My Personal Approach to Psychotherapy

Introduction

           I often look back and ponder my life’s narrative. How did I get here and where I am headed? In many ways I am a student of the world having learned lessons from both real world and academic settings alike. If nothing else I can say that I am a large proponent of crossroads theory – a theory that I partly formulated that emphasizes the importance of decisions both conscious and not. In each facet of our lives we are faced with many‘cross-roads moments,’ moments which will shift our trajectories in deep and impactful ways. None of these moments are the same except for the fact that they are powerful. Arguably one of the most significant cross-roads moments in my life came when I decided to study psychology and become a therapist back in the summer of 2007. Since then, nearly everything that I have done has been in service of this goal and dream. It is safe to say that after a decade of work in the field and in academics, I am ready to flesh out my own personal approach to therapy based primarily on experiential learning and my academic endeavors as well as my own work in therapy.

 It is commonplace to hear therapists describe themselves as ‘eclectic.’ It sounds nice, but what does this really mean? Are we drawing on so much that our interventions get lost in the shuffle? At time it could be argued that yes this is the case. However, when you have no approach it would be likened to playing darts with a moving target, blind-folded. You might hit on something, but chances aren’t in your favor. For me I would also ironically describe myself as eclectic but I will state how. After studying Gestalt, Adlerian and Rogerian therapy during an undergraduate counseling practicum at Stonehill College, several things became clear to me about me and my (somewhat) inherent and developed approach to therapy.

           First and foremost it is my belief that no one treatment approach, theory or intervention is adequate enough for the complexity of the whole human condition. After all, we are indeed treating whole people and not merely the assemblage of their presenting problems – the deep-rooted difficulties that are so often existential in nature. Yet, it is important to be guided by principles and theories which you relate to and believe in an authentic way to avoid the blind-folded darts scenario laid out previously. I found that there are parts about certain approaches which I ascribe to. For example, Freud extensively laid out the importance of the early years of development and how they impact us throughout the lifespan. Adler and Fritz Perls drew from more holistic models intended to treat the person and each facet of their life. Carl Roger’s separation from the pure medical model to the humanistic and person-centered approach was powerful; it posits that each person has the power and ability to guide their own treatment and to solve their own problems. John Sarno talks about the importance of the brain on somatic and psychiatric illness while existentialists like Irvin Yalom have spent years focused on the “givens” of life and of the subconscious existential strife that we suffer. Finally, to Albert Ellis and Aaron Beck, the psychologists to which I draw from the most who combined the behavioral and cognitive schools together which focuses on the cognitive processing and how often time we interpret life in a distorted way. Each of these theories and approaches from psychodynamic, to person-centered, to Gestalt, to existential to cognitive-behavioral has informed the way I approach psychotherapy. To put it somewhat simply I would describe myself as a mix of cognitive-behavioral and psychodynamic that has a relatable, psycho-educational and actions-oriented approach to treatment which often comes from the peer-support model as well. Even that is quite the mouthful.

The Assumptions

           My father always said, “Be careful not to assume – if you do you might make an ass out of “u” and “me.” For the most part I agree with him and my life’s story might confirm that notion. In life, I can truly say that I do not (consciously) assume anything about anyone and I never judge. In essence, people are like icebergs – much more lies beneath the surface. In overly simplistic terms, Freud might say that people need an expert to help solve their ills, while Rogers might assume that all people, no matter what the circumstance or illness, people can find the solutions within themselves. I say that it depends on the person and the issues.

Each person comes to us with a different set of beliefs, skills, pathology and life story. In the case of Sigmund and Carl, I never assume either is the case right off the bat. For some people, they were not given the tools to succeed and at times they may need a guide to help them in a very direct way. Others may be stuck in maladaptive patterns and need only to be shown options for which they can decide to move towards. Focusing on people’s strengths and intrinsic resilience while also teaching tangible lessons is what I lean towards. It is my belief that most of one’s troubles stems from maladaptive thinking and behavioral patterns coupled with unconscious drives and “unfinished business” that needs to be addressed. In my mind, much of what Beck recognized in the CBT model is informed by the psychodynamic theory that focuses in on unconscious drives. While CBT identifies the thoughts and behaviors that are maladaptive – psychodynamic theory shows why they are present in the first-place.

Conceptualization of Personal Symptoms and Interpersonal Problems

           The ever-present question – “Where do mental health problems come from?” The academic answer would be that it is a combination of things. Genetic aspects, psycho-social development, trauma, psychophysiological dynamics, and environmental factors all can contribute to psychopathology and interpersonal struggles alike. Recent empirically-based, peer-reviewed research has shown that there is a large genetic component or predispositions to mental illness such as in the case of major depression, anxiety, schizophrenia, and bipolar disorder. “In quantitative genetic studies, correlations between environmental and genetic factors are pervasive (Jaffee & Price, 2012), which suggests that genetic confounds may account for the statistical associations between putative environmental risk factors and developmental outcomes” (Donofrio et. al, 2013). Environmental factors have a large say on whether or not they will ever become present. Take for example the diathesis-stress model. “Diathesis refers to a predisposition or vulnerability for the development of a pathological state. Diathesis-stress models argue that certain pathological states or diseases emerge from the combination of a predisposition with stressful events (Zuckerman, 1999). Most models specify that neither the diathesis nor stress alone is sufficient to produce the disorder. Instead, stress activates the diathesis, which then leads to the disorder. More broadly, diathesis-stress models are similar to the idea of risk-factors for stress-related diseases” (Belsky & Pluess, 2009).

The diagnostic criterions from which we draw upon are focused on one’s personal functioning. How does each illness effect social and vocational functioning? I believe that much of what we term as illness and interpersonal problems come from maladaptive thinking patterns and exaggerated or otherwise inaccurate interpretations of impactful events. It is my belief that faulty cognitions coupled with maladaptive behavioral patterns tied with the impact of our early development will have the most impact on our mental health and overall functioning. Much of what we identify as being unhealthy stems directly from our own false beliefs, assumptions and interpretations. Lastly, how one frames themself in terms of self-efficacy is also deeply significant in that it shows one’s ability or perceived ability to function in healthy ways. This may also inform how the course of therapy will unfold.

The Goals of Therapy

Understandably for each client the goals both short-term and long-term will be different yet, there are some inherent similarities for all with whom I intend to work with. These include:

1.    To identify and re-frame negative thinking patterns.

2.    To identify and change negative behavioral patterns.

3.    To increase one’s quality of social and vocational functioning.

4.    To provide advocacy, resources and referrals when needed.

5.    To increase the quality of the client’s intimate life.

6.    To identify potential illness and reduce symptoms.

7.    To provide a safe and open environment.

8.    To have the client decide which issues to work on first.

9.    To teach life skills and to promote positive action.

10. To help one identify their true, core self.

11. To promote genuineness and congruency in each facet of the client’s life.

12. To allow one to “actuate their inherent potentialities” (as Rogers would say).

The Role of the Therapist

           We’ve often heard the terms ‘facilitator,’ ‘guide,’ and ‘navigator’ when it comes to identifying the role of the therapist. The truth is it depends on the client, the therapist, the presenting problem and the orientation of the clinician. My personal approach is that I am to first be a model of healthy thinking. At different times I may need to be a coach, a support, a cheer-leader, a drill sergeant, a colleague, a confidant, and an advocate respectively. Obviously with boundaries in mind, I see myself being able to acquiesce and shift roles based on the needs of each individual client. Because of my CBT and psychoeducational approach, I will often be providing direct feedback however; there will also be times where I will promote evocative empathy, encouraging my client to search for their own solutions and inner-strength. Because people and therapy alike are apt to shift and move, the role of the therapist should be the same while also working to provide consistency.

The Main Techniques

           There are several well-developed techniques from CBT that I will likely draw from. First would be to ID cognitive distortions as well as automatic negative thoughts (ANTS). This will primarily be done through a process known as thought journaling. I will have my client record their thoughts throughout the day as well as the scenarios to which they came. From there we work to either validate or challenge their beliefs and assumptions based on their cognitive processes. The next technique will be a great deal of cognitive restructuring or re-framing if needed. In an effort for the client to interpret events accurately, cognitive re-framing has been shown to greatly reduce negative thinking patterns and maladaptive behaviors alike. I will draw from my psychodynamic leanings as well in completing a full bio-psycho-social assessment while centering in on significant events in each of the client’s developmental stages. A focus will be on interpersonal relationships and objects-relations specific to the family of origin.

 As Alder once said, it is true that it is imperative to have a great many techniques from which to draw from; whether it be to reduce symptoms in anxiety disorders, depression, thought disorders and personality drivers, the complexity of the person is often coupled with the complexity of their problems and no one singular technique will be a ‘cure-all.’ With all of that being said, it is indeed the therapeutic relationship between the client and the therapist that is the greatest determining curative factor above all else.

The Role of the Client

           When it comes to the role of the client in therapy there are several things to be taken into consideration. I will have a well-developed screening process. I will ask a number of things in service of this. First, are they a good fit for my style and approach? Not all clients will be. Secondly, do they require a clinician with very specific expertise – is their diagnosis outside of my purview or would they be best served by another? Also, are there factors for which you see yourself being comprised as a clinician? For example, does this client trigger something in me or is the counter-transference impeding therapy? Lastly, is this a client population that I would like to work with one for which I am equipped to work with?

It is important from the outset of therapy that both the client and the therapist know what is expected of each other – research has demonstrated that these expectancies are strongly related to the strength of the therapeutic relationship. “In a more recent study, Joyce and Piper (1998) examined the relationship between client expectancies about the “typical” therapy session and alliance between the therapist and the client. In addition, the relationship between expectancies and outcome was explored. A stronger relationship seemed to be demonstrated between expectancies and quality of the alliance than between expectancies and outcome (Joyce & Piper, 1998). This study utilized a measure of expectancies that focused on general qualities of the therapy session (eg. “good-bad”, “easy-difficult”), not on role expectations” (Shappell, 2004).

Here I will l ay out my expectation of my clients as I see them:

1.    To be open to change and new perspectives

2.    To take an active role in therapy

3.    To work to become introspective and mindful

4.    To be honest with yourself and the therapist

5.    To know your yourself limitations and to accept help when needed

The Effectiveness of this Approach and its Appropriateness for Various Clienteles

           One of the many things that I like about the CBT model is that by focusing on the behavioral piece it lends itself well to child and adolescent populations. Obviously, there will be developmental considerations for each client. For example, I wouldn’t necessarily work on cognitive re-frames with a five year old – their physiology would not allow this to be effective. However, I would promote behavioral techniques such as operant and classical conditioning interventions. For clients who are well-developed or who have been in therapy for many years, a strict CBT approach may not work well with them. They may know their distortions, their pathologies and their patterns. In this case, the goal would be to help them to emotionally process all of these things. It is one thing for a client to be aware of the problem, it is another to have them understand it, and process it.

The Congruence of this Approach with Me

           The term congruence – it’s very important to the Rogerian approach. It speaks to the nature of harmony or compatibility in oneself or within two or more. For me the key to the therapist and the client’s success in therapy is genuineness. To be genuine is to be congruent. “Congruence is the most important attribute, according to Rogers. This implies that the therapist is real and/or genuine, open, integrated and authentic during their interactions with the client. The therapist does not have a facade, that is, the therapist's internal and external experiences are one in the same. In short, the therapist is authentic. This authenticity functions as a model of a human being struggling toward greater realness. However, Rogers' concept of congruence does not imply that only a fully self-actualized therapist can be effective in counseling” (Corey, 1986). Growing up in the blue collar world of construction and the trades there is a strong part of me that is highly solutions-oriented, results-driven as well as pragmatic; I’m to break things down in their respective parts. The philosophical and academic parts of me are very analytical and thought-provoking, hence my propensity for CBT. Another side of me is warm, accepting and probing, hence my love for the psychodynamic model as well. I could not be an effective therapist if I didn’t believe in the process of therapy and the models of psychodynamic psychology and CBT. I bring my own experiences in therapy to the table well as I would never expect a client to process their own life without having done the same and more myself.

Closing

           I believe each therapist brings their own story to the proverbial therapeutic table. Regardless of the level of education, therapeutic or theoretical orientation, academic prowess or research expertise, above all else our ability to know ourselves through and through and our ability to demonstrate authenticity are paramount to everything else. Years of research and meta-analyses and new taxonomy and nomenclature are but a thread in the twine that ties all of the facets of psychology together. I got into this field for two main reasons. The obvious one is I want to help people. The less obvious one is that our field is both a science and an art form. We draw on a vast array of disciplines. There are no hard and fast solutions to the ills of the world and the difficulties that we face as existential beings. Being a harbinger of truth and light in a world that can be so dark for people I find to be both an honor and a blessing. I am very much looking forward to it.

Sources

Belsky, J., & Pluess, M. (2009). Beyond diathesis stress: Differential susceptibility to environmental influences. Psychological Bulletin, 135(6), 885–908.

Corey, G. (1996). Theory Practice of Counseling and Psychotherapy:Second Edition. Pacific Grove, CA: Brooks/Cole Publishing Company. Pp. 89-129,196-219.

Donofrio, B., Class, Q., Lahey, B. and Larsson, H. (2014), Testing the Developmental Origins of Health and Disease Hypothesis for Psychopathology Using Family-Based, Quasi-Experimental Designs. Child Dev Perspect, 8: 151–157. doi:10.1111/cdep.12078

Nichols, M. P. (2010). Family therapy: concepts and methods. Boston: Pearson.

Shappell, S. L. (2004). The Development of a Measure of Client Expectations for Therapy. Electronic Theses, Treatises and Dissertations . Retrieved June 20, 2017, from https://diginole.lib.fsu.edu/islandora/object/fsu:176274/datastream/PDF/view

Zuckerman, M. (1999). Vulnerability to psychopathology: A biosocial model. Washington, DC: American Psychological Association.

David A. Kapolis, M.S.