Developing Your Counselling and Psychotherapy Skills and Practice

Ladislav Timulak

• Publisher: SAGE Publications Ltd
• Year: 2010
• Print ISBN: 9781848606241, 9781848606234
• eBook ISBN: 9781446242162
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

This book offers a helping hand to trainees wishing to make the transition to the next level in their counselling and psychotherapy training. With wide-ranging content closely aligned to actual practice, this intermediate level text covers the research-informed skills, interventions, processes and issues that students need to know once they?ve covered the basics. It includes:

- Specific techniques from different therapeutic orientations

- How to tailor the skills or approach used to the specific client problem

- Case conceptualisation and management

- Therapeutic alliance; establishing and exploring the relationship

- Ethics

- Multidisciplinary working

- How to deal with situations such as silence, crying, and aggression.

Integrating cognitive, behavioural, person-centred/experiential and psychodynamic approaches, the author provides research-informed practical instructions on how to deliver therapy and includes extracts from counselling sessions to demonstrate the skills in action.

This is essential reading for postgraduates on Counselling and Psychotherapy Diplomas and Masters courses, and will also be of benefit to Clinical and Counselling Psychology students.

Part I

Introduction

One

Current Psychotherapy and Counselling

Abstract

This chapter presents the current field of psychotherapy and counselling in the context of their historical development. The emphasis is on research-informed developments within or across the distinct theoretical approaches (psychodynamic, cognitive-behavioural, humanistic and integrative). References for helpful resources are provided as well.

Psychotherapy is a healing activity that attempts to alleviate human suffering. It uses psychological means to influence psychopathological symptoms, problematic experiencing, behaviour, and personality characteristics as well as general functioning in life (see Kratochvíl, 2002). To start with, we will have a look at the current research-informed psychotherapy.

Theoretical approaches to psychotherapy and counselling

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Counselling and psychotherapy were traditionally developed within several major and distinct paradigms, though most recently there is probably a growing trend towards psychotherapy integration and a more generic understanding of psychotherapy (see Grawe, 2004; Norcross & Goldfried, 2005). Often four main therapy paradigms are recognised: psychodynamic, cognitive-behavioural, humanistic, and integrative and eclectic therapies (see the four volumes of Comprehensive Handbook of Psychotherapy edited by F.W. Kaslow, 2004). Systemic approaches that developed in the tradition of family and couple therapy and its relatives, such as narrative therapy and constructivist therapies, can probably be considered as another distinct paradigm. Outside those major paradigms there are a significant number of other therapeutic approaches (see Corsini & Wedding, 2007). We will now focus on three broadly defined mainstream paradigms that have received most theoretical and research attention. A more complete overview is provided, for instance, in McLeod (2009).

Psychodynamic approaches represent the first theoretical block. These approaches stem from Freud’s psychoanalysis and its long tradition (egopsychology, object relations, etc.). There is growing empirical evidence that supports these approaches (see Shedler, 2010). The developments of empirically studied interpersonal therapy can be loosely assigned to the psychodynamic paradigm as well (see Weissman, Markowitz, & Klerman, 2000).

Cognitive-behavioural approaches represent the second main theoretical paradigm. These approaches currently dominate the field of psychotherapy. This tradition emphasises empirical outcome research, which is well respected in the current era of accountability. Cognitive-behavioural approaches stem originally from two different traditions, cognitive and behavioural. Their combination is probably a pragmatic step as the two paradigms are closely aligned with scientific positivism and ‘hard facts’.

Humanistic therapies represent a group of quite distinct approaches, such as person-centred therapy, Gestalt therapy, different existential conceptualisations and, more recently, emotion-focused therapy, all of which are focused on the person more holistically.

Eclectic and integrative therapies represent either a combination of therapies or therapeutic principles from different major paradigms that can be tailored to individual clients’ problems (e.g. Beutler & Harwood, 2000), or an attempt to create a more comprehensive theoretical framework (e.g. Prochaska & Norcross, 2003) or a formulation of psychotherapy as a generic activity based on psychological, research-informed principles (Grawe, 2004). The traditional paradigms define the main focus and principles of psychotherapeutic practice. Their development is shaped by clinical experience, theoretical thinking and by research findings.

Psychodynamic approaches

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Psychodynamic therapies build on Freud’s psychoanalysis from the end of the nineteenth and the beginning of the twentieth century. Freud described several theoretical concepts relevant to psychopathology and psychoanalytic therapy. They covered, for instance, a motivation theory, where a central role was played by libido and pleasure-seeking behaviour. Freud also outlined a theory of human development, according to which psychopathology is created on the basis of unmastered developmental tasks of pleasure-seeking (libido-gratifying) behaviour. The psychopathological problems are then fixated in the different developmental stages, such as the oral stage, the anal stage, the phallic stage, the latent stage and the genital stage. Freud also developed a theory of psychological defences that reduce anxiety induced by the conflict between wishes and internal or external obstacles hindering their fulfilment. The defences were linked to individual developmental stages. Freud also described the so-called topographic model of the mind (consciousness, sub-consciousness and unconsciousness) and the structural model of mind (id, ego and superego) that represented a framework in which psychological processes are happening.

The basic element of psychopathology was, according to Freud, conflict of opposing motives, which he assumed to be in the unconsciousness. Neurotic symptoms were, according to him, a compromise between opposing unconscious motivational forces (the psychodynamics of latent wishes), which due to the fact that psychological energy stays the same, show in conversion symptoms (see Milton, Polmear, & Fabricius, 2004). The basic motives were then typically of a sexual or aggressive nature.

With regard to principles of treatment, Freud was emphasising that psychoanalytic work focuses on the uncovering of unconscious functioning. The tool of the therapist was the interpretation of unconscious conflicts which became visible through free associations, dreams and the transference of unconscious conflicts to the relationship with the therapist.

Freud’s concepts were, over the generations, well received by a number of mental health professionals, and have subsequently been built on, developed and revised by other psychoanalysts. The most comprehensive concepts were:

• ego-psychology (dating from the 1950s onwards and associated with authors such as Hartman and Mahler), which stressed the cognitive functions of the ego and their use in treatment;
• object relations theory (associated with British authors Klein and Winnicott, and with Kernberg in America, originating in the 1940s and 1950s), which supposes that the object of wishes is the other person and that early interpersonal functioning in intimate relationships, and the cognitive and affective processes mediating this functioning, creates stable patterns of interpersonal relating (see Westen & Gabbard, 1999);
• self-psychology (originating in the 1970s and 1980s and particularly associated with Kohut), which emphasises motives connected to self-esteem and the experience of self-esteem, including identification with significant others in early childhood and empathy in treatment;
• in recent years, especially in North America, one can find relational psychoanalysis, which focuses on the reflection of interpersonal functioning between the analyst and the patient (cf. Mitchell, 1997).

Current empirical knowledge and psychoanalytic concepts

The richness of psychoanalytic theoretical conceptions was not always recognised in the mainstream of psychology. Despite this fact, many of the psychoanalytic conceptions, based on the analysts’ clinical experience, correspond nicely with current psychological knowledge. This is illustrated by the American analysts Drew Westen and Glen Gabbard (1999; see also Westen, 1998) in their overview comparing psychoanalytic personality theories with current empirical psychological knowledge. For instance, Westen and Gabbard point to the proved importance of emotions as primary motivational mechanisms that have a potential to be adaptive. They cite evidence showing that people are motivated by parallel motivational systems which potentially lead to conflict. The presence of conflict is, according to them, also suggested by the existence of ambivalence in human experiencing, visible in the fact that positive and negative emotions correlate only moderately.

Westen and Gabbard (1999; cf. Westen, 1998) further emphasise the existence of an empirically-based agreement that a lot of mental life is unconscious; that stable structures of personality are formed in childhood; that needs and motives are influenced through the internalisation of the needs and motives of significant others. In addition, Westen and Gabbard document evidence that mental representations of self and others influence interpersonal functioning and psychological symptoms (for instance, differentiated, benign and interacting perceptions in projective tests correlate with psychological health). Similarly, people who do not report problems in self-rating scales, but whose childhood descriptions are incoherent or are describing a distressed childhood, have higher blood pressure and heart activity, both visible symptoms of anxiety that would suggest the presence of defences in self-reflection or self-presentation.

Westen and Gabbard’s (1999; Westen, 1998) review also points to research studies showing the relationship between personality features in childhood and psychopathology in adulthood. They also refer to research studies that show how often cognitions are in the service of emotions and motivational processes. They stress the associative nature of human psychological functioning and parallel information processing, the awareness of which may be hindered by human wishes, fears and values.

Current psychodynamic scene

Psychodynamic approaches to psychotherapy are diverse and may differ according to traditions in different countries. They represent variations of the main paradigm, which assumes that psychopathology stems from unconscious motivational conflicts that are part of personality structures and of interpersonal functioning. These unconscious conflicts have their roots in personal history, especially in early experiences with significant others. The therapeutic work attempts to provide, with the help of the therapist and in the therapeutic relationship, insight and experiential working-through of the beliefs that are part of the conflicting motivation.

Traditional psychoanalytic training, with an emphasis on long-term personal analysis, still exists. Psychoanalytic associations (e.g. the International Psychoanalytic Association and the American Psychoanalytic Association) play a central role. Psychoanalytic and psychodynamic therapies are influenced by developments in mainstream psychotherapy, such as the emphasis on the brevity of therapy and the manualisation of the therapist’s work. For example, time-limited therapy has influenced the development of focal psychoanalytic and psychodynamic treatment manuals (e.g. Luborsky, 1984; Strupp & Binder, 1984). More recently, handbooks were devoted to different psychoanalytic and psychodynamic approaches addressing different types of psychopathology (e.g. Barber & Crits-Christoph, 1995).

Empirical investigations of psychotherapy and psychodynamic constructs

Several psychodynamic constructs have been examined in empirical investigations. Probably the most studied construct is that of the therapeutic alliance (e.g. Bordin, 1979). There are different conceptions of this construct, the majority of which were elaborated by psychoanalytic theoreticians (see Horvath & Bedi, 2002). Several instruments exist that assess the quality of the alliance as perceived by therapists, clients and external raters. In general, the therapeutic alliance (especially as experienced by the client) appears to be a significant predictor of psychotherapy outcome (Martin, Garske, & Davies, 2000; Horvath & Bedi, 2002).

Interpretation as the main treatment tool of psychodynamic therapists is also well studied. Interpretations seem to be differentially effective depending on the client’s quality of object relations (the lower the quality, the more counterproductive are interpretations of transference; see Crits-Christoph & Connolly-Gibbons, 2002), though this may be moderated by the quality of interpretation (Høglend et al., 2006). The empirical overview of Crits-Christoph and Connolly-Gibbons (2002) suggests that, especially in brief therapies, interpretations should focus on central interpersonal themes, but not necessarily as manifested in transference.

Significant attention in empirical research is also devoted to investigations of transference (the expression of the client’s central interpersonal functioning in the relationship with the therapist) and psychodynamic case formulation (Luborsky et al., 1993). Good evidence shows that it is possible to capture empirically the client’s problematic central interpersonal stance after only a few sessions in therapy (we will discuss this more closely in Chapter 3). It has also been shown that this stance is mirrored in the client’s relationship with the therapist (Luborsky & Crits-Christoph, 1990). Furthermore, it has been proven that in successful psychodynamic therapies this stance changes into a more constructive form (Crits-Christoph & Luborsky, 1990).

Countertransference has also been empirically investigated. It has been shown that countertransference emanates from the therapist’s unresolved conflicts, even though it is moderated by the client’s behaviour and therapy-related factors (Gelso & Hayes, 2007). Once the countertransference is present, it may be difficult for the therapist to maintain appropriate therapeutic distance from the client, although it does not always have to affect the therapy negatively (Gelso & Hayes, 2007). The central feature that was studied with regard to countertransference is its therapeutic use. The factors that seem to contribute to its therapeutic use are:

(1)	the ability of the therapist to be aware of problematic inner experience together with the ability to understand its roots;
(2)	the therapist’s healthy personality structur...

Table of contents

• Cover Page
• Title
• Copyright
• Dedication
• Contents
• Acknowledgements
• Introduction: The Goal and Organisation of the Text
• Part I Introduction
• Part II Basic Skills of Conducting Psychotherapy and Counselling
• Part III Adjusting Therapeutic Strategy
• Afterword
• References
• Index