A Theoretical Integrative Approach: Client-Centered & Cognitive Behavioural Therapy
Stephanie Janzen EDPS 602 Dr. Jennifer Malcolm Dec. 1, 2013
PERSONAL POSITION PAPER
2 In discussing and analyzing the various theoretical approaches to counseling, I feel that therapy can be both an art and a science. The human mind cannot be measured, and so a certain amount of creativity and ingenuity is needed on the part of the practitioner in order to access those thoughts and emotions. Furthermore, everyone who enters the therapy process is a unique individual with his or her own issues and problems and aspirations, therefore no textbook approach can be utilized for everyone in uniform fashion. At the same time, each person can be thought of as a scientist, posing hypotheses, and testing these hypotheses with experiments. For although one can uncovering the reasons why they may act as they do, such scientific techniques should be used to encourage behavior change and identify errors in thinking. This is why I am drawn to a theoretical integrative perspective that combines both the Client-Centered and Cognitive Behavioral approach, as it draws on both the exploration as to why one acts and behaviors as they do, and then how to create and maintain change.
Philosophical Assumptions Similar to that of Albert Adler, I believe that humans are neither good nor bad but that they may choose to be good or bad (or both) (Mosak & Maniacci, 2010). It is then those formative first six years of life that primarily shapes who we are and how we will later behave and react to lifes challenges. Our behavior and identity is also shaped according to how we are all each striving to reach our ideal self and achieve some sort of significance in our lives. Or, as Carl Rogers might say, to enhance ourselves (Raskin, Rogers, & Witty, 2010, p.149). I believe that people PERSONAL POSITION PAPER
3 generally desire to be better and so move toward those goals that they feel will give them a place in the world, will provide them with security, and will preserve their self-esteem (Mosak & Maniacci, 2010). People are rarely stagnant in their life. Rather, everyone typically has goals or dreams that they hope to achieve in their future. Consequently, a large part of our existence is spent attempting and struggling to achieve these. As Adler so eloquently states, the life of the human soul is not a being but a becoming (Adler, 1963, p. 9). I dont think that people are necessarily trying to better themselves in terms of goodness, but rather that goals pertain more to survival and bettering themselves. Some may have that drive to become a better, more moral person, and I believe people should, but it is not a uniform manifestation across all individuals. The development of ones personality, I believe, is shaped both through our genetics and our environment, and the interplay between them. I do prescribe to some Adlerian principals of personality development, such as the search for significance. For example, a child may have certain inherited traits, but as a result of being the middle child, they will strive to find significance within their family structure, thus affecting their decisions and reactions. Adler gave some emphasis to things such as birth order, and while I do see how they might affect an individual, I am hesitant to assign as much weight to it as he does. I believe that human behavior is much more flexible than that, and that expected behaviors are due more to family dynamics as opposed to expected characteristics based on birth order. Family dynamics then has much to do with personality development according to cognitive behavioral assumptions. For example, those early years of PERSONAL POSITION PAPER
4 life help to develop personal schemas. As Beck and Weishaar state, schemas contain peoples perceptions, of themselves and others and of their goals, and expectations, memories, fantasies, and previous learning (2010, p. 277). These schemas dictate our patters of thinking and can become so ingrained that they facilitate aspects of our personality. For example, if a young child was born into a family of many children, he may learn that he has to be very humorous in order to receive the attention that he craves. If successful, this pattern of thinking becomes part of his psyche and thus a part of his personality. Therefore, even in adulthood, this individual will always feel that he has to be the life of the party in order to feel validated. As Beck and Weishaar state, this can be interpreted as an interpersonal strategy developed in response to the environment (2010, p. 284). I believe that the root of healthy functioning lays within the family subsystem first and foremost. This is because our first opportunities to have an emotional connection and have needs attended to, as well as to react and control our environment, arise within our childhood years. I borrow then from psychoanalytic theory that believes that events that happen in our childhood can have a lasting impact and affect our functioning later in life. Therefore if a parent meets a childs relational needs, then those feelings of love and acceptance will be internalized, which helps the child develop into a mentally healthy adult. As children grow older, healthy behaviors can be established through classical conditioning, operant conditioning and modeling. For instance, if a child receives appropriate punishment and rewards as a result of specific behavior, and if they have healthy relationships that they can model, then they might have a good PERSONAL POSITION PAPER
5 foundation for mental health later in life. This will help then respond in resilient ways to lifes challenges and obstacles. If families can be the primary tool of healthy functioning, then it stands to reason that it too can be the cause of problems as well. As previously mentioned, young children need to feel emotional closeness and have their needs met by their caregivers. If this fails to happen then the child will internalize both the characteristics of the lost object and the accompanying anger and resentment over the loss (Goldenberg, Goldenberg & Pelavin, 2010). The resulting unresolved conflict then develops into frustration and self-defeating habits in the adult life. The adult will the find themselves unconsciously and unsuccessfully making unhealthy decisions (such as consistently choosing the wrong partner) (Goldenberg, Goldenberg & Pelavin, 2010). This again is also an example of how dysfunctional families create unhealthy and maladaptive stimulus and rewards patterns which accounts for ones learning history. For instance, someone who was severely punished as a child for minor infractions creates a response in the child of anger and resentment, causing them again to act out in defiance. At the same time, there are also innate, biological, developmental and environmental factors all at play in such scenarios. Therefore there really is not single cause of psychopathology (Beck and Weishaar, 2010). Although a child might have grown up in a loving household, they may not have learnt any useful coping mechanisms for later in life. Therefore, if one does encounter issues in one area of life, and those mechanisms do not immediately kick in to deal with the situation or they do not know how to appropriately respond, then PERSONAL POSITION PAPER
6 those normal emotional reactions become manifested in exaggerated and persistent ways (Beck and Weishaar, 2010). Beck and Weishaar give the example of depression where one might react by being sad initially and then moving on, while another can experience an intensified and prolonged sense of sadness and loss of interest. At the same time I must also note that temperament and biological predisposing factors also play a large role in mental health. For example, some people are naturally born with personality traits that are impatient or uncommunicative . Although this may not necessarily be the cause of maladaptive behavior later in life, it can certainly be a contributing factor. Biology and disease also too play a role. For example a susceptibility to depression can be genetically determined and so can be linked from generation to generation. Despite all of the factors that can contribute to mental health problems, as previously mentioned, I do believe that people have the capability to change and better themselves. While some people may have the insight to rationally assess their problems and address them accordingly, for those with more major issues, I do believe that guidance and advice (whether it is in the form of a trusted individual or through therapy) is necessary to correct those maladaptive thought and actions. I agree with authors Yontef and Jacobs who state that to the extend that people learn from mistakes and grow, therapy is not necessary. Psychotherapy is indicated when people routinely fail to learn from experience. People need psychotherapy when their self-regulatory abilities do not lead them beyond the maladaptive repetition patterns that were developed originally as creative PERSONAL POSITION PAPER
7 adjustments in difficult circumstances (2010, p. 359). Therefore I think that if such maladaptive patterns are so ingrained into their psyche, they will not have the insight or awareness to address them without professional help. Only those who recognize their behavior as abnormal and unhealthy have the ability to address them and pursue change.
The Counselling Experience My definition of counselling is providing my clients with a safe, warm and supportive environment, where they might have the freedom and encouragement to express their emotions and explore their inner processes. This process of awareness is to understand and acknowledge why an individual acts and thinks as they do. Once this has been accomplished, counseling is then directed towards problem solving, wherein the client is encouraged to challenge their pre-existing beliefs and behaviors in order to find more healthy alternatives. My own process of therapy draws firstly from client-centered techniques. This means that the therapist has no particular agenda in mind but gives the client space to share their experiences while the therapists goal is simply to understand their worldview. Thus, the therapist has to be comfortable with to both speech and silence, and letting the client determine the flow and content of the conversation. The therapist in turn, will recognize and accept their feelings but will not try to steer the conversation in any one direction. While client-centered therapy states that reassurances and advice giving are not necessarily helpful and may communicate a subtle lack of confidence in the PERSONAL POSITION PAPER
8 clients own approach to his or her life difficulties (p. 166), I tend to disagree. Most often patients do not pay a therapist to simply hear him or herself talk, rather they are looking for help in overcome obstacles and find solutions to their problems. Clients typically recognize that therapists are highly trained individuals, and thus can, and should, help when appropriate. Therefore if a client asks for advice, I do think it prudent to ask the client what they think they should do, but then provide an alternative if that suggestion does not seem appropriate. For this phase of therapy I believe that the counselor-client relationship should be one based on mutual respect, understanding and empathy. This means that the counselor does not judge the client based on anything they say or do, but attempts to only understand them. Although the client-centered view places great emphasis on unconditional positive regards, I do think that this is a very difficult thing to accomplish and is due more to the temperament of the therapist. I believe that some people are inherently more understanding and accepting than others, so while it is important to provide this type of support, it is not absolutely imperative. Sessions would typically last an hour, though the duration of the sessions should not be determined ahead of time. Some who must work through several issues may require many sessions, while others may just need a few. Thus a therapist should judge progress on a week-by-week basis. This first phase of exploration and awareness should be focusing primarily on the past and on the present. It is the process by which clients will delve into their current feeling, as well as past and present problems, and attempt to understand why such problems exist. PERSONAL POSITION PAPER
9 Depending on the person and the context of the problem, I also believe that family therapy is also a good option. For example, if the client still resides with the family and many of their problems stem from or exasperate family functioning, then it would be important to look at the family as a system in which reciprocal causality can cause dysfunction. In some situations it may be imperative to understand that family as a whole in order to fully appreciate and understand the client as an individual. Thus, I think there is great benefit in having a combination of session formats, where some might include the entire family, other sessions may include only some members of the family, while others are for individuals only. During this first half of therapy, I do think it important to pay attention to the internal experiences and outer process and signs, and how they are all connected. For instance I think that a clients beliefs and emotions do affect behavior. Beck and Weishaar summarize this well in saying that the individuals view of the self and personal world are central to behavior (2010, p. 280), meaning that if someone believes themselves to be unworthy or unconfident, they will avoid those situations that put themselves out there and call for some bravery. Therefore it will be helpful to look for patterns in not only their behavior during sessions but also in retelling of events and activities as a form of communicating their thoughts, beliefs and emotions. Body language can also be telling of a persons thoughts and emotions. This can include posture, breathing patterns, eye contact (or lack thereof), or even where they sit or whom they sit next to. Without the client even being aware, such small signs can be good indicators of their internal thought processes, which can help the counselor in assessing their mood and in querying responses. Lastly, the PERSONAL POSITION PAPER
10 combination between all three is imperative to understand from a psychological aspect because it is largely understood that emotions play a role in cognitive change, in that when emotions are triggered, learning is enhanced (Beck & Weishaar, 2010). After the first phase of awareness and exploration has completed (and the client now understands what has triggered their current thoughts and behaviors), the counselor and client can now move towards the problem-solving phase of treatment. For although the client may now understand why they act as they do, such new insight may not necessarily alter current maladaptive patterns. Thus I believe that cognitive-behavioral therapy should be utilized primarily as a way to establish more healthy alternatives (Beck & Weishaar, 2010, p.290). During this phase it is now assumed that the problem has been established, and those automatic thoughts that cause those issues are now to be challenged by examining their validity, adaptiveness and utility for the patient (Beck & Weishaar, 2010, p. 294). This means encouraging them to experience the cognitions and test them within the therapeutic framework, and then examining the evidence for and against the distorted automatic thoughts, and then substituting them for more realistic interpretations (Beck & Weishaar, 2010). There are a few techniques that can be utilized in examining faulty cognitions such as decatastrophizing, reattribution, redefining, and decentering. Other techniques that focus on maladaptive behaviors include assigning homework, hypothesis testing, exposure therapy, rehearsal and role-playing etc. (Beck & Weishaar, 2010). As this phase of therapy requires more focus and directions, the counselor now shifts from being non-directive and passive to helpful and effective. So that PERSONAL POSITION PAPER
11 now, rather than allowing the client to lead the session and talk about whatever he or she wishes, the therapist should encourage the client to become proactive and focus on testing and altering current beliefs and behaviors. Though in doing so, the counselor must be careful not to change the nature of the counselor-client relationship. There should not be a switch that turns on in the attitude of the counselor between phase one and two, rather they should retain the attitude of empathy and understanding, but direct it now towards problem solving and adapting. But above all else, it is imperative that the client retain the sense of trust and security that developed in the first phase, as it will be necessary in order for the client to feel comfortable taking such risks. Despite the counselor now taking more of a leadership role, the client should be ready to tackle these problems and be ready for change. Therefore, even though the counselor now tells the client that those thoughts and behaviors are maladaptive and wrong, the client must be ready to decide whether to reject, modify or maintain all personal beliefs, and then also be aware of the consequences (Beck & Weishaar, 2010). Thus the pace and direction of the therapy is still controlled by the client. They may also be able to choose which techniques they wish to implement, and then when they will try them out outside of therapy. In this way, the pace of change may vary between patients, as well as the number of sessions that might be required. Some patients may see results with only a few sessions, while others may require years of therapy. In this phase of treatment, the goal is to modify beliefs and correct exaggerated emotions so that it may then change behaviors. At the same time, by PERSONAL POSITION PAPER
12 modifying behavior, it can also result in changing beliefs. This seems to be a bi- directional relationship, so that change if made in one, it can then result in change in the other. For example, if a depressed individual is able to recognize the positive aspects of his life and learn to appreciate them, then he may find himself more willing to engage in some activities. At the same time, if a depressed individual makes an attempt to go outside and interact with friends or exercise, him may experience a positive change in mood. The actual process of change occurs when the patient is ready to challenge those thoughts that interfere with functioning, so that he or she has the opportunity to consider those underlying assumptions that generate such thoughts (Beck and Weishaar, 2010). Then they can recognize the power of these thoughts and how it has impacted their life for the negative. This process of change includes working with the therapist to modify those thoughts, examining their validity and utility, and then replacing them with more adaptive ways of thinking . The tools necessary for such a process involves a comprehensible framework, the patients emotional engagement in the problem situation, and reality testing in that situation (Beck and Weishaar, 2010). Although some may flow through this process of change seamlessly, most will at some point show some resistance to change This occurs when they oppose or deny an emotion or idea for the purpose of avoiding any feelings of vulnerability or ridicule or being uncomfortable (Yontef, Jacobs, 2010). As conflict is explored in therapy, it is not uncommon for most to show some resistance in the form of avoidance or anger. The strength of this type of integrative therapy though, is that it PERSONAL POSITION PAPER
13 allows the client to address topics of their choosing. Therefore, although they might be resistant to a topic or feeling at the beginning, it is likely that through the process of exploration, they will address those topics that produce resistance at some point or another during their sessions. In attempting to replace maladaptive thoughts and behaviours with new ones, several methods can be utilized. The first is collaborative empiricism. According to Beck and Weishaar, this techniques involves determining the goals for treatment, eliciting and providing feedback, and thereby demystifying how therapeutic change occurs (2010, p. 291). This means that together the therapist and client will test the assumptions and then study the evidence to determine whether it should support or reject their cognitions. In this way they are using a very objective method to determine what is helpful for the patient and what is not. Another methods is Socratic Dialogue. This involves having the therapist propose a series of questions that cause the client to identify, question, examine and assess the consequences of their maladaptive thoughts and behaviours. This is a useful method in that it does not necessitate any action, but rather causes him to arrive at some logical conclusion (Beck and Weishaar, 2010). This is especially useful for those clients whose problems are not easily testable (such as believing that theyll never get what they want in life). Another intervention technique is guided discovery. This involves clarifying problems and errors in logic by using behavioural experiments that cause the patient to adapt new skills and perspectives. In using this techniques the therapist encourages the patients use of information, facts and probabilities to obtain a PERSONAL POSITION PAPER
14 realistic perspective (Beck & Weishaar, 2010, p. 292). This is useful for those patients whose problems lie in obviously false ideas, such as everyone hates me. In such a theoretical integrative model of therapy, success should be defined in two ways. During the first phase of therapy, success is when the client is able to unearth hidden or denied feeling or experiences that have caused the client to feel or behave in maladaptive ways (Raskin, Rogers, & Witty, 2010). Thus, through non- directive discussions with the therapist, the client has been able to identify those past events and situations that were the basis of future functioning. It is not until this has been accomplished that the client can then move on to phase two. In the second phase of therapy, success is apparent when the client has not only been able to replace thought and behaviours with more adaptive ones, but when he takes control of the processes and is able to independently use the interventions himself to solve problems. Thus success is not only solving problems within the framework of therapy, but also when the client can use those cognitive and behavioural techniques in his personal life without the therapists help or support (Beck and Weishaar, 2010). Within the first phase of therapeutic exploration, it is imperative that the therapist remain free from judgment and bias. Therefore the therapist must be cognizant and sensitive to issues pertaining to sexual orientation, gender, race, religion, ethnic group or social class (Raskin, rogers, & Witty, 2010). Although those theorists that subscribe to this form of therapy admit that no therapist is without their own covert biases, the process of therapeutic understanding directs the therapist to not assume difference except as the client asserts how he or she PERSONAL POSITION PAPER
15 experiences self as different (Raskin, Rogers, & Witty, 2010, p. 182). In the cognitive-behavioural phase of therapy, it is important that the therapist understand the cultural context of the client that is described during phase one, so that they can determine whether their beliefs are at odds with the cultural values around them. For instance it would be important to understand that in some cultures, it is typical for them to keep their problems to themselves rather than reach out for help. Reflection The first weakness of my personal theory is that is assumes that some problems presented by patients will fit the framework of both the exploration phase and the problem solving phase. Yet this is not always the case. For instance, some may benefit more from the cognitive behavioral phase in that their issues are obvious and identified, and dont necessarily stem from past injuries or issues. At the same time, someone may get great benefit from the client-centered stage yet their issues are not appropriate for CBT (such as dealing with the death of a family member). This process also relies on client directedness, but in exploring their feelings and thoughts as well as in choosing CBT techniques and implementing them, some may not appreciate such freedom. Therefore it does not provide the more dictating style that some patients might require or prefer. This theory also fails to consider other techniques that could be helpful. Thus the therapist cannot rely on other therapeutic techniques that could be at their disposal were they to be more integrative in their approach (Norcross & Beutler, 2010). It relies on the one solution to fit all approach which is denying the patient PERSONAL POSITION PAPER
16 of other useful techniques that could be beneficial. It also assumes that the change process is consistent from patient to patient (self-awareness to self-correction) while this might ignore others who show variations or have trouble transitioning from one phase to the other. I am drawn to this theoretical integration approach to therapy, because I firmly believe that it is important to not only address the psychological problems through action-oriented approaches, but to also understand why those problems were presented in the first place. Thus there needs to be an emphasis on both contemplation and understanding, as well as action and maintenance. Combining both client-centered therapy and cognitive behavioural techniques addresses these two concerns, so that the patient can achieve peace, resolution, and experience real change so that he might live a more healthy and fulfilling life. I also am drawn to these two approaches because they do not rely merely on feeling and intuition but also on scientific approaches. For when you combine the two, I feel that you are drawing upon two different yet reliable sources of information that can produce better results and form better relationships, as opposed to relying on just one approach. For instance by using only non-directive exploration, the client might only have the benefit of catharsis. Yet by including a more scientific evidence based approach, we can confirm that interventions will indeed produce positive results (if implemented correctly). Thus I believe we are getting the best of both worlds. In conclusion, I feel that the integrative model will provide the framework for my counselling techniques in the future. I hope to help my patients by utilizing both PERSONAL POSITION PAPER
17 intuition and apathy, as well as structured hypothesis testing. In using both elements of theory I feel that I can apply the best of both worlds
PERSONAL POSITION PAPER
18
References
Beck, A. T. (2005). The current state of cognitive therapy: a 40-year retrospective. Archives of General Psychiatry, 62(9), 953. Beck, A. T., & Weishaar, M. E. (2010). Cognitive Therapy. Current psychotherapies (pp. 276-309). Itasca, Ill.: F.E. Peacock Publishers. (Original work published 1973) Mosak, H. H., & Maniacci, M. (2010). Adlerian Psychotherapy. Current psychotherapies (pp. 67-112). Itasca, Ill.: F.E. Peacock Publishers. (Original work published 1973) Raskin, N. J., Rogers, C. R., & Witty, M. C. (2010). Client-Centered Therapy. Current psychotherapies (pp. 148-195). Itasca, Ill.: F.E. Peacock Publishers. (Original work published 1973) Watts, R. E. (2003). Adlerian therapy as a relational constructivist approach. The Family