intro to counseling final

Difference between counseling and psychotherapy

* counseling is usually relatively brief & focusing on solving a particular symptom/problem


* psychotherapy is usually longer & attempts more broad personality change (most likely to dive into the past)

confidentiality

disclosure of things; most clients must be informed about the limits of confidentiality (usually included in the informed consent & verbally discussed)

limits of confidentiality

most things are confidential except when:

* there is evidence that the client plans on killing (not harming) themselves or someone else
* there is risk of harm to a child or an elderly person
* a court orders the therapist to reveal info about the case

privileged communication

communication that cannot be used as evidence in court (up to client but can be overrode in some cases)

intake

initial interview used to gather data about client (triage, short assessment, asks 1. do you want to kill yourself or someone else?) ^^(unstructured & structured^^)

info obtained during an intake

* demographic info


* presenting problem
* past treatment history
* medical history
* mental status (the degree of competence shown by a person in intellectual, emotional, psychological, & personality functioning)
* personal & social history
* possibility of risk (pay attention to how the client speaks, thinks, feels & evaluates situations) 

What is associated with successful therapy

personal characteristics of the therapist & the therapeutic relationship as key factors in a successful therapy 

→ feeling comfortable w themselves, ability to change, interpersonal skills, boundaries, counselor’s values

What are contextual factors in therapy

* the therapeutic alliance


* personal & interpersonal skills of the therapist
* client agency
* extra-therapeutic factors

therapeutic alliance

bond & working relationship between therapist & client personal & interpersonal skills of the therapist

extra-therapeutic factors

other factors of therapy (^^EX:^^ theoretical orientation of therapist, mode of therapy – group therapy for eating disorders might not be effective)

client agency

client willingness & ability to make positive changes

multicultural competence:

the ability to interact effectively with people of different cultures & socio-economic backgrounds (good to be aware of biases, own values…)

cultural encapsulation

having an ethnocentric perspective in turn, they do not fully understand the culture disposition of their client, creating a serious gap in the counseling process

ethnocentrism

evaluating other people & cultures according to the standards of one’s own culture

acculturation

the adoption of the thinking/behavior patterns of the surrounding culture (people will assimilate into another culture faster if there is no one they can identify with)

the 5 Ethical principles that underlie professional codes

1. Beneficence
2. Nonmaleficence
3. Fidelity
4. Integrity
5. Justice
6. Respect for People’s Rights & Dignity

Beneficence

counselors make decisions that should benefit others

Nonmaleficence

counselors should make decisions that do no harm

Fidelity

counselors should be trust-worthy

Integrity

counselors should be honest & truthful

Justice

counselors should be fair to clients & equal access to treatment. They could be more aware of how biases could affect others

Respect for People’s Rights & Dignity

counselors should respect the autonomy of others & a person’s right to privacy

evidence based practice

the use of current credible research (may be deemed problematic if there is no evidence) in making decisions about the treatment of the individual client (*simplest practice*)

→ it means integrating individual clinical expertise w/ the best available external clinical evidence from systematic research 

strengths of EBP

* counselors use treatments that have been validated by empirical research


* treatments are usually brief & standardized (every therapist is capable of using it)
* are preferred by many insurance companies bc their goal is to get your money & give as little as possible so a shorter treatment is better
* calls for accountability among mental health professionals to provide effective treatment

weaknesses (criticisms) of EBP

* considered by some to be mechanistic & insensitive to individual differences (EX: someone assigned to log stuff might not be good bc they’re not good w logs)


* not well suited for working w existential concerns bc it is so simple (“why am i here” is different from depression, anxiety)
* difficult to measure both relational & technical aspects of a psychological treatment (client-clinician relationship)
* has potential for misuse as a method of cost containment for insurance companies instead of a method of efficacious treatment for clients (“they should be fine in # sessions, if not, we won’t pay more”

Multiple & Dual relationships

occurs when a counselor is in a professional role w an individual, and that, in addition to this professional role, **one** of 3 conditions is met 

multiple & dual relationships conditions

a multiple relationship occurs when a counselor is in a professional role w a person and


1. At the same time is in another role with the same person
2. At the same time is in a relationship with a person closely associated with or related to the person with whom the counselor has the professional relationship
3. Promises to enter into a relationship in the future w the person or a person closely associated with or related to the person (EX: “i think you’d make a good counselor, you should come work for me in the future”)

psychoanalytic theory

abnormal symptoms are the result of conflict among unconscious forces

Who was the father of psychoanalytic therapy?

Sigmund Freud (1886-1939)

id

instant gratification

* Part of the personality **present at birth** (babies cry, people whenever they want want w/o consideration) and completely **unconscious & stays throughout your life**

Pleasure principle

principle by which the __**id**__ functions; the immediate satisfaction of needs w/o regards for the consequences (not just sexual; it is just something we’d like to do)

libido

the **instinctual energy** that may come into conflict with the demands of a society’s standards for behavior (^^EX^^: you want a Porsche and go buy it even if it’s out of your budget)

ego

* Part of the personality that develops out of a need to deal with **reality** (less strong when you’re tired)


* Mostly conscious, rational, & logical
* “**Executive**” part of personality
* **Mediates** among the demands of the id, superego, and reality

Reality principle

principle by which the ego functions; the satisfaction of the demands of the id only when negative consequences will not result (^^EX^^: you buy a cheap car instead or porsche) 

superego

Part of the personality that acts as a moral center

* The part of personality that presents **internalized ideals** (mostly unconscious but some is preconscious bc you have internalized values but they can be available to you)

ego ideal

part of the superego that contains the standard for mental behavior 

Conscience

part of the superego that produces **pride or guilt** depending on how well behavior matches or does not match the ego ideal (“don’t do things that make you guilty, do things that make you proud”)

Preconscious

level of the mind in which info is available but not currently conscious (you’re not thinking of it until asked; ^^EX^^: “what did you eat for breakfast”)

Conscious

level of the mind that is aware of immediate surroundings & perceptions (you’re thinking about it right now; ^^EX^^: “it’s cold in this room”)

Unconscious

level of the mind in which thoughts, feelings, memories, and other info are kept that are not easily or voluntarily brought into consciousness

Clinical evidence for postulating the unconscious

* Dreams


* Slips of the tongue (say something we don’t mean)
* Posthypnotic suggestions (been used for childbirth to not feel pain during labor) (“you will be pricked w/ a need & 3 dots of blood will come out” & that happened)
* Material derived from free-association & projective techniques 
* Symbolic content of psychotic symptoms 

psychoanalytical therapist

analyst

what do analysts help do?

Analysts help clients to achieve insight into their problems, increase their awareness of ways to change, and this again make control over their lives

→ Pushing the client too rapidly or offering ill-timed interpretations will render the process ineffective

What is the goal of psychoanalytic therapy? 

To **gain insight** – make the unconscious conscious & strengthen the ego so that behavior is based more on reality & less on instinctual cravings or irrational guilt

Typical frequency and duration of psychoanalytic therapy

3 times a week, for 3-5 years

Blank-screen

the analyst discloses very little about themselves so that the client can use the relationship to work on unconscious forces (^^EX^^: client’s dad cannot come to therapy & therapist is stoic so they become like the dad & if the dad was judgmental, client will see therapist as judgemental too, BUT this way, dynamics can be changed)

Free association

client reports immediately w/o censoring any feelings or thoughts (therapist doesn’t give feedback & can’t see client so client just speaks bc nobody or nothing is giving indication for you to stop or not say something)

Transference

occurs when the client reacts to the therapist as he or she did to an earlier significant other (more helpful than countertransference)

Countertransference

is the reaction of the therapist toward the client that may interfere with objectivity (**therapist sees client as someone they are reminded of** - probably not a good idea to tell them if you find them attractive, instead consult w/ someone else)

resistance

if anything that works against the progress of therapy and prevents the production of unconscious material (EX: you stop talking or change topic)

four basic problem areas of Interpersonal Therapy

1. unsolved grief
2. role disputes
3. role transitions
4. interpersonal deficits

unsolved grief

grief which is either delayed & experienced long after the loss or distorted grief, in which the person may not feel emotions, but instead experiences w/ other symptoms (doesn’t have to include death, can be a breakup or family separation)

role disputes

the patient & significant people in his life have different expectations about their relationship (^^EX^^: boss expects you to not use your paid days while business is busy)

role transitions

a person’s role changes & he/she doesn’t know how to cope with the change (^^EX^^: you marry, have a baby, lose your job)

interpersonal deficits

problems w forming & maintaining good quality relationships

existential theory

based on philosophy of 1800s 

* Humans are in constant state of transition, evolving & becoming
* Clients are searching for meaning in their subjective worlds
* The existential tradition
* We’re never experiencing the same thing as someone else

existential tradition

a set of beliefs that seeks a balance between recognizing the limits & possibilities of human life

Existential anxiety

unavoidable anxiety that comes from realizing the inevitably of death, freedom, choice, isolation, meaningless

neurotic anxiety

anxiety which we are typically unaware of – anxiety about concrete things that are **out of proportion** to the situation

freedom

a concept that implies we are responsible for our lives, our actions, & failures to take action

Existential guilt

the idea of being aware of having evaded an opportunity to make a choice

* We may feel incomplete or think that we are not what we might have become

Authenticity

this concept applies to the state of being when we are living by **being true** to our own evaluation of what is viable existence for ourselves

Inauthenticity

not accepting responsibility for the choice we make (^^EX^^: “I’m this way because I grew up in a dysfunctional family”)

Authentic need to be with others

healthy relationships are based on our desire for fulfillment, **not based on deprivation** (^^EX^^: you find a classmate interesting after a conversation and you decide to befriend them)

Neurotic dependence

relationships that spring from our sense of deprivation are clinging, parasitic, & symbiotic (^^EX^^: you reach out because you feel lonely)

Why we need to think about death

It is necessary to think about death if we are to think significantly about life. Death provides the motivate for us to take advantage of appreciating the present moment

The capacity for Self-Awareness: The Therapy

Clients have to **learn that increasing awareness comes with a price**

* As we become more aware, it is more difficult to “go home again” (^^EX^^: the movies you enjoyed as a child don’t hit the same anymore)


* Ignorance of our condition may have brought contentment…and partial deadness. **Increasing awareness increases turmoil and the potential for more fulfillment**

Freedom & Responsibility: The Therapy

Clients who refuse to accept responsibility by blaming others for their problems are not likely to benefit from therapy (why it’s difficult w narcissistic clients)

* Therapists **teach clients that they can accept that they have choices, even though they may have spent most of her life to avoiding them**
* Clients often have mixed feelings when it comes to choices. They resent times when they did not get to choose but are anxious when they have to choose __Mixed feelings over choices – we want to believe we have the choice but that we don’t have to make the decision)__
* Therapists **help client to recognize how they have allowed others to decide for them and encouraging them to take steps toward choosing for themselves**

Identity & Relationship: Therapy

* Existential therapist may ask clients to allow themselves to **intensify the feeling that they are nothing more than the sum of others expectations (being more than expectations of others)**


* How do they feel now? Are they stuck this way forever? Is there a way out?


* The therapy process itself is often frightening for clients when they realize **that in the therapy relationship they will have to assume their freedom again** (sometimes have to break out of relationships/roles to be more free to figure it out)

The search for meaning: The Therapy

Questions that the therapist might ask are:

* “Do you like the direction of your life?” “Are you pleased with what you now are and what you are becoming?” “If you are confused about who you are and what you want for yourself, what are you doing to get some clarity?”


* When clients embark on the struggle for meaning, they often times discard some of their traditional values. At this time, they may feel lost and the therapist is tasked with **helping clients create a value system based on a way of living that is consistent with their way of being** *(EX: a person has strong religion values and then they go through something & their perspective on religion changes – a person at 8 and at 30 focus on different aspects of religion)* (therapist helps clients find their values)

Therapy Techniques: Existential Therapy

Existential psychotherapy is not technique oriented

* Techniques from other models can be used within the context of striving to understand the subjective world of the client, but they must be used in an integrated fashion

Process (including difficulties) in getting clients to accept they have choices.

Clients often have mixed feelings when it comes to choices. They resent times when they did not get to choose but are anxious when they have to choose __Mixed feelings over choices – we want to believe we have the choice but that we don’t have to make the decision)__

* Therapists **help client to recognize how they have allowed others to decide for them and encouraging them to take steps toward choosing for themselves**

person-centered theory

* Humans are trustworthy & positive, each person is a unique individual


* Humans are capable of making changes & living productive, effective lives
* Humans innately gravitate toward self-actualization 

Who was father of Person-Centered Therapy?

Carl Rogers (1902-1987)

Self-actualization

moving towards one’s potential

Real self and ideal self: Harmony vs. mismatch

Match = harmony & Mismatch = Anxiety

real self

actual perception of characteristics, traits, & abilities

ideal self

the perception of what one should be or would like to be

Unconditional positive regard

an attitude of total acceptance toward another person (basically positive regard that is given w/o conditions or strings attached) (allows you to grow) (you accept them as a person, but you don’t have to accept all of their behaviors)

Conditions of worth

the tendency for acceptance of a person to be based on specific conditions that have to met (^^EX^^: “I won’t love you anymore if you do that”, “I will only accept you if you’re a certain way”) ^^(OPPOSITE^^ of unconditional positive regard)

person-centered therapy

Approach emphasizes:

* The person’s innate striving for self-actualization 
* The personal characteristics of the therapist & the quality of the therapeutic relationship
* The counselor’s creation of a “growth-promoting” climate
* People are capable of self-directed growth if involved in a therapeutic relationship

How to create a growth promoting climate

* congruence
* unconditional positive regard
* accurate empathic understanding)

congruence

genuineness or realness (^^one of the most importan^^t) (“hey i’ve seen the good in you but this behavior is not constant with how you act”) (can be helpful to think about how it is w/ family – you love them despite some behaviors)

Accurate empathic understanding

the ability to deeply grasp the subjective world of another person (try to put yourself in their shoes)

active listening

the listener to feed back what they hear to the speaker, by way of restating or paraphrasing what they have heard in their own words

reflective listening (reflection of content & feelings)

 communication strategy involving active listening with the added component of focusing on the client’s feelings when reflecting back the message (“you seem to be struggling with…AND feeling…)

gestalt theory

An organized whole that is perceived as more than the sum of its parts

→ Perls maintain that people often fragment their lives & sabotage their potential by losing touch with their inner selves, and by not coming to terms with unfinished business

Who was the father of Gestalt theory?

Fritz Perls

Focus on here and now

Gestalt therapy stresses being aware of what is happening in the present & the unity of mind, body, feelings

* “Our power is in the present” – nothing exists except the now & the past is gone & the future has not yet arrived 

Unfinished business

feelings about the past that are unexpressed feelings, or lack of closure to significant life events such as such (associated w distinct memories & fantasies & linger in the background and interfere with effective contact)

* Result in preoccupation, compulsive behavior, wariness oppressive energy and self-defeating behavior

Figure formation process (figure and ground)

how an individual organizes experiences from moment to moment

Figure (foreground)

aspects of the individual’s experience that are most salient at any moment

Ground (background)

aspects of the client’s presentation that are often out of his/her awareness

contact

interfering with nature & with other people without losing one’s individuality

Boundary disturbances/resistance to contact

the defenses we develop to prevent us from experiencing the reality

gestalt therapy

designed to help people experience the present moment more fully & gain awareness of they are thinking, feeling, & doing

2 goals of gestalt therapy

1. Move the client from environmental support to self-support
2. Reintegrating the disowned parts of the client's personality

empty chair technique

role-playing technique involving the client and an imaginary person in the other chair. The client plays his or her tole & the role of an imaginary person or partner

Alternative empty chair

a conversation between the two selves

topdog

the part of the personality that demands perfection – it usually adheres to societal norms (^^EX^^: “I should always make an A in my classes”)