Narrative Therapy

Narrative Family Therapy

John Stafford

Brandman University

Abstract

Narrative therapy emerged from the post-modern therapy movement as a powerful therapeutic technique that encompasses numerous methods specifically designed to help an individual or family identify their problems as being separate from the person. While other approaches to therapy may promote this concept, narrative treatment does so in the unique way of helping the patient[s] turn a problem situation or history into a story that both themselves and others can view from outside the problem. As this paper will demonstrate, the benefits of narrative therapy reach far beyond simple approaches and directive therapies designed to help clients overcome obstacles.

Keywords:  postmodern therapy, narrative therapy, family therapy, individual therapy, therapeutic approaches

Narrative Family Therapy

Mental health therapy has taken many forms over the decades, from the early days of Freud to new and modern methods that seek to find new and innovative ways of treating clients and the plethora of conditions that arise. Postmodern approaches apply new and sometimes unorthodox modalities to work with individuals, couples, and families seeking help. One such postmodern approach is narrative therapy. Although some of the process’ in narrative therapy may appear familiar, or at least hold some resemblance to other theories, the underlying perspective is that people and their problems are separate, and that each person has his or her interpretation of events, or what is commonly referred to in narrative therapy as “their story.” Narrative therapy strives to help the client tell their story and feel more profound empowerment to make changes in thoughts and behaviors to re-write their life story for a more positive future that encompasses a purpose, a person, and capabilities wholly separated from their problems.

Because of narrative therapy’s approach to helping people who define themselves by their problems learn to externalize and reauthor the issue[s], narrative therapy shows excellent benefit to individuals, couples, and families alike. Of primary focus is encouraging the client[s] to become the active author of their life by giving verbal accounts of their experiences and how they affect their perceptions (Bardin, 2018). The oral reports viewed as stories that build over time. Based on events that occur in the indiviudal[s] life with varied levels of significance, these stories often stemming from negative life experiences or events play a crucial role in shaping the indiviudal[s] identity. The therapist role in narrative therapy is to regard the client stories as a life rich with undiscovered possibilities. A significant aspect of the therapist role is to direct the conversation. He or she will ask the client what they want to discuss to get the conversation started. The questioning and conversational stage usually reveals the presenting problem and the client is encouraged to continue their story.

Another emphasis of narrative therapy is a cultural perspective. The theoretical assumptions emphasize a comprehensive understanding and importance of how culture plays a role in the development of an individual’s identity (Morris, 2006). To state that narrative therapy simple views people like stories to be re-authored is a short-sale at best. A more in-depth look, narrative therapy is rooted in solid assumptions. One assumption is that truth becomes overridden by different interpretations of reality and that meaning is an individual's construction of cultural, political, and social contexts. Further assumptions assert that an individual’s life gets modified by the stories told by others and by the individual and that multiple selves make the individual. Lastly, narrative therapy makes a cultural statement by asserting that culture in itself is a collection of stories combined to be the most influential aspect of a person’s life (Morris, 2006).

The art of narrative therapy is not just telling stories, externalizing problems, and approaching the client with cultural competency. If this were the case, the theory itself would not effectively help a client resolve presenting issues. There is a human aspect in the method that requires the therapist to view the client[s] as a unique individual lacking in deficiency and defectiveness. The client should never feel that he or she is the blame of the presenting problem[s], nor should they blame anyone else, and that the client is the ultimate expert on his or her life in the therapeutic relationship, and that words people use have a significant impact (Bardin, 2018; Positive Psychology Program, 2018). These human aspects are vital to working with any client. When working with couples or families, the human component has more profound implications because the therapist is now working with multiple personalities and stories to help the family or couple recognize the influence the problem has on the family, and the influence the family has on the problem (Bardin, 2018). As the couple or family begins to tell the individual stories associated with the perceived problem, the therapist could start to help them deconstruct the problem-saturated story. Deconstructing the problem story reveals both or multiple sides of the story that adds to the overall frustration the couple or family is experiencing. It helps them recognize that negative thoughts become a self-fulfilling prophecy (Bardin, 2018). The positive aspects of the process reveal hope, individual abilities, courage, determination, and self-efficacy and esteem, all leading toward the ability to re-author the story to a new, positive version (Bardin, 2018).

Although the tenents of narrative therapy appear appealing and innovative at a certain level, some issues need careful review. Postmodern therapies could serve as a third-wave of therapeutic approaches that aim to modernize many aspects of psychotherapy. However, proving the efficacy of any form of treatment takes time and research. Narrative therapy is relatively new in comparison to traditional therapeutic methods. There is a shortage of scientific research supporting the overall effectiveness of this approach. Additionally, certain types of clients would not qualify as good candidates for narrative approaches, in particular, clients with psychotic issues, or who have limited intellectual, language, or cognitive skills. Finally, clients with difficulties in articulating their problems could exhibit discomfort being placed in the role of “expert” as it pertains to their own lives in the narrative therapy process (Addiction.com, n.d.).

Working with children introduces additional complications to therapy that vary depending on the age of the child. Younger children are still developing communication skills and gaining an understanding of the world they live. Older children, while more developed, are still learning social skills and mental and emotional maturity. These issues complicate the therapeutic process because the therapy sessions require tailoring to meet the comprehension and communication levels of the young client. Contrary to common belief, children are not as resilient as once thought. Failure to address childhood traumas like abuse or neglect resulting in potential affective, behavioral, and cognitive dysfunction is a paramount concern (May, 2005; Ramey, Young, & Tarulli, 2010).

Regarding narrative therapy, a child who experiences maltreatment from parental figures most likely constructs a chaotic and incoherent story; in many cases, this story includes scenarios of death and violence that have no comforting resolution (May, 2005). When a child is removed from their birth-home and placed in foster care or with relatives, another concern arises. The child, accustomed to an abusive relationship with his or her birth parent[s] likely views any attempt of caring and compassion from others as suspect, or the forefront to further abuse. He or she is unlikely to trust the motives of others and resist any forms of positive connections (May, 2005). One narrative intervention that figures prominently with children is externalization. At the core of this intervention, the child can name, objectify, and sometimes personify the problem, which allows them to put the problem issues in a separate space and view them as not being an internalized issue (Ramey, Tarulli, Frijters, & Fisher, 2009). Another form of externalizing showing positive results with children is the scaffolding conversations map that involves the creation of several steps of mapping out the problem or initiative with the child in various levels of importance. This process allows the child and therapist to create a visual map of the child’s story that enables him or her to establish more control in the shaping of their life (Ramey, Tarulli, Frijters, & Fisher, 2009).

Case Conceptualization

Ivan has endured a tremendous amount of trauma that started with the physical, emotional, and verbal abuse he was exposed to by his birth parents. He most likely has severe issues with abandonment and an inability to trust authority figures. Additionally, his life experiences being as they were, Ivan was not able to learn how to respond to compassion or love from adults in a positive and trusting manner. All Ivan has learned in his young life is violence and emotional neglect. His mental development is such that these issues have formed his story destructively. Ivan’s story, defined by depression and trauma appears hopeless to him and affects his sense of self-worth. His foster mother’s stated desire to care for Ivan and his unwillingness to let her or other family members into his life reflects a story of frustration that internalizes feelings of rejection.

Neither Ivan or his foster mother discuss any situations where previous attempts to correct the issues have worked. Ivan’s repeated foster care placements also indicate that his feelings of abandonment have become more of an expectation and that his acting out serves as a self-fulfilling prophecy. It is unclear from the vignette if his foster family includes other children, which could add additional complications for Ivan because his behavior could result in further isolation and frustration as the other children react negatively. The family talks about the situation with a deep sense of failure and internalization of the issues. The foster mother talks about Ivan’s behaviors as his problems instead of problems affecting him and the family. Ivan is made central to the entire situation. Ivan also views himself as a fundamental problem. He considers himself as worthless and undeserving of a loving family environment.

The task of the therapist in this situation appears an undaunting task. However, understanding the traumatic experiences Ivan has endured, and the willingness of his foster parents to provide Ivan with a caring home is a solid launching point. Mapping the influence the problem has, and on the family and the impact the family has on the problem, the family begins to externalize and deconstruct the issues. They will start shifting away from Ivan being the disruptive force in the family and view the problems as being the destructive force. By doing this, the family can remove focus from Ivan and feelings of failure or rejection. They can start re-authoring the story with a focus on the problems that negatively affect Ivan and the family, and he can begin re-authoring his story with a stronger sense of self-worth and acceptance of compassionate relationships.

The Goals

            The ultimate goal for this case is to alleviate Ivan’s trauma, depression, and feelings of unworthiness. Doing this will enhance Ivan’s ability to re-author his life story in a positive manner that will enable him to see himself as worthy of a loving family structure. Furthermore, the family will be able to re-author the negative experiences in a positive way that will provide Ivan with supporting and understanding infrastructure. It may sound easy, but changing problem-stories involves dedication and participation from the entire family. The three goals are overcoming trauma and depression, removing self-blame, and integration into the family unit. Reauthoring the family narrative which is being held back by the current stories for Ivan and the foster mother prohibit the family from moving forward because Ivan focuses on his internalization of the abuse and feelings of worthlessness, and his adoptive mother focuses on Ivan being the problem and her failure to reach him.

The Therapist

The therapist conducts the sessions in a respectful and non-blaming manner that emphasizes the client[s] as being the expert in their life story. He or she initiates the meetings by asking questions designed to map the influence the problems have on the family, and the impact the family has on the issues. This process of mapping provides a diagram of sorts and creates a sense of empathy between the client[s] and therapist that invokes a healthy and empowering experience for the family and the therapist alike (Nichols, & Davis, 2016).

Telling the Story

            Telling an individual’s story can take several forms. Because of Ivan’s age, it may be easier for him to express his story by starting with drawing or playing with objects that have a significant representation of his life. Doing these exercises allows the child to experience the problem issues by acting them out or visualizing them in drawings that help him or her start imagining a separation between the experiences and themselves. The current narrative is one of despair and internalization of problems viewed as Ivan’s fault. This narrative prohibits the family from recognizing the issues as external influences on the family that maintain the chaotic atmosphere, which in turn, continues the problems.

Deconstructing and Externalizing

            Deconstructing the problems is a crucial aspect for this scenario. Ivan and the family are overwhelmed by the number of issues, which maintain the problem-saturated story[s]. By deconstructing the narratives, we can look at each problem in a smaller context and remove any overgeneralizations associated with them. The process of deconstruction also allows the client[s] to explore the issue more and begin to understand how those problems block his or her ability to gain what they want their story to be. Once the matters become deconstructed, the next goal is to externalize and depersonalize them. Doing this removes the person[s] from being the root cause and emphasizes that the problems are not the person. Additionally, separating the person from the problem removes stigma, whether internally or externally imposed, and provides a higher degree of control over the issues.

Look for Unique Outcomes

            As Ivan and the family progress in the previous goals, unique outcomes should begin to surface. These unique outcomes provide moments where the family experiences positive results and interactions. Focusing on the individual strengths and accomplishments that lead to these sparkling moments aids all members of the family to begin re-authoring their story based on positive aspects of their life and maintain an emphasis on the benefits of preserving externalization of the problems that contributed to the dysfunction in the family. The process encourages family members to strive for higher goals as they progress.

Conclusion

Narrative therapy is a postmodern theory showing potential for the treatment of numerous scenarios. Although the approach lacks much empirical study data, there is enough research to assert that certain individuals, couples, and families benefit from the processes involved in the narrative therapy process. In the case of Ivan and his foster family, narrative therapy provides ample opportunity to the child and foster family to identify the main problems by telling their individual and combined stories, deconstructing those stories into manageable chunks and externalizing the issues, so the indiviudal[s] are no longer viewed as the problem. The narrative therapy approach, in this case, allows the therapist to work with the family members on different levels, which benefits the child and the adult by employing various techniques designed to provide comfort and empowerment at the same time, ultimately enhancing the overall therapeutic process.

 References

Addiction.com. (n.d.). Narrative therapy | Definition. Retrieved from https://www.addiction.com/a-z/narrative-therapy/

Bardin, G. (2018). Narrative Therapy. Lecture presented at PSYU 556 in Brandman University, Palm Desert.

Erbes, C. R., Stillman, J. R., Wieling, E., Bera, W., & Leskela, J. (2014). A Pilot Examination of the Use of Narrative Therapy With Individuals Diagnosed With PTSD. Journal of Traumatic Stress,27(6), 730-733. doi:10.1002/jts.21966

May, J. C. (2005). Family Attachment Narrative Therapy: Healing The Experience Of Early Childhood Maltreatment. Journal of Marital and Family Therapy,31(3), 221-237. doi:10.1111/j.1752-0606.2005.tb01565.x

Morris, C. C. (2006). Narrative theory: A culturally sensitive counseling and research framework. Retrieved from https://www.counseling.org/resources/library/Selected Topics/Multiculturalism/Narrative_Theory.htm

Nichols, M. P., & Davis, S. D. (2016). Family therapy: Concepts and methods. Upper Saddle River: Pearson.

Positive Psychology Program. (2018, August 10). 19 Narrative Therapy Techniques, Interventions Worksheets [PDF]. Retrieved from https://positivepsychologyprogram.com/narrative-therapy/

Ramey, H. L., Tarulli, D., Frijters, J. C., & Fisher, L. (2009). A Sequential Analysis of Externalizing in Narrative Therapy with Children. Contemporary Family Therapy,31(4), 262-279. doi:10.1007/s10591-009-9095-5

Ramey, H. L., Young, K., & Tarulli, D. (2010). Scaffolding and Concept Formation in Narrative Therapy: A Qualitative Research Report. Journal of Systemic Therapies,29(4), 74-91. doi:10.1521/jsyt.2010.29.4.74

Collaborative Therapy

Collaborative Therapy

John Stafford

Brandman University

Abstract

Postmodern therapy gave rise to new and innovative theories and approaches to working with clients experiencing a variety of problems. A vital aspect of the postmodern movement is the divergence from traditional methods of how the therapist and client interact sessions. Collaborative therapy is one example of how the postmodern movement has taken an innovative approach to using a conversational technique that allows both the client and therapist to work together in a collaborative process without the traditional diagnosis and hierarchical methods.

Keywords:  Postmodern Therapy, Collaborative Therapy, Psychology, Family Therapy, Individual Therapy, Couples Therapy

Collaborative Therapy

Postmodern therapies are considered a new generation of psychotherapy that started development in the latter part of the twentieth century and spawned from the belief that alternative methods to psychotherapeutic practices could challenge historically sustained premises of existing therapeutic process[s] (Lebow, 2008). The practitioners and theorists of this movement chose not to focus on a single model but instead introduced numerous theories including, collaborative, discursive, conversational, narrative,  and social-constructionist, to name a few (Lebow, 2008). Collaborative therapy, which this paper focuses on, is an approach designed to create a process where the therapist and client establish a collaborative, shared experience where both parties explore the client’s story and learn as that story progresses. To do this, the postmodern approaches needed to create a paradigm shift from some of the traditional practices like providing a diagnosis, the therapist and client not being viewed as equals, and adding an emphasis that the therapist must learn the client’s language (Bardin, 2018).

The views of postmodern therapy approaches assert that the client is the expert on his or her own life story and truths. There is also a belief that individuals communicate and share knowledge and experiences through forms of attitude, language, the tone of voice, bodily expressions, and even the words chosen during conversation (Anderson, & Gehart, 2006). The construction of language, both spoken and unspoken, is a representation of how the individual interprets and constructs his or her world and expresses or communicates those experiences to others. According to Anderson & Gehart (2006) “Knowledge is not an individual activity or passive process: knowledge cannot be sent to or received by another (p.9). What this means is that what people create through the use of language is a multifaceted collaboration of events and experiences curated through a social construct that is fluid and always changing (Anderson & Gerhart, 2006).

Collaboration serves as a primary practice of different therapeutic approaches for working with clients (Sutherland, & Strong, 2011). People are not passive transmitters or receivers of information, nor does the individual process information in an identical manner as another. Even if two people with the same upbringing, career path, and social environment who experience the same event, they will both have a different truth (Hansen, 2006). The reason individuals interpret similar experiences differently is due to variations, both major and minor, are their respective social constructs and ability to construct and understand the world around them (Hansen, 2006; Anderson, & Gehart, 2006). Because of this, social constructionists view therapeutic collaboration as a process involving mutual coordination, sharing, and the construction of meaning (Sutherland, & Strong, 2011). Language, as referenced above is not simply the language one uses in the cultural construct. Instead, it is a primary method that people use when constructing and making sense of their world and truth. Language gains meaning and value because of its meaning or roots when used to transmit information about one's life experiences (Bardin, 2018).

Additionally, when we look at the therapeutic process, notable differences emerge. In traditional or commonly used therapeutic approaches like Cognitive Behavioral, Dialectical, Solution-Focused, or Acceptance and Commitment therapies, the therapist is notably in control of the therapeutic session. Barring the most crucial aspect that of creating the therapeutic alliance, the therapist takes the role of inquisitor asking questions, providing a diagnosis, and helping the client explore his or her presenting problem before developing a treatment plan designed to improve the client’s ability to come to their conclusions and resolutions. In contrast, the collaborative approach might appear as if the client and therapist are engaged in a casual conversation. But a closer look reveals that the therapist acts as a guest in the client’s story and aims at focusing on the uniqueness of the client as an individual, ignoring similarities, and centers of the client's unique experience[s] by asking pertinent questions and talking about things within the client’s context (Bardin, 2018).

Effective counseling has a general purpose of enhancing the well-being of an individual client, a couple, or a family unit. No matter the theoretical perspective used, the general process includes forging a solid therapeutic alliance in which the client[s] are free to express their problems [story] in a safe environment where they feel the receiving party [the therapist] is genuinely attuned, attentive, and empathetic. In collaborative therapy, the therapist and client engage in a conversational approach to articulate and align with one another on shared goals (Horvath & Symonds, 1991: Hubble, Miller, & Duncan, 1999). Adherently, this conversational process is not without particular difficulties. Cultural differences introduce variations in verbal and non-verbal language, and generational or gender differences may complicate the conversational method. The therapist needs to consider and compensate for any perceived complications that make the collaborative process more difficult for the client by learning the client’s preferred way of verbal and non-verbal language and helping construct the conversational direction.

Collaborative Family Therapy

Family therapy introduces additional complexities into a therapeutic situation because the therapist is not focusing on a single person. He or she is balancing the individual personalities and difficulties that impact the entire family unit. Hoffman (2003) eloquently states “An autonomous system is any composite unity formed of elements that may or may not themselves be autopoietic” (p.18). Similar to a computer network, if a single node within the network fails to operate to specification, the remaining nodes become taxed with the additional workload to keep the network functioning. If multiple nodes experience system malfunctions, the network becomes bottlenecked, data transmission slows or becomes corrupted, and data gets lost in confusion. The failure results in what is called a network-wide failure. Families operate on the same premise. For the family to function effectively, all family members need to communicate and work together. The commonality is open lines of communication and shared operational structure or goals. However, humans cannot alter those shared regularities at whim because the autonomy of social and biological systems cannot be erased and reformatted as in a computer network (Hoffman, 2003). A primary difference is that a failed node can easily be replaced without disrupting the computer network, whereas a family member cannot. If a family member gets dysfunctional or removed the family structure changes entirely, and damage to the family is imminent. However, similar to the computer network, the loss or alterations may only be temporary if proper maintenance is initiated. Similarly, in both cases, the restoration of communication becomes the primary emphasis.

Collaborative family therapy approaches family dysfunction from a communicative perspective. It views the family structure from a systemic framework that focuses on human determination and reciprocality that impacts human behaviors. At the core of this perspective is how the family communicates with each member and as a whole unit (Tuerk, McCart, & Henggeler, 2012). Families experiencing difficulties usually prolong the issues by trying, generally without success, to deal with the underlying problems on their own. Problem children might sometimes get labeled as going through a phase or are just bad seeds that should be sent to boarding schools or to live with relatives. Problems within the marital dyad can result from issues ranging from financial matters to infidelity, or even just a feeling that the spark in the relationship has died. The common thread in many of these issues is the lack of active collaboration within the family. In the nuclear family, many of these issues got ignored because the family presentation was an essential aspect of societal expectation. In modern society, technology has added additional complications to familial communication because the art of talking face-to-face is slowly becoming obsolete. Collaborative therapists aim, in some ways, to reintroduce family members by helping them share their own stories and truths (Tuerk, McCart, & Henggeler, 2012). The therapist is a guest in the family story that can walk with the family and each family member as they collaborate on the issues, thoughts, and feelings that impact the individuals and the family as a whole. By doing this, the family members learn valuable collaborative skills that enable them to understand one another from a different perspective.

The Family in Trouble

The vignette presents a family in severe distress and dysfunction. Juliet is troubled by her past abusive marriage that resulted in addiction issues and the loss of custody of her child. She is overcompensating for these haunting experiences by overindulging her two children. Romeo is troubled by the fact that Juliette is overindulging the children and feels neglected. He is frustrated and hurt by what he perceives as Juliet favoring the children over him and views divorce as the only way to resolve the issue. Both parents have an unhealthy desire to be central in the children’s lives, and the possibility of divorce will lead to a bitter custody battle for the children. The marital issues have overflowed into the entire family dynamic. The daughter, Elizabeth has become withdrawn from the family, and her grades in school are negatively affected. Of more significant concern is the son, Ceasar who has grown angry at his parents and has made threats of harm towards others as a way of getting his parents attention. Current attempts at couples therapy appear to produce little to no resolution in the presenting issues.

Conceptualization

There are severe failures in the family resulting from the lack of communication skills and understanding where each family member is emotionally and mentally. Juliet is experiencing difficulties coping with the loss of her first child, her addiction, and abandonment issues. Romeo is feeling ignored and irrelevant in Juliet’s life in comparison to the children. He feels abandoned in his own home and believes that the love between them has died, or possibly never existed. The children think they are the subjects of a tug-of-war between the parents and suffer the adverse effects of the hostility and turmoil the parents believe they have been successfully hiding from them. Elizabeth, most likely the timider of the two children resorts to alienating herself from the issues and has lost the ability or desire to focus on her scholastic activities. Caesar, naturally the stronger of the two has taken a path of being angry at the situation and is lashing out at his parents and, more concerning appears to start harboring dangerous thoughts towards others. Although it is difficult to tell if his threats are real or just a ploy to get his back at his parents, the severity of his threats requires immediate action.

How it Came to Be

A common denominator in this family’s problems is the lack of proper communication and the ongoing individual stories that keep the issues active. It is apparent that neither of the parents is collaborating with or hearing each other's truths behind their feelings and actions. In turn, the children mostly left to interpret the uncomfortable and tumultuous atmosphere in the household are left to make their assumptions, thereby creating their realities. At the forefront of all of the issues are the issues Juliet holds from her past and how they influence her relationship with the children and Romeo. Additionally, Romeo’s inability to put Juliet’s past into context and work with Juliet to find a happy middle-ground are compounding the problems and ultimately affecting the children and their ability to be active participants in a harmonious family unit.

Can it be Fixed

It is too early to say the problems will resolve, nor would I assume that the family will remain together. The outcome will result from how the family, in particular, the parents, decide what direction is best for them at the end of therapy. Either way, there are stories to be told and heard from each family member that becomes a journey of exploration, learning, and understanding. The ride starts by helping the family understand that they are not talking with one another, but instead of one another. When people talk to one another, the meaning lost, emotions miscommunicated, needs are unspoken, stories left unrevealed. If Romeo and Juliet learn how to speak with one another, to hear each other's stories, and understand the language, each other is using to communicate, their ability to work together as a couple improves. Harmony improves as the family begins to understand the language, both verbal and non-verbal, that each person is expressing. Their stories start to unfold and realign to bring the family together.

However, there is another side to how the problems may cease to exist. IN learning to talk with and hear one another. To understand each other’s stories and language, the potential of realizing there is no ability to reestablish the family as it once was. Separation or divorce could be the eminent solution. In this case, the family, using what they have learned, will start to spin new stories and collaborate to find a suitable and amicable dissolution of the current family structure and provide a positive experience for the couple and the children. In either outcome, the family has a tremendous task ahead of them.

Family Goals

The first goal is to establish effective communication strategies that allow each member of the family to collaborate on restoring homeostasis to the family unit. We start by exploring communication and a collaborative effort that creates acceptance through the use of language, learning to understand the differences in individual perceptions, evaluating the strengths and weaknesses of each member, and what each member needs from the family unit to feel accepted, loved, and understood.

The second goal would be to enhance the first goal by learning how each family member’s reality differs based on their perceptions of the situation and how their language is either hampering or helping the condition exist. Learning how to collaboratively communicate how each member of the family perceives issues and how it affects their individual feelings is a primary consideration. Initially, the family members will exhibit apprehension to express their opinions, but being able to explore those apprehensions in session will enable them to gain comfort in communicating them at home. If open discussion appears too difficult, possibly asking each member to journal their thoughts to share in session could be a starting point.

The third goal is to remove blame, guilt, and anger. The family needs to learn that there is no singular truth involved and that each family member holds a different perception of reality. A family is a socially constructed unit impacted by numerous factors. Similar to a planet being hit by a meteor shower, every single impact leaves a distinct mark. To paraphrase Hansen (2006), singular truths are not revealed by the passive or disinterested investigation of a phenomenon, but are in-fact, discovered by attentive observation with the observers providing meaning.

The Therapist Role

As mentioned earlier in this paper, the postmodern theory asserts that the client is the ultimate expert of his or her own life. Understanding this allows the therapist to take the role of a guest in the client’s journey or story as they collaborate to seek new meanings and creating an environment for change. Because the therapist is a guest in the story, he or she should take the not knowing position. The not knowing stance places the therapist as a blank slate that is open, and willing to learn the nuances of the client and their story. As the story starts, the therapist and client begin to discover one another’s internal voice, or language and build a rapport of understanding and communication. The therapist should also employ the technique of circular questioning and reframing as he or she walks the path of the client’s story to reveal hidden nuances and meanings behind the client’s perceptions of his or her truth.

Conclusion

The conclusion to this story is not one of simplicity. Some complexities affect every aspect of the family’s existence. Each member has individual perceptions of truth and reality that once explored, reveal a family in severe dysfunction. Also, there is no reliable method of predicting how the family’s story will unfold. The therapist must rely on his or her ability to join the family in a journey of exploration and learning through collaboration, and understanding individual perceptions. Teaching the family how to interpret the language each member uses, how they perceive events and issues, and how to collaborate with one another to openly express their feelings and thoughts, instead of talking at one another, will give the family a substantial advantage in either resolving their issues, or finding an amicable way of dissolution. Collaborative therapy provides these unique tools in a method that differs from conventional treatments that view the client as sick, or that focuses on a single presenting problem. Collaborative therapy teaches the skills of honestly expressing and hearing every aspect of what another person is relaying because it shows people that there is no absolute truth and that everyone’s story is a learned journey.

 References

Anderson, H., & Gehart, D. R. (2006). Collaborative therapy in action: Bridging the gap between theory and practice. London: Routledge.

Bardin, G. (2018, October 31). Postmodern Therapy. Lecture presented at PSYU 556 in Brandman University, Palm Desert.

Hansen, J. T. (2006). Counseling Theories Within a Postmodernist Epistemology: New Roles for Theories in Counseling Practice. Journal of Counseling & Development,84(3), 291-297. doi:10.1002/j.1556-6678.2006.tb00408.x

Hoffman, L. (2003). Exchanging voices: A collaborative approach to family therapy. London: Karnac.

Horvath, A. O., & Symonds, B. D. (1991). Relation between working alliance and outcome in psychotherapy: A meta-analysis. Journal of Counseling Psychology,38(2), 139-149. doi:10.1037//0022-0167.38.2.139

Hubble, M., Duncan, B., & Miller, S. (1999). The Heart and Soul of Change. American Psychology Association.

Lebow, J. L. (2008). Twenty-first century psychotherapies: Contemporary approaches to theory and practice. Hoboken, NJ: Wiley.

Sutherland, O., & Strong, T. (2010). Therapeutic collaboration: A conversation analysis of constructionist therapy. Journal of Family Therapy,33(3), 256-278. doi:10.1111/j.1467-6427.2010.00500.x

Tuerk, E. H., Mccart, M. R., & Henggeler, S. W. (2012). Collaboration in Family Therapy. Journal of Clinical Psychology,68(2), 168-178. doi:10.1002/jclp.21833

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The Counseling Process

The Counseling Process

John R. Stafford

Brandman University

Abstract

The counseling process is an in-depth exploration of a client, and a problem or a combination of the issues presented. Through thorough assessment, proper diagnosis, effective treatment plans, and decent connection with the client, the therapist compels the client to explore, understand, and ultimately acquire the appropriate skills to address the reasons he or she sought therapy. Severe situations like traumatic exposure create extreme stressors on the individual’s consciousness, interactions with others, and ability to function in normal daily routines. We will explore how such an event does this and the process of helping the client process the meaning of associated emotions, feelings, and responses to control the impact the initial event maintains over daily functionality.

Keywords:  Clinical Counseling, Counseling Processes, Clinical Assessment, Clinical Diagnosis, Clinical Treatment Plans, Trauma Exposure

The Counseling Process

Individuals and families enter counseling for a variety of issues that somehow impact their ability to function in certain aspects of daily life. For this reason, the therapeutic process and the therapist must maintain a level of fluidity while keeping a clinical perspective. Although this process may appear an easy task, or even as simple as conversational interaction, we quickly learn that not to be a correct assumption. Therapy requires an in-depth understanding of the client, the presenting problem[s], and other factors that produce a direct and indirect influence on the therapist’s ability to effectively work with the client.

The clinical process requires an in-depth exploration of the client’s fears, emotions, feelings, and reactions to significant events like a loss, stressful interactions, traumatic experiences, and illness. Other relevant information like employment, spiritual beliefs, sexual orientation, relationship status, and family history are gathered during the initial assessment to be incorporated into the case conceptualization because this information is paramount to understanding the invccdivual[s] in treatment (Bucci, French, & Berry, 2016). Additionally, the therapist uses the evaluation to determine the client’s stability, if he or she is of harm to self or others, support mechanisms, and to develop an initial concept of how to proceed in therapy. By definition, case conceptualization is an alternative explorative process to medically derived approaches that use a person-specific and flexible method to assess mental health concerns (Bucci, French, & Berry, 2016).

The process of exploration aids the client in ways of discussing and ultimately making sense of the problems to develop robust methods of managing those issues effectively. Although the reasons a person enters therapy and the theoretical processes used to work with the patient varies, the core foundations of the clinical process remain constant. Productive and responsible therapists begin the process by performing an initial assessment, which provides an overview of the client’s daily life, general capabilities, and presenting problems (Ridley, & Jeffrey, 2017).

Upon completion of this initial assessment, the therapist is better informed about several aspects of the client as a whole person and can develop an initial hypothesis about the presenting problem that he or she will use in helping the client address and work through the issues presented in the initial session (Zubernis, Snyder, & Neale-McFall, 2017). It is also time for the initial hypothesis to be confirmed or modified based on follow-up exploration with the client. Using a concept map to help form a case conceptualization is one method used to provide the client with a visual aspect of how the information gathers comes together in a relational manner (Liese, & Esterline, 2015). In some cases, the therapist might discover that the presenting problems are minor and the client needs a compassionate sounding-board. However, other clients may present with issues of more severe nature that require a tremendous amount of exploration to overcome (Zubernis, Snyder, & Neale-McFall, 2017).

No matter the reason an individual seeks counseling, he or she is seeking help from a trusted professional. The onus falls to the therapist to develop a productive alliance with the client through thoughtful, professional and empathetic collaboration, development of proper diagnosis and treatment plans that align with the client’s presenting problems and personal values and moral structure (Zubernis, Snyder, & Neale-McFall, 2017). A critical variable in the process is the theoretical orientation the clinician uses to work with the client. Clinicians are inclined to gravitate to a specific theoretical perspective, and some practices may provide enhanced results for particular issues. No single view is a one-stop solution because each client and every presenting problem is unique as it relates to the client seeking treatment (Zubernis, Snyder, & Neale-McFall, 2017).

Assessment

The assessment process is a crucial component of any therapeutic process. It is the cornerstone of providing proper treatment to the client (Liese, & Esterline, 2015). Although the assessment process is designed to gather as much valuable information regarding the client and the presenting problem[s], it also provides the opportunity to address areas like informed consent, so the client is aware of the benefits and limitations to the therapeutic process. Many of the questions in the initial assessment are a constant fact-finding process used to gather general information about the client’s life. However, as the client and therapist explore the presenting problem[s], the therapist will undoubtedly formulate additional questions to help broaden his or her understanding of all facets involved.

Important Questions

In the case of Catherine, there is additional information needed to compile a useful hypothesis of the presenting problem and underlying factors.

Ideations of self-harm or of being harmful to others

An important aspect is her current or past ideations of self-harm or causing harm to others. This information is critical because of the nature of her presenting problem relates to a violent and traumatic attack, and helps the therapist identify any immediate concerns for the client’s well-being.

Intimate relationships within the immediate family

This information will deliver an idea of how close relationships with immediate family members has been affected by the attack and what her emotional state is when she is in personal environments. Many victims experience mild to severe inability to relate with family members as they did before the incident. These complications could arise from the individual not being able to share his or her experience[s] with those closest to them, or the traumatic experience has rendered them unable to provide an emotional connection to those they share daily life.

Impacts on social interactions

In cases of violent assaults, the victim may experience difficulties in normal social interactions. Stressors become exacerbated when the individual is in the same, or similar, environment as where the attack took place because of familiarity of surroundings and the victim's potential to relive the experience. Interactions with friends in social settings and colleagues in work environments are both essential topics for exploration to determine if Catherine has withdrawn from friends and colleagues or have those interactions remained consistent.

What are the client’s Spiritual beliefs

Spirituality is often a significant aspect of recovering from a violent situation. It touches one of the core aspects of the individual’s moral structure and adds a layer to the healing process. Spiritual beliefs and what those beliefs are usually aligned with the person’s cultural history and learned experiences. Typically a person with strong religious practices has access to additional social interactions and other support structures than those who do not engage in spiritual practices.

Her attacker remaining at large

Knowing that her attacker is still at large is bound to affect her daily functioning. The client references how often she thinks about the perpetrator, cries, and fear she has in other situations. However, there is a much stronger undercurrent to this question and how the topic profoundly affects her emotional stability. Exploring this particular issue also permits the therapist to gather more information for the assessment process.

Investment in finding her attacker

The client states that she is determined to locate her attacker. This statement needs additional exploration for several reasons. First, how much time and energy is she investing in finding the individual. It is essential to understand if the client is spending more energy on this process than healing from the assault or is the search helping the process. Other information we want to discover is the potential for the victim to be obsessing over the attacker because finding him is the only way she can feel safe.

Finding her attacker

I believe this is a crucial follow-up question because of potential outcomes that reflect her emotional commitment and assessment of retribution. A concern is how the client would handle coming face-to-face with the assailant on an emotional level, and how the interaction would conclude. There is potential for the victim to commit a harmful or dangerous act, contact authorities, or utterly shut-down in an emotional break.

What it means to be a survivor

Surviving a violent or traumatic situation is more than just being alive. Based on the information already gathered and additional details from further exploration, the state of being a survivor appear associated with the simple fact that she survived the assault with no permanent physical ailments. It is vital to gain her perspective of what being a survivor is and explore how she feels about her mental well-being in the overall picture.

Feelings of hatred toward men

An issue that needs clarification is the expression of disgust towards men. Emotions and feelings become convoluted when a person is a victim of violent crimes. There are many questions as to why the crime happened, what levels of shame and self-blame the victim may experience, and what feelings the victim has toward the perpetrator. Feelings of anger and fear toward the perpetrator might project to individuals that meet a generalized similarity. Recoiling from the touch of a loved one could easily read as a feeling of hatred. This feeling toward men is most likely hurting the client’s relationships both at home and in social settings.

Previous treatments or coping mechanisms

Knowing if the client has undergone any earlier procedures for trauma exposure is very important because it will enhance the historical knowledge of what the client has done to combat the emotions and feelings associated with the experience. It will also tell us whether or not the client has received any prescription treatments along with any counseling she may have had. Additionally, if the client has not received any form of therapy, more questions regarding what she has done to combat the trauma on her own.  

If the client has not received any professional treatment, we would want to explore what she has done in the past to help combat the emotional distress. Knowing this will aid in understanding what things she has done were successful or not. It also opens the door for additional discussion on pinpointing what she is doing or experiencing when or if she does try to mitigate the emotional distress on her own.

Alcohol or substance abuse

This question is crucial to ask the client because alcohol or substance abuse frequently occurs with victims of violent crimes. Those who suffer violent or traumatic experiences that do not seek adequate treatment or even those in treatment are more prone to self-soothing with alcohol or other substances as a coping mechanism to aid in sleep, relieving anxiety, or in an attempt to forget the experience altogether.

Clinical Conceptualization

The client presents with obvious trauma symptoms of anxiety and depression resulting from a violent assault. She appears to have a stable family life, but the anger towards her assailant is most likely interfering with her marital life and interactions with children, as indicated by the short references to both her husband and children. Her experiences probably affect her interactions at work, even though she may appear to be functioning normally. The effects most likely influence her social activities and interactions, possibly causing her to alienate herself from friends and extended family members. She would undoubtedly have daily reminders of the assault because of the location that serves as a constant reminder of the incident, which causes additional stressors on a regular basis. Although the client does not appear to have suicidal ideation, she does emphasize finding her attacker. The concern is that she could be placing too much energy into this particular activity that could lead to an unhealthy obsession. Another matter is her stated hatred toward men. While this feeling is not uncommon for victims of assault, it does raise concerns regarding her interactions with friends, family, colleagues, and typical daily interactions in public spaces.

Furthermore, concerns for this emotional state combined with the search for her assailant could lead to a severe situation should she encounter the individual or even someone who she mistakenly identifies as the individual. The client states that because she is a survivor because she survived the attack. However, just relating to being a survivor does not necessarily mean the individual is healing from time and experience. The assumption is that she realizes that merely surviving a violent assault is only part of becoming a true survivor and that she needs to heal emotionally as well as physically.

Diagnosis

Physical healing does not bring closure to a victim of violent assault or other violent crimes. Those who experience severe traumatic experiences are prone to suffer prolonged effects of acute stress disorder [ASD] and posttraumatic stress disorder [PTSD] (Guay, Sader, Boyer, & Marchland, 2018). Depression and anxiety are common feelings for victims of traumatic experiences, but these emotions also become entangled with feelings of anger, self-doubt, self-blame, and in some cases a sense of shame over the initial exposure (Kunst, Winkle, & Bogaerts, 2011).

DSM-V Classification[s]

Posttraumatic Stress Disorder [F43.10]

The client experienced a violent attack that resulted in extreme physical and emotional injury. The following DSM-V criteria are noted. Client experienced a traumatic event [A.1.]. Client experiences recurring distressing memories of the event [B.1.]. Client Experiences prolonged psychological distress and reactions to external cues associated with the event [B.4., B.5.]. Client expresses anger and hatred toward men [C.4]. Experiencing marked alterations in arousal and reactivity [E.1., E.3.]. Clinical symptoms have been experienced for more than one-month [F] and are not attributable to substance abuse [H] (American Psychiatric Association, 2013).

Treatment Plan

A treatment plan for traumatic exposure consists of a variety of processes that aim to help the client understand his or her emotions, feelings, and behaviors associated with the initial event. Treatment usually includes cognitive behavioral therapy techniques like psychoeducation, exposure therapy, relapse prevention and possibly group therapy sessions with other victims of violent crimes to provide additional support structures. Self-reporting assessments also produce insight into the initial status of the client and provide follow-up data the therapist can use to gauge progress.

Self-reporting Assessments

I would recommend the client engages in several self-reporting assessments as the first step of the treatment process. The Beck Depression Inventory-II [BDI-II], The Modified PTSD Symptom Scale – Self Report [MPSS-SR] are helpful to both the client and the therapist as part of the treatment plan because it gives the client a visual representation of her emotions, and provides the therapist with a proper inventory of the client’s status (Guay, Sader, Boyer, & Marchland, 2018).

Cognitive Behavioral Therapy – Individual and with Significant Other

Psychoeducation is very important in aiding the client’s understanding of how emotions, feelings, and behaviors become altered after experiencing a traumatic event. By understanding these interactions, the client is open to working with the therapist to identify and change the maladaptive thoughts and behaviors the client is experiencing. This process includes learning techniques to manage anxiety by performing mindfulness exercises like diaphragmatic breathing (Guay, Sader, Boyer, & Marchland, 2018). Because the client experiences heightened levels of distress when she is around the event location, exposure therapy would be appropriate to aid in overcoming the emotions associated with the parking lot. Sessions with her husband would assist in enhancing communications surrounding the event and the subsequent feelings, thoughts, and behaviors to restore any maladaptive relationship issues.

Group Therapy

Attending group therapy with other survivors of violent crimes is a good step in helping the client associate with other people that have had shared experiences. Group therapy usually adds a layer of support for the victim and aids in alleviating alienating feelings. Exposure to stories of other victims also helps normalize feelings of anger or helplessness and provides the client with various perspectives of violent incidents and how other group members learn to cope with the event[s].

Conclusion

The counseling process is not merely engaging in discussions with a client. It is a complex and detailed process that includes understanding the client’s presenting problems, the underlying issues causing those problems, and building a relationship with the client that establishes a therapeutic direction. Although therapeutic disciplines differ based on the therapist's education, preferred methods, and sometimes the nature of the presenting problem, one constant part of the process is the clinical interview and assessment. In the case of Catherine, the initial information did not yield enough data to produce an accurate assessment. Additional questions need to be formulated to fill in the gaps. The treatment plan needed to be designed to meet the dire needs of the client and facilitate her recovery as efficiently as possible.

References

 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Arlington, VA: American Psychiatric Association.

Bucci, S., French, L., & Berry, K. (2016). Measures Assessing the Quality of Case Conceptualization: A Systematic Review. Journal of Clinical Psychology,72(6), 517-533. doi:10.1002/jclp.22280

Guay, S., Sader, J., Boyer, R., & Marchand, A. (2018). Treatment of acute stress disorder for victims of violent crime. Journal of Affective Disorders,241, 15-21. doi:10.1016/j.jad.2018.07.048

Kunst, M. J., Winkel, F. W., & Bogaerts, S. (2011). Posttraumatic Anger, Recalled Peritraumatic Emotions, and PTSD in Victims of Violent Crime. Journal of Interpersonal Violence,26(17), 3561-3579. doi:10.1177/0886260511403753

Liese, B. S., & Esterline, K. M. (2015). Concept mapping: A supervision strategy for introducing case conceptualization skills to novice therapists. Psychotherapy,52(2), 190-194. doi:10.1037/a0038618

Ridley, C. R., & Jeffrey, C. E. (2017). Thematic Mapping in Case Conceptualization: An Introduction to the Special Section. Journal of Clinical Psychology,73(4), 353-358. doi:10.1002/jclp.22355

Zubernis, L., Snyder, M., & Neale-Mcfall, C. (2017). Case Conceptualization: Improving Understanding and Treatment with the Temporal/Contextual Model. Journal of Mental Health Counseling,39(3), 181-194. doi:10.17744/mehc.39.3.01

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Social Anxiety: How Body Image Impacts Interpersonal Relationships

Social Anxiety: How Body Image Impacts Interpersonal Relationships

John Stafford

Brandman University

Table of Contents

Vignette. 4

Social Anxiety: How Body Image Impacts Interpersonal Relationships. 5

Cultural Issues. 5

Sexuality Issues. 5

Suggested Referrals. 6

DSM Criteria. 6

Symptoms. 6

Comorbidity Concerns. 7

Justification of Diagnosis. 7

Therapeutic Methods. 8

Acceptance and Commitment Therapy. 9

Acceptance and Defusion. 9

Values-Based Action. 10

General Treatment Overview.. 10

Cognitive Behavioral Therapy. 11

Cognitive Restructuring. 11

Mindfulness. 12

General Treatment Overview.. 12

Treatment Plan. 13

Short-Term Goals. 13

Long-Term Goals. 13

Termination. 14

Conclusion. 14

References. 16

Vignette

Seth is a 50-year-old African American male who tells you about his counseling history intake paperwork that he identifies as bisexual. He reports these feelings about questioning his sexuality had begun about a year ago when he started going out to gay bars and nightclubs. Seth tells you that he is deeply insecure to start any relationships and that he feels very lonely. Seth indicates he is extremely self-conscious and it is hard for him to attend social events because he is always comparing himself to his thinner friends. Seth reveals he does not eat a balanced diet, hardly exercises, and his doctor told him he is in the “morbidly obese” category, which made him “never want to go to a doctor out of my house ever again.”

Keywords:  Social Anxiety, Anxiety, Depression, LGBTQ, Eating Disorders, Obesity, Interpersonal Relationships. Acceptance and Commitment Therapy

Social Anxiety: 

How Body Image Impacts Interpersonal Relationships

Social anxiety is a standard issue in any culture and social structure. However, additional pressures related to personal perception, sexuality, social constructs, body image, and cultural acceptance may add other stresses that compound existing internal deficits. For example, an individual struggling with both body image and sexuality is more likely to experience heightened anxiety levels when he or she is attempting to assimilate into a specific environment.

Seth is experiencing aspects of internal acceptance of his sexuality that include confusion, cultural expectations, ageism, and self-consciousness associated with his current physical state. These issues make every-day life complicated and frustrating for Seth as he attempts to navigate his expectations of interpersonal relationships, and overall satisfaction with his everyday life.  

Cultural Issues

Seth comes from an African American culture. Understanding the cultural diversity of working with different cultures is essential as African Americans approach therapy from a different perspective than the Anglo-Saxon culture. Seth will most likely be more responsive to direct communication that offers more direction than other vague forms of treatment that only guide the client to find his or her answers. Family concerns are also significant in the African American culture as they view family bonds as more important than societal relationships.

Sexuality Issues

Seth’s sexual orientation is an issue that requires attention. The LGBTQ community can be very superficial, and body shaming is common amongst gay men. Bisexuality as another issue that can be met with mixed opinions in the gay community because many gay men view bisexual males as being less desirable. Furthermore, safe-sex practices add additional complications for bisexual men because modern preventative treatments like PreP have changed how gay men approach sexual relationships.  

Suggested Referrals

Several aspects come into play when considering referrals. Seth has an admitted weight concern that he wants to address, along with concerns he has surrounding his sexuality. Seth has stated that he had a bad experience with his current doctor when the issue of weight, so I would suggest referring him to a weight loss specialist that can help him formulate a comprehensive dietary program. Additionally, I would recommend that Seth attend group therapy at a local LGBT center for men dealing with bisexuality. Seth would gain tremendous insight and increased comfort levels being part of a group of other men experiencing the same emotions and feelings he is currently experiencing.

DSM Criteria

Social anxiety disorder or social phobia is a disorder that affects an individual in social settings. Symptoms can manifest as discomfort in social interactions, concerns about being embarrassed in public spaces, or of being judged by others (American Psychiatry Association, 2013). Individuals experiencing social anxiety disorder are likely to display heightened levels of anxiety and fear associated with autonomic arousal that includes apnea, diaphoreses, nausea, tachycardia, and tremors and can range in discomfort, including minor symptoms to disabling fear (National Institute of Health, n.d.; Anxiety and Depression Society of America, n.d.).  

Symptoms

The DSM-V lists ten different diagnostic criteria for social anxiety disorder that include; 1. Fear or anxiety specific to social settings,
2. Fear of experiencing social rejection due to displaying anxiety,
3. Provoked distress during social interaction,
4. Avoidance, or painfully and reluctant social interaction,
5.  Fear of disproportionate anxiety in comparison to the situation
6. Fear or anxiety associated with social situations that persist for six-months of longer,
7. Personal distress and impairment of functioning in one or more domains, including interpersonal and occupational functioning,
8. The symptoms not associated with adverse medication effects, substance abuse, or a medical disorder,
9. The signs not related to another mental disorder,

10. Another medical condition results in excessive self-consciousness

(American Psychiatric Association, 2013).

Comorbidity Concerns

            Comorbidity occurs when social anxiety disorder combined with other anxiety disorders, depression, and substance abuse (American Psychiatry Association, 2013). A primary comorbidity concern is a depression brought on by isolation and inability to make social contracts, which leads to extreme loneliness (National Institute of Mental health, n.d.; American Psychiatric Association, 2013.; Anxiety and Depression Society of America, n.d.).  Seth has indicated that he does experience loneliness, which raises concern for depression as a secondary diagnosis.

Justification of Diagnosis

            Based on the information from Seth’s intake, several of the criteria for social anxiety disorder are applicable. Seth indicated that his insecurities associated with self-image make is uncomfortable and awkward for him to engage in social settings. It would suggest that he is excessively self-conscious about his weight and that he is isolating himself from participating in social activities to avoid being judged by others and rejected for both his physical appearance and his anxiety or discomfort when he is in a social setting. Additionally, because Seth experiences loneliness resulting from an inability or fear of personal relationships, the concern for depression is a factor not to be overlooked and reflect in the diagnosis.

Therapeutic Methods

            The DSM-V indicates that cognitive behavioral therapy [CBT] is the most common modality of treatment for social anxiety disorder. It is commonly performed using exposure therapy in which the client gradually exposes himself to anxiety-provoking situations, and then associating the distressing stimulus with a relaxation or indifference response also referred to as systemic desensitization (National Institute of Mental Health, 2014). However, due to additional circumstances like body image and sexual identity issues Seth is experiencing, I believe that his social anxiety symptoms coincide with these issues and that addressing his social anxiety alone will not alleviate the underlying concerns. As a result, I think that Acceptance and Commitment Therapy [ACT] is a viable option of treatment for Seth. Because Seth has multiple issues that require attention, I believe that adding a CBT component to his treatment plan would provide additional benefit. CBT has demonstrated consistent success in helping clients experiencing weight loss problems. Using the CBT/ACT combination to focus on his weight loss in conjunction with a referral to a weight loss specialist, I believe Seth will be successful in understanding, setting, and meeting his goals.

Acceptance and Commitment Therapy

            The goal of ACT is to help the client accept issues associated with his or her presenting problems and make a commitment to living life by embracing those issues as part of oneself (Hayes, & Lillis, 2012). A critical aspect in ACT is enlisting the client to be an active participant in the therapeutic process, focus on the present, consciousness, and values that he or she wants to live. The therapist is required to assist the client in becoming more aware of themselves as a “whole person” by getting in touch with their feelings, thoughts, and live by their values (Hayes, & Lillis, 2012).  

Seth’s presenting problems are related to his social anxiety, but the underlying issues of his body image are emphasizing both his sexual identity issues and causing his social awkwardness. Treating Seth’s social tension as the primary issue will effectively only be putting a bandaid on his mental well-being because the underlying causation[s] is not alleviated. While treating the social anxiety may help Seth in some social settings in the short term, his body image issues will continue to plague his ability to function in social environments and prohibit functional interpersonal relationships.

Acceptance and Defusion

            The goal is to work with Seth to accept his feeling and thoughts without acting on them. The process includes walking through Seth’s feelings and emotions when he is in social settings and recognizing that obsessing or worrying about them is what makes him feel stuck or suffocated. By letting the thoughts and feelings happen without an impulsive reaction, Seth will be able to begin taking more control over how he feels, thinks, and reacts to his anxiety. Using techniques that help Seth observe the physical feelings associated with his fear, he will be able to identify how he interprets the experience and begin to replace the negative thoughts with realistic ones, ultimately providing him a new outlook on how he sees and reacts to the maladaptive expressions of his anxiety.

Values-Based Action

Seth struggles with social and interpersonal interactions because he believes he is grossly obese. Weight issues are a frequent contributor to social dysfunction because individuals feel that they get judged on their appearance. It would, in many cases, be a correct assumption. If Seth wants to be healthy and remove the stressors associated with his weight issues, he needs to act on his values of living a happy and healthy life with improved social interactions. This phase includes pulling from his values to help him recognize the need for a proper diet and exercise regimen that start producing those results.

General Treatment Overview

The treatment plan for Seth should start by helping him understand and accept the thoughts associated with his social anxiety to minimize their impact when he is in a social setting. Additionally, assisting Seth to get in touch with his values of how he wants his life experiences to will help him understand that much of his anxiety and interpersonal interactions are a result of his weight and body image issues.

By focusing on his values and making cognitive changes, Seth can start working on a plan to work on his weight, hence reducing his social anxiety problems. Additionally, by using defusion and mindfulness techniques to help him understand and stop avoiding his thoughts and feelings when he is in a social setting will have an additional positive impact on his self-esteem as friends and people he interacts within social environments start noticing changes in his physical appearance.

Cognitive Behavioral Therapy

            Cognitive Behavioral Therapy [CBT] is widely used to treat a variety of different mental health problems. In the area of weight loss, CBT is proven the most successful therapy modality for treating patients suffering from binge eating disorders. Most studies show that dieting alone does not provide successful outcomes in weight loss. A comprehensive program of dieting, exercise, and a cognitive component that retrains the client’s thoughts and processes of eating is a well-rounded program geared for success (Greenberg, 2011; Leigh, 2004). Considering the biological factors that impact weight loss, no one-stop solution guarantees success. Cognitive Behavioral Therapy offers a variety of techniques like mindfulness-based eating awareness, self-monitoring, and cognitive-based coping skills for weight loss (Greenberg, 2011).

            The second consideration for CBT is Seth’s social anxiety. Cognitive behavioral therapy, recognized as one of the prominent treatments for social anxiety disorder, provides the client with specific tools and goals for successful treatment. By helping the client modify maladaptive thoughts and emotions, CBT teaches the client to be more assertive, cope with guilt, anger, and embarrassment, and correct misconceptions he or she has about their abilities and self-worth (Cuncic, 2018).

Cognitive Restructuring

            The benefit of cognitive restructuring applies to both dietary issues and social anxiety. The process teaches the client to identify upsetting ideas, mental image, and negative self-talk that induces both eating disorders and social fears by comparing them to real-life evidence and experiences. By doing so, the client can begin reformulating how he or she views things and adapt maladaptive thoughts to constructive thoughts and attitudes toward similar experiences. However, this is only the beginning of the cognitive modification process.

Mindfulness

Learning mindfulness techniques will provide a considerable advantage in addressing both social anxiety and weight loss. Mindfulness gives the client the needed tools to identify and replace maladaptive thoughts and feelings while refocusing on the moment and desired goals. In social situations, mindfulness techniques help the individual return to or stay in the moment allowing for more comfortable interactions with others. For weight loss, learning mindfulness techniques enable the client to remain focused on their eating habits, the desired changes, and stay focused on their weight loss program.

General Treatment Overview

Cognitive behavioral therapy provides a solid treatment plan for social anxiety and weight loss issues. Seth would benefit from this therapeutic model because it will help him learn various skills needed to overcome the blockers that affect his presenting problems. Using a combination of mindfulness exercises and cognitive restructuring, Seth will be able to identify, control and modify the maladaptive thoughts, emotions, and behaviors associated with his weight and social issues.

The cognitive restructuring includes the identification of maladaptive thoughts and feelings resulting in undesired behaviors and outcomes. Learning to identify these thoughts and replacing them with positive thoughts will result in enhanced interactions in social environments and address underlying issues that affect dietary difficulties. Mindfulness techniques include meditation and other exercises that aid the client in tuning into his or her body cues and emotional processes. Using mindfulness exercises will help Seth stay focused and relaxed during stressful social encounters and reduce emotional eating issues.

Treatment Plan

            A treatment plan should represent a comprehensive program that includes a set of goals and treatment modalities that both the therapist and client agreed to. It should consist of any suggested referrals to outside providers who provide services that will benefit the client. One of the critical aspects of the treatment plan are the short and long-term goals easily measured against the presenting problems and client satisfaction. Finally, termination of therapy should involve discussion with the client to determine his or her perspective on the effectiveness of treatment, how the termination process works, and to make sure the client understands that the therapist is available for any needed follow-up sessions, should the client need.

Short-Term Goals

            Any therapy plan requires realistic short-term goals the client wants to meet. Seth wants to address his social anxiety and weight loss. Although weight loss is a long-term process, there are short-term goals needed to begin the path. Because Seth’s weight is also underlying causation of his social anxiety, the first step in the treatment process is to help Seth get into a comprehensive weight loss program that includes referral to a weight loss specialist, an exercise program, and therapy sessions. Secondarily, beginning work on Seth’s social anxiety will help in multiple ways. Becoming more comfortable in social settings will help Seth experience less stress and reduce the potential for stress-induced eating habits.

Long-Term Goals

            Meeting short-term goals provides a sense of accomplishment and satisfaction for the client. However, these can quickly become detrimental if the client is not focused on long-term goals, even if they are the same or similar to short-term. Seth has a long road ahead of him with his weight loss issues. Typical weight loss programs have setbacks that can be discouraging to the client. Maintaining a therapeutic direction that focuses on the long-term outcome will help decrease the disappointment associated with any delays, and help Seth retain focus. Because Seth’s weight affects his social anxiety, there will need to be a long-term goal of continuing work on his social issues. Another component for Seth is joining a group for bisexual men. Over time, Seth will learn to become more comfortable with his sexuality, and as his other issues begin to improve, Seth will become more comfortable engaging in personal relationships.

Termination

            As the Seth progresses through the phases of treatment, he should be able to begin social interactions with less stress as he works on the primary issue contributing to his social and interpersonal interaction issues. His ability to defuse from the dysfunctional thoughts and emotions associated with anxiety and continuing work on his body image issues will have multiple positive effects over the long-term. Understanding upfront that his weight issues do not align with his values and not an unresolvable situation will also produce a positive social impact as he interacts with people and notices physical improvements.

Conclusion

            Working with patients is not a one-step process with natural solutions. Each client has different presenting problems compounded with multiple symptoms and underlying causes. A client that presents with various issues like weight loss, social anxiety, and sexual identity problems presents a challenge for the therapist when it comes to which therapeutic techniques are best suited to treat the client. What a single therapeutic method can accomplish may not be the answer for that particular client. Blending techniques can seem convoluted but may produce a much more desired process and results. Acceptance and Commitment Therapy and Cognitive Behavioral Therapy are two very different theories that, if used correctly, blend to provide the client with a well-rounded therapeutic process that provides tremendous benefit to the client.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Arlington, VA: American Psychiatric Association.

Anxiety and Depression Association of America. (n.d.). Social Anxiety Disorder. Retrieved from http://www.adaa.org/understanding-anxiety/social-anxiety-disorder

Cuncic, A. (2018). How Cognitive-Behavioral Therapy Can Treat Social Anxiety Disorder. Retrieved from https://www.verywellmind.com/how-is-cbt-used-to-treat-sad-3024945

Greenberg, M. (2011). To Lose the Weight, Change How You Relate (to Food). Retrieved from https://www.psychologytoday.com/us/blog/the-mindful-self-express/201102/lose-the-weight-change-how-you-relate-food

Hayes, S. C., & Lillis, J. (2012). Acceptance and commitment therapy. Washington, DC: American Psychological Association.

National Institute of Mental Health. (2014). Anxiety Disorders. Retrieved from http://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml

National Institute of Mental Health. (2016). Anxiety Disorders. Retrieved from http://www.nimh.nih.gov/health/topics/social-phobia-social-anxiety-disorder/index.shtml

Rich, L. E. (2004). Bringing More Effective Tools to the Weight-Loss Table. Monitor on Psychology,35(1). Retrieved from http://www.apa.org/monitor/jan04/bringing.aspx