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1 Go to the following web site and read the Principles of Effective Treatment:

1 Go to the following web site and read the Principles of Effective Treatment: www.drugabuse.gov/PODAT/podatindex.html In your own words, describe the thirteen principles of effective treatment.

2 Read the in-service training packet for TIP 35 located in Module Notes. Answer the following questions: How might training like this help you in developing effective counseling skills? Why is motivational counseling so important? What was the most important aspect of this training program to you?

3 Go to the following web site and read one of the articles (sections) in Approaches to Drug Abuse Counseling:http://archives.drugabuse.gov/ADAC/ADAC1.html State which article you read, and then write a 300 word summary of the article in your own words.

4 In your module notes or workbook, we discuss 10 different counseling techniques. Pick three that you like, or feel are effective, and do the following for each: State which technique it is, and who the key figure(s) are; What do you see, based on the facts given, as the pros and cons of this therapy; and How do you see this technique working with an alcoholic client?

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Module Five

Overview of Counseling Techniques

 

This module will focus on counseling theories, and basic techniques and principles of individual and group counseling.  The counseling theories to be discussed include: Psychoanalytic, Adlerian, Existential, Person-Centered, Gestalt, Reality, Behavior, Cognitive-Behavior, and Transactional Analysis.  The information on counseling theories has been taken from Gerald Corey’s books: Theory and Practice of Counseling and Psychotherapy Fourth and Fifth Editions, published by Brooks/Cole.  Definitions of key terms and concepts for this module can be found at the end of the module/lecture notes.  In reviewing the major counseling theories it is important for you to realize that few counselors subscribe to only one model or theory, instead most counselors have developed an eclectic approach to counseling, using a variety of techniques and philosophies from several of the theories, adjusting as needed for the individual client.

 

Psychoanalytic Therapy

 

Key Figures

 

Psychoanalysis was originated by Dr. Sigmund Freud and is based on a deterministic philosophy.  One cannot study counseling theories without spending some time studying Psychoanalytic; for it is the foundation upon which most counseling theories are formed.  While psychoanalysis is not used extensively in its pure form in counseling individuals with substance use disorders; terms and concepts from it are.  We have discussed earlier the role of denial in creating client resistance to treatment, denial is a defense mechanism, an understanding of defense mechanisms is one of the major contributions of psychoanalysis.

 

Key Concept

 

According to Freud, normal personality development is based on successful resolution and integration of the psychosexual stages of development.  Inadequate resolution of these developmental stages results in a number of different problems, depending on what stage the individual is fixated at.   Freud envisioned that the personality is divided into three systems: the id, ego and superego.   The id which is the original system of the personality is child like, and is ruled by the pleasure principle.  The second system is the ego.  This system is the regulator of the personality, it is ruled by the reality principle and is the seat of intelligence and rationality, helping to keep the id under control.  The third system is the superego.  This is the judicial branch of the personality, it represents the ideal rather than reality, constantly striving for perfection.  The superego’s role is to inhibit the id and convince the ego to substitute moralistic goals for realistic ones.

 

One of Freud’s greatest contributions to counseling is his concept of the existence of the unconscious.  According to Freud, much behavior is motivated at the unconscious level.  While the unconscious cannot be studied directly there are a number of behavioral indicators of its existence such as slips of the tongue, and selective forgetting.  Other information can be gathered from therapeutic techniques such as free association, hypnosis, and dream analysis.  Anxiety is seen as a function of repressed threatening material.  Ego defense mechanisms are an unconscious protective devise which helps to prevent the ego from being overwhelmed by anxiety.

 

Ego Defense Mechanisms

 

Acting-out:  Behaviors that originate on an unconscious level to reduce anxiety and tension.  Anxiety is displaced from one situation to another in the form of observable behavioral responses (e.g., anger, crying, or violence).  The person acts without reflection or apparent regard for negative consequences.

 

Blocking:  A sudden obstruction or interruption in the spontaneous flow of thinking or speaking that is perceived as an absence or deprivation of thought.

 

Conversion:  The unconscious transfer of anxiety to a physical symptom that has no organic cause.

Adaptive use:  Before taking a math exam, a young girl develops a headache.

Maladaptive use:  A girl develops an inability to speak in the context of protecting a sexually abusive father.

 

DenialBlocking painful or anxiety – producing aspects of reality out of consciousness.  Reality is either completely disregarded or transformed so that it is no longer threatening.  A mechanism in which the person fails to acknowledge some aspect of external reality that would be apparent to others.

Denial generally operates as a healthy mechanism, protecting the individual from the immediate shock of reality.  In time, denial usually diminishes and the person gradually begins to face, accept, and deal with the harsh realities.  Sometimes, however, denial is directly harmful to the individual, as when a man or woman refuses to see that they have a drinking or drug problem.  In such cases, the motivation for the client’s behavior should be assessed.

Adaptive use:  A child insists his mother is not dead, just “out of town for a few days.”

Maladaptive use:  A woman with a chronic drinking problem refuses to see the roll her drinking is having on her job performance, despite numerous warning from her boss.

 

DevaluationThe individual deals with emotional conflict or stress by attributing exaggeratedly negative qualities to self or others.

 

Displacement: An individual transfers an emotion or feeling from the actual object that aroused those feelings to a less dangerous or threatening substitute.

A person angry with a supervisor at work or school may feel too threatened to confront that individual with his anger; instead, he may go home and vent his anger on a family member.  The person who displaces feelings usually has no awareness of doing so.  Later, however, he may look back on the events and realize that, because he was angry with someone he could not comfortably express his feelings with, he took it out on someone safer.  Clients may express inappropriate anger to the counselor when they are actually angry at someone or something else.  Displacement differs from projection in that people who use displacement are not distorting their feelings and attributing them to someone else.  The feelings are clear, and the person acknowledges them.  They are simply being directed at the wrong person.

Adaptive use:   A child directs hostility toward a parent to a teacher.

Maladaptive use:  A man is verbally or physically aggressive toward all authority or oppressive figures.

 

Dissociation:  Threatening thoughts or feelings are put out of conscious awareness before they are able to trigger overwhelming and intolerable anxiety; similar to repression.

 

Fantasy:  Is a form of non-rational mental activity that enables the individual to escape temporarily the demands of the everyday world.  Fantasy may offer temporary relief from pressures, but people who spend too much time in fantasy may be unable to meet the requirements or reality.

Adaptive use:  A housewife faced with a sink full of dirty dishes dreams she has a live-in maid.

Maladaptive use:  A woman lives in a fantasy world and makes no effort to tend to her basic needs.

 

Identification:  A person unconsciously adopts the personality characteristics, attitudes, values, and behavior of another person.  It represents a turning away from the individuals own personality.  One specific manifestation of identification is passiveness in relationships.  Identification can be seen in clients who rely heavily on the counselor’s guidance and support.  They expect that all their needs will be met and that nothing will be expected of them.

Adaptive use:  A teenager changes her hairstyle to that of an idolized rock star.

Maladaptive use:  A teenager imitates socially unacceptable or harmful behavior.

 

IntellectualizationA person uses his intellectual powers of thinking, reasoning, and analyzing to blunt or avoid emotional stress.  Intellectualization is the process of separating the emotion aroused by an event from ideas or opinions about the event because the emotion itself is too painful to acknowledge.  The painful emotion is avoided by means of a rational explanation that divests the event of any personal significance.  Failures are made less significant by telling oneself that the situation could have been worse.

Intellectualization resembles rationalization in that it provides a verbal means of dealing with anxiety.  Its use closes off the possibility of accepting and working out problems.  Clients often use intellectualization at the onset of a crisis, and the need for this defense may decrease in a supportive counselor – client relationship.

Adaptive use:  A man who has recently lost his wife, is asked to share his feelings.  He reviews all the stages of death and dying as identified by Kubler-Ross.

Maladaptive use:  A client goes in to a long dissertation on the meaning of life, when in fact he is considering suicide.

 

Isolation of AffectThe individual deals with emotional conflict or internal or external stressors by the separation of ideas from the feelings originally associated with them.  The individual loses touch with the feelings associated with a given idea (e.g., a traumatic event) while remaining aware of the cognitive elements of it (e.g., descriptive details).

 

Passive Aggression:  The individual deals with emotional conflict or internal or external stressors by indirectly and unassertively expressing aggression toward others.  There is a facade of overt compliance masking covert resistance, resentment, or hostility.  Passive aggression often occurs in response to demands for independent action or performance or the lack of gratification of dependent wishes but may be adaptive for individuals in subordinate positions who have no other way to express assertiveness more overtly (e.g., behavior includes lateness, forgetting, “mistakes,” and obtuseness.

 

ProjectionAttributing to others characteristics and feelings that one does not want to admit are one’s own.  Projection is an unconscious means of dealing with personal difficulties or unacceptable wishes by seeing them in others.  The individual blames other people for their own shortcomings or sees others as harboring their own unacceptable feelings or thoughts.

People who make excessive use of projection tend to attribute to others hostile or seductive motives that do not actually exist.  This prevents them from forming trusting and reciprocal relationships.  A tendency toward projection may also interfere with problem solving.

Adaptive use:  A woman criticizes a neighbor for being a terrible gossip when in fact the woman herself gossips.

Maladaptive use:  A man blames his family for his alcoholism.

 

RationalizationThe individual substitutes acceptable reasons for the real or actual reasons motivating behavior. Through rationalization, a person justifies behavior or conceals disappointments.  Rationalization helps to avoid social disapproval and to bolster flagging self-esteem.

Many people use rationalization because they wish to prove to themselves or others that their actions are governed by reason and common sense-even though they may not fully understand the reasons for their own behavior.  Such explanations may be essential to maintain personal integrity.  They are not destructive as long as they do not prevent one from solving everyday problems.  Clients may use rationalization to soften the blow of accepting responsibility for their addiction.  Counselors must respect their client’s need to rationalize fears and insecurities they cannot face.  However, counselors must hold out to clients the possibilities for change.  Counselors can help clients face the reality of their situation by encouraging them to explore ways they can change to deal with it more effectively.

Adaptive use:  A student who fails an exam because she didn’t study says that the teacher didn’t cover the material in class.

Maladaptive use:  A man always gives reasons for not attaining his goals and refuses to accept self-responsibility for not achieving them.

 

Reaction Formation: An individual acts in a way that is the opposite of how he feels.  Reaction formation is a defense where undesirable impulses are kept out of awareness by emphasizing their opposite.  Hostility may be concealed behind a facade of love and kindness.  The desire to be sexually promiscuous may be concealed behind a moralistic demeanor.  People who use this defense are not conscious of their true feelings.

Reaction formation can be useful.  It can help us maintain socially approved behavior and avoid awareness of desires that are not socially acceptable.  But his defense, too, results in self-deception, because it is not under conscious control.  It may result in exaggerated or rigid behaviors that leave the individual ill equipped to deal with crisis.

Adaptive use:  A woman shows great interest and concern for her mother-in-law, whom she dislikes.

Maladaptive use:  A young woman is always unnaturally sweet and loving and is unable to consider the possibility of being angry.

 

RepressionThe individual unconsciously excludes distressing emotions, thoughts, or experiences from awareness.  Repression is the basis of all defense mechanisms, it is the dynamic behind much of “forgetting”.  From the individual’s point of view, a repressed memory is “forgotten” and cannot be deliberately brought to awareness.

Adaptive use:  A young woman who was raped and was brought to the outpatient clinic by her roommate says she feels very anxious but cannot remember the events of the past few hours.

Maladaptive use:  A woman excludes a number of events from memory.

 

Splitting:  The individual deals with emotional conflict by compartmentalizing opposite affect states and failing to integrate the positive and negative qualities of the self or others into cohesive images.  A primitive defense in which the individual sees themselves or others as all good or all bad.

 

Sublimation: The individual transforms unacceptable sexual or aggressive drives into socially acceptable pursuits.

Adaptive use:  A young man who is very competitive and aggressive uses this energy to become a pro-football player.

Maladaptive use:  A pro-football player spends all of his time working out or at football practice, and he has no time left to spend with his family.

 

SuppressionAn individual consciously excludes certain thoughts or feelings from his mind.  This is the only defense mechanism that operates fully on a conscious level.  It is an intentional act that helps to keep thoughts, feelings, wishes, or actions that cause anxiety out of conscious awareness.    Clients may refuse to consider their difficulties by saying that they “don’t want to talk about it” or that they will “think about it some other time”.

Adaptive use:  A student “forgets” to bring his books home to do his homework.

Maladaptive use:  A man files his income tax return late and has to pay a penalty.

 

UndoingAn act or behavior unconsciously motivated to make up for or negate a previous act or behavior (e.g., bringing the boss a present after talking about him unfavorably to other coworkers).

 

References for the ego defense mechanisms:

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; 1994.

Foundations of Psychiatric Mental Health Nursing, Second Edition; 1990.

Psychiatric Nursing, Fourth Edition; 1992.

 

Basic Philosophies

 

Human are basically determined by psychic energy and early experiences.  Unconscious motives and conflicts are central in determining present behavior.  Irrational forces are strong and the person is driven by sexual and aggressive impulses.  Early development is of critical importance, because later personality problems have their roots in repressed childhood conflicts.

 

Goals of Therapy

 

The primary goal of therapy is to make the unconscious conscious and to reconstruct the basic personality.  The function of the therapist is to assist clients in reliving earlier experiences and working through repressed conflicts, thus gaining intellectual awareness.

 

The Therapeutic Relationship

 

The therapist reveals very little of themselves to the client so that the client can project unconscious material onto them.  Clients undergo long-term analysis and engage in free association to uncover conflicts, and gain insight by talking.  The therapist makes interpretations to teach the client the meaning of current behavior as related to the past.

 

Techniques of Therapy

 

The key techniques of this theory include: interpretation, dream analysis, free association, analysis of resistance, and analysis of transference.  All are designed to help clients gain access to their unconscious conflicts, which leads to insight and eventual assimilation of new material by the ego.  Diagnosis and testing are often used.

 

Application of the Approach

 

Psychoanalytic therapy is not recommended for self-centered and impulsive clients or for clients who are severely impaired by psychosis.  The techniques of psychoanalysis can be applied to both individual and group therapy.

 

Contributions of the Approaches

 

More than any other theory, this approach has generated controversy.  It has provided a detailed and comprehensive description of personality structure and functioning.  It has placed an emphasis on the  unconscious as a determinant of behavior and the role of trauma during the first six years of life.  It has developed techniques for tapping into the unconscious, and it  has contributed the therapeutic use of transference and the concepts of countertranference, resistance, anxiety, and ego defense mechanisms.

 

Limitations of the Approaches

 

This particular theory requires lengthy training for therapists and much time and expense for clients.  “The model stresses biological and instinctual factors to the neglect of social, cultural, and interpersonal ones.  Its methods are not applicable to clients in lower socioeconomic classes and are not applicable for many ethnic and cultural groups.  Many clients lack the degree of ego strength needed for “transference neurosis” therapy.  It is inappropriate for the typical counseling setting” (Corey, 1996).

 

One of Freud’s contributions was his theory of human development.  While the Psychosexual Theory of Development is still studied Erik Erikson’s Psychosocial Stages of Development, modeled after Freud’s but expanding on the concepts of psychosocial theory is more widely accepted today.

 

Erickson’s Eight Stages of Development

 

Stage Age Central Task Indicators of Positive Resolution Indicators of Negative Resolution
Infancy Birth to 18 months Trust versus Mistrust Learning to trust others Mistrust, withdrawal, estrangement
Early Childhood 18 months to 3 years Autonomy versus Shame & Doubt *Self-control without loss of self-esteem

*Ability to cooperate and to express oneself

*Compulsive self-restraint or compliance

*Willfulness and defiance

Late Childhood 3 to 5 years Initiative versus Guilt *Learning the degree to which assertiveness and purpose influence the environment

*Beginning ability to evaluate one’s own behavior

*Lack of self-confidence

*Pessimism, fear of wrongdoing

*Over control and over restriction of own activity

School Age 6 to 12 years Industry versus Inferiority *Beginning to create, develop, and manipulate

*Developing sense of competence and perseverance

*Loss of hope, sense of being mediocre

*Withdrawal from school or peers

Adolescence 12 to 18 years Identity versus Role Confusion *Coherent sense of self

*Plans to actualize one’s abilities

Confusion, indecisiveness, and inability to find occupational identity
Young Adulthood 18 to 25 years Intimacy versus Isolation *Intimate relationship with another person

*Commitment to work and relationships

*Impersonal relationships

*Avoidance of relationships, career or life-style commitments

Adulthood 25 to 65 years Generativity versus Stagnation Creativity, productivity, concern for others Self-indulgence, self-concern, lack of interest and commitments
Maturity 65 years to death Integrity versus Despair *Acceptance of worth and uniqueness of one’s own life

*Acceptance of death

Sense of loss, contempt for others

Sources: Adapted from E. H. Erikson, Childhood and Society, 2nd Ed. (New York: W.W. Norton and Co., 1963.

Adlerian Therapy

 

Key Figure

 

Alfred Adler was a major contributor to the development of Psychoanalytic theory, but broke with Freud to further develop the concept of the social and cultural factors which contributed to the development of the individual.  Adlerian therapy is a  growth model, it stresses taking responsibility for ones live, creating one’s destiny, and finding meaning and goals to give life direction.

 

Basic Philosophies

 

A positive view of human nature is stressed.  Adler believed that humans are motivated by social interest, by striving toward goals, and by dealing with the tasks of life.  People are in control of their fate, not victims of it.  Each person at an early age creates a unique style of life, which tends to remain relatively constant throughout life.

 

Key Concepts

 

The approach emphasizes the individual’s positive capability to be a contributor to society.   People are motivated by social interest and by finding goals to strive for.  Therapy is a matter of providing encouragement and assisting clients in changing their cognitive perspective.

 

Goals of Therapy

 

The primary goal of therapy is to challenge the client’s basic thoughts and goals, to offer encouragement so they can develop socially useful goals.

 

The Therapeutic Relationship

 

The emphasis is on joint responsibility, on mutually determining goals, on mutual trust and respect, and on equality.  A cooperative relationship is manifested by a therapeutic contract.  Focus is on examining lifestyle which is expressed by the client’s every action.

 

Techniques of Therapy

 

Adlerian’s draw from many techniques, a few of which are paraphrasing, providing encouragement, confrontation, interpretation, gathering life history data (family constellation, early recollections), therapeutic contracts, and  homework assignments.  Using genograms, which will be discussed in a later module is a technique drawn from the study of family constellations.

 

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