he formally introduced self-psychology as its own framework in the 1970s.

CONCEPTUALIZATION OF PERSONALITY Each of the relational psychoanalytic approaches emphasizes the importance of individual experience and context in understanding personality. They are all departures from traditional Freudian concepts of personality and provide more complex interpretations of the development of personality.

Adler’s Wholeness and Lifestyle Conceptualization of Personality Adler believed that human personality was complex and unique to everyone. He used the term individual to refer to the whole person, including their environment and social context (Sweeney, 1998). Adler was optimistic about the human condition, believing that healthy humans rely on the support of others and want to contribute to the betterment of society. Adler did not believe that individuals held innate goodness or badness within themselves, but rather each human is striving toward perfection, and behavior may result from achieving a result that differs from what they were imagining. Adler believed that people are more than the sum of their parts, and he insisted that individuals must understand these parts in connection with each other (Mosak & Maniacci, 2013) Lifestyle, which is first developed in childhood and continues to evolve as a person ages, is the cornerstone of personality in Adlerian psychoanalysis. As a person develops, they begin to organize their feelings, thoughts, and behaviors consistent with a schema of the world that Adler names private logic. Private logic is composed of a combination of one’s immediate and long-term goals and hidden motivation, and it plays a role in the choices one makes as they develop (Mosak & Maniacci, 2013). For example, an individual with the long-term goal of being strong may have the short-term goals of (a) being seen as competent and (b) being able to do anything they are asked. While these goals seem clear, the individual may have hidden reasons of “I can’t share my problems with anyone” and “I must always have an answer.” These hidden reasons may create inadvertent obstacles for themselves and with individuals who may wish to engage in a genuine relationship with them. Other individuals might perceive them as a know-it-all, inauthentic, shallow, or unwilling to enter into a meaningful relationship. The individual’s private logic impacts their ability to develop belongingness, which is central to personal wellness. One might wonder how individuals develop lifestyle and private logic. Adlerian psychoanalysts believe that birth order and early recollections (ER) are the building blocks for lifestyle in children. These early-life experiences create a framework with which to organize their experiences (Watkins, 1984). Lifestyle, in its simplest terms, is a person’s way of thinking and behaving based on perceptions developed in childhood. Adler believed that each child engages in familial relationships during development based on their birth order and thus learns patterns of behavior and coping unique to their position within the family. Adler emphasized the psychological situation a child is born into, rather than their actual birth order, as the important determinant of the impact of birth order. For example, a second-born child who follows a sickly and withdrawn firstborn may actually take the psychological position of firstborn despite his ordinal position. For this reason, it is important to understand that Adler focused less on ordinal position and more on the psychological situations when developing his concept of birth order (Shulman & Mosak, 1977). Families today are quite complex, and it can be difficult to apply Adler’s theories on birth order to many family structures. However, many counseling approaches embrace

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the underlying principle that a person’s familial context, which is influenced by their birth order, is an important part of their personality.

Beyond a Male Conceptualization of Personality Karen Horney departed from Freud and his views about women and their place in psychology. Horney believed that personality had historically been normed based on male experiences, and she pushed the field of psychiatry to recognize this bias and account for female experiences (Vena, 2015). Although this might seem somewhat elementary today, it was groundbreaking at the time. When Horney was developing her theory, women were believed to be psychologically inferior to men and “hysteria” was seen as a problem only impacting women. In short, Horney sought to de-pathologize the experiences of women. Similar to Adler, Horney avoided a deficit focus and focused on the purpose of behavior. Her definition of personality de-emphasized male experiences and accounted for contextual influences during development (Horney, 1951‌‌‌‌‌‌).

The Development of the Narcissistic Personality Kohut’s most prominent work is the text The Analysis of the Self, published in 1971, which was focused on narcissistic personality disorder and psychoanalytic treatment. Kohut proposed that early-life experiences were key to understanding the development of personality. Specifically, Kohut believed that a lack of empathy from parental figures in childhood created individuals who were constantly striving for validation. Narcissism, according to Kohut, was characterized by individuals who vacillated between overvaluing their skills and abilities and getting lost in feelings of inferiority. As individuals develop, they continue seeking the empathy they did not receive in childhood from those around them in ways that represent narcissistic personality traits (Kohut, 1968; McLean, 2007). Kohut also departed from traditional psychoanalysis by focusing on the role of the conscious self in personality. Specifically, Kohut believed that the personality consists of multiple different selves that interact with each other in various ways. Kohut theorized that these selves may disagree with each other, fight with each other, and compromise and otherwise interact in the same ways that individuals interact with each other (Strozier et al., 2022). This was a significant departure from the previous singular self identified by Freud. Each of the relational psychoanalytic theories emphasized early-life experiences as the primary cause of later mental health concerns, but they differ in terms of primary cause and potential treatments.

Inferiority and Superiority Adler believed that mental health challenges were primarily related to a lack of belonging and feelings of inferiority. Adler believed that in childhood, individuals developed perceptions about the world, which impacted how they related to others throughout their lifetime. These perceptions may lead individuals to develop feelings of inferiority or lack of belonging, which interfere with the achievement of important life tasks. Adler believed these perceptions, bound in early-life experiences, were the primary cause of dysfunction later in life and that most dysfunction could be traced back to an unmet need for belonging or feelings of inferiority (Adler, 2013a, 2013b). When a person is unable to compensate for feelings of inferiority or alternatively overcompensates for these feelings, they may develop what Adler termed an inferiority complex. The primary dysfunction of an inferiority complex is centered on individuals spending their lives trying to feel successful and constantly striving to avoid feelings of inferiority. A superiority complex develops because a person attempts to avoid feelings of inferiority through proving they are superior (Adler, 2013a, 2013b).

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Comparison Creates Dysfunction The fields of psychiatry and psychology have not historically allowed women as scholars or theorists to contribute to the field; therefore, using frameworks or definitions made by and based on men is inherently biased. Our culture pathologizes the female experience as inferior or cause for a mental health diagnosis, rather than creating a new baseline for “normal” or “healthy” that includes behavior long considered “feminine.” Karen Horney’s work involved developing her own theoretical framework, which she called the “theory of neurosis,” and refuted some of Freud’s foundational psychoanalytic theoretical tenants. Furthermore, Horney was a leader in the fields of psychology and psychiatry. She cofounded the American Institute for Psychoanalysis and the Association for the Advancement of Psychoanalysis. Lastly, she defined narcissistic personality disorder in 1950. This was almost two decades prior to Kohut’s 1971 definition (Solomon, 2006‌‌‌‌‌‌). Regarding her disagreement with traditional psychoanalytic theory, she contended with the Freudian notion of penis envy in girls. While Freud labeled certain behavior as penis envy, psychologists grounded in work that includes Horney and other inclusive scholars noted that when girls and women desire more access to resources, status, and power, which are traditionally reserved for boys and men in patriarchal society, it was pathologized or considered uncharacteristic of the gender. The conflict between a desire for equal power and status and a culture that prevents it through marginalization and oppression causes behavior that is quickly labeled as a mental health concern, which is not the same as having penis. Horney suggested that the opposite might actually be true: that perhaps men envied the wombs of women and their ability to bring life into the world (Kelman, 1967). Horney recognized neurotic psychological dysfunction in people of all genders. The theory of neurosis was one of her main contributions to the field of psychiatry and mental health. She noted many potential sources of neurosis including some that came from well-intentioned individuals who may overly care for others or from overly harsh or unloving relationships. Practitioners operating within this theoretical school emphasize shedding light on the destructive environmental factors that fail to support children as being their own individual who has something meaningful to offer the world. According to feminist psychology, a lack of recognition of one’s wholeness, primarily due to environmental influences rather than personal shortcomings, can be a source of pathology. Adults who were not able to feel a sense of security within themselves as children may develop unhelpful patterns in relationships as adults. An adult might desperately seek out ways of feeling secure that result in maladaptive behavioral patterns. At the core of this dysfunctional behavior was a rejection of one’s real self and the disguising of one’s new self in response to anxiety provoked by a caregiver (Jacobs & Capps, 2018). Horney identified 10 neurotic needs that may result from an individual striving to feel secure (Horney, 1942, 1951). These needs and their descriptors are listed as follows: 1. The Need for Affection and Approval — Individuals with a need for affection and approval seek out others who like them. They often want to perform in a way that garners the approval of others. They fear rejection and criticism and work hard to avoid negative reactions from others. 2. The Need for a Partner — Individuals with this need rely on a partner to feel okay with their experience. They overrely on this person for safety and care and have an extreme fear of being abandoned. 3. The Need to Restrict One’s Life — These individuals make themselves small to protect themselves. They tend to place their needs second to others and struggle to recognize their own unique contributions to the world. They walk through life hoping to go unnoticed and asking for very little from others.

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4. The Need for Power — These individuals might be described as power hungry and are always looking for ways to gain more power. They have an intense fear of appearing helpless or lacking control in situations and will do everything they can to make sure they stay on top in groups. They will be critical of any form of weakness and will not hesitate to exploit that weakness for the sake of attaining more power. 5. The Need to Exploit Others — These individuals choose relationships based on what an individual has to offer them and what they can gain by being connected to the person. These individuals are often manipulative in relationships to gain things they want, including power and money. 6. The Need for Prestige — These individuals need for others to recognize and appreciate them. They may seek this recognition via accomplishment or possessions only pursuing things that will provide them with more public recognition. Even their own characteristics and relationships are chosen based on the ways they will improve their own position. These individuals work hard to retain social status and fear a “fall from grace.” 7. The Need for Personal Admiration — These individuals think very highly of themselves and expect others to feel the same way. They do not want anyone to see them as they truly are, but instead seek to portray themselves consistent with the narcissistic understanding of themselves to seek admiration. 8. The Need for Personal Achievement — These individuals work hard to achieve personal goals to make up for their insecure sense of self. They are terrified of failure and consistently push themselves to accomplish more and more to be better than others and better than their prior selves. 9. The Need for Independence — These individuals work hard to be independent and avoid relying on others. They distance themselves from relationships to avoid being dependent and may be described as “loners.” 10. The Need for Perfection — These individuals feel they must live life perfectly. They constantly seek, find, and “fix” any flaws they may have. They work hard to make up for any potential flaw and make sure that others do not see these parts of themselves. Unfortunately, these neurotic needs result in patterns of behavior that create unfulfilling relationships. Horney identified three primary directions that relationships might move based on the neurotic needs of individuals: toward people, against people, and away from people. Individuals who move toward people are likely to be highly dependent on others for validation and acceptance. Those with neurotic needs for affection and approval or for a partner might fit into this category. They may exhibit helpless behaviors that prompt others to take care of them and reinforce their value, leading to an overdependence on others to feel loved and safe. They are especially attuned to what others think of them and understand themselves primarily as others see them. Movement against people describes individuals who may aggressively respond to others. Individuals with neurotic needs for power or achievement may fit into this category. The tendency to pursue these needs at all costs may result in behaviors that push others away and appear hostile. In contrast, movement away from people is behavior that seeks distance from others to remain safe. Individuals with neurotic needs for independence or perfection may fit into this category. These individuals are detached from their own feelings and lack a sense of connection with others or the desire to fight. These individuals feel they must do everything on their own and isolate themselves from others and similarly from themselves and their needs.

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These neurotic needs are often unknown to the individual and cause them to behave in ways that give them the opposite of what they want. In attempting to repress pieces of themselves, individuals may lean into the opposite of their real selves in response to anxiety. These neurotic needs, and the resultant movement, each ultimately serve to create distance between others and to avoid conflict within oneself and within relationships, thus protecting the individual. Ultimately, extreme neurotic behavior can lead to negative outcomes for mental health and increased risk for a variety of mental health challenges including depression and anxiety (Widiger & Oltmanns, 2017). In addition, people with strong neurotic tendencies may show more negativity and struggle to integrate negative feedback (Ozer & Benet-Martínez, 2006). Finally, poor outcomes in general health, either directly related to neurotic behaviors or because of an individual’s response to pathology grounded in neuroticism, are common (Ozer & Benet-Martínez, 2006; Turiano et al., 2020).

When Self-Love Becomes Too Much Kohut recognized that traditional psychoanalysis was not effective when working with people who had narcissistic tendencies. He explored the importance of empathy and the potential that self-love was not truly a harmful part of the human experience (Kohut & Wolf, 1978). Kohut believed that mental health concerns arise in childhood when individuals do not receive the kind of empathetic responses they need from their parents. As a result, they do not learn to self-soothe or develop the self-esteem necessary to self-regulate. Kohut proposed that dysfunction arises when individuals overrely on “self-objects,” or others outside of themselves, to get their needs met and move through life without meaning. While it is normal for children to need self-objects or people outside themselves that help them soothe and regulate, as they grow older, individuals should begin to function internally in the way that self-objects have functioned for them externally. Extreme overreliance on the approval of others is conceptualized as narcissism within self-psychology (Baker & Baker, 1987; Kohut & Wolf, 1978). Kohut aligned with Freud regarding the centrality of transference and the idea that individuals may put onto others needs that arise from their childhood. In self-psychology, the concept of transference is specifically related to places where in childhood, people did not receive what they needed from self-objects and thus they seek those things from others through transference. Self-psychology conceptualizes people from three distinct types of transference: mirroring, idealizing, and twinship/alter ego. Mirroring refers to times when individuals are using others to provide them with a mirror that reflects the positive pieces of themselves. In this way, mirroring helps a person to see their own positive traits via another individual identifying them rather than because these ideas are internalized. While a certain amount of mirroring is normal and can even be helpful in relationships (Gottman, 1999), extreme amounts of mirroring create situations where an individual’s self-worth and esteem are fully dependent on the approval of someone else, and the absence of that approval has significant impact on the individual’s evaluation of themselves. This does not allow space for the complex shifting and changing of relationships, which happens naturally over time and puts individuals at risk of significant damage to their self-image when relationships change. Idealizing refers to situations where an individual has an unmet need for soothing or comfort. When engaging in idealizing, an individual who may not have received the comfort they needed as a young child seeks this similar comforting and soothing presence as an adult, often from a singular individual. Idealizing can create challenges in balancing roles in relationships and puts individuals in situations where they are unable to hold complex views of the individuals they are in relationship with, thus potentially allowing inappropriate or harmful behavior to go unrecognized.

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Finally, self-psychologists identify a third type of transference called twinship/alter ego. In this type of transference, an individual experiences another as a person that represents characteristics of themselves. It is normal for children to seek out alikeness in others around them, and as they grow, the expectation is that they will begin to internalize these images rather than relying on someone else. When an individual fails to do this, they develop a need for this to be met in another. This is the beginning of twinship or alter ego transference.

CONCEPTUALIZATION OF WELL-BEING The foundation of relational psychoanalytic emphasized hope and the potential for wellness and rejected the idea that well-being cannot be achieved even when a client presents with significant dysfunction.

Adler’s View Unlike Freudian psychoanalysts, Adler did not believe in an unconscious that was beyond one’s ability to understand consciously. According to Adler (1988), “Aren’t we all able to carry things in conscious which we do not grasp conceptually, but which are nevertheless there?” (p. 436). Adler emphasized the human capacity to choose and have agency in one’s life. He emphasized personal responsibility and believed that people could choose behaviors that would help them resolve conflict within their lives. Adler strongly believed that wellness is represented in actions oriented toward overcoming feelings of inferiority. Well, individuals can adapt to feelings of inadequacy, inferiority, and increased feelings of adequacy and mutual respect. Alder was not proposing that moving away from inferiority meant moving toward feelings of power. He was quite clear that would be a misrepresentation of Adlerian thought; rather, completeness and overcoming are seen as the goals for Adlerian practitioners. Adler also emphasized the importance of social interest and community feeling. Community feeling refers to an individual’s sense of being part of something greater than themselves and their desire to contribute to society because of that connectedness (Eife et al., 2020; Mosak & Maniacci, 2013; Watkins, 1984). According to Adler, social interest is an action derived from community feeling. In other words, Adler believed that individuals who feel empathetically connected to the world around them would be interested in improving the lives of others, thus acting out of social interest.

Horney’s View Horney emphasized true integration of the personality and changing patterns within relationships from destructive to constructive (Horney, 1945). In contrast to relationships defined by the neurotic needs, Horney believed that individuals arrive at wellness when they can be their whole selves in relationship with others and with themselves (Horney, 1937).

Kohut’s View Kohut believed that an individual who has a strong nuclear self, which he considered the foundation of personality, should be able to recognize their own unrealistic beliefs about themselves and others. Individuals who are well can see themselves and others as complex with both helpful and unhelpful traits (Baker & Baker, 1987; Kohut & Wolf, 1978).

ROLES OF CLIENT AND COUNSELOR Adlerian-oriented counselors join with clients collaboratively by evaluating their lifestyle and helping them gain a better understanding of why they may act in specific ways.

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Adlerian counseling is centered on the therapeutic relationship and involves working to develop a relationship with the client that is collaborative, is empathetic, and conveys a sense of belonging (Rasmussen, 2011; Watts, 1999). Specifically, Adlerian counselors encourage clients to better understand how their birth order may have impacted their early-life experiences and, thus, the lifestyle they developed in childhood and continue to refine in adulthood. Adlerian counselors believe that experience shapes behavior and reinforces one’s perceptions, memory, and symbols (Watts, 1999). The Adlerian framework helps clients claim agency in their lives and choose behaviors that move them toward feelings of worth and belonging in four phases of counseling: engagement, assessment, insight, and reorientation.

Counseling With Patience and Thoroughness Horney, much like Freud, emphasized the need for patience and comprehensiveness in a counselor’s work with clients. The temptation to jump to conclusions or to quickly develop a conceptualization of clients should be avoided. Horney believed that the rush to know and understand would close counselors off from possibilities and cause them to choose a path too quickly without fully understanding the implications. In addition to working slowly, Horney believed that counselors should remain nonjudgmental in their work with clients. Horney believed that counselors should take on a sort of meditative attitude toward clients, seeing and accepting each piece of them without becoming overly attached to any of it. Horney believed this would allow counselors to sit with clients and hear their stories in a way that does not try to fit them into a box or predict the next therapeutic move (Horney, 1987).

Empathy and Corrective Experiences Kohut was one of the first psychoanalysts to emphasize the importance of empathy in working with clients. Specifically, he believed that through providing a space that was empathetic and attuned to the needs of the client, counselors could provide a new experience that might help them see other potential in their own relationships. This corrective emotional experience requires counselors to enter the world of the client, something Kohut called temporary indwelling and involved using transference to meet client’s unmet childhood needs (Baker & Baker, 1987; McLean, 2007).

NATURE OF HUMAN DEVELOPMENT Adler took a task approach to human development and believed that everyone is working to achieve three basic areas of life: work, friendship, and love. As individuals develop, they focus their behavior on achieving these three tasks and much of development can be understood through this framework. An individual’s development is stunted when they encounter challenges in any of these areas. Adler believed that people have a creative force within their mind, the teleological function, which pushes individuals forward to continue developing and meeting their needs (Mosak & Maniacci, 2013; Shifron, 2020).

Developing Toward Wholeness Feminist psychologists believe strongly in the capacity of individuals to change and to move toward wholeness and congruence within and outside of themselves. Feminist psychologists work to help individuals be without pretense; to be emotionally sincere; and to be able to put the whole of oneself into one’s feeling, one’s work, and one’s belief. By working to help individuals recognize the basic human need at the polar end of their

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neuroticism, they can help individuals develop in ways that produce growth and move them toward greater wholeness. It is this strong belief in the human capacity that allows feminist psychologists to set high goals for their clients and enact change with all people (Horney, 1937).

The Impact of Parents on Development Much of self-psychology focuses on the role of parents in helping children to navigate development of their nuclear self through empathetic relationship. To achieve healthy development, parents must respond to the need for mirroring, idealization, and twinship with empathy. For example, a young child might stack blocks for the first time and exclaim proudly, “Look, Mom, I did it!” A parent responding empathetically to this child’s need might respond, “Wow, I am so proud of you. I love that tower you created. You are getting so good at stacking blocks!” In this way, the child receives a mirror of their own talent from a caregiver. Parents attuned to their children’s idealization needs provide a calm and soothing foundation from which children can begin to develop their own goals. For example, imagine a young child who fears thunderstorms runs to their parent following a loud clap of thunder. Perhaps the parent responds with “Oh no, that was scary for you. Come sit with me while the storm passes.” The parents might then cover the child’s ears when loud thunderclaps sound and sing songs with the child while the storm passes. The child learns that they can rely on this adult to comfort them and idealizes the parent because they are able to make bad things go away. Children may choose to imitate their parent to seek likeness in their caregivers as a form of twinship. An example might be a young girl who wants to apply makeup or straighten her hair “like mommy.” Kohut believed that children would learn to develop a self that could achieve this self-fulfillment without the parents if parents continue to respond empathetically to these needs during their development. He proposed that children should eventually learn to self-soothe and see value and power within themselves rather than needing an outside self-object to provide this for them. Kohut also believed that when children’s needs are not met in childhood, it can have negative repercussions in development. He theorized that the need for mirroring, idealization, or twinship are narcissistic and, while “normal” in childhood, are negative when they persist into adulthood. These individuals eventually become psychologically fragmented, and this fragmentation is the root of dysfunctional adult relationships, according to self-psychology. Kohut aligned with Freud regarding the centrality of transference and the idea that individuals may put onto others' needs from childhood that were unmet. In self-psychology, the concept of transference is specifically related to childhood experiences where people did not receive what they needed from self-objects and thus seek those things from others through transference. Each of the narcissistic needs of childhood thus also becomes a potential source of transference in adulthood. A child whose mirroring needs are not met in the early stages of development may seek approval from others in unhealthy ways in adulthood. In extreme situations, the individual’s self-worth and self-esteem are fully dependent on the approval of someone else, and the absence of that approval has a significant impact on the individual’s evaluation of themselves. If this takes place in counseling, the result might be an overreliance on a clinician to validate and approve a client’s behavior and a strong negative reaction to that counselor’s lack of approval. If a child had a limited number of healthy adults to idealize, they may have idealized unhealthy models or have no role model at all. This limits their abilities to

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maintain healthy relationships as adults, either because they are mimicking behavior that they idealized as children that is counterproductive or they are allowing inappropriate or harmful behavior in relationships to go unrecognized. It is normal for children to seek out likeness in others around them, and as they grow older, Kohut expected that they would begin to internalize these images rather than relying on someone else. When an individual fails to do this, they develop a need for this to be met in another (i.e., a need for connection and relationships). When they notice differences in another person or in how another person relates, they might seek out someone who better represents a sense of likeness. Self-psychologists also identified different types of personalities that may emerge from dysfunction. The first of these is called the “merger-hungry” personality, where someone may seek to control people to feel more secure or have difficulty identifying which parts of themselves are truly theirs and which parts belong to others around them. They may be overwhelming to others due to their constant need for comfort and security. In contrast, “contact-shunning” personalities may want and need closeness with others, but they may also be afraid of rejection because of the intensity of their needs. Thus, they choose to avoid closeness to ensure they are not rejected. Finally, individuals with “alter ego” personalities seek out others who will change themselves to be more like them. They often struggle when others seek to differentiate themselves in terms of beliefs, values, and lifestyle or move way from likeness in other ways. The theory of self-psychology depicts the counselor as an empathetic presence that provides reparative experiences for the client. Kohut was revolutionary for his time in his firm belief in the value of empathy and its power to create change. He believed that an empathetic response to narcissistic transference would help to restart development that stalled in childhood. Through empathetic attunement and continual navigation of narcissistic transference, the counselor would help the client to begin to develop a nuclear self, increase self-esteem, develop goals, see themselves as complex, and believe in their independence (Kohut & Wolf, 1978).

PROCESS OF CHANGE Adlerians help clients move through the change process using the four phases of counseling: engagement (relationship), assessment, insight, and reorientation. Adlerian counselors begin with a relationship that empowers clients to change their experience. They use the assessment phase to understand how clients’ lifestyles, community feelings, and social interest impact their current lives. Adler emphasized counseling as a process that accesses people’s innate goal-directedness through believing in their ability to change. Using empathy and encouragement, Adlerians work to demonstrate their belief that all clients have the ability to move toward unity and belongingness (Adler, 1988). According to Adlerians, “the individual is both the picture and the artist. He is the artist of his own personality” (Ansbacher & Ansbacher, 1956, p. 177).  Through accessing the agency to develop their own perceptions and interpretations grounded in their lifestyle, people thus can cocreate their realities.

Assessment During the assessment phase, Adlerians work to understand the client’s early memories and family dynamics to determine how they may have impacted the client’s thinking, acting, and feeling. Counselors using Adler’s framework use informal observations like birth order or more formal assessments to understand the complexity of a client’s early experiences. In

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this assessment phase, Adlerians are especially attuned to ways in which clients may have developed feelings of inferiority and work to understand the private logic of clients. These counselors actively “investigate the nuances, the uniqueness of the objective, the uniqueness of a person’s opinion of himself and of the tasks of life” (Adler, 1988, p. 433). From here, one can move through the other stages of Adlerian counseling. An individual’s way of coping with feelings of inferiority or lack of community helps an Adlerian counselor to begin to understand how early childhood experiences have an impact on the client. If we use Adler as an example, he might see his illnesses as a child and his early experiences of death influenced feelings of inferiority and lack of belonging. These early experiences may have been the motivation to become a doctor and make a difference for other young children. While we can only speculate about Adler’s personhood, this could be an example of how a healthy individual might use their feelings of inferiority to press toward goals.

Insight Counselors working within Adlerian theory provide the client with a potential interpretation of their experiences during the insight phase. They seek to help clients understand how their past experiences may be contributing to their current problems. While providing these interpretations is an important part of Adlerian counseling, it is also important to remember that clients are the authors of their own stories and get to decide whether these interpretations align with their experience and are useful for their development.

Reorientation Once the counselor and client have arrived at an interpretation that helps a client understand current hurdles or obstacles and their possible root causes, Adlerian counselors work to help the client develop a new lifestyle or strategy. The collaborative nature of Adlerian work means that clients are ready to engage in new behaviors because they have been involved in identifying the need for them. This reorientation phase involves helping clients identify ways to use feelings of inferiority to move toward their goals and contribute to society, rather than feeling discouraged.

Theory of Neurosis Horney believed that the true self “when strong and active enables us to make decisions and assume responsibility for them. It therefore leads to genuine integration, and a sound sense of wholeness, oneness” (Horney, 1951, p. 157). The counselor works to balance creating safety and challenge within the counseling space. By beginning with the evident mental health symptoms and working to help clients recognize the ways they are separate from their true selves, a counselor works to help clients discover or develop their true self. Counselors might use techniques such as mindfulness that assist clients in maintaining their presence in the moment. The focus on mindfulness allows clients to be fully present without judgment or limits. This connects deeply to Horney’s ideas about wholeheartedness (Horney, 1951).

Adlerian Role of Community Feeling in Maintaining Change Adler believed that as a person moves toward a healthier, more productive lifestyle, they develop community feeling or a turning outward toward others. Community feeling creates an “immediate experience of life; a letting go of safeguard tendencies and an acceptance of life in all its manifestations as joy and love or suffering and sorrow” (Eife et al., 2020). This acceptance of what is and the focus on overcoming obstacles for the sake of the greater good is at the core of maintaining change within Adlerian thought.

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CLINICAL ASSESSMENT Lifestyle Assessments Adlerian counseling typically involves an in-depth lifestyle assessment meant to help counselors understand an individual’s familial relationships and the impact of these relationships on a person’s personality. Lifestyle assessments assist clinicians in gathering information about birth order, sibling relationships, parent–child relationships, ER, dreams, and hidden reasons.

Narcissism and Self-Object Needs Assessments Assessments for narcissism and self-object needs may be helpful for practitioners of self-psychology. The Pathological Narcissism Inventory assesses individuals for pathological indicators of narcissism (Ellison et al., 2013). Two additional questionnaires, the SelfObject Needs Inventory and the Self-Psychology Questionnaire, have also proven useful in clinical practice (Snyman, 2010). The Self- Object Needs Inventory is an assessment designed to identify factors within a person that relate to the three self-object needs identified by Kohut. Specifically, this inventory identifies ways in which people may exhibit tendencies for approach and avoidance within relationships using. Finally, the Self-Psychology Questionnaire measures an individual’s needs for (a) nurturance, (b) guidance, and (c) social isolation. The Self-Psychology Questionnaire is a valid and reliable instrument for measuring a persons need for external direction or to be self-sufficient. It is also a reliable and valid measure for assessing the degree that a person seeks others’ approval and attention or demonstrates a strong internal sense of self-esteem. It is less reliable in measuring an individual’s isolation needs (Brems, 1997).

SPECIFIC THEORETICAL TECHNIQUES A Selection of Adlerian Techniques Adlerian counselors might use several specific techniques to move individuals through the stages of counseling. An Adlerian counselor might use a strengths-based interview to gain a more comprehensive understanding of a client and the unique strengths they bring to the counseling space (see Table 5.1). These interviews are designed to elicit strengths and resources clients use to overcome and strive. The goal is to help clients develop a holistic view of their strengths and how they can be used as resources as they work to achieve any of the three life task areas. An Adlerian counselor might ask a client to think back to their earliest memory and work to fill in as many details as possible about that memory. Next, they might use visualization to help clients access their thoughts, feelings, and behaviors within this memory. Then they would work to help the client connect these early experiences to their present-day ways Table 5.1 Adlerian Technique: Strengths-Based Interview Technique

Example

Strengths-based interview: The counselor helps the client to understand their strengths and how they can leverage them to overcome inferiority and strive to achieve the three life task areas.

Counselor: Mark, I wonder what are some things that you do already that make you a good dad? Client: Well, I don’t know. I try really hard to make sure they know that they have my full attention when we’re together. I put my phone away. I don’t do any work. My employees know when my daughters are with me because that means they should not reach out unless it is an actual emergency.

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of being. For example, a client might share an early memory of playing with a peer, and instead, the peer stole their toy and refused to play with them. The client might recall feeling sad and hurt, believing something was wrong with them. Connecting this to current experience, a counselor might highlight how themes of feeling something is wrong with oneself are showing up in current relationships. Perhaps this early experience created a fear of rejection, and a need to protect oneself from rejection is the result. An Adlerian counselor would then work with the client to develop an alternate interpretation of this early experience and change how this event was perceived. One might ask the client to think of another time when the other child was willing to play together. Comparing and contrasting these experiences can help a client gain a more complex view of the event and new perspectives about its meaning. Specifically, in the following Table 5.2, a counselor might hear themes of disappointment and feeling uncertain about what to expect. In Table 5.3, a counselor might hear a need for love and belonging, along with a sense of failure and feelings of inferiority. Work with this client could focus on understanding what contributed to these fears and what might help find love and belonging. Acting as if is a technique Adlerians use to help client’s practice new behaviors and explore the impact of the behaviors. In this technique, a counselor would ask the client to think about their desire and to think through what specific actions might help fulfill that desire. The counselor and client work together to think through what a client wants, what behaviors might help them achieve those goals, and how they could be implemented. The practitioner would then encourage the client to try that behavior during the next week. When implementing this type of technique, counselors must not overwhelm clients and ask them to implement too many changes at a time (Mosak & Maniacci, 2013). It would be appropriate for a client to only try this new behavior once in one specific situation over the week. After this, a counselor and client would talk about what worked and what did not and work to either adjust or, more broadly, implement the new behavior. Table 5.2 Adlerian Technique: Early Recollections (ER) Technique

Example

ER: ER help the counselor understand the basis for the client’s lifestyle and help them provide avenues for change.

Counselor: What is your earliest recollection from your childhood? Client: Oh gosh. Um…I remember the first week of first grade. My brother and sister were only maybe 2 and 4—they hadn’t started school yet. My parents and both siblings drove me to school on the first day. I was excited that everyone was seeing me off and because I thought it would be like kindergarten. But first grade was full day, kindergarten was half day. I was not prepared for that.

Table 5.3 Adlerian Technique: The Question Technique

Example

The question: The question is intended to help clients think about what realities exist outside of the problem. From the client’s response, Adlerian counselors look to understand the nature of the client’s psychological or physiological problem.

Counselor: How would your life be different if you didn’t have this problem? Client: I would have a life partner whom my children and I both love. They wouldn’t think I am trying to replace them or their mother. I wouldn’t feel lonely, and I wouldn’t feel like a failure as a father. I wouldn’t be so angry with myself and with my failed marriage.

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Interpretations are an important part of moving clients to a place where they are willing to act as if. Specifically, they help clients understand their own actions and thus help them think about how they might be able to get their needs met through other behaviors. In Table 5.4, the counselor emphasizes an early feeling of abandonment and its development within the client. Later work might help the client to modify behaviors that resulted from this early experience of abandonment. Adler described a process of reflecting a person’s behavior to them in a way that highlights the self-defeating nature of the behavior as “spitting in the client’s soup.” Adler believed that it would call a client’s attention to their role in maintaining their own problems. For example, if a client is rejecting the idea that they might have to try a new behavior to build a relationship, an Adlerian counselor might say, “Perhaps you should just wait forever for others to come to you, so you can make sure you never experience another rejection.” In this way, the counselor is bringing attention to how the client behaves and its relationship to the problem (see Table 5.5). Catching oneself is a technique where clients learn to catch their own behaviors. In catching oneself, clients work to understand their patterns of behavior and then seek to catch themselves when developing a self-defeating pattern earlier and earlier. For example, clients may begin to recognize triggers that lead to problematic behaviors or understand how their behaviors link together so they can catch an early problematic behavior. Catching oneself is an important Adlerian technique for helping clients maintain any positive change they have made in counseling. Table 5.4 Adlerian Technique: Interpretation Technique

Example

Interpretation: The counselor offers an interpretation of the client’s experience to help the client gain insight into their motivation and behaviors. The counselor always offers the interpretation as a suggestion, hunch, or question, leaving room for client to accept, reject, or alter the interpretation.

Counselor: Could it be that you felt abandoned by your family? Client: Kind of. Yes, somewhat. But more than that, I felt like I was abandoning my brother and sister. Like I had traded them in for all these other kids, my classmates. Counselor: So, it was less that you felt abandoned, but rather you felt you had abandoned them? Client: Yes, I remember thinking, “What if Brandy and Ray think I’m not coming back? They will be so sad.” I just wanted to leave to tell them I loved them.

Table 5.5 Adlerian Technique: Spitting in the Client’s Soup Technique

Example

Spitting in the client’s soup: A metaphor used to describe the counselor reflecting the client’s behavior to highlight the self-defeating nature of the behavior. It is used to increase client’s awareness of the impact of their own choices.

Client: Loving them is easy, but it would probably be easier to show it if the loneliness…But that’s my job. I am their dad, I am responsible for them, not the other way around. Counselor: Your role as dad is clearly important to you and you feel like making sacrifices for your daughters is part of your role. So, I guess you have to accept the loneliness and never date again to be a good dad.

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Attunement and Transference Unlike Adlerian psychology, self-psychology and the theory of neurosis do not emphasize the use of techniques. Kohut emphasized the empathetic attunement mentioned earlier in this chapter. Through empathetic attunement, the counselor learns about their client, enters their world, and becomes the object of transference. Through responding in different ways from an individual’s parents, empathetic attunement allows self-psychologists to create reparative emotional experiences, the cornerstone of self-psychology (Rowe & Mac Isaac, 2000). Horney, meanwhile, was unique in advocating for self-analysis and believed that people were the in best position to understand themselves. Within self-analysis, Horney advocated for many traditional psychoanalytic techniques including free association and dream analysis. Horney believed that self-analysis required individuals to be completely honest with themselves and to pay attention to all pieces of oneself, even the uncomfortable ones. In paying attention to all pieces of the self, even those one might like to ignore, individuals can come to understand themselves and what might be influencing their motivations, both conscious and unconscious. Horney also emphasized the importance of contradictions and exaggerations in everyday life. By engaging in self-analysis and taking note of strong reactions to events that would not typically elicit a strong response, an individual might learn to better understand their motivations. Horney believed that through developing insight about self, an individual could build the capacity to do something different and improve their relationships. Ultimately, each of these techniques are common to psychoanalysis and are focused on building insight, but applying these techniques through self-analysis is unique to Horney’s interpretation (Horney, 1942, 1945).

MULTICULTURAL, INTERSECTIONAL, AND SOCIAL JUSTICE ISSUES Adler was an early supporter of feminism and believed that feelings of superiority and inferiority were often gendered and expressed symptomatically in characteristic masculine and feminine styles. He was not as attuned to the ways that other identities might impact an individual’s lifestyle; however, there is significant room within Adlerian counseling to attend to these issues. Several writers have considered the ways in which style of life can be utilized to understand the experiences of marginalized populations across the life span (Sapp, 2014). Using lifestyle assessments, counselors can explore the impact of background, values, familial structure, social norms, environment, acculturation, and other aspects of life with specific attention to the influences of identity in each of these areas. Adlerian counselors understand the ways individuals are embedded in society and believe that individuals are best understood within their social-relational context and their environments and thus are well equipped to bridge these understandings to include aspects of individual culture. Contrary to its title (individual psychology), Adler’s emphasis on community feeling and connectedness with something bigger than oneself lends itself well to adaptation to many cultures. Decolonization of mental health systems requires counselors to understand people within the context of oppressive structures and to reject assumptions that problems are typically located within individuals (Singh, 2020‌‌‌‌‌‌). Adlerian counselors focus on the interaction between environment and the individual. This relational constructivist paradigm offers a way for counselors to intentionally decolonize their practice and attend to both the individual and the influences of lifestyle and the impact of systems and structures outside of clients. In contrast, counselors practicing from an Adlerian perspective should be careful to consider how a person’s location in the world and relevant identities may impact their access to community feeling. For example, Eife et al. (2020) asserted that Western society’s exploitation of resources and people may result in a lack of resonance and community feeling which leaves individuals feeling unfulfilled.  Furthermore, communities of color within predominantly

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White institutions (PWI’s) may not have access to the same level of community connectedness because of the societal structures that limit their access. Similarly, individuals who have been exploited for their labor, such as rural Appalachian Americans, may insulate themselves into smaller communities and therefore experience limited access to their community.

Beyond Gender in Feminist Psychology It is important to note critiques of early feminist psychoanalysis and its focus on the experiences of women, specifically White women. Like many theories, feminist psychoanalysis is based on the experience of its founder and thus comes from a primarily White perspective. Horney’s critique of Freudian theoretical concepts are primarily focused on his problematic beliefs about women while ignoring his anti-Semitic and queerphobic conceptualizations of problems. Contemporary feminist ideals have moved toward a more intersectional lens in understanding that gender is just one of many identities that was problematized in early psychoanalysis. While Horney acknowledges the role of the environment in creating neurotic needs, she focused primarily on relationships between people. Contemporary practitioners should broaden this understanding to incorporate other environmental conditions that may serve to create neurotic needs and behaviors within individuals. For example, it is possible that a Latina woman who has low socioeconomic status (SES) and has consistently received feedback that she will never make it might have high neurotic needs centered on achievement. Understanding the broader impact provides an additional way for counselors to intervene and emphasizes the need for advocacy and understanding in combination with the relational change that happens in the counseling room.

Adding Societal Context to Psychoanalytic Conceptualization Similar to other psychoanalytic theories, self-psychology focuses on pathology and the individual. This potentially leaves limited space for the social context that influences individuals and can lead to them overemphasizing their role in a problem, rather than acknowledging how social constructs and systems influence experiences and coping mechanisms. The success of self-psychology centers on an individual’s access to others who can serve as good self-object relationships. An individual who is isolated or lacks relationships may struggle to experience the benefits of an approach like self-psychology. Furthermore, self-psychology may be limited in its ability to honor the diversity of the human experience and context. It was specifically developed in the context of White and primarily Western norms regarding behavior. For individuals whose culture may have other expectations for behaviors and relationships, self-psychology may need to be adapted. An additional limitation to self-psychology is the lack of acknowledgment regarding the influence of society on developing maladaptive self-object needs. Emphasis is placed primarily on early-life experiences within the context of family relationships. An understanding of the context in which relationships exist is missing from the theory. Practitioners should pay careful attention to the impact of the client’s environment (e.g., poverty, racism, sexism, hate) and how these factors influence the types of relationships that are developed.

RESEARCH TRENDS Researchers continue to explore a variety of applications of relational psychoanalytic thought across the disciplines of counseling including within counseling supervision. Multiple supervision models have incorporated Adlerian concepts within the last 15 years including the respectfully curious inquiry/therapeutic empowerment (RCI/TE) model, the individual psychology supervision model, the Adlerian-based solution-focused supervision model, the Adlerian alliance supervisory model, and Shifron’s model emphasizing ER (Devlin et al., 2009; Lemberger & Dollarhide, 2006; McCurdy, 2006; Milliren et al., 2006; Shifron, 2020).

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DETAILED CASE CONCEPTUALIZATION PRAGMATICS AND TRANSCRIPT Mark is a 42-year-old, Black, cisgender male who works as a project manager for a general contracting company. He is divorced and lives with his two daughters. Mark is seeking counseling for anxiety, sadness, and anger that occurred following his divorce. Mark has expressed feeling lonely and guilty for wanting to start dating again because it “takes me away from my daughters.” Mark’s development is stunted by challenges working toward love, a basic area of life. Mark is motivated and desires to find companionship after his divorce, but his guilt associated with divorce and responsibility to his daughters has led him to an unfulfilling lifestyle. Due to his struggle to achieve this life task, Mark has feelings of inferiority. Inferiority, for Mark, has manifested in his experience of anxiety, sadness, and anger. The counselor must consider Mark’s social context and utilize the four phases of Adlerian therapy (engagement, assessment, insight, and reorientation) to help mark realize his own potential to achieve important life tasks. Lifestyle assessment, with attention to early childhood experiences and family constellation, will be applied to increase understanding and insight for both the counselor and client. The counseling process will allow Mark to move away from feelings of inferiority and toward adequacy and wholeness. Transcript

Skill(s) Demonstrated

Counselor: Hello, Mark. What brings you in today?

Open-ended question (Counselor uses an open-ended question to open the session.)

Client: Well, it’s really one thing. I’ve been thinking about dating again, but I don’t think it’s a good idea…because of the girls. Counselor: You were married for 12 years, and have Summarizing been divorced for 2 or 3 years? (Counselor uses recall to summarize ­information from previous sessions.) Client: We were married for 12 years and divorced 3 years ago. I haven’t dated anyone seriously since. I know I’m lonely and want someone in my life, but how it would make the girls feel concerns me. I feel really guilty, like I’m a bad dad for even having the desire to date. Counselor: You think that dating again will hurt your daughters.

Reflection of meaning (Counselor reflects Mark's statement emphasizing the underlying meaning.)

Client: Yes. I hated seeing my parents date after their divorce. Counselor: Your parent’s divorce was hard on you.

Paraphrasing (Counselor paraphrases Mark’s ­experience with his parent’s divorce.)

Client: It was terrible for me and my siblings. Counselor: You remember you and your siblings Lifestyle assessment struggling with the divorce. What is your earliest rec- (Counselor asks about Mark’s early childollection from your childhood? hood recollection to understand the impact of familial relationships on his personality and behaviors.) *Lifestyle assessment includes but is not limited to early recollections (ER). It is intended to increase understanding and insight into the client’s private logic.

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Client: Oh gosh. Um…I remember the first week of first grade. My brother and sister were only maybe 2 and 4—they hadn’t started school yet. My parents and both siblings drove me to school on the first day. I was excited that everyone was seeing me off and because I thought it would be like kindergarten. But first grade was full day, kindergarten was half day. I was not prepared for that.

Family constellation (Though counselor did not directly ask for it, Mark provides information about birth order and nuclear makeup.)

Counselor: Your parents were still married?

Closed-ended questioning (Counselor is interested in a particular detail related to Mark’s parents.)

Client: Yes. They divorced the following year. Now that I think about it, though, things were not good between them. They had probably been having problems in their marriage for a while by this point. Counselor: You remember that your parent’s relationship was rocky, and on this day, you were excited to have your whole family there to send you off to school.

Paraphrase and reflection of feeling (Counselor is working to ensure Mark feels understood and validated.)

Client: Oh yes. In kindergarten, with the half day, it was like a quick trip away from my family and I got to come home and tell them all about the fun I’d had. After half a day of first grade I felt nervous, like why aren’t they coming to get me? Counselor: Could it be that you felt abandoned by your family?

Interpretation (Counselor offers an interpretation of Mark’s experience and allowing room for him to accept, reject, or alter the interpretation.)

Client: Kind of. Yes, somewhat. But more than that, I felt like I was abandoning my brother and sister. Like I had traded them in for all these other kids. Counselor: So it was less that you felt abandoned, but rather you felt you had abandoned them?

Encouraging insight (Counselor adjusts initial interpretation to help Mark gain insight into his motivation and behaviors.)

Client: Yes. I remember thinking, “What if Brandy and Ray think I’m not coming back? They will be so sad” and I just wanted to leave to tell them I loved them. Counselor: You were the oldest, you felt responsible Birth order for them, and you didn’t want to let them down. (Counselor emphasizes Mark’s birth order as part of the lifestyle assessment.) Client: They would laugh if they heard you say that. I always felt responsible for them, for setting a good example. To this day, they mock me saying I try to protect them from everything. Counselor: So, as a child, you were hurt by your parents’ divorce. As the oldest, you felt responsible for your siblings and blamed yourself for not protecting them from the challenges of the divorce and for not being there to protect them when you were away. Because of these early experiences, you believe that dating again will take time away from your daughters, time that you should be using to protect them from the hurt of your divorce.

Integration and summarization (Counselor provides a summary of Mark’s private logic based on family constellation and developmental data as it connects to here-and-now behaviors and concerns.)

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Client: Yes, exactly. Counselor: That’s a lot for one person to hold. Mark, I wonder what are some things that you do already that make you a good dad?

Strengths-based interview (Counselor increases Mark’s understanding of himself and his unique strengths to help identify existing resources he can use to overcome and strive.)

Client: Well, I don’t know. I try really hard to make sure they know that they have my full attention when we’re together. I put my phone away. I don’t do any work. My employees know when my daughters are with me because that means they should not reach out unless it is an actual emergency. Counselor: You give them all of yourself.

Paraphrasing (Counselor paraphrased the strength.)

Client: I think so. Yes. And I tell them how special and loved they are. I want them to be confident and know that I am proud of them, so I tell them often. Counselor: You tell them you love them and that they are deserving of that love. And they feel that when you give them your full attention and set other important things aside, because they are most important. It sounds like you are a good dad.

Summarizing and encouragement (Counselor summarizes content to acknowledge and emphasize strengths.)

Client: I hope so. Counselor: Could it be that it is hard at times to give so much love and protection while you feel so lonely?

Encouraging insight (Counselor offers an interpretation or hunch to help Mark gain insight into client’s motivation and behaviors.)

Client: Loving them is easy, but it would probably be easier to show it if the loneliness…But that’s my job. I am their dad, I am responsible for them, not the other way around. Counselor: Your role as dad is clearly important to you. You feel like making sacrifices for your daughters is part of your role. So, I guess you have to accept the loneliness and never date again to be a good dad.

Spitting in the client’s soup (Reflection of Mark’s behavior to highlight the self-defeating nature of the behavior. It is used to increase Mark’s awareness of the impact of his own choices.)

Client: Do you really think so? Counselor: It seems like you think so. How would your life be different if you didn’t have this problem?

The question (Counselor asks ‘“he question” to help Mark think about new realities that might be available to him. The counselor tries to understand the nature of his psychological or physiological problem.)

Client: I would have a life partner whom my children and I both love. They wouldn’t think I am trying to replace them or their mother. I wouldn’t feel lonely, and I wouldn’t feel like a failure as a father. I wouldn’t be so angry with myself and with my failed marriage. Counselor: You would feel more content, less anxious, and angry about your experience. You would have more of your needs met and feel like you are fulfilling your responsibilities as a father. Client: Yes. I could find someone who would fit into my life, into my daughters' lives without them resenting me.

Summarization (Counselor summarizes Mark’s experiences and feelings related to his role as a father.)

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Counselor: I’m wondering, Mark, if your daughters do experience hurt feelings when you start dating again, is it possible to accept that hurt? To allow them to feel sorrow, and strive toward overcoming that sorrow together?

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Reorientation (Counselor provides a hunch by suggesting how Mark might foster his relationship with his daughters by promoting community feeling.)

Client: What do you mean? Counselor: Allowing them to react and feel their own experience, feel supported in those feelings by their loving dad, and then to overcome for the greater good of the whole family may actually increase your connection with your daughters.

Reorientation (Counselor provides insight by highlighting the resulting emotion of community feeling. Social interest is a life task that turning outward toward others and toward his daughters might inspire the same turning outward by his daughters. By doing so, they let go of safeguard tendencies to fully experience life, good or bad, and feel motivated to overcome for the benefit of the greater good. In this case, for the benefit of the entire family.)

Client: I never thought of it that way. You are right, though. I am trying, but I am not at my best right now and they probably notice more than I realize. If they see me struggling and can be a part of my life in new ways, I think it could make our relationships stronger, even if bringing in new people is challenging for them. Counselor: I think you are probably right that your daughters sense some of that, too. I also experience your genuineness and see how capable you are of taking on a new phase of your life in a way that will ultimately benefit your family.

Encouragement (Counselor acknowledges strengths and belief in Mark’s ability to make and maintain change.)

Client: Thanks for the perspective. I hadn’t thought enough about how my loneliness might be negatively impacting them, only about how dating again might hurt them. It feels like I have a new way to include them in the process instead of avoiding it. Counselor: To include them in a way that brings you closer to what you want for your daughters and for yourself. Is it possible to talk to your daughters directly about how you feel?

Reorientation (Counselor uses Mark’s goals and insight to propose potential action.)

Client: I think that would be a good start. It will help bring them into it and empower them to talk to me about their feelings to help us figure out how to work through it as a family. Counselor: Sounds like you are ready to try on a new perspective and new approach. I look forward to hearing about it the next time we meet.

Five Theoretically Based Techniques In Table 5.6, we intentionally review five core Adlerian techniques in a transcript based on the case of Mark Stockton. To differentiate this section from the main transcript, we place the skill name and definition within the left column and the transcribed skill example within the right column.

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Table 5.6. Five Core Adlerian Techniques Technique

Example

Early recollections (ER): ER help the counselor understand the basis for the client’s lifestyle and help them provide avenues for change.

Counselor: What is your earliest recollection from your childhood?

Strengths-based interview: Strengthsbased interviews are used to gain a fuller perspective of the client and the unique strengths they bring to the counseling space. The counselor helps the client to understand their strengths and how they can leverage them to overcome inferiority and strive to achieve the three life task areas.

Counselor: Mark, I wonder what are some things that you do already that make you a good dad?

Interpretation: The counselor offers an interpretation of the client’s experience to help the client gain insight into their motivation and behaviors. The counselor always offers the interpretation as a suggestion, hunch, or question, leaving room for the client to accept, reject, or alter the interpretation.

Counselor: Could it be that you felt abandoned by your family?

Client: Oh gosh. Um…I remember the first week of first grade. My brother and sister were only maybe 2 and 4—they hadn’t started school yet. My parents and both siblings drove me to school on the first day. I was excited that everyone was seeing me off and because I thought it would be like kindergarten. But first grade was full day, kindergarten was half day. I was not prepared for that.

Client: Well, I don’t know. I try really hard to make sure they know that they have my full attention when we’re together. I put my phone away. I don’t do any work. My employees know when my daughters are with me because that means they should not reach out unless it is an actual emergency.

Client: Kind of. Yes, somewhat. But more than that, I felt like I was abandoning my brother and sister. Like I had traded them in for all these other kids, my classmates. Counselor: So it was less that you felt abandoned, but rather you felt you had abandoned them? Client: Yes. I remember thinking, “What if Brandy and Ray think I’m not coming back? They will be so sad” and I just wanted to leave to tell them I loved them.

Spitting in the client’s soup: A metaphor used to describe the counselor reflecting the client’s behavior to highlight the self-defeating nature of the behavior. It is used to increase client’s awareness of the impact of their own choices.

Client: Loving them is easy, but it would probably be easier to show it if the loneliness…But that’s my job. I am their dad, I am responsible for them, not the other way around.

The question: The question is intended to help clients think about what realities exist outside of the problem. From the client’s response, Adlerian counselors look to understand the nature of the client’s psychological or physiological problem.

Counselor: How would your life be different if you didn’t have this problem?

Counselor: Your role as dad is clearly important to you and you feel like making sacrifices for your daughters is part of your role. So, I guess you have to accept the loneliness and never date again to be a good dad.

Client: I would have a life partner whom my children and I both love. They wouldn’t think I am trying to replace them or their mother. I wouldn’t feel lonely, and I wouldn’t feel like a failure as a father. I wouldn’t be so angry with myself and with my failed marriage.

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THEORETICAL LIMITATIONS Psychoanalytic work requires clients to be willing and able to explore their early-life experiences. For individuals who are resistant to exploring these experiences or who may not have the resources to explore these experiences, psychoanalytic approaches would not be an appropriate form of counseling. Those who need short-term therapy due to the nature of their concerns, financial resources, or other reasons may also not be well suited for psychoanalytic counseling due to the long-term nature of the approaches. While the many psychoanalytic counseling techniques can be helpful, it is important to note that there is little empirical data to support the myriad techniques and their efficacy with clients. This is partly due to the less concrete nature of the means of change within psychoanalytic counseling and not due to a shortcoming within the theories themselves.

Summary This chapter provided an overview of the three post-Freudian psychoanalytic approaches that all emphasize early-life experiences as foundational in the work of counselors. Counselors practicing from any of these theoretical approaches spend a significant amount of counseling time focused on understanding how these early-life experiences influence current functioning. Each of these theories provides a step forward from traditional Freudian psychoanalysis in integrating context and culture into the work of counseling. Although counselors will need to continue working to build on the work of the founders in attending to diverse experiences, these theories provide opportunities for counselors to consider how life experiences rooted in cultural identity might impact an individual development and, thus, their current functioning. This provides counselors who value clinically exploring early-life experiences with a means of integrating new developments in counseling into traditional psychoanalytic and psychodynamic work. VOICES FROM THE FIELD This chapter features a digitally recorded interview entitled Voices From the Field. The interview explores multicultural, social justice, equity, diversity, and intersectionality issues from the perspective of clinicians representing a wide range of ethnic, racial, and national backgrounds. The purpose of having chapter-based authors interview individuals representing communities of color or who frequently serve diverse populations is to provide you, the reader, with relevant theory-based social justice and multiculturally oriented conceptualization, contemporary issues, and relevant skills.

Access the video at https://bcove.video/46iVwdL

Evan Sorenson, LMFT, is a 52-year-old, White male therapist from the North Atlantic Region of the United States. He has a graduate degree in marriage and family therapy from a Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE)-accredited graduate program and has been practicing from a relational psychodynamic approach for the past 20 years. He is currently in fulltime private practice and his work focuses primarily on couples, but he also treats individual clients. As a therapist, Evan utilizes an insight-oriented approach that centers on early-life experiences as foundational to the development of self. He believes in the power of corrective experiences and the importance of counseling as a space where clients can experience this empathetic attunement from a clinician.

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STUDENT EXERCISES Exercise 1: Early Recollections

Directions: Think back to your childhood, between 6 and 8 years of age. What is your earliest recollection? What do you remember about it? Write down as much detail about the memory as you can. Please consider the following prompts as you reflect on this memory. ■ ■ ■

Describe the environment you were in. How is your environment changed? Who was around you during this time? How has that changed? Describe what your familial expectations were at that time.

Exercise 2: A Deeper Dive Into Early Recollections

Directions: Take time to reflect on your earliest recollections. What stands out to you about your recollection? Do you notice any themes? How did it feel to recollect this memory in such detail?

Exercise 3: Family Constellations

Directions: Write or map out your family constellation. What is your psychological birth order? How did your birth order and family constellation affect you when you were younger? How does your birth order and family constellation affect you in your life now?

Exercise 4: Primary Direction of Relationships

Directions: Think about the primary directions of relationships identified by Karen Horney in feminist psychology. With which primary direction of relationships do you most closely identify? How so? How does your primary direction of relationships connect to Horney’s 10 neuroses?

Exercise 5: Understanding Self-Objects

Directions: As you consider Heinz Kohut’s self-psychology, who are the self-objects in your life? If you were a self-psychologist, how would you characterize your adult relationships? Please consider the following questions as you reflect on this question. ■ ■ ■

Are you overreliant on self-objects? Do you have a nuclear self? How do you know?

RESOURCES Helpful Links ■ ■ ■ ■ ■

North American Society of Adlerian Psychology Social Justice Taskforce: www.alfredadler.org/sjtf1 A Movement for Justice: Socially Responsible Practice: www.adler.edu/wp-content/ uploads/2020/08/SRP-Document-A-Movement-For-Justice.pdf Society for the Psychology of Women: www.apadivisions.org/division-35 AdlerPedia All Things Adlerian (managed by the Center for Adlerian Practice and Scholarship): www.adlerpedia.org Psychology’s Feminist Voices: https://feministvoices.com

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Helpful Books ■ ■ ■ ■ ■ ■ ■

Adler, A. (2013). The case of Miss R. (psychology revivals): The interpretation of a life story. Routledge. Bowman, S. L. (2014). The Oxford handbook of feminist multicultural counseling psychology. Oxford University Press. Burman, E. (1998). Deconstructing feminist psychology. Sage. Lee, R. R., & Martin, J. C. (2013). Psychotherapy after Kohut: A textbook of self psychology. Routledge. Sheppard, P. I. (2011). Black women and self-psychology: Toward a usable dialogue. In Self, culture, and others in womanist practical theology (pp. 111–125). Palgrave Macmillan. Westkott, M. (1986). The feminist legacy of Karen Horney (p. 66). Yale University Press. Yoder, J. D. (1999). Women and gender: Transforming psychology. Prentice-Hall, Inc.

Helpful Videos ■ ■ ■ ■ ■

https://sk.sagepub.com/video/theory-in-action-feminist-approach https://video.alexanderstreet.com/watch/adlerian-therapy-3 https://video.alexanderstreet.com/watch/brief-integrative-adlerian-couples-therapy https://video.alexanderstreet.com/watch/incorporating-race-and-culture-with-other-­ aspects-of-anxiety-choices-contexts-and-strategies https://video.alexanderstreet.com/watch/ culturally-informed-psychoanalytic-psychotherapy

A robust set of instructor resources designed to supplement this text is available. Qualifying instructors may request access by emailing [email protected].

REFERENCES Adler, A. (1988). Personality as a self-consistent unity. Individual Psychology: Journal of Adlerian Theory, Research and Practice, 44(4), 431–440. Adler, A. (2013a). The science of living. Routledge. https://doi.org/10.4324/9780203386750 Adler, A. (2013b). Understanding human nature (psychology revivals). Routledge. https://doi. org/10.4324/9780203438831 Allen, T. W. (1972). The individual psychology of Alfred Adler: An item of history and a promise of a revolution. The Counseling Psychologist, 3(1), 3–24. https://doi.org/10.1177/001100007100300102 Ansbacher, H. L., & Ansbacher, R. R. (Eds.) (1956). The individual psychology of Alfred Adler. Basic Books. Baker, H. S., & Baker, M. N. (1987). Heinz Kohut’s self psychology: An overview. American Journal of Psychiatry, 144(1), 1–9. https://doi.org/10.1176/ajp.144.1.1 Brems, C. (1997). Development of the self-psychology questionnaire. Clinical Psychology & Psychotherapy, 4(1), 7–14. https://doi.org/10.1002/(SICI)1099-0879(199703)4:13.0.CO;2-1 Devlin, J. M., Smith, R. L., & Ward, C. A. (2009). An Adlerian Alliance Supervisory Model for School Counseling. Journal of School Counseling, 7(42), n42. http://files.eric.ed.gov/fulltext/EJ886162.pdf Eife, G., Ferrero, A., Neudecker, B., & Prina, P. (2020). Looking back on the development of Alfred Adler’s individual psychology in parts of Europe on the 150th anniversary of his birth. The Journal of Individual Psychology, 76(1), 31–42. https://doi.org/10.1353/jip.2020.0013 Ellison, W. D., Levy, K. N., Cain, N. M., Ansell, E. B., & Pincus, A. L. (2013). The impact of pathological narcissism on psychotherapy utilization, initial symptom severity, and early-treatment symptom change: A naturalistic investigation. Journal of Personality Assessment, 95(3), 291–300. https://doi.org /10.1080/00223891.2012.742904 Gottman, J. M. (1999). The marriage clinic: A scientifically based marital therapy. W.W. Norton. Horney, K. (1937). The neurotic personality of our time. Routledge. https://doi.org/10.4324/9781315010533 Horney, K. (1942). Self-analysis. Routledge. https://doi.org/10.4324/9781315010564

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Horney, K. (1945). Our inner conflicts: A constructive theory of neurosis. W. W. Norton & Co. https://doi. org/10.4324/9781315010557 Horney, K. (1950). Neurosis and human growth: The struggle toward self-realization. Routledge. https://doi. org/10.4324/9781315010526 Horney, K. (1951). Neurosis and human growth: The struggle toward self-realization. Routledge. https://doi. org/10.4324/9781315010526 Horney, K. (1967). Feminine psychology. Norton. Horney, K. (1987). Final lectures (D. H. Ingram, Ed.). W.W. Norton & Co. Jacobs, J. L., & Capps, D. (2018). Religion, society, and psychoanalysis: Readings in contemporary theory. Routledge. https://doi.org/10.4324/9780429497711 Kelman, H. (1967). Karen Horney on feminine psychology. American Journal of Psychoanalysis, 27(2), 163– 183. https://doi.org/10.1007/BF01873051 Kohut, H. (1968). The psychoanalytic treatment of narcissistic personality disorders: Outline of a systematic approach. The Psychoanalytic Study of the Child, 23(1), 86–113. https://doi.org/10.1080/00797308. 1968.11822951 Kohut, H., & Wolf, E. S. (1978). The disorders of the self and their treatment: An outline. International Journal of Psychoanalysis, 59, 413–425. https://doi.org/10.4324/9780429483110-10 Lemberger, M., & Dollarhide, C. T. (2006). Encouraging the supervisee’s style of counseling: An Adlerian model for counseling supervision. Journal of Individual Psychology, 62(2), 106–125. McCurdy, K. G. (2006). Adlerian supervision: A new perspective with a solution focus. The Journal of Individual Psychology, 62(2), 141–153. https://web.s.ebscohost.com/ehost/pdfviewer/ pdfviewer?vid=0&sid=4372c996-5159-441f-835c-7f6e532dfa76%40redis McLean, J. (2007). Psychotherapy with a narcissistic patient using Kohut’s self psychology model. Psychiatry (Edgmont), 4(10), 40–47. http://www.ncbi.nlm.nih.gov/pubmed/20428310 Milliren, A., Clemmer, F., & Wingett, W. (2006). Supervision: In the style of Alfred Adler. Journal of Individual Psychology, 62(2), 89–105. Mishne, J. M. (1994). The evolution and application of clinical theory: Perspective from four psychologies. https:// doi.org/10.1176/ajp.151.8.1239 Mosak, H. H., & Maniacci, M. (2013). A primer of Adlerian psychology: The analytic-behavioral-cognitive psychology of Alfred Adler. Routledge. Ozer, D. J., & Benet-Martínez, V. (2006). Personality and the prediction of consequential outcomes. Annual Review of Psychology, 57, 401–421. https://doi.org/10.1146/annurev.psych.57.102904.190127 Rasmussen, P. R. (2011). Individual psychology: The perspective of Alfred Adler. In The quest to feel good (pp. 59–100). Routledge. Rowe, C., & Mac Isaac, D. (2000). Empathic attunement: The “technique” of psychoanalytic self psychology. Rowman & Littlefield Publishers, Inc. https://doi.org/10.1176/appi.psychotherapy.1990.44.3.452 Shifron, R. (2020). The miracle of early recollections in Adlerian psychotherapy and supervision. The Journal of Individual Psychology, 76(1), 110–127. https://doi.org/10.1353/jip.2020.0022 Shulman, B. H., & Mosak, H. H. (1977). Birth order and ordinal position: Two Adlerian views. Journal of Individual Psychology, 33(1), 114–121. Singh, A. (2020). Building a counseling psychology of liberation: The path behind us, under us, and before us. The Counseling Psychologist, 48(8), 1109–1130. https://doi.org/10.1177/0011000020959007 Snyman, B. (2010). Kohut’s self-object needs: Mirroring, idealization and twinship [Edith Cowan University]. https://ro.ecu.edu.au/theses/1858 Solomon, I. (2006). Karen Horney and character disorder: A guide for the modern practitioner. Springer Publishing Co. Strozier, C. B. (2007). Heinz Kohut and the meanings of identity. Contemporary Psychoanalysis, 43(3), 399– 410. https://doi.org/10.1080/00107530.2007.10745917 Strozier, C. B., Pinteris, K., Kelley, K., & Cher, D. (2022). The new world of self: Heinz Kohut’s transformation of psychoanalysis and psychotherapy. Oxford University Press. Sweeney, T. J. (1998). Adlerian counseling: A practitioner’s approach (4th ed.). Taylor & Francis. Turiano, N. A., Graham, E. K., Weston, S. J., Booth, T., Harrison, F., James, B. D., Lewis, N. A., Makkar, S. R., Mueller, S., Wisniewski, K. M., Zhaoyang, R., Spiro, A., Willis, S., Warner Schaie, K., Lipton, R. B., Katz, M., Sliwinski, M., Deary, I. J., Zelinski, E. M., … Mroczek, D. K. (2020). Is healthy neuroticism associated with longevity? A coordinated integrative data analysis. Collabra: Psychology, 6(1). https://doi.org/10.1525/collabra.268

Vena, J. (2015). Karen Horney. In D. L. Dobbert & T. X. Mackey (Eds.), Deviance: Theories on behaviors that defy social norms (pp. 48–57). Praeger. Watkins, C. E. (1984). The individual psychology of Alfred Adler: Toward an Adlerian vocational theory. Journal of Vocational Behavior, 24(1), 28–47. https://doi.org/10.1016/0001-8791(84)90064-2 Watts, R. E. (1999). The vision of Adler: An introduction. In Interventions and strategies in counseling and psychotherapy (pp. 1–13). Taylor & Francis. Widiger, T. A., & Oltmanns, J. R. (2017). Neuroticism is a fundamental domain of personality with enormous public health implications. World Psychiatry, 16(2), 144–145. https://doi.org/10.1002/wps.20411

SECTION III

PERSON-CENTERED, EXPERIENTIAL, AND EXISTENTIAL THEORIES

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PERSON-CENTERED COUNSELING AND RELATED EXPERIENTIAL APPROACHES Elizabeth K. Norris, Tyler Wilkinson, and Jeff D. Cook

LEARNING OBJECTIVES After reaching this chapter, you will be able to: ■ Recognize the history and background of person-centered counseling, process emotional theory, and emotionally focused therapy (EFT) ■ Describe the roles of clinicians and how to maintain progress using person-centered counseling, process emotional theory, and EFT ■ Summarize key techniques and limitations to person-centered counseling, process emotional theory, and EFT ■ Analyze how person-centered counseling, process emotional theory, and EFT may be integrated into their own professional development and practice

INTRODUCTION This chapter will cover person-centered counseling, process experiential (PE) counseling, and EFT under the umbrella of the humanistic tradition. While there are some distinct differences among these theories, readers will find overlap within the conceptual frameworks, especially in how they build upon each other. All three of these theories place primacy on the character, disposition, and development of the counselor. Therefore, it is vital for counselors to do their personal work toward healing and growth, as this has a direct impact on their work with clients. These theories are not cognitive, prescriptive, or diagnostic in any fashion; their focus is on the subjective experience of the client. A goal of each of these theories is to connect deeply with the person of the client in the midst of their story rather than focus on problems. As such, these theories bring humanity back into the counseling room.

LEADERS AND LEGACIES OF PERSON-CENTERED AND RELATED EXPERIENTIAL THEORIES Carl Rogers Carl Ransom Rogers (1902–1987) was the fourth born of six children in Oak Park, Illinois. Influenced by their religious fundamentalist Christianity, his parents, while loving, were also strict and controlling, prohibiting activities such as dancing, drinking, and going to the theater (Rogers, 1961). In reflecting on his upbringing, Rogers explained that he was subjected to conditions of worth placed upon him by his parents (Rogers, 1961). He was very influenced by his father’s learning of scientific agriculture on the family farm and

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spent most of his time applying the scientific method to learning about raising animals and insects. These early experiences on the farm influenced his agricultural pursuits and his love of research. Rogers attended the University of Wisconsin, originally studying agriculture. During this time, he was one of 12 students chosen to represent the United States in China as a delegate to the World Student Christian Federation Conference. While on that trip, he encountered religious perspectives more open and less rigid than that of his fundamental background, which resulted in a transformation of his own beliefs. He returned home, changed his major from agriculture to history, and graduated in 1924. Following his marriage to Helen Elliot, he continued his academic pursuits by attending the Union Theological Seminary in hopes of becoming a minister. Two years into his seminary education, he shifted routes once more by leaving the seminary and enrolling in a doctoral program in clinical and educational psychology at Columbia University. The beginning of his career was marked by 12 years at the Society for the Prevention of Cruelty to Children in Rochester, New York, where he practiced traditional psychoanalysis. Finding the approach to be lacking, he leaned into his clinical experience and eventually became more nondirective. It was during this time that he first began researching the outcomes of clinical treatment. He held several academic appointments, including at Ohio State University, the University of Chicago, and the University of Wisconsin. Throughout his tenure, Rogers developed his theory of client-centered counseling and began viewing individuals seeking counseling as clients rather than patients who had problems needing treatment. He published several articles articulating his theoretical hypotheses and subjected them to empirical research. After leaving academia, he moved to California to work with the Western Behavioral Sciences Institute before joining colleagues to establish the Center for Studies of the Person. In his later years, Rogers expanded his focus beyond individual counseling to include marriages, education, business, administration, international relations, and politics. It was this expansion that resulted in the change from client-centered counseling to person-centered counseling. Rogers revolutionized the psychotherapy of his day through his approach to counseling. Dedicating more than 60 years to understanding people, personality change, and the counseling process, he is known as one of the most influential theorists, transforming counseling from science to an artform. Taking a drastic departure from the prevailing theoretical perspective of the time (i.e., Freudian psychoanalysis) that placed primacy on directive approaches and therapist expertise, Rogers insisted that more nondirective engagement would lead to long-lasting change. While much of Rogers’ theoretical approach aligns with his personal experience, his concepts have been subject to empirical research and have become foundational to academic training in clinical mental health.

Abraham Maslow Abraham Maslow (1908–1970) was born in Brooklyn, New York, as the first of seven children to a family that immigrated from Russia. Maslow spent the better part of his adolescent years pouring himself into books in the public library. He first went to school to study law at the City College but later switched to psychology and received his bachelor’s, master’s, and doctoral degrees from the University of Wisconsin. As an American psychologist, Maslow began his career in academia at Brooklyn College until the early 1950s. Refuting the Freudian drive instinct and the stimulus–response exchange, Maslow based his theory on motivations, explaining that inherent needs guide individuals (Maslow, 1943). This understanding contributed to the conception of the hierarchy of needs, making him a forerunner in humanistic psychology. Maslow’s‌ hierarchy of needs is represented by a triangular image that illustrates the basic needs of all humans

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to progress toward self-actualization, including physiological, safety, love/belonging, and esteem needs. Maslow’s work influenced Rogers’ conceptualization of client development and growth. Both Maslow and Rogers believed certain conditions were needed for individuals to be able to live fully and reach their potential.

Otto Rank Otto Rank (1884–1939), originally named Otto Rosenfeld, was an Australian psychologist who began his career deeply embedded in psychoanalytic thought. He was connected with Freud in his early twenties after Rank wrote a manuscript on the interpretation of art through psychoanalytic concepts. Impressed by Rank’s work, Freud hired him as the secretary of the Vienna Psychoanalytic Society, which began their two decades of work together. During this time, Rank received his PhD from the University of Vienna. Rank cofounded the Psychoanalytic Association, published numerous psychoanalytic articles and books, and was appointed editor of two psychoanalytic journals. Rank’s theories began to shift away from that of psychoanalysis, evidenced by his assertion that neuroses began in a child through the trauma of childbirth. Due to this deviation of beliefs, Freud and Rank broke all ties in 1926. Rank’s theories evolved to emotions, choices, experiencing the present, nondirectivity, client as expert, and the therapeutic relationship. His post-Freudian perspectives were of great inspiration to Rogers and are seen as a major contributor to humanistic psychology, among other theories, including existential and gestalt.

Process Experiential Approach Process-experiential/emotionally focused therapy (PE-EFT) developed in the late 1980s and early 1990s with the strong leadership of Leslie Greenberg. The development of this 40-year empirically supported approach can be found within the traditions of person-centered, gestalt, and existential thought. PE-EFT developed as an empathy-based theory that is informed by both attachment literature and social, affective neuroscience (Davis et al., 2015; Elliott & Greenberg, 2007‌‌‌‌‌‌‌‌‌‌‌‌). During the early development of PE-EFT, EFT was also developing and, during these early years, was a related approach but distinguished with its focus on couples therapy. However, since the late 1990s, EFT has also found a home within individual therapy (Elliot & Greenberg, 2007). PE-EFT holds a positive view of the self and development. PE-EFT is considered a relational theory with a strong theory of emotion and pulls from both attachment theory and the field of neuroscience. A theory of emotion reveals that emotions are regulated and misregulated throughout the course of life and create the basic building blocks of personality. Emotion is the “primary motivational system activated during the making and breaking of attachment bonds” (Davis et al., 2015, p. 17). At its core, PE-EFT is an emotion-based theory. Leslie Greenberg is a primary founder of PE-EFT, and an understanding of Greenberg will provide additional insight into the theory of PE-EFT. LESLIE GREENBERG

Leslie Greenberg was born in the year 1945 in Johannesburg, South Africa. Greenberg is a distinguished professor in psychology at the York University in Toronto, Ontario, and the director of the York University Psychotherapy Research Center. Laura Rice, a Carl Rogers student, was a mentor to Greenberg with an emphasis on emotional expression. He wrote with Pascual-Leone (mentored by Piaget), who developed a complex model of the mind. Greenberg is known by many as one of the leading authorities in the world on the role of emotions in therapy, the development of a theory of emotion, and as a primary developer of EFT. Greenberg’s journey toward becoming a world-renowned leader in emotion research began in his younger years in South Africa. Greenberg was encouraged by a guidance

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counselor to pursue a degree in engineering because of his interest in math, science, and relationships. During Greenberg’s professional life in South Africa, he received his master’s degree in engineering and began to work as an engineer; he married, discovered he was fascinated with emotion, and worked toward social equality amidst the apartheid government. As it turned out, Greenberg would leave South Africa as a refugee and further his education. Greenberg arrived in Canada in the 1960s and found that psychology allowed him the freedom to explore the role of emotion from a strong research platform while also allowing for the integration of personal and relational experience (https://­societyforpsychotherapy.org/ psychotherapists-face-face-dr-leslie-greenberg/).

Emotionally Focused Therapy SUE JOHNSON

Dr. Sue Johnson is a Canadian psychologist who is an early innovator and initial contributor to EFT (“About Sue Johnson,” 2022) with Dr. Les Greenberg in the late 1980s (Johnson & Greenberg, 1985; Johnson & Campbell, 2022). EFT is an integration of experiential-­ humanistic and systemic approaches to counseling with attachment theory as its theoretical foundation (Johnson & Greenberg, 1987; Johnson, 2020; Johnson, 2022; Wiebe et al., 2017). Initially, EFT was developed as an approach to assist couples through relational conflict during a time when behavioral approaches to relationships were popular (Johnson & Greenberg, 1987). Since its development, EFT has over 30 years of peer-reviewed, empirically validated research (Doss et al., 2022; Johnson, 2022; Snyder & Halford, 2012; Wiebe et al., 2017). Sue Johnson is the founder of the International Center for Excellence in Emotionally Focused Therapy (ICEEFT), and she has received numerous awards from the American Psychological Association (APA) and the American Association for Marriage and Family Therapy (AAMFT).

ORIGIN AND NATURE OF MENTAL HEALTH CONCERNS Relational theory foundationally argues that humans are wired for relationships and the regulation and dysregulation of affect is a human endeavor from birth onward. The humanistic tradition views mental health in the context of relationships. Behavior is viewed as functional in the sense that it strives to meet a relational need, even if the behavior in itself is destructive. This tradition points to an innate drive toward relationship and emotion regulation in contrast to impulsivity. Relational theory places emphasis on the role of affect in behavior, in contrast to the traditional Freudian emphasis on drive. Mental health concerns emerge as individuals have a damaged or shameful sense of self; an individual’s conditions of worth become dependent upon others precisely because it is within the context of a relationship that individuals thrive. The experience of shame leads to dysregulation, which quickly becomes concretized in destructive behavior (acting in, i.e., depression, or acting out, i.e., risk-taking). The humanistic tradition places emphasis upon relationships as the conduit for healing relational disruption and, therefore, an emphasis upon emotion as the conduit for healing emotion.

Person-Centered Therapy Rogers refuted the historical perspective that humans were inherently irrational and impulsive and, if not controlled, would cause damage to self and others (Rogers, 1963). Instead, he viewed individuals as persons with whom to relate (Rogers, 1950). From the perspective of person-centered therapy (PCT), mental health concerns stem from internal incongruence within the client. Rogers, however, would use a different term, such as

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maladaptive personality, instead of “mental health concerns.” Afterall, his therapy is person centered, not problem centered. Rogers believed that difficulties arise through an individual’s disintegration of self and subsequent incongruence. He describes internal incongruence as a result of internalizing the expectations of others throughout one’s life. From his perspective, infants are all born with an internal valuing system, knowing what they do and do not like. An infant knows if it doesn’t like peas, for example. But it is actually more than an internal value system; it is a sense of self, a sense of who you are. Unfortunately, as infants grow, they begin to experience a conflict between what they want and how to get those needs met by others. Consequently, the child modifies their behavior based on what is necessary to meet their needs. They ultimately learn to embody external ideals and behave in tandem to diminish the discomfort of unmet needs. These are known as introjects, or the internalization of real or perceived expectations of others that, if followed, will result in the individual’s needs getting met. He later described these as conditions of worth. Introjects, or conditions of worth, create an external valuing system that confuses or distorts the internal valuing system of infancy. As persons grow up, they internalize the conditions placed upon them by parents or caregivers that make them feel worthy of love. As a child, one may learn that in order to receive attention, they must act out. Our innate needs for love, attention, affection, etc., sometimes come out sideways. A child bites and receives attention, but it is negative attention. The child is shamed for the behavior, but due to the lack of complex processing, the negative attention or shame is internally associated with the desire and not the behavior. Ultimately, he starts to believe that his needs or desires are bad/wrong and that he is bad. Another familiar example is the young girl who learns that her achievements please her parents. She experiences more love and attention from her parents when she expresses her desire to become a lawyer over and above that of a counselor. She personalizes and internalizes this experience, maybe even at the subconscious level, and focuses all her energy on becoming a lawyer. In both examples, the individuals trade the internal valuing system (internal sense of self) they once had in order to experience love and belonging from others. While this may result in all parties experiencing positive feelings, the individuals in the examples are left with internal dissonance. Internal desires are ignored or suppressed for the sake of experiencing love from others. In doing so, the person develops self-doubt, insecurities, and distrust of self, leaving the individual dependent upon the expectations and desires of others (i.e., determined by introjects or conditions of worth). This is further compounded as it also benefits the individual since they are rewarded with positive experiences, such as love, affection, belonging, and others. As individuals receive these rewards, they will continue to do what is needed to maintain these positive experiences, even suppressing their internal valuing process. The individual learns that their internal valuing process does not always lead to needs being met, so they adapt to behave based on the external stimuli. This process creates incongruence within the individual. After doing this for a long time, the individual loses sight of their internal value system altogether. What they are left with is a segregated sense of self. On the one hand, there are suppressed internal desires, and on the other, there is the urge to behave in a way that will ultimately meet their needs. Rogers believed that this incongruence is the root of additional issues for the client, as it leads to becoming a rigid and defensively organized person. According to Rogers (1957), “When an individual has no awareness of such incongruence in himself, then he is merely vulnerable to the possibility of anxiety and disorganization” (p. 828). This type of person lacks the ability to weigh one need over another (Rogers, 1963). As a result, there is an extreme overreliance on an immediate need to be met (i.e., sex) over the deeper need (i.e., intimacy, connection, love). If, however, there is some awareness of this incongruence, the individual will feel a level of tension or anxiety.

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Process Experiential Approach PE-EFT is a process-oriented encounter that views emotion as the fundamental principle of human experience. Emotion is viewed as a complex motivational system that is the chaperone to attachment, goal-directed behavior, and meaning making (Greenberg, 2022). Process experiential research maintains that affect drives the human experience. It is as Daniel Seigel articulates in his research in neuroscience that people are feelers who think rather than thinkers who feel. If, indeed, emotion is central to human experience, then it also can be concluded that emotion is central to many forms of dysfunction (Greenberg, 2022). Emotion is a complex experience that involves physiological, experiential, and behavioral responses. Greenberg pulls from Damasio (1999) and the image of a large leafy tree in an attempt to differentiate between the terms affect, emotion, and feelings. This distinction will then set up a paradigm of thought that points to the origin of mental health concerns. In this image of a tree, affect is compared to the roots and trunk of the tree. It is the human physiological reactions that transcend cultures, such as excitement, fear, or a sense of calmness. The large branches of the tree are then seen as emotion, which can be categorically labeled as sadness, anger, and fear. Lastly, the small leafy branches may be compared to feelings that are more socially and cognitively influenced, like frustration, mistrust, or disappointment. As such, emotions are a complex system of human experience that can be understood as important to responsiveness and meaning making and as fundamentally connected to human needs. Therefore, a lack of emotional awareness or blocking of affective experience creates the foundation of mental health concerns. It is a lack of affective awareness and/or regulation that then impacts the categorization of emotions and experience of socially constructed feelings, leading to a variety of symptoms such as depression, anxiety, relational difficulties, and others (Greenberg, 2022). Complicating matters, emotions can be viewed as either healthy and adaptive or unhealthy and maladaptive, all of which has a shaping effect on the relationship with self and others.

Emotionally Focused Therapy EFT is significantly informed by attachment theory as a way of understanding interpersonal interactions, and individual intrapsychic beliefs are seen as shaping key emotional responses in how individuals interact with others and the world (Johnson & Greenberg, 1987; Johnson, 2019; Johnson, 2020). Attachment theory was originally outlined by John Bowlby (1969) as a way of understanding early childhood development and early attachment with caregivers. EFT expands the understanding of human attachment to adult relationships and interactions (Johnson, 2019; 2020). Attachment theory views individuals as fundamentally social creatures who seek to build bonds with others. This bonding and seeking out connection is viewed as a fundamental survival strategy for individuals (Johnson, 2019). Within this theory, emotions are seen as an indicator of one’s experience of themselves and others; as such, the focus of EFT is to help individuals access, identify, and reprocess their emotional experiences underlying their interactions with others (Johnson, 2020; Johnson & Greenberg, 1987). Fear is a significant emotion of interest in EFT, which is seen as an indicator of attachment anxieties surrounding threats to connection with others which leads to existential concerns of helplessness and vulnerability. Mental health concerns grow out of one’s ability to deal with these threats (Johnson, 2019). EFT has identified core ideas to describe the nature of attachment with adults (Johnson, 2019, 2020, 2022; Mikulincer & Shaver, 2016; Cassidy & Shaver, 2016). Attachment to others is considered to be a basic survival mechanism where emotional and social proximity to others is seen as a primary human goal. Secure attachment leads to emotional health and positive views of self. Individuals can acknowledge their attachment needs, thereby allowing them to risk reaching out to attachment figures to create or

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maintain connections. When the attachment figure responds in a manner that creates safety, trust is established, leading to greater coping throughout life. Security in relationships is related to higher sexual satisfaction in relationships. Relationships with secure attachment demonstrate higher levels of arousal, pleasure, and intimacy. Sexual bonding can manifest differently based on different attachment styles (Johnson, 2017). Insecure attachment with self and others is a risk factor for many mental health problems. Securely attached individuals can address and process distressing emotions without the fear of losing control. The inability to effectively regulate emotions leads to intrapsychic and interpersonal difficulties. Johnson (2019) defines affect regulation as “a process moving with and through an emotion, rather than reactively intensifying or suppressing it, and then being able to use this emotion to give direction to one’s life” (p. 11). Research studies have demonstrated links between insecure attachment and symptoms of depression, anxiety, and post-traumatic stress disorder (PTSD; Johnson, 2019). Moreover, attachment insecurities have been linked with externalizing behavior personality disorders, addictive behaviors, and disorders in children/ adolescents (Krueger & Markon, 2011‌‌‌‌‌‌‌‌‌‌‌‌; Johnson, 2019). Threats to perceived attachment to others can come from within or outside of individuals, which can lead to existential concerns over death, loss, isolation, and loneliness. As a result, individuals strive to create a safe haven that allows for the creation of predictable physical and emotional connections with key attachment figures (e.g., romantic partners, parents, siblings, friends). The creation of a safe haven can actually calm the nervous system and create a felt sense of safety in the world (Johnson, 2019, 2020, 2022). Additionally, establishing secure attachment leads to the establishment of what attachment theorists call a secure base. An attachment figure who is predictable and safe creates a metaphorical home from which individuals can step into a chaotic world and take risks. This leads to interdependence whereby individuals develop resilient autonomy. When safe connections and secure bases with others get disrupted, one’s view of self can become disrupted and disorganized, leading to negative views which can cause the individual to engage in predictable patterns of distress responding (Cassidy & Shaver, 2016; Johnson, 2019, 2020, 2022; Mikulincer & Shaver, 2016). These predictable patterns of distress responses are activated when a secure connection is threatened or lost. Threats to isolation or disconnection with secure attachment figures are inherently traumatizing, which can lead individuals to engage in behaviors that are broadly described as protesting or withdrawing patterns. Protesting patterns tend to utilize behaviors such as pleading, clinging, or demanding, while withdrawing patterns may utilize behaviors such as despair, detaching, or avoiding. These distress responses are seen as purposive albeit unsuccessful attempts to mitigate against the perceived threat or loss (Cassidy & Shaver, 2016; Johnson, 2019, 2020, 2022; Mikulincer & Shaver, 2016). In this distress, individuals are trying to determine if the attachment figure is accessible, responsive, and emotionally engaged (A.R.E.). According to Johnson (2019), this drive is a key question underlying most attachment pursuits: “Are you there for me?” (p. 7). These response patterns are connected with our nervous system. Individuals who have experienced others as unsafe form insecure patterns of attachment and develop different ways of engaging with others and regulating attachment. When activated, these patterns of engagement follow fight-or-flight strategies associated with threats to the nervous system (Coan et al., 2006; Mikulincer & Shaver, 2016). While all people will use these strategies at times to seek feelings of safety, they can be disruptive when they become rigid and habitual, preventing individuals from effectively engaging with others. These are typically seen as three different insecure attachment styles (Ainsworth & Bell, 1970; Johnson, 2019): (a) anxious attachment, (b) avoidant attachment, or (c) disorganized attachment. Anxious individuals are primarily driven by their “fight” instinct, whereby threats of distance and loss are protested with the goal of the other person paying more attention to them and offering reassurance. These individuals tend to stay

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in a hyper-aroused state that can present as demanding, angry, or protesting. Individuals with an avoidant style tend to be driven by their “flight” instinct, where they attempt to minimize fears and distress through distancing themselves from others. These individuals tend to stay in a hypo-aroused state by withdrawing from others and situations that are seen as dangerous or uncaring. Individuals engaging in a disorganized style often switch quickly between anxious and avoidant patterns of interaction. Often, individuals with this attachment style may have experienced trauma with an early attachment figure whereby individuals are seen as both safe and fearful at the same time (Johnson, 2019, 2020, 2022). It should be noted that attachment styles are adaptive and can change with time. It is important to consider that all attachment styles are driven by feelings of distress by individuals in response to perceived attachment threats or loss. Importantly, adult attachment is more symbolic and representational compared to that of children. Expectations, beliefs, views of self, biases, and prior experiences lead to internalized mental representations of self and others (Jurist & Meehan, 2009). This means that attachment security is not a fixed trait. Overall, attachment patterns change, and individuals can feel secure in one relationship and insecure in another relationship. In adult relationships, attachment relationships are reciprocal as compared to child–caregiver relationships. Internalized representations of self and others are constantly being reworked based on one’s experiences in the world. Our beliefs and cognitions consistently trigger prior experiences that guide strategies that equate to a series of potential interactions. Adult relationships do not rely solely on physical proximity; these internal cognitions drive symbolic representations of proximity than can trigger attachment concerns.

EMOTIONAL AND PSYCHOLOGICAL WELL-BEING The humanistic tradition is just that. It is humanistic! Theorists within this tradition tend to view humanity as leaning toward growth and relationship. These growth-oriented models are affirming to issues like cultural sensitivity, appreciation, and advocacy. Humanistic traditions suggest that within the context of a relationship, people have all they need to grow and flourish. In short, humans thrive within the context of a relationship. A significant state of well-being within this perspective is an individual’s development of trust. Trust in self requires a depth of emotional awareness and emotion regulation. Emotions inform a person; they are not necessarily right or wrong but rather are information centers that inform decisions and behavior. Emotional responses are information that facilitates an individual’s ability to respond with confidence and, as informants, allows for greater awareness of self and, therefore, greater trust of self.

Person-Centered Therapy Rogers was optimistic about the capacity for growth in all human beings (Rogers, 1957). Throughout his career, he asserted that all individuals possessed what was needed to become fully integrated persons (Rogers, 1957, 1958), a process he called the actualizing tendency. Self-actualization is an inherent drive to become more autonomous, congruent, self-determined, and fulfilled (Corey, 2017). To reach this tendency, it is imperative for all clients to unlearn the introjects and begin again to trust the self. Rogers believed we are all a culmination of our introjects, and the work of therapy is to effectively reacquaint and reconnect with the internal valuing process once held in infancy. The experience of feeling fully seen, known, and accepted by the therapist gives the client emotional permission to return to their core sense of self. As a result, self-actualization is becoming congruent, increasing the ability to trust oneself, become more flexible and adaptable to new experiences, and continue to get to know an ever-evolving self.

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Process Experiential Approach According to emotion theory, which has received significant attention from PE-EFT therapists, emotion provides information and action tendencies. Emotions inform what is and is not meeting someone’s expectations and whether one’s needs are being met in a relationship. Emotions are invitations to greater awareness and engagement in life and could even be compared to a flag waving in an attempt to get a person’s attention and invite them to attend to something important. Emotions can be the first step in defining problems. Naturally, if emotions are not attended to, important information is missed, or worse, warning signs are missed. Emotional and psychological well-being is intimately connected to emotional awareness, regulation, and transformation. A lack of awareness means that a person is missing key information provided by emotions and responding behaviorally. As emotion informs a person of key information, it also provides an opportunity to center a person or regulate them during life events. Remember, emotions provide information; they are not sensations to be controlled. Emotion regulation refers to a person’s ability to modulate or shape emotional responses in a way that serves the person and provides for important needs to be met. Unfortunately, many view emotion as something to be controlled rather than as an important part of what it means to be human and an important part of a person’s ability to live fully in the world and in a relationship. Much of the literature around emotion has fallen into the temptation to refer to emotion on a spectrum ranging from good or bad rather than on a spectrum ranging from painful to pleasant. For many, this lens has created a heightened desire to avoid ‘bad’ emotions rather than respond with curiosity about what information is being provided and what response may or may not be warranted. In contrast, a tendency to suppress (overregulate) emotion is common, especially if the alternative is dysregulation of affect, which can be destructive to both self and others. Research on the suppression of affect reinforces that this dampening of emotions actually leads to heightened feelings, poor memory, and less relational satisfaction (Roth et al., 2014‌). PE-EFT works to help clients’ acceptance of emotions and subsequent change of response. As mentioned previously, affective experience is universal, as is the need for emotion regulation. An important dialogue continues to be the overuse of psychopharmaceuticals in an effort to control or contain emotion when the primary issue is affect regulation (https://societyforpsychotherapy.org/­ psychotherapists-face-face-dr-leslie-greenberg/). Coping means learning to have a greater awareness of emotion so as to modulate or shape it. Sadly, medication often does the opposite; it creates an opportunity to be less aware. Certainly, there are cases when medication is necessary for reasons of safety, and the invitation here is to consider how our lens on emotion theory impacts an overprescribed Western culture. To further this conversation, emotional awareness and regulation enhance and change a person’s neurophysiology (similar to the effect of medication). When considering the neurobiology of trauma, and perhaps something such as neglect that may be considered a little “t” trauma, one can return to reprocess a reworking of the trauma at a level in which they can remain present to the affect of the experience. Indeed, all the work in trauma in recent years has focused on bringing emotion back into the current research.

Emotionally Focused Therapy Similar to PE-EFT, affect regulation is a primary feature of EFT, yet there is also a heavy focus on connection with secure figures and how this relates to well-being (Johnson, 2019). Having safe and secure connections with others is associated with a strong sense of self, including factors such as high self-esteem, resilience, confidence, assertiveness, and a sense of belonging (Jurist & Meehan, 2009). It seems that secure attachment helps individuals maintain emotional balance to engage confidently and take risks in the world. Moreover,

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secure attachment leads to more openness, compassion, ability to handle disagreement, and greater empathic attunement (Johnson, 2019). When securely attached, individuals can often stay calm and available to others to respond in reciprocal and caring ways.

ROLES OF THE CLIENT AND COUNSELOR Person-centered counseling, process emotional theory, and EFT are all relational approaches to counseling, viewing the counselor as an important factor in client therapeutic outcomes. In these approaches, the relationship between the counselor and the client is an integral aspect of the overall progress. Across these approaches, you will see that the counselor is aware of the here-and-now relationship and how the counselor responds as part of the change process.

Person-Centered Therapy Throughout Rogers’ career, he was interested in understanding personality change and the process that would be necessary for such change to occur (Rogers, 1957, 1958, 1963). Based on his professional experience and empirical research, Rogers hypothesized the following components as necessary for personality change to occur: (1) There must be two persons in a counseling relationship; one must be a client presenting with anxiety, vulnerability, or incongruence; the other must be a therapist who is “congruent and integrated into the relationship;” (2) the therapist must experience empathy and unconditional positive regard for the client; and (3) the client must, to some degree, receive the empathy and unconditional positive regard extended by the therapist (Rogers, 1957, p. 827). ROLE OF THE CLIENT

The client comes to counseling with a presenting problem, experiencing incongruence, rigidity, or defensiveness. While therapy is cocreated by the counselor and client, the client is seen as the expert and shares their subjective experience with the counselor. The client’s work is learning how to welcome and embrace being received by the counselor. Overtime, and as the client perceives being fully received, the client’s introjects will begin to loosen, and they will start to accept themselves. During this process, the client will begin making decisions more congruous with their inherent sense of self (based on their internal valuing system). While there are obvious benefits to reconnecting with one’s lost sense of self, this will likely be difficult and even evoke fear in the client since they do not know that side of themselves anymore. There may be fear of what they will find in getting to know their true self again and fear that they will lose both internally and externally in the process of discovering who they truly are. ROLE OF THE COUNSELOR

The role of the counselor is much more involved than that of the client. PCT relies heavily on the therapeutic relationship and the active and collaborative role of the therapist. The therapist is viewed as a therapeutic tool, actively listening to the client, clued into themes, and engaging in the deeper experience under the client’s words (Rogers, 1958). Both the counselor and the client are fully engaged in therapy. It is the job of the therapist to create a conducive environment for the change process to take place. This environment is created by the nondirective approach of the counselor and the core conditions of genuineness, unconditional positive regard, and empathy. NONDIRECTIVE APPROACH

The aim of the person-centered therapist is to engage with the client non-defectively. A nondirective counselor is highly reflective (Prochaska & Norcross, 2014), uses minimal interpretations, and refrains from imposing personal beliefs about the client or the presenting concerns (Rogers, 1950). When a counselor reflects on what they are hearing from the client,

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they are communicating a desire to understand, see, and get to know the client. When feelings were clarified by the counselor, clients were able to experience deeper self-awareness, catharsis, and insight. In a study early in Rogers’ career, he found that nondirective therapists were more inclined to listen, speaking less than half as much as the client, whereas directive therapists spoke as much as three times more than the client (Rogers, 1942). However, in the same study, he discovered that across the board, counselors were more directive than they assumed themselves to be. In this vein, Rogers asserted that there are certain violations by the counselor that can impede or hinder therapeutic growth, such as “a probing, directive question, an interpretation given too early, remarks which push the client into expressing repressed attitudes, some unintentional advice or suggestions, a failure to recognize an ambivalence which was expressed” (Rogers, 1942, p. 432). Counselors who are truly nondirective will make a few of these mistakes. CORE CONDITIONS

PCT hinges on the core conditions of genuineness, unconditional positive regard, and empathy. Rogers believed that these core conditions are necessary and sufficient to begin the process toward self-actualization; they are the impetus for change (Rogers, 1957). It is not enough to merely possess one or two of these conditions; the therapist must possess all three for a period in order for them to be sufficient (Rogers, 1958). These conditions present within therapy enable the client to feel fully received and accepted, ultimately leading to their self-acceptance. Rogers asserted that regardless of knowledge, skill set, or theoretical orientation, if a counselor possessed these core conditions, change in the client would be inevitable (Rogers, 1957; Kirschenbaum & Jourdan, 2005; Quinn, 2008). It is a theory, but it is really atheoretical. Genuineness. Genuineness, or congruence, indicates the counselor’s ability to be a real, authentic, integrated presence in the counseling room. Rogers believed in the importance of the therapist being fully functioning, integrated, and congruent. This allows the counselor to be self-aware, completely themself in the therapy room, and able to accurately reflect their present experience (Rogers, 1957). There may be times when the counselor needs to talk through certain things in the therapy room, whether with a counselor, supervisor, colleague, or in some cases, the client. When counselors fail to address what has been ignited within themselves, it can hinder the change process for the client. Whether verbalized to the clients or bracketed from therapy, we must not forget that every aspect of who we are as counselors impacts the therapeutic relationship and the client. Therefore, counselors must be aware of anything that creates distance between themselves and the client as it provides information to the counselor about what they must actively address. Remember, the objective is for the counselor to remain fully present, integrated, and connected with the client. Unconditional Positive Regard. Unconditional positive regard implies that the counselor is genuinely able to accept the client, extending a depth of warmth and concern for the individual (Rogers, 1950). Rogers (1957) explains that “to the extent that the therapist finds himself experiencing a warm acceptance of each aspect of the client’s experience as being a part of the client, he is experiencing unconditional positive regard” (Rogers, 1957, p. 829). This can only be attained once all judgment and evaluation are removed from the therapeutic encounter. This is a belief in and an acceptance of the person regardless of their circumstances, presenting problems, or personality. However, Rogers admits that it is not always possible to feel this level of acceptance toward the client. Yet when there is an active dislike, disrespect, or other negative feelings toward the client, client growth has been restricted. When the client is able to experience unconditional acceptance, they will be able to experience and accept themselvesfully (Rogers, 1963). Only when clients experience being fully received can they begin accepting themselves.

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Empathy. Rogers believed in the importance of feeling with his clients. It is the job of the counselor to seek to understand the subjective experience of the client. Empathy is the ability to perceive the inner world of another person as if it were your own but without ever losing yourself to it (Rogers, 1957). It is the therapist’s goal to perceive the client’s emotional experience accurately and reflect that understanding back to them (Rogers, 1957). It is this very condition that PCT is built. Accurate empathic understanding on behalf of the client and their circumstances communicates the counselor’s depth of understanding of the client. Furthermore, empathic attunement is integral to the development of the therapeutic relationship, atheoretical, and foundational for all therapy approaches (Corey, 2017). Through the counselor’s ability to accurately empathize with the client, the client can move toward a more authentic knowing of self.

Process Experiential Approach When considering the roles of the client and the counselor when working from a PE-EFT perspective, it is best to consider the roles of the counselor as primary. Each client will enter therapy with different views on the importance of emotion. This author recalls a clinical encounter with a high-level executive who insisted on being given homework weekly. At the end of the third session, this counselor responded to the client’s request for additional homework by stating, “You have already established both in your career and in completing the homework the past two weeks that you are excellent at getting things done. What you need is to slow down and to begin to become aware of your emotional experience as we work together.” What this simple case reinforces is the need for the counselor to help the client develop clarity on whether the clinical focus is on changing emotion as it relates to experience or changing a person’s relationship to emotion. In other words, the clinician’s role may be to help a client name and process the emotions in response to a traumatic event or a severed relationship. Alternatively, the clinician may determine that a client is unaware of emotional experiences, views emotions as dangerous, unhelpful, or not to be trusted, and, therefore, has learned to either overregulate or under-regulate emotional experience. Regardless of which clinical focus is taken, there are three primary roles that the counselor must grow in when working from a PE-EFT perspective. PE-EFT counselors must first develop a friendly attitude toward emotion and emotional experience. This requires the counselor to become aware of their emotions and to be skilled at regulating emotion and transforming emotional experience rather than overregulating or under-regulating emotion. In turn, this will lead to the capacity to be available to be moved by and/or contain the emotions of the client. Robert Stolorow (2002), who writes from an intersubjective lens, is fond of saying that clients are looking for a relational home for their pain. That home is the counselor who is able to attune emotionally with the client's emotional experiences. Greenberg addresses this need by addressing a common phrase repeated in counselor education programs. He writes, “The ethic of ‘know thyself’ is better stated as ‘be aware of and accept one’s own emotions’” (Greenberg, 2022, p. 13). As many have stated before, counselors cannot lead clients through foreign territory. First, they must be emotionally aware and responsive to their emotional experiences to be equipped to do so with their clients. Second, counselors must have a general awareness of the nature and role of emotion within the human experience. Counselors must be aware of how emotional experience impacts decision-making, relationships, goal setting, and behavioral outcomes. This requires the counselor to be skilled in facilitating emotional awareness, emotional regulation, and emotion transformation. Sandage et al. address this challenge: “The core skills of any effective psychotherapist are right-brain implicit capacities which include empathy, the regulation of one’s own affect, the ability to receive and express nonverbal communication, the sensitivity to register very slight changes in another’s expression and emotion, and an immediate awareness of one’s own subjective and intersubjective experience” (2020, p. 164).

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This process requires a counselor to be empathically attuned to each moment, to direct clients to a bodily awareness of the emotion, to work with a client’s ability to stay with the emotional experience, and to discover what keeps them from experiencing their emotions (Greenberg, 2022). This section examines the role of the counselor and the client from a PE-EFT perspective. As mentioned previously, some clients will be able to emotionally engage with life events quite quickly, while others will present as resistant, having learned that emotion is not to be trusted, regarded as useless, or overwhelming. The emphasis in PE-EFT is not on the role of the client but rather on the counselor’s ability to lead the client toward living emotionally integrated.

Emotionally Focused Therapy In EFT, the primary focus is on activating, processing, and regulating emotions to promote corrective emotional experiences (CEE) with clients. Counseling sessions are experiential, with counselors primarily focused on the here-and-now emotions. Counselors act as process consultants, heightening the emotional experiences of their clients (Johnson, 2019; 2020). Counselors first seek to promote emotional safety in sessions. The counseling session must serve as a safe haven whereby clients can view counselors as a secure base, allowing for exploration and engagement of emotions (Johnson, 2019; 2020). Counselors are not concerned with client change in early sessions but instead must attune to the emotions of clients to meet and accept them where they are. Clinicians using the EFT approach are non-pathologizing, attempting to understand how intrapsychic processes perpetuate patterns of engagement that keep individuals stuck in negative cycles. It is common for counselors practicing EFT to construct the emotional experiences of their clients collaboratively, using the clients’ own words as much as possible. Counselors work to be as specific as possible with their language, often repeating what clients are saying or speaking very slowly with clients.

THE NATURE OF HUMAN DEVELOPMENT The nature of human development within the humanistic tradition begins in the womb. Rogers argued that individuals lean toward growth and have a natural inclination to know themselves. This inclination is easily seen as the infant looks to a caregiver for a sense of self. The development of the self, the fulfillment of developmental longings, and the development of emotion regulation occur within a relational container in the earliest days of an infant’s life. This development creates a tendency to live from the outside in, looking to those outside of the self for value and worth. The humanistic tradition strives to value this process while facilitating a move from outside-in living to inside-out living—living grounded in the sense of self and emotion regulation rather than dependent upon the view of others for a cohesive sense of self.

Person-Centered Therapy Rogers believed that all individuals are born with an internal valuing system or, in other words, an innate sense of self (Rogers, 1964). This value system lies within the self, is based on likes and wants, and lacks uncertainty. This is evident in the infant’s expressions as to what is liked or disliked, when more sustenance is desired or when they are all done. At such a point in the individual’s life, decisions are not influenced by anyone else’s desires, preferences, or input but solely based on the infant’s senses (Rogers, 1964). Over time, this valuing process shifts from inherently internal to more external due to the evaluation of others. This is a byproduct of learning how to behave in an effort to get

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one’s needs met. Certain behaviors are rewarded or rejected by someone outside of the individual, which ultimately teaches which behaviors will receive the desired outcome and, thus, satisfy the individual. The complicated part is that the experience of love from others becomes dependent upon behavior. This learned phenomenon is what Rogers described as introjects or conditions of worth. Introjects, or conditions of worth, create an external valuing system that confuses or distorts the internal valuing system of infancy. By shifting focus to meet the expectations of others, individuals begin to distrust themselves. As the individual can fully accept themselves, their introjects loosen, and they are able to move toward internal congruence. Part of the outcome of therapy is to become a more differentiated person so that one knows self apart from others (external valuing system). Rogers believed that all persons are born with an actualizing tendency. As clients are able to connect with their true, authentic selves, this actualizing tendency is released, and the client will be able to become a fully functioning, differentiated, and integrated person.

Process Experiential Approach The PE theories’ view of human development is shaped by existential thought and the relational approach of those such as Carl Rogers and Otto Rank. According to PE-EFT, human development starts in the womb and is influenced by close attachment figures and the affectivity of relational encounters. Human development is grounded in the notion that humans are inextricably social and suggests that we are we, before we are I. An infant’s beliefs about self are formed from caregivers’ feelings and desires about the infant. The baby’s brain is wired through connection and develops through face-to-face connection. Infants are a wonderful model of the role of affective experience (the tree trunk) as hunger pains roll through the infant's body or during those precious moments as a caregiver gazes into their infant’s eyes. A gaze can result in an emotional connection or an emotional disruption depending upon how long the gaze lingers. This gaze has the potential to produce a physiological response (oxytocin response) that equates to being loved or leads to affective discomfort. Such infant research reinforces the notion that the infant’s definition of self literally begins in the womb. Robert Stolorow writes that emotion is something that is regulated or misregulated within the context of relational experience from birth onward (2002). Furthermore, “Personal experience is pictured as fluid, multidimensional, and exquisitely context-sensitive, with multiple dimensions of experience oscillating between figure and ground, within an ongoing intersubjective system of reciprocal mutual influence” (Stolorow & Atwood, 1992, p.13). This framework sets the stage for the pursuit of relational motivations throughout development that include fulfillment of developmental longings, the capacity to hold onto a cohesive sense of self, and the ability to maintain key relational ties (Greenberg, 2022; Cook, 2015; Stolorow et al., 2002).

Emotionally Focused Therapy EFT views attachment theory as the way to explain human emotional regulation. In EFT, attachment is seen as a primary motivation for human beings (Johnson, 2019, 2020). Human beings are driven toward finding safe, secure connections with others and the outside. When human beings attach to a secure base, they can develop optimal interdependence which leads to greater risk-taking, higher self-esteem, and fewer mental health symptoms (Johnson 2019, 2020). Further, secure attachment can help mitigate existential concerns of death, isolation, and loneliness (Johnson, 2019, 2020). When attachment needs are lost or go unmet, “fight-or-flight” physiological threat responses are activated in an effort for the individual to create safety. These are predictable responses that an individual may experience should they find their survival threatened. Over time, experiences of loss or abandonment become increasingly symbolic and representational, which can lead to quicker fight-or-flight

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responses for individuals. Often, threat responses come off as anger, in either demanding/ protesting patterns or withdrawing/distancing patterns (Johnson, 2020). EFT attempts to unpack the primary emotions underneath the anger that are representative of the perceived attachment threats or loss (Johnson, 2020).

PROCESS OF CHANGE PCT, PE, and EFT all have conceptualized steps to explain the change process. To understand the differences among the theories in this section, it might be helpful to see them as a funnel, with PCT on the wide end (broad, foundational, less detailed) and EFT on the narrower end. In general, however, the change process for all three of these theories leads to a greater connection with self. In order to reconnect with and solidify a sense of self, the client must first accept themselves, a process that is only possible through the corrective emotional experience provided by another (e.g., a counselor).

Person-Centered Therapy Rogers had a profound interest in understanding personality and the change process. First and foremost, PCT is hinged upon the presence of the necessary and sufficient conditions of genuineness, unconditional positive regard, and empathy. It is not merely enough for the counselor to possess these conditions; they must be experienced by the client, and the client must feel fully received by the counselor (Rogers, 1957; 1958). These conditions are the impetus for change. However, this takes time, and even the therapist's ability to receive the client when the client is resisting being received aids in the process. For the client to progress to the top of the staircase of being fully received, they must take each step of engaging the moments of receiving. Within this metaphor of the staircase, both the counselor and the client reach the top when they are fully engaged in the process of receiving and being received. Within such an environment, the client will be able to heal what has been broken (Quinn, 2008), mitigate inner conflict, change behavior, and lessen the discrepancy between true and adaptive self (Rogers, 1957). Historically, change was explained in three ways: (1) when the person was adjusted to society; (2) when the person moved from a diagnostic criterion considered pathological to that of normal; or (3) when the person achieved positive mental health. However, he questioned who defines society, normality, or positive mental health (Rogers, 1963). Rogers described the psychological change experienced through counseling as: Change in the personality structure of the individual, at both surface and deeper levels, in a direction which clinicians would agree means greater integration, less internal conflict, more energy utilizable for effective living; change in behavior away from behaviors generally regarded as immature and toward behavior regarded as mature. (Rogers, 1957, p. 827) As a result of his extensive research on personality change, he established a seven-stage change process to be viewed on a continuum from rigidity to flexibility, stagnation to growth, and incongruence to congruence (Rogers, 1958). While growth is a continual process, Rogers believed typical progress falls within these seven stages. In the first stage, the individual is characterized by rigidity in meaning making, lack of self-awareness, immature emotionality, inability to take responsibility, lack of close relationships, no internal locus of control, inability to recognize problems, and an absence of desire to change. Once a client experiences themself as being received by the counselor, then they progress to the second stage. Much like the first stage, clients in Stage 2 have rigid constructs (or meaning making) and are blocked in their ability to take responsibility and communicate experiences based on the past. Additionally, clients in this stage externalize problems, communicate feelings without taking ownership of

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them, and begin to express feelings even though they may not be connected to them. Rogers describes the importance of Stages 3 and 4 yet admits that little is understood about the experience of clients feeling received in these early stages of the change process. For an individual to progress to the fifth stage, they are able to express feelings more freely in the present moment. Despite the fear of the full and immediate experience, clients are more apt to take ownership of their emotions, experience less rigidity and more flexibility with meaning making, loosen the association between feelings and meaning, and increase self-acceptance and intrapersonal relationship. A person in this stage is on their way to becoming more integrated, fluid, and closer to being a fully accepting self. Individuals within this stage seem to experience a dramatic shift where they experience relief or freedom in places that originally felt blocked, engage in the immediacy of feelings and accept what comes of it, experience self in a more present and integrated way, and communicate internally with more fluidity. Discrepancies exist between who that individual wants to be and who they think they dissipate into. Ultimately, person-centered clinicians are encouraging clients to become a more congruent person who is able to live more subjectively and presently with their experiences. According to Rogers (1958), “these moments of immediate, full, accepted experiencing are in some sense almost irreversible” (p. 148). Due to the propensity of the sixth stage to be irreversible, Rogers noticed that clients tend to move into the seventh stage without much assistance from the counselor. A person in this stage is not only described as fully congruent and integrated, but they are also able to engage and incorporate new feelings and experiences as they arise. This stage is marked by continual growth, trust in the process, acceptance and trust in self, and an ability to hold constructs loosely and allow meaning making to evolve (Rogers, 1958). As clients progress through this change process, they inevitably become more integrated, congruent, and flexible. It is also evident that this process results in clients moving from maladaptive to adaptive decision-making, from fear of true authentic relationships to greater intimacy, and from anxiously undifferentiated to differentiated (Rogers, 1958). According to Rogers (1963), a fully functioning and self-actualized person would be trusting of self, relationally adept, able to remain present and congruent with self and others, free to become the truest version of self, and constantly discovering self in the ever-evolving change process. These individuals would also be flexible and less rigid in their meaning making, cognizant of needs and possess the ability to meet them, open and adaptive to new experiences, and able to discern between surface-level desires and the deeper longings. Additionally, they will be more self-aware and self-enhancing, their behavior will be seen to be more dependable, and there will be evidence of more realistic thought patterns (Rogers, 1963).

Process-Experiential Approach Over the course of several decades of development, PE-EFT’s approach to treatment and change has remained consistent while also becoming more succinct. This approach has always involved an active counselor willing to engage client affect, contain client affect, and be emotionally moved by the client’s affective experience. In the early to mid-2000s, empathic attunement, therapeutic bond, and task collaboration were seen as treatment principles that needed to be present in each clinical encounter (Elliot & Greenberg, 2007). The clinical tasks that then unfolded included moment-by-moment processing of emotional experience in real time and the emotional blocks or resistance that occurred within the experiential process. This process of self-development provides the client with greater responsibility and empowerment in the context of emotional experience (Elliot & Greenberg, 2007; Vanaerschot, 2007). PE was then refined by some PE-EFT clinicians to include three primary stages. In the first stage, the clinician should facilitate the client’s emotional awareness, followed by vocalizing emotion. Next, empathic understanding (i.e., approaching painful emotions) and empathic

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validation (i.e., “you make sense to me”) are followed by evocative questions, then invite clients to feel more deeply the emotions of the moment. Naturally, the increased arousal of this stage leads to Stage 2, emotion regulation (Davis et al., 2015). Emotions are not to be controlled but rather regulated. Emotions are to be named, felt, shaped, molded, and used as information for decision-making and responsive behavior. Emotion regulation is the process of naming and modulating emotion so that it can be experienced at an optimal level, which invites further reflection and integration into living. The goal of PE-EFT is not emotional catharsis but rather emotional processing that informs meaning making, decisions, behavior, and view of self, others, and the world (Davis et al., 2015). From this perspective, there is no such thing as good and bad emotions but rather a spectrum of emotions ranging from painful to pleasant that provide information about how to show up in the world. The third and final stage is emotion transformation, which is directly focused on maladaptive emotions that may have developed in response to attachment rupture and/or trauma. Three primary tasks are used. The first is identifying and naming the crisis-of-meaning marker—the emotional marker and meaning that the client made of an experience that violated cherished beliefs about self, others, or the world. Some PE-EFT clinicians use the empty chair technique to bring into the moment the emotion of this marker. Empathic exploration and strong emotion regulation skills are necessary for the use of this technique (Davis et al., 2015). As the theory of emotion and process-experiential work has evolved, much has remained the same, and as stated previously, it has also been refined. Process-experiential work continues to develop a robust theory of emotion and the process of clinical change. Greenberg (2022) argues that working with emotion can be understood as having two phases which he refers to as arriving and leaving. The first phase is the client’s ability to arrive at experiential processing. This phase is much like the awareness stage, with elements of emotion regulation included. The leaving phase includes the transformation of core painful, maladaptive emotions. This phase includes identifying the impact of maladaptive emotion on self, others, and/or the world, which allows for the development of new emotional experiences. Greenberg (2022) refers to Phase 1 as the feel it to heal it phase. Clients must arrive at the emotional experience and work their way through it without losing themselves before they can leave the emotional experience. Reinforcing the importance of a strong theory of emotion, a clinician might say: “Your emotions are important; they are telling you that this is important to you. Let’s work on allowing them and getting their message” (Greenberg, 2022, p. 34). Gaining awareness means paying attention to emotion and making contact with it. Clients learn to welcome emotion, dwell on it, and breathe. Clients come to be familiar with the bodily sensation of emotion and to be informed by it, rather than controlled, which takes the form of under-regulation (i.e., controlled by emotion in a way that disconnects a client from self, others, and the world) or overregulation (i.e., disconnected from self, others, and the world by emotional dampening). These different forms of interruption of emotional experience are central to the development of underlying psychopathology (Greenberg, 2022). The second phase builds upon Phase 1 as emotional awareness and emotion regulation create opportunities for new emotional experiences and a sense of self. For this to occur, feelings must be explored and fully accepted. When feelings are judged as unacceptable, they cannot be changed because they have not been accepted as a part of the person’s experience. Recall that emotions are not about being “right” but rather about being “informative." Greenberg writes that there are three core maladaptive feelings that are experienced: fear– anxiety, shame, and sadness. The experience of feeling fragile and insecure (fear–anxiety) most often connects to a view of self as being alone or without support. This is a weak me self. The experience of feeling unworthy reveals a view of self as a failure or a defective self. This is a bad me self. The experience of the self as abandoned is often a sad me self. Often clients will experience any one of these views of self as a negative voice in their heads. Clients first have to access these core vulnerabilities, identify the wound, and experience it with a safe other in order to begin to develop new ways of viewing themselves. It is the introduction of

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new, regulated emotions and views of the self that further deconstruct the previously negative beliefs. Greenberg writes: This step is at the core of the leaving phase and involves changing emotion with emotion. . . Having accessed adaptive emotions and needs, and having developed a healthier, internal voice, people create a new narrative using their emotion to change their old narrative. (2022, p. 37)

Emotionally Focused Therapy The goal of EFT is to heighten emotional awareness of one’s interpersonal cycles of responses to perceived attachment threats and loss to be able to identify the attachment needs, as well as ask for and offer support to others (Johnson, 2019, 2020, 2022) more accurately. EFT typically follows a three-stage model to facilitate change (Johnson, 2019, 2020, 2022). The task in Stage 1 is to build a strong, safe alliance with clients and to help stabilize their emotional experiences (Johnson, 2022). It is during this initial stage that the counselor seeks to assess and clarify the client’s emotional engagement. The counselor stays emotionally engaged and responsive to the client while trying to draw out patterns of attachment. In the second stage, the counselor seeks to heighten the clients’ emotions by drawing out and going deeper to identify primary emotions. During this stage, the client and the counselor have established a secure base, allowing for more intense processing of core vulnerabilities such as loss, fear, sadness, and shame. The counselor helps change the clients’ internal models of themselves and others through corrective emotional experiences. Themes in this stage can also become increasingly existential in tone (Johnson, 2022). Finally, the counselor moves into the consolidation stage of the process, helping clients integrate new models of their identity and others into new patterns of engaging the world. In this stage, clients’ narratives may shift in how they describe themselves and others. Based on the addressed attachment patterns, potential risks in the future can be planned for and anticipated.

THE PROCESS OF MAINTAINING PROGRESS Maintaining change within the humanistic tradition locates itself within a renewed experience of self and others in real time. When clients are known and understood by a counselor, they are confronted by their own experience of self. Over time, this confrontation prompts a new emotional experience of the self and others, one that creates lasting neurological and relational change. A change that leads to new and expansive ways of being in the world and has significant application not only to the maintenance of relational health but as applied to cultural humility and appreciation.

Person-Centered Therapy As a person progressed through the sixth stage of the change process outlined previously, Rogers believed that advancement and maturity are irreversible (Rogers, 1958). Rogers believed that once a client experienced being fully received by the counselor and was thus able to receive themself, the client would become more and more reconnected with his internal valuing process (i.e., core sense of self). This creates internal congruence where the person the client views themself as matches who they are externally. Seeing as this is the undoing of the learned conditions of worth, the client is able to maintain this progress as they continue to discover and evolve amidst life changes and challenges.

Process Experiential Approach Progress is maintained for the client through the practice of slowing down. Viktor Frankl wrote, “between stimulus and response there is a space. In that space lies our freedom to

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choose our response” (as cited in Greenberg, 2022, p. 289). Clients learn to self-soothe, to slow down and take a breath, to develop an awareness of and space from emotions rather than becoming overwhelmed by them. This process will facilitate an ability to discern between primary emotions and secondary emotions and to be curious about them. The space that is created is further fostered as clients come to care for the body, mind, and spirit. This care often looks like physical activity, solid nutrition, and good sleep. Research has continued to reinforce the integrated nature of humanity and the notion that a healthy body leads to a healthy mind and emotional balance (Greenberg, 2022). Progress is further maintained with a mindset of the sacredness of the present moment rather than living in the past or living in the future. Both existential and gestalt therapy speak to this process. Gestalt therapy encourages mindfulness practices that lead to present living. This lens for life reinforces to clients a practice of awareness of emotion, thought, and physical sensation, each of which strengthens emotion regulation capacity. There is certainly a vulnerability that takes courage in this practice, a vulnerability that remains open to painful feelings and open to the acceptance of suffering. Acceptance of this vulnerability is necessary for the exploration of emotional experiences, present living, the art of slowing down, and helping clients maintain an expansive life.

Emotionally Focused Therapy Heightening emotional awareness and promoting acceptance of attachment patterns lead to individuals’ ability to integrate new ways of relating to others. Because EFT is a non-pathologizing approach to counseling, individuals’ insecure attachment responses are viewed as purposive attempts to seek out safety and connection. As awareness and insight are gained around the representational internal cognitive models of self and others and processed in counseling, they can then begin to rework these models while also taking greater risks to ask for unmet attachment needs with others. Additionally, individuals become empowered to understand better methods for seeking out safety to keep regulating their emotional arousal when feeling attachment threats.

PROCESS OF CLINICAL ASSESSMENT All assessments within these three theories can be traced back to learning the client’s subjective world. These theories are non-pathologizing, meaning assessment will be more subjective and grounded in the client’s perspective. While typical assessment looks at problems to be solved, these theories explain processes that focus less on problems and more on the impetus, maintenance, and other factors related to internal discord. Assessment methods related to each of these theories are about thoroughly learning the client so the counselor can best reflect on an experience that will ultimately allow the client to accept themselves.

Person-Centered Therapy PCT does not rely on diagnosing, pathologizing, or treating problems. The term “assessment” highlights a counselor’s expertise and clients’ problems, whereas Rogers asserted that the client is the expert, and the counselor must focus on relating to the person. From this theoretical perspective, the focus of the counselor is on getting to know the subjective world of the client. Rogers believed it was the incongruence resulting from introjects or conditions of worth that created much of the client’s discord (Rogers, 1957). Within a person-centered view, it matters far more how the client self-assesses than it does the counselor’s assessment. As such, the counselor seeks to accurately understand and attune to the incongruence or disintegration within the client (Rogers, 1957).

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Even though person-centered therapists typically do not ascribe to assessment measurements, many instruments have been found to have person-centered components, especially for individuals with dementia (Mast et al., 2021). One example is the Control, Autonomy, Self-Realization, and Pleasure Scale (CASP-19), developed by Hyde et al. (2003), which is based on humanistic principles. This instrument specifically measures quality of life, defining it as the fulfillment of the four domains identified in its title (Hyde et al., 2003). The CASP-19 is a 19-item questionnaire scored on a 4-point Likert scale ranging from 0 (never) to 3 (often). This instrument was originally normalized on a sample of older adults (i.e., 60–75 years old; Hyde et al., 2003) and has since been found to have acceptable psychometric properties with a dementia sample (Stoner et al., 2018). Scores range from 0 to 57 (M = 42.2), with increased scores reflecting increased quality of life. Reliability has been deemed acceptable for all domains, α = .59 (control), α = .65 (autonomy), α = .74 (pleasure), and α = .77 (self-­realization; Hyde et al., 2003). Within a sample of persons with dementia, internal consistency for the entire measurement was found to be strong (α = .86), as well as test–retest reliability (i.e., ICC = .76 – .92; Stoner et al., 2018). Convergent and concurrent validity has also been established for the CASP-19 (Hyde et al., 2003; Stoner et al., 2018).

Process-Experiential Approach PE-EFT clinicians are well versed in the dance that often occurs as clients shift from a place of cognition into emotion and then escape back to a safe cognitive place. An effective clinician is well versed in following this dance as a way of attuning with the client and then skillfully moving the client to a place of emotional experience only to move back to safety. In time, this process is named as a part of the moment-by-moment work of process-experiential therapy. Some clients work hard not to feel emotion because there is a deficit in emotional experiences, while other clients actively avoid emotion as a defensive posture that suppresses either intentionally or unintentionally in response to some form of past trauma. Both reactions can be described as non-awareness or a lack of expression of emotion. Treatment with those clients who have difficulty identifying and expressing emotion involves skill training, which begins with physiological responses to emotion and journaling about emotions (Greenberg, 2022). Clients focus on acquainting themselves with the spectrum of emotion in daily living and holding a nonjudgmental approach to emotion. The adapting to emotions in a judgmental manner can be likened to a beautiful mosaic tapestry with a multitude of colors. Each color represents emotions from painful to pleasant. A day lived is a day that the client is aware of each color, allowing the emotional colors to express themselves and then having the ability to step back and see the colors in the larger context of the tapestry. On the other hand, clinical assessment or the clinical dance may reveal that the client intentionally or unintentionally inhibits emotion. The client most often is aware of emotions but chooses to disown them as separate from the self. Clients who block emotional experiences are active agents in the process of avoiding their emotions. Greenberg writes, They [clients] are not passive recipients, as implied by statements like, “I just went blank” or “My sadness suddenly disappeared.” “In therapy, clients are helped to see themselves as agents who do things to interrupt their experience and block their expression of emotion, and to see that they cut themselves off from the adaptive information associated with the emotions. (2022, p. 162)‌‌‌‌‌‌‌

Emotionally Focused Therapy Initially, counselors are looking to accurately assess the emotions clients are bringing to the counseling session. Early assessment in EFT is focused on being collaborative and specific. Counselors work hard not to assume anything about the clients’ emotions and spend early

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sessions making sure that their language and understanding of the clients’ emotions are highly accurate and specific. This is done by repeating and frequently clarifying the accuracy of emotional assessment in early sessions. After counselors have assessed their clients’ presenting emotional state, they become focused assessing the attachment processes that clients tend to engage in when feeling a perceived attachment threat or loss. Johnson (2019, 2020, 2022) calls this the EFT tango. Clients are assessed for how they tend to engage in response to the attachment threat. Next, the counselor assesses the attachment pattern (e.g., anxious, avoidant) clients typically engage in when their fear response is activated. Finally, counselors assess the meaning clients assign to their emotions, attachment patterns, and understanding of negative experiences (Johnson 2022). Researchers have worked over the years to develop different measures of attachment styles based on the works of early attachment theories (Ainsworth & Bell, 1970; Bowlby, 1969). A thorough review can be found in the work by Mikulincer and Mario (2016). A commonly utilized measure of attachment style is the Experiences in Close Relationships (ECR) scale. The ECR is a 36-item instrument (Johnson, 2019) developed by Brennan et al. (1998) that consists of two 18-item subscales that measure the level of agreement related to avoidance style items and anxious style items using a 7-point Likert scale (Parker et al., 2011). The ECR has demonstrated acceptable internal reliability with Cronbach’s results ranging from .90 to .94 (Parker et al., 2011). Construct validity has been demonstrated with factor analysis (Brenna et al., 1998; Parker et al., 2011), though there is some evidence that items on the anxious subscale may be interpreted differently by men compared to women (Parker et al., 2011). The ECR has been translated into 17 different languages (Mikulincer & Shaver, 2016).

SPECIFIC THEORETICAL TECHNIQUES While person-centered counseling, process emotional theory, and EFT are not heavily technique-driven approaches, their main focus is on facilitating an authentic counseling relationship, as seen in the roles of the counselor and the client. Techniques used in these approaches are designed to cultivate a safe, accessible therapeutic environment where clients can experience and express their emotional concerns.

Person-Centered Therapy Typically, different therapeutic approaches utilize distinct techniques to assist the client and advance the therapeutic encounter. However, PCT is not technique driven. Rogers would not view the core conditions of genuineness, unconditional positive regard, and empathy as techniques per se, as they are foundational tenants of this theory and internal qualities of the counselor using the approach. These core conditions were believed to be powerful enough to be sufficient to evoke growth in the client. Stemming from a relational approach to therapy, Rogers viewed the counselor as a tool, seeing as humans impact humans. One of the primary factors needed for effective counseling is for the counselor to be congruent and integrated (Rogers, 1957). The counselor’s utilization of themselves is necessary for the client to begin to see themselves accurately, as the counselor is only able to connect with others to the depth that they are connected to themselves.

Process-Experiential Approach Consistent within the humanistic approach, technique is found in the clinical relationship and within the theory of emotion. The client and counselor enter into a dynamic relationship upon meeting, a relationship in which affect is regulated and mis-regulated over time. This relational encounter becomes the container for the client’s unarticulated experience and emotion. A focus on the role of emotion within the clinical relationship

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necessitates a slowing down of the clinical process. A counselor will work with the client to both acknowledge and feel those feelings that present within the relational encounter. This requires a slowing down of the clinical work. Space is encouraged with the intent of the client to feel the emotion in their body and explore the nature of emotion in the presence of a caring clinician (Greenberg, 2022). This work will require the counselor to possess high emotional intelligence and to have the courage to both feel and use emotion as the very technique of therapy. Work between sessions will often focus on identifying emotions with a goal of pinpointing the uniqueness of each emotion. Journaling‌‌‌‌‌‌‌ will include not only using simple feeling words like “angry” but also giving time to feel the anger and perhaps further define it as “frustrated,” “annoyed,” or “agitated” (Greenberg, 2022). Clinical work of this nature requires counselors to connect emotionally, to be moved by the client’s affect, and to engage in a real relational encounter. An example or application of this style of clinical work includes intentional supervision that views videotape with an emphasis on process over content and the role of emotion within the clinical encounter (and the supervisory encounter).

Emotionally Focused Therapy As with the other approaches discussed in this chapter, EFT is not technique heavy. The use of certain techniques is used to draw out the emotion clients are experiencing primarily in the present counseling session. The goal is to create a safe environment where clients can have a corrective emotional experience. An EFT-oriented counselor will use reflection and validation to help clients draw out their lived experiences. Reflection entails the mirroring of the clients’ language, patterns, and meanings such that they can hear back how they are articulating their inner experience with the counselor (Johnson, 2019). Counselors try to bring the embodied experience of the client. While engaging in this behavior, the counselor will also frequently validate clients’ experiences. The purpose is to accept and normalize clients’ experiences so safety can be established (Johnson, 2019). For example, a counselor might say, “I see that when you discuss this particular part of your trauma you get very tense. You even use the word hellish to describe this experience and you start to become quiet. I want you to know that this manner of describing the situation makes sense given what you have gone through. You’re going quiet is how you try to keep your emotions under control.” As safety is established in the therapeutic relationship, the counselor can heighten the clients’ emotionality. Techniques that are used to do this are evocative questioning and deepening engagement. These two techniques have a similar goal to elicit the underlying emotion of a particular experience and heighten that experience. With evocative questioning, the counselor is deliberately using questions structured to heighten the underlying emotional experience of the client (Johnson, 2019). For example, a counselor may be very direct in a question to ask, “When you shared that experience with me just now, what happened? What came up for you as you shared this experience? Where did you feel that in your body?” In deepening engagement, the counselor will intentionally slow down and use repetition to help the client increase their emotional engagement (Johnson, 2019). This technique is experiential in nature. The acronym RISSSC (Repeat, Image, Simple, Slow, Soft, and Client’s words) is often associated with this technique to assist the counselor in drawing out emotion (Johnson, 2019). When attempting to heighten an emotional experience, using the RISSSC acronym can be helpful. Consider the following example of a counselor heightening a client’s emotional experience. “It’s like when you say it is too dangerous to share with me. It’s not just you not wanting to engage…it is something more than that. You are feeling literal fear that something very terrible will happen to you. That to share with me is extremely dangerous so you opt to go quiet to try to shut down. Is that it?” It is important to note that with EFT, the tone and speed of the words is also a critical part of the successful use of these techniques.

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THEORETICAL, MULTICULTURAL, INTERSECTIONAL, AND SOCIAL JUSTICE ISSUES Over the course of the last two decades, significant growth has occurred within the humanistic tradition as it concerns the topic of cultural humility and social advocacy. The advent of PCT offers what would seem to be timeless ways of being with a client through unconditional positive regard, empathic understanding, and genuineness. This assumption has been challenged by social psychology, philosophy, and the arts and revealed the need for counselors to grow in awareness of social location, its benefits, and the manner in which such location has shaped the way in which a counselor listens, empathizes, and lives out genuineness with a client who comes from a very different cultural location. The integration of a theory of emotion and the person of the counselor within a cultural context has paved the way for humanistic work to embrace cultural competence and advocacy within the global economy.

Person-Centered Therapy There are many discrepancies regarding the cultural sensitivity of PCT. According to Rogers, this therapy and the necessary and sufficient conditions are not culture bound. He asserted that this therapeutic modality would benefit any client, with any presenting problem, from any cultural background (Rogers, 1963). PCT has been used with clients with diverse backgrounds across differing geographic borders (Quinn, 2012). Any client who experiences being fully received by the counselor will engage in the process of becoming fully realized, integrated, and congruent. Other researchers, however, argued that self-actualization is limited and overlooks social, cultural, and political factors (Waterhouse, 1993; Knight, 2007; Kensit, 2000; Bozarth & Moon, 2008; Quinn, 2008; Weaver, 2008). According to Swan and Ceballos (2020), critics of PCT have misinterpreted the meaning behind self-actualization as a desired outcome rather than a process. Additionally, these critics believe that focusing on client change is not enough; the therapist must also be concerned with societal change (Waterhouse, 1993; Kensit, 2000; Weaver, 2008). However, Rogers maintained that the factors associated with PCT parallel what is needed for effective change in government and the society at large (Rogers, 1950).

Process Experiential Approach One study using PE-EFT was conducted in 2015 and considered the process of grief among third culture kids. This study looked at children who had formed two or more cultural identities due to being raised in families whose parents' occupations (i.e., missionaries) required them to move within different cultural contexts. PE is suggested to be an ideal theory as it has humanistic-experiential, existential, and attachment roots, which makes it uniquely qualified for counseling such children. This approach is essentially counseling that views emotion and behavior within a context rather than pathologizing or taking a more ­manual-based approach (Davis et al., 2015).

Emotionally Focused Therapy EFT is grounded in humanistic-experiential perspectives first promoted by Carl Rogers. This approach is rooted in the idea that respecting and valuing all individuals is the core of sound clinical practice. Moreover, attachment theory views core emotions, vulnerabilities, protective strategies, and the need to feel a safe connection with others to be a universal experience. Two key terms used in EFT are belonging and becoming, which are viewed as universal societal goals. The goal of EFT counselors is to be responsive and respectful of every

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individual’s experience of the world, maintaining an openness that their experiences of the world are often unique.

RELEVANT THEORY-BASED SCHOLARSHIP AND RESEARCH TRENDS Person-Centered Therapy Due to the criticisms of the utilization of PCT for diverse populations along with the rise in multicultural and social justice advocacy, continued research has been conducted to establish a baseline of the theory’s applicability. Quinn (2012) presented a historical overview and current trends in PCT, displaying evidence of the theories appropriateness with individuals of diverse cultures and presentations. Rogers’ original claims on the efficacy of this theory in practice for persons of all backgrounds, races, and presenting problems were further substantiated by Swan and Ceballos (2020). Of specific note, these authors explain that the actualizing tendency must take place in an optimal environment that can only be created when the client experiences being fully received. It is only then that the client will be able to perceive the impact of the oppressive and controlling factors that have been internalized and begin to fully receive themselves as they are (Swan & Ceballos, 2020). In addition to Swan and Ceballos, other more recent research trends include using PCT with gender-diverse persons (Knutson & Koch, 2022‌‌‌‌‌‌‌‌‌‌‌‌) and for early trauma work (Murphy et al., 2019), although continued research is needed on its utilization with continued trauma work.

Process Experiential Approach The past two decades has seen a theory on emotion develop in conjunction with a move toward integrative clinical work. Emotion is a universal experience and central to the human experience and thriving. The concept of changing emotion with emotion has also come to be seen as a universal component of the change process within counseling. The role of emotion in human functioning begs for a unified approach to counseling that serves as a metatheory for diagnosis, an understanding of theory, and cultural competence. In this regard, maladaptive emotional processing is a primary area of concern that underlies disorder and maladaptive functioning (Greenberg, 2022).

Emotionally Focused Therapy Attachment needs are viewed as a primary human motivation. Attachment is survival. Recent research trends have attempted to draw a better understanding of neurological and physiological responses to attachment (Cassidy & Shaver, 2016). In one study (Coan et al., 2006), it was shown that when threatened with the possibility of a shock, individuals in high-quality relationships holding their spousal partner’s hands showed lower threat activations in the brain (hypothalamus and anterior insula) as compared to the threat of a shock while alone. The power of attachment and proximal closeness can be seen as a mitigating factor to stress. Moreover, Johnson et al. (2013) conducted a similar study looking at the role of EFT as an intervention and found that post-EFT, there had been a significant further reduction in certain threat activation areas of the brain. Additionally, EFT research trends are focusing increasingly on the impact trauma has on attachment styles (e.g., Peng et al., 2020‌‌‌‌‌‌‌‌‌‌‌‌; Murphy et al., 2019), the role culture plays in developing and defining attachment patterns (Nightingale et al., 2019), and the process attributes counselors can bring to an EFT approach that help in achieving post outcomes with clients (Brubacher & Wiebe, 2019).

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DETAILED CASE CONCEPTUALIZATION PRAGMATICS AND TRANSCRIPT The following transcript will demonstrate the application of EFT skills to the case of Mark. The EFT counselor conceptualizes Mark’s anxiety and sadness as reactions to real and perceived attachment loss. Mark is divorced which is a real attachment loss, but Mark will go on to express his desire to start dating again which creates perceptions of perceived loss in attachment with his own daughters. The quote “it takes me away from my daughters” indicates a fear of loss in the attachment he has with his daughter with the conflict of his loneliness and desire to create new romantic attachment. The counselor will try to focus Mark on these attachment fears and to draw attention to the emotions that are connected to the fears. Transcript

Skill(s) Demonstrated

Counselor: Hello Mark. What brings you in today?

Open-ended question (Counselor uses an open-ended question to open the session.)

Client: I have been feeling lonely and anxious but not sure if I should start dating again. Counselor: You were married for a while and been divorced for a few years. It makes sense to be feeling anxiety and loneliness.

Validation (Counselor provides validation of the client’s experience and emotions.)

Client: Yeah. I am ready to move on with another relationship, but I am concerned how this will take me away from my daughters. Counselor: Take you away from your daughters?

Reflection (Counselor reflects the client’s language using a soft, similar tone of voice.)

Client: Yes, they are 9 and 12. They are at an age where they really need their father there for them. I don’t want them to feel neglected if they see me with another woman. Counselor: I see. It’s like you are concerned they will see you as letting them down, like they will see you giving attention elsewhere. Almost as if they may interpret your dating as they are now less important? Am I understanding correctly?

Reframing (Counselor reframes the client’s ­feelings to start bringing attention to the potential attachment ruptures the client may anticipate with his daughters.)

Client: Yes, since the divorce I have put all of my energy in raising my two girls. I want them to know that they will always be very important to me. But I am 42 and been single for over three years. I know they will eventually grow up, move out. I don’t want to be alone as I get older. I miss sharing life with a partner. Counselor: It sounds like you’re concerned about how it would affect Elle and Carla. But go a bit deeper. It’s more than how it will impact them. I wonder if there is a fear that you will be abandoning them as their father?

Reflection of feeling with evocative questioning (Counselor seeks to go beneath the surface to help client identify deeper emotional experiences.)

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Client: Yes, I have found that my ability to continue to be a father for my girls has helped the sadness at relatively manageable levels. But I now feel so much guilt for wanting to do something for myself. Counselor: The guilt seems to be a fear that they will see you as abandoning them, leaving them alone. If they look to see if you are going to be there, you are afraid that they will see you as gone. And you don’t want that. You want them to know you are still going to be there to support them and protect them. Am I hearing that correctly?

Heightening (Counselor is highlighting the guilt to attach it to attachment fears.)

Client: Yes, it’s very stressful carrying these feelings. Like I’m a bad dad for even having the desire to date.

THEORETICAL LIMITATIONS Person-Centered Therapy According to the American Counseling Association’s Code of Ethics, counselors must pay careful attention to providing adequate diagnoses (E.5.a; ACA, 2014). From this, and the traditional medical model perspective, PCT’s lack of primacy on diagnosing could be viewed as a limitation. According to Kirschenbaum and Jourdan (2005), the core conditions are not necessary for client change, and even with their presence, not all clients change. The primacy of self-actualization has also been criticized, asserting that not everyone possesses the innate desire to self-correct (Bozarth & Moon, 2008) and that it overlooks social, cultural, and political factors (Waterhouse, 1993). Lastly, there is a belief that clients cannot reach the actualizing tendency on their own, and therefore, a more directive approach is deemed necessary (Kahn, 2012).

Process Experiential Approach While emotion is a universal experience and forms a much-needed metatheory for clinical work across cultures, within theory development, and across diagnosis, there are cultural and individual differences tied to emotional expression. Emotion as a metatheory to healing and clinical work therefore will require clinicians who exhibit cultural sensitivity as emotional expression is explored within the contexts of unique personal and cultural experience.

Emotionally Focused Therapy Attachment theory has been suggested as a metatheory to help understand what drives individuals in relationships (Johnson, 2019). While attachment theory has been researched with children for many years, understanding of the complexities with adult attachment is still in its beginning stages. EFT does a great job in articulating how attachment theory can inform a counseling session and how a counselor can be mindful to help establish safety and security in a therapeutic environment; however, a limitation is that individuals wishing to fully understand the complexities of attachment theory in individuals may need to look outside of EFT to original work in object relations theory, emerging trends in neuroscience research, and ongoing development in understanding trauma. Moreover, EFT historically has not explicitly addressed the potential impact culture, belief, and personality may have on understanding attachment. EFT is only recently beginning to look at the role of

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attachment theory from an intrapsychic perspective where it has historically been applied to couples counseling (Johnson, 2019).

SUMMARY This chapter covered the humanistic theories of person-centered, process-experiential, and emotionally focused therapies. As you read throughout the chapter, there are some clear overlaps in the treatments, yet each possesses unique qualities and perspectives. All theories presented in this chapter focus on the importance of counselor growth, character, disposition, and development, as the counselors’ level of health directly impacts the therapeutic work with clients. The therapeutic relationship lies central to these theories and counselors direct their attention to the subjective experience of their clients. An essential focus of the counselor is to connect deeply with the person of the client amid their current experience and to oppose to being problem oriented. These humanistic theories were a reaction and response to the prescriptive, interpretive, and diagnostic perspective of psychoanalysis, which as the name bears, acknowledges humanity within the counseling room. VOICES FROM THE FIELD This chapter features a digitally recorded interview entitled Voices From the Field. The interview explores multicultural, social justice, equity, diversity, and intersectionality issues from the perspective of clinicians representing a wide range of ethnic, racial, and national backgrounds. The purpose of having chapter-based authors interview individuals representing communities of color or who frequently serve diverse populations is to provide you, the reader, with relevant theory-based social justice and multiculturally oriented conceptualization, contemporary issues, and relevant skills.

Access the video at https://bcove.video/46jzXtw

This 35-minute interview with Dr. Edward Ewe engages a humanistic approach to clinical work with an emphasis on cultural awareness. Dr. Edward Ewe is an integrative clinical counselor who utilizes emotion-­focused therapy in his work with individuals and couples. Dr. Ewe was born and raised in Malaysia, completed his doctorate in Counselor Education at Oregon State University (CACREP), and currently serves as Assistant Clinical Professor at the Oregon State University (Bend campus). Dr. Ewe is a Licensed Professional Counselor (Oregon), a licensed Mental Health Counselor (Washington), a National Certified Counselor, and an Approved State Clinical Supervisor in both Oregon and Washington. His private practice is located in Bend, Oregon.

STUDENT EXERCISES Exercise 1: Reflective Freewrite

As you consider implementing experiential theory, take 20 minutes to freewrite in response to the following prompts: What did you learn about conflict growing up? What did you learn about emotions in your younger years (e.g., are they dangerous, informative, not to be trusted, overwhelming, etc.)? What does emotion regulation look like for you, and how can you take steps toward greater regulation?

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Exercise 2: Social Location Walk

Experiential theory suggests that the person of the counselor greatly impacts what happens within a clinical encounter. Who you are matters, and who you are shapes your clients’ clinical experience. Take a notebook and pen and enjoy a 30-minute walk. Reflect upon the ways in which you were shaped as it pertains to culture, geographical location, and family structure. What is your social location?

Exercise 3: The Role of Shame

It is challenging, if not impossible, to move through life without experiencing shame or what Rogers has termed conditions of worth. When are you most hard on yourself? And how might this answer impact the way in which you encounter clients?

Exercise 4: A Theory of Emotion

A theory of emotion would suggest that mental health is directly correlated with emotional awareness and expression. Create a mosaic tapestry of color on a piece of paper by taking a set of colored pencils and a notebook with you on a given day. Give yourself permission to pay attention to the many different emotions and choose a color to represent these emotions. Begin to create your mosaic tapestry by adding color to your notebook. By the end of the day, the more colorful your notebook, the more present you were to your many emotions. Emotions that are not to be deemed as bad or good, but rather on a spectrum ranging from painful to pleasant. Emotions that are informative.

Exercise 5: Right or Relationally Right

Practice listening to conversations/dialogue and responding nonjudgmentally and empathically (i.e., without trying to solve or jump ahead of what the person has shared). Notice when you feel led to correct another rather than to be curious. What is the difference between a pursuit to being right versus an effort to be relationally right? What prompts you to feel the need to be “right”?

RESOURCES Helpful Links ■ ■ ■ ■ ■

World Association for Person-Centered and Experiential Psychotherapy and Counseling (WAPCEPC): https://www.pce-world.org/index.php Association for the Development of the Person-Centered Approach (ADPCA): https:// adpca.org/ The International Centre for Excellence in Emotionally Focused Therapy (ICEEFT): https://iceeft.com/ Emotion Focused Therapy.Com: http://www.emotionfocusedtherapy.org/Meet%20Les. htm The Association for Humanistic Counseling: https://www.humanisticcounseling.org/

Helpful Books ■ ■ ■

Rogers, C. (1995). On becoming a person: A therapist’s view of psychotherapy. HarperOne. Rogers, C. (2021). Client-centered therapy: Its current practice, implications, and theory. Robinson. Johnson, S. M. (2019). Attachment theory in practice: Emotionally focused therapy with ­individuals, couples, and families. Guilford Press.

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Johnson, S.M., Campbell, T. L. (2022). A primer for emotionally focused individual therapy. Routledge. Greenberg, L. (2022). Changing emotion with emotion: A practitioner’s guide. American Psychological Association.

Helpful Videos ■ ■

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Shostrom, E. L. (Director). (1965). Carl Rogers and Gloria [Film]. Psychological and Educational Films. Western, B. (December 10, 2012. Carl Rogers on ­empathy [Video]. YouTube. https://www.youtube.com/watch?v=iMi7uY83z-U&list=PL9w3l7GkGUr1yxU4s2PiggyCbOO3XfpRf&index=1&t=0s Magnavita, J. J. (Host). (2012). Psychotherapists face-to-face with Leslie Greenberg, Ph.D. [Video file]. https://focus.psychiatryonline.org/doi/10.1176/foc.8.1.foc32 Bourne, D. (2022). Dr. Leslie Greenberg’s development of emotion focused therapy, his thoughts on CBT, and his journey [Video]. YouTube. https://www.youtube.com/watch?v= PHCRLnK0eLo International Centre for Excellence in Emotionally Focused Therapy. (1993). Emotionally focused therapy for couples: Healing broken bonds [Video].

A robust set of instructor resources designed to supplement this text is available. Qualifying instructors may request access by emailing [email protected].

REFERENCES Ainsworth, M. D. S., & Bell, S. M. (1970). Attachment, exploration, and separation: Illustrated by the behavior of one-year-olds in a strange situation. Child Development, 41(1), 49–67. https://doi.org/10.7312/ stei93738-006 American Counseling Association. (2014). ACA code of ethics. Author. Bowlby, J. (1969). Attachment and loss: Vol. 1. attachment. Basic Books. Bozarth, J. D., & Moon, K. A. (2008). Client-centered therapy and the gender issue. Person-Centered & Experiential Psychotherapies, 7(2), 110–119. https://doi.org/10.1080/14779757.2008.9688457 Brennan, K., Clark, C., & Shaver, P. (1998). Self-report measurement of adult attachment: An integrative overview. In J. Simpson & W. Rholes (Eds.), Attachment theory and close relationships (pp. 46–75). The Guilford Press. Brubacher, L. L., & Wiebe, S. A. (2019). Process-research to practice in emotionally focused couple therapy: A map for reflective practice. Journal of Family Psychotherapy, 30(4), 292–313. https://doi.org/10.1080 /08975353.2019.1679608 Coan, J. A., Schaefer, H. S., Davidson, R. J. (2006). Lending a hand: Social regulation of the neural response to threat. Psychological Science, 17(12), 1032–1039. https://doi.org/10.1111/j.1467-9280.2006.01832.x Cook, J. (2015). Intersubjectivity as a deepening of the counseling experience. The Wisconsin Counseling Journal. Accession #: 115542266 Corey, G. (2017). Theory and practice of counseling and psychotherapy (10th ed.). Cengage Learning. Council for Accreditation of Counseling and Related Educational Programs. (2016). Section 2:‌‌‌‌‌‌‌‌‌‌ Professional counseling identity. https://www.cacrep.org/section-2-professional-counseling-identity/ Davis, P., Edwards, K., & Watson, T. (2015). Using process-experiential/emotion-focused therapy techniques for identity integration and resolution of grief among third culture kids. Journal of Humanistic Counseling, 54(3), 170–186. https://doi.org/10.1002/johc.12010 Doss, B. D., Roddy, M. K., Wiebe, S. A., & Johnson, S. M., (2022). A review of the research during 2010–2019 on evidence-based treatments for couple relationship distress. Journal of Marital and Family Therapy, 48(1), 283–306. https://doi.org/10.1111/jmft.12552 Elliot, R., & Greenberg, L. (2007). The essence of process-experiential/emotion-focused therapy.  American Journal of Psychotherapy, 61(2), 241–254. https://doi.org/10.1176/appi.psychotherapy. 2007.61.3.241

Greenberg, L. (2022). Changing emotion with emotion: A practitioner’s guide. APA. Hyde, M. Wigging, R. D., Higgs, P., & Blane, D. B. (2003). A measure of quality of life in early old age: The theory, development and properties of a needs satisfaction model (CASP-19). Aging & Mental Health, 7(3), 186–194. https://doi.org/10.1080/1360786031000101157 Johnson, S. M. (2017). An emotionally focused approach to sex therapy. In Z. Peterson (Ed.), The Wiley handbook of sex therapy (pp. 250–266). Wiley. Johnson, S. M. (2019). Attachment theory in practice: Emotionally focused therapy with individuals, couples, and families. Guilford Press. Johnson, S. M. (2020). The practice of emotionally focused couple therapy (3rd ed.). Routledge. Johnson, S. M., Burgess Moser, M., Beckes, L., Smith, A., Dalgleish, T., Halchuk, R., Hasselmo, K., Greenman, P. S., Merali, Z., & Coan, J. A. (2013). Soothing the threatened brain: Leveraging contact comfort with Emotionally Focused Therapy. PLOS ONE, 8(11), 1–10. https://doi.org/10.1371/­ journal.pone.0079314 Johnson, S. M., & Campbell, T. L. (2022). A primer for emotionally focused individual therapy. Routledge. Johnson, S. M., & Greenberg, L. S. (1985). The differential effectiveness of experiential and problem-solving interventions in resolving marital conflict. Journal of Consulting & Clinical Psychology, 53(2), 175–184. https://doi.org/10.1037/0022-006x.53.2.175 Johnson, S. M., & Greenberg, L. S. (1987). Emotionally focused marital therapy: An overview. Psychotherapy, 24(3), 552–560. https://doi.org/10.1037/h0085753 Jurist, E. L., & Meehan, K. B. (2009). Attachment, mentalizing, and reflective functioning. In J.H. Obegi & E. Berant (Eds.), Attachment theory and research in clinical work with adults (pp. 71–73). Guilford Press. Kahn, E. (2012). On being “up to other things”: The nondirective attitude and therapist-frame responses in client-centered therapy and contemporary psychoanalysis. Person-Centered & Experiential Psychotherapies, 11(3), 240–254. https://doi.org/10.1080/14779757.2012.700285 Kensit, D. A. (2000). Rogerian theory: A critique of the effectiveness of pure client-centered therapy. Counselling Psychology Quarterly, 13(4), 345–351. https://doi.org/10.1080/713658499 Kirschenbaum, H., & Jourdan, A. (2005). The current status of Carl Rogers and the person-centered approach. Psychotherapy: Theory, Research, Practice, Training, 42(1), 37–51. https://doi. org/10.1037/0033-3204.42.1.37 Knight, T. A. (2007). Showing clients the doors: Active problem-solving in person-centered psychotherapy. Journal of Psychotherapy Integration, 17(1), 111–124. https://doi.org/10.1037/1053-0479.17.1.111 Knutson, D., & Koc‌‌‌‌‌‌‌‌‌‌‌‌h, J. M. (2022). Person-centered therapy as applied to work with transgender and gender diverse clients. The Journal of Humanistic Psychology, 62(1), 104–122. https://doi. org/10.1177/0022167818791082 Krueger, R. F., & Markon, K. E. (2011). A dimensional-spectrum model of psychopathology: Progress and opportunities. Archives of General Psychiatry, 68(1), 10–11. https://doi.org/10.1001/ archgenpsychiatry.2010.188 Magnavita, J. J. (Host). (2012). Psychotherapists face-to-face with Leslie Greenberg, Ph.D. [Video file]. http:// www.societyforpsychotherapy.org/psychotherapists-face-face-dr-leslie-greenberg Maslow, A.H. (1943). A theory of human motivation. Psychological Review, 50(4), 370–396. https://doi. org/10.1037/h0054346 Mast, B. T., Molony, S. L., Nicholson, N., Keefe, C. K., & DiGasbarro, D. (2021). Person-centered assessment of people living with dementia: Review of existing measures. Translational Research &. Clinical Interventions, 7(1), 1–6. https://doi.org/10.1002/trc2.12138 ​​Mikulincer, M., & Shaver, P. (2016). Attachment in adulthood: Structure, dynamics, and change (2nd ed.). Guilford Press. Murphy, D., Elliott, R., & Carrick, L. (2019). Identifying and developing therapeutic principles for trauma-focused work in person-centered and emotion-focused therapies. Counselling & Psychotherapy Research, 19(4), 497–507. https://doi.org/10.1002/capr.12235 Nightingale, M., Awosan, C. I., & Stavrianopoulos, K. (2019). Emotionally focused therapy: A culturally sensitive approach for African American heterosexual couples. Journal of Family Psychotherapy, 30(3), 221–244. https://doi.org/10.1080/08975353.2019.1666497 Parker, M., Johnson, L., & Ketring, S. (2011). Assessing attachment of couples in therapy: A factor analysis of the experiences in close relationships scale. Contemporary Family Therapy: An International Journal, 33(1), 37–48. https://doi.org/10.1007/s10591-011-9142-x‌ Peng, J., Zhang, J., Zhao, L., Fang, P., & Shao, Y. (2020). Coach-athlete attachment and the subjective well-being of athletes: A multiple-mediation model analysis. International Journal of Environmental Research and Public Health, 17(13), 4675. https://doi.org/10.3390/ijerph17134675

Prochaska, J. O., & Norcross, J. C. (2014). Systems of psychotherapy: A transtheoretical analysis (8th ed.). Brooks/Cole. Quinn, A. (2008). A person-centered approach to the treatment of combat veterans with posttraumatic stress disorder. Journal of Humanistic Psychology, 48(4), 458–476. https://doi.org/10.1177/ 0022167808316247 Quinn, A. (2012). A person-centered approach to multicultural competence. Journal of Humanistic Psychology, 53(2), 202–251. https://doi.org/10.1177/0022167812458452 Rogers, C. R. (1942). The use of electrically recorded interviews in improving psychotherapeutic techniques. American Journal of Orthopsychiatry, 12(3), 429–434. https://doi.org/10.1111/j.1939-0025.1942. tb05930.x Rogers, C. R. (1950). Where are we going in clinical psychology? Journal of Consulting Psychology, 15(3), 171–177. https://doi.org/10.1037/h0059653 Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21(2), 95–103. https://doi.org/10.1037/h0045357 Rogers, C. R. (1958). A process conception of psychotherapy. American Psychologist, 13(4), 142–149. https:// doi.org/10.1037/h0042129 Rogers, C. R. (1961). On becoming a person: A therapist’s view of psychotherapy. Houghton Mifflin Company. Rogers, C. R. (1963). The concept of the fully functioning person. Psychotherapy: Theory, Research & Practice, 1(1), 17–26. https://doi.org/10.1037/h0088567 Rogers, C. R. (1964). Toward a modern approach to values: The valuing process in the mature person. Journal of Abnormal and Social Psychology, 68(2), 160–167. https://doi.org/10.1037/h0046419‌‌‌‌‌‌‌‌‌‌‌ Roth, G., Benita, M., Amrani, C., Shachar, B., Asoulin, H., Moed, A., Bibi, U., & Kanat-Maymon, Y. (2014). Integration of negative emotional experience versus suppression: Addressing the question of adaptive functioning.  Emotion, 14(5), 908–919. https://doi.org/10.1037/a0037051 Snyder, D. K., & Halford, W. K. (2012). Evidence-based couple therapy: Current status and future directions. Journal of Family Therapy, 34(3), 229–249. https://doi.org/10.1111/j.1467-6427.2012.00599.x Stolorow, R., & Atwood, G. (1992). Contexts of being: The intersubjective foundations of psychological life. Routledge. Stolorow, R., Atwood, G., & Orange, D. (2002). Worlds of experience: Interweaving philosophical and clinical dimensions in psychoanalysis. Basic Books. Stoner, C. R., Orrell, M., & Spector, A. (2018). The psychometric properties of the control, autonomy, self-realization, and pleasure scale (CASP-19) for older adults with dementia. Aging & Mental Health, 23(5), 643–649. https://doi.org/10.1080/13607863.2018.1428940 Swan, A. M., & Ceballos, P. (2020). Person-centered conceptualization of multiculturalism and social justice in counseling. Person-Centered & Experiential Psychotherapies, 19(2), 154–167. https://doi.org/10.1080 /14779757.2020.1717981 Vanaerschot, G. (2007). Empathic resonance and differential experiential processing: An e­ xperiential process-directive approach. American Journal of Psychotherapy, 61(3), 313– 330. https://doi. org/10.1176/appi.psychotherapy.2007.61.3.313 Waterhouse, R. L. (1993). “Wild women don’t have the blues”: A feminist critique of “person-centered” counselling and therapy. Feminism & Psychology, 3(1), 55–71. https://doi.org/10.1177/ 0959353593031004 Weaver, L. (2008). Facilitating change in men who are violent towards women: Considering the ethics and efficacy of a person-centered approach. Person-Centered and Experiential Psychotherapies, 7(3), 173–184. https://doi.org/10.1080/14779757.2008.9688463 Wiebe, S. A., & Johnson, S. M. (2016). A review of the research in emotionally focused therapy‌‌‌ for couples. Family Process, 55(3), 390–407. https://doi.org/10.1111/famp.12229 Wiebe, S. A., Johnson, S. M., Burgess Moser, M., Dalgleish, T. L., & Tasca, G. A. (2017). Predicting follow-up outcomes in emotionally focused couple therapy: The role of change in trust, relationship-specific attachment, and emotional engagement. Journal of Marital and Family Therapy, 43, 213–226. https:// doi.org/10.1111/jmft.12199

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EXISTENTIAL-HUMANISTIC APPROACHES Joel Givens, Phillip L. Waalkes, and Paul H. Smith

LEARNING OBJECTIVES After reading this chapter, you will be able to: ■ Understand the theoretical and philosophical foundations of Irvin Yalom’s existential psychotherapy, Victor Frankl’s logotherapy, and Fritz Perls’s gestalt therapy ■ Learn existential-humanistic approaches to mental health concerns and definitions of wellness ■ Apply knowledge of existential-humanistic considerations of the counselor and client relationship, the nature of human development, and the process of change ■ Demonstrate awareness of the process of clinical assessment, several theoretical techniques, and case conceptualization pragmatics ■ Integrate several multicultural/intersectional/social justice issues and future research trends in the practice of existential-humanistic counseling ■ Consider theoretical limitations, helpful exercises, and resources

INTRODUCTION We sail within a vast sphere, ever drifting in uncertainty, driven from end to end. When we think to attach ourselves to any point and to fasten to it, it wavers and leaves us. —Blaise Pascal, Pensées

The philosopher Blaise Pascal (1623–1662) expressed the human struggle for stability and constancy in the face of change, transience, and death. Counselors who use existential and humanistic theories courageously explore the topics that many individuals avoid or ignore. Indeed, these approaches involve an attitude of wonder, curiosity, and genuineness rather than a set of skills or techniques. Consider this chapter in the context of the textbook you are reading. Perhaps you are cramming for a paper or exam, or you are attempting to glean key concepts to assist with a case conceptualization, assessment, or treatment plan. Now, consider a fond memory of feeling the wind blow against your face as a child. Reflect on the wonder you sensed at the time. Now, ponder the inevitable fact that you, your family, and your friends will eventually die. After reflecting on death, you might find it difficult to return to the mundanity of midterm exams and treatment plans. You consider your own freedom in light of the absurdity of human existence. As you continue reading this chapter, you might proclaim, “I choose to read this chapter” rather than “I have to read this chapter.” After all, you are responsible for making meaning of your existence from now until you perish. In this chapter, we endeavored to present the material with an attitude of wonder, curiosity, and genuineness. This approach, we believe, captures the spirit and not just the letter of

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existential-humanistic approaches. Counselors need to adopt this attitude in order to effectively use existential-humanistic theories in practice. Although we will discuss how to apply these theories with the use of assessments and techniques, you should understand that these approaches do not lend themselves to formulaic agendas, simplistic answers, or tidy little boxes. One must courageously face the mysteries of life and the difficult realities of existence. The wonder, curiosity, and genuineness postulated by existentialist philosophers laid the groundwork for existential-humanistic approaches. In the following section, we provide a brief overview of existentialist philosophy.

LEADERS AND LEGACIES OF EXISTENTIAL AND HUMANISTIC THEORIES Existentialist theorists and philosophers explored the topics of meaning, freedom, responsibility, anxiety, guilt, loneliness, death, the body, and lived experience (van Deurzen, 2010). Wrestling with challenging questions, existentialist philosophers embraced ambiguity and affirmed the mystery of existence. These philosophers embodied an attitude of wonder and awe when contemplating the full range of human experiences. Moreover, existentialist philosophers lived passionately and courageously; they loved, dreamed, despaired, and suffered. Soren Kierkegaard’s (1813–1855) profound love for, engagement to, and subsequent separation from Regine Olsen (1822–1904) inspired most of his philosophical texts (Hannay, 2003). Kierkegaard worked through his grief, anxiety, and despair in and through his writings. After wrestling with the decision to marry or not to marry Regine, Kierkegaard proposed that a person experiences anxiety or dread when confronted with the freedom to choose several different possibilities (May, 1996). Kierkegaard (1844/2014) argued that dread lacks a definite object; one dreads “nothing” or “no thing” (p. 44). He provided the example of a man standing on the edge of a cliff to illustrate anxiety as a sense of vertigo in which a person experiences the “dizziness of freedom” when faced with various alternatives. The man on the cliff might fall or even choose to jump to his death. For Kierkegaard, dread awakens a person’s freedom and responsibility. Similar to Pascal, Kierkegaard was a Christian philosopher who believed that one must make an absolute commitment to God to overcome despair (Nielsen, 2018). He sacrificed his love for Regine much like the biblical Abraham sacrificed his son Isaac. For Kierkegaard, a person commits to an absolute decision and chooses faith in an augenblick or “in the blink of an eye” (Dreyfus, 2004). Kierkegaard’s concept of the augenblick as the opportune moment influenced several other existentialist thinkers. Similar to the title character in Thus Spoke Zarathustra, Friedrich Nietzsche (1844–1900) developed several concepts while wandering through European cities and villages (Hollingdale, 1999). Nietzsche, unlike Kierkegaard, championed brief, temporary practices rather than absolute commitments. Indeed, Nietzsche valued the strength of the person who, as a free spirit, might engage in novel forms of self-creation. Nietzsche famously proclaimed “God is dead” to indicate the lack of a foundation for human practices and moral choices (van Deurzen, 2010). The absence of God, for Nietzsche, signified new possibilities for the individual. Although Nietzsche’s oeuvre was often poetic and open to interpretation, Nietzsche offered various aphorisms and images that were useful for existential philosophers and psychologists. Nietzsche proposed that a person might affirm life and create new values. In one of his earliest works, Nietzsche (1872/1994) discussed the Apollonian and the Dionysian forces in the context of Greek tragedy. The former refers to order, logic, and rationality, whereas the latter corresponds to chaos, instinct, and passion. Nietzsche envisioned the integration of the Apollonian and Dionysian forces and the coalescing of reason and passion. Moreover, Nietzsche (1883/2008) suggested that a person chooses each moment as

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if each moment could return again and again for eternity. Without a God or a transcendent source of meaning, a person was free to develop a unique style of life. Edmund Husserl (1859–1938) was the founder of phenomenology, which, although distinct from existentialism, influenced other existentialist thinkers including Jean-Paul Sartre (1905–1980; Spiegelberg, 1960). Phenomenology, according to Husserl (1913/2017), involves a rigorous method of describing the essential features of human consciousness. When a person sets aside or brackets pre-reflective assumptions, they have a glimpse at how a sunset appears beautiful, a lover becomes desirable, or a conversation seems meaningful. Phenomenology underscores the centrality of human experience and illuminates the interconnectedness between person and world. Martin Heidegger (1889–1976), Husserl’s student, also demonstrated the interconnectedness of person and world. Heidegger (1927/2010) applied the phenomenological method in his analysis of human being. Heidegger explored human existence as Dasein, which can be translated as “being there” or “being-in-the-world.” Heidegger also challenged traditional dualistic assumptions regarding subjective and objective, inner experience and outer environment. In his analysis of Befindlichkeit or mood, he argued that public outer moods sway a person’s inner subjective feelings. As Dasein, a person always finds themselves as being already there in context, inside and outside, swept up in moods, meaningfully interpreting events, engaged in activities, coping with problems, and living with others. According to Heidegger, a person initially finds themselves conforming to social norms and what everyone else does (Dreyfus, 2004). A person adhering to social norms does not own their choices and would be considered inauthentic. When the person experiences anxiety or confronts the reality of death, the person loses a sense of stability, takes ownership of their life, and moves toward authenticity. In a stroke of irony, Heidegger himself fell into conformity with the tenets of national socialism and was later given the opportunity to own his choices (Stolorow et al., 2010). Heidegger’s reflections on choice, anxiety, and death inspired other existentialist thinkers and psychologists. Notably, Sartre (1943/2018) believed that a person was fundamentally responsible for their choices and thereby condemned to be free. Sartre proposed that a person, unlike animals, objects, and things in the world, is nothing or no thing and free to make meaning in novel ways and transcend the conditions of their existence. Sartre (1939/2015) also believed that a person experiences emotions that magically transform the world (p. 58). Similar to the story of the fox who transforms unreachable grapes into sour grapes, Sartre argued that an angry person transforms the world into a furious world, whereas a happy person creates a joyful world. The existential philosopher Martin Buber (1878–1965) emphasized the possibility of meaningful encounters between persons (1923/2010). Buber believed that a person can either relate to another person as an it or an object to be manipulated, or as a sacred thou worthy of dignity and respect. For Buber, an I–thou relationship involves mutual authenticity and presence. Whereas the I–it relationship entails the communication of information from one person to another, the I–thou relationship invites open dialogue between persons and fosters a relationship of openness, presence, directness, and immediacy. Additional theorists inspired existential therapists and are thus worth discussing in this section. Simone de Beauvoir (1908–1986) pioneered a feminist existentialism and developed an ethical philosophy for individuals struggling with the ambiguity between the freedom to create oneself and the immutable facts of existence (van Deurzen, 2010). Comparing human existence to the myth of Sisyphus pushing a rock up a hill for eternity, Albert Camus (1913– 1960) proposed that a person might enjoy and make meaning of the most tedious, repetitive, and pointless life tasks (Camus, 2013). Moreover, Merleau-Ponty (1908–1961) integrated contemporary psychological and neurological research in his phenomenological explorations of embodiment. Trained as an anthropologist, Ernest Becker (1973/1997) suggested that humans developed practices, traditions, and religions to repress and deny the inevitability of death. Karl Jaspers (1883–1969) theorized that a person faces several limit situations

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or moments that they cannot change. For Jaspers, these include the reality of death, suffering, and guilt (Jaspers, 1971). Finally, the theologian Paul Tillich (1886–1965) emphasized the role of courage in facing a person’s fear of nonbeing and the importance of committing one’s life to an ultimate concern or life purpose. In the following section, we discuss the foundations of existential therapy (ET) and counseling. Please see Table 7.1 for more information on each existential thinker.

Theory Founders of Existential Therapy Maintaining a close, lifelong friendship with Sigmund Freud (1856–1939), Ludwig Binswanger (1881–1966) was one of the first psychiatrists to integrate the philosophies of Husserl, Heidegger, and Buber in the practice of psychotherapy (van Deurzen, 2010). Binswanger focused on how each person relates to the world (Ghaemi, 2001). According to Binswanger, the umwelt or “around world” refers to a person’s relationship with the environment. This might include trees, grass, cars, animals, and the bright sun on a warm day. A person’s mitwelt or “with world” corresponds to a person’s social relationships with culture, friends, family, and community. Binswanger also considered the eigenwelt or “own world,” which refers to a person’s subjective experience of self. Additionally, Binswanger was interested in a person’s lived experience of time and space. Medard Boss (1903–1990), a colleague of Binswanger, applied Heidegger’s philosophy of Dasein in the development of Daseinanalysis (Boss, 1988). Boss proposed that a person illuminates the world around them and that psychotherapy involves a process of bringing to light aspects that remain shrouded in darkness. Integrating Heidegger’s concept of mood as attunement, Boss suggested that a person’s mood tunes into the world and shapes their experience. A heartbroken individual, according to Boss, tunes into painful and lonely features of the world. Boss also explored how a person’s lived body opens up and shines forth Table 7.1. List of Existential Pioneers and Major Contributions Existential Pioneer

Life Range

Major Contributions

Soren Kierkegaard

1813–1855

The Concept of Anxiety (1844), Fear and Trembling (1943)

Friedrich Nietzsche

1844–1900

The Birth of Tragedy (1872), On the Genealogy of Morality (1887)

Edmund Husserl

1859–1938

The Crisis of European Sciences and Transcendental Philosophy (1936)

Martin Heidegger

1889–1976

Being and Time (1927)

Jean-Paul Sartre

1905–1980

Being and Nothingness (1943), Sketch for a Theory of the Emotions (1939)

Martin Buber

1878–1965

I and Thou (1927)

Simone De Beauvoir

1908–1986

The Second Sex (1949), The Ethics of Ambiguity (1947)

Albert Camus

1913–1960

The Myth of Sisyphus (1942)

Maurice Merleau-Ponty

1908–1961

Phenomenology of Perception (1962), The Visible and the Invisible (1968)

Ernest Becker

1924–1974

The Denial of Death (1973)

Karl Jaspers

1883–1969

Philosophy of Existence (1938)

Paul Tillich

1886–1965

The Courage to Be (2018)

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new possibilities. Boss was one of the first existential practitioners to consider dreams as a source of illumination and meaning. Expanding on Kierkegaard’s concept of anxiety, Rollo May (1909–1994) stressed the importance of courage when facing one’s possibilities and creating the self (May, 1996). May was also a student and close friend of Paul Tillich, and he integrated Tillich’s writings on courage in facing the fear of nonbeing (van Deurzen, 2010). May (1969) also proposed the concept of the daimonic, which refers to a system of needs or daimons that motivate human behavior. Although the Greek word daimon means “little god” and is the root of the word demon, May did not use this term in a spiritual or religious context. Daimons, for May, might include the need for food, love, sex, and pleasure. If the system of needs is out of balance, a daimon can take over a person and motivate destructive behavior. May’s concept of the daimonic is similar to Jung’s archetype of the shadow and represents a stark difference between ET and Carl Rogers’ (1902–1987) optimistic person-centered theory. In the next section, we discuss the major contributors to existential-humanistic approaches.

Major Contributors Although Rollo May and Carl Rogers disagreed on human nature, they remained close friends who admired each other’s work (May, 1982). Thus, ET became associated with humanistic approaches and was categorized as “existential-humanistic therapy,” hence the title of this chapter. In the United States, James Bugental (1915–2008), Irvin Yalom, Kirk Schneider, and others developed existential-humanistic approaches, whereas scholars in the United Kingdom articulated existential-phenomenological psychotherapy (van Deurzen, 2010). Victor Frankl’s (1905–1997) logotherapy is also associated with the key concepts of other existential-humanistic approaches. Fritz Perls (1893–1970), who developed gestalt therapy, also applied existential and phenomenological concepts in his theory. In this section, we introduce Irvin Yalom, Victor Frankl, Fritz Perls, and Emmy van Deurzen, who developed ET in the United Kingdom. Irvin Yalom was initially trained as a psychoanalyst but integrated existential concepts after encountering the writings of Rollo May (Serlin, 1994). While providing therapy for patients with terminal cancer, Yalom met with May as a client in psychotherapy. Yalom and May became close friends after concluding therapy and, through numerous conversations, explored death anxiety, the role of creativity, and the philosophies of Kierkegaard and Nietzsche. Yalom (1980) synthesized existential philosophy, case studies, and empirical findings in the articulation of a systematic approach to ET. Retaining a dynamic approach that aligned with his psychoanalytic roots, Yalom proposed that inner conflicts, both conscious and unconscious, prompt anxiety, which might lead a person to develop defense mechanisms. The nature of these conflicts, according to Yalom, corresponds with universal existential concerns. In addition, Yalom expanded on Jaspers’s concept of limit situations and Tillich’s texts on the “ultimate concern” as the human response to the threats of nonbeing (van Deurzen, 2010). After surviving the horrors of several concentration camps and enduring the loss of his father, mother, wife, and brother, Victor Frankl (1984) developed his own unique approach to psychotherapy that he named logotherapy. Frankl adopted the Greek root logos, which can be translated as “meaning,” and proposed that helpers focus on human meanings when practicing logotherapy. Initially trained as a neurologist and psychiatrist in Vienna, Frankl corresponded with Sigmund Freud and attended Alfred Adler’s society meetings (Barnes, 2000). Frankl later distanced himself from Freud and Adler in advancing his belief that the search for meaning, and not pleasure or power, motivated human behavior (Ameli & Dattilio, 2013). According to Frankl, a person can endure hardships, even the unimaginably cruel suffering in a concentration camp, if the person has a sense of purpose or a why that gives meaning to the suffering. Frankl recounted that after a Nazi guard confiscated a draft

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of his book, his desire to write another book provided a sense of purpose. Although Frankl explored existential themes including death, freedom, guilt, and responsibility, his personal experiences and conversations influenced his approach more than the writings of existential philosophers. In articulating the foundational concepts of gestalt theory, Frederick (Fritz) Perls integrated existential philosophy, phenomenology, Buber’s dialogical philosophy, field theory, psychoanalysis, Eastern philosophy, and additional influences (Höll, 2020; Resick, 2020). He also appropriated his background in theater to develop psychodrama techniques (Brownell, 2010). Perls opted for the biological terms of organism, environment, and homeostasis rather than existential concepts (Perls et al., 1951). However, Perls’s theory of the interconnectedness of organism and environment, despite terminological differences, parallels the interdependence of being and world or Dasein as Heidegger proposed. As the public, charismatic face of gestalt therapy in the 1960s and 1970s, Perls’s style was often extravagant, sometimes provocative, and occasionally abrasive (Brownell, 2010). Indeed, we, the authors, find that counseling students often perceive Perls’s demonstrations as harmful and thereby avoid gestalt theory. Alternatively, Fritz Perls’s spouse, Laura Perls, developed a less abrasive and more tactful approach to gestalt therapy that focused on interpersonal dialogue. Laura Perls drew on her background in dance and music as well as her connection to Martin Buber to develop a style with a greater emphasis on the body, movement, and the authentic encounter between therapist and client (Brownell, 2010). Following Fritz Perls’s initial developments and demonstrations of gestalt therapy, several scholars contributed additional concepts and interventions. Emmy van Deurzen (2013) developed her own unique approach to ET in the United Kingdom. For van Deurzen, the client’s experiences of anxiety and/or depression are related to the impermanence of human existence rather than symptoms of mental illness. She emphasized the importance of authentically confronting both limitations and possibilities with an attitude of openness and flexibility. Expanding on Binswanger’s dimensions of existence, van Deurzen proposed the term uberwelt to describe the spiritual dimension of experience. The uberwelt refers to a person’s values, meanings, and beliefs regarding right and wrong. Additionally, van Deurzen suggested that the client’s emotions provide a sense of direction regarding their values. van Deurzen advocated for a phenomenological approach to describe rather than explain the lived experience of the client. The process of ET involves a process of collaboratively exploring meaning, taking stock of the present moment, working through contradictions and paradoxes, accepting responsibility for one’s life creation, and discussing dreams.

ORIGIN AND NATURE OF MENTAL HEALTH CONCERNS Existential-humanistic counselors adopt a phenomenological approach to mental health concerns and focus on the lived experience of the individual (Winston, 2015). Although existential and gestalt theorists propose a slightly different explanation of the origin and nature of mental health concerns, scholars in both traditions emphasize the person’s way of viewing the world. Existential therapists, including Yalom and Frankl, consider problems in the context of the human search for meaning, relationship, and responsibility in the space between birth and death. Mental health concerns are viewed as “problems of living” and “attempts at solution” (Heidenreich  et al., 2021, pp. 210–211). Similarly, gestalt therapists posit that problems stem from disruptions in the human endeavor to connect meaningfully with others or to seek one’s needs. We describe the account of the origin and nature of mental health concerns in the context of Yalom’s existential psychotherapy, Frankl’s logotherapy, and Perls’s gestalt therapy in the following section. According to Yalom (1980), mental health concerns stem from a person’s ineffective strategies for coping with anxiety related to the four givens of existence: death, freedom,

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isolation, and meaninglessness. Yalom believed that the manner in which a person confronts the four givens affects their personhood. The sense of anxiety, conscious or unconscious, prompts the person to develop effective or ineffective coping strategies. Focusing on the person’s struggle with the inevitability of death, Yalom proposed that a person tends either toward individuation or fusion with another. A person who demonstrates the individuation approach believes that they are special, indestructible, or that the laws of nature do not apply to them. The belief in one’s specialness might lead to grandiosity, narcissism, or other mental health problems. Conversely, a person who adopts the fusion approach puts faith in an ultimate rescuer, perhaps a supernatural being or another person, who will save the person from their demise. The desire to fuse with another or trust a supernatural being might lead to dependence, depression, or other problems. Over time, a person’s defensive strategies inhibit growth and lead to a displeasing life. Yalom contended that attempts to deny or repress existential isolation, freedom, and meaninglessness lead to similar ineffective coping mechanisms. Frankl (1984) proposed that a person’s inner emptiness or what he called an existential vacuum led to depression, aggression, addiction, boredom, and other noogenic neuroses. Replacing the Greek root psyche with nous, which means “mind,” Frankl contended that mental health concerns stem from challenges with finding meaning. In an attempt to fill the existential vacuum, a person might get caught up in a vicious cycle of addiction to pleasure. Another person might become stuck in a cycle of anxiety in which the anticipation of a feared event prompts more anxiety. For Frankl, noogenic neuroses are often cyclical in nature. Frankl was, however, critical of medical, pathological, and reductive approaches to human suffering, and would have likely taken issue with the phrase “mental health concerns” as this language is often associated with psychiatric diagnoses. Indeed, Frankl advocated for the humanization of the field of mental health and a perspective of the person as transcending the reductive language of psychiatry. For Perls and colleagues (1951), a gestalt refers to a perceptual structure or schema that organizes an experience. A gestalt includes a feature that stands out, or the figure, and the aspects that remain peripheral, or the ground. Take a moment and move your eyes to different objects around you including the light in the room, your phone, and furniture. Listen to movement in the space around you. If you have water or a beverage close to you, take a sip. In these experiences, your gestalt is your sense of the whole experience of glancing around, listening to sounds, or sipping a drink. Your eyes, ears, and lips make contact with what you see, hear, and sip, respectively. The beverage becomes figural when drinking and everything else slips into the background. In most cases, your organism spontaneously makes contact with your environment when you look around, hear something close, quench your thirst, or consume food. You then withdraw from the object after completing the activity; perhaps you are no longer hungry after eating. Moreover, you destroy the food in the process of eating, and many activities require that the organism aggressively destroy an object (e.g., an apple) to meet needs. Mental health problems stem from interruptions in the process of contact and withdrawal from the environment. A person might avoid applying for a job or the pursuit of a romantic relationship. In the latter example, the person must be willing to aggressively “destroy” their own sense of comfort when asking the romantic interest on a date. Over time, these interruptions can become fixed, inflexible patterns of behavior or what Perls and colleagues call character. The aggressive impulse is turned inwards toward the organism and the person struggles to respond to the environment flexibly and spontaneously. Moreover, the person lacks awareness of these inflexible patterns of behavior. The neurotic individual, according to Perls and colleagues (1951), interrupts or blocks the ongoing process of self-regulation. Due to a sense of frustration or a perceived threat, the person deliberately controls an impulse and fails to make contact with the environment. The person might clench their jaw to hold back a statement, and, over time, jaw clenching becomes rigid and habitual. Moreover, the person represses knowledge of the initial response

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and engages in the behavior without awareness. In each new situation, the clenched jaw corresponds to the interrupted and unfinished business. Perls and colleagues suggested that individuals demonstrate four specific strategies or creative adaptations to interrupt contact. A person introjects or “swallows whole” others’ attitudes and beliefs and make it their own (Perls, 1973, p. 33). Conversely, projection puts the blame on the environment or others for thoughts and feelings that originate in the self. When a person can no longer differentiate between self and environment, the person remains in confluence. A person retroflects when they turn an instinctive drive to meet a need back against the self. In retroflection, an individual might turn shame toward themselves due to a fear of expressing disappointment to another. Polster and Polster (1973) later added deflection, which involves a shifting away from contact with another person. When deflecting, a person might laugh or intellectualize in order to avoid the present moment.

WHAT CONSTITUTES EMOTIONAL AND PSYCHOLOGICAL WELL-BEING According to existential-humanistic theorists, emotional/psychological well-being corresponds with a meaningful, satisfying, interconnected, and vibrant life (van Deurzen, 2013). Existential theorists are sometimes associated with a melancholy, pessimistic perspective of the human experience. Indeed, Yalom (1980) provides scant descriptions of life at its best. He occasionally explores well-being as the product of successful psychotherapy, but he does not articulate an explicit model of a healthy, happy life. On the other hand, Frankl (1984) offers a perspective of well-being as a process of shifting a person’s exclusive focus on inner thoughts or feelings and toward external meanings, people, or causes. Gestalt therapists, including Perls and colleagues (1951), suggest that well-being involves a spontaneous and flexible stance to the environment. We outline the theorists’ approach to well-being in the following section. For Yalom (1980), an awareness and acceptance of the four existential givens promote emotional/psychological well-being. The client can develop effective coping strategies to manage anxiety related to the ultimate concerns of life. Yalom contended that life satisfaction is inversely related to death anxiety. In other words, a person who is more pleased with their life will feel less dread regarding death. Life satisfaction is related to understanding what a person desires, making a decision to pursue their desires, and taking action to achieve what they want. Moreover, a person who confronts their own isolation can pursue meaningful relationships with others. A person can also explore their own values in order to make meaning of their life circumstances. To live life at‌‌‌‌ its best, Frankl (1984) suggested that an individual creates meaning through personal accomplishments, impactful experiences, love relationships, and suffering. A person might reflect on memories, both pleasant and unpleasant, as “footprints” in the sands of a meaningful life (Frankl, 1984, p. 124‌‌‌‌). In a love relationship, an individual finds purpose in discerning the possibilities of the other person. According to Frankl, a person must look outside to the world rather than inside the mind. Frankl advanced that a person should seek “self-transcendence,” which involves devotion to something or someone beyond the self (Frankl, 1984, p. 114‌‌‌‌). Challenging the assumption that a person might achieve self-­ actualization, Frankl argued that a person only finds actualization in and through devotion to a cause or another person. Indeed, Frankl’s initial manuscript was confiscated when he was imprisoned at Auschwitz. In order to survive sickness, malnutrition, and abject cruelty, Frankl devoted himself to developing another manuscript. He created speeches in his mind and jotted down ideas on scraps of paper (Frankl, 1984, p. 47‌‌‌‌). Thus, well-being, for Frankl, requires a different attitude or perspective that focuses outward on the world. Perls and colleagues (1951) proposed that the organism creatively adapts to the environment and aims toward growth. Providing the example of children at play, Perls et al.

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suggested that children spontaneously make contact with the environment and flexibly adapt to novel stimuli. Well-being, for Perls et al., involves a similar flexibility to new situations. A person exists in a dynamic relationship within a biological, social, and cultural field and must be able to drink when thirsty, eat when hungry, seek companionship when lonely, and pursue a new job when unsatisfied. In each instance, the person makes contact with an aspect of the environment, and then the person withdraws and reorients to a different aspect in the environment. The person can become increasingly aware of the various interruptions that prevent contact, inhibit growth, and keep the person “out of touch” with the environment. With increased awareness, a person can be more like the child at play: fully present in the here and now and spontaneously engaged with others, new situations, and objects in the world. According to Perls et al. (1951), the self spontaneously maintains contact with others and the environment. In good contact, the person fulfills needs or gestalten, integrates new experiences, and exists as fully actualized. A person might sense an appetite for food and shifts focus to the figure of an apple. The person then makes contact with the apple and consumes it. In the process of eating the apple, the person experiences an integration of perception, movement, and emotion. Subsequently, the person completes the gestalt and withdraws contact from the apple. The healthy individual, for Perls and colleagues, is fully alive and takes responsibility for choices. Thus, psychological well-being includes a ­process of ongoing maturation.

DESCRIPTIONS OF THE ROLES OF CLIENT AND COUNSELOR Central to existential-humanistic counseling is the relationship formed between the counselor and the client. Drawing from the terms directly, existentialism assumes the importance of self-defined meaning, thereby informing how the counselor should create a relational environment that invites a client to explore their own meaning and belief system. Relatedly, humanism assumes the centrality of the whole person, not simply the sum of their parts (e.g., thoughts, emotions, actions). Taken together, existentialism and humanism, while distinct concepts, offer a unique foundation for understanding the development of the client–counselor relationship. The client–counselor relationship from Frankl’s (1984) perspective revolves around the discovery of meaning and a higher purpose in life. A logotherapist would be directive with focusing on questions related to discovering the client’s hopes and increasing self-knowledge. The counselor would de-emphasize the importance of focusing on emotions, privileging the client’s development of personal meaning and purpose in life (Reitinger, 2015). Frankl, also, felt it central to integrate noetic or spiritual exploration in counseling in logotherapy. Existential therapy, as described by Yalom (1980), is particularly attuned to the client–counselor relationship. The counselor is tasked with creating a unique experience for the client that is responsive to existential concerns and the in-the-moment interactions between the counselor and client (i.e., the here and now). There requires an approach of “unknowing” by the counselor to mitigate assumptions that might be imposed on the client (Spinelli, 2014). The goal would be to resituate power in the client–counselor relationship, whereby there is joint power and collaboration to explore the client’s concerns (Overend, 2021). Existential therapy, while at times focusing on philosophical notions of the self and meaning, also is rooted in the experience of the client–counselor relationship. The happenings within the relationship can illuminate the distress of the client. For example, a counselor could use the here and now to explore loneliness and disconnection experienced by a client. By commenting on and inviting discussion on how the client experiences the relationship with the counselor, a deeper understanding could emerge about the client’s connection or disconnection with others.

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Taken from Perls’s (1969) vantage point, the counselor helps the client directly experience themselves in the counseling relationship. Similar to Yalom (1980), there can be a present focus nature to the counseling relationship whereby what happens between the counselor and the client is noticed and explored. This feature is also congruent with Martin Buber’s I–thou concept that highlights the humanity in the relationship (Buber, 1923/2010). This intentional awareness facilitates and promotes the client’s ability to change themselves and clarify meaning in their life (Resnick, 2020). The counselor helps the client see themselves more clearly, like a mirror, in order to develop integration and wholeness in the client. This dynamic can be very interactive, for example, noticing or encouraging the exaggeration of body language. The goal in the relationship is to work past the maya, or fantasy world, and be able to directly experience oneself through the senses.

THE NATURE OF HUMAN DEVELOPMENT A common thread in the existential-humanistic perspectives is a de-emphasis on classic understandings of human developmental theories and more focus on certain goals embedded in human nature, like meaning making or integration. Within logotherapy, human development is focused on meaning making (Frankl, 1984). As exemplified through the life of Frankl, the assumption is that meaning could be cultivated regardless of circumstances. This meaning would be self-discovered in the context of the social environment and one’s own conscience. Although existentialism does not have a distinct developmental focus, the trajectory of human development is defining and describing one’s meaning or purpose in life. Sartre (1946/2007) clarified the idea that existence precedes essence, meaning that one’s essence (or meaning) is only developed after coming into the world. The need, therefore, in human development is to cultivate a sense of purpose and meaning in life, similar to logotherapy. At its core, existentialism was an antecedent to postmodernism, challenging distinct, uniform human development models. Purpose in life is subjective and dependent on an individual and their relationship to their life and social environment. Perls (1969) focused on understanding a client in their environment. Their development cannot be understood in isolation for their context or simply by an age or life stage (Resnick, 2020). Situating the client in context, while commonplace now, was a novel approach during his time. This context is connected to field theory that highlights the relatedness and connectivity of key relationships in one’s life. Specific to development, Perls understood the goal of a person's homeorhesis (a return to direction or goal) versus homeostasis (a return to baseline). Human development was ongoing and aspirational to discover oneself more deeply and completely, all while becoming more independent and self-actualized. His philosophy of human development is captured in the first few lines of what is called the Gestalt Prayer, “I do my thing and you do your thing. I am not in this world to live up to your ­expectations…” (Perls, 1969).

THE THEORY’S PROCESS OF CHANGE According to Yalom (1980), being human implies that we are continually discovering ourselves and making meaning of our existence. Our existence is never fixed, but we are in a constant state of evolution and reinvention in response to the tensions and conflicts in our lives. We grow when we are self-aware of and view our lives as a series of choices, and we languish when we refuse to make choices to flee from our pain and existential angst in favor of a more comfortable but more inauthentic and restrictive life. As we increase our awareness of the ways that our lives are a series of choices, we increase our sense of responsibility for the consequences of our choices. Rather than burying our pain, ET invites us to confront our turmoil, confusion, contradiction, and yearning and see the opportunities behind these

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challenges to increase our awareness of our freedom to choose and sense of responsibility to make choices. Therefore, the objective of ET is not to make all suffering go away, but to welcome suffering as evidence of our positions in the world in ways that serve as catalysts for our ongoing process of leading a full, meaningful life (Van Deurzen, 2010). According to Frankl (1984), humans are distinguished from other mammals by the resources of the human spirit. In other words, as humans, we have the capacity to learn from our mistakes, a sense of humor, a conscience, the ability to love others, and a passion for causes. We can use these assets to withstand adversity, pain, guilt, despair, and death and to help us leverage life transitions into opportunities to alter ourselves. Using these uniquely human resources, we can turn suffering into achievement based on the perspective we approach the suffering with and the choices we make resulting from the suffering. Similar to ET, the way we grow from a logotherapy perspective is through the ongoing process of discovering our true identities and our place in the world and by engaging with the world in ways that will make life more meaningful for ourselves and others. We must awaken our sense of responsibility to make choices that lead a meaningful life. Perls (1969) believed that change occurs in the whole person (i.e., a holistic connection of the mind, body, and spirit that is larger than the sum of its parts). This belief is rooted in field theory, or that human behavior must be viewed holistically within the context of the person (called the figure) in interaction with their environments (called the ground). Humans and their environments exist in a constant process of interrelated flux. In this process of the gestalt cycle, which illuminates this holistic interrelationship, humans differentiate themselves from their environment while engaging in an ongoing process of connection with their environments (contact) and separation from their environments (withdrawal). In other words, we must be aware of and in contact with our internal and external worlds and unify the parts of our internal selves that are disconnected from our external environments. The gestalt cycle of which occurs in seven stages: sensation, awareness, energy mobilization, action, contact, integration and assimilation, and withdrawal. In the sensation stage, the individual’s steady state is disrupted by an experience with the environment that causes them to experience feelings and thoughts related to an underlying need. They become more aware of the sensation and seek to interpret its meaning in the awareness stage. Then, in the energy mobilization stage, they experience a sense of energy compelling them to seek satisfaction in meeting this need. In the action stage, they take action to release the energy by making contact with the environment in a way that will satisfy their need. In the integration and assimilation stage, the individual assimilates something new or different from the contact into themselves resulting in change in the individual. Then, the cycle starts again, as the individual returns to their steady state. As evident in this process, being in contact with our worlds from a gestalt therapy perspective serves as the lifeblood of growth that facilitates change (Polster & Polster, 1973) and helps us become more aware of our boundaries between ourselves and the world. By interacting with our world with our whole selves, we can live our lives with more intentionality (i.e., an intensification of general awareness into a holistic sensory experience). This process often requires that we re-own parts of ourselves that we have disowned and incorporate them back into our whole. This unification process is often done by focusing on and gaining awareness around where energy is located for us physically, emotionally, and spiritually; how it is used; and where it is blocked. According to gestalt therapy, bodily symptoms often represent blocked energy between sensation and awareness.

DESCRIPTION OF HOW PROGRESS IS MAINTAINED Yalom (1980) believed that clients progress in ET by continuing to grow more aware of their freedom to seek meaning, even in situations of suffering. Clients do not make progress in a linear and tidy fashion, but rather learn moment to moment in their lives to bring their

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awareness to existential concerns in their lives and how these concerns present opportunities for meaning making. Although this process of seeking meaning might sound straightforward, it requires continually confronting difficult thoughts and emotions and leaning into new choices and identities despite feeling scared and nostalgic for the comfort of one’s old self. Similarly, the search for meaning in logotherapy is unique and deeply personal for each individual (Frankl, 1984). It is a continual journey of discovery throughout life that evolves as life’s circumstances evolve. Therefore, similar to ET, progress occurs in ongoing efforts to focus on our personal responsibilities and freedom to seek meaning in our creations, experiences, relationships, and attitudes. Like with ET, progress is ultimately found in a shift in perspective more than measured behavioral changes. Like ET and logotherapy, gestalt therapy (Perls et al., 1951) also focuses more on increasing client awareness and choice rather than goal setting. This awareness involves knowing and accepting ourselves, setting boundaries between ourselves and our environments, and making choices to make contact with our environment. With this awareness, we strive for integration between ourselves and our environments and wholeness with the different parts of ourselves, which requires becoming more aware of the unfinished business within ourselves and confronting the reasons why we might have distanced ourselves from this business.

PROCESS OF CLINICAL ASSESSMENT The Purpose in Life (PIL) Test, originally developed by Crumbaugh and Maholick (1969), measures Frankl’s concept of “existential vacuum,” or a state of emptiness due to a lack of meaning and purpose in life (Braun, 1981). The test consists of three parts. In part A, test takers rate themselves on 20 items on a 7-point scale. Each item has different criteria for the ends of the scale. For example, item 4 begins with: “My personal existence is:.” Then it lists “utterly meaningless, without purpose” with the 1 on the scale and “very purposeful, meaningful” with the 7. So, higher scores represent higher levels of meaning in life. Part B involves 13 sentence completion items and part C asks test takers to write a paragraph on their personal ambitions and goals. The PIL Test can be used to screen for the presence of an existential vacuum in clients and to evaluate the effectiveness of existential or logotherapy counseling (Crumbaugh & Maholick, 1969). For part A, the reliability evidence is strong for the PIL. Test–retest reliability‌‌‌‌ coefficients include 0.83 for a 1-week window with 57 church members, 0.79 for a 6-week window with 31 college students, and 0.68 for a 12-week window with 17 penitentiary inmates (Davies et al., 2014). Split-half reliability coefficients range from 0.77 to 0.85 and alpha coefficients range from 0.86 to 0.97 (Davies et al., 2014). In terms of convergent validity, the PIL has shown positive correlations (ranging from 0.49 to 0.68) with measures of existential vacuum and measures of happiness. In terms of discriminant validity, the PIL shows small to moderate negative relationships (–0.30 to –0.65) with scores on neuroticism, anxiety, and depression assessments (Davies et al., 2014). Assessment, when viewed from a perspective of developing an objective diagnosis or having the client take formal instruments, is often viewed as antithetical to the purposes of gestalt therapy (Joyce & Sills, 2018). Gestalt therapists often view traditional assessment practices as the counselor losing contact with the client in the here and now and maintaining a relational focus. However, gestalt therapists see value in viewing assessment more broadly in therapists intentionally gaining awareness about clients’ repeating patterns and styles of contact with the world (Joyce & Sills, 2018). Delisle (1999) developed a set of questions for therapists to ask themselves to assess client’s contact functions. In other words, the counselor is assessing how the client uses their five senses to make contact and become more aware of their world. The questions are broken up into five categories: (a) looking/seeing

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contact function, (b) voice/speech contact function, (c) listening/hearing contact function, (d) touch/movement contact function, and (e) appearance. For example, within the looking/seeing contact function, the counselor would evaluate: “When does the client look at you and when does the client look away from you?” In the voice/speech contact function, the counselor would ask: “What do I feel in response to this [person’s] voice and what emotions do I imagine this voice best expresses?” These questions can serve as helpful reflective tools for the counselor to conceptualize their client from a gestalt therapy perspective. These questions should be part of an ongoing assessment process and should be assessed in the contest of the situation and the client. It is also important to consider that gestalt therapy is a two-way dialogue and the client on some level is assessing the effectiveness of the counselor’s contact functions as well (Mann, 2010).

SPECIFIC THEORETICAL TECHNIQUES Broadly speaking, existential theorists developed few techniques, whereas gestalt theorists offer multiple techniques. Yalom (1980) described little to no techniques in his approach to existential psychotherapy. In rare instances where Yalom discusses techniques, he cited Perls and other theorists’ approaches. Likewise, Frankl (1984) proposed minimal techniques and focused more on the collaborative process of exploring meaning. Perls and other gestalt theorists suggested several experiments that counselors might use to promote awareness and foster integration (Perls, 1969, 1973; Perls et al., 1951). In the following section, we discuss one of Yalom’s techniques, two of Frankl’s techniques, and five techniques that Perls and colleagues developed in the context of gestalt therapy. In Table 7.2, each technique is presented in the left box and an example of how a counselor might use the technique in practice is provided in the right box.

THEORETICAL MULTICULTURAL, INTERSECTIONAL, AND SOCIAL JUSTICE ISSUES Humanistic theories are often situated as points of comparative analysis with theories developed with a distinct multicultural focus. Historical reasons underlie this phenomenon. Humanistic theories are commonly referred to as the “third wave” of counseling and psychology, which shifted the field to a more holistic view of the self. The previous waves (psychoanalysis and behaviorism, respectively) understood human distress and healing in a more reductionistic manner. In the late 20th century, there were calls in the profession to widen the understanding of psychological distress beyond the self and directly consider the social environment and cultural differences as central to the work of counseling. This multicultural wave created needed attention to the sociocultural‌‌‌‌ aspects of the self and the marginalization of certain people in the counseling profession. Despite this shift in the profession, many multicultural ideals persist in humanistic theories. Comas-Diaz (2012) highlights the aspects of humanistic theories that connect to non-Western philosophies, such as the importance of holism, interconnectedness, and meaning derived from the self in context. Existential psychotherapy, logotherapy, and gestalt therapy all prioritize the client’s ability to develop meaning and healing depending on their subjective understanding of their life. The client is viewed as the expert in their life and their healing process. This approach centers the agency and power with the client, not the counselor. Counselors should consider their own cultural background so as not to impose their worldview and beliefs on the client. Despite the decentered power in the counseling relationship, humanistic theories have been criticized for being too individualistic and assuming that the client has agency to change, inconsiderate of sociocultural barriers to change (Hoffman, 2016). The key figures in the development of humanistic-existential philosophy focus Western ideals about the development of the self (e.g., Rollo May), a bias

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Table 7.2. Gestalt Techniques Technique

Example

Death Desensitization: Irvin Yalom proposed that a client, through repeated exposure, can get accustomed to the inevitability of death. The death desensitization technique is similar to other behavioral approaches that involve exposure to increase the client’s tolerance. The counselor repeatedly mentions the fact that the client will die in order to help the client confront and accept the reality of death.

Client: I hate my job and working under my boss. I usually drink myself to sleep every night. I think I might start looking for a new job in about 2 to 3 years when I get some savings in the bank.

Dereflection: The counselor encourages the client to shift their focus away from the symptom to other meaningful aspects of the experience. The technique supports the client in diverting their attention on their own inner suffering to something or someone beyond the self. This is consistent with the focus on self-transcendence in logotherapy.

Client: I’m so tired of working so hard to pay the bills and making ends meet. I am burned out and irritated at everything and everyone. I haven’t been able to get a facial at the spa with my friends in over 3 years.

Paradoxical Intention: The counselor encourages the client to wish for an event to occur that they fear happening. Rather than avoiding the feared event, the client faces the feared event through exaggeration. The client adopts an attitude of detachment and, through humor, makes light of the feared event. This technique breaks the vicious cycle of anxiety toward a feared experience.

Client: I am terrified of giving presentations in front of the class. I start to blush, and everyone can see my bright red face.

Awareness Exercise: The counselor instructs the client to use the phrase “Now I am aware” and to describe sensations, feelings, gestures, breathing, facial expressions, voice, thoughts, wants, and/or needs the client experiences in the present moment. The client practices this activity at the beginning of counseling and throughout counseling to increase awareness. The counselor guides the client in being aware of various aspects of their experience. This technique promotes understanding of interrupted or unfinished events in a client’s past.

Client: He makes me so mad every time he uses that condescending tone with me. It is like he enjoys pushing my buttons and watching me get more and more irritated.

Dream Work: According to Perls, every aspect of a dream is a part of the self. Perls recommended that a client write down every aspect of a dream or discuss each aspect with the counselor. The client then attempts to relive or become each aspect of the dream through roleplay or by imagining each part. The counselor guides the client in increasing awareness of each aspect of the dream and explores what that part senses, feels, wants, and/or wishes to say. The client changes the pronoun of it to I when asking the client to play the role of the part of the dream.

Client: I had the strangest dream last night. A bear was chasing me down a dark street that I didn’t recognize. I felt like my legs wouldn’t move and I couldn’t hide because I knew the bear would find me.

Counselor: You certainly could do that, but then again, you could get into a fatal accident after leaving my office. I wonder if you would remain in your job if you thought about the fact that you could die at any moment.

Counselor: I hear that you are tired, and I also remember that you said it was important for you to earn money so that your kids would not have to worry about getting involved with sports and doing fun things with their friends.

Counselor: I have an idea. Next time that you have to speak in front of the class, try to make your face as red as possible. Blush as much as you can.

Counselor: I want to pause for a moment. Use the phrase “Now I am aware” and describe what you notice. This activity will take several minutes as I want you to describe everything you sense in your body, your voice, your feelings, and your sensations.

Counselor: I would like to take a moment and relive the dream. The bear and the dark street are parts of you. Take a moment and be the bear. What do you sense? What do you feel? What do you want? As the bear, say out loud what you want using the statement “I want….” Then, we will take a moment to explore what you sense as the dark street. (continued)

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Table 7.2. Gestalt Techniques (continued) Technique

Example

Shuttling: For this technique, the counselor guides the client to become aware of an inner conflict or split. The shuttling technique involves moving one’s attention back and forth between both sides of the conflict. The client might shift between thoughts and feelings, desires, and inhibitions or between the self and another person such as a parent or partner. The empty chair intervention is a version of shuttling in which a counselor asks the client to address the other side of the conflict in an empty chair in the room. The client speaks directly to an imagined person or part of the self. Then, the client shuttles to the other chair and addresses the self as the other person or part. The client shuttles back to the original self and speaks back to the person/part. This process continues with the client moving back and forth from chair to chair until they have finished saying what they want to say.

Client: Sometimes, I get so down that I want to smoke a cigarette. I really shouldn’t do that because it isn’t good for my health, but sometimes a little nicotine makes me feel better.

Topdog/Underdog Intervention: Perls suggested that a person experiences a conflict between a part of the self that is the voice of their conscience or sense of what they “should” do and a separate part that is defensive or apologetic. He referred to the former as the “topdog” and the latter as the “underdog.” He believed that these two parts of the self struggle for control of the person. The counselor might provide psychoeducation regarding these parts of self and/or engage these parts in dialogue through the empty chair technique.

Client: I really should be working out more and getting more sleep, but I can’t seem to get myself motivated. I guess there’s always tomorrow. That is what I tell myself, but I don’t feel any better.

Approaching Confusion: Counselors using this technique will focus on the client’s lack of understanding or awareness when attempting to make contact with the environment. According to Perls, many individuals avoid confusion by developing explanations and rationalizations. This technique involves direct experience of the sense of confusion without attempting to avoid the feeling. After a person directs their awareness to the sense of confusion, the person might experience a sense of “blankness” or what Perls calls “withdrawal into the fertile void.” The fertile void is a state of awareness or consciousness that is directed to the here and now and resembles mindfulness.

Client: I was thinking about a memory that I had when I was about five or six. The memory is a bit fuzzy, but I remember playing baseball and hurting my knee. My father said, “There is no need to cry about it,” or something like that. I read somewhere that clients might introject values from parents. I think that is why I won’t let myself cry.

Counselor: I get the sense that you are torn between a part of you that wants the cigarette and a part that says, “No! You shouldn’t.” I would like to try an experiment. Imagine that the part of you that says you shouldn’t have the cigarette is in this chair in front of you. Tell that part how a cigarette would make you feel better. Then, I want you to stand up and move to that other chair and tell the part of you that wants the cigarette the reason for not smoking. Then, move back to this chair and reply. Go back and forth from chair to chair until you have said what you need to say.

Counselor: It sounds like there is a part of you that is bossing you around and telling you that you should be working out more and getting more sleep. We call this the topdog part. Then, there is another part of you that is making excuses and saying “I can’t.” We call that part the underdog. I get the sense that your topdog and underdog get into conflict and then you are not sure what to do.

Counselor: Maybe we can talk about introjection in a moment, but right now, I want you to focus on the sense of confusion about your memory with your father. Take a moment and reflect on the fuzzy memory. What do you sense? What do you notice in your body?

toward not following social norms (e.g., Heidegger), and underlying assumptions about individual freedom (e.g., Sartre, Kierkegaard). To be relevant, humanistic-existential theories must resituate the ideals within a culture and diverse societies that might not understand the self in the same way (Hoffman, 2016). Systemic oppression, racism, sexism, and

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xenophobia are a few of the factors that challenge implicit, unfettered individual agency in humanistic theories. Victor Frankl (1984), informed by his experiences during the Holocaust, developed logotherapy. His profound beliefs emerged from this suffering—meaning could be found in the direst of situations. Multicultural and social justice perspectives invite counselors to consider the other elements of Frankl’s suffering, the social injustice of the Nazi concentration camps, and Frankl’s own cultural worldview. Humanism, multiculturalism, and social justice, when integrated, offer an understanding of the self that is open and responsive to the full experience of our clients—relevant individual agency, cultural differences, and systemic influences and injustices.

RELEVANT THEORY-BASED SCHOLARSHIP AND RESEARCH TRENDS Scholars in existential-humanistic approaches, including gestalt theorists, expanded key aspects of the theory (Cooper, 2016; Polster & Polster, 1973; Schneider, 2016; Spinelli, 2014; van Deurzen, 2013‌‌‌‌‌; Yontef, 2002) and applied the theory with unique populations (Bell, 2018; Billies, 2021; Degeneffe, 2019; Desmond, 2016; Kondas, 2008; Ratanashevorn & Brown, 2021‌‌‌‌‌; Vereen et al., 2017; White & Palacios, 2020; Ziaee et al., 2022) or specific mental health topics (Baalan, 2010; Cavaleri, 2020; Didelot et al., 2012; Hoffman, 2021; Pintus, 2017; Spagnuolo Lobb, 2020; Zyromski et al., 2018). According to Greenberg and colleagues (1994), gestalt techniques are as effective or better than other psychotherapies. However, few scholars completed outcome studies (Brownell, 2020; Raffagnino, 2019; Vos et al., 2015‌‌‌‌‌). The complexity and nuance of existential-humanistic concepts do not easily lend themselves to empirical scrutiny, randomized controlled trials (RCTs), or manualized procedures. Thus, the terms empirically supported and evidenced based rarely apply to these theories, which, as we will discuss in a later section, presents challenges when counselors choose to apply these theories in mental health settings. The lack of empirical support, however, begs the question if evidence is necessary to justify the importance of exploring relationships, meanings, and a person’s perspective of death, topics that are inherently difficult to operationalize or measure. In the following section, we discuss scholarship and research trends in existential-humanistic approaches. Contemporary existential, existential-humanistic, and existential-phenomenological scholars delved further into existential and phenomenological philosophy and articulated new ways to approach the human experience. As discussed in a previous section, van Deurzen proposed the concept of the uberwelt to describe a person’s spiritual world. Spinelli articulated a perspective of the person as fundamentally interconnected with others and engaged in an ongoing process of becoming. Additionally, Schneider (2016) proposed an existential integrative (EI) theory with an emphasis on the importance of presence, the role of human choice, and the barriers that inhibit freedom. In the context of gestalt theory, Yontef (2002) advocated for a relational approach that highlights the respectful, compassionate dialogical process that transforms both counselor and client. Yontef was critical of gestalt therapists who shamed clients, therapists who were often following Perls’s example. Moreover, Polster and Polster further articulated the concept of the contact boundary between the person and the environment. The authors also developed the concept of deflection as a creative adaptation in which a client turns away from contact with another through laughter, intellectualizing, or some other avoidance strategy. Investigating key concepts with unique populations, researchers explored the effectiveness of ET and acceptance and commitment therapy (ACT) with a sample (N = 36) of incarcerated males (Ziaee et al., 2022). The researchers found a significant decrease in irrational thoughts for subjects in the ET and ACT group, but a significant increase in hope only for subjects in the ET group. Additionally, Ratanashevorn and Brown (2021)‌‌‌‌‌ considered the

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efficacy of Yalom’s ET with LGBTQIA+ clients. Bell (2018) considered the application of existential concepts when providing career counseling to Black male clients. Moreover, Vereen et al. (2017) advanced Black existentialism to counter Eurocentric existentialist approaches, and White and Palacios (2020) discussed an inclusive existential approach to Black sexual minority youth. Integrating gestalt therapy concepts with Black liberation approaches including intersectionality, Billies (2021) provided a case example to illustrate ways to foster liberation from anti-Black racism. Degeneffe (2019) considered gestalt therapy concepts for rehabilitation counselors working with clients with traumatic brain injury (TBI). Furthermore, Kondas (2008) discussed gestalt therapy for gay male survivors of domestic violence, and Desmond (2016) explored the possibility of LGB equity in light of the persistence of homophobia in the “field” of experience. Researchers also applied existential-humanistic concepts to specific mental health topics. Hoffman (2021) explored an existential-humanistic approach to crisis intervention in the context of COVID-19 and other disasters. According to Hoffman, existential-humanistic counselors focus on the demonstration of presence when providing crisis intervention support. Moreover, Zyromski et al. (2018) developed an existential approach to clients with adverse childhood experiences (ACEs). Didelot et al. (2012) considered a logotherapeutic approach in work with clients with internet addiction (IA) and discussed the importance of assisting clients with finding meaning. In the context of gestalt therapy, Cavaleri (2020) and Spagnuolo Lobb (2020) applied gestalt therapy concepts for counselors supporting clients during the COVID-19 pandemic. Baalen (2010) articulated a gestalt therapy approach to bipolar disorder, and Pintus (2017) applied gestalt concepts in an exploration of addiction and trauma. In a meta-analysis of the effect of ET on therapeutic outcomes, Vos et al. (2015)‌‌‌‌‌ reviewed 15 studies that used RCTs to explore outcomes. The authors found a large effect with meaning therapies, which correspond to Frankl’s logotherapy approach, but little to no effects with other ETs. Moreover, the authors contended that research supported the effect of meaning therapy with physically ill patients. The authors recommended that future outcome studies investigate the benefits of specific existential interventions for different clients. According to Raffagnino (2019), few outcome studies have demonstrated the efficacy of gestalt therapy. The author noted that most of the literature includes personal reflections of practitioners, discussions of clinical examples, and articles on gestalt concepts or interventions. Raffagnino conducted a systematic review of 11 studies on gestalt therapy outcomes and found evidence that gestalt therapy was useful in improving conduct in group therapy settings. However, the author contended that there were no outcome studies on individual, couples, and family therapy. Brownell (2020) discussed several research studies but advocated for an increase in empirical support for gestalt therapy.

DETAILED CASE CONCEPTUALIZATION PRAGMATICS AND TRANSCRIPT Consistent with the other chapters in this textbook, we provide an example of a counselor working with Mark, who is a 42-year-old, Black, cisgender male. Mark is seeking counseling for anxiety, sadness, anger, guilt, and loneliness related to his recent divorce, his desire to date, and his concern about spending time away from his daughters. In the process of counseling Mark, the counselor applies gestalt therapy concepts and develops an explanation of the factors that are contributing to Mark’s experience of suffering. Existential-humanistic practitioners consider the deeper meanings of the client’s problems rather than focusing on pathological symptoms that need to be reduced or eliminated (Frankl, 1984; Yalom, 1980). Moreover, existential-humanistic practitioners view problems in the context of the complexities, ambiguities, and paradoxes of human experience.

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In this section, we apply Perls’s (1969) gestalt theory in the conceptualization of the client. This corresponds to the transcript presented in the next section that includes examples of gestalt therapy techniques. In actual practice, existential-humanistic practitioners emphasize the collaborative process of meaning making and rarely apply techniques. We included techniques to match other chapters in this textbook, but counselors who focus on the demonstration of techniques are no longer representing the spirit of existential-­humanistic theories. Indeed, many existential-humanistic theorists, including Perls (1969), were highly critical of the use of techniques in practice. Perls referred to techniques as “gimmicks” and consistent with “phony therapy” that prioritizes instant results and thereby prevents growth (p. 1). On the other hand, Perls advocated for what he called experiments in order to try out new possibilities with the client. Mark is attempting to make contact with others in his environment. Struggling between a desire to date and a desire to spend time with his daughters, he interrupts his need for contact and remains disconnected from others. Mark might be turning against himself rather than reaching out to his environment. Additionally, Mark becomes caught between his sense of what he should do and a sense of helplessness. In gestalt therapy, a person’s conscience or sense of what one should do is called the topdog, and the person’s sense of helplessness is called the underdog. Mark also experiences confusion as he imagines asking a woman out on a date. Rather than focusing on his needs in the present moment, Mark remains stuck in regret over the past and worry about the future. In the next section, we present an example of a counselor working with Mark. The counselor explores Mark’s ambivalence regarding his desire to date and his sense of responsibility for his daughters. Additionally, the counselor helps Mark approach his feelings of confusion and increase awareness of his topdog and underdog. Mark mentions a dream and the counselor explores various parts of the dream as different aspects of Mark. The counselor also supports Mark in improving awareness of his thoughts, feelings, and sensations in the present moment. The shuttling technique helps Mark to realize his pattern of interrupting his need for contact with others. Transcript

Technique Demonstrated

Counselor: Hello, Mark. Last session, we discussed how you feel confusing tension between wanting to be a good dad by focusing on your girls and wanting to date so you don’t feel lonely. Right now, it sounds like this tension has pushed you to avoid dating even if it makes you feel lonely. Client: It’s still confusing, but I am leaning toward focusing on my daughters. Dating again really isn’t what my daughters need from me right now. I need to give them my undivided attention. Counselor: I want you to focus on this confusion that you feel about dating. What is it like when you are feeling this confusion? What do you notice in your body?

Approaching confusion (The counselor believes Mark is ­avoiding dwelling on the confusion he feels regarding his decision to date by ­rationalizing why he should focus on his daughters. The counselor uses ­approaching confusion to encourage Mark to experience his confusion in the moment rather than avoiding feeling the confusion by rationalizing why he should avoid dating.)

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Client: Well, I feel lost and lonely. I feel like a huge weight on me having to make this decision. My stomach feels upset and I feel this tightness in my forehead. And I feel guilty about not being good enough to my ex and having to put my girls through this divorce. I must overcompensate for putting them through this by being the best dad I can to them. But I will keep feeling lonely if I just focus on my daughters. Counselor: It sounds like the part of you who wants to focus on your daughters is bossing around the part of you that wants to date again. Let’s call this bossy part the topdog and the part that doesn’t want to feel lonely the underdog. The topdog part believes you have an obligation to right the perceived wrongs you have done to your daughters and pushes down your own need for companionship. But that part won’t go away and when these two parts fight, you feel confusion that can be overwhelming.

Topdog/underdog intervention (The counselor uses psychoeducation to point out the topdog and underdog parts of Mark and the ways they contribute to his feelings of confusion about dating.)

Client: That’s a helpful way to look at it. I do feel a lot of guilt about my daughters and push aside my own needs. It reminds me of a dream I had last night that I was at a park and I couldn’t find my oldest daughter, and then she was hiding behind a tree. Counselor: Let’s dwell on that dream for a minute then. Be the tree that is hiding your daughter from you. What do you sense? What do you feel? What do you want?

Dream work (The counselor explores different parts of the dream and asks Mark to imagine being each part. The counselor will then ask Mark to imagine being his hidden daughter. The counselor asks Mark what he senses, feels, and wants.)

Client: As the tree, I guess I want to distract myself from what is most important. I want to hide my daughters long enough to get the guts to get out and date again. I feel excited and guilty at the same time, like I am doing something I shouldn’t or like I am trying to trick myself. Counselor: It sounds like you are feeling conflicted thinking about all these possibilities involved in dating and the impact on your daughters. Let’s pause for a moment and sit with this guilt. Use the phrase “Now I am aware” and describe what you notice in your body, your voice, and your feelings.

Awareness exercise (The counselor guides Mark in being aware of various aspects of his experience and helps Mark to understand this awareness in terms of interrupted or unfinished events in his past.)

Client: Now I am aware of the heaviness on my shoulders and my sweaty palms and the discomfort in my stomach. Now I am aware of the uncertainty and softness in my voice. Now I am aware that I am afraid and guilty. Now I am aware that thinking about dating and experiencing these feelings makes me feel exhausted almost instantly and how I want to escape it. Counselor: Good. It’s important to be aware of these bodily sensations and feelings inside us as they can often underlie interruptions where we are disconnected from our environment. They can help reveal something unfinished inside us that can cause us to withdraw into ourselves.

Awareness exercise (The counselor helps Mark connect his awareness of his feelings and bodily ­sensations with unfinished events.)

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Client: My fear of dating makes me not put myself out there. It’s safer and I won’t be rejected if I don’t try. Maybe I use my daughters as an excuse, but it’s more about my fear of rejection and inadequacy. Counselor: You sound torn between a part of you that wants to get out there and date again to find companionship and a part that wants to avoid rejection and stay safe. Imagine that the part of you that wants to date again is in this chair in front of you. Tell that part of you why you should avoid dating.

Shuttling (The counselor uses shuttling to help Mark become more aware of the conflict within him between the part of himself that wants to avoid rejection by not dating and the part of himself that wants connection by dating.)

Client: Mark, who is going to want to date you? You have one failed marriage, and you are 42 years old. You haven’t been on a date with someone other than your ex in almost 20 years. You don’t know how dating works now. What if no one wants to be with you? What would your daughters think of that? It’s safer and easier to not put yourself out there. Counselor: Okay. Now, I want you to stand up and move to that other chair and tell the part of you that wants to avoid dating why you should put yourself out there again.

Shuttling (The counselor continues the process of shuttling by asking Mark to take on the perspective on another part of himself.)

Client: Mark, you are going to keep feeling lonely until you get yourself back out there. It takes a risk, but the reward is so worth it if you can find a meaningful connection. You deserve to feel loved. Counselor: Now, move back to this chair and reply. We will keep going back and forth from chair to chair until you have said what you need to say.

Shuttling (To facilitate greater depth in his ­awareness of this inner conflict with the purpose of making the parts whole, t­ he counselor invites Mark to continue this conversation with the parts of himself.)

THEORETICAL LIMITATIONS When applying existential-humanistic approaches in practice, counselors might find little guidance on how to structure a session, when to use an intervention, or how to integrate existential themes with a treatment plan. We have presented an example of a session and case conceptualization, but, as we discussed in the introduction, existential-­humanistic counseling work does not fit well into tidy little boxes. Counselors and clients need to embrace ambiguity and the unexpected. Thus, the existential-humanistic approach might be less effective in brief counseling, with clients who prefer concrete solutions for mental health problems, and with clients who favor more structure. Moreover, there is limited research that supports the efficacy of existential-humanistic approaches in practice. We discuss specific limitations to Yalom’s existential psychotherapy, Frankl’s logotherapy, and Perls’s gestalt therapy approaches in the following section. According to van Deurzen (2010), Yalom merely supplements his psychiatric, behavioral practice with existential themes and thereby fails to develop a systematic existential approach. Yalom’s commitment to the medical model belies his focus on the existential givens, which correspond to a different philosophical account of human suffering. Indeed, Yalom emphasizes the reduction rather than acceptance of anxiety as an inherent feature of human existence. Yalom thus departs from the richness, history, and legacy of ET and

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philosophy. Due to the contradictory philosophical assumptions and the lack of structure of Yalom’s approach, counselors might find it challenging to apply the theory in practice. Yalom also proposes an atheistic approach to ET, which might be challenging for religious or spiritual counselors and clients. Similar to Yalom’s approach, Frankl offers minimal guidance on how to structure the process of counseling. Frankl was more directive and guided his clients toward meaning and self-transcendence. In the dereflection technique, counselors applying logotherapy might instruct the client to focus beyond the self to a person or cause. Counselors thus communicate preferred ways to make meaning of one’s life. Rollo May expressed concerns that logotherapy was potentially authoritarian and that practitioners might impose values and prevent clients from taking responsibility for their lives (Bulka, 1978). When applying logotherapy with clients, counselors might experience difficulty assuming the role of expert in directing clients toward people and causes beyond the self. The limitations of Perls’ gestalt therapy approach stem from his provocative and theatrical live demonstrations that showcased techniques but minimized the importance of the therapeutic relationship (Dolliver, 1981). In our experience as counselor educators, counseling students either eschew gestalt theory after viewing Perls with Gloria or attempt to implement gestalt techniques such as the empty chair without an in-depth understanding of gestalt theory. Counselors must be willing to engage in personal work, explore their own unfinished business, and commit to increasing their understanding of gestalt concepts. Rather than attempting to emulate Perls, counselors need to be willing to make close contact with clients, a practice that involves vulnerability, risk, and self-disclosure. Counselors might be hesitant to engage in intense personal work and reluctant to initiate close interpersonal contact with clients. Similar to Yalom’s theory and Frankl’s logotherapy, counselors might find little guidance regarding how to structure a counseling session.

SUMMARY In this chapter, we provided an overview of the philosophical foundation of ­existential-humanistic counseling. We also described the origin of mental health concerns, the criteria for well-being, and the role of counselor and client in Yalom’s existential psychotherapy, Frankl’s logotherapy, and Perls’s gestalt therapy. Additionally, we considered development, the process of change, the factors that maintain progress, and clinical assessment. We presented techniques and gestalt experiments, addressed case conceptualization, and provided a demonstration of techniques in practice. Finally, we articulated multicultural/social justice concerns, research trends, and limitations of the theories. In the following sections, we discuss exercises and resources that might be useful for counseling students. VOICES FROM THE FIELD This chapter features a digitally recorded interview entitled Voices From the Field. The interview explores multicultural, social justice, equity, diversity, and intersectionality issues from the perspective of clinicians representing a wide range of ethnic, racial, and national backgrounds. The purpose of having chapter-based authors interview individuals representing communities of color or who frequently serve diverse populations is to provide you, the reader, with relevant t­ heory-based social justice and multiculturally oriented conceptualization, contemporary issues, and relevant skills.

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Access the video at https://bcove.video/46j8Yyc

Alfredo (Fredo) F. Palacios identifies as a cisgender male existential psychotherapist. Fredo is 34 years old and identifies as Hispanic or Mexican American Chicano. He graduated from a Council for Accreditation of Counseling and Related Educational Programs (CACREP)-accredited master’s level and doctoral program, and he currently resides in the Rocky Mountain region. Fredo specialized in clinical mental health counseling and school counseling in his master’s level counseling program. Additionally, he is a licensed professional counselor in Colorado and Alabama and a licensed mental health counselor in New Mexico. He has been practicing counseling for 8 years and is currently practicing counseling.

STUDENT EXERCISES Exercise 1: Journal Reflection on Freedom

Directions: Reflect or journal on what parts of your life you think you have the most individual agency or freedom. What makes you feel that way? What are areas that you think you have the least agency or freedom? Why? And lastly, consider those areas where you feel the least amount of agency or freedom. What are small ways that you have some agency in those contexts? As you consider these concepts, help consider the intersection of humanism and multiculturalism/social justice.

Exercise 2: Meaning of Life Discussion

Directions: Comparing similarities and differences can help you notice the diversity of meaning in peoples’ lives and how people develop meaning based on different factors. Discuss with a peer about what gives them meaning in their life. How did they get to that understanding? How similar or different is their meaning in their life compared with yours?

Exercise 3: Stories, Characters, and Values

Directions: Exploring stories and characters can be an insightful way to work with clients to help clarify their identity and worldview.  Stories are powerful mediums for meaning. Consider characters in stories (e.g., movies, books) that capture your attention and fascination. What about them draws you in? What values or meaning do you see in their life that you want in your own life?

Exercise 4: Interrupting the Automatic

Directions: Interrupting ourselves in our day-to-day life can lead to reflection on how making small changes in our life can create a bodily reaction. Bringing awareness on some of the smaller behaviors can provide insight about how we might react with larger changes in our life. Think about something that you do automatically in your day-to-day life. This behavior could be as simple as opening a door, checking your phone, or zipping up your jacket. Try one or two of these automatic activities, but then stop midway through. Try a couple automatic activities. What feelings do you notice in your body? Do you have an urge to complete the task? Did you experience any discomfort?

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Exercise 5: Topdog/Underdog Activity

Directions: In groups of two or three, explore Fritz Perls's topdog and underdog concepts. Have one student sit in one chair facing an empty chair. Invite that student to reflect on an upcoming assignment or big task. First, have them take the perspective of the topdog talking to the underdog. This part focuses on the perceived “oughts” and “shoulds” and perceived social standards. For example, “You need to study more.” Or “You are always underprepared.” After a minute or two, have them switch seats and take the perspective of the underdog talking to the topdog. This perspective focuses on why that standard should not or cannot be met. After both these roles are finished, explore as a group what you noticed and what insights emerge about that individual’s relationship to that assignment or task.

RESOURCES Helpful Links The following links provide more information on existential-humanistic counseling and emphasize multiculturalism, diversity, and social justice: ■ ■ ■

■ ■ ■ ■

An Introduction to Existential-Humanistic Psychology and Therapy: https://existential-therapy.com/ Emmy van Deurzen’s life and writings: www.emmyvandeurzen.com/ Resources on existential therapy for practicing counselors, psychotherapists, counseling psychologists and other mental health professionals: https://mick-cooper.squarespace. com/existential The Gestalt Centre: https://gestaltcentre.org.uk/what-is-gestalt/ The New York Institute for Gestalt Therapy: https://newyorkgestalt.org/ Existential-Humanistic Institute: https://ehinstitute.org/existential-therapy/ International Association for the Advancement of Gestalt Therapy: https://iaagt.org/

Helpful Books ■ ■ ■ ■ ■ ■ ■

Cooper, M. (2016). Existential therapies. Sage. Dreitzel, H. P. (2021). Human interaction and emotional awareness in gestalt therapy: Exploring the phenomenology of contacting and feeling. Routledge. Polster, E., & Polster, M. (2013). From the radical center: The heart of gestalt therapy. Gestalt Press. Schneider, K. J. (2011). Existential-integrative psychotherapy: Guideposts to the core of practice. Routledge. Schneider, K. J. (2020). The depolarizing of America: A guidebook for social change. University Professors Press. Schneider, K. J. (2020). The polarized mind: It’s killing us and what we can do about it. University Professors Press. Van Deurzen, E., & Arnold-Baker, C. (2018). Existential therapy: Distinctive features. Routledge.

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Helpful Videos ■ ■ ■ ■ ■ ■ ■

Existential-Humanistic Psychotherapy: www.psychotherapy.net/video/existentialhumanistic-psychotherapy Irvin Yalom in Session: www.psychotherapy.net/video/irvin-yalom-psychotherapyeugenia Psychotherapy With the Unmotivated Patient: www.psychotherapy.net/video/polstergestalt-therapy Gestalt Therapy With Children: www.psychotherapy.net/video/oaklander-gestaltchild-therapy Fritz Perls and Gloria, Counselling (1965) Full Session: www.youtube.com/watch?v= MIsPg4YDgHY Death, Grief and Meaning of Life, Part 2: www.youtube.com/watch?v=NH9o4rH3HhM Alfried Laengle Demonstration Session with Digby 2015: www.youtube.com/ watch?v=4QD9VBejy5k

A robust set of instructor resources designed to supplement this text is available. Qualifying instructors may request access by emailing [email protected].

REFERENCES Ameli, M., & Dattilio, F. M. (2013). Enhancing cognitive behavior therapy with logotherapy: Techniques for clinical practice. Psychotherapy, 50(3), 387–91. https://doi.org/10.1037/a0033394 Baalen, D. V. (2010). Gestalt therapy and bipolar disorder. Gestalt Review, 14(1), 71–88. https://doi. org/10.5325/gestaltreview.14.1.0071 Barnes, R. C. (2000). Viktor Frankl’s logotherapy: Spirituality and meaning in the new millennium. TCA Journal, 28(1), 24–31. https://doi.org/10.1080/15564223.2000.12034561 Becker, E. (1973/1997). The denial of death. Simon & Schuster. Bell, T. J. (2018). Career counseling with Black men: Applying principles of existential psychotherapy. The Career Development Quarterly, 66(2), 162–175. https://doi.org/10.1002/cdq.12130 Billies, M. (2021). How/can gestalt therapy promote liberation from anti-Black racism? British Gestalt Journal, 30(1), 31–38 Boss, M. (1988). Recent considerations in daseinanalysis. The Humanistic Psychologist, 16(1), 58–74. https:// doi.org/10.1080/08873267.1988.9976811 Braun, J. R. (1981). The purpose in life test [Test review]. In O. K. Buros (Ed.), The seventh mental measurements yearbook. Buros Center for Testing. Brownell, P. (2010). Gestalt therapy: A guide to contemporary practice. Springer Publishing Company. Brownell, P. (2020). Gestalt therapy research. International Journal of Psychotherapy, 24(3), 41–50. Buber, M. (1923/2010). I and thou (R. G. Smith, Trans.). Martino Publishing. Bulka, R. P. (1978) Is logotherapy authoritarian? Journal of Humanistic Psychology, 18(4), 45. https://doi. org/10.1177/002216787801800406 Camus, A. (2013). The myth of Sisyphus. Penguin UK.‌‌‌‌‌ Cavaleri, P. A. (2020). A gestalt therapy reading of the pandemic. The Humanistic Psychologist, 48(4), 347–352. https://doi.org/10.1037/hum0000214 Comas-Diaz, L. (2012). Humanism and multiculturalism: An evolutionary alliance. Psychotherapy, 49(4), 437–441. https://doi.org/10.1037/a0027126‌‌‌‌‌ Cooper, M. (2016). Existential therapies (2nd ed.). Sage. Crumbaugh, J. C., & Maholick, L. T. (1969). Manual of instructions for the Purpose in Life test. Viktor Frankl Institute of Logotherapy. Davies, G., Klaassen, D., & Längle, A. (2014). Purpose in life test. In A. C. Michalos (Ed.), Encyclopedia of quality of life and well-being research. Springer. https://doi.org/10.1007/978-94-007-0753-5_2336‌ Degeneffe, C. E. (2019). Understanding traumatic brain injury from a gestalt approach. Journal of Applied Rehabilitation Counseling, 50(4),

252–267. https://www.proquest.com/openview/2fab3baa2d234d8849217a2e66a74729/1. pdf?pq-origsite=gscholar&cbl=35933#:~:text=DOI%3A10.1891/JARC_50_4_01_Degeneffe Delisle, G. (1999). Balises II: A gestalt perspective on personality disorders. Le Reflet. Desmond, B. (2016). Homophobia endures in our time of changing attitudes: a ‘field’ perspective. British Gestalt Journal, 25(2), 42–52. Didelot, M. J., Hollingsworth, L., & Buckenmeyer, J. A. (2012). Internet addiction: A logotherapeutic approach. Journal of Addictions & Offender Counseling, 33(1), 18–33. https://doi.org/10.1002/j.2161-1874.2012.00002.x Dolliver, R. H. (1981). Some limitations in Perls’ gestalt therapy. Psychotherapy: Theory, Research & Practice, 18(1), 38. https://doi.org/10.1037/H0085959 Dreyfus, H. L. (2004). What could be more intelligible than everyday intelligibility? Reinterpreting Division I of Being and Time in the light of Division II. Bulletin of Science, Technology & Society, 24(3),  265–274. https://doi.org/10.1177/0270467604264993 Frankl, V. E. (1984). Man’s search for meaning. Simon & Schuster. Ghaemi, S. N. (2001). Rediscovering existential psychotherapy: The contribution of Ludwig Binswanger. American Journal of Psychotherapy, 55(1), 51–64. https://doi.org/10.1176/appi.psychotherapy. 2001.55.1.51 Greenberg, L., Elliott, R., & Lietaer, G. (1994). Research on experiential therapies. In A. Bergin & S. Garfield (Eds.), Handbook of psychotherapy and behavior change (pp. 509–539). Wiley. Hannay, A. (2003). Kierkegaard: A biography. Cambridge University Press. Hoffman, L. (2016). Multiculturalism and humanistic psychology: From neglect to epistemological and ontological diversity. The Humanistic Psychologist, 44, 56–71. https://psycnet.apa.org/doi/10.1037/ hum0000016 Heidegger, M. (1927/2010). Being and time (J. Stambaugh, Trans.) Suny Press. Heidenreich, T., Noyon, A., Worrell, M., & Menzies, R. (2021). Existential approaches and cognitive ­behavior therapy: Challenges and potential. International Journal of Cognitive Therapy, 14(1), 209–234. https://doi.org/10.1007/s41811-020-00096-1 Hoffman, L. (2021). Existential–humanistic therapy and disaster response: Lessons from the COVID-19 pandemic. Journal of Humanistic Psychology, 61(1), 33–54. https://doi.org/10.1177/0022167820931987 Höll, K. (2020). The gestalt of the “self” in gestalt therapy: A suggestion for a new configuration of theory. Gestalt Review, 24(1), 33–59. Hollingdale, R. J. (1999). Nietzsche: The man and his philosophy. Cambridge University Press. Husserl, E. (1913/2017). Ideas: General introduction to pure phenomenology (W. R. Boyce Gibson, Trans.). Martino Fine Books.‌ Jaspers, K. (1971). Philosophy of existence (Vol. 1010). University of Pennsylvania Press.‌‌‌‌‌ Joyce, P., & Sills, C. (2018). Skills in gestalt counselling & psychotherapy (4th ed.). Sage. Kierkegaard, S. (1844/2014). The concept of anxiety: A simple psychologically oriented deliberation in view of the dogmatic problem of hereditary sin. (A. Hannay, Trans.) WW Norton & Company.‌‌‌‌‌ Kondas, D. (2008). Existential explosion and gestalt therapy for gay male survivors of domestic violence. Gestalt Review, 12(1), 58–74. https://psycnet.apa.org/doi/10.5325/gestaltreview.12.1.0058 Mann, D. (2010). Gestalt therapy: 100 key points and techniques. Routledge. May, R. (1969). Love and will. WW Norton & Company. May, R. (1982). The problem of evil: An open letter to Carl Rogers. Journal of Humanistic Psychology, 22(3), 10–21. https://doi.org/10.1177/0022167882223003 May, R. (1996). The meaning of anxiety. WW Norton & Company.‌ Nielsen, K. (2018). Kierkegaard and the modern search for self. Theory & Psychology, 28(1), 65–83. https:// psycnet.apa.org/doi/10.1177/0959354317742741 Nietzsche, F. W. (1872/1994). The birth of tragedy (S. Whiteside, Trans.). Penguin Classics. Nietzsche, F. (1883/2008). Thus spoke Zarathustra: A book for everyone and nobody (G. Parkes, Trans.). Oxford University Press.‌ Overend, P. (2021). Working with power in existential therapy. Existential Analysis: Journal of the Society for Existential Analysis, 32(2).‌ Perls, F. S. (1969). Gestalt therapy verbatim. Bantam Books. Perls, F. (1973). The gestalt approach & eye witness to therapy. Science & Behavior Books. Perls, F., Hefferline, G., & Goodman, P. (1951). Gestalt therapy. Julian Press. Pintus, G. (2017). Addiction as persistent traumatic experience: Neurobiological processes and good ­contact. Gestalt Review, 21(3), 221–232. https://doi.org/10.5325/gestaltreview.21.3.0221

Polster, E., & Polster, M. (1973). Gestalt therapy integrated: Contours of theory and practice. Brunner/Mazel. Raffagnino, R. (2019). Gestalt therapy effectiveness: A systematic review of empirical evidence. Open Journal of Social Sciences, 7(6), 66–83. https://doi.org/10.4236/jss.2019.76005 Ratanashevorn, R., & Brown, E. C. (2021). “Alone in the rain (bow)”: Existential therapy for loneliness in LGBTQ+ clients. Journal of LGBTQ Issues in Counseling, 15(1), 110–127. https://doi.org/10.108 0/15538605.2021.1868375‌‌‌‌‌ Reitinger, C. (2015). Viktor Frankl’s logotherapy from a philosophical point of view. Existential Analysis, 26(2), 344–357. Resnick, R. W. (2020). Gestalt therapy and homeorhesis: Evolution with movement, discrimination, and grace. Gestalt Review, 24(2), 200–221. https://doi.org/10.5325/gestaltreview.24.2.0200 Sartre, J. P. (1939/2015). Sketch for a theory of the emotions (P. Mairet, Trans.) Routledge. Sartre, J. P. (1943/2018). Being and nothingness: An essay in phenomenological ontology. (S. Richmond, Trans.). Routledge. Sartre, J. P. (1946/2007). Existentialism is a humanism (C. Macomber, Trans.). Yale University Press.‌ Serlin, I. (1994). Remembering Rollo May: An interview with Irvin Yalom. The Humanistic Psychologist, 22(3), 268–274. https://doi.org/10.1080/08873267.1994.9976954 Schneider, K. J. (2016). Existential-integrative therapy: Foundational implications for integrative practice. Journal of Psychotherapy Integration, 26(1), 49–55. http://dx.doi.org/10.1037/a0039632 Spagnuolo Lobb, M. (2020). Gestalt therapy during coronavirus: Sensing the experiential ground and “dancing” with reciprocity. The Humanistic Psychologist, 48(4), 397–409. https://doi. org/10.1037/hum0000228 Spiegelberg, H. (1960). Husserl’s phenomenology and existentialism. The Journal of Philosophy, 57(2), 62–74. https://doi.org/10.2307/2022808 Spinelli, E. (2014). Practicing existential therapy: The relational world (2nd ed.). Sage. Stolorow, R. D., Atwood, G. E., & Orange, D. M. (2010). Heidegger’s Nazism and the hypostatization of being. International Journal of Psychoanalytic Self Psychology, 5(4), 429–450. https://doi.org/10.1080/ 15551024.2010.508211‌ van Deurzen, E. (2010). Everyday mysteries: A handbook of existential psychotherapy (2nd ed.). Routledge. van Deurzen, E. (2013). Existential counseling and therapy in practice (3rd ed.). Sage. Vereen, L. G., Wines, L. A., Lemberger-Truelove, T., Hannon, M. D., Howard, N., & Burt, I. (2017). Black existentialism: Extending the discourse on meaning and existence. The Journal of Humanistic Counseling, 56(1), 72–84. https://doi.org/10.1002/johc.12045 Vos, J., Craig, M., & Cooper, M. (2015). Existential therapies: A meta-analysis of their effects on psychological outcomes. Journal of Consulting and Clinical Psychology, 83(1), 115–128. https://doi.org/10.1037/ a0037167‌‌‌‌‌ White, D., & Palacios, A. (2020). A culturally responsive existential phenomenological approach for counseling black sexual minority youth. The Journal of Humanistic Counseling, 59(2), 74–85. http://dx.doi. org/10.1002/johc.12131 Winston, C. N. (2015). Points of convergence and divergence between existential and humanistic psychology: A few observations. The Humanistic Psychologist, 43(1), 40–53. https://doi.org/10.1080/0887326 7.2014.993067 Yalom, I. D. (1980). Existential psychotherapy. Basic Books. Yontef, G. (2002). The relational attitude in gestalt therapy theory and practice. International Gestalt Journal, 25(1), 15–34. Ziaee, A., Nejat, H., Amarghan, H. A., & Fariborzi, E. (2022). Hope and irrational beliefs among male prisoners: The comparative effectiveness of Existential Therapy (ET) and Acceptance and Commitment Therapy (ACT). Electronic Journal of General Medicine, 19(2), em349. https://doi.org/10.29333/ ejgm/11548 Zyromski, B., Dollarhide, C. T., Aras, Y., Geiger, S., Oehrtman, J. P., & Clarke, H. (2018). Beyond complex trauma: An existential view of adverse childhood experiences. The Journal of Humanistic Counseling, 57(3), 156–172. https://doi.org/10.1002/johc.12080

SECTION IV

BEHAVIORAL AND COGNITIVE THEORIES

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BEHAVIORAL APPROACHES Lynne Guillot Miller

LEARNING OBJECTIVES After reading this chapter, you will be able to: ■ Explain the legacy of the theory founders of behavioral approaches ■ Describe the key uniting tenets of behavioral approaches ■ Understand the origin and nature of mental health concerns related to the behavioral approaches ■ Analyze the role of counselors and clients in behavioral approaches ■ Differentiate the theory of change in behavioral approaches from other counseling theories and approaches ■ Explore how assessment and techniques are used in behavioral approaches to bring about client change and maintain progress in counseling ■ Understand multicultural and social justice issues associated with behavioral approaches ■ Compare and contrast behavioral approaches with other counseling theories and approaches ■ Understand the benefits and limitations of using behavioral approaches

INTRODUCTION Historically, the theory of behaviorism postulates that behavior can be explained in terms of conditioning within the environment with little attention given to cognitions or emotions and that the treatment of psycho​​logical concerns is best performed by manipulating or altering patterns of behavior. Behavior therapy has traditionally relied upon highly focused and specialized evidenced-based practices and protocols to change exhibited behaviors that support maladaptive behavioral patterns in clients. Interventions such as psychoeducation, shaping, and modeling of desired behaviors occur for a short duration until the client learns and maintains more adaptive and socially acceptable behaviors. Behaviorism, in its earliest wave of contributions to psychology, originated as an alternate treatment option for psychiatric conditions due to the view of psychoanalysis as vague and lacking empirical support (Ferguson & O’Donohue, 2015). While psychoanalysis focused often on the influence of childhood experiences, behaviorists suggested that psychological disorders could occur in response to environmental factors (Guercio, 2018). The mid-20th century saw the emergence of contemporary forms of behavior therapy including contributions from individuals such as Joseph Wolpe, Hans Eysenk, and B. F. Skinner. Their work provided the empirical studies that psychoanalysis was lacking and strengthened the

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theory’s influence across multiple fields such as psychology, education, and human services. This second wave of behaviorism guiding the field through the latter half of the 20th century, led to the exploration by researchers on total behavior that included internal states, such as cognitions and emotions, that could potentially influence behavior (Guercio‌‌‌, 2018). The third wave of behaviorism has given rise to behavioral approaches with more humanistic perspectives (McLaughlin, 2019). While behavior change is still a primary purpose of current approaches, humanistic tenets, such as understanding and acceptance of experiences including thoughts and emotions are considered. Additionally, modern approaches give clients autonomy in discovering the types of strategies that may work best for them and in weighing the congruence of strategies and behaviors with their values (Antony, 2019). These more modern behavioral approaches, such as acceptance and commitment therapy (ACT) and dialectical behavior therapy (DBT), while popular, have not been as empirically sustained as effective compared to other behavioral therapies. See the section of this chapter, Emerging Behavioral Approaches, and Chapter 9 on Cognitive Behavioral Therapy for descriptions of approaches associated with the third wave of behaviorism. Today, behavioral approaches are supported and advanced by several organizations and journals. The Association for Behavioral and Cognitive Therapies (ABCT) promotes the science of behavioral approaches. Its mission includes the commitment, “to the enhancement of health and well-being by advancing the scientific understanding, assessment, prevention and treatment of human programs through the global application of behavioral, cognitive, and biological evidence-based principles” (ABCT, 2022). The flagship journal of ABCT is Behavior Therapy. Division 25 of the American Psychological Association (APA) promotes behavioral analysis conducted on both humans and animals and its application to improve the lives of people (APA, 2022). The Association for Contextual Behavioral Science is an organization committed to the study of functional contextualism and seeks to empirically support therapies such as acceptance and commitment therapy through its organizational activities and publication of the Journal of Contextual Behavioral Science (Association for Contextual Behavioral Science, n.d.). Other interdisciplinary peer-reviewed journals such as Behavior Modification and Behavior Research and Therapy contribute to a robust empirical foundation for behavioral approaches among clinicians.

LEADERS AND LEGACIES OF BEHAVIORAL THEORY Ivan Pavlov (1849–1936) Ivan Pavlov was a Russian physiologist best known for his work in classical conditioning. Recipient of a Nobel Prize in Physiology or Medicine for his work related to secretions in digestion, Pavlov conditioned and counterconditioned salivation in dogs by pairing a neutral stimulus (bell sound) with an unconditioned stimulus (food). Dogs instinctively salivated in the presence of food, and with the pairing of the bell with food, the dogs were conditioned to salivate at the sound of the bell without the food present. Additionally, counterconditioning occurred when the food was not paired with the bell, which led to the dogs ceasing to salivate at the sound of the bell. His work in conditioning and his development of experimental procedures that drive the empirical studies in conditioning and behaviorism continue to impact behavioral approaches (Wolpe & Plaud, 1997).

Edward L. Thorndike (1874–1949) Edward L. Thorndike was a staunch supporter of quantitative, scientific approaches to studying behaviorism and is credited with developing the puzzle box, the first experimental apparatus to study operant conditioning (Chance, 1999). The puzzle box demonstrated that cats could learn how to escape a box using trial and error. Once outside of the box, they

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were rewarded with food. This positive reinforcement influenced the cats’ learning where Thorndike began to observe that the cats took less and less time to escape the box. This classic example of stimulus–response theory is the premise of operant conditioning where behaviors that are rewarded are strengthened and repeated. Subsequent versions of this theory demonstrated that connections are more quickly and easily established if the subject perceives that the stimuli and responses are connected in some way. He found later in his career that while reinforcement strengthened learning, punishment did not. Some of his major works include Animal Intelligence published in 1911 and The Fundamentals of Learning published in 1932.

John B. Watson (1878–1958) John Watson’s work in classical conditioning in the 1920s set the foundation for behavioral approaches and led to him becoming known as the “Father” of behaviorism (Guercio, 2018). Watson’s book, Behaviorism, published in 1924, is considered a seminal work in the field of behavioral theory. Watson believed that “psychology as the behaviorist views it is a purely objective, experimental branch of natural science” (Watson, 1924, p. 158). This early notion of what would become “radical behaviorism” stated that scientists could predict and control behaviors. Watson believed that human minds begin as a “blank slate” and everything, including behavioral responses, develops from birth. Watson sought to extend Pavlov’s work in order to observe if conditioning could actually occur in human behavior. Though considered ethically unsound according to current practices, he and graduate student, Rosalie Rayner, conducted what has come to be known as the “little Albert” experiment in which they were able to condition and recondition a child to fear a white rat by pairing the presentation of the white rat with a loud noise. Additionally, the child demonstrated the generalization of that fear to other white, furry objects. What is especially troublesome ethically about this experiment is that the child was never unconditioned (Aalai, 2015). Ethics aside, this most famous work of Watson’s demonstrated the utilization of Watson’s behavioral theory in that human behavior could be observed, predicted, and controlled.

Burrhus Frederic (B. F.) Skinner (1904–1990) B. F. Skinner, influenced by the work of Watson, built upon the “blank slate” notion and is credited with the study of radical behaviorism. Radical behaviorism is based upon the basic principles of behaviorism and adds that the study of behavior is a natural science. This implies that behavioral events may be studied in relation to past and present environmental experiences and structures (Baum, 2011) and include all behavior including cognitions and emotions specific to an individual. Skinner’s work supported and validated operant conditioning and the concept that behaviors could be learned or altered through the administration of rewards and punishments. He developed what has become known as the “skinner box.” The skinner box is an operant conditioning chamber that consists of a bar or lever that, in its basic form, an animal would press, when hungry, and receive a positive reinforcement (water or food). The animal would learn that pressing the bar would result in a reward and, over time, learn to press the bar more frequently and with shorter durations between presses. Skinner boxes have been used for various animals and various forms of reinforcement including negative reinforcement with the pressing of the bar causing electric shock of the animal within the box to cease. While Skinner continued his research with positive and negative reinforcers, he also worked with the concepts of positive and negative punishment. Later in his career, he proposed that the study of behavior and behavioral concepts could positively impact society in the books Walden II (1948) and Beyond Freedom and Dignity (1971).

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Joseph Wolpe (1915–1997) Joseph Wolpe’s work in reciprocal inhibition arose from his feelings of futility and his quest for more productive practices in his work after World War II. His most substantial work occurred during his tenure at Temple University in his treatment of anxiety (Salkovskis, 1998). His work, highly influenced by Pavlov’s conditioning, led to the discovery that desirable and undesirable behaviors could not occur simultaneously (Poppen, 1998‌‌‌‌‌) and actually competed with each other. This formed the basis for his creation of systematic desensitization which is “the procedure of gradual, progressive reexposure to traumatic situations.” He was effectively able to connect theory, research, and clinical practice leading to his cofounding of the Association for the Advancement of Behavior Therapies with scholars such as Cyril Franks and Arnold Lazarus and served almost 30 years as editor of the Journal of Behavior Therapy and Experimental Psychiatry. Wolpe’s work continues to influence the field of counseling in his belief that the best way to reduce anxieties is by confronting them. Today, his ideas regarding empirically supported approaches to mental health are common practice and his work supported the development of cognitive behavior therapy (CBT; Salkovskis, 1998‌‌‌‌‌). Wolpe’s publications include Psychotherapy by Reciprocal Inhibition published in 1958, The Practice of Behavior Therapy published in 1969, and Life Without Fear: Anxiety and Its Cure published in 1988.

KEY TENETS OF BEHAVIORAL APPROACHES Behavioral approaches represent a vast collection of theories and approaches including, but not limited to, classical conditioning, operant conditioning, CBT, applied behavior analysis (ABA), behavior modification, and DBT. Despite their diversity, traditionally, behaviorists have relied on key tenets that characterize their work: ■

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All behavior is learned, has a purpose based on environmental factors (Choudhury, 2017‌‌‌‌‌), and is included in a modifiable behavioral repertoire (Seaberg, 1982). Maladaptive behaviors may be changed, or new behaviors acquired through this form of learning (Antony et al., 2020‌‌‌‌‌). Behaviorists view the development and maintenance of personality as a product of the environment of the individual as well as the rewards and punishments they experience within the environment (Bishop et al., 2017). Personality, which Skinner labeled as “self,” is directly associated with learning and reinforcement and is exhibited in patterns of behaviors. Behaviors that are reinforced tend to be repeated and form a behavioral repertoire (Phelps, 2015). Behavior therapy was founded utilizing scientific methodology that depended on structured and empirical processes to study behaviors and interventions. Behavioral approaches emphasize the “practice of objective observation and measurement of the phenomena of interest” (Copper et al.‌‌‌, 2020‌‌‌‌‌). Behaviorists continue to provide substantial empirical support for behavioral approaches and conduct research related to the efficacy of interventions (Choudhury, 2017). Behaviorists focus on observable behaviors while not denying the internal process of learning that includes cognitions and emotions (Mariani & Zyromski, 2019‌‌‌‌‌). However, behaviorism tends to focus on the outward expression of these internal processes rather than the processes themselves. Behaviorism focuses on the present and the client’s past is explored only to ­determine how learning was conditioned for the client (Choudhury, 2017‌‌; Guercio, 2018). Behaviorists attempt to explore clients’ current surroundings to determine antecedents and consequences influencing behaviors (Goldenberg et al., 2017).

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Behaviorists apply “the experimental method to the therapeutic process” (Choudhury, 2017‌‌‌‌‌). Assessment is an ongoing process in behavioral approaches and is used to gather information related to the determinants of behaviors in order to design an individualized treatment plan that intervenes on operationally defined behaviors with measurable outcomes for the client. The tailored interventions and acquisition of client outcomes are continuously assessed for effectiveness and modified or revised accordingly (Goldenberg et al., 2017). Behavioral treatments are active with both clients and counselors engaged in clients’ behavioral changes in session and clients’ working to establish more adaptive behaviors outside of sessions (Antony, 2019; Choudhury, 2017‌).

Emerging Behavioral Approaches Current behavioral approaches are typically a mix of behavior and cognitive approaches and rely heavily on humanistic principles (e.g., mindfulness; Hayes, 2004). Traditionally, behaviorists who focused solely on observable antecedents of behavior were known as methodological behaviorists. However, the more current approaches reflect the views of radical behaviorists in that the antecedents of behavior are studied, but also value is placed on private events such as thoughts or emotions that traditional methodological behaviorists, such as Watson, would find to be subjective and of no value. Some theories that have emerged (e.g., cognitive behavioral [CB]) include both internal (cognitions and emotions) and external (behaviors) events that shape behaviors. Some of the most prominent are included in this section. ABA is associated with more traditional behavioral approaches and stems from an operant approach. The other emerging behavioral approaches highlighted in this section tend to be integrative approaches intentionally and systematically incorporating cognitions, mindfulness, and acceptance of current emotions and cognitions and environmental circumstances. APPLIED BEHAVIOR ANALYSIS

ABA is a behavioral approach that uses operant conditioning principles to allow clients to learn and modify behaviors of social importance. The approach relies on interventions that are delivered systematically with enough detail to allow for replicability (Copper et al., 2020‌‌‌‌‌). ABA is most commonly used with clients who are diagnosed with autism spectrum disorders. The practice of ABA involves clinicians attaining additional training and certification. COGNITIVE BEHAVIORAL THERAPY

As the notion that internal processes such as cognitions and emotions also played a role in the development of behavior began to fill the voids left by earlier forms of behaviorism, the emergence of theories such as CBT, which includes the influence on cognitive distortions and their impact on behavior, began to develop. CBT acknowledges and addresses the reciprocity of cognitions and behavior development. This empirically driven approach allows for the evaluation of both cognitions and behaviors to determine the faulty or unhealthy thoughts or behaviors and the assessment of how they are influencing each other. CBT then, utilizing various techniques, provides for a means of therapy to aid in manipulating either or both to achieve the desired outcome for the client (see Chapter 9 for a comprehensive description of CBT). DIALECTICAL BEHAVIOR THERAPY

Originally developed as a treatment for patients with suicidal intent in the 1970s by Dr. Marsha Linehan, DBT now serves clients with a multitude of behaviors. Incorporating CB strategies, DBT is a comprehensive, empirically supported program consisting of individual and group counseling along with consultation and ongoing support. Counselors typically work in consultation and collaboration with members of a team to deliver treatment.

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Clients enhance skills in tolerating stress, regulating emotions, developing mindfulness, and relating interpersonally to manage stress through psychoeducation and practice. DBT has demonstrated effectiveness in treating clients with a range of disorders including borderline personality disorder, post-traumatic stress disorder (PTSD), anxiety, depression, and substance use disorders. Because of the prevalence of DBT in clinical counseling practice, we have included more information in relevant sections that follow. ACCEPTANCE AND COMMITMENT THERAPY

ACT, developed in the 1980s by Steven Hayes, is an approach that combines techniques from behavioral and CB theories along with humanistic and mindfulness practices. Clients learn to become more aware of thoughts and emotions including those that historically have led to harmful or unwanted behaviors and, rather than trying to change them, they are accepted and the individual commits to changing behaviors. Along with the counselor, clients work to identify their values in different areas (e.g., career, relationships, etc.) and mindfully chooses behaviors that are based on these values rather than maladaptive thoughts, emotions, or circumstances. More information on ACT can be found at the Association for Contextual Sciences website and the book Acceptance and Commitment Therapy: The Process and Practice of Mindful Change (Hayes et al., 2011).

THE ORIGIN AND NATURE OF MENTAL HEALTH CONCERNS Mental health concerns may arise from biological, genetic, or environmental factors (Weir, 2012). Behaviorists focus primarily on these environmental factors and how they play a role in our learning and, at times, our mental health concerns. What behaviors are attributable to conditioning, conscious learning, and/or unconscious learning? How do these behaviors, shaped by learning within our environment, contribute to mental health concerns? Learning within the environment may take place consciously or unconsciously (Spiegler & Guevremont, 2020). As an individual interacts with their environment, they will experience reinforcers for their behaviors as well as punishments. They will also experience and develop unconscious connections between stimuli in their environment. Mental health concerns may arise through this learning or through a person’s negative experiences associated with this learning (Spiegler & Guevremont, 2020). A person will increase behaviors that are rewarded and decrease behaviors for which they are punished (Hayes et al., 2011‌‌‌‌‌). It is this punishment and other negative consequences of their behaviors that can be the source of mental health concerns.

Classical Conditioning Classical conditioning, also known as stimulus–response model or respondent conditioning, occurs when a response is paired with an environmental condition. Many of the behaviors that we exhibit daily are the result of involuntary responses. In much the same way that Pavlov conditioned dogs with a bell and food, certain behaviors are increased or decreased due to various stimuli being present in a person’s environment (Mariani & Zyromski, 2019‌‌‌‌‌). Some unconditioned stimuli and responses may be adaptive in nature. Imagine a child touching a hot iron (unconditioned stimulus). They react by pulling away instinctively (unconditioned response). This is adaptive in that the unconditioned response minimizes the injury to the child. Similarly, that same child may experience the neighbor’s dog that recently bit their sibling. The dog barking that was previously a neutral stimulus has now become paired with the fear of being bitten (unconditioned response) and becomes a conditioned stimulus. The child now experiences fear when hearing the dog bark. This example of adaptive conditioning provides a degree of protection for the child. While it is not necessarily adaptive for the child to fear all barking dogs, it aids in the child’s safety when engaging with the neighbor’s dog.

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Within the context of classical conditioning, mental health concerns may arise from pairing of a neutral stimulus with a respondent condition. This can be relatively complicated and possibly maladaptive. An individual with an abusive parent may experience anxiety when that parent arrives home from work leading to behaviors associated with anxiety (e.g., panic attack, jitters). When that parent arrives home, the garage door always opens. Soon, the individual may begin to associate the sound of the garage door (neutral stimulus) with the anxiety felt (respondent condition) toward the parent’s arrival and display the behaviors associated with that anxiety at the sound of the garage door alone. This, and other similar situations the individual experiences, causes the anxiety that once was associated solely with this parent to begin to be associated with any number of other, previously neutral stimuli. In regard to mental health, the individual now, rather than solely processing the existence of an abusive parent, has behaviors and emotions associated with previously neutral stimuli that they must work to extinguish. Such a situation creates‌‌‌ an additional layer of complexity to therapy and treatment and, if given certain circumstances, may lead to symptomatology associated with a particular disorder (e.g., generalized anxiety disorder).

Operant Conditioning Mental health concerns can arise from learning within the context of operant conditioning. While individuals increase the frequency of and strengthen behaviors that are reinforced and decrease the frequency of and weaken behaviors that are punished, the consequence of this can create complexities within an individual’s life. A person may experience a reward for maladaptive behavior and, per operant conditioning, continue to repeat that maladaptive behavior to the detriment of their mental health. Likewise, an individual may display positive behavior that is not rewarded or reinforced. This may lead that individual to remove that positive behavior from their behavioral repertoire. While such experiences may occur in an individual’s life, given the correct circumstances, they could lead to mental health concerns. Take, for instance, an adolescent who is encouraged by their friends (rewarded) to use drugs and take unhealthy risks. This individual is rewarded with attention from friends and possibly a sense of belonging to a group. This, given the correct circumstances, can impact school performance as well as college and job opportunities and contribute to increased drug use that has multiple mental and emotional implications. This lifestyle, and the mental health and emotional concerns associated with it, originated with negative behaviors being reinforced as opposed to being punished. Conversely, a child who does many things correctly and exhibits positive behaviors but is never praised (reinforced) or shown love may view the withholding of praise and love as a form of punishment. The child may learn that “it doesn’t matter if I do everything right” or that no one cares. This, in turn, can impact that individual in later years as they struggle to please others and get the praise they never received or they cease to exhibit such positive behaviors altogether. In such a situation, the mental health concerns originated within operant conditioning where the child did not receive reinforcement for positive behavior and, in some ways, was punished for positive behavior. Such experiences may lead to feelings of depression, hopelessness, or any number of other mental health concerns.

Dialectical Behavior Therapy DBT involves client’s interpersonal struggles with opposing forces in their lives. Dialectics includes the belief that for every point there is a counterpoint and that people can grow and develop competence when these polarities are accepted and explored (Almagor, 2011‌‌‌‌‌). For example, a parent may enter counseling wanting to explore their desires to be a nurturing and loving parent while sharing interactions with their children that are typically considered

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discouraging and unloving. When clients try to deny feelings or struggle to find the “right way” to believe or behave, these things that cause concern may intensify (Cress et al., 2021). DBT offers clients an opportunity to review these opposing forces within themselves and their circumstances and decreases the negative responses of dilemmas faced by clients when having to choose only one of these opposing positions. This aids clients in moving to a position where they can synthesize polarities of experiences, beliefs, and feelings to come up with a “truth” for themselves that they can accept and act upon more constructively.

EMOTIONAL AND PSYCHOLOGICAL WELL-BEING Well-being is the experience of health, happiness, and prosperity and includes factors such as mental health and life satisfaction. It is, in its simplest form, the experience of feeling well (Davis, 2019). Emotional and psychological well-being are an extension of this basic concept and would include one’s perception that the emotional or psychological aspects of their beings are healthy or acceptable. Behaviorism describes a person’s mental and emotional well-being by the premise that individuals learn from their environment that shapes and impacts their behavior in various ways. While not entirely behavioral in nature, models of well-being (Ryff, 1989) reflect the results of behavioral constructs that lead to adaptive behaviors playing a role in increased well-being.

Classical Conditioning One’s sense of well-being may be impacted through the experiences in life that can be attributed to classical conditioning. Individuals experience a variety of stimuli throughout their lives and unknowingly pair unconditioned stimuli with neutral stimuli. These pairings may represent either positive or negative experiences for the individual. An individual may learn to fear all dogs due to being conditioned during childhood by the neighbor’s angry dog. When hearing a dog bark, that individual may exhibit particular behaviors that express the fear being experienced. Positive emotions may be related to something like hearing holiday music in a store. When an individual hears the music, they may feel and behave in a more cheerful manner. Well-being, as it applies to classical conditioning, can be impacted by inconsistencies that may be experienced when neutral stimuli are presented. For example, if an individual has always been afraid of dogs due to early conditioning experiences but later has positive experiences with dogs and during these experiences, fear is not present, the new experiences will impact their overall perception of dogs and the individual’s well-being may increase. However, it may be perceived as negative in that the individual may be slightly confused as to why something they have always felt is no longer present. This could impact the sense of well-being in a negative manner. In essence, the unconditioning of the pairing of neutral stimuli with unconditioned stimuli that individuals experience throughout their lives, given the correct circumstances, may impact the perception of well-being in both positive and negative ways.

Operant Conditioning The learning that occurs via the rewards and punishments that are experienced in one’s environment constitutes the basis of operant conditioning. One’s perception of the positive or negative nature of their emotional or psychological well-being may be influenced by the operant conditioning one experiences in daily life. If one individual experiences punishment and correction more often than rewards, that individual may begin to perceive their overall well-being in a more negative manner. The most basic form of this experience could be described as “life is not going well.” There can be a sense that life is difficult or that they

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are doing everything wrong and the individual’s well-being suffers. Conversely, as healthy choices are made in an individual’s life, it is not uncommon for the individual to experience rewards for such choices. Such experiences may have a positive impact on one’s emotional or psychological well-being in that individuals begin to feel that things are going “right” and all is well. Such conditioning may be limited to one area of a person’s life or apply to many areas of life. One’s emotional and psychological well-being may be negative at work due to the impact of punishment or correction while their perception of well-being in other areas of their life may be quite positive due to the experience of rewards. These experiences of positive and negative well-being that are influenced by operant conditioning are shaped by how quickly and how well the individual learns and adapts to the reinforcers or punishments they experience. Additionally, one’s perception of well-being itself may serve as a reinforcer if positive well-being is experienced or punishment if negative well-being is experienced.

Dialectical Behavior Therapy In DBT, psychological well-being is considered strong when people accept experiences (even those that are painful) and react to them in constructive ways. Clients who have successfully worked in DBT programs feel more complete when countering the incompleteness that may arise from experiences in their lives and develop what Neacsiu et al. (2021) described as the “capacity for sustained contentment” (p. 400).

THE ROLES OF THE CLIENT AND COUNSELOR Counselors working from behavioral theoretical lens tend to focus on overt behaviors and measurable outcomes. They take on an active role in identifying maladaptive behaviors, and they work with clients to “learn new, appropriate ways of acting or modify or eliminate excessive actions; adaptive behaviors replace those that are maladaptive” (Gladding, 2022, p. 103).

Classical Conditioning While counselors and clients must work together in counseling in order for meaningful progress to occur, within the context of classical conditioning utilized in therapy, they have unique and distinct roles. Clients are largely responsible for identifying behaviors they would like to alter or eliminate. Counselors will aid clients in this exploration, but it is largely the clients who make the alteration of such behaviors a priority. Counselors may need to, through questioning or other means, provide clients with objective insights into unhealthy behaviors that may relate to clients’ concerns. These objectively based insights would likely not be noticed by clients. For example, a client seeks counseling to reduce anxiety and stress and, in therapy, discusses their busy life and schedule. The counselor notices that the client instinctively reaches for their pocket every time their phone buzzes even though, out of respect for the counselor, the client has no intention of answering the phone. In this case, the counselor may simply discuss with the client the observation of the client reaching for their phone instinctively. In addressing anxiety and a stressful lifestyle, it may be that this instinctive reaction to a phone buzzing is something the client would like to alter in order to “slow down” life and reduce stress. In continuing this example, the role of the counselor is one that helps identify the pairing that has occurred in the client’s life. The counselor is also responsible for developing a plan with the client in order to uncondition this response. In this case, both client and counselor would need to arrive at a meaningful process by which that pairing would be unconditioned. The counselor has the responsibility of ensuring that the actions decided upon will,

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in fact, work to uncondition the pairing. The client has the responsibility of executing the actions and process of unconditioning outside of the therapy session. The counselor may work to hold the client accountable for their actions or inactions and evaluate, on a regular basis, the effectiveness of the course of actions being taken to uncondition the response.

Operant Conditioning In counseling, operant conditioning relies on the use of reinforcement or punishment to shape or change behavior as well as modeling and interventions such as token economies. The roles of the client and counselor are unique in this approach but also rely on each other in the development and execution of their individual tasks and goals. The counselor will work in collaboration with the client or significant others (e.g., teachers, guardians, etc.) in the client’s life to determine behaviors they would like to see increase and reinforcers (rewards) that the client sees as valuable (Hayes et al., 2011‌‌). Once behavior targets and rewards are defined, the counselor, client, or significant others in the client’s life will reinforce the behaviors by providing them with rewards when the behavior is exhibited. Conversely when clients, counselors, and significant others work collaboratively to find behaviors that they desire to be reduced, a punishment or reductive technique is used to decrease or eliminate the target behavior. In operant conditioning, the counselor is responsible for the complicated and complex task (Seaberg, 1982) of discovering the most valuable and effective reinforcers for the client. Delivering reinforcers as continuous reinforcement (i.e., the client is awarded following each instance of the target behavior) tends to be the most effective schedule to use in establishing new behaviors. Counselors may also use intermittent schedules known as fixed schedules of reinforcement in which the reinforcement is provided after a predetermined time (interval) in which the desired behavior occurs or number of times (ratio) the desired behavior is exhibited. Additionally, counselors may use a variable schedule of reinforcement in which desired behaviors are reinforced at varying rates associated with time or occurrence. Variable schedules of reinforcement are when behaviors are reinforced on a seemingly random and inconsistent schedule yet tend to produce the most long-lasting patterns of behaviors. The influence of variable schedules of reinforcement are observed in the addictive behaviors exhibited by gamblers using slot machines. When utilizing techniques and approaches related to operant conditioning, the counselor manages the use of the intervention, is responsible for determining the effectiveness of the approach, and serves as a source of accountability that the client must answer to in order for such approaches to be effective. In managing the approach, the counselor works with the client to determine the most impactful rewards or punishments that will aid the client in achieving their goals in counseling. The client will provide insight and feedback to the counselor and the counselor will then manage the execution or provide oversight to the interventions and strategies developed. The counselor also, when utilizing this approach, is responsible for periodic evaluation of the effectiveness of the approach. This may require continued discussions with the client and other stakeholders about the intervention and strategies or about particular rewards and punishments. Finally, the counselor will hold the client accountable to provide an accurate evaluation of goal attainment to determine their effectiveness. As noted, the client’s role provides clarity and definition to the counselor’s role. The client is responsible for providing the counselor feedback in the development of the rewards and punishments approach being utilized. Rewards and punishments must be meaningful and unique to the client in order for their utilization to be effective. It is necessary for the client to communicate such information directly to the counselor to assist the counselor in the effective execution of the approach. The client is also responsible for the work necessary to change the behavior in question. They must be open to learning from the results of the interventions and

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strategies based in operant conditioning. In using behavioral approaches, the counselor will facilitate the interventions and strategies and provide a source of accountability, but the accurate evaluation and the behavior change needed for long-term growth and learning is the client’s responsibility.

Dialectical Behavior Therapy Clients and counselors gain awareness of dialectical forces in their lives and make life changes related to this awareness. DBT arose out of the need for counselors and clients to go beyond what some saw as a singular and limiting focus on change in behavioral approaches and introduced humanistic principles including acceptance and validation for clients’ experiences and feelings (Salsman, 2022). Counselors aid clients in gaining an understanding of what influences their feelings and actions and works with clients to help them regulate emotions and behaviors to decrease the reactions to circumstances that are concerns for counseling. Through collaborative relationships, counselors explore clients’ situations and emotions and their behavioral responses to them and test these responses based on reality. This can result in an acceptance or validation of thoughts, feelings, and actions or in clients learning about how these responses may be maladaptive given the circumstances. While a fundamental principle of DBT is that clients are doing the best they can in current circumstances (Linehan, 1993), when responses are viewed as maladaptive, counselors and clients work together to find more adaptive reactions, thus changing behavioral responses.

THE NATURE OF HUMAN DEVELOPMENT Behaviorism postulates that all human development is grounded in the learning or conditioning that is experienced throughout life. Classical conditioning asserts that we grow and learn based on a lifetime of pairings of unconditioned stimuli with neutral stimuli. In doing so, individuals develop instinctive responses to stimuli throughout their lives. This may be further manipulated or edited in therapy or by natural processes and experiences. However, the behaviors of individuals throughout their development and various stages of life may be attributed to the classical conditioning one experiences. While operant conditioning asserts the same general notion that the foundation of human development is centered on the learning or conditioning that takes place in one’s life, it continues to move beyond unconscious pairings and focuses instead on the reinforcers of our behavior. Operant conditioning, as it applies to human development, would state that it is the series of rewards and punishments one experiences throughout life that shapes behaviors and life itself. From a small child touching a hot iron and getting burned to an adult being rewarded for practicing professional behavior in the workplace, individuals learn and develop throughout their lifetime via operant conditioning.

PROCESS OF CHANGE Behavioral approaches attempt to change behaviors by altering the environmental conditions (antecedents and consequences) that maintain them. Once learned, associations can be unlearned through changes in environmental contingencies causing counterconditioning and more adaptive behaviors can be used by clients. This modification in behavior can be accomplished by using principles of learning in which particular behaviors are rewarded and punished resulting in their increase, decrease, and/or extinction. Change is determined by observation (Mariani & Zyromski, 2019‌‌‌‌‌). Change may also occur through behavior therapies, such as exposure therapy, where the client learns to control reactions or behaviors given a particular situation or behavioral stimulus (APA, 2017b).

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Classical Conditioning Classical conditioning relies on associations that we make between stimuli that impact our learning and produce behaviors. Much like a dog associating a bell with food, we may also associate neutral stimuli with unconditioned stimuli to produce a variety of responses given any particular stimulus. The process of change within classical conditions begins with the identification of the desired behavior (response). In therapy, the client and counselor must first know what response is desired before moving forward. The next step is to determine what unconditioned stimuli aid in producing that desired response. Once both of these factors are known, the counselor and client may then work together to associate a neutral stimulus with the unconditioned stimulus so that the desired response may be controlled by the client as needed. For example, a client may want to be more efficient at work (desired response) and knows that a clean workspace helps them to naturally work more effectively (unconditioned stimuli). Now the work of associating a neutral stimulus, such as a particular time of day, with the unconditioned stimulus, is necessary. The client works to develop a routine for starting the workday. Each day, when they arrive at work, they take a few moments to organize their desk. This associates a neutral stimulus (arriving at work) with an unconditioned stimulus (a clean workspace) that leads to an unconditioned response (more productive work). Considering the process of change for classical conditioning, responses may be strengthened, eliminated, or associated with new neutral stimuli, as needed, throughout therapy in order for necessary change to occur and to be maintained.

Operant Conditioning The premise of operant conditioning is grounded in the concept of law and effect that suggests that behaviors are likely to be repeated if they are followed by consequences that are pleasurable or enjoyable. At the most basic level, operant conditioning relies on this simple concept and related concepts to enact change within an individual and to continue that process of change or learning. The process of change within operant conditioning begins with the identification of the behavior or behaviors for which change, or alteration, is desired, otherwise known as target behaviors. Often, this may occur in counseling where the client works in concert with the counselor in developing a meaningful and effective treatment plan. Once the behaviors are identified, operant conditioning postulates such behaviors can be manipulated or changed through the development and execution of a reinforcement schedule. Through a series of rewards and punishments, desired behaviors can be reinforced and, thereby, replicated as the individual learns to repeat behaviors that result in a positive consequence. Likewise, undesired behaviors can be reduced or eliminated with the presentation of a negative consequence. The continual application of such an approach will work to alter behavior patterns to whatever degree an individual chooses. Many different interventions and approaches may be utilized to enact behavioral change following the constructs of operant conditioning. One approach developed by Skinner is shaping. Shaping involves the application of rewards for approximations of the targeted behavior. The premise of shaping is often a more useful approach because it does not require the target behavior to be displayed in entirety before a reinforcement is provided. Behavior modification often occurs gradually and shaping provides for reinforcement of that gradual change while relying on the notion that growth and learning will continue to occur in the direction of the target behavior if small rewards are provided for approximations of that behavior. While this still allows for notable changes in behavior where the targeted behavior

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is displayed relatively quickly and rewarded, it also provides for conditions where more gradual change may occur.

Dialectical Behavior Therapy The DBT approach expands on the fundamental opposing forces of humanistic and behavioral approaches that are incorporated to bring about behavior change (Pederson, 2013). DBT involves a pretreatment phase to determine if DBT would be the most effective treatment for the client. If it is determined that DBT would be helpful to the client, then four separate stages in counseling follow. Stages are not chronological, allowing clients to move through and return to stages as new information or concerns arise (Vaughn, 2023). Stage 1 includes learned skills in order to regulate emotions that often lead clients to destructive behaviors and low quality of life. Because DBT was originally designed to serve clients who were suicidal, this step involves those skills that help clients in eliminating life-threatening behaviors (Vaughn, 2023). Clients are introduced to and learn basic skills that are pertinent to them, thus increasing their competency and potentially increasing their commitment to counseling. Stage 2 involves introducing the histories of traumatic events (Vaughn, 2023) and childhood in clients’ lives, addressing symptomatology related to experienced trauma such as abuse, and exploring the impact on their current functioning from messages they have developed related to experiences. Clients should have control and be able to manage responses that would surface when describing experiences that they view as traumatic (Salsman, 2022). Stage 3 is characterized when skills are beginning to be generalized by the client outside of sessions resulting in their ability to manage ordinary life tasks and the rise and fall of emotions by trusting one’s ability to do so. Stage 4 involves deeper meaning through self-respect, spiritual fulfillment, and goal attainment. Clients in Stage 4 can feel sustained joy and freedom (Salsman, 2022). The stage in which a client begins is dependent on the struggles of the client when they enter counseling. For example, if a client is struggling with severe problem behaviors (e.g., self-harm, destructive addiction), then they would enter counseling in Stage 1 for counselor and client to manage behaviors collaboratively. If a client enters counseling with behaviors that are non-life-threatening or highly destructive with a commitment to change, then they may enter Stage 2 (Vaughn, 2023).

MAINTENANCE OF PROGRESS As with all counseling, behaviorally oriented counselors assist client with their progress toward goals, continual growth, and learning. Both classical and operant conditioning embody unique characteristics that influence the roles and responsibilities of all parties involved in therapy. These factors impact the continuation of client progress.

Classical Conditioning Throughout the course of therapy, classical conditioning is utilized to alter a client’s behavior, and continual assessment of progress is required. This assessment will allow both the client and counselor to know whether progress is being made and will influence the actions taken to maintain that progress. Both clients and counselors are responsible for the maintenance of progress. Clients are responsible for continuing to work, both in and out of session, on whatever process has been decided upon to alter the behavior in question. Clients are also responsible for accurate reporting of behaviors to the counselor and for discussing openly if the process for altering behavior using classical conditioning techniques is not effective. Counselors are responsible

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for thoroughly exploring what progress has been made and deciding if there are any factors that are impeding progress. This may be done through simple questioning of the client about life changes or experiences where progress in altering the behavior in question has been hindered. In addition, once the alteration of the behavior in question has occurred, both parties are responsible for examining factors that impact the longevity of the desired behavior. In the example provided earlier, if the client is making notable progress in not instinctively reaching for their phone when it buzzes, but a very stressful situation at work has caused the client to begin to react instinctively to the buzzing of the phone, that situation should be discussed and the process of change evaluated to see what steps should be taken in order to continue making progress toward the desired behavior. In classical conditioning as it is used in counseling, the willingness of both the client and counselor to openly evaluate and edit the process of unconditioning the response is necessary for progress to continue.

Operant Conditioning When clients and counselors engage in therapy that involves techniques, interventions, or approaches related to operant conditioning, it is essential, as with all therapy, that progress toward a client’s goals be maintained and enhanced. Both the counselor and client assume responsibilities in the maintenance of client progress. It is essential that clients continue to work toward their goals and beyond by continuing to utilize the interventions and approaches decided upon by the therapist in consultation with the client. Counselors often use homework between sessions to transfer client learning from the counseling office to the client’s environment (Antony, 2019). It is important for the client to address any changes in their life that may interfere with the approaches being utilized. If something changes in the client’s life that reduces the impact of the reward or punishment being utilized in the approach, it is important for the client to discuss this with the counselor and work to define a new set of rewards or punishments as they work toward their goal. Likewise, counselors must regularly evaluate the effectiveness of the rewards and punishments being utilized and suggest changes as necessary in order for the approach to continue to be meaningful to the client. Additionally, both the counselor and the client must work in concert with one another to edit goals as previous goals are achieved. This allows for continual growth in areas of concern and, at the same time, can serve as a reward for, and acknowledgment of, accomplishing a prior goal. The goal of any behavior therapy is to maintain desirable and adaptive behaviors. Success in behavioral counseling approaches is determined if the changes made in therapy positively impact the client’s life and that these impacts endure posttreatment (Spiegler & Guevremont, 2020‌‌‌‌‌). Once the behavior has been established, it is possible to change to a partial schedule of rewarding the individual. This should be done slowly by gradually reducing the frequency of providing reinforcement. Diebert and Harmon (1973)‌‌‌‌‌ suggested first decreasing reinforcement patterns to reinforce 80% of the time, then 50%, then 30%, and, finally, only occasionally.

PROCESS OF ASSESSMENT The main purpose of behavioral assessments is to clarify specific maladaptive behaviors or collections of behaviors and the events (antecedents and consequences) associated with them (Richard, 2010‌‌‌‌‌). Behavioral assessment approaches historically have relied exclusively on the observation of client behaviors, specifically a target behavior that is a focus in counseling. As behavioral approaches and assessment evolved, internal states (cognitions and emotions) have become part of some assessments. Throughout, there is a continual reliance on the evaluation of presenting behaviors and the evaluation of the effectiveness of interventions and strategies. Typical assessment procedures include observations or interviews

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as well as formal scales and inventories to gather information and evaluate client behaviors and progress.

Functional Behavioral Analysis Functional behavioral analysis is an assessment technique utilized in behavioral approaches and is based on functional contextualism involving behavior as a function of the environment of the client. Clinicians conduct formal observations or interviews with clients in order to determine the target behavior that is to be changed or extinguished and its dimensions such as frequency, duration, and intensity of the behavior and events that serve as antecedents and consequences for client behaviors. An ABC model‌‌‌ is utilized in which A, represents antecedents, B, the exhibited target behavior(s), and C, the consequences of these behaviors. The antecedents and behaviors serve to maintain the target behaviors in clients and in the techniques that follow. Through functional behavioral analysis, the counselors will obtain information on how to influence the maintaining antecedents and behaviors that maintain the behavior in order to bring about behavioral changes. For example, an adolescent client may be referred to the school counselor for disrespectful behaviors exhibited in an English/language arts class. The counselor, following a behavioral approach, would begin by thoroughly examining the behaviors of the adolescent and specifying a target behavior along with its antecedents and consequences. In this example, the behavior may be a student continuing to look at social media after being asked by the teacher to discontinue this practice and to begin the assigned reading. In this case, the counselor would want to note the frequency of this behavior exhibited by the adolescent. This will also serve as a baseline and can be used to assess how well interventions are working once implemented. Antecedents in a‌‌‌ functional behavioral analysis can consist of components that are directly observed, for example, a teacher asking a student to put their phone away and to begin reading. Alternatively, they can be private events such as cognitions or emotions such as the student’s desire to continue exploring social media or anger at being told what to do. In this example, the behavior is the student continuing to explore social media. The counselor could interview the adolescent and teacher to gain information about antecedents that are unobservable. The consequences that are provided are also explored. In the case discussed previously‌‌‌, the teacher either ignores the student who continues to explore social media or sends them to the office where the student can continue to explore social media on their phone while they wait for the school disciplinarian. In each case, the consequences are positively reinforcing behaviors as the behavior continues. After a functional behavior assessment, the counselor can work directly with the client and others in the client’s life to change the relevant antecedents and consequences.

Behavior Assessment for Children, 3rd Edition The Behavior Assessment for Children, 3rd Edition (BASC-3; Reynolds & Kamphaus, 2015) is the latest edition for one of the most widely used formal assessments to help in understanding both adaptive and problem behaviors and emotions of clients who range from preschool-aged children to young adults. The assessment is a multidimensional approach that includes documentation ratings and questionnaires from teachers, parents, and clients as well as observational components and the gathering of the client’s detailed developmental history. Training and supervision are provided to clinicians in the administration and interpretation of results. Additionally, the BASC-3 includes a collection of evidenced-based interventions for use by parents and teachers as well as a tool for tracking intervention progress. The BASC-3 has shown both high reliability and validity for its scales and subscales with the coefficient alpha reliabilities all exceeding .80. One-month test-retest reliabilities for some of the self-report scales dipped below .80 at .78 for children in their self-report

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of clinical and adaptive scales measuring such things as anxiety, depression, self-esteem, and parental relations and .76 for adolescents and young adults on the sub-scales measuring for anger control, ego strength, and test anxiety. Interrater reliabilities for the BASC-3 Teacher and Parent Rating scales ranged from .77 when rating preschool children’s functional impairment to .82 for the composite of the parent rating scales. The BASC historically has shown high correlation with other child and adolescent measures such as the Child Behavior Checklist, Achenbach’s Teacher Report Form, Conners’ Teacher Rating Scales, and the Minnesota Multiphasic Personality Inventory (MMPI).

Achenbach System of Empirically Based Assessment The Achenbach System of Emprically Based Assessment (Achenbach, 2015)‌‌ relies on teachers, parents, observation, and interviews to gather information related to problems in cognitions, emotions, relationships, and behaviors. Described as perhaps the “gold standard of behavior rating scales” (Achenbach, 2015‌‌‌‌‌), the system is widely used by counselors in a variety of settings such as hospitals, schools, and agencies and is comprised a variety of separate age and developmentally appropriate instruments that can be used individually or in combination on clients from ages 18 months to over 90 years of age. Recent updates are related to ensuring the multicultural integrity of the instruments related to ethnicity and gender identity (ASEBA, 2023). Results reported quantitatively and qualitatively are related to cognitive abilities, adaptive functioning, and problems, and the system can be used to monitor intervention effectiveness and progress. Included in the manual is a multicultural supplement and the website provides information on how to administer assessments and interpret results in a non-biased manner (ASEBA, 2023‌‌‌). In his review of the ASEBA, Kranzler (2017) describes the psychometric properties as exceptional with alpha coefficients ranging from 0.71 to 0.95 on the various forms and scales. Moderate to strong correlations ranging from 0.49 to 0.58 were found for teacher’s ratings, and between mothers and fathers, strong correlations ranged from 0.60 to 0.76 on various scales.

Dialectical Behavior Therapy The gathering of biopsychosocial data related to clients’ recent and current concerns in initial sessions forms the basis for further treatment. The use of Linehan’s Social History Interview (Weissman & Bothwell, 1976) helps counselors in gathering information related to a client’s “predisposition to high emotionality, experiences of invalidation in the environment, and the transaction between the two” (p. 301), which aids to uncover the origins of the client problems (Salsman, 2022‌‌‌‌‌). In pretreatment sessions, counselors can gain information on client’s history related to self-reported suicidal behaviors using the Suicidal Behaviors Questionnaire or addictions using the Substance Abuse History Interview (Behavioral Research & Therapy Clinics, University of Washington, 2023‌‌‌‌‌). Throughout treatment, counselors are assessing clients’ commitment to change, barriers to counseling, motivation, variables that maintain client destructive beliefs and behaviors, client knowledge and use of skills, fit related to the stage of counseling, and the progress of counseling (Salsman, 2022‌‌‌‌‌). In consultation sessions, counselors may use the Therapist Interview to assess the counselor’s perceptions of client progress (Behavioral Research & Therapy Clinics, University of Washington, 2008). For additional assessments associated with the work of Dr. Linehan and colleagues in DBT, see https://depts.washington.edu/uwbrtc/resources/assessment-instruments/.

THEORETICAL TECHNIQUES The majority of techniques in behavioral approaches can stem from classical conditioning (e.g., systematic desensitization) or operant conditioning (e.g., behavior modification

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programs; Choudhury, 2017). The process of behavioral counseling outlined by Spiegler (2021) and Cress et al. (2021)‌‌‌‌‌ involves strategies and techniques that typically focus on identifying the behavior to be changed, modified, or extinguished (target behavior) and analyzing that behavior for antecedents, consequences, and characteristics (e.g., frequency, duration, severity). Goals related to desired counseling outcomes are then set and techniques/strategies are developed to support clients in meeting their goals. Strategies and techniques are incorporated in a plan for behavioral change. As strategies and techniques are utilized in and outside of sessions, goal attainment is formally and objectively assessed with client progress measured. Revisions are made to the plan to best support clients in making and maintaining changes. Typically, the focus of counseling intervention is on singular behaviors and additional behaviors are addressed in counseling consecutively (Speigler & Guevremont, 2020‌‌‌‌‌). A sampling of techniques practiced in behavioral counseling approaches are described in the following sections‌‌‌.

Classical Conditioning and Exposure Therapies Exposure therapies encompass many of the techniques utilized within classical conditioning. Exposure therapies are often utilized in the treatment of phobias. In such situations, people may not only avoid particular situations or things but also anything that may potentially elicit similar responses in them. Exposure therapy, through a variety of techniques, aims to expose the client to the situation or item so as to reduce the anxiety associated with that situation or item. This may be performed slowly, beginning with the client simply imagining the situation. Or the counselor may choose to challenge the client by placing them in the situation immediately. Take, for instance, a person experiencing arachnophobia. The counselor may have the client first imagine a spider and discuss their experience. They may then move on to the client holding a picture of a spider and then, eventually, move to being in the presence of a spider. Another option could be having the client go to the local zoo daily to see spiders behind a protective glass and repeat this process continually until the anxiety is reduced. There are several common techniques, reciprocal inhibition, systematic desensitization, and flooding, utilized under the umbrella of exposure therapy in classical conditioning. RECIPROCAL INHIBITION

Reciprocal inhibition is‌‌‌ developed by Wolpe (1958)‌‌‌‌‌ and based on his hypothesis that incompatible responses cannot occur simultaneously. For example, anxiety as a response to anxiety-provoking stimuli cannot occur in the presence of relaxation techniques such as progressive muscle relaxation used to decrease anxiety. Reciprocal inhibition is often used to treat anxiety, phobias, and fear responses. It is a therapeutic technique that attempts to reduce the effect of a negative stimulus by pairing a desirable stimulus with the negative undesirable stimulus. Counterconditioning of the response is the goal. This counterconditioning requires a desirable stimulus that is incompatible with the negative powerful and repeated enough to counter the response. An example would be if anxiety inhibits a person’s ability to enjoy travel, but then if travel becomes exciting enough, then they can be used to counter anxiety. Or a woman who is anxious in social settings uses an emotional support animal to counter her feelings of anxiety. In this case, the calm response evoked by the emotional support animal is strong enough to inhibit the anxious response brought up by the social situations. The effectiveness of this approach is considered high when clients can use their desired responses on a regular and consistent basis. SYSTEMATIC DESENSITIZATION

Systematic desensitization, an exposure strategy developed by Wolpe, is based on reciprocal inhibition that asserts that people cannot feel both anxious and relaxed at the same moment. Clients and counselors collaborate to develop a hierarchy of stimuli that provokes fear or

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anxiety in the client. The clients are then taught relaxation strategies (e.g., deep breathing, muscle relaxation) and use these developed skills as they are introduced via visualization or reality to these stimuli from weakest to strongest while using the relaxation techniques. At times, clients and counselors may need to return to facing weaker stimuli in order to remaster relaxation techniques (Henderson & Thompson, 2011). Counterconditioning occurs when clients replace anxiety with relaxation techniques and exhibit fewer sensitive responses when faced with situations that once aroused anxiety and fear in them. For example, a client who experiences agoraphobia will work with the counselor to develop a list of situations where they experience agoraphobia to a notable degree. The counselor then will work with the client in visualizing being in any one of these situations while in the counseling sessions. Next, therapy continues as relaxation techniques, as well as other techniques, are introduced to the client to aid in abating the emotions evoked from the visualizations of the situations. FLOODING

Flooding is the opposite of systematic desensitization in that the strongest anxiety-inducing stimuli are imagined or experienced first and rapidly repeated or endured over a prolonged exposure in order to desensitize clients quickly to a specific stimuli. Clients are prevented from using unhealthy coping strategies during this exposure allowing clients to learn that feared consequences may not occur as the result of these once distressing situations thus leading to a decrease in the anxiety and fear behaviors once associated with them. Because client distress may increase initially, it is important that clients are kept informed of the procedures involved in flooding and it is used after a trusting relationship is established between the client and counselor (Choudhury, 2017). Flooding may be utilized in therapy if, for example, a client notes an irrational fear of being left alone in a small room. The counselor will leave the room, leaving the client alone, and force the client to face this fear rather than simply visualizing or imagining it. This is repeated at regular intervals until the client becomes desensitized to being alone in a small room. Throughout this process, the counselor works with the client to find effective ways of processing the anxiety and fear.

Operant Conditioning MODELING

Modeling is based on social learning theory and operant conditioning. In modeling, the client observes a model demonstrating a particular behavior that resembles the maladaptive behavior to be replaced or extinguished or the more adaptive behavior that will be the replacement behavior. The client observes the model being reinforced or punished for exhibiting these behaviors thus leading to learning and the client exhibiting the more socially acceptable behaviors in similar contexts and situations. There are certain criteria that increase the effectiveness of the technique including the model’s similarity (e.g., age, sex, race, etc.) to the client, which enables the client to see themselves in the model. Exceptions to models holding similar characteristics to clients include celebrities or those perceived as having prestige or influence (Austin, 2018). For example, this technique can be used in counseling an adolescent who is exhibiting poor behavior in school and possibly life in general. The counselor may work to provide the client with real-life examples of individuals who continued on a similar path of maladaptive behavior in school and in life in order to demonstrate the pitfalls of such behaviors. The counselor may then introduce more positive models that demonstrate a variety of adaptive behaviors. In addition, there are often questions and discussions about what the client wants their life to be like and introspection about the choices they have and can make in life. REINFORCEMENT

Reinforcement involves the process in which consequences lead to behaviors being strengthened or more likely repeated. Positive reinforcement involves the addition or increase of

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something. Negative reinforcement is the prevention or removal of aversive stimuli. The reinforcer is unique to the client thus requiring a thorough investigation of what is reinforcing to them. The effectiveness of reinforcement is higher when the reinforcer occurs immediately or shortly thereafter the behavior is exhibited, there is contingency between the behavior and the reinforcer, meaning that the client learns that if the behavior is exhibited, then the reinforcer is likely to occur. A simple example of positive reinforcement in everyday life is a child receiving their allowance immediately after weekly chores are completed. This is effective because the reinforcement occurs shortly after the task is completed. Similarly, an example of negative reinforcement would be when the parent reduces the number of chores the child has to do whenever the child works hard to complete the weekly chores at the beginning of the week. This helps the child to learn that if they work hard at the beginning of the week, they will be rewarded with not having to do as many chores. As with positive reinforcement, negative reinforcement should follow the desired behavior in a timely fashion. PUNISHMENT

Converse to the results of reinforcement, punishment results in the decreasing or weakening of behaviors as the result of introducing an aversive stimuli (positive punishment) or removing reinforcing stimuli (negative punishment). Like reinforcement, the effectiveness of punishers depends on the immediacy and consistency of the delivery punisher. To be most effective, a punishment should be delivered as soon as and each time the behavior is exhibited. Additionally, punishers are client dependent, meaning that a punishment for one client may not be considered punishment by another. Following the examples for reinforcement, positive punishment would be a parent adding chores to the list of weekly chores whenever the child waits until the “last minute” to complete chores. If the desired behavior is for the child to complete chores throughout the week, adding additional chores (positive punishment) whenever the child does not do this will work to reduce the child’s behavior of waiting until the end of the week to start completing chores. Negative punishment may work in a very similar manner. If the desired behavior is for the child to complete chores throughout the week, the parent may reduce the amount of the allowance anytime the child waits until the end of the week to start the chores. The removal of this positive factor (allowance) serves as negative punishment in this case. As with reinforcement, punishment should occur shortly after the undesired behavior occurs in order to be most effective. EXTINCTION

Extinction involves the removal of reinforcers to eliminate unwanted responses. An extinction procedure often employed in behavior modification programs for children is ignoring the undesirable behaviors or removal from the environment in the form of time-outs. In using time-outs, a client is removed from a reinforcer or away from positive reinforcement (Johnson & Melton, 2021‌‌‌‌‌). Time-out is commonly used when the client’s behaviors may be disruptive and harmful to themselves or others if they remain in the current situation or environment (Austin, 2018). An example of extinction may involve a client who cries intensely each time their partner leaves for a social outing with friends, because they do not want to be alone. In the past, this behavior has been reinforced with the partner canceling plans to be with the client. In extinction, the counselor would work with the partner to not reinforce the crying, but instead leave for the social engagement thus removing the reinforcement.

Dialectical Behavior Therapy DBT incorporates behavioral approaches based on classical conditioning, operant conditioning, and observational learning (Salsman, 2022) with building therapeutic relationships and mindfulness practices to form acceptance of a variety of historical (e.g., invalidating

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experiences of childhood) and present aspects (e.g., negative feelings and resistance). Counseling relationships can be long-term (e.g., at least 1 year) with a mixture of individual counseling sessions and group skills training sessions. Through techniques, such as exposure therapies, clients learn to utilize mindfulness to experience painful emotions without being overwhelmed by them or adversely reacting to them. This requires training in mindfulness practices, such as meditation, present-focus awareness, and self-compassion. DBT includes a structured model involving four modes of therapy delivery to bring about change. These include weekly 1-hour individual counseling that includes assessments of client commitment, motivation, and strategies to manage their unique challenges and weekly 2.5-hour group skills training with two leaders to build skills in distress tolerance, emotional and behavioral regulation, and interpersonal relationships. Counselors participate in weekly consultation sessions to find support. Additionally, clients utilize telephone, email, or text-message coaching that occurs between individual counseling and group skills training sessions to decrease feelings of isolation and obtain in-the-moment support. The focus or targets of each stage mentioned earlier, and modality, differ depending on the method of delivery. For example, individual counseling may include more personalized skills training based on the client’s unique experiences whereas group sessions may be more general in nature and include strategies that build skills based on interactions between members.

MULTICULTURAL, INTERSECTIONAL, AND SOCIAL JUSTICE ISSUES The extensive use of behavioral approaches in a multitude of settings from schools to agencies and hospitals allows for counselors to practice with a wide range of clients of intersecting identities related to age, race, ethnicity, religion, gender identity, socioeconomic status (SES), and abilities that merits an exploration of strengths and challenges of behavioral approaches from a multicultural, intersectional, and social justice perspective. Traditional behavioral approaches that viewed counselors as the expert and driver of goal selection have given way to more modern approaches focusing on the working relationship between client and counselor that is more collaborative in nature. This can allow for discussions related to cultural norms and values that influence behaviors. This focus on client authenticity related to goal attainment allows clients and counselors working in modern behavioral approaches to explore cultural influences on behaviors (McLaughlin, 2019). What may have once been framed as maladaptive may, when viewed from a cultural lens, be seen as adaptive. For example, a client who remains in isolation and refuses to leave the house because of continued discrimination and violence that has occurred may be viewed as protective rather than maladaptive when viewed from the purpose the behavior serves for the client (C. Lloyd, personal communication, January 6, 2023). Behavioral approaches have been used extensively in education settings. Oxley and Holden (2021) criticized traditional behavioral approaches, particularly positive punishment techniques, for failing to maintain some key foundational principles of social justice including dignity, equity, and access. They propose that shame and guilt may be inherent in positive punishment delivery to students and aversive stimuli such as detention and suspensions may decrease “full access” to students’ education. In their review of more modern approaches to behavior management being implemented in English and Scottish schools, they explored restorative justice practices, positive behavioral interventions and supports, and collaborative and proactive solutions which all include behavioral concepts and interventions and found that all aligned with key social justice principles. All approaches avoid punishment and espouse characteristics of more modern behavioral approaches including cognitions and mindfulness, social learning theories, contextual and developmental theories

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related to youth and organizations, and collaborative problem-solving. For a more extensive review of each approach, please see the websites provided in the Resources section. Behavioral approaches have either been found to be effective or easily adapted to serve a variety of clients. Ching (2022)‌suggested that the directive role of the counselor may be preferential for clients from an Asian background and behavioral approaches have been adapted for work with Asian American clients with anxiety and depression. Neal-Barnett and Smith (1996) proposed an Afrocentric approach to behavior therapy for children using radical Black behaviorism, an approach developed by William Hayes. This approach espouses an Afrocentric worldview with focus on the relational aspects of therapy and interventions rather than the individual. The counselor works with the client to bring about communal change that honors its diversity. Neacsiu et al. (2012) provided support of DBT as a treatment that is culturally sensitive as well as adaptable for a variety of clients regardless of race, SES, or age. As mentioned previously, if cultures desire active and directive approaches with a counselor that mirrors, this may find satisfaction in behavioral approaches (Antony, 2019). However, the individual focus of the client may not meet the needs of clients from collectivist cultures. More traditional behavioral approaches may need to be modified to explore and understand the wide range of complex factors that may be influencing a client’s behavior (Law & Woods, 2018). For example, systemic racism, biological factors, and relational factors such as bias may influence client’s behaviors that are viewed as maladaptive by counselors who do not gain a clear understanding of client’s worldviews and experiences.

Dialectical Behavior Therapy DBT approaches have been used successfully with clients from diverse backgrounds. A primary view of DBT involves the interactions between clients and the environment. Linehan (1993) contends that “individual functioning and environmental conditions are mutually and continuously interactive, reciprocal, and interdependent. The environment and the individual adapt to and influence each other” (p. 39). This view allows the counselor and client to explore the impact of and response to oppressive and invalidating environments that many marginalized clients from diverse backgrounds experience. The delivery modalities in DBT encourages cultural responsiveness on the part of the counselor. Individual counseling in DBT requires that counselors address the individual needs of the clients which allows for honoring of individuals and their experiences. Validation of client experiences requires counselors to gain understanding of client worldviews and perspectives thus increasing the cultural responsiveness of the counselor. Consultation sessions allow for the counselor to investigate areas in which they need to gather more information and address any potential biases that may prevent them from fully understanding clients (Salsman, 2021‌‌‌‌‌). Studies show the potential of DBT’s effectiveness with women (Linehan et al., 2006), transgender, gender-nonconforming individuals (Sloan et al., 2017), veterans (Decker et al., 2019), individuals with disabilities (Koons et al., 2006), and ethnic minority (Hispanic/ Latino and African American/Black) adolescents (Yeo et al., 2020). However, there should be caution in using culturally adapted DBT approaches because in a systematic review of literature on culturally adapted DBT, Haft et al. (2022)‌‌‌‌‌ found that there was not sufficient evidence to point to their effectiveness over nonadapted DBT approaches.

SCHOLARSHIP AND RESEARCH TRENDS As mentioned previously, behavioral approaches have a long history characterized by empirical rigor and research to develop and substantiate its use in counseling and psychology. Its core tenets and therapeutic process are founded on assessment and research. The traditional approaches including classical conditioning and operant conditional principles

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have been proven effective in medicine, psychology, and education. Research continues to show the effectiveness of second wave approaches including DBT. While behavioral approaches have been used to effectively treat a multitude of mental health and psychological conditions including anxiety disorders, autism spectrum disorders, bipolar disorders, depression, alcohol and substance use disorders, phobias, and trauma-related disorders, more modern approaches that tend to focus on relational and internal contexts lack measurable constructs and have not proven that these approaches are as effective as more traditional approaches.

DETAILED CASE CONCEPTUALIZATION PRAGMATICS AND TRANSCRIPT Case conceptualization for behavioral approaches focuses on the observable behaviors and its antecedents and consequences that maintain the behaviors targeted for change. Specifics of target behaviors are reported including the target behaviors frequency, rate, intensity, duration, and latency (time from the antecedent to the behavior) along with antecedents and consequences. Obtaining this information allows counselors and clients to establish goals of counseling and decide which behavioral interventions may be most effective for clients and stakeholders in modifying environments or behaviors to bring about behavior change. Establishing baselines helps in measuring client progress and in determining refinements that need to be made to interventions. As new information is obtained, conceptualizations are updated to encompass the new evidence. The conceptualization of client problems is a key factor in behavioral assessments and, when completed accurately and effectively, strengthens the choice of intervention and its implementation in counseling. Mark is a 42-year-old, Black, cisgender male who works as a project manager for a general contracting company. He is divorced and lives with his two daughters. Mark is seeking counseling for anxiety, sadness, and anger that occurred following his divorce. Mark has expressed feeling lonely and guilty for wanting to start dating again because it “takes me away from my daughters.” Transcript

Skill(s) Demonstrated

Counselor: (After initial greeting) Mark, would you tell me what behaviors specifically you would like to see changed as a result of counseling?

Indirect functional behavior analysis (While the counselor is unable to directly observe Mark, she would like to gather information on behaviors that Mark would like to change.)

Mark: I would like to control my anger related to the divorce. Counselor: Describe for me specifically what behaviors you exhibit when you are angry.

Defining the target behavior

Mark: Well, when I think about the divorce, I tend to get angry and my body starts to get really hot. I have been known to punch walls or throw things around my apartment. I don’t like it when my daughters see me so upset.

Defining the target behavior

Counselor: So it sounds like that the behavior you would want to change is to not damage things when you are angry? Is that correct? Mark: Correct? Can you help me?

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Counselor: I may be able to help you to control your behaviors when you are angry, but I would like to gather a little more information if that is okay. Mark: Sure. Counselor: Great. How often does the problem occur?

Positive reinforcement and gathering frequency of behaviors

Mark: I would say about four times per week. Usually when I start to feel lonely when I am at my apartment by myself. I just get so mad that the divorce happened. Counselor: Thanks. Not only did you provide me with information about frequency, but you let me know where it most likely occurs. How long does this behavior last?

Noting the environment/context where behavior is most likely to occur (The counselor then hopes to obtain how long this behavior lasts. In a functional behavior analysis, the counselors gain information related to specifics of behaviors [frequency, duration, context, etc.]. This may also be an exploration of the antecedents to the behavior Mark would like to change.)

Mark: I can’t really say. I would say about 30 seconds to an hour. It depends. Sometimes breaking something helps or I find something to do that makes me less angry. Sometimes one of my daughters will come home and it will stop. Counselor: So you mentioned that your daughter walking in or finding something better to do helps in stopping when you are destroying things. Mark: Yes. I remember how my dad would act when he was angry and it led to a lot of problems. He would often get arrested for destroying someone’s property and his anger scared us and now we don’t talk to him. He is just an angry old man who is alone. I don’t want that to happen to me. Counselor: Mark, your dad is someone that you don’t want to be like. This seems really important to you. In the past, you have described the importance of the relationship with your daughters. Let’s find a way for you to not act out when you are angry, okay?

Modeling (The counselor is using Mark’s dad as a model. He was arrested and negatively punished with his desired freedom being taken away.)

Mark: Yes. Counselor: Okay. What do you typically find to do that makes you less angry or that doesn’t allow you to act out when angry?

Reciprocal inhibition (The counselor is trying to find something the client can do in place of the behavior.)

Mark: In my divorce classes, they taught us to think about how we wanted to be seen by others and so I picture my girls. I also pick up this little game that I have on my table. It makes you put the balls in the holes. That usually takes my mind off of things and gives me something to do with my hands. It sounds funny, but it works. I don’t want to scare my girls and that game is calming to me. I love to tinker with things.

(Mark has found that when he can focus on the game, he is focused on his anger. The counselor has also helped Mark to see things that he values. This is a part of ACT. While he is still angry, he may be able to accept that, but focus on what he values, and relationship with his daughters, and commit to changing his behaviors despite how he feels.)

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Counselor: That is awesome, the way you have found something that works for you. How do you feel about that?

External positive reinforcement (The counselor is providing praise to the client. The counselor is also trying to elicit how Mark feels that could lead to internally delivered positive reinforcement.)

Mark: It makes me proud during those times that I can be the father who my girls need me to be. I wish I could do that all the time. Counselor: Earlier, you said that you get angry and punch the wall or throw things four times per week. Is that correct? Mark: Yes. Counselor: Can we set a goal that you will remember the value you put on the relationship with your daughters and play the game at least two times when you get angry this week?

Goal setting with the client to use ­reciprocal inhibition

Mark: I can try. Counselor: Can I get a commitment from you that you will do this at least two times when you get angry this week? Mark: Yes. Not only will I try, but I will do this. Counselor: Thanks, Mark. I appreciate your willingness to work on this goal and I look forward to hearing what happens the next time we meet.

THEORETICAL LIMITATIONS Behavioral approaches have a number of strengths including its long-standing empirical support, concrete techniques and interventions, and emergence as a more holistic model of counseling; however, it is not without its limitations. Traditional approaches such as operant conditioning are still focused on the alteration of behaviors and do not discount the existence of cognitions or emotions. On the contrary, the meaningfulness of reinforcers and punishments relies heavily on the cognitive and emotional impact of such reinforcements. That stated, with the focus of operant conditioning on behaviors over cognitions and emotions, one may find utilizing operant conditioning concepts to alter emotions notably more challenging than using those same concepts to alter behaviors. Another limitation of behavioral approaches may be with individuals diagnosed with acute mental or emotional disorders. As stated, in order for change to occur, target behaviors must be identified, and then meaningful and effective rewards and punishments decided upon. Certain individuals, due to the severity of their mental health disorder, may find that rewards and punishments have little impact on their behavior. Imagine an individual diagnosed with an acute case of major depressive disorder. Under the right circumstances, it may be virtually impossible to find rewards or punishments that will enact any meaningful change for that individual due to the hopelessness and emptiness that can sometimes accompany depression. Rewards and punishments simply may not matter to that individual. In such cases, pursuing the utilization of operant conditioning approaches may not be useful.

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Additionally, behavioral approaches, with its focus on the observable, may limit a counselor from exploring underlying factors contributing to behaviors and more traditional approaches may not take into account the environmental or contextual influencing behaviors. This disregard can also extend to cultural norms. With a high level of focus and interpretation from the counselor, it can be easy to misinterpret cultural norm behaviors as maladaptive if a counselor is unfamiliar with how behaviors serve clients culturally. With the majority of assessment techniques, including observation or interviews, behavioral assessments are prone to client reactivity, observer bias, and over- or under-reporting by clients or other stakeholders leading to validity and reliability issues. Being observed may result in clients behaving more favorably or negatively thus limiting the observer from gaining a true sense of the problems. During interviews, clients may over- or under-report behaviors or misrepresent the intensity of the behaviors. Observers and clients must be trained to understand the specific behaviors in which they are recording as well as trained in the techniques associated with the intervention protocols in order to increase the likelihood of success. An example could be an observer not fully understanding the differences in behavioral manifestations of anxiety in children compared to adults and missing them during observations. Additionally, observers must be aware of their biases, which they may be unaware of, related to the client to prevent them from influencing recordings. Clients may have behaviors such as aggression that give rise to observer negative thoughts or feelings thus clouding observations or interviews. Behavioral approaches often rely on a client’s work outside of the counseling sessions. While this can be a strength in that the client may learn to become their own therapist (APA, 2017a), it also creates the potential for limitations. Clients’ day-to-day motivation and understanding of assignments may impact their ability to effectively monitor and understand their behaviors as well as thoroughly and accurately report experiences to the therapist at the following session. Behavior approaches are largely dependent on whether or not the client is doing their homework and reduces therapists’ control over the execution of the techniques. Theoretical limitations of DBT are most often associated with its delivery as a multimodal treatment. The individual counseling, group skills training, and coaching and consultation sessions may place a strain on resources of agencies and may not be available to those in private practice (Swenson et al., 2002). Some (Linehan, 2015; McMain et al., 2017‌‌‌‌‌) have proposed the removal of individual counseling for clients who meet certain criteria (e.g., no recent suicidal or self-harming behaviors) and have found comparable results to the full delivery model of DBT (Linehan, 2015; Lying, 2020). DBT also requires a substantial time commitment from clients with counseling lasting 6 to 12 months.

SUMMARY While the field of behaviorism originated with the basic concepts of observing and exploring the possibilities of altering behavior, it has developed into a multifaceted approach to human and animal behavior. Though behaviorism has evolved and grown to include the examination of cognitive and emotive influences, unlike some theoretical approaches, it still holds true to its foundational components. Behavior can be observed and modified through conditioning. The knowledge that behavior is naturally developed through the unconscious pairings of stimuli but also impacted by reinforcements and punishments in the environment has influenced psychology and virtually every aspect of human services professions and continues to do so. New theories of human behavior, building upon the foundational tenets of behaviorism, and treatments of mental and emotional disorders continue to be developed.

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VOICES FROM THE FIELD This chapter features a digitally recorded interview entitled Voices From the Field. The interview explores multicultural, social justice, equity, diversity, and intersectionality issues from the perspective of clinicians representing a wide range of ethnic, racial, and national backgrounds. The purpose of having chapter-based authors interview individuals representing communities of color or who frequently serve diverse populations is to provide you, the reader, with relevant theory-based social justice and multiculturally oriented conceptualization, contemporary issues, and relevant skills.

Access the video with the QR code or at https://bcove.video/3rDkSnw

Christina Lloyd has served as a counselor for 7 years. She is a licensed professional clinical counselor with a supervisory credential in the state of Ohio. She is also a nationally certified counselor. She describes herself as a Black woman residing in Northeast Ohio. She graduated with her master’s degree from a CACREPaccredited program in Clinical Mental Health Counseling.

STUDENT EXERCISES Exercise 1: Exploring the Second Wave of Behaviorism

Directions: Choose a figure associated with the second wave of behaviorism and explore their contributions. How did their contributions influence the modern behavioral approaches?

Exercise 2: Role of the Counselor

Directions: Compare and contrast the role of the counselor in operant and classical conditioning.

Exercise 3: Behavioral Interventions for Anxiety

Directions: Break into small groups. Develop a series of interventions using behavioral approaches for an adolescent female who struggles with anxiety in social situations such as classroom and extracurricular, social events. How would you work with the client to change behaviors and maintain behavior changes? Present your interventions to the class.

Exercise 4: Behaviorism and Multiculturalism

Directions: Assign students a specific group. Consider how you would work with clients from diverse backgrounds using behavioral approaches. How would you alter approaches? What benefits may these approaches have for your assigned groups? What challenges may these approaches have for your assigned groups? Consider the backgrounds that students will encounter in their future work (e.g., age, culture, ethnicity, ability, etc.). Assign each group a background. For example, if you want students to explore race, one group may explore White clients, one group may explore Black clients, one group may explore Asian clients, etc. If you want students to explore age, one group may explore children, one group may explore adolescents, one group may explore midlife adults, etc.

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Exercise 5: Functional Analysis

Directions: Work in pairs and share a current behavior that one person would like to change. Conduct a functional analysis. Ask questions to obtain a description of the specific target behavior that is desired for change and explore the antecedents and consequences that are maintaining the target behavior. You can extend the discussions to explore cognitions and emotions surrounding the target behaviors, but the main focus is on the observable target behavior(s) and its observable antecedents and consequences. Lastly, develop a behavioral goal that the person can work toward.

RESOURCES Helpful Links ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Association for Behavior Analysis International: www.abainternational.org/­welcome. aspx Association for Behavioral and Cognitive Therapies: www.abct.org/ Association for Contextual Behavioral Science: http://contextualpsychology.org/ Association for Positive Behavioral Supports: www.apbs.org/ Behavior Online, Inc.: https://behavior.net/ B. F. Skinner Foundation: www.bfskinner.org/ Center on PBIS: Positive Behavioral Interventions and Supports: www.pbis.org Collaborative and Proactive Solutions: www.cpsconnection.com/ Division 25 of the American Psychological Association: www.apadivisions.org/ division-25 International Institute for Restorative Practices: www.iirp.edu/

Helpful Books ■ ■ ■ ■

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Bedics, J. (2020). Handbook of dialectical behavior therapy: Theory, research, and evaluation. Academic Press. Chapman, A. L., & Dixon-Gordon, K. L. (2020). Dialectical behavior therapy. American Psychological Association. Cipani, E. (2017). Functional behavioral assessment, diagnosis, and treatment: A complete system for education and mental health settings. Springer Publishing. Harris, R. 2009. ACT made simple: An easy-to-read-primer on acceptance and commitment therapy. New Harbinger Publications, Inc. www.actmindfully.com.au/upimages/ACT_ Made_Simple_Introduction_and_first_two_­chapters.pdf Johnson, M. M. & Melton, M. L. (2021). Addressing race-based stress in therapy with Black clients: Using multicultural and dialectical behavior therapy techniques. Routledge/Taylor & Francis Group. Roemer, L., & Orsillo, S. M. (2020). Acceptance-based behavioral therapy: Treating anxiety and related challenges (4th ed.). The Guilford Press. Spiegler, M. D. (2016). Contemporary behavior therapy. Cengage Learning. Staats, A. W. (1996). Behavior and personality: Psychological behaviorism. Springer Publishing. Weersing, V. R., Gonzalez, A., & Rozenman, M. (2021). Brief behavioral therapy for anxiety and depression in youth: Therapist guide. Oxford University Press. https://doi-org.proxy. library.kent.edu/10.1093/med-psych/9780197541470.001.0001

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Helpful Videos ■

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PESI. (2020, January 1). Adolescence in Crisis: Racial Trauma and Identity: A Trauma-Focused DBT Perspective. https://catalog.pesi.com/item/ adolescence-crisis-racial-trauma-identity-traumafocused-dbt-perspective-67182 Chapman, A. L., & Tullos, J. M. (2014). Dialectical behavior therapy. American Psychological Association.‌‌‌ Australian Institute of Professional Counsellors. (2011, January 1). Counselling Therapies, Session 3: Behaviour Therapy. Hayes, S. C. (2012). Acceptance and Commitment Therapy. Psychotherapy.net. Linehan, M., Yalom, V., & Yalom, M.-H. (2013). Dialectical Behavior Therapy. https://www.psychotherapy.net/video/dialectical-behavior-therapy-linehan Pakenham, K. (2014, July 1). Transitioning to the Third Wave Behaviour Therapies and Their Relevance to Self-Care and Resiliency. Audio Visual Archives. Swales, M. A., & Heard, H. L. (2017). Dialectical Behavior Therapy: Distinctive Features. http://ebookcentral.proquest.com/lib/kentstate/detail.action?docID=471778

A robust set of instructor resources designed to supplement this text is available. Qualifying instructors may request access by emailing [email protected].

REFERENCES Aalai, A. (2015). Rethinking John B. Watson’s legacy: Should Waston be taught to students with a disclaimer. Psychology Today. https://www.psychologytoday.com/us/blog/the-first-impression/ 201511/rethinking-john-b-watsons-legacy Achenbach System of Empirically Based Assessment. (2023). ASEBA overview. https://aseba.org/ aseba-overview/ Achenbach, T. M. (2015). The Achenbach system of empirically based assessment (ASEBA): Development, findings, theory, and applications. University of Vermont Research Center for Children, Youth, and Families.‌‌‌‌‌ Achenbach, T. M., Rescorla, L. A., McConaughey, S. H., Pecora, P. J., Wetherbee, K. M., Ruffle, T. M., ... & Ivanova, M. Y. (1980). Achenbach system of empirically based assessment [2015 update]. University of Vermont Research Center for Children, Youth, & Families. Almagor, M. (2011). The functional dielectric system approach for therapy with individuals, couples, and families. University of Minnesota Press.‌ American Psychological Association. (2017a). Division 12 what is cognitive behavioral therapy? https://www.apa.org/ptsd-guideline/patients-and-families/cognitive-behavioral American Psychological Association. (2017b). Division 12 what is exposure therapy? https://www.apa. org/ptsd-guideline/patients-and-families/exposure-therapy American Psychological Association. (2022). Division 25 behavior analysis. https://www.apadivisions. org/division-25 Antony, M. M. (2019). Behavior therapy. In D. Wedding & R. J. Corsini (Eds.), Current psychotherapies (11th ed., pp. 199–236). Cengage Learning, Inc. Antony, M. M., Roemer, L., & Lenton-Brym, A. P. (2020). Behavior therapy: Traditional approaches. In S. B. Messer & N. J. Kaslow (Eds.), Essential psychotherapies; Theory and practice (4th ed., pp. 111–141). The Guilford Press.‌‌‌‌‌ Association for Behavioral and Cognitive Therapies. (2022). Core values, mission, and vision. https://www. abct.org/about/core-values-mission-and-vision/ ‌‌‌‌‌ Austin, D. R. (2018). Therapeutic recreation: Processes and techniques (8th ed.). Sagamore Publishing, LLC. Baum, W. M. (2011). What is radical behaviorism? A review of Jay Moore’s conceptualization of radical behaviorism. Journal of the Experimental Analysis of Behavior, 95(1), 119–126. https://doi.org/10.1901/ jeab.2011.95-119 Behavioral Research & Therapy Clinics, University of Washington. (2008). Therapist interview-4. http:// depts.washington.edu/uwbrtc/wp-content/uploads/Therapist-Interview-4-V1.pdf Behavioral Research & Therapy Clinics, University of Washington. (2023). Assessment instruments. http:// depts.washington.edu/uwbrtc/resources/assessment-instruments/

Bishop, S. K., Dixon, M. R., Moore, J. W., & Lundy, M. P. (2017). Behavioral perspectives on personality. In V. Zeigler-Hill & T. K. Shackelford (Eds.), Encyclopedia of personality and individual differences. https://doi.org/10.1007/978-3-319-28099-8_962-1 Chance, P. (1999). Thorndike’s puzzle boxes and the origins of the experimental analysis of behavior. Journal of the Experimental Analysis of Behavior, 72(3) 433–440. https://doi.org/10.1901/ jeab.1999.72-433 Ching, T. H. W. (2022). Culturally attuned behavior therapy for anxiety and depression in Asian Americans: Addressing racial microaggressions and deconstructing the model minority myth. Cognitive and Behavioral Practice, 29(4), 723–737. https://doi.org/10.1016/j.cbpra.2021.04.006 Choudhury, R. R. (2017). Behavior therapy. International Society for Green Sustainable Engineering and Management. Copper, J. O., Heron, T. E., & Heward, W. L. (2020). Applied behavior analysis (3rd ed.). Pearson Education Inc. Cress, V. E., Seligman, L., & Reichenberg, L. W. (2021). Theories of counseling and psychotherapy: Systems, strategies, and skills (5th ed.). Pearson Davis, T. (2019). What is well-being? Definition, types, and well-being skills: Want to grow your well-being? Here are the skills you need. Psychology Today. https://www.psychologytoday.com/us/ blog/click-here-happiness/201901/what-is-well-being-definition-types-and-well-being-skills Decker, S. E., Adams, L., Watkins, L. E., Sippel, L. M., Presnall-Shvorin, J., Sofuoglu, M., & Martino, S. (2019). Feasibility and preliminary efficacy of dialectical behaviour therapy skills groups for veterans with suicidal ideation: Pilot. Behavioural and Cognitive Psychotherapy, 47(5), 616–621. https://doi. org/10.1017/S1352465819000122 Deibert, A. N., & Harmon, A. J. (1973). New tools for changing behaviors (2nd ed.). Research Press.‌‌‌‌‌ Ferguson, K. E., & O’Donohue, W. (2015). Behavior therapy: Background, basic principles, and early ­history. In, 412–417. International encyclopedia of the social & behavioral sciences (2nd ed.). Elsevier, Ltd. https://doi.org/10.1016/B978-0-08-097086-8.21054-4 Gladding, S. T. (2022). Theories of counseling (3rd ed.). Rowman & Littlefield Publishing Group, Inc. Goldenberg, I., Stanton, M., & Goldenberg, H. (2017). Family therapy: An overview (9th ed.). Cengage Learning. Guercio, J. M. (2018). The importance of a deeper knowledge of the history and theoretical foundations of Behavior Analysis: 1863–1960. Behavior Analysis: Research and Practice American Psychological Association 2018, 18(1), No. 1, 4–15. https://doi.org/10.1037/bar0000123 Haft, S. L., O. G. S. M., Shaller, E. A. L., & Liu, N. H. (2022). Cultural adaptations of dialectical b ­ ehavior therapy: A systematic review. Journal of Consulting and Clinical Psychology, 90(10). https://doi. org/10.1037/ccp0000730‌‌‌‌‌ Harris, R. (2009). ACT made simple: An easy-to-read-primer on acceptance and commitment therapy. New Harbinger Publications, Inc. https://www.actmindfully.com.au/upimages/ACT_Made_ Simple_Introduction_and_first_two_chapters.pdf Hayes, S. (2004). Acceptance and commitment theory, relational frame theory, and the third wave of behavior and cognitive therapies. Behavior Therapy, 25, 639 –665. https://doi.org/10.1016/ S0005-7894(04)80013-3 Hayes, S. C., Strosahl K., D., & Wilson, K. G. (2011). Acceptance and commitment therapy: The process and ­practice of mindful change (2nd ed.). Guilford. Koons, C. R., Chapman, A. L., Betts, B. B. O’Rourke, B., Morse, N., & Clive, R. (2006). Dialectical b ­ ehavior therapy adapted for the vocational rehabilitation of significantly disabled mentally ill adults. Cognitive and Behavioral Practice, 13(2), 146–156. https://doi.org/10.1016/j.cbpra.2005.04.003 Kranzler, J. H. (2017). Test review of Achenbach system of empirically based assessment [2015 Update]. In J. F. Carlson, K. F. Geisinger, & J. L. Jonson (Eds.), The twentieth mental measurements yearbook. http:// marketplace.unl.edu/buros/ ‌‌‌‌‌ Law, E. C., & Woods, K. (2018). The representation of the management of behavioural difficulties in EP practice. Educational Psychology in Practice, 34, 352–369. Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. The Guilford Press. Linehan, M. M. (2015). DBT skills training manual. Guilford Press. Linehan, M. M., Comtois, K. A., Murray, A. M., Brown, M. Z., Gallop, R. J., Heard, H. L., Korslund, K. E., Tutek, D. A., Reynolds, S. K., & Lindenboim, N. (2006). Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry, 63(7), 757–766. https://doi.org/10.1001/ archpsyc.63.7.757

Lying, J., Swales, M. A., Hastings, R. P., Millar, T., Duffy, D. J., & Booth, R. (2020). Standalone DBT group skills training versus standard (i.e. all modes) DBT for Borderline Personality Disorder: A natural quasi-experiment in routine clinical practice. Community Mental Health Journal, 56(2), 238–250. Mariani, M., & Zyromski, B. (2019). Cognitive-behavioral therapy in the schools. In C. T. Dollaride & M. E. Lemberger-Truelove (Eds.), Theories of school counseling for the 21st century (pp. 101–126). Oxford University Press.‌‌‌‌‌ McLaughlin, J. E. (2019). Humanism’s revival in third-wave behaviorism. Journal of Humanistic Counseling, 58(1), 2–16. https://doi.org/10.1002/johc.12086 McMain, S. F., Guimond, T., Barnhart, R., Habinski, L., & Streiner, D. L. (2017). A randomized trial of brief dialectical behaviour therapy: Theoretical and empirical observations. Journal of Clinical Psychology, 62, 459–480.‌‌‌‌‌ Neacsiu, A. D., Zerubavel, N., Nylocks, K. M., & Linehan, M. M. (2021). Borderline personality disorder. In D. H. Barlow (Ed.), Clinical handbook of psychological disorders: A step-by-step treatment manual (6th ed., pp. 381–442). The Guilford Press. Neacsiu, A. D., Ward-Ciesielski, E. F., & Linehan, M. M. (2012). Emerging approaches to counseling intervention. The Counseling Psychologist, 40(7), 1003–1032. https://doi.org/10.1177/0011000011421023 Neal-Barnett, A. M., & Smith, J. M., Sr. (1996). African American children and behavior therapy: Considering the Afrocentric approach. Cognitive and Behavior Practice, 3(2), 351–369–369. https://doi. org/10.1016/S1077-7229(96)80023-X Oxley, L., & Holden, G. W. (2021). Three positive approaches to school discipline: Are they compatible with social justice principles? Educational & Child Psychology, 38(2), 71–81. https://eric.ed.gov/?redir= https%3a%2f%2fshop.bps.org.uk%2feducational-child-psychology-vol-38-no-2-june-2021-­educationand-social-justice Pederson, L. (2013). Dialectical behavior therapy in dual disorder treatment settings. Premier Publishing and Media. Phelps, B. J. (2015). Behavioral perspectives on personality and self. Psychological Record, 65, 557–565. https://doi.org/10.1007/s40732-014-0115-y Poppen, R. (1998). Joseph Wolpe: 1915–1997. Journal of Behavior Therapy and Experimental Psychiatry, 29, 189–191. Reynolds, C. R., & Kamphaus, R. W. (2015). Behavior assessment system for children (3rd ed.) (BASC-3). Pearson. https://pearsonclinical.in/solutions/behavior-assessment-system-for-children-thirdedition-basc-3/ Richard, D.C.S. (2010). Computerized behavioral assessment. https://doi.org/10.1002/9780470479216. CORPSY0214 Ryff, C. D. (1989). Beyond Ponce de Leon and life satisfaction: New directions in quest for successful aging. International Journal of Behavioral Development, 12(1), 35–55. https://doi. org/10.1177/016502548901200102 Salkovskis, P. (1998). Changing the face of psychotherapy and common sense: Joseph Wolpe, 20 April 1915-4 December 1997. Behavioural and Cognitive Psychotherapy, 26, 189–191. Cambridge University Press. Salsman, N. L. (2022). Dialectical Behavior Therapy case formulation of individuals who are chronically suicidal. In T. D. Eells (Ed.), Handbook of psychotherapy case formulation (3rd ed., pp. 281–319). The Guilford Press. Seaberg, J. R. (1982). Operant conditioning and differential association. Journal of Offender Counseling Services Rehabilitation, 5(3–4), 53–64.‌ Sloan, C. A., Berke, D. S., & Shipherd, J. C. (2017). Utilizing a dialectical framework to inform conceptualization and treatment of clinical distress in transgender individuals. Professional Psychology Research and Practice, 48, 301–309. Spiegler, D.M., & Guevremont, D.C. (2020). Contemporary behavior therapy (6th ed.). Cengage Learning. Spiegler, M. D. (2021). Behavior therapy. Salem Press Encyclopedia of Health: Psychology and Behavioral Health. Swenson, C. R., Torrey, W. C., & Koerner, K. (2002). Implementing dialectical behavior therapy. Psychiatric Services, 53, 171–178. Vaughn, S. (2023). The 4 stages and targets of DBT treatment. https://psychotherapyacademy.org/dbt/ the-4-stages-and-targets-of-dbt/ Watson, J. B. (1924). Behaviorism. Norton. Weir, K. (2012). The roots of mental illness: How much of mental illness can the biology of the brain explain? Science Watch, 43(6), 30.

Weissman, M. M., & Bothwell, S. (1976). Assessment of social adjustment by patient self-report. Archives of General Psychiatry, 33, 1111–1115. Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. Stanford University Press.‌‌‌‌‌ Wolpe, J., & Plaud, J. J. (1997). Pavlov’s contributions to behavior therapy: The obvious and the not so obvious. American Psychologist, 52(9), 966–972. https://doi.org/10.1037/0003-066X.52.9.966 Yeo, A. J., Germán, M., Wheeler, L. A., Camacho, K., Hirsch, E., & Miller, A. (2020). Self‐harm and self-regulation in urban ethnic minority youth: A pilot application of dialectical behavior therapy for adolescents. Child & Adolescent Mental Health, 25(3), 127–134. https://doi-org.proxy.library.kent. edu/10.1111/camh.12374

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COGNITIVE APPROACHES Dodie Limberg, Alexander M. Fields, Donya Wallace, Rawle D. Sookwah, and Sabrina M. Johnson

LEARNING OBJECTIVES After reading this chapter, you will be able to: ■ Identify the similarities and differences between cognitive behavioral therapy (CBT), social learning theory (SLT), and acceptance and commitment therapy (ACT) ■ Describe the role of the counselor and client in cognitive approaches ■ Understand how progress is maintained and assessed in cognitive approaches ■ Appreciate the importance of multicultural, intersectional, and social justice issues in cognitive approaches ■ Apply practical cognitive techniques ■ Recognize limitations of cognitive approaches

INTRODUCTION In this chapter, we focus on three main cognitive approaches: CBT, SLT (i.e., social cognitive theory), and ACT. These three approaches overlap and centered around thoughts and behavior. However, we describe‌‌‌ how they are unique in terms of their origins and approach to emotional and psychological well-being and provide practical examples of how counselors can utilize and clients may experience all three approaches. We examine the‌‌‌ process of change and progress and provide examples of assessment and practical application of techniques within cognitive approaches. Additionally, we highlight multicultural, intersectional, and social justice issues and research trends within cognitive approaches. We provide a detailed case conceptualization to offer context for what cognitive approaches are used in therapeutic settings.

LEADERS AND LEGACIES OF COGNITIVE THEORY Many scholars, therapists, and sociologist have played a role in the development of cognitive approaches. Table 9.1 highlights early major contributors of cognitive approaches.

Emerging Cognitive Theoretical Efforts Although the early contributors of cognitive approaches provided a strong foundation, the lack of diversity within the group of contributors cannot be overlooked. Social justice counseling calls upon practitioners to develop a critical consciousness of how theories like CBT, ACT, and SLT inform our conceptualization of client experiences (Singh et al., 2020a).

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Table 9.1. Cognitive Leader and Major Contribution Contributor

Major Contribution

Aaron Beck

Father of cognitive behavioral therapy

Albert Bandura

Developed social cognitive theory

Albert Ellis

Pioneered rational emotive behavior therapy

Marvin Goldfried

Focused on the common principles of change across theoretical orientations

Richard Lazarus

Emphasized the impact of emotion on cognition, specifically within the cognitive-mediational theory

Donald Meichenbaum

Developed cognitive behavior modification

Lynn Rehm

Focused on behavioral and cognitive approaches to treating depression

Martin Seligman

Established positive psychology and introduced the idea of learned helplessness

Stephen Hayes

Developed acceptance and commitment therapy

Paul Gilbert

Founded compassion-focused therapy

Traditional theories like CBT and SLT have historically been criticized for the absence of cultural considerations in their development (Hays, 2009; Sue et al., 1992). Scholars have highlighted the fact that these theories were not developed with the goal of addressing social inequalities or oppression (Singh et al., 2020a‌‌‌‌). According to Singh, counselors using such may miss the social context of client issues altogether, particularly when centering the client thinking patterns as the source of the issue. However, Iwamasa and Hays (2018) found CBT and its tenets to be a good fit for addressing the needs of communities that have been historically marginalized when applied using a culturally responsive approach. The researchers suggested counselors begin the process with reflection on their inherent biases using a cultural self-assessment. This is then followed by an exercise using the ADDRESSING acronym:(age, development or other disability, religion/spiritual orientation, ethnicity, socioeconomic status, sexual orientation, indigenous heritage, national origin, and gender; Hays, 2016) to identify identities of privilege and marginalized status. A culturally responsive approach acknowledges issues of privilege and power existing in the therapeutic relationship and theory.

ORIGIN AND NATURE OF MENTAL HEALTH CONCERNS The crux of cognitive approaches is attunement to the triangular relationship that occurs between our thoughts, feelings, and behaviors. The interplay between these three experiences is examined in the context of a trusting therapeutic relationship to achieve corrective emotional experiences and adaptive thought patterns. Problems impact human functioning across biological, psychological, and social domains; notable severity and persistence of the issue often precede entry to psychotherapeutic assistance. Restructuring thoughts that are contributing to the client’s experienced limitation is the primary focus of therapy. The theoretical approach operates with simultaneous acknowledgment of objective qualities to the cognitive triangle of content while exploring the subjective phenomena of interpretation in the process of therapy.

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EMOTIONAL AND PSYCHOLOGICAL WELL-BEING If you are distressed by anything external, the pain is not due to the thing itself, but to your ­estimate of it; and this you have the power to revoke at any moment. —Marcus Aurelius

The cognitive model maintains that activating events precede automatic thoughts and the subsequent physiological responses to the interpretation of thought content. Emotions contribute to goal-directed behaviors and signal incongruencies between language-laden expectations and the experienced reality. Examination of the interplay between these factors evokes the client’s beliefs about self, other, the world, and their future. The belief systems that guide behavior occur in response to external events and assist the return to homeostasis following contact with stressors. Terming the “cognitive specificity hypothesis,” the content of beliefs and processes of thinking is used to infer emotional states and resolve ensuing syndromes (Greenberg & Beck 1989‌‌‌‌). Cognitive theories propose the term “cognitive distortions” for thoughts that are irrational and disrupt goal acquisition. Fully expressing thought content in the context of the therapeutic relationship enables clients to experience a new perspective on internal conflict. This disattribution technique is a persistent component of the theoretical approach, which aspires to mitigate the impact client thoughts have on other domains of functioning (Prochaska & Norcross, 2018).

Cognitive Behavioral Therapy The CB approach to psychotherapy emerged as early integration of theoretical traditions in response to a deepened understanding of information processing systems. The primary goal of CBT is to reduce symptoms through disruption of the chained cognitive, emotional, and behavioral responses that comprise the defined problem (Craske, 2017). CBT practitioners maintain that pathology stems from cognitive distortions and maladaptive patterns of thinking that yield outcomes incongruent with the individual’s subjective appraisal of efforts toward the goal. Restructuring of thoughts yields relief from rigid thought patterns termed schemas. Experiences produce patterns of thought that calcify into beliefs that do not necessarily maintain their adaptive qualities under different conditions. The thoughts that drive disordered experiences are often automatic and ingrained. The acronym ANTs shortens the “automatic negative thoughts” to a memorable phrase that invokes imagery of numerous crawling disruptions to our best-planned picnics. CBT practitioners aspire to produce long-term self-maintaining effects through restructuring thoughts away from the “should,” “ought,” and “must” assumptions that prevent growth away from the problem (Beck, 2011). The operationalized definitions for common cognitive processes that originate from cognitive theories are a boon to psychotherapeutic practice. Assisting clients through intentional homework assignments that alter the identified problem patterns can be readily accomplished through the abundant worksheets and resources produced by practitioners who maintain fidelity to these terms. Identifying cognitive distortions is an insight-laden tool that can assist movement away from states of dysfunction. The contributions of CBT to the evidence base of psychotherapy are numerous, and outcome studies are invaluable in advocacy for the service. Concerns that arise when applying cognitive theories include the limited attention to the role of environment, alienation of emotion, and application within cultures that approach “knowing” differently from the thought-centered approach. The guiding assumption that thoughts are a primary driver of dysfunction is a form of the same overgeneralization that cognitive approaches can reduce. Cognitive theories are intellectualizing or rationalizing

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clients out of their feelings with an authoritative relationship as the driver of change through thought replacement (Prochaska & Norcross, 2018). Feelings are not necessarily suggestive of dysfunction, as cognitive theories sometimes respond to them as cues of deeper disorders. Scary movies produce elation, fear, and relief in quick succession to thrilled consenting audiences without any known group pathology to be restructured.

Social Learning Theory Proposed in 1954 by Rotter and popularized by Alfred Bandura, SLT is primarily concerned with the impact of observations and the environment on the change process. Theorist Alfred Bandura drew attention to the role of modeling adaptive and desirable behaviors in the cycle of learning. Bandura expanded on the importance of self-efficacy and self-regulation in education at a time when cognitive models were gaining interest and research support. Change occurs through social prescription or identification of highly functional qualities to the action. Through repeated observation, learners begin to incorporate principles of action without explicit facilitation. The internalized principles become a component of the learner’s approach to self-regulation and self-efficacy. For example, in counseling, a client may exhibit more positive self-talk without explicit direction due to repeated contact with a counselor who speaks positively with and about them. Factors contributing to efficacy expectations are personal accomplishments, vicarious experiences, verbal persuasion, or experiences of emotional arousal (Bandura, 1977). SLT differs from other cognitive approaches in its attention to the learner’s social experience as a facilitator of change. The purely cognitive approach of altering thoughts that yield unpreferred emotions contributes to problem resolution less than facilitating a successful performance and corrective experience. Modeling is the primary mechanism of change. Modeling is a behavioral chain of paid attention, retention, and rehearsed replications of the desirable behaviors. Learning facilitates attention to the reactions or responses that emerge from the new undertaking and continuously shaped toward the preferred outcomes (Bandura, 1977). The learner or client applies SLT with careful consideration of their self-efficacy and self-regulation. Learned helplessness can emerge from conditions that promote the belief that current negatively interpreted experiences are unchangeable and inescapable. Developing a relationship that offers emotional reprieve without inculcating skills or awareness that further client progress beyond the interpersonal connection can lend itself to codependency. Additionally, while repetition and repeated exposure contribute to the retention of learning, it must also be considered that states of elevated stress diminish the gains of new information and must be attended to in the scaffolding process within the relationship. Finally, practitioners of SLT must remain attuned to the client’s locus of control, guarding against attempts to externalize through overt advice-seeking and ensuring that ethics of preserving individual autonomy are normed in the relationship (Bandura, 1977).

Acceptance and Commitment Therapy The body is not a thing, it is a situation: it is our grasp on the world and our sketch of our project. —Simone de Beauvoir

Practitioners of ACT conceptualize problems by attending to the rigidity of maladaptive thoughts and the limits to experiencing positives in the present. The goal of ACT is to engage life with psychological flexibility, relinquishing attempts to control life and experiences in ways that disrupt present well-being. Establishing a flexible relationship with thoughts is an alternative to the rigid control patterns that comprise the problem. Mindful acceptance is

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taught to replace the problem-maintaining patterns of experiential avoidance. ACT applies mindfulness, committed action, value orientation, cognitive defusion, acceptance, and “self as context” to resolve problems that emerge from rigidity and avoidance. Mindfulness practices, such as deep breathing, have long been practiced in Eastern cultures to facilitate awareness of the present moment and yield stress-relieving benefits (Evans, 2015‌‌‌‌). Mindful awareness of the present enables a more accurate appraisal of the experience and selection of actions that align with current values. Problems that emerge from our unwanted experiences and the helpless feelings they produce are made more malleable by the therapist’s facilitative relationship, anchoring the client to a perspective that is accepting of their whole experience. The mechanisms applied to change dysfunctional patterns are intended to create psychological distance from the presenting dysregulation, enabling nonjudgmental realignment with values and experiences that yield well-being (Messer & Gurman, 2011). The ACT approach to professional helping is heavily equipped with guided imagery, mindfulness techniques, and value orienting interventions. The abstractions present in ACT’s frequently referenced metaphors can be difficult to grasp for clients who approach thought more concretely. Clients who exist on the spectrum of neurodiversity may exhibit behaviors aligned with the guidance of ACT, reducing the severity or persistence of a problem’s behavioral components but not experiencing the alleviation of psychological distress (Garcia et al., 2022‌‌‌‌). Philosophical differences around the goal of “acceptance” in the healing process exist between ACT and other approaches to therapy. ACT terms the resistance that fuels dysfunction “experiential avoidance,” which is similar to psychodynamic “defenses.” Both theories encourage clients to recontextualize themselves through speaking openly, creating space for private difficulties to be reexperienced from a less distressing and novel perspective. ACT places this alleviation through acceptance as a final goal, while other therapies incorporate it through other terms and conceptualize its role in therapy differently. Changes that contribute to a well-functioning view of the future are the overarching aim of psychotherapy; acceptance is one stop on the long journey of healing (Prochaska & Norcross, 2018).

THE ROLES OF THE COUNSELOR AND CLIENT CBT, SLT, and ACT have a cognitive and/or behavioral foundation; thus, the role of the counselor and client may present similarly in many instances. Also, the role of the counselor and client may differ with each theoretical approach. This section will highlight the ways in which the role of the counselor and the role of the client are similar and different based on the theoretical approach.

Cognitive Behavioral Therapy ROLE OF THE COUNSELOR

Counselors implementing a CB approach have similar roles as social learning theorists, as well as differences. Like social learning theorists, CB therapists’ role is to provide structure to the counseling session, formulating ongoing case conceptualizations that allow for understanding client’s presenting concerns (Beck, 2011). For example, counselors implementing CBT may formulate a cognitive conceptualization outlining the relationship between client’s automatic thoughts, behaviors, and emotions. Another primary role of counselors using CBT is to facilitate relief and remission of symptoms experienced by clients by using appropriate interventions that foster cognitive, behavioral, and emotional changes for the clients (Beck, 2011). CB therapists also utilize agenda and goal setting to provide structure to sessions. Furthermore, counselors implementing CBT assume the role of collaborative educator, collaborating with clients to establish strong therapeutic alliances

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with clients throughout the counseling process and providing psychoeducation on useful cognitive skills to facilitate client’s efforts in resolving their presenting concerns (Beck, 2011). Counselors using a CBT approach also serve as evaluators and researchers, implementing psychometric assessments (i.e., Beck’s Depression Inventory) to measure client’s progress over the course of treatment. ROLE OF THE CLIENT

Regarding CBT, clients are tasked with being a part of the therapeutic team. Clients are asked to be a collaborator and active participants in their own counseling experience, which allows them to contribute to the development of the therapeutic alliance and ensures their goals and needs are identified as well (Beck, 2011). Clients also are tasked with taking on a student role, positioning them to “be their own therapist” (Beck, 2011, p. 9). This role involves learning the necessary skills to identify maladaptive cognitive patterns and behaviors and better implementing strategies such as cognitive restructuring and evidence-­seeking to reduce the impact of maladaptive thoughts and behaviors on their functioning.

Social Learning Theory ROLE OF THE COUNSELOR

Counselors implementing an SLT approach are structured in navigating the counseling process. They establish goals with clients and develop contingency plans that identify and outline the required change process needed to meet clients’ goals. The foundational tenet of SLT, as described by Albert Bandura, is that learning is influenced by observation within social contexts, suggesting that individuals learn from the actions modeled by counselors, self, and others (Aubrey & Riley, 2019; Chavis, 2011). Therefore, counselors act as therapeutic tools, teaching and modeling desired skills and behaviors that clients can engage in to produce change. Furthermore, Bandura also suggested that individuals are more likely to engage in change if others believe they are capable, what he termed social persuasion, thus supporting the modeling role of counselors implementing this approach (Aubrey & Riley, 2019). Also, counselors using a social learning approach should focus on supporting the development of client’s self-efficacy. Additionally, counselors take on an evaluative role, using empirical data to support the use of this method, as well as implementing interventions that provide data on client’s progress. For example, social learning theorists gauge client concerns and progress by implementing assessment tools such as symptoms checklists (i.e., post-traumatic stress disorder [PTSD] symptoms checklist) or identifying ways to measure client behaviors to evaluate client progress. Through these roles, SLTs are better able to help clients identify and eliminate maladaptive behaviors while replacing them with more adaptive behaviors. ROLE OF THE CLIENT

Bandura highlights the importance of being self-efficacious or displaying the belief that one is capable of achieving the desired level of performance (Aubrey & Riley, 2019; Bandura, 1977). Therefore, clients engaging in change processes using a social learning lens are charged with displaying a level of self-efficacy that can support and bring forth change. Clients are also responsible for taking on a role of intellectual efficacy, which requires clients to develop cognitive skills that promote adaptive behavioral changes (Aubrey & Riley, 2019). This role is facilitated by modeling the desired behaviors of self and others, mastering self-efficacy, learning through the vicarious experiences of others, strengthening their self-efficacy through social persuasion, and learning to effectively manage the physiological and emotional stress responses that impact one’s self-efficacy (Aubrey & Riley, 2019).

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Acceptance and Commitment Therapy ROLE OF THE COUNSELOR

As social learning theorists and CB therapists implement some form of case conceptualizations throughout treatment, counselors utilizing ACT are no different. One role of ACT therapists is to formulate case conceptualizations based on the six core principles of ACT to comprehend and organize a client’s or counselor’s concerns. Furthermore, counselors also assume the role of modeling skills and behaviors when using ACT, providing in vivo experiences to clients (Gordon & Borushok, 2017). For example, counselors using ACT are encouraged to practice and implement the six core principles of ACT in their own lives, as well as in session; thus, they may use self-disclosure to acknowledge if they are struggling during the session. Counselors may then model acceptance of this uncomfortable experience by engaging in a mindfulness exercise to ground themselves during the session. Furthermore, the concept of social persuasion is relatable in ACT as well, as another role of counselors using this approach is to focus on helping clients to move toward the quality of life they want instead of focusing on the negative events occurring within or around them (Gordon & Borushok, 2017). Therefore, this role differs from the role of counselors using SLT and CBT as counselors align the goal of treatment with amplifying actions that align with client values instead of focusing on eliminating maladaptive behaviors like with SLT and CBT. The last role of counselors using ACT is to facilitate the psychological flexibility within clients in order to increase their willingness and acceptance while decreasing emotional avoidance, an action exacerbated by fusing with negative or painful experiences. When assuming this role, counselors also focus on addressing the language used to describe these painful experiences and facilitating the development of language that helps clients to create distance between the present and their internal negative experiences. ROLE OF THE CLIENT

Much like clients who exhibit self-efficacy under a social learning pretext, clients who engage in ACT-based therapy are tasked with displaying a level of willingness that allows for psychological flexibility and increased ability to view one’s experiences through a different lens (Gordon & Borushok, 2017; Hayes et al., 2006). By taking on a role of willingness, clients will also increase their ability to understand and experience painful experiences in a way that aligns with their values. Furthermore, the role of the client engaging in ACT-based therapy is to implement mindfulness and acceptance. When implementing mindfulness, clients honor the ACT core principle of being present-focused, which allows them to experience their internal cognitive events in the here and now (Gordon & Borushok, 2017). Being mindful and present also positions clients to view the self as context, allowing clients to defuse painful private cognitive traps and remain present with an experience. Lastly, clients are committing to engaging in value-based actions that align with their desired outcomes for life.

THE NATURE OF HUMAN DEVELOPMENT Cognitive theories grew parallel to advances in computer information systems and deepened understanding of the mechanisms involved in classical conditioning (Mahoney, 1977). These advances highlighted the relevance of environment, learning, and memory to internal cognitive processes. Memory activation by a conditioned stimulus results in an unconditioned stimulus. Maladaptive assumptions and beliefs become activated upon exposure to a conditioned stimulus that memory suggests precede an aversive event occurring. Cognitive reevaluation strategies, such as practicing positive self-talk, work by reducing the aversiveness of expectancies and promoting the growth of the individual.

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Human beings receive the input of myriad environmental cues and experience reactions that manifest in adaptive or maladaptive outcomes toward a goal. Reactions are formed through repetition, and patterns that yield desirable outcomes become ingrained and automatic. The emotional freedom and limited vocabulary of childhood yield incongruencies in expression that can develop into disordered rumination and maladaptive behaviors. Streams of consciousness, including self-talk, are shaped through contact with environments that produce patterns of interaction called schemas. Schemas are cognitive-emotional structures that comprise individual identity and assist orientation toward goals across contexts. Schemas emerge from early experiences and yield responses that may be adaptive or maladaptive as conditions change. Humans form identities around their experience of consciousness and work to form a healthy and sustainable relationship with their internal content and its external manifestations. This identity grows increasingly complex as expectations of consequence and attempts to control outcomes grow in tandem with the increased efficacy of adulthood.

PROCESS OF CHANGE Cognitive approaches involve a structured therapeutic process grounded in challenging maladaptive thoughts or cognitions and co-constructing experiential opportunities to promote a more adaptive cognitive schema. Clients are viewed as experts in their own life, and the process of cognitive therapy involves the client learning to become their own therapist. Cognitive therapists introduce concepts of the cognitive triad (i.e., the reciprocal relationship between thoughts, emotions, and behaviors) early in the therapeutic process and encourage clients to incorporate this in their day-to-day lives. Through a scaffolding process, clients gradually learn to challenge their automatic thoughts without prompting from their therapist. In fact, cognitive approaches tend to value independent client work over the client–therapist relationship. You may have seen cognitive therapy-based workbooks advertised as an alternative to traditional talk therapy or may have even used them yourself. These workbooks typically ask the reader to identify their automatic thoughts based on situational cues and the resulting emotion and behavior. Then, the reader can self-appraise their emotional and behavioral reactions to challenge the benefit of their automatic thought with the goal of identifying a more adaptive cognition. These workbooks are often referred to as “manualized treatment,” and there are hundreds of manualized treatments available to the public for a variety of presenting concerns and mental illnesses (Craske, 2017). Growing evidence has suggested that manualized treatment for cognitive therapy has comparable benefits to cognitive talk therapy (Craske, 2017); however, it is important to note that the therapeutic relationship remains one of the biggest predictors of positive therapeutic outcomes (Prochaska & Norcross, 2018). Please see the resource list at the end of this chapter for manualized treatment examples. The self-directed nature of cognitive approaches is a noted difference from other theories presented in this text and makes it appealing for clients with ranging presenting concerns (Craske, 2017). Through the process of becoming their own therapist, clients learn to identify their maladaptive cognitions, pair their cognitions with an emotional response and behavior, and develop hypotheses that can be tested within and between sessions. Prochaska and Norcross (2018) further described this therapeutic process toward symptom relief as both behavioral activation and contingency management. Through behavioral activation, clients are challenged to engage in behaviors that result in desired emotional states and more adaptive cognitions. The therapist may ask the client to select a behavior that is meaningful to them and requests that they document their emotional reaction and resulting cognition through out-of-session homework. Furthermore, the contingency management process involves adapting the environment and internal contingencies to match the desired cognitive, emotional, and behavioral outcome. Environmental contingencies follow principles of

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operant conditioning, and clients are provided positive reinforcement when engaging in a desired cognition and punishment when engaging in an undesired cognition. In addition, in environmental contingency, clients can adjust their reactions to external consequences through internal contingency management. Prochaska and Norcross labeled this process as reevaluation. The following subsections will further describe these processes for the therapist and client with respect to SLT, CBT and ACT.

Cognitive Behavioral Therapy As you may have inferred from the name, the process of CBT places equal importance on reevaluating an individual’s cognitions and behaviors. Craske (2017) noted that this is a multistep approach that usually begins with a functional analysis. The functional analysis labels maladaptive cognitions and behaviors and identifies where change should begin, as well as client goals. In more technical terms, functional analysis is the process of breaking down the operant and respondent conditioning in an effort to better understand the importance an individual places on their thoughts and behaviors (Yoman, 2008). The importance can include but is not limited to the individual’s emotional reactions and value system. After identifying the maladaptive cognitive and behavioral patterns, the therapist is better suited to collaborate with the client to select strategies to establish more adaptive patterns. This involves hypothesis testing, which is the process of the client experimenting with new thought patterns and behaviors to determine more appropriate cognitions and behaviors to meet their desired output or goals. Hypothesis testing can create experimental opportunities that target to facilitate change through both cognitive and behavioral strategies (Craske, 2017). Cognitive strategies challenge an individual’s irrational beliefs and dysfunctional thought patterns in an effort to strengthen the functionality of their cognitions. Examples of cognitive strategies include activity scheduling, cognitive restructuring, and distancing (Prochaska & Norcross, 2018). Behavioral strategies aim to increase the frequency of desired behaviors by targeting the reinforcers, rewards, and consequences of their behaviors. Examples of behavioral strategies include social skills training, token economies, and counterconditioning through stimulus control (Prochaska & Norcross, 2018). Through the course of therapy, the client ideally learns to independently complete the multistep CBT approach to assess and challenge their maladaptive cognitions and behaviors autonomously.

Social Learning Theory Based on the work of Bandura, SLT posits that individuals develop their cognitive schema and behaviors based on modeling and observation of others. More specifically, Bandura (1977) proposed that SLT is a reciprocal relationship between three factors: personal factors (i.e., cognitions), behavioral factors, and environmental factors. SLT conceptualizes pathology as an individual receiving maladaptive rewards for learned behaviors, and the goal of therapy is to establish adaptive rewards in the individual’s environment that are congruent with the desired cognition and behavior. Traditionally, this goal is accomplished through a mediating process of strengthening the individual’s self-efficacy. Bandura (1997) described self-efficacy as “one’s capabilities to organize and execute the courses of action required to produce given attainments” (p. 3). In other words, self-efficacy refers to an individual’s belief in their ability to achieve a goal and understanding the resulting environmental consequences. Self-efficacy has close parallels with self-confidence; however, self-confidence is a strong belief about one’s abilities, whereas self-efficacy is situational and refers to one’s self-perceived belief to accomplish a certain task. Through therapy, an individual learns to strengthen their self-efficacy with the support of their therapist, thus resulting in increased competence to complete their goal(s). Furthermore, Bandura (1977)‌‌‌‌ supported the notion

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that enhanced competency also results in success in future attempts. Thus, focusing on the mediating process of self-efficacy in counseling reinforces continued success for an individual to achieve their goals autonomously.

Acceptance and Commitment Therapy ACT builds off traditional cognitive processes of identifying dysfunctional and maladaptive thought patterns and incorporates aspects of insight development, mindfulness, and cognitive defusion. Through the process of ACT therapy, an individual learns to conceptualize their thoughts as hypotheses, as opposed to being a universal truth. This typically begins with the individual learning about the intrusive nature of their thoughts and potential causes of thought suppression (e.g., cultural influences, messages received throughout their childhood, and influential figures), as well as the consequences of thought suppression. Following this understanding, the therapist may target the client’s insight development through a consciousness raising process (Prochaska & Norcross, 2018). The client is encouraged to experience catharsis and freely express their thoughts and emotions. Furthermore, the client may learn more about their authentic beliefs about thought and emotional expression through an exploration of their values. Next, the client is introduced to tenets of mindfulness: awareness and acceptance. Awareness occurs when an individual labels their reactions to environmental cues, whereas acceptance is a nonjudgmental stance that acknowledges these reactions for what they are. Following mindfulness, the therapist introduces aspects of cognitive defusion in the session. Cognitive defusion is the process of individuals learning to lean into their thoughts, as opposed to running away or suppressing them. The therapist may facilitate this process in the session by collaborating with the client to identify self-regulation strategies for them to manage potentially uncomfortable reactions to their thoughts. Lastly, the client engages in the process of labeling their thoughts as hypotheses that should be tested.

HOW PROGRESS IS MAINTAINED The scientific and step-by-step nature of cognitive therapies provides a framework to monitor an individual’s therapeutic progress. Goals for cognitive therapies should be measurable (e.g., ‌‌‌SMART [Specific, Measurable, Attainable, Realistic, and Time-sensitive] goals) and focused on cognitive restructuring and reducing the frequency of maladaptive thought patterns. As goals are determined toward the onset of treatment, the counselor can continuously evaluate whether their client is working toward their established goals and can collaboratively reestablish goals as necessary. Furthermore, cognitive therapies emphasize the importance of clients learning to demonstrate cognitive restructuring independently, and measuring therapeutic progress should consider how the individual functions independently of the therapist. Progress is determined through self-reports, counselor observation, and empirical measures.

Cognitive Behavioral Therapy A cornerstone of CBT is the idea that clients can learn to assess their own thought patterns and behaviors without input from the therapist. As such, progress is maintained through the client engaging in behavioral experimentation and out-of-session homework. Toward the beginning of therapy, the therapist introduces concepts of CBT through scaffolding, a process of modeling concepts until the individual is ready to engage without expert input. The therapist will provide the structure and offer their input with respect to behavioral experimentation and assessing dysfunctional thought patterns. Then, the client learns to engage in the therapeutic process with minimal therapist prompting. Homework may begin with the therapist suggesting out-of-session tasks and then progress toward the client developing

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their own homework tasks with minimal or no feedback from the therapist. After the client can demonstrate independence in selecting their in-session and out-of-session behavioral experimentation, the client must demonstrate their ability to assess their thought patterns appropriately. This may involve an honest reflection on their automatic thoughts and strategies to challenge their dysfunctional thought patterns. Throughout CBT treatment, goals should be revisited and evaluated to understand if they are meeting the unique needs of the client. Toward the end of counseling, the client should be completing their own functional analyses, setting their own goals, and describing how they will engage in tenets of CBT after the termination of treatment.

Social Learning Theory Social learning theorists view progress as the individual’s ability to demonstrate desired outputs and behaviors through their self-efficacy, the mediating factor between an individual’s personal goals and behaviors. Bandura (1977) described the development of self-­ efficacy through a process of (a) performance accomplishments, (b) vicarious experience, (c) verbal persuasion, and (d) emotional arousal. Therefore, progress is maintained through continuously providing the individual opportunities to engage in each of these processes through modeling, direct instruction, or behavioral experimentation. Following opportunities within a session, the individual is encouraged to identify how they can continue building their self-efficacy to engage in certain behaviors outside of the session. Furthermore, therapeutic growth through self-efficacy can be maintained by encouraging the client to engage in reflective practices to assess their continued ability to engage in their desired behaviors. This contributes to a feedback loop where the individual continues to strengthen their self-efficacy due to prior experiences and enhances their belief that they can continue to accomplish their goals.

Acceptance and Commitment Therapy Progress maintenance for ACT closely parallels CBT as the individual learns to complete independent functional analyses and set their own behavioral goals outside of the session, with the additional processes of demonstrating psychological flexibility and continued mindfulness practices. For psychological flexibility, progress is demonstrated when the individual is able to acknowledge that their thoughts are hypotheses and not a universal truth and maintained when they can apply this principle across multiple situations. Hayes et al. (2011) developed the Flexibility Rating Sheet that can be used to monitor the progress of the individual progressing toward psychological flexibility. This assessment uses Likert scale questions to assess the individual’s ability to demonstrate psychological flexibility across the following scales: (a) present moment, (b) self, (c) acceptance, (d) defusion, (e) values, and (f) committed action. Additionally, mindfulness practices are developed through processes of awareness and acceptance. The individual demonstrates progress through awareness of their current thought patterns and emotional state, as well as nonjudgmental acceptance of their thought patterns and emotional state. Then, progress can be maintained by the client learning to apply these tenets to multiple situations in their life and learning to sit in uncomfortable emotional states for longer periods of time. This typically involves behavioral strategies (e.g., deep breathing and body scans) introduced in session and used by the individual out-of-session.

CLINICAL ASSESSMENT Compared to other theories presented in this text, cognitive approaches arguably have the highest number with strong psychometrics. This can be attributed to the empirical nature of cognitive approaches and the value placed on measurement. Brown and Clark (2015) define

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cognitive assessments as‌‌‌ “systematic empirically derived protocols, procedures, or instruments intended to measure the frequency, intensity, and salience of meaningful information comprising the thoughts, images, and beliefs that characterize psychopathological states” (p. 5). In other words, cognitive assessments measure symptoms of cognitive dysfunction and provide the therapist insight into potential pathology. Cognitive assessments are a useful tool for therapists that adhere to managed care expectations as they provide justification for continued treatment. Typically, cognitive therapy begins with a formal assessment process, and the therapist selects from a variety of informal and formal assessments. Informal assessments are when the therapist does not have a normative group for comparison and uses unstructured procedures to collect data on the individual’s cognitions. Examples of informal assessments include unstructured questions about the individual’s cognitive schema and therapist-developed worksheets. In addition to informal assessments, formal assessments are standardized measures that have a normative group for comparison. These measures are commonly integrated into an intake packet or biopsychosocial when a counselor first begins their work with an individual. Examples of formal assessments include the General Self-Efficacy Scale (GSE; Schwarzer & Jerusalem, 1995) and Beck Depression Inventory (BDI; Beck et al., 1961), both outlined in the following two sections‌‌‌. Best practices typically involve the use of both unstructured and structured assessments.

General Self-Efficacy Scale The GSE (Schwarzer & Jerusalem, 1995) assesses an individual’s perceived self-efficacy to cope with daily stressors and ability to adapt after facing adversity. This scale was developed in accordance with Bandura’s (1977) theory of self-efficacy as a mediating factor between an individual’s personal goals and desired behaviors. The GSE is a 10-item self-report scale and can be administered through pen and paper or an electronic device, and the authors report an average completion time of 4 minutes. Typically, the GSE is clinically administered in addition to a variety of other assessments during an intake process. Participants respond to questions through a 4-point Likert scale, with 1 representing “not true at all” and 4 representing “exactly true.” An example question is, “I can solve most problems if I invest the necessary effort” (Schwarzer & Jerusalem, 1995). Respondents’ answers across the 4-point Likert scale are summed and equate to a number between 10 and 40, with 40 indicating an individual’s self-perceived self-efficacy across multiple situations and challenges. Additionally, the GSE has been studied across multiple cultures and participant identities and contains strong psychometrics. The authors reported criterion-related validity with positive coefficients for favorable emotions, general optimism, and work satisfaction, as well as negative coefficients for depression, anxiety, stress, health complaints, and job burnout. Furthermore, the GSE has been studied across 23 nations and had Cronbach’s alphas ranging from 0.76 to 0.90, with an average in the high 0.80s. The authors also note that this scale does not assess a particular behavior or situation, instead assessing an individual’s perceived self-efficacy as it comes to generally producing the desired output in the face of adversity. More specific behavioral and situational scales are in press and should be considered case-by-case. For example, the Self-Efficacy for Exercise Scale (SEE; Resnick and Jenkins, 2000) can be administered specifically to assess an individual’s self-efficacy to engage in exercise behaviors.

Beck Depression Inventory The BDI (Beck et al., 1961) is one of the most widely used clinical assessments. Aaron Beck, one of the originators of cognitive therapy and discussed earlier in this chapter, developed the BDI to assess depressive symptoms. The original BDI contains 21 self-reported items, and each question has four responses with scores ranging between 1 and 3. Scores from

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each question are summed, and the respondent receives a score between 0 and 63, with a score of 40 or higher indicating “extreme depression.” See Beck et al. (1961) for additional information on the clinical cutoff scores. The original BDI has strong psychometrics and has been studied across multiple demographics. Internal consistency for the BDI ranges with Cronbach’s alphas ranging from 0.81 to 0.86 for nonpsychiatric and psychiatric populations, respectively. Validity was reported through strong criterion validity based on similar measures of depressive symptoms. Furthermore, Beck revised this instrument and introduced the BDI-II (Beck et al., 1996). The BDI-II is updated to reflect DSM-IV symptomatology for depression and has strengthened clinical sensitivity. As with the BDI, the BDI-II contains 21 self-reported items, with each item having four responses ranging from 0 to 3, and the scores of each question are summed for a total score between 0 and 63. There are disagreements in the literature on standard cutoff scores, and the reader is encouraged to visit Pearson Assessments for their manual on the BDI-II, as well as additional information on purchasing the assessment. Psychometrics for the BDI-II is also strong. Wang and Gorenstein (2013) reviewed 118 studies that used the BDI-II and reported an average internal consistency Cronbach’s alpha score of 0.9, with retest reliability ranging from 0.73 to 0.96. They also reported criterion-based validity based on similar measures of depression. Lastly, Beck has produced other measures for various clinical presentations that demonstrate high validity and reliability. Two examples include the Beck Anxiety Inventory (BAI; Beck et al., 1988) and Beck Hopelessness Scale (BHS; Beck et al., 1974).

THEORETICAL TECHNIQUES IN COGNITIVE APPROACHES Cognitive approaches tend to involve therapeutic techniques that challenge the individual’s dysfunctional thought patterns that lead to undesired emotional states and behaviors. If you have read through this chapter and noticed an affinity toward the tenets and processes, you are in luck, as you will have a variety of evidence-based techniques and interventions at your disposal. Therapists across multiple treatment settings can apply cognitive theory techniques to their practice, and a growing body of evidence continues to support these applications. Moreover, therapists adhering to managed care expectations may find the following techniques, or other cognitive techniques, advantageous due to their cost and time effectiveness (Seligman & Rechenberg, 2014). This section will outline specific interventions from SLT, CBT, and ACT; however, please note that this is not an exhaustive list, and resources will be provided at the end of the chapter for continued exploration.

Cognitive Behavioral Therapy CBT techniques simultaneously target the individual’s cognitions and behaviors. As noted by Seligman and Reichenberg (2014), CBT techniques involve a continual process of cognitive restructuring that is followed by desired thought patterns and behaviors. As with SLT approaches, CBT approaches are first introduced in session and then solidified by practicing outside of session. The following sections will outline psychoeducation, homework, behavioral activation, thought stopping, and reframing. PSYCHOEDUCATION

Due to the unique and structured nature of CBT, providing the client with psychoeducation can provide a primer that promotes client engagement and understanding. Typically, a CB therapist will begin the therapeutic relationship by explaining the basic tenets of CBT and providing their client(s) an opportunity to ask questions about the process. During these initial stages, it is important to describe the CBT model and the influence our cognitions have on behaviors and emotions, and vice versa. It is recommended that clinicians have a variety of educational sources to support diverse learners, such as visual handouts and audio recordings. Furthermore, psychoeducation can and should be used when describing

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specific CBT skills. When introducing a new skill, the clinician should outline the premise of the skill, how the skill can support their therapeutic goals, examples of how to use the skill, and model the use of the skill. Psychoeducation should be an ongoing process of CBT and lessons should be revisited throughout the therapeutic relationship. HOMEWORK

Assigning homework is not solely for CB therapists but is a staple of this approach. Homework is the process of giving clients out-of-session challenges or tasks that reinforce the work that is done within a session. This can involve structured worksheets, journaling, or engaging in outside-of-session behavior skills training. The process of homework should follow (a) identifying the presenting concern causing distress in the client’s environment, (b) collaborating with the client to identify a task or challenge that meets their unique needs, (c) a thorough discussion on when the client will complete the homework and how to address potential barriers, (d) a summary at the end of the session about the client (consider asking the client to summarize back to you), (e) reviewing the homework in the following session, and (f) evaluating the need for continued homework tasks. If a client does not complete their homework, it is important to remember that it is not necessarily resistance. In this situation, barriers to completing the homework should be revisited, and client interest should be gauged. Lastly, clients should create their own homework as termination approaches. BEHAVIORAL ACTIVATION

Behavioral activation is the process of establishing behaviors that an individual will complete at scheduled times throughout their day-to-day routines. Typically, this process begins by identifying pleasurable activities the individual has neglected and contributes to the presenting concern. Through a collaborative process, the individual indicates when they will engage in the pleasurable activity and discusses potential barriers to following through with the behavior. It may even be beneficial for the client to set alarms to remind themselves of the activity they agreed to complete and consider potential positive reinforcements after they complete the activity. Next, the individual should document their experience completing the activity (preferably involving a Likert scale) and obstacles that made the activity difficult. These reports are further processed in session, and future behavioral activation strategies are developed. Furthermore, behavior activation strategies should start small and gradually build as the client gains confidence and self-efficacy. Behavior activation is a well-documented strategy for clients that present with depressive symptoms, as these individuals tend to neglect important life tasks and receive no positive reinforcement to initiate the behaviors independently (Sperry & Binensztok, 2019). THOUGHT STOPPING

Individuals are frequently presented with undesired thoughts. Thought stopping is a process of recognizing these thoughts and stopping them as they arise. Erford (2020)‌‌‌‌ outlined thought stopping in four steps: (a) identifying the undesired thought, (b) naming situations that will likely result in the undesired thoughts, (c) interrupting the thought with the command “stop,” and (d) replacing the undesired thought with a more pleasurable thought. When engaging in the “stop” command, it is often encouraged that the client first picture a symbol that represents a stop, such as a stop sign or a stop light. Thus, they can pair the command with a visual to immediately replace the unwarranted thought. Additionally, Erford noted that clients are more likely to follow through with thought stopping if they create a list of more pleasurable thoughts in session. It is recommended that the client and therapist collaborate to have this list readily available when the client experiences the undesired thought. Thought stopping is a common strategy introduced to clients that present with anxiety symptoms and can be a quick intervention for time-limited therapy (Sperry & Binesztok, 2019).

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REFRAMING

An alternative to having an individual stop the thought altogether is to have the client reframe their thought. If you have taken a therapeutic skills course or are currently enrolled, you may recognize this approach. Young (2020) introduced reframing for helpers and described it as a change approach that can be used to challenge your client to gain a new perspective on a situation. From a CBT standpoint, the goal of therapy is to assist the client in living independently and applying CBT techniques without prompting from their therapist. Therefore, the therapist can educate the client on the tenets of reframing so they can use it in their day-to-day life. From the client’s perspective, reframing is the ability to recognize an undesired or negative thought and identify a perspective that is more positive and beneficial. Clients are challenged to embrace optimism when faced with their negative thoughts and consider how they can look at this situation from another perspective. Metaphors are also commonly encouraged. Looking at the “glass as half full” as opposed to the “glass as half empty” is a common metaphor that embodies the principles of reframing. See Table 9.2 for example of theoretically based techniques.

Table 9.2. Cognitive Techniques and Examples Technique

Example

Psychoeducation

“Before we go further, I want to make sure we take time to discuss my view of counseling. I practice from a cognitive behavioral therapy, or CBT, model. Within the CBT model, I want to help you better understand how your cognitions, or thoughts, affect your behaviors and emotions. During therapy, I will challenge you describe different thoughts that you have and then we will explore how those are impacting how you act and how you feel. There may be times where I also ask you to describe your thoughts after certain behaviors and emotions, too. This is because I believe that our thoughts, behaviors, and emotions are all connected. What initial questions do you have?”

Homework

“Okay, we are getting near the end of today’s session, and you have voiced that you would like something to practice over the next week. I believe that is a great idea and will help you continue working on things that we have discussed in today’s session. Whatever we collaboratively decide on will be discussed at the beginning of next week’s session. Based on our conversations today, what do you believe is a good homework task for you to work on over the next week?” Having the client logging their negative thoughts throughout the week and describing the situation or environment during their negative thought

Behavioral activation

A client that enjoys cooking, but has given up cooking as a result of depression symptoms (e.g., lack of motivation), can schedule times to cook. For example, the client will cook a meal of their choosing at 6:00 pm on Tuesday and Friday of 1 week and will document their feelings and thoughts during the planned behavior.

Thought stopping

A client that has negative thoughts surrounding their recent divorce can be asked to engage in thought stopping whenever they think about the divorce. When presented with thoughts of the divorce, the client will recognize it as a negative thought, recognize the situation around the negative thought, “stop” the thought by internally or externally saying “stop,” and replace the negative thought surrounding the divorce with a more positive thought.

Reframing

A client that is feeling guilty about dating because it takes them away from their daughters can reframe “I am a bad father because I am spending time dating instead of time with my daughters” into “I am modeling healthy behaviors for my daughters, such as safe dating strategies and how to take care of yourself in a relationship.”

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Social Learning Theory Techniques adhering to SLT follow principles of modeling and learning from observation, as opposed to operant conditioning and contingency management strategies (i.e., reinforcements, punishments, and rewards). Counselors using these techniques will provide direct instruction in session and model behaviors for their clients to practice. Following practice within the session, clients find opportunities to engage in these desired behaviors out-ofsession. The following section will outline behavioral rehearsal. BEHAVIORAL REHEARSAL

Commonly referenced as “role-plays,” behavioral rehearsals are a common strategy to assist individuals in becoming more comfortable engaging in the desired behavior. More specifically, behavioral rehearsals are when a therapist provides their client an opportunity to develop and practice behaviors in anxiety-provoking situations. Erford (2020) reported that behavioral rehearsals involve the therapist modeling the behavior for the client, providing the client feedback as the client learns the behavior, and practicing the behavior multiple times within the session before the client attempts the behavior out-of-session. First, the therapist models the behavior by providing direct observation or demonstrating the behavior through an outside outlet (e.g., media representation). The client is encouraged to ask questions and receive clarification on the modeled behavior. Next, the client begins practicing the behavior in a therapeutic environment that resembles the anxiety-provoking situation as close as possible. During this process, the client continuously receives feedback from their therapist and is encouraged to report their level of comfortability. Lastly, the client identifies instances in their life where they can practice the behavior outside of the session and then reevaluate their comfort level afterward.

Acceptance and Commitment Therapy In contrast to directly challenging cognitions, therapists using an ACT approach collaborate with their clients to develop strategies to accept and adapt their thoughts to meet their authentic worldview and value system. Through accepting and adapting their thoughts, clients learn to view themselves in a nonjudgmental manner and externalize their problems. As ACT is considered a third-wave approach, limited empirical techniques exist compared to other theories presented in this text. Current ACT approaches emphasize tenets of value clarification and mindfulness. The following section will outline values assessment. Hayes et al. (2011) encourage reading for those interested in learning about more specific ACT techniques. VALUES ASSESSMENT

Common in the practice of motivational interviewing, a values assessment aims to build insight into an individual’s value system and gain clarity into factors that motivate the individual (Miller & Rollnick, 2013). In ACT therapy, interventions that target the individual’s value system assist the client in their insight development into how they would like to authentically choose their behaviors, as opposed to choosing behaviors that are a result of controlling messages from their cultural context (Prochaska & Norcross, 2018). With a deeper understanding of their value system, the individual is better suited to understand the context of their thoughts and accept their thoughts and behaviors. Miller and Rollnick outlined the values card sort, which provided an example of how this can be facilitated in session. The client is presented with a set of cards that list a variety of common values and asked to sort all of the cards into the following five categories: “most important,” “very important,” “important,” “somewhat important,” and “not important.”‌‌‌ Ideally, the client is evenly distributing the cards among these categories, and it may require the client to complete multiple rounds of categorization until there is a more even

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distribution. Following the card sort, the therapist and client discuss the process of identifying their most important values and how these values have potentially contributed to their thought patterns and behaviors. This values card sort can be found at www.guilford. com/p/miller2.

MULTICULTURAL, INTERSECTIONAL, AND SOCIAL JUSTICE ISSUES Mental health impacts of social inequality and discrimination are well documented in the literature (see Bryant-Davis & Ocampo, 2005). The COVID-19 pandemic, political upheaval, anti-Hispanic and LGBTQIA rhetoric, and violence against African Americans and Asian Americans revealed long existing patterns of inequalities, oppression, and racism in our society. Rates of mental distress among African Americans and Asian Americans soared in the weeks following the murder of George Floyd and the racial hate crimes targeting Asian American women (Thomeer, 2021). Siegel and Mallow (2021)‌‌‌‌ estimated the number of clients seeking mental health support rose by over 800%, highlighting the need for counselor preparation that demonstrates awareness of the sociopolitical factors impacting client well-being. As the diversity of clients increases, a critical examination of theory is needed to ensure a standard of care that is reflective of the social justice and cultural needs of society and those we serve (Ratts et al., 2016‌‌‌‌; Singh et al., 2020b). Social justice advocacy, recognized as the fifth force in counseling, acknowledges issues of oppression, power, and privilege as factors impacting client well-being (Ratts, 2009). This acknowledgment decenters‌‌‌ euro-heteronormative perspectives as standard and challenges deficit models of conceptualization that situation dysfunction within the client. Evidence of Euro‌‌‌-heteronormative perspectives is often embedded in assumptions underpinning theory. The multicultural and social justice counseling competencies (MSJCC; Ratts et al., 2016) called on counselors to critically examine the assumptions underlying theory and how those assumptions guide counselor conceptualization of client needs and issues of power, privilege, and oppression (Ratts et al., 2016). The MSJCC, a revision of the multicultural counseling competencies (MCC; Sue et al., 1992‌‌‌‌), emphasized advocacy as a means of addressing disparities linked to inequality by expanding the MCC framework of attitudes and beliefs, knowledge, ‌‌‌ and skills to include action‌‌‌ as the fourth competency (Hays, 2020). The MSJCC identified four areas of competence (a) counselor self-awareness; (b) client worldview; (c) counseling relationship; and (d) counseling and advocacy interventions. Each of these areas creates a pathway for counselors to develop a social justice orientation that acknowledges power and privilege in the therapeutic relationship. The fourth competency, action‌‌‌, is possible at six levels: interpersonal, intrapersonal, institutional, community, public policy, and global/international, creating opportunities for counselors to engage in social justice action that disrupts systems of injustice through advocacy (Singh et al., 2020a). In this section, we will examine culturally responsive approaches to CBT, ACT, and SLT in treating clients impacted by intersectionality and social inequality. Using a social justice/intersectional/ multicultural lens, recent research will be presented that highlights the effective use of these therapies for enhancing client outcomes.

Cognitive Therapy and Social Justice Counseling A social justice approach considers how client dysfunction is maintained by systemic factors such as inequality and oppression and engages in advocacy both in and outside of the therapeutic session to disrupt oppressive systems impacting client well-being (Hays, 2020). A key factor in social justice counseling is clinician integration of awareness, knowledge, skill, and action against marginalization and the inequality of power and privilege embedded in traditional theory (Atewologun, 2018). CBT can be used responsibly to address

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issues of inequality and oppression by targeting and modifying cognitions originating from oppressive social messaging (Richey & Pointer, 2022). For example, Steele (2020) theorized a ­cognitive-developmental model for addressing internalized racism. The model employed an adapted model of CBT that targeted client assumptions and core beliefs driven by relevant social and childhood experiences. Crumb and Haskins (2017) infused relational concepts of relational-cultural theory (RCT) with CBT to address systemic concerns and make CBT more culturally responsive. The integrative model encouraged the exploration of values and belief systems not often enforced in traditional CBT and addressed sociocultural and relational connections and factors by empowering the client through self-advocacy. The researchers identified four suggestions for applying integrated CBT that is also applicable to adapting SLT: 1. The use of transparency in diagnosing and assessing client 2. Assuming a shared expert role to address issues of power and privilege in the therapeutic relationship 3. Responsible use of cognitive restructuring that honors the client’s worldview 4. Use of cognitive techniques to address oppressive social messaging impacting well-being

Cognitive Therapy and Intersectionality Intersectionality examines the ways discrimination is experienced across multiple intersecting identities. The theory, coined by Kimberly Crenshaw, originated as a legal concept to decenter hegemonic perceptions of race and gender as mutually exclusive in the lives of Black women (Crenshaw, 1991; Singh et al., 2020a). When applied broadly, intersectionality considers race, gender, sexual orientation, social class, disability, and ethnicity on issues impacting functioning and well-being (Evans, 2019). A different lens than multiculturalism, which often focuses on cultural adaptation of existing theory, intersectionality considers the role of within-group differences on client lived experience and the implications for therapeutic need. Acknowledging intersectionality as a wellness factor impacting mental health, counselors can examine theory to remain attuned to issues of power and privilege and actively engage in advocacy efforts against inequalities adversely affecting mental health. Richey and Pointer (2022) utilized an intersectional lens as they applied an abbreviated four-session model of CBT to support a female-identifying client with a focus on issues of discrimination against motherhood and sexism. The researchers cited societal issues of oppression, power, and privilege as factors impacting the mental health of women healthcare workers during the COVID-19 era. The CBT protocol was used to validate the client’s thoughts and feelings of gender-based oppression and challenge anxiety-based thinking patterns perpetuated by societal inequalities. Langroudi and Skinta (2019)‌‌‌‌ used culturally adapted ACT and compassion-focused therapy (CFT) to address experiences of shame among Muslim, gender, and sexual minorities. The authors emphasized the importance of counselors gaining knowledge of the experiences specific to a client’s identities. In this case, they stressed the importance of clinician awareness of Islamaphobia, racism, and sexual racism as intersecting issues that are idiosyncratic and nongeneralizable. This finding is echoed in Hunter et al. (2020) who found that rehabilitation counselors working with queer clients with disabilities needed to assess, support, and validate client’s sexual, gender, and disability identities to bolster self-­acceptance, a key factor of resilience. Counselors who engage in a critical examination of theory support a social justice orientation to counseling that acknowledges the ways in

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which well-being is impacted by intersectionality and social political factors such as systemic racism and discrimination.

THEORY-BASED SCHOLARSHIP AND RESEARCH TRENDS There is a lot of research focused on cognitive approaches in the helping profession’s literature. This is beneficial to scholars and practitioners who align with cognitive approaches, and most importantly for clients who benefit from the outcomes. The plethora of research allows cognitive approaches to be viewed as evidence-based approaches, which means they are frequently used in settings that bill insurance. Additionally, they are often used in clinical trials and/or research studies because cognitive approaches often allow researchers to make direct observations and measurements. It is worthy to note that just because cognitive approaches are well researched, it does not make them superior than other approaches. However, it is exciting to see scholars starting to suggest adapting cognitive approaches to address the needs of diverse populations (e.g., see Wallace et al., 2021; Williams et al., 2022).

DETAILED CASE CONCEPTUALIZATION PRAGMATICS AND TRANSCRIPT Mark is a 42-year-old, Black, cisgender male who works as a project manager for a general contracting company.  He is divorced and lives with his two daughters.  Mark is seeking counseling for anxiety, sadness, and anger that occurred following his divorce. Mark has expressed feeling lonely and guilty for wanting to start dating again because it “takes me away from my daughters.” Transcript

Skill(s) Demonstrated

Counselor: Hello, Mark. How was your previous week?

Open-ended question (The counselor uses an open-ended question to open the session.)

Client: I’ll be honest. This week has been pretty difficult. The holiday season can be lonely at times having to split the time with my daughters with my wife. Counselor: You feel depressed when you spend time alone at your house and it is more often around the holiday season.

Reflection of feeling, paraphrase (The counselor reflects the feeling of depression and follows it with a paraphrase based on the client’s response.)

Client: Yeah…. The more time I spend alone at my house, the more I start to think how nice it would be to start dating again. Then, I start to feel bad that I want to date and potentially spend more time away from my daughters. Counselor: You find yourself in a cycle of wanting to date again, but then feeling guilty and depressed.

Client: Exactly!

Paraphrase (The counselor paraphrases the client’s report of feeling guilty and then depressed after thinking about dating.)

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Counselor: I appreciate you telling me this and bringing up the feelings of guilt and depression we have previously talked about. Did you have an opportunity to work on the homework “task” we agreed upon last week?

Homework (The counselor brings up the mutually agreed-upon homework “task” at the beginning to check in and incorporate the “task” into the session.)

Client: I did get a chance to practice what we talked about last session, though I found it to be much harder than I expected. Counselor: Please tell me about your experience with thought stopping.

Encourager (The counselor uses a minimal encourager to get the client to expand upon a previous response.)

Client: Well, l, I know last week we talked about thought stopping and how it could possibly help with my frequent feelings of guilt when I think about dating. At first, I found it hard because I would feel guilty again soon after stopping the thought, but it got better as I did it more. Counselor: At first, you found yourself going back to the negative thoughts and feeling guilty, but then you were able to have less frequent negative thoughts. Tell me your process of thought stopping.

Paraphrase, encourager (The counselor paraphrased the client’s initial report of thought stopping and asked them to expand more.)

Client: When I started thinking that I was a bad father because I want to start dating, I would try to remind myself that it was a “negative thought.” If I was able to recognize that it was a negative thought, I simply would say, “Stop!” in my head. Sometimes, it would take me about 5–10 times of saying “stop” before it would click.

Thought stopping (The client provides an example of how they used thought stopping outside of the counseling session.)

Counselor: You were not always able to stop with your first attempt but had more success when you said it more.

Paraphrase (The counselor paraphrased the client’s experience with thought stopping.)

Client: Yes. Sometimes it helped to picture a stop sign like we talked about last week. Counselor: Great to hear! Can you give me an example of a thought you would replace the negative thought with?

Encourager (The counselor requested that the client expand upon their process of thought stopping.)

Client: Yes. On Tuesday, I was starting to have negative thoughts around dinner time. When I was able to successfully stop the thought, I started thinking about a recent promotion I got at work. Counselor: I see. You have previously told me that you worked hard for that promotion!

Paraphrase (The counselor paraphrased the client’s experience replacing a negative thought with a positive thought.)

Client: I did work hard and it was nice to remind myself that I am not completely messing up my life. Counselor: You are proud of yourself for doing well at work and that was a much more pleasant thought.

Reflection of feeling (The counselor reflected the client’s feeling during their positive thought.)

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Client: I am proud of myself! Counselor: You should be! I am curious, what did you think of thought stopping compared to reframing (the skill we talked about two weeks ago)?

Open-ended question (The counselor used a question to learn more about the client’s experiences with different CBT skills.)

Client: I have found them both useful, but I am not sure which one I prefer more. They have both been challenging to learn and they have both stopped me from thinking so bad about myself. Counselor: Sometimes these two skills can be used together! For example, when you stop the negative thought, you can replace the negative thought with a reframed positive thought.

Psychoeducation (The counselor uses psychoeducation to describe thought stopping and reframing used together.)

Client: Oh, so instead of thinking about something different, I could use reframing right after I stop the negative thought? Counselor: Yes! You previously mentioned that you thought you were a bad father because you wanted to start dating again and this might take time away from your daughters. How could you reframe this thought?

Reframing (The counselor invited the client to reframe a previously negative thought.)

Client: It is hard for me to think about that any differently. The only other way I thought about my guilt is that I am finding ways to enjoy my life. Counselor: And we previously talked about how it is important for you to show your daughters healthy habits. I am wondering if you starting to date again is healthy modeling for your daughters to do things in life to take care of yourself.

Reframing (The counselor uses the negative thoughts and attempts to reframe it to something more positive.)

Client: When you put it like that, it sounds like I am showing my daughters that it is important to do things for yourself sometimes. Counselor: I agree! Can I hear you say it?

Encourager (The counselor encourages the client to engage in reframing.)

Client: Getting back into the dating scene is a healthy way for me to model taking care of myself and proper dating behaviors. These are things that I want my daughters to be able to understand. Counselor: That was a great reframe! When you are engaging in thought stopping over the next week, I encourage you to try incorporating opportunities to reframe and see how your thoughts change. Before we move farther into today’s session, I also want to see how you’re doing with you being able to cook at least two meals a week. Have you been able to work on that task? Client: I was only able to do it one time this week. I was too depressed to do it the other time.

Closed question, behavioral activation (The counselor asks a yes/no question about the client engaging in behavioral activation.)

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Counselor: You were able to cook one meal this week, but you found it difficult to get up the second time. That is understandable! Tell me about the time that you did cook.

Paraphrase, encourager (The counselor paraphrased the client’s report and encouraged them to expand upon this report.)

Client: On Tuesday, I was too depressed to get up and cook at the scheduled time we had previously discussed. However, it was easier on Friday. So, I cooked myself my favorite burger with fries last Friday. I will be honest, it was the last thing I wanted to do on Friday at 6:00 p.m. when I was feeling down and out, but it really did help my mood. I even noticed myself smiling while I was cooking.

Behavioral activation (The client recounted their experience engaging in a positive behavior that was at an agreed-upon time.)

Counselor: While it was initially difficult to cook for yourself on Friday at 6:00 p.m., you were able to work through the negative feelings and noticed yourself in a better mood because of it. You even mentioned that you were happy and smiling.

Paraphrase, reflection of feeling (The counselor paraphrased the client’s report of behavioral activation and reflected their feeling of happiness.)

THEORETICAL LIMITATIONS As with all therapeutic theories and techniques, there are limitations to cognitive approaches that practitioners should consider. Although CBT is well researched and is supported by many studies, it is important to recognize the reasons it is an easier approach to study due to its ability to observe direct behavior that can be quantified. Additionally, not all of the studies conducted using cognitive approaches are inclusive of marginalized populations. Furthermore, many of the founders of this theory share similar characteristics, which may present bias within the early development of the theory. It is also important to consider that the structured nature of cognitive approaches may be too rigid for some individuals or therapists and that clients are encouraged to conceptualize experiences in a linear fashion (e.g., emotions are influenced through thoughts and behaviors) and do not account for other sociocultural factors.

SUMMARY In Chapter 9, we described cognitive approaches. We focused on three main approaches, CBT, SLT, and ACT, and their similarities and differences. We described the role of the counselor and the client in cognitive approaches, the limitations within the approaches, and how to assess progress. Additionally, we highlighted the importance of multicultural, intersectional, and social justice issues in cognitive approaches. Finally, we provided practical cognitive techniques and a case example. VOICES FROM THE FIELD This chapter features a digitally recorded interview entitled Voices From the Field. The interview explores multicultural, social justice, equity, diversity, and intersectionality issues from the perspective of clinicians representing a wide range of ethnic, racial, and national backgrounds. The purpose of having chapter-based authors interview individuals representing communities of color or who frequently serve diverse populations is to provide you, the reader, with relevant theory-based social justice and multiculturally oriented conceptualization, contemporary issues, and relevant skills.

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Access the video at https://bcove.video/3Q5Azxt

LaNita Jefferson, MRC, LPC, LPC-S, is a Black, cisgender female therapist working in the Columbia, South Carolina area. LaNita holds a master’s degree in clinical rehabilitation counseling and plans on finishing her doctorate in counselor education and supervision from the University of South Carolina in Spring 2023. She has worked with clients from diverse backgrounds over 5 years and utilizes a CBT approach to meet the unique needs of her clients. She serves individuals with physical and/or mental disabilities and assists those individuals with addressing their physical and mental limitations to improve their quality of life. Her research interests include the intersection of hip hop and therapy, as well as Black mental health and wellness.

STUDENT EXERCISES Exercise 1: The Origin of Mental Health Concerns

Directions: Reread the section in this chapter on the origin and nature of mental health concerns for one of the theories covered in this chapter (CBT, ACT, or SLT). After reading the section, do the following: 1. Identify the underlying assumptions of the theory. 2. What do those assumptions say about the causes of client dysfunction? 3. How might those assumptions marginalize the identities of clients who hold identities that have historically or are currently oppressed?

Exercise 2: Article Review

Directions: Select and read one article that uses a case study to demonstrate cultural adaptation of the theory you have chosen with a client from a group/population that has been historically marginalized. 1. What differences do you notice between the traditional theory and its cultural adaptation? 2. How do these adaptations reflect multiculturalism as defined in this section?

Exercise 3: Exploring Popular Media’s Cognitive Distortions

Directions: Think of a favorite TV show, movie, or book character. What are three to five cognitive distortions experienced by that character? What evidence do you have that suggest it is a cognitive distortion? Break off into group of two to three and discuss the cognitive distortions.

Exercise 4: Advertising CBT

Directions: You have a new client that recently heard about CBT on their favorite morning talk show. This client saw that you advertise yourself as a CB therapist and chose you specifically. However, they are still confused on what CBT consists of. Practice with a peer giving the client a 1- to 2-minute description of CBT for your new client. Remember, clients may prefer the explanation in layman’s terms.

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Exercise 5: Social Cognitive Theory

Directions: Your client, Kaleb, has reported that they want a promotion at work. Over the last 2 months, you have worked with Kaleb to address their negative thoughts and self-talk surrounding their ability to get a promotion. Last session, they said that they are ready to have a discussion with their boss; however, they expressed they are anxious about asking their boss and request support. Due to your theoretical approach incorporating SLT (i.e., social cognitive theory), you believe a role-play will help Kaleb work through their anxiety. Partner with someone and practice a 10- to 20-minute session facilitating a mock session with your client, Kaleb. In turn, have your partner practice being the counselor and play the role of Kaleb.

RESOURCES Helpful Links ■ ■ ■

Therapy worksheets related to CBT: www.therapistaid.com/therapy-worksheets/cbt Resources for mental health professionals and students: https://beckinstitute.org/ cbt-resources/resources-for-professionals-and-students Sleep, meditation, and relaxation app: www.calm.com

Helpful Books ■ ■ ■ ■ ■ ■

DiTomasso, R. A., Golden, B. A., & Morris, H. J. (Eds.). (2010). Handbook of cognitive ­behavioral approaches in primary care. Springer Publishing Company. Iwamasa, G., & Hays, P. (Eds.). (2018). Culturally responsive cognitive behavior therapy: Practice and supervision (2nd ed.). American Psychological Association. Hayes, S. C., & Strosahl, K. D. (2005). A practical guide to acceptance and commitment t­ herapy. Springer Science+ Business Media. Joyce-Beaulieu, D., & Sulkowski, M. L. (2015). Cognitive behavioral therapy in K-12 school settings: A practitioner’s toolkit. Springer Publishing Company. Jun, H. (2018). Social justice, multicultural counseling, and practice: Beyond a conventional approach. Springer. Singh, A.A. (2019) The racial healing handbook. New Harbinger Publications, Inc.

Helpful Videos ■

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PESI Inc. (Producer). (2020). Racial Trauma: Assessment and Treatment Techniques for Trauma Rooted in Racism. [Video/DVD] PESI Inc. https://video.alexanderstreet.com/ watch/racial-trauma-assessment-and-treatment-techniques-for-trauma-rooted-in-racism Alexander Street (Producer). (2019). Cognitive-Behavioral Therapy. [Video/DVD] Alexander Street, a ProQuest Company. https://video.alexanderstreet.com/watch/ cognitive-behavioral-therapy Rats, M.J. (Director). (2012). Fifth Force: The Social Justice Counseling Session. [Video/DVD] Microtraining Associates. https://video.alexanderstreet.com/watch/ fifth-force-the-social-justice-counseling-session

A robust set of instructor resources designed to supplement this text is available. Qualifying instructors may request access by emailing [email protected].

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Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2011). Acceptance and commitment therapy: The process and practice of mindful change. Guilford Press. Hunter, T., Dispenza, F., Huffstead, M., Suttles, M., & Bradley, Z. (2020). Queering disability: Exploring the resilience of sexual and gender minority persons living with disabilities. Rehabilitation Counseling Bulletin, 64(1), 31–41. https://doi.org/10.1177/0034355219895813 Iwamasa, G. & Hays, P. (Eds.). (2018). Culturally responsive cognitive behavior therapy: Practice and supervision (2nd ed.). American Psychological Association. Langroudi, K. F., & Skinta, M. D. (2019). Working with gender and sexual minorities in the ‌‌‌‌context of Islamic culture: A queer Muslim behavioural approach. The Cognitive Behaviour Therapist, 12(21), 1–12. https://www.10.1017/S1754470X19000096 Mahoney, M. J. (1977). Reflections on the cognitive-learning trend in psychotherapy. American Psychologist, 32(1), 5–13. https://doi.org/10.1037/0003-066X.32.1.5 Messer, S. B., & Gurman, A. S. (Eds.). (2011). Essential psychotherapies: Theory and practice (3rd ed.). Guilford Press. Miller, W. R., & Rollnick, S. (2013). Motivational interviewing (3rd ed.). Guilford Press. Pearson Assessments (n.d.). Beck Depression Inventory-II. Retrieved from https://www.pearsonassessments. com/store/usassessments/en/Store/Professional-Assessments/Personality-%26-Biopsychosocial/ Beck-Depression-Inventory/p/100000159.html?tab=product-details Prochaska J. O. & Norcross J. C. (2018). Systems of psychotherapy: A transtheoretical analysis (9th ed.). Oxford University Press. Ratts, M. J. (2009). Social justice counseling: Toward the development of a fifth force among counseling paradigms. Journal of Humanistic Counseling, 48, 160–172. https://doi.org/10.1002/j.2161-1939.2009. tb00076.x Ratts, M.J., Singh, A.A., Nassar-McMillan, S., Butler, S.K., & ‌‌‌‌ McCullough, J.R. (2016). Multicultural and social justice counseling competencies: Guidelines for the counseling profession. Journal of Multicultural Counseling and Development, 44, 28–8. https://doi.org/10.1002/jmcd.12035 Resnick, B., & Jenkins, L. S. (2000). Testing the reliability and validity of the self-efficacy for exercise scale. Nursing Research, 49(3), 154–159. Richey, R., & Pointer, O. (2022). Clinical case study of abbreviated cognitive behavioral therapy through in intersectional lens for women health-care workers during the era of covid-19. Psychotherapy, 59(2), 234–244. https://doi.org/10.1037/pst0000385 Schwarzer, R., & Jerusalem, M. (1995). Generalized self-efficacy scale. In J. Weinman, S. Wright, & M. Johnston (Eds.), Measures in health psychology: A user’s portfolio. Causal and control beliefs (pp. 35–37). Windsor. Seligman, L, & Rechenberg, L. W. (2014). Theories of counseling and psychotherapy: Systems, strategies, and skills (4th ed.). Pearson Education. Siegel, R.M., & Mallow, R.J. (2021). The impact of COVID-19 on vulnerable populations and ­‌‌‌‌implications for children and health care policy. Clinical Pediatrics, 60(2), 93–98. https://doi. org/10.1177/0009922820973018 Singh, A. A., Appling, B., & Trepal, H. (2020a). Using the multicultural and social justice competencies to decolonize counseling practice: The important roles of theory, power and action. The Journal of Counseling & Development, 98, 261–271. https://doi.org/10.1002/jcad.12321 Singh, A. A., Nassar, S. C., Arrendondo, P., & Toporek, R. (2020b). The past guides the future: Implementing the multicultural and social justice counseling competencies. The Journal of Counseling & Development, 98, 238–252. https://doi.org/10.1002/jcad.12319 Sperry, L., & Binensztok, V. (2019). Ultra-brief cognitive behavioral interventions: A new practice model for mental health and integrated care. Routledge. Steele, J.M., (2020). A CBT approach to internalized racism among African Americans. International Journal of Advanced Counselling, 42, 217–233. https://doi.org/10.1007/s10447-020-09402-0 Sue, D. W., Arredondo, P., & McDavis, R. J. (1992). Multicultural counseling competencies and ­standards: A call to the profession. Journal of Multicultural Counseling and Development, 20, 64–88. https://doi. org/10.1002/j.2161-1912.1992.tb00563.x Thomeer, M.B., Moody, M.D., & Yahirun, J. (2021). Racial and ethnic disparities in mental health and ­mental health care during the COVID-19 pandemic. Journal of Racial and Ethnic Health Disparities. https://doi.org/10.1007/s40615-022-01284-9 Wallace, D. D., Carlson, R. G., & Ohrt, J. H. (2021). Culturally adapted cognitive-behavioral therapy in the treatment of panic episodes and depression in an African American woman: A clinical case illustration. Journal of Mental Health Counseling, 43(1), 40–58. https://doi.org/10.17744/mehc.43.1.03

Wang, Y. P., & Gorenstein, C. (2013). Psychometric properties of the Beck Depression Inventory-II: A ­comprehensive review. Brazilian Journal of Psychiatry, 35, 416–431. Williams, M. T., Holmes, S., Zare, M., Haeny, A., & Faber, S. (2022). An evidence-based approach for ­treating stress and trauma due to racism. Cognitive and Behavioral Practice, 6. https://doi. org/10.1177/24705470221145126 Yoman, J. (2008). A primer on functional analysis. Cognitive and Behavioral Practice, 15(3), 325–340. Young, M. E. (2020). Learning the art of helping: Building blocks and techniques (7th ed.). Pearson Education.

SECTION V

SYSTEMIC AND POSTMODERN THEORIES

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SYSTEMIC APPROACHES Tiffany Nielson and Timothy J. Hakenwerth

LEARNING OBJECTIVES After reading this chapter, you will be able to: ■ Summarize core concepts of systemic thinking ■ Compare and contrast three fundamental approaches to working with family ­systems: multigenerational, human validation process model, and structural theory ■ Articulate how systems theories differ from individual approaches ■ Critically evaluate the application of systems approaches with diverse populations

INTRODUCTION When referring to systemic approaches, we are speaking to the foundational theories and systemic philosophies that ground various models for working with couples and families. Family counseling has a unique history with origins that were parallel to and informed by that of individual counseling. However‌‌‌‌‌‌‌‌‌‌‌‌‌, it also deviated and broadened to encompass its own unique path. With origins in science, anthropology, and hypnosis, this chapter will cover some of the research, major contributors, and frameworks of three foundational systemic theories. Many of the major contributors described in this section collaborated or overlapped in their research, and there was also a general excitement and shift toward researching and treating entire families in the mid-20th century. As this chapter covers various family systems concepts, an overarching lens of diversity and implications for social justice also gives context for how to apply these models to contemporary client populations.

LEADERS AND LEGACIES OF SYSTEMIC THEORY Nathan Ackerman (1908–1971) Trained originally in psychiatry, Nathan Ackerman became involved with researching families in a small Pennsylvania mining community (Broderick & Schrader, 1981). Seeing how the relationships in the family influenced the father’s depression challenged the original thought that psychosis was purely internal. As director of the Menninger Child Guidance Clinic, beginning in 1937, Ackerman later experimented with meeting with the family and treating the family as a unit. This continued in the 1950s when he created the Family Mental Health Clinic at Jewish Family Services in New York City and later the Ackerman Institute (originally called The Family Institute). His contribution to the field broadened the definition of the treatment unit and diagnosis to include the family. He published works and helped found the Family Process, along with Don Jackson and Jay Haley, a peer-reviewed journal which is still in print as a leader in family counseling research today.

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Gregory Bateson (1904–1980) Gregory Bateson was trained as an anthropologist and was integrative across multiple disciplines through his research efforts. Bateson and his research team, which included clinicians/scholars Don Jackson, Jay Haley, and researcher Paul Watzlawick, through their studies on families with a member with schizophrenia, identified many fundamental concepts, including the central role of nonverbal communication, complementary and symmetrical relationships, homeostasis, and double binds (Bateson, 1972; Watzlawick et al., 1967). One of his great contributions is the expansion of the computer science concept of cybernetics to conceptualizing the interactions of human systems. Cybernetics refers to the ability of a system to maintain its equilibrium. Family systems practitioners refer to equilibrium as homeostasis (a term popularized by Don Jackson). Bateson described this self-correcting process for a family system to sustain homeostasis, which involves varying degrees of feedback, with some feedback encouraging change (positive feedback) and other feedback moving the system back to its natural state of homeostasis (negative feedback). The terms positive and negative are not evaluative as good or bad but rather descriptive of whether there is a change away from (positive feedback) or a return to (negative feedback) homeostasis. In human systems, people give feedback through interactions and communication, both verbal and nonverbal (e.g., the parent giving the child a knowing look when they misbehave or a spouse moving closer to their partner, seeking closeness and reconnection). Homeostasis is also not inherently good or bad. The metaphor of cruise control on a car gives an example of these concepts. When driving on the highway, the cruise control may be set to a desired speed. However, when encountering merging traffic, it becomes vital for the driver to adjust the cruise to accommodate the oncoming traffic (a move away from homeostasis through positive feedback). The driver may now have a new homeostasis set through their cruise control. They may decide, once traffic is clear, that they can return to their original speed and reset their cruise. This would be a move toward ‌‌‌‌‌‌ homeostasis through negative feedback. It is important to consider that the set speed, or homeostasis, may or may not be desirable or helpful. Too fast of a speed may result in a speeding violation, and too slow may increase the amount of time to get to a destination or interfere with the flow of traffic. Similarly, family systems may find some comfortability in homeostasis, although not always desirable or helpful. This is a simplistic example of these concepts, and in human applications, homeostasis is an ever-evolving and moving target. Broader social systems experience similar changes. Through the COVID-19 pandemic, the term new normal became popularized with a recognition that as a society, a return to pre-pandemic functioning is not feasible, helpful, or realistic.

Don Jackson (1920–1968) In addition to the work with Gregory Bateson, Don Jackson, alongside Richard Fisch, founded the Mental Research Institute (MRI) in Palo Alto. This served as the bedrock training center from which many of the fundamental systemic theories became solidified. Key clinicians/theorists included Jay Haley, Virginia Satir, and Paul Watzlawick.

Jay Haley (1923–2007) Known for his work in developing strategic family therapy, Jay Haley worked on the Bateson research team and at the MRI. Haley developed a pragmatic and provocative counseling style which brought in new ways of challenging the status quo or homeostasis of family systems. One such example is the use of paradox as an intervention in family therapy. Haley, along with his wife, Cloé Madanes, founded the Family Therapy Institute. Strategic family

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therapy became the seeds from which solution-focused brief therapy later evolved through the Milwaukee Brief Family Therapy Center with Insoo Kim Berg and Steve de Shazer.

Theodore Lidz (1910–2001) Trained in psychoanalysis, Lidz, like many others at the time, worked with clients with schizophrenia. He developed the familial terms to describe the quality of the parent–child relationship. A “skew” described a “domineering” parenting style, while a “schism” was “distant and hostile” (Broderick & Schrader, 1981, p. 21). Identifying the familial patterns was another mechanism to shift the perspective of mental health toward a systems view.

Murray Bowen (1913–1990) Murray Bowen is considered by many as the father of family therapy. He was the founder of Bowen family systems therapy, also referred to as multigenerational family therapy, a transgenerational approach that explicitly views the family transactions across multiple generations. Bowen began his work as a psychiatrist at the Menninger Clinic in the 1940s, in which he worked directly with the families of patients in treatment. Although originally trained in psychoanalysis, that model was lacking in understanding the families he encountered (Kerr & Bowen, 1988). He later moved to the National Institute of Mental Health, where entire families that had a schizophrenic member were brought in to live inpatient. It was through this research that his theory of family systems emerged. Initially, the relationship between mother and child became a central figure in conceptualizing schizophrenia. More specifically, Bowen noted how the stress of previous generations of the family system had built up to an “intensity” that surfaced as a symbiotic relationship between mother and child, and thus to deal with this intensity of the system, the child developed a diagnosis of schizophrenia (Kerr & Bowen, 1988, p. 5). They soon discovered that the intensity of the mother–child relationship was experienced across the entire family system. Through this work, there was a shift from causal thinking, focused on one person being the problem, to noticing the reciprocity in family interactions and the emotional push and pull played by all members of the family (Kerr & Bowen, 1988). They began to challenge psychoanalytic thinking, which was prevalent at the time and put under the microscope the inner psyche, and shifted to create a cohesive theory for understanding the entire family unit, noticing their context, and the process of relationships. In his later work at Georgetown, working with families with less severe psychosis, similar processes and patterns emerged. Through these experiences, the core tenets of Bowen family systems were developed and continue to be practiced internationally.

Virginia Satir (1916–1988) Virginia Satir is a world-renowned family therapist known for her down-to-earth style of working with families and groups. She‌‌‌‌‌‌‌‌‌‌‌‌‌ was part of the foundational efforts of family therapy and began her work in Palo Alto at the MRI. She also attended the early family therapy conventions, which included many of the other founders (described previously). Trained as a social worker (Master of Social Work, MSW), she was a clinician first and theorist/ researcher second. Her strength was in her ability to work with people, in the field, traveling nationally and internationally to work with diverse communities. As one of few women leaders at the time, her voice differed from that of her male peers and brought sincerity and warmth, with a foundation in the inherent self-worth of individuals and how that can be fostered from a systemic perspective. She also brought focus to the spiritual dimensions of human nature.

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Satir was a dynamic personality, much of which is evident in the experiential nature of her treatment model. She wrote a number of books which describe her treatment approach to families. Her theory is known by a number of titles, including conjoint family therapy and Satir’s transformational systemic therapy. For this chapter, the more common title, the human validation process model, will be used to describe the systemic model created by Virginia Satir.

Salvador Minuchin (1921–2017) Salvador Minuchin is the creator of structural theory. Trained originally as a psychoanalyst, in the 1960s, he began working with African American families at the Wiltwyck School for Boys in Harlem, New York. He soon realized that the changes the boys made did not last once they returned to their homes. Influenced by the new wave of family therapy as described in Don Jackson’s article, “The Question of Family Homeostasis” (1957), he began bringing families in for therapy. After marrying his wife Pat, they lived in Israel for a few years, in which he worked with refugee children from the European Holocaust and surrounding Arab countries. When returning to the United States in the mid-1960s, he continued his work as the director of the Philadelphia Child Guidance Clinic, which became a leading treatment center for families. As a native Argentinian, his life experience of being Jewish and experiencing anti-Semitic attitudes at a young age shaped the way he viewed family systems and the counseling process. In his later writing, he reflected that he carried the identity in his family as the “responsible one” which led him on a path of “social justice” (Minuchin et al., 2014, pp. 66–67). Multiple experiences in his personal and professional career of being the “other” allowed him to take a tentative and empathic approach to working with families, which was contrary to the often expert stance that historically guided psychiatry and even family counseling. His ability to see the inherent possibility and strength in the clients he worked with was evident. His efforts with minority and marginalized families is a testament to his lifelong journey of social justice in family therapy.

Emerging Theoretical Effort THE GOTTMAN METHOD

John and Julie Gottman are the founders and creators of the Gottman method, a highly researched contemporary model for treating couples and families. John Gottman, a trained clinical psychologist, has received numerous awards for his research contributions to the field. Julie Schwartz Gottman is a clinician at heart and brings to life the clinical applications from the rich research foundations of their model. In contrast to other theoretical approaches which starts with philosophical ideas that are later researched, the Gottman method began with research that later evolved into a treatment model. The groundbreaking research of John Gottman included research particularly with couples and newlyweds (Cartensen et al., 1995; Gottman & Levenson, 2000; Gottman & Levenson, 2002). The research in the love lab has transformed the way that research can influence clinical practice. In the love lab, couples were invited to stay for a duration of time in which researchers would track the couple interactions. This data was coded to track the couple interactions. Over time, this research evolved to identify key couple patterns and interactions that influence the health of the couple relationship. Gottman gained renown for being able to predict the outcome of a couple (whether they get divorced) with 90% accuracy, based on a brief observation of their interactions (Gottman & Levenson, 2002). The sound relationship house is a theoretical framework the Gottmans developed from their research that specifically guides the clinical process with couples (Gottman, 1999; Schwartz Gottman, 2004). Originally developed as a method for working with couples, it has expanded to include group work, parenting practices, and families. As is common in

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many contemporary approaches, their method is integrative in nature, including components of cognitive behavioral and experiential theories. The Gottmans are also known as public figures for couple counseling, making accessible their research through books and other media resources for the layperson. Their contribution revitalized couple counseling, legitimized the effectiveness of systems work through their continued research, and sets a standard for researching human behavior.

THE ORIGIN AND NATURE OF MENTAL HEALTH CONCERNS AND HUMAN DEVELOPMENT General systems perspective provides a radical shift from individual thinking regarding the origin of mental health and nature of human development. Rather than residing simply internal to the individual, a systems perspective broadly explores contextual dimensions such as family interactions that influence growth. Additionally, the systemic approach looks not just at the mental health of the individual; it broadens the view to the functioning of a system as a whole, in this case, the entire family unit. The notion of circular causality is central to viewing the entire system. Circular causality, defined simply, means that each member of a system is both an actor and a receiver at all times. Ultimately, this means the entire family system shares responsibility; all members of a system are both part of the problem and the solution while no single person is to blame on their own. Singling out one member as the problem, the identified patient, is ineffective and results from linear thinking (simple cause-and-effect-type thinking). See‌‌‌‌‌‌ an example in the following case conceptualization how labeling one member as the identified patient denies the complexity of context and the interaction of others within the systems.

Case Conceptualization: Family Counseling and the Human Validation Process Model This is a hypothetical case and session that is based on the human validation process model. This is an elaboration of the client of Mark used throughout this text and also described for the genogram in Figure 10.2. Mark (age 42) and his two daughters, Elle (age 9) and Carla (age 12), are seeking family counseling to work on some ongoing conflicts in their home. Mark and his ex-wife, Candace, had a conflictual divorce 3 years ago that resulted in shared custody of their daughters. Candace has since moved states and sees the girls primarily on holidays or summer vacation. Mark has taken primary custody of the girls and is determined to be a good father, but he is struggling with balancing his work and parenting responsibilities. Elle and Carla have been having more sibling conflicts lately, and Carla complains that Elle tags along with everything she does. Prior to the divorce, Carla would often side with her father in arguments, while Elle was particularly close with her mother. Mark is concerned about their relationship dynamics and wants to improve their communication and bond. Mark grew up in what he describes as a close family where “everybody’s loud, has opinions, yet has each other’s back.” His mother, Gloria (age 71), and father, Dennis (age 72), have been married for 43 years. They have three children together, Rob (age 45), Mark, and Alicia (age 36). When younger, Mark looked up to Rob as a role model and had a difficult time when he left for the military at age 18. Rob has struggled with addiction and instability in relationships, and Dennis and Rob have an estranged relationship. Growing up, Mark experienced pressure from his father to be successful and not end up like his older brother, Rob. Gloria and Dennis were not supportive of Mark and Candace getting a divorce and would frequently give marital advice. Now as a single parent, Mark fears disappointing his father and continues to strive for his approval. Additionally, he is

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starting to feel lonely and wants to start dating, but he is worried about how his daughters will react and fears that it might negatively impact their relationship. Rather than considering the inner psyche of the individual as the origin and nature of mental health, a systems perspective takes into account the health of the system as the origins for both family and individual health. Additionally, when considering the challenges of a system, Walsh (2015) posited the importance of a shift from the term dysfunctional families, which can be blaming, labeling, and static. Rather, it is more appropriate to identify patterns or interactions that influence the family. Each theoretical perspective described in this chapter has a different way of describing or identifying these patterns or interactions in families that influence the health of the system and varying degrees in which they discuss individual mental health.

Multigenerational Family Therapy Multigenerational approaches to family therapy developed at the origins of family therapy to describe the role of multiple generations and family relationships that influence current interactions. This is a transgenerational theory, a theoretical framework which includes the ideas of Murray Bowen, Ivan Boszormenyi-Nagy, Barbara Krasner, and James Framo (Ballard et al., 2016). The concepts described throughout this chapter will draw from Bowen’s multigenerational approach. Bowen described the “family as the unit of illness” (Bowen, 1978). This phrase separates from the individual theories, that the dysfunction is in the individual, to the systems perspective of seeing the family as a whole, distinct organism. This aligns with the systemic assumptions previously described in this chapter. The family ego mass, or later termed nuclear family emotional system, was a term developed early on to describe the “emotional oneness” of families (Bowen, 1978). Bowen ‌‌‌‌‌‌‌‌‌‌‌‌‌ fluctuated on his use of this term and ultimately relied on it descriptively to articulate the interactional dynamic of differentiation within the system, namely, looking at the nuclear family as its own organism and ability to function. In its origins, the shift from individual thinking to viewing the family ego mass was researched and practiced with clients with schizophrenia. Rather‌‌‌‌‌‌‌‌‌‌‌‌‌than just treating the individual with schizophrenia, they would meet with entire families and view the schizophrenia as a manifestation that the family ego mass held the illness and that its not an individual mental illness. Of this work, Bowen stated, “these families are not really helpless. They are functionally helpless” (Bowen, 1978, p. 85). Meaning, the families had the capacity to function, yet their family relationships were riddled with interactions and processes that were debilitating. Bowen developed eight core processes to understand systems. The eight processes are summarized from Hall (1981) in Table 10.1.

The Human Validation Process Model For Satir, “Problems are not the problem; coping is the problem” (Satir & Baldwin, 1983). Coping is the central differentiator that defines health or dysfunction for individuals and families. It is not about the circumstances or family composition; it is about what they do and how they cope that influences their functioning. Connected to the ability to cope are the self-worth, family rules, and communication styles (Satir, 1967, 1972; Satir & Baldwin, 1983). Systems are responsible for supporting new children. When a child enters the world, they are limited in their ability to get their needs met. It is the system’s (parent/caregiver) responsibility to offer a space of nurturance, responsibility, uniqueness, and safety. Typically, the way in which a family governs and operates is through rules, both verbally expressed and unspoken. When the rules of a system do not provide these conditions, the self-worth of the individuals and the system as a whole suffer (Satir, 1972). For example, in a family, there may be an unspoken rule that children are to be seen but not heard. This sends the message to certain members of the system (children) that there are limits to what parts of themselves

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Table 10.1. Multigenerational Eight Core Processes Multigenerational Eight Core Processes Differentiation of self

The ability to distinguish between the intellect, feeling, and emotion often presented as being calm, thoughtful, and intentional in actions and interactions with others. There‌‌‌‌‌‌‌‌‌‌‌‌ is a vast range of differentiation that is more synonymous with maturity than diagnostic criteria (Hall, 1981). Higher levels of differentiation would be described as a solid self, separate from others, with an ability to hold their own personal values and beliefs while maintaining a level of connectedness. Pseudo-self is present in lower levels of differentiation, with the opinions of others holding a great deal of power in their identity, reactions, and behaviors. This often appears as too great of distance or cutoff from relationships or a fusion to attach closely to others, in an effort to borrow their identity or maturity.

Triangles

A common interactional pattern in family systems is a triangle (or triangulation) as a means to diffuse anxiety in the system. Bowen described a two-person relationship (dyad) as often unstable. The emotional intensity of this dyad will often result in bringing in a third party to reduce the stress of the system. A common triangle is two parents and a child. The parents may have marital issues or conflicts, and rather than addressing them directly, they pull in a child to form a triangle. Much of the stress in the marriage is then directed toward the child which often looks like ­parent–child conflict or deviant child behaviors.

Nuclear family emotional system

This is also referred to as the family ego mass and described the emotional processes in the smaller family units (typically a couple and their children) that are influenced and influenced by each member of the unit. Predictable patterns within this family unit emerged and are described in the various processes. The couples' individual differentiation from their family of origin will influence their relationship as a couple and with their children.

Family projection process

This more specifically describes the process through which differentiation passes from one generation to the next. Particularly a parent may project their low levels of differentiation onto their children.

Emotional cutoff

This term describes the relationships in which a member of a system removes contact with another, and yet the emotional intensity of the ­relationship remains. When an emotional cutoff occurs or is a pattern in a family system, this typically signals low differentiation and high anxiety in the system. Emotional cutoffs are detrimental to the family and subsequent generations that inherit the anxiety.

Multigenerational transmission process

Fundamental to transgenerational approaches is the multigenerational transmission process, which posits that the function or dysfunction in a family system is passed to succeeding generations. This includes the interactional patterns, ways of relating, and general anxieties in the system. When looking at current family systems, to understand the way they function, it is important to explore at least three generations of family relationships.

Sibling position

Sibling position takes into account the role that birth order and gender may influence differentiation and the functioning of each individual.

Emotional process in society

This concept broadens the idea of the family emotional unit to broader social systems. This includes both how the family unit and expanded social systems are interactive and how the processes seen in smaller nuclear family units are parallel with the patterns found in society. Functioning as a whole, civilization moves either toward “extinction” or “adaptation” (Hall, 1981). This concept, in particular, highlights how some of Murray Bowen’s concepts drew from the theory of evolution.

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they can share or express in that family. The rules also specify what roles each person may take in the family. Ultimately, the rules and roles of a system influence the self-worth of individuals. Both the individual and system suffer from a lack of congruence, creativity, and spontaneity that are vital to living (Satir, 1972; Satir et al., 1975). As systems encounter challenge, it is their ability to cope with such stressors that determine the health of the system. Low self-worth is a drive for power. This is often learned in childhood, sometimes before we have speech (Satir & Toms, 1984). Satir identified five communication stances which represent different ways of coping (see Table 10.2). Satir (1972) described how each communication stance represents varying degrees of acknowledging the following dimensions: self, other, and context. ■

■ ■ ■

■

Congruent: This is the desired way of expression in which a person is able to be aware of and acknowledge their own thoughts and feelings, that of the other person, and the unique context at hand. Placater: The self is denied or sacrificed for the benefit of others. Ultimately the belief and message sent here are that others’ needs are more important than their own. Blamer: Others’ thoughts, feelings, or needs are ignored, and instead, others are pointed at for the cause of the distress. Super reasonable (or computer): The context is emphasized while the self and others are ignored. This stance is seeking control, control of emotions and events at the expense of authenticity or spontaneity. Irrelevant (or distracter): The self, others, and context are denied, and this stance changes the focus to something entirely unrelated. This stance distracts the system and is often scared to stay present.

Structural Family Therapy As is evident in the name of the theory, the physical and relational composition, or structure, of a family unit are central to understanding the health and challenges of a system. When a system is experiencing challenges, symptoms of concern from the structural perspective center around the rules and roles of the system that create boundaries both within the family and with external systems. When considering symptomology, it is important to reject the notion that it is an individual problem; in other words, the symptom of the individual is merely a symptom of the challenges within the system. As described in the case study of Table 10.2. Example: A Mother of a Family Comes Home and Announces That She Was Just Laid Off From Her Job Technique

Example

Congruent

Spouse: Oh my goodness, I am so shocked to hear that. I know how dedicated you have been to that job and can only imagine how disappointed you are. Come here [reaches out for a hug].

Placater

Child: It’s all my fault. I should have quit the volleyball team. I knew it was too much to ask of you to pick me up from practices after school. I can’t believe I did this to you.

Blamer

Spouse: Well here we go again. This happened with your last job. If you could just hold on to a job, we might be able to get ahead of our finances.

Superreasonable

Spouse [pulls up spreadsheet]: Don’t worry. I’ve got a plan all figured out. We’ve got exactly 3 months of savings in the bank and with my income. I’ve got it all under control.

Irrelevant

Child: I just learned a new trick on the trampoline today. Can I show you?

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Mark, the concerns are not individual but rather in the family system. Minuchin identified the challenges of the individualistic ideology of the West that encourages “unattachment” or viewing the individual as separate (Fishman & Rosman, 1986). Rather, each unit (e.g., individual, nuclear family, extended family) is “both a whole and part, not more one than the other, not one rejecting or conflicting with the other” (p. 13). For structural family therapy, when problems arise, they are in the interactions of the system, the transactions that allow the symptoms to reside within one person. The interactions of a system both builds upon and are influenced by the boundaries of that family unit. Boundaries can be described as either rigid or diffuse. Rigid boundaries in a system do not allow space for connection and lead to disengagement. It is as if each family member lives in a silo, unable to connect with or reach the others. Similarly, rigid boundaries emerge in the way in which rules are enforced, typically through an authoritarian parenting style. This style could also be described as a cold-and-distant dictator approach, with little room for flexibility or emotional connection. On the other hand, diffuse boundaries are seemingly nonexistent or inconsistent rules. In terms of the way in which family members relate to one another, this often results in enmeshed relationships. Diffuse boundaries lead to an overinvolvement and blending of identities within the system. Rules are more permissive, with the difference between parent and child status being blurred. It is also important to explore the interactions of the family system within their surrounding systems, such as school or church. Depending on the involvement and influence of these external systems, the family would fall somewhere on the continuum between being an open or closed system. To the extreme, an open system operates on one end of the continuum in which the boundaries with other systems are diffuse (or nonexistent). This would mean that other systems would have just as much influence on the family, with little clarity on what defines or separates the family from other external systems. A closed system, on the other hand, is shut off from external influence, as if living on its own island. No system is entirely open or closed. To operate functionally, systems develop hierarchies and subsystems which assist in defining the roles and distribution of power. The parental subsystem is central to establishing the rules in the family. Dysfunction in the parental subsystem will impact the entire family unit. Additionally, if the parent subsystem is poorly defined, the system will be chaotic. The child or sibling subsystem also creates its own system. Within the sibling subsystem, gender and sibling position influence the roles and relationships. Family members typically have multiple roles and subsystems that overlap and interact. For example, an older child may have more leadership in the sibling subsystem, yet they are still expected to obey the rules established by the parents. As a family system experiences stress, members adjust either individually or as a whole to alleviate the stress (Minuchin, 1974). This commonly takes the form of coalitions, a form of alliance in which two or more members of a family form a team at the expense of other family members (Minuchin, 1974). A common example is a parent–child coalition. For example, an exasperated parent may complain to their child about their marital issues. While this is an adaptive response of the system, it is not helpful in balancing the long-term structure and leaves direct conflicts unresolved.

WHAT CONSTITUTES EMOTIONAL AND PSYCHOLOGICAL WELL-BEING Multigenerational Family Therapy From the multigenerational perspective, no family unit is free from challenge or anxiety. Each of the eight processes previously described is present to some degree in all family and

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social units. It is in the ability of the unit to navigate the anxiety that influences its ability to function. The health of the system and the individual is indicated by the system’s level of differentiation. There is both individual differentiation and the differentiation in relationships. Individually, Bowen described the importance of differentiating between the thinking and feeling systems. Emphasis is placed on being able to think without being flooded or reactive to emotions. Differentiation in relationships is the ability of the individual to balance being in relation to others while maintaining awareness and expression of their thoughts and emotions. A higher level of differentiation represents health. Bowen created the “differentiation of self scale” ranging from 0–100 to describe the differing levels of differentiation, with zero being low and 100 being high (1978, p. 472). Multigenerational family therapists use this scale more qualitatively as a frame to conceptualize the range of differentiation. It is important to distinguish differentiation from functioning in other avenues of life. It is common in families or couple relationships to have an asymmetrical‌‌‌‌‌‌ relationship in which one member is overfunctioning while the other is underfunctioning. The overfunctioner may be the one who excels or keeps things together for the family, while the underfunctioner may be more symptomatic. Superficially, it may appear that the overfunctioner must have a high level of differentiation, when in actuality, they may be quite emotionally intertwined in caregiving for the underfunctioner in a way that limits their awareness and openness in the relationship. There is often a high level of anxiety in such relationships that is indicative of lower levels of differentiation for both members of the system.

The Human Validation Process Model In contrast to unwell systems, healthy systems have flexible rules and roles and are open to uniqueness with a belief in the worth of each member of that system. The parent–child triad can be a survival or nurturing triad, a unique term identified by Satir (1988). In contrast to the triangulation described by Bowen, Satir saw the nurturing triad (relationship between one child and parents/caregiver) to be one of strength and healing. Given the right conditions, growth and maturity ensue. Rules within a family will be flexible and firm. The family system will support the growth of the family and allow for the individuality and multifaceted personalities and expressions of each person. Satir described her model as the seed model, with the voraciously humanistic belief all people are born whole with an inherent capacity and drive toward growth. Worth and “wholeness” is inherent and not something that is achieved by status, gender, age, or achievement (Satir & Toms, 1984). Indicators of the self-esteem of individuals and family systems are in their ability to be creative, be congruent in their communication, and use energy positively to contribute to smaller and broader systems. There is a spiritual element to this model that acknowledges the role of the life force. Satir described the importance of acknowledging the sacredness that each person has life force within (Satir & Toms, 1984).

Structural Family Therapy Structural family therapy has a range in which families can self-define their own ideal in terms of boundaries and roles. In that sense, there is a phenomenological element in which families self-define their ideals within a range of health. To define family health, the focus is less on what type of family it is (e.g., single-parent family, gay couple, or blended family) and more on the quality of the boundaries, roles, and rules that guide the interactions of the family unit. In general, family health from a structural perspective would include clear boundaries that are consistently adhered to while also being flexible. Typically, this requires a firm and cohesive parental subsystem to provide nurture and structure for the children consistently. While there is a range of healthy boundaries, the ideal structure allows for a balance of individual identity and “mutuality” (Minuchin, 1974, p. 120).

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Structural therapists assume that all families possess, inherently, the resources they need to create a system that is supportive and flexible. This does not diminish the recognition of the discrepancy of external resources such as those we see experienced by marginalized communities; many changes are needed in external systems to support the efforts of families. The belief in the inherent capacity of each family acknowledges the strength and encourages a building off of family strengths to achieve desired outcomes.

ROLES OF THE CLIENT AND COUNSELOR Multigenerational Family Therapy The counselor from this approach is often referred to as a coach. Like that of a coach, the counselor takes more of an expert stance, through bringing in their knowledge and observations, facilitating problem solving, and giving homework. The‌‌‌‌‌‌‌‌‌‌‌ counselor often exhibits calmness, neutrality, and clear boundaries, which exemplifies Bowen’s notion of differentiation. Additionally, the multigenerational family therapist needs to have a high level of differentiation in order to work with family systems effectively. This often requires them to have done their own personal and family work to maintain awareness of thoughts, emotions, and personal biases that may present themselves in counseling. The counselor in this approach must keep a systemic perspective on the presenting issues. This is central to the change process and also allows them to remain neutral (unbiased) with some emotional distance from the clients as they engage throughout the clinical process. If (or more likely, when) the counselor is emotionally pulled into the family dynamics, it becomes important to be aware of this as soon as possible. The ability to maintain an unbiased neutrality assists in the ability to coach the family in reducing their own anxiety. The role of the coach also describes the counselor’s role of guiding and teaching the family in the therapeutic process. This often includes teaching the family unit about the core concepts of systems thinking and helping them critically evaluate their relationships. The counselor also stays focused on process, what is happening in the interactions, and the big picture type thinking, in contrast to the content or what‌‌‌‌‌‌ of the stories or arguments. The counselor varies their level of involvement and directing throughout the therapeutic process based on how the family is working together.

The Human Validation Process Model There are four assumptions that clinicians using this model adhere to in their role as a counselor. As‌‌‌‌‌‌ described by Satir and Baldwin (1983), the following four assumptions are commitments that influence the way a counselor works with families: 1. 2. 3. 4.

Having an appreciation of life and the growth model personally and professionally Believing in the seed model and the client’s inherent capacity for growth Adhering to a systemic perspective Using their own humanness in counseling

The counselor in this theory is committed to the philosophical foundations regarding the seed model, the belief in the inherent growth and wholeness of others. Following this framework of the client as the seed, the counselor takes the role of the gardener who provides the necessary ingredients to foster growth (Satir & Baldwin, 1983). This was also described as a midwife “who, by following the person’s labor contractions, encourages the birth of new possibilities but is not their creator” (Satir & Baldwin, 1983, p. 227). As the fourth commitment highlights, counseling is a human to human experience. The very heart of this theory is to honor one’s inner voice, and counselors need to be deeply in tune with who they are as a person in order to use their own humanness in the counseling

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process. This includes finding a balance of being an expert while being vulnerable and honest, taking risks, and making contact with clients. Satir was such a dynamic personality that for some who have studied or watched her work, it could be intimidating to fill her shoes. At‌‌‌‌‌‌‌‌‌‌ the same time, it is important for the counselor in this model to be personally congruent and not try to be someone they are not (avoid merely copying the interventions). For Satir, her congruence as a counselor came out as being spontaneous with intention, playful, nurturing, and confident. It is the task of the counselor using this model to have the professional knowledge to guide their work while being personally grounded in order to be reachable, humble, and vulnerable.

Structural Family Therapy The counselor, from a structural perspective, is a director. In ‌‌‌‌‌‌‌‌ this role, the counselor fluctuates between being part of the therapeutic stage, participating in the interactions, and, at other times, facilitating the movement of the play. In other words, the structural counselor uses distance and closeness with a family intentionally throughout the therapeutic work. Each position, ranging from close to distant, serves a varying function in the therapeutic process (Minuchin et al., 2014). Minuchin described this as “an expander of context, [which] creates a context in which exploration of the unfamiliar is possible” (Fishman & Rosman, 1986, p. 15–16). In this way, the structural counselor challenges the family assumptions, encourages possibilities, and creates a therapeutic structure that allows for multiple perspectives to be shared and valued. Characteristics that often describe the counselors in this approach include being intentional, personable, and empathetic with an ability to move into and join the family dynamic without becoming enveloped by them. While the counselor takes a very active role in facilitating the counseling process, Minuchin advocated for a tentativeness he described as being an “uncertain expert” (Minuchin et al., 2014, p. 67). In contrast to the purposeful boundary of the multigenerational counselor, structural counselors first task is to join with the family in a way that is inherently relational and involved. Not just focusing on an individual relationship, as with individual approaches, joining is becoming part of the family system as an interventive strategy. Ultimately, the core of joining is an empathic relating with the family (see intervention strategies that follow). The client in this approach is the family unit. Minuchin worked with many families, particularly families with a child that had been labeled as a delinquent. This approach is present oriented and invites the families to engage in real-time conversations directly. Having the key players of the system present is necessary for the process of change.

PROCESS OF CHANGE Multigenerational Family Therapy With the goal to increase differentiation guiding the therapeutic process, navigating anxiety becomes central to that change process. While a sign of differentiation is the lower levels of anxiety, the change process also requires building a tolerance for anxiety in order to reduce chronic anxiety individually and within the system. When a system attempts to change or deviates from the family homeostasis, there is greater anxiety felt in the system. If the system retreats or attempts to minimize any or all anxiety, it prevents growth. Fundamental to growth, then, is the ability for the system to mature as they deal with their anxiety. It is vital for the counselor to have their own tolerance for counseling and convey the message that “anxiety does not harm people. It only makes them uncomfortable” (Bowen, 1978, p. 85). The structure of therapy often includes both times to focus on each individual and the system as a whole. Originally‌‌‌‌‌‌ developed in an inpatient setting, later work was adapted

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to outpatient setting. There is great variability with which members of a family system the counselor meets with, often fluctuating throughout the therapeutic journey. Some variations seen in the literature include the following: ■

■ ■ ■

■

Splitting a session to allow each partner or member a set amount of time in which they are the central focus. While in the hot seat, they would explore their family of origin, problem-solve new ways of interacting with family and raise awareness of family processes. The other partner or family members take a back seat and observe. This gives them an opportunity to gain greater awareness of the family member in the hot seat (Baker, 2015). Taking turns across multiple sessions. For example, one week is the mom’s turn and the following week the counselor focuses on the child. Working in triads. Later work, Bowen described meeting with family triads (two parents and a child). Working with parents when a child is the presenting concern. This often supports the detriangulation process and encourages the parents to attend to the anxieties in their couple relationship. In any of the variations, having the family members present can be important as they learn about their partner differently and can also support the awareness of the family. Young children are not often part of this approach.

Through increased awareness, the family is able to be intentional in their words and actions and think without being emotionally reactive. At the same time, while awareness (intellect) takes center stage in the change process, the ability to maintain awareness of emotion and connectedness with others is also a goal in improving differentiation. The multigenerational counseling process is focused on gaining awareness of the past and making future plans. The implementation of those plans is sometimes part of the therapeutic work and more often occurs outside of the therapeutic room.

The Human Validation Process Model The goal of the counseling process is to transform, to open up the possibility for growth (Satir & Baldwin, 1983). While a rather dynamic and fluid process, over time, a general process of counseling emerged with the focus on experiencing the present moment. Three stages in the counseling process give a general framework for how change occurs from the human validation process model. STAGE 1: MAKING CONTACT

Making contact could also be described as building rapport with the entire family system. While an emotional process, this is also done physically. The counselor may use physical touch or proximity to make contact with clients, for example, a handshake, high five, or touch on the knee. When working with families, it is important to take time to give attention to each family member. Physically, this can be done through eye contact and posture; for example, the counselor may move throughout the room by changing or moving their seat to give attention to each family member. This is also done verbally through reflecting verbal validation and understanding of each member’s perspective and taking time to balance the dialogue, directly prompting each member to speak. Other characteristics of this phase are to be nonjudgmental and non-assumptive. The counselor creates an informal or even playful environment that allows for creativity. They may also use self-disclosure or humor throughout to develop some openness in the system and to encourage playfulness and creativity with the system’s problems. Throughout this first stage of counseling, the counselor is also assessing the family to understand key features of the system. This includes the rules, their styles of communication, and their self-esteem.

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Rather than focus on defining the problem, this model would facilitate expression of what each person wants or hopes (Satir & Baldwin, 1983). Key aspects of this stage include transparently sharing observations with the family without judgment and highlighting the multiple perspectives within the family. STAGE 2: CHAOS

As systems enter chaos, their ability to cope will support the movement to integration. It is in their inability to cope that we see systems returning to the status quo or staying stuck in a constant state of chaos (it is often at this point that clients present or return for counseling). At the stage of chaos, one or more members of a family are breaking from the typical homeostasis through taking risks and vulnerability, for example, to say the unspoken or do the forbidden. This will often be met with overwhelming feelings of fear or hopelessness. The fear that clients experience at the chaos stage is described as a similar fear that an infant experiences when separated from their caregiver, moving from a safe and secure place to “unknown territory” (Satir & Baldwin, 1983, p. 216). It is only through stepping into the unknown that clients will experience growth and change. The counselor’s task at this stage is to encourage such risk-taking through firmness with trust in the therapeutic relationship. It is also vital at this stage to keep the clients in the present. At times when clients are flooded with the intensity of vulnerability, they shift into talking about the past or worrying about the future. These are coping stances that stunt the growth process and attempts to stay at the status quo; the counselor needs to be keen on keeping the client in their present moment experience, what is really happening as it is happening. As the chaos stage requires risk from the clients, the counselor is equally taking risks, moving into unpredictable spaces with the clients. STAGE 3: INTEGRATION

Integration is described as a space of resolution, specific to whatever issue of concern was raised at previous stages. Systems experience this as hope, openness to change, and flexibility in moving forward. The end of a session may often have minor moments of integration, with the greater resolution being experienced throughout prolonged therapeutic work. While stages are described, it is important to note that this is also not always a linear process. Additionally, in systems work, it is common for each family member to be at a different place in the change process. The counselor leads the family through this change process, attending to the multifaceted nuance of each person’s readiness and how that influences the system while giving them opportunities to experience differently and find new ways of coping that support their desired changes. This three-stage cycle repeats itself throughout life and often multiple times in a therapeutic encounter. When the clients find the resolutions they seek, sometimes new issues emerge, which may continue to be addressed in counseling. Counselors collaborate with clients to determine the termination of counseling.

Structural Family Therapy Structural family therapy is a present-focused approach that encourages behavioral changes within the family in real time. Throughout the therapeutic work, the counselor is the expert on the process. In the counseling session, active work is done to shift the rules, roles, and boundaries of the family system to find a new balance that fits the family’s desired outcome. In systems language, the counseling process disrupts the homeostasis of the family and challenges them to find a new, more functional way to operate. Through the counselor’s work to support the system in this change, they direct and influence the interactions to encourage new ways of viewing and being. The first step in the process of change is to join with the families. Joining can be considered a way of being and an overall attitude of respect and empathy for the family. Actions often described with joining include matching the perspective and culture of the family

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throughout the therapeutic journey. This includes taking on the worldview of the family, using their language, or even mirroring body language or tone of voice (mimesis) to become part of their system and influence the family system while in the therapeutic space together. On the other hand, joining can also include challenging the family or requiring the family to adapt to the counselor (Fishman & Rosman, 1986). In the end, the counselor’s use of self plays a central role in the process of therapy. It is important to do this at the beginning of counseling and maintain this attitude throughout, while the counselor will vary in their closeness and distance. The counselor also assesses for the structure of the family. This includes identifying the boundaries of the system and subsystems, coalitions, and rules that govern their relationships. This assessment is an ongoing and often informal process. The bulk of the change process is then to restructure the system. As families encounter different perspectives, experience new ways of interacting and disrupt old power structures, they become open to new possibilities. Often this requires a restructuring of power within the system and subsystems. For example, when boundaries are rigid, a loosening is required to allow for flexibility and closeness. The techniques throughout the therapy support the change process of the system to find a new structure.

MAINTAINING PROGRESS Multigenerational Family Therapy To support ongoing progress, it is common for this approach, particularly when applied to outpatient settings, to be spread across months or years. This may include tapering down in the frequency of sessions as decided with the family (e.g., meeting once a month or quarterly). The counselor coaches the counseling process, and clients are taught many of the concepts and ideas of the theory. This then supports the client’s ability to continue to evaluate their current and future challenges. It gives them the tools necessary to maintain progress. It is not uncommon for families to return for a check-in session to support ongoing progress.

The Human Validation Process Model It is human nature to lean toward growth, which is seen in the ongoing progress of individuals, families, and broader social systems. The three stages described in the change process occur naturally and are descriptive of human progress both in and out of counseling. As clients experience new ways of coping in counseling, they can then learn to apply them when new issues emerge outside of the counseling room. The counseling process can lead to this change process, and it is also naturally occurring for many systems. Clients can move in and out of counseling as they see fit to support their ability to cope with the ongoing change process.

Structural Family Therapy Structural family therapy can be brief as it is focused on present behavioral changes. With the counselor acting as director, they will intentionally shift their level of influence in the system to support change. As families near termination, the counselor becomes less entrenched in the interactions. Simon (2015) described this as a two-act play. The first act of destabilizing and restructuring the system requires the therapist to be both a director and, at times, an actor in the play. As they move to the second act, the therapist moves to a supporting role to nurture the changes established in act one. This shift can even be described as an “audience” member, as families “spontaneously” enact the new structure (p. 375). The end of the counseling relationship becomes natural, as the counselor has slowly tapered their involvement.

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PROCESS OF CLINICAL ASSESSMENT A variety of assessments for couples and families are available for use. Generally, the theories described in this chapter have more informal and qualitative means of assessment. The genogram is one such qualitative way of assessing for family processes. Outside of these theoretical approaches, family systems assessments are widely available. One such assessment is the Revised Dyadic Adjustment Scale (RDAS), which is described in this section.

Genogram With roots in the multigenerational approaches, the genogram is a visual representation of the family structure and interactions across multiple generations. The information includes both factual information often found on a family tree and symbols that represent different patterns, interactions, and symptoms. When multiple generations are mapped, this highlights how patterns continue across generations (multigenerational transmission process). It gives a way for the client to understand the influence of the family system and how that connects to the way in which one relates to their family and others. Counselors co-construct genograms with their clients but may also require the client to do additional work outside of counseling to gather information. See Figure 10.1 for an example of this intervention. In the figure, you can see an example of some of the symbols used in the genogram. This includes symbols for gender, relationship status, and emotional relationships. This is not a comprehensive list of all symbols; a complete guide to genogram symbols can be found in resources such as McGoldrick (2020) and computer programs like GenoPro. In the genogram, you can see the dashed line with railroad tracks that connects the father, Dennis, and son, Rob, which is a symbolic way of describing a cutoff relationship. An arrow from Dennis to son, Mark, symbolizes that Mark is focused on a similar pattern present between Mark and his own child, Carla. For this family, being focused on comes with extra responsibilities and higher expectations. The visual representation also makes clear the following interaction of family dynamics: ■ ■ ■ ■

Mark and Candace having conflict in their marriage (squiggly line) Carla being focused on (arrow toward Carla from Mark) Elle having a close relationship with the mother, Candace (two parallel lines) The two daughters being in conflict with one another

With ‌‌‌‌‌‌‌‌ the genogram, counselors can gain an understanding of family patterns, see the interactions within family units, and identify the larger systemic influences of previous generations. It can also be valuable to graph multicultural dimensions such as race, ethnicity, socioeconomic status, and religion/spirituality, as those contextual dimensions also give meaning to emotional relationships in families (see Figure 10.2).

Revised Dyadic Adjustment Scale The Dyadic Adjustment Scale (DAS) was developed as a self-report measure to assess relationship quality in couples and was an improvement on previous assessments with poor psychometrics (Spanier, 1976). This measure is one of the most common measures for relational adjustment in family therapy (Busby et al., 1995). The revised scale parsimoniously assesses overall relational quality, as well as three subscales of consensus, satisfaction, and cohesion in 14 questions (Busby et al., 1995). The RDAS has rigorous psychometric properties, including high reliability (α = .90), and demonstrated construct validity and discriminant validity (Busby et al., 1995). The RDAS has a cutoff score of 48, with scores 47 and below indicating relational distress and 48 and above indicating non-distress (Crane et al., 2000).

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Genogram Symbols

Male

Female Female Male Adopted Foster Pregnancy Miscarriage Death to Male to Female Child Child

Twins

Lesbian

Gay

Family Relationships Marriage

Engagement

Casual Relationship or Dating (Short-Term)

Symbols Denoting Addictions and Physical or Mental Illnesses

Separation in Fact

Engagement and Cohabitation

Temporary Relation/ One-Night Stand

Physical or mental illness

Legal Separation

Cohabitation

Love Affair

Divorce

Nonsentimental Cohabitation

Committed Relationship

Alcohol or drug abuse Suspected alcohol or drug abuse

Emotional Relationships Indifferent/Apathetic

Harmony

Hostile

Violence

Abuse

Manipulative

Distant/Poor

Friendship/Close

Distant-Hostile

Distant-Violence

Physical Abuse

Controlling

Cutoff/Estranged

Best Friends/Very Close

Close-Hostile

Close-Violence

Emotional Abuse

Jealous

Cutoff Repaired

Love

Fused-Hostile

Fused-Violence

Sexual Abuse

Fan/Admirer

Discord/Conflict

In Love

Fused

Focused On

Neglect (Abuse)

Limerence

Hate

Emotional Connection

Distrust

Focused On Negatively

Never Met

Plain/Normal

FIGURE 10.1‌‌‌‌. Genogram key. ‌‌ Source : Figure created using GenoPro.

Gloria

Dennis

Rob

Mark

Candace

Carla

FIGURE 10.‌‌‌‌ 2. Genogram. ‌‌ Source : Figure created using GenoPro.

Elle

Alicia

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While not attached to a specific counseling theory, this assessment is inherently systemic given its application to partnered dyads and would be useful for any counselor working with coupled systems. Even when the client system is larger than a dyad (i.e., a family), practitioners may find it useful to evaluate the smaller partnered subsystems, as is often the focus in structural theory. Therapists can use this assessment to initially discriminate between distress and non-distress and then continue its use over the length of treatment to reliably indicate treatment outcomes.

SPECIFIC THEORETICAL TECHNIQUES Multigenerational Family Therapy FOCUS ON PROCESS

Bowen’s approach focused more on maintaining a theoretical consistency with systems thinking than it did on a specific technique. As the counselor is truly seeing the family as the unit of treatment, they will interact with the process and particularly target the interactional processes that impede differentiation. This often includes questions to encourage awareness of the emotional processes at hand. TEACHING

The counselor may also use psychoeducation as an intervention to teach clients about systems concepts, to view their issues as part of the system rather than an individual mental illness. This may include assigning bibliotherapy, taking time in the counseling session to define the core concepts of the theory or explaining the family processes. Sharing of information is best delivered when clients are not in a heightened emotional state, and often the most impactful teaching revolves around educating clients on the multigenerational processes from their family of origin through the use of questions (Kerr, 1981). Transcript

Skill(s) Demonstrated

Counselor: So, when we map this out on your family tree, do you see how it forms a triangle?

Teaching triangulation through genogram

Client: Yeah, I had never thought if it in that way, but I ­definitely felt the pressure to take care of my dad, which my mom seemed to resent. Counselor: This is something we sometimes see in families, and I think what you described about the conflict between your parents is what often happens in families. The anxiety was so high in your parents’ marriage that you were brought in as a way to release some of that. And yet you were stuck in the middle, with these interactions. You each played a role in this back-and-forth triangle.

Teaching triangles and introducing systems thinking

GENOGRAM

Described previously, a genogram is a visual map of the family structure and relationships. This serves as both an assessment and interventive strategy for multigenerational counselors. It is also widely used among clinicians working with families from a diversity of theoretical approaches. RELATIONAL EXPERIMENTS

Improvement in differentiation includes changing the way that members interact and react. Through gaining awareness of past and present processes in the family/extended family, multigenerational counselors guide clients in trying out new ways of being. The counselor will ask the clients about their desired change and take time to explore alternatives. They will

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encourage the clients, when at home, to notice their emotional reactivity and pay attention to their personal responses. In ‌‌‌‌‌‌‌‌ the counseling room, the family will report on what happened, and counselors then work with the clients on creating a plan for how they will interact differently. These experiments occur outside of the counseling session and can extend to the family of origin relationships as well. FAMILY VISITS

Parallel to family experiments, clients are encouraged to contact and visit their family of origin. Often the clients will discuss with the counselor how they plan to interact and take a different role in their family prior to family visits. Encountering their family allows clients to solidify gains in their differentiation and often becomes pivotal in the change process.

The Human Validation Process Model Practitioners need to tailor the way in which interventions are used from this model to each client. Satir emphasized the art‌‌‌‌‌‌‌‌ of counseling and avoided deducing the process to a manual. It is much more important to consider the timing and fit of each intervention, being flexible to adapt and move with the family at any moment (Satir & Baldwin, 1983). The interventions described are an example of the interventions possible, and clinicians are encouraged to be creative in their use of technique. SCULPTING

Sculpting is a way in which the family is able to use the body to represent the family relationships physically. To do so, a therapist would instruct the family to move each family member into different physical positions to be like a molded statue. The counselor may lead in constructing the sculpt or ask the clients to create the sculpt. For example, see the following dialogue between a counselor working with a mother and two children, Andre (age 10) and Jason (age 7). Transcript

Skill(s) Demonstrated

Counselor: I know, at times, that it can be difficult to use words to tell us how you see the family. So, we are going to try something new. Are you willing to try out something with me?

Inviting participation

Andre: Sure, OK I guess. [The rest of the family nods yes.] Counselor [looking at Andre first]: What I want you to do is to make an image of your family, just the way you see it. But instead of having the image on paper or on a phone, we are going to use you, your mother, and your brother as statues to make a 3D image of your family. You get to be in charge of this one, so you can tell your mother and brother what position and even where in this room you want them to be.

Setting up the sculpt

[Andre‌‌‌‌‌‌‌‌ moves his mother into the middle of the room, with the younger sibling sitting at her feet in a begging-like stance. Hethen places himself in a chair in the corner, separate and alone, looking a bit lost.]

In the example described in the previous transcript, the counselor would then take the time to allow each family member to experience the stance, to heighten the emotional intensity, for example, of “being in the corner,” “begging,” or “being in the middle.” The noticing of the entire body includes physical sensations, emotions, and thoughts. The counselor processes this with the family, all while taking this form. The counselor may encourage or shift the sculpting at any moment, spontaneously allowing the family to make contact with their way of being or try a new way of being.

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TOUCH

This model is known for its use of touch in the therapeutic process. Therapists can use touch to direct clients, restructure the interactions and way families interact, and convey nurture and closeness. Satir was confident in her use of touch, both metaphorically and literally, to make contact with her clients. She would often greet them with a handshake or other neutral gestures, with a belief in the power of human to human contact. DRAMA

Descriptive of many types of interventions, drama allows for role-playing, taking on different ways of being, and experimentation. Satir described communication games as a form of role play; this allows clients to experiment and exaggerate different forms of communication (Satir, 1972). This allows the client to recognize their use of different communication stances. Drama was often combined with sculpture to use different postures to experience both the emotion and the words of each mode of expression. Within this, there was also the use of “parts parties.” This would include the clients first identifying each of the unique dimensions that make up their whole self. Often, people undervalue certain parts of themselves (something that is learned through the family) and these parts also hold different ways of coping. Some parts may be more aggressive, while others are more passive. Through a parts party, the client engages in role-play to enact different parts of themselves, which mirrors different ways of being and communicating. METAPHOR

Metaphor allows the counselor to give a description or bring in abstractions to articulate an idea or concept. For example, when describing self-worth, Satir referred to a pot both in therapy and in her writings (Satir, 1972). When helping the family understand systemic concepts, practitioners may use a rope to show the interactional nature of relationships. HUMOR

Humor is used therapeutically as a way to connect with clients and encourage spontaneity or flexibility. Even in the intensity of the work, the family and therapist can use humor empathically. Laughter supports the family’s ability to cope (Satir & Baldwin, 1983). FAMILY CHRONOLOGY

Descriptive of a number of different interventions, the counselor would explore the history of the family and significant events. This would allow a thorough exploration of the rules that influence their way of being. One example of how to explore this history is to bring the salient themes or patterns from the family history to the present moment through the use of melodrama. GROUP WORK

It was common for role-plays and variations of these techniques to occur in group counseling. Members of the group would play various family members in role-play-type settings, giving opportunities to play out different relationships.

Structural Family Therapy The many writings of Minuchin describe a variety of techniques. This list includes many of the fundamental systemic techniques and is not exhaustive of all of his works. CHALLENGE THE FAMILY'S CERTAINTY

This technique is connected to the counselor’s role in challenging homeostasis. Families often come in with their own definition of the problem, which is typically linear and focused on one person as the problem. To open the family to possibility and change, the counselor must first challenge their definitions or the things they are certain of. This often challenges

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the notion of linear causality, to convince the family that both the problem, their individual and family identities, and what is possible are much larger and more multifaceted than originally perceived. The intention is to foster hope and instill a sense of the possible. ENACTMENT

The use of enactment is a present-oriented intervention which focuses on the direct interactions between the family members. More specifically, enactments are set up to have the family talk directly to one another, often to reenact recent conflicts. This can serve as a method of assessing the family. Minuchin preferred to see the family actually engaging in the conversation rather than a reflective retelling of the interaction, as the latter is influenced by each member’s perspective and their ability to remember such interaction. Generally, from the structural approach, the counselor is in an observational role (Minuchin et al., 2014). While observing, the counselor keys into the process of the interactions, as opposed to the fight. In the case study session example, you will see how the counselor uses an enactment to notice how ‌‌‌‌‌‌‌‌ the couple argues. Enactments are a widely used intervention by clinicians working with couples and families, regardless of theoretical orientation. It serves as an intervention to “map, track, and modify” (Gehart, 2018, p. 138). Transcript

Skill(s) Demonstrated

Counselor: I hear you each telling me about the fight you had on Friday. I want you to talk to each other directly and show me how that goes. I will observe for a moment, as if a fly on the wall.

Setting up the enactment

Client 1‌‌‌‌‌‌‌ [talking to the counselor]: We’ve had this fight so many times, I don’t know why we need to revisit this.

Client 2 [talking to Client 1]: I know I dragged you here. If you don’t want to make this work, just say it already. [Client 1 avoids eye contact with Client 2 and keeps looking at the counselor for direction.] Counselor: It looks like you are both diving into the fight already [turning to Client 1]. Go ahead and respond to your partner [gesturing to Client 2]. Show me what actually happens, so I can get a taste of how you argue. I am here to watch, so I can really understand what’s going on.

Re-inviting the enactment Setting boundaries with the family

SYSTEMIC REFRAMING

Reframing is a verbal intervention in which the counselor attaches new meaning to family behavior, particularly from a circular causality perspective. For example, a 10-year-old child may have been labeled by the family as a needy and clingy child. In an attempt to shift the way they relate to one another, the structural counselor might reframe the clinginess as a desire for closeness, a way of assuring that the family will not leave them as they had recently lost a grandparent. They might then go on to note the way that the parent responds to the child when they are clingy. Noting the interactions of the system, reframing the “problem” as circular, and even as a source of strength, helps attach new meaning to old behavior. RESTRUCTURING

Restructuring includes a variety of strategies to support the system toward a new way of interacting. Typically, this includes unbalancing, complementarity, and boundary making. Unbalancing is an intentional use of the counselor’s influence to shift the structure. This is particularly helpful in renegotiating power. Unbalancing often entails the counselor joining the system to shift the hierarchies and the role of power. To support boundary making, the counselor may use their influence to strengthen the power of particular members or subsystems to be more firm. This is particularly helpful when boundaries are diffuse or rules are

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passively applied. On the other hand, they may challenge other family members to soften when boundaries are rigid. Structural therapists do this intentionally to challenge the system to renegotiate boundaries and roles and encourage a restructuring. Additionally, the enactments serve as a method for intervening. As the structural counselor gets an idea of the family interactional patterns (which give clues to the boundaries, rules, and roles in the system), they can also use enactments to change the family structure. The structural counselor may coach or redirect the interactions so that the family does not continue to get stuck in the same loops that they do outside of the counseling office.

MULTICULTURAL, INTERSECTIONAL, AND SOCIAL JUSTICE ISSUES Multigenerational Family Therapy The concept of self-differentiation has been described as limiting in its application to diverse populations. In its infancy, the focus on autonomy and identity being separate from the family system can be viewed as an individualistic Western European value that does not apply to all families, particularly those from communities of color or marginalized backgrounds (McGoldrick & Hardy, 2019). Additionally, the emphasis on controlling emotions and valuing cognition leans toward more historically Western and masculine ideals. Understanding the origins of this theoretical approach, being developed in the 1950s by a Caucasian male, helps give context to the concepts of the theory. Amidst the limitations of the theory, there have been efforts to expand this approach to diverse clientele. Current applications of this model give greater balance to the role of autonomy and connectedness, in addition to highlighting the variability of the desirability of these two factors that may influence perceived differentiation. For example, Monica McGoldrick overlays the role of culture within genogram work with clients, and in her collaborative efforts with Hardy (2019), they challenge the history and future of the field of family therapy in addressing diversity and combat the historical antecedents that were rooted in dominant perspectives. In her prolific writing efforts, she has given examples of working with diverse populations both clinically (McGoldrick & Hardy, 2019) and in examining the genograms of significant historical figures from varied backgrounds (McGoldrick, 2011; McGoldrick et al., 2020). Contemporary efforts of this approach have incorporated multicultural dimensions in understanding family dynamics.

The Human Validation Process Model Virginia Satir was known for her global presence and outreach nationally and internationally. In her time as a counselor, she reached many Asian populations in her international efforts. Nationally, she worked closely with a number of Native American tribes. Her personable style of interacting with people of diverse cultural backgrounds was a strength, as she entered with respect to learn from those she worked with. Her presence in the world and ability to reach the emotional center of all she encountered were a testament to her commitment to heal the world with love. It is also important to note that Virginia Satir had to work hard to have a seat at the table of the founders of family therapy. As one of few women, her approach to therapy brought in dimensions that are typically viewed as more feminine (e.g., nurture, touch, the emotional vulnerability of the counselor) that had altogether been dismissed in the therapeutic work of that era. Ongoing applications of the human validation process model include expansions to Asian cultures. The spiritual dimensions of the approach lend itself to Eastern spiritual practices. Current writings actually note that the model is more popularly practiced in Asian countries than in the United States (Banmen & Maki-Banmen, 2014). There are Satir institutes across the globe that perpetuate the work to diverse client populations.

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In 2021, the Virginia Satir Global Network led an anti-racism initiative to create funds in support of Black-led community projects to address systemic racism. This is part of ongoing efforts to continue the legacy of Satir. Satir was outspoken about the need for equality, particularly in her time, for gender and age equality. In an interview with Michael Toms (Satir & Toms, 1984), she described the ongoing cultural climate of seeking gender equality. Part of the process of restructuring as a culture or within families, to allow for an equality of men and women, includes a period of chaos.

Structural Family Therapy “I have developed a respect for the diverse, a curiosity for learning from others, and the comfort to work in situations of ignorance” (Minuchin et al., 2014, p. 68). Salvador Minuchin did transformative work often with families of color that had been labeled as troubled. His theory was both impacted and continued to be informed by his work with African American families and the time he spent in Israel with Jewish and Arab families. There has been some criticism regarding the label of enmeshment, as it could be used to minimize the importance of attachment and the need for human connection. From a Eurocentric individualistic perspective, misunderstanding collectivistic values and ideals in relationships may result in mislabeling enmeshment and misinterpreting boundaries. It is essential to maintain awareness of the counselor’s bias when assessing the family structure. Theoretically, the emphasis on joining the family gives the structural counselor the skills to take on the client’s perspective. This allows diverse clients to lead in the therapeutic journey and define their ideal formation as a family. Feminists have historically been critics of traditional structural family therapy, as the typical emphasis on joining with the father seemed to reinforce patriarchy and emphasized giving the father more‌‌‌‌‌‌‌ power in the family unit. However, research on this theory shows strength in its ability to work with traditional families. Particularly, the emphasis in the parent subgroup on maintaining leadership in the home is consistent with many traditional family values. Recent research studies have shown its applicability with Iranian single-parent families (Dehghani & Bernards) and Chinese families with an adult diagnosed with autism (Ma et al., 2020). Daniels (2022) identified ecosystemic structural family therapy (ESFT) as an effective model for working with families of color in dealing with racial traumas. Harry Aponte has pioneered the efforts of ESFT through a contemporary adaptation of structural theory, which integrates attachment theory, multiculturalism, and trauma.

RELEVANT THEORY-BASED SCHOLARSHIP AND RESEARCH TRENDS Systemic counseling has evidence that shows positive outcomes for a myriad of presenting concerns. Both individual diagnoses and systemic issues have shown benefit from systemic theories. Table 10.3 provides an overview of some of the trends in the past decade of clinical research. The Journal of Marital and Family Therapy routinely publishes reviews of current research trends in the field. Their recent review of the past ten years of research identified a number of specific systemic interventions to various presenting concerns based on current evidence-based criteria as defined by Southam-Gerow and Prinstein (2014). The‌‌‌‌‌‌‌ Level 1 (well established) or Level 2 (probably efficacious) treatments for a variety of presenting concerns are summarized in Table 10.3. There is nuance to the varying degrees with which the treatments outlined in Table 10.3 demonstrate efficacy. The table merely displays the vast variety of presenting concerns that can be addressed using systemic therapies. There are many other approaches that are likely efficacious that show promise and need further research. Additionally, others may not be described in the evidence-based literature due to lack of research or using small designs

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Table 10.3. Overview of Research Trends From 2010 to 2019: Journal of Marital Family Therapy Review Presenting Concern

Level 1 or 2 Treatment Support in Research

Infant and early childhood mental health

Behavioral, tiered interventions, and home visits (Kaminski et al., 2022)

Child and adolescent disruptive behaviors

Behavior therapy (family and parent groups), cognitive behavioral therapy (CBT), family therapy, and emotion-focused therapy (parent groups) (Sheidow et al., 2022)

Attention deficit hyperactivity disorder (ADHD)

Integrated parent–child treatments and parent-directed treatments such as behavioral parent training (Babinksi & Sibley, 2022)

Anxiety (youth and adult)

Family-based treatmenta (Goger & Weersing, 2022)

Depression and bipolar disorder

CBT and behavioral couple and family, psychoeducational family interventions, integrative couple interventions (Wittenborn et al., 2022)

Suicide

Dialectic behavioral therapy with family skills group, systemic principles, CBT with parent training or systemic principles, psychoeducation (Frey et al., 2022)

Substance use

Systemic family therapy, behavioral family or couple therapy (Hogue et al., 2022)

Trauma

Systemic youth–caregiver interventions, couple treatment (McWey, 2022)

Violence

Relationship education (reduce intimate partner violence), parenting program using in vivo coaching such as parent–child interaction therapy, parent education (reduce child maltreatment) (Stith et al., 2022)

Couple distress

Behavioral couple, CBT couple, emotionally focused therapy, integrative behavioral couple therapy, insight-oriented couple therapy (Doss et al., 2022)

 The studies in this review did not meet the criteria of Level 1 or Level 2. However, they showed similar ­performance to individual treatments of that presenting concern. a

such as case study research. Dwanyen et al. (2022) advocated for increased attention to racial and ethnic minorities in family research. In their review, 25% of the couple and family research in the past decade attended to racial and ethnic minorities. When applying research to a clinical population, it is vital to recognize the limitation of applying the research to marginalized communities and people of color. Greater attention is needed in ongoing research to reduce this disparity and improve clinical effectiveness for various populations. Along with the treatment modalities listed in Table 10.3, there are specific theoretical approaches to working with couples or families that have also met the rigorous criteria to be considered evidence-based approaches. These include and are not limited to, emotionally focused therapy, functional family therapy, cognitive behavioral therapy, parent–child interaction therapy, integrative couples therapy, and theraplay. While there has been increased attention to research of different approaches, more research is needed for the myriad of treatments available for couple and family treatment. Many treatments show promise, including the specific theories described in this chapter, yet lack the rigorous research methods needed to meet the standard as evidence based. Continued focus on the inclusion of marginalized racial, ethnic, and sexual populations is needed to not only fill the gap but also ensure best practices when working with diverse groups.

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DETAILED CASE CONCEPTUALIZATION PRAGMATICS AND TRANSCRIPT In the following session, you will see a counselor from the human validation process model work with Mark, Carla, and Elle. Based on the current information provided in the case conceptualization, there are multiple family systems at play: the extended family (family of origin), the parent and co-parent unit, and the smaller unit of Mark and his daughters. From this theoretical perspective, the counselor explores the family of origin to understand the rules that Mark has learned since his childhood, which continue to influence the family he creates with Elle and Carla. There appear to be some values of men being strong, invulnerable, and loyal. Their way of coping as a system appears to bring in varying communication stances (such as blaming and placating) that at times interfere with authentic connection and self-worth. The family system and the individuals of the system are struggling with their self-worth, with limited acceptance of different perspectives and goals. As a first session, the counselor is in the first stage of making contact with the system and individuals. Making contact includes physical and emotional contact. The counselor uses creativity to build a relationship and begin to frame the family’s challenges within a systemic lens. In this session, the counselor explores each perspective in the family and gives validity to each voice. This reinforces the core systemic view of circular causality and the value of each member in the system. It is also important for the counselor working with this family to make contact, foster self-worth, and create flexibility and creativity to navigate their current challenges. Systemic Transcript: Human Validation Process Model Part 1: Making Contact and Introductions Transcript

Skill(s) Demonstrated

Counselor: Hello Mark, so lovely to meet you. [Greets Mark with a handshake.]

Use of touch (Simple uses of human touch allow for connection. It is also important to allow the client to lead in appropriate touch, thus asking for preferences from minors or other clients.)

Mark: Hi, same to you. Counselor: And Elle and Carla, I’m very excited to learn more about each of you. Handshake, fist bump, or high five? [Elle holds out her fist and the counselor gives a fist bump. Carla firmly holds her hand out for a handshake.] Counselor: As we work together today, I want to get an idea of who you are as a family and as unique people. What would you like me to know about who you are and what you are hoping for? Mark: Well, I don’t really even know. It’s really just the three of us. Their mom, Candace, sees them sometimes, but we got divorced three years ago. I guess things have been rocky. A lot of fighting between the girls. Counselor: So as a family, you have had some tough times that you’ve weathered together. Mark: Yeah, and it’s not getting any easier. That’s why we’re here. I thought we’d find our groove as a family. But it just seems to be getting worse. Counselor [turning to Carla and Elle]: Do you agree things have been rough? [Elle nods.] Carla: Oh yeah [emphatically].

Highlights the role of the family and individual (This seeds the idea that they are each unique and have a right to their differences.)

Paraphrase

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Counselor: You seem pretty sure about that. Mark: Oh, she’s sure about lots of things. Counselor: Well, I find that being sure is a way of letting people know where you stand. Something that teenagers, or soonto-be teenagers, can be pretty good at. Mark: That’s for sure. Counselor [turning back to Carla]: Do you agree that you’re pretty sure on things? [Elle giggles; Carla glares at her.]

Encouraging congruent communication (This‌‌‌‌‌‌‌ highlights the importance of honest communication and the role of adolescent development.)

Carla: I guess so. Elle calls me bossy but I don’t think I am. Counselor: No? I’m curious to hear Elle’s thoughts. But first, I want to hear how you would describe it. Carla: I just know what I want and don’t let anyone push me around. Counselor: It sounds like you are firm in your opinions. Where do you think you learned this way of being sure about what you want and not being pushed around? [Carla shrugs her shoulders.] Counselor: Sometimes, these are things we learn from other people, particularly in our family.

Build self-worth (This reinforces the ­individual perspectives and value of different strengths in the family.) Family of origin exploration

Carla: Probably grandma. Dad says I’m just like his mom. Counselor: So, you’ve heard before that you are similar to your grandmother in this skill of “knowing what you want and not being pushed around.” Perhaps something that has helped you deal with some of these tough times lately. [Turns to Elle.] I haven’t had a chance to hear from you yet. What would you like to share? Elle: I dunno. Counselor: Hmmm, well I am really curious what you think. Your dad gives one view, Carla another. And I’m curious, what you see happening. Think of it like this. A house often has lots of different windows, and depending what window you look in, you’ll see different things, the kitchen, living room, or a bedroom. You each help give a different look into your family. A different window, perhaps. If I were to come to your house and see you as a family together, what would I see? Elle: I’d probably just be alone. Dad works late and Carla’s always just in her room. Counselor: Seems lonely. [Leans in to be closer to Elle.]

Making contact (This‌‌‌‌‌‌‌ balances session and ensures each person has a chance the speak.) Metaphor and encouraging congruent communication (While subtle, the use of “I don’t know’” is often a move away from congruent communication, a placating stance. Encouraging Elle to state her opinion for herself is a simple way to move toward congruent speech.) Feeling reflection

Part 2 Later in Session: Congruent Expression of Feelings Counselor: I can hear the fear in your voice as you talk about not knowing how to be a single father to two daughters. Can you look at Elle and Carla and tell them what you’re scared of? What will help them understand your fear? Mark: I’m worried I’ll hurt them more than I already have. And teenage girls, things just seem to be getting harder. And their mom really isn’t around much and the girls are fighting all the time. Don’t get me started on their school work. It has been impossible to get them to keep up with things.

Facilitating emotional expression and congruent communication

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Elle: I’m sorry dad. I know I could be better at school, and if Carla‌‌‌‌‌‌‌ wasn’t down my throat all the time maybe we’d have some peace and quiet so I could actually do my homework. Carla: It’s not my fault you’re dumb at math! Elle: And you think you’re so perfect, huh? Carla: You’re one to talk. You think you can get away with anything. Mark: Stop it girls. Carla, don’t call your sister dumb. Counselor: I want to pause you, to help you in talking to your daughters. Go back to starting your statements with, “I.” That helps them know what you feel and think. Let’s start with what you said earlier, of feeling scared.

Coaching congruent communication

Mark: I guess I feel bad. I worry that I already made their life… Counselor: [motions to direct him to talk directly to Carla and Elle] Mark: …made your life so difficult going through the divorce, and now that you two are growing up and maturing, I just don’t know how to be a parent to two girls, let alone almost teenage girls. My teenage years were terrible. I don’t want you to have to go through what I did.

Encouraging genuine communication to talk directly to others rather than through the counselor

Carla: We don’t need your protecting dad. Mark: But I see it as my job to protect you no matter how old you are. Counselor: So somewhere along the way, you’ve learned that being a father means protecting your children, even though I’m hearing from Carla that that may not be what they want. Carla: Seriously. Remember when we used to just‌‌‌‌‌‌‌ have fun? It seems like lately, all you do is tell me what not to do, make sure I’m following all the rules, and hardly get to even leave the house any more. Counselor: So, let’s move around a bit. I want to show you what I’m seeing in the family and you can help me with it, too. Carla you come over here [has Carla stand up firm, with finger pointed toward Elle]. Now Mark you stand here. Try to be as big as you can [standing near Carla with folded arms]. [Elle is placed to the side, waving her arms for attention.] So, it seems that Carla has taken a role of being in charge of Elle, and at the same time, she is also growing up; something you can’t avoid. And Mark, you stand firm, impenetrable, perhaps in an attempt to keep things under control. Meanwhile, Elle is working hard over here for some attention. So, when you girls fight [to Carla and Elle], Mark, how might you respond? [Mark steps in between them like a referee.] Then what happens? Elle: We fight. He sends me to my room. Counselor: OK, so now the three of you are in separate spaces [moves them across the room from each other]. Then what happens?

Identifying family rules and roles

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Mark: We usually have a good few days, but this happens a lot [silence]. I guess I feel stuck, like either I’m constantly putting out fights or I’m just alone, failing as a father. Counselor: Yeah, I can hear the loneliness and helplessness in your voice, the not knowing what to do. Mark: Exactly Counselor: And it seems as you feel that helplessness that you want to hold on tighter and tighter to your girls. And the more you try to control or protect them, the more they push back, even right now.

THEORETICAL LIMITATIONS In general, with systems work, there are some contraindications and cautions to working with a couple or family. In couple counseling, current domestic or sexual violence would not be appropriate in the couple setting. There is a nuance in when and how a couple with a history of violence or abuse may move into conjoint therapy. Similarly, a family with a history of abuse requires knowledge and skill of applying trauma-informed practices with the system. At the same time, the family can serve as a source of strength and healing when painful experiences, such as abuse, have been shared (Walsh, 2015). Skilled systemic counselors are in high demand, and many clinicians find themselves diving into this work unexpectedly. Because of the intensity and complexity of working with systems, counselors are encouraged to seek the competence needed to be effective with this population.

Multigenerational Family Therapy The exploration of the family of origin that is central to this theory may not be fitting for all clients. Some clients may not find the relevance of their family history with their current presenting concerns. Additionally, for some clients, their history may be triggering or retraumatizing. It may not be helpful for clients with painful family histories to revisit these memories or relationships. For some, intentional distance has been important to their healing, and being sensitive to the timing of this family exploration is important. While initial applications of this theory were from an expert stance, when a client has a history of abuse, trauma-informed practice encourages the client to lead and have greater autonomy in the therapeutic process. This can allow the client to self-direct their own personal/familial exploration in a way that is meaningful, healing, and helpful. It can also take time and resources to gather the data to make meaning of the multigenerational process. This may make it a time-consuming process, including visits to family and work outside of the counseling room. This theory also has limited application to working with young children. While some adaptations may allow for the inclusion of young children, the emphasis on cognitive processing and insight would not be developmentally appropriate for all ages or client populations. When applied to diverse client populations, contemporary approaches must consider the role of culture when defining fluid terms such as differentiation or fusion. Finally, Connolly (2005) acknowledged that the original genogram does not address areas of unresolved hurt in connection to nonfamily members and may not address important larger systems that affect clients, such as community and political systems, which may be particularly impactful for ­marginalized clients.

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The Human Validation Process Model One frequently cited limitation of the human validation process model is rooted in the dynamic personality of Virginia Satir herself. Some wonder how much of the theory is connected to the personality of Satir in contrast to something replicable for other clinicians (a common challenge of humanistic-experiential theories, as so much of the theory relies on the self of the counselor). We‌‌‌‌‌‌‌ have frequently heard students being intimidated by the theory in recognizing that they cannot be Satir and fearing that this means that they cannot effectively use the theory. As an inherently experiential-humanistic theory, it is vital for the counselor to find their own authenticity with this approach. It would be contrary to the model to try to “be” Satir, as that would then move the clinician to a place of inauthenticity. This then leaves the counselor with the task to identify what is the theory‌‌‌‌‌‌‌, and what is the personality‌‌‌‌‌‌‌ of Satir. One prime example is the use of touch. While certainly there may be ethical implications in our current clinical best practices, the use of touch can be incredibly therapeutic if used effectively (see, for example, the evidence to support approaches such as theraplay). However, when done inauthentically or inappropriately, it serves as a detriment to the therapeutic process. Again, this leaves to task the personal work of the clinician using this model, to have sound clinical judgment as well as knowing themselves to find their own authentic way of being in this theoretical approach. The emotional intensity of this approach may not suit all clients. It would be important to be adaptable to each family and their personal comfort with experiments, vulnerability, and creativity. Today, the Satir Global Network serves as a platform to offer training and collaboration nationally and internationally. More research is needed to support the clinical effectiveness of this approach.

Structural Family Therapy This therapeutic approach requires the active participation of the family. Depending on the family, willingness and comfort to engage in this process will greatly influence the outcome of treatment in this approach. And while the counselor does work to join the family perspective and works collaboratively on goals, there is still a range in the desired structure (e.g., parental hierarchy, clear boundaries). The counselor is cautioned not to impose their own definition of desired structure on the family. As the counselor takes an expert stance, there is a risk of imposing their own values or personal definitions of family structure (e.g., closeness, distance, and appropriate hierarchy in a family). Individualistic and collectivistic cultures vary in the range of close and distant relationships; a counselor from an individualistic culture might make assumptions that a family is enmeshed. Layering the concepts of the theory with multicultural competence will assist the structural counselor in being flexible to meet the unique composition of the diversity of families.

SUMMARY Systemic theories bring a valuable perspective to attend to context and multiple perspectives. The multigenerational approach focuses on the insight of the transgenerational process to increase personal and interpersonal differentiation. The human validation process model is a humanistic-experiential approach that works to build the self-esteem of the individual and family. Through ‌‌‌‌‌‌‌ encouraging congruent communication, practitioners foster connection, creativity, and spontaneity, which in turn create healthy coping. Structural theory looks directly at the organizational composition of the family in regard to power, rules, and closeness. Through the therapeutic process, the structural counselor supports the

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family in restructuring to allow for clear, consistent, and flexible boundaries with an established hierarchy. The three theories described in this chapter are foundational approaches that began the systemic movement in the 1950s and 1960s. This work continues to inform contemporary approaches to couple and family counseling. Many contemporary models tend to be integrative, pulling in aspects from each of these, and other, systemic approaches. Increased attention to social justice and multicultural competence and the increasing demand for ­evidence-based practice theories, such as the Gottman method, are examples of the current trends in the field of couple and family counseling. VOICES FROM THE FIELD This chapter features a digitally recorded interview entitled Voices From the Field. The interview explores multicultural, social justice, equity, diversity, and intersectionality issues from the perspective of clinicians representing a wide range of ethnic, racial, and national backgrounds. The purpose of having chapter-based authors interview individuals representing communities of color or who frequently serve diverse populations is to provide you, the reader, with relevant ­theory-based social justice and multiculturally oriented conceptualization, contemporary issues, and relevant skills.

Access the video at https://bcove.video/3Q9xSLb

We (the authors) welcomed an interview with Dr. Shawn Parmanand, a Licensed Clinical Professional Counselor (LCPC) and National Certified Counselor (NCC) in the Rocky Mountain region who has been in practice for approximately 10 years. At the time of interview, Dr. Parmanand identified as a multiracial, 41-year-old cisgender male. He graduated from a CACREP-accredited master’s and doctoral program in counseling and counselor education, specializing in marriage, couple, and family counseling. He identified currently practicing from an integrative systemic theory and has frequently worked with couples. We hope you enjoy and learn much from this rich interview.

STUDENT EXERCISES Exercise 1: Personal Application of Circular Causality

It is vital for the family counselor to have a deep awareness of their family of origin and the impact it may have on their role as a counselor. Take time to reflect on each question and journal about each prompt. 1. Identify an ongoing challenge from your family of origin and apply the concept of circular causality to this challenge. a. Notice how applying circular causality changes how you define the problem. b. How does this change in defining the problem also shift how one might address the problem? 2. How would you self-evaluate your own level of self-differentiation? 3. How does your family culture and multicultural identities influence your view of counseling?

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4. What would a family counselor need to know about your family in order to be effective? Consider multicultural dimensions in this response.

Exercise 2: Genogram

Nadia (age 29) and her son, Dominic (age 10), live together in a small one-bedroom apartment. Nadia was raised by her mother, Angie, and her two younger half-siblings. Nadia had little contact with her father growing up and had few opportunities to engage with her father’s side of the family. While her father is Venezuelan, Nadia does not consider herself Hispanic, as she was raised by her Caucasian mother in a predominately White community. Nadia has fair skin and “passes” as White in most places, although she has experienced some racism and isolation within her family, with no one else in her immediate or extended family being multiracial. As the oldest child growing up, Nadia had a lot of responsibilities to care for her two younger brothers. Nadia had a conflictual relationship with her mother and was historically very close until recent events caused a split in their relationship. Nadia never told Dominic’s father that she was pregnant, as they split up before she knew. While Dominic occasionally asks about his father, Nadia has been his sole caregiver since birth, with her mother helping her in the first 2 years of his life. Nadia saw her mother successfully raise her and her siblings and did not want him to be upset if his father was not consistent in visiting him. Dominic’s father is African American, and Nadia knows very little about Black culture and what it is like to be an African American male. At school, Dominic has friends from multiple races and seems to get along with most kids. Recently, Nadia has been concerned about the current social and political environment and how that is impacting her son. While Nadia has been mostly silent on the issue of Black rights, she is finding it harder to be silent as she sees the potential dangers that lie ahead for her son. At a recent family event, several family members were vocal in not believing that racism was an issue and made multiple subtle racial slurs in front of Dominic. Nadia, upset, yelled at her family members, expressing that they would never understand what it is like not being White. She quickly left the party and has avoided contact with her family since. Dominic is very angry that he does not get to see his cousins and is lashing out at Nadia. Nadia is coming to counseling with Dominic, seeking help in knowing how to talk about race and why she does not want to visit family. Build a genogram that includes the following: ■ ■

Key family members in each generation (e.g., Dominic, his parents, his grandparents). Include family members even if some details, such as names, are unknown. Draw emotional relationship symbols between family members.

Exercise 3: Systemic Conceptualization

Using the case in Exercise 2, explore the following questions to further expand on the ­systemic conceptualization of this family. Be sure to use systems concepts in your responses. DISCUSSION QUESTIONS

1. Utilizing the multigenerational theory, what patterns do you see in this family? 2. What hypotheses do you have about the communication stances used to cope in this family? 3. How might the racial identity development of Nadia and Dominic be connected to their current self-worth? 4. From a structural theory perspective, describe the role of boundaries and hierarchy in this family? Describe the subsystems and explore the role of power.

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Exercise 4: Personal Application

It is vital for the family counselor to have a deep awareness of their family of origin and the impact it may have on their role as a counselor. Take time to reflect on each question and journal about each prompt. ■ ■ ■

Identify an ongoing challenge from your family of origin and apply the concept of circular causality to this challenge. Notice how applying circular causality changes how you define the problem. How does this change in defining the problem also shift how one might address the problem?

Exercise 5: In the Research

Identify a specific multicultural identity/group and perform a brief literature review on the use of family therapy with this population. Select an article and write a brief outline of the article. Also note the following: ■ ■ ■

theoretical approach recommendations strengths and limitations of family therapy gaps in the literature for the identified group

RESOURCES Helpful Links ■ ■ ■ ■ ■ ■ ■

Minuchin Center: https://minuchincenter.org/ Numerous publications on working with diverse populations: https://minuchincenter. org/publications/ The Multicultural Family Institute: https://multiculturalfamily.org/ Steph Anya YouTube Channel: www.youtube.com/c/StephAnya The Satir Global Network: https://satirglobal.org/ The Bowen Center for the Study of the Family: www.thebowencenter.org/ multigenerational-transmission-process The Gottman Institute: www.gottman.com/

Helpful Books ■ ■ ■ ■ ■ ■

Aponte, H. (1994). Bread & spirit: Therapy with the new poor: Diversity of race, culture, and values. W.W. Norton. St. George, S., & Wulff, D. (Eds.). (2016). Family therapy as socially transformative practice: Practical strategies. AFTA. Kelly, S. (Ed.). (2016). Diversity in couple and family therapy: Ethnicities, sexualities, and ­socioeconomics. Praeger. McDowell, T. (2015). Applying critical social theories to family therapy practice. AFTA. https://doi.org/10.1007/978-3-319-15633-0 McGoldrick, M., Giordano, J., & Garcia-Preto, N. (Eds.). (2005). Ethnicity and family therapy (3rd ed.). Guilford Press. McGoldrick, M., & Hardy, K. V. (Eds.). (2019). Re-visioning family therapy: Addressing ­diversity in clinical practice (3rd ed.). Guilford Press.

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Helpful Videos ■ ■ ■ ■ ■

Racism, Family Secrets and the African American Experience by Monica McGoldrick and Elaine Pinderhughes: www.psychotherapy.net/video/mcgoldrick-racism-family-secrets The Legacy of Unresolved Loss: A Family Systems Approach by Monica McGoldrick: www.psychotherapy.net/video/mcgoldrick-family-systems A House Divided: Structural Therapy with a Black Family by Harry Aponte: www.psychotherapy.net/video/aponte-structural-family-therapy-black-family Blended Family With a Troubled Boy by Virginia Satir: www.psychotherapy.net/video/ satir-blended-family Reflections on Family Therapy. Minuchin, S. (Director). (2011). [Video/DVD] Milton H. Erickson Foundation: https://video.alexanderstreet.com/watch/ reflections-on-family-therapy

A robust set of instructor resources designed to supplement this text is available. Qualifying instructors may request access by emailing [email protected].

REFERENCES Babinski, D. E., & Sibley, M. H. (2022). Family-based treatments for attention-deficit/hyperactivity disorder: A review of family functioning outcomes in randomized controlled trials from 2010 to 2019. Journal of Marital and Family Therapy, 48(1), 83–106. https://doi.org/10.1111/jmft.12572 Baker, K. G. (2015). Bowen family systems couple coaching. In A. S. Gurman, J. L. Lebow, & D. K. Snyder (Eds.), Clinical handbook of couple therapy (5th ed., pp.246–267). The Guildford Press. Ballard, M., Fazio-Griffith, L., & Marino, R. (2016). Transgenerational family therapy. The Family Journal: Counseling and Therapy for Couples and Families, 24(2), 109–113. https://doi.org/10.1177/ 1066480716628564 Banmen, J., & Maki-Banmen, K. (2014). What has become of Virginia Satir’s therapy model since she left us in 1988? Journal of Family Psychotherapy, 25(2), 117–131. https://doi.org/10.1080/08975353.2014.909706 Bateson, G. (1972). Steps to an ecology of mind. Chandler. Bowen, M. (1978). Family therapy in clinical practice. Jason Aronson. Broderick, C. B., & Schrader, S. S. (1981). The history of professional marriage and family therapy. In A. S. Gurman & D. P. Kniskern (Eds.), Handbook of family therapy (pp. 5–35). Brunner/Mazel. Busby, D. M., Christensen, C., Crane, D. R., & Larson, J. H. (1995). A revision of the Dyadic Adjustment Scale for use with distressed and nondistressed couples: Construct hierarchy and multidimensional scales. Journal of Marital and Family Therapy, 21(3), 289–308. https://doi.org/10.1111/j.1752-0606.1995. tb00163.x Connolly, C. M. (2005). Discovering “family” creatively: The self-created genogram. Journal of Creativity in Mental Health, 1(1), 81–105. https://doi.org/10.1300/J456v01n01_07 Crane, D. R., Middleton, K. C., & Bean, R. A. (2000). Establishing criterion scores for the Kansas Marital Satisfaction Scale and the Revised Dyadic Adjustment Scale. American Journal of Family Therapy, 28(1), 53–60. https://doi.org/10.1080/019261800261815 Daniels, A. D. (2022). Combining family systems approaches to address BIPOC families’ racial trauma amidst the global pandemic. The Family Journal, 30(2), 157–163. https://doi. org/10.1177/10664807221078969 Dehghani, M., & Bernards, J. (2022). The effectiveness of structural family therapy in repairing behavioral problems and improving family functioning in single‐­parent families in Iran. Journal of Marital and Family Therapy, 48(4), 1040–1058. Doss, B. D., Roddy, M. K., Wiebe, S. A., & Johnson, S. M. (2022). A review of the research during 2010–2019 on evidence-based treatments for couple relationship distress. Journal of Marital and Family Therapy, 48(1), 283–306. https://doi.org/10.1111/jmft.12552 Dwanyen, L., Holtrop, K., & Parra-Cardona, R. (2022). Reducing mental health disparities among racially and ethnically diverse populations: A review of couple and family intervention research methods (2010–2019). Journal of Marital and Family Therapy, 48(1), 346–365. https://doi.org/10.1111/jmft.12573

Fishman, H. C., & Rosman, B. L. (Eds.). (1986). Evolving models for family change: A volume in honor of Salvador Minuchin. Guilford Press. Frey, L. M., Hunt, Q. A., Russon, J. M., & Diamond, G. (2022). Review of family-based treatments from 2010 to 2019 for suicidal ideation and behavior. Journal of Marital and Family Therapy, 48(1), 154– 177. https://doi.org/10.1111/jmft.12568 Gehart, D. R. (2018). Mastering competencies in family therapy: A practical approach to theories and clinical case documentation (3rd ed.). Cengage Learning. Goger, P., & Weersing, V. R. (2022). Family based treatment of anxiety disorders: A review of the literature (2010–2019). Journal of Marital and Family Therapy, 48(1), 107– 128. https://doi.org/10.1111/jmft.12548 Gottman, J. M. (2009). Time-series analysis: A comprehensive introduction for social scientists. Cambridge University Press. Gottman, J. M., & Levenson, R. W. (2000). The timing of divorce: Predicting when a couple will divorce over a 14-year period. Journal of Marriage and Family, 62(3), 737–745. https://doi. org/10.1111/j.1741-3737.2000.00737.x Gottman, J. M., & Levenson, R. W. (2002). A two-factor model for predicting when a couple will divorce: Exploratory analyses using 14-year longitudinal data. Family Process, 41(1), 83–96. https://doi. org/10.1111/j.1545-5300.2002.40102000083.x‌‌‌‌‌‌‌‌‌‌‌‌‌‌ Hall, C. M. (1981). The Bowen family theory and its uses. J. Aronson. Hogue, A., Schumm, J. A., MacLean, A., & Bobek, M. (2022). Couple and family therapy for substance use disorders: Evidence-based update 2010–2019. Journal of Marital and Family Therapy, 48(1), 178– 203. https://doi.org/10.1111/jmft.12546 Kaminski, J. W., Robinson, L. R., Hutchins, H. J., Newsome, K. B., & Barry, C. M. (2022). Evidence base review of couple- and family-based psychosocial interventions to promote infant and early childhood mental health, 2010–2019. Journal of Marital and Family Therapy, 48(1), 23– 55. https://doi. org/10.1111/jmft.12570 Kerr, M. E. (1981). Family systems theory and therapy. In A.S. Gurman & D.P. Kniskern (Eds.), Handbook of family therapy (pp. 226–264). Brunner/Mazel. Kerr, M. E., & Bowen, M. (1988). Family evaluation: An approach based on Bowen theory. W. W. Norton. Ma, J. L. C., Wong, C., & Xia, L. L. L. (2020). Helping a depressed Chinese adult with high functioning autism reconnect with his family through structural family therapy. Journal of Family Therapy, 42(4), 518–535. https://doi.org/10.1111/1467-6427.12281 McGoldrick, M. (2011). The genogram journey: Reconnecting with your family. W. W. Norton. McGoldrick, M., Gerson, R., & Petry, S. (2020). Genograms: Assessment and treatment (4th ed.). W.W. Norton. McGoldrick, M., & Hardy, K. V. (Eds.). (2019). Re-visioning family therapy: Addressing diversity in clinical practice (3rd ed.). Guilford Press. McWey, L. M. (2022). Systemic interventions for traumatic event exposure: A 2010–2019 decade review. Journal of Marital and Family Therapy, 48(1), 204– 230. https://doi.org/10.1111/jmft.12547 Minuchin, S. (1974). Families & family therapy. Harvard University Press. Minuchin, S., Reiter, M. D., & Borda, C. (2014). The craft of family therapy: Challenging certainties. Routledge, Taylor & Francis. Satir, V. (1967). Conjoint family therapy: A guide to theory and technique (Rev. ed.). Science and Behavior Books. Satir, V. (1972). Peoplemaking. Science and Behavior Books. Satir, V. (1988). The new peoplemaking. Science and Behavior Books. Satir, V., & Baldwin, M. (1983). Satir step by step: A guide to creating change in families. Science and Behavior Books. Satir, V., Stachowiak, J., & Taschman, H. A. (1975). Helping families to change. J. Aronson. Satir, V., & Toms, M. (1984, June 14). Becoming whole. New Dimensions Radio [Radio broadcast]. https:// programs.newdimensions.org/products/becoming-whole-with-virginia-satir Schwartz Gottman, J. (Ed.). (2004). The marriage clinic casebook. W.W. Norton. Sheidow, A. J., McCart, M. R., & Drazdowski, T. K. (2022). Family-based treatments for disruptive behavior problems in children and adolescents: An updated review of rigorous studies (2014–April 2020). Journal of Marital and Family Therapy, 48(1), 56–82. https://doi.org/10.1111/jmft.12567 Simon, G. M. (2015) Structural couple therapy. In A.S. Gurman, J. L. Lebow, & D. K. Snyder (Eds.), Clinical handbook of couple therapy (5th ed., pp. 358–384). Guildford Press. Southam-Gerow, M. A., & Prinstein, M. J. (2014). Evidence base updates: The evolution of the evaluation of psychological treatments for children and adolescents. Journal of Clinical Child & Adolescent Psychology, 43(1), 1–6. https://doi.org/10.1080/15374416.2013.855128

Spanier, G. B. (1976). Measuring dyadic adjustment: New scales for assessing the quality of marriage and similar dyads. Journal of Marriage and the Family, 38, 15–28. https://doi.org/10.2307/350547 Stith, S. M., Topham, G. L., Spencer, C., Jones, B., Coburn, K., Kelly, L., & Langston, Z. (2022). Using systemic interventions to reduce intimate partner violence or child maltreatment: A systematic review of publications between 2010 and 2019. Journal of Marital and Family Therapy, 48, 231–250. https:// doi.org/10.1111/jmft.12566 Walsh, F. (2015). Family resilience: Strengths forged through adversity. In F. Walsh (Ed.), Normal family ­processes: Growing diversity and complexity (4th ed., pp. 399–427). Guilford Press. Watzlawick, P., Bavelas, J. B., & Jackson, D. D. (1967). Pragmatics of human communication: A study of interactional patterns, pathologies, and paradoxes. W. W. Norton. Wittenborn, A. K., Woods, S. B., Priest, J. B., Morgan, P. C., Tseng, C.-F., Huerta, P., & Edwards, C. (2022). Couple and family interventions for depressive and bipolar disorders: Evidence base update (2010– 2019). Journal of Marital and Family Therapy, 48(1), 129–153. https://doi.org/10.1111/jmft.12569

11

POSTMODERN APPROACHES Michelle S. Hinkle and Caroline Perjessy

LEARNING OBJECTIVES After reading this chapter, you will be able to: ■ Understand postmodern assumptions as a theoretical foundation for solution-focused brief therapy (SFBT), narrative therapy, and constructivist therapy ■ Evaluate how SFBT, narrative therapy, and constructivist therapy are similar and different ■ Identify the theoretical structure and application of SFBT, narrative therapy, and constructivist therapy ■ Apply SFBT, narrative therapy, and constructivist therapy to a specific client scenario ■ Understand how counselors operating from a postmodern theoretical perspective develop their knowledge and usage of specific theory ■ Identify specific theoretical limitations, multicultural considerations, and case conceptualization components of SFBT, narrative therapy, and constructivist therapy

INTRODUCTION The rise of postmodern epistemological perspectives in the 20th century influenced the counseling profession by providing new ideas in contrast to modern philosophies. Until then, counseling theories had their foundation in modern assumptions, but postmodern philosophy spurred the evolution of new counseling theories rooted in alternative epistemologies (Hansen, 2006). Theories such as SFBT, narrative therapy, and constructivist therapy began to evolve and gain popularity. Though each differs in counseling approach, these theories share common theoretical foundations. To understand each and use their respective interventions intentionally, counselors must first grasp their shared theoretical underpinnings to have a basis for understanding the purpose and meaning of the theories for use in counseling (Hansen & Scholl, 2018‌‌‌‌‌‌). This chapter will provide such information by explaining postmodern assumptions about human nature and the implications for counseling. Each theory, SFBT, narrative therapy, and constructivist therapy, will be described through a review of their distinctive qualities that shape the counseling experience and process for both counselor and client.

Postmodern Assumptions of Human Nature and Development with Implications for Counseling To begin the exploration of postmodern approaches in counseling and psychology, one must first know how the related theories fundamentally differ from the ones that came before. Until the postmodern influence on counseling and psychology, previously crafted theories shared a similar modern epistemological foundation (Hansen, 2006). Related assumptions

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from modernism posit that a singular and observable objective reality exists (Gergen, 2009). Therefore, problems that bring people to counseling are made sense of through a singular lens, leading to clear and defined ways to conceptualize and treat mental health concerns. Though each modern theory is different, their shared reductive assumption is that presenting problems can be reduced to shared characteristics that the healing powers of the theory can address, thus providing a clear way to facilitate change. That is, depending on the theory, such tasks as challenging cognitive distortions, addressing unfinished business, or seeking self-actualization can be ways to facilitate therapeutic change. Counselors, then, are the authority in facilitating that change, as they have the skill set provided and are guided by the theory. While theories somewhat differ in the role and responsibility clients have in the therapeutic process, counselors ultimately position themselves as experts with the tools required to implement change. Clients can then absorb the counseling experience to make internal changes to achieve their goals (Hansen & Scholl, 2018). Postmodern assumptions contributed alternative viewpoints to these modern ideas, with a few major and relevant assumptions that provided a starting place for the evolution of additional theories to emerge. First is the notion that multiple realities, rather than one singular reality, can simultaneously exist because phenomena can be viewed and understood in varying ways based on who is making the observation (Hansen, 2006). Relatedly, people constantly construct what they observe and make sense of these observations based on their unique experiences, values, and beliefs (Anderson, 1990). How we understand any phenomenon is not based on a singular investigation or observation but rather on a perception of perspectives through which we apply our unique meaning. A resulting implication is that there is no singular way to conceptualize a client’s experience or presenting problem, nor can a counselor have a priori knowledge of how to facilitate change. Similarly, there is no one way to define mental health, as it would be unique to each person. Influenced by postmodern tenets, constructivism and social constructionists provide additional nuances informing postmodern counseling approaches. Constructivism postulates that individuals actively create and ascribe unique meaning to what they observe and experience (Hansen, 2004; Hansen & Scholl, 2018). Social construction also informs meaning-making processes by specifying that discernment of reality and meaning is not an individual act but rather a social act that emerges in communities through language and discourse (Gergen, 2009). Gergen described language, such as word choice and the combination of words, as revealing underlying values and messages. He goes on to point out that words can create binaries of existence, in that to be one thing implies the absence of something else. For example, to be depressed means the absence of happiness. Over time, this binary can create an all-or-nothing situation as the more particular words and descriptions are used, the more noticed and valid they become. This runs the risk of marginalizing other possibilities. What is described often represents the privileged vantage points perpetuated by the dominant culture, thus revealing certain truths as more valid than others. The more communities, families, or individuals describe phenomena or experiences, the more real they seem with the consequence of not noticing, or marginalizing, other possibilities. These ideas of constructivism and social construction, though different, imply that counselors rely on clients as experts on their own unique meanings. Furthermore, counselors must be curious and learn how discourse, at the macro and micro level, influences individual perception—both their own and clients. This will inherently put the counselor in a less powerful position as they are learning from the client. An egalitarian counseling relationship, in which both the client and counselor have influence and expertise in the process, is a feature of postmodern approaches (Hansen, 2006). When counselors take this curious stance, they can learn how meaning-making processes, via either a constructivist or social construction lens, influence a person’s understanding of themselves and others. Relatedly, postmodernist assumptions imply that individuals have multiple selves that are constantly evolving and have continuously advancing perceptions. For example, some people might

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be different when with family than they are in the workplace. Counseling then becomes less about advancing to a clearer understanding of a static self and more about redescribing ever-changing identities (Hansen & Scholl, 2018). Postmodern perspectives will be revisited throughout this chapter, as they provide the underpinnings to SFBT, narrative therapy, and constructivist therapy. Each of these theories has defining characteristics from one another, but all echo the postmodern assumptions. Each theory will be described by their hallmark features, culminating in a case conceptualization.

LEADERS AND LEGACIES OF POSTMODERN THEORY As postmodern assumptions began to question the modern epistemologies and ways of knowing, mental health practitioners began to integrate its tenets into their work. Harlene Anderson and Harold Goolishian (1992), two prominent family therapists, cofounded the postmodern collaborative approach. In their work at the Galveston Family Institute in Galveston, Texas, United States, they further developed their approach as they considered the importance of language and dialogue as a change agent. They determined that language used to describe people and scenarios could influence how individuals understand such things. Thus, the words used in counseling could shape perspectives. Self-awareness and personal reflection on how language describes and creates meaning are useful for understanding these perspectives. Anderson and Goolishian also challenged the modernistic assumption that the counselor is the authority by suggesting that clients are the experts of themselves. This made way for a new type of relationship in the counseling experience, one in which the counselor takes a nonexpert and curious approach. Through their early 1980s work at the Milwaukee Brief Family Therapy Center in Wisconsin, United States, Insoo Kim Berg and Steve de Shazer collaborated on their co-developed theory, SFBT. Both had worked previously at the Mental Research Institute in Palo Alto, California, United States, where they studied and worked as family therapists. Their work included influence from Milton Erickson, who viewed clients as customers (rather than clients) that had strengths and resources to solve problems, and Jay Haley, who discussed patterns of behaviors that kept families entrenched in problems (de Shazer, 1985‌‌‌‌‌‌; Walter & Peller, 2000). de Shazer and Berg, along with colleagues at the Milwaukee Brief Family Therapy Institute, introduced the idea of an inductive (i.e., examining specific scenarios to make larger conclusions) approach to counseling rather than deductive (i.e., applying general conclusions or information to make sense of specific scenarios). In a shift away from what other theories at the time emphasized, Berg and de Shazer postulated that counselors do not need to know the history of clients or complaints to help them solve problems. Rather, current observations and future-based exploration could lead to a discussion of clients’ strengths and solutions. They applied the postmodern ideas that language and conversation could build perspectives and that clients’ individual strengths can uniquely solve their problems, thus making language a tool to facilitate change. Others have created theories or nuanced approaches stemming from SFBT. Bill O’Hanlon and Michele Weiner-Davis (2003) later cocreated solution-oriented therapy. Sharing a similar philosophy to SFBT, this theory offers a more flexible approach to exploring the history of the problem. Bill O’Hanlon later renamed this theory possibility therapy, in which he emphasized the process of validating clients’ emotions and experiences (González et al., 2011; O’Hanlon & Beadle, 1997). Walter and Peller (2000) are also well-known solution-­ focused counselors. They further detailed the importance of the therapeutic relationship and the use of language in counseling, introducing additional ways to thicken solution-­ oriented realities by looking for “signs” of change. Michael White, a trained social worker from Adelaide, Australia, questioned the power dynamics in psychology and looked outside of the psychology discipline for concepts and theories that could inform his work (White, 2011). He studied the work of philosophers, such

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as Michael Foucault’s notions on unitary knowledge that perpetuate dominant ideas of what is “true,” and that knowledge and power are interchangeable. Gregory Bateson’s writings about interpretation and meaning making and Jacques Derrida’s concept of deconstruction through which one can find multiple meanings in a singular story also shaped White’s ideas (White & Epston, 1990). As he continued his study, his friend and colleague in Auckland, New Zealand, David Epston, added to White’s conversation. Together they would consult their work and share ideas, eventually co-developing narrative therapy. In 1990, they published ​​their book Narrative Means to Therapeutic Ends, known as an introduction to the theory. Narrative therapy exemplifies postmodern assumptions, as well as social construction, as it is rooted in such beliefs that multiple realities exist, and language and dialogue create the meaning ascribed to our perceptions of the world. White’s interest in text analogy, in which people ascribe meaning to events that happen over time, informed his belief that stories are metaphors for life, thus providing framework and structure to people’s interpretations of their experiences (Bubenzer et al., 1994; White & Epston, 1990). These narratives are rooted in underlying social, cultural, and political perspectives that construct dominant “truths” by way of marginalizing and pathologizing other ideas or experiences that do not exist within the framework of the dominant narrative. There are other influential social constructionist practitioners related to narrative therapy. For example, Tom Andersen (1987), a Norwegian psychiatrist, developed the idea of using reflecting teams in family therapy. He found that when an outside group observed a family therapy session and reflected on new perspectives, alternative ideas, and posed curious questions, the family benefited from hearing their conversation. Though White had some critique of Andersen’s ideas, he acknowledged his influence, as well as Barbara Myerhoff’s work related to outsider witnesses in definitional ceremonies, through which others would help authenticate marginalized individuals’ experiences and collective identity, to his inclusion of outsider witnesses in therapy as a distinguishing factor of narrative therapy (White, 1995). Jill Freedman and Gene Combs are also well-known narrative therapy practitioners and researchers known for their advancements in the theory and discussion related to the intricate nuances of the collaborative relationship between counselor and client and social justice efforts. Theoretical advancements in narrative therapy have emerged as well. Neuro-narrative therapy (Zimmerman, 2017; Zimmerman & Beaudoin, 2015) has been developed in recent years, in which affect and body responses are integrated with traditional narrative therapy in an effort for clients to internalize and make emotional meaning of cultural discourse. Attachment narrative therapy (Dallos, 2004), which explores attachment patterns to understand how they contribute to people’s narratives, has also been developed. According to Mahoney (2002, 2003), there are many 20th century theorists who are considered major constructivists, including Alfred Adler, Albert Bandura, Viktor Fankl, Kenneth Gergen, Jean Piaget, George Kelly, and many others. These diverse perspectives fall along a continuum from more individual, cognitively related constructivists to more relational, social constructivists (Watts, 2017). One of these theorists, George Kelly, is considered the first person to develop a theory of therapy along the constructivist lines during the 1930s and 1940s (Neimeyer, 2003). Kelly (1955)‌‌‌‌‌‌ is considered a more cognitively oriented constructivist and developed a theory of personality that helped shape the future of constructivist therapies. George Kelly, born in 1905 and growing up on a farm, was influenced by this agricultural life throughout his developing self. As an only child to two highly religious parents who frequently moved the family about, George’s education was fragmented (Neimeyer, 2003). When he went away to college, he was made aware of new ideas, eventually earning a master’s in educational psychology and later obtaining a PhD in Speech and Reading. This, all while never having completed high school and having to drop out of his undergraduate degree due to an inability to pay for his schooling. Kelly’s own personal journey with his education and career prompted his interest in helping others who struggled with career decisions, making him interested in becoming

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a psychotherapist. He was trained in the therapeutic methods of Freudian psychoanalysis (Taber, 2020). Still, he found the perspective that early-life experiences lead to neurosis unsatisfactory for his work with clients who were deeply troubled. It was in the‌‌‌‌‌ U.S. Navy where he formed The Psychology of Personal Constructs (Kelly, 1955), which was based on his philosophy that “one does not have to disprove one proposition before entertaining one of its alternatives” (Kelly, 1958/1969, p. 55), later calling this philosophy “constructive alternativism” (Kelly, 1958‌‌‌‌‌‌/1969‌‌‌‌‌‌, p. 64). His theory has been part of a “metatheory” (Cottone, 2001‌‌‌‌‌‌, p. 190), which serves as a paradigm framework to help explain mental health services, how to provide them, and what the roles of the counselor and client consist of (Cottone, 2001). These ideas contributed to constructivist therapy‌‌‌‌‌, which is less of a technique than an overarching philosophy through which therapy is done (Anderson, 1990). As indicated earlier, many theorists have contributed to the philosophy of constructivist theory. As a philosophy, constructivism and social constructionism share similar theoretical and philosophical roots (Watts, 2017), both “stress the ongoing process of psychological organizing, disorganizing, and reorganizing” (Mahoney, 2003, as cited in Watts, 2017). However, in social constructionism, meaning is developed in coordination with others, whereas constructivists’ meaning making focuses on an individual cognitive and biological basis (Sommers-Flanagan & Sommers-Flanagan, 2018). Cognitive constructivists differ from social constructivists too. Social constructivists purport that what is “known or understood derives from communities of understanding rather than an individual operating as an isolated ‘psychological’ entity” (Cottone, 2001, p. 193). Meaning making is negotiated and understood through language and relationships, which are crucial to understanding truths (Cottone, 2001). Ultimately, language, dialogue, and relationships create individual interpretations. In more cognitively oriented constructivist epistemologies, the nature of knowledge is constructed through an individual’s experience and interpretation of such experience (Neimeyer & Feixas, 1990). The primary focus is on the individual, how they interpret their world, and the meaning derived from the experience (Watts, 2017) versus the social constructivists, who focus more on relationships and the ensuing meaning derived through language and dialogue. In the psychological world, Gergen’s “The Social Constructionist Movement in Modern Psychology” (1985) serves as a seminal source in the development of social construction in psychology; however, Kelly’s psychology of personal construct theory delivers a structured and organized framework in the utilization of constructivism in therapy. Several other psychological theories fall under the umbrella of constructivist paradigm approaches, which include narrative, solution focused, and cognitive consensual (Cottone, 2001). The psychology of personal constructs espouses a constructivist perspective, which promotes a philosophy of therapy that eschews premeditated and preordained techniques and interventions (Heatherington & Johnson, 2019). Kelly believed that‌‌‌‌‌ individuals could develop alternative perspectives to those that were unproductive and unhelpful and impacted them in negative ways. According to Taber (2020), Kelly’s constructivist theory also helped to develop a methodology for exploring learners’ developing thinking, offering insight into teachers’ classroom challenges.

THE ORIGIN AND NATURE OF MENTAL HEALTH CONCERNS Solution-Focused Brief Therapy SFBT emphasizes the idea that multiple realities coexist, and problem-based conversation perpetuates a reality where the presenting issues are central. Therefore, the origin of a problem is due to the complaint gaining more attention in conversation, thus limiting the lens through which a client interprets the related meaning of experiences (de Shazer, 1991). This problem-oriented focus leads individuals not to notice times when the problem does not

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exist or when there is an exception to the problem. For example, the postmodern assumption would say that depression coexists with the absence of depression. However, if conversation surrounds the reality in which depression is the focus, the times when it is not present goes unseen and, therefore, undiscussed. Clients can feel surrounded by the problem without identifying how to get past it or recognize their strengths and solutions that could help. Thus, the problem-oriented language limits what people believe is possible, and they find it difficult to know how to live outside of the problem. The inductive nature of SFBT espouses that counselors do not need to know about the problem in order to help clients find solutions. Relatedly, De Jong and Berg (2013) critiqued the medical model of the helping professions that classifies symptomatology into diagnostic labeling. They shared that the medical model suggests one must first know what the problem is to help solve it, thus limiting possible solutions by implying there might be specific ones to follow. They further suggested that during the process of case consultation, practitioners move away from presenting clients as their diagnosis and instead share clients’ goals, strengths, and solutions. As a result of these assumptions, problem-focused conversation is not the focus of sessions, as it sustains the problem reality that brings clients to counseling.

Narrative Therapy Narrative therapy suggests that mental health concerns arise when lived experience, or the meaning provided to experience, does not exist within dominating stories or ideals (White & Epston, 1990). This can happen when an individual’s experience does not reflect the ideals they want for themselves; for example, they present a problem-saturated story versus their preferred identity. Additionally, problems can exist if a person’s experience does not fit into the stories that others have placed upon them (White, 2011). When either or both of these circumstances occur, it limits the meaning people make for themselves and restricts their ability to think and act in ways not maintained by this problem narrative. This also keeps people from recognizing occurrences outside the problem. Underlying these assumptions of problem-saturated narratives is the social constructionist perspective that ways of being deemed as truthful or valid exist only because they dominate the discourse. Nondominant or marginalized ideas that exist on the periphery are less valid. That is, presenting problems can occur when individuals’ identities are oppressed by narratives that do not include them or when their experiences are not supported by dominant ideas of what society might deem as “truth.” This is largely driven by sociocultural and political norms held by those that are privileged (Combs & Freedman, 2012). For example, ideas deemed as more valued might dominate thoughts in some places while there is another cultural norm elsewhere. Both are equally valid, though they differ based on the values of the local community. By simply moving a person from one place to another, a problem that might have existed in one environment might be less visible someplace else. Narrative therapy also challenges pathology, particularly via diagnosis. Related to the idea that knowledge and power impose truths that reflect the dominant culture, the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychological Association [APA, 2022]) lists diagnoses with reductive criteria created by a group of people deemed as experts (Hansen & Scholl, 2018). White (2011) proposed that the act of diagnosing inherently reflects the use of power in ways that impose dominant ideas of mental health onto others. He further challenged pathology as it internalizes the problem within the person rather than acknowledging the sociocultural and political cause of problems. With this in mind, narrative therapists help others to view the problem as the problem and not the person (White & Epston, 1990). Further, they are cautious of diagnosis and work to deconstruct its meaning, demystify the process of diagnosing, and even avoid making diagnoses if possible.

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Constructivist Therapy Kelly’s more cognitively oriented constructivist perspective (1955) argued that individuals are anticipatory in nature and, thus, create rules and ways of perceiving the world that may not be healthy or helpful. Mental health concerns arise when individuals assume that beliefs and perspectives are considered absolute truths, never to be negotiated or considered otherwise. However, Kelly’s perspective on the matter encourages diversity of thought and perception. Consider the freedom many would experience from emotional distress if they were to take into consideration Kelly’s advice: “No one needs to paint himself into a corner; no one needs to be completely hemmed by circumstances; no one needs to be the victim of his biography” (Kelly, 1955, p. 15). Moreover, Kelly (1955) believed that people “place an interpretation upon what is construed,” which creates a framework from which to categorize and organize all other information (p. 50). The definitions of personal constructs are the actions our minds take that anticipate and interpret events (Kelly, 1955). As a result, we become constrained by our tendency to interpret and analyze incoming information rapidly. Our tendency to quickly ascertain meaning can result in erroneous or unhealthy determinations, leading to a pattern of constructs steeped in mistrust, anger, or other uncomfortable emotions. As people create constructs of experience, over time, in efforts to self-soothe, they may engage in other unhealthy behaviors to counteract negative emotions, leading to substance abuse, eating disorders, and other compulsive behavior. Other constructivists take this a step further, arguing that those who exhibit psychological damage do so because they have chosen to numb their inner experiences, which may have been traumatic, and, as a result, show a decreased ability to be introspective and demonstrate empathy toward others (Leitner, 2007‌‌‌‌‌‌). This lack of connection to others creates the ability to behave badly in relationships, harming others and the self.

WHAT CONSTITUTES EMOTIONAL AND PSYCHOLOGICAL WELL-BEING Solution-Focused Brief Therapy Solution-focused counselors believe that people inherently have emotional well-being, as well as the strengths, skills, and experiences they uniquely need to solve complaints (de Shazer et al., 2021). Through recognition of their resilience and confidence in their abilities, they can see complaints as temporal and only part of the overall picture of their experiences. This, then, leads to an expanded repertoire of words to describe themselves in relation to a problem and, thus, solution-oriented conversations in which they situate themselves as being capable of solving their problems. Solution-oriented language and discussion enhance well-being when people focus on solutions and have the flexibility to manage problems in expanded ways.

Narrative Therapy In narrative therapy, emotional well-being is something that exists when dominating truths and knowledge is not imposed on people. Emotional well-being is always present, but dominating ideals and stories provide the illusion that it is not present for all people. If this did not occur, individuals would be free to make meaning of their lived experiences in such ways that did not discount or neglect aspects of their experiences that do not fit with their dominant narratives. Simultaneously, community and discourse agree upon the notion of well-being, and what it means to be “well.” Therefore, conversations that deconstruct expert truth and unitary knowledge enrich well-being. People, then, can incorporate marginalized experiences or

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ideals into their narratives without restriction. They can respond more flexibly and widen their perspectives of themselves and take personal agency over outside influence (White, 2011). Since identity is relational (Combs & Freedman, 2016), with the help of others who (a) engage in these conversations, (b) observe others incorporating new meaning and behaviors into their lives, and (c) reflect upon these observations to make their own meaning of it, alternative realities and stories can gain traction. This provides freedom from living in a binary of being either/or (e.g., I can either be a depressed person or I can be a happy person) and opens the alternative notion that individuals can be complex with multiple identities and simultaneous experiences (e.g., I sometimes have feelings of sadness, and I sometimes have feelings of happiness).

Constructivist Therapy Constructivists generally believe that for people to be emotionally and psychologically healthy, there must be a connection to, and relationships with, others (Leitner, 2007). In addition, there is also the awareness that relationships can be difficult, hurtful, and cause injury to the person(s) involved in the relationships. Thus, negotiating these dialectics and managing how to balance the needs of being in relationships while also ensuring personal safety is an ongoing priority (Leitner, 2007). Constructivism also emphasizes concepts of freedom and responsibility in human existence (Peavey, 1995‌‌‌‌‌‌), which speaks to the contemporary societal struggle of those who believe their individual freedoms are greater than others. Thus, while accepting this freedom and the consequences of having such freedom, which includes understanding the impact they have on others, psychological well-being can be obtained. For example, as we consider the current sociopolitical climate in 2023, we are aware of how “freedom” has been construed by many, with varying definitions, some more healthy than others. As Kelly indicated, “whatever nature may be, or howsoever the quest for truth will turn out in the end, the events we face today are subject to as great a variety of construction as our wits will enable us to contrive” (Kelly, 1955‌‌‌‌‌‌, as cited in Fransella, 2003, p. 3). Kelly (2003) also said, “This is not to say that one construction is as good as any other, nor is it to deny that at some infinite point in time human vision will behold reality out to the utmost reaches of existence” (p. 3). Thus, through changes in how we construe our experiences, emotional wellness can be enhanced. It is an obligation to ourselves and others to attempt to do so.

DESCRIPTIONS OF THE ROLES OF CLIENT AND COUNSELOR Solution-Focused Brief Therapy A solution-focused counselor’s stance in the therapeutic relationship is “positive, collegial, [and] solution-focused,” with an attitude that is “positive, respectful, and hopeful” (de Shazer et al., 2021, p. 4). Recognizing the hierarchy in counseling, a counselor works to make the process more cooperative and egalitarian. They do this by avoiding interpretations of what clients share and instead asking questions that elicit the direction clients want to go and the solutions they want to explore (de Shazer et al., 2021). Relatedly, clients are trusted to know what they want for themselves, and they are viewed as competent in their ability to identify their solutions, strengths, and skills (De Jong & Berg, 2013). Clients actively participate in goal setting to identify what they want for themselves, and they collaborate with counselors in building conservation oriented toward these goals and solutions. Counselors also focus on solutions and the future rather than problems and the past. This is a direct implication of the theory’s foundational tenet that knowing about the history of the problem is not necessary in order to find solutions (de Shazer et al., 2021). In using

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carefully crafted strength-based and future-oriented questions to elicit rich descriptions of what clients want for themselves, counselors listen with a keen ear for clients’ solutions and exceptions to the problem in order to repeat them back. Cocreating a solution-focused conversation with clients is intentional, as solution-focused counseling reflects the social construction tenet that discourse and language create flexible possibilities for the future. Keeping the underlying philosophy of solution-focused counseling in mind, and using interventions intentionally to reflect these assumptions, will lead to techniques being more effective (Lipchik, 2002).

Narrative Therapy Narrative therapists aim to decenter themselves from the therapeutic process and instead lift and raise clients’ knowledge, experience, and skills as the center of counseling (White, 2011). By removing themselves from the central aspect of the counseling relationship, narrative therapists have the flexibility to be curious about their clients’ experiences and learn from them. This curiosity helps clients and counselors alike dive deeper into conversation and look for moments of meaning making, unique perspectives, and client lived experiences. Clients can inspect their lives as they deconstruct messages that are imposed on them and discover how their experiences might have been shaped and influenced by cultural and societal “rules.” In this process, counselors act curiously and ask questions to create a reflective space between what clients already know and what they are creating in conversation (White, 2011). White (2011) proposed a two-way relationship, as opposed to a one-way counseling relationship where “expert” counselors influence their clients. He challenged counselors to consider ways they learn and benefit from being part of the therapeutic process. Relatedly, White emphasized that counselors are not neutral participants and must be acutely aware of their role in the therapeutic process. He said counselors have a responsibility to be aware of their experiences in a political world, acknowledge their clients’ experiences, and address the implications in counseling so as not to replicate hierarchical power and, instead, disassemble the imbalance of the therapeutic relationship (White, 2011).

Constructivist Therapy The therapeutic relationship is described as “cooperative,” “respectful,” “collaborative,” and “optimistic,” among others, in constructivist counseling (Watts & Pietrzak, 2000 p. 443). Counselors operating from this perspective begin by using a framework of safety, warmth, and trust of the client (Watts, 2017). Relationship building is essential in exploring the meaning of individuals; thus, Rogerian principles and utilizing skills such as reflection of feeling are instrumental in developing the client–counselor relationship (Leitner, 2007). Since the relationship is of utmost importance, the client is the one intended to lead the process as the expert on their own life; therapist techniques are secondary to the client’s needs and preferences (Neimeyer, 2009). As a result, diagnosis and labeling of a client based upon their symptoms is not a priority. However, at the same time, Kelly viewed clients and individuals as scientists who systematically observe problems, develop tentative hypotheses about behavior inductively and deductively, and practice test runs and experiments to see what information can be gleaned from them. People process their reality as scientists, becoming co-experimenters with a therapist (Viney, 1998). Results obtained can lead to cautious predictions and generalizations of behavior, which can be revised depending on experimental outcomes. This model seeks to comprehensively and intentionally understand human behavior and shape it as needed (Kelly, 1958/1969). As you can see, constructivist therapies require the counselor to strike

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a delicate balance of promoting client self-awareness and insight, encouragement to experiment with new ways of experiencing the world while also maintaining the individual’s construct system until some alternative constructions can be adopted by them (Winter & Neimeyer, 2015).

PROCESS OF CHANGE Solution-Focused Therapy de Shazer (2021) posited that complaints originate from a lack of discourse and language, or words, available to support different ways of being. As such, a goal of solution-focused counseling is to transform conversation away from being problem-focused toward one that is solution-focused, in which solutions, strengths, and resiliency are front and center. This results in clients having more possibilities through a diverse range of actions and, thus, building a reality where they have confidence in their strengths and abilities to determine solutions for problems. The therapeutic process of change is approached pragmatically, driven by interventions of varying questions and tasks, all undergirded by the basic assumptions of the theory. The foundation for the counseling process, from the time the appointment is made until termination, adheres to the following tenets: 1. 2. 3. 4. 5. 6.

If it isn’t broken, don’t fix it. If it works, do more of it. If it’s not working, do something different. Small steps can lead to big changes. The solution is not necessarily directly related to the problem. The language for solution development is different from that needed to describe a problem. 7. No problems happen all the time; there are always exceptions that can be utilized. 8. The future is both created and negotiable (de Shazer et al., 2021, pp. 1–3). Solution-focused counselors believe that change is ongoing, so from the very first appointment, they ask clients what change has already occurred between contacting the counselor and the first session. This exploration of presession change (de Shazer et al., 2021) immediately provides the foundation for solution-focused conversation that is persistent through the remainder of the appointments. There is little to no focus on the problem that brings clients to counseling; the aim is to have clients discuss what they want for themselves. This is related to the social construction assumption that language and discourse create expanded possibilities and ways of being. Therapeutic conversation is centered on a rich description of clients’ goals and how their lives would be without the problem. During counseling, the counselor tentatively steers the conversations toward solutions. Clients are trusted to know what they want for themselves, and counselors believe clients have strengths and ideas to help them solve their problems in unique ways (O’Hanlon & Weiner-Davis, 2003). Aligned with the postmodern tenet that there are multiple realities, counselors understand that (a) there is not a pre-described way to solve a complaint and (b) clients have times when their problems do not exist. Counselors follow the lead of clients to come up with their own solutions. Furthermore, they listen for when exceptions to problems are shared to facilitate a thick and descriptive conversation about these exceptions. When clients begin to create and notice changes in their lives, counselors will help them consider ways to maintain these changes while also recognizing there might be times when

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the complaint still arises. Ultimately, clients will know they have resources and strengths to address the problem when necessary and feel confident in doing so.

Narrative Therapy A goal of narrative therapy is for people to expand their possibilities by re-authoring their story to provide flexibility in the way they ascribe meaning to their experiences. The process to achieve this is multilayered and begins with the client describing a rich history of the problem (Bubenzer et al., 1994). This provides the counselor an opportunity to be curious and pose questions that deconstruct the problem and offer new ways of understanding its origins and meaning in someone’s life. The counselor and client are then challenged to consider how aspects of external power, knowledge, or societal and cultural “truths” influence how clients make sense of their lived experiences. While stressing that the problem is the problem, not the person, the client is encouraged to name the problem (White, 2011; White & Epston, 1990). This naming of the problem helps to externalize the problem to an outside position rather than internal within the client. The space between person and problem that this creates aids in the ability to view the problem as something that the counselor and client can see from a different perspective. Eventually, the client can discuss ways the problem has been influential on their life. This can help them identify how it has been oppressive in nature and creates space to build personal agency against the problem. Simultaneously, the counselor is listening to the client’s story and tracking the “problem” that takes center focus in a problem-saturated story while also looking for times when the problem does not exist. Although the client will often see this exception, or sparkling moment, as a fluke (or perhaps not see it at all), it still exists on the periphery. The counselor will gain curiosity about these parts of the story, identifying them as subplots that coexist with the problem-­ saturated story and asking questions to highlight their existence. From this questioning, the client will explore these subplots and ascribe meaning to them. As social constructionists and narrative therapists believe that conversation will create the future (Gergen, 2009), the client and counselor begin to co-construct expanded stories to make new meaning of their experiences by discussing these subplots where the problem does not exist. This will pave the way for new alternative stories from which people can see themselves so that they can ultimately live in ways that support their preferred reality and way of being (Combs & Freedman, 2016).

Constructivist Therapy The process of change, according to Kelly’s personal construct psychology (PCP ‌‌‌‌‌), requires reconstruction of the client’s meaning. To foster this, the counselor must understand the client’s construct in order to help revise the system (Paz et al., 2016). This is vastly different from traditional cognitive behavioral therapy (CBT)-based therapy, which emphasizes modification of beliefs, processing errors, and behaviors. Some authors have contended that focusing on first-order change or “peripheral”-level change does not create the higher-level change that constructivist therapy can provide (Watzlawick et al., 1974). As a result, change can be longer lasting and achieve more permanence in one’s life because reconstruction of the client’s internal process and how they conceptualize their world has far-reaching consequences. In comparison to more modernistic approaches, which may be short-term, focused on the here and now, and aimed to reduce or eliminate the presenting problem, constructivist approaches are historically and developmentally focused. Instead of focusing on a “presenting problem,” constructivist therapists help identify how the client’s current capacity meets, or does not meet, some developmental challenge. Additionally, treatment is creative, is individualized, and promotes meaning making and personal development of the client (Neimeyer, 1995; Neimeyer & Harter, 1988).

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DESCRIPTION OF HOW PROGRESS IS MAINTAINED Solution-Focused Brief Therapy When language centered on solutions are the focus of conversation, new ways of being and alternative actions and thoughts become more available. The more organic and frequent this occurs, progress in counseling is sustained. Since it is impossible and theoretically antithetical to postmodern thought for complaints never to exist, it becomes important for people to prepare for them to maintain progress. Flagging and navigating minefields (Sklare, 2014), or preparation for instances when conditions might invite complaints, is built into the therapeutic process for people to recognize and plan for success during such times. The following are examples of minefield questions: “How will you know when the complaint might return, and you will need to remember these solutions?” or “When you find yourself in a situation that might trigger this complaint, what is the first thing you can do to prevent it from becoming a problem?” These types of questions challenge clients to consider when they might be vulnerable to problems and anticipate how they might lean toward their strengths and solutions. These skills become useful later when they are working to maintain a solution-oriented focus.

Narrative Therapy Progress in narrative therapy is made by continuing to dialogue about alternative stories and preferred realities. As unique outcomes and unique accounts are identified and explored, they begin to be linked together to build an alternative and simultaneous story so that the problem-saturated story loses power and shrinks in dominance. As the alternative story grows, clients have flexibility in making new meaning of their lived experiences and expand their future possibilities. They also have personal agency in taking responsibility for the way they can direct their lives and the meaning they make of their experiences (White, 2011). As identities are relational (Combs & Freedman, 2016), narrative therapists also work with others to expand the conversation of new stories beyond their sessions by helping clients create an audience for alternative stories and preferred ways of being. There are numerous ways to achieve this. One such method is through documents from therapy in which the counselor creates letters, certificates, or lists to bear witness to the new story (White & Epston, 1990). Barbara Myerhoff’s cultural anthropology concept of outsider-influences and definitional ceremonies influenced another way narrative therapists can support having an audience to alternative stories (White, 1995). White adapted her ideas to narrative therapy by involving others close to the client in the therapy process to observe, make meaning of, and reflect on alternative stories and subplots (White, 1995). These are just two examples that can provide a lasting audience to new stories: a necessary component in creating preferred realities beyond counseling.

Constructivist Therapy Progress is maintained in constructivist therapy through the mechanism and ongoing systematic analysis of how behaviors are developed in relation to perceiving. In using Kelly’s theory, the client is engaging in a rigorous and active process that requires a profound willingness to take risks, remain vulnerable, and engage in new behaviors. As such, clients maintain progress through the act of developing new ways of being and perceiving. Over time, the framework with which we view the world changes and is maintained through the development of the construct system. The construct system, consisting of several components, works together to reflect a broad range of understanding and content that describes how we attribute meaning to life events, people, and all other experiences (Taber, 2020). To

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maintain a changing awareness of perceiving, clients must continue to challenge and reinforce existing constructs in the process of developing new ones.

PROCESS OF CLINICAL ASSESSMENT Clinical assessment is an ongoing process in postmodern therapy in that counselors are constantly gathering information on how clients make meaning of their lived experiences, particularly as it is constantly evolving. Rather than using assessment information to pathologize clients, postmodern counselors assess clients’ strengths, resources, exceptions to problems, and the meaning they give to their experiences. Aligned with this, assessment procedures aimed to enhance conversation that deconstructs how societal and cultural knowledge influences a person can be useful. This deconstruction of the problem is of particular importance in narrative therapy. Example questions are‌‌‌‌‌ as follows: “Where did the idea of ‘guilt when not with your children’ first make itself known to you?” or “How have messages you received, from the time you were young, influenced this presence of ‘guilt’ in your life?” Solution-focused counselors, who presuppose clients have strengths and resources to aid complaints, begin looking for signs of these traits immediately in counseling. To reflect this theoretical assumption‌‌‌‌‌, and in response to most assessment instruments being pathologizing or deficiency focused, Smock and colleagues (2010) and Smock Jordan (2014) created and validated the Solution Building Inventory (SBI). This inventory uses language carefully to presuppose clients have resources and solutions. Statements such as “I have successfully overcome challenges in the past,” “I am aware of small changes that I make,” and “I have made steps toward improving my life” orient the client, and counselor, immediately toward capabilities, strengths, and progress (Smock Jordan, 2014, p. 82). Similarly, social constructivist assessments focus on the exploration and interpretation of an individual’s construct system and hierarchy, which is based upon their unique experiences (as cited in Caputi et al., 2011). Thus, traditional assessment practices, which typically include an instrument centered on finding information, are eschewed by constructivists. Rather, constructivist assessment practices focus on the counselor to further challenge and dialogue about preconceived notions and ideas. For example, in Kelly’s personal construct theory (1955), assessment interventions, which will be discussed in further detail later, might include grids, resistance to change, self-­ characterizations, ladders, and other ways to assess personal meaning (Neimeyer & Bridges, 2003), all of which are done in collaboration and in concert with the clients. These are not assessment practices that “are given to” clients; rather, they are practices done in concert with them. These methods elicit how the individual makes sense of their world, offering a more nuanced interpretation of this experience than can be discovered through more traditional assessments. Laddering, a personal construct therapy (PCT) clinical assessment technique, is a technique used to understand the central core value, or constructs, and the placement of the preferred self within them (Neimeyer et al., 2001). When using laddering, the counselor asks the client a series of straightforward and recursive questions that helps depict a bipolar construct from the client. The counselor then inquires the client which of the poles they prefer to associate with in order to generate another construct. The counselor seeks to understand the client’s preference, reason, or advantage, and the contrasting response is a cyclical pattern of questioning until the client starts repeating themselves or finds it difficult to find another construct. The outcome usually reveals a hierarchy of personal meanings, which tend to represent higher-order values provided by the specific constructs given at the beginning of the assessment. Ladders have been found useful in clinical settings as an assessment and intervention tool across various client populations. This technique is popular due to its flexibility and relatively straightforward administration (Hardison & Neimeyer, 2007).

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SPECIFIC THERAPEUTIC TECHNIQUES Solution-Focused Brief Therapy PRESESSION CHANGE QUESTIONS

Solution-focused counselors believe that clients have already begun the change process before their first session. Aimed to immerse clients in solution-oriented language from the start, counselors inquire about these so-called presession changes (de Shazer et al., 2021) during their first session. Questions such as “In what way has the complaint eased for you since you called for this session?” or “How have you already started to address this complaint?” can begin to take the focus off the problem and onto solutions and strengths, by instilling clients are capable of making changes for their future. THE MIRACLE QUESTION AND OTHER FUTURE-ORIENTED QUESTIONS

To learn more about what clients want for themselves, solution-focused counselors employ the miracle question. This question asks people to describe what their life might look like if they were to wake up one day and realize that overnight, a miracle occurred and erased the complaint from their life: Suppose that one night, while you were asleep, there was a miracle, and this problem was solved. How would you know? What would be different? (de Shazer, 1988, p. 5) When used intentionally, this technique can facilitate a rich description of what people will be doing, thinking, and feeling without the complaint in their life (De Jong & Berg, 2013) and can invite goal setting by describing what clients want for their life (O’Hanlon & Weiner-Davis, 2003). In discussing such goals, solution-focused counselors frame them positively rather than from a perspective of deficit (i.e., increase happiness versus decreasing depression; De Jong & Berg, 2013). de Shazer and others (2021) offered some guidelines to introduce the miracle question and improve its likelihood of success: (a) Start by asking permission to pose a question, (b) uniquely apply it to the person’s context (e.g., incorporating their routine or circumstances when leading up to the miracle), (c) use imagery to invite the client to visualize their home and details, (d) pause and speak slowly, (e) specify that the miracle erases the problem that specifically brought them to counseling, (d) point out that they do not know the miracle has happened, and (e) end with questions that explore differences in the morning (p. 42–43). De Jong and Berg (2013) recommended speaking slowly and softly with frequent pauses while presenting the miracle question, introducing the miracle dramatically by indicating that it is a strange or unusual idea, and using follow-up probes to deepen the solution-oriented conversation (p. 86). The miracle question is a future-oriented question, as it asks clients to consider a future in which the problem does not exist. To follow up the miracle question, counselors can incorporate other future-oriented questions, such as: “What will you be doing when this problem is not present?” Walter and Peller (2000) added to these types of questions by asking people to indicate “signs” of knowing. For example, “What will be some signs that the complaint is no longer an issue for you? What will you, or others, notice?” Though future-oriented questions can help thicken the conversation after the miracle question, they can be used any time. Regardless of the structure and timing, the purpose of future-oriented questions is to maintain conversation toward solutions to build a preferred future. SCALING QUESTIONS

Scales can help clients track progress, assess their goals, discuss conditions to create solutions and exceptions, and create conversations of action. For example, “On a scale of 1 to 10, with 1 being a low motivation to change and 10 being the most motivated to change, where would you rate yourself?” Regardless of placement on the scale, clients can describe what

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it looks like to be at different positions and build future-oriented conversations about what they will be doing if they move to another notch. Client: I think I’m at a 5 right now. Right in the middle. Counselor: I’m curious…what might you be doing differently right now if you were at a 6? Client: If I was at a 6, I would probably be participating more. Counselor: What would that participation look like at a 6? Client: I’d be paying attention and not thinking about what I’m going to do after our session. Counselor: So, to be more motivated to change, you’d be more attentive, and your mind would be on what we’re talking about. EXCEPTION QUESTIONS

Counselors listen closely to hear exceptions to the problem, or times when the complaint is not present or less significant. Sometimes, exceptions spontaneously enter into the conversation unbeknownst to the client, and the counselor will repeat them back to the client, amplify their existence, and ask related descriptive questions: “You just mentioned that you felt less depressed yesterday. What were you doing that signaled you were less depressed?” or “What were you doing instead of being less depressed?” These instead questions are useful to solution-focused counselors when exploring exceptions because they invite conversation that allow clients to consider their chosen actions in contradiction to the problem and could lead to identifying solutions. For example, “You said that instead of being depressed, you were feeling happy when you were spending time with your family. How can you incorporate more time with them into your day in order to feel happier?” By providing a solution of family time leading to feelings of happiness and less depression, the counselor can tentatively suggest the client do this more, as gently “nudging to do more of what is working” is an important aspect of SFBT (de Shazer et al., 2021, p. 5). When exceptions are not spontaneously revealed, they can be actively sought during the session. Questions such as “When were you feeling happy last week? or “When was the last time you got out of bed and looked forward to the day?” can elicit conversation around an exception yet identified. These questions can also come from an outsider perspective, such as: “What did your friend notice about you when you were happy?” or “What would I be seeing you do when you were happy?” Notice that regardless of the question, they are phrased in such a way that presuppose there were exceptions (i.e., when was a time rather than if or was there a time). These presuppositional questions (O’Hanlon & Weiner-Davis, 2003) give the message that exceptions exist and invite clients to consider them before defaulting to problem-oriented talk or disavowing them. COMPLIMENTS

Providing feedback to clients in the form of compliments, in which strength and progress are accentuated, is an important part of SFBT (de Shazer et al., 2021). Complimenting can be used to identify past success and should be a direct reflection of what clients are sharing and what they have done, rather than simply being kind (De Jong & Berg, 2013). Not only will counselors share compliments with clients, but they will also notice when clients are complimenting themselves (De Jong & Berg). For example, “You just mentioned you were proud of yourself. What was it like to feel this sense of pride?”

Narrative Therapy

NAMING AND EXTERNALIZING THE PROBLEM

As emphasized in narrative therapy, the problem is positioned outside of the person. This space allows for reflection on ways that the problem-saturated story, with underlying

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cultural implications, has been impactful to the person and encourages the person to deconstruct its meaning in their experiences. Naming the problem is a start at creating this space between person and problem, and the process can take time and many evolutions (Payne, 2006). The problem that clients come in with might be deduced into something different, often described in multiple ways when it is deconstructed. Once clients give words to the problem, the counselor uses externalization to build a “characterization” of the problem, and clients take on the role of “investigative reporter” to explore how it has been part of their lives (White, 2011, p. 88). Examples of such questions include: “How does control stand between you and your brother?” or “What does control tell you when the two of you don’t get along?” Externalized language can be useful to bring problems to life and should be explored in neutral ways, as opposed to negatively, because there might be times when problems are useful (Bitter, 2020). Instead, White (2011) indicated the importance of re-authoring relationships with problems by diminishing their power and ascribing them new meaning because aspects of problems never go away. QUESTIONS TO RE-AUTHOR AN ALTERNATIVE STORY

Narrative therapy is a theory of questions that invite an exploratory conversation and generate meaning making (Combs & Freedman, 2012; Freedman & Combs, 1996). Aside from externalizing inquiries, White (1988) proposed four additional categories of questions that aim to build alternative stories and use them to ascribe expansive meaning to associated experiences. These questions are related to unique outcomes, unique accounts, unique redescriptions, and unique possibilities. Unique outcome questions are used to identify and explore sparkling moments, or those experiences that occur in contradiction to the dominant problem-saturated story. A question such as “When are the times when you and your brother get along?” can elicit a conversation that expands moments of getting along versus arguing. When a counselor notices something in the periphery of conversation that opens the potential for a new story, unique outcome questions can also be used. For example, “I noticed you said you almost didn’t argue with your brother. What was happening in the almost not arguing part of your interaction with him?” This question has the purpose of highlighting a hesitation to arguing that could have been easily missed but opens opportunity to a subplot of what could have been. Unique account questions can be used with the purpose of developing and thickening these subplots to the problem-saturated story. Essentially, the counselor would use these questions to learn how the client accounts for unique outcomes: “What were you and your brother doing when you were getting along and having fun?” or “What were you feeling when you almost didn’t argue, or when you almost got along? Unique outcomes and unique account questions internalize the ability to live in alternative, rather than problem-saturated, stories. Unique redescription questions and unique possibility questions have the purpose of making meaning from unique outcomes to re-author narratives and identities. Questions such as “What do these moments of getting along with your brother say about your connectedness with him?” and “How would your family members describe these moments of the two of you getting along; what does it say to them?” invite someone to describe themselves in new ways. Unique possibility questions, then, help a person to fashion their future and see how this new story might continue to play out and inform them: “Knowing that you have this ability to get along with him, how might you approach future times when you disagree?” or “With your value of connectedness in mind, what do you see for the future of your sibling relationship?” THERAPEUTIC DOCUMENTS

David Epston introduced great contributions of the usefulness in using therapeutic documents as a way to thicken new and emerging alternative stories (White & Epston, 1990). Certificates and awards to recognize achievements in counseling can be an out-of-session and long-lasting reminder of clients’ ability to overcome problem-saturated stories or of

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their new alternative stories (Fox, 2003). Therapeutic letters from counselor to client can also be used as ways to maintain curiosity, highlight and explore unique outcomes, and be an audience to preferred realities. BUILDING AN AUDIENCE

Since identity is relational (Combs & Freedman, 2012), building an audience to preferred realities is important in their maintenance. White discussed outsider witnesses (2011), in which he would invite others into session to provide insight or reflection. Sometimes, they might be former clients or others who have had similar experiences. Influenced by Tom Andersen’s reflecting teams (1987) and Barbara Myerhoff’s definitional ceremonies, White adapted the notion of having outsider witnesses (1995) to his work, in which a group of people reflects on the meaning they get from listening to clients’ preferred or re-authored stories and then the group, client, and counselor come together to process with one another.

Constructivist Therapy Constructivist techniques are eclectic, with an emphasis on helping the client reconstrue meaning and to increase awareness of constructions (Winter & Neimeyer, 2015). These techniques also help the counselor determine how the client views their world. Constructivist therapy techniques are more likely to be reflective and personal, rather than analytical and instructive. Constructivist therapists aim to be more exploratory with clients, rather than directive, and tend to target the family systems of the client (Feixas, 1992). Rather than reduce or eliminate cognitive distortions, they facilitate broader development of the client’s narratives to establish enhanced meaning making for them (Neimeyer & Harter, 1988). CASUAL ENACTMENT

A seminal technique, casual enactment‌‌‌‌‌, used in George Kelly’s PCT and considered the first form of brief therapy, allowed for the clients to “enact fictional identities in their daily lives” (Neimeyer, 2000, p. 280). By practicing different roles with the therapist, who played acquaintances, authority figures, and family members, the client would be able to try out new personas and ways of being. At the end of therapy, the client would reach their realistic goals in life by setting aside their roles and discussing, with the therapist, the extent the client can change and shift their life through the exploration of various personal constructions and changes in perspective (Viney et al., 1989). Kelly’s desire was for individuals to change the way they construed their realities through demonstrating, testing, and accepting alternative constructions (Taber, 2020), which appeals to those in science education and other more modernist tendencies. REPERTORY GRID

Another PCT (Kelly, 1955) technique that promotes increased awareness of self is the repertory grid ‌‌‌‌‌, in which the person rates or ranks various elements of their experience in terms of personal constructs through a structured interview that assess how individuals view people and situations in their world (Kelly, 1955). CONSTRUCT REPERTORY TEST

In the technique role construct repertory test (REP test)‌‌‌‌‌, the counselor‌‌‌‌‌ would have the client determine discriminations (i.e., constructions of the world) without applying specific criteria. To begin, the counselor would prepare a deck of cards from which numerous triads can be used for presentation. The clients would be asked about significant people in their lives so that cards would have the roles of names of family, friends, coworkers, and more important figures in their lives. A verbal label would be provided, offering the ability to differentiate and discriminate between the roles and the space they held in the client’s life. Repertory grids were used in almost 90% of empirical studies of PCT (Neimeyer et al., 1990).

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This technique offered significant insights into how the client made meaning of their world through the scaling and rating of items asked. SELF-CHARACTERIZATION

In using the technique self-characterization‌‌‌‌‌, the client is asked to write an autobiographical character sketch as if it was written by a kind friend. A different version of this technique is fixed role therapy‌‌‌‌‌, in which the therapist writes a sketch of a hypothetical person who is somewhat different from, but not the opposite of, the client. The client is instructed to pretend they are this person for 2 weeks, during which time there are frequent rehearsals of the role with the therapist. At the end of therapy, the client’s old self is invited to return, and the client can determine which elements of the role they would like to take on more permanently (Winter & Neimeyer, 2015).

MULTICULTURAL, INTERSECTIONAL, AND SOCIAL JUSTICE ISSUES The postmodern theories described in this chapter value and affirm individuals’ unique perspectives and experiences that contribute to a diverse world. Postmodernism espouses a way of thinking that acknowledges multiple simultaneous experiences and enforces the idea that nothing is a singular reality. Our shifting cultural, sociopolitical, and environmental landscape creates opportunities for more nuanced interpretation of meaning, and these factors influence how people make sense of their experiences (Tilsen & Nylund, 2016‌‌‌‌‌‌). Counselors prioritize clients’ internal frame of reference and inherent subjectivity, which largely aligns with postmodern theories. For example, narrative therapists aim to decenter themselves from the therapeutic process by asking curious questions that seek to understand the client’s unique experiences and values while being keenly aware of their own power and privilege (White, 2011). Solution-focused counselors, too, aim for a collaborative relationship in which they learn clients’ goals, strengths, and resources. While doing this, Selekman (1997) suggested that solution-focused counselors, particularly those that are White, consider their own identities and experiences with privilege and power to improve counselor competence. Postmodern theories recognize that there are social and cultural influences perpetuated by those who hold power and privilege, which shape how individuals make meaning of their experiences. The poststructuralist nature of these theories, particularly narrative therapy, aims to contextualize the meaning people make of their lived experiences and question these authoritative discourses to determine how they have been a part of presenting problems (Combs & Freedman, 2012). Counselors question the etiology of a problem and espouse that it exists outside of the client, imposed by outside discourse, and thus challenges pathology-based diagnosis (Combs & Freedman, 2012; De Jong & Berg, 2013; White, 2011). For example, how are patriarchy, white supremacy and racism, homophobia, transphobia, and ableism, among other injustices, part of the problem? By separating the problem from the person and using questions that deconstruct problems to illuminate how they could have multiple meanings, clients can shift the understanding and influence they ascribe to them (White, 2011; White & Epston, 1990). Further, it creates space for counselors to honor clients’ unique cultural and societal solutions to problems (McDowell et al., 2022‌‌‌‌‌‌). Though SFBT has had some criticism for not including multicultural aspects into the model (Thomas, 2007), there is an opportunity to include such perspectives into sessions. McDowell and colleagues (2022) emphasized that examination of the societal effect on presenting problems can elicit a wider range of exceptions and strengths and thus expand possible solutions. Bitter (2020) suggested incorporating this examination into sessions and offered questions such as: “When there is improvement in society and the community in which you live with regard to racism, sexism,

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or other forms of discrimination, what differences will you notice?” (p. 291). Narrative therapists integrate social justice within their work by way of theory and techniques, as they highlight the oppressive and marginalizing nature of dominant discourses that leave out the clients’ experiences (Combs & Freedman, 2012). Regardless of the postmodern theory, counselors strive to advocate for clients’ needs based upon knowledge and awareness related to sexual and gender identity, racial development identity, and other aspects of culture. The intersectionality of emerging identities for clients creates multiple avenues to explore with them, fostering the opportunity to utilize any of the postmodern theories in a variety of ways as clients continue to explore themselves in relation to others. Though multiplicity and sociopolitical and cultural influence on lived experiences is a focus of postmodern therapies, D’Arrigo-Patrick and colleagues (2017) sought to address its critique for not implementing social justice activism. They explored how postmodern therapists also implement critical theory, which centers on activism by way of “intentionally seeking to and attend to and disrupt oppressive socio-political contexts and processes” into their work (p. 580‌‌‌‌‌). Participants revealed two positions from which they vacillated, activism through countering (i.e., counselors took a more active stance on consciousness raising and privileging critical inquiry) and activism through collaborating (i.e., a client led approach to challenge oppressive discourse and social education by being tentative and meeting clients where they are) (D’Arrigo-Patrick et al., 2017). Thus, social activism can be incorporated into postmodern theories when counselors are aware and intentional.

RELEVANT THEORY-BASED SCHOLARSHIP AND RESEARCH TRENDS Empirical research provides a supportive foundation for postmodern theories. For example, there have been multiple studies supporting the effectiveness of SFBT’s strength-based and solution-oriented interventions (Franklin et al., 2017). Outcome research shows evidence that solution-focused counseling yields positive results across the life span and with multiple presenting problems. Studies have proved that it can be useful for behavioral issues (Bond et al., 2013; Carr et al., 2017; Kim & Franklin, 2009), including those that are internalizing (Kim, 2008; Schmidt et al., 2016) and externalizing (Hsu et al., 2021). There are also promising studies related to substance use (González Suitt et al., 2019; Kim et al., 2018), depression (see Gingerich & Peterson, 2012‌‌‌‌‌‌), trauma (Kim et al., 2018), and outcomes for family counseling (Carr et al., 2017; Kim et al., 2019). Narrative therapy is effective for a variety of presenting problems. For example, there are studies showing its effectiveness for children’s social and emotional skills (Beaudoin et al., 2016) and managing alcoholism through improving stress response, self-esteem, and insight (Park & Kim, 2021). It has also shown effectiveness for depression (Lopes et al., 2014; Robinson et al., 2015; Vromans & Schweitzer, 2011‌‌‌‌‌‌). The technique of externalization has shown usefulness for eating disorders and family counseling (Medway & Rhodes, 2016), and childhood obsessive compulsive disorder (Banting & Lloyd, 2017). Kelly’s constructivist therapy, a highly structured and technical form of therapy, resulted in over 2,000 publications in a variety of subject areas, such as teacher education (Neimeyer, 1993). In 2016, a group of researchers (Paz et al., 2016) explored how anxiety changed in 47 participants who received metabrief integrative constructive therapy. While scores on symptom and personal construct measures decreased after treatment, they were not all statistically significant. Metcalfe and colleagues (2007) conducted a systematic review and meta-analyses of PCT and found that clients benefited more from PCT than from no treatment or standard treatment.

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DETAILED CASE CONCEPTUALIZATION PRAGMATICS AND TRANSCRIPT In working with Mark, an SFBT counselor would have the following assumptions that would guide their work. First, they would know that Mark’s presenting problems of anxiety, sadness, and anger, as well as loneliness and guilt, are present because he is immersed in conversation and description about himself (i.e., descriptions he ascribes himself, as well as how others describe him) that supports these experiences. Further, there might be dialogue surrounding the notion that dating would “take away time from his daughters” that is leading him to these feelings. Due to the limited conversation and words available to describe him, he is overwhelmed by the complaint as it limits his available thoughts, feelings, and actions. This, then, leads to his difficulty in finding solutions. A socially attuned SFBT counselor would consider that there may be social conversations imposed that are also influencing the way in which he makes meaning of experiences and the way he, and others, describe him (McDowell et al., 2022‌‌‌‌‌‌). For example, there are media messages that wrongly depict a characterization that Black men and fathers are “absent, disengaged, and dangerous” (Hannon, 2022, p. 1). For Mark, there could be narratives that impact how he, and others, makes sense of his intersecting identities as a single Black father in his 40s with custody of his children. A therapeutic goal would be to use counseling sessions to engage Mark in conversations that are solution-oriented and socially aware in an effort to build the conversation needed to sustain difference and solutions. Second, a counselor practicing SFBT would know that Mark experiences exceptions to the emotions and associated experiences he names as his primary complaints. These exceptions are out of his awareness and not part of the meaning he makes of his experiences, and thus, he does not speak of himself or describe himself through them. Relatedly, the counselor would amplify such exceptions through various techniques to help Mark bring them into his awareness. This would also help Mark generate his unique solutions to the complaint and help him identify strengths and resources he has to sustain them. As sessions begin, the counselor will assess for presession changes. Throughout therapy, the counselor will keep the conversation present and future oriented, as well as ­solution-focused. Mark will identify unique goals that he has for himself, and the counselor will facilitate conversation to keep the goals positive and strength based rather than deficit based. As Mark begins to identify solutions and build a reality around the future he wants, the counselor will help him anticipate any issues that arise during which he might have to regain focus on solutions. Before and during the counseling process, it is also imperative that the counselor be aware of their own intersectional identities and any biases that could impact counseling. This is important as to not implicitly perpetuate any cultural or societal messages that contribute to Mark’s complaint. It is also important in the event the counselor shares any identities or experiences with Mark in precaution to not overidentify and fail to be curious about the unique meaning he gives to his experiences. Transcript

Skill(s) Demonstrated

Counselor: Hi, Mark, thanks for making the appointment today. I’m curious. In what ways have things changed for you since we scheduled this time?

Presession change question: The counselor immediately facilitates solution-oriented conversation.

Mark‌‌‌‌‌: I am unsure of how to answer that...I got divorced about 2 years ago and want to try dating again. I’m not sure how to do that or whether it’s even the right thing to do. I’ve been feeling down since the divorce and want someone to talk to about all of this.

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Counselor: Sounds like it’s been a difficult couple year. You said you’ve been “wanting to start dating again” and “could use someone to talk to.” Tell me about the steps you have made in these efforts.

Solution-oriented conversation: Mark didn’t know how to answer the presession change question and instead described his presenting problem. The counselor does not spend time discussing the problem any further; rather, the counselor invites conversation related to strengths and exceptions Mark has already revealed.

Mark: I called you to have someone to talk to. In terms of dating, my friend suggested a matchmaking website. I have two daughters, though, and feel guilty about taking time away from when I start dating. Counselor: So, you have found two people to talk to: me and your friend who gave you the advice. You said “when” you start seeing someone…sounds like this dating is in your future. How will you know when the time is right?

Compliment: This highlights Mark’s progress in finding people to talk to. Future-oriented question: The counselor highlights the word “when,” as opposed to “if,” he starts dating and asks a future-oriented question. This keeps his focus on the future and gives the message he will know for himself when the time is right.

Mark: I guess when I feel less guilty. Dating takes time and effort and it’s time I could be with my daughters or doing something for them. Counselor: On a scale of 1 to 10, with 10 being the most guilt you feel about this and 1 being the least, where would you rate yourself?

Scaling question

Mark: I would say I am probably at a 6. Counselor: So, you are at a 6. How will it be different when you are at a 5…feeling slightly less guilt? What will you be doing differently than you are doing now?

Future-oriented questions: As a probe to the scale, these questions keep the conversation on the future and possible solutions that are unique to Mark.

Mark: I’d be taking time for myself. Feeling slightly less guilty about the possibility of dating. I might be more happy and less angry about the past too. Counselor: You’d be taking more time for yourself, happier, and less guilty and angry. Let’s explore this more. I’m going to ask you a question that might sound unusual. Are you willing to consider it?

Introduction to the miracle question

Mark: Sure. Counselor: Let’s say after you leave here today, you go home and make dinner for your daughters. You enjoy the meal together and afterward you clean up and start settling in for the night. You help the kids with homework, have some time to relax, and say goodnight to the girls and put them to bed. Then, you go to bed yourself. Does this sound like a typical evening? Mark (engaged): Yes, it does.

Set up for the miracle question

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Counselor: Okay…so, while everyone is fast asleep a miracle occurs (pause), and the miracle is that the guilt, sadness, worry, second-guessing about dating…everything that brought you here…goes away.

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Continuing the miracle question

Mark (smiles hesitantly): Okay…. Counselor: But you don’t know that this miracle has occurred, so you wake up unknowingly and go about your morning. What would be some signs that signaled to you the miracle has happened?

Closing the miracle question

Mark: I would wake up feeling freer. I wouldn’t put so much pressure on myself to be the perfect parent. I would feel happier and less angry about the circumstances of the divorce and my ex. I would be less weighed down with loneliness, and the guilt from wanting to do something about it. Maybe I’d check that online app to see if I had a match! (Laughs) Counselor: You’d be happier, give yourself grace in parenting, and maybe you’d be part of that dating app you mentioned earlier. And what would your daughters notice differently about you?

Future-oriented question about others: Thickening the solution-focused reality by asking what his kids would notice

Mark: I think they’d see me as more carefree. We’d have more fun instead of all business in the morning with getting them ready for school. I’d be smiling. Counselor: Is it safe to say a goal you have in coming here is to be happier and freer? Maybe feeling more present with your daughters and potentially exploring the possibility of a romantic relationship?

Exploring goal setting: Summarizing what the client said he wants and keeping goals positive-focused, rather than deficit

Mark: Yes, it’s safe to say. If I was happier, I would not be as anxious about doing this on my own and that would be freeing. The divorce was hard. Single parenthood is hard, but I know I can do it. It would be nice, though, to have companionship along the way. Counselor: You said, “I know I can do it on my own.” What is it like knowing this about yourself? That you can parent on your own.

Compliment

Mark: It’s a good reminder. It’s hard for single dads. Sometimes people don’t believe in us; maybe think we’re incompetent to parent as well as mothers can. And I’m a Black single dad. Teachers address notes to their mom. Their friends’ moms ask for their mom to arrange playdates and seem surprised when I say it’s just me, and I’m not sure they want to send their kids over. I don’t need to prove myself to anyone, but it’s tiring. Therefore, I feel guilty about taking time away from my daughters and hesitant to invite someone else into our lives. I don’t want room for anyone to question that I can’t do this. Counselor: You’ve shared many important things here, including experiences you have had being a single Black dad. How do you thrive as a parent amid these experiences and microaggressions you described?

Exception question: This question seeks exceptions and strengths.

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Mark: I know that I’m a good dad, and my kids love me and know I’m there for them. I have friends who are great dads, too, and my family as a support. Counselor: What do your friends and family see you doing that show them you are a competent dad no ­matter what? One that is capable of parenting while also seeking companionship, as you mentioned earlier.

Exception question from the perspective of others: Thickening the conversation around exceptions Using client’s words: “companionship”

Mark: They see me giving my all to my kids. They see me balancing my roles, and they see me trusting my instinct to know when my girls need me and when I can take some time for myself. Counselor: So, they know that you can be a good parent and still seek companionship so that you can feel less lonely and happier. They also see you trusting yourself. Mark: They support me and want the best for me. I’m glad I have them nearby. In fact, my parents help. They watch the girls sometimes when I have work meetings, which is a relief for me. Counselor: It’s a “relief?” So, this is a time when you don’t feel guilty leaving them. What are you feeling, instead of guilt, when you take time away from the kids and leave them with your parents?

Amplifying an exception Exception question: Asking what he does instead of feeling guilty

Mark: They love the time together…without me (laughs). I feel okay with it. I know my parents look after them. Counselor: Sounds like they have built a strong ­grandchild–grandparent relationship when they can spend time together. Mark: I had a good relationship with my grandparents so I’m happy my kids get that too. I guess I can ask my parents, too, to watch the kids if I ever were to join that dating website. Counselor: So, this would be an idea for you. You would not feel guilty because you know the girls are taken care of and they would get to spend time with their grandparents.

Summarizing client-identified solution

Mark: I’ll give it some thought. Counselor: Our time is coming to an end. Between now and next week, keep thinking about this. Find times when you’re not with the girls without feeling guilty and report back next time.

Anticipating exceptions between appointments

THEORETICAL LIMITATIONS Solution-Focused Brief Therapy Due to the versatility of SFBT interventions, some counselors might incorporate interventions in a perfunctory way without applying the assumptions that underlie the techniques

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(Lipchik, 2002‌‌‌‌‌‌). This can be limiting to their usefulness as solution-focused interventions. Some have questioned whether solution-focused techniques ignore clients’ emotions (de Shazer et al., 2021) or underlying issues (Thomas, 2007). De Jong and Berg (2013) expressed that empathy is a microskill that adds to the process, though not a change agent. Further, the concept of “underlying issues” is antithetical to the theory’s assumptions. Though this may be a limitation of this theory for some, it might be less important for those using the theory as a home base. Finally, Thomas (2007) warned against the optimistic nature of SFBT and suggested counselors be aware of helping clients set realistic goals.

Narrative Therapy The nonstandardized treatment procedures of narrative therapy could be a limitation for those working with managed care (Webber & Mascari, 2018). Further, a limitation could be that insurance companies often look toward brief therapies focused on clear evidence-based practices (Wheat & Whiting, 2018). Wheat and Whiting (2018) wrote that narrative therapy is not taught to great extent in counselor education programs, thus leading to counselors using the techniques without a firm theoretical foundation. Should counselors want to use this theory to its full potential, it would be useful for them to seek additional information and training.

Constructivist Therapy In terms of theoretical limitations, those trained to adhere to managed care and evidence-based practices that promote objectivity in treatment and standardized approaches may struggle with constructivist therapy. Constructivist counseling, particularly Kelly’s PCT, emphasizes theoretical rationale to substantiate any interventions or techniques. Thus, the subjectivity inherent in this decision-making process leaves some clinicians feeling uncomfortable. Additionally, training in this model may be difficult to obtain and consistently utilize in practice. For some clients, this type of therapy may not be realistic or feasible.

SUMMARY The shift toward postmodern philosophies provided expanded beliefs and thoughts regarding human nature and, thus, counseling. The implications for counseling provided a new framework for the conceptualization of presenting problems and the course of counseling, treatment goals, and the therapeutic relationship. With empirical and clinical support, as well as connections to promoting social justice and multicultural considerations, SFBT, narrative therapy, and constructivist therapy offer counselors ways to implement postmodern assumptions into counseling. This chapter is just the beginning in understanding each of these theories. With increased study and dedication, counselors can use these theories as a therapeutic home in their clinical work. VOICES FROM THE FIELD This chapter features a digitally recorded interview entitled Voices From the Field. The interview explores multicultural, social justice, equity, diversity, and intersectionality issues from the perspective of clinicians representing a wide range of ethnic, racial, and national backgrounds. The purpose of having chapter-based authors interview individuals representing communities of color or who frequently serve diverse populations is to provide you, the reader, with relevant theory-based social justice and multiculturally oriented conceptualization, contemporary issues, and relevant skills.

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Access the video at https://bcove.video/46zz1RA

Dr. Josephine Rodriguez is the practitioner for this Voices From the Field interview. Dr. Rodriguez is a licensed mental health counseling (LMHC) therapist and licensed marriage and family therapist (LMFT) in the state of Florida. She has been practicing solution-focused and oriented counseling since 2011 and utilizes this theoretical orientation primarily in her work with clients. Dr. Rodriguez identifies as a White, of Middle Eastern descent, cisgender female from the southern region of the United States. As part of our conversation, Dr. Rodriguez described how she uses this approach in her clinical work with clients.

STUDENT EXERCISES Exercise 1: Postmodern Versus Modern Assumptions

How do postmodern assumptions inform counseling in different ways than modern assumptions? Which of these beliefs do you support or question? Create a list of ways they differ and include your own critique for each one.

Exercise 2: The Miracle Question

Consider a situation in your own life, for which you would like a miracle to occur so it would be less influential, or perhaps gone. Write a miracle question, as well as future-oriented ­follow-up questions that you could ask yourself and answer them.

Exercise 3: Externalizing a Problem

Externalization is an important, but difficult, skill and technique in narrative therapy. Practice externalizing by choosing a presenting problem (e.g., anxiety, substance use, depression) and listing various externalizing questions. Practice saying them with a classmate and get feedback.

Exercise 4: What Would You Do?

Review the transcript between Mark and the counselor. Identify places where you would have responded differently, while staying within SFBT, and rewrite new dialogue. Alternatively, write a script from one of the other postmodern theories.

Exercise 5: Further Exploration

Of the three postmodern theories presented in this chapter, which do you find most intriguing? List some specific things you can do to learn more about the theory beyond this chapter.

RESOURCES Helpful Links ■ ■ ■

The Dulwich Centre: https://dulwichcentre.com.au/ Evanston Family Therapy Center: www.narrativetherapychicago.com/ The George Kelly Society: www.kellysociety.org

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Institute for Solution-Focused Therapy: https://solutionfocused.net/ what-is-solution-focused-therapy/ The Taos Institute: www.taosinstitute.net/ Solution-Focused Brief Therapy Association: www.sfbta.org/

Helpful Books ■ ■ ■ ■ ■ ■

de Shazer, S., Dolan, Y., Koman, H., Trepper, T., McCollum, E., & Berg, I. K. (2021). More than miracles: The state of the art of solution-focused brief therapy. Routledge. Kelly, G. (1991). The psychology of personal constructs, volume 1: A theory of personality. Routledge. Kim, J. S. (2014). Solution-focused brief therapy: A multicultural approach. Sage. McDowell, T., Knudson-Martin, C., & Bermudez, J. M. (2022). Socioculturally attuned family-therapy: Guidelines for equitable theory and practice (2nd ed.). Routledge. White, M. (2011). Narrative practice: Continuing the conversation. Norton. White, M., & Epston, D. (1990). Narrative means to therapeutic ends. Norton.

Helpful Videos ■ ■ ■

■

■ ■

Carlson, J., & Keat, D. (2002). Child therapy with the expert series: Narrative therapy with ­children with Stephen Madigan. [Video/DVD]. Psychotherapy.net. Carlson, J., & Kjos, D. (1997). Psychotherapy with the experts series: Solution-focused therapy with Insoo Kim Berg. [Video/DVD]. Psychotherapy.net. Winslade, J., & Monk, G. (Directors). (2008). Narrative therapy: A process for the ­postmodern world [Video/DVD]. Microtraining Associates. https://search.alexanderstreet.com/ view/work/bibliographic_entity%7Cvideo_work%7C1778963 Edwards, D., & O’Hanlon, B. (Directors). (2020). The solution oriented approach to change: brief therapy method to finding the answers within clients. [Video/DVD]. Milton H. Erickson Foundation. https://search.alexanderstreet.com/view/work/ bibliographic_entity%7Cvideo_work%7C5135593 Dole, D. (2010). Ken Gergen talks about social construction ideas, theory, and practice [Video]. Vimeo. https://vimeo.com/15676699 Central Washington University. (2009). Schepman one [Video]. Youtube. www.youtube. com/watch?v=53DHIKenUqs

A robust set of instructor resources designed to supplement this text is available. Qualifying instructors may request access by emailing [email protected].

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Beaudoin, M-N., Moersch, M., & Evare, B. S. (2016). The effectiveness of narrative therapy with children’s social and emotional skill development: An empirical study of 813 problem-solving stories. Journal of Systemic Therapies, 35(3), 42–59. https://doi.org/10.1521/jsyt.2016.35.3.42 Bitter, J. R. (2020). Theory and practice of family therapy and counseling (3rd ed.). Brooks/Cole. Bond, C., Woods., K., Humrhrey, N., Sumes, W. Y., & Green, L. (2013). Practitioner review: The effectiveness of solution-focused brief therapy with children and families: A systematic and critical evaluation of the literature from 1990-2010. Journal of Child Psychology and Psychiatry, 54(7), 707–723. https://doi. org/10.1111/jcpp.12058 Bubenzer, D. L., West, J. D., & Boughner, S. R. (1994). The narrative perspective in therapy. The Family Journal, 2(1), 71–83. Caputi, P., Viney, L. L., Walker, B. M., & Crittenden, N. (2011). Personal construct methodology. John Wiley & Sons. Carr, A., Hartnett, D., Brosnon, E., & Sharry, J. (2017). Parents plus systemic, solution-focused parent ­training programs: Description, review of the evidence base and meta-analysis. Family Process, 56(3), 652–668. https://doi.org/10.1111/famp.12225 Combs, G., & Freedman, J. (2012). Narrative, poststructuralism, and social justice: Current practices in narrative therapy. The Counseling Psychologist, 40(7), 1033–1060. https://doi. org/10.1177/0011000012460662 Combs, G., & Freedman, J. (2016). Narrative therapy’s relational understanding of identity. Family Process, 55(2), 211–224. https://doi.org/10.1111/famp.12216 Cottone, R. R. (2001). A social constructivism model of ethical decision making in counseling. Journal of Counseling & Development, 79(1), 39–45. https://doi.org/10.1002/j.1556-6676.2001.tb01941.x‌‌‌‌‌‌ Dallos, R. (2004). Attachment narrative therapy: Integrating ideas for narrative and attachment theory in systemic family therapy with eating disorders. Journal of Family Therapy, 26, 40–65. https://doi. org/10.1111/j.1467-6427.2004.00266.x D’Arrigo-Patrick, J., Hoff, C., Knudson-Martin, C., & Tuttle, A. (2017). Navigating critical theory and postmodernism: Social justice and therapist power in family therapy. Family Process, 56(3), 574–588. https://doi.org/10.1111/famp.12236 De Jong, P., & Berg, I. K. (2013). Interviewing for solutions (4th ed.). Brooks/Cole. de Shazer, S. (1985). Keys to solution in brief therapy. Norton.‌‌‌‌‌‌ de Shazer, S. (1988). Clues: Investigating solutions in brief therapy. Norton. de Shazer, S. (1991). Putting differences to work. Norton. de Shazer, S., Dolan, Y., Koman, H., Trepper, T., McCollum, E., & Berg, I. K. (2021). More than miracles: The state of the art of solution-focused brief therapy. Routledge. Feixas, G. (1992). Personal construct approaches to family therapy. In R. A. Neimeyer & G. J. Neimeyer (Eds.), Advances in personal construct psychology (Vol. 2, pp. 217–255). JAI Press. Franklin, C., Zhang, A., Froerer, A., & Johnson, S. (2017). Solution-focused brief therapy: A systematic review and meta-summary of process research. Journal of Marital and Family Therapy, 43(1), 16–30. https://doi.org/10.1111/jmft.12193 Fransella, F. (2003). International handbook of personal construct psychology. John Wiley & Sons.‌‌‌‌‌‌ Freedman, J., & Combs, G. (1996). Narrative therapy: The social construction of preferred realities. Norton. Fox, H. (2003). Using therapeutic documents: A review. International Journal of Narrative Therapy and Community Work, 4, 26–36. www.dulwichcentre.com.au Gergen, K. J. (1985). The social constructionist movement in modern psychology. American Psychologist, 40(3), 266–275. https://doi.org/10.1037/0003-066X.40.3.266 Gergen, K. (2009). An invitation to social construction (2nd ed.). Sage. Gingerich, W. J., & Peterson, L. (2012). Effectiveness of solution-focused brief therapy: A systematic ­qualitative review of controlled outcome studies. Research on Social Work Practices, 23(2), 266–283.‌‌‌‌‌‌ González, M. T., Estrada, B., & O’Hanlon, B. (2011). Possibilities and solutions: The differences that make a difference. International Journal of Hispanic Psychology, 3(2), 185–200. González Suitt, K., Geraldo, P., Estay, M., & Franklin, C. (2019). Solution-focused brief therapy for individuals with alcohol use disorders in Chile. Research on Social Work Practice, 29(1), 19–35. https://doi. org/10.1177/1049731517740958 Hannon, M. D. (2022). Introduction. In M. D. Hannon (Ed.), Black fathering and mental health: Black fathers’ narratives on raising their children across the family life cycle (pp. 1–4). Peter Lang.‌‌‌‌‌‌

Hansen, J. T. (2004). Thoughts on knowing: Epistemic implications of counseling practice. Journal of Counseling & Development, 82, 131–138. https://doi.org/10.1002/j.1556-6678.2004.tb00294.x Hansen, J. T. (2006). Counseling theories within a postmodern epistemology: New roles for theory in counseling practice. Journal of Counseling & Development, 84(3), 291–297. https://doi. org/10.1002/j.1556-6678.2006.tb00408.x Hansen, J. T., & Scholl, M. B. (2018). Introduction to postmodern perspectives on contemporary counseling issues. In M. B. Scholl & J. T Hansen (Eds.), Postmodern perspectives on contemporary counseling issues (pp.1–21). Oxford. Hardison, H. G., & Neimeyer, R. A. (2007). Numbers and narratives: Quantitative and qualitative convergence across constructivist assessments. Journal of Constructivist Psychology, 20, 285–308. https://doi. org/10.1080/10720530701503827 Heatherington, L., & Johnson, B. (2019). Social constructionism in couple and family therapy: Narrative, solution-focused, and related approaches. In B. H. Fiese, M. Celano, K. Deater-Deckard, E. N. Jouriles, & M. A. Whisman (Eds.), APA handbook of contemporary family psychology: Foundations, methods, and contemporary issues across the lifespan (pp. 127–142). American Psychological Association. https://doi.org/10.1037/0000099-008 Hsu, K-S, Eads, R., Lee, M. Y., & Wen, Z. (2021). Solution-focused brief therapy for behavior problems in children and adolescents: A meta-analysis of treatment effectiveness and family involvement. Children and Youth Services Review. Elsevier. https://doi.org/10.1016/j.childyouth.2020.105620 Kelly, G. (1958/1969). Clinical psychology and personality: The selected papers of George Kelly. In B. Maher (Ed.), Clinical psychology and personality: The selected papers of George Kelly (pp. 46–65). John Wiley & Sons. Kelly, G. A. (1955). The psychology of personal constructs. Norton. Kelly, G. A. (2003). A brief introduction to personal construct theory. In F. Fransella (Ed.), International handbook of personal construct psychology (pp. 3–20). Wiley.‌‌‌‌‌‌ Kim, J. S. (2008). Examining the effectiveness of solution-focused brief therapy: A metaanalysis. Research on Social Work Practice, 18(2), 107–116. https://doi.org/10.1177/1049731507307807 Kim, J. S., Akin, B. A., & Brook, J. (2019). Solution-focused brief therapy to improve child well-being and family functioning outcomes with substance using parents in the child welfare system. Developmental Child Welfare, 1(2), 124–142. https://doi.org/10.1177/2516103219829479 Kim, J. S., Brook, J., & Akin, B. A. (2018). Solution-focused brief therapy with substance-using individuals: A randomized controlled trial study. Research on Social Work Practice, 28(4), 452–462. Kim, J. S., & Franklin, C. (2009). Solution-focused brief therapy in schools: A review of the outcome literature. Children and Youth Services Review, 31(4), 464–470. https://doi.org/10.1016/j. childyouth.2008.10.002 Leitner, L. M. (2007). Theory, technique, and person: Technical integration in experiential constructivist psychotherapy. Journal of Psychotherapy, 17, 1, 33–49. https://doi.org/10.1037/1053-0479.17.1.33 Lipchik, E. (2002). Beyond technique in solution focused therapy. Guilford Press. Lopes, R. T., Gonçalves, M. M., Fassnacht, D. B., Machado, P. P., & Sousa, I. (2014). Long-term effects of psychotherapy on moderate depression: A comparative study of narrative therapy and cognitive-behavioral therapy. Journal of Affective Disorders, 167, 64–73. https://doi.org/10.1016/j. jad.2014.05.042 Mahoney, M. J. (2002). Constructivism and positive psychology. In C. R. Snyder & S. J. Lopez (Eds.), Handbook of positive psychology (pp. 745– 750). Oxford University Press. Mahoney, M. J. (2003). Constructivist psychotherapy: A practical guide. Guilford. McDowell, T., Knudson-Martin, C., & Bermudez, J. M. (2022). Socioculturally attuned family-therapy: Guidelines for equitable theory and practice (2nd ed.). Routledge. Medway, M., & Rhodes, P. (2016). Young people’s experience of family therapy for anorexia nervosa: A qualitative meta-synthesis. Advances in Eating Disorders, 4(2), 189–207. https://doi.org/10.1080/ 21662630.2016.1164609 Metcalfe C., Winter D, & Viney L. (2007). The effectiveness of personal construct psychotherapy in clinical practice: A systematic review and meta-analysis. In Database of Abstracts of Reviews of Effects (DARE): Quality-assessed reviews. Centre for Reviews and Dissemination (UK). https://www.ncbi.nlm.nih. gov/books/NBK74788/ Neimeyer, R. A. (1993). Constructivist approaches to the measurement of meaning. In G. J. Neimeyer (Ed.), Constructivist assessment (pp. 58–103). Sage. Neimeyer, R.A. (1995). Constructivist psychotherapies: Features, foundations, and future directions. In R.A. Neimeyer & M.J. Mahoney (Eds.), Constructivism in psychotherapy (pp. 11–38). American Psychological Association.

Neimeyer, R. A. (2000). Constructivist psychotherapy. In A. E. Kazdin (Ed.), Encyclopedia of psychology (Vol. 2, pp. 279–281). Oxford University Press. Neimeyer, R. A. (2003). The Internet encyclopedia of personal construct psychology.http://www.pcp-net. org/encyclopaedia/kelly.html‌‌‌‌‌ Neimeyer, R. A. (2009). Constructivist psychotherapy. Routledge. Neimeyer, R. A., & Feixas, G. (1990). Constructivist contributions to psychotherapy integration. Journal of lntegrative and Eclectic Psychotherapy, 9, 4–20. Neimeyer, R. A., & Harter, S. (1988). Facilitating individual change in personal construct therapy. In G. Dunnett (Ed.), Working with people (pp. 174–185). Routledge & Kegan Paul. Neimeyer, R. A., Anderson, A., & Stockton, L. (2001). Snakes versus ladders: A validation of laddering ­technique as a measure of hierarchical structure. Journal of Constructivist Psychology, 14, 85–105. Neimeyer, R. A., Baker, K. D., & Neimeyer, G. J. (1990). The current status of personal construct theory: Some scientometric data. In G. J. Neimeyer & R. A. Neimeyer (Eds.), Advances in personal construct psychology (Vol. 1, pp. 3–22). JAI Press. Neimeyer, R. A., & Bridges, S. K. (2003). Postmodern approaches to psychotherapy. In A. S. Gurman & S. B. Messer (Eds.), Essential psychotherapies (2nd ed., pp. 272–316). Guilford. O’Hanlon, B., & Weiner-Davis, M. (2003). In search of solutions: A new direction in psychotherapy (Rev. ed.). Norton. O’Hanlon, W. H. & Beadle, S. (1997). A guide to possibility land. Norton. Park, J. W., & Kim, H. S. (2021). The effects of group counseling utilizing narrative therapy on self-esteem, stress response, and insight for individuals with alcohol dependency. Journal of Creativity in Mental Health, 18(2), 219–248. https://doi.org/10.1080/15401383.2021.1972885 Payne, M. (2006). Narrative therapy (2nd ed.). Sage. Paz, C., Pucurull, O., & Feixas, G. (2016). Change in symptoms and personal construct structure in anxiety disorder: A preliminary study on the effects of constructivist therapy. Journal of Constructivist Psychology, 29(3), 231–247. https://doi.org/10.1080/10720537.2014.943914 Peavy, R. V. (1995). Constructivist career counseling. ERIC Clearinghouse on Counseling and Student Services. Robinson, T., Jacobsen, R., & Foster, T. (2015). Group narrative therapy for women with attention-deficit/hyperactivity disorder. Adultspan Journal, 14(1), 24–34. https://doi.org/10.1002/ j.2161-0029.2015.00034.x Schmidt, E. L., Schmit, M. K., & Lenz, S. A. (2016). Meta-analysis of solution-focused brief therapy for treating symptoms of internalizing disorders. Counseling Outcome Research and Evaluation, 7(1), 21–39. Selekman, M. D. (1997). Solution-focused therapy with children: Harnessing family strengths for systemic change. Guilford. Sklare, G. B. (2014). Brief counseling that works: A solution-focused therapy approach for school counselors and other mental health professionals. Sage. Smock, S. A., McCollum, E. E., & Stevenson, M. (2010). The development of the solution-focused inventory. Journal of Marital and Family Therapy, 34, 499–510. https://doi.org/10.1111/j.1752-0606.2010.00197.x‌‌‌‌‌‌ Smock Jordan, S. (2014). Asking different questions: Validation of the solution building inventory in a clinical sample. Journal of Systemic Therapies, 33(1), 78–88. https://doi.org/10.1521/jsyt.2014.33.1.78 Sommers-Flanagan, J., & Sommers-Flanagan, R. (2018). Counseling and psychotherapy theories in context and practice: Skills, strategies, and techniques (3rd ed.). John Wiley and Sons. Taber, K. S. (2020). Constructive alternativism: George Kelly’s personal construct theory. In B. Akpan & T. Kennedy (Eds.), Science education in theory and practice: An introductory guide to learning theory. Springer. Thomas, F. N. (2007). Possible limitations, misunderstandings, and misuses of solution-focused brief therapy. In T. S. Nelson & F. N. Thomas (Eds.). Handbook of solution-focused brief therapy: Clinical applications. (pp. 391–408). Haworth Press. Tilsen, J., & Nylund, D. (2016). Cultural studies methodologies and narrative family therapy:‌‌‌‌‌‌Therapeutic conversations about pop culture. Family Process, 55(2), 225–237. https://doi.org/10.1111/famp.12204 Viney, L.L. (1998) Should we use personal construct therapy? A paradigm for outcomes evaluation. Psychotherapy: Theory, Research, Practice, Training, 35(3), 366–380. https://psycnet.apa.org/ doi/10.1037/h0087785 Viney, L. L., Benjamin, Y. N., & Preston, C. (1989). An evaluation of personal construct therapy for the elderly. British Journal of Medical Psychology, 62, 3541. https://doi.or‌‌‌‌‌‌g/10.1080/10503301003591792

Vromans, L. P., & Schweitzer, R. D. (2011). Narrative therapy for adults with major depressive disorder: Improved symptom and interpersonal outcomes. Psychotherapy Research, 21(1), 4–15. https://doi. org/10.1080/10503301003591792 Walter, J. L. & Peller, J. E. (2000). Recreating brief therapy: Preferences and possibilities. Norton. Watts, R. (2017). Adlerian and constructivist therapies: A Neo-Adlerian perspective. The Journal of Individual Psychology, 73(2), pp 135–155. https://doi.org/10.1353/jip.2017.0012 Watts, R. E., & Pietrzak, D. (2000). Adlerian “encouragement” and the therapeutic process of solution-focused brief therapy. Journal of Counseling and Development, 78(2), 442–447. https://doi. org/10.1002/j.1556-6676.2000.tb01927.x Watzlawick, P., Weakland, J.H., & Fisch, R. (1974). Change: Principles of problem formation and problem resolution. W.W. Norton. Webber, J.M, & Mascari, J. B. (2018). Restorying the survivor narrative with sexually abused adolescents. In M. B. Scholl & J. T Hansen (Eds.), Postmodern perspectives on contemporary counseling issues. (pp.121– 143). Routledge. Wheat, L. S., & Whiting, P. P. (2018). Using narrative reconstruction as a postmodern approach with grieving children and adolescents. In M. B. Scholl & J. T Hansen (Eds.), Postmodern perspectives on contemporary counseling issues (pp. 93–120). Routledge. White, M. (1988). The process of questioning: A therapy of literary merit? Dulwich Centre Newsletter, Winter. White, M. (1995). Re-authoring lives: Interviews and essays. Dulwich Centre Publications. White, M. (2011). Narrative practice: Continuing the conversation. Norton. White, M. & Epston, D. (1990). Narrative means to therapeutic ends. Norton. Winter, D., & Neimeyer, R. (2015). Constructivist therapy. In E. Neukrug (Ed.), The SAGE encyclopedia of theory in counseling and psychotherapy (pp. 222–225). SAGE Publications, Inc. https://dx.doi. org/10.4135/9781483346502.n86 Zimmerman, J. (2017). Neuro-narrative therapy: Brain science, narrative therapy, poststructuralism, and preferred identities. Journal of Systemic Therapies, 36(2), 12–26. http://dx.doi.org/10.1521/ jsyt.2017.36.2.12 Zimmerman, J., & Beaudoin, M. N. (2015). Neurobiology for your narrative: How brain science can influence narrative work. Journal of Systemic Therapies, 34(2), 56–71. https://doi.org/10.1521/ jsyt.2015.34.2.59

SECTION VI

INTEGRATIVE AND BRIEF COUNSELING THEORIES

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INTEGRATIVE APPROACHES W. Bradley McKibben and Seneka R. Gainer

LEARNING OBJECTIVES After reading this chapter, you will be able to: ■ Explain psychotherapy integration and the multiple pathways to integrating various approaches ■ Understand the three integrative approaches presented in this chapter ■ Describe how to integrate treatment strategies based on the three approaches presented in this chapter ■ Identify strengths and limitations of the integrative approaches, both in general and from a multicultural perspective

INTRODUCTION As you have read this book, you likely have seen how some theories overlap, either conceptually, practically, or both. Some theoretical models are very different from one another. Whether the counselor emphasizes the present or the past; focuses on thoughts, feelings, or behaviors; or examines individual, couple, family, group, or systemic factors, the ultimate goal of counseling is to help clients find relief from the troubles that brought them in, to accomplish their treatment goals, and to achieve and sustain wellness across the life span (Kaplan et al., 2014). You may find that you incline toward, or perhaps disfavor, one or more of the approaches you have read about thus far, which offers you some insight into your own counseling style and preferences. When it comes to clinical practice, the interplay of your personal counseling style; your clients’ needs, goals, and preferences; diverse, intersecting identities and cultural backgrounds (for you and your clients); and systemic forces such as privilege and marginalization all coalesce into nearly infinite ways in which a counselor might approach working with clients. The American Counseling Association (ACA, 2014) standard A.1.c. states in part that “counselors and their clients work jointly in devising counseling plans that offer reasonable promise of success and are consistent with the abilities, temperament, developmental level, and circumstances of clients.” Because the counselor must attend and respond to a wide variety of client factors in the counseling process, many counselors find that a singular therapeutic approach is insufficient for every client and every situation. Many find it necessary to have a “psychological toolbox” of varying approaches or techniques. This speaks to an integrative approach, which is the focus of this chapter. Integrative approaches refer to forms of counseling and psychotherapy wherein the counselor draws from a variety of therapeutic models and techniques, depending upon the client’s presenting concerns, needs, and preferences for treatment. Integration follows a variety of approaches, including theoretical integration, assimilative integration, common

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factors, and technical eclecticism. In theoretical integration, several theories, or elements from different theories, are infused into a more comprehensive approach. For example, acceptance and commitment therapy (ACT) infuses concepts from cognitive approaches, behavior therapy (BT), mindfulness, language, and communication in an effort to better explain the interplay of cognitive and behavioral pathways to change. In assimilative integration, the counselor has a primary theoretical orientation from which they conceptualize and intervene, but they also are willing to draw in other ­theory-based conceptualizations or techniques, depending upon the client and related circumstances. For example, the primarily Adlerian counselor who engages one of their clients in thought journaling and a shame attacking exercise has assimilated cognitive elements into their approach. Common factors refer to emphasizing shared elements across theoretical models, rather than theory-specific techniques, in an effort to streamline the counseling process and maximize counseling outcomes. This idea dates back to the 1930s when Saul Rosenzweig (1936) posited that all therapeutic approaches were equally effective. Multiple researchers have since produced studies suggesting that specific techniques are less impactful on counseling outcomes than common factors, such as the therapeutic alliance, client factors (e.g., attitude toward counseling), and counselor factors (e.g., warmth, positive attitude). A prominent integrative model, the transtheoretical model (TTM) of behavior change, identifies stages and levels of change that are common across any theoretical approach (hence the name “transtheoretical”), as well as processes of change that draw on varying techniques to match the client’s readiness (Prochaska & DiClemente, 2019; Prochaska & Norcross, 2018). Because of its popularity and adaptation across helping professions, we focus on the TTM in depth throughout this chapter. Finally, in technical eclecticism, the counselor relies less on a particular theoretical model and more on empirical research to guide the selection of intervention strategies and techniques that best match the client’s presenting concerns, needs, preferences, and culture. This focus on “what works best” aligns closely with the evidenced-based practice movement popular in the United States. Historically, purists who believed strongly in a particular theoretical model resisted integration, due at least in part to the marked differences in philosophies and ideas of mental health among the earlier theories to emerge (e.g., psychoanalysis, behaviorism). However, integrative models have evolved over time into respected and validated approaches to counseling. In this chapter, we delve into three integrative approaches that are widely utilized and research-supported: integrative psychotherapy by John Norcross, Larry Beutler, and others; the TTM from the work of James Prochaska and Carlo DiClemente; and eclectic counseling from the work of Arnold Lazarus and colleagues.

LEADERS AND LEGACIES OF INTEGRATIVE THEORY One of the earliest proponents for integration was Frederick Thorne (1909–1979), who staunchly rejected a singular therapeutic approach and advocated for eclecticism. As a graduate student at Columbia in the early 1930s, he was strongly influenced by his mentor Alfred Adler (Krawiec, 1979), who himself departed from Freudian psychoanalysis and sought a more comprehensive understanding of the human condition (North American Society for Adlerian Psychology, n.d.). In his clinical work, he found eclecticism to be a better fit for the complexity of human nature and the issues that brought them in for treatment. He often tried to publish empirical work on eclectic approaches, but it was largely downplayed or ignored by the journals of publishers of the time in which singular therapeutic models were dominant. In response, Thorne founded the Journal of Clinical Psychology (Krawiec, 1979), which is still actively publishing to this day. The 1960s to 1980s saw an increase in work on integration. An early influencer was Arnold Lazarus (1932–2013). As a graduate student at the University of Johannesburg, South Africa,

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Lazarus contributed to the origin of BT and was the first to use it in the professional literature, South African Medical Journal, in 1958. In the 1960s to 1970s, Lazarus was responsible for expanding his behavior-based therapy into cognitive behavior therapy (CBT), as introduced in his book Behavior Therapy and Beyond in 1971 (Lazarus, 2006‌‌). However, rising out of a realization of significant limitations of BT and CBT in the late 1970 to 1980s, Lazarus innovated a multifaceted, eclectic psychotherapy known as multimodal therapy (MMT; Lazarus, 1989), which we discuss throughout this chapter. Lazarus founded the Multimodal Therapy Institute in Kingston, New Jersey, and established additional Multimodal Therapy Institutes in New York, Virginia, Pennsylvania, Illinois, Texas, and Ohio. His most well-known book, Multimodal Behavior Therapy, was published in 1976. Sol Garfield (1918–2004) held a number of academic and clinical positions across his career, including serving as director of Washington University’s Clinical Psychology Training program and working at several Veterans Administration hospitals (Society for Psychotherapy Research, n.d.). Garfield was a strong proponent that clinical psychology should be an evidence-based practice grounded in empirical research. As a result, he was vocal in his critiques of singular therapeutic models, particularly psychoanalysis which he saw as empirically unsupported, and much of his scholarship focused on challenging psychology to adhere to what research showed was effective (Beutler & Simons, 2010). In 1970s to 1980s, James Prochaska (1942–) and Carlo DiClemente set out to identify how client change occurs across various therapeutic approaches (Prochaska & DiClemente, 1982). Their work led to the development of the TTM, which has since been studied extensively and refined into an empirically supported metatheory. Prochaska, a professor emeritus at the University of Rhode Island, was interested in health promotion and cancer prevention, which led him to study how people alter their behavior toward healthier alternatives. Similarly, DiClemente, a professor emeritus at the University of Maryland Baltimore County, studied addiction and health behaviors. It is perhaps unsurprising, then, that the TTM has been studied heavily with smoking cessation, addiction recovery, weight loss, exercise, and safe sex practices, in addition to mental health–related behavior change. Two prolific pioneers of integration, who remain active today, are John Norcross and Larry Beutler. Norcross (1957–) is a distinguished professor and chair of psychology at the University of Scranton, as well as a clinical professor of psychiatry at SUNY Upstate Medical University. Beutler (1941–) is a distinguished professor emeritus at Palo Alto University and professor emeritus at the University of California. These two, along with a host of their colleagues, have produced hundreds of peer-reviewed articles, books, and book chapters delineating pathways to psychotherapy integration. They have been primary figures who have brought integration into the current mainstream of mental healthcare, primarily through their own integrative psychotherapy model, which rests on the principle of using empirical research to guide the therapy process and selection of techniques rather than a theoretical model. We explore their integrative psychotherapy throughout this chapter.

Emerging Integrative Approaches Although singular therapy models remain popular, integrative approaches have become more mainstream in mental healthcare (Norcross & Beutler, 2019). Many of the newest psychotherapy models that have emerged in the last few decades are integrative. For example, the popular DBT merges Eastern philosophies (i.e., dialectics) with CBT ideas and techniques in an effort to balance acceptance with change. Similarly, emotionally focused therapy combines theoretical formulations and techniques from attachment theory, person-centered therapy, and structural systems theories in detailing an approach to working with couples, families, and individuals (Brubacher, 2017‌‌‌‌‌‌; Johnson, 2019‌‌‌‌‌‌). The three-stage model of helping skills proposed by Clara Hill stratifies techniques from

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different theories based on the stage of the helping process (Hill, 2020). This model has allowed helping skills to be taught effectively to professionals in and beyond the mental health disciplines.

ORIGIN AND NATURE OF MENTAL HEALTH CONCERNS Unlike many theories throughout this book, most integrative approaches do not rely on a singular theoretical explanation of mental health. Across these approaches is an assumption that clients’ presenting concerns are complex and unique to the individual, and thus no one set of techniques or one theory can sufficiently explain mental health concerns in and of themselves. Indeed, it was the inadequacy of singular therapeutic approaches that spurred the development of integrative approaches. Personality functioning; symptomatology and diagnoses; intrapsychic conflicts; culture and systemic forces; and individual beliefs, values, and preferences are just some of the factors of interest to integrative approaches. Most of the common factors or eclectic approaches to integration are not aimed at trying to explain the origins of a client’s mental health concerns; rather, they are interested in aligning treatment approaches that will enhance counseling effectiveness. This is true of integrative psychotherapy, and the TTM discussed in the following section‌‌‌‌.

Integrative Psychotherapy Integrative psychotherapy holds no implicit assumptions about the origin and nature of mental health concerns. Because this approach relies on data-informed decision-making, the counselor does not necessarily need to know the origin of a client’s mental health concerns to be able to help them. Rather, the counselor is interested in which strategies are most likely to result in client change (Norcross & Beutler, 2019). To do this, the counselor seeks a holistic picture of the client and their presenting concerns, gained largely through clinical assessment (described later), that can inform a collaboratively designed treatment plan. The counselor considers a variety of factors, based on empirical research, in understanding how a client came to have their presenting concerns, including organic (e.g., biology, genetics, medical, developmental issues), intrapersonal (e.g., personality functioning, readiness to change, coping), interpersonal (e.g., relationship functioning), and systemic (e.g., family systems, community, and environment, sociocultural influences, life span issues). Researchers have identified six client factors that exert some of the greatest influence on counseling outcomes: diagnosis, stage of change, coping, reactance, preferences, and culture (Beutler et al., 2000; Norcross & Beutler, 2019). We delve deeper into these factors later in this chapter when talking about clinical assessment, but integrative psychotherapy is keenly interested in targeting these six factors in counseling, given the empirical support for their strong influence on the change process. Integrative psychotherapy does lean on diagnostic classification systems, such as the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD), as one organizing principle for identifying intervention strategies to address mental health concerns. This approach offers primarily biological, neurological, and medical explanations of mental health, and it relies on categorizing mental health concerns based on symptom presentation, severity, and functional impairment. Although narrowly focused on higher acuity psychiatric symptoms, pathology, and mental health deficiencies, the DSM and ICD offer a common language for research and practice that is widely utilized across mental health professions and healthcare systems. In integrative psychotherapy, diagnosis can function as one possible starting point for treatment planning, as well as a benchmark for progress throughout the course of counseling (i.e., assessing symptom reduction in response to treatment).

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Transtheoretical Model The TTM does not propose a theory of how an individual developed a mental health concern. However, it does explain a person’s awareness and appraisal of, and readiness to act upon, a problem in a constructive way (Prochaska & Norcross, 2019). The TTM aligns with other integrative approaches, as well as postmodern perspectives such as solution-focused brief therapy (SFBT), in postulating that the counselor need not know the origins of a problem in order to help the client address their presenting concerns. The TTM proposes multiple stages of change readiness, as well as processes and levels of change. The stages of change are perhaps the most widely known. According to the TTM, a client progresses through precontemplation, contemplation, preparation, action, maintenance, and termination stages of change (Prochaska & Norcross, 2019; see Table 12.1 for a description and example of each stage). Similar to integrative psychotherapy, the goal in identifying which stage of change a client is in is to implement treatment strategies from across therapy models that align with the client’s current stage of change readiness and can help the client move to the next stage of change. The earlier stages of change are primarily affective and cognitive experiences, whereas the middle and later stages tend to be more behavioral. We discuss intervention strategies for these stages later in the chapter. In addition to stages, the TTM also differentiates presenting concerns in terms of complexity. Namely, there are five levels across which change occurs, and they are arranged in order of increasing complexity: symptom or situational problems, maladaptive cognitions, current interpersonal conflicts, family system conflicts, and intrapersonal conflicts (Prochaska & Norcross, 2019). Many clients may initially come to counseling seeking help for symptoms or a situational issue, but as they progress in counseling over time, they may delve deeper into current or new issues in a more nuanced way (Fromme, 2011). Thus, counselors should not assume that a client’s stage of change at one level translates to other levels as well. Finally, the TTM defines processes of change, which describe mechanisms for how a client moves through the stages of change. We discuss these later in the chapter.

Eclectic Counseling MMT is rooted in a foundation of social and cognitive learning theory. Therapeutically, MMT recognizes response deficits and excesses within and across the BASIC ID (Behavior, Affect, Sensation, Imagery, Cognition, Interpersonal relationships and Drugs or biological processes). While rejecting theoretical integration (i.e., trying to blend often incompatible theories of psychology), multimodal counselors use practical strategies from diverse approaches without subscribing to the theories that generated them—technical eclecticism. Instead, counselors preferentially rely on evidence-based and empirically supported methods. Technical eclecticism in counseling is an integrative approach, warranted when established treatments of choice do not exist for a particular disorder or set of symptoms or when these documented orientations, independently, are not achieving the desired results. Since the 1980s, the underpinnings of technical eclecticism have been more comprehensively viewed as a unified psychological therapeutic approach known as MMT and originated by Arnold Lazarus. Moving away from the rigidity of theoretical integration, MMT proposes that psychological issues are multifaceted and multilayered. Thus, MMT calls for a thorough assessment of transactional factors in which individuals operate. Namely, Lazarus (1985) argued that people do not just act; people also think, feel, sense, imagine, and interact. In conceptualizing how an individual has developed a mental health concern, MMT considers interaction effects among a person’s biology, environmental factors, and social learning. MMT can be used to treat various emotional and psychological concerns. Lazarus, however, found that the relapse rate following therapy remained very high for clients experiencing anxiety and panic disorders, obsessive compulsive issues, depression, and family and marital

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Table 12.1. Transtheoretical Model Stages of Change With an Addiction Example Stage of Change

Description

Example

Precontemplation A person is unaware of the problem or its impact on their lives, and a person is unprepared to take action to address the problem. If confronted about the problem by others, the person may downplay or dismiss that there is a problem. The person may also be discouraged and experience low self-efficacy in relation to change.

A client with an opioid addiction presents to a residential recovery center. The client denies that they have an addiction, making statements such as “I don’t have a problem” and “I can quit any time I want.” The client makes excuses for their actions, including the reason why they are in treatment (e.g., “I’m only here because my partner gave me an ultimatum and I’m trying to pacify them”).

Contemplation

A person becomes aware of the problem and its impact on their lives, but remains ambivalent about taking immediate action to address the problem. At this stage, the individual begins to weigh the pros and cons of changing against consequences of not changing.

The client begins to recognize the impact of addiction on their life. The client makes observations such as “I can see how pills are taking over my life” and “my partner and I fight because I’m high all the time.” They may even make statements such as “I admit that I am an addict.”

Preparation

A person is aware of the problem and is committed to taking action to address the problem. The individual may begin making plans, strategizing, and may begin to take small steps toward change.

The client commits to recovery and begins to explore what this looks like. They explore total sobriety versus medication management. They speak with their counselor, and others in recovery, about how to “get clean” and begin to map out their journey.

Action

A person makes observable reforms to their problematic behaviors and is actively striving toward healthier alternatives.

The client abstains from opioid use. The client also engages in recovery efforts, such as attending and participating in AA/NA ‌‌‌‌ meetings.

Maintenance

A person has remained in the action stage for at least 6 months and is working on maintaining their gains and preventing relapse of problematic behaviors.

The client has sustained recovery for about 6 months. They report that “some days are harder than others” because they still have some cravings. They also are learning how to face life stressors and difficulties without opioids and to adjust to their new normal. They continue to attend AA/NA regularly and to utilize strategies learned in counseling.

Termination

A person has maintained their gains, successfully prevented relapse of problematic behaviors, experiences no urges to return to prior behaviors, and is confident that the problematic behaviors will not return.

The client feels confident in their recovery, reports few to no cravings, and can readily apply appropriate coping skills and wellness strategies to deal with any cravings and stressors. The client feels more defined by their recovery than their addiction.

AA, Alcoholics Anonymous; NA, Narcotics Anonymous.

difficulties (Lazarus, 1985). He, therefore, materialized MMT, which includes examining and treating seven distinct but interrelated psychological parameters. MMT involves a complete assessment of the individual and treatments explicitly conceived for that individual. Lazarus developed his approach, in part, by examining the factors that aided clients in treatment.

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EMOTIONAL AND PSYCHOLOGICAL WELL-BEING Similar to their views on the origins of mental health concerns, many of the integrative approaches do not have a singular guiding definition of well-being. Although this speaks beyond the approaches described in this chapter, we believe that a useful model for operationalizing well-being across the integrative approaches is the indivisible self (IS) model of wellness (Myers & Sweeney, 2004). The IS is an empirically derived model defining wellness across five interrelated factors of creative, coping, social, essential, and physical selves (Myers & Sweeney, 2005b, 2008). The IS also considers local, institutional, global, and chronological contexts that impact wellness. These wellness factors and contexts conceptually parallel the idea of levels of change within the TTM. A comprehensive review of the IS is beyond the scope of this book, and we recommend consulting Myers and Sweeney (2005b) for a more thorough review. Because the IS is an evidence-based model, operationalizes domains of wellness that can be explicitly discussed and assessed in counseling, and also has ways to measure wellness (e.g., Five-Factor Wellness Inventory [5F-WEL‌]‌; Myers & Sweeney, 2005a), we suggest that the model provides a useful definition of, and benchmark for, measuring well-being when operating from an integrative approach.

Integrative Psychotherapy Because integrative psychotherapy does not subscribe to any one particular theory, it does not propose a singular guiding definition of wellness or well-being. That is not to say that integrative psychotherapy dismisses or downplays the importance of this concept; indeed, by helping clients to accomplish their therapy goals, it is hoped that clients also are working toward more generalized healing and wellness. In this vein, one could conceptualize progress toward well-being as movement through the TTM stages, which integrative psychotherapy recognizes as a key agent of client change. Should a client have a specific wellness treatment goal, identifying areas of wellness to address in counseling using the IS model or assessing and tracking a client’s wellness using the 5F-WEL may be worthwhile.

Transtheoretical Model As a metatheory of change, the TTM conceptualizes readiness to change toward healthier behaviors. That is, when seeking to understand a client’s readiness to change, that “readiness” is in relation to some sort of action that will improve their quality of life (e.g., stopping smoking, increasing exercise, pursuing a healthier diet). Although the “state” of well-being may look different for each person based on their goals, an individual in the action stage of change who is taking behavioral steps to remedy problematic behaviors can certainly be considered to be increasing their wellness. Similarly, one who effects change and sustains it into the maintenance stage is increasing their wellness as problematic behaviors have been replaced by healthier alternatives. In sum, the TTM does not specifically define well-being but does articulate how clients make changes that result in healthier lifestyles.

Eclectic Counseling Multimodal therapists view BASIC ID as a model of human personality and phenomenology (Lazarus, 2006). MMT considers psychological well-being as distinctive and personal. The BASIC ID represents the uniqueness of individuals; it reflects one’s basic identity. MMT thoroughly assesses behavior, cognition, affect, imagery, sensations, interpersonal relationships, and biological factors, resulting in a 7-point assessment framework. The BASIC ID framework serves as a tool for multimodal counselors to approach treatment and operate from a holistic point of view of the whole person.

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ROLES OF THE CLIENT AND COUNSELOR Across the integrative approaches, the counselor and client are both active participants in the treatment process. The counselor seeks to understand the personhood of the client as comprehensively as possible and to align a treatment approach to best serve the client. A word that summarizes the counselor’s role in integration is scaffolding: understanding where the client is at and tailoring a counseling approach along the leading edge of the client’s experiences and abilities. To this end, integrative approaches do not involve haphazard, random selection of treatment interventions. Rather, the counselor assesses the client’s needs and responds intentionally based on the integrative framework they are utilizing. The integrative approaches adopt the Rogerian concept of following the client’s direction in counseling. The client is invited to share what has prompted them to seek help, to educate the counselor about themselves and what they need from the counselor, and to work with the counselor to develop and implement the treatment plan. Clients commit to change strategies and work on achieving their treatment goals and objectives during and between counseling sessions.

Integrative Psychotherapy In this approach, the client and counselor work together collaboratively toward the client’s treatment goals. One of the counselor’s first and primary goals is to build a therapeutic relationship with the client. Recall that integrative psychotherapy is based on what works. Empirically, the therapeutic alliance is a significant contributor to client change in counseling, above and beyond specific techniques or interventions, so the therapeutic alliance is prioritized in this approach. Lest this sound too formulaic, integrative psychotherapy operates from what we know about counseling in general—that change and healing occur within the context of a safe and trusting relationship. The counselor seeks to provide the level of empathy, caring, and safety needed for the client to be able to open up, explore, and make change. In addition to building a therapeutic alliance, the counselor’s role is to gain a thorough understanding of the client, their presenting concerns, and their accompanying counseling goals. This is often accomplished via formal and informal assessment procedures. Based on what the counselor learns about the client, the counselor works with the client to develop and implement a treatment plan. A good treatment plan not only delineates a treatment approach but also clearly defines the client’s overall goals and specific objectives for counseling. Indeed, understanding what a client wishes to accomplish in counseling is important to effectively integrating treatment strategies (Norcross & Beutler, 2019). A treatment plan defines treatment strategies, techniques, and interventions that the counselor will implement, as well as the treatment setting format and level of care to be provided (Norcross & Beutler, 2019). For example, based on the acuity of the client’s presenting concerns, will interventions be provided at an outpatient, intensive outpatient, partial hospitalization, inpatient hospitalization, or residential level of care? These varying settings and levels of care can considerably influence the type and frequency of treatment interventions provided. Will the counselor and client meet weekly, biweekly, monthly, or perhaps daily? How long will the counselor and client need to meet? A person in acute crisis and receiving treatment in an inpatient setting is likely to be provided a higher frequency of interventions in a shorter period of time to promote crisis stabilization and de-escalation, whereas a person receiving outpatient care may engage in treatment more gradually (e.g., weekly) over time. Will the client engage in individual, group, couple, and/or family sessions? Are medications warranted, and if so, does psychopharmacology need to be part of the treatment plan? How will the client maintain their gains in counseling and avoid relapse? Each

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of these decisions should be informed by the client’s presenting concerns, strengths, needs, abilities, preferences, personality, and culture. The counselor utilizes empirical research to identify treatment interventions most fitting to relevant client factors and the treatment milieu. Integrative psychotherapy is not an impersonal approach in which the counselor selects and applies techniques or interventions in a robotic fashion. Neither is the approach about the counselor being the sole d ­ ecision-maker or prescriber of interventions for a client. The client is an active participant in the treatment process, and their preferences are honored and respected.

Transtheoretical Model The TTM is primarily focused on conceptualizing the client rather than the counselor. Nevertheless, the counselor’s overall role is to assess the client’s level of change related to their presenting concerns, as well as their current stage of change readiness, and to target relevant change processes (e.g., consciousness raising, contingency management) that help the client move through the stages of change. To do this, the counselor needs to build a therapeutic alliance in which the client feels safe discussing their needs and that fosters a commitment to work toward making change. When using the TTM, the counselor must be cognizant to stay attuned to the client’s readiness to change so that they can accurately identify the most relevant change mechanisms and respond to those with appropriate intervention strategies. The client is an active participant in the therapeutic process. Because change is central to the TTM, it is critical that the client buys into counseling and commits to working on change during and between sessions. The client need not be immediately ready to make change (e.g., planning, action) upon entering counseling, but the client’s role is to engage with the counselor in identifying what change they wish to make in their lives, to set realistic and achievable goals, and to work toward achieving those goals.

Eclectic Counseling Lazarus (1985) hypothesized that most psychological issues are multifaceted and that comprehensive treatment calls for a careful assessment of seven dimensions in which individuals function—behavior, affect, sensation, imagery, cognition, interpersonal relationships and drugs or biological processes. Therefore, the therapeutic relationship in MMT is pivotal. Rapport and compatibility between the client and counselor create safe spaces for assessment and serve as the foundation that enables the techniques to take root. Essentially, effective MMT calls for appropriate techniques, correctly administered, within the context of a trusting and caring therapeutic relationship (Fay & Lazarus, 1993). The therapeutic relationship educates, motivates, develops, cultivates, and separates issues and solutions (Lazarus, 2006). The BASIC ID is a helpful acronym for the seven dimensions of human personality and the fundamental zones of psychological functioning (Lazarus, 2006). Despite all individuals having all seven dimensions of the BASIC ID, no two individuals are the same in how they experience their psychological life. The dimensions reflect the uniqueness of each individual. For example, just as all musical arrangements can be reduced to the seven notes in the musical scale, no two musical pieces are the same despite being based on the same fundamental notes (Lazarus, 2006). Therefore, in addition to the fundamental dimensions of someone’s psychological framework, the BASIC ID can be considered as an individual’s “basic identity,” unique to them. One of the significant objectives of the therapeutic process is to help a person achieve a certain level of self-actualization, that is, to move from one’s current self a few steps closer toward one’s ideal self. While one might never actualize their full potential, applying the BASIC ID model can help pinpoint essential areas for modification that, when changed, will have one a lot closer to their ideal self (Lazarus 2006).

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The role of the client and counselor is to collaboratively engage in Lazarus’s (2006) MMT and BASIC ID approach and reflect on the following types of questions: ■ ■ ■ ■ ■ ■ ■

Behavior: “What specific action do you want to do more or less of?” Affect: “What emotion would you like to increase or decrease?” Sensation: “What sensation would you like to have more often or experience less frequently?” Imagery: “What mental picture would you like to 'see' more often or less often in your 'mind’s eye'?” Cognition: “What specific thought would you like to increase or decrease, start or stop?” Interpersonal relationships: “What specific social change would you like to make?” Drugs/health/biology: “What specific change in a health habit or physical issue would you like to make?”

To illustrate, Lazarus (2006) offers a typical example that a counselor and client might come up with during a session: ■ ■ ■ ■ ■ ■ ■

Behavior: Take more walks after dinner instead of watching TV. Affect: Reduce stress and anxiety. Sensation: Experience less muscle tension. Imagery: Visualize more success. Cognition: Reduce self-criticism and increase self-affirmations. Interpersonal: Spend more time with friends. Drugs/health/biology: Eat more vegetables and less processed food.

A single positive change in only one BASIC ID dimension is an essential step toward change. Intrinsically, some goals are more accessible to attain than others and may require professional clinical aid (e.g., reducing stress and anxiety or learning to manage anger). Applying the MMT BASIC ID, several changes across several modalities can be made and sustained. As a result, the client will have moved significantly closer to their “basic identity.”

NATURE OF HUMAN DEVELOPMENT Integrative approaches bring together a variety of theoretical perspectives and technical approaches, and thus do not propose a new or unique view of human growth and development across the life span. However, an integrative counselor would certainly draw broadly upon developmental theories to guide case conceptualization and to scaffold interventions. Expected and unexpected issues that impact people across the life span may serve as the focus of counseling or may help the counselor better understand their client and what approaches may work best for them. Such issues might include divorce; blending families; death of a friend, family member, or partner; physical illness; empty nesting; or aging. Likewise, integrative approaches would be interested in developmental considerations, such as chronological and developmental age, in an effort to scaffold interventions that will be of most use to the client. A 5- year-old child, for example, may not have developed the metacognition abilities required for CBT-based interventions but may comprehend and respond to BT interventions. From an integrative standpoint, human growth and development is important to selecting impactful intervention strategies that can affect‌‌‌‌ therapeutic gains.

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PROCESS OF CHANGE By now, you may sense a theme of “it depends” when it comes to explaining concepts through an integrative lens, and this mantra holds true for describing change processes. The integrative approaches hold that there are multiple pathways to change, healing, and wellness across the life span. No one theoretical model and its techniques can sufficiently explain the complexity of human nature, development, wellness, pathology, and change. Multiple change processes call for a flexible counseling approach that can adapt to clients’ complex needs and goals that are encapsulated within individual and systemic contexts.

Integrative Psychotherapy and the Transtheoretical Model The process of change is of primary interest in integrative psychotherapy and aligns very closely with the TTM in understanding and promoting change. The integration of various techniques and strategies is secondary to identifying and focusing on the mechanism of change for a given client. A client who is grieving the loss of a spouse may have a different process than a client experiencing gender-based discrimination and harassment in their workplace. True to its emphasis on empiricism over theory to guide the approach, integrative psychotherapy relies on research to identify mechanisms of change, which become the primary focus in counseling. Perhaps unsurprisingly, integrative psychotherapy draws on the TTM to describe the change process, given its robust empirical support for how people make change. Research into the TTM has identified general change processes that people use to solve problems (Norcross & Beutler, 2019; Prochaska & DiClemente, 2019; Prochaska et al., 1995), and integrative psychotherapy prioritizes these processes as well: ■ ■ ■ ■ ■ ■ ■ ■ ■

Consciousness raising: increasing self-awareness and awareness of presenting concerns Helping relationships: being heard, validated, and understood by close others Self-liberation: believing in one’s ability to change, choosing, and committing to action Social liberation: advocating for marginalized persons and for equity, access, and inclusion Counterconditioning: replacing problematic behaviors with healthier alternatives Self-reevaluation: reflecting on thoughts and feelings related to a problem Environmental control: altering one’s environment to address a problem Contingency management: rewarding self or others for change Emotional arousal: expressing emotions related to a problem

As you review these change processes, you can likely see how many of the theories throughout this book touch on one or more of these processes in their own way. In integrative psychotherapy, the whole point of integration is to target these change processes as they are relevant to a client. When devising those previously mentioned treatment plans, the integrative counselor is far more interested in these change processes than a specific intervention technique. Unlike a singular theoretical approach, integrative psychotherapy does not prioritize or favor any of these change processes more than others. All are considered equally valid possibilities for a treatment strategy, depending on relevant client factors (e.g., needs, preferences). Because these change processes come from the TTM, knowing the client’s readiness to change in relation to their presenting concerns is particularly useful for knowing which processes to prioritize. According to the TTM, a change process refers to some sort of activity that an individual does or experiences as they seek to modify behavior, thinking, or emotion

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related to a problem situation (Prochaska & DiClemente, 2019). The nine change processes consistently identified across theoretical models reflect the limited number of ways that people approach problem-solving. Whereas most singular therapy models will only target a few of these change processes, people may utilize or need to address many, if not all, of these processes across stages and levels of change. Thus, the counselor needs to be alert to the client’s current stage and level of change in order to target the most impactful change processes that can help the client progress in change readiness.

Eclectic Counseling MMT uses several diverse approaches to increase the likelihood of behavior change. As such, the techniques used in MMT are drawn from various cognitive, behavioral, and psychodynamic strategies (Lazarus, 2006; Pearsall, 2011). The MMT approach assumes that treatment will likely overlook significant concerns unless the seven modalities of BASIC ID are appropriately assessed, which inevitably begins the change process. The MMT change process includes modifying behavior in a manner that is appropriate and positive so that the individual can improve functioning. Another goal is to find effective methods that will aid the client in setting realistic goals for future behaviors. Many psychotherapeutic approaches are trimodal, addressing affect, behavior, and cognition (ABC). The MMT approach provides clinicians with an exhaustive framework to identify salient concerns that call for change. The MMT orientation is most widely applicable by separating sensations from emotions, differentiating images and cognitions, highlighting intraand interpersonal behaviors, and emphasizing the biological substrate (Lazarus, 2006). Assessing a client’s BASIC ID provides a change template and aids clients in realizing their ideal selves.

HOW PROGRESS IS MAINTAINED Across the integrative approaches, a common conceptualization of progress is the client’s movement through the TTM stages of change. Counselors may be lulled into thinking that the action stage is synonymous with client progress because it is the stage in which the client is modifying behaviors and taking direct action to remedy a problem situation. However, transitioning between any of the stages of change reflects forward progress in addressing a problem. The client struggling with an alcohol use disorder, for example, has made progress when they move from a precontemplation denial of the problem to contemplation of how alcohol use is impacting their life and relationships. A primary goal in maintaining progress is preventing relapse to a previous stage of change. Progress through the stages of change is prompted and maintained by the change processes described previously. In other words, the processes whereby a client moves from one stage to another is also a channel for sustaining the progress made. If consciousness raising helped our client move from precontemplation to contemplation of their alcohol use, then sustaining that increased awareness is important to the client maintaining the contemplation stage as they also work toward the next stage of planning. Recall that the TTM includes a maintenance stage as part of the overall change process. In this stage, the client has consistently been in the action stage for at least 6 months, has either successfully reached their goal or has made steady progress toward it, and has begun to focus on maintaining the gains made in the action stage. For example, a client seeking to lose 20 pounds would be considered in the maintenance stage after sustained actions to lose those pounds (e.g., implementing healthy eating habits, exercise) that result in achieving or getting close to the identified weight loss goal over at least a 6-month period. As with any stage of change, the key to remaining in the maintenance stage and avoiding relapse to a previous stage of change lies in the processes of change. For the maintenance stage, this

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might include sustaining the relationships that support the client’s change efforts, including the counselor, if appropriate. Remaining methodical with behavior changes, as well as any rewards or incentives used to make change (contingency management), are important in this stage. Some clients may need to reevaluate rewards and incentives in the maintenance stage if they become more intrinsically motivated. Related, advocacy for others and community engagement (social liberation) may provide ongoing reward and incentives to maintain personal gains, as well as offer meaning and identity around the changes the client has made. For example, many people who achieve sobriety through Alcoholics Anonymous find immense reward in sponsoring others, and this service to others often helps maintain their own sobriety. Some propose that relapse should be considered an additional stage of change, but relapse is considered to be more of a process wherein a person returns to problematic behavior and/or a previous stage of change. This can happen at any stage, for example, a client expressing a desire to lose weight and in the preparation stage might become overwhelmed or discouraged by the extent of their weight loss goals or a healthy eating plan that they have devised for themselves, sending them back to ambivalence about making change (contemplation stage). Similarly, a client who recently stopped smoking (action stage) might not only resume smoking but also may resume denial of the health risks posed by smoking and seek to rationalize their use (precontemplation stage). This latter example highlights an important principle: If a client relapses to a previous stage, it may not be just one stage back from the current stage. A client can relapse at any stage. This, too, highlights two broader principles to remember when using the TTM: (a) Change is often nonlinear, and clients may oscillate back and forth through stages on the road to behavior change, and (b) clients may spend a long time at one stage and progress through others quickly.

PROCESS OF CLINICAL ASSESSMENT True to their name, the approaches covered in this chapter integrate general clinical assessment practices while adding other areas of focus as needed. The primary goal of assessment is to gain a thorough understanding of the client and what interventions are most likely to be effective based on client characteristics (Norcross & Beutler, 2019). Each client is unique, and their lives are infinitely complex and layered, making it seemingly impossible to gain a comprehensive understanding of the client. Integrative counselors are primarily interested in assessing client factors that research has shown have the greatest influence on therapy outcomes (i.e., diagnosis, stage of change, coping, reactance, preferences, culture). Although not exhaustive, assessing and understanding these facets of a client can assist the counselor in selecting treatment interventions that stand the most optimal chances of success for the client. An integrative approach commonly makes use of biopsychosocial intake assessments that gather clinically relevant information about a client’s presenting concerns, history of the problem, family history, and medical history. These data serve as useful information for establishing treatment goals, objectives, and interventions. The counselor may wish to use diagnostic assessments or symptom inventories to understand better the nature and severity of the client’s presenting concerns, particularly if a mental health diagnosis seems present. The American Psychiatric Association (APA, n.d.) provides free assessments on its website based on the DSM-5-TR (APA, 2022), including self-, other-, and clinician-rated symptom and severity measures for adults and children; diagnostic personality inventories; background development measures; and cultural formulation interviews. The counselor may also wish to use symptom inventories backed by empirical research; for example, the Symptom Checklist-90-R has shown utility at screening a variety of symptoms and also has shown sensitivity to symptom change over time in response to interventions (Derogatis & Savitz, 1999). Such measures may work well not only for clarifying a client’s presenting

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concerns but also for tracking client change over time in counseling. As stated previously, most integrative counselors are more interested in utilizing diagnostic information for purposes of knowing how to best help a client and which interventions are most likely to be effective, and assessment serves this same purpose. That is, information gleaned from biopsychosocial assessments, diagnostic assessments, and symptom inventories serve as one source of information for establishing treatment goals with a client, selecting optimal treatment interventions, and defining benchmarks for measuring progress in counseling. Beyond diagnostics and psychopathology, counselors may also wish to utilize assessment to learn more about client factors relevant to the treatment process. Understanding the client’s readiness to change within the TTM is a vital piece of information in selecting treatment approaches. Many counselors can likely attest to clinical examples in which they attempted to engage a client at the action stage of change, only to be seemingly met with resistance because the client was in a different place related to making change. This “client resistance” can be reframed as the counselor’s failure to understand their client fully and to meet the client where they are; thus, the counselor is very interested in understanding their client’s readiness to change in order to maximize the likelihood of treatment success. The HABITS Lab at the University of Maryland, Baltimore County, houses multiple TTM-related assessments, such as the URICA, which measures stages of change, and the Processes of Change Questionnaire, which measures how shifts occur between the TTM stages. Both of these assessments have versions for alcohol and drug use, and there is a general psychotherapy version of the URICA (HABITS Lab, n.d.). Counselors may find these assessments, which are available freely in the public domain (https://habitslab.umbc.edu/ttm-­measures/), useful for formally assessing a client’s readiness to change and for using the results to have a therapeutically meaningful discussion with clients about making change. Integrative psychotherapy is also interested in a client’s coping style. When faced with difficult situations, people tend to respond along a continuum of externalizing or internalizing behaviors. Those with an externalizing style turn outward, often leaning on more impulsive, stimulation-seeking methods of coping, as well as seeking out and talking with others. Those with an‌‌‌‌ internalizing style turn inward and may be more inhibited and self-critical and will withdraw from others. Scaffolding a counseling approach to be more symptom-­ focused for clients with externalizing coping styles and more insight-focused for clients with internalizing coping styles can yield better therapy outcomes (Beutler et al., 2011a; Beutler et al., 2018b). Reactance level, or a client’s propensity for resistance, is also of interest to integrative psychotherapy because it helps the counselor to know how directive to be with a client. The counselor who prides themselves on being generally “blunt” or “confrontational” with their clients may inadvertently push away a more reactive client or create unhealthy storming within the therapeutic relationship. Thus, the integrative counselor assesses the client’s level of reactance as a means of tailoring interventions. Although it seems common sense, it is important to inquire about and honor a client’s preferences for treatment, as long as it is clinically appropriate to do so and would not harm the client or others. Client preferences can vary widely and may include preferences for the counselor (e.g., age, sex, gender, race, ethnicity, affective identity), a therapeutic approach or style (e.g., action versus insight oriented), or treatment options (e.g., individual, couple, group; Norcross & Beutler, 2019). Some biopsychosocial intake assessments include a SNAP, an assessment of a client’s strengths, needs, abilities, and preferences. Integrative counselors would be very interested in these data for purposes of tailoring interventions that fit a variety of relevant client aspects, notably their preferences for treatment. See Figure 12.1 for an example of items that might be included on a SNAP assessment. From an integrative perspective, cultural factors are critically important to understanding the client holistically and to tailoring interventions that will optimize therapeutic outcomes. The clinical picture shifts, for example, when the counselor understands that their adolescent client presenting with a depressed mood is facing homelessness after coming

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Strengths

Needs

Abilities

Preferences

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h Determined

h Fast learner

h Social supports

h Finances

h Creative

h Organized

h Spirituality

h Housing

h Goal oriented

h Resilient

h Other:

h Coping skills

h Sleep

h Social supports

h Finances

h Communication

h Grief/loss

h Medical care

h Housing

h Addiction

h Employment

h Other:

h Artistic

h Time management

h Take meds

h Insightful

h Computer skills

h Money management

h Assertive

h Empathic

h Reading/writing

h Organized

h Other:

h Individual counseling

h In-home counseling services

h Group counseling

h Telehealth appointments

h Couple or family counseling

h Specific days/times:

h Outpatient services

h Counselor gender:

h Language spoken:

h Other:

FIGURE 12.1‌‌‌ Example of a SNAP assessment. Note: Most SNAP assessments are longer and more comprehensive than the one shown here, but most are in checklist format to allow the client to complete the assessment quickly and for the counselor to be able to scan the client’s responses and initiate conversations based on the responses.

out to their parents. Culture can refer to a variety of identities and associated experiences, including race, ethnicity, nationality, sex, gender expansive identities, affective identity, age, ability, religion, and spirituality, among others. At an individual level, understanding a client’s cultural identities is important to selecting interventions that fit and respect the client’s cultural beliefs, values, and ways of knowing. How a client understands their presenting concerns, the therapeutic relationship, their role as a client, the counselor’s role, and the other characteristics discussed in this section can all be influenced by culture. Systemically, it is important to understand that cultural identities intersect and can afford privilege or marginalization in society, which impacts the client in a myriad of ways. Thus, clinical assessment across the integrative approaches is incomplete without some level of formal or informal assessment of culture. Finally, counselors utilizing MMT use the BASIC ID as a template for clinical assessment and subsequent treatment. The BASIC ID serves as a biopsychosocial approach to assessment and theoretically consistent, technically eclectic psychotherapy (Lazarus, 2006). That is, in discerning how to integrate techniques that can best help a client, the 7-point MMT framework is used as an assessment tool: behavior (our actions), affect (our emotions), sensation (our senses), imagery (our ability to visualize, imagine, and think in pictures), cognition (our language-based thinking), interpersonal relationships (our intimate connections and other social involvements), and drugs (our physical bodies, health behaviors, medical matters). For example, as a client describes their presenting concerns, the counselor may inquire about what the client is doing to try to solve the problem or what they are doing that perpetuates the problem; what emotions are present and how they are experienced; what physical sensations are present (positive or negative); what fantasies, dreams, or self-images

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are present; what attitudes, beliefs, and values the client holds; how the client is functioning in relationships with close others; the overall quality of the client’s health (including medical concerns); and whether or not the client is using any medications or substances. Often, the MMT counselor assesses these seven areas of BASIC ID informally via open-ended questions, but a formal biopsychosocial intake process can also elicit much of this information. Overall, by assessing each of the areas of BASIC ID, the counselor aims to take a broad or vague presenting concern and translate it into a specific issue that can be addressed with concrete interventions.

THEORETICAL TECHNIQUES Integrative Psychotherapy Integrative psychotherapy does not contain its own set of techniques. Rather, the purpose of integrative psychotherapy is to apply techniques and strategies from across therapeutic models that will enhance the therapeutic process and promote optimal chances of success for the client. The key to this process is matching empirically supported treatments to client factors that bear the greatest impact on treatment outcomes (i.e., diagnosis, stage of change, coping, reactance, preferences, culture). If a client has an identified psychiatric diagnosis, the counselor would consult the research literature to identify treatment approaches that have demonstrated efficacy with that specific disorder or that diagnostic group. For example, researchers have found that DBT is effective for clients with borderline personality disorder, as well as other depressive and anxiety disorders. Prolonged exposure therapy, cognitive processing therapy, and eye movement desensitization and reprocessing each has empirical support for trauma and stressor-related disorders. Some approaches may have a manualized or stepwise method in which techniques are applied. Diagnoses and corresponding treatment approaches are a starting point, but counselors must also consider the other client factors, as well as the client’s stated goals for treatment. Recall that research on coping styles has revealed that people tend to respond to problem situations along a continuum of external and internal coping strategies. Action-oriented and skill-building approaches (e.g., BT, CBT approaches, SFBT) may better fit a client with an external coping style, whereas psychodynamic and other insight-oriented approaches may better fit a client with an internal coping style. Researchers have found that highly reactive clients may report more therapeutic gains when the counselor adopts a nondirective and reflective approach (Beutler et al., 2018a). Thus, these clients may respond better to psychodynamic, ­person-centered, and narrative approaches. In contrast, clients with lower reactivity may respond well to more directive interventions (Beutler et al., 2011b), such as BT, CBT approaches, or SFBT. Finally, counselors ensure that techniques are culturally inclusive and responsive, including making sure that interventions are adapted as needed to the client’s language or understanding of language and culture. The counselor learns about the client’s intersecting identities and ensures that any techniques respect and honor the client’s way of knowing and their values. An important distinguishing characteristic of this approach is that the specific intervention or technique is less important than the process of change (Norcross & Beutler, 2019). Integrative psychotherapists draw on a variety of techniques, sometimes from theoretical paradigms that are decidedly different in their views of human nature and change, but the most important piece of integrating techniques is helping the client to achieve some degree of change toward their treatment goals. Techniques are a means to an end, and the counselor is most interested in how the client can make, achieve, and sustain change within counseling.

Transtheoretical Model Similar to integrative psychotherapy, the TTM does not contain its own set of techniques. Indeed, the TTM was not created specifically as a model of therapy but as an empirically

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derived description of how people make changes in their lives. Nevertheless, a counselor utilizing the TTM would integrate techniques from across therapeutic modalities that align with the client’s stage of change. With a goal to help clients advance through the stages of change, the best way to integrate techniques is to align techniques to the change processes associated with movement among the stages (see Table 12.2). Remember that processes of change in the TTM refer to how an individual actually makes a shift from one stage of change to the next. By identifying a client’s current stage of change and the processes most likely to help the client advance to the next stage of change, the counselor can integrate therapeutic techniques that address these processes and promote change readiness.

Eclectic Counseling As an eclectic approach, MMT integrates techniques from a variety of therapeutic modalities depending upon the client’s presenting concerns and the most relevant needs gleaned from a BASIC ID assessment. For example, an MMT counselor might incorporate operant conditioning or psychoanalytic techniques without subscribing to the theories that gave rise to the employed methods (Lazarus, 2006). Instead of integrating any specific theoretical viewpoints, the counselor operates out of a broad-based social cognitive learning framework. According to Lazarus (1989), when using various techniques, MMT counselors tend to avoid making interpretations (e.g., “you do or feel x because of y”) because interpretations come across as presumptuous. Lazarus staunchly delineated between psychodynamic interpretations and behaviorally based interpretive suggestions. Instead of interpretations, MMT uses curiosity to facilitate open dialogue. For example, an MMT counselor can employ listening and reflecting techniques, cognitive restructuring methods, and behavior rehearsal strategies during a counseling session (Lazarus, 1995). The techniques selected align favorably with the client’s specific needs and expectations. Table 12.3 provides examples of techniques that might be applied based on an assessment of a client’s BASIC ID. According to MMT, integration does not have to refer solely to attempts at a theoretical amalgamation (Bernard & Snipes, 1996; Lazarus, 1995). For example, integrating individual and group therapy will benefit some clients. For others, psychosocial and pharmacological integration may be strongly warranted. The focus of integration in MMT may be on applying various treatment combinations in addition to techniques, in which case progress will be more likely to occur. In turn, this could result in more attention to the factors and processes that genuinely facilitate therapeutic change (i.e., matching appropriate techniques with different relationship styles and unique personalities; Lazarus, 1995, 2006; Lazarus & Beutler, 1993). Table 12.2. Therapeutic Models and Techniques Based on Transtheoretical Model Change Processes Change Process

Techniques

Consciousness raising

Psychoeducation, motivational interviewing

Helping relationships

Person-centered therapy (e.g., core conditions), therapeutic alliance

Self-liberation

Behavior therapy, cognitive behavioral approaches, goal setting

Social liberation

Feminist therapy, narrative therapy, social justice advocacy

Counterconditioning

Behavior therapy, solution-focused brief therapy, reality therapy

Self-reevaluation

Cognitive behavioral approaches, insight-oriented therapies

Environmental control

Behavior therapy, solution-focused brief therapy, reality therapy

Contingency management

Behavior therapy, solution-focused brief therapy, reality therapy

Emotional arousal

Motivational interviewing, gestalt therapy

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Table 12.3. Therapeutic Techniques Based on the BASIC ID BASIC ID Domain

Techniques

Behavior

Operant conditioning, classical conditioning, exposure therapy

Affect

Rational emotive imagery, gestalt empty chair, role-playing

Sensation

Mindfulness exercises, DBT distress tolerance skills (e.g., self-soothing)

Imagery

Mindfulness exercises, free association

Cognition

Cognitive restructuring, thought journaling, psychoeducation

Interpersonal relationships

Role-playing, immediacy, genograms, systems approaches

Drugs

Psychopharmacology

MULTICULTURAL, INTERSECTIONAL, AND SOCIAL JUSTICE ISSUES The integrative approaches discussed in this chapter prioritize holistically understanding the client and tailoring a counseling approach based on the client’s needs. Any integrative counselor that hopes to accomplish this feat cannot overlook the influence of culture and a client’s intersecting identities. Counselors must be aware of their client’s worldviews, values, and beliefs, as well as their own cultural context. Counselors must also account for systemic issues, such as privilege, marginalization, and oppression, that influence the client, counselor, and therapeutic process. That said, a limitation shared across the approaches in this chapter is that they conceptualize and intervene with clients’ presenting concerns at the individual level rather than on systemic levels. That is, although culture is integrated into these approaches, the onus for change lies with the individual. Working at an individual level with clients who are being systemically and intentionally marginalized and oppressed can stigmatize the individual while also missing the mark of where change needs to occur.

Integrative Psychotherapy In integrative psychotherapy, cultural responsiveness is key. Research has shown that a client’s culture is a clinically significant predictor of change in counseling, and it is considered one of the “big six” client factors that contribute to change. Therefore, the counselor integrates the client’s various identities (e.g., race, ethnicity, age, sex, gender, ability, sexual, affective) and how they may intersect into the treatment process when considering interventions and when building and maintaining a therapeutic alliance. Importantly, integrative psychotherapy emphasizes two concepts: (1) Do not assume that any one particular cultural identity defines the client or their experiences, and (2) have a conversation with the client about culture at the outset of counseling and determine which cultural variables are most important to the client in the therapeutic setting (Norcross & Beutler, 2019). Following these guidelines can assist the counselor in effectively bringing in and respecting the client’s culture throughout the therapeutic process.

Transtheoretical Model The counselor using the TTM attempts to tap into processes of change that can assist the client in moving through the stages of change. From a multicultural perspective, there may

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be considerable variability in which change processes clients find motivating across the various stages of change. For example, Benitez et al. (2017) conducted focus groups with Mexican/Mexican American women to identify what processes of change were most relevant as they tried to increase their physical activity. The researchers found that challenges, replacement behaviors, and rewards/incentives were common but also occurred in the context of caring for family and children and emphasizing the importance of relationships. It is important that a counselor using the TTM must be aware of and responsive to the client’s cultural context and values in order to effectively engage the client in change processes. The TTM also identifies social liberation (i.e., advocacy) as a process of change, which challenges the counselor to not only be aware of systemic issues impacting clients but to be willing and able to intervene at systemic levels.

Eclectic Counseling MMT is a holistic approach that focuses on treating the whole person rather than focusing too narrowly on specific symptoms. MMT can treat emotional and psychological problems and address several physical conditions that have a psychological component or cause, such as pain, fatigue, and insomnia. MMT’s most noteworthy feature is that it transcends simple diagnostic labels and promotes highly individualized therapy (Lazarus, 1991). The stigma of diagnoses significantly impacts marginalized communities and does not consider the variations in symptomatology based on culture. People with the same diagnosis can experience distinct symptoms and thus require different treatment plans. For example, one person diagnosed with major depression might report insomnia, anger, agitation, loss of appetite, anxiety, helplessness, rumination, and social withdrawal. However, another person with the same “depression” diagnosis might describe experiencing hypersomnia (i.e., sleeping too much), lethargy, trouble concentrating, guilt, worthlessness, crying, loss of pleasure, and thoughts of suicide (Lazarus, 1991). MMT therapists can focus treatment on the issues most relevant to the individual’s unique issues and experience by utilizing interventions from different modalities rather than just one.

SCHOLARSHIP AND RESEARCH TRENDS The integrative approaches centralize research as a guiding principle in clinical decision-making. Perhaps ironically, the “customization of psychotherapy” that each approach in this chapter calls for can make research on the approaches difficult. At their core, integrative approaches spurn the idea of a singular therapeutic approach, which is clinically useful, but the lack of standardization makes research efforts difficult to conduct. Additionally, across the broad range of integrative approaches that exist, it can be difficult to discern which are truly integrative and eclectic approaches. Nevertheless, outcome research has steadily increased in the last few decades.

Integrative Psychotherapy Integrative psychotherapy is difficult to study as a distinct approach because interventions are selected to match relevant client characteristics (i.e., what we have referred to in this chapter as “the big six”). However, research has consistently supported the utility of focusing interventions on those six client characteristics. For example, in a meta-analysis of 587 studies, Swift and Greenberg (2014) found that integrative approaches had the lowest dropout rates among clients with depressive disorders and post-traumatic stress disorder (PTSD). They also found that a client’s decision to continue counseling tended to hinge more on common factors and client and counselor characteristics rather than the therapeutic approach

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being applied. Boswell et al. (2019) offer an in-depth review of randomized controlled trials in which various treatment approaches were aligned with client diagnoses. Regarding coping styles, several meta-analytic studies have shown that tailoring a counseling approach to be more symptom-focused for externalizing coping styles and more insight-focused for internalizing coping styles yielded medium to large treatment effects (Beutler et al., 2011a; Beutler et al., 2018b). Similarly, meta-analyses on client reactance have shown that adopting a less directive stance with highly reactive clients yielded large treatment effects (Beutler et al., 2011b; Beutler et al., 2018a). A meta-regression using data from 33 studies found that matching treatment interventions to client preferences resulted in improved therapy outcomes and decreased likelihood of terminating counseling prematurely (Swift et al., 2013). Finally, cultural competence and responsiveness have been extensively researched and discussed across the mental health disciplines. The ACA and its divisions have produced multiple competency documents for effectively working with a variety of diverse client populations, including LGBQIQA, transgender, disability-related, spiritual and religious, multiracial, and military populations. These competencies are available at www.counseling. org/knowledge-center/competencies. Integrative psychotherapy also emphasizes the importance of the relationship in counseling. Multiple meta-analyses of hundreds of studies with thousands of clients have shown that a strong working alliance predicts greater therapy outcomes (e.g., see Flückiger et al., 2018). A meta-synthesis of nine qualitative studies on the client’s perspective on how the therapeutic alliance forms in early sessions revealed themes of meeting a competent and warm therapist; being understood as a whole person; feeling appreciated, tolerated, and supported; gaining new strength and hope for the future; and overcoming initial fears and apprehension about psychotherapy (Lavik et al., 2018). The therapeutic alliance has been so strongly supported as a key agent of change above and beyond theory or technique that many consider it the primary common factor of change in counseling.

Transtheoretical Model The TTM is perhaps one of the most well-researched integrative models to date. There have been hundreds of meta-analyses, systematic reviews, and outcome and process studies across health-related behavior change, addiction, smoking cessation, and psychotherapy, just to name a few. Most of these studies highlight the utility of the TTM. For example, in a systematic review of 57 TTM studies focused on health behaviors for chronic diseases, Hashemzadeh et al. (2019) found that most studies found positive support for the TTM, and very few studies reported negative outcomes. A meta-analysis of 39 studies on psychotherapy found that a client’s stage of change strongly predicted therapy outcomes and premature termination of therapy (Norcross et al., 2011). Similarly, Krebs et al. (2018) conducted a meta-analysis of 76 psychotherapy studies and found therapy outcomes were linked to a client’s stage of change prior to entering counseling. The farther along a client was in the stages of change prior to beginning counseling, the better the outcomes in counseling. Collectively, the robust research on the TTM supports the model’s effectiveness for conceptualizing a client’s readiness to change and in aligning techniques with relevant change processes that can help a client advance through the stages of change.

Eclectic Counseling Although MMT remains popular clinically, research studies into the approach are older. Additionally, some of the research into MMT has shown mixed results, although it is worth noting that many of the techniques commonly integrated into MMT, particularly the CBTbased and behavioral techniques, have considerable research support. In an outcome study

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of middle school students at risk for dropping out of school, Gerler et al. (1990) found that MMT significantly improved attitudes for female (but not male) students, but MMT had no significant effect on behavior or academic performance. Williams (1988) found that MMT was effective for working with children with learning disabilities, and Kwee (1984) found that MMT was effective for inpatient clients diagnosed with obsessive compulsive–related disorders and phobias. Similar to other integrative approaches, it can be difficult to study MMT because of its heterogeneous clinical implementation, but additional research on this approach is needed.

DETAILED CASE CONCEPTUALIZATION PRAGMATICS AND TRANSCRIPT In this section, we apply the three integrative approaches to the case of Mark. We will conceptualize Mark’s presenting concerns and offer a sample transcript for the TTM in a session with Mark. From the outset, neither integrative psychotherapy nor the TTM holds any implicit assumptions about where Mark’s presenting concerns came from or how they have developed over time. From the lenses of these two models, the counselor is not interested in explaining the origins of Mark’s concerns, but the counselor is very interested in helping the client to address them. Rather than rely on theory, integrative psychotherapy would begin with a thorough clinical assessment that will allow the counselor to gain a holistic understanding of Mark and his presenting concerns. The counselor would engage with Mark in completing a biopsychosocial assessment that addresses areas such as Mark’s presenting problems (with particular emphasis on any diagnostic symptomatology), a detailed clinical history of those concerns (e.g., when they began, how often they occur, whether they come and go or are constant), a risk of harm assessment, a detailed medical history, a detailed family history, social and interpersonal issues, and a SNAP assessment. Because Mark reported feeling anxiety, sadness, and anger, the counselor may wish to formally assess these symptoms with a DSM-related symptom inventory to help rule out any potential diagnoses. The counselor might also wish to formally assess Mark’s stage or process of change with a URICA or Processes of Change Questionnaire. Based on the results of these assessments, the counselor would then work with Mark to complete a treatment plan that outlines his goals for counseling and the interventions that the counselor will provide to help Mark reach his therapy goals. Mark’s distress resulting from his divorce and his oscillation between loneliness and guilt are two presenting concerns and thus potential areas to address in counseling. The counselor would work from here to help Mark identify goals that are SMART (Specific, Measurable, Attainable, Realistic, and Time-sensitive). Relevant to designing a treatment plan with SMART goals are the therapeutic milieu (i.e., outpatient, individual counseling) and how much time the counselor and Mark have together. If Mark is using his insurance to pay for counseling, there may be a limited number of sessions, which would impact what can realistically be accomplished in counseling. The counselor would also use the information gained from the assessments to identify the “big six” client factors. Diagnostically, Mark reports symptoms of anxiety, sadness, and anger. These symptoms could point to a variety of mood or anxiety disorders, but a close examination of his presenting concerns suggests that these symptoms are in response to environmental stressors (i.e., divorce). If a diagnosis is warranted or required, the counselor may find an adjustment disorder to be a fitting explanation for his symptoms. Psychoeducation and action-oriented approaches (i.e., solution-focused) are often indicated for adjustment disorders and may work well for Mark.

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The assessment process can also give the counselor insight into Mark’s coping style and reactance level. As the counselor asks questions in the biopsychosocial assessment, how does Mark react to the counselor? If Mark seems reactive to the counselor, then the counselor may find that being less directive could be more effective. Close attention to Mark’s preferences for treatment is important in this case. For example, Mark mentioned guilt over dating because it may take time away from his daughters. Assessing and responding to any preferences for individual or family therapy can improve his engagement and success in counseling. Would Mark feel more comfortable with a male or female counselor? With a counselor who also is Black? Related, it is important to consider Mark’s cultural identities. It is insufficient to assume that Mark’s race, sex, or gender are all-encompassing. Rather, the counselor needs to engage Mark in a discussion about what it means to him to be an African American man dealing with the concerns that have brought him to counseling. Any cultural similarities or differences between Mark and the counselor need to be explored as well. From a TTM perspective, Mark’s presenting concerns appear to reflect a symptom level of change. However, as counseling unfolds and Mark delves into working on these concerns, the counselor may discover that more complex inter- or intrapersonal conflicts are present, particularly in his loneliness and guilt. It is important for the counselor to stay tuned into the level of change throughout the counseling process because Mark may be in different stages of change readiness in relation to varying levels of change. The counselor needs to identify Mark’s stage of change readiness for each stated counseling goal. Mark appears to recognize that he has unresolved feelings in relation to his divorce, and he seems aware of his conflicted feelings about dating again. These insights suggest at least a contemplation stage of change for each goal, though additional probing from the counselor is needed to see if Mark is any farther along in the stages. Based on his stage of change, the counselor would identify associated change processes and focus on these in treatment. For example, if Mark was in the contemplation stage of change, the associated processes of change to help move him to the preparation stage are helping relationships and self-reevaluation. In this case, focusing on building the therapeutic alliance and providing Rogerian core conditions (helping relationships), along with cognitive behavioral (CB) or insight-oriented strategies (self-reevaluation), can help Mark to explore his concerns in more detail and move toward preparing for change. Transcript

Skill(s) Demonstrated

Counselor: Mark, we have been talking about a couple of things that are bothering you, including dealing some lingering feelings from your divorce. You’re also wanting to move forward and date again because you feel lonely, but you’re also feeling guilty because dating might take away time with your daughters. I’m curious where you’d like to start in addressing these concerns?

Paraphrasing, open-ended question, and assessing stage of change (The counselor paraphrases the client’s concern and follows up with a question related to goal setting. This question relates to the self-liberation process of change, which is associated with the preparation stage. Because the counselor can infer that the client is at least in contemplation, this question can assess if Mark is beyond contemplation and in preparation.)

Mark‌‌‌‌ [pauses]: I honestly have no idea. I feel stuck. The loneliness is awful, but at the same time, the thought of not spending time with my daughters to go on a date with someone I may not even like doesn’t sound great either.

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Counselor: Yeah, I can sense that feeling stuck. Stuck between two not-so-great alternatives: Do I carry on feeling lonely like I do now, or do I try to do something about that and date and feel guilty about it?

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Empathic reflection (Mark’s response earlier‌‌‌‌ indicated he is aware but not yet ready to take action. The counselor then pivots to an empathic reflection, a skill from the helping relationships process of change, which is associated with the contemplation stage.)

Mark: Yeah exactly. That’s exactly what it feels like. My daughters are so important to me, and I want to be a good dad to them. Counselor: I’m curious, what does it mean to be a good dad to your daughters?

Insight-oriented question (Questions and reflections designed to promote client reflection and insight are consistent with the self-reevaluation process of change, which aligns with the contemplation stage.)

Mark: Somebody who’s there for them, you know what I mean? I promised them when their mother and I divorced that I would always be there. My dad wasn’t there much for me growing up. He was always working or with his friends. I don’t want to be that way for my kids. Counselor: That does make sense. So, when you think about going on a date with someone, what is the very first thought that runs through your mind?

Open-ended question aimed at identifying automatic thoughts (Cognitive behavioral approaches also assist with self-reevaluation during contemplation. Here, the counselor challenges Mark to reflect on automatic thoughts that might be driving his guilt.)

Mark: The first thought that runs through my mind is “You’re abandoning your kids to go have fun.” Counselor: If I go on a date with someone and try to have a good time, then I must be abandoning my daughters. This date sounds like the worst possible thing that could ever be done to them!

Reflection with a bit of exaggeration to identify cognitive distortion (The counselor sticks with a cognitive intervention here and begins to help Mark explore how his all-or-nothing thinking may be impacting the guilt he feels.)

Mark [laughs]: Well, when I hear it put that way, it does sound a little extreme.

MMT would conceptualize Mark through its roots in social learning theory and its cognitive and behavioral tenets. Recall that MMT believes in the notion that behavior is shaped and sustained through environmental factors. In Mark’s case, his distress related to his divorce and his feelings about dating are assumed to be environmentally based and multifaceted. Assessment of the BASIC ID domains can help the counselor translate Mark’s broad concerns of anxiety, sadness, anger, loneliness, and guilt into more concrete issues that can be addressed with integrative techniques. Here are questions that the counselor might ponder or ask Mark directly in assessing the BASIC ID: ■

Behaviors: What is Mark doing that sustains or exacerbates his distress? What actions could Mark take that would reduce his distress?

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Affect: Divorce and single parenting can carry a range of emotional experiences, and Mark has reported quite a few. For example, he reports feeling anxiety, sadness, anger, loneliness, and guilt. The counselor might assess how often each of these emotions occur, as well as the intensity of each when they arise. The counselor would also assess the context in which these emotions occur for Mark—what occurs that precipitates these emotions? Are negative thoughts present that need to be addressed in relation to the emotions? What does Mark do (behavior) in response to these emotions, and could this be an avenue for intervention? Sensation: Does Mark have any somatic complaints? With his anxiety, for example, where does he carry it in his body? Does he notice any other bodily sensations? Because MMT sees the elements of BASIC ID as interconnected, the counselor would also explore the extent to which thoughts, emotions, and behaviors are related to any of Mark’s sensations. Imagery: Mark’s statement that dating might take him away from his daughters could offer some insight into his self-concept, or his image of himself within his family. It is possible that Mark’s identity as a father to his daughters is very important to him. The counselor may wish to explore this self-image, what it means to him to be a “good father,” and how he sees balancing his image of “father” with dating again. Any other images or fantasies that Mark may have would be explored, including how they connect to thought, feelings, behaviors, etc. Cognition: What does Mark say to himself? How does he evaluate his life and circumstances? When he feels the anxiety, the sadness, the guilt, what messages is he sending himself? What are Mark’s attitudes, beliefs, and values, and how do they influence his emotions, behaviors, and other areas of the BASIC ID? If any clear irrational beliefs or cognitive errors are evident, CBT-based interventions may be indicated. Interpersonal: Mark’s relationships with his daughters appear to be very important to him. What is his relationship like with each of his daughters? What does Mark want or expect from his relationship with them? Is family counseling warranted? Additionally, Mark reports feeling lonely, so it would be worthwhile to explore what Mark wants in a relationship. Drugs/health/biology: Does Mark have any health or medical concerns? Is he physically healthy? Does he take any medications or substances? How are his sleep and eating habits? Does he exercise regularly? Sleep, diet, and exercise are particularly relevant to Mark’s case given his distressing emotions, working, and living with his two daughters as a single parent, all of which can impact a person physically.

THEORETICAL LIMITATIONS Despite the increasing popularity of integrative approaches, there are limitations. We covered just three approaches in this chapter, but there are many approaches that fall under technical, theoretical, or assimilative integration or a common factors approach. A limitation across the approaches is that there is no unifying philosophy that guides them. The varying approaches may have vastly different perspectives on the nature of mental health, wellness, and human development. Some approaches, such as integrative psychotherapy and the TTM, may offer no perspective on these areas at all. Theory helps a counselor make sense of a client’s experiences and presenting concerns, and they guide the counselor on how to respond and intervene. Operating without a clear theoretical framework or with a complex framework consisting of multiple theories can potentially overwhelm or confuse counselors.

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Successful integration requires considerable experience and expertise in several areas, such as knowledge of multiple theoretical models, proficiency in applying a diverse range of techniques, competence in clinical assessment, and connection to clinical research studies (including an ability to discern strong and weak studies). Counselors may be surprised to find that the seemingly simple premise of aligning treatment techniques to relevant client factors (i.e., integrative psychotherapy) is actually much more complex than it seems. Similarly, the deceptively simple stages of change outlined in the TTM require an accurate and precise technique to be able to hone in on the processes of change that will help the client to advance in their change readiness. Developing integrative expertise requires reflective practice over time. While MMT offers a comprehensive orientation that is highly flexible and aims to match the best and most effective methods with the appropriate treatments for each individual, there do exist several circumstances in which one may elect not to work multimodally (Lazarus, 2006). For example, a clinician treating a client with severe psychopathology (e.g., active delusions, extreme depression, pervasive anxiety) would likely experience challenges getting the client to complete the Multimodal Life History Inventory. Further, certain circumstances call for an immediate, highly focused crisis intervention sequence, with emphasis on intense yet time-sensitive methods (Lazarus, 2006). Another potential limitation includes the therapist’s level of theoretical knowledge and skill. Lazarus emphasized that a blend of different theories will likely result in profound confusion for some. Many seemingly compatible ideas are irreconcilable upon closer scrutiny. Therapists must have a broad scope of knowledge and experience with many different psychological approaches to utilize them together effectively. MMT often emphasizes the proper and appropriate use of techniques that meet an individual’s unique BASIC ID, not the integration of the theories.

SUMMARY Integrative approaches are a powerful way to address a variety of client concerns. In the current climate of mental healthcare dominated by managed care, evidence-based practice, and brief therapy, integrative approaches allow counselors to rise to these challenges with flexible and honed interventions that offer robust opportunities for client improvement. Whether you find yourself drawn to integrative psychotherapy, the TTM, MMT, or perhaps a different integrative approach not discussed in this chapter, these approaches centralize the client’s strengths, needs, abilities, preferences, and culture, perhaps more so than any singular therapeutic approach is capable of doing. Despite their appeal, we caution readers that fluency with integration requires considerable experience and expertise gained through clinical supervision, consultation, and reflective practice. With time and experience, integrative approaches are arguably the wave of the future in mental healthcare.

VOICES FROM THE FIELD This chapter features a digitally recorded interview entitled Voices From the Field. The interview explores multicultural, social justice, equity, diversity, and intersectionality issues from the perspective of clinicians representing a wide range of ethnic, racial, and national backgrounds. The purpose of having chapter-based authors interview individuals representing communities of color or who frequently serve diverse populations is to provide you, the reader, with relevant theory-based social justice and multiculturally oriented conceptualization, contemporary issues, and relevant skills.

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Access the video at https://bcove.video/3RNoFJJ

Tyra Roy (she/her) is a 37-year-old, biracial (Black/African American and White), cisgender woman. She is a registered mental health counseling intern in Florida. She graduated with a Council for Accreditation of Counseling and Related Educational Programs (CACREP)-accredited master’s degree in the University of South Dakota. Tyra has 6 years of clinical experience in private practice; in-home, residential addiction, and inpatient treatment settings. She uses an integrative approach that focuses on elements of CBT and person-centered therapy.

STUDENT EXERCISES Exercise 1: Pathways to Theoretical Integration

Review the pathways to theoretical integration. Which one stands out as potentially most useful to you and why?

Exercise 2: Integrating Your Own Theoretical Orientation

Write down the theories that you like and that you can see yourself using in your own clinical work. Try to list at least two or three. For each theory you wrote down, list any theoretical assumptions from those theories that resonate with you. Next, list your favorite techniques or interventions from each theory. Now, take a close look at your list: Do the theories, their assumptions, and their techniques meld together naturally or are their differences? If you were to integrate these theories into your own counseling style, how might you go about it?

Exercise 3: Your Theoretical Orientation and the Transtheoretical Model

Using the list that you generated in Exercise #2, review the interventions and techniques that you wrote down as important to you. Compare those techniques to the TTM stages and processes of change. Are the techniques aligned with any particular stage of change? Which processes of change do your preferred interventions target? Are any processes of change missing from your toolbox of preferred intervention strategies? Based on this review, do you feel prepared to help clients at all stages of change readiness? Are there stages or processes of change with which you feel less prepared? How so?

Exercise 4: Evidence-Based Practice

Integrative psychotherapy does not rely on theory to understand a client, but rather on research and clinical assessment. What do you see as the pros and cons of this approach? Do you think that you could practice in this way? Why or why not?

Exercise 5: Multimodal Therapy

MMT proposes that our problems are formed and reinforced by our environment. Do you agree or disagree with this idea? Why?

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RESOURCES Helpful Links ■

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ALGBTIC. (2010). American Counseling Association competencies for counseling with transgender clients. Journal of LGBT Issues in Counseling, 4(3), 135–159. https://­wsaigecounseling. org/wp-content/uploads/2019/07/Competencies-for-Counseling-Transgender-Clients.pdf‌‌‌‌ ALGBTIC LGBQQIA Competencies Taskforce, Harper, A., Finerty, P., Martinez, M., Brace, A., Crethar, H. C., Loos, B., Harper, B., Graham, S., Singh, A., Kocet, M., Travis, L., Travis, L., Lambert, S., Burnes, T., Dickey, L. M., & Hammer, T. (2013). Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling competencies for counseling with lesbian, gay, bisexual, queer, questioning, intersex, and ally individuals. Journal of LGBT Issues in Counseling, 7(1), 2–43. https://saigecounseling.org/wp-content/ uploads/2019/07/Competencies-for-Counseling-with-LGBQQIA-Individuals.pdf‌‌‌‌ Benitez, T. J., Tasevska, N., Indiana, K. C., & Keller, C. (2017). Cultural relevance of the transtheoretical model in activity promotion: Mexican American women’s use of the ­process of change. Journal of Health Disparities Research & Practice, 10(1), 20–27. https://digitalscholarship.unlv.edu/jhdrp/vol10/iss1/2‌‌‌‌ Marshall Lee, E. D., Hinger, C., Lam, H., & Wood, K. A. (2022). Addressing deep poverty-related stress across multiple levels of intervention. Journal of Psychotherapy Integration, 32(1), 34–48. https://doi.org/10.1037/int0000255 Ratts, M. J., Singh, A. A., Nassar-McMillan, S., Butler, S. K. and McCullough, J. R. (2016). Multicultural and social justice counseling competencies: Guidelines for the counseling profession. Journal of Multicultural Counseling and Development, 44, 28–48. https://doi. org/10.1002/jmcd.12035

Helpful Books ■

Palmer, S., & Woolfe, R. (Eds.). (2000). Integrative and eclectic counselling and ­psychotherapy. Sage.

• Contains chapter on “Multicultural issues in eclectic and integrative counselling and ­psychotherapy” by Lago and Moodley. ■

Norcross, J. C., & Goldfried, M. R. (Eds.). (2019). Handbook of psychotherapy integration (3rd ed.). Oxford University Press.

• Contains chapters on:

“Integrative psychotherapy with culturally diverse clients” by Harris et al.

“International themes in psychotherapy integration” by Gómez et al.‌‌‌‌ ■

Norcross, J. C., & Lambert, M. J. (Eds.). (2019). Psychotherapy relationships that work. Volume 1: Evidence-based therapist contributions (3rd ed.). Oxford University Press.

• Contains chapters on: “Alliance in child and adolescent psychotherapy” by Karver et al. “Alliances in couple and family therapy” by Friedlander et al.‌‌‌‌ ■

Norcross, J. C., & Wampold, B. E. (Eds.). (2019). Psychotherapy relationships that work. Volume 2: Evidence-based responsiveness (3rd ed.). Oxford University Press.

• Contains chapters on: “Cultural adaptations and multicultural competence” by Soto et al. “Gender identity” by Budge and Moradi “Religion and spirituality” by Hook et al. “Sexual orientation” by Moradi and Budge‌‌‌‌

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Prochaska, J. O., & Norcross, J. C. (2018). Systems of psychotherapy: A transtheoretical analysis (9th ed.). Oxford University Press.

• Contains chapters on systemic therapies, gender-sensitive therapies, multicultural ­therapies, and constructivist therapies.

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Broderson, G. (Director). (2006). Prescriptive eclectic psychotherapy [Video/DVD]. American Psychological Association. https://video.alexanderstreet.com/watch/prescriptive-eclectic-psychotherapy. In this video, John Norcross demonstrates an eclectic approach to counseling, emphasizing an individualized approach to client factors and situations. BU Center for Psychiatric Rehabilitation. (2012, May 24). Helping populations progress through the stages of change [Video]. YouTube. https://youtu.be/8XUaq2iqzA0. In this video, James Prochaska discusses how to apply the TTM to diverse issues and populations. Lazarus, A. (n.d.). Arnold Lazarus: Live case consultation [Video]. psychotherapy.net. www. psychotherapy.net/video/lazarus-live-consultation. In this video, Arnold Lazarus consults with two practitioners on complex client concerns. The clients present with diverse issues such as divorce and fostering/blended families. Norcross, J. C. (2013). Integrative therapy [Video/DVD]. American Psychological Association. https://video.alexanderstreet.com/watch/integrative-therapy-2. In this video, John Norcross discusses the tenets of integrative psychotherapy, including the role of a client’s culture as central to therapeutic change. Psychotherapy Expert Talks. (2016, April 14). John Norcross on psychotherapy research and integration in 2016 [Video]. YouTube. https://youtu.be/oSQYh4ZZbqA. In this video, John Norcross reviews integrative psychotherapy, including how to i­ ntegrate diverse client preferences into the therapeutic process.

REFERENCES American Counseling Association. (2014). 2014 ACA code of ethics. American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text revision). American Psychiatric Association. (n.d.). DSM-5-TR online assessment measures. https://www.psychiatry. org/psychiatrists/practice/dsm/educational-resources/assessment-measures Benitez, T. J., Tasevska, N., Coe, K., & Keller, C. (2017). Cultural relevance of the Transtheoretical Model in physical activity promotion: Mexican-American women’s use of the processes of change. Journal of Health Disparities Research and Practice, 10(1). https://digitalscholarship.unlv.edu/jhdrp/vol10/ iss1/2 Bernard, T. J., & Snipes, J. B. (1996). Theoretical integration in criminology. Crime and Justice, 20, 301–348. http://www.jstor.org/stable/1147647 Beutler, L. E., Edwards, C., & Someah, K. (2018a). Adapting psychotherapy to patient reactance level: A meta-analytic review. Journal of Clinical Psychology, 74(11), 1952–1963. https://doi.org/10.1002/ jclp.22682 Beutler, L. E., Harwood, T. M., Kimpara, S., Verdirame, D. & Blau, K. (2011a). Coping style. Journal of Clinical Psychology, 67(2), 176–183. https://doi.org/10.1002/jclp.20752 Beutler, L. E., Harwood, T. M., Michelson, A., Song, X. & Holman, J. (2011b). Resistance/reactance level. Journal of Clinical Psychology, 67(2), 133–142. https://doi.org/10.1002/jclp.20753 Beutler, L. E., Kimpara, S., Edwards, C. J., & Miller, K. D. (2018b). Fitting psychotherapy to patient coping style: A meta-analysis. Journal of Clinical Psychology, 74(11), 1980–1995. https://doi.org/10.1002/ jclp.22684 Beutler, L. E., & Simons, A. D. (2010). Sol L. Garfield: A pioneer in bringing science to clinical psychology. In L. G. Castonguay, J. C. Muran, L. Angus, J. A. Hayes, N. Ladany, & T. Anderson (Eds.), Bringing psychotherapy research to life: Understanding change through the work of leading clinical researchers (pp. 309–317). American Psychological Association.

Boswell, J. F., Newman, M. G., & McGinn, L. K. (2019). Outcome research on psychotherapy integration. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (3rd ed., pp. 405–431). Oxford University Press. Brubacher, L. (2017). Emotionally focused individual therapy: An attachment-based e­ xperiential/systemic perspective. Person-Centered & Experiential Psychotherapies, 16(1), 50–67. Derogatis, L. R., & Savitz, K. L. (1999). The SCL-90-R, Brief Symptom Inventory, and Matching Clinical Rating Scales. In M. E. Maruish (Ed.), The use of psychological testing for treatment planning and outcomes assessment (pp. 679–724). Lawrence Erlbaum Associates Publishers.‌ Flückiger, C., Del Re, A. C., Wampold, B. E., & Horvath, A. O. (2018). The alliance in adult psychotherapy: A meta-analytic synthesis. Psychotherapy, 55(4), 316–340. https://doi.org/10.1037/pst0000172 Fromme, D. K. (2011). Systems of psychotherapy: Dialectical tensions and integration. Springer. Gerler, E. R., Drew, N. S., & Mohr, P. (1990). Succeeding in middle school: A multimodal approach. Elementary School Guidance & Counseling, 24, 263–271. https://www.jstor.org/stable/42869111 HABITS Lab. (n.d.). URICA: Overview of the URICA. University of Maryland Baltimore Campus, HABITS Lab. https://habitslab.umbc.edu/urica/ Hashemzadeh, M., Rahimi, A., Zare-Farashbandi, F., Alavi-Naeini, A. M., & Daei, A. (2019). Transtheoretical Model of health behavioral change: A systematic review. Iranian Journal of Nursing and Midwifery Research, 24(2), 83–90. https://doi.org/10.4103/ijnmr.IJNMR_94_17 Hill, C. E. (2020). Helping skills: Facilitating exploration, insight, and action (5th ed.). American Psychological Association. Johnson, S. M. (2019). Attachment theory in practice: Emotionally focused therapy (EFT) with individuals, couples, and families. Guilford Publications. Kaplan, D. M., Tarvydas, V. M., & Gladding, S. T. (2014). 20/20: A vision for the future of counseling: The new consensus definition of counseling. Journal of Counseling & Development, 92(3), 366–372. https:// doi.org/10.1002/j.1556-6676.2014.00164.x Krawiec, T. S. (1979). Obituary: Frederick C. Thorne (1909–1978). American Psychologist, 34(8), 715. https:// doi.org/10.1037/h0078292 Krebs, P., Norcross, J. C., Nicholson, J. M., & Prochaska, J. O. (2018). Stages of change and psychotherapy outcomes: A review and meta-analysis. Journal of Clinical Psychology, 74(11), 1964–1979. https://doi. org/10.1002/jclp.22683 Kwee, M. G. T. (1984). Klinishe multimodale gedragtstherapie. Swets & Zeitlinger. Lavik, K. O., Frøysa, H., Brattebø, K. F., McLeod, J., & Moltu, C. (2018). The first sessions of psychotherapy: A qualitative meta-analysis of alliance formation processes. Journal of Psychotherapy Integration, 28(3), 348–366. https://doi.org/10.1037/int0000101‌ Lazarus, A. A. (1971). Behavior therapy and beyond. McGraw-Hill.‌‌‌‌‌‌ Lazarus, A. A. (1985). Marital myths. Impact Publishers. Lazarus, A. A. (1989). The practice of multimodal therapy. Johns Hopkins University Press. Lazarus, A. A. (1995). Different types of eclecticism and integration: Let’s be aware of the dangers. Journal of Psychotherapy Integration, 5(1), 27–39. https://doi.org/10.1037/h0101169 Lazarus, A. A. (2006). Brief but comprehensive psychotherapy: The multimodal way. Springer. Lazarus, A. A., & Beutler, L. E. (1993). On technical eclecticism. Journal of Counseling & Development, 71(4), 381–385. https://doi.org/10.1002/j.1556-6676.1993.tb02652.x Lazarus, C. N. (1991). Conventional diagnostic nomenclature versus multimodal assessment. Psychological Reports, 68(3), 1363–1367. https://psycnet.apa.org/doi/10.2466/PR0.68.4.1363-1367 Myers, J. E., & Sweeney, T. J. (2004). The indivisible self: An evidence-based model of wellness. The Journal of Individual Psychology, 60(3), 234–244.‌ Myers, J. E., & Sweeney, T. J (2005a). The five factor wellness inventory. Mindgarden, Inc. Myers, J. E., & Sweeney, T. J. (Eds.). (2005b). Wellness in counseling: Theory, research, and practice. American Counseling Association. Norcross, J. C., & Beutler, L.E. (2019). Integrative therapies. In D. Wedding & R. J. Corsini (Eds.), Current psychotherapies (11th ed., pp. 527–560). Cengage. Norcross, J. C., Krebs, P. M., & Prochaska, J. O. (2011). Stages of change. Journal of Clinical Psychology, 67(2), 143–154. https://doi.org/10.1002/jclp.20758 North American Society for Adlerian Psychology. (n.d.). Alfred Adler. https://www.alfredadler.org/ alfred-adler Pearsall, P. (2011). 500 therapies. WW Norton & Co.

Prochaska, J. O., & DiClemente, C. C. (1982). Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory, Research & Practice, 19(3), 276–288. https://doi.org/10.1037/h0088437 Prochaska, J. O., & DiClemente, C. C. (2019). The transtheoretical approach. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (3rd ed., pp. 161–183). Oxford University Press. Prochaska, J. O., & Norcross, J. C. (2018). Systems of psychotherapy: A transtheoretical analysis (9th ed.). Oxford University Press. Prochaska, J. O., Norcross, J. C., & DiClemente, C. C. (1995). Changing for good. Avon. Rosenzweig, S. (1936). Some implicit common factors in diverse methods of psychotherapy. American Journal of Orthopsychiatry, 6(3), 412–415. https://doi.org/10.1111/j.1939-0025.1936.tb05248.x Society for Psychotherapy Research. (n.d.). Obituary for Sol L. Garfield. https://www.psychotherapyresearch.org/page/52 Swift, J. K., Callahan, J. L., Ivanovic, M., & Kominiak, N. (2013). Further examination of the psychotherapy preference effect: A meta-regression analysis. Journal of Psychotherapy Integration, 23(2), 134–145. https://doi.org/10.1037/a0031423 Swift, J. K., & Greenberg, R. P. (2014). A treatment by disorder meta-analysis of dropout from psychotherapy. Journal of Psychotherapy Integration, 24(3), 193–207. https://doi.org/10.1037/a0037512 Williams, T. A. (1988). A multimodal approach to assessment and intervention with children with learning disabilities [Unpublished doctoral dissertation]. University of Glasgow.

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BRIEF COUNSELING APPROACHES Derek X. Seward and Brittany A. Williams

LEARNING OBJECTIVES After reading this chapter, you will be able to: ■ Identify key concepts, origins, and foundational theory figures for brief counseling theories ■ Describe the origins and nature of mental health distress for brief counseling approaches ■ Describe the counseling process for different brief counseling theories including the nature of human development, process for change, and dynamics of the counselor–client relationship facilitative of treatment goal attainment ■ Identify brief theoretical multicultural, intersectional, and social justice issues across brief counseling approaches ■ Discuss relevant theory-based scholarship and research for brief counseling approaches

INTRODUCTION Over the last several decades, there has been increased utilization of brief counseling approaches across treatment modalities. This trend can be attributed to corporate-managed care requirements for practitioners to provide quality, evidence-based treatment within a shorter time frame (Gladding & Newsome, 2018); client interest in receiving expedient treatment (Coren, 2020; Steenbarger, 1992); mental health agency efforts to reduce treatment waitlists (Kinnan et al., 2019; Mireau & Inch, 2009); and budgetary and staffing constraints at K–12 schools and university counseling centers (Center for Collegiate Mental Health, 2022; Hannor-Walker et al., 2022). Additionally, traditional perceptions that client concerns require lengthy ongoing treatment to produce effective outcomes have been challenged. Literature indicates that brief counseling can be similarly as effective as longer-term treatments (Abbass et al., 2021; Bruce, 1995; Driessen, 2015; Orlinsky et al., 2004). Brief counseling refers to a broad category of treatment approaches that share key similarities. As the term implies, brief counseling involves a shorter counseling duration. Some practitioners have indicated that treatment occurs over a shorter number of sessions falling between 12 and 25, which contrasts with longer-term counseling considered to be more than 25 sessions (Parry et al., 2005). However, brief counseling is not solely defined by the number of counseling sessions or time duration of the counseling. Brief counseling refers to an intentionally planned short-term treatment process with specific treatment parameters considered essential for therapeutic change to occur. Brief counselors tend to value pragmatism and parsimony as they use the least invasive treatments (Cameron, 2006). Within brief

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counseling approaches, the promotion of healthy rapid client change is the primary focus with less emphasis on the client’s understanding of their symptomatology (Miller & Marini, 2015). There are five key philosophical aspects regarding the nature of the therapeutic process that uniquely characterize a counseling approach as brief: (a) maintenance of a clear treatment focus, (b) conscious and conscientious use of time, (c) limited goals with clearly defined outcomes, (d) rapid assessment and integration of assessment into treatment, and (e) a high level of client–therapist activity (Cameron, 2006). Maintenance of a clear and specific treatment focus reflects a counselor’s collaboration in helping clients identify and remain focused throughout treatment on the selected treatment problem. Conscious and conscientious use of time reflects counselors’ acknowledgement that clients may not want or require long-term counseling. Meetings may not reflect a traditional 50-minute session that meets weekly for 12 months but instead be shorter in duration and contracted to end after a few sessions. Treatment goals in brief counseling are mutually agreed upon, limited in scope, achievable, observable, and behavioral. During the treatment process, counselors must quickly begin their assessment process and use their ongoing assessments to inform their counseling. Also, within the brief counseling process, the counselor is active, often using candid reframes, challenges, and interpretations intended to help the client clinically improve rapidly. Across brief counseling approaches, varying emphasis is placed on these philosophical aspects. Some brief approaches require a set number of treatment sessions, whereas others posit that client growth leading to treatment termination can occur within a single session. The role of the counselor can vary based on the counseling approach with some approaches requiring the counselors to be highly active and directive in session as opposed to less directive and more passive. Other approach variations include differences regarding treatment focus, goals, and acceptable treatment outcomes. It is also important to note that individual counselors within specific brief counseling approaches may alter their attention to these aspects.

LEADERS AND LEGACIES OF BRIEF COUNSELING THEORY Contemporary conceptualizations of brief counseling approaches can trace their origins to key figures in the late 19th and early 20th centuries. In his early work, Sigmund Freud conducted experimental treatments with clients suffering from milder mental health distress that lasted no longer than a few months. At the time, Freud’s therapy required his active involvement as interpretation and insight facilitation were believed to lead to client symptom reduction, which was the treatment focus (Coren, 2020). It was not until later that Freud developed his psychoanalytic theory that began to favor a longer treatment duration, therapist passivity, free associations, and attention to past experiences. Freud’s psychoanalytic theory focused on patients’ intrapsychic psychological drives that could create dissonance when not satisfied. Although psychoanalytic theory became the dominant treatment at the time, theorists such as Alfred Adler, Sándor Ferenczi, Otto Rank, Franz Alexander, and Thomas Morton French criticized Freud’s therapeutic approach for ignoring the role that interpersonal and environmental factors play in client’s mental distress (Coren, 2020). These theorists challenged Freud’s assertions that treatment should (a) focus on past relationships and experiences, (b) implement protocols rigidly without adapting to client specific needs, (c) ignore the therapeutic relationship, and (d) not have a predetermined termination date. The broader treatment community that was dominated by psychoanalytic theorists resisted these criticisms. However, foundational ideals of ­shorter-term treatment were introduced. Milton Erickson, a psychiatrist notable for making hypnosis a respected clinical treatment modality, played a major role in advancing contemporary notions of brief therapy. Erickson’s clinical treatment involved a solution-oriented, practical approach that did not require lengthy,

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theory-driven interventions that explored a patient’s subconsciousness, which was characteristic of other psychotherapies. He believed symptom improvement could occur for patients within a short time frame, leading him to meet with some patients just once. Erickson’s treatment effectiveness lay in his ability to craft novel interventions and adapt existing ones in response to individual patient needs. He did not have a specific treatment protocol to which he adhered. Erickson’s nonprescriptive treatment approach deviated from other approaches that emphasized rigid application of intervention protocols no matter the client. Influenced by Milton Erickson, Jay Haley, a psychotherapist credited as the founder of strategic therapy, is highly regarded as one of the great thinkers of the 20th century for his innovative criticisms of psychoanalysis, which served as the prevailing treatment through the 1970s. According to Haley, therapists should view the origins of mental health problems as developing from interactions between people and the environment, not innate psychological drives as psychoanalysts purported (Haley & Lebow, 2010). He advocated for a systems theory treatment approach that required attending to relational and contextual factors. Haley criticized psychoanalysts for their assumptions and intervention methods that seemed illogical and difficult to test (Haley & Lebow, 2010). Haley (1963) stated that “although Freud assumed that the patient’s self-exploration produced change, it is argued here that change occurs as a product of the interpersonal context of that exploration rather than the self-awareness which is brought about in the patient” (p. 63). He believed that interactional patterns between people could be altered to produce positive therapeutic results without focusing on innate psychological drives. For Haley, attention to therapy outcomes was paramount. He criticized psychoanalysts for focusing on the treatment process rather than achievement of positive therapeutic outcomes. Strategic therapy, Haley’s model of treatment initially developed in the 1960s, reflected Erickson’s belief that clinicians should initiate what occurs in therapy and develop specific interventions for unique client problems to optimize therapeutic results. A proliferation of brief counseling approaches has emerged over the last 40 years that have been impacted by the key figures discussed. These brief counseling approaches reflect various theoretical frameworks including psychodynamic, relational, cognitive, and behavioral, very brief counseling (i.e., crisis counseling) and eclectic approaches (Parry et al., 2005). These theoretical frameworks outline inferences, assumptions, interpretations, and hypotheses counselors use to make sense of client concerns and facilitate change (Parsons, 2014). Counselors use theory to distill and reorganize complex, seemingly unrelated client information into cogent conceptualizations useful in determining treatment direction. The theoretical frameworks detail presuppositions about human cognitions and behavior including about the origins of mental health concerns, what constitutes well-being, and necessities for a therapeutic counseling environment. In this chapter, we focus on three brief counseling approaches: Adlerian brief therapy (ABT), solution-focused brief counseling and therapy, and brief eclectic psychotherapy (BEP). It is beyond the scope of this chapter to review the plethora of brief counseling approaches (see Farber, 2020; Messer et al., 2013; Parry et al., 2005 for overviews). ABT is a present- and future-oriented approach that strives to help clients identify and gain insight into their patterns of behavior to motivate them toward positive behavioral action rapidly. It is characterized by its time-limited orientation, focused treatment on a specific issue or concern, directive and supportive counselor behavior, view of clients’ presenting behavioral patterns as potential treatment solutions, and assignment of behavioral tasks and homework (Nicoll et al., 2000). At its core, ABT reflects principles of individual psychology (Bitter & Nicoll, 2000). Clients are viewed in a holistic manner, not as fractured parts, where the intrapsychic self can be separated. Client behaviors are considered to be best understood in a social context in which all actions are teleological or serve a purpose. In addition, treatment serves to facilitate changes in client cognitions and behaviors. Major contributors to ABT are William G. Nicoll and James R. Bitter.

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Alfred Adler is the founder of individual psychology on which ABT is based. Adler was Sigmund Freud’s colleague at the Vienna Psychoanalytic Society. During his 10-year tenure, Adler’s views on the roots of mental health illness and treatment increasingly differed from Freud. Alder believed that cognitions and behavior are socially embedded. He considered that how individuals interact with their social environment and make meaning of those interactions can impact their mental health (Nicoll & Nicoll, 2018). He challenged the belief that humans are helpless victims controlled by their unconscious intrapsychic desires, as Freud asserted (Carlson et al., 2016). Adler’s mental health treatment involved helping clients understand how flawed cognitions about their interpersonal interactions and social contexts led to mental distress. Adler believed treatment should focus on addressing maladaptive social interactions to help clients achieve their mental health goals rather than exploring intrapsychic drives. Differences between Adler and Freud led to a splitting within the psychotherapy community, resulting in Adler’s social context-oriented, directive treatment approach and Freud’s psychoanalytic approach (Nicoll & Nicoll, 2018). BEP is a 16-session trauma-focused treatment for post-traumatic stress and other trauma disorders. BEP’s manualized treatment is focused on helping trauma survivors dealing with grief and difficult emotions reduce symptoms and learn from their ordeals. BEP is categorized as a trauma-focused psychotherapy similar to therapeutic approaches such as trauma-focused cognitive behavioral therapy and eye movement desensitization and reprocessing (Schnyder et al., 2015). BEP involves helping clients to extinguish fear responses to their trauma events and habilitation, which is similar to other trauma-focused therapies (Schnyder et al., 2015). However, it is uniquely different from other trauma-focused therapies in its focus on encouraging clients to experience and embrace emotions such as anger, mourning, and sorrow. Acknowledgment and processing of traumatic emotions for BEP clients is essential to post-traumatic growth (i.e., the transformational healing process that follows a traumatic event; Gersons et al., 2020a). Berthold Gersons, a psychiatrist, developed BEP working in the Netherlands with Amsterdam police officers dealing with trauma from shootings in the 1980s. Berthold’s early work with the police involved using short-term psychodynamic therapy (Luborsky, 1984). Despite having initial success addressing the police officers’ avoidance symptoms, Berthold’s efforts did not produce symptom reduction for the officers’ intrusive post-­ traumatic stress disorder (PTSD) symptoms. Berthold modified his treatment approach in response, choosing an eclectic approach that incorporated psychodynamic therapy, cognitive therapy, grief therapy, and crisis intervention (Gersons et al., 2020b). BEP studies have been found efficacious in reducing police officers’ PTSD symptoms and increasing their return to work (Gersons et al., 2000; Smit et al., 2013). Beyond law enforcement, BEP has been found to be an effective treatment for clients dealing with traumatic events including childhood trauma, war violence, disasters, and sexual and nonsexual assault (Lindauer et al., 2005; Nijdam et al., 2013; Schnyder et al., 2015). Other notable BEP contributors are Mirjam Nijdam, Geert Smid, Marie-Louise Meewisse, and Ulrich Schnyder—all of whom have published with Berthold. Solution-focused brief therapy (SFBT) is a goal-oriented, strength-based treatment approach in which a counselor collaboratively works with their client to identify constructive solutions to client behavioral and mental health concerns (de Shazer et al., 2021). SFBT focuses on present and future dynamics. Historical aspects are not considered essential to helping clients. Identification of solutions to client problems is the focus rather than exploring origins of client pathology, limitations, or deficiencies (Burwell & Chen, 2006). Clients are presumed to possess the strength and capacity to improve their lives through the identification of attainable goals. SFBT seeks to bring into client consciousness strengths and resiliencies developed from dealing with past challenges that can be leveraged to work toward swift, incremental change.

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SFBT was developed by Steve de Shazer and Insoo Kim Berg and advanced by colleagues at the Brief Family Therapy Center located in Milwaukee, Wisconsin, during the 1980s (Miller & Marini, 2015). SFBT’s origins are rooted in observational data of actual counseling sessions in contrast to conceptually driven theoretical models (de Shazer et al., 2021). de Shazer, Kim Berg, and colleagues conducted qualitative observations, program evaluations, and quasi-experimental studies in which they examined hours of counseling sessions to identify counselor statements and interventions consistently facilitative of client advancement toward their goals (Kim et al., 2019; Lipchik et al., 2012). Those counselor behaviors facilitative of positive growth helped to form the foundation of SFBT principles. In the years following these early investigations, there has been a proliferation of outcome research using randomized control trials (RCTs) and meta-analyses (for a review, see Kim et al., 2019; 2010). These studies have solidified SFBT as an evidence-based practice. Notable contributors to SFBT include Yvonne Dolan, Terry Trepper, Eric McCollum, and Janet Bavelas.

THE ORIGIN AND NATURE OF MENTAL HEALTH CONCERNS Brief counseling approaches vary in their assumptions about the origins of human mental health concerns. Differences among brief approaches can be explained by the unique metatheories or theoretical frameworks that undergird each counseling approach. For instance, individual psychology serves as the metatheory for ABT that provides the core theoretical assumptions about what is psychological wellness and what constitutes a mental health concern. Key theoretical foundations related to how mental health concerns are conceptualized within different brief counseling approaches are presented in this section. ABT positions client mental health concerns as connected to three individual psychology principles of personality: purposiveness, lifestyle, and social embeddedness (Nicoll et al., 2000). Within ABT, all behaviors and emotions are viewed as purposeful, goal directed, or teleological. Clients may be unaware that their thoughts, feelings, and actions are functioning unconsciously to accomplish specific ends. According to Alfred Adler, humans are psychologically driven starting in childhood to strive to overcome a sense of inferiority in hopes of achieving a goal of superiority. Adler (1924) asserted that the quest for superiority is at the core of personal discord. He stated: …this goal introduces into our life a hostile and fighting tendency, robs us of the simplicity of our feelings and is always the cause for an estrangement from reality since it puts near to our hearts the idea of attempting to over-power reality. (p. 8) Human motivation to achieve goals can lead to problematic and unhealthy living if the endpoint is toward selfish personal interests rather than seeking relationships and communing with others. The principle of lifestyle or style of life refers to the totality of an individual’s human experiences. Ansbacher and Ansbacher (1956) defined lifestyle as “...that unity in each individual, in his thinking, feeling, acting, in his so-called conscious and unconscious, in every expression of his personality” (p. 175). Lifestyle includes an individual’s cognitive schemas and ways of understanding themselves and perceiving others (Nicoll et al., 2000). Individuals that conceptualize themselves as inferior may develop unhealthy lifestyle thoughts, emotions, or behaviors as they are driven to overcome their inferiority perceptions. The social embeddedness principle relates to understanding human behavior from a systems perspective. Humans are innately social creatures who are part of social contexts (e.g., cultures and subcultures) upon which they impact, but also that impact the individual’s perceptions and behavior. Examples of social contexts include familial systems and educational or occupational systems. When these environments provide nurturing and healthy support, humans can thrive. These environments or social contexts provide opportunities for individuals to engage with others in pursuit of community or social interests, which

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Adler referred to as Gemeinschaftsgefühl. Social interest is assumed to be a human psychological drive within ABT. Clients who struggle or cannot develop their social interest are disconnected and considered to be living an unhealthy lifestyle. Those individuals may think, feel, or behave in ways that are counterproductive to development of their social interest. BEP conceptualizes trauma symptoms as emanating from a person’s inability to accept and tolerate intense emotions like overwhelming fear and helplessness that can result from a traumatic experience. Suppression and denial of emotions after a traumatic event is viewed as the primary cause of post-traumatic symptoms. Affect avoidance can lead to unhealthy symptom management patterns. Within BEP, there are three key theoretical underpinnings related to mental health pathology: acceptance of emotions, understanding the meaning of emotions, and facing the often horrific reality of the traumatic event (Nijdam et al., 2022). Individuals dealing with trauma symptoms immensely struggle to accept their emotions. They can become overwhelmed immediately after the traumatic event or loss. Individuals can experience panic or exhaustion resulting from their heightened affective state leading them to engage in extreme avoidance measures. Over time, an individual’s functioning can be further negatively impacted as they may become emotionally flooded with disturbing recollections of the trauma, experience psychosomatic symptoms, and develop maladaptive character distortions about themselves and others. BEP assumes that an individual’s denial and suppression of their emotions is what leads to mental health concerns. Understanding the meaning of emotions is the second theoretical underpinning related to mental health pathology. BEP posits that individuals must not only accept their intense feelings but also seek to make meaning of that affect. The ability of an individual to comprehend they have encountered and outlasted intense emotions during an immensely difficult time holds potential to be uplifting to the psyche. Self-compassion, self-acceptance, and a desire to move forward can emerge from reflecting on the traumatic situation (Nijdam et al., 2022). However, individuals may remain in a place of helplessness and hopefulness that interferes with their ability to reflect on their traumatic situation in a healthy way. The inability to make meaning of their emotions in a healthy way can prolong negative symptoms and unhealthy behaviors. The third BEP theoretical underpinning involves facing the often horrific reality of the trauma. This involves individuals recognizing that life as they knew it previously no longer exists. Not only must individuals deal with losses (e.g., death, property, personal identity) connected to the traumatic event but also realize their daily life likely will significantly change. Individuals often need to abandon or at least adjust previously effective life strategies to develop new ways of living. BEP posits that individuals who avoid dealing with reality and its consequences will have sustained mental health symptoms. SFBT positions clients as the authority in identifying what their mental health concerns are. Clients know themselves best and what is best for them. SFBT is grounded in social constructivism that contends that individuals create their own understanding of reality based on their observations and interactions with others and the physical environment (Corey, 2016). There is no universal reality from this perspective. Individuals come to understand society and define themselves in their own way based on their interactions. Culture is an important factor in social constructivism. Individuals formulate their understandings within cultural contexts that are influenced by location, time in history, and cultural dynamics (e.g., race, ethnicity, affectional orientation, socioeconomic status [SES], nationality; Kim, 2014). Within SBFT, the client is considered an expert on their reality and experience. It follows then that clients identify what constitutes a mental health concern or problem for which they want help.

EMOTIONAL AND PSYCHOLOGICAL WELL-BEING Helping clients rapidly move through the change process toward a healthier state of functioning characterizes the goal of brief counseling approaches. This raises questions

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regarding how brief approaches define what well-being is. The Centers for Disease Control and Prevention (CDC, 2018) state: …at minimum, well-being includes the presence of positive emotions and moods (e.g., contentment, happiness), the absence of negative emotions (e.g., depression, anxiety), satisfaction with life, fulfillment and positive functioning. In simple terms, well-being can be described as judging life positively and feeling good. For public health purposes, physical well-being (e.g., feeling very healthy and full of energy) is also viewed as critical to overall well-being. (para. 3) The CDC’s definition provides an overarching conceptualization of well-being applicable to brief approaches. However, it does not capture the ways specific approaches perceive what constitutes well-being. There is no universal way in which brief counseling approaches describe what is healthy. ABT grounds well-being in the concept of holism. Individuals are viewed as whole entities whose psyche and actions operate jointly within social contexts of society (e.g., family, community) as individuals live their lives. Key to a person’s well-being are two innate psychological drives: striving for superiority and social interest or gemeinschaftsgefühl (Ansbacher & Ansbacher, 1956). Striving refers to an individual pursuing a goal to achieve mastery and avoid feelings of inferiority (Cottone & Wagner, 2017). Healthy individuals are in a constant state of striving. They find ways to motivate themselves to identify and work toward goals across the various social contexts. Social interest refers to an internal desire to nurture a sense of connectedness with others and their well-being (Drout at al., 2015). Within ABT, healthy individuals want to increase their sense of belonging through engaging with others to better their community. Well-being for BEP is conceptualized as the ability of an individual to encounter traumatic situations and deal with the corresponding intense and strong emotions in a healthy manner (Gersons et al., 2022a). Strong emotions are not to be feared but faced. A healthy individual can make meaning of their intense emotions in ways that facilitate compassion for themselves and the struggles they have endured. Additionally, healthy individuals accept the reality of life after the traumatic event despite the challenges that come with it such as encountering uncertainty and moving forward with different internal and external resources (e.g., altered sense of self, sense of safety, familial support, fiscal support). Mardi Horowitz (1986, 2021), a psychiatrist and neoanalytic scholar who detailed a stage model of the prototypical responses to traumas and losses, provides a context in which to further understand how BEP frames well-being. BEP is grounded in his work. In Horowitz’s model, response to a stressor begins with an outcry or initial emotional response that can be extremely intense and uncontrolled. Denial, numbing, and avoidance characterize the next phase as individuals employ emotional regulation strategies to evade thinking about the traumatic event. This is followed by intrusions, pangs, and repetitions in which conscious memories and feelings emerge. The next stage working through involves individuals reassessing the trauma and their views toward it. Vacillating between intrusions and avoidance is typical in this stage. The final stage restoration of equilibrium consists of individuals returning to pre-trauma functioning. Healthy individuals are able to progress through this stress response process without displaying pathological responses including extended periods of panic or exhaustion, extreme avoidance, and persistent flooded states. Ideally, healthy individuals do not need a mental health professional to help them deal with their trauma (Gersons et al., 2022b). SFBT assumes that individuals are healthy, competent, and capable of generating solutions that can improve their lives (Miller & Marini, 2015). Individuals are assumed to possess the capacity to encounter life challenges, identify solutions, and implement them. However, sometimes individuals can get stuck. They can have difficulty identifying internal and external resources that can be leveraged as they try to resolve their challenges. SFBT

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counselors collaborate with clients to help them identify their strengths and help them generate solutions for themselves that meet their needs. Still, it is the client who determines what is healthy for them.

ROLES OF CLIENT AND COUNSELOR The role of the client in brief counseling approaches is that of being a willing and active participant. This is the overarching role for clients across brief modalities. Clients with good interpersonal functioning, knowledge of their strengths and resources, a willingness to participate in counseling, and hope for a positive therapeutic result are likely to optimally use the brief counseling space (Franklin et al., 2017; Leichsenring & Schauenburg, 2014; Nai & Rodgers, 2017; Steenbarger, 1992). Being an active participant begins with clients joining with counselors to identify the specific problems on which treatment will focus. To the best of their capacities, clients need to assess and provide information that details their concerns at the onset of treatment. This information is crucial to the collaborative identification of treatment goals. Clients often need support from counselors to identify the specific goals and outcomes that can be realistically achieved in a short time frame. During treatment, clients have a responsibility to fully participate and put forth effort to maximize therapeutic gains. As counseling progresses, clients should evaluate their progress regularly and share that information so the therapeutic dyad can collaboratively identify strategies that maintain treatment gains. Due to the brevity of treatment, clients must actively work on their identified concerns outside of counseling sessions. This is a crucial aspect for brief counseling approaches to be effective. Counselors may assign homework or tasks to facilitate client’s ongoing engagement with the therapeutic process. Homework allows clients an opportunity to practice and strengthen skills in between sessions. Across brief counseling approaches, the role of counselors can include that of collaborator, facilitator, optimist, encourager, and analyst. Counselors tend to have a more egalitarian relationship with clients as they jointly work to identify the specific problems to be addressed in treatment and their solutions. As collaborators, counselors seek to develop a strong therapeutic relationship with clients. Establishment of a strong working alliance is considered essential if brief approaches are to be effective (Steenbarger, 1992; Stevens et al., 2007). Counselors play a catalytic role as facilitators of the sessions tasked with keeping the treatment process progressing and focused only on the identified treatment concerns. The role of optimist is reflected in counselor’s efforts to help clients understand that positive change is achievable within the brief treatment. They try to expand the possible choices clients might consider as solutions. As clients engage in the challenging work to improve their lives, counselors serve as encouragers who provide unconditional support even in times when client progress may appear limited or temporarily stalled. The role of analyst refers to how counselors are constantly evaluating client information to identify patterns useful in treatment decision-making. Brief counseling time constraints do not allow counselors extended periods for problem identification, assessment, or implementation of interventions, especially nondirective interventions. Counselors develop treatment hypotheses with limited information that they must be willing to adjust as additional information is obtained (Cameron, 2006). To optimize session time, counselors tend to be highly directive, forthright, and challenging. Distinct brief counseling approaches vary the focus of counselor roles based on their specific therapeutic frames. ABT counselor roles are that of analyst, collaborator, and encourager (Cottone & Wager, 2017). The role of collaborator within ABT closely mirrors the role already described. Through collaborating with clients, ABT counselors work to engender confidence and trust that they are committed to helping clients improve their situation. As an analyst, the counselor is listening for information about the client’s strivings and social interests. The counselor seeks to gain insight into the cognitive, affective, and behavioral

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lifestyle patterns that reflect counterproductive solutions that contribute to the client’s mental health concerns. ABT counselors do not perceive client’s presenting lifestyle patterns as problems, but ineffective efforts to deal with their concerns. Counselors make clients aware of their counterproductive patterns as part of the lifestyle reorientation process during which clients are encouraged to strive for healthy goals and make meaningful connections with others through attempting new behaviors (Nicoll et al., 2000). Counselors embrace the role of the encourager as empathy and compassion are used to support clients throughout the treatment process but especially during the reorientation process as clients are developing new lifestyle rules. For BEP, the role of the counselor entails that of a teacher and listener (Nijdam et al., 2022). The first session in the 16-week BEP treatment protocol focuses on psychoeducation (Gersons et al., 2011). The role of the counselor is one of a teacher during this session as the connection between trauma and dysfunction is explained. Counselors help clients understand the utility of their psychological and physiological reactions to traumatic events as well as the debilitating functionality of sustaining those behaviors once the traumatic event or danger has passed (Nijdam et al., 2022). Counselors attempt to develop a therapeutic alliance by asserting that change is possible and presenting themselves as trustworthy. The role of the counselor as listener requires compassionate care, which is essential when clients recount the horrific details of their traumatic events. As treatment progresses, counselors also serve as collaborators who join with clients to assist them in making meaning from the positive personal transformations resulting from the survival of their trauma. Scholars refer to this process as post-traumatic growth (Calhoun & Tedschi, 2014). Within SFBT, counselors provide a supportive environment for clients to identify their concerns, define their treatment goals, and explore solutions. Counselor acceptance, nonjudgment, and avoidance of providing interpretations are central to valuing clients’ volition and autonomy in treatment decisions (de Shazer et al., 2021). SFBT counselors cultivate a democratic, nonhierarchical therapeutic relationship that is collaborative. The role of the SFBT counselor is that of collaborator, optimist, and encourager. Counselors present with an optimistic deposition oriented toward helping clients frame their concerns as solvable. As part of the change process, counselors work together with clients to identify their strengths, brainstorm potential solutions, and support the implementation process (de Shazer et al., 2021).

THE NATURE OF HUMAN DEVELOPMENT Brief counseling approaches represent a diversity of treatment perspectives. Many approaches do not postulate a theory of human development. Understanding what historical aspects in a client’s life have contributed to their current state of being is perceived as unnecessary to assisting them improve their life. SFBT is an example of an approach in which the counselor is not concerned with contextualizing the client’s past experiences within a developmental framework. There are brief approaches rooted in human development theories that are used to conceptualize clients. For example, ABT is grounded in individual psychology, which proffers a developmental model regarding client’s goal striving and social interest growth. Although ABT counselors place greater emphasis on the client’s present and future over their past, they do investigate the client’s early-life recollections, family constellation, and life tasks to understand the client’s lifestyle patterns (Bitter & Nicoll, 2000).

PROCESS OF CHANGE The process of counseling varies from brief approach to brief approach. Depending on the approach, counseling procedures, which sometimes include discrete sequential counseling stages, detail the specific objectives, events, assessments, interventions, and expected

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outcomes that should be employed as counseling progresses. Steenbarger (1992) identified a three-phase brief counseling process of change model. In the first phase, engagement, the counselor is focused on developing a collaborative alliance quickly and framing the treatment parameters (e.g., developing rapport, determining the appropriateness of brief counseling, assessing client patterns, establishing a treatment plan). Discrepancy is the second phase during which the counselor leverages their therapeutic alliance and interventions to compassionately challenge clients to attempt new behaviors and discard stressful patterns. The final phase, consolidation, is focused on helping clients test and adopt healthier behaviors. Counselors seek to reinforce client’s progress and growth. Steenbarger’s model is useful for understanding brief approaches, regardless of the approach’s specific theoretical leanings or intervention. However, each specific brief counseling approach posits its own unique process of change framework. ABT is an insight-oriented brief approach that utilizes a four-stage strategic process to increase client’s insight to motivate them toward positive action (Bitter & Nicoll, 2000; Nicoll, 1999; Nicoll et al., 2000). The process is conceptualized as sequential stages within which counselors may vary their focus to be responsive to specific clients and their unique concerns. The stages can be understood using the acronym BURP (Behavioral description of the presenting issue, Underlying rules of interaction identification, Reorientation of the clients’ rules of interaction, and Prescribing new behavior rituals; Nicoll et al., 2000). In the first stage, the counselor focuses on obtaining a behavioral description of the clients’ presenting concerns. Counselors ask questions to learn about when clients experience symptoms. Counselors want to identify how clients think and feel in those moments and what function the symptoms serve for the client and inquire about the client’s rules of interaction (i.e., the client’s idiosyncratic cognitive schema that leads them to consciously or unconsciously choose specific behaviors). These three levels of behavior must be understood if the counselor is to develop a full picture of how the problematic symptoms aid the client (Nicoll et al., 2000). In session, clients are directed to describe their presenting concerns using behavioral terminology. Specifically, counselors encourage clients to use action verbs (i.e., words ending in “-ing” that convey doing) instead of possessive verbs (i.e., words that indicate belongingness; Nicoll et al., 2000). For instance, a client would be encouraged to avoid saying “I suffer from depression” or “I am depressed.” Instead, counselors ask clients to describe instances when they experience depression and talk about how they navigated their ordeals. The counselor might ask, “What did you do in that situation?” or “What happens when you are depressed?” For both clients and counselors, it is important to refrain from using language that implies the client is a helpless victim with an external locus of control. When implementing interventions, counselors will use action-oriented language to suggest to clients they have agency. For instance, imagine if a client says, “My bed had a hold of me and would not let go all weekend.” In response, the counselor might say, “You chose to stay in bed all day and not go outside.” The counselor wants to convey to the client that they possess the ability to make changes in their lifestyle right at the start of the counseling process. In the second ABT stage, underlying rules of interaction identification, counselors try to learn about the client’s beliefs that guide their actions. Although counselors develop hypotheses about what purpose the client’s problematic behaviors serve from information directly shared by clients in earlier sessions, they continue to seek insight into clients' cognitive framework and subsequent behavioral choices. Counselors use various techniques to learn about clients' rules of interaction including asking “the question” and inquiring about early childhood recollections (both techniques are described later in the chapter). Besides obtaining information directly from the client, counselors will engage in client perspective taking. Counselors envision themselves as the client to increase their ability to understand and empathize with the client’s problematic behavioral decisions. Nicoll et al. (2000) assert that perspective taking can assist counselors in developing an understanding of client’s

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decision-making patterns related to their symptomatology. Moreover, the client’s choices should seem logical based on the client’s rules of interaction. But also, counselors should be able to identify that there are other courses of action clients might pursue especially if the client’s rules for interaction were different. Reorientation of the client’s rules of interaction is the next stage. Counselors focus on facilitating cognitive change related to the presenting concern. Counselors want to help clients consider alternative ways of thinking and being. To do that, counselors use interventions aimed at changing the client’s rules of interaction (i.e., perspectives). The goal is for clients to generate new insight and knowledge that leads to viewing their rules of interaction from a fresh perspective—one that will eventually allow for new, healthier behavior choices. Nicoll et al. (2000) note this is a critical time in the change process as change is unlikely to occur without a shift in the client’s perspective. At this stage, counselors use therapeutic interventions intended to revamp the client’s rules of interaction such as reframing, relabeling, and using Columbo tactics (Nicoll et al., 2000). The final stage in the ABT process of change is prescribing new behavioral rituals. Nicoll et al. (2000) define rituals as “…regular, repeated actions that serve to reaffirm or maintain underlying rules of interaction for a system” (p. 237). Counselors assist clients in developing new behavioral options that clients try out outside of counseling sessions (i.e., homework). These interventions require clients to repeatedly and often practice their new behaviors so that they bolster the client’s new rules of interaction if they are to become lasting rituals. BEP uses a 16-week, 45 minutes per week manualized curriculum that focuses on two mechanisms of change: catharsis and acceptance of the strong trauma emotions, and domain of meaning (Gersons et al., 2011, 2020a, 2020b). Catharsis and acceptance are the primary focus during the first 6 weeks of counseling. The treatment process involves the counselor helping the client to emote and acknowledge the immense feelings they have related to their traumatic event. The goal is to reduce their trauma-related symptoms. These sessions are sequenced in the following order: psychoeducation (session 1), imaginal exposure (sessions 2–6), and writing tasks and mementos (sessions 3–6). Within the same session, counselors may use interventions from imaginal explore and writing tasks, thus the overlapping sessions numbers. The first BEP session is dedicated to psychoeducation. For this session, the client and another trusted person (i.e., significant other, family member, friend) is invited into the counseling space. Counselors provide the client information about the psychological and physiological aspects of trauma and how dysfunction can result from individuals remaining highly aroused in a fight-or-flight state even after the threat is no longer present. Counselors tailor the psychoeducation to the client’s specific trauma or situation. During this initial session, counselors also provide an overview of the BEP treatment process and therapeutic tools employed so clients are informed and not surprised. Imaginal exposure (sessions 2–6) involves exposing or returning clients to their disquieting memories and associated emotions that they avoid. Helping clients express and name feelings related to their traumatic experience is the primary aim of imaginal exposure, but reduction of anxiety can also result (Gersons et al., 2011). At the start of these sessions, counselors facilitate a relaxation exercise (i.e., breathing exercise or muscle relaxation activity) to help the client concentrate and focus. Immediately following the relaxation exercises, counselors spend the first half of these sessions compassionately assisting clients to recount their trauma experiences. Counselors provide support as clients describe in meticulous detail aspects of their trauma experience. Nicoll et al. (2000) emphasize that clients should talk in first person, close their eyes, and detail, in chronological order, what happened. The counselor’s responsibility is to pay attention particularly to hotspots or moments of intense arousal indicated by a change in the client’s tonality, rate of speech, body language shift, opening of their eyes, topic shift, or other noticeable change. In these hotspots, the counselor uses reflection to accentuate the client’s feelings of anger, grief, and sorrow.

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During the second half of these sessions, counselors help clients explore any awareness that occurred during the re-experience of the trauma. Counselors pay particular attention to helping clients avoid any self-blame or assignment of guilt to themselves for their trauma. In BEP, this imaginal exposure process is repeated until all aspects of the trauma experience have been explored with the client having identified and expressed associated emotions sufficiently (Nijdam et al., 2013). Writing tasks and mementos (sessions 3–6) are used in BEP treatment to also assist clients in expressing and accepting their emotions. Nijdam et al. (2022) notes that clients often have mementos from their traumatic experiences such as newspaper articles, pictures, clothes, or other artifacts that can be used to facilitate a clients’ emotional release. Counselors have clients hold and look at their mementos and discuss its importance to them. Counselors assist clients in understanding what their emotions mean during this process. BEP counselors also use letter writing to encourage clients to emote. As a homework assignment, clients write a letter that expresses their anger, frustrations, and other feelings to a specific person or entity the client connects to their traumatic experience. The letter is not to be sent, but used in sessions as a mechanism to allow the client to express and embrace their emotions. The second half of BEP treatment focuses on the domain of meaning. Nijdam et al. (2022) contend that clients should have increased energy and focus to work on making sense and learning from their trauma experiences having sufficiently accepted and expressed their trauma-related emotions. Fostering post-traumatic growth is the primary goal for the remainder of treatment. Meaning and integration (sessions 7–16) consists of helping clients begin the difficult work of reimagining how they perceive and understand themselves and others. Counselors work with clients to explore how their trauma experiences can be transformed into useful and healthy ways to understand and interact with others. Trust is an important topic of exploration for many clients during this stage. BEP treatment ends with a farewell ritual (sessions 13–16) that acknowledges the challenging experience of the client’s loss but also their post-traumatic growth. Counselors invite clients and their trusted person to develop a farewell plan they believe is commensurate with the meaning of the trauma. Gersons et al. (2011) contend that counselors should begin to withdraw from the treatment process to allow for the client’s trusted person to provide support. Farewell plans typically involve cleansing, burning, destroying, or discarding mementos. The farewell ritual is a celebratory act that marks the end of treatment and ability of the client to move forward. SFBT consists of counselors developing a collaborative, strength-emphasizing relationship with clients to identify a solvable concern right at the start of the counseling process (de Shazer et al., 2021). The SFBT process of change begins in the first session with the counselor seeking to learn about the client’s rationale for pursuing counseling. After an initial introduction, counselors ask questions to learn about the nature of the concern from the client’s perspective and orient themselves to the client’s terminology. If a client states they have anxiety, the counselor might ask questions such as “What does anxiety mean to you?” Counselors seek clarity to better understand how clients think about and experience their concern. Counselors then pivot to focus on how clients have coped with their concerns. Often, this begins with asking clients presession change questions such as “What changes have happened or have you noticed since you scheduled this appointment?” Based on the client's response, counselors make a determination regarding how to proceed with treatment. If no changes are reported, counselors will ask clients about how the session could be best used or what they would like to accomplish in the session. In these moments, counselors are listening for clients to share their goal for the session. Also, counselors will emphasize to clients that smaller, more manageable goals can be highly useful as meeting those goals can lead to addressing larger or longer-term concerns (de Shazer, 2021). If clients report changes in response to pre-change questions, counselors may inquire about what clients have done to initiate or maintain the changes they have noticed. One of

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the SFBT tenets is if it works, do more of it (de Shazer et al., 2021). In this instance, SFBT counselors will compliment clients on their agency and seek to learn more about the client’s internal strengths that led to the positive changes. No matter how small the movement, counselors accentuate the client’s positive action toward solving their concern. de Shazer et al. (2021) emphasize that SFBT operates from a tenet that small steps can lead to big changes. If clients report decompensation or that problems have worsened in the time immediately before their first counseling session, counselors would encourage clients to discard those ineffective behaviors. If a solution is not working, SFBT indicates that the particular action being used is not a solution and something different should be attempted. Central to the SFBT change process is solution talk. de Shazier et al. (2021) describe solution talk as counselor interventions aimed at helping clients identify a solvable concern and encouraging them to take actions that address the concern while avoiding actions that have not worked. As part of solution talk, counselors would ask clients miracle questions such as “If you had a crystal ball that could see into the future, what would your life be like without your concerns?” Miracle questions inquire about how life would be different if problems did not exist. Counselors use these questions to help clients identify their goals (Bannink, 2007). Exploring exceptions is another aspect of the solution talk process. Counselors ask exception questions such as “What are times like when you are not anxious?” or “What is different in those times when you are not anxious?” A key tenet of SFBT is that no problem happens all the time as there are exceptions that can be utilized to motivate action (de Shazier et al., 2021). Counselors work with clients to discuss what dynamics and actions are occurring when the concerns are not present in the client’s life. The counselor’s role is to partner with clients as they co-generate possible solutions to prolong instances without symptoms. Asking coping questions can be useful when clients struggle to identify exceptions (Cottone, 2017). Coping questions require clients to reflect on how they have managed to live with their problems. Examples of coping questions include “How are you managing to deal with this?” and “How have you kept this from becoming a bigger concern?” Counselors may use these questions to highlight client’s strengths and resiliency in navigating their circumstances. Scaling questions are used in the solution talk process to explore a client’s level of commitment to a solution or level of distress (Cottone, 2017). Scaling questions ask clients to select a point on a scale that represents their current level of functioning within a range, usually between 1 and 10. Scaling question examples include “On a scale of 1 to 10, with 1 being not motivated and 10 being completely motivated, how committed are you to solving your problem?” and “What would it look like if you ranked yourself 1 point higher on the scale?” Scaling questions may be used at any point during the counseling process. Toward the end of sessions, counselors will ask clients to evaluate how close they are to meeting their goal (Bannink, 2007). Counseling may be terminated if clients are content with their progress. Alternatively, counselors will work with clients to identify what steps might need to be taken next. Counselors will provide clients with feedback and tentative suggestions aimed at focusing the client on future actions they might consider to solve their concern. In addition, counselors gently encourage clients to attempt experiments in between sessions that reinforce what clients are already doing to support reaching their goal (Trepper, 2012). Additionally, counselors will invite clients to develop homework assignments for themselves. de Shazier et al. (2021) contends if the assignment is client generated, the client will be less resistant to completing the task and will likely rely on aspects of previously successful solutions. Future counseling sessions begin by inquiring about the client process with the counselor seeking to compliment client gains and explore results of experiences and homework.

MAINTENANCE OF PROGRESS Brief counseling approaches are predicated on the notion that clients can have therapeutic change in a short period of time. To accomplish this, brief approaches focus on supporting

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clients when there is progression in the treatment progress or therapeutic markers are reached. Clients need to at least maintain their progress if the counseling process is to advance toward problem resolution. Avoidance of therapeutic setbacks in which clients regress or relapse into previous maladaptive patterns of behavior is a responsibility of the counselor. As with other treatment approaches, the ability of the client to maintain their progress in treatment is based on the specific skills of the counselor to identify challenges and provide support or interventions. It is well established that a strong working alliance contributes to the effectiveness of brief counseling approaches (Stevens et al., 2007). Although counselor use of the therapeutic relationship to support clients with positivity and unconditional positive regard can serve as an initial catalyst for change with clients, it is the counselor’s use of directed activities that can help sustain clients therapeutic progress (Steenbarger, 1992). Examples of directed activities include in-session exercises (e.g., role-plays, use of imaginary, desensitization interventions), between-session homework, and interventions designed to anticipate and address problems (Steenbarger, 1992). Counselor interventions to help clients maintain their progress varies as brief approaches handle treatment maintenance and setbacks uniquely. ABT counselors use two types of therapeutic interventions focused on maintaining client progress: compliance-based interventions and noncompliance-based interventions (Nicoll et al., 2000). Compliance-based interventions are used with clients who are highly motivated to change their behaviors and willing to work with the counselor to make those changes. Motivated clients are given behavioral tasks or rituals to be practiced regularly and repeated to solidify the client’s positive rules of interaction. Noncompliance-based interventions involve the counselor taking an ironic stance in which the client is cautioned that they should not change or slowly change their behaviors. The goal is to motivate the client to decide if they intend to change their behavior or refuse to change. Noncompliance-based interactions are only to be used if clients are resistant to change or self-sabotage is a concern. Nicoll et al. (2000) identified three specific noncompliance-based tactics: prescribing the problem, paradoxical positioning, and restrain change. Prescribing the problem involves the client being encouraged to engage in their problematic behavior in a manner different from their usual pattern (i.e., try the behavior in a different location or at an accelerated pace). The goal is to help clients understand they have control over their behavior because they chose to enact their problematic behavior in a different manner. Paradoxical positioning involves an ironic counselor suggestion that the client continue their problematic behavior because change could be too complicated if attempted. Here, the goal is to shift clients' positionality so they want to prove the counselor wrong and attempt behavioral change. Restrain change involves the counselor encouraging clients who may be prone to self-sabotage or be resistant to change to take slow steps in their behavioral change. BEP relies on counselors’ abilities to understand and read the client’s comfort level, exploring their trauma to help clients maintain their progress. During the imaginal exposure sessions, counselors must pay close attention to help clients remain engaged when exploring their difficult emotions. Nijdam et al. (2022) note that during the exposure activities, counselors must monitor client’s arousal to ensure an optimal level for processing the trauma. Clients who are hyper-aroused can become distracted, unable to process their thoughts. In contrast, clients who are hypo-aroused may be unable to get in touch with emotions, thus preventing the emoting work from occurring. Counselors must be able to change the focus and pace of their interventions to help clients remain connected to their emotions. But also, counselors must demonstrate patience, compassion, and sympathy throughout the multi-session exposure process, even adding additional sessions if necessary (Gersons & Schnyder, 2013). Throughout the other BEP sessions, counselors work to assist clients in maintaining their therapeutic gains. For instance, clients may struggle with letter writing homework assignments. Clients may shun the task to avoid being emotionally flooded with anger or guilt.

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BEP counselors may use in-session writing to help clients feel safe and explore feelings that arise during the writing task (Nijdam et al., 2022). The goal is to help clients develop confidence to complete the homework activity in between sessions without counselor assistance. Counselors also work to assist clients in maintaining their therapeutic gains by conducting interventions from different stages within the same session. Counselors may determine that a client has not fully accepted or expressed their emotions during a session designated for meaning and integration. As such, the counselor may decide to facilitate an in-session writing activity before moving forward with focusing on the clients' post-traumatic growth. Another example is that counselors may provide psychoeducation based on client need at any time during the treatment process, not just during the first session when it is the session theme (Gersons & Schnyder, 2013, Gersons et al., 2011). Maintaining treatment progress within SFBT involves the counselor monitoring client motivation and readiness to change. Counselors will adjust their treatment approach accordingly to encourage clients to maintain positive energy toward solving their concerns. SFBT focuses on what is working for clients. SFBT counselors are not concerned about the potential solutions that have not worked for clients beyond encouraging them to discard those options. Any indications of hesitancy or resistance to potential solutions are met with compassionate understanding and optimism that there are other solutions to be explored. Client unwillingness to pursue specific solutions are not examined. Instead, counselors acknowledge clients’ efforts to resolve their concerns even if unsuccessful. Counselors may encourage clients to identify and use past actions that solved their problems or improved their circumstances in future situations (Trepper, 2012). Toward the end of SFBT sessions, it is common to have a short break. Counselors use this time for session reflection and to determine feedback to be delivered to clients. This feedback can include compliments and suggestions. Counselors give clients compliments to reinforce that clients possess the capacities and resiliency to address their concerns (Bannink, 2007). Counselors may point out specific client abilities or actions that are contributing to client advancement in solving their problems. Suggestions may include specific in-between session homework activities focused on problem-solving. SFBT counselors are careful not to convey any judgment or blame toward clients if they do not follow the counselor’s suggested actions. For instance, if a client does not complete a homework assignment or fails to try a solution previously discussed in treatment, the counselor displays acceptance of client ambivalence and setback (Nai & Rodgers, 2017). Also, the counselor joins with the client to generate alternative, more viable options that the client might attempt. It is typical of SFBT sessions to end with the client evaluating how close they are to meeting their goal. Bannink (2007) notes that scaling questions can be asked to determine if clients are sufficiently satisfied with addressing their problems. If not, the counseling dyad can dialogue about what needs to occur before treatment can be terminated.

PROCESS OF CLINICAL ASSESSMENT Assessment within brief counseling approaches requires that counselors determine rather quickly if clients are appropriate for shorter-term counseling. Suitability for brief counseling can be understood as “the [client’s] possession of psychological characteristics which facilitate participation in psychotherapy, i.e. cooperates with the therapist in establishing and maintaining a therapy alliance both at a relational and task level” (Valbak, 2004, p. 165). Assessment of treatment suitability involves more than the counselor determining if the client's problem or DSM diagnoses may interfere with the treatment process (Dewan, 2023). Counselors are evaluating clients to determine if they (a) present with a problem appropriate for counseling; (b) are motivated to use counseling to make changes in their life; (c) have the capacity to work with the counselor to jointly develop realistic, specific treatment goals; (d) want to use an appropriate brief treatment approach that requires an

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intensive therapeutic relationship; and (e) possess realistic therapeutic expectations (Bor et al., 2017). Additionally, counselors are evaluating clients to determine if they are unfit for brief counseling. Clients unsuitable for brief counseling treatment include individuals (a) incapable of understanding the counselor due to their mental or physical state, (b) with no motivation to make life changes, (c) mandated to treatment without an intrinsic motivation to change, (d) with rigid expectations of what counseling must entail, and (e) incapable of therapeutic dialogue (Bor et al., 2004). It is important to note that clients also have a voice in the suitability process as they decide whether to engage in the brief counseling process to address their concern. Assessment of treatment suitability occurs at the beginning of the counseling process and continues throughout treatment as both counselor and client ensure the appropriateness of brief counseling has not changed (Nakjima et al., 2019). This is in juxtaposition to long-term approaches in which assessment occurs before the counseling process as a distinct experience from the treatment. During the early part of brief counseling, counselors use clinical interviews that rely on their expertise to determine treatment suitability. The first face-to-face interaction between the counselor and client allows for an initial in-depth opportunity for assessment that includes evaluating for suitability and more typical assessment tasks (e.g., mental status exam, cultural interview). Let us consider brief psychosexual approaches for an assessment example. Irvin and Pullen (2017) describe a person-centered theory approach to brief psychosexual treatment that involves counselors conducting an unstructured interview focused on empowering clients to value themselves and become collaborative partners in the treatment process. Counselors use open-ended questions at the start of the first counseling session to invite clients to disclose their reason for seeking treatment, related challenges, and any additional information clients believe is important for counselors to know. As the first session progresses, counselors incorporate specific questions about the client’s experiences to convey empathic understanding toward building therapeutic rapport. Counselors also strive to understand how person-centered aspects (e.g., conditions of worth, self-structure, actualizing tendency) contribute to client sexual function difficulty (Irvin & Pullen, 2022). Throughout this unstructured process, counselors evaluate the client’s suitability for brief counseling. This process is in stark contrast to the traditional psychosexual therapy evaluative process that involves a series of three or more formal assessment sessions that contribute to a power imbalance in the therapeutic relations with the counselor positioned as the expert (Irvin & Pullen, 2017). Another example of brief counseling assessment can be gleaned from brief psychodynamic approaches. Early in the treatment process (i.e., the first two sessions), counselors conduct psychiatric and psychodynamic evaluations to determine suitability. Diagnostic criteria that support selection for inclusion in brief psychodynamic therapy include mild to moderate adjustment disorders, depression, anxiety, opioid dependence, and personality disorders (Dewan et al., 2023). Contraindications include severe mental health concerns such as suicidal ideation, major depression, and paranoia (Messer et al., 2013). Besides the type of mental health condition, counselors also assess for personal characteristics acceptable for the treatment modality such as the client’s ability to be insight oriented.

SPECIFIC THEORETICAL TECHNIQUES The Question. This technique involves counselors asking the client a question related to their presenting issue. This question can be asked in various ways such as “What would you be doing if you did not have these symptoms or problems?” or “What if you had a magic wand to wave away your problems. How would your life be different?” Client responses to these questions provide insight into the life tasks (e.g., social responsibility, intimacy, education, occupational goals) they have chosen to avoid. Imagine a client responding to “the question” saying, “If I wasn’t anxious, I would spend more time going out to restaurants

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and bars with friends. I would look to make new friends. I would go out to new places and try new cuisines.” ABT counselors might now understand that clients have chosen to avoid the challenging tasks that go along with making new friends or going to a new restaurant. In this example, the client is choosing to be anxious rather than do the work to make new friends or explore novel cuisines. Counselors use this technique to identify the rule or cause of a client’s resistance to change. Early Childhood Recollections. ABT counselors ask clients to reflect on their early childhood experiences (i.e., preferably before the age of 10). Clients are asked to share a single specific memory of an event in as much detail as possible including their feelings and thoughts. Counselors will solicit no less than three memories. The purpose of this is to identify the client’s early rules of interaction and make connections between their current rules of interaction. For example, the counselor might ask the client to notice any commonalities between the early memories and their current situation. Additionally, the counselor may explore with the client how their early memories help to enhance their understanding of their current rules of interaction. Acting as If. This technique involves asking clients to temporarily try out new behaviors. Clients are asked to identify a situation for which they want to change. Clients are asked to imagine or pretend what it would be like to have their ideal interaction. ABT counselors help clients to identify the specific behaviors that might contribute to a successful outcome and then encourage clients to “act as if” or try those behaviors out in a real-life situation. If a client expresses difficulty with perspective taking, the counselor may assist the client in identifying ways the other person may think or feel in a given situation. Then the counselor can engage the client to try the behaviors of the other person. Afterward, the counselor can process with the client what it was like “acting as if.” Reframing. From the start of counseling, clients are encouraged to describe their presenting issues using behavioral language. Counselors encourage clients to view their presenting issues in relational terms to others and the physical environment. For example, a counselor would invite a client who stated that they suffer from panic attacks to instead talk about what actions they chose to engage in when they experienced their panic attack symptoms. Catching Oneself. This technique involves inviting clients to identify their problematic behaviors without the counselor’s help. Essentially, clients are calling themselves out or catching themselves when they begin to revert to old problematic behaviors. Client awareness of their cognitive and affective triggers is necessary if they are to avoid enacting their problematic behaviors. An example of this technique would be if a client engages in negative self-talk or self-defeating behaviors and through continued practice the client learns to anticipate situations that trigger their negative self-talk; recognize when their thoughts and perceptions are becoming self-defeating; and take steps, like deep breathing or positive affirmations, to modify their thinking and behavior.

Brief Eclectic Psychotherapy Techniques Relaxation Exercises. The beginning of each imaginal exposure session can involve progressive muscle relaxation and breathing exercises. Progressive muscle relaxation involves tightening and releasing specific muscles to increase client’s concentration and awareness in preparation for re-experiencing their trauma. Breathing exercises are paired with muscle relaxation to increase the body’s physiological relaxation response. First, counselors explain the activity to clients. Counselors highlight that the purpose of the exercise is to relax as much as possible while staying alert and in control. To ensure clients understand the exercise, counselors will often demonstrate this activity before facilitating it with clients. During the activity, counselors invite clients to sit in a chair and relax as much as possible. Clients

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are then gently told to take a deep breath and hold it for a small amount of time (approximately 10–15 seconds). While still holding their breath, counselors ask clients to tense, hold, and then release a muscle group (e.g., hands). After relaxing their muscle group and exhaling, clients are encouraged to relax. This process is repeated for other muscle groups (e.g., feet, shoulders, forehead). Working Through Distrust. Developing and maintaining a strong therapeutic relationship is important if the client is to feel comfortable exploring deeply personal and horrific experiences. In the first session, counselors explicitly talk about distrust as a normal outgrowth of surviving trauma. The counselors invite the client and their trusted person to dialogue about trust. The goal is to start the trust-building process. Counselors present additional psychoeducation throughout the counseling process as necessary. Examples of psychoeducation might include explaining the symptoms of trauma as resulting from the traumatic experiences so the client can start to understand that they are not crazy and that the symptoms have had their function in the face of real danger. Working Through Detachment. BEP is focused on helping clients dealing with trauma reengage with emotions they may have suppressed or avoided such as anger, grief, and fear. Although counselors supportively encourage clients to reconnect with their feelings throughout the treatment process, it is particularly important in the imaginal exposure sessions as counselors are cautiously moving to help narrate their trauma story and talking about mementos. Counselors can partner with clients to develop cues or signals if the exposure process is moving too quickly or leading the client to become hyper-aroused. Working Through Anger. Writing tasks such as writing an angry letter is a technique to help clients deal with their strong emotions (Gersons et al., 2020b). It is meant to provide clients with a sense of control and power. Counselors invite clients to write a letter to a deceased person, a perpetrator, a bystander, an agency, a government, or other they associate with their trauma. Clients are encouraged to be uninhibited in their language use and expression of anger. The letter is not to be sent, but instead discussed in counseling as part of the catharsis and acceptance process. Attending to Dissociative Episodes/Flashbacks. Clients may experience a dissociative episode or flashback during the imaginal exposure. It is critical counselors help clients reorient themselves to the present reality in which they are not in enduring danger. Grounding techniques can be used for trauma clients who enter a dissociative state or present with extreme emotion such as intense debilitating anger (Schnyder et al., 2015). To ground clients, counselors may also provide reassurance and psychoeducation or include support persons if doing so can help clients maintain treatment engagement (Gersons et al., 2020b). Efforts should be taken, to prevent dissociative episodes whenever possible, by counselors working with clients to develop hand signals, for example, to alert the counselor the imaginal exposure process is progressing in a problematic manner (i.e., too challenging, too intense; Gersons et al., 2000b).

Solution-Focused Brief Therapy Techniques Presession Change. SFBT counselors want to understand very early in the treatment process what changes clients have noticed from the time they scheduled their counseling appointment to attending their first session. The counselor views the client as expert regarding his or her own circumstances and, consequently, supports client autonomy for treatment decision-­ making. A solution-focused brief therapist fosters a collaborative therapeutic alliance instead of a hierarchical therapist–client relationship in order to best facilitate presession change. Miracle Question. This technique is used to help a client articulate a desired future in which problems would no longer exist. Miracle questions may be utilized during the first session

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where the counselor poses a “miracle scenario” followed by a question to elicit a change response from the client. The client may provide numerous responses to the scenario and consider alternative examples of how their life could change if the problem no longer existed. The counselor can then assist the client in imagining a perception of what life would be like to serve as an indicator for subsequent tasks and goals. For example, after the counselor has posed a scenario, one can ask the client, “When you wake up tomorrow, what would be the small change that would make you feel the problem has disappeared?” or “Imagine the problem you were just describing didn’t exist anymore; what would that look like? How would it be different from today?” The goal of the miracle question is to assist the client in identifying changes that need to occur in order for a problem to end and the client can notice different events in their world once the problem disappears. Scaling Questions. As part of the goal planning/discussion process, and assisting clients in thinking about goals, the counselor can ask scaling questions that ask a client to rate how things are going using a 10-point scale. An example of a scaling question could be, “On a scale of 1 to 10, with 1 being the worst you’re feeling and 10 being the best you’ve been feeling, where do you feel you would rate your feelings today?” Should the client report making positive progress, their rating could segway into a discussion about the exceptions and how they impacted the client’s current feelings. Further descriptions of exception questions will be forthcoming. Exception Questions. As a way to assist clients in identifying times when problems are not present, the counselor utilizes exception questions. The purpose of this technique is to aid the client in finding reasons why the problems didn’t interfere with their daily activities. Through the feedback from the client, the counselor can highlight instances when the problem didn’t occur while also acknowledging strengths and coping strategies within the identified exceptions. The act of predicting exceptions increases the frequency of such predictions and clients may find they can use these as resources in future situations. The expectation is the client will gain awareness of times when the problem is not present, predict a time when they will overcome the problem, and then assess the accuracy of their prediction with hopes that the more regular the exceptions become, the more distant the problem appears. An example of the counselor asking an exception question would be “What was different about that moment?” Compliments. A feedback technique is used to validate the tasks that the client does well, highlight what is working, and promote continuation of effective problem-solving behaviors and strategies. An SFBT counselor can acknowledge the reality of a client’s struggles, which sends a message that the counselor is attentive, caring, and fully expects that successful solutions will come about during therapy. This technique can help a client recognize specific competencies through affirmations and bridging statements and reframe problems and demonstrate progress to the client. An example of a compliment could be the counselor providing positive feedback on how a client is utilizing their identified coping resources and linking their strengths to an identified problem-solving strategy.

MULTICULTURAL, INTERSECTIONAL, AND SOCIAL JUSTICE ISSUES Brief counseling approaches have been criticized for being grounded in theoretical assumptions that contrast with multicultural and social justice (MCSJ) counseling ideals. Steenbarger (1993) identified four issues with brief counseling approaches broadly: locus of client problems, criteria of client inclusion in brief counseling, therapeutic methods, and therapeutic aims. First, brief counseling tends to conceptualize client issues as intrapersonal and resulting from intrapsychic difficulty or problematic behavioral patterns that the client must

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work to change. Contextual factors (e.g., societal oppression, marginalization) that contribute to client's presenting issues may not be examined. Moreover, societal or institutional level efforts to ameliorate contextual factors that adversely impact clients (e.g., advocating to change oppressive systems at institutional, community, public policy levels) may not be considered. Within brief counseling approaches generally, the locus of client problems is not viewed as an interplay between the client and their environment. Second, brief counseling approaches make assumptions about client treatment suitability based on a restrictive inclusion criterion (Steenbarger, 1993). Counselors assess suitability based on the client’s ability to develop a working alliance with the client (Valbak, 2004). Working alliance can be impacted by the interplay of conscious and unconscious cultural dynamics between the counselor and client. Counselors can strengthen the working alliance by conveying an appreciation for cultural diversity, acknowledging the clients’ cultural experiences, and reflecting on their own sociocultural identities and contexts (Duan, 2020). Brief counselors that assess working alliance without considering the interplay of cultural dynamics between the counseling dyad may erroneously evaluate interpersonal cultural aspects as intrapersonal, pathological characteristics that make a client unsuitable for brief counseling (Steenbarger, 1993). Third, brief counseling treatment methods are shorter in duration, which forces counselors to hastily cultivate the working alliance in a manner that may be counter to the clients’ culturally preferred method of developing trust over a longer period of time (Steenbarger, 1993). Counselors in their haste may stereotype, overgeneralize, or otherwise fail to consider the uniqueness of each client (i.e., acknowledge there is variability within cultural groups; Echemendia & Nunez, 2012). Related, the future action-oriented focus of brief counseling may conflict with client's worldviews of time, such as being in the present moment or having a past time orientation (Feltham, 1997). Fourth, brief counseling therapeutic goals have been criticized for focusing on symptom reduction and changing behavioral patterns while being less attentive to cultural identity empowerment and development (Steenbarger, 1993). Brief counseling approaches have tended not to substantially address in their theoretical foundations how to account for multicultural or social justice aspects (Xie, 2014). As such, brief counselors have less theoretical guidance for how to attend to cultural empowerment and identity development. Essential to practicing multicultural and socially just competent counseling, counselors are expected to consider how privilege and power dynamics impact the counseling relationship, contextualize client problems within a cultural context, and employ strategies with and on behalf of clients to intervene across individual, interpersonal, and systemic levels (Ratts et al., 2016). Individual psychology theoretical foundations, which is specific to ABT, have been perceived as respectful to diversity considerations. Watts (2000) noted that individual psychology is grounded in social equality concepts and valuing how sociocultural contexts can impact clients' lives. Culturally appropriate ABT components include (a) positioning clients within their familial context; (b) considering how sociocultural factors impact clients’ sense of inferiority, social interest, and goal striving; and (c) honoring clients' cultural values and decisions by not dictating specific treatment goals or behavioral changes (Newlon & Arciniega, 1983). BEP is an efficacious trauma-focused treatment that has been researched with diverse ethnic and national populations, clients across the life span, individuals of different genders, and individuals within specific professions (e.g., police officers; Gersons et a., 2020a). BEP ideals (i.e., acceptance of emotions, meaning making of emotions, facing realities resulting from trauma) require that counselors be sensitive to how clients’ cultural backgrounds are intertwined with how they experience trauma and recover. BEP counselors are trained to be mindful of how clients’ cultural backgrounds, as well as cultural dynamics between clients and themselves, may necessitate altering the treatment protocol (Gersons et al., 2011). For instance, additional time for psychoeducation may be required for individuals

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distrusting of counselors or new to the counseling process. Related, BEP considers how clients’ meaning making during the post-traumatic growth period of training (i.e., domain of meaning sessions) can be impacted by clients’ unique cultural values, customs, and worldviews (Smid et al., 2015). What remains unclear is how BEP ideals of embracing emotions and meaning align with clients from cultural backgrounds that value muted or restricted expression of emotion. SFBT is a proven successful approach for working with a diverse array of clients, including adults, children, and individuals of varied racial and ethnic backgrounds (de Shazer et al., 2021; Kim, 2014). SFBT principles that align with multicultural and social justice counseling competencies (MSJCC) likely contribute to its effectiveness. The collaborative appropriate to identification of treatment goals and deference to clients regarding pursuit of problem solutions positions clients as leading their treatment. Throughout the counseling process, SFBT principles encourage counselors to work with clients from a not knowing approach (Kim, 2014). This approach allows counselors to privilege clients as experts with perspectives that should be respected and not challenged. Additionally, this approach reduces hierarchical aspects that could adversely impact the working alliance. There are SFBT principles that potentially clash with MCSJ ideals. For instance, discord may arise between the counseling dyad if clients with marginalized sociocultural identities want to focus on historical or oppression experiences. SFBT’s future-focused positionality does not allow for considerable exploration of the past (Rossiter, 2000). Another consideration is that SFBT is an action-oriented approach that encourages clients to identify solutions and take action to resolve their problems. This stance is potentially problematic if clients value interdependence and community as individual action-taking may be perceived as culturally inappropriate.

THEORY-BASED RESEARCH TRENDS Over the last several decades, brief counseling approaches have established themselves as viable alternatives to traditional longer-term treatment approaches for a variety of mental health concerns including depression, anxiety, substance use, and behavioral problems. Randomized clinical trials examining brief versus longer-term therapies have largely found the treatments are equally as effective in producing favorable outcomes (e.g., see Kim et al., 2019). However, there are lingering concerns about the applicability of these findings as the controlled research study environments do not account for real-world factors such as variations in counselor competency and availability of treatment options (Parry et al., 2005). For instance, Ormel et al. (2022) noted that treatment of depression is significantly overestimated for both short- and longer-term approaches, is significantly less effective in real-world noncontrolled settings, and likely differs for chronic versus non-chronic clinical presentations. Continued research into the effectiveness of brief counseling approaches across mental health concerns under real-world conditions remains necessary.

DETAILED CASE CONCEPTUALIZATION PRAGMATICS AND TRANSCRIPT Given the focus of SFBT is goal-oriented and strength based, the approach utilized by a counselor is considered collaborative and client-led. This approach is based on solution building rather than problem-solving. In accordance with SFBT, the counselor focuses on present and future dynamics in order to identify solutions to client’s problems. Utilizing techniques such as the scaling question or the presession change question, the counselor seeks to bring into client’s consciousness their strengths and resiliencies to work toward swift and incremental change. There are four key tasks of the counselor for a typical first session: (1) Inquire about what the client is hoping to achieve in counseling, (2) identify

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what the client’s life would look like if these hopes were achieved, (3) assess what the client is already doing or has done in the past that may contribute to achieving their goals, and (4) elicit what might be different if the client made one small change toward accomplishing their goal. The following section presents a transcription of a counselor working with the client, Mark, who is navigating a divorce. It is the counselor’s responsibility to assist the client in developing a picture of solutions and discovering the necessary resources to achieve them. In this case, Mark is a 42-year-old, Black, cisgender male who works as a project manager for a general contracting company. He is divorced and lives with his two daughters. Mark is seeking counseling for anxiety, sadness, and anger that occurred following his divorce. Mark has expressed feeling lonely and guilty for wanting to start dating again because it “takes me away from my daughters.” Transcript

Skill(s) Demonstrated

Counselor: Hello, Mark. Thank you for coming in today. What are your hopes for this session?

Open-ended question (The counselor uses an open-ended question to open the session.)

Mark: I don’t know, really. I was thinking about that on my drive here. I’ve been feeling lonely a lot lately, but I don’t know…. Counselor: It sounds like feelings you’ve been ­having for a while and I’m wondering how have things changed from the time you scheduled your ­appointment to you coming in today?

Paraphrasing, presession change (The counselor uses a brief paraphrase and then assesses Mark’s autonomy for treatment decision-making.)

Mark: I don’t think much has changed. I noticed I feel more lonely and guilty, and just a range of ­emotions since this divorce. Counselor: You have been divorced for a while so do you think it would be useful to work through your feelings about this today?

Paraphrasing, open-ended question (The counselor uses a brief paraphrase and then provides an open-ended question.)

Mark: Well, I suppose it could be useful. I really don’t think my daughters would want me to start dating again. Counselor: What makes you think so?

Open-ended question (The counselor uses an open-ended question to determine how Mark is feeling.)

Mark: Because they know it would take time away from them and I wouldn’t want them to feel like I love them less. Counselor: Hmm. Love them less?

Mark: Yes, I know I’m lonely and would like to have someone in my life, but how it would make the girls feel concerns me. I feel so guilty!

Open-ended question (The counselor uses an open-ended question to determine how the client is feeling.)

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Counselor: It sounds like you’re concerned about how it would affect your daughters. I wonder if you could imagine that tonight while you’re asleep, a miracle happens and your feeling of guilt is resolved. What will you notice different in the morning that begins to tell you that you’re no longer feeling guilty?

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Reflection of feeling, miracle question (The counselor reflects Mark’s guilt and asks a miracle question.)

Mark: Well…I don’t know. I can’t imagine that. Counselor [pauses]: Take your time.

Silence (The counselor intentionally uses silence to allow Mark time to continue to process.)

Mark: Hmm. I would imagine I would feel relaxed. Almost like I wasn’t keeping a secret from my daughters. I would feel like they’re going to be okay. Counselor: So it seems you would feel a weight is lifted. Can you think of what you might do to achieve this more relaxed feeling?

Paraphrasing, open-ended question (The counselor uses a brief paraphrase and an open-ended question to identify changes that need to occur.)

Mark: See that’s the hard part. I think I would need to tell them that I want to date again. My oldest daughter has asked me if I would ever get married again, but I completely panicked and said that I’m not worried about that at this time. I just don’t know if they would be okay with my new partner. I feel like I’m working myself up about something that hasn’t even happened though. I don’t know why I do this but this is very distressing to me. Counselor: Wow, I hear you. On a scale of 1 to 10, with 1 being extremely distressing and 10 being not distressing at all, where do you feel you would rate your level of distress in this moment?

Minimal encourager, scaling question (The counselor used a minimal encourager to track and a scaling question to assist Mark’s thinking about goals.)

Mark: I feel like sometimes it keeps me up at night, but right now I would say I’m feeling around a 6. Counselor: A 6 feels slightly in the middle. What feels different in this moment?

Paraphrase, exception question (The counselor paraphrased Mark’s rating and used an exception question to aid the client in identifying when the problem doesn’t occur.)

Mark: Well, I don’t know. It seems like I don’t need to worry talking with you. I guess I could just say how I feel to them. I know they know they are my focus, but I would want them to know if I date they won’t become less important to me. I don’t want to be lonely, and I want to be a good dad too. Counselor: I hear you saying being a good dad is really important to you. When you think about what being a “good dad” means to you, I wonder what you could do to demonstrate that?

Reflection of content, open-ended question to begin goal setting (The counselor reflects Mark’s values and uses an open-ended question to begin goal setting with Mark.)

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THEORETICAL LIMITATIONS As with all theoretical approaches to counseling, there are limitations. Brief counseling approaches are not a panacea. Not all client problems can be addressed via brief counseling as not all clients are fit for brief counseling treatment. Individuals with significant psychological dysfunction are not suitable for this modality. For individuals that participate in brief counseling, these approaches may encourage clients to withhold raising serious or other concerns that were not identified at treatment onset (Feltham, 1997). Counselors redirect clients toward addressing the mutually agreed-upon problems during treatment, which may lead to overlooking contextual dynamics that impact client goal attainment. Brief counseling approaches require clients to be clinically adept especially considering the shortened time frame and quicker treatment pace. Inexperienced counselors may struggle with identifying individuals unfit for treatment, focusing the treatment rapidly, relinquishing their “expert” status, and partnering with clients to support them as they navigate the treatment process. Inexperienced counselors may overly rely on manualized treatment adherence ignoring unanticipated situations, which may adversely impact the counseling process (Wampold, 2015). Each of the brief counseling approaches discussed in this chapter have theoretical limitations. With its theoretical foundation in individual psychology, ABT frames behavior through a lens of addressing feelings of inferiority that are connected to clients’ early familial structure that impacts goal striving and social interest. For example, ABT counselors interpret data collected on an individuals’ birth order within their family to make interpretations about the clients’ lifestyle (i.e., ways of being and beliefs). Individual psychology has been criticized for being too simplistic as these concepts reflect common sense and may be based on stereotypes (Mosak & Maniacci, 1999). BEP is a manualized 16-week treatment for PTSD and other trauma-related disorders. It is well received as an evidence-based treatment for PTSD and trauma disorders. However, it is an inappropriate treatment for other diagnoses. SFBT is an action-oriented approach in which counselors encourage clients to discard actions that are not working or fail to resolve problems. Strict theoretical adherence can lead counselors to be inflexible in tailoring the counseling process to each client and their unique needs (Thomas et al., 2021). Counselors may dismiss or foreclose on problem-solving options too quickly based on adhering to theoretical fidelity or personal bias for certain actions. Moreover, counselors may position clients toward action that have implications worthy of consideration but may be overlooked due to the focus on action. What are the consequences to the client and others (i.e., family, community) by choosing certain actions? Client solutions are culturally embedded. What cultural implications are there for the client in their decision-making? As an action-oriented therapy, SFBT has been criticized for ignoring or excluding emotions and feelings. de Shazer et al. (2021) contend that SFBT focuses on observed behavioral manifestations of one’s emotional state, not as internal experiences that are disconnected from a behavioral context, which is traditional in other psychotherapies. Another component of SFBT is the promotion of optimism, which can motivate clients but may be harmful if not grounded in reality (Thomas et al., 2021). SFBT counselors want to be careful to avoid fostering false hope of problem resolution.

SUMMARY In this chapter, brief counseling approaches were explored with particular attention to three approaches: ABT BEP, and SFBT. An historical overview of brief counseling approaches was presented and key aspects of each theory’s major concepts, techniques, MCSJ considerations, trends, and theoretical limitations were addressed. ABT focuses on helping individuals gain insight and change their patterns of behavior. Underlying this approach are the principles of individual psychology. BEP is a trauma-focused treatment modality for

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survivors dealing with grief and difficult emotions. The goal of treatment is to reduce clients’ PTSD and trauma symptoms. Differing from other trauma-informed practices, BEP focuses on encouraging clients to experience and embrace negative emotions connected to their traumatic experiences. In its goal-oriented nature, SFBT helps clients identify and take action to resolve their programs rather than focusing on the origins of problems or past unsuccessful resolution efforts. An in-depth description of the origins and nature of mental health distress for brief counseling approaches was provided for a comprehensive understanding of the counseling approaches for each brief counseling theory presented. This chapter described a broad overview of the nature of human development, processes for change, and dynamics of counselor–client relationships facilitated through treatment goal attainment for each brief counseling approach outlined in this chapter. VOICES FROM THE FIELD This chapter features a digitally recorded interview entitled Voices From the Field. The interview explores multicultural, social justice, equity, diversity, and intersectionality issues from the perspective of clinicians representing a wide range of ethnic, racial, and national backgrounds. The purpose of having chapter-based authors interview individuals representing communities of color or who frequently serve diverse populations is to provide you, the reader, with relevant theory-based social justice and multiculturally oriented conceptualization, contemporary issues, and relevant skills.

Access the video at https://bcove.video/3ZFoUbP

Bradford Hill  is a licensed clinical  mental health counselor and nationally certified counselor based out of Raleigh, North Carolina. Graduating from North Carolina Agricultural and Technical State University with a bachelor’s  degree in psychology, and a master’s degree in clinical mental health counseling from The University of North Carolina at Pembroke, Bradford has been a student affairs professional for the past 5 years postgraduation and is currently a generalist counselor in the North Carolina State Counseling Center, a member of the sports psychology team within University Athletics, and owner of an independent private practice.

STUDENT EXERCISES Exercise 1: Universal Aspects to Brief Counseling

Directions: Define three characteristics universal to all brief counseling approaches and how these approaches differ from traditional counseling approaches. Connect with a peer and compare and contrast your responses.

Exercise 2: Understanding the Leaders and Legacies of Brief Counseling Approaches

Directions: Name two key figures in the development of brief counseling approaches and their unique contributions. How will the contributions of these key figures impact your future work?

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Exercise 3: Compare and Contrast the Theories of Change

Directions: Describe and contrast the theories of change for two brief counseling approaches. What similarities do you see among these approaches? What differences do you notice?

Exercise 4: Developing Your Own Approach

Directions: Pair with a partner and discuss aspects of brief counseling that fit with your approach to counseling.

Exercise 5: Understanding the Pros and Cons of Brief Counseling

Directions: What are arguments for or against utilizing a brief counseling approach?

RESOURCES Helpful Links ■ ■ ■ ■ ■ ■ ■

Brief Counseling Center: www.brieftherapycenter.org European Brief Counseling Association: www.ebta.eu Idaho Society of Individual Psychology: https://adleridaho.org/ National Psychodrama Centrum: www.traumabehandeling.net/en North American Society of Adlerian Psychology: www.alfredadler.org Solution-Focused Brief Therapy Association: www.sfbta.org Kim, J. S., Smock, S., Trepper, T. S., McCollum, E. E., & Franklin, C. (2010). Is solution-­ focused brief therapy evidence-based? Families in Society, 91(3), 300–306.

Helpful Books ■ ■ ■ ■ ■ ■ ■ ■

■ ■ ■

Clark, T. E., Stein, H. T., Stein, L. J., & Wolf, J. J. (Eds.). (2011). Classical Adlerian brief therapy: The innovative techniques of Anthony Bruck. The Classical Adlerian Translation Project. Dierolf K., Hogan D., Van der Hoorn S., & Wignaraja S. (Eds.). (2020). Solution focused practice around the world. Taylor & Francis Group. Gerrard, B. A., Selimos, E. D., & Morrison, S. S. (Eds.). (2022). School-based family counseling with refugees and immigrants. Taylor & Francis. Kim, J. S. (Ed.). (2014). Solution-focused brief therapy: A multicultural approach. SAGE Publications, Inc. https://dx.doi.org/10.4135/9781483352930 Ouer, R. (2015). Solution-focused brief therapy with the LGBT community: Creating futures through hope and resilience (1st ed.). Routledge. https://doi.org/10.4324/9781315744360 Parsons, R. (2023). Brief psychotherapy: Time-limited and effective treatments. Cognella. Nelson, T. S. (2018). Solution-focused brief therapy with families. Routledge. Skare, G. (2014). Brief counseling that works: A solution-focused therapy approach for school counselors and other mental health professionals. Corwin and American School Counseling Association. Sperry, L., & Carlson, J. (2014). How master therapists work. Routledge. Smid, G. E., & Boelen, P. A. (2021). Culturally sensitive approaches to finding meaning in traumatic bereavement. In New techniques of grief therapy (pp. 46–54). Routledge. Taylor, E. R. (2019). Solution-focused therapy with children and adolescents: Creative and play based approaches. Taylor & Francis Group.

Helpful Videos ■

Carlson, J. (Director). (2003). Brief integrative Adlerian couples therapy [Video/DVD]. Microtraining Associates.

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Carlson, J. (Director). (2008). Solution-focused brief counseling with Insoo Kim Berg [Video/DVD]. Psychotherapy.net. Carlson, J. (Director). (2010). Brief couples therapy [Video/DVD]. Milton H. Erickson Foundation. Sklare, G. (Director). (2005) Solution-focused brief counseling: Two actual interviews with a child. [Video/DVD]. Microtraining Associates.

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Index

ABCT. See Association for Behavioral and Cognitive Therapies ABT. See Adlerian brief therapy ACA. See American Counseling Association acceptance and commitment therapy (ACT), 203–204, 220, 246–247 change process, 252 client’s role, 249 counselor’s role, 249 progress maintenance, 253 values assessment, 258–259 accreditation, 6–9 acculturation, 47 Achenbach System of Empirically Based Assessment (ASEBA), 230 Ackerman, Nathan, 271 ACT. See acceptance and commitment therapy “acting as if” technique, 377 Adlerian brief therapy (ABT), 363–364 change process, 370–371 client and counselor role, 368–369 emotional and psychological well-being, 367 limitations, 384 mental health concerns, 365–366 multicultural and social justice (MCSJ) issues, 380 progress maintenance, 374 techniques, 376–377 Adlerian techniques, 132, 152 early recollections (ER), 144 interpretations, 145 question, 144 spitting in the client’s soup technique, 145 strengths-based interview, 143 advocacy, 62 affirmative intersectional rehabilitation counseling (AIRC), 57–58, 57–59 AIRC. See affirmative intersectional rehabilitation counseling alter ego personality, 141 American Counseling Association (ACA), 23, 184 anxious attachment, 165–166 applied behavior analysis (ABA), 219 approaching confusion, 202

ASEBA. See Achenbach System of Empirically Based Assessment assertiveness training, feminist theory, 93–94 Association for Behavioral and Cognitive Therapies (ABCT), 216 avoidant attachment, 166 awareness exercise, 201 BASIC ID model, 341–342, 347–348, 350 affect, 356 behaviors, 355 cognition, 356 drugs/health/biology, 356 imagery, 356 interpersonal relationships, 356 sensation, 356 Bateson, Gregory, 272 Beck Depression Inventory (BDI), 254–255 Becker, Ernest, 190 behavioral activation, 256 behavioral rehearsals, 258 behavioral theory, 17–18 behavioral therapy acceptance and commitment therapy, 220 Achenbach System of Empirically Based Assessment, 230 applied behavior analysis, 219 assessment, 228–230 Behavior Assessment for Children, 3rd Edition, 229–230 case conceptualization, 236–238 change process, 226–227 cognitive behavioral therapy, 219 dialectical behavior therapy, 219–220 emotional and psychological well-being, 222–223 human development, 225 leaders and legacies, 216–218 limitation, 238–239 maintenance of progress, 227–228 mental health concerns, 220–222 multicultural, intersectional, and social justice, 234–235 Pavlov’s work, 216

389

390  |  Index behavioral therapy (cont.) scholarship and research trends, 235–236 Skinner’s work, 217 techniques, 230–234 tenets, 218–219 transcript, 236 Watson’s work, 217 Wolpe’s work, 218 Behavior Assessment for Children, 3rd Edition (BASC-3), 229–230 behaviorism, 215–216 Bem Sex Role Inventory (BSRI), 95 BEP. See brief eclectic psychotherapy bibliotherapy, 93 Binswanger, Ludwig, 191 Black liberation approaches, 204 blamer technique, 278 Boss, Medard, 191 Bowen, Murray, 273 Breuer, Josef, 106 brief counseling theory, 19 case conceptualziation, 381–383 change process, 369–373 client and counselor role, 368–369 clinical assessment, 375–376 emotional and psychological well-being, 366–368 human development, 369 leaders and legacies, 362–365 limitations, 384 mental health concerns, 365–366 multicultural and social justice (MCSJ) issues, 379–381 philosophical aspects, 362 progress maintenance, 373–375 research trends, 381 theoretical techniques, 376–379 transcript, 381 brief eclectic psychotherapy (BEP), 364 change process, 371 client and counselor role, 369 emotional and psychological well-being, 367 mental health concerns, 366 multicultural and social justice (MCSJ) issues, 380–381 progress maintenance, 374–375 techniques, 377–378 trauma symptoms, 366 Brücke’s theory, 107 Buber, Martin, 190 CACREP. See Council for Accreditation of Counseling and Related Educational Programs Camus, Albert, 190 CAS. See counselor advocate–scholar model case conceptualization, 6 biopsychosocial model, 14 factors influencing, 14 Sperry and Sperry’s eight P’s, 14–15

CASP-19. See Control, Autonomy, Self-Realization, and Pleasure Scale casual enactment, 320 catching oneself technique, 377 cathartic method, 106 CBT. See cognitive behavioral therapy CEE. See corrective emotional experiences circular causality, 275 classical conditioning change process, 226 client–counselor relationship, 223–224 emotional and psychological well-being, 222 flooding, 232 human development, 225 maintenance of progress, 227–228 mental health concerns, 220–221 reciprocal inhibition, 231 systematic desensitization, 231–232 classic psychoanalytic conflict/drive perspective, 119 change process, 115 client and counselor role, 112–113 dream interpretation and analysis, 119–120 emotional and psychological well-being, 112 free association, 119 human development, 114 mental health concerns, 109–110 personality development, 108 cognitive behavioral therapy (CBT), 217, 245–246 behavioral activation, 256 change process, 251 client’s role, 248 counselor’s role, 247–248 homework, 256 intersectionality, 260–261 progress maintenance, 252–253 psychoeducation, 255–256 reframing, 257 social justice counseling, 259–260 techniques, 257 thought stopping, 256 cognitive theory, 17–18. See also acceptance and commitment therapy; social learning theory case conceptualization, 261–264 clinical assessment, 253–255 emotional and psychological well-being, 245–247 human development, 249–250 leaders and legacies, 243–244 limitations, 264 mental health concerns, 244 scholarship and research trends, 261 techniques, 255–259 transcript, 261 Collaborative Assessment and Planning (CAP) model, 62 common factor models, 19–22 concientizacion, 60 congruent technique, 278

Index

constructivism, 305, 308, 311 constructivist therapy casual enactment, 320 change process, 314 client and counselor roles, 312–313 emotional and psychological well-being, 311 limitations, 327 mental health concerns, 310 progress maintenance, 315–316 repertory grid, 320 role construct repertory test, 320–321 self-characterization, 321 contact-shunning personality, 141 Control, Autonomy, Self-Realization, and Pleasure Scale (CASP-19), 178 corrective emotional experiences (CEE), 171 Council for Accreditation of Counseling and Related Educational Programs (CACREP), 6–9 counseling theory, 5–6 counseling history, 10, 12–13 dialectic-centered, 28–29 gestalt therapy, 10 theoretical grouping, 11–12 counselor advocate–scholar (CAS) model, 54–56 countertransference, 113, 118–119 COVID-19 crisis intervention, existential-humanistic approach, 204 telebehavioral health, 24 critical race theory, 45, 86 cultural activism and social justice (CAS) model, 70 cultural identity, 44 cybernetics, 272 DBT. See dialectical behavior therapy death desensitization, 201 deideologized reality, 60 dereflection, 201 dialectical behavior therapy (DBT), 219–222 assessments, 230 change process, 227 client–counselor relationship, 225 emotional and psychological well-being, 223 mental health concerns, 221–222 multicultural, intersectional, and social justice, 235 techniques, 233–234 dialectic-centered counseling theory, 28–29 disorganized attachment, 166 dodo bird effect, 20 dream work, 201 Dyadic Adjustment Scale (DAS), 286 dysfunctional families, 276

early childhood recollections, 377 early recollections (ER) technique, 144

  |  391

eclectic counseling change process, 344 client and counselor roles, 341 emotional/psychological well-being, 339 mental health concerns, 337 multicultural perspective, 351 scholarship and research trends, 352–353 theoretical techniques, 349–350 eclecticism, 22 ecological model of multicultural counseling psychology processes (EMMCPP), 48–49 EFT. See emotionally focused therapy EMMCPP. See ecological model of multicultural counseling psychology processes emotional and psychological well-being Adlerian brief therapy (ABT), 367 behavioral therapy, 222–223 brief counseling theory, 366–368 brief eclectic psychotherapy (BEP), 367 classical conditioning, 222 classic psychoanalytic conflict/drive perspective, 112 cognitive theory, 245 constructivist therapy, 311 dialectical behavior therapy (DBT), 223 emotionally focused therapy (EFT), 167–168 existential-humanistic approaches, 195–196 human validation process model, 280 Jungian psychology, 112 multigenerational family therapy, 279–280 narrative therapy, 310–311 object relations theory, 112 operant conditioning, 222–223 person-centered therapy (PCT), 166 postmodern theory, 310–311 process-experiential approach (PE-EFT), 167 solution-focused brief therapy, 310, 367–368 structural family therapy, 280–281 systemic theory, 279–281 emotionally focused therapy (EFT) case conceptualization, 183 change process, 176 client and counselor’s role, 171 clinical assessment, 178–179 emotional and psychological well-being, 167–168 human development, 172–173 leaders and legacies, 162 limitations, 184–185 maintaining progress, 177 mental health concerns, 164–166 multicultural and intersectional issues, 181 scholarship and research trends, 182 social justice issues, 181 technique, 180 empathy, person-centered therapy, 170 empowerment counseling, 62 enactment, 291 Erickson, Milton, 362–363

392  |  Index exception questions, 379 existential-humanistic approaches case conceptualization, 204–207 change process, 197–198 client–counselor relationship, 196–197 clinical assessment, 199–200 contributors, 192–193 emotional and psychological well-being, 195–196 gestalt techniques, 201–202 human development, 197 leaders and legacies, 189–191 limitations, 207–208 maintaining progress, 198–199 mental health concerns, 193–195 multicultural and intersectional issues, 200, 202–203 scholarship and research trends, 203–204 theory founders, 191–192 transcript, 205 existential-humanistic theories, 17 existential integrative (EI) theory, 203 existential vacuum, 194 exosystem, EMMCPP, 48 Experiences in Close Relationships (ECR), 179 extinction procedure, 233 family chronology, 290 feedback technique, 379 feminist counseling theory approaches and interventions, 92–95 assertiveness training, 93–94 assessment, 95 bibliotherapy, 93 case conceptualization, 96 diversity and ethics, 94–95 feminist worldview change, 90 client experience, 91–92 human nature, 89–90 therapeutic process, 90–91 Friedan’s work, 80 gender role and power analysis, 92–93 internalized oppressive beliefs, 82 gender performance, 83 Gilligan’s work, 80–81 philosophy, 78 post-structural and postmodernist perspective, 82 psychoanalytic perspective, 83–89 psychological theorists, 84 Rousseau’s work, 79 transcript, 97–98 Wollstonecraft’s work, 78–79 women’s movement, 78 feminist theory, 16 flooding, 232 Focus Fish tool, 24

formal psychoanalytic assessments, 117–118 Frankl, Victor, 192 free association tool, 119 Freud, Sigmund, 106–107 functional behavioral analysis, 229 Garfield, Sol, 335 General Self-Efficacy (GSE) Scale, 254 genogram, 286, 287, 288 genuineness, person-centered therapy, 169 Gersons, Berthold, 364 gestalt techniques, 10, 194, 201–202 Gottman method, 274–275 Greenberg, Leslie, 161–162 Haley, Jay, 272–273 Health Information Technology for Economic and Clinical Health Act (HITECH), 25 Health Insurance Portability and Accountability Act (HIPAA), 24 Heidegger, Martin, 190 HIPAA. See Health Insurance Portability and Accountability Act HITECH. See Health Information Technology for Economic and Clinical Health Act homeostasis, 272 Horney, Karen, 132 human development behavioral therapy, 225 classical psychoanalytic perspective, 114 cognitive theory, 249–250 existential-humanistic approaches, 197 Jungian psychology, 114 object relations approach, 114–115 person-centered therapy (PCT), 171–172 process-experiential approach (PE-EFT), 172 relational psychoanalytic approach, 139–141 humanism, 87–88 humanistic theoretical approaches, 13 human validation process model change process, 283–284 chaos, 284 client and counselor’s roles, 281–282 drama, 290 emotional and psychological well-being, 280 family chronology, 290 group work, 290 humor, 290 integration, 284 limitations, 299 making contact, 283–284 mental health concerns, 276 metaphor, 290 multicultural and social justice issues, 292–293 sculpting, 289 touch, 290 humility, 29

Index

humor, 290 Husserl, Edmund, 190 I-CARE technique, 62–63 inferiority complex, 134 insecure attachment styles, 165–166 integration, 22 integrative awareness, R/CID model, 48 integrative psychotherapy change process, 343 client and counselor roles, 340–341 cultural responsiveness, 350 emotional/psychological well-being, 339 mental health concerns, 336 scholarship and research trends, 351–352 theoretical techniques, 348 integrative theory, 19 case conceptualization, 353–356 change process, 343–344 clinical assessment, 345–348 emotional/psychological well-being, 339 human development, 342 leaders and legacies, 334–336 limitations, 356–357 mental health concerns, 336–338 progress maintenance stage, 344–345 transcript, 354 interpretations, 145 Inventory of Microaggressions Against Black Individuals (IMABI), 95 Jackson, Don, 272 Jaspers, Karl, 190–191 Johnson, Sue, 162 Jungian psychology, 107 change process, 115–116 client and counselor role, 113 emotional and psychological well-being, 112 human development, 114 mental health concerns, 110 multicultural and intersectional issues, 122 personality development, 108–109 Sandtray and Mandalas, 121 social justice issues, 122 Kierkegaard, Soren, 189 Kohut, Heinz, 132–133 laddering, 316 Lazarus, Arnold, 334–335 liberal feminist theory, 87–88 liberation psychology concientizacion, 60 deideologized reality, 60 macro level, 59

  |  393

mesosystem, 59 microsystem, 59 realismo-critico, 60 Lidz, Theodore, 273 lifestyle, 133–134 principle, 365 relational approach, 143 logotherapy, 192, 199 mandalas, 121 Maslow, Abraham, 160–161 MCT. See multicultural counseling theory mental health concerns Adlerian brief therapy (ABT), 365–366 behavioral therapy, 220–222 brief eclectic psychotherapy (BEP), 366 classical conditioning, 220–221 classical psychoanalytic perspective, 109–110 classic psychoanalytic conflict/drive perspective, 109–110 cognitive theory, 244 constructivist therapy, 310 defense mechanisms, 110, 111 dialectical behavior therapy (DBT), 221–222 eclectic counseling, 337 emotionally focused therapy (EFT), 164–166 existential-humanistic approaches, 193–195 human validation process model, 276 integrative psychotherapy, 336 integrative theory, 336–338 Jungian psychology, 110 multigenerational family therapy, 276 narrative therapy, 309 object relations theory, 110, 112 operant conditioning, 221 person-centered therapy (PCT), 162–163 postmodern theory, 308–310 process-experiential approach (PE-EFT), 164 solution-focused brief therapy (SFBT), 308–309, 366 structural family therapy, 278–279 systemic theory, 275–279 transtheoretical model (TTM), 337 “merger-hungry” personality, 141 mesosystem, EMMCPP, 48 metaphor, 290 metatheory, 308 microsystem, EMMCPP, 48 mindfulness practices, 247 minority stress, 60–61 miracle question, 378–379 MMBB. See multidimensional model of broaching behavior Multicultural and Social Justice Counseling Competencies (MSJCC) model, 53–54 multicultural counseling theory (MCT), 15–16 case conceptualization, 64–69 client and counselor’s role, 56–57

394  |  Index multicultural counseling theory (MCT) (cont.) counselor training limitations, 45 culturally nuanced approach, 35 dismantling systemic exclusion, 44–45 intersecting layers CAS model, 54–55 cultural gap, 55 MSJCC model, 53–54 leaders and legacies Arredondo’s competency tools, 39–41 Helms’s racial and ethnic identity development, 38–40 Pedersen’ cultural identity, 41–42 Sue’s legacy, 37–38 Vontress’s cultural difference, 36–37 liberation psychology, 59–60 limitations, 70 metatheoretical nature, 42–43 modalities broaching, 49–51 EMMCPP, 48–49 NTU therapy, 49 personal dimensions of identity model, 51 racial and cultural identity development, 46–48 relational-cultural theory (RCT), 51–52 scholarship and research, 60–63 social activism, 70, 71 social justice, 45 sociopolitical factors, 35 theoretical constructs, 43–44 theoretical techniques and process, 57–60 transcripts, 66 multidimensional model of broaching behavior (MMBB) inter-REC domain, 50–51 intracounseling, 50 intraindividual domain, 50 intra-REC domain, 50 multigenerational family therapy, 273 change process, 282–283 client and counselor roles, 281 eight core processes, 277 emotional and psychological well-being, 279–280 family visits, 289 genogram, 288 limitations, 298 mental health concerns, 276 progress maintaining, 285 relational experiments, 288–289 teaching, 288 techniques, 288–289 Multimodal Life History Inventory, 357 Narcissism, relational psychoanalytic approach, 143 narcissistic personality, 134 narcissistic transference, 141

narrative therapy, 307 audience, 320 change process, 314 client and counselor roles, 312 emotional and psychological well-being, 310–311 limitations, 327 mental health concerns, 309 problem naming and externalizing, 318–319 progress maintenance, 315 therapeutic documents, 319–320 unique question categories, 319 neuro-narrative therapy, 307 neurotic needs, 135–137 Nietzsche, Friedrich, 189–190 nondirective psychotherapy, 13 noogenic neuroses, 194 Norcross, John, 335 object relations theory, 85, 119 change process, 116 client and counselor role, 113 emotional and psychological well-being, 112 holding and containment tools, 120–121 human development, 114–115 mental health concerns, 110, 112 multicultural and intersectional issues, 122–123 personality development, 109 relational responses, 119 operant conditioning, 221 change process, 226–227 client–counselor relationship, 224–225 emotional and psychological well-being, 222–223 extinction, 233 human development, 225 maintenance of progress, 228 mental health concerns, 221 modeling, 232 punishment, 233 reinforcement, 232–233 Outcome Questionnaire Therapeutic Alliance (OQ-TA), 95 Outcome Rating Scale (ORS), 95 paradoxical intention, 201 parental impacts, human development, 140–141 Partners for Change Outcome Management System (PCOMS), 95 Pathological Narcissism Inventory, 143 Pavlov, Ivan, 216 PCT. See person-centered therapy PDI model. See personal dimensions of identity model PE-EFT. See process-experiential approach Perls, Fritz, 192, 193 personal dimensions of identity (PDI) model, 41, 51

Index

personality Adler’s wholeness and lifestyle, 133–134 development classical psychoanalytic perspective, 108 Jungian psychotherapy, 108–109 object relations, 109 idealizing, 137 inferiority and superiority, 134 male conceptualization, 134 mirroring, 137 narcissism, 134 neurotic psychological dysfunction, 135–136 self-objects, 137 self-psychology, 137 twinship/alter ego transference, 138 person-centered counseling, 17 person-centered therapy (PCT) case conceptualization, 183 change process, 173–174 client’s role, 168 clinical assessment, 177–178 counselor’s role, 168 emotional and psychological well-being, 166 empathy, 170 genuineness, 169 human development, 171–172 leaders and legacies, 160–161 limitations, 184 maintaining progress, 176 mental health concerns, 162–163 multicultural and intersectional issues, 181 nondirective approach, 168–169 scholarship and research trends, 182 social justice issues, 181 techniques, 179 transcript, 183 unconditional positive regard, 169 placater technique, 278 pluralism, 23 postmodernism, 88–89 postmodern theory, 18–19 case conceptualization, 323–326 change process, 313–314 client and counselor roles, 311–313 clinical assessment, 316 emotional and psychological well-being, 310–311 human nature and development, 304–306 leaders and legacies, 306–308 limitations, 326–327 mental health concerns, 308–310 progress maintenance, 315–316 scholarship and research trends, 322 social and cultural influence, 321–322 transcript, 323 poverty, 61–62 poverty counseling best practices (PCBP), 63 presession change, 378 private logic, 133–134

  |  395

process-experiential approach (PE-EFT) case conceptualization, 183 change process, 174–176 client and counselor’s role, 170–171 clinical assessment, 178 emotional and psychological well-being, 167 human development, 172 leaders and legacies, 161–162 limitations, 184 maintaining progress, 176–177 mental health concerns, 164 multicultural and intersectional issues, 181 scholarship and research trends, 182 social justice issues, 181 technique, 180–181 techniques, 179–180 Prochaska, James, 335 psychoanalytic approaches, 16 case conceptualization, 124–126 client and counselor’s role, 112–113 clinical assessment, 116–118 dream interpretation and analysis, 119–120 emotional and psychological well-being, 112 evidence and empirical support, 123 free association tool, 119 holding and containment tools, 120–121 leaders and legacies, 106–108 limitations, 126 maintenance of progress, 116 mental health concerns, 109–112 multicultural and intersectional issues, 121–123 nature of human development, 114–115 personality development, 108–109 process of change, 115–116 relational responses, 119 resistance interpretations, 120 Sandtray and Mandalas, 121 scholarship and research, 123 social justice issues, 121–123 transference, 118 treatment frame, 118 psychoanalytic perspective, feminist theory cognitive behavioral (CB) approach, 86–87 cultural constraints, 84–85 cultural feminist perspective, 85–86 Horney’s contributions, 85 humanism, 87–88 object relations theory, 85 postmodernist perspective, 88–89 radical feminist, 85 sociological theory of intersectionality, 86 White women’s experiences, 86 psychodynamic approaches, 376 psychodynamic diagnostic manual (PDM), 117 psychoeducation, 255–256 psychosexual approaches, 376 Purpose in Life (PIL) Test, 199

396  |  Index racial and cultural identity development (R/CID) acculturation, 47 conformity stage, 47 dissonance stage, 47 identity models, 46 integrative awareness, 48 introspection, 48 resistance and immersion, 47–48 Racial Microaggression Scale (RMAS), 95 radical behaviorism, 217 Rank, Otto, 161 R/CID. See racial and cultural identity development RDAS. See Revised Dyadic Adjustment Scale realismo-critico, 60 reciprocal inhibition, 231 reframing approach, 257, 291, 377 reinforcement, 232–233 relational conceptualization, 16–17 relational-cultural theory (RCT), 51–53, 94 relational psychoanalytic approach assessment phase, 141–142 case conceptualization, 148–151 change process, 141–142 client and counselor’s role, 138–139 clinical assessment, 143 empathetic attunement, 146 empathy and corrective experiences, 139 human development, 139–141 insight phase, 142 leaders and legacies, 131–133 lifestyle assessments, 143 limitations, 153 maintaining change, 142 multicultural and intersectional issues, 146–147 narcissism, 143 personality, 133–138 reorientation phase, 142 research trends, 147 self-analysis, 146 self-object needs assessments, 143 social justice issues, 146–147 theory of neurosis, 142 transcript, 148 well-being, 138 relaxation exercises, 377–378 Revised Dyadic Adjustment Scale (RDAS), 286, 288 Rogers, Carl, 13, 159–160 role construct repertory (REP) test, 320–321 sandtray, 121 Satir, Virginia, 273–274 scaling questions, 317–318, 379 secure attachment, 164–165 self-actualization, 166 self-characterization, 321 self-object needs assessments, 143 Self-Object Needs Inventory, 143

self-psychology, 133, 140–141 idealizing, 137 mirroring, 137 societal context, 147 transference, 138 Self-Psychology Questionnaire, 143 Session Rating Scale (SRS), 95 shuttling technique, 202 SLT. See social learning theory SNAP assessment, 346, 347 social activism, 70, 71 social construction, 305 social embeddedness principle, 365 social interest, 138, 366 social justice, 45 social justice theory, 23–24 social learning theory (SLT), 86, 246 change process, 251–252 client’s role, 248 counselor’s role, 248 progress maintenance, 253 techniques, 258 solution-focused brief therapy (SFBT), 364–365 change process, 313–314, 372–373 client and counselor role, 369 client and counselor roles, 311–312 compliments, 318 emotional and psychological well-being, 310, 367–368 exception questions, 318 limitations, 326–327, 384 mental health concerns, 308–309, 366 miracle question, 317 multicultural and social justice (MCSJ) issues, 381 presession change questions, 317 progress maintenance, 375 scaling questions, 317–318 techniques, 317–318, 378–379 stimulus–response model, 220–221 stimulus–response theory, 217 structural family therapy change process, 284–285 client and counselor roles, 282 counselor’s role in challenging homeostasis, 290–291 emotional and psychological well-being, 280–281 enactment, 291 limitations, 299 mental health concerns, 278–279 multicultural and social justice issues, 293 progress maintaining, 285 reframing, 291 restructuring, 291–292 self-differentiation, 292 Substance Abuse and Mental Health Services Administration (SAMHSA), 95 systematic desensitization, 231–232

Index

systemic racism, 43–44 systemic theory, 18 Ackerman’s contribution, 271 Bateson’s contribution, 272 Bowen family systems therapy, 273 case conceptualization, 295–298 change process, 282–285 client and counselor, 281–282 clinical assessment, 286–288 emotional and psychological well-being, 279–281 Gottman method, 274–275 Haley’s work, 272–273 Jackson’s work, 272 Lidz’s work, 273 limitations, 298–299 mental health concerns, 275–279 Minuchin’s structural theory, 274 progress maintaining, 285 Satir’s approach, 273–274 scholarship and research trends, 293–294 techniques, 288–292 transcript, 295 telebehavioral interventions, 24–27 ethical standards, 26–27 The Little Lion Who Lost Someone tool, 24 theory, definition, 5 theory of neurosis, 142 therapeutic documents, 319–320 Thorndike, Edward L., 216–217 thought stopping, 256 Tillich, Paul, 191 topdog/underdog intervention, 202 transference, 113, 118 transtheoretical model (TTM) change process, 343–344 client and counselor roles, 341

  |  397

emotional/psychological well-being, 339 mental health concerns, 337 multicultural perspective, 350–351 progress maintenance stage, 344–345 scholarship and research trends, 352 stages of change, 338 theoretical techniques, 348–349 unconditional positive regard, person-centered therapy, 169 unitary theory of practice, 22 van Deurzen, Emmy, 193 Voices From the Field Ewe, Edward, 185 Hill, Bradford, 385 Jefferson, LaNita, 265 Lloyd, Christina, 240 Palacios, Alfredo F., 209 Parmanand, Shawn, 300 Quintana, Taqueena, 72 Rodriguez, Josephine, 328 Robertson, Patricia, 99 Roy, Tyra, 358 Sorenson, Evan, 153 Spiegelhoff, Sarah, 127 WAI. See Working Alliance Inventory Watson, John B., 217 Wholeness, human development, 139–140 Winnicott, Donald W., 107–108 Working Alliance Inventory (WAI), 117–118 Worry Bugs tool, 24 Yalom, Irvin, 192