Core Competencies in Counseling and Psychotherapy

Becoming a Highly Competent and Effective Therapist

Len Sperry

• Publisher: Routledge
• Year: 2011
• ISBN:
  9781135927868
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

Core Competencies in Counseling and Psychotherapy addresses the core competencies common to the effective practice of all psychotherapeutic approaches and includes specific intervention competencies of the three major orientations. The book provides a research-based framework to aid clinicians in applying these competencies in their own practice. It begins by identifying and describing the core competencies and skills of expert therapists, thenelaborates six core competencies and related supporting competencies and skill-sets. Instead of a review of psychotherapy theory and research or a cookbook of methods and techniques, Core Competencies in Counseling and Psychotherapy is a highly readable and easily accessible book that can enhance the knowledge and skill base of clinicians – both novice and experienced – in all the mental health specialties.

Section II
Core Competency 1: Conceptual Foundations

2
Conceptual Foundations

It has been said that there is one requisite clinical competency to which all other clinical competencies are anchored. That requisite competency is a theoretical framework or map “of personality, psychopathy, and therapeutic process” (Binder, 2004, p. 26). First, therapists need a theoretical understanding of the normal process of development and functioning, that is, a theory of personality. Second, therapists need a theory of how functioning goes awry and becomes maladaptive, that is, a theory of psychopathology. Third, therapists need a theory of how maladaptive processes can be changed, that is, a theory of therapeutic processes.

Possessing such a theoretical framework guides what and how a therapist observes and collects client information, how that information is conceptualized, and how the interventions based on that conceptualization are planned, implemented, and evaluated. “Therapists must have a conscious cognitive map or working model of the immediate therapeutic situation, including just enough theory to comprehend the problem context and design intervention strategies, but not so much as to get in the way of attunement to the patient and spontaneous reactions to the changing context” (Binder, 2004, p. 27).

Although therapists may consider themselves eclectic in orientation, research indicates that all therapists espouse at least one basic theoretical orientation that informs their understanding of personality, psychopathology, and the therapeutic process. This cognitive map also serves to guide their therapeutic efforts in a consistent, confident, and effective manner (Binder, 2004). This chapter provides a brief overview of three of the most commonly practiced theoretical orientations in the United States: dynamic, cognitive–behavioral, and systemic approaches. Each is described in terms of its assumptions or premises, its basic theory and methods. It also describes the “conceptual map” of each approach with regard to personality, psychopathology, and the therapeutic process.

COMPETENCY OF APPLYING A CONCEPTUAL MAP

The following essential clinical competency is associated with the core competency of conceptual foundation.

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Apply a Conceptual Map to Understand and Direct the Therapeutic Process

This competency involves the capacity to utilize a theoretical understanding and conceptual map of personality, psychopathy, and the therapeutic processes to assess, conceptualize, plan, and implement a course of therapy in a consistent and effective manner.

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The “Tri-Y Model”

Chapter 1 briefly described a novel integrative framework, the “Y-model,” for visually representing the psychiatry requirement that trainees demonstrate competency in three psychotherapy approaches (Plakun et al., 2009). It is named for the letter Y in which the “stem” represents the core competencies common to all therapy approaches (including supportive therapy) while one “branch” represents the specialized competencies of cognitive–behavioral therapy (CBT) and the other “branch” represents specialized competencies of the dynamic therapies.

Because individuals experiencing severe and chronic mental disorders are commonly treated with medication and supportive therapy, requiring psychiatrists to be competent in supportive therapy makes good sense. However, this requirement makes less sense for nonmedical therapists who are less likely to work with this patient population and because these therapists are more likely to have involvement with couples and families, even if only in consultation. Thus, training in systemic approaches makes more sense. Today, the CBT, dynamic, and systemic (particularly solutionfocused therapy) approaches are commonly practiced in the United States and much of the Western world. Accordingly, these three approaches are represented in this book. This chapter focuses on the foundational elements of each, while Chapters 8 through 10 focus on selective CBT, dynamic, and systemic intervention competencies. These three approaches can be visually represented as the Tri-Y model, in which the core competencies of psychotherapy are represented in the stem, and the CBT, dynamic, and systemic approaches are represented in the three branches (Figure 2.1).

DYNAMIC APPROACHES

Dynamic refers to psychological theories that view thoughts, feelings, and behaviors as the manifestation of inner or unconscious drives and processes and their interaction. Dynamic is used in this book to represent a broad category of approaches that encompass psychoanalysis and other psychoanalytic and psychodynamic therapies. Generally speaking, dynamic therapies endeavor to bring unconscious material and processes into full consciousness so individuals can gain more control over their lives. These therapies have their origins in psychoanalysis and stem from the work of Sigmund Freud and others who have made major contributions and reformulations to Freud’s original theory. These reformulations include ego psychology, object relations theory, self psychology, and the interpersonally oriented dynamics therapies, including time-limited dynamic psychotherapy. Although there are important differences in both theory and practice among these different approaches, they share certain common principles (Blagys & Hilsenroth, 2000; Gabbard, 2004). These include the following:

1. Unconscious. Much of mental life involves and is influenced by unconscious processes.
2. Resistance. The exploration of resistance, including ambivalence to change, and defenses is a focus of therapy.
3. Transference. The exploration of transference, including the reenactment of the past in response to the therapist.
4. Symptoms and behavior. Symptoms and behavior serve multiple functions, which are determined by complex and usually unconscious forces.
5. Exploration. Therapy emphasizes exploration of basic assumptions about self and the world and/or maladaptive relational patterns rather than simply focusing on symptom relief.

Figure 2.1 “Tri-Y Model”: Relationship of Three Therapy Approaches to Core Competencies.

The Evolution of Dynamic Therapy

Dynamic therapy has evolved considerably since Sigmund Freud’s time. Five phases of this evolution can be identified. These phases, also called psychologies (Pine, 2003), can be summarized with the key terms drive, ego, object, self, and relationship. This section briefly describes each of these phases.

Drive: Classical Psychoanalysis

The first drive-based dynamic approach is called classical psychoanalysis and was developed by Freud (1940). In classical psychoanalysis, the analysand (client) verbalizes thoughts, free associations, fantasies, and dreams, from which the analyst (therapist) identifies the unconscious conflicts causing the client’s symptoms and characterological issues, which include unconscious aspects of the therapeutic alliance. The analyst’s interventions include confrontation, clarification, interpretation, and working through the process by which a new awareness generalizes to other aspects of the client’s life.

Drive: Psychoanalytic Psychotherapy

Another drive-based dynamic approach is psychoanalytic psychotherapy. It is a modified form of classical psychoanalysis that is more widely practiced than classical psychoanalysis today. It is less intense and less concerned with major changes in the client’s personality structure and focuses on the client’s current concerns and the way these concerns relate to early conflicts.

Ego: Ego Psychology

Ego psychology evolved out of Freud’s later thinking and was the dominant form of psychoanalysis practiced until the 1970s. Freud’s daughter, Anna Freud, played a significant role in its development (Freud, 1936). It focuses on the ego’s normal and pathological development and its adaptation to reality. Unlike the focus on libidinal and aggressive impulses of classical psychoanalysis, ego psychology focuses directly on the ego and its defenses. Through clarifying, confronting, and interpreting the client’s commonly used defense mechanisms, the goal is to assist the client in gaining control over these mechanisms.

Object: Object Relations

Since the 1970s, major reformulations of psychoanalysis have emerged. Among these was object relations theory, which emphasizes interpersonal relations especially between mother and child. Melanie Klein was a key architect of this approach (Klein, 1975). Object refers to a significant other who is the object of another’s feelings or intentions. Relations refers to interpersonal relations and to the residues of past relationships that affect a person in the present. Object relations theory focuses on internal images or representations of the self and other and their manifestation in interpersonal situations. This therapy focuses on the ways the client projects previous object relationships into the relationship with the therapist. The goal is to assist clients in resolving the pathological qualities of past relationships through the corrective emotional experience. While some interpretation and confrontation may be involved, the working through of the original pathological components of the patient’s emotional world and the objects is the primary intervention strategy.

Self: Self Psychology

Another reformulation, initiated by Heinz Kohut, was self psychology, which emphasizes the development of a stable and cohesive or integrated sense of self through empathic contacts with significant others, that is, self-objects (Kohut, 1977). Self-objects meet the developing self’s needs for mirroring, idealization, and twinship, and serve to strengthen the developing self. Treatment proceeds through transmuting internalizations in which the client gradually internalizes the self-object functions provided by the therapist.

Relationship: Relationally Oriented Dynamic Therapies

There are also some reformulations based on relational themes. Interpersonal psychoanalysis emphasizes the nuances of interpersonal interactions, especially the way in which individuals protect themselves from anxiety by establishing collusive interactions with others. Relational psychoanalysis combines interpersonal psychoanalysis, object relations theory, and intersubjective theory. Relational psychoanalysis emphasizes how the individual’s personality is shaped by both real and imagined relationships with others and how these relationship patterns are reenacted in the interactions between therapist and client.

Time-limited dynamic psychotherapy (TLDP) is a brief, relationally oriented dynamic therapy that was originally developed for clients with chronic, pervasive, dysfunctional ways of relating to others (Strupp & Binder, 1984). TLDP is influenced by attachment, object relations, interpersonal, experiential, cognitive–behavioral, and system approaches (Levenson, 1995). It focuses primarily on changing cyclic maladaptive relational patterns rather than on symptom reduction per se. The therapist identifies the client’s cyclical maladaptive pattern, which consists of inflexible, self-defeating expectations and behaviors and negative selfappraisals that lead to maladaptive interactions (Binder, 2004). TLDP has two therapeutic goals: new experiences and new understandings. In the course of treatment, the therapist provides clients the opportunity to disconfirm their interpersonal schemas, promoting a corrective emotional– interpersonal experience.

The focus of treatment is derived from the client’s cyclical maladaptive pattern, which becomes a blueprint for the treatment in that it provides a problem description and goals, a guide for interventions, and a means of anticipating transference reenactments and understanding counter-transferential reactions (Binder, 2004). Treatment is based on a therapeutic strategy, and intervention based on various theoretical orientations is utilized to facilitate the treatment goals.

Basically, this approach assumes that over the course of their lives, clients have unintentionally developed self-perpetuating, maladaptive patterns of relating to others and that these patterns underlie their present problems. The therapist’s role is to use the therapeutic alliance to facilitate in clients a new experience of relating, which allows them to break their maladaptive pattern and thereby resolve their presenting problem (Levenson, 1995).

Dynamic Perspective on Personality, Psychopathology, and Psychotherapeutic Process

Personality

From an object relations perspective, personality is viewed in terms of interactional structures, that is, self-object representations, resulting from the internalization of particular interpersonal experiences. Early factors such as temperament influence interactional styles, just as later internalizations can modify these internal structures. These internalizations approximate what actually occurs when interpersonal stress is minimal, but when such stress is significant (i.e., when a person experiences trauma), perceptual and cognitive functions are impaired and distortions of interpersonal occurrences are internalized and can have a significant effect on personality development. Unlike classical psychoanalysis, which holds that personality is crystalized by the end of the Oedipal phase of development, TLDP considers personality to be dynamically changing as it interacts with others (Levenson, 1995; Strupp & Binder, 1984).

Psychopathology

Disturbances in adult interpersonal relatedness typically stem from faulty relationship patterns with early caregivers. These early experiences result in dysfunctional mental representations—also called mental models or schemas—which are maintained in the present (Binder, 2004). These mental models engender maladaptive pattern interpersonal interactions or relationship styles that are reflected in symptoms and occupational and interpersonal distress and dissatisfaction.

Psychotherapeutic Process

The client’s maladaptive interpersonal patterns are reenacted in therapy, and the therapist will be influenced by the client’s enactment and will reciprocate. Thus, treatment is focused on modifying both the mental model and the maladaptive interpersonal pattern. This central focus on interactions distinguishes this from other psychoanalytic approaches that emphasize personality reconstruction (Levenson, 1995).

COGNITIVE–BEHAVIORAL THERAPIES

Cognitive–behavioral therapy (CBT) is a category of psychotherapeutic approaches that emphasize the role of cognitions in feelings and behavior. There are several approaches to CBT, including behavior therapy, cognitive therapy, schema therapy, dialectic behavior therapy, cognitive–behavioral analysis system of psychotherapy (CBASP), and mindfulness-based cognitive therapy.

Common Characteristics

Although there are differences among these approaches, they all share a number of common characteristics. Based on an empirical review of the literature, the following factors were found to characterize the commonalities shared by all CBT approaches (Blagys & Hilsenroth, 2002).

1. Focus on cognitive and behavioral factors. A basic premise of CBT is that clients’ emotions and behavior are influenced by their beliefs or thoughts. Because most emotional and behavioral reactions are learned, the goal of therapy is to help clients unlearn unwanted responses and to learn a new way of responding. By evaluating, challenging, and modifying maladaptive beliefs and behaviors, clients are able to gain control over problems previously believed to be insurmountable.
2. Direct session activity. CBT is a directive approach in which therapists typically direct session activity by setting an agenda, deciding and planning in advance what will be discussed during the session, and actively directing discussion of specific topics and tasks. Cognitive–behavioral therapists also endeavor to stimulate and engage clients in the treatment process and these decisions.
3. Teach skills. Because CBT is also a psychoeducational approach, cognitive–behavioral therapists teach clients skills to help them cope more effectively with problematic situations. Dealing directly with skill deficits and excesses is central to clients achieving and maintaining treatment gains.
4. Provide information. Cognitive–behavioral therapists also discuss the explicit rationale for their treatment and the specific techniques being used. They may provide clients with detailed information (e.g., books or handouts) to orient clients to the treatment process, to increase their confidence in treatment, and to enhance their ability to cope with problematic situations.
5. Use homework and between-session activities. Homework and between-session activities are a central feature of CBT. Such activities provide clients the opportunity to practice skills learned in sessions and transfer gains made in treatment to their everyday lives. Such activities can also foster and maintain symptom reduction.
6. Emphasize present and future experiences. CBT focuses on the impact clients’ present maladaptive thoughts have on their current and future functioning. In addition, skills learned in therapy are designed to promote more effective future functioning.

The Evolution of CBT

The term cognitive–behavioral therapy came into usage about 30 years ago. It evolved from both cognitive and behavioral traditions in psychotherapy. A useful way of understanding this evolution is in terms of what has been called the “three waves” of CBT (Hayes, Follette, & Linehan, 2004).

First Wave

The first wave emphasized traditional behavior therapy, which focused on replacing problematic behaviors with constructive ones through classical co...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Foreword
• Preface
• Section I Introduction
• Section II Core Competency 1: Conceptual Foundations
• Section III Core Competency 2: Therapeutic Relationship
• Section IV Core Competency 3: Intervention Planning
• Section V Core Competency 4: Intervention Implementation
• Section VI Core Competency 5: Intervention Evaluation and Treatment
• Section VII Core Competency 6: Cultural and Ethical Sensitivity
• Section VIII Conclusion
• Bibliography