Basic Counseling Techniques: A Beginning Therapist's Toolkit

Basic Counseling Techniques:

A Beginning Therapist’s Toolkit

C. Wayne Perry, D.Min., LMFT

© 2002 C. Wayne Perry, D. Min, LMFT. All rights reserved.

No part of this book may be reproduced, stored in a retrieval system, or transmitted by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the author.

ISBN: 1-4033-8326-X (e-book)

ISBN: 978-1-4033-8326-6 (ebook)

ISBN: 1-4033-8327-8 (Paperback)

1stBooks-rev. 11/15/02

Contents

Acknowledgments

Foreword

Introduction

1The Metasystems Model

Social Control

Levels of Perception

Rituals, Ghosts, and Baggage

THE FUNDAMENTALS

Chapter 1-The First Interview

Setting Up the Room

The First Few Seconds

The Formal Interview Begins

The Presenting Problem

Concluding the First Interview

Last Issues

Chapter 2-Structuring Skills

Planning the Therapy Hour

Prescriptions

Stopping Chaotic/Destructive Interactions

Terminating Therapy

Chapter 3-Process Skills

The Developing Therapist.

Effective Questioning

Relabeling

Making the Covert Overt

Summary

Chapter 4-Administrative Skills

Record Keeping Basics

Process Notes

Referrals

Conclusion

INDIVIDUAL COUNSELING SKILLS

Chapter 5-Solution Focused/Problem Solving Skills

Defining Achievable Goals

Exceptions; Miracle Questions

Getting Beneath The Presenting Problem

When Clients Are Stuck

Summary

Chapter 6-Cognitive Therapy Skills

Clients with Whom this Therapy Is Appropriate.

Defining Dysfunctional Thoughts.

Action Research.

Creating Alternative Explanations.

Testing Alternatives.

Chapter 7-Behavior Therapy Skills

Brief Review of Behavior Theory

Types of Clients for Whom Behavior Therapy is Appropriate

Defining Change in Behavior Terms

Basic Behavior Therapy Techniques

Schedules of Reinforcement

Conclusion

Chapter 8-Depth Counseling Skills

Types of Problems For Which Depth Counseling Is Best Suited

Early Recollections

Family Constellation

Lifestyle Analysis

Private Fiction; Fictional Finalism

The Metasystems Variation

Conclusion

INTERPERSONAL COUNSELING SKILLS

Chapter 9-Psychoeducational Approaches

Types of Situations Where These Are Appropriate

Prevention Programs

Intervention Programs

Conclusion

Chapter 10-Get Them On Their Feet

Situations Where Kinesthetic Techniques Are Appropriate

Sculpting

Role Play

Enactments

Conclusion

Chapter 11-Diagraming Interactions

Types of Situations Where Diagraming Is Appropriate

Genograms

Structure Grams

Ecomaps

Conclusion

Living Into the Lesson

Chapter 12-Drug/Alcohol Interventions

Systemic Interventions for an Individual Problem

Cognitive/Behavioral Interventions

Spiritual Interventions

Conclusion

Chapter 13-Disarming the Bomb

The Meaning and Function of Anger

Confronting Anger in Intimate Relationships

Using Private Fictions and Teleology With Couples/Families

Conclusion

Attachment Styles for Adults

Chapter 14-Exorcizing Ghosts

When is exorcism appropriate?

Divorce and post-divorce therapy

Multigenerational legacies

This text is dedicated to my wonderful wife, Donna. She loved me enough to encourage me in my clinical work, and she loved me enough to force me to practice in my personal life what I teach in my professional life. She has been and continues to be a real blessing of God.

Acknowledgments

I wish to sincerely thank the students in my Basic Counseling Techniques classes at Southern Christian University during 2002. They critiqued this text in its draft form and helped me make needed improvements. To the extent that I achieve my goal of providing a text that the beginning counselor or therapist will find truly useful, these students deserve a big Thank you.

I also want to thank my wife for her careful proof-reading of this text. Her careful attention to even the most minute details was invaluable in producing the final edition.

Finally, I want to thank God for giving me the high privilege of being a therapist. As a Christian saint from the Middle Ages, Anthony of Padua, once said, I bandaged his wounds. God healed him. For more than 30 years I have read the research and taken courses in an attempt to learn how to bandage emotional wounds more skillfully, more appropriately, more effectively. My clients deserve nothing less than my very best, and that definitely includes my best efforts to stay current on the trends of my chosen profession. Even so, I am keenly aware that every healing I get to witness in the therapy room is the result of God’s work, not my skill. As the kids say today, It’s a God thing. When lay people ask me how I listen to my client’s troubles for hour after hour, day after day, I tell them this is how: I get to watch a miracle unfold before my eyes. I can ask for no greater privilege than this.

-Wayne Perry

Foreword

I did not set out to write a textbook of counseling and therapy techniques. My original purpose was to find a textbook I could use for a class I would be teaching beginning master’s level students. What I found, to my surprise, is that I could find no suitable book. There are many books of theories, and many books which address important issues that this one does not. This text aims to fill in the gaps left by those other texts, to supplement them and not to replace them. Specifically, the purpose of this text is to give the beginning therapy or counseling student the nuts-and-bolts of how to actually apply some of the major theories. I assume that in other courses the student will study theories of therapy in depth to gain a more complete understanding, and I assume the student will take a practicum or internship to learn how to actually do therapy. No book, including this one, can teach someone how to counsel. You learn therapy by doing therapy under the careful guidance of a skilled supervisor.

I do want to express my gratitude to my clients over the last twenty-five years. They have taught me so much. All of the case material in this text is drawn from my clinical experience with these wonderful people. Their actions do not necessarily reflect this author’s position on moral issues, but they do reflect the reality of therapy as I have experienced it. Some of the clients in this text are actual people. Others are composites of several real people. In all cases, enough of the facts are altered so that the client’s confidentiality is protected. If you, the reader, think you recognize one of these clients, chalk that up to the universality of human experience and know that you cannot possibly identify who these real people are. Please do read these cases carefully to get a feel of the client and the client’s situation. Use your imagination to put yourself in the client’s shoes. This is a skill which will not only help you get the most out of this text, it will also serve you well in your future profession.

I also want to express a word of caution to those beginning counselors and therapists who read this text. All of the case material in this text comes out well. The client gets better. That is not always the case in real life therapy. Most of us know that, but no one ever tells you that even the best therapy properly performed will not be 100-percent successful. Do work hard to improve your skills and remember that, sadly, some people are more dedicated to staying in their illness than they are to improving. If we therapists could fully understand the client’s world from the client’s point of view, we could understand why that makes sense to them and perhaps help them move toward health. However, as Salvador Minuchin reminds us, Life is more complex than that. You will always lose some.

There is one more word of caution. This text presents a variety of techniques because no one style of therapy has yet been proven superior to all other styles in all cases. Likely, you will gravitate toward one or two styles of therapy because they fit your personality, and that is usually a good thing. The therapist’s primary tool is his or her personality, so finding a style of therapy which allows the therapist to make the most of that tool is a great goal. When that usual style does not work, however, be ready to change your way of working. If you do not see behavior change in the client by the second session, whatever your style of therapy, your client is non-verbally telling you that there is a disconnect between your preferred style and this particular client’s needs. Do something different. As I often remind my supervisees, Insanity can best be defined as doing the same thing over and over expecting different results every time. That applies to us as well as to our clients.

I wish you the best as you learn how to help people. Therapy is an honorable profession with many frustrations and many joys. May your joys outweigh your frustrations.

Wayne Perry

November 2001

Introduction

When there is a disagreement between the book and the bird, always believe the bird.-James Audubon

I will never forget that September afternoon when, for the first time in my life, I set foot on a locked ward in a mental hospital. This was the second week of internship during my master’s degree work, and I was frightened out of my wits. A thousand questions zipped through my mind. What will I say? What will I do? Will I hurt someone? Will they hurt me? My supervisors had done their best to prepare me, and certainly I knew the theories that were supposed to be helpful. Still, walking toward that first encounter with the unknown, I felt a lump in my throat the size of Alaska.

Like most interns I have known, I eventually had a good learning experience. By the time the year was over, I was relaxed and enjoying my work. I had become comfortable in what had previously been a frightening, unknown setting. At the time I was too happy to have survived and to have actually learned a few things to think very deeply during the experience of those first, very uncomfortable weeks. Now, however, I think about those weeks a lot. I see my experience repeated again and again in the lives of the interns I now supervise. With years of experience behind me, I have come to believe there has to be a better way to train budding professionals than simply giving them theories about swimming for two years, then taking them to the deep end of the pool and throwing them in, without ever giving any specific, practical tips on how one swims. This book is specifically written as an attempt to discover that better way. Students, after reading this book and doing the practice units, should start to feel like they have been there, done that.

There is a second major purpose for this book which is closely related to the first. Virtually every handbook of therapy is intellectual or academic and lists a variety of schools of therapy, each with its own history and star figures. Broderick and Schrader (1991, p. 34.) quote Carlos Sluzki as calling the rise of so many competing schools of therapy a Balkanization of the field into sectors based on political rather than scientific boundaries… . The consequence of all this has been the development of more and more ‘brand-name’ models and increased bickering about whose technique washes whiter. Yet Broderick and Schrader go on to say that they believe that the future of therapy belongs not to any one of these many schools of therapy, but rather to some form of integrated therapy. Indeed, it seems that ever year that passes, the differences that separate practicing clinicians become less distinct. Clinicians still praise their favorite stars of the therapy world, but practice from a patchwork of theoretical models.

The problem for the beginning student is that there are so few guidelines for actually doing this work of integration. My experience as a supervisor of therapy teaches me that what usually happens is that students fly by the seat of their pants, grabbing a little bit of technique from this school, that technique from another school, without ever thinking about how any of this fits together. The net result of this un-examined patchwork is that therapy feels and looks patched together. Clients and therapists alike come away wondering what happened. Should the work actually be successful, the therapist likely will be unable to repeat the success since she or he will have no clear idea just what they did or why. They lack a good model for integrating techniques.

Therefore, the second major purpose of this book is to provide a model for integrating techniques from a variety of schools and perspectives. Naturally, given the first purpose of providing a practical how-to guide for the beginning professional counseling/therapy student, this book will be limited to the basics. Subtle nuances and advanced developments will have to wait for another volume.

¹The Metasystems Model

The model for integrating these basic skills followed throughout this book is the Metasystems Model. The name is quite descriptive. Systems refers to the multiple layers of connections of which we are all a part. Meta is a Greek word which means with or along side of. So metasystems is an integrated model of therapy which places the individual with or along side of the multiple systems of which the individual is an integral part. It is a practical application of what Nichols (1987) called the Self in the system."

From the moment of our conception we are part of multiple systems. The first system is, of course, the womb, and it is primarily (if not exclusively-I won’t enter into that debate) a biological system. After birth we are part of a system called a family. As we grow older, our system expands to the neighborhood, and then to the community, and later to the nation (perhaps even the world). Throughout our development we are still the same individual, and yet we change as we interact with our various systems. Of course, our interactions influence the systems of which we are a part, just as we are influenced by them. The fundamental premise of the Metasystems Model, then, is in order to understand behavior, one must understand both the individual and the system. A very closely related corollary is that all change takes place within the individual. The individual makes changes and thus changes the systems of which she or he is a part (Nichols, 1987).

Not all of this is available to our conscious awareness, of course. Erving Goffman (1956) provided a helpful concept by describing human social behavior in terms of a theater metaphor. Metasystems builds on that metaphor. All human life takes place either on Front Stage or Back Stage.

Near the city where I live is the Alabama Shakespear Festival-rated as one of the top five Shakespear theaters in the world, according to their publicity. Anyone who pays the admission price can enter the theater and watch the play being presented. The action that the audience sees takes place on front stage. It is the public part of the theater. However, as anyone who has worked around theater knows, there is a great deal of action taking place back stage, where it is hidden from the view of the audience. In fact, there is some action taking place back stage that is hidden even from the actors. Still, all of this back stage action combines to make possible the action the audience sees on the front stage.

The same is true of human behavior. Part of our lives are lived on the front stage. This is the public part of us, the part of which we are consciously aware, and the part of which others could become aware if they were to pay the admission price-i.e., take the time to get to know us. However, there are parts of our lives which are certainly hidden from others, and some parts which are hidden even from our own conscious awareness. This is the back stage. Obviously, the back stage includes the areas that traditional psychodynamic psychology labeled as the unconscious, but it is a much broader concept than that.

The distinction between front stage and back stage is more substantive than just being descriptive of awareness. It also defines how change takes place. Because front stage is open to conscious awareness, change can take place through education, psychoeducation, relabeling or reframing, or similar techniques that address the neocortex of the brain. To change the back stage requires the application of techniques which can tap into more developmentally primitive parts of the brain (e.g., the amygdala and other parts of the limbic system)-techniques such as dream interpretation, lifestyle analysis, or revising schemas or private fictions².

Even the most neophyte counseling/therapy student has heard that the presenting problem isn’t necessarily the real problem. The Metasystems Model helps the beginner determine which part of the life space-front stage or back stage-contains the real problem. Once that is accomplished, selecting the appropriate intervention comes easily. The main body of this book will develop a variety of therapeutic situations and demonstrate when an intervention might be appropriate and which tools the therapist/counselor might employ to produce the desired change.

What are the various systems of which one is a part? As already indicated, the family of origin (first order family) is the first system. The Metasystems Model is grounded in Adlerian psychology which understands that each person is unique (hence Adler’s term individual psychology for his theory ), and yet each person is influenced by the social system of the family. On the front stage, birth order becomes a major influence (Tomm, 1993). Just as obviously, gender is a front stage influence. Children learn very quickly, for example, I am a girl and I am older than my brother. Not only do children learn these facts, but they also learn the family’s emotional meaning of those facts. Perhaps in this family girls are more highly favored than boys, or perhaps the younger child, being a boy, receives more privileges than his older sister because he is a boy. Parents communicate these values, whatever they may be, both verbally and non-verbally through their interactions with their children. Depending on the family constellation, the extended family (e.g., grandparents, aunts, uncles, etc.) may be just as significant influences as the birth parents-perhaps even more so. So the child’s basic identity and sense of personal competence are forged first of all in the first order family.

Very quickly another significant influence comes on the scene. This is the second order family. Second order family includes all of those people who are not biologically related to the child but who are nevertheless uniquely important to the child. Some examples of second order family might include scout leaders, church or synagogue teachers, school teachers, or even a neighbor down the street. Street gangs are, unfortunately, also a form of second order family, which illustrates the reality that second order family, while potentially even more influential on the child than first order family, is no more likely to be truly functional than first order family. For better or worse, the value of the second order family is that it provides additional opportunities for the child to learn appropriate social behavior by observing others. In turn, this helps confirm the self-concept the child had already developed in those early interactions in the first order family. For the 27 percent of U.S. children who live in single parent families, second order family can supply some of the relationship pieces missing in first order family. For the 54 percent of U.S. children from birth through the third grade who regularly receive child care from someone other than a biological relative, learning from second order family becomes inevitable (America’s Children 2000, 2000). However, even children in intact traditional families can benefit from the enrichment of second order family relationships.

Also on the front stage for both first and second order family is health issues. As any parent knows, children are acutely aware of any difference from normal (i.e., like me). Children with physical characteristics desirable to their peers will be more popular, and thus will move more easily toward the healthy goal of personal superiority. On the other hand, children who have some physical inferiority (e.g., vision defects, over weight, poor coordination, etc.) will have to compensate in some way (Lundin, 1989). Whether these compensatory mechanisms are healthy (i.e., promoting the child’s ultimate welfare and growth) or not will depend on a host of other factors.

One powerful example of the influence the family has on the health issues of the individual is a study which showed that in families where parents and grandparents were clinically depressed, a discomforting 49 percent of the grandchildren showed signs of psychopathology, with a very high risk of anxiety disorders (Warner, Weissman, Mufson, and Wickramaratne, 1999). Whether this is genetically determined to some degree or is purely the result of social learning can be debated. The clear fact is that health patterns do tend to repeat in families across generations. Children cannot help but learn the emotional meaning of these patterns.

On the back stage for both first and second order family is personality issues. The more we learn about child development, the more clear it becomes that basic temperament is genetically influenced. As any parent knows, some children are born very active and happy, while other children come into the world cranky and fearful. There is evidence that these observations are biologically based. Some studies have shown, for example, that fearful children have a higher heart rate in the womb than the average child, and their amygdalas (which controls learned fear) may be more excitable than normal (Personality Disorders, 2000). Bandura’s concepts of reciprocal determinism and self-system (1978) help make sense of the complexity of real human life. Human behavior is determined by genetic and environmental factors, but humans in turn select, through a variety of cognitive (though unconscious) processes, to which stimuli they will respond and how they will respond. All of this is happening back stage, beyond the individual’s consciousness, guiding the front stage interactions with family, friends, and community.

Social Control

As humans develop, the number of systems with which they interact expands. On the front stage, humans learn a variety of gender, ethnic, sociocultural, and subcultural rules. Through observation and sometimes through direct teaching, children learn boys do this, girls do that. Take a very common example: at a holiday gathering, the male child, hungry for attention, wanders into the adult gathering and performs some feat. If the adults respond, Oh, isn’t he smart! Look what he can do!, the boy will quickly learn that boys in this culture are rewarded for doing. However, if a female child, just as hungry for attention, wanders into that same gathering and receives a response from the adults like, Oh, isn’t she sweet! Look how cute she is!, she will quickly learn that girls in this culture are rewarded for being. Euro-Americans follow rules which stress individualism, while Asian-Americans tend to follow rules which stress family and group loyalty.

The function of these rules is, of course, to teach the right perceptions. This behavior conforms to the rules and therefore is right. That behavior does not follow the rules and therefore is wrong. At least to this degree, perception, and therefore behavior, is socially constructed. While few people consciously think about these many layers of rules, they remain front stage because anyone can, with sufficient effort, list them. In keeping with Adler’s concept of fictionalism, it really does not matter whether these rules are true. We follow them as if’ they were true (Lundin, 1989). Many older African-Americans, for example, can testify how the rules of American society prior to the 1960s tightly restrained where they could eat, where they could sleep, or even in what part of the bus they could sit. These Jim Crow laws, as they were known, were enforced as if’ society depended on it, and everyone knew that this was the way things were done in America.

The back stage of awareness contains secrets. However, not all secrets are created equal. Evan Imber-Black (1998) makes some useful distinctions. There are sweet secrets. These are time-limited and made for the purpose of fun. Some common examples of sweet secrets would include surprise parties, gifts, or unexpected visits. Since sweet secrets are by definition time-limited, they do not linger on the back stage.

Then there are essential secrets. These are secrets which appropriately protect boundaries. For example, one essential secret between couples would be their sexual intimacy. This secret contains activity that only they share and thus draws them closer together. It truly is no business at all of others. Incidentally, violations of these essential secrets such as adultery are so deeply hurtful precisely for this reason-the offended party rightfully feels that their partner has stolen something essential from the relationship.

There are also toxic secrets. Toxic secrets poison relationships and haunt the back stage of life for long periods of time. The 1999 film American Beauty bitingly portrays the effect of toxic secrets on a relationship. The film is, in fact, full of toxic secrets, all of which combine to literally prove fatal by the end of the film. Toxic secrets usually build up like arsenic, until their cumulative effect is fatal to the relationship if not to human life.

Finally, there are dangerous secrets. In contrast to toxic secrets, which usually build over long periods of time before they cause serious harm, dangerous secrets can explode suddenly, inflicting great harm. A common