Realms of Therapeutic Issues

     It is becoming clearer and clearer to me that a respectable counselor does not just query a client about the problem at hand.  Sure, a client may come in with a presenting concern, but is that issue their true problem?  I think that a lot of counselors would find this doubtful.  Exploring a client's whole self is of utmost importance.  What I would like to understand are all the realms of self that a counselor would and should cover.  I guess a first step in this understanding is to attempt a creation of a list of these "realms." Here we go:

• Childhood
• Family
• Current relationships (romantic)
• Work
• Friends/Other influencers
• Strengths/Weaknesses
• Fears
• Current life events/issues
• Long term event/issues
• Exercise/Diet
• Financial Issues
• Values

Steps in Therapy (Under Constant Revision)

December 4th, 2012

Steps in Therapy --> to be revised!!

1. Question:  What are you looking to gain from therapy?
2. Joining - Try to create a sense of "us" with client so that they feel more comfortable and are more willing to disclose
3. RESPECTFUL model - This will give a therapist a great look at the client's situation and their part in it
4. Bronfenbrenner's Ecological Theory Model - I think that this is somewhat similar to the RESPECTFUL model in that it shows off the environment around the client

New Step 1:  Talk about confidentiality, roles, and meeting for communicating outside the sessions (as well as Duty to Warn and other limitations on confidentiality)

New Step 1:  Introduce self.  This is amazingly important due to the fact that any first introduction paves the road for future communication.  It teaches them not only more about the therapist, but also gives them a mini lesson in how to communicate.

Last Step (per session):  Document what happened in the session

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December 6th, 2012

Steps in Therapy

1. Introduce self
2. Discuss payment
3. Discuss confidentiality et al.
4. Ask why they are here and what they hope to accomplish
5. Joining
6. Systems models (RESPECTFUL, wellness, Bronfenbrennarian/Ecological)

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January 9th, 2013

     About a month ago, I wrote a more succinct progression of steps when beginning psychotherapy.  To look at some details on these steps, consider the explanations in the first log.  After seeing an abbreviate session in one of my classes, I was told - and later saw the logic in the statement - that a priority in therapy is to understand the client.  I believe that my steps attempt that, but that they lack that word choice.  I think that step six's intent is to understand the greater context of the individual.  But we also need to understand the individual.  So, rather than just ask questions and seek information about his/her environment, seeking information about the person is integral.

     I also think that step five should not be a step in and of itself, but rather the title "joining" hould consist of multiple steps/phases.  I'm not exactly sure what these should be at this time.  I think that the steps should be revised to look like this:

Steps in Therapy

1. Introduce self
2. Discuss payment
3. Discuss ethical considerations in therapy
4. Ask purpose of visit and prospective achievements
5. Discuss number of appointments and method of therapy
6. Rogerian interviewing to understand client
7. Systems models

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January 10th, 2013

     Because I am in my program's ethics course right now, I am sure that some of my future writings will introduce concepts taught or thought up in class.  This is one such entry.  I've been attempting to create steps in the beginning of a successful psychotherapy and I think I've thought of a new step one.  The first step, before formally introducing oneself with credentials and so forth after sitting down in the chairs, would be to give the client pertinent sign-able documents.  These papers would include confidentiality rules and regulations as it pertains to the ACA (or whatever ethical organization is important).  So the steps now are:

1. Disperse and collect paperwork pertaining to ethical and legal issues
2. Introduce self and explain relevant education and licenses
3. Discuss payment
4. Discuss ethical considerations in therapy
5. Ask purpose of visit and prospective therapeutic achievement
6. Discuss number of appointments and method of therapy
7. Commence therapy starting with Rogerian interviewing to understand client
8. Systems models
9. Remember to console client with universality (if applicable)

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January 14th, 2013

     Going off of my previous steps in counseling, I have come to realize more steps and a change in the overall model.  The steps to add include 1) an explanation of counseling, 2) an assertion of more to come, 3) a discussion on client-centered variables in counseling, and 4) the agenda for the first meeting.  Let me elaborate a bit more on each one.

     The first idea stems from misunderstandings in what counseling is and what it entails.  Clients think that counseling is a "quick fix," one that takes a session or two and . . . done!  Instead, it takes work and the ability to change.  This is important for both a resistant client and a client who has been forced into therapy.  Better said, if they don't want to change, therapy will do nothing for them.  

     The second idea is both a phrase meant for comfort and a business practice.  It is very important, first of all, to ensure that a client does not despair in his or her first meeting with the therapist.  The first session is an information-gathering one and can therefore, due to lack of therapeutic merit, be very disconcerting to the client.  To avoid this feeling, it is important to make sure the client realizes that more therapy will commence when information is gathered.

     The third item here is about clients.  A lot depends on the client:  willingness (as previously mentioned), attitude, skills, etc.  Honestly, I jumped the gun on the first point.  Change should have been in this paragraph.

     The last item is talking about the agenda for the first meeting.  This is designed to make sure that the client knows what's in store for the session.  This can alleviate anxiety and the possible feelign of being jipped.

     Moving on, I think that putting these steps into "steps" might be a bad idea.  I think to set these into such a format might give them some kind of permanence as a list.  Rather, I think that they are better used as suggestions or points of discussion.  Also . . . I don't want to hampered by so many formal steps.

     I think that some of these points of discussion could be cleared up in a pre-therapy discussion or a pre-therapy paperwork.  Information about ethical and legal issues could be disseminated this way, but should be followed up.  Payment can be easily outlined via paper and may cause the therapist to avoid such a sensitive matter.

     It is possible that some of the other information can be explained via paper, as well.  Information regarding agenda for the first meeting, self information about education, and number of appointments can be presented in a document also, but should be followed-up as well.  

     Let me try to portray this new model again with all the other information:

Pre-therapy documents

• Ethical paperwork
• Payment information
• First meeting agenda
• Short biography including schooling and license(s)
• Policy for number of appointments
• Short description about method

Points of discussion

• Follow-ups
• Ethics paperwork
• Payment information
• Method description
• First meeting agenda
• Self introduction
• Purpose of visit and prospective goals

Beginning of therapy

• Rogerian interviewing and systems models
• these are used in order to understand the client from their point of view and in their context

     It is probably important to cite on-going techniques of merit in therapy also . . .  At this time, I will forego this, but will put it in my agenda for future writings.

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January 28th, 2013

     More points of discussion to add.  They are:

• themes and values in life/family
• developmental thought process location
• introduction of self outside of therapy

     The first point is very much an existential/psychodynamic one (and systems, obviously).  It mentions the important or underlying points in an individual's life.  Through asking the client about their own thoughts about family, life, etc., the therapist might glean at least a small amount of information about the client without their own resistances coming forth.

     The second point is from something I learned from one of my professors.  He talked about thought across the lifespan.  In particular, three of conventional thought (going from moral thought).  The first stage is pre-conventional thought.  It is a stage when a person is mainly concerned with the self.  From a Freudian personality component theoretical model the pre-conventional thought stage is closely related to the id.  The second stage in the model is conventional thought.  In this stage, closely related to the superego, the person harnesses externally-based thought.  While this is an attractive notion, it means that the client thinks of himself/herself in terms of other people's opinion.  This can be potentially harmful.  The third step is post-conventional thought.  It represents the integration of abstract thought into life.  Abstract thought allows the client to form unique ideas and identify both pre-conventional and conventional thought.  This stage is most closely related to the Freudian ego.

     The third point is critical if the therapist might have contact with the client.  If the therapist lives in a small town, the probability of seeing any number of previous or current clients is higher than living in a large city.  It is important to determine means of introduction, complete with proper salutation (Mr., Dr., etc.).  Since multiple relationships are not healthy for the client-therapist relationship, knowing how to act in these situations is important.

     With this line of thought comes obvious paperwork designed to pry information from the client.  I think at least one good piece to have is information about family and friends.  Let's recap the process:

Pre-therapy documents

• Ethical paperwork
• Payment information
• First meeting agenda
• Short biography including schooling and license(s)
• Policy for number of appointments
• Short description about method
• Family/friend information (w/ addresses, contact information, etc.)

Points of discussion

• Follow-ups
• Ethics paperwork
• Payment information
• Method description
• First meeting agenda
• Beginning of therapy
• Rogerian interviewing
• Systems models
• Depth themes
• Lifespan thought process model

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January 27th, 2014

Pre-therapy documents

• Ethical paperwork (consents/confidentiality)
• Payment information (include insurance information)
• First meeting agenda (include demographic and basic information)
• Short biography including schooling and credentials
• Introductory policy as far as number of visits
• Method description
• Family systems information

First Session Points of Discussion

• Brief repeat of:
• Ethics paperwork
• Payment information
• Method description
• First meeting agenda
• Self
• Questions
• Goals of Therapy
• Reasons for entering therapy (what is client's definition of wellness?)
• Mental Status Exam
• Ask about room structure/formation
• Previous therapy experience
• Medication?
• Post-counseling dual relationships

Multi-Faceted Learning

     I'm not sure if I've talked about this before, but I think that mentioning my thoughts about a broader education-style might be pertinent.  I really think that understanding, or at least literacy in, some other academic area is a way to innovate in the realm of psychology/psychotherapy/counseling. This other education could be anything - economics, modern languages, literature, biology, mathematics, etc.
     For lack of a better metaphor, this kind of education is like a reinforced rope - rather than just having one strand that can only rely on itself, this rope wraps itself or weaves itself in other layers, allowing for more support.
     I think that therapists have to make the effort to me more broadly-educated in general.  Clients come in from differing ethnic, cultural, religious, and educational backgrounds.  This means that their myriad experiences should be open to inclusion in the session at hand.  A good therapist in this situation is one that can talk to a bunch of these interests and past situations.  This means reading up on different religions, knowing a bit about classical literature and philosophy, and possibly having another language tucked in your back pocket.
     In the end, more broad education - even if it's self-education - can only help the professional.  He or she will feel more competent in their craft and the client will feel more related to.

Required Seminal Reading

     It's my opinion that every counselor worth their salt should read and understand the seminal work (especially in their favorite theory).  While some counselors only subscribe to certain theories (I'll most likely post about counseling learning models later), I think a more general view is better.  Without getting too much into the weeds as to why I think that a more differentiated seminal theory education is better, here is my list of books every competent counselor should read:

Behaviorism

1. Behaviorism by John Watson
2. About Behaviorism by B. F. Skinner
3. Walden Two by B. F. Skinner

Humanism

1. Client-Centered Therapy by Carl Rogers
2. The Farther Reaches of Human Nature by Abraham Maslow

Cognitive-Behavioral

1. A Guide to Rational Living by Albert Ellis (there is a newer book called The Essential Albert Ellis: Seminal Writings on Psychotherapy that could be useful)
2. Cognitive Theory of Depression by Aaron Beck

Existential

1. Existential Psychotherapy by Irvin Yalom
2. Man's Search for Meaning by Viktor Frankl
3. Love and Will by Rollo May

Psychoanalysis/Analysis/Psychodynamics

1. The Interpretation of Dreams by Sigmund Freud (there are a couple of newer books that could be chosen based on the interest of the reader - they are The Basic Writings of Sigmund Freud and Complete Psychological Works of Sigmund Freud)

Family/Developmental

1. Family and Family Therapy by Salvador Minuchin
2. Family Evaluation by Michael Kerr and Murray Bowen (there is probably a better choice out there . . . I just couldn't find it)
3. Attachment by John Bowlby

Reality

1. Reality Therapy: A New Approach to Psychiatry by William Glasser
2. Control Theory: An Explanation of How We Control Our Lives by William Glasser
3. Choice Theory: A New Psychology of Personal Freedom by William Glasser

Group Practice

1. The Theory of Group Psychotherapy by Irvin Yalom

     These are just a few titles to get a good prospective therapist started.  I will update this post when I think of another worthy seminal book.

A New Model of Counseling Education

August 27th, 2013

     I've had a thought about another article that I could write that has to do with a different way to go about counselor education than the current model.  At first, this thought was hatched when I figured that every student of psychotherapy should have to write a seminal theory paper.  I later realized that this might not be wholly feasible.  At the least, it is worth it to at least think about their own method of therapy in an in-depth manner.
     My method looks like a cupcake.  The main base of my method is a classical knowledge of psychotherapy by way of the seminal literature on the topic.  This should be required of the student by the professors and administration, but also be the responsibility (mainly) of the student.  I've written about some of the more seminal articles before.  Some include (but are not limited to):
     - Irvin Yalom's Existential Psychotherapy
     - Sigmund Freud's psychoanalysis (many different readings)
     - Glasser's Reality Therapy
     - Rogers's Client-Centered Therapy
     - Beck's Cognitive Behavior Therapy: Basics and Beyond
     - Ellis's A Guide to Rational Living
     - Skinner's On Behaviorism
These are some of the foundation books that describe the very roots of therapy.
     These texts not only give prospective therapists the knowledge they need in order to be competent therapists, they also provide a rich historical view on the subject.  I think that, though most people spurn him and his ideas (which were wholly appropriate for his time period), Freud and his followers (which are all of us, really) need to be understood as to their connections with one another ant heir link to that-day culture.

     Classical literature learning should really be in the hands of the student.  I think that this must be tempered in some way by a professor.  Who knows that wild conclusions a new student would come to without the correction of a competent professional!  At the same time, it might be good to have unguided learning in abstract theory.      Professors/professionals really come back into the equation when we talk about venues.  I take venues to mean avenues to apply the theoretical knowledge learned in the previously-read books.  the above figure shows these venues.  I think that my way of going about things would allow students to learn more about specific venues per the time they spend in class.  These venues include (but, again, are not limited to):
     1. Crisis
     2. Multicultural counseling
     3. Ethics/Policy
     4. Entrepreneurship/Billing/Healthcare
     5. Marriage and Family
     6. Drug and Alcohol
     7. Group Therapy
     8. Developmental/Lifespan
     9. Grief/Loss
     10. Interviewing techniques and postmodernism
These could also be seen as specialties, but I hesitate to call them such because that word makes me think that they should be off-shoot "majors" or programs, which they very well might be able to be.  They are simply more specific avenues through which a practitioner can apply their theory. 
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August 28th, 2013

     It seems to me that Counselor Education programs are under-respected when compared to other Master's or even PhD programs.  I'm trying to figure out why this is.  Could it be the accreditation process yield a curriculum that does not produce enough graduates of proper scholastic mind?  Could it be that the students are not ready or even qualified or disciplined enough to gain the amount of knowledge that is expected of them and is relational to other institutions?  There are definitely other reasons for this, including lack of research and availability of the professor/student.
     To a degree, I posit a degree for students who are there to do the work.  When I look around the classroom, I do not see movers and shakers.  I see middle-of-the-heap quasi-professionals.  To a degree, I understand that not every school can have programs that raise a student to the highest level.  But should not all schools aspire to a higher plane of academia?
     I posit that we create more barriers to entry for incoming students.  I don't think that students of questionable academic merit should even be accepted (this would also lead to lesser attrition down the road) into the program.  Counselor Education programs, in my opinion, should include both research and experiential learning.  As an added factor, some kind of thesis or end-of-term project should be required.  The amount of research that this model prescribes is prohibitive to the lazy student.

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     Going off my previous discussion about required classical reading, I forgot to mention a very valuable resource.  The American Psychological Association has a very comprehensive monograph collection of different theories.  While these are not seminal articles from the theorist who originally thought of it, the authors tend to be modern experts in those fields.  I am unsure of the number of these monographs.

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     Moving on, after the classical literature understanding is delved into (which could be one class really . . . maybe one semester . . . worth 6-9 credits?), and on the post about venues, experiential learning is the next key portion of the model I am writing about.  Whereas the classical literature portion is more student-based (though the class would most likely discuss the theories read at home, which involves a professor) and the venues portion of the academic projection involves a professor-led educational experience, the experiential section is student-led, but professor-observed.  I think that supervision is an amazing and integral part of the education experience.  It allows experienced or practiced professionals to share their knowledge in a hands-on environment.  Supervision is obviously done during practicum/internship.  I would actually suggest one of two things (or both) when it comes to these.  The first is more time spent in the field.  It is hard to argue, I think, against more time participating in the craft.  The second is to spend time in more varied sites.  While classical literature is a good way to point oneself in the direction of a specific type of therapy that a student might be interested in (actually, the venues portion is even more appropriate here) the experiential portion really allows a student to figure out their "specialty," I think that they will eventually be better therapists for it.

     The normal (or current) method to complete experiential learning is one practicum and one internship.  As I said before, I think more is better than less.  At some point in this writing, I will write out a semester by semester schedule for this self-designed program.

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August 29th, 2013

     Here is a very preliminary schedule for 60 credits in my model:

Semester #	Course(s) and credit	Total credit #
1	Classical Literature (6) / Interviewing and Postmodernism (3)	9
2	Multicultural (3) / Ethics (3) / Developmental (3)	9
3	Crisis (3) / Grief and Loss (3) / Drug and Alcohol (3)	9
4	Group (3) / Marriage and Family (3) / School (3)	9
5	Practicum (3) / Internship 1 (3) / Research (3)	9
6	Internship 2 (3) / Internship 3 (3) / Research (3)	9
7	Thesis (6)	6

     This schedule really pushes that "theorist scholar practitioner" model that I believe I mentioned before.  Normally, three classes per semester would be a good idea.  I think that it wouldn't be too much or too little.  I've split the education (which would take seven semesters or two years and a semester) into three sections to allow faculty and supervisors to cut as needed.  I believe that professors are the gatekeeper and should very closely guard students.

     The first level here is very much like candidacy in other programs.  If a student can't hack it through understanding the classical literature and basic interviewing, it is my opinion that they should not continue the program.  I can see the argument that this model starts out pretty quickly.  Classic literature can be quite daunting (especially if the graduate student does not have a background in a psychological studies discipline).  So, with that in mind, I could see a possible switch between semester one and two on this list.  Semester two is very introductive and could (and I stress could, not should) switch with the semester marked one.  I will assume, for the rest of this, that classical literature and interviewing skills/postmodern theories will be done in the first semester.  While my current program (in university) has introductory courses in the things like community mental health, marriage and family therapy, and school counseling (these are actually covered, to a degree (except for the first one) in my model). 

     The second level expands on the first and really outlines the venues that I mentioned before.  These are curricular-based and allows the student to investigate these specific areas both for concentration purposes and applied core knowledge areas as well as eventual internship opportunities.

     The third level is all about experiential learning and research.  This is the time for students to really figure out what they want to do.  The table also mentions that the thesis is a requirement.  It is hard to stress enough that students interested in a degree (and a CACREP-approved final degree) should include not only experiential but academic work.

Matching Theory to Client

     We are told that the therapy used must match the client.  A deeper meaning here is that it must match both client and counselor.  If a counselor is unfit to use a technique due to lack of knowledge or experience, obviously he or she should not use that method.  I am not wholly convinced, though that the previous over-arching statement is complete.
     I think that a therapy has to complete three hurdles in order to the usable and useful.  The first has already been mentioned:  The counselor must be both competent and comfortable with the method.  The second step is to ensure that the client can grasp the therapy being "prescribed."  Without such understanding it is obvious that the client would not benefit from therapy.  The third stage here is much more difficult and might not necessarily differ all that much from the second.  This step expects the theory being used to match the problem at hand.  It might sound as if I am making a case for therapies that have empirical efficacy when matched with certain disorders.  While I agree with that train of thought, I am not writing about that.  Instead, I am writing about the specific problem's theoretical roots.
     Seeing as how each person experiences stimuli differently, it is important to ascertain the form in which the problem has occurred.  This is a difficult concept to explain.  Let me put it this way:  While some (or most) people would treat a phobia behaviorally, there are those that would treat it with psychodynamic psychotherapy.  Perhaps this choice had more to do with steps one or two, but, nevertheless, the client becomes well quickly.  In this situation, it seems that the therapist stumbled upon the third step.  The phobia had a deeper meaning or root that only (or mainly) a psychodynamicist could have spurred to health.
     While this description is amazingly inadequate, I am glad I got it down for future reference.

Using Disorder as a Tool

     We throw around disorder names like obsessive-compulsive and conduct as if they are singular entities.  Many people, upon seeing victims of these illnesses, tell themselves that they are glad to not have these disorders.  I argue that such behaviors are inherent in all of us.  Everyone, at some point, has experienced a moment of "enhanced behavior" . . . some alternate state when their actions were just a tad off, but this change allowed them to do remarkable or abnormal things.
     Perhaps the next step in psychology or therapy is not to suppress these tendencies, but rather to have the ability to bring them on at will.  Such an endeavor would allow us to change our moods, work habit, levels of aggression, etc., almost instantaneously.  Certain conditions warrant such change.  I think that these changes should be self-driven and cognitive, not medical or biologically-started.  With this change, one would learn supreme self-control; indeed, he or she who masters such a technique would almost have to rank on Maslow's hierarchy as self-actualized.
     Almost as important (likely just as important) as creating this change would be its ending.  To be able to switch on an aggressive mood and be able to turn it off would be a disaster and would most likely lead to immediate outside action.  I would hope that having the mental dexterity to start such a change would automatically allow the person control over the opposite action.
     As I mentioned earlier, these "moods" are present in us at all times.  The reason that they don't show in our actions is because another "mood" is balancing it out, just as one drug can balance out the effects of another.  Similarly with that analogy, there are still side-effects to the process.  Anxiety, lack of energy, and depression are three consequences that come quickly to mind.
     I think that insanity is a person or brain that finds such a state to be preferable to the current situation.  Sure, there are some disorders that don't necessarily have a positive function, but I don't believe these to be singular issues.  Instead, they are simply the progression of a more "useful" mood.  While a situation has pushed a person from the "normal" part of the behavioral spectrum, past any useful state and into insanity, such people do not possess the skill to bring themselves back.