MSW's Students (2007-2009), Christ College, Bangalore, India

Friday, April 4, 2008

Counseling Notes

History of Counselling & Psychotherapy

Although psychological therapies trace their history back to the contributions of Freud, many modern approaches to counselling and psychotherapy are now much more firmly grounded in other bodies of thought.

* Contents

* Freud and His Successors
* The Medical vs. Non-Medical Split
* The Counselling vs. Psychotherapy Divide
* Counselling and Psychotherapy Today
* Further Discussion

Freud and His Successors

Modern psychological therapies trace their history back to the work of Sigmund Freud in Vienna in the 1880s. Trained as a neurologist, Freud entered private practice in 1886 and by 1896 had developed a method of working with hysterical patients which he called 'psychoanalysis'. Others such as Alfred Adler, Snador Ferenczi, Karl Abraham and Otto Rank were also analysed by Freud and had brief apprentice-type training from him before becoming psychoanalysts in their own right.

In the early 1900s, Ernest Jones and A.A. Brill, from the UK and US respectively, visited Freud in Vienna and returned to their own countries to promote Freud's methods; Freud himself began a lecture tour of North America in 1909. Gradually many such as Ferenczi, Adler, Rank, Stekel and Reich began to develop their own theories and approaches, which sometimes differed markedly from Freud's. Jung in particular, a close collaborator of Freud's from 1907-1913 who was in some sense 'groomed' as Freud's intellectual successor, eventually split from Freud and pursued the development of his own school of analytical psychology, drawing heavily on both Freud's and Adler's ideas. All these immediate descendants of Freud's approach are characterized by a focus on the dynamics of the relationships between different parts of the psyche and the external world; thus the term 'psychodynamics'.

A separate strand of psychological therapies developed later under the influence of psychology and learning theory and leading thinkers such as B.F. Skinner. Rejecting the notion of 'hidden' aspects of the psyche which cannot be examined empirically (such as Freud's rendition of the 'unconscious'), practitioners in the behavioural tradition began to focus on what could actually be observed in the outside world.

Finally, under the influence of Adler and Rank, a 'third way' was pioneered by the US psychologist Carl Rogers. Originally called 'client-centred' and later 'person-centred', Rogers's approach focuses on the experience of the person, neither adopting elaborate and empirically untestable theoretical constructs of the type common in psychodynamic traditions, nor neglecting the internal world of the client in the way of early behaviourists. Other approaches also developed under what came to be called the 'humanistic' branch of psychotherapy, including Gestalt therapy and the psychodrama of J.L. Moreno. The figure below illustrates some of the historical links between these three main strands which developed from Freud's original contributions.


Three strands of development in the history of counselling and psychotherapy
The Medical vs. Non-Medical Split

Freud strongly supported the idea of lay analysts without medical training, and he analysed several lay people who later went on to become leading psychoanalysts, including Oskar Pfister, Otto Rank and his own daughter Anna Freud. He published two staunch defenses of lay analysis in 1926 and 1927, arguing that medicine and the practice of analysis were two different things. When Ernest Jones brought psychoanalysis to the UK in 1913, he followed Freud's preferences in this area, and the tradition of lay involvement continues to this day in the UK, where most psychoanalysts, psychotherapists and counsellors have a lay background.

In the US, however, Freud's analysand A.A. Brill insisted that analysts should be medically qualified -- even though there were already many lay analysts practising in the US who, like Brill, had trained with Freud in Vienna. Brill prevailed, however: in 1926 the state of New York made lay analysis illegal, and shortly thereafter the American Medical Association warned its members not to cooperate with lay analysts. To this day, almost all US psychoanalysts are medically qualified, and counsellors typically study psychology as undergraduates before becoming counsellors.
The Counselling vs. Psychotherapy Divide

It was largely in response to the US prejudice against lay therapists that Carl Rogers adopted the word 'counseling', originally used by social activist Frank Parsons in 1908. As a psychologist, Rogers was not originally permitted by the psychiatry profession to call himself a 'psychotherapist'. Ironically, Rogers himself became renowned as one of the most influential empirical scientists in the fields of psychology and psychiatry, introducing rigorous scientific methods to psychology and psychotherapy that psychoanalysts themselves had long resisted (and, in the view of many, still largely resist today). He became a joint Professor in the Departments of Psychology and Psychiatry at the University of Wisconsin as well as Head of the Psychotherapy Research Section of the Wisconsin Psychiatric Institute.

In the field as it now stands, the argument as to whether counselling differs significantly from psychotherapy is largely academic. Those from psychodynamic traditions sometimes equate 'psychoanalysis' and 'psychotherapy' -- suggesting that only psychoanalysts are really psychotherapists -- but this view is not common anywhere else. Others use 'psychotherapy' to refer to longer-term work (even though some psychotherapists offer brief therapy) and 'counselling' to refer to shorter term work (even though some counsellors may work with clients for years). The two terms are commonly used interchangeably in the US, with the obvious exception of 'guidance counseling', which is often provided in educational settings and focuses on career and social issues.
Counselling and Psychotherapy Today

Modern counselling and psychotherapy have benefited tremendously from the empirical tradition which was given such impetus by Carl Rogers, even though the research agendas of psychology and counselling have diverged greatly over the last half century. Additional work in cognitive psychology, learning theory and behaviour has informed many therapeutic approaches. The richness of the bodies of both empirical and theoretical work which are now available, coupled with the raw complexity of human beings, has led to a profusion of different approaches to the field. By some accounts, the different strands of counselling and psychotherapy now number in the hundreds. Mainstream approaches, however, are much fewer in number, and over time it is likely that many of the less well-grounded schools of thought will fade away, while more new ones will emerge to take their place. While the main approaches continue to develop, and others appear and then fade away, clients are left to choose for themselves what might be best for them. Hopefully the information provided by this site (incomplete though it very definitely is!) will be of some help in this process.

Difference between coaching, counseling and psychotherapy
Coaching tends to be future oriented, goal focused and asks the client to be accountable to themselves according to the specific goals agreed upon. Counseling tends to be oriented in equal measure to the past, present and future as well as problem and solution focused but less on psychopathology than psychotherapy.[citation needed]
Psychotherapy tends to deal more with individuals who wish to get to the source of their clinical depression, anxiety or personality disorder. This distinction is not hard and fast however, as in both common and professional usage counseling and psychotherapy are interchangeable, whilst coaching is perceived as different and limited to either executive or sports coaching, yet includes therapeutic coaching in its realm. This leads to confusion for both customers and practitioners in a complex service industry that now includes marriage mentoring, for example. The differences are usually to do with the type of training, accreditation and special interests of each type of coach, counselor or psychotherapist.
Coaching arose from management consultancy and leadership training, and has grown into traditional counseling and psychotherapy fields such as conflict coaching and systemic coaching. Coaching and counseling tend to arise from a humanistic and client-centered approach. Counselors attend to both normal social, cultural and developmental issues as well as the problems associated with physical, emotional, and mental disorders. These are nonpathologizing views of the person in context. A vital ingredient is their view that coaching and counseling are a meeting between practitioner and client, which invites the creative possibilities of dialogue in contrast to treatment of a disorder and in mentoring, a partnership of colleagues of greater and lesser experience. Many personal coaches and counselors use movement, psychodynamic and cognitive-behavioral approaches in their work, usually integrating these aspects into the process when appropriate and beneficial to their client.
Coaching, psychotherapy and counseling all encourage self help as a resource for change, but to different degrees. For example, will a person believed to be suffering a mental disorder think about self-help in a disordered way - using aluminum foil wrapping of the skull to prevent their thoughts being broadcast to a television set, for example. This could be considered disordered self-help. By contrast, in an approach that does not pathologize the person, the practitioner is unlikely to pathologize the client's self help strategy and some may even research the science of experience to find information about the effectiveness of a skullcap.
Coaching, psychotherapy and counseling, taken together and used together represent an eclectic approach and serve as perhaps the best approach when taken together, since clients come from various backgrounds and circumstances and represent different needs and issues.
An Introduction to Person-Centred Counselling
Taking the view that every individual has the internal resources they need for growth, person-centred counselling aims to provide three 'core conditions' (unconditional positive regard, empathy and congruence) which help that growth to occur.
• Contents
• Underlying Theory of Person-Centred Counselling
• Therapeutic Approach of Person-Centred Counselling
• Criticisms of Person-Centred Counselling
• Best Fit With Clients
• Further Reading on Person-Centred Counselling
• External Reading Suggestions on Person-Centred Counselling
Underlying Theory of Person-Centred Counselling
The person-centred approach views the client as their own best authority on their own experience, and it views the client as being fully capable of fulfilling their own potential for growth. It recognizes, however, that achieving potential requires favourable conditions and that under adverse conditions, individuals may well not grow and develop in the ways that they otherwise could. In particular, when individuals are denied acceptance and positive regard from others -- or when that positive regard is made conditional upon the individual behaving in particular ways -- they may begin to lose touch with what their own experience means for them, and their innate tendency to grow in a direction consistent with that meaning may be stifled.
One reason this may occur is that individuals often cope with the conditional acceptance offered to them by others by gradually coming to incorporate these conditions into their own views about themselves. They may form a self-concept which includes views of themselves like, "I am the sort of person who must never be late", or "I am the sort of person who always respects others", or "I am the sort of person who always keeps the house clean". Because of a fundamental need for positive regard from others, it is easier to 'be' this sort of person -- and to receive positive regard from others as a result -- than it is to 'be' anything else and risk losing that positive regard. Over time, their intrinsic sense of their own identity and their own evaluations of experience and attributions of value may be replaced by creations partly or even entirely due to the pressures felt from other people. That is, the individual displaces personal judgements and meanings with those of others.
Psychological disturbance occurs when the individual's 'self-concept' begins to clash with immediate personal experience -- i.e., when the evidence of the individual's own senses or the individual's own judgement clashes with what the self-concept says 'ought' to be the case. Unfortunately, disturbance is apt to continue as long as the individual depends on the conditionally positive judgements of others for their sense of self-worth and as long as the individual relies on a self-concept designed in part to earn those positive judgements. Experiences which challenge the self-concept are apt to be distorted or even denied altogether in order to preserve it.
Therapeutic Approach of Person-Centred Counselling
The person-centred approach maintains that three core conditions provide a climate conducive to growth and therapeutic change. They contrast starkly with those conditions believed to be responsible for psychological disturbance. The core conditions are:
1. Unconditional positive regard
2. Empathic understanding
3. Congruence
The first -- unconditional positive regard -- means that the counsellor accepts the client unconditionally and non-judgementally. The client is free to explore all thoughts and feelings, positive or negative, without danger of rejection or condemnation. Crucially, the client is free to explore and to express without having to do anything in particular or meet any particular standards of behaviour to 'earn' positive regard from the counsellor. The second -- empathic understanding -- means that the counsellor accurately understands the client's thoughts, feelings, and meanings from the client's own perspective. When the counsellor perceives what the world is like from the client's point of view, it demonstrates not only that that view has value, but also that the client is being accepted. The third -- congruence -- means that the counsellor is authentic and genuine. The counsellor does not present an aloof professional facade, but is present and transparent to the client. There is no air of authority or hidden knowledge, and the client does not have to speculate about what the counsellor is 'really like'.
Together, these three core conditions are believed to enable the client to develop and grow in their own way -- to strengthen and expand their own identity and to become the person that they 'really' are independently of the pressures of others to act or think in particular ways.
As a result, person-centred theory takes these core conditions as both necessary and sufficient for therapeutic movement to occur -- i.e., that if these core conditions are provided, then the client will experience therapeutic change. (Indeed, the achievement of identifying and articulating these core conditions and launching a significant programme of scientific research to test hypotheses about them was one of the greatest contributions of Carl Rogers, the American psychologist who first began formulating the person-centred approach in the 1930s and 1940s.) Notably, person-centred theory suggests that there is nothing essentially unique about the counselling relationship and that in fact healthy relationships with significant others may well manifest the core conditions and thus be therapeutic, although normally in a transitory sort of way, rather than consistently and continually.
Finally, as noted at the outset, the person-centred approach takes clients as their own best authorities. The focus of person-centred therapy is always on the client's own feelings and thoughts, not on those of the therapist -- and certainly not on diagnosis or categorization. The person-centred therapist makes every attempt to foster an environment in which clients can encounter themselves and become more intimate with their own thoughts, feelings and meanings.
Criticisms of Person-Centred Counselling
A frequent criticism of the person-centred approach is that delivering the core conditions is what all good therapists do anyway, before they move on to applying their expertise and doing the real work of 'making clients better'. On the face of it, this criticism reflects a misunderstanding of the real challenges of consistently manifesting unconditional positive regard, empathic understanding and congruence. This is especially true of congruence: to the extent that some therapeutic techniques deployed in some other traditions depend on the counsellor's willingness to 'hold back', mentally formulate hypotheses about the client, or conceal their own personal reactions behind a consistent professional face, there is a real challenge in applying these techniques with the openness and honesty which defines congruence. It may also demonstrate something of a reluctance to take seriously the empirical research on counselling effectiveness and the conclusion that the quality of the client-counsellor relationship is a leading predictor of therapeutic effectiveness -- although this is somewhat more controversial, since one might argue that providing the core conditions is not the only way to achieve a quality relationship. (See the page on Comparing Effectiveness.)
At a deeper level, however, there is a more sophisticated point lurking, which many expositions of person-centred theory seem to avoid addressing head-on. Namely, given that the self is the single most important resource the person-centred counsellor brings to the therapeutic relationship, it makes sense to ask: what (if anything) is it important that this self has, apart from the three core conditions? I.e., manifesting of the core conditions does not by itself tell us what experiences or philosophies the counsellor is bringing to the relationship. It tells us that the client will have transparent access to that self -- because the counsellor is congruent -- but it doesn't tell us anything else about that self. Whether or not that self should be developed in any particular way, or whether that self should acquire any particular background knowledge, seems to me a question which is more often side-stepped than answered within the person-centred tradition.
(Another way to understand this point is this: given two counsellors, each of whom manifests the core conditions to some specified degree, what else, if anything, matters? Would it be better for a given client to have the one who is an expert at astrophysics or the one who is an economist? Would it be better for a given client to have the one who struggled through a decade of ethnic cleansing in a war-torn country or the one who went to private school in an affluent suburb and subsequently worked as a stockbroker? Aside from academic expertise and personal history, what about personal philosophy, parenthood, and other factors?)
Best Fit With Clients
Clients who have a strong urge in the direction of exploring themselves and their feelings and who value personal responsibility may be particularly attracted to the person-centred approach. Those who would like a counsellor to offer them extensive advice, to diagnose their problems, or to analyse their psyches will probably find the person-centred approach less helpful. Clients who would like to address specific psychological habits or patterns of thinking may find some variation in the helpfulness of the person-centred approach, as the individual therapeutic styles of person-centred counsellors vary widely, and some will feel more able than others to engage directly with these types of concerns.
Further Reading on Person-Centred Counselling
The Annotated Bibliography includes pointers to additional reading on this and other therapeutic approaches. Mearns and Thorne (1999) provide a very readable account of person-centred counselling, while Rogers (1961) is a much more in-depth collection of papers. Barrett-Lennard (1998) offers a very detailed and scholarly treatment of the field.
A separate paper in the 'Critical Engagements' section of this site critically compares person-centred and existential counselling.
External Reading Suggestions on Person-Centred Counselling
The following books are presently bestsellers at Amazon in the area of person-centred counselling; the fact they're bestsellers doesn't necessarily imply anything good or bad about them as books, but it does imply that these are some of what people are buying in this field.
Underlying Theory of Rational Emotive Behaviour Therapy

Rational emotive behaviour therapy ('REBT') views human beings as 'responsibly hedonistic' in the sense that they strive to remain alive and to achieve some degree of happiness. However, it also holds that humans are prone to adopting irrational beliefs and behaviours which stand in the way of their achieving their goals and purposes. Often, these irrational attitudes or philosophies take the form of extreme or dogmatic 'musts', 'shoulds', or 'oughts'; they contrast with rational and flexible desires, wishes, preferences and wants. The presence of extreme philosophies can make all the difference between healthy negative emotions (such as sadness or regret or concern) and unhealthy negative emotions (such as depression or guilt or anxiety). For example, one person's philosophy after experiencing a loss might take the form: "It is unfortunate that this loss has occurred, although there is no actual reason why it should not have occurred. It is sad that it has happened, but it is not awful, and I can continue to function." Another's might take the form: "This absolutely should not have happened, and it is horrific that it did. These circumstances are now intolerable, and I cannot continue to function." The first person's response is apt to lead to sadness, while the second person may be well on their way to depression. Most importantly of all, REBT maintains that individuals have it within their power to change their beliefs and philosophies profoundly, and thereby to change radically their state of psychological health.

REBT employs the 'ABC framework' -- depicted in the figure below -- to clarify the relationship between activating events (A); our beliefs about them (B); and the cognitive, emotional or behavioural consequences of our beliefs (C). The ABC model is also used in some renditions of cognitive therapy or cognitive behavioural therapy, where it is also applied to clarify the role of mental activities or predispositions in mediating between experiences and emotional responses.




ABC model.

The figure below shows how the framework distinguishes between the effects of rational beliefs about negative events, which give rise to healthy negative emotions, and the effects of irrational beliefs about negative events, which lead to unhealthy negative emotions.

Negative events and healthy vs. unhealthy responses.

In addition to the ABC framework, REBT also employs three primary insights:

1. While external events are of undoubted influence, psychological disturbance is largely a matter of personal choice in the sense that individuals consciously or unconsciously select both rational beliefs and irrational beliefs at (B) when negative events occur at (A)
2. Past history and present life conditions strongly affect the person, but they do not, in and of themselves, disturb the person; rather, it is the individual's responses which disturb them, and it is again a matter of individual choice whether to maintain the philosophies at (B) which cause disturbance.
3. Modifying the philosophies at (B) requires persistence and hard work, but it can be done.

Therapeutic Approach of Rational Emotive Behaviour Therapy

The main purpose of REBT is to help clients to replace absolutist philosophies, full of 'musts' and 'shoulds', with more flexible ones; part of this includes learning to accept that all human beings (including themselves) are fallible and learning to increase their tolerance for frustration while aiming to achieve their goals. Although emphasizing the same 'core conditions' as person-centred counselling -- namely, empathy, unconditional positive regard, and counsellor genuineness -- in the counselling relationship, REBT views these conditions as neither necessary nor sufficient for therapeutic change to occur.

The basic process of change which REBT attempts to foster begins with the client acknowledging the existence of a problem and identifying any 'meta-disturbances' about that problem (i.e., problems about the problem, such as feeling guilty about being depressed). The client then identifies the underlying irrational belief which caused the original problem and comes to understand both why it is irrational and why a rational alternative would be preferable. The client challenges their irrational belief and employs a variety of cognitive, behavioural, emotive and imagery techniques to strengthen their conviction in a rational alternative. (For example, rational emotive imagery, or REI, helps clients practice changing unhealthy negative emotions into healthy ones at (C) while imagining the negative event at (A), as a way of changing their underlying philosophy at (B); this is designed to help clients move from an intellectual insight about which of their beliefs are rational and which irrational to a stronger 'gut' instinct about the same.) They identify impediments to progress and overcome them, and they work continuously to consolidate their gains and to prevent relapse.

To further this process, REBT advocates 'selective eclecticism', which means that REBT counsellors are encouraged to make use of techniques from other approaches, while still working specifically within the theoretical framework of REBT. In other words, REBT maintains theoretical coherence while pragmatically employing techniques that work.

Throughout, the counsellor may take a very directive role, actively disputing the client's irrational beliefs, agreeing homework assignments which help the client to overcome their irrational beliefs, and in general 'pushing' the client to challenge themselves and to accept the discomfort which may accompany the change process.
Criticisms of Rational Emotive Behaviour Therapy

As one leading proponent of REBT has indicated, REBT is easy to practise poorly, and it is from this that one immediate criticism suggests itself from the perspective of someone who takes a philosophical approach to life anyway: inelegant REBT could be profoundly irritating! The kind of conceptual disputing favoured by REBT could easily meander off track into minutiae relatively far removed from the client's central concern, and the mental gymnastics required to keep client and therapist on the same track could easily eat up time better spent on more productive activities. The counsellor's and client's estimations of relative importance could diverge rather profoundly, particularly if the client's outlook really does embody significant irrationalities. Having said all that, each of the preceding sentences includes the qualifier 'could', and with a great deal of skill, each pitfall undoubtedly could be avoided.

Perhaps more importantly, it would appear that the need to match therapeutic approach with client preference is even more pressing with REBT than with many others. In other words, it seems very important to adopt the REBT approach only with clients who truly are suitable, as it otherwise risks being strongly counter-productive. On this point, however, it is crucial to realize that some clients specifically do appreciate exactly this kind of approach, and counsellors who are unable or unwilling to provide the disputation required are probably not right for those clients.
Best Fit With Clients

REBT is much less empirically supported than some other approaches: the requisite studies simply have not been completed yet, and the relevant data points for determining the best match with clients are therefore thin on the ground. However, one may envision clients responding particularly well who are both willing and able to conceptualise their problems within the ABC framework, and who are committed to active participation in the process of identifying and changing irrational beliefs (including performing homework assignments in support of the latter). Clients will also need to be able to work collaboratively with a counsellor who will challenge and dispute with them directly, and a scientific and at least somewhat logical outlook would seem a pre-requisite. REBT would be less suitable for clients who do not meet one or more of the above. And as hinted above in the section on Criticims, one might also speculate that clients who are already highly skilled in philosophical engagement could find the approach less useful. (Perhaps REBT-style self help could be of more benefit for such clients?)
Further Reading on Rational Emotive Behaviour Therapy

The Annotated Bibliography includes pointers to additional reading on this and other therapeutic approaches. The comment referenced in the section on Criticisms, on the easiness of practising REBT poorly, is due to Dryden (2002b), p. 367; the notion of 'selective eclecticism' is due to Dryden (1987). Note that REBT is closely related to cognitive therapy and is viewed by many as a subset of it.
External Reading Suggestions on Rational Emotive Behaviour Therapy

The following books are presently bestsellers at Amazon in the area of rational emotive behaviour therapy; the fact they're bestsellers doesn't necessarily imply anything good or bad about them as books, but it does imply that these are some of what people are buying in this field.

An Introduction to Cognitive Therapy & Cognitive Behavioural Approaches

Cognitive therapy (or cognitive behavioural therapy) helps the client to uncover and alter distortions of thought or perceptions which may be causing or prolonging psychological distress.

* Contents

* Underlying Theory of Cognitive Therapy
* Therapeutic Approach of Cognitive or Cognitive Behavioural Therapy
* Criticisms of Cognitive Therapy and CBT
* Best Fit With Clients
* Further Reading on Cognitive Therapy
* External Reading Suggestions on Cognitive Therapy

Underlying Theory of Cognitive Therapy

The central insight of cognitive therapy as originally formulated over three decades ago is that thoughts mediate between stimuli, such as external events, and emotions. As in the figure below, a stimulus elicits a thought -- which might be an evaluative judgement of some kind -- which in turn gives rise to an emotion. In other words, it is not the stimulus itself which somehow elicits an emotional response directly, but our evaluation of or thought about that stimulus. (Some practitioners use Ellis's ABC model, described in the section on rational emotive behaviour therapy, to describe the role of thoughts or attitudes mediating between events and our emotional responses.) Two ancillary assumptions underpin the approach of the cognitive therapist: 1) the client is capable of becoming aware of his or her own thoughts and of changing them, and 2) sometimes the thoughts elicited by stimuli distort or otherwise fail to reflect reality accurately.

Stimulus --> Thought --> Emotion.



A common 'everyday example' of alternative thoughts or beliefs about the same experience and their resulting emotions might be the case of an individual being turned down for a job. She might believe that she was passed over for the job because she was fundamentally incompetent. In that case, she might well become depressed, and she might be less likely to apply for similar jobs in the future. If, on the other hand, she believed that she was passed over because the field of candidates was exceptionally strong, she might feel disappointed but not depressed, and the experience probably wouldn't dissuade her from applying for other similar jobs.

Cognitive therapy suggests that psychological distress is caused by distorted thoughts about stimuli giving rise to distressed emotions. The theory is particularly well developed (and empirically supported) in the case of depression, where clients frequently experience unduly negative thoughts which arise automatically even in response to stimuli which might otherwise be experienced as positive. For instance, a depressed client hearing "please stop talking in class" might think "everything I do is wrong; there is no point in even trying". The same client might hear "you've received top marks on your essay" and think "that was a fluke; I won't ever get a mark like that again", or he might hear "you've really improved over the last term" and think "I was really abysmal at the start of term". Any of these thoughts could lead to feelings of hopelessness or reduced self esteem, maintaining or worsening the individual's depression.

Usually cognitive therapeutic work is informed by an awareness of the role of the client's behaviour as well (thus the term 'cognitive behavioural therapy', or CBT). The task of cognitive therapy or CBT is partly to understand how the three components of emotions, behaviours and thoughts interrelate, and how they may be influenced by external stimuli -- including events which may have occurred early in the client's life.



Thought-Emotion-Behaviour interrelationship.
Therapeutic Approach of Cognitive or Cognitive Behavioural Therapy

Cognitive therapy aims to help the client to become aware of thought distortions which are causing psychological distress, and of behavioural patterns which are reinforcing it, and to correct them. The objective is not to correct every distortion in a client's entire outlook -- and after all, virtually everyone distorts reality in many ways -- just those which may be at the root of distress. The therapist will make every effort to understand experiences from the client's point of view, and the client and therapist will work collaboratively with an empirical spirit, like scientists, exploring the client's thoughts, assumptions and inferences. The therapist helps the client learn to test these by checking them against reality and against other assumptions.

Often this process will continue outside the therapeutic session. For instance, a client whose fear of dying in a car crash is causing them great anxiety when it comes time to drive to work might record on a slip of paper their estimate of the odds of dying in a car crash at various points in the morning -- when they first get up, when they are nearly ready to leave the house, when they are almost to the car, and when they are actually driving. (For someone experiencing such anxiety, these odds might go something like: 1,000 to 1 against when first getting up; 20 to 1 against when nearly ready to leave the house; 2 to 1 against when almost to the car; 5 to 1 in favour of dying in a car crash when actually driving.) This can help the client to see that their estimated odds of actually dying in a car crash are changing just as they move about the house and complete the morning routine. This can be the first step toward making those estimates more realistic and reducing the anxiety which accompanies the thought that one is very likely to die in a crash while driving.

Because of the interrelationship between thoughts, feelings and behaviours, therapeutic interventions frequently involve the client's behaviour. For instance, a client with a strong fear that squirrels will jump onto their head if they walk under trees may go to great lengths to avoid walking under trees. This behaviour will prevent the client from acquiring information that contradicts their thought that "if I walk under a tree, a squirrel will jump onto my head" or perhaps their mental image of a squirrel jumping onto their head the moment they step under a tree. The therapist may help the client to overcome this avoidance of walking under trees as part of the process of correcting the distorted thought that walking under trees will lead to squirrels jumping on the client's head.

Throughout this process of learning, exploring and testing, the client acquires coping strategies as well as improved skills of awareness, introspection and evaluation. This enables them to manage the process on their own in the future, reducing their reliance on the therapist and reducing the likelihood of experiencing a relapse.
Criticisms of Cognitive Therapy and CBT

On first hearing of the basic cognitive therapeutic approach, many people will observe that simply being told that a view doesn't accurately reflect reality doesn't actually make them feel any better. They might say, "I know squirrels aren't likely to jump on my head, but I can't help worrying about it anyway". But to suggest that a cognitive therapist merely tells the client something is wrong is to caricature the approach (and, in fact, few cognitive therapists would actually tell a client some view doesn't reflect reality anyway; they would help the client to explore whether it reflects reality). This would be like criticising the person-centred approach on the grounds that a therapist merely telling a client they are free to discuss anything they like, without judgement from the therapist, doesn't make it feel any easier to talk about difficult problems.

A more salient criticism for some clients may be that the therapist initially may fulfil something of an authority role, in the sense that they provide problem solving experience or expertise in cognitive psychology. Some people may also feel that the therapist can be 'leading' in their questioning and somewhat directive in terms of their recommendations.
Best Fit With Clients

Clients who are comfortable with introspection, who readily adopt the scientific method for exploring their own psychology, and who place credence in the basic theoretical approach of cognitive therapy, may find this approach a good match. Clients who are less comfortable with any of these, or whose distress is of a more general interpersonal nature -- such that it cannot easily be framed in terms of an interplay between thoughts, emotions and behaviours within a given environment -- may be less well served by cognitive therapy. Cognitive and cognitive-behavioural therapies have often proved especially helpful to clients suffering from depression, anxiety, panic and obsessive-compulsive disorder.
Further Reading on Cognitive Therapy

The Annotated Bibliography includes pointers to additional reading on this and other therapeutic approaches. The basic cognitive therapy framework is explained well by Beck (1976), and Trower, et al (1988) offer a good introduction to the modern cognitive behavioural approach.
At different points in life most people experience some kind of crisis. A crisis is defined as a situation or event in which a person feels overwhelmed or has difficulty coping. A crisis might be caused by an event such as the death of a family member, the loss of a job, or the ending of a relationship. During such times people experience a wide range of feelings, and each person's response to a crisis is different. It is normal to feel frightened, anxious, or depressed at such a time.

Crisis counseling involves providing support and guidance to an individual or a group of people such as a family or community during a crisis. The purpose of crisis counseling is to decrease emotional pain, provide emotional support, make sure that the person in crisis is safe, and help develop a plan for coping with the situation. Sometimes it also involves connecting a person to other community or health services that can provide long-term support.

Crisis counseling can be linked to health education if it is used to increase knowledge of how to avoid or cope with a crisis in the future. It can also be used to change people's attitudes and beliefs about people in crisis, and to provide people with information about help available in their community. Public health professionals, for example, might educate a community on how to cope with a natural disaster such as a hurricane or an earthquake.

Crisis counseling is also related to health promotion. People can be taught useful skills that will help them to anticipate and cope with a crisis. Skills, information, and support services gained through crisis counseling can also help a person or a group of people to improve their health and quality of life. Crisis counseling can also be tied to health promotion through the development of health-related public policy and supportive environments. For example, public health professionals might create a policy to build crisis counseling centers or to develop a peer counseling program in high schools or colleges.

A valuable tool for public health, crisis counseling has several advantages over other types of counseling or health services. It is relatively low-cost and simple to provide, and it is flexible and easy to learn. A wide variety of health professionals, including doctors, nurses, psychologists, and social workers, can be taught to help people through the application of crisis counseling techniques. Crisis counseling services can also be provided in a wide variety of places or settings, including hospitals, community clinics, military bases, and police stations, as well as through telephone-based services. New technologies have also created the possibility of Internet-based crisis counseling.

Such services provide an important link between a community and the health care system. By using these resources people can sometimes get the help they need without using more expensive health care services, and they can often take advantage of twenty-four-hour crisis services. People with chronic health problems such as schizophrenia or depression can also get help from twenty-four-hour services when their physician or psychiatrist is not available. Many communities have developed peer counseling programs for specific groups such as adolescents and senior centers.

Public health professionals who offer crisis counseling have been faced with a growing variety of issues and clients. Many communities are home to an increasing number of people from a wide variety of cultural and ethnic backgrounds. There are also more older people in society than ever before. These trends have increased the number of incidents of elder abuse, hate crimes, and cultural clashes. These types of events, along with issues such as AIDS (acquired immunodeficiency syndrome), have increased the workload of crisis counselors. The field has also grown with the development of "first response" programs. Police officers, firemen, paramedics, and others are being trained to deliver on-the-spot crisis counseling. People working in public places such as stores and airline terminals are also learning how to do crisis counseling in order to deal with unhappy or violent customers. These types of programs only add to the importance of crisis counseling for individuals, families, and communities.

Generic Counseling Principles
Given that crisis counseling is different from usual school counseling and
has the aforementioned gcals, it is useful to indicate a general strategy for
helping people in a crisis situation. What follows is a generic model taken
from the work of Lindemann (1944), Caplan (1964), and Rusk (1971) and oth¬
ers (see Golan, 1978; Roberts, 2000, or Slaikeu, 1990 for an exhaustive model).
An individual counselor will change and adapt these techniques depending
on the type of crisis, the age of student, and the specifics of the type of crisis.
Although I have outlined the principles in the general order that they are ap
plied in a crisis, they are not necessarily sequential in practice.In working with a pupil in crisis:
1. Begin counseling immediately. By definition, a crisis is a time when a
child is in danger of becoming extremely impaired emotionally. The longer
the pupil remains in a hazardous situation and is unable to take action, the
more difficult it will be to facilitate coping and a return to equilibrium (Nader
& Pynoos, 1993). When a person remains in a state of confusion without any
kind of human support, anxiety and pain are sure to result.
2. Be concerned and competent. The pupil will need a certain amount of
reassurance during a crisis situation. The more the counselor can present
him or herself as a model of competent problem solving and demonstrate
the process of taking in information, choosing between alternatives, and tak

ng action, the more the child will be able to begin to function appropriately.
This higher functioning will come about both from a sense of safety and secu­
rity and from observeing a clear model. The counselor does not call atten­
tion to his or her competence but keeps it in the background as the counsel­
ing goes on.
3. Listen to the facts of the situation. Before proceeding, the counselor
must carefully gather information about the events leading up to the crisis,
eliciting as many details as possible. Not only will solutions come from these
facts, but concrete knowledge of the situation will also put into perspective
the pupil's behavior-Is this child behaving rationally or irrationally? Such a
determination allows the counselor to judge the severity of the crisis and to
proceed accordingly.
4. Reflect the individual's feelings. The counselor should explicitly focus
the discussion on the pupil's affective experience and encourage its appro­
priate expression. The objective here is not only to create empathetic under­
standing, but also to legitimize affect. The child must learn that feelings can
be discussed and are an important part of problem solving. By reflecting feel­
ings the counselor also “primes the pump” in that it gives the counselee a
way to begin and continue exploration of what occurred. Reflecting feelings
is an important strategy to make psychological contact (Slaikeu, 1990). Koo­
cher and Pollin (1994) identified eight fears associated with a medical crisis
that must be expressed and dealt with: Fear of loss of control, loss of self­
image, depencency, stigma, abandonment, isolation, death, and expressing
anger.
5. Help the child realize that the crisis event has occurred. Do not accept
the child's defensiveness or let the mechanisms of denial or other defensives
operate and prolong the crisis situation unnecessarily. Some denial may ac­
tually be coping, in that it gives the child a chance to be desensitized to what
has occurred. Prolonged or complete denial may not lead to coping. Encour­
age the pupil to explore the crisis events without becoming overwhelmed.
By asking appropriate well-timed questions, the counselor can control the
pace of exploration. Roberts (2000) suggested questioning to determine pre­
vious coping methods and dangerousness or leathality.
6. Do not encourage or support blaming. This strategy also is a way of
avoiding the pupil's defensiveness and of encouraging coping. If one can put
blame aside, and focus on what has occurred, the child may more quickly
move on. Dwelling on being a victim leaves one in a passive position rather
than moving on to an active role. The focus should be shifted to selfesteem
issues and internal strengths rather than remaining oriented toward exter­
nal causation and guilt.
7. Do not give false reassurance. The counselor should always remain
truthful and realistic, even though it is tempting to offer unrealistic comfort.
The individual in crisis will always suffer anxiety, depression, or tension, and

-14-

Publication Information: Book Title: Handbook of Crisis Counseling, Intervention and Prevention in the Schools. Contributors: Jonathan Sandoval - editor. Publisher: Lawrence Erlbaum Associates. Place of Publicat


Definition
Gestalt therapy is a humanistic therapy technique that focuses on gaining an awareness of emotions and behaviors in the present rather than in the past. The therapist does not interpret experiences for the patient. Instead, the therapist and patient work together to help the patient understand him/herself. This type of therapy focuses on experiencing the present situation rather than talking about what occurred in the past. Patients are encouraged to become aware of immediate needs, meet them, and let them recede into the background. The well-adjusted person is seen as someone who has a constant flow of needs and is able to satisfy those needs.
Description
Gestalt therapy has developed into a form of therapy that emphasizes medium to large groups, although many Gestalt techniques can be used in one-on-one therapy. Gestalt therapy probably has a greater range of formats than any other therapy technique. It is practiced in individual, couples, and family therapies, as well as in therapy with children.
Ideally, the patient identifies current sensations and emotions, particularly ones that are painful or disruptive. Patients are confronted with their unconscious feelings and needs, and are assisted to accept and assert those repressed parts of themselves.
The most powerful techniques involve role-playing. For example, the patient talks to an empty chair as they imagine that a person associated with an unresolved issue is sitting in the chair. As the patient talks to the "person" in the chair, the patient imagines that the person responds to the expressed feelings. Although this technique may sound artificial and might make some people feel self-conscious, it can be a powerful way to approach buried feelings and gain new insight into them.
Sometimes patients use battacca bats, padded sticks that can be used to hit chairs or sofas. Using a battacca bat can help a patient safely express anger. A patient may also experience a Gestalt therapy marathon, where the participants and one or more facilitators have nonstop group therapy over a weekend. The effects of the intense emotion and the lack of sleep can eliminate many psychological defenses and allow significant progress to be made in a short time. This is true only if the patient has adequate psychological strength for a marathon and is carefully monitored by the therapist.

ransactional analysis, commonly known as TA to its adherents, is a psychoanalytic (ie, consciously post-Freudian) theory of psychology developed by Canadian-born US psychiatrist Eric Berne during the late 1950s.
The fact is that TA is not only post-Freudian but according to its founder's wishes consciously extra-Freudian. That is to say that while it has its roots in psychoanalysis - since Berne was a psychoanalytic-trained psychiatrist - it was designed as a dissenting branch of psychoanalysis in that it put its emphasis on transactional, rather than "psycho-", analysis.
With its focus on transactions, TA shifted its attention from internal psychological dynamics to the dynamics contained in people's interactions. Rather than believing that increasing awareness of the contents of unconsciously held ideas was the therapeutic path TA concentrated on the content of people's interactions with each other. Changing these interactions was TA's path to solving emotional problems.
In addition Berne believed in making a commitment to "curing" his patients rather than just understanding them. To that end he introduced one of the most important aspects of TA; the contract. The contract is an agreement--entered into by both client and therapist--to pursue specific changes that the client desires.
Revising Freud's concept of the human psyche as composed of the id, ego, and super-ego, Berne postulated instead three "ego states"—the Parent, Adult, and Child states—which were largely shaped through childhood experiences. These three were all parts of Freud's ego: neither represented the id or superego.
Unhealthy childhood experiences could damage the Adult or Parent ego states, which would bring discomfort to an individual and/or others in a variety of forms, including many types of mental illness.
Berne considered how individuals interact with one another, and how the ego states affected each set of transactions. Unproductive or counterproductive transactions were considered to be signs of ego state problems. Analysing these transactions, according to the person's individual developmental history, would enable the person to "get better". Berne thought that virtually everyone has something problematic about their ego states and that negative behaviour would not be addressed by "treating" only the problematic individual.
Berne identified a typology of common counterproductive social interactions, identifying these as "games".
Berne presented his theories in two popular books on transactional analysis: Games People Play (1964) and What Do You Say After You Say Hello? (1975). As a result of this popularity, TA came to be disdained in many[citation needed] mainstream mental health circles as an example of "pop psychology". I'm OK, You're OK (1969), written by Berne's longtime friend Thomas Anthony Harris, is probably the most popular TA book. Many TA therapists regard I'm OK, You're OK as an oversimplification or worse.
TA was also dismissed by the conventional psychoanalytic community[citation needed] because of its radical departures from Freudian theory. However, by the 1970s, because of its non-technical and non-threatening jargon and model of the human psyche, many of its terms and concepts were adopted by eclectic therapists as part of their individual approaches to psychotherapy. It also served well as a therapy model for groups of patients, or marital/family counselees, where interpersonal (rather than intrapersonal) disturbances were the focus of treatment. Critics[1] have charged that TA—especially as loosely interpreted by those outside the more formal TA community—is a pseudoscience; when it is in fact better understood as a belief system.
TA's popularity in the U.S. waned in the 1970s, but it retains some popularity elsewhere in the world.[1] The more dedicated TA purists banded together in 1964 with Berne to form a research and professional accrediting body, the International Transactional Analysis Association, or ITAA. The organization is still active as of 2007.
TA outline
TA is a theory of personality and a systematic psychotherapy for personal growth and personal change.
• As a theory of personality, TA describes how people are structured psychologically. It uses what is perhaps its best known model, the ego-state (Parent-Adult-Child) model to do this. This same model helps understand how people function and express themselves in their behaviour.
• As a theory of communication it extends to a method of analysing systems and organisations.
• It offers a theory for child development.
• It introduces the idea of a "Life (or Childhood) Script", that is, a story one perceives about ones own life, to answer questions such as "What matters", "How do I get along in life" and "What kind of person am I". This story, TA says, is often stuck to no matter the consequences, to "prove" one is right, even at the cost of pain, compulsion, self-defeating behaviour and other dysfunction. Thus TA offers a theory of a broad range of psychopathology.
• In practical application, it can be used in the diagnosis and treatment of many types of psychological disorders, and provides a method of therapy for individuals, couples, families and groups.
• Outside the therapeutic field, it has been used in education, to help teachers remain in clear communication at an appropriate level, in counseling and consultancy, in management and communications training, and by other bodies.
Key ideas of TA
TA emphasizes a pragmatic approach, that is, it seeks to find "what works" in treating patients, and, where applicable, develop models to assist understanding of why certain treatments work. Thus, TA continually evolves. However some core models and concepts are part of TA as follows:
The Ego-State (or Parent-Adult-Child, PAC) model
At any given time, a person experiences and manifests their personality through a mixture of behaviours, thoughts and feelings. Typically, according to TA, there are three ego-states that people consistently use:
• Parent ("exteropsychic"): a state in which people behave, feel, and think in response to an unconscious mimicking of how their parents (or other parental figures) acted, or how they interpreted their parent's actions. For example, a person may shout at someone out of frustration because they learned from an influential figure in childhood the lesson that this seemed to be a way of relating that worked.
• Adult ("neopsychic"): a state in which people behave, feel, and think in response to what is going on in the "here-and-now," using all of their resources as an adult human being with many years of life experience to guide them. This is the ideal ego state, and learning to strengthen the Adult is a goal of TA. While a person is in the Adult ego state, he/she is directed towards an objective appraisal of reality.
• Child ("archaeopsychic"): a state in which people revert to behaving, feeling and thinking similarly to how they did in childhood. For example, a person who receives a poor evaluation at work may respond as they did in their childhood, by looking at the floor, and feeling shame or anger, as they used to when scolded as a child.
Berne differentiated between the Parent, Adult and Child ego states by using capital letters when describing them; and actual adults, parents and children. The ego-states may or may not represent the relationships that they act out: In the workplace, an adult supervisor may take on the Parent role, and scold an adult employee as though he were a Child. Or a child, using his Parent eg- state, could scold his actual parent as though the parent were a Child.
Within each of these ego states are subdivisions. Thus Parental figures are often either nurturing (permission-giving, security-giving) or criticizing (comparing to family traditions and ideals in generally negative ways), Childhood behaviours are either natural (free) or adapted to others. Each of these tends to draw an individual to certain patterns of behaviour, feelings and ways of thinking, which may be beneficial (positive) or dysfunctional/counterproductive (negative).
Ego-states do not correspond directly to Sigmund Freud's Ego, Superego and Id, although there is an obvious parallel. Rather, ego states are consistent for each person and are argued by TA practitioners as more readily observable than the hypothetical Freudian model. In other words, the particular ego state that a given person is communicating from is determinable by external observation and experience.
There is no "universal" ego-state; each state is individually and visibly manifested for each person. For example, each Child ego state is unique to the childhood experiences, mentality, intellect, and family of each individual; it is not a generalised childlike state.
Ego states can become contaminated, for example when a person mistakes Parental rules and slogans, for here-and-now Adult reality, and beliefs are taken as facts. Or when a person "knows" that everyone is laughing at him, because "they always laughed". This would be an example of a childhood contamination, insofar as here-and-now reality is being overlaid with memories of previous historic incidents in childhood.
Ego states also do not correspond directly to thinking, feeling, and judging, as these behaviours are present in every ego state.
Berne suspected that Parent, Adult and Child ego states might be tied to specific areas of the human brain; this idea has not been proved.[1]
In more recent years the three ego state model has been questioned by a marginal TA group in Australia, who have devised a "two ego-state model" as a means of solving perceived theoretical problems in it:-
"The two ego-state model sought to correct inaccuracies in the three ego-state model Berne devised: namely, that there were Parent, Adult and Child ego-states. The two ego-state model says that there is a Child ego-state and a Parent ego-state. The Adult ego-state is placed in the Parent ego-state. The Adult ego-state is one part of the Parent ego-state. The information we learn at school is all Parent ego-state introjects. How we learn to speak, add up and learn how to think is all just copied from our teachers. Just as our morals and values are copied from our parents. There is no absolute truth where facts exist out side a person’s own belief system. Berne mistakenly concluded that there was and thus mistakenly put the Adult ego-state as separate from the Parent ego-state." For anyone interested in sourcing this deviation from mainstream TA
A Cognitive Behavioral Therapy (CBT) is a psychotherapy based on modifying cognitions, assumptions, beliefs and behaviors, with the aim of influencing disturbed emotions. The general approach developed out of behavior modification, Cognitive Therapy and Rational Emotive Behavior Therapy, and has become widely used to treat various kinds of neurosis and psychopathology, including mood disorders and anxiety disorders. The particular therapeutic techniques vary according to the particular kind of client or issue, but commonly include keeping a diary of significant events and associated feelings, thoughts and behaviors; questioning and testing cognitions, assumptions, evaluations and beliefs that might be unhelpful and unrealistic; gradually facing activities which may have been avoided; and trying out new ways of behaving and reacting. Relaxation and distraction techniques are also commonly included. CBT is widely accepted as an evidence and empirically based, cost-effective psychotherapy for many disorders and psychological problems. It is sometimes used with groups of people as well as individuals, and the techniques are also commonly adapted for self-help manuals and, increasingly, for self-help software packages.
The basics
CBT is commonly based on the idea that how we think (cognition), how we feel (emotion and affect), and how we act (behavior) all interact and go together. Specifically, that our thoughts influence our feelings and behavior, our feelings influence our behavior and thoughts and our behavior influence our emotions and thoughts. These modalities are therefore interrelated, and change in one modality will in all probability influence at least one of the others.[1]
An example will illustrate this process. Someone who, after making a mistake, thinks "I'm useless and can't do anything right." This has a negative impact on mood, making the person feel depressed; the problem may be worsened if the individual reacts by avoiding activities and then behaviorally confirming his negative belief to himself. As a result, a successful experience becomes more unlikely, which reinforces the original thought of being "useless." In therapy, the latter example could be identified as a self-fulfilling prophecy or "problem cycle," and the efforts of the therapist and client would be directed at working together to change this. This is done by addressing the way the client thinks and behaves in response to similar situations and by developing more flexible ways to think and respond, including reducing the avoidance of activities. If, as a result, the client escapes the negative thought patterns and destructive behaviors, the feelings of depression may, over time, be relieved. The client may then become more active, succeed more often, and further reduce feelings of depression.
The objectives of CBT typically are to identify irrational or maladaptive thoughts, assumptions and beliefs that are related to debilitating negative emotions and to identify how they are dysfunctional, inaccurate, or simply not helpful. This is done in an effort to reject the distorted cognitions and to replace them with more realistic and self-helping alternatives.
Cognitive behavioral therapy is not an overnight process. Even after patients have learned to recognize when and where their mental processes go awry, it can take months of concerted effort to replace any dysfunctional cognitive-affective-behavioral processes or habit with a more reasonable, salutary one.
The cognitive model especially emphasized in Aaron Beck's cognitive therapy says that a person's core beliefs (often formed in childhood) contribute to 'automatic thoughts' that pop up in every day life in response to situations. Cognitive Therapy practitioners hold that clinical depression is typically associated with negatively biased thinking and irrational thoughts.
Cognitive behavioral therapy is often used in conjunction with mood stabilizing medications to treat bipolar disorder. Its application in treating schizophrenia along with medication and family therapy is recognized by the NICE guidelines (see below) within the British NHS.
Cognitive Behavioral Therapy
CBT can be seen as an umbrella term for many different therapies that share some common elements.[2] While similar views of emotion have existed for millennia, the earliest form of Cognitive Behavior Therapy was developed by Albert Ellis (1913-2007) in the early 1950s. Ellis eventually called his approach Rational Emotive Behavioral Therapy, or REBT, as a reaction against popular psychoanalytic methods at the time.[1] Aaron T. Beck independently developed another CBT approach, called Cognitive Therapy, in the 1960s.[3] Cognitive therapy rapidly became a favorite intervention to study in psychotherapy research in academic settings. In initial studies, it was often contrasted with behavioral treatments to see which was most effective. However, in recent years, cognitive and behavioral techniques have often been combined into cognitive behavioral treatment. This is arguably the primary type of psychological treatment being studied in research today.
Concurrently with the pioneering contributions of Ellis and Beck, starting in the late 1950s and continuing through the 1970s, Arnold A. Lazarus developed what was arguably the first form of "Broad-Spectrum" Cognitive-Behavior Therapy. Indeed, in 1958, Arnold Lazarus was the first person to introduce the terms "behavior therapy" and "behavior therapist" into the professional literature (i.e., Lazarus, A. A. New methods in psychotherapy: a case study. South African Medical Journal, 1958, 32, 660-664).[citation needed] He later broadened the focus of behavioral treatment to incorporate cognitive aspects (e.g., see Arnold Lazarus' 1971 landmark book "Behavior Therapy and Beyond," perhaps the first clinical text on CBT). When it became clear that optimizing therapy's effectiveness and effecting durable treatment outcomes often required transcending more narrow focused cognitive and behavioral methods, Arnold Lazarus expanded the scope of CBT to include physical sensations (as distinct from emotional states), visual images (as distinct from language-based thinking), interpersonal relationships, and biological factors. The final product of Arnold Lazarus' approach to psychotherapy is called Multimodal Therapy and is, perhaps, the most comprehensive form of CBT in addition to REBT that also shares many of the same assumptions and theorizing.
Cognitive Behavioral Group Therapy (CBGT) is a similar approach in treating mental illnesses, based on the protocol by Richard Heimberg.[4] In this case, clients participate in a group and recognize they are not alone in suffering from their problems.
A sub-field of cognitive behavioral therapy used to treat Obsessive Compulsive Disorder makes use of classical conditioning through extinction (a type of conditioning) and habituation. (The specific technique, Exposure with Response Prevention (ERP) has been demonstrated to be more effective than the use of medication—typically SSRIs—alone). CBT has also been successfully applied to the treatment of Generalized Anxiety Disorder, health anxiety, Social phobia and Panic Disorder. In recent years, CBT has been used to treat symptoms of schizophrenia, such as delusions and hallucinations. This use has been developed in the UK by Douglas Turkington and David Kingdon.
Other types of Cognitive Behavioral Therapy include Dialectical Behavior Therapy, Self-Instructional Training, Schema-Focused Therapy and many others.[5]
CBT has a good evidence base in terms of its effectiveness in reducing symptoms and preventing relapse. It has been clinically demonstrated in over 400 studies to be effective for many psychiatric disorders and medical problems for both children and adolescents. It has been recommended in the UK by the National Institute for Health and Clinical Excellence as a treatment of choice for a number of mental health difficulties, including post-traumatic stress disorder, OCD, bulimia nervosa and clinical depression.
Cognitive Behavioral Therapy most closely allies with the Scientist-Practitioner Model of Clinical Psychology, in which clinical practice and research is informed by a scientific perspective; clear operationalization of the "problem" or "issue;" an emphasis on measurement (and measurable changes in cognition and behavior); and measurable goal-attainment.
Depression
Negative thinking dominates when a person experiences depression. The depressed person can experience negative thoughts as being beyond their control, thereby allowing them to become automatic and self-perpetuating.
Negative thinking can be categorized into a number of common patterns called "cognitive distortions." The cognitive therapist provides techniques to give the client a greater degree of control over negative thinking by correcting these distortions or correcting thinking errors that abet the distortions, in a process called cognitive restructuring.
Negative thoughts in depression are generally about one or more of three areas: negative view of self, negative view of the world and negative view of the future. These constitute what Beck called the "cognitive triad."
Attributional style
An approach to depression based upon attribution theory in social psychology is related to the concept of attributional style. First put forth by Lyn Abramson and her colleagues in 1978, this approach argues that depressives have a typical attributional style —they tend to attribute negative events in their lives to stable and global characteristics of themselves.[6] There is considerable evidence that depressives do exhibit such an attributional style, but it is important to remember that Abramson et al. do not claim that an attributional style of this nature is necessarily going to cause depression — only that it will lead to clinical depression if combined with a negative event. This theory is sometimes known as a revised version of learned helplessness theory.
In 1989, this theory was challenged by Hopelessness Theory.[7] This theory emphasised attributions to global and stable factors, rather than, as in the original model, internal attributions. Hopelessness Theory also emphasises that beliefs about the consequences of events and rated importance of events may be at least as important in understanding why some people react to negative events with clinical depression as are causal attributions.
The ABCs of Irrational Beliefs
A major aid in cognitive therapy is what Albert Ellis called the ABC Technique of Irrational Beliefs.[1] The first three steps analyze the process by which a person has developed irrational beliefs and may be recorded in a three-column table.
• A - Activating Event or objective situation. The first column records the objective situation, that is, an event that ultimately leads to some type of high emotional response or negative dysfunctional thinking.
• B - Beliefs. In the second column, the client writes down the negative thoughts that occurred to him or her.
• C - Consequence. The third column is for the negative disturbed feelings and dysfunctional behaviors that ensued. The negative thoughts of the second column are seen as a connecting bridge between the situation and the distressing feelings. The third column C is next explained by describing emotions or negative thoughts that the client thinks are caused by A. These could be anger, sorrow, anxiety, etc.
For example, Gina is upset because she got a low mark on a math test. The Activating event, A, is that she failed her test. The Belief, B, is that she must have good grades or she is worthless. The Consequence, C, is that Gina feels depressed.
• Reframing. After irrational beliefs have been identified, the therapist will often work with the client in challenging the negative thoughts on the basis of evidence from the client's experience by reframing it, meaning to re-interpret it in a more realistic light. This helps the client to develop more rational beliefs and healthy coping strategies.
From the example above, a therapist would help Gina realize that there is no evidence that she must have good grades to be worthwhile, or that getting bad grades is awful. She desires good grades, and it would be good to have them, but it hardly makes her worthless. If she realizes that getting bad grades is disappointing, but not awful, and that it means she is currently bad at math or at studying, but not as a person, she will feel sad or frustrated, but not depressed. The sadness and frustration are likely healthy negative emotions and may lead her to study harder from then on.


Home
Counselling Skills
Why are these important skills now?
The speed and complexity of modern life continue to increase as do people's expectations from it. Coping well requires autonomous and flexible thinking and clear decisions. Unfortunately most of us have been conditioned to conform, not think for ourselves.
Counselling skills help people to change as they learn to think things through for themselves and make their own decisions, free of the effects of past conditioning.
What is counselling for?
When we seek, or accept, help with an issue we have been unable to resolve on our own, there is often an emotional component in the situation. We often feel bad about needing help. The problem may itself cause confusing feelings "I like my boss but she/he drives me mad doing X, dare I level with her/him?". In the latter case feelings of liking, irritation and anxiety are present together.
It is extremely difficult to think clearly when we are feeling strong feelings whether good or bad. The primary function of counselling is to help people think clearly when feelings are present. The feelings can arise from an experience in the present. Hearing "Your job is redundant" would obviously generate negative feelings in most people. Someone who got into trouble with head teachers at school might equally find meeting a senior administrator intimidating. This would remind that person of the earlier painful experience. He or she would then find it hard to think.
What are counselling skills?
The counsellor's job is to help the other person, the client, help him/her self. If the client is to feel safe enough to be open about her/his thoughts and feelings, he/she needs to feel safe, respected and understood. I list some skills below.
The counsellor must
So that the client can
Listen
Develop his/her thinking
Not judge
Feel safe and respected
Pay attention
Know you care
Accept the client's feelings
Know he/she is not being judged
Understand the client's world and feelings, put yourself in the client's shoes. Express that understanding.
Know you are with him/her
Think about the client
Get the best help possible
The counsellor may
So that the client can
Ask questions
Develop her/his own thinking
Summarise
Hear her/his thoughts and know she/he is understood.
Ask the client to try new behaviour in the counselling session
Release blocking emotion such as. unexpressed anger or sadness.
Counsellors should not
This will make the client
Argue
Defensive
Dwell on their own difficulties
Withdraw
Solve the problem for the client
Dependant
Give advice
Dependant or hostile
Belittle the clients' concern
Withdraw or attack
Avoid painful areas
Be frustrated
How does counselling work?
I assume that all humans have immense potential and are intrinsically intelligent, powerful, co-operative, zestful and loving. Unfortunately, this basic nature is often obscured as we grow older.
Our nature is such that we are easily hurt and when hurting our thinking process shuts down. When we act without thinking, the consequences often cause further hurts (distress) which reduce our capacity to think in the situation still further. We then behave in a rigid, stereotyped way every time we experience a situation that reminds us enough of the original situation in which we were hurt. This complex process develops rigid (patterned) responses to situations rather than a flexible appropriate response.
Fortunately, we had highly effective mechanisms for discharging our hurts and thus recovering our ability to think in any situation. A child that is experiencing, or has experienced hurt, will typically find someone, often an adult, and get this person to pay attention to him/her. The child will then talk actively, laugh, sweat, shake, have a tantrum (storm), cry or yawn. If the adult can stay in touch with the child, perhaps offer a warm hug or hold a hand, the child will discharge the painful emotion exhaustively and then go back to playing etc. quite freely and with no rigidities installed by the hurtful experience.
The above describes the counselling process in its natural state. Unfortunately most adults have had their discharge processes thoroughly interfered with in their childhood so will suppress the exhaustive discharge required because it disturbs them. Children quickly learn that discharging painful emotion is punished and learn further rigid ways of controlling their feelings, when discharging them would be helpful.
In the counselling process the counsellor provides the love, safety and attention necessary for the client to feel her/his feelings and discharge them. The feelings that condition behaviour in rigid patterns may arise from present hurts or past hurts. It is necessary for the counsellor to examine many ways to identify and outwit the client's patterns, including the control patterns, so they can discharge.
Isolation is a component in almost all hurts so simple, warm, attentive listening is often enough. Where it is not, the counsellor has to listen well enough to understand where the client is hurting. Then he or she must think how to show to the client that the rigid injunctions he/she feels are distress not reality and do so. An example could be a client whose hurt is about being accommodating and being exploited who says "I have to put up with it, I am lucky to have a job". The counsellor might ask the client to stand proudly and say in a confident tone "I am NOT going to be a victim ever again". S/he would find this difficult to say and would laugh, cry, sweat and perhaps get angry trying to do so. This would, when persisted in, discharge the hurts that installed the victim pattern in the first place. Following discharge, the client can think clearly about the painful experiences and decide what to do freely without the compulsion of the "victim" pattern.
There are literally hundreds of techniques like the above to deal with particular distresses.
What are the implications for organisations?
Staggering! Most of the problems of organisations require people to work together to solve them. Listening is the key skill required. Counselling training is the best way to get people to appreciate the value of listening and want to listen well.
Organisational performance depends on the quality of the thinking of staff at all levels. Counselling enhances the ability of the client to think and his/her willingness to act powerfully.


COGNITIVE LEARNING
A change in the way information is processed as a result of experiences that a person or animal has had.

PLACE LEARNING
The learner is shown events to be associated but no reinforcement is given for particular responses. The learner is often but not always, physically restrained, so that no movement is possible when the new information is given.

IMITATION AND MODELING
A person watches or hears someone else say or do something and attempts to copy it.
Ability to model one’s own behavior.

INSIGHT LEARNING
It is a form of learning in which there is a perceptual reorganization of one’s experience. It can be partly explained as a transfer from previous learning in which the individual has formed learning sets- that is learned learn.

1 comment:

JimH said...

Good stuff here, but can I point out that that Adler was not analysed by Freud and was never Freud's "apprentice" as you put it. Any book on Adler would verify this.
All the best,
Jim