Chapter 5: Helping Relationships (Intro to Counseling/Advance Counseling/Practicum)

Question 1

There are over 400 approaches to psychotherapy and counseling worldwide. Most counselors claim they use several approaches and thus would be classified as eclectic or integrative.

Question 2

The Helping Myth

Research demonstrates that having a counselor and a client of the same gender and ethnicity does not necessarily produce a better therapeutic relationship. The data are not strong and clearly, more research is necessary.

Question 3

Happiness

Most people overestimate the impact an event will have on their degree of happiness or unhappiness. For example, individuals believe that marriage or winning the lottery will make them happy. The happiness boost for marriage lasts roughly two years, while the increase from winning the lottery spans about six months, In general, people are poor at forecasting affective/emotional reactions.

Question 4

Psychotherapy and Counseling are Cost-Effective

Cost-Benefit Analysis (CBA) reveals that therapy reduces mental health expenditures in the community. Unfortunately, insurance and managed care firms primarily push medications as the first line of treatment for mental health issues.

Question 5

Sigmund Freud’s Psychodynamic Psychoanalysis

Psychoanalysis is a theory of personality and a form of psychotherapy. It is a long-term form of treatment often lasting three to five years or more. In classical analysis, the patient (the analysand) is seen four of
five times per week. This form of therapy is said to be historic since it focuses on the past.

• The patient is asked to engage in free association which is saying whatever comes to mind.
• Dreams are very important.
• Unconscious material is examined.
• Freud emphasized ego defense mechanisms:
  
  • repression (most important)— something that is too painful to face, is totally forgotten;
  • displacement—taking your anger out on a safe target rather than the source of your anger; projection—you can’t accept a quality about yourself so you attribute it to others (i.e., you think that you are looking out a window but you are really looking in a mirror);
  • reaction formation—you deny an unacceptable unconscious impulse by acting in the opposite manner;
  • sublimation (often cited with career counseling)—you express an unacceptable impulse in a socially acceptable manner;
  • rationalization—when a person overrates or underrates a reward or outcome;
  • identification—Joining a feared person (such as a gang) to relieve your anxiety;
  • suppression or denial (not unconscious or automatic)—occurs when you purposely don’t think of a situation.
• Transference is also a key principle. The analysand (client)
  behaves as if the analyst is a parent or caretaker from the past.
• The discharge of repressed emotions is called abreaction or catharsis.
• According to Freud’s structural theory the personality has three systems,
  
  • a superego (the moral seat of the mind housing two entities the conscience and the ego ideal);
  • the ego or reality principle that balances the id and the superego;
  • and the id which houses biological forces, especially sex and aggression The id operates on the pleasure principle striving for immediate gratification and tension reduction.
• Eros is the life instinct, thanatos the death instinct.
• Critics charge he used only case studies to test analysis rather than using true scientific experiments.

Question 6

Carl Jung’s Analytic Psychology

Carl Jung broke away from Freud in 1914 because he felt Freud overemphasized the role of sexuality. His approach, like Freud’s is psychodynamic.

• The unconscious has two parts: a
  
  • personal unconscious (very similar to what Freud postulated) and the collective unconscious (an unconscious that one inherits which is common to all individuals). The collective unconscious is composed of archetypes passed down through the ages.
• Archetypes include the persona: a social mask the person wears.
  
  • To explain gender Jung cites the animus or the masculine side of the female and the anima or feminine side of the male.
  • Individuals are said to be androgynous, having both male and female characteristics.
  • He also speaks of the shadow or the so called dark side of the personality related to animal instincts.
  • The self is symbolized via a mandala (a magic circle in Sanskrit) /or a balance between the personal unconscious and the collective unconscious.
• Jung created the extroversion/introversion typologies. Jung felt that we possess both, however, one is dominant. The Myers-Briggs Type Indicator (MBTI) has its roots in his work.
• Individuation was Jung’s term for becoming a unique human being.

Question 7

Alfred Adler’s Individual Psychology

Alfred Adler broke away from Freud to create his own theory. Adler’s individual psychology is a psychodynamic approach that focuses on the fact that behavior is one’s unconscious attempt to compensate for feelings of inferiority. An individual constructs a lifestyle which is chosen.

• Adler stressed the “will to power” to generate feelings of superiority.
• The theory adheres to the principle of fictional finalism or the notion that behavior is motivated primarily by future opportunities rather than the past.
• Adler felt birth order (also called place in the family constellation) was important. First-born children are conservative leaders. Second-born kids tend to be more competitive and rebellious. Sibling interaction can have a greater impact than parent–child interaction. Since Adler felt behavior is highly influenced by future goals rather than one’s past, this is a teleological theory.

Question 8

Behaviorism, Behavior Modifi cation, and Behavior Therapy
John B. Watson coined the word behaviorism while Arnold Lazarus
created the term behavior therapy. Counselors who use these approaches assume that behavior is based on learning rather than insight into the unconscious mind. The criticisms of behavior therapy
are that it does not yield insight, it treats symptoms not the root cause,
and it can be manipulative and often changes behavior but not underlying feelings.
B.F. Skinner’s radical behaviorism purports that behavior is
molded solely by its consequences. This paradigm is known as
operant or instrumental conditioning.
A positive reinforcer is a stimulus that raises the probability
that a behavior will be repeated. The reinforcer must come after
the behavior (or operant).
Negative reinforcers also raise behavior. For example, a
recruit in the military makes a bunk bed to avoid being yelled at by a drill instructor. All reinforcers, whether positive or negative
raise behavior. All reinforcers are said to follow or come after
a behavior (e.g., a youngster gets a prize after she completes a
math problem).
Albert Bandura speaks of social learning theory. Here the
person’s own behavior increases when he or she sees somebody
else getting reinforced for it; also referred to as vicarious learning
or modeling.
Punishment is intended to lower behavior.
Behaviorists champion role playing (e.g., assertive behavior).
Extinction (such as time-out) will lower behavior after an initial
extinction burst or response burst.
Ratio schedules of reinforcement rely on work output
whereas interval schedules rely on time.
Continuous reinforcement occurs when each behavior is
reinforced.
Intermittent reinforcement occurs when some, but not all of
the desired behaviors are reinforced (e.g., a child gets a treat for
every third math problem he completes).
Shaping with successive approximations is reinforcing small
chunks of behavior that lead to the desired behavior.
Differential reinforcement of other behaviors (DRO)/
differential reinforcement of alternative behavior (DRA)
takes place when the helper reinforces behaviors other than
the dysfunctional behavior to reduce the dysfunctional target
behavior (e.g., you want a child to quit talking in class so you give
him a gold star only when he is doing his work and not talking).
In Skinnerian operant conditioning, the behavior is affected
by the consequences that come after the behavior.
Ivan Pavlov popularized what is now known as classical
conditioning. Behavior modifi cation is generally based on
Skinner, while behavior therapy usually has its roots in Pavlov.
Joseph Wolpe’s systematic desensitization can be conducted
individually or in a group to curb fears and abate anxiety. His
technique of counterconditioning is based on Pavlov and relies
on relaxation and imagining feared stimuli.
Behaviorists may also use implosive therapy where the client
imagines scary or feared stimuli in the safety of the counselor’s
offi ce.

Biofeedback devices are used to enhance the client’s selfcontrol (such as muscle tension) and are a form of operant
conditioning.
Criticisms of behavior therapy: It does not yield insight; it is
mechanistic; it treats symptoms and not the cause; it can be
manipulative; generally ignores developmental stages; and
it often changes behavior but not underlying feelings. This
approach deals with behaviors rather than the whole person.
Hint: A great way to determine whether a question is referring to
refl exive classical conditioning or Skinner’s operant conditioning
is to ask yourself a simple question: Would the conditioning
work with every member of the species who is not disabled? If
the answer is yes, then it is most likely Pavlovian conditioning
(e.g., all dogs salivate when they eat meat, so it’s Pavlov).

Question 9

Carl R. Rogers’s Person-Centered Humanistic Therapy
This approach has also been called client-centered, Rogerian, nondirective, or self-theory. The basic notion (a very positive one) is that
human beings can self-actualize and reach their full potential in a
therapeutic setting that fosters growth; classifi ed as an optimistic form
of therapy.
Three conditions for effective helping: The therapist must
show empathy; be genuine/congruent; and display unconditional
positive regard (UPR).
Empathy is not sympathy! It is the ability to subjectively
understand the client’s world in the here-and-now—to
walk in his or her shoes—and convey this to the client.
Robert Carkhuff created a fi ve-point empathy scale with a
level fi ve response as the best response.
The counselor must be genuine/congruent. The counselor
cannot be a phony. Words must match (i.e., be congruent) with
actions.
The counselor accepts the client regardless of his or her behavior.
This does not imply that you necessarily agree with the client.
This is called unconditional positive regard.
The counselor will often use refl ection or open-ended
questions.

Counselor strives to improve congruence so that the person is
more like his or her ideal self.
Rogerians are not big fans of traditional diagnosis and testing.
Moreover, they do not believe in the unconscious. Humans
can control their own behavior. Critics are concerned that this
approach is too optimistic and may not be the treatment of choice
for severely disturbed individuals or very young children.

Question 10

Albert Ellis’s Active-Directive Rational Emotive Behavior
Therapy (REBT)
Previously known as RET. This is a cognitive behavioral (CBT) form of
therapy. Change your thinking (cognitions) and you can change your
life. Essence of the treatment captured in the saying of Epictetus, a
fi rst century Stoic philosopher, “Men are disturbed not by things, but
of the view which they take of them.” Irrational beliefs (IBs) are replaced by rational beliefs (RBs) via the counseling process.
Uses the ABC or ABCDE model of personality. A is an
activating event. B is the client’s belief system. C is the emotional
consequence. At D the counselor disputes the irrational belief
at B. E is a new emotional consequence that occurs when B
becomes rational.
Humans have an innate tendency to think in an irrational,
illogical, unscientifi c manner. Thought is referred to as self-talk
or internal verbalizations.
Shoulds, oughts, musts, terriblizing, and awfulizing causes
irrational thought.
This is an active directive form of therapy utilizing lots of
homework, bibliotherapy and even rational imagery (RI).
Critics charge that the approach does not emphasize, feelings,
the counselor client relationship, and that REBT is mechanistic
or even sterile. May be too complex for those with psychosis or
thought disorders.

Question 11

Aaron T. Beck’s Cognitive Therapy
Beck’s cognitive therapy is similar to REBT emphasizing that the client has automatic thoughts which are distortions of reality such as polarized black-or-white thinking, overgeneralizing based on a single event, personalization— wrongly attributing an event to yourself,
and drawing conclusions without real evidence. Clients are urged to
keep a record of dysfunctional thoughts.

Question 12

Fritz Perls’ Gestalt Therapy
This experiential/existential approach focuses on the here-andnow in an attempt to help the client become whole again. Gestalt is
an experiential form of therapy and it relies on dream work, role-playing, confrontation, the top dog/underdog concept, hot seat, and the
empty chair technique. Modern gestalt therapists are not as abrupt
with clients as Perls. The therapy is now considered a softer gentler
treatment.
Gestalt is a German word that basically means “organized
whole.” The view of human nature is that humans want to be
self-actualized and complete (whole).
Dreams are the royal road to integration. Counselor asks
client to recount the dream as if it is occurring in the present
moment.
What and how questions are used more than why questions
(e.g. “What is your foot doing now?”).
Goal is for the client to take responsibility and achieve awareness
in the here-and-now. Doing is emphasized over just talking
about problems.
Laura Perls (Fritz Perls wife) helped develop the approach and
made it more popular with women in therapy.
Critics charge that this approach is “gimmicky,” puts little or no
stock in diagnosis and psychological testing, and at times is “antitheoretical.” On occasion, the approach can abet self-centeredness.

Question 13

Eric Berne’s Transactional Analysis (TA)
A here-and-now approach that took Freudian terminology and made
it fun and easy to understand. The theory took into account transactions between individuals. It is often combined with Gestalt. Critics
charge this is like mixing water and oil since TA is cognitive and Gestalt is experiential. Others say this is desirable since the two complement each other. The person develops a life plan called a life script.

Ego states are the Parent, Adult, and Child (PAC). These
states roughly correspond to Freud’s superego, ego, and id.
Uses Tom Harris’ life positions. I’m Ok, You’re Okay, healthy;
I’m Ok, You’re not Ok, I’m not Ok, You’re Ok; and I’m not Ok,
You’re not Ok.
Games are played to avoid intimacy. Somebody is always hurt in
a game.
Stephen B. Karpman’s drama triangle (aka Karpman’s
triangle). A person changes his or her position from victim to
persecutor to rescuer during the discussion.
Critics note that TA promotes game calling.

Question 14

William Glasser’s New Reality Therapy with Choice Theory
This therapy focuses on present behavior. Clients are taught that
they create their own personal reality with the behaviors they choose.
Glasser believes that “Behavior is the control of our perceptions”
and that a success identity is the result of being loved and accepted.
Glasser has been criticized for downplaying the role of the environment in terms of impacting ethnic minorities. Reality Therapy has also
been deemed “weak” in terms of not dealing with dreams, the past,
or traumatic memories. According to Glasser psychiatric medicines
or “brain drugs” are not the answer. This paradigm challenges the
medical model of psychiatry.
The eight steps of reality therapy: build a relationship with
the client; focus on present moment behavior; help the client
to evaluate his or her current behavior; develop a contract with
an action plan; have the client commit to the plan; accept no
excuses; do not use punishment; and refuse to give up on your
client. The approach emphasizes short term treatment and is
very concrete.
Psychological needs include belonging, power, freedom, and
fun.
Critics charge that reality therapy is a bit too simplistic, does not
take into account developmental stages, and has changed its focus
over the years.

Question 15

Postmodern Social Constructivist Theories
Social constructionism emphasizes that realities are socially constructed. Brief therapy and narrative therapy are constructivist approaches.
Narrative Therapy (NT) by Michael White (Australia) and
David Epston (Auckland, New Zealand)
Narrative Therapy postulates that individuals construct their lives
by stories they tell about themselves and stories others create about
them. Stories create meaning and this becomes the client’s identity.
Therapy consists of the client describing his or her life experiences
and then rewriting or reauthoring the narrative in a new way.
A narrative therapist externalizes the problem in his or her
progress notes and sends it to the client as a letter between
sessions.
Rather than saying “You are a cocaine addict,” a narrative
therapist will tell the client, “Cocaine has been trying to wreck
your life.” Again, clients reauthor their lives with new stories and
fresh language.
The narrative therapist sees him- or herself as a consultant
or collaborator with the client. Some cultures want an expert
therapist, and thus (at times) this can create a problem for
multicultural counseling.
Solution focused brief therapy (SFBT) Steve DeShazer and
Insoo Kim Berg
SFBT focuses on solutions and not on an understanding of the problem. The focus is on exceptions to the rule—what is working.
Using so-called exception questions: a client who is depressed is
asked: “When aren’t you depressed?”
Goals are small and realistic. The client is also asked the miracle
question: “If a miracle took place while you were sleeping, how
would you know the problem was solved? How would things be
different?”
SBFT also uses formula fi rst session task (FFST). This is a
homework assignment prescribed after the fi rst session.

Recently, this approach has gained popularity in group treatment
settings.
Brief therapy (BT) is becoming the norm in many instances since
managed care fi rms (hellbent on cutting costs!) often restrict the
number of sessions the client can attend. Most counselors dislike
managed care feeling that the managed care company is micromanaging their practice. In some states managed care fi rms cannot be sued
for their actions. Insurance and managed care policies are responsible
for the fact that many counselors spend as much time dealing with
business issues as they do actually counseling their clients. On the
positive side, managed care forces counselors to look at outcome
measures such as the DSM GAF Scale that will demonstrate the effectiveness of the counseling process.
Psychotherapy Integration by Frederick Thorne
Psychotherapy Integration uses strategies from a number of counseling schools. Instead of merely using techniques from the approaches
in eclecticism, the integrative approach assumes that using or integrating two or more theories will often produce results that are superior to a single school of therapy. Today support is mounting for this
approach.
Family Counseling
Family counseling asserts that the pathology resides in the family system and not in an individual. The client is the family and not the
identifi ed patient. Family therapists believe in circular rather than
linear causality. First-order change occurs when a client makes a
superfi cial change to deal with a problem, but the change does not
alter the underlying structure of the family. Second-order change
alters the underlying structure and thus makes a difference that is
longer lasting.
Case Integration
Case integration takes place when several helpers from the same
agency or different agencies work together without duplicating services to help an individual client.

Milieu Therapy
Milieu therapy urges helpers to change the client’s entire environment (social and physical) to help the client. Hence, treatment is not
limited to counseling sessions. In most instances, this takes place in
inpatient treatment facilities.

Question 16

Famous Family Therapists
Nathan Ackerman used the psychoanalytic or psychodynamic approach.
Experimental conjoint family therapist Virginia Satir popularized the notion that in times of stress, family members use four inept
patterns of communication. The placator (who tries to please everybody in the family); the blamer; the reasonable analyzer (who intellectualizes); and the irrelevant distracter (who interrupts and changes
the topic to something irrelevant).
Experimentalist Carl Whitaker could be very wild, radical,
and creative, and often utilized a cotherapist.
Murray Bowen is a key name in Intergenerational Therapy. His
approach is often referred to as Extended family systems therapy.
Triangulation (also referred to as triangles) occurs when two
people who are stressed, bring in a third party to reduce the
dyad’s stress level and restore equilibrium.
Genograms are actually graphic diagrams of the family from a
minimum of three generations.
Fusion is a blurring of the psychological boundaries between
the self and others. A person driven by fusion can’t separate
thinking and feeling well.
Differentiation (the opposite of fusion) is the ability to
control reason over emotion. People often secure their level of
differentiation from a multigenerational transmission process.
Salvador Minuchin is the leading name behind structural
family therapy The technique of joining or blending in with the
family is used. The therapist uses a popular strategy of joining known
as mimesis to imitate or copy the family’s communication and patterns. The therapy proposes that changes in the family system, subsys-tems, and family organization must take place in order for individual
family members to resolve their systems. Structural therapy is directive and performed in the here-and-now.
Jay Haley and Cloe Madaness are powerful names in strategic family counseling (also called MRI model and the communications model). In this paradigm the therapist gives directives or
prescriptions, often paradoxical (e.g., telling a client who is afraid
he will shake to shake as much as he can; actually prescribing the
symptom). Reframing and relabeling problems is common in this modality. This approach warns us that double-bind communication
(e.g., a parent telling a child she loves her while beating her severely)
could cause serious psychopathology, even schizophrenia.
Other brief strategic therapists that champion paradox or
prescribing the symptom in individual or family therapy include:
Milton H. Erickson, Steven DeShazer, Bill O’Hanlon, Paul
Watzlawick, Don Jackson, and Michelle Weiner Davis.
Solution focused brief therapists (SBFT) speak of fi rst order
change which is superfi cial and second order change that includes
actual changes in the rules and structure of the organization.
SFBT or BT, brief therapy, is not the same as crisis intervention.
Crisis intervention is used for persons who are experiencing an expected normal reaction to stress. Therapy on the other hand, is aimed
at reducing abnormal and pathological behaviors and symptoms.
The Milan Model uses a treatment team with a one-way
mirror.
Consultation occurs when you voluntarily assist a counselor or
counselors (known as consultees) who will be helping clients.
Contact with the helpees is indirect.
Gerald Caplan is known as the father of mental health
consultation.
Edgar Schein’s purchase of expertise model (where you buy the
person’s information and knowledge); his doctor–patient model
(here you aren’t sure what the problem is, so you hire an expert
to diagnose and treat it); and his process consultation model
(where the consultant helps the consultee with the process).

Process models focus on the process while content models
focus on the imparting knowledge to the consultee.