PSYCHOTHERAPY

PSYCHOTHERAPY
LEWIS R. WOLBERG, M.D.

Psychotherapy is the treatment, by psychological means, of problems of an emotional nature in

which
a trained person deliberately establishes a professional relationship with the patient with the
object of (1)
removing, modifying, or retarding existing symptoms, (2) mediating disturbed patterns of
behavior, and
(3) promoting positive personality growth and development.
This formulation requires additional elaboration.
Psychotherapy is the treatment. No matter how much we attempt to dilute what we do in
psychotherapy, it constitutes a form of treatment. Such terms as reeducation, helping process,
and
guidance are merely descriptive of what happens in the course of treatment and do not really
disguise the
therapeutic nature of the process. Forms of intervention other than therapy do exist in the
mental health
field and will be described later.
Psychological means. Psychotherapy is a generic term covering the entire spectrum of
psychological
treatment methods. These range from designed maneuvers of the therapist-patient relationship
to
indoctrinations fashioned to change value systems, to tactics aimed at intrapsychic processes,
and to conditioning techniques that attempt to alter neural mechanisms. The repertoire of
strategies is thus
legion, and formats are varied, e.g., individuals, couples, and groups. They are all, nevertheless,
dependent
upon the establishment of adequate communication, verbal and non-verbal. Excluded are such
modalities
as somatic therapies (drugs, convulsive therapy, surgery, etc.) and “trial action” therapies such
as
occupational therapy, dance therapy, music therapy, psychodrama, etc. that, though
psychotherapeutic in
effect, are not, strictly speaking, forms of psychotherapy.
Problems of an emotional nature. Emotional problems are diverse, influencing every facet of
human
functioning. They are manifest in distortions in the individual’s psychic, somatic, interpersonal,
and
community life. Manifestations of emotional illness are thus multiple, involving the total human
being. In
view of this totality of disturbance, it is arbitrary and unsound to dissociate psychic from
interpersonal,
social, and psychophysiological difficulties, aspects of which are usually concurrent, though not
always
obvious.
A trained person. In search of relief, the individual is apt to involve oneself in a relationship with
a
friend or authority. The motivations that prompt such a relationship are disabling symptoms or a
realization that one’s happiness and productivity are being sabotaged by inner forces that one is
neither
able to understand nor to control. Sometimes the consequences of this relationship are
registered in a
restoration of homeostasis, a product of healing forces liberated by the helping process. At other
times,
particularly when attempts are made to handle the sufferer’s emotional turmoil in depth, the
relationship
may become disastrous to both participants. Dealing most adequately with an emotional
problem requires
a high degree of skill that may best be acquired through extensive postgraduate training and
experience.
Deliberately establishing a professional relationship. The relationship, the core of the
therapeutic
process, is deliberately planned and nurtured by the therapist. Unlike non-professional
relationships,
which are part of the social nature of man, the therapeutic relationship is a collaborative
undertaking, started and maintained on a professional level toward specific therapeutic
objectives. More than one
therapist (cotherapist, multiple therapists) may work together.
The patient. An individual in psychotherapy receiving treatment is best called a patient rather
than
some other designation such as a client. The therapist may relate capably to more than one
patient during a
session, as in marital or group therapy.
The object is removing existing symptoms. A prime goal in therapy is to eliminate the patient’s
suffering as well as to remove the handicaps imposed by symptoms.
Modifying existing symptoms. Despite our wish for complete relief, certain circumstances may
militate
against this objective. Chief deterrents are inadequate motivation, diminutive ego strength, 1
and
limitations in the patient’s available time or finances. These will impose restrictions on the extent
of help
that can be rendered and make for modification rather than cure of the patient’s symptoms.
Retarding existing symptoms. There are some malignant forms of emotional illness, such as
certain
fulminating schizophrenic and organic brain disorders, in which psychotherapy, no matter how
adroitly
applied, serves merely to delay an inevitable deteriorative process. This palliative effect is
eminently
worthwhile, however, often helping to preserve the patient’s contact with reality.
Mediating disturbed patterns of behavior. The recognition in recent years that many
occupational,
educational, marital, interpersonal, and social problems are emotionally inspired has extended
the use of
psychotherapy into fields hitherto considered provinces of the psychologist, teacher, sociologist,
religious
leader, and lawmaker. Realization that the character structure is involved in all emotional illness
has
broadened the objectives of psychotherapy from mere symptom relief or removal to correction of
disturbed interpersonal patterns and relationships.
Promoting positive personality growth and development. The final use of psychotherapy is as a
vehicle for personality maturation. This has introduced a new dimension into the field of
psychotherapy—a dimension that deals, on the one hand, with problems of immaturity of the
so-called
normal person and, on the other, with characterologic difficulties associated with inhibited
growth
previously considered inaccessible to treatment. Here psychotherapy aims at a resolution of
blocks in
psychosocial development in order that the individual may aspire to a more complete creative
self-fulfillment, more productive attitudes toward life, and more gratifying relationships with
people. The
goals of psychotherapy thus extend from the limited objective of helping to control symptoms to
the
liberation of the rich resources of the human mind from neurotic obstructions that thwart its
purpose and
stunt its growth.
MODELS of COUNSELLING
DEFINITIONS OF COUNSELLING
Counselling is a process by means of which the helper expresses care and
concern towards the person with a problem, and facilitates that person's personal
growth and brings about change through self-knowledge.
The British Association for Counselling (BAC) may have been the first
professional association to adopt a definition of professional counselling. In
1986 it published the following definition: “Counselling is the skilled and principled use of
relationship to
facilitate self- knowledge, emotional acceptance and growth and the optimal
development of personal resources. The overall aim is to provide an
opportunity to work towards living more satisfyingly and resourcefully.
Counselling relationships will vary according to need but may be concerned
with developmental issues, addressing and resolving specific problems,
making decisions, coping with crisis, developing personal insights and
knowledge, working through feelings of inner conflict or improving
relationships with others. The counsellor’s role is to facilitate the clients work
in ways that respect the client’s values, personal resources and capacity for
self-determination.”
In 1997 the Governing Council of the American Counselling Association
(ACA) accepted the following definition of professional counselling: “Counselling is the
application of mental health, psychological or human
development principles, through cognitive, affective, behavioural or systemic
interventions, strategies that address wellness, personal growth, or career development, as well
as pathology”. The definition also includes these
additional attributes: • Counselling deals with wellness, personal growth, career, and
pathological
concerns. In other words, counsellors work in areas that involve relationships.
These areas include
intra- and interpersonal concerns related to finding meaning and adjustment in
such settings as schools, families, and careers. • Counselling is conducted with persons who
are considered to be functioning
well and those who are having more serious problems. Counselling meets the
needs of a wide spectrum of people. • Counselling is theory based. Counsellors draw from a
number of theoretical
approaches, including those that are cognitive, affective, behavioural, and
systemic. These theories may be applied to individuals, groups, and families. • Counselling is a
process that maybe developmental or intervening.
Counsellors focus on their
clients’ goals. Thus, counselling involves both choice and change. In some
cases, “counselling is a rehearsal for action”.

MODELS OF COUNSELLING

[Link] and Hackney Model of Counselling

Counselling can be conceptualized as a series of stages or steps that lead
one through the counselling process. Cormier and Hackney (1987) described a
five-stage process: relationship building, assessment, goal setting, interventions,
and termination and follow-up. Each of the stages is discussed in detail.
Stage One: Relationship Building
The successful outcomes in counselling is associated with the counsellor- client relationship
which is the outcome of all therapeutic efforts. There are two
necessary conditions. They are:
1. Counsellor-offered conditions: The core conditions for successful
counselling are
empathic understanding(Empathic understanding as a process that
involves communicating a sense of caring and understanding)
unconditional positive regard (counsellor communicating to clients that
they are of value and worth as individuals)
congruence(Behaving in a manner consistent with how one thinks and
feels)
respect(focuses on the positive attributes of the client)
immediacy(direct, mutual communication )
confrontation(Pointing out discrepancies in what the client is saying and
doing)
concreteness (Helping clients discuss themselves in specific terms)
self-disclosure(Making the self-known to others)
These eight core conditions are necessary and sufficient for constructive
personality change to occur.
2. . Counsellor-and client offered conditions
The working alliance is another concept that can be used to describe the
counselling relationship. It goes beyond focusing on counsellor-offered
conditions and includes counsellor- and client-offered conditions.
The working alliance is composed of three parts. They are:
agreement between the counsellor and client in terms of the goals of
counselling
agreement between the counsellor and client in terms of the tasks of
counselling
emotional bond between thecounsellor and client.
The strength of the working alliance depends on the degree of agreement
relating to goals and tasks of counselling and the level of emotional attachment
between the counsellor and client.
Stage Two: Assessment and Diagnosis
Assessment and diagnosis help a counsellor develop an in-depth
understanding of a client and identify mental disorders that require attention.
This understanding can facilitate goal setting and also suggest types of
intervention strategies.
Assessment procedures can be divided into two categories
 standardized measures – include psychological tests that have standardized
norm groups
non standardized measures–include strategies such as the clinical interview
and assessment of life history.
Stage Three: Formulation of Counselling Goals
Three functions that goals serves in the counselling process:
Motivational function: The clients are involved in establishing the
counselling goals. They may be more motivated when they have specific,
concrete goals to work toward. It is also important for counsellors to encourage
clients to make a verbal commitment to work on a specific counselling goal.
Educational function: Clients can learn new skills and behaviours that they
can use to enhance their functioning. For example, a counselling goal might be
to become more assertive. During assertiveness training clients can learn skills
to enhance their functioning in interpersonal situations.
Evaluative function: Clear goals allow the counsellor and client an
opportunity to evaluate progress.
Counselling goals may also be conceptualised as either process or
outcome.
Process Goals: These establish the conditions necessary to make the
counselling process work. These goals relate to the issues of formulating
positive relationship by promoting the core conditions. Process goals are
primarily the counsellor's responsibility.
Outcome goals: These specify what the client hopes to accomplish in
counselling. The counsellor and client should agree on these goals and modify
them as necessary. Five types of outcome goals include:
Facilitatingbehaviour change
Enhancing coping skills
Promoting decision-making
Improving relationships
Facilitating the client's potential.
Stage Four: Intervention and Problem Solving
The counsellor and client may choose strategies to implement from a
variety of interventions, including individual, group, couples, and family
counselling. It may be best to begin with individual counselling for clients with problems of an
intrapersonal nature. Couples or family counselling may be
more appropriate for clients with difficulties of an interpersonal nature, as in a
marital or parent-child conflict. The counsellor should provide an overview of
the different treatment approaches available; describe the role of the counsellor
and client for each procedure; identify possible risks and benefits that may
result; and estimate the time and cost of each procedure. In addition, it is
important for the counsellor to be sensitive to client characteristics such as
values and beliefs when selecting an intervention strategy. Counsellors should
also be aware of a client's personal strengths and weaknesses in selecting a
counselling approach.
A six-stage model for problem solving strategies include:
• problem detection
• problem definition
• identification of alternative solutions
• decision -making
• execution
• verification
Stage Five: Termination and Follow-Up
Termination can be done when clients have worked through their
concerns and are able to proceed forward in their lives without the counsellor's
assistance. At this point, counselling can be terminated. It is usually best for the
counsellor and client to agree on a termination date, reducing the chance of
premature termination or feelings of ambivalence.
Termination should be planned several weeks in an advance to provide an
opportunity for the client to prepare psychologically. The counsellor should also
arrange for appropriate follow-up with the client. An appointment for a formal
follow-up counselling session can be made 2 to 4 weeks after the final session.
This can allow the counsellor and client adequate time to evaluate how things are going without
counselling. Clients should be reassured that they will be able
to obtain additional counselling services if the need arises. They should also be
informed as to how they can request these services in the future.

[Link] Model of Counselling

Helping and human relationship theory is a theory of professional interaction developed by

Robert R. Carkhuff.
In Carkhuff’s model, he began by forming definitions and observing the interactions during any
helping behavior.
He believed that all human interactions are helping behaviors.
Some interactions are more equal than others.
There are interactions where one person is the leader and attempts to give the other person
reasons to change, usually to their point of view.
Other interactions involve a trade, where each member of the interaction is seeking a specific
goal.
Carkhuff believed that most professional interactions are helping relationships.
He included among these teaching, medicine, parenting, training and repairmen. In short, the
helper skills are universal among human beings.
Carkhuff drew up his model of helping and human relations theory to use to conclude successful
interactions and to evaluate the success of the interaction.
Nursing is one of the helping professions, involving an interaction that will improve the situation
of the client. Nursing theory includes theory on the helper relationship.
This nursing theorist framework for the art of helping and human relationship fits very well with
the nurse-client relationship.
Robert R. Carkhuff’s model begins around the four components of any helping relationship.

Attending
Responding
Personalizing
Initiating

Four Components of Carkhuff’s Model of helping relationship.

[Link].
Attending involves the initiation of the interaction.
It includes a greeting, introduction by each member of the relationship and an attempt to put the
client at ease.
According to Carkhuff’s model of helping and human relationship theory, the nurse must be
physically present during the interaction.
This means the nurse’s attention is all directed to the client, and he or she looks at, directs
actions and words toward the client to make sure the client is aware that the nurse is there for
the client’s benefit.
The nurse should observe all the reactions of the client. Is the client withdrawing from the
interaction? Is the client ready to be open about their problem? Are they talking about
something else to put off the needed interactions?
The nurse needs to listen to the client and verify that they fully understand what the client is
trying to say.
He/ she needs to let the client complete his or her version of the situation.
The nurse should be trained in professional communication strategies to be able to verify that
the client has communicated what the nurse believes she has heard.
This process is crucial to the nurse-client interaction. Without completing the attending step
properly, the interaction will be a failure.
Attending Skills:

Here are specific skills that assist with the Attending stage:

Noting both nonverbal and verbal behaviors

Responding to basic messages by paraphrasing
Focusing discussion by clarifying issues
Review beliefs of client concerning their problem

2. Responding.
Once the establishment of purpose of the interaction occurs and the client agrees with it, the
nurse should begin to let the client know what the response will be and options available, if any.
The helper begins to respond to the client. She looks for feelings to give a response to.
She looks for content to fill in the reasons for the client needing help.
Lastly, the nurse should be able to able to understand the meaning of the situation to the client.
Together the client should work with the nurse in developing a way forward that they can both
agree to undertake.
Responding Skills:

Like attending, responding has its own set of shills. Skill to emphasize are:

Empathy with the client’s needs.

Respect the client’s opinions.
Use rephrasing to verify your understanding of the client.
3. Personalizing.
This is the step where the client agrees to take on the needed steps to complete the goals that
have been established.
The way to be most successful at this level is to relate these goals to a past action or situation.
The more positive the situation is, the better the results.
However, a situation that did not go well could be used to show how the client can change the
results in the future.
Perhaps an addict who was clean for a time returned to drug use due to pressures in his life.
The focus of this interaction would be to examine options when he feels pressured and to
develop new skills to deal with this situation.
Personalizing Skills:

Personalizing uses a different set of skills. Here are some to develop:

Describing feelings
Sharing personal feelings with client
Confrontation skills with client
Reflective phrasing to verify goals

4. Initiating.
Once they agree upon the steps to change, the nurse then assists the client to implement or
initiate these changes in their life.
The part includes developing clear goals and checklists to reach these goals.
The client should be aware of all of the steps and how to reach the nurse if they have a problem
with completing the goals.
The client should be made aware that many clients need to revise their treatment plan once
they start fitting it into their lives and not feel like a failure for having to come up with a revised
plan.
The goal should be to succeed; not simply to follow one and only one set of goals and
checkpoints.
Each professional should also include a feedback stage where they look at both their success
with this client and any areas where they had problems.
This will also give the caregiver a guide to behaviors he or she needs to work on to improve
their results with clients.
Carkhuff went on to specifically investigate what skills assisted with each of his four steps.
Therefore, this allows the helper to work on those skills that do not come naturally to them.
Some of the four steps have more skill areas than the others.
Initiating Skills:

This step sets up the path for success and for verification of the interaction. Skills needed here
are:

Ability to define useful goals

Capability to provide options in case of problems
Also ability to conduct focused inquiries to verify goal completion
Reference,
Carkhuff, R. R. The Art of Helping, 9th Edition, PP, Inc. Amhurst, MA, 2009

Carkhuff, R. R. Helping and Human Relations: A Primer for Lay and Professional Helpers;
Selection and Training, Vol. 1

APA Citiation for refering this article:

Niwlikar, B. A. (2022, June 9). Carkhuff’s Model of Counselling Skills. Careershodh.
[Link]
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