How Therapists Act

Combining Major Approaches To Psychotherapy And The Adaptive Counselling And Therapy Model

Don W. Nance

• Publisher: Taylor & Francis
• Year: 2020
• ISBN:
  9781317763482
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

In this edited casebook, therapists identified with major theoretical approaches demonstrate how they use the Adaptive Counselling and Therapy ACT Model in combination with their preferred theoretical perspective. Differences in each therapist's tone and approach are captured in six case chapters. Weaving the integrative thread of ACT throughout the tapestry of cases, this text combines illustrative material from specific theoretical approaches.; A major focus of the volume involves combining ACT with Cognitive Behaviour Therapy, Humanistic Psychotherapy, Systems Theory, Time-Limited Psychodynamic Counselling and Eclectic Counselling for women and men.; Serving as a text for graduate-level methods and theory courses in counselling, psychology, mental health counselling and counselling guidance, this book can also be used as a resource for practitioners in the same areas. It emphasises tasks, readiness, and adapting therapist behaviour and treatments to each client.

Chapter 1
GETTING READY: INTRODUCTION AND OVERVIEW

Don W. Nance
Wichita State University

What am I going to do?

How should I behave?

How am I supposed to act?

These questions could be voiced by a beginning practicum student in anticipation of meeting with a “real live” client for the first time. The questions also could be asked by a master therapist with years of successful experience. The questions and the issues reflected by the questions are fundamental constants for therapists. The basic questions have a myriad of variations. The experienced therapist, for example, may not share the practicum student’s concern for “What do I do if the client doesn’t talk?” and “How do I explain the tape recorder?” Questions about how to behave in therapy take a variety of forms:

Do I listen attentively and offer support?

Do I confront?

Do I inform, educate, instruct, or teach?

Do I self-disclose?

Should I initiate a topic?

Should I shift the focus?

Should I follow the client’s lead?

If I am able to do all these behaviors, when do I do what?

The Adaptive Counseling and Therapy model offers a systematic way of answering questions about what behaviors are likely to be therapeutic in a clinical situation. More easily identified by its acronym, ACT, the model is aptly named since it focuses on how therapists act or behave in therapy. The central tenet of ACT is that to be effective with a range of clients and problems the therapist needs to adapt his/her behavior to fit the client.

ACT is a relative newcomer among the models and theories used by mental health professionals. As such, some relevant issues need to be explored. One issue concerns exclusivity. You may ask questions such as, “Do I have to give up my preferred theoretical orientation(s) to use ACT?” and “Can I integrate ACT concepts into my existing framework and methods?” From its initial published presentation, ACT has been presented as an integrative metatheoretical model (Howard, Nance, & Myers, 1986). Fundamental to such a claim is the ability of ACT both to integrate or organize a variety of theoretical perspectives and to demonstrate its utility to those practitioners operating from within a particular theoretical perspective. In terms common to research design, the question becomes, “Can the utility of the model be demonstrated both between theoretical perspectives and within a given theoretical orientation?”

The organizing theme of this book is to illustrate how practitioners utilized the ACT model in clinical practice while operating from within a generally recognized theoretical perspective. The use of cases enables the reader to experience vicariously the myriad of choice points in the process of counseling. The chapters demonstrate how the ACT model is used to identify the most appropriate therapist behaviors in particular situations. In each chapter, the contributing author brings to the surface important aspects of processes that frequently are internal. How does the therapist conceptualize the client, the issues, and the goals of treatment? How does the therapist develop a plan for the course of therapy? Through the use of verbatim transcripts and summarized dialogue, the reader has an opportunity to gain insight into how the plans are carried out.

The purposes of this initial chapter are to provide an orientation to the organization of the book, a brief overview of the ACT model, the rationale for the selection of orientations and authors, and an acknowledgement of limitations and restrictions. The accomplishment of these tasks will increase your readiness to read each of the remaining chapters. Each chapter illustrates the use of a major theoretical approach with particular aspects of ACT and identifies how ACT assists in the treatment process. Each chapter is unique in tone and style reflective of both the contributing author and the orientation being presented. No attempt was made to homogenize the various approaches or to remove the differences in writing style and emphasis.

KEY CONCEPTS OF ACT

Therapist behaviors can be organized into two dimensions. The direction dimension deals with task definition and accomplishment. What’s the problem? What needs to change? What is involved in the process of change? How is the progress determined? Other terms sometimes associated with this dimension are “task” and “structure.” Support is the second dimension. Support behaviors of a therapist include all the “core conditions” of caring, empathy, positive regard, and nonverbal attending behaviors. Positive and negative reinforcement also are elements of this dimension. Other terms sometimes include “relationship,” “social-emotional support,” and “caring.”

Both dimensions are continuums. Effective counseling situations require 100% of direction (answering the task/structure questions of What? How? Who? When? Where? and Why?) and 100% of support (providing attention, concern, empathy, feedback, and reinforcement). Treatment decisions are based on the answers to the questions: How much direction and how much support are supplied by the client? How much by the counselor? Over the course of therapy, what changes is the source(s) of the direction and support/reinforcement. Fundamental to the process is allowing the client to utilize his or her own resources as much as possible. The counselor need only provide as much direction and support as is required to assist the client in his or her progress toward internalized, independent functioning with regard to particular counseling goals. In Figure 1 the two dimensions, direction and support are divided at each midpoint creating four quadrants of styles. This categorization of these continuous dimensions is intended to aid understanding, application, and research. The four quadrants are labeled by the styles associated with each: Style 1—Telling, when the therapist’s behavior is very directive with little support; Style 2—Teaching, when the therapist offers high amounts of both direction and support; Style 3—Supporting, when the supportive behaviors of the therapists predominate over any directive elements; and Style 4—Delegating, when the therapist provides little support and little direction, thereby delegating the direction and support responsibilities to the client.

Figure 1. Therapist dimensions and styles.

The various options for actions available to a therapist can be characterized as having varying degrees of direction and support. The behavior of the psychoanalyst during free association is low in both direction and support (S 4). Prototypic client-centered behavior is high on support and low on direction (S 3). The instructive teaching of various cognitive behavioral methods is high on direction and also may be high on support and positive reinforcement (S 2). The clear contingencies of a behavioral modification program or the confrontation of denial in chemical dependency treatment is likely to be high on therapist direction and low on therapist support (S 1).

Thus far, the two dimensions of therapist behavior, direction and support, have been identified, and the four styles of therapist behavior have been described and illustrated briefly. Now let’s turn the focus to the client. Client readiness is another of the key concepts in ACT. The therapist adapts his/her style based on the assessment of how ready the client is to accomplish the counseling task at hand. The therapeutic goal may be to get a job, choose a major, differentiate from enmeshed family of origin, be less anxious or less depressed, or be more responsible. Client readiness is likely to vary depending on the task.

The three components of readiness are willingness, ability and confidence. These components are not independent of each other. A client’s confidence may impact willingness. Increases in ability may build confidence and increase willingness.

Willingness is the client’s current motivation for working on the therapeutic task. Is the client eager to change? Ambivalent? Resisting? Coerced? Ability is the client’s current ability level on the task. Information, knowledge, and skills are aspects of ability. If the task is to get a job, one client (by experience, training, and connections) may be quite able to accomplish the job search task, while another hasn’t got a clue about where to start and what to do. One client may be eager to engage in the job search, while another may be resistant to the search process. The amounts of direction and support from the therapist need to be different depending on each client’s level of current ability and willingness. If the task requires abilities or skills the client is incapable of developing, then the task/goal and/or the path to the goal need to be reevaluated.

The client’s own view of his or her ability to be successful at the task is one way to view the third component of readiness—confidence. How does the client’s view match the therapist’s impressions? Does the client’s confidence match with ability? Is confidence unrealistically high or too low? How does confidence impact the client’s willingness?

The three components of client readiness are displayed in Figure 2 in various combinations. The readiness dimension ranges from willing, able, and confident at the high end (R 4) to unable, unwilling, and unconfident at the low end (R 1). Also presented in Figure 2 are the developmental cycle and the regressive cycle. If the client is becoming more willing, able, and/or confident, the movement is in a developmental direction toward R 4. The regressive cycle represents those instances when the client’s readiness is decreasing or moving backwards. Decreases in readiness most often are tied to changes in confidence or motivation. If ability seems to have decreased, it may be that the task has changed.

Figure 2. Client readiness.

The basic therapeutic mechanisms for the therapist are

1. to increase ability, provide direction, and support while teaching skills.
2. to address unwillingness on critical, essential tasks, use direction, power, and contingencies. If lacking power or contingencies, the therapist should choose not to work on those tasks for which the client is unmotivated.
3. to develop confidence, use support, feedback, and increased ability.

The ACT concept of match and move is illustrated in Figure 3 by the vertical arrows that go from readiness level to a corresponding therapist style. If the client’s readiness for the task is R 2, willing but unable, the therapist style of choice is to teach using high direction and high support. That’s the match. The move takes place by systematically altering the amounts of direction and support as the client’s readiness increases. The bell shaped curved line in Figure 3 represents this process. Movement in a developmental direction is actually a step-wise process of reducing direction while increasing support through Styles 1 and 2 and reducing both direction and support through Styles 3 and 4. The movement is forward or backward one step or style at a time. The client who is regressing from functioning independently, R 4, with the therapist providing little attention, direction, or support to the topic or task (S 4) is likely to need an increase in support (S 3) rather than lots of direction (S 1).

Figure 3. Matching therapist style and client readiness.

SELECTION PROCESS FOR ORIENTATIONS AND AUTHORS

The major theoretical orientations within the helping professions are included here—cognitive behavioral, humanistic, and psychodynamic. Those selections are supported by surveys reported in the literature (Zook & Walton, 1989). The systems orientation also is included. This orientation is central to marriage and family therapy work and increasingly employed by mental health practitioners across academic disciplines. Additionally, much of mental health, particularly counseling psychology, is rooted in the developmental perspective and two chapters are included using a developmental conceptual framework. Thus, the orientations and authors to be presented are

• Cognitive Behavioral—Jerry Deffenbacher
• Psychodynamic—Steve Robbins and Karen Lese
• Humanistic—Willis Poland
• Developmental Issues: Women—Eileen Nickerson
• Systems—Pennie Myers
• Developmental Issues: Men—Gordon Hart

The two chapters on the developmental issues for women and for men represent another major theoretical perspective—eclectic. The question of whether eclectic can be considered a “theory” and the debate over conceptual purity vs. eclecticism (Nance & Myers, 1991) do not alter the fact that many practitioners apply the eclectic label to identify their theoretical orientation. The psychodynamic and humanistic threads in Eileen Nickerson’s chapter (Chapter 6) are apparent and acknowledged. Similarly, Gordon Hart uses an awareness of the developmental issues for men to conceptualize t...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• TABLE OF CONTENTS
• LIST OF FIGURES
• PREFACE
• CHAPTER 1 GETTING READY: INTRODUCTION AND OVERVIEW
• CHAPTER 2 COGNITIVE-BEHAVIOR THERAPY AND ACT
• CHAPTER 3 HUMANISTIC PSYCHOTHERAPY AND ACT
• CHAPTER 4 TIME-LIMITED PSYCHODYNAMIC COUNSELING AND ACT
• CHAPTER 5 SYSTEMS THEORY AND ACT
• CHAPTER 6 AN ECLECTIC APPROACH TO COUNSELING WOMEN
• CHAPTER 7 DEVELOPMENTAL ECLECTIC COUNSELING WITH MEN
• CHAPTER 8 UPDATING ACT
• INDEX
• ABOUT THE AUTHOR