“It is more important to know what sort of person has a disease than to know what sort of disease a person has”

We need to know how our clients view the world, how they think problems originate and how they get resolved. Then, we can ask ourselves if their worldview sounds reasonably similar to any of the philosophies or theories we’re familiar with as a starting point. The only reason we’d need to know what theories the therapist likes is to either avoid bias toward it or if they’re in the client seat! Reflect on whether or not you’ve pushed a theory on clients, and if you use the same theoretical/philosophical approach with 90%+ of your clients, imagine I’m shouting this at you: Meet your clients where they’re at.

I prefer minimally invasive interventions, conceptualizing problems as mere skill deficits when possible. Clients describe their history, the problem, and what they’d like to be different. As a starting point, I consider what skills might help them, simply adding that skill into their existing way of navigating the world. I never mention theory to clients unless they bring it up (and I find those discussions endlessly tedious). I try to be very human in my interactions with clients; I think some therapists hide behind overly technical and clinical language, but effective communication is what is easily understood by normal people.

As a psychologist, I value human relationships, empathy, stage matched interventions (TTM), common factors, and microskills more than theory. Research, best practice, and treatment outcomes matter far more than my opinion.

“Models are the vehicles through which common factors operate,” (Sprenkle & Blow, 2004). As I discussed in the characteristics of effective therapists, the research on common factors and the Dodo bird verdict is clear: what theory you use has a relatively minor impact on therapy outcomes, yet newer therapists tend to be over-focused on what model they’re using. So, focus your energy proportionally. Actions that build alliance are key. A crisis agency I used to volunteer at had a mantra: “rapport is the solution”.

Useful theories serve several functions: structure for the therapy, aid in conceptualizing human nature, and based on that, suggest how change might occur. We need to have an approach to make sense of a client’s worldview, behaviour, and how to affect change, and it should likely address independence, community, motivations, principles, decision making, and so on.

Theory gives us a way to “organize clinical data, make complex processes coherent, and provide conceptual guidance for interventions,” (Hansen, 2006). Regardless of the particular theory, it gives clients a way to ‘re-story’ their experience, which is essential for healing. People often show up feeling an area of their life is chaotic, confusing, or un-tamable. Counselling gives clients a way to organize that experience that makes sense, “promoting mastery over experiences that were formerly unmanageable,” (Hansen). I prefer theories that leave lots of room for a client’s worldview, such as SFT, narrative approaches, etc.

As an overarching way to think about how therapy works, Wampold shared the contextual model in The Cycle of Excellence (2017):

The alliance is foundational to progress in the contextual model. Beyond that, they suggest three avenues through which therapy functions, as seen here above. First, leveraging the power of that empathetic connection for healing and socially corrective experiences. Second, we generate hope via some rationale that connects their experience and provides a way forward (a theory that fits within their worldview). Lastly, Wampold describes therapy requiring specific ingredients; all therapy involves some ritual. There is significant overlap between many major therapeutic approaches and interventions, so trying a ‘new’ technique may be less of a step outside of your theory or comfort zone than it first appears.

Typically these ingredients consist of actions clients can take that are inherently healthy to be doing, which involves expectation and hope (leading back to the second branch). Wampold concluded by saying “it is not assumed that these specific ingredients exert a direct effect through the medical model by repairing an apparent deficit, but rather that, in general, they stimulate healthy actions that are beneficial to patients.”

Further, Bruce stated that “effective therapists make it clear that patients’ progress toward achieving therapeutic goals is paramount—that is, the focus of the therapeutic encounter is on the patient’s problems and their solution” (p. 58). For every client I try to reflect on “how does this person think about change?” And I simply ask them questions such as:

• How do you think problems develop?

• How do you think problems get solved?

• Who gives you the best advice? How or why is it helpful to you?

A balanced approach that I enjoy and many people use is “technical eclecticism”. Here, you generally still use a single theory to guide decision making and make sense of experience, but additional techniques and tools from other therapeutic approaches can be mixed in as seems appropriate to the case. For example, sometimes doing an ‘empty chair’ exercise is the perfect fit, and I wouldn’t want to disregard it just because I was mostly doing CBT work with that client.

Lastly, Cozolino (2004) provided the following insight:

All orientations to therapy are designed to lessen suffering, reduce symptoms, and increase a client’s ability to cope with the stressors of life. In the process of successful therapy we learn to experience, understand, and regulate emotion. Finally, each form of therapy teaches some new way of thinking about the self, others, and the world. In this part of the learning process, a new story of the self is formed through the interactions of client and therapist.

It can be tempting to hold tightly to one or a few theories, and that’s common for new therapists. It’s common for experienced therapists too! It allows one to develop more expertise and to feel some comfort or familiarity during the otherwise fairly uncomfortable, uncertain therapeutic encounter. Some professors and supervisors even encourage students to pick one theory and stick with it for about a year.

Being grounded in a cogent theory helps us conceptualize cases and change, but it has to be balanced by collaboration, humility, and humanity. Try to keep your focus on what’s best for your client, and keep an eye out for your ego.

Engagement:

• What did you react to in this article? Why?

• Have you pushed the importance of theory too hard in session? What happens when you’ve let go of theory completely?

• Have there been sessions where you fumbled or missed organic opportunities because you were distracted by an element of theory?
  

Sources:

Hansen, James. (2006). Counseling Theories Within a Postmodernist Epistemology: New Roles for Theories in Counseling Practice. Journal of Counseling & Development. 84. 10.1002/j.1556-6678.2006.tb00408.x.

Sprenkle, D.H. and Blow, A.J. (2004), Common Factors and our Sacred Models. Journal of Marital and Family Therapy, 30: 113-129. doi:10.1111/j.1752-0606.2004.tb01228.x

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