IntroductionTIC

Evolution of Counseling/Therapy Model

Psychodynamic – Freud and beyond Cognitive-behavioral (60’s, 70’s, 80’s) Systems approaches Outcome-oriented brief therapy

approaches- managed care models- these approaches have an ecological perspective.

Ecological Model

Person can not be fully understood unless influences of larger systems taken in to account.

Culture, race, religion, sexual orientation, class, race, ethnicity...(see Okun, Figure1.1,page 2 and Table 1.1, page 7- Ecological Intake Sheet)

Client/Therapist Woes

Can you name some of stressors clients are facing in the 21st Century culture?

Can you name some of stressors therapists are facing in servicing clients in the 21st Century culture?

Ecology, Managed Care and DSM-IV

Managed Care companies define “medical necessity” in terms of “global level of functioning”— Is the individual able to function in social and work environments (Axis V).

MC is also concerned with the psychosocial stressors faced by client (Axis IV).

MC will ask on treatment request forms whether you are utilizing community resources, whether you have contacted PCP, medications client is taking… (biopsychosocial perspective)

• MC company is concerned about interrelationship of client and environment

Some of the Ways Counselors Help?

Diagnose/assess and refer, if necessary Offer symptom relief Engage in psychoeducation Restructure faulty, self-defeating beliefs Help develop realistic goals Teach communications skills Increase tolerance of differences…In other words, we are professional helpers

Success as a Professional Helper-

Helper w/ graduate level training.

What makes helper successful? Okun mentions these three factors

I. Empathy

II. Awareness of Personal Values

III. Comfort in Applying Techniques

What’s More Important-Strategies or Relationship

To a degree, the answer is dependent on the approach. Why?

Okun makes an interesting point (page 21)

Reciprocal Model of Relationship Vs. Strategies- Pedoto

• Personal view- I agree that a robust relationship creates a tolerance for the failure of certain strategies.

• However, expert use of strategies also enhances the relationship (i.e. successful use of strategies gives the client a sense that I care about his/her well-being and am working hard to assist them).

Okun’s Three Dimensional Model of Helping Process

Model provides a broad conceptual perspective of three integrated dimensions which essentially describe what constitutes effective helping (pages 23-25).

Dimensions

I. Relationship/Strategies/Strategies

II. Communications Skills

III. Values Clarification/ethical matters

Beck and Ellis

Beck developed s/term tx for depression in 1960’s (CBT). Beck is a psychiatrist.

Expanded tx model to encompass many other mental disorders.

Ellis started RT in the mid-50’s. Was disenchanted w/ Psychoanalysis. Ellis was a sex therapist early on. Obtained Ph.D. and went to Karen Horney Institute in NYC.

Cognitive TherapiesMajor Principles of Helping Theory

REBT Clients need to take responsibility for their own upset

and own fates. People are influenced by biological and environmental

conditions, not controlled by them. Thought/beliefs processes mediate emotions- problems

caused by irrational beliefs not events. People are inborn with tendency toward both rational and

irrational thinking.

REBT

People are susceptible to social conditioning and they learn to re-indoctrinate or teach themselves to become more and more irrational. They refuse to accept reality, and insist on having things their way-the way things should be. Philosophical change is needed.

Active-directive form of therapy is needed to uproot irrationalities (disputing, in-vivo behavioral work…other homework)

Ellis Postulates A B C Theory Employs cognitive, emotive and behavioral techniques.

CBT Helping Theory

Therapist needs to focus on systematic errors in reasoning and restructure (information processing model).

Negative automatic thoughts disrupt one’s mood. Leads to spiraling down…

Distorted reasoning based on systematic logical errors.

Therapy is an active process (eliciting self-talk/interpretations, gathering evidence against interpretation, setting up experiments-homework)

CBT

Therapist enters “collaborative” relationship w/ client.

The therapy is very structured following an agenda typically starting w/ review of HW and ending w/ summary

Case Exerpt

•Read Case Excerpt- p.3-4, Beck book

CBT-General Principles

1)Formulate problem in cognitive terms:

What aspects of client’s current thinking acts to maintain problematic emotions and behaviors?

*Therapist might also be concerned w/ precipitating factors (context)- what environmental events might have influenced perceptions

CBT-Principles

*CBT and other cognitive therapist would also be interested in developing hypotheses about key developmental events and enduring patterns of interpreting these events.

Example: early childhood loss of father and tendency to deal poorly with later loss.

partner.

CBT Principles

2) Therapy requires a sound alliance

Warmth, caring, genuine regard…

How is this shown…

• Listening closely

• Empathizing

• Accurately summarize thoughts and

emotions

CBT Principles

3) Collaboration and active participation-

*Encourage client to view therapy as

teamwork

*Assign work between sessions

*Over time, give client more responsibility to

direct session.

CBT Principles

4) Cognitive Therapy is goal-oriented and problem-focused

• Client encouraged in initial session to develop a problem list

• Set specific goals of a behavioral nature-lonely- develop new friendships-develop plan, set HW

• Identify thoughts interfering w/goal(s)

Principles-CBT

5) Present focused- here-and-now emphasis at first…want to reduce symptom stress.

Attention shifts to past when a) client expresses strong desire, b) work on present problems produces little change in cognitions, emotions, behaviors, c) important dysfunctional ideas developed in the past (If I always do well, I am ok…if I don’t do well I am a turd)

Principles-CBT

6) Cognitive therapists aim to educate the person so that they can be their own therapist (self-help) using the techniques learned in therapy.

7) Therapy is intended to be time-limited (4-14 sessions) however this is not always possible.

8) CBT and cognitive therapy is structured.

CBT-Principles

9) Cognitive therapy teaches clients to identify, evaluate, and respond to their dysfunctional thoughts and beliefs

• The most basic question is to ask, “What was going through your mind when ____.”

In other words, “What were you telling yourself.”• Then evaluate the validity of the thought via Socratic

Questioning…where is it written that what you told yourself is true…and even if it were true, is it really as bad as you tell yourself (REBT).

• CBTer’s use collaborative empiricism- helping determine accuracy and utility of an idea…REBT uses disputing

CBT-Principles

• Cognitive therapists use a variety of change techniques to help people *cognitive- Socratic Questioning, Downward Arrow Technique, Thought Records

*emotive- rational-emotive imagery, empty chair

*behavioral experiments, in-vivo HW

CBT Principles

10) Cognitive Therapists vary their techniques to meet the needs of the individual client (see Beck pages 9-10).