Intentional Intervention in Counseling and Therapy

Goals and process in client engagement

Peter Geiger

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781351785310
• Edition: 1
• Topic: Psychology
• Subtopic: Psychoanalysis
• Index: Psychology

Intentional Intervention in Counseling and Therapy answers three questions: what heals in counseling and therapy and how? What actions in clinical decision making ensure anoptimal outcome for the client? And why are some clinicians more successful than others, apparently remaining so over time? Incorporating citations across multiple disciplines, referencing authorities in both CBT and psychodynamic models, and interwoven with composite case material and session transcripts, this book unmasks the dialectic between goals and process in clinical work.

Part I

Phenomenology of clinical decision making

1
Theory

Observation and construction • evolutionary aggregation and the developmental metamodel

Theory, the clinician and “good” therapy • theory of the dialectic • theory as historically contextualized work-in-progress • theory and neuroscience

Metatheory of developmental counseling and therapy

(Dr. Allen Ivey)

The rider and the elephant (Dr. Jonathan Haidt)

Thesis, antithesis and synthesis • observable phenomena

Roads to Rome

The reification “theory” describes a constructed way of thinking about and languaging what has befallen the client and what it is we may seek to do about that. Through theory we find ways to understand people and conceptualize our many divergences. The first divergence concerning us is that each of us, educators and students alike, has an ingrained preference for treating the client either with an active therapy of doing, predominantly targeting symptoms, or, predominantly targeting personality, by means of feeling into an understanding of the client. We judge and draw from theory accordingly. In responding to theory we are reflexive and selective. It is therefore insufficient merely to describe or compare theory; it is necessary in addition, as Truscott urges, to consider and communicate our own personal interaction with and response to theory, including our conceptualization of how theory is brought to life and put to use in the therapy room for the benefit of our clients.¹ And we must examine closely why we, each of us, dislike one or more theories.

In our classrooms we teach the evolution of modern psychology theory from Austrian neurologist Sigmund Freud to the present day. The discourse is often of progression: older theories are dated and incomplete; newer is better, and newest is most useful to us. There is considerable truth to these ideas. Counseling and therapy is an essentially localized endeavor and, as times, context and locality change, so does demand for psychological services. As Bengali American philosopher Haridas Chaudhuri puts it, “Each culture and time produces its own answer to its own need.”² Theory, then, evolves as response to environmental challenge.

Thus Freud, an educated, minority citizen of culturally prolific but politically fractured Central Europe, analyzed himself and took his insights into his work with his middle-class patients; his theory was a constant work-in-progress, built, dismantled, re-built, re-written, changed and refined over his long working life. George Washington University psychologist Robert Kramer traces Freud’s influence through Austrian American psychoanalyst Otto Rank to University of Chicago psychologist Carl Rogers.³ Almost fifty years junior to Freud, Rogers’ observations in his work after World War II were of patients of an altogether different demographic. Each authority constantly shapes and re-shapes his theory and practice so that he can be of better use to his clients at the time and in context.

Theory on theory

Chaudhuri, whose integral philosophy teaches that “every action is succeeded by a counteraction of equal force,”⁴ would not have been at all surprised by the responses in the second part of the twentieth century to Freudian theory. He would see it as entirely necessary, fitting and inevitable that the great man of cognitive theory, University of Pennsylvania psychiatrist Aaron Beck, trained in psychoanalysis, found the old to be incomplete, even misguided, and established an entirely new way of understanding emotional suffering and how we may seek to alleviate it, bequeathing us new languaging that has completely changed the discourse.

Yet we may not understand Chaudhuri’s evolutionary pendulum swing to imply that the counteraction and new discourse void the preceding action. Psychoanalysis and its insights still exist. As discourse, time and context progress and evolve, the Good Therapy Archetype necessarily informs each manifestation of theory. This means that no theory is discardable and all are valuable. We may prefer Satir over Bowen. But Bowen was a great scholar and committed helper who wrote about things he saw and experienced passionately and who (correctly) believed his conceptualizations can help us. He must have had good reasons for his formulations, and if we pay attention to Bowen (though we feel more comfortable with Satir), we may learn something to assist our understanding and we may use that increment of learning to help a client. This is the discourse of theory progression and aggregation: Beck builds on and adds to Freud.

Such is the ideal synthesis. Yet there are problems in teaching and learning theory. The discourse of theory progression and synthetic aggregation yields easily to the discourse of supersession. It is apparent that the insights of the newest or newer theory or theories are most informed and most relevant to the times. Humans, as we shall go on further to explore, gravitate to certainty and lean toward extrapolation. The process thesis also has its antagonists. In academic programs highlighting or emphasizing change tasks in therapies of doing, some of us will inevitably over-rely on half the story, that of treating symptoms: CBT replaces psychodynamic theory.

For Truscott, our theory antagonism, our liking or disliking for one or more theories, begs investigation. I may dislike a theory for a number of reasons. I do not fully understand it or do not myself possess or have not developed the skills to use it effectively. That theory and I are not a “fit.” Perhaps the theory comes with unsettling memories: a clinician once used it on me, and it didn’t feel comfortable or didn’t work. Or perhaps its authorities write in technical languaging that is simply too difficult for me to read. Perhaps the theory comes with unpalatable ideas and associations pertaining to human nature, which my belief system rejects. And I may also reject a theory because it requires more of me in either goals or process than I am in a position to give the client.

Now we can begin to understand the origins of the polarization of cognition in the psychotherapy debate. Our theory partisanship is reflexive and defensive and comes from a position—this has to be the correct analysis of the countertransference—of fear and alienation. More crucially, our theory partisanship is not useful. Is it not rather more useful to the client if I ask myself the question: what is it I do not see about this theory that the theory’s authorities do see and how does it come about that they are able to use the method effectively and I am not?

For surely the only “good” theory, the only theory of any interest, is the one we can use now to help this client. If, conversely, we are not right now succeeding in helping this client, perhaps we should broaden our scope and look past our fear and outside our comfort zone to master an alternate, ancillary theoretical stance that will improve our work? Surely we must, in ethics, do this, lest our theory partisanship become an obstructive countertransference. Once we add these ideas to our working hypothesis, the inescapable conclusion is that it is no longer good enough for us to say, “That theory is not for me.” The risk of missing something of vital importance to our work with a client—even one client—is simply too great. Rather we must, with Truscott, “continuously revise and expand [our] personal theory by assimilating the rationale, goals and change tasks from other theories.”⁵

The codification of new theory always involves new languaging describing what has befallen the client and what it is we may seek to do about that. New languaging always results from and confers new insights and may be striking. But often what is being talked about or emphasized in the new way is not, in and of itself, new. Thus, when we teach that Rogers postulated his three (as I call them) “essential therapist qualities” of congruence, unconditional positive regard and empathy, how do we intend our students to understand the significance of what they hear? In seeking to highlight Rogers’ contribution to theory are we implying that therapists before his codification did not exhibit such qualities and therefore their work was necessarily inferior to Rogers’? Or do we believe that these earlier therapists did exhibit, must have exhibited the “Rogerian” qualities, perhaps languaging or positioning them differently in their theoretical writings, and that it is Rogers’ positioning, emphasizing and languaging we feel has a clearer voice for us today, which is why we like to teach it? The question and distinction are significant in good education, the elimination of theory partisanship and to the pursuit of our quest.

Good theory

I am indebted to British psychiatrist Jeannette Josse for the construct of Good Therapy.⁶ We were talking about school-based family counseling and therapy (SBFC&T), a then relatively unpublicized metamodel predicated upon the goal of school success. Jeannette asked me what the clinician does that makes it SBFC&T, as opposed to, say, school counseling, family therapy or school social work. I described these things and she said, “Oh. Good therapists have always done that.” Indeed. University of San Francisco professor emeritus Brian Gerrard tells me he first made the formulation “school-based family counseling” in 1983 upon the launch of a new program in San Francisco Bay Area schools; the new program, he says, deserved new languaging.⁷ The new languaging has, over time, afforded new theoretical insights, which is the great evolutionary benefit conferred by new reification; yet although the languaging is new the practitioners and proponents of SBFC&T, including University of British Columbia emeritus professor John Friesen, trace the model’s lineage to Viennese physician-psychotherapist Alfred Adler.⁸

The things school-based family clinicians do predate the formulation.

Similarly, while Rogers codified, languaged and wrote extensively about congruence, unconditional positive regard and empathy, these essential therapist qualities existed at all times before Rogers and independently of his theorizing. Freud, in order to help his patients with Good Therapy, must have practiced and manifested these essential therapist qualities in his way: according to his last surviving patient, Margarethe Lutz, he was, in 1936, “fatherly, friendly, full of understanding. A friend. [PG’s translation of: “väterlich, freundlich, verständnisvoll. Ein Freund.”]⁹

And, as we shall see in the following chapter, Freud did indeed language these things and constellate them into his theoretical writings in his own way.

And so we can begin to look at our accumulated body of theory in a somewhat different fashion, perhaps making it easier for us to follow Truscott and Norcross in rising above the culture wars and the discourse of supersession. For theory is built in increments, each increment augmenting what has gone before. Each authority draws from the Archetype of Good Therapy, which synthesizes goals and process, to build on pre-existing theory and seeks to describe and teach us those things he or she sees and which seem to her or to him to be either useful or important or both. Each successive theorist seeks to redirect and refine our focus and, in so doing, builds new languaging. As much as the new languaging may help our understanding, neither the new way of looking at the situation, nor the new theory nor the newly redirected and refined focus mean that the actions or intent behind or described by the languaging are new or that, importantly for our purposes in this argument, the new languaging, focus and theory are, necessarily for us, new shortcuts to or guarantors of Good Therapy. Or that we should view the old languaging of preceding theorists as “wrong.” Should we not rather view each contribution to our aggregated theory as an auxiliary perspective or thesis, promising additional pertinent, potentially valuable information that we may be able to use to broaden our understanding and our clinical skills now with this client?

A particular individual theory is a response to its time. Our aggregated theory exists so that we can extract from it what is useful, applicable and perennial. San Francisco therapist and feminist Sarah Soul, educated in a predominantly goals-based academic program, believes: “There are some things in psychology for which the only adequate explanation is [psycho]analytic.”¹⁰ If Soul is correct then we need to look at our theory and its developmental trajectory in new ways. Presaging Norcross, Wampold and Truscott, Michigan State University’s Adrian Blow and colleagues seek to delineate the relationship between therapist and theory. As Blow puts it:¹¹

We believe that effective clinical models are an indispensable part of good therapy—not because a particular model contains un...

Table of contents

• Cover
• Title
• Copyright
• Contents
• Acknowledgements
• Preface: The adroit clinician, neuroscience and the dialectic between goals and process
• Prologue: Two theses in theory implementation • cognition and discourse in evidence, practice and outcome
• PART I PHENOMENOLOGY OF CLINICAL DECISION MAKING
• PART II THE THERAPIST-SELF
• PART III PHENOMENOLOGY OF CLINICIAN DEVELOPMENT
• Epilogue: Working hypothesis for intentional intervention • implications for the education of clinicians
• Appendix: What Is Your Preferred Style of Helping?
• Glossary
• Author Index
• Subject Index