Chapter 3: Theoretical Base of Counselling PDF

CHAPTER 3 Theoretical Base of Counselling Counselling theories - an overview............................................... 79 Psychoanalytic therapy...................................................................... 80 Adlerian therapy.........................

CHAPTER 3 Theoretical Base of Counselling Counselling theories - an overview............................................... 79 Psychoanalytic therapy...................................................................... 80 Adlerian therapy................................................................................... 87 Person-centred therapy..................................................................... 90 Gestalt therapy...................................................................................... 93 Behaviour therapy................................................................................ 96 Cognitive-behaviour therapies:.....................................................101 A. Rational emotive behaviour therapy (REBT).................101 B. Cognitive therapy....................................................................104 C. Cognitive-behaviour modi!cation (CBM)......................106 Reality therapy......................................................................................108 Solution-focused therapy..................................................................110 Family therapy.......................................................................................113 Brief therapy...........................................................................................116 References...............................................................................................118  THEORETICAL BASE OF COUNSELLING 79 Counselling theories - an overview „ There are many theories that seek to explain human behaviour. „ Each theoretical approach: y Seeks to identify influences that shape the personality of an individual y Presents an explanation about how and why dysfunctional behaviour develops y Explains what can be done to help people change in a way that allows them to achieve their full potential. „ There are no right or wrong theories. Instead each theory views human behaviour by focussing on certain aspects. „ There are practitioners who specialise and carry out interventions based on one speci!c theoretical approach. However, many use of combination of techniques drawn from variety of approaches. „ The choice of therapy to be used depends upon the training and personal interest of the counsellor. „ Understanding the concepts related to each theory helps one appreciate the challenges involved and understand clients at a deeper level. „ The ideas presented in each approach can be applied to individual as well as group settings. „ This study guide presents some of the well known theories and therapy interventions developed based on it. „ This information does not prepare us to practice a form of therapy but can help us understand the importance of speci!c issues. „ This study guide presents information about: y The persons who largely developed the theory y Signi!cant features of the theory y Brief explanation of the therapy process and tools used y Highlights of the strengths and challenges of the approach. „ Ten therapy approaches are discussed in this study guide, namely: y Psychoanalytic theory y Adlerian theory y Person-centred therapy y Gestalt therapy. A 80 CHAPTER 3 y Behaviour therapy y Cognitive-behaviour therapies y Solution-focussed brief therapy y Reality therapy y Family therapy y Brief therapy. „ Two theories that trace personality development from early years on to the adult years are Freud’s ‘Psychosexual development’ and Erikson’s theory of ‘Psychosocial development’. Both have been discussed in this study guide. 1. Psychoanalytic theory Background „ The Psychoanalytic theory was developed by Sigmund Freud (1856 – 1939) and the therapy based on this theory is referred to as ‘psychoanalysis’. „ Sigmund Freud is recognised for developing the most comprehensive theory of personality and this formed the foundation on which many other theories were developed. „ Though Freud’s classical psychoanalysis is not practiced in SUD treatment settings today, many concepts introduced by Freud are widely used. „ Defense mechanisms, transference and countertransference issues are some of his contributions. View of personality and symptom development „ Freud believed that the person’s personality is shaped by unconscious needs and drives. He believed that the conscious mind is only a small part and that most of our experiences and memories are in the unconscious. Therapy thus focused on recognising the unconscious influences and developing new ways to deal with it. „ Freud’s approach is termed as ‘deterministic’ as personality was believed to be shaped largely by early childhood experiences and not based on the person’s freewill. „ Personality development takes place in !ve stages and is well formed by six years of age. If the child’s needs were not adequately met, personality development would be affected. Three stages of development: A  THEORETICAL BASE OF COUNSELLING 81 y Oral stage: First year of life: Nurturing relationship with the caregiver usually the mother would develop the ability to love and trust others. If this stage’s need is not met, greed, inability to trust others and difficulty in intimate relationships would follow. y Anal stage: 1 – 3 years of life: Learns independence and expresses feelings of anger and aggression. If not, the helplessness interferes with his sense of autonomy and the person is unable to recognise, express and deal with negative feelings. y Phallic stage: 3 – 6 years of age: In this stage sexual attitudes develop based on how the parents and caregivers respond. The child learns to be comfortable with his sexual identity. y Freud also described the stage of latency (6 to 12 years) when sexual interests are replaced with school, sports and other social relationships. y The rest of the life period was described as the genital stage. „ Freud believed that the personality consists of three psychological structures: y The Id, Ego and Superego y These do not operate separately but the personality functions based on these three components. Component and principle Role Id „ Biological component: „ Operates from the present at birth unconscious „ Pleasure principle „ Illogical, and demanding „ Functions based on instinct „ Driven to satisfy needs and drives „ Does not think but acts Ego „ Psychological component „ Uses intelligence and plan „ Reality principle of action to satisfy needs „ Functions based on logic „ Functions like an executive and reality to balance instinct and moral code Superego „ Social component „ Judicial branch of „ Perfection principle personality „ Operates from the moral „ Represents the ideal of code based on values and what he wants to be ideals of parents and society „ Seeks perfection A 82 CHAPTER 3 „ There is a constant struggle between the three components giving rise to anxiety. y The id seeks to satisfy the basic aggressive and sexual drives. y The superego wants to restrict the id and make sure that we behave based on what parents or society wants us to do. y The ego tries to negotiate between the two and maintain a balance. „ This gives rise to anxiety as there is a constant fear that : y Instinct or id will get out of hand and one would act based on instinct and do something wrong y One would not act according to the superego leading to guilt. „ Ego defence mechanisms help the individual cope with the anxiety. Defence mechanisms deny or distort reality and operate in the unconscious. These are normal behaviours that help us adapt as long it is not used to avoid facing reality. „ Some of the common defence mechanisms are : Defense mechanism Example Repression: Thoughts and feelings are Forgetting things that are painful or suppressed in the unconscious unpleasant e.g. accident or trauma Denial: Not being able accept something Being unable to recognise that one is that is true addicted when the evidence is clear Displacement: Transferring your feelings Being angry with spouse and instead to someone else not connected with the shouting at the child unnecessarily incident Projecting: Seeing the unwanted aspects Being jealous and stating that others are of yourself in others jealous Reaction formation: Dealing with Being very nice to others when you dislike unwanted emotions by doing the opposite them Rationalization: Giving reasons that are not Missing the job promotion and saying that true to explain something uncomfortable it is better that way as it would have been stressful and boring if he had got it. Sublimation: Diverting by engaging in Diverting aggressive feelings into sports socially acceptable behaviour Regression: Going back to an earlier stage Children may start thumb sucking, bed of development when stressed wetting or using baby talk again when stressed A  THEORETICAL BASE OF COUNSELLING 83 Role of therapist: „ Goal of therapy is to bring the unconscious to the level of the conscious „ This helps strengthen the ego and help develop behaviour based on reality instead of instinct or guilt. „ Childhood experiences are discussed, interpreted and analysed to : y Experience the feelings related to the memories y Gain understanding of the reason behind the symptoms (why) y Identify and understand defence mechanisms and y Gain more control over their lives. „ The therapist maintains a ‘blank screen approach’ making it easy for the client to talk without hesitation about whatever comes to his mind (free association). Dream analysis is another tool used. „ By allowing the client to be on the couch and maintaining an objective, aloof approach the therapist makes it easy for the client to talk about conflicts. Resistances are seen as defences against anxiety. „ The client usually shifts the feelings related to others on to the therapist and this is referred to as transference. These positive and negative feelings expressed towards the therapist are interpreted to hasten the process of getting in touch with the unconscious. The therapist watches for countertransference issues that can affect interpretations. Strengths and challenges: „ The focus on early developmental tasks, importance of understanding roots of symptom development and handling client resistance are signi!cant contributions of the approach. „ The long duration of therapy and the money involved makes it less appealing. „ Psychoanalysis deals with long-term personality changes and may not be suitable for those who approach the therapist to deal with a crisis. „ This nondirective approach may not be appealing for clients who prefer a more structured approach to treatment. „ Some of the psychoanalytic concepts can be applied while conducting psychodynamic group therapy. Even when the process of psychoanalysis is not used, the group therapist can think psychoanalytically to understand how a person’s past is influencing the way they act in groups and their daily lives. A 84 CHAPTER 3 „ Group situations often recreate early life situations of clients. Transference towards the therapist and other group members is common. Clients tend to express feelings of anger, avoidance, competition or even attraction which reflect their early relationships. This can help the therapist identify and deal with the unresolved conflicts. „ Recognition of therapist factors influencing therapy through countertransference is also a contribution of the approach. Countertransference issues can help one become aware of own biases, remain sensitive to cultural issues and use the power of the group with care. Later developments in the Psychoanalytic approach of Sigmund Freud. „ The psychoanalytic approach was further developed by others who built on Freud’s concepts. Some are: y Carl Jung who emphasised that people are driven to !nd meaning in life and work to ful!l their capabilities and are not influenced by instincts alone. Jung also believed that people strive towards living up to their potential. y Alfred Adler who worked with Freud and Jung later developed his own approach which is discussed in the next section. y Later neo-Freudians such as Karen Horney, Erich Fromm and Harry Stack Sullivan contributed to this approach. y Psychodynamic approaches (different from psychoanalytic approaches) were later developed which offered therapy in a shorter duration. Basic techniques of psychoanalytic therapy such as free association, interpretation etc., were used. But, the focus was on limited objectives rather than restructuring the personality. Moreover, the therapist took a more active role with expression of support, self- disclosure etc., Erikson’s Individual life cycle development – Psychosocial development Erik Erikson (1902-1994) developed the theory of psychosocial development which describes eight stages of development. Like Freud, Erikson also conceptualised the development of personality as taking place in stages. However, Erikson focused on the social influences in the development of the personality. Of the eight stages, the !rst !ve stages focus on the individual’s development of identity and skills while the last three stages are largely related to interpersonal issues. Erikson believed that in each stage speci!c tasks needed to be mastered. Each stage built on the previous stage and the outcome paved the way for the next stage of development. A brief description of each stage is presented below: A  THEORETICAL BASE OF COUNSELLING 85 Stage 1: From birth to one year of age Conflict : Trust vs mistrust In this stage, the child is completely dependent on the parents, usually the mother as the primary caretaker. If the basic physical and emotional needs are met well, the child feels safe and secure. If the caregiver is inconsistent in meeting the child’s basic needs such as food or fails to show adequate love and care, the child is unable to develop trust, is guarded and views the world as inconsistent and unpredictable. Stage 2: Two to three years of age Conflict : Autonomy vs shame and doubt From being totally dependent, the child now attempts to do things on his own and develops self-con!dence. By feeding or dressing self, using the toilet etc., the child experiences a sense of control and independence. Patience and encouragement from parents helps while demanding or restricting too much or ridiculing early attempts at self-sufficiency, may result shame and doubt. The sense of ‘will’ and being able to act independently is a key quality in this stage. Stage 3: Preschool years (four to five years) Conflict : Initiative vs guilt The child’s curiosity and initiative to try new things in this stage needs to be managed with balanced restrictions and consistent messages. When too many restrictions are placed and even normal playful actions are prohibited the child feels guilty. Balancing independence with self-control is a key aspect in this stage. With encouragement and help to make appropriate choices, the child takes the initiative to undertake activities and achieves a sense of competence. If he experiences too much disapproval, is restricted or if this is done inconsistently it can build a sense self doubt and guilt and lead to a lack of initiative. Stage 4: Six to twelve years Conflict : Industry vs inferiority The focus here is on setting and attaining personal goals related to social and academic demands. The child wants to be responsible, do the right things and do it well. When he is successful, a sense of accomplishment and pride in his ability develops. When he is unable to achieve these tasks, he starts doubting his ability to be successful. The sense of competence the child develops is an important aspect of this stage. A 86 CHAPTER 3 Stage 5: Twelve to eighteen years (adolescence) Conflict: Identity vs role confusion Being at the cross roads of development, the adolescent is deciding the kind of person he wants to be. Peers and role models have a great deal of influence. They may experiment with variety of activities leading to conflicts with adults about religious or political orientations. Choices regarding careers need to be made and may be contradictory to what the others want them to do. The emphasis is on achieving a self-identity. Achieving a sense of balance between the standards and expectations of society and what they are and want to be is an important aspect of this stage. Stage 6: Eighteen to thirty five years (early adulthood) Conflict: Intimacy vs isolation Intimacy refers to the ability to be close to others by developing friendships, !nding a partner and being able to care for and love others. People who developed a strong sense of personal identity are able to move through this stage with ease. They explore and develop close, committed relationships. On the other hand, people with a poor sense of self are more likely to feel isolated, and suffer from loneliness and depression. They may !nd it difficult to commit themselves into lasting relationships and move in and out of relationships. Stage 7: Thirty five to sixty five years Conflict : Generativity vs stagnation Here the focus is on the career and the family and about helping the next generation. ‘Generativity’ refers to caring for others and doing things that make the world a better place. Recognising the contribution they have made, taking pride in one’s achievements and watching their children grow into adulthood are important aspects of this stage. When the person sees oneself as being unable to contribute and remain uninvolved with their community and with society as a whole, ‘stagnation’ sets in. Blaming, complaining and being dissatis!ed with oneself and others can result. Stage 8: Sixty five years and above Conflict : Integrity vs despair Being able to reflect back on his life with a sense of satisfaction and feel worthwhile marks a successful achievement of this stage of development. They accept the aging process gracefully and see death as part of the life cycle. People, who feel that their life has been wasted or that they have been cheated, feel angry and resentful and bitterness and despair can set in. A  THEORETICAL BASE OF COUNSELLING 87 2. Adlerian theory Background „ Alfred Adler (1870 – 1937) worked closely with Freud and later developed his own approach. „ Adler differed from Freud and viewed personality as being influenced by: y Interpersonal issues (social connectedness) rather than by intrapsychic conflicts only y Conscious, goal - directed, purposeful activity rather than being determined by conflicts at the level of the unconscious. Adler stressed on individual choice and responsibility. „ Adler emphasised the need to: y View clients holistically and as part of the social systems he lives in and is recognised as the !rst therapist to use the systems approach y Understand the client’s values, beliefs, attitudes and goals and his individual perception of reality even though it is subjective. „ Rudolf Dreikurs is credited for applying Adler’s ideas in various !elds. View of personality and symptom development „ Adler named his approach as ‘Individual Psychology’. However, he stressed that people need to be understood as a whole and in relation to all aspects of his life. Adler emphasised the context of family, school, work and culture. „ Adler believed that feelings of inferiority were present in everybody. However this was not viewed in a negative manner. Due to the sense of inferiority, people worked towards developing competence and aim for perfection. It was emphasised that individuals can be understood only in terms of the goals they are working towards. „ Based on the way a person views self, others and the world, he develops a characteristic or a speci!c way of thinking and acting. This was termed as his ‘style of life’ or ‘road map of life’. This was developed by the time a person is six years old and following events and experiences influence it. „ Interpretation of the events or the way the person viewed these experiences (subjective reality) is considered more important than the actual event. y Interpreting these events in a faulty manner can lead to dysfunction. y Modifying the faulty assumptions and making changes can help clients create a new style of life. A 88 CHAPTER 3 E.g. The person may believe that nobody cares and decide that he is unlovable. The person may develop depression following this and he avoids contact with others which further intensi!es the depression. During therapy he will learn to challenge his logic that he is unlovable. „ Social interest is another distinct concept of Adler. He believed that feelings of inferiority reduced when people were able to relate to others meaningfully and contribute to the welfare of others. The psychological capacity for friendship and belonging, contribution and self-worth and cooperation was fundamental for healthy functioning. Dysfunction in any of these was an indication of psychological disorder (American Psychiatric Association, 2000). „ Mastery over three universal life tasks was considered important: y Building friendship (social task) y Establishing intimacy (love – marriage task) y Contributing to society (occupational task) Later, other therapists (Dreikurs and Mosak) added need for self acceptance and developing our spiritual dimension (including values, life goals etc.,). The aim of therapy was to help clients modify their life style and achieve these tasks. Role of therapist Adlerian counselling can be examined as a four phase process. Phase 1: Establish the relationship. The therapist focuses on the person rather than the problem and builds a positive relationship by listening, responding and expressing hope and faith in their ability to change. The caring relationship is considered important. Phase 2: Exploring the psychological dynamics: Based on detailed interviewing with the client, an assessment is carried out to understand „ Family constellation: Family atmosphere, birth order and cultural issues „ Early recollection of incidents that happened before the age of 10 „ Identifying mistakes in the messages drawn from the past. Phase 3: Encouraging self understanding and insight: The !ndings of the assessment are interpreted and carefully presented to help the person understand: „ What motivates the behaviour „ How this contributes to the problem and A  THEORETICAL BASE OF COUNSELLING 89 „ What can be done to correct it Phase 4: Reorientation and re-education: The insight developed is used to make changes in his life. The therapists may act as the teacher or guide and provide information and encouragement to help make the change. In this phase, encouragement is seen as the most important tool. Strengths and challenges „ Recognising the importance of social influences and the freedom of choice that the individual has in shaping his destiny are signi!cant strengths of this approach. „ The importance to cultural issues and the flexibility involved made it possible to apply the Adlerian approach to variety of settings and groups (couple counselling, parent education, group counselling etc.) „ The basic ideas have been used by several other approaches and almost all of the approaches presented in the following sections. „ Some of the challenges in applying this approach are: y Clients may not recognise the purpose of detailed analysis of one’s early life experiences to deal with current problems. y In some cultures, the therapist is expected to function as an expert and provides solution for their problems. In this approach, the therapist focus on teaching alternative ways to cope with the problem can be disappointing. „ Some of Adler’s concepts can be used in SUD treatment. For people with SUD, substance use is often a response to cope with feelings of inferiority and clients can be helped to: y Review their interpretation of the past y Address faulty assumptions y Strengthen their social connection with people around them and there by y Strengthen recovery. „ The therapist uses encouragement as a therapy tool and providing hope about recovery is emphasized. „ Research support for the effectiveness however is limited. „ By and large, the ideas presented by Adler are used by other approaches but practice of the Adlerian approach has lost prominence. Carlson and Englar-Carlson (2008) commented saying ‘Whereas Adlerian ideas are alive in other theoretical approaches, there is a question whether Adlerian theory as a stand-alone approach is viable in the long-term’. A 90 CHAPTER 3 3. Person-centred therapy Background „ The Person-centred Approach was largely based on the work of Carl Roger (1902 – 1987). „ When Rogers presented this approach, it was distinctly different from the psychoanalytic approaches that focussed on the past and the behavioural approaches that were being practiced. Techniques such as interpretation, teaching, diagnosis and the idea that the ‘counsellor knows best’ was challenged by Rogers. „ Carl Rogers’s humanistic approach emphasised that all human beings have potential and will automatically grow in positive ways if provided with the right conditions. View of human nature and therapeutic intervention „ Person-centred therapy focuses on the person and not the problem. This (phenomenological) approach examines the problem based on the client’s perception of experiences rather than the interpretation of the therapist. „ The approach is based on the !rm belief that people are capable of healing themselves, move away from maladaptive behaviour and towards psychological well being. „ The aim of therapy was to assist clients in their growth process to help them cope better with current and future problems. „ Client-centred therapy views the client as being in a state of incongruence and there is a difference between the way they are and the way they want to be. E.g. the person with SUD may want to be recognised for his skills and contribution but SUD related damages prevent this. „ By providing a safe environment, the therapist helps them explore the full range of their experience and deal with it. In the counselling environment, the client feels understood, accepted and safe and is able to : y View self, others and their situation more accurately y Recognise conflicting and confusing feelings y Understand parts of themselves which they had previously ignored y Understand and accept others. A  THEORETICAL BASE OF COUNSELLING 91 „ Applied to crisis situations (e.g. an illness or a disaster) being heard and understood increases calmness, helps them think clearly and make better decisions. This also helps motivate people to do something to resolve the crisis. Role of therapist „ The personal characteristics of the therapist and the quality of the client therapist relationship were seen as signi!cant factors for effective outcome. „ In this approach the attitude of the therapist was considered as the most effective and only tool necessary for therapy. „ The three qualities that the therapist needed to possess are: 1. Congruences: (Genuineness): The inner experience and outer expression match and counsellor can openly express their thoughts, feelings, reaction and attitude. Counsellors do not present a false front (pretend) and being genuine builds trust. 2. Unconditional positive regard (acceptance and caring). The counsellor does not judge or express opinion about the ‘good or bad’ of the client’s feelings, thoughts or behaviour. It is one of accepting the client as he is. So clients are free to express themselves without risking the loss of acceptance by the counsellor. This acceptance is based on recognition of the client’s right to have certain feelings or behave in a particular way. It does not mean that it is approval of all behaviour. 3. Accurate empathetic understanding: (ability to understand the world of client). This involves: Š Understanding the client’s experiences Š Being sensitive to the feelings and Š Ability to identify the feelings experienced by the client This encourages the clients to get in touch with their feelings and recognise their situation. A 92 CHAPTER 3 Strengths and challenges „ Meeting someone who is truly able to listen and understand may present a truly healing experience for many clients. „ The approach can be applied in variety of cultural settings and can be used in many treatment settings. „ Carl Rogers showed great willingness to subject his approach to research. An extensive body of research reflects the effectiveness of this therapy with a range of client and age groups. However, the research methodology has been criticised by some theorists. „ During group counselling, using these techniques create an atmosphere wherein people can appreciate and trust themselves and others. This nondirective approach points out that interpretation by a therapist in a group can make members self conscious and slow down the process. Instead it should come from clients themselves because groups are fully capable of expressing and working towards their own goals. „ The approach has been criticised on certain counts: y When clients approach for help to deal with a crisis or cope with everyday problems, they expect a structured approach and a directive counsellor. This approach may not meet their needs. y Clients may be uncomfortable with direct expression of empathy or disclosure that is an essential part of this approach. y The focus on individual autonomy and personal choices may be uncomfortable for people from a collectivistic cultural background. They may focus more on what is good for the community or family and the common good than on individual choices. y The emphasis on the qualities of the counsellor is a challenge. Rogers believed and reported research !ndings that showed that greater the levels of caring and accepting behaviours, better the chances of success in therapy. Such a strong focus on the personal qualities of a counsellor can be a barrier. y Moreover, the fact that the approach supports clients without being challenging may limit the effectiveness of the intervention. A  THEORETICAL BASE OF COUNSELLING 93 4. Gestalt therapy Background „ Frederick S. Perls, usually referred to as Fritz Perls (1893 to 1970) was the chief contributor of the Gestalt therapy. However, it was his wife Laura Posner Perls (1905 – 1990) who is credited for developing the approach through her consistent efforts through the New York Institute for Gestalt Therapy. „ As a psychiatrist with training in psychoanalysis, Fritz Perls was influenced by the psychoanalytic concepts. However, his approach differed signi!cantly. „ Perls’ work with brain damaged soldiers helped him recognise the need to understand people in their entirety. Perls took a holistic view of the personality and believed that dealing with the present was more important than the past. He also stressed that it was essential for clients to understand ‘what they were doing and how instead of tracing the roots of the problem and understanding ‘why’. „ ‘Gestalt’ is a German word for ‘whole’. The term referred to ‘a form that cannot be separated into parts without losing its essence’. Gestalt therapists deal with all aspects of a person - thoughts, feelings, behaviours, body movements, memories and dreams. One aspect was not treated as being more important than the other. Even gestures and tone of voice are signi!cant forms of expression and it was important to understand it in relation to the rest of the person. View of human nature and therapeutic intervention „ Gestalt therapy works based on the understanding that people are ultimately in control of their lives and need to accept responsibility for their growth. „ People also have the capacity to change when they become aware of what is happening in and around them. „ ‘Building awareness’ is the core issue in Gestalt therapy. „ Helping clients recognise their contact with what was happening in and around them was important. Therapy focussed on ‘re-owning’ parts of themselves that they have disowned. „ Unacknowledged feelings need to be brought to the level of awareness and resolved. If not this ‘un!nished business’ would interfere with functioning and lead to physical sensations or problems. „ In therapy, clients were helped to get in touch with the sensations within their body as well as their thoughts, feelings, images, memories etc. Clients are helped to recognise A 94 CHAPTER 3 the level of contact with the external environment – seeing, hearing, behaving etc. Increasing awareness helps clients make informed choices and live meaningfully. „ When people accept all parts of themselves without judging or denying, they can lead meaningful lives. „ Gestalt therapy’s focus is on: y Here and now y What and how y I – thou of relating Š Focusing on the past or future was seen as a barrier to understanding and dealing with the present. Gestalt therapy focused on the present. For example if the client talked about his feelings about an incident that happened earlier, he would be encouraged to become aware of his feelings now and at the present when talking about the incident. The client may be encouraged to enact the past incident as if it was taking place now. Š ‘What and how’ aspects were explored and the ‘why’ was not the focus. The therapist may ask the client ‘What are you experiencing now?, How are you experiencing the feeling? etc. Š The nature of relationship between the client and therapist was important in this process of change. Role of therapist „ By directing the process of therapy, the therapist creates an environment that helps clients increase awareness, make their own interpretations and decide how they will act on it. „ The therapist functions as a guide and catalyst, presents experiments to increase awareness and shares observations to help the client change. „ Three stages of integration sequence described by Miriam Polster (1987): 1. Discovery: Realisation about themselves or a new point of view of a situation or of a relationship 2. Accommodation: Recognising that they have a choice and try new behaviours 3. Assimilation: Based on the changes that have taken place, the client changes the way he deals with issues in the external world. „ The therapist supports the client in this process by: A  THEORETICAL BASE OF COUNSELLING 95 y Paying attention to body language: Noticing clenched !st may prompt the therapist to ask, “If your hands could speak, what would they say?’ y Encourage ‘I’ statements y Inviting the client to present statements instead of stating their thought in a question form (e.g. I wonder if I am being unnecessarily anxious...) y Staying sensitive to metaphors and explore it further. For example, if the client says, “I feel crushed” the therapist may ask ‘Who is crushing you? What are your feelings now? etc. „ Gestalt therapy uses experiments as tools to increase awareness, bring out emotions or encourage action. Some are presented below: y The empty chair technique: People often need help to deal with two aspects of their personality. The client is invited to sit on a chair and play the part of the ‘top dog’ and talk like the authoritarian, demanding and critical parent part of themselves. Next, the client plays the ‘underdog’ role in which the helpless, weak and passive part comes in to play. The technique helps the client get in touch with feelings and different aspects of themselves. y In other experiments, the person may be asked to imagine a situation they may encounter in future, role play by being the parent, doing something that is the opposite of what they usually do etc. y The client may be encouraged to stay with the feeling and experience it deeply in order to be able to experience it rather than avoid it y In dream work, the client plays the part of every person or event in the dream to recognise the issues involved. „ Developing a trusting relationship with the client, recognising their cultural issues and preparing the client are of course important. Strengths and challenges „ Gestalt is especially useful in helping people get in touch with conflicting feelings within themselves. „ The focus is on growth and enhancement and the belief that people strive for self actualisation and does not view them as being sick or pathological. „ Gestalt therapy can be engaging and lively for clients. „ It is possible to apply these techniques in group settings too. „ Research studies have demonstrated the effectiveness of the approach with variety of groups including substance use. A 96 CHAPTER 3 „ Emphasising personal responsibility for growth can be particularly useful in a SUD treatment setting. The focus of getting in touch with feelings to help client think clearly can be of great help to clients in recovery. The empty chair technique can help clients resolve issues of ambivalence. „ Gestalt therapy can be used in variety of cultures because it can be tailored based on the individual. However, open expression of feelings and rehearsing to discuss conflicts with parental !gures may be inappropriate in some cultures and needs to be handled carefully. Some issues of concern are: „ Gestalt approach focuses on building awareness and facilitates client’s own process of recovery. The therapist does not play the role of a teacher to take the process further. „ Experiments can invoke strong feelings and when used by a therapist with inadequate training the effects can be painful and disastrous. Empathy and respect to the client is extremely important and without it can easily turn into situation where there is an abuse of power by the therapist. „ A great level of training and supervision is required to implement this approach. „ Moreover, therapists need to have a high level of personal growth to play their role appropriately. This restricts application of this approach. 5. Behaviour therapy Background „ In this approach the focus is on changing observable behaviour, identifying current influences on the behaviour and developing an intervention to promote change. „ Initially, the focus on this group of therapies was only on behaviour and later on cognition or thinking was also incorporated. „ Initially, behaviour therapy was developed based on principles related to: 1. Classical conditioning 2. Operant conditioning 3. Social learning theory Each of these three approaches is discussed below. „ These three approaches explained how behaviour was shaped or developed. However, from the 1970’s, the importance of cognition (thoughts and beliefs) was recognised and cognitive elements were included into therapy. A  THEORETICAL BASE OF COUNSELLING 97 „ The distinction between behaviour therapy and cognitive therapy is less in today’s practice and therapy addresses behaviour as well as cognition. Today, the term ‘cognitive-behaviour therapy’ has largely replaced ‘behaviour therapy’ (Corey G, 2009). „ Behaviour therapy is also referred to as behavioural modi!cation. This approach believes that behaviour is learnt and therefore can be unlearned or changed by altering the factors that influence behaviour. „ Classical conditioning was illustrated by Ivan Pavlov through experiments with a dog. In Pavlov’s experiment, a dog salivated to the smell and sight of food. The salivation is a natural or unconditioned response to food. Unconditioned Stimulus (UCS) Unconditioned Response (UCR) (Smell of food) (natural) (Salivation) Over time any individual or object associated with the Unconditional Stimulus (UCS) can bring about the same response as if exposed to the UCS. This is called as a Conditioned Response (CR). In Pavlov’s experiment, the food was presented after ringing a bell. This was repeatedly done and over a period of time the dog started salivating at the sound of the bell. In this situation, the bell is the Conditioned Stimulus (CS) and the dog’s salivation was the Conditioned Response (CR). Unconditioned Stimulus (UCS) Conditioned Response Bell + (Smell of food) (CR) (salivation) Conditioned Response LATER Conditioned Stimulus (CS) (Bell) (CR) (salivation) By the same principle if the bell rang (CS) but no food was provided over a period of time the dog stopped salivating to the sound of the bell. Classical conditioning showed that based on what was already learnt, one could create the same response by pairing the stimulus with another stimulus. „ Operating conditioning showed how behaviour is learnt by the consequences that follow. y If the behaviour was reinforced (rewards are available), it increases the behaviour. A 98 CHAPTER 3 y Using a system of rewards and punishments, behaviour can be shaped. y B. F. Skinner (1904-1990) is credited for developing behaviour therapy approaches based on operant conditioning. y Behaviour therapy utilises: Š Reinforcements to increase target behaviour Š Punishments to decreases target behaviour a) Positive reinforcement – something of positive value is provided (money, praise, food etc.) to increase or strengthen the behaviour. b) Negative reinforcement – something of negative value is removed and this encourages the person to display desired behaviour. Here wanting to escape or avoid the negative stimuli influences behaviour. For example: the !ne that was imposed earlier is not collected on account of good performance. c) Extinction: By withholding (not giving) the reinforcement previously received, the behaviour that was maintained earlier reduces. For example, if the parent gave what the child wanted after a temper tantrum, the behaviour is reinforced by the parent. If the parent does not give the chocolate bar even after the tantrum, this will eliminate the behaviour through the extinction process. d) Punishment or aversive control as a consequence of the behaviour results in decrease of the behaviour. Punishment can be positive or negative: - Positive punishment: The aversive or unpleasant stimulus is given after the unwanted behaviour to reduce the frequency of the unwanted behaviour (e.g. !ne imposed after driving over the speed limit). - Negative punishment: A reinforcing or positive stimulus is removed to discourage unwanted behaviour (e.g. the child is not permitted to watch television because the household duty was not done). „ Skinner was opposed to use of punishments and recommended using reinforcements to encourage behaviour change. He believed that punishment does not teach lessons and can be used only after use of reinforcements have been tried. „ Social learning approach was developed by Albert Bandura (1925) wherein the role of observing and learning through role modelling was presented as a important factor in shaping behaviour. The approach which was named as Social Learning Theory was later renamed as Social Cognitive Theory. A  THEORETICAL BASE OF COUNSELLING 99 View of human nature and therapeutic intervention „ In the earlier forms of behaviour therapy, behaviour was seen as a result of or product of the stimulus they were exposed to. In the present days, the role of the individual in influencing the environment is also taken into consideration. „ In behaviour therapy: y Treatment goals are identi!ed and speci!cally stated. y Assessment is conducted to decide which behaviour to change. y Functional assessment is carried out using the A, B, C model wherein the behaviour (B) is influenced by: A – Antecedent events (that is what happened before) and C – Consequences that maintain behaviour. Functional assessment is sometimes referred to as behavioural analysis. „ The focus is on the current problem and influencing factors rather than issues in the past that may have lead to the problem behaviour. „ Goals are discussed and agreed upon with full involvement of the clients. „ Clients are active participants in therapy. Homework assignments, role plays during sessions are basic part of the approach. Learning new behaviours is viewed as a core aspect of therapy. „ Developing insight is not a goal in behaviour therapy. On the other hand behaviour change may lead to a better understanding of the problem. „ Treatment interventions are tailored for each individual. Even for similar problems, different behaviour techniques may be used. „ Behaviour therapy involves monitoring and evaluating the change. When the technique used is not leading to desired change, the therapist chooses another one. Role of therapist: „ The therapist chooses techniques based on the assessment and treatment plan developed in partnership with the client. „ The ability to establish a collaborative working relationship, skill in applying a wide variety of behaviour techniques, monitoring progress made during treatment and maintaining follow-up are considered important tasks. „ Factors such as warmth or empathy are considered necessary but are not emphasised as much as in other approaches. A 100 CHAPTER 3 „ Some of the behaviour techniques are: y Relaxation: The patient is taught to tighten muscles in different parts of the body, experience the tension and relax the muscles. By repeating this daily the client learns to maintain a relaxed position. This is often used in combination with other techniques. y Systematic desensitisation: The therapist identi!es and ranks aspects that make a person anxious and creates a hierarchy. The client is helped to handle the situation that is least anxiety provoking and moves on to other difficult situations. This technique is helpful to treat phobias, asthmatic attacks, insomnia etc., y In Vivo exposure: The person is exposed to situations in the presence of the therapist and learns to handle it. y Social skills training such as assertion training etc., y The therapist’s role is that of a teacher focusing on development of speci!c skills through instruction, modelling and performance feedback. Strengths and challenges: „ Behaviour therapy has generated research based evidence of its effectiveness. As assessment of treatment outcomes is part of the therapeutic approach, behaviour interventions have been more rigorously assessed than any other approach. „ The time duration for therapy is short compared to other approaches. „ The involvement of the clients in every stage of therapy is another strong point. „ It has been used with clients of different cultural backgrounds. „ In SUD treatment, clients can be helped to identify what reinforced substance use, understand how faulty learning and imitation may have influenced substance use. „ Behaviour techniques commonly used in SUD treatment !eld include: y Contingency management with rewards for abstinence and other behaviour changes. y Assertiveness training to develop skills needed to avoid relapses. y 12 steps group approaches that provide positive role models for recovery. Some issues of concern are: „ It has been pointed out that behaviour therapy may change behaviours but not feelings. Critics of this approach often caution that the person may adopt a different negative behaviour as a result. A  THEORETICAL BASE OF COUNSELLING 101 „ The approach does not recognize the role of feelings or building insight and treats the symptoms rather than the causes. „ Behaviour therapists may not recognise the challenges involved in making the change. Changing behaviours can sometimes have negative consequences. E.g. being assertive with family members may bring forth negative reactions in some cultures. 6. Cognitive-behaviour approaches Background „ Cognitive-Behaviour Therapy (CBT) combines cognitive and behavioural principles. „ CBT has been used in variety of settings and groups and has generated more amount of research evidence than any other approach. „ The core idea in CBT is that: y Thought disturbances lead to psychological distress y By changing thought patterns one could change feelings and behaviours. „ The theoretical basis of these approaches is similar. All emphasise: y Collaborative relationship with the client y Cognitive disturbances are cause of distress and need to be altered to bring about changes in affect and behaviour y Time limited and structured approach to therapy. „ In this section, speci!c therapies based on CBT principles are discussed: i) Rational Emotive Behaviour Therapy (REBT) developed by Albert Ellis who is referred to as the ‘grandfather of cognitive-behaviour therapy’. ii) Cognitive therapy was developed by Aaron Beck. iii) Cognitive-behaviour modi!cation was by Donald Meichenbaum. „ All the therapies focus on the present, are directive, problem oriented, and make use of homework assignments. A. Rational emotive behaviour therapy (REBT) „ REBT is considered to be the parent of many cognitive-behavioural approaches. Albert Ellis, the developer of this approach acknowledges the contribution of others such as Greek philosophers, neo-Freudians and especially Adler who focused on goals, purpose of life and values. A 102 CHAPTER 3 „ People have the potential for rational as well as irrational thinking. Helping people recognise and alter their irrational thought patterns is a core issue in REBT. View of human nature and therapeutic intervention „ Irrational beliefs are learnt during childhood. By repeatedly doing things based on these beliefs, it becomes a part of their thought processes. Ellis believed that there are three irrational ‘musts’ that lead to symptom development: y I must do well and win others approval or else I am no good. y Others should treat me kindly and in exactly the way I want them to treat me. If they don’t, they are no good and must be condemned. y I must get what I want, when I want it and I must not get what I don’t want. Otherwise it is a terrible situation and I can’t stand it. „ These ‘should and musts’ create emotional disturbance. „ Blame is seen as the core of most emotional responses and must be stopped. „ Ellis emphasised that we need to accept ourselves as creatures who will make mistakes and we need to be more accepting of ours as well as other’s negatives. „ REBT theory and practice is based on the ABC frame work. y A - Activating event y B - Belief (beliefs, emotions and behaviour) y C - Emotional and behavioural consequences or reactions that could be healthy or unhealthy. Ellis emphasise that the event (A) does not lead to the consequence (C). Instead it was our belief (B) that led to negative feelings or behaviour. Though initially B was only seen as being a belief, later on Ellis recognised the emotional and behavioural elements and added it to the concept of B or belief. As B is the central element altering it in therapy is the focus. For example: „ There may be an event (A) such as losing a job which is seen as the trigger for the person feeling depressed. Depression (C) is the consequence but A (loss of job) does not automatically lead to C. „ REBT emphasises the belief (B) is part of the picture and it is this belief that influences the way the event (A) is viewed. If the person believes that the loss of job shows that he is a failure or that he is worthless, this leads to depression as a consequence (C). A  THEORETICAL BASE OF COUNSELLING 103 „ On the other hand, if the loss of job is viewed with a different set of beliefs such as ‘these things happen and I can !nd another one’, it would be less likely to lead to depression as a consequence. In terms of intervention, D (disputing the belief ) could lead to E (effective philosophy) which would create a healthy new set of F (feelings). It is emphasised that: y One should accept that we are largely responsible for our emotional problems. y We have the ability to change. y Recognising that our irrational beliefs are the cause of symptoms is important. y Identifying these beliefs and making efforts to change our beliefs that lead to feelings and dysfunctional actions is essential. A (Activating event) B (Belief ) C (Consequence) (Disputing intervention) D E (Effect) F (New feeling) Role of therapist: „ The REBT therapists accept clients unconditionally and help them accept themselves and others. Ellis stated that the two main related goals of REBT was to help clients achieve: y Unconditional Self Acceptance (USA) and y Unconditional Other Acceptance (UOA). „ On the other hand, Ellis believed that too much of warmth and acceptance expressed by the therapist interfered with therapy. He also believed that people have the ability to change. „ REBT therapists are often open and willing to share their own imperfections and establish an equal, nonthreatening relationship with the client. „ The therapist uses variety of techniques that may be focussed on the cognitive, emotional or behaviour aspect. Some are described below : A 104 CHAPTER 3 „ Cognitive methods: y Disputing irrational beliefs: The therapist actively questions the client repeatedly to reduce the intensity. E.g. The therapist may ask, ‘Why must everything go right for you?’. By helping the client raise questions such as ‘How can I become a total failure just because I lost a job? and so on may help the client view the situation differently saying, “It is sad that I lost my job but it is not the end of the world”. y Doing cognitive home work: Home work assignments help the client track the ‘shoulds and musts’ of their internalised messages and apply the ABC model. y Changing one’s language: Clients are taught to replace ‘shoulds and musts’ with preferences. ‘E.g. It would be preferable if people treated me with respect’ y Psycho education methods: Providing information, books or CDs that describe REBT approaches are also helpful. „ Emotive techniques: y Rational Emotive Imagery: Clients are helped to imagine the worst thing that could happen to them. Later, they are helped to experience the feelings and imagine themselves thinking, feeling and behaving differently. By repeatedly doing this they are able to function in a healthy manner in real life. y Role playing, using humour to show the absurdity (foolishness or funny side) of the situation and shame attacking exercises wherein the person risks doing something that they would not normally do (singing loudly on the street etc.) „ Behavioural techniques: y Relaxation, modelling etc. B. Cognitive therapy Background „ Aaron T. Beck developed Cognitive Therapy around the same time as Ellis developed REBT. Though both developed their approaches independently, Cognitive Therapy (CT) shares many techniques with REBT. „ The CT’s focus is on recognising and changing negative thoughts and maladaptive beliefs. „ The goal is to change automatic thoughts and restructure them. This is done by encouraging clients to gather evidence in support of their belief. A  THEORETICAL BASE OF COUNSELLING 105 Basic principles of CT „ Automatic negative thoughts interfere with the way people view reality and these cognitive distortions influence behaviour. Some examples are listed below: y Arbitrary inferences: making conclusions without evidence. (e.g. student telling oneself that she will not be able to understand concepts in the training, fail in the exam, people at work and home will be upset etc. even when the programme has just started). y Selective abstraction: ignoring other pieces of information and focussing only on one or few incidents that did not go well (e.g. not doing well in one test and not taking into consideration her other strengths such as her good performance in other tests, her experience in the !eld etc.). y Overgeneralisation: making a decision based on one incident (e.g. not having good marks in one test means that she will not do well in any of the others tests too). y Dichotomous thinking : looking at situations in extremes (e.g. if she did not get a high score, it means it is a failure - passing does not count) „ Clients are helped to identify the distorted, dysfunctional thoughts and test these by examining the evidence for these inferences. „ These thoughts reflect the rules that people live by and when these rules are inappropriate it affects their beliefs and interfere with the way they think. These beliefs need to be examined and altered. For example, when people see themselves as inadequate, they interpret situations in a negative way and by projecting these into the future; they tell themselves that things are going to be difficult. They do not expect things to change and this adds to their negative mood state. „ Clients are often asked questions related to these beliefs. (e.g. Where is the evidence for....?). By repeatedly asking these questions, and carrying out home work assignments based on these assumptions, clients understand how these thoughts influence their actions. „ The client learns ways to modify these negative thought patterns and engage in more realistic ways of thinking. A 106 CHAPTER 3 Role of therapist: „ The therapist develops a case conceptualisation to understand how clients view their world. This is done by helping clients to describe their thoughts, feelings, behaviour and about the environment. „ This case conceptualisation provides a structure and focus to the therapy. „ CT believes in engaging the client in all stages of therapy from identifying thoughts, summarising their understanding and designing homework assignment. The level of involvement of client contributes to the long-term impact of therapy. „ The therapist establishes a warm, empathetic and collaborative relationship with the client. Socratic dialogue (questions that help the client think) is largely used. E.g. What would happen if you try to do? How do you know that it is useless to even try? „ The therapist functions as a catalyst and a guide who stays actively involved in the process of identifying and changing thoughts and beliefs. „ Home work may be provided with graded tasks doing the easier one !rst and gradually attempting more difficult ones. „ CT has extensive research based evidence of effectiveness especially in relation to depression. The short-term focus and cost effectiveness are strengths of this approach. C. Cognitive-behaviour modification (CBM) by Donald Meichenbaum „ CBM focuses on self-talk (statements) that affect the person’s behaviour. „ While REBT and CT focus on maladaptive thoughts, CBM focuses on clients becoming aware of their self-talk (instructions they give to themselves). „ Cognitive restructuring (changing the pattern of thinking) is important. „ CBM can be understood as a process that takes place over three phases: y Phase 1: Self-observation: clients are helped to become aware of negative self statements and images they carry in their minds. Becoming more sensitive to their feelings and behaviour, they understand how their self-talk influences them. y Phase 2: Starting a new internal dialogue with the help of the therapist. By changing the talk, they are able to change their thought patterns. y Phase 3: Learning new skills. They learn how to behave differently in real life situations and because of this others also react to them differently. A  THEORETICAL BASE OF COUNSELLING 107 „ The stories people tell about themselves and important events in their lives are used to help clients understand how they view reality and how it can be viewed differently. On completion of therapy the same technique can be used to evaluate outcome. Is the client able to describe himself differently, does he take credit for the changes made etc., may be some of the aspects that are considered. „ Coping skills programme developed using this approach has been used with many problems including SUD and stress disorders. Here, role playing and imagery is used to help clients recognise their level of anxiety, the link with their thoughts and changing these by altering their self statements. „ Stress inoculation training was developed using the CBM approach. y The clients are helped to understand the nature of stress and the role of thoughts in creating and maintaining stress. y The therapist may provide information, use Socratic questioning and help clients understand the stress in terms of the environment. y By monitoring their internal statements and the dysfunctional behaviour that follow the statements that they make to themselves, clients become aware of their own role in creating stress. y The therapist helps them understand their fears about stressful situations, learn ways to handle their stress by doing something different and learning how to relax. The clients may also learn time management, ways to develop their social skills etc. Strengths and challenges of the cognitive approaches: „ The empirical evidence that the approach works is a signi!cant strength. „ The structured approach and involvement of the client demysti!es therapy and helps the client understand the process of change. „ The shorter duration and focused approach makes it appealing to clients. „ The involvement of clients and making them responsible for the direction of therapy is a positive aspect of this approach. „ As cognitive-behaviour therapy approaches are based on understanding the client’s beliefs, it can be easily applied in different cultures. „ REBT’s focus on independence can be difficult to use with clients from cultures that value interdependence. „ Cognitive therapy has been criticised for being too technique oriented and focusing only on eliminating the symptoms without understanding the underlying causes. A 108 CHAPTER 3 „ Moreover, in these approaches emotions or feelings are not dealt with in detail and the focus is on cognition and behaviour. 7. Reality therapy Background „ William Glasser (b.1925) is largely credited for this approach. Glasser worked on the ‘Control Theory’ developed by William Powers which emphasised that clients accept responsibility for their behaviour. Later, by working on it for about 10 years, he developed the ‘Choice Theory’. „ Reality therapy is based on this ‘Choice Theory’. „ Robert Wubbolding extended the practice of reality therapy and made the ‘Choice Theory’ more practical and usable. „ ‘Choice Theory’ explains ‘why and how’ people function in a particular way and reality therapy describes the intervention by which people can be helped to take control of their lives. View of human nature and therapeutic intervention „ ‘Choice Theory’ states that we are born with !ve needs that drives our lives. y Survival y Love and belonging y Power or achievement y Freedom or independence y Fun. „ When one or more of these needs are not met, we are in pain and try to !nd ways to feel better. „ All of us have a mental picture of what we would like to have and the ways by which we want to satisfy these needs. We choose to behave in a way that will give us control over our lives and meet these needs. The client may choose a behaviour that is dysfunctional. „ Reality therapist’s belief that the underlying problem of most people lies in the fact that they are in unsatisfying relationships. People choose behaviours to deal with the frustration that arises out of poor relationships. A  THEORETICAL BASE OF COUNSELLING 109 „ Glasser believed that anxiety, depression or any other mental disorder are only behaviours that people choose to deal with problems in relationships. „ The goal of reality therapy is to help people ful!l their needs by providing with them tools to make the changes they desire. The focus is on what can be done rather than on what cannot be done. „ Glasser believed that for people to change they need to be: y Convinced that the present behaviour is not getting them what they want and y Choose other behaviours that will get them closer to what they want. „ Wubbolding used the acronym WDEP to describe the key tasks involved: y W – Wants: Clients are helped to discuss their wants and hopes y D – Direction and doing: The key question may be ‘what are you doing’ y E – Evaluation: Asking clients to examine if what they are doing is getting them closer to what they want y P – Planning and action: Identifying ways to ful!l their wants and needs. Role of therapist: „ Reality therapists teach clients to evaluate their present situation, examine effectiveness of choices and emphasise that they are totally in control. The core idea that they convey to the client is that ‘The only person you can control is yourself’. „ The focus in therapy is on the present as needs can be satis!ed only in the present. If the client talks about the past, the therapist would listen to it only for a short period of time and focus on what can be done now. Reality therapists often tell clients that more the time one spends in looking back, the more we avoid looking forward. „ Reality therapists do not spend time on discussing the symptoms or even the feelings associated with it. These are seen as ways to avoid focussing on the current, unhappy relationships. „ The therapist functions like a teacher and mentor. Reality therapists are gentle but !rm and focus on issues at hand. The questions raised by the therapist may appear challenging but help clients to evaluate the choices they have made. For example: ‘Is what you are doing getting you closer to the person?’. „ Therapist functions with optimism and deals with clients ‘as if’ they have choices and manages to convey that there is hope. A 110 CHAPTER 3 Strengths and challenges: „ The WDEP system can be easily adapted to group counselling. „ In reality therapy, focus is on helping clients examine their lives, evaluate for themselves and choose ways that can help them achieve their needs. This focus on the client’s choices helps reduce resistance in both individual and group settings. „ The focus on doing something about it rather than the focus on insight alone are positive aspects of the approach. „ In SUD treatment settings emphasising personal choice and control works well. Underlying the fact that the only person they can change is themselves is a very important and useful message for clients as well as their families. „ The positive orientation of the therapist about what can be done and that people can change is strength of this approach. „ Being able to provide clients with tools to change during the relatively short-term therapy is another strength of this approach. Some issues of concern are: „ Even though the approach seems simplistic, applying it with clients can be challenging. „ The lack of focus on building insight and influence of the past are seen as drawbacks. „ Reality therapy also does not value the positive effect of expressing feelings and the therapeutic value of catharsis is underplayed. „ Glasser’s view that all mental disorders are chosen behaviours is of concern. Especially with depression, conveying the message that they are choosing to be depressed can add to their guilt. „ There are aspects in life over which one has no control. Some of the limitations may be cultural and issues such as gender imbalance and power issues can restrict choices. Moreover issues like racism etc., are also challenges that cannot be over looked. 8. Solution-focused brief therapy (SFBT) Background „ Steve de Shazer was the !rst to consider the solution-focused approach. Solution- focused brief therapy was developed in collaboration with many other therapists including Insoo Kim Berg. „ Apart from SFBT there are many other solution-focused therapies. „ The common ingredients are discussed here. A  THEORETICAL BASE OF COUNSELLING 111 Key concepts „ Solution-focused therapies focus on the present and future and not on the past. This approach believes that tracing the cause of problems is not necessary because solutions are not related to causes of problems. Moreover, multiple solutions may be available for a problem and what works for one person may not work for the other. „ Diagnosis or history taking is not emphasised. „ SFBT focuses on where people are and helps !nd solutions. This is done by focusing on parts of their lives that are going well rather than focusing on the problem parts of their lives. „ Four steps of SFBT: y Finding out what the client wants. y Look for what the client is already doing and which works well. y If what the client is doing is not working, encourage them to try something different. y Keep therapy brief; expecting each session to be the last. „ Importance is given to help clients de!ne their goals. Goals are stated positively, are focused on doing something about it and structured in the ‘here and now’. The solutions are identi!ed by the client and achievable. „ The goal can be focused on changing the way one views the situation, changing the way one contributes to the problem development or by using client’s strengths and resources to alter the situation. „ Some of the techniques used by solution therapists are: y Pre-therapy change: Just making an appointment is seen as a positive shift. The therapist may ask, ‘What have you done since you made the appointment that has made a difference to your problem?’. This helps the client focus on what they have already done well and brings into focus their own resources to deal with the problem. y First session talk: The SFBT therapist on the very !rst session asks the client to observe things that they enjoy or would like to continue. This is discussed in the second session. This increases the sense of hope and helps the client look at the positives and invites them to build on it. y Exception questions: The therapist asks for situations from the client’s life which were different – the problem did not exist, the problem was not so intense or it was avoided. This opens the possibility of the identifying solutions. This is often referred to as ‘change talk’. A 112 CHAPTER 3 y Miracle question: This is SFBT’s main technique. The therapist asks ‘If a miracle happened and the problem had been solved overnight, how would you know that it was solved and what would be different?’ This helps the client shift the ways the problem is viewed, thinks about future possibilities and starts thinking about life in which the problem is not present. y Scaling questions: Clients are asked to assess the level of their problems on the scale of 0 to 10 and asked to look at where they stand as of now. This helps client assess where they are and what they can do to make the change they desire. y Feedback to clients: Every session ends with the feedback of about 5 to 10 minutes. The summary has three parts: Š Complements about what the client is already doing to solve issues. Š Bridge that links the complement to the tasks or homework that will be given. Š Suggestion about what the client can do. The client may be asked to do something or observe some aspects of their life. y Terminating: Therapists frequently asked scaling question to monitor progress. The therapeutic relationship is terminated when client is able to !nd a solution. Clients are helped to identify things they would like to continue and additional help is made available whenever needed. Role of therapist: „ The therapist plays a major role in helping people shift from the problem focused view to a solution-focused one and see the future with new possibilities. „ SFBT believes that people have a capacity to change and that small changes make way for larger changes. „ The client is the expert of what will work for him. The therapist does not play the role of an expert. Walter and Peller (2000) even discouraged the use of the word ‘therapy’ and suggested that they see the therapist as offering ‘personal consultation’. „ The therapist makes a lot of effort to build the collaborative relationship based on respect, trust, open discussion and hope. This is seen as a critical component for therapy. Strengths and challenges: „ SFBT emphasises the positive, the resources and strengths rather than the negatives. „ The techniques of SFBT can be used in individual as well as group settings. A  THEORETICAL BASE OF COUNSELLING 113 „ SFBT is a practical, cost effective approach. „ By focusing on strengths rather than pathology the client is helped to draw on their resources and initiate changes. „ SFBT techniques can be valuable to help clients in recovery from SUD. 9. Family therapy „ A family system is the unique interaction and relationship of family members to one another. „ Each family operates like a system. Each family is made up of individuals who are constantly influencing each other through their interactions. „ The growth and development of the family is based on the interaction between its members and with other systems in the environment such as schools, work places, religious houses, government etc. There are four important aspects in a family system. „ Structures which refer to the way the family system is organised or put together. „ Process which describe family interactions and communication patterns. „ Stability refers to the level of consistency to ensure a predictable pattern of functioning. „ Change refers to the flexibility or the ability or the family to change and function differently. „ Families develop their own structures to maintain stability. „ Structural aspects of the family in family systems approach: y Roles: What a person does in the family? (Bread winner, cooking and cleaning, disciplining etc.). y Rule: Rights and wrongs of behaviour (respecting elders, returning home before 8 pm, etc.). y Routines & Rituals: What happens when and how? (dinner time, festivals or celebrations). y Hierarchy: The power structure (parents have more power and are higher in the hierarchy than the children). y Boundaries: Invisible barriers that regulate the level of contact with the other (the parents as a subsystem have a boundary with the children, neighbours are seen as ‘others’ while family members are seen ‘us’). A 114 CHAPTER 3 „ A healthy family system maintains a balance between stability and change. „ Families establish structures such as rules and roles that provide a predictable pattern of functioning. This provides stability and protects the family system because too much of change can lead to chaos. „ On the other hand, resisting change makes the family stagnant and interfere with growth and development. For example, the adolescent needs autonomy and rules which were imposed on him when he was a younger child can no longer be applied. Functional families and dysfunctional families: „ Functional families have ability to respond to changes and adapt even if there is a crisis. On the other hand, dysfunctional families are unable to do so. „ Functional families operate out of love, care, respect, and concern for each other. They are able to function in a stable manner. In event of some disturbance or crisis they are able to solve problems and make decisions. All the members are interdependent and work together with cooperation. „ The family members are able to communicate with each other and when there is a difference of opinion they are able to negotiate or disagree without fear of rejection or losing the relationship. „ Functional families have adequate levels of closeness and emotional dependence on each other. In dysfunctional families when boundaries are too rigid, members move away from each other, become detached and lose trust. When boundaries are enmeshed, they become too close and suffer a loss of individual identity. „ When a family member has a substance use disorder, the family system changes because all of its elements and functions are affected. In families with SUD, the members may not be able to satisfy their needs as they focus all of their attention on the member who is addicted. „ On the other hand, substance use may also be symptomatic of dysfunction in the family. SU problems may emerge as a response to problems in the family. For example: y The adolescent who is unable to develop an individual identity as an adult may start using substances. y The couple may use alcohol to express themselves freely and alcohol use becomes part of their problem solving repertoire which gradually evolves into problematic use. A  THEORETICAL BASE OF COUNSELLING 115 „ Even if the person who is using substances accesses treatment and becomes abstinent, the family system may continue to be dysfunctional. The family members may be unable to change even when it is needed. Family members may have difficulty living joyfully, even though the family members has stopped using substances. „ There are many forms of family therapy such as couple and marriage therapy, Bowen’s family therapy, Structural family therapy, Strategic family therapy etc. „ In family therapy, the family as a unit is treated as the client and the focus is on changing the way the family works which will in turn alter substance use. Family therapists also emphasise ‘process’ , the way in which issues are presented or dealt with rather than only the content of what, where , how etc. Codependency: „ Being in a close relationship with a dysfunctional person can lead to development of codependency traits. „ ‘Being overly concerned with problems of another to the detriment of attending one’s own wants and needs’ is viewed as codependency (CoDA). „ The codependent person displays extreme and often inappropriate attention to the needs of another. This term was initially used to describe spouses of alcohol dependents and was later used in connection with other problems too. „ Wegscheider - Cruse described !ve dysfunctional codependency roles from a systems perspective. Each member in the family played a speci!c role and by playing these roles each family member helps to maintain the family balance. „ People with codependency may take on dysfunctional roles such as: y Enabler: Often this role is played by the codependent spouse. The enabler protects the family member from the negative consequences of their substance use and unknowingly supports continuation of substance use. The person protects the person with an addiction, makes excuses for others especially the substance user and tries to keep everyone happy. The person gives the impression that everything is okay in the family. The enabler feels helpless and inadequate as they are unable to stop the person from using substances and lives in fear and anxiety. y Family Hero (responsible child): This person takes on responsibilities for others in the family and is achievement oriented. By planning, organising and generally taking charge, the person tries to make life more comfortable. The hero tries to be successful, to be good and to help the family. He tries to ignore the problem and do things for others or achieve something. In spite all the efforts there are underlying feelings of fear, guilt, and shame. A 116 CHAPTER 3 y Mascot (placater) plays the ‘peace maker role’ in the family and tries to distract family members from the painful reality often with humour. This entertainer in spite of the appearance of being happy carries a lot of shame and anger. y Lost child (adjuster) decides not to make any demands and remain unnoticed in the family system. This is the silent family member. The person is lonely, feels neglected, carries a lot of anger or guilt. y Scapegoat or the acting out child displays dysfunctional behaviour such as getting into !ghts, breaking rules etc., in order to gain some attention. This person is sometimes seen as the problem in the family. The scapegoat often has unexpressed feelings of shame, guilt, and emptiness. y Except the ‘enabler role’ which usually refers to the spouse, children in families affected by SUD, play the roles of hero, mascot, lost child or scapegoat. 10. Brief therapy „ Brief therapy is not a speci!c theoretical approach and may be based on a variety of approaches which are delivered in a shorter period of time. „ Cognitive-behaviour approaches, solution-focused therapy, family therapy etc., have been adopted and delivered as brief therapy. „ Compared to longer term therapy, brief therapy: y Deals with the present problem y Does not focus on the root cause of the problem y Emphasises use of tools to be able to bring about change in a shorter period of time y Focuses on bringing about speci!c behavioural change rather than large scale changes. „ In SUD treatment, short-term therapies have been shown to be as effective as the lengthier ones. „ Brief therapy is usually delivered within 6 – 22 sessions. „ Brief therapy is not suitable for all clients. Clients who are more likely to bene!t from therapy are clients with : y Short duration of problem substance use and y Support or strong ties with family, work or community. A  THEORETICAL BASE OF COUNSELLING 117 „ Some clients access brief treatment instead of other long-term programs because of lack of !nancial resources, inability to stay in treatment for longer periods, lack of access to other programmes because of long waiting lists or medical or mental health conditions. „ The effectiveness of brief therapy depends on : y The level of skill of therapist y Comprehensive assessment y Selection criteria to identify clients who are likely to bene!t from treatment. „ Components of brief therapy: a) Screening and assessment to : Š Understand range and severity of problems Š Assess suitability of client for brief therapy Š Select appropriate goals and needs in therapy Š Identify areas wherein referrals would be required. b) Maintenance strategies providing education about SUD related issues including relapse, developing a plan to deal with high risk situations, using personal strengths, strengthening motivation and developing an after care or follow up plan. c) Termination is planned in advance and carried out when the agreed upon changes have been made even if the agreed upon number of sessions have not been completed. A 118 CHAPTER 3 References: Corey G, Theory and Practice of Counselling and Psychotherapy, Eighth Edition, Thomson Brooks, CA, 2009. Treatment for Substance Use Disorders – The Continuum of Care for Addiction Professionals, Trainer Manual, The Colombo Plan International Centre for Credentialing and Education of Addiction Professionals Training Series, draft version 2015. Family Therapy - history, theory and practice by Gladding S.T, 2007. Erik Erikson’s Psycho-Social Stages of Development,http://socialscientist.us/nphs/psychIB/ psychpdfs/Erikson.pdf Erikson’s Stages of Psychosocial Development www.siskiyous.edu/class/ece3/ eriksonsstagesthroughidentity.pdf downloaded December 2014. Working with families with substance use disorders, The Colombo Plan’s International Centre For Certi!cation And Education Of Addiction Professionals (ICCE), Intermediate Level Curriculum, Universal Treatment Curriculum, 2015 (in print). Brief Interventions and Brief Therapies, Treatment Intervention Protocol No.34, Substance Abuse and Mental Health Services Administration (SAMHSA), Centre for Substance Abuse Treatment, US Department of Health and Human Services, 2004. A