Goals of Therapy

In a formal and/or informal way therapist and client begin therapy by setting goals for therapy. These goals fall into one or more of these six categories:

1. Crisis Management / Stabilization e.g. A spouse has an affair, and the couple is faced with
immediate issues of trust and betrayal before deciding whether or not to continue the relationship and confront the process of healing, re-committing, and re-gaining intimacy.

2. Development of Coping Strategies to Handle Future Problems This is akin to prevention,

e.g. After a long struggle with depression a woman is feeling better with medication, but wants to learn skills to deal with environmental stressors that might trigger depression in the future.

3. Long-term Pattern / Personality Change e.g. A man is repeatedly unable to sustain

relationships with women due to his fear of intimacy/vulnerability related to his family of origin dynamics.

4. Symptom Reduction e.g. A woman has been highly anxious for many months leading to a lack
of productivity at work and social withdrawal, or a man wants anger management strategies to help express feelings more constructively.

5. Self-examination e.g. Someone who wants to understand him/herself more, either as a

continuation of previous therapy or comes into first-time therapy with this as the initial goal. Or a gay man has recently come out at work, experiencing conflicted feelings about doing so and wants to understand his inner struggle.

6. Prevention of Relapse / Stabilization / Maintenance e.g. A person with chronic, painful

medical condition seeks a supportive therapy, focusing on optimal daily functioning. Or someone has recently begun recovery from an alcohol, drug, or behavioral addiction, and wants to learn skills to prevent sliding back into the addiction. These goals are not mutually exclusive. More often than not, one goal will morph in another, e.g. crisis management quickly turns into development of coping strategies, which evolves into long-term pattern change, yet again transforming into self-exploration. When this happens it is a good sign that therapy is working, evidenced by the organic changing of the clients needs.

Stages and Sub-Stages of Therapy

Regardless of type, all effective therapy moves through the same general six stages: 1. The issue(s) are defined with respect to 2. History, 3. Present context, and 4. Further direction, from which 5. The goals naturally arise, and all the while 6. Therapeutic alliance is simultaneously being formed.

If change is the chief goal of therapy, then this process of change is further divided into six sub-stages:

1. Relinquishing an old pattern internal, e.g. thought process, and/or external, e.g. behavior 2. Initiating a new pattern 3. Maintaining the new pattern 4. Applying current understanding to the past, changing ones personal narrative/memory-set (subjective biography) 5. Incorporating the new pattern into current life 6. After leaving therapy, continuing to use the skills/patterns. The nature of outpatient therapy, by definition, usually means that the client spends 167 hours a week away from the therapist, making it crucial to supplement the 50 minute session with interventions for the client outside of the office. These include an infinite number and type of homework assignments, e.g. readings, journaling, self-help groups and/or therapy groups, practicing behaviors, self-observations, implementing communication strategies, dreamwork, relaxation techniques, etc.

Overarching Principles of Therapy

Effective therapists have a solid grounding in the basics of psychotherapy, a stylistic disciplined flexibility. This means that the therapist structures ways to adjust theories to his/her personality, as well as to the individualized needs of the client (Bankoff and Howard, Journal of Psychotherapy Integration ((4) 1992:273-294). The key is for the therapist to move about seamlessly and easily, while prudently strategizing for maximum, efficient change. This change is effected by using the following overarching principles: 1. Disciplined flexibility, as defined above 2. Theory and technique are authentic to the individual personality of each therapist. No matter how leaders of schools try to churn out followers in their own image, practitioners seem to adjust their chosen theoretical orientation to their own interpersonal style. This is a good thing because the last thing you, as the client, would want is your therapist play-acting and behaving in a way thats incongruent or uncomfortable (and hence ineffective) for him/her. 3. Therapists adjust to qualities clients bring to the psychotherapy relationship, and strive to match client characteristics with the most potentially aligned interventions. Rather than forcing clients into therapist-imposed restrictive formats, therapists need to respond empathically to the individuality of each client. 4. Experienced therapists learn to move readily between commonly accepted change paradigms. The three meta-strategies that guide how therapist apply techniques are:

A.

Key Change Strategy Sometimes the available evidence suggests that one intervention

offers the quickest, most efficient avenue to change. For example, a woman comes in with a phobia of spiders. The techniques of exposure, systematic desensitization, progressive

relaxation methods, and cognitive rebuttals are used.

B.

Shifting Change Strategy Therapy begins with the most indicated and easily used

technique. If not effective, switch to another strategy. For example, a couple comes in because theyve been arguing about commitment issues. Techniques begin with exploration of interpersonal dynamics, communications training, empathic alliance and meta-level observational homework exercises all in a couples format. This is simultaneously later supplemented with anger management and emotional expressivity work with the man, while the woman focuses on psychodynamic family of origin issues both in individual formats.

C.

Maximum Impact Strategy With complex or multi-dimensional cases therapists work

simultaneously on several patterns: parallel processing. Instead of hoping for a sequential effect, therapists work for a synergistic effect, as multiple changes mass together to bring about the desired change. This relies on the principle of using the least amount of energy to produce greatest output. For example, a man comes into therapy in the early stages of recovery from alcohol addiction with a recent concomitant diagnosis of multiple sclerosis, and symptoms of chronic anxiety, depression, and insomnia. He has frequent outbursts with his live-in girlfriend and conflicts with co-workers. His boss has also placed him on a six month probation for unreliability and low productivity. He is overwhelmed and stressed to the point of near non-functionality. Interventions used in this case might include: erecting necessary psychosocial supports, i.e. 12 step groups and/or group treatment, anti-alcoholic medications, identifying internal/external triggers in order to maintain abstinence and to prevent relapse. This is in addition to possible referrals to a primary care physician (to rule out organic causes of depression, e.g. hypothyroidism) and to a psychiatrist for medication evaluation/management of mood disorder. The therapy sessions provide guided structuring of the preceding, plus supportive therapy with a chronic illness management focus: assertiveness training about work issues, communications work regarding his girlfriend, and meditation skills for his insomnia may also be implemented. Cognitive work identifying and rebutting maladaptive automatic thoughts may also be used; awareness based homework assignments within a larger framework of relational developmental, familial history, suing psychodynamic templates all this would be standard for such a complex case (Prochaska, DiClemente, Norcross; American Psychologist (9), 11021114:1992). 2. Seasoned therapists reflect on and analyze their own thinking/emotional responses, looking to their internal experiences with the client in order to differentiate their own subjective reality from clientinduced ones. These insights and observations help clients in their therapy goals and also help therapists grow as human beings and as professionals. 3. Theory and technique are influenced by the cultural context in which they are practiced. In turn, the practice of psychotherapy also dialectically informs the culture in which it grows.

Overall, the common denominator of these six overarching principles is an ethical one; everything a therapist says and does is intended to help the client.

General Tools of Therapy

Clients change during psychotherapy for many reasons, where many therapeutic and pharmacologic studies demonstrate a time effect. The factors contributing to this effect fall into three further categories: A.Spontaneous Remission (outside of the therapeutic relationship) B.Placebo Response (positive expectancies within the therapeutic relationship) C.Construct Effects of Interventions B and C contain the tools of therapy, and address the question how does psychotherapy work? (Lambert and Bergin, 1994). The primary tools of psychotherapists are: 1. Relationship Skills: Formative, careful management of the therapeutic alliance, i.e. nonjudgmental acceptance, trust respect, warmth, etc. This is a strong predictor of outcome (Horvath and Greenberg, 1994). 2. Activation of Clients Observing Self: Activating clients capacity to self-observe, which often leads to insight, creates choices, regulates emotion, and fosters behavior change. In service of this meta-level self-awareness, therapists may use empathic reflections, cognitive homework, affective exercises, interpretations, behavioral instructions, analysis of dynamics, plus a wide array of other interventions to initiate and maintain changes (Deikman, 1982). 3. Knowledge of basic developmental psychological difficulties. Therapists implement theoretical patterns/themes of understanding in order to conceptualize clients struggles/symptoms. These vary widely, i.e. anxiety, depression, addictions, phobias, grief, traumatic memories, interpersonal strife, etc; many issues reflect prevailing cultural currents, as we are psychosocial beings. 4. Inductive Reasoning: Therapists use disparate bits of information presented by the client to generalize about explicit, enduring patterns of functioning. This information is gathered directly, i.e. questioning, clarifying, confronting, etc., and indirectly, i.e. observations, therapist reactions to client, homework assignments, data from significant others. 5. Persuasion: This is not in the traditional sense of the word, but more as therapists encourage clients to increase emotional awareness, modify cognitions, and change behavior, re-defining the self in relation to others. These strategies guide clients to face their fears, changing their narratives of the past, experience of the present, and anticipation of the future. In so doing, clients are re-designing their role-relationship schematas and scripts (Frank, 1991).