Tag Archives: CBT

The Evidence Base for Psychoanalytic Therapies: It Just Might Be Better Than You Think

Sunset 2019In recent days there’s been a bit of a kerfuffle on Twitter regarding the relative efficacy of psychoanalytic and cognitive-behavioral therapies (CBT). Of course, the standard mantra in the media and among many mental health professionals is that the science shows that CBT is superior and the treatment of choice for many, if not most, mental and emotional problems. Well, as is often the case in life and psychotherapy, reality is much less clear.

This post isn’t about fake news or alternative facts. Instead, I hope it’s about a balanced perspective. As a psychotherapist-counselor-professor-clinical psychologist, I like to think I don’t have an allegiance to any single therapy approach. Although I know I can’t claim perfect objectivity, I do have a broad view. One factor that has helped me have a broad view is that I read lots of professional journal articles in order to be able to write my theories of counseling and psychotherapy textbook.

Below, I’ve inserted an excerpt from the end of the psychoanalytic chapter of our textbook. Whether you’re a CBT or psychoanalytic fan, or perhaps a fan of a different approach, I hope you find this short review of psychoanalytic treatment efficacy interesting. The bottom line for me is captured by an old quotation from Freud (who wasn’t known for his flexible thinking). Purportedly, he said, “There are many ways and means of conducting psychotherapy. All that lead to recovery are good.” I might add the following to Freud’s comment: There are many different clients with many different problems and many different individual and cultural perspectives. I’m convinced that most clients are best served if therapists tweak their approaches to fit the client, rather than expecting the client to fit into narrow clinical procedures based on pure (or rigid) theoretical perspectives.

Here’s the excerpt . . .

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Conducting rigorous research on longer-term treatments, such as psychoanalytic therapy, is challenging and cost prohibitive. Psychoanalytic approaches are often less symptom- or diagnosis-focused, seeking instead to facilitate client insight and improve interpersonal relationships. Because empirically supported treatments focus on whether a specific psychological procedure reduces symptoms associated with a medical diagnosis, “proving” the efficacy of complex therapy approaches is difficult—especially when compared to the lesser challenges inherent in evaluating symptom-focused treatments. Partly because of these complexities, some reviewers contend that psychoanalytic psychotherapies are less efficacious than cognitive and behavioral therapies (Busch, 2015; Tolin, 2010).

The good news for psychoanalytic therapy fans is that evidence is accumulating to support treatment efficacy. The less good news is that some of the research support remains methodologically weak and the wide variety of psychoanalytic approaches makes it difficult to come to clear conclusions. Nevertheless, the most recent meta-analytic studies, literature reviews, and individual randomized controlled studies support the efficacy of psychoanalytically oriented therapies for the treatment of a variety of mental disorders. According to Leichsenring, Klein, and Salzer (2014), there is empirical support for the efficacy of psychoanalytic psychotherapies in treating:

  • Depressive disorders.
  • Anxiety disorders.
  • Somatic symptom disorders.
  • Eating disorders.
  • Substance-related disorders.
  • Borderline personality disorder.

The evidence for the efficacy of psychodynamic approaches for depressive disorders is strong. In a recent meta-analysis, Driessen and colleagues (2015) evaluated 54 studies, including 3,946 patients. They reported that short-term psychodynamic psychotherapy (STPP) was associated with improvements in general psychopathology and quality of life measures (d = 0.49–0.69) and all outcome measures (d = 0.57–1.18); they also noted that patients continued to improve at follow-up (d = 0.20–1.04). Further, no differences were found between STPP and other psychotherapies. On anxiety measures, STPP appeared significantly superior to other psychotherapies at post-treatment (d = 0.35) and follow-up (d = 0.76).

In a previous meta-analytic review, Shedler (2010) also concluded that psychodynamic therapies were equivalent to “. . . other treatments that have been actively promoted as ‘empirically supported’ and ‘evidence based’” (p. 107). He also reported that psychodynamic therapies had more robust long-term effects.

Table 2.2 provides a sampling of meta-analytic evidence supporting psychodynamic therapies. For comparison purposes, the original meta-analyses conducted by Smith and colleagues are included (Smith & Glass, 1977; Smith et al., 1980). Notably, Smith, Glass, and Miller reported that psychodynamic approaches were significantly more efficacious than no treatment and approximately equivalent to other therapy approaches.

Table 2.2 also includes the average effect size (ES or d; see Chapter 1) for antidepressant medications (ES = 0.31 for serotonin-specific reuptake inhibitors or SSRIs). This comparison data shows that psychodynamic psychotherapy is more effective than SSRI treatment for depression. Additionally, the benefits of psychoanalytic therapy tend to increase over time (Driessen et al., 2015; Shedler, 2010). This implies that psychoanalytic psychotherapy clients develop insights and acquire skills that continue to improve their functioning into the future—which is clearly not the case for antidepressant medication treatment (Whitaker, 2010). One of the ways psychotherapists explain this difference in longer term efficacy is with the statement: “A pill is not a skill.”

Table 2.2 A Sampling of Psychodynamic Psychotherapy Meta-analyses

Authors Outcome focus Number of studies ES or d
Abbass et al. (2009) General psychiatric symptoms 8 0.6
Anderson & Lambert (1995) Various 9 0.85
de Maat et al. (2009) Long-term treatment 10 0.78
Driessen et al. (2015) Depression 54 0.57–1.18
Comparison research
Turner et al. (2008) Meds for Major depression 74 0.31
Smith et al. (1977) Different therapies 375 0.68
  Many problems    
Smith et al. (1980) Different therapies 475 0.75
  Many problems    

Note: This is a sampling of meta-analytic psychoanalytic psychotherapy reviews. We’ve omitted several reviews with very high effect sizes partly because of criticisms related to their statistical methodology (see Driessen et al., 2015, and Shedler, 2010, for more complete reviews). This table is not comprehensive; it’s only a reasonable representation of psychoanalytic psychotherapy meta-analyses.

We recommend you take the preceding research findings (and Table 2.2) with a grain of salt. Conducting systematic research on something as subjective as human mental and emotional problems always includes error. One source of error is the allegiance effect (Luborsky et al., 1999). The allegiance effect is the empirically supported tendency for the researcher’s therapy preference or allegiance to significantly predict outcome study results.  Luborsky and colleagues (1999) analyzed results from 29 different adult psychotherapy studies and reported that about two thirds of the variation in outcome was accounted for by the researcher’s theoretical orientation (e.g., psychoanalytic researchers reported more positive outcomes for psychoanalytic therapy and behavior therapists discovered that behavior therapy was more effective).

The implications of the allegiance effect help explain why, shortly after Shedler’s (2010) publication extolling the virtues of psychodynamic psychotherapy, several critiques and rebuttals were published (Anestis, Anestis, & Lilienfeld, 2011; McKay, 2011). The critics claimed that Shedler’s review was biased and accused him of overlooking weaknesses within the meta-analyses he reviewed (e.g., poor outcome measures, pooling the effects of small samples with little power and poor designs, lack of treatment integrity effects). Although Shedler’s critics raised important points, the critics themselves had their own biases. The problem is that all researchers (and writers) have an allegiance of one sort of another.

One of our favorite ways of understanding the allegiance effect is articulated in a story about the great New York Yankee baseball player, Yogi Berra. One day, when a player on Yogi’s team was called out on a close play at second base, Yogi went charging on to the field to protest. The umpire explained that he, unlike Yogi, was an objective observer and that he, unlike Yogi, had been only about 5 feet from the play, while Yogi had been over 100 feet away, in the dugout. When Yogi heard the umpire’s logic, he became even angrier and snapped back, “Listen ump, I wouldn’t have seen it, if I hadn’t believed it” (adapted from Leber, 1991).

The “I saw it because I believed it” phenomenon is also called confirmation bias (Masnick & Zimmerman, 2009; Nickerson, 1998). Confirmation bias involves seeking, interpreting, and valuing evidence that supports pre-existing beliefs, while ignoring and devaluing evidence contrary to preexisting beliefs. Consequently, psychoanalytically oriented individuals see support for their perspective and behavior therapists see support for theirs. However, despite these caveats, based on accumulating research, psychodynamic approaches have a reasonably good record of efficacy.

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Although this particular review has many limitations, I’m convinced that most of us, most of the time, are better off following the advice of Marvin Goldrfried (and others) and focusing on the common therapeutic factors, or, as Norcross calls a subset of common factors, empirically-supported relationships.

For more information, check out Goldfried’s recent article on obtaining consensus in psychotherapy:  https://www.stonybrook.edu/commcms/psychology/_pdfs/clinical/Goldfried%20AP%20Consensus%20AP.pdf

 

Alfred Adler All Day Long

alfred adler photo small

It’s too bad, but IMHO we don’t ever seem to take enough time to celebrate the ideas and deeds of Alfred Adler. If, by chance, you’re not sure who the heck I’m talking about, then I’ll take that as validation of my point. Who was Alfred Adler? . . . sadly, that’s a question many people can’t answer.

Today, April 4, 2019, I’m doing a webinar on the similarities and distinctions between Alfred Adler’s “Individual Psychology” (aka Adlerian therapy) and cognitive-behavioral therapy. Most people who study these things, including Albert Ellis, recognize that Adler’s work was ahead of his time and much of what he wrote about can be considered foundational to cognitive therapy. Staunch Adlerians sometimes put it more dramatically when they say, “In the beginning, there was Adler.”

Today’s webinar has inspired me to renew my efforts to spread the gospel of Alfred Adler. If you read this blog regularly, you know I’ve done this before. You can read some of my previous Adler posts by clicking here: https://johnsommersflanagan.com/tag/adler/

Today, I feel like I’m taking the lazy way out. But Adler would likely correct me. He didn’t much believe in the word lazy. Instead, Adler would reformulate lazy as discouraged, or more specifically, in this, and many cases (think of your children, perhaps), what appears to be laziness is a function of having goals and aspirations that are beyond one’s reasonable skills and available time. I think that could be the case here. Although I’d like to shower you with lots of new and exciting Adlerian information, instead, I’m posting the first five pages of the Adlerian chapter of our Counseling and Psychotherapy theories textbook. Here it is . . . five pages of the start of a chapter that only begins to describe the life and work of the amazing Alfred Adler.

Chapter 3: Individual Psychology and Adlerian Therapy

We often wonder about Alfred Adler. Who was this man whose theories and approach predate and contribute substantially to ego psychology (Chapter 2), the cognitive therapies (Chapter 8), reality therapy (Chapter 9), feminist therapy (Chapter 10), and constructive perspectives (Chapter 11)? How did he develop—over 100 years ago—influential and diverse ideas that are foundational to so many different approaches to therapy, and so thoroughly infused into contemporary culture? His beliefs were so advanced that he seems an anomaly: He’s like a man from the future who landed in the middle of Freud’s inner circle in Vienna.

Introduction

Despite the ubiquity of Adler’s ideas, many contemporary mental health professionals don’t recognize, acknowledge, or appreciate his contributions to modern counseling and psychotherapy (Carlson & Englar-Carlson, 2017). Perhaps this is because Adler provided services for working class people, rather than the wealthy elite; or because he was an early feminist; or because his common sense ideas were less “sexy” than Freud’s.

What is Individual Psychology? (. . . and what is Adlerian Therapy?)

Individual psychology was the term Adler used to describe the psychotherapy approach he founded. Watts and Eckstein (2009) recounted Adler’s rationale for choosing the name Individual Psychology: “Adler chose the name individual psychology (from the Latin, individuum, meaning indivisible) for his theoretical approach because he eschewed reductionism” (p. 281).

Most people know individual psychology as Adlerian therapy, the contemporary applied term. Adlerian therapy is described as “a psychoeducational, present/future-oriented, and brief approach” (R. E. Watts & Pietrzak, 2000, p. 22). Similar to psychoanalytic psychotherapy, Adlerian therapy is also insight-oriented. However, therapists can use direct educational strategies to enhance client awareness.

Adler was a contemporary—not a disciple—of Freud. During their time, Adler’s ideas were more popular than Freud’s. Adler’s first psychology book, Understanding Human Nature, sold over 100,000 copies in six months; in comparison, Freud’s Interpretation of Dreams sold only 17,000 copies over 10 years (Carlson & Englar-Carlson, 2017). Jon Carlson (2015) referred to Adler as “the originator of positive psychology” (pp. 23-24).

Adler wove cognition into psychotherapy long before Albert Ellis and Aaron Beck officially launched cognitive therapy in the 1950s and 1960s. In the following quotation, Adler (1964; originally published in 1933) easily could be speaking about a cognitive rationale for a computerized virtual reality approach to treating fears and phobias (now growing in popularity in the 21st century):

I am convinced that a person’s behavior springs from his [or her] idea.… As a matter of fact, it has the same effect on one whether a poisonous snake is actually approaching my foot or whether I merely believe it is a poisonous snake. (pp. 19–20)

In his historical overview of the talking cure, Bankart (1997) claimed, “Adler’s influence on the developing fields of psychology and social work was incalculable” (p. 146). This chapter is an exploration of Alfred Adler’s individual psychology and his vast influence on modern counseling and psychotherapy.

Alfred Adler

Alfred Adler (1870-1937) was the second of six children born to a Jewish family outside Vienna. His older brother was brilliant, outgoing, handsome, and also happened to be named Sigmund. In contrast, Alfred was a sickly child. He suffered from rickets, was twice run over in the street, and experienced a spasm of the glottis. When he was 3 years old, his younger brother died in bed next to him (Mosak, 1972). At age 4, he came down with pneumonia. Later Adler recalled the physician telling his father, “Your boy is lost” (Orgler, 1963, p. 16). Another of Adler’s earliest memories has a sickly, dependent theme:

One of my earliest recollections is of sitting on a bench bandaged up on account of rickets, with my healthy, elder brother sitting opposite me. He could run, jump, and move about quite effortlessly, while for me movement of any sort was a strain and an effort. Everyone went to great pains to help me, and my mother and father did all that was in their power to do. At the time of this recollection, I must have been about two years old. (Bottome, 1939, p. 30)

In contrast to Freud’s childhood experience of being his mother’s favorite, Adler was more encouraged by his father. Despite his son’s clumsy, uncoordinated, and sickly condition, Adler’s father Leopold, a Hungarian Jew, firmly believed in his son’s innate worth. When young Alfred was required to repeat a grade at the same middle school Freud had attended 14 years earlier, Leopold was his strongest supporter. Mosak and Maniacci (1999) articulate Adler’s response to his father’s encouragement:

His mathematics teacher recommended to his father that Adler leave school and apprentice himself as a shoe-maker. Adler’s father objected, and Adler embarked upon bettering his academic skills. Within a relatively short time, he became the best math student in the class. (p. 2)

Adler’s love and aptitude for learning continued to grow; he studied medicine at the University of Vienna. After obtaining his medical degree in ophthalmology in 1895, he met and fell in love with Raissa Timofeyewna Epstein, and married her in 1897. She had the unusual distinction of being an early socialist and feminist. She was good friends with Leon and Natalia Trotsky and she maintained her political interests and activities throughout their marriage (Hoffman, 1994).

Historical Context

Freud and Adler met in 1902. According to Mosak and Maniacci (1999), Adler published a strong defense of Freud’s Interpretation of Dreams, and consequently Freud invited Adler over “on a Wednesday evening” for a discussion of psychological issues. “The Wednesday Night Meetings, as they became known, led to the development of the Psychoanalytic Society” (p. 3).

Adler was his own man with his own ideas before he met Freud. Prior to their meeting he’d published his first book, Healthbook for the Tailor’s Trade (Adler, 1898). In contrast to Freud, much of Adler’s medical practice was with the working poor. Early in his career, he worked extensively with tailors and circus performers.

In February 1911, Adler did the unthinkable (Bankart, 1997). As president of Vienna’s Psychoanalytic Society, he read a highly controversial paper, “The Masculine Protest,” at the group’s monthly meeting. It was at odds with Freudian theory. Instead of focusing on biological and psychological factors and their influence on excessively masculine behaviors in males and females, Adler emphasized culture and socialization (Carlson & Englar-Carlson, 2017). He claimed that women occupied a less privileged social and political position because of social coercion, not physical inferiority. Further, he noted that some women who reacted to this cultural situation by choosing to dress and act like men were suffering, not from penis envy, but from a social-psychological condition he referred to as the masculine protest. The masculine protest involved overvaluing masculinity to the point where it drove men and boys to give up and become passive or to engage in excessive aggressive behavior. In extreme cases, males who suffered from the masculine protest began dressing and acting like girls or women.

The Vienna Psychoanalytic Society members’ response to Adler was dramatic. Bankart (1997) described the scene:

After Adler’s address, the members of the society were in an uproar. There were pointed heckling and shouted abuse. Some were even threatening to come to blows. And then, almost majestically, Freud rose from his seat. He surveyed the room with his penetrating eyes. He told them there was no reason to brawl in the streets like uncivilized hooligans. The choice was simple. Either he or Dr. Adler would remain to guide the future of psychoanalysis. The choice was the members’ to make. He trusted them to do the right thing. (p. 130)

Freud likely anticipated the outcome. The group voted for Freud to lead them. Adler left the building quietly, joined by the Society’s vice president, William Stekel, and five other members. They moved their meeting to a local café and established the Society for Free Psychoanalytic Research. The Society soon changed its name to the Society for Individual Psychology. This group believed that social, familial, and cultural forces are dominant in shaping human behavior. Bankart (1997) summarized their perspective: “Their response to human problems was characteristically ethical and practical—an orientation that stood in dramatic contrast to the biological and theoretical focus of psychoanalysis” (p. 130).

Adler’s break from Freud gives an initial glimpse into his theoretical approach. Adler identified with common people. He was a feminist. These leanings reflect the influences of his upbringing and marriage. They reveal his compassion for the sick, oppressed, and downtrodden. Before examining Adlerian theoretical principles, let’s note what he had to say about gender politics well over 90 years ago:

All our institutions, our traditional attitudes, our laws, our morals, our customs, give evidence of the fact that they are determined and maintained by privileged males for the glory of male domination. (Adler, 1927, p. 123)

Raissa Epstein may have had a few discussions with her husband, exerting substantial influence on his thinking (Santiago-Valles, 2009).

Reflections

What are your reactions to Adler as a feminist? Do you suppose he became more of a feminist because he married one? Or did he marry a feminist because he already was one?

Theoretical Principles

Adler and his followers have written extensively about the IP’s theoretical principles. Much of what follows is from Adler (1958), Ansbacher and Ansbacher (1956), Mosak and Maniacci (1999), Carlson, Watts, and Maniacci (2006), Sweeney (2009), and Carlson & Englar-Carlson, 2017).

People are Whole and Purposeful

Adler emphasized holism because he believed it was impossible “. . . to understand an individual in parts” (Carlson & Johnson, 2016, p. 225). Instead of dichotomies, he emphasized unity of thinking, feeling, acting, attitudes, values, the conscious mind, the unconscious mind, and all aspects of human functioning. This holistic approach was in direct contrast to Freud’s id, ego, and superego. The idea of an id entity or instinct separately pushing for gratification from inside a person was incompatible with Adler’s holism.

A central proposition of individual psychology is that humans are purposeful or goal-oriented (Sweeney, 2009). We don’t passively act on biological traits or react to the external environment; instead, we behave with purpose. Beyond nurture or nature, there’s another force that influences and directs human behavior; Adler (1935) referred to this as “attitude toward life” (p. 5). Attitude toward life is composed of a delightful combination of human choice and purpose.

Everyday behavior is purposeful. When Adlerian therapists notice maladaptive behavior patterns, they focus on behavioral goals. They don’t aggressively interrogate clients, asking, “Why did you do that?”—but are curious about the behavior’s purpose. Mosak and Maniacci (1999) articulated how Adler’s holism combines with purposeful behavior:

For Adler, the question was neither “How does mind affect body?” nor “How does body affect mind?” but rather “How does the individual use body and mind in the pursuit of goals?” (pp. 73–74).

Rudolph Dreikurs (1948) applied the concept of purposeful striving to children when he identified “the four goals of misbehavior” (see Putting it in Practice 3.1).

Putting it in Practice 3.1

Why Children Misbehave

Adler’s followers applied his principles to everyday situations. Rudolph Dreikurs posited that children are motivated to grow and develop. They’re naturally oriented toward feeling useful and a sense of belonging. However, when children don’t feel useful and don’t feel they belong—less positive goals take over. In his book The Challenge of Parenthood, Dreikurs (1948) identified the four main psychological goals of children’s misbehavior:

  1. To get attention.
  2. To get power or control.
  3. To get revenge.
  4. To display inadequacy.

Children’s behavior isn’t random. Children want what they want. When we discuss this concept in parenting classes, parents respond with nods of insight. Suddenly they understand that their children have goals toward which they’re striving. When children misbehave in pursuit of psychological goals, parents and caregivers often have emotional reactions.

The boy who’s “bouncing off the walls” is truly experiencing, from his perspective, an attention deficit. Perhaps by running around the house at full speed he’ll get the attention he craves. At least, doing so has worked in the past. His caregiver feels annoyed and gives him attention for misbehavior.

The girl who refuses to get out of bed for school in the morning may be striving for power. She feels bossed around or like she doesn’t belong; her best alternative is to grab power whenever she can. In response, her parents might feel angry and activated—as if they’re in a power struggle with someone who’s not pulling punches.

The boy who slaps his little sister may be seeking revenge. Everybody talks about how cute his sister is, and he’s sick of being ignored, so he takes matters into his own hands. His parents feel scared and threatened; they don’t know if their baby girl is safe.

There’s also the child who has given up. Maybe she wanted attention before, or revenge, or power, but no longer. Now she’s displaying her inadequacy. This isn’t because she IS inadequate, but because she doesn’t feel able to face the Adlerian tasks of life (discussed later). This child is acting out learned helplessness (Seligman, 1975). Her parent or caregiver probably feels anxiety and despair as well. Or, as is often the case, they may pamper her, reinforcing her behavior patterns and self-image of inadequacy and dependence.

Dreikurs’s goals of misbehavior are psychological. Children who misbehave may also be acting on biological needs. Therefore, the first thing for parents to check is whether their child is hungry, tired, sick, or in physical discomfort. After checking these essentials, parents should move on to evaluating the psychological purpose of their child’s behavior.

Social Interest or Gemeinschaftsgefühl

Adler believed that establishing and maintaining healthy social relationships was an ultimate therapy goal. He developed this belief after working with shell-shocked soldiers from World War I (K. Adler, 1994; Carlson & Englar-Carlson, 2017). He became convinced that individualism and feelings of inferiority were destructive; in contrast, he viewed social interest and community feeling as constructive. Another way of thinking about this theoretical principle is to consider humans as naturally interdependent. Lydia Sicher (1991) emphasized this in the title of her classic paper “A Declaration of Interdependence.” When we accept interdependence and develop empathy and concern for others, social relationships prosper.

Adler used the German word, Gemeinschaftsgefühl, to describe what has been translated to mean social interest or community feeling. Carlson and Englar-Carlson (2017) elaborated on the meaning of this uniquely Adlerian concept.

Gemein is “a community of equals,” shafts means “to create or maintain,” and Gefühl is “social feeling.” Taken together, Gemeinschaftsgefühl means a community of equals creating and maintaining social feelings and interests; that is, people working together as equals to better themselves as individuals and as a community” (p. 43, italics in original)

Adlerians encourage clients to behave with social interest (Overholser, 2010). Watts (2000) emphasized that, “The ultimate goal for psychotherapy is the development or enhancement of the client’s social interest” (p. 323). Research has shown that social interest is positively related to spirituality, positive psychology, and health (G. K. Leak, 2006; G. K. Leak & K. C. Leak, 2006; Nikelly, 2005), and inversely related to anger, irritability, depression, and anxiety (Newbauer & Stone, 2010). Some writers consider the positive aspects of religion to be a manifestation of social interest. This was Adler’s position as well (Manaster & Corsini, 1982; Watts, 2000).

Various writers, and Adler himself, noted that Gemeinschaftsgefühl essentially boils down to the edict “love thy neighbor” (Alizadeh, 2012; Watts, 2000). Carlson and Englar-Carlson described it as being the “same as the goal of all true religions” (p. 44). Although Adler wasn’t especially religious, he had no difficulty embracing the concept of love thy neighbor as a social ideal. In contrast, Freud (1930/1961) concluded, “My love is something valuable to me which I ought not to throw away without reflection” (p. 56). This is one of several distinctions between Adler and Freud; for Adler, love is valuable, powerful, and abundant. It should be freely given; for Freud, love is also valuable, but should be conserved.

Striving for Superiority

Adler believed that the basic human motive is the striving for superiority. However, like Gemeinschaftsgefühl, this concept requires a detailed explanation.

The term superiority is an oversimplification. Heinz Ansbacher provided a more comprehensive description of Adler’s striving for superiority in a published interview:

The basic striving, according to Adler, is the striving for Vollkommenheit. The translation of Vollkommenheit is completeness, but it can also be translated as excellence. In English, only the second translation was considered; it was only the striving for excellence. The delimitation of the striving for excellence is the striving for superiority.

Basically, it all comes from the striving for completeness, and there he said that it is all a part of life in general, and that is very true. Even a flower or anything that grows, any form of life, strives to reach its completeness. And perfection is not right, because the being does not strive—one cannot say to be perfect—what is a perfect being? It is striving for completeness and that is very basic and very true. (Dubelle, 1997, p. 6)

Striving for individual superiority can take on a Western, individualistic quality. This wasn’t Adler’s perspective. He viewed excessive striving for self-interest as unhealthy; Adler once claimed he could simplify his entire theory by noting that all neurosis was linked to vanity. Striving for self-interest translates into striving for superiority rather than for social interest (Watts & Eckstein, 2009).

When it comes to basic human nature and potential, Adlerian theory is like Switzerland: Adler was neutral. He didn’t believe in the innate goodness or destructiveness of humans. He believed we are what we make ourselves; we have within us the potential for good and evil.

Striving for superiority is an Adlerian form of self-actualization. More concretely, it occurs when individuals strive for a perceived “plus” in themselves and their lives. Mosak and Maniacci (1999) applied this concept to a clinical situation:

How can self-mutilation move someone toward a plus situation? Once again, that may be a “real” minus, especially in the short-term situation. Long-term, however, that person may receive attention, others may “walk on eggshells” when near that person (so as to not “upset” him or her), and he or she may gain some sense of subjective relief from the act, including a sense of being able to tolerate pain. (p. 23)

Adler observed that people often compensate for their real or perceived inadequacies. Individual inadequacies can be in any domain (e.g., physical, psychological, social). Adler may have believed in compensation partly because he experienced it himself, while growing up. Being inadequate or deficient is motivating. “The fundamental law of life is to overcome one’s deficiencies” (Ansbacher & Ansbacher, 1956, p. 48). Compensation is the effort to improve oneself in areas perceived as weak. The existential philosopher Friedrich Nietzsche expressed the same sentiment, “What does not kill me makes me stronger.”

In an ideal situation, individuals strive to (a) overcome their deficiencies, (b) with an attitude of social interest, and (c) to complete or perfect themselves. Watts (2012) has argued that the Adlerian social interest and striving for superiority are foundational to positive psychology—despite the fact that Adler’s work remains largely unacknowledged within the positive psychology discipline.

 

CBT and Spirituality

Evening Snow Absarokee

We have a friend who is the pastor of a church in Absarokee, Montana. My impression is that she frequently talks about theories of counseling and psychotherapy . . . even though I’m sure she hasn’t planned to integrate psychological theory into her sermons. The fact that I hear psychological theories as she talks theology is just another way in which the lens of the listener frames what is heard, seen, and experienced.

Today she was preaching about feelings of inferiority. She made the case, as Adler would, that inferiority feelings are natural and normal. Then she shifted to God’s acceptance or grace. Surprisingly (to me) her focus on acceptance reminded me of Albert Ellis’s REBT and his concept of universal self-acceptance. Although my friend was speaking about God’s acceptance of all humans, regardless of our warts and behaviors, I found myself thinking of times when I’ve heard parents express deep acceptance of their children and of when clients have strived to experience greater self-acceptance.

All this brought me to a place where I started thinking about how Ellis and his REBT model might actually have a spiritual dimension. “That was pleasantly unexpected” I thought to myself . . . which prompted me to write this Sunday evening spirituality post.

The following is an excerpt (preview) from the cognitive behavior chapter of the forthcoming 3rd edition of Counseling and Psychotherapy Theories in Context and Practice. Please let me know what you think.

CBT and Spirituality

Like all therapists, cognitive behavior therapists work with religious or spiritual clients. Given that cognitively oriented therapists routinely identify and challenge (either through disputation or collaborative empiricism) client beliefs, there’s a risk that clients’ deeply held religious or spiritual beliefs might also be challenged. Additionally, practiced as a radical modernist scientific paradigm, CBT has been critiqued for overlooking transcendence, grace, and evil (Stewart-Sicking, 2015).

Looking at the situation logically (which cognitive theorists would appreciate), CBT practitioners have three options:

  1. Ignore client religion and spirituality.
  2. Freely challenge religious beliefs, whenever they cause emotional distress.
  3. Integrate religious/spiritual knowledge into practice in a way that supports nuanced discussions of religion and spirituality. Unhelpful or irrational thoughts might be questioned, as needed, but not central religious values (Johnson, 2013).

Historically, cognitive therapists have followed these first two options, mostly ignoring religion, or questioning its rational foundations (Andersson & Asmundson, 2006; Nielsen & Ellis, 1994). However, in the past decade or two, interest in integrating religion/spirituality into counseling and psychotherapy has increased (Stewart-Sicking, 2015).

It can help to think about client religion/spirituality as a multicultural/diversity issue. If so, the general guide is for therapists to (a) seek awareness of their own spiritual and religious attitudes and how they might affect counseling process and specific clients, (b) obtain relevant knowledge about religion/spirituality, (c) learn religion/spirituality specific skills, and (d) advocate for individuals who are oppressed on the basis of religion/spirituality as needed and as appropriate. Each of these cultural competence components can be stimulating for individual practitioners.

For practitioners interested in religion/spirituality integration with cognitive approaches, the following two areas can provide focus for further training and development.

Gain and Apply Scriptural Knowledge with Clients

Gaining knowledge regarding how to use specific religious scriptures to dispute irrational or maladaptive cognitions may seem daunting. However, from an REBT perspective, Nielsen (2001) wrote:

Since clients usually upset themselves through their awfulizing, demanding, frustration intolerance, and human rating, REBTers need only search Scriptures that decatastrophize life, suggest forbearance in the face of uncontrollable people and situations, tolerance of life’s frustrations, and that affirm basic human equality. The prominent religious writings of most major world religions emphasize such rational values. (p. 38)

Using scriptural knowledge would be most appropriate when working with clients who have similar religious beliefs. Nielsen (2001) is advocating general knowledge, but general knowledge could prove problematic. For example, if a Jewish therapist quoted the Koran to a Muslim client, the discussion might quickly shift away from being therapeutic. On the other hand, having general knowledge, if used sensitively, could represent appreciation of religious diversity and enhance the working alliance.

Use Spiritual Principles of Acceptance for Managing Disturbing Cognitions.

Contemporary CBT approaches (covered in Chapter 14) offer an alternative way of viewing and handling so-called irrational or maladaptive cognitions. These approaches include acceptance and commitment therapy (ACT), dialectical behavior therapy (DBT), and mindfulness-based cognitive therapy (MBCT). ACT, DBT, and MBCT integrate religious/spiritual philosophy (e.g., Buddhism, contemplative Christian, etc.) and generally view cognitions as disturbing, but not necessarily pathological. Acceptance of all cognitions is advocated; encouraging clients to dispute or restructure their thoughts, memories, and experiences can increase suffering (Hayes, 2016).

 

Counseling Theories Lab Activities

With Wubbolding

Hi All.

Below I’m pasting links to a variety of lab activities that I’ve used in teaching Counseling and Psychotherapy Theories. Although I’ve got a textbook that I’d love you to use: http://www.wiley.com/WileyCDA/WileyTitle/productCd-1119084202.html, this post is about free stuff that I’m happy to share to help make your theories teaching experiences more practical and more fun.

Here are the activities:

This is a short guide to conducting an Adlerian Family Constellation Interview: Chapter 3 Family Constellation Interview and Earliest Memories

This is a short guide for doing and debriefing a person-centered interview: Chapter 5 Person Centered Activity

Dreamwork can be enlightening. This guide helps students explore each other’s dreams: Chapter 6 Jungian and Gestalt Dream Work

This handout helps your students practice conducting a behavioral or cognitively oriented symptom interview. Chapter 7 Analyzing Symptoms Interview

This isn’t really an activity, just a sample Ellis ABCDE form. Chapter 8 Ellis ABCDE

These two handouts provide tips for doing a CBT Six Column intervention, as well as a sample Six Column form, filled out using an angry teen example. Chapter 8 Six Column CBT Tips  and Chapter 8 Six Columns Youth Anger Example

Here’s a video clip (just a snippet) of me doing a CBT example:https://www.youtube.com/watch?v=LQ8hNDHoyDU

This is an interview activity to give students and role-play clients a taste of solution-focused interviewing: Chapter 11 Solution-Focused Activity

I hope these materials are helpful for you. As always, if you have feedback to share, you can share it on this blogsite or via email: johnsf@mso.umt.edu

 

 

 

 

 

 

 

 

When the Yellow Grows into Gold and Happy Breaks Out

Lower Grove Creek 7 14 17This morning the clock said 3:51am. My lungs felt refreshed. Then a memory from last night bubbled up. You know how they do.

Rita and I discovered mold in our garden. It was yellow and green and it shared its spores with my lungs before we recognized or best option: retreat inside to formulate our battle plan in response  to the attack of the multicolored mold.

Google was waiting. All the postings were about White mold or Black mold, or even yellow dog-vomit mold. Nothing fit our mold. I read with great and trepidiacal interest of a U.K. man who died from inhaling compost mold; my lungs were burning. Not good.

But sleep came.

Then 3:51am came.

And then the thoughts came.

At 3:52am it seemed odd that I could hear my pulse in my ear on the pillow. It seemed fast. That U.K. man had a rapid pulse. I could either choose to lift my head and take my pulse and while waiting for the digital clock to move to the next minute, or I could look at my fit bit. But my fit bit is charging. But I decide, anyway, to roll over and grab it and attach it to my wrist and look at the pulse rate. It flashes, 113. Not good. I check again, 112. Not good. Not normal. I compulsively check again, 111. The fit bit is probably still adjusting, now it’s 109. Stop checking, the voice in my head says. Let it be. Let it settle. Thirty seconds later, it’s 55. I am normal again.

At 3:54am, I find another troubling thought. Today is July 14, 2017. My Theories text revision is due in 31 days. I have five more chapters to revise. That’s six days per chapter. Plus references. Plus table of contents and preface and . . . . Not good. I’m a bad author.

At 4:12am, I’m up, turning on the computer. I’m a bad author and a bad husband and a bad father and a bad friend. All I do is write meaningless drivel that maybe 12 people a year will read and then immediately forget. Forgettable, I am. Even my own students can’t answer my pop theories quiz questions when they drop by my office. I wonder why they don’t stop in so much anymore.

Good thing I’m revising CBT today. God and Albert Ellis know, I sure as Hell need it.

One of today’s content areas is called, Thinking in Shades of Gray. It’s a description of a cognitive technique to help people get out of destructive, irrational, and maladaptive black-white (aka polarized) thinking. It’s boring. Of course it’s boring. Shades of gray? It’s a technique to help with depressive thoughts. I can hear the Albert Ellis voice in my head. WTF? You work with depressed people and you teach them how to think in shades of gray. What the Holy Hell are YOU thinking?

Later this morning, as I ride through Lower Grove Creek with yellow flowers and the Beartooth Mountains looming, I stop for a photo. There are no cars, no deer, and not even a trace of fungal spores. Just me and my breath and my bike and the yellow flowers and shades of gray, black, and white rising above. Why are there no colors in the shades of gray activity? There’s more to our thinking (and our client’s) thinking than black, white, and gray. Today, with the wind in my face and Tippet Rise to my starboard, I want to be an art therapist. “Let’s put a little yellow there,” I say. And the yellow grows into gold and happy breaks out.

But sooner or later, you and I know. We. Know. The yellow will catch dust and lose its sparkle and turn to mold, until a future morning at 3:51am, when a red seed of awareness gets planted among the anxiety bushes and purple flowers bloom, replacing the moldy browned-up yellow, and then we will remember. We have been here before. And it was wondrous and terrible and everything in between.

At that point, it’s not a bad idea to find your fit bit, take your pulse, and embrace the ever disintegrating now that is morning. You have your next 31 days and I have mine. Let’s meet somewhere in the middle and celebrate the next disintegrating now with all the passion and monotony we can muster. You know we can. We’ve done it before.

Five Recommendations for Developing a Positive Working Alliance

The working alliance is one of the most robust predictors of positive counseling and psychotherapy outcomes. This excerpt, from the forthcoming 6th edition of Clinical Interviewing, describes five recommendations. You can always email me directly if you have questions about these resources I post. Have an excellent Wednesday evening.

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Therapists who want to develop a positive working alliance (and that should include everyone) will employ alliance-building strategies beginning with first contact. Using Bordin’s (1979) model, alliance-building strategies focus on (a) collaborative goal setting; (b) engaging clients in mutual therapy-related tasks; and (c) development of a positive emotional bond. Progress monitoring is also recommended. The following list includes alliance-building concepts and illustrations:

  1. Initial interviews and early sessions are especially important to alliance-building. Many clients will be naïve about psychotherapy. This makes role inductions essential. Here’s a cognitive-behavioral therapy (CBT) example:

For the rest of today’s session, we are going to be doing a structured clinical interview. This interview assesses a range of different psychological difficulties. It is a way to make sure that we “cover all of our bases.” We want to see if social anxiety is the best explanation for your problems and also whether you are having any other difficulties that we should be aware of. (Ledley, Marx, & Heimberg, 2010, p. 36)

  1. Asking clients direct questions about what they want from counseling and then integrating that information into your treatment plan helps build the alliance. In CBT this includes making a problem list (J. Beck, 2011).

Clinician:     What brings you to counseling and how can I be of help?

Client:         I’ve just been super down lately. You know. Tough to get up in the morning and face the world. Just feeling pretty crappy.

Clinician:     Then we definitely want to put that on our list of goals. Can I write that down? [Client nods assent] How about for now we say, “Find ways to help you start feeling more up?”

Client:         Sounds good to me.

  1. Engaging in collaborative goal-setting to achieve goal consensus is central to alliance-building. In CBT this involves transforming the “problem list” into a set of mutual treatment goals.

Clinician:     So far I’ve got three goals written down: (1) Find ways to help you start feeling more up, (2) Help you deal with the stress of having your sister living with you and your family, and (3) Improving your attitude about exercising. Does that sound about right?

Client:         Totally. It would be amazing to tackle those successfully.

Problem lists and goals are a good start, but clients engage with clinicians better when they know the treatment plan (TP) for moving from problems to goals. The TP includes specific tasks that will happen in therapy and may begin in the first clinical interview. Here’s an example of a “Devil’s Advocacy” technique where the clinician takes on the client’s negative thoughts and then has the client respond (Newman, 2013). You’ll notice that collaboratively engaging in mutual tasks offers spontaneous opportunities for deeper connection and clinician-client bonding:

Clinician:     You said you want a romantic relationship, but then you start thinking it’s too painful and pointless. Let’s try a technique where I take on your negative thinking and you respond with a reasonable counter argument. Would you try this with me?

Client:         Sure. I can try.

Clinician:     Excellent. Here we go: “It’s pointless to pursue a romantic relationship because they always come to a painful end.”

Client:         That’s possible, but it’s also possible to have some good times along the way toward the painful end.

Clinician:     [Smiles, breaks from role, and says] . . . That’s the best come-back ever.

  1. Soliciting feedback from clients from the first session on to monitor the quality and direction of the working alliance contributes to the alliance. Although you can use an instrument for this, you can also ask directly:

We’ve been talking for 20 minutes and so I want to check in with you on how you’re feeling about our time together so far. How are you doing with this process?

  1. Making sure you’re able to respond to client anger without becoming defensive or counterattacking is essential to positive working relationships. We usually apply radical acceptance (Linehan, 1993). Here’s an excerpt from an initial session with an 18-year-old male where the clinician accepted the client’s aggressive message and transformed it into a relational issue:

Clinician:     I want to welcome you to therapy with me and I hope we can work together in ways you find helpful.

Client:         You talk just like a shrink. I punched my last therapist in the nose (client glares at therapist and awaits a response) (J. Sommers-Flanagan & Bequette, 2013, p. 15).

Clinician:     Thanks for telling me that. I’d never want to have the kind of relationship with you where you felt like hitting me. And so if I ever say anything that offensive, I hope you’ll just tell me, and I’ll stop.

 

How to Use the Six Column CBT Technique

A Description of the Six Column CBT Technique

In contrast to popular belief, CBT requires counselors to be warm and compassionate. Also, the focus of CBT is on experiential psychoeducation. Aaron Beck emphasized collaborative empiricism. Never forget that term. Collaborative empiricism is the bedrock of good CBT. It emphasizes the process of counselors and clients working together to test the accuracy and usefulness of specific thoughts and behaviors. As a therapeutic process, collaborative empiricism is also central to Person-Centered and Motivational Interviewing approaches. Remember: We want the client to have a central role in determining the usefulness and dysfunctionality of his or her cognitions and behaviors.

The six column technique is simply a procedure that helps clients and counselors organize, explore, and discover how situations, thoughts/beliefs, emotions, behaviors, and emotional/interpersonal/psychological outcomes are inter-related. This is my own particular version of the six column technique. It’s derived from the work of Aaron Beck, Albert Ellis, Judith Beck, and other cognitive behavioral therapists. You can see a short clip of me using this technique at: http://www.wiley.com/WileyCDA/WileyTitle/productCd-1118402537.html

Here’s a description of the six columns:

Column #1: The Situation

BE THINKING ABOUT LINKING EMOTIONS TO SPECIFIC SITUATIONS

It may be that you’ll begin with whatever emotional distress the client is experiencing or reporting. Or you may begin with thoughts and beliefs that are clearly linked to specific client emotions and behaviors. Or you may begin with the situation or “trigger” for the cognitions and subsequent emotions.

Here’s an example of a situation as reported by a client:

“My in laws are staying in my home     .”

“They’re messy and lazy and I have to pick up after them”

Column #2: Automatic Thoughts and Automatic Behaviors

HELP CLIENTS SEE THAT AUTOMATIC THOUGHTS ARE OFTEN THE BRIDGE BETWEEN SITUATIONS AND EMOTIONS

Here are some examples of the automatic thoughts the clients thinks when she faces the previously described situation:

“They’re old enough to pick up after themselves.”

“Sometimes I stand in front of the television they’re watching to block their view as I pick their stuff up.”

Sometimes if “she” says she’ll do the dishes, I say, “No thanks. I want them to get done in the next two weeks.”

REMEMBER THAT AN EXPLORATION OF YOUR CLIENTS AUTOMATIC THOUGHTS AND BEHAVIORS OFTEN WILL SHED LIGHT ON DEEPER CORE BELIEFS ABOUT THE SELF, THE WORLD, AND THE FUTURE.

Column #3: Emotions and Sensations

SOMETIMES IT IS VERY NATURAL TO START HERE BECAUSE YOUR CLIENT’S EMOTIONS AND SENSATIONS MAY BE A WAY THAT THE MIND AND BODY ARE VOICING HIS OR HER DISTRESS (or you may find the best entry point into the six column technique is somewhere else)

Here are the ratings and descriptions the client provided for column #3:

Anger = 75 (on a 0-100 scale with 0 = totally mellow and 100 = explosive distress)

Discomfort = 75

EMOTIONS AND SENSATIONS MAY BE WHAT IS MOST TROUBLING TO CLIENTS AND THAT’S WHY THEY’RE TYPICALLY RE-EXAMINED IN COLUMN #6: NEW OUTCOMES

Column #4: Helpful Thoughts

HELPFUL THOUGHTS ARE ALSO SOMETIMES REFERRED TO AS “COOL THOUGHTS.” THIS IS ESPECIALLY TRUE WHEN WORKING WITH ANGER AND AGGRESSION BECAUSE COOL THOUGHTS HELP CALM OR COOL OFF THE ANGER AND REDUCE THE POTENTIAL FOR AGGRESSION.

Here are some thoughts that the client identified as helpful. Helpful thoughts are often seen as adaptive or more accurate or more “rational” (which is an Albert Ellis term).

“This is important for my husband.”

“I can see this as a challenge for me to become more direct and assertive.”

“They mean well.”

A WAY OF ASKING ABOUT HELPFUL THOUGHTS IS TO JUST ASK DIRECTLY: WHAT ARE SOME THOUGHTS OR BELIEFS THAT YOU THINK WOULD BE HELPFUL TO YOU IN THIS SITUATION? YOU MAY NEED TO HELP CLIENTS WITH THIS BY PROVIDING EXAMPLES . . . BUT NOT BY TELLING THEM WHAT THEY SHOULD THINK. ENCOURAGE THEM TO FIND THEIR OWN WORDS.

Column #5: Helpful Behaviors

SIMILAR TO THE PRECEDING COLUMN, WE CAN THINK OF BEHAVIORS AS “HOT” OR “COOL” BEHAVIORS. HOT BEHAVIORS MAKE THE SITUATION AND/OR EMOTIONS WORSE; COOL BEHAVIORS MAKE THE SITUATION AND/OR EMOTIONS BETTER.

Here are some behaviors the clients said she thought might be helpful:

“I could sit down and talk with them about picking up their messes at a regular time.”

“I could ask my husband to talk with them.”

“I could go to a Yoga class two nights a week.”

WHEN IT COMES TO BOTH HELPFUL THOUGHTS AND HELPFUL BEHAVIORS, IT’S USEFUL TO THINK OF THEM AS OCCURRING (A) BEFORE, (B) DURING, OR (c) AFTER THE SITUATION ARISES. SOME BEHAVIORS (E.G., GETTING ENOUGH SLEEP) HELP THE SITUATION AS A PROACTIVE OR PREVENTATIVE ACTION. OTHER BEHAVIORS (E.G., DEEP BREATHING) MAY BE CRUCIAL DURING THE SITUATION. STILL OTHER BEHAVIORS (E.G., VENTING TO A FRIEND OR PROVIDING SELF-REINFORCEMENT) MAY BE HELPFUL AFTER THE SITUATION IS OVER.

Column #6: New Outcomes

AFTER IMPLEMENTING THE HELPFUL COGNITIONS AND HELPFUL BEHAVIORS, IT’S A GOOD IDEA TO RE-EVALUATE THE CLIENT’S EMOTIONS AND SENSATIONS (OR DISTRESS).

In this case, the client provided the following ratings:

Anger = 40

Discomfort = 40

ONE OF THE GOALS OF CBT IS TO REDUCE DISTRESS AND REDUCE SYMPTOMS AND MAKE LIFE A LITTLE BETTER. YOU MAY NOT CREATE VAST IMPROVEMENTS, BUT IMPROVEMENTS ARE IMPROVEMENTS. THIS IS ALSO JUST THE BEGINNING OF CBT (OR WHATEVER APPROACH YOU’RE USING) BECAUSE THE WHOLE POINT IS THAT LIFE IS AN EXPERIMENT AND THAT WE COLLABORATIVELY AND INTERACTIVELY ARE HELPING CLIENTS TRY OUT NEW THOUGHTS AND BEHAVIORS THAT MAY (OR MAY NOT) LEAD TO IMPROVEMENT. AND IF THE IMPROVEMENT ISN’T OPTIMAL . . . THE CBT WAY IS TO GO BACK TO THE BEGINNING AND REWORK THE PROCESS TO SEE IF FURTHER IMPROVEMENTS CAN OCCUR.

CBT Tips

Here are a few tips on how to integrate CBT in your work.

Some counselors or mental health professionals resist using CBT and complain that it’s too sterile or too educational or not focused enough on feelings. Basically, I think this is a cop-out similar to CBT folks who say that person-centered therapy is ineffective. My belief (and I think it’s rational and so it must be (smiley face) is that when mental health professionals don’t understand how to implement a particular approach, they blame the approach rather than admitting their lack of knowledge or skill. Instead, I encourage you to try this six column CBT model, but use it with whatever other model you prefer. In other words, you can be a person-centered CBT person or an existential CBT person . . . especially if you just use this six column technique as a means for exploring and understanding different dimensions of your client’s personal experience.

Goal-setting is essential to counseling. From the CBT perspective, goal-setting is initiated by generating a problem list. However, your IR clients may not have a problem listJ. That’s why you may need to use your excellent active listening skills to help your clients focus in on a distressing emotion. Then you can begin with the distressing or disturbing emotion and build the six columns from there.

Good CBT involves adopting an experimental mindset (never forget collaborative empiricism). All you’re doing is helping your client look at his/her daily experiences and identify patterns. It helps to organize the client’s experience into Situation, Automatic Thoughts/Behaviors, Emotions and Sensations, Helpful (Cool) Thoughts, Helpful (Cool) Behaviors, and New Outcomes. You can explore these common dimensions of human experience collaboratively.

It’s very important to know and remember that giving behavioral assignments can be disastrous. This is part of why a good CBT counselor is better than a technician. If you’re brainstorming possible helpful behaviors, your client (and you) may zero in on a behavior that, if enacted, has a strong possibility of a negative outcome. New behaviors expose clients to risk. The risk may be worth it; but there also may be too much risk.

Avoid asking questions like: “Have you thought about talking directly to your in-laws?” This sort of question implies that your client should talk directly to the in-laws. It’s better to step back and brainstorm behavioral options with your client. Then, emphasize that behavioral goals must always be in the client’s control. Then, after your nice list of behavioral options has been generated, you can look at the different options and engage in “consequential thinking.” In other words, you ask your client to explore the possibilities of what is likely to happen if: “You (the client) directly confront the in-laws about their messy behaviors? “ (See sample six column worksheet).

There are many ways you can get to your client’s underlying core beliefs or cognitive dynamics. For example, you could ask: “What stops you from telling them to pick up after themselves?” The client might respond with a different emotion and new content (e.g., I’m afraid of getting into a conflict). You can pursue this further: “What is it about being in conflict makes it scary?” She might say, “I’m afraid my husband will side with them and leave me.” As a consequence, this conflict is viewed as something she needs to manage independently and gets at a deeper schema: “I must keep the peace and deal with everything or bad things (e.g., abandonment) will happen.” There are two problems with this: (a) If she overfunctions she feels angry and acts passive-aggressively; and (b) there may be truth to this schema/belief. This is why we can’t just push her into being assertive. We must always keep the corrective emotional experience rule in mind. New behavioral opportunities need to be free from the likelihood of re-traumatization.