Proper Therapy for All Populations

     A reoccurring theme in counselor education is the subject of abstaining from giving treatment based on a client's past behavior.  This includes religious affiliation, race, sexual orientation, or even crime.  I'm not sure that a counselor who discriminates due to these has any right to call himself or herself a counselor.  I think that it shows the counselor's hand fully to make a distinction thusly in clients and shows a counselor who must deal with his or her own issues before engaging clients of any kind.  As counselors, we are there to model correct behavior to not only clients who we directly serve, but also the general public.  If we show discrimination, does this not put a bad face on counseling as a whole?  We should be there for anyone, not just those who society (or even we as counselors) think is worthy of our time and efforts.
     I can see two immediate holes in this argument.  Counselors should not enter into contact with anyone who we do not know how to serve.  This is obvious as "do not harm" meets "best practices".  That being said, I think, to a point, that common factors can control for clients who are "outside the norm," whether that be religion or any other demographic.  Unless the client is entering counseling specifically for religious guidance (he or she should most likely not be in therapy, then), the client should be accepted and therapy should take place.  The other hole has to do with counselor safety.  If the counselor doesn't feel safe with a specific client for whatever reason, therapy itself would be a stunted mutation of itself, and would do neither body any good.
     This entire entry comes from the thought that counselors, to a degree, are, or must have the ability to be, blank slates, only giving an opinion or interjecting their own beliefs when it is deemed 100% appropriate and beneficial to the client.  While I do not specifically enjoy the image of a true Freudian psychoanalyst sitting as a true blank screen on which a client is supposed to transfer his or her own feelings or thoughts, I think that the feeling behind the idea gives it credence.
     I'm not sure how I feel about "compartmentalizing" either . . .  This practice seems hazardous at best and almost distracting and detracting from the counselor's attention on the client.  Having to bind off a section of the psyche in order to function seems oxymoronic to me and leads me to believe that the counselor just needs some counseling himself or herself.

Domains in Life

     I am trying to figure out what the main domains for my life are.  What do I look forward to?  Where do I spend my time?  What's important to me?  I've boiled it down to four things:  Self, Others, Future, Reality.  It seems that most of my thought processes run through these areas.  I'll discuss these themes and how I got to each of them.

     I tried listing in my head the main things that I think about during the day.  I t went a little something like this:  Exercise, Relationships, Study, and Work.  I tried to make them a little more general so that they might be applied to other situations.  Exercise = Self, Relationships = Others, Study = Future, Work = Reality.

     The first domain is all about the self.  What makes us feel better?  How do we seek to improve ourselves?  For me, I think that food and exercise are chief factors in the self.  These make me feel good and help me strive for self-betterment.  Self is about the body and of the mind, but only insofar as personal understanding in improvement are concerned.

     The second is Others.  Others includes interactions, thoughts, and feelings with, about, and toward any other person.  These relationships could be romantic or plutonic.  Main questions here are:  Who do I want to talk to?  To whom do I look up?  Whose opinion or advice do I value?

     Future is a very large factor in this thought process.  My original thought was study.  I don't really mean planning for the future in this way, but rather more like, "What do I leave the future for having been here?"  I guess Future, in this sense, is more allied to people rather than events.  For me, my course of study is something that I would like to become somewhat of an expert in so that I can eventually  make a small, yet important, contribution.  How do I leave my mark?  How will people know I existed?

     The last factor is Reality.  I had to add work in some way into this mix, but I didn't originally know how.  I think that Reality could be re-named Society or some such.  While the other three factors are mostly intrinsic, Reality is very extrinsic.  I think that Reality has more to do with future planning, possibly, as well as money-making, politics, etc.

     I understand that spirituality is nowhere in this "model."  I did that on purpose to an extent because this has no place among my four.  Perhaps I could see this model almost as a foundation or definition for spirituality, but I will not include it inside.  

     Perhaps a therapist could use this to go into deeper insight into a client.  I think that all clients, to some degree or another, can express their own understandings of life so far through a pattern of thought like this. 

Different Theories of Learning Therapy

     I frequently think about how a counselor education programs teaches students about theoretical orientations.  Where I am learning, they tell us that it is popular and ethical to have one that we specialize in.  We should learn the ins and outs of this practice, understanding all its subtleties.
     There are a couple other ways to understand the education of counselors that don't involve a "major" in a certain theory.  These include technical eclecticism, common factors, and theoretical integration.  Before I talk about these, I think that it's important to discuss assimilative integration.
     Assimilative integration is the theory that drives the behavior of counselors to learn the entirety of a theory and add in practices and techniques from other schools when a deficit is found in the "home theory."  An example of this is talking to a lower cognitive client when a therapist's main understanding is existential psychotherapy. While this may be a good starting point for a beginning counselor, I am hesitant to recommend it to a more experienced one because it disallows, to a certain extent, the total learning of a second (or third/fourth/fifth, etc.) theory.  Instead, it values throwing many theories together without sufficient understanding behind any but one.  This seems irresponsible to me.
     Common factors is an approach to psychotherapy that promotes finding the core beneficial elements of all/any therapies and using that as the main point in therapy.  I think it appropriate to cite Rogers' elements in successful therapy.  He mentions the therapeutic alliance, genuineness, empathy, and unconditional positive regard (among others).  These foundational points in therapy, according to Rogers, can benefit any therapist/client relationship.  From here, a counselor would, like assimilative integration, add techniques in from other theories.  Again, I don't agree with that point of view.
     Technical eclecticism pushes a more evidence-based approach to selection in therapies.  This understanding merits selection based on what has worked the most for others, researching studies on specific illnesses and their positive treatments.  This isn't the worst idea ever as it is a more problem-oriented approach (I mean this in a very different sense than strengths-based approach).
     Theoretical integration is the idea of adding different theories together in order to be able to react to any and all problems.  This is more my own understanding, but I think that it could be take a step further.
     Teaching the philosophy of theories for psychotherapy is like selecting proper camping knives.  A camper can choose any number of knives for survival.  In my opinion, an assimilative integrationist would choose a cheap multitool and a really nice machete.  Someone who studies theoretical integration would choose a nice Leatherman and a Kaybar.
     An assimilative integrationist, as mentioned, chooses one theory as a home theory or backdrop theory and include others (specifically their techniques) when it fails.  The machete symbolizes the home theory.  It's good at what it does, but it has certain limitations.  It can stab and cut, but can it saw or sew?  That's what the cheap multitool is for.  Unfortunately, it is sub-par.  It frequently fails or breaks.  Such is the limitations of not truly understanding another theory.
     A theoretical integrationist would understand theories much more completely; he would be able to utilize them efficiently and without thought for failure.  The Leatherman and Kaybar would both do their duties as they were manufactured to do.
     My own ideas on teaching theories is somewhat more radical than the others.  I believe that every competent theorist should strive to learn as many theories to their limit as possible.  This can give counselors multiple perspectives, techniques, and opinions to open their minds.  To go back to the metaphor, it would be like taking a kit or roller of tools to ensure that every possible eventuality could be controlled for.  Obviously this is an unwieldy metaphor . . . taking so many tools is uncalled for.  Understanding all theories is impossible as well.
     In the end, a counselor should really try to make his own theory.  This theory should be singular to the counselor.  Freud's theory is an extension of hi sown psychosexual infantile needs and drives.  Rogers' theory is based on his own attitude toward others.  We can only do our best to take on all the information that we can and make our own small changes to increase their results.
     It almost seems like the other theories of learning are equipped to stop the further complete learning of theories.  This seems irresponsible to me.

Symptoms, Education, Depth

     I'm coming more and more to the conclusion that therapy is less about what theory the therapist decides to employ overall, but move when he or she decides to use it.  Since I haven't written in this for a while, I forget about what I have previously written; my apologies if I repeat messages.  I think that a successful therapist is a journeyman of a couple of different therapeutic disciplines or orientations.  To practice otherwise would be to decrease effectiveness and the amount of clients able to be seen.

     It seems like there are three stages to successful therapy:  1) Symptoms, 2) Education, 3) Depth.  As I've previously written, one difference between the Wellness Model and the Medical Model is the fact that the former endeavors to make the person better than they were when they were normal.  I think that numbers two and three attempt to do this.  Number one adheres more strictly to the medical model, strictly controlling symptoms.

     Perhaps I should explain this progression first.  Number one is Symptoms, should be a therapy that helps immediately control the negative behavior that brings the client into the office.  The most base example of this is behaviorism.  Through behavioral techniques, controlling presenting symptoms would be possible.  If this were the starting point in therapy, it almost seems to me that the process of joining would be secondary to the work at hand.  The therapeutic relationship would stagnate until further along in therapy.  

     Number two is Education.  What I meant here is that a possible re-education may have to occur.  Two examples of this, depending on the presenting problem, would be CBT or emotion-focused therapy.  I think that both of these types of therapy attempt to teach skills to clients that they can use later in their lives.  Not only can they use specific skills, but I think that both of these theories would push the client to create new general means of thinking or feeling.

     The third step would be Depth.  Obviously this level of therapy would institute theories like existentialism or psychodynamics.  The main goal would be to really find the root of whatever issue is plaguing the client.

Normalcy or Being Abnormal in Therapy

     We keep on acting as if people are not normal.  I have already discussed normality and universality - two terms that halfway disprove total uniqueness (and adding "normal" back into the equation) - so I won't go into them.
     Should counselors be trying to change someone's personality?  Should an individual seek that sort of permanent alteration?  I'm unsure.  While actions show normality and universality, thoughts trend more into the realm of the unique (most likely because actions are bordered by physics, whereas imagination is infinite depending on the mind).  This being the case, that one does not translate into the other 100% of the time, should we try to construct further barriers to true unique thought by instituting outside action?
     An example is probably in order.  Sometimes I get skittish around people.  To a degree, it may be due to genes and a possibility of depression in my ongoing family and lack of sociability when I was a child.  This feeling might be detrimental to the counseling environment.  Perhaps a mood swing takes me in the middle of a session.  What then?  Should I not seek to reverse this trend and create inside of myself a feeling of calm and self assurance?  Would this not provide an inhospitable environment for mood swings?
     The answer:  perhaps.  But what would I be giving up were I to undergo such a change?  Would I lose part of myself?  Again:  perhaps.  This is a tangential thought adhering itself to the main purpose of this idea.  I don't know how to change myself in this manner.  What I want to figure out is how to live with my behavior and thoughts and feelings.  Generalizing this more:  How does a therapist advise on their presenting behavior?  Do we ask them to stop it?  Mask it?  Let it out?  Obviously this depends on the behavior and should be assessed on an individual-by-individual basis, but still . . .
     I think it comes down to this:  Good advice to a client (for me) might sound something like this:  "I hear what you're saying and really what comes to mind is the topic of acceptable consequences.  Are you willing to be responsible for your behavior?  If you are, then perhaps it is 1) not too severe and 2) worth the energy put into it.  If you are not, then perhaps we can look into some techniques that will allow you to act a little differently in certain situations."
     The counselor must also assess the behavior for himself also.  If the client enjoys killing people and is totally OK with the repercussions, the statement above is defunct.  We must stick to our ethical guidelines.  Personality disorders and irrational thought have the ability to destroy such a statement of consquences.

Universality Versus Normalizing

     Some of my classmates (and even some of my professors) confuse the terms universality and normalizing.  Both of these are terms that have to do with the understanding of one's problem or issue as normal.  They differ only in context, but it is this difference that makes them unique.
     Universality is an idea that promotes an understanding of one's problematic behavior through the idea that:  others have suffered in the same way, or similarly, in the past; are suffering in such a way in the present; and will most likely continue to suffer like they have in the future.  This promotes the feeling and idea that they are not alone and that others have either been "cured" or have learned to solve their problem/cope with it in a way that they can live a happy life.  This is one of Yalom's group theory therapeutic factors and makes a lot of sense when the immediate group can support the therapist or show their own similar behaviors/strategies on their own.
     Normalizing is more of an intrapersonal topic.  Instead of highlighting extrinsic factors, it describes the idea that the behavior itself is normal.  All behavior is normal.  Any mental illness is a product of all experiences of the past.  This means that the psychotic is normal because he or she is just performing the actions that make sense to them given what has happened in the past/what happens to them every day.  Carl Whitaker is very well known for accepting clients' behaviors as normal.
     While similar in intent, these concepts are dissimilar in context.  It is important not to mix them up because they are attributed to two different thinkers.

To a Better Approach to Finding a Therapist

     I am starting to think that the current model of psychotherapy initiation and execution is flawed and inefficient.  The current mode for client intake goes something like this:

1. Client searches internet/newspaper or asks advice from friends/family about a practice they know and trust.
1. If they search the internet exclusively, they forego knowledge of therapy jargon and choose based on the marketing skill and beauty of the site.  
2. Client calls therapist and hopefully asks some probing questions about means of therapy and history of the therapist.
3. Client agrees (or disagrees) with therapist, shows up (or doesn't), and is counseled. 
4. Client leaves therapy in relief of symptoms/presenting problem (could take time) or leaves therapy frustrated and upset that they lost money (or sanity).

     I think what irks me the most here is that the client dos not have the means to make an intelligent and educated choice about the therapist.  If a therapist works for Ralph, my friend's brother's boss, how do I know that the therapist will help me?  Word-of-mouth is inaccurate.  Looking over internet websites, while more accurate, is prone to folly when it comes to word choice, money spent, and therapist countenance.  It seems like there are too many factors with which a therapist could accidentally hang himself.

     There is a much better way to advertise counseling correctly/accurately.  It starts with understanding who the client is.  Steps three and four above describe the counseling process and any reaction afterward.  Any negative remark about therapy would be avoided if proper screening occurs at the front end.  I think there should be some kind of questionnaire that the client is required to take that shows what type of therapy might work best for him.  Therapists speak of "meeting the client where they are" - something that, I think, extends far beyond what questions to ask.  Certain clients might do better with a behaviorist while others could gain relief with an emotion-focused practitioner.  If such an exam could be constructed, it would be simple to match clients of a certain temperament to a counselor that would best fit them.

     There are two complications that come to mind here.  Other than the overhaul of the system (which no one likes).  The first is insurance and the second is accreditation.  I think that insurance companies would subsidize only the top nth percent of the therapists who provide care, based on the democratic process of choosing the ones who practice must.  This means that those practicing CBT would land insurance money while analysts wouldn't (this, of course, assumes that CBT would be matched to more people while psychoanalysis wouldn't)!  This would ensure that more therapists would train as CBT practitioners (and that schools would only teach CBT) and that fringe clients would have a mismatch when seeking treatment.  

     Accreditation here refers to the process through which a therapist gains the right to practice a certain orientation.  More schools would open up (probably called institutes, offering certificates) and more specialized training would be received.  

     I talked on December 24th, 2012 about abstract versus concrete practice.  I rather think that such a topic also has relevance here.  How constrictive would a therapist be in his practice?  Could they use techniques from other schools?  How is such a thing maintained?  Would therapists be required to amass further training in the future?

     This prompts yet another issue that would be the backlash to such a stunt.  If we made it normal to test clients on their "therapeutic temperament," would we not also require this of therapists?  If a prospective therapist is interested in such a study, would it not behoove him to take such a test to find out which speciality is best for him?  I am unsure of this.  To take it further, if a current student of existential psychotherapy takes the exam in the middle of his education and receives back an answer of behaviorism, would he then be required to change tracks or relocate his education?

     A huge part of this discussion is choice.  I think I put it on ice for awhile with this.  Should clients have the right to choose their therapists as they see fit?  Yes! Even if it doesn't help them?  Yes!  That's the beauty of choice.