Tag Archives: counseling and psychotherapy theories

Theories Highlights II: The Story of Freud’s Seduction Hypothesis

Let’s put it this way: When it comes to the history of counseling and psychotherapy, there’s plenty of conflict and drama. In the following excerpt from Chapter 2 of Counseling and Psychotherapy Theories in Context and Practice, you’ll get to read about Freud and his formulation and then recanting of the seduction hypothesis. Is it all true and factual? Probably not. Is it fascinating? As Freud would have likely said, “Hell yes!”

Historical Context

As suggested toward the end of Chapter 1, psychological theories are partly a product of the prevailing Zeitgeist and Ortgeist. Bankart (1997) stated:

To fathom Freud’s near-obsession with the sexual foundations of emotional distress is also to come to a fuller awareness of the sexual repression and hypocrisy in the lives of the Austrian middle class at the turn of the…[nineteenth] century and the effect of this repression on the mental health of adolescents and young adults during the time when Freud derived his theories. (p. 8)

A good illustration of psychoanalytic historical context and of Freud’s dominant persuasive powers is the dramatic story of Freud’s development and subsequent recanting of the seduction hypothesis. This story captures his psychoanalytic thinking along with the social dynamics of his time. Interestingly, there’s conflict over the truth of this story—which further illustrates the divisive nature of Freud and his legacy. As you read through the drama of the seduction hypothesis, keep in mind that certain points have been contested…but the unfolding of a spectacular drama around sexuality, sexual fantasy, and sexual abuse in a sexually repressed society is likely accurate.

The Seduction Hypothesis

In 1885, Freud went to France to study under the famous neurologist Jean Charcot. According to Jeffrey Masson, former projects director of the Freud Archives, it’s likely that Freud visited the Paris Morgue, observing autopsies of young children who had been brutally physically and sexually abused (Masson, 1984). Masson speculated that Freud’s exposure to the grisly reality of child abuse combined with stories of abuse he heard from his patients, led him to believe that hysteria was caused by child sexual abuse.

Later, Freud presented a paper titled “The Aetiology of Hysteria” at the Society for Psychiatry and Neurology in Vienna (Freud, 1896). In this paper, he outlined a controversial hypothesis:

I therefore put forward the thesis that at the bottom of every case of hysteria there are one or more occurrences of premature sexual experience, occurrences which belong to the earliest years of childhood, but which can be reproduced through the work of psychoanalysis in spite of the intervening decades. (Freud, 1896, cited in Masson, 1984, p. 263)

Note that Freud stated, “. . . at the bottom of every case of hysteria.” He was emphasizing a clear causal connection between childhood sexual abuse and hysteria. This presentation was based on 18 cases (12 women and 6 men), all of which included childhood sexual abuse. At least three key points are important in this presentation:

  1. Freud’s idea about the connection between childhood sexual abuse and subsequent psychopathology may represent an early formulation of the contemporary diagnosis of Posttraumatic Stress Disorder and/or Dissociative Identity Disorder.
  2. Critics contend that in Freud’s paper, “the ‘facts’ of specific case histories are never provided” (Wilcocks, 1994).
  3. Freud may have been constructing sexual memories both through a direct pressure technique and by distorting what he heard to fit with his pre-existing ideas (Esterson, 2001).

Despite a lack of supporting detail in his presentation and the possibility that he was building evidence to support his theory, Freud goes on to suggest that hysterical symptoms don’t arise immediately, but instead develop later:

Our view then is that infantile sexual experiences…create the hysterical symptoms, but…they do not do so immediately, but . . . only exercise a pathogenic action later, when they have been aroused after puberty in the form of unconscious memories. (Freud, 1896, cited in Masson, 1984, p. 272)

It appears that Freud continued to believe his clients’ sexual abuse stories (or perhaps he believed his own constructed version of his client’s sexual abuse stories) until the late 1800s or early 1900s.

Recanting the Seduction Hypothesis

Imagine yourself alone with a great and horrible insight. In Masson’s version of the seduction hypothesis story, this was Freud’s situation. Masson (1984) describes the reception Freud received after presenting his hypothesis (and this part of the seduction hypothesis story is not disputed):

The paper…met with total silence. Afterwards, he was urged never to publish it, lest his reputation be damaged beyond repair. The silence around him deepened, as did the loneliness. But he defied his colleagues and published “The Aietology of Hysteria.” (pp. xviii–xix)

Five days after presenting his paper, Freud wrote about the experience to his friend and otolaryngologist (ear, nose and throat physician) Wilhelm Fliess. Freud’s anger is obvious:

[My] lecture on the aetiology of hysteria at the Psychiatric Society met with an icy reception from the asses, and from Kraft-Ebing [the distinguished professor and head of the Department of Psychiatry at the University of Vienna] the strange comment: “It sounds like a scientific fairy tale.” And this after one has demonstrated to them a solution to a more than thousand-year-old problem, a “source of the Nile!” They can all go to hell. (Schur, 1972, p. 104)

Although it’s clear that Freud’s lecture received “an icy reception” it’s less clear why the audience was unimpressed. According to Masson, the reception is icy because Freud is bringing up sex and sexual abuse and that psychiatry (and most professionals and citizens at the time) were uncomfortable with facts linked to high sexual abuse rates. Alternatively, others have suggested that Freud’s style, perhaps a combination of arrogance along with an absence of scientific rigor or detail, moved the audience to rebuke him. For example, Wilcocks (1994) wrote:

The inferential support offered—without detail, of course—is that in eighteen cases out of eighteen, Freud has “discovered” the same etiological factors. But since neither we nor his audience are/were privy to the circumstances of any of his cases, this claim—whatever it’s other inferential mistakes—is simply useless. (p. 129)

It may never be clear whether Freud’s motives in presenting the seduction hypothesis were noble or manipulative. However, regardless of motive, the ensuing years following his “Aetiology of Hysteria” lecture were difficult. Reportedly, his private practice was in decline and his professional life in shambles. It was at this time that Freud began what has been described as “his lonely and painful self-analysis” (Prochaska & Norcross, 2003, p. 29). His 2-year self-analysis included uncovering memories of yearning for his mother and equally powerful feelings of resentment toward his father (Bankart, 1997).

Eventually, Freud discarded his seduction hypothesis in favor of the Oedipus complex (where the child holds unconscious wishes to have sexual relations with the parent of the opposite sex). Some suggest this was because he began noticing seductive patterns in so many parent-child interactions that it was unrealistic to assume that child sexual abuse occurred at such a ubiquitous rate. Others believe Freud was ahead of his time in discovering child sexual abuse, but buckled under the social and psychological pressure, abandoning the truths his patients shared with him. Still others contend that while Freud was constructing his theoretical principles, he was projecting and mixing his own fantasies into his clients’ stories. The following statement illustrates the highly personalized nature of some of Freud’s theorizing:

I found in myself a constant love for my mother, and jealousy of my father. I now consider this to be a universal event in childhood. (R. A. Paul, 1991)

Eventually, in 1925, long after he recanted the seduction hypothesis, he reflected on his struggle:

I believed these stories, and consequently supposed that I had discovered the roots of the subsequent neurosis in these experiences of sexual seduction in childhood.… If the reader feels inclined to shake his head at my credulity, I cannot altogether blame him.… I was at last obliged to recognize that these scenes of seduction had never taken place, and that they were only fantasies which my patients had made up. (Freud, 1925, cited in Masson, 1984, p. 11)

In the creation and recanting of the seduction hypothesis, it’s difficult to sort out fact from fantasy. Perhaps this is as it should be, as it illustrates at least one formidable lesson about psychology. That is, when diving headlong into the deep psychological processes of humans, it’s possible to elicit confused and confusing storylines and to knowingly or unknowingly (unconsciously) mix (or project) our own personal issues into the plot. In the end, it may be that we create Kraft-Ebing’s “Scientific fairy tale” or, alternatively, something with lasting and meaningful significance. More likely, we create a combination of the two. (See Table 2.1 for three possible conclusions about Freud and the seduction hypothesis.)

Table 2.1: Freud’s Seduction Hypothesis: Three Conclusions

The official Freudian storyline goes something like this: Sigmund Freud was an astute observer who had to discard his earlier views about child seduction and sexual abuse to discover the more basic truth of the power of internal fantasy and of spontaneous childhood sexuality.

Although he initially believed his clients’ sexual abuse reports, he later discovered that it was not actual abuse, but imagined sexualized relationships (fantasies) between children and caretakers—aka: the Oedipus complex—that caused psychopathology.

Masson’s (1984) version, subsequently labeled “a new fable based on old myths” (Esterson, 1998), suggests that Freud was ahead of his time in recognizing child sexual abuse. These abuses were real and it was correct of Freud to identify them and to develop his seduction hypothesis. However—and unfortunately—Freud abandoned his sexually abused clients by recanting the seduction theory. He abandoned them because of pressure from medical and scientific colleagues and because society was not ready to face the reality of rampant child sexual abuse. Freudian critics suggest that Freud was an exceptionally bright, persuasive, and powerful speaker and writer, but he was practicing bad science. He was more interested in building his theory than psychological reality. Consequently, he twisted his clients’ stories, mixing them with his own issues and fantasies, and created an elaborate theory initially around sexual abuse and later around sexual fantasy. His theories, although fascinating and capturing much about the projective potential in human thinking, are more about Freud than they are about his clients.

Theories Highlights I: What’s the difference between counseling and psychotherapy?

My younger daughter has graduated, our video shoots for the Clinical Interviewing text are “in the can,” my time with the grandkids has passed, and the family reunion is over. Now, as the summer sun blazes, I’ve retreated to my standing desk and dived head-first into revising the 3rd edition of our Counseling and Psychotherapy Theories textbook. Later today, I’ll refresh myself with a different sort of dive into the beautiful and frigid Stillwater River.

As I work on revising this textbook I’ll be posting a series of “Theories Highlights.” They will be short excerpts from the forthcoming 3rd edition. Here’s the first one. As always, I’d love feedback if you feel like sharing.

From Chapter 1:

Definitions of Counseling and Psychotherapy

Over the years, many students have asked: “Should I get a PhD in psychology, a master’s degree in counseling, or a master’s in social work?”

This question usually brings forth a lengthy response, during which we not only explain the differences between these various degrees, but also discuss additional career information pertaining to the PsyD degree, psychiatry, school counseling, school psychology, and the psychiatric nurse practitioner credential. This sometimes leads to the confusing topic of the differences between counseling and psychotherapy. If time permits during these discussions, we also share our thoughts about less-confusing topics, like the meaning of life.

Sorting out differences between mental health disciplines is difficult. Jay Haley (1977) was once asked: “In relation to being a successful therapist, what are the differences between psychiatrists, social workers, and psychologists?” He responded: “Except for ideology, salary, status, and power the differences are irrelevant” (p. 165). Haley articulated the reality that many different professional tracks can lead you toward becoming a successful therapist, despite a few ideological, salary, status, and power differences.

In this section we explore three confusing and sometimes conflict-ridden questions: What is psychotherapy? What is counseling? And what are the differences between the two?

What Is Psychotherapy?

Anna O., an early psychoanalytic patient of Josef Breuer (a mentor of Sigmund Freud), referred to the treatment she received as “the talking cure.” This is an elegant, albeit vague description of psychotherapy. Technically, it tells us very little, but at the intuitive level, it explains psychotherapy very well. Anna was saying something most people readily admit: Talking, expressing, verbalizing, or sharing one’s pain and life story is potentially healing. This definition isn’t satisfactory as a research definition, but it provides an elegant historic and foundational frame.

As we write today, heated arguments about how to practice psychotherapy continue (Baker & McFall, 2014; Laska, Gurman, & Wampold, 2014). This debate won’t soon end and is directly relevant to how psychotherapy is defined (Wampold & Imel, 2015). We explore dimensions of this debate in the pages to come. For now, keep in mind that although historically Anna O. viewed and experienced talking as her cure (an expressive process), many contemporary researchers and writers emphasize that the opposite is more important—that a future Anna O. would benefit even more from listening to and learning from her therapist (a receptive process). Based on this perspective, some factions in the great psychotherapy debate believe therapists are more effective when they actively and expertly teach their clients cognitive and behavioral principles and skills (aka psychoeducation).

We have four favorite (and different) psychotherapy definitions we’d like to share:

  • A conversation with a therapeutic purpose (Korchin, 1976).
  • The purchase of friendship (Schofield, 1964).
  • [A] situation in which two people interact and try to come to an understanding of one another, with the specific goal of accomplishing something beneficial for the complaining person (Bruch, 1981).
  • When one person with an emotional disorder gets help from another person who has a little less of an emotional disorder (J. Watkins, personal communication, October 13, 1983).

What Is Counseling?

In some settings, an evaluative or judgmental distinction is made between counseling and psychotherapy. Alfred Adler, whom we’ll get to know more intimately in Chapter 3, might say that counseling has an inferiority complex with respect to its older sibling, psychotherapy (Adler, 1958). Or, perhaps it could be that psychotherapy has a superiority complex toward its younger rival, counseling. Either way, at some point you may notice or experience people passing judgment on the relative merits of psychotherapy and counseling.

Counselors have struggled to define their craft in ways similar to psychotherapists. Consider, Kottler and Brown’s (2008) perspective:

Counseling is indeed an ambiguous enterprise. It is done by persons who can’t agree on what to call themselves, what credentials are necessary to practice, or even what the best way is to practice—whether to deal with feelings, thoughts, or behaviors; whether to be primarily supportive or confrontational; whether to focus on the past or the present. Further, the consumers of counseling services can’t exactly articulate what their concerns are, what counseling can and can’t do for them, or what they want when it’s over. (pp. 16–17)

As with the term psychotherapy, a good definition of counseling is hard to find. Here’s a sampling:

  • Counseling is the artful application of scientifically derived psychological knowledge and techniques for the purpose of changing human behavior (Burke, 1989, p. 12).
  • Counseling consists of whatever ethical activities a counselor undertakes in an effort to help the client engage in those types of behavior that will lead to a resolution of the client’s problems (Krumboltz, 1965, p. 3).
  • [Counseling is] an activity…for working with relatively normal-functioning individuals who are experiencing developmental or adjustment problems (Kottler & Brown, 1996, p. 7).

We now turn to the question of the differences between counseling and psychotherapy.

What Are the Differences Between Psychotherapy and Counseling?

Years ago, Patterson (1973) answered this question directly: “There are no essential differences between counseling and psychotherapy” (p. xiv). On this issue, we agree with Patterson and Corsini and Wedding (2000), who wrote:

Counseling and psychotherapy are the same qualitatively; they differ only quantitatively; there is nothing that a psychotherapist does that a counselor does not do. (p. 2)

This statement implies that counselors and psychotherapists engage in the same behaviors—listening, questioning, interpreting, explaining, and advising, but may do so in different proportions.

For the most part, the professional literature implies that psychotherapists are less directive, go a little deeper, work a little longer, and charge a higher fee. In contrast, counselors are slightly more directive, work more on developmentally normal—but troubling—issues, work more overtly on practical client problems, work more briefly, and charge a bit less. In the case of individual counselors and psychotherapists, each of these tendencies may be reversed. For example, some counselors work longer with clients and charge more, whereas some psychotherapists work more briefly with clients and charge less. Additionally, although it used to be that counselors worked with clients who displayed less severe problems and psychotherapists worked with patients who display more severe problems, now, perhaps because obtaining services from master’s-level counselors or social workers is less expensive, counselors often work with lower income clients whose financial stress interacts with and complicates their personal and family problems.

A Working Definition of Counseling and Psychotherapy

At the very least, there are strong similarities between counseling and psychotherapy. Because the similarities vastly outweigh the differences we use the words counseling and psychotherapy interchangeably. And sometimes we use the word therapy as an alternative.

For the purposes of this text and to keep things simple, we offer a 12-part general definition of counseling and psychotherapy (in case you weren’t sure, this reference to keeping things “simple” is an example of sarcasm). Counseling or psychotherapy is:

(a) a process that involves (b) a trained professional who abides by (c) accepted ethical guidelines and has (d) competencies for working with (e) diverse individuals who are in distress or have life problems that led them to (f) seek help (possibly at the insistence of others) or they may be (g) seeking personal growth, but either way, these parties (h) establish an explicit agreement (informed consent) to (i) work together (more or less collaboratively) toward (j) mutually acceptable goals (k) using theoretically-based or evidence-based procedures that, in the broadest sense, have been shown to (l) facilitate human learning or human development or reduce disturbing symptoms.

We should note that, although this definition is long and multifaceted, it’s still probably insufficient. For example, it wouldn’t fit for any self-administered forms of therapy, such as self-analysis or self-hypnosis—although we’re quite certain that if you read through this definition several times, you’re likely to experience a self-induced hypnotic trance-state.

 

 

 

Attachment-Informed Psychotherapy

In the past decade or so I’ve been fascinated over the immense growth in popularity of all things “attachment.” Don’t get me wrong, I believe attachment concepts are robust, interesting, and sometimes useful. I guess I’m not on the attachment bandwagon . . . but I’m not altogether off the bandwagon either.

Here’s an excerpt from our Counseling and Psychotherapy Theories text on Attachment-Informed Psychotherapy. I wonder, before you read this do you know the MAIN difference between attachment-informed psychotherapy and psychoanalytic psychotherapy? I ask this because mostly psychoanalytic psychotherapy is in disfavor, but attachment approaches are all the rage. Do you know the difference?

Attachment-Informed Psychotherapy

Attachment, both as a model for healthy child development and as a template for understanding human behavior is immensely popular within the United States (Cassidy & Shaver, 2008; Wallin, 2007). This is especially ironic because attachment theory’s rise to glory parallels decreasing interest in psychoanalytic models. If you were to ask a sample of mental health professionals their thoughts on attachment theory, you’d elicit primarily positive responses—despite the fact that attachment theory is a psychoanalytically oriented approach.

John Bowlby, who was raised primarily by a nanny and sent to boarding school at age seven, began writing about the importance of parent-child interactions in the 1950s. He was a psychoanalyst. Similar to other neo-Freudians, Bowlby’s thinking deviated from Freud’s. Instead of focusing on infant or child parental fantasies, Bowlby emphasized real and observable interactions between parent and child. He believed actual caretaker-infant interactions were foundational to personality formation (aka the internal working model).

In 1970, Mary Ainsworth, a student of Bowlby’s and scholar in her own right, published a study focusing on children’s attachment styles using a research paradigm called the strange situation (Ainsworth & Bell, 1970). Ainsworth brought individual mother-child (6 to 18 months) pairs into her lab and observed them in a series of seven 3-minute episodes or interactions.

1. Parent and infant spending time alone.
2. A stranger joins parent and infant.
3. The parent leaves infant and stranger alone.
4. Parent returns and stranger leaves.
5. Parent leaves; infant left completely alone.
6. Stranger returns.
7. Parent returns and stranger leaves.

During this event sequence, Ainsworth observed the infant’s:

  • Exploration behavior.
  • Behavioral reaction to being separated from parent.
  • Behavioral reaction to the stranger.
  • Behavior when reunited with parent.

Based on this experimental paradigm, Ainsworth identified three primary attachment styles. These styles included:

1. Secure attachment.
2. Anxious-resistant insecure attachment.
3. Anxious-avoidant insecure attachment.

In 1986, Ainsworth’s student and colleague Mary Main (1986, 1990), identified a fourth attachment style labeled, disorganized/disoriented attachment.

Many contemporary therapists view attachment theory in general, and Ainsworth and Main’s attachment style formulations in particular, as having powerful implications for human relationships and the therapy process (Eagle, 2003; Wallin, 2007). For example, one of the most popular approaches to couple counseling relies heavily on attachment theory principles (Johnson, 2010). In addition, attachment theory has profoundly influenced child development and parent training programs (J. Sommers-Flanagan & R. Sommers-Flanagan, 2011).

At its core, attachment theory involves an effort to understand how early child-caretaker interactions have been internalized and subsequently serve as a model for interpersonal relationships. This is, of course, the internal working model—with an emphasis on how real (and not fantasized) early relationships have become a guide or template for all later relationships. Byrd, Patterson, and Turchik (2010) describe how attachment theory can help with selecting appropriate and effective interventions:

Therapists may be better able to select effective interventions by taking the client’s attachment pattern into consideration. For instance, a client who is comfortable with closeness may be able to make good use of the therapeutic relationship to correct dysfunctions in his or her working models of self and others. On the other hand, a client who is not comfortable with closeness may find it difficult to change internal working models through the therapeutic relationship. Finally, knowing that a client is not comfortable with closeness would allow the therapist to anticipate a relatively impoverished alliance, and therefore avoid interventions such as insight oriented or object relations therapies that rely heavily on the alliance. (p. 635)

As an internal working model, attachment theory also has implications for how therapists handle within-session interpersonal process. Later in this chapter we provide an attachment-informed psychoanalytic case example (see the Treatment Planning section).

It should be emphasized that many criticisms of attachment theory exist. Some critiques have similarities to criticisms of psychoanalytic theory. Perhaps the greatest criticism is the tendency for individuals to take the Mary Ainsworth’s 21 minutes of behavioral observations with one primary caregiver and generalize it to the entire global population. In this sense, the theory is not especially multiculturally sensitive. It seems obvious that there are many divergent ways to raise children and not all cultures subscribe to the “American” overemphasis and perhaps preoccupation with the infant’s relationship with a single caregiver (usually the mother).

Although scientific critiques have sought to reign in attachment theory as it has galloped its way into pop psychology and the media (Rutter, 1995), its popularity continues to escalate and the consequences seem to magnify the importance of an overly dramatized dance of love between a child and his or her mother. In the following excerpt from A general theory of love, you can see the language is absolute and, interestingly, rather sexist—in that children are typically portrayed as male and parents as female.

One of a parent’s most important jobs is to remain in tune with her child, because she will focus the eyes he turns toward inner and outer worlds. He faithfully receives whatever deficiencies her own vision contains. A parent who is a poor resonator cannot impart clarity. Her inexactness smears his developing precision in reading the emotional world. If she does not or cannot teach him, in adult-hood he will be unable to sense the inner states of others or himself. Deprived of the limbic compass that orients a person to his internal landscape, he will slip through his life without understanding it. (Lewis, Amini, & Lannon, 2001, p. 156)

Take a moment to imagine how Karen Horney or Mary Ainsworth might respond to this overgeneralization of attachment concepts and blaming of mothers for their children’s emotional deficiencies.

John and Nora

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.