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15An Integrative Perspective

1. Explain psychotherapy integration and why it is increasing in popularity.

2. Identify some specific advantages of psychotherapy integration.

3. Examine some of the main challenges of developing an integrative approach.

4. Discuss how multicultural issues can be addressed in counseling practice.

5. Discuss how spiritual and religious values can ethically and effectively

be integrated into counseling practice.

6. Understand a basis for effectively drawing techniques from various theories.

7. Examine what research generally shows about the effectiveness of psychotherapy.

8. Describe feedback-informed treatment and explain how this is related to enhanced therapeutic outcomes.

L e a r n i n g O b j e c t i v e s

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428 CHAPTER FIFTEEN

Introduction This chapter will help you think about areas of convergence and divergence among the 11 therapeutic systems covered in this book. Although these approaches all have some goals in common, they have many differences when it comes to the best route to achieve these goals. Some therapies call for an active and directive stance on the therapist’s part, and others place value on clients being the active agent. Some ther- apies focus on experiencing feelings, others stress identifying cognitive patterns, and still others concentrate on actual behavior. The key task is to find ways to integrate certain features of each of these approaches so that you can work with clients on all three levels of human experience.

The field of psychotherapy is characterized by a diverse range of specialized models. With all this diversity, is there any hope that a practitioner can develop skills in all of the existing techniques? How does a student decide which theories are most relevant to practice? Looking for commonalities among the systems of psychotherapy is relatively new (Norcross & Beutler, 2014). Practitioners have been battling over the “best” way to bring about personality change dating back to the work of Freud. For decades, counselors resisted integration, often to the point of denying the validity of alternative theories and of ignoring effective methods from other theoretical schools. The early history of counseling is full of theoretical wars.

Since the early 1980s, psychotherapy integration has developed into a clearly delineated field. It is now an established and respected movement that is based on combining the best of differing orientations so that more complete theoretical mod- els can be articulated and more efficient treatments developed (Goldfried, Pachan- kis, & Bell, 2005). The Society for the Exploration of Psychotherapy Integration, formed in 1983, is an international organization whose members are professionals working toward the development of therapeutic approaches that transcend single theoretical orientations. As the field of psychotherapy has matured, the concept of integration has emerged as a mainstay (Norcross & Beutler, 2014).

In this chapter I consider the advantages of developing an integrative perspec- tive for counseling practice. I also present a framework to help you begin to integrate concepts and techniques from various approaches. As you read, start to formulate your own personal perspective for counseling. Look for ways to synthesize diverse elements from different theoretical perspectives. As much as possible, be alert to how these systems can function in harmony.

Visit CengageBrain.com or watch the DVD for the video program on Chapter 15, Theory and Practice of Counseling and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you view the brief lecture for each chapter prior to reading the chapter.

The Movement Toward Psychotherapy Integration A large number of therapists identify themselves as “eclectic,” and this category covers a broad range of practice. At its worst, eclectic practice consists of haphaz- ardly picking techniques without any overall theoretical rationale. This is known as syncretism, wherein the practitioner, lacking in knowledge and skill in selecting interventions, looks for anything that seems to work, often making little attempt to

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AN INTEgRATIVE PERsPECTIVE 429

determine whether the therapeutic procedures are indeed effective. Such an uncriti- cal and unsystematic combination of techniques is no better than a narrow and dogmatic orthodoxy. Pulling techniques from many sources without a sound ratio- nale results in syncretistic confusion, which is detrimental to the successful treat- ment of clients (Corey, 2015; Neukrug, 2016; Norcross & Beutler, 2014).

Pathways Toward Psychotherapy Integration Psychotherapy integration is best characterized by attempts to look beyond and across the confines of single-school approaches to see what can be learned from other perspectives and how clients can benefit from a variety of ways of conduct- ing therapy. The majority of psychotherapists do not claim allegiance to a particular therapeutic school but prefer, instead, some form of integration (Norcross, 2005; Norcross & Beutler, 2014). In a 2007 survey, only 4.2% of respondents identified themselves as being aligned with one therapy model exclusively. The remaining 95.8% claimed to be integrative, meaning they combined a variety of methods or approaches in their counseling practice (Psychotherapy Networker, 2007). A panel of psychotherapy experts has predicted an increase in the popularity of integrative therapies in the next decade, particularly with regard to mindfulness, cognitive behavioral, multicultural, and integrative theories (Norcross, Pfund, & Prochaska, 2013).

The integrative approach is characterized by openness to various ways of inte- grating diverse theories and techniques, and there is a decided preference for the term integrative over eclectic (Norcross, Karpiak, & Lister, 2005). The ultimate goal of integration is to enhance the efficiency and applicability of psychotherapy. Norcross and Beutler (2014) and Stricker (2010) describe four of the most common path- ways toward the integration of psychotherapies: technical integration, theoretical integration, assimilative integration, and common factors approach. All of these approaches to integration look beyond the restrictions of single approaches, but they do so in distinctive ways.

technical integration aims at selecting the best treatment techniques for the individual and the problem. It tends to focus on differences, chooses from many approaches, and is a collection of techniques. This path calls for using techniques from different schools without necessarily subscribing to the theoretical positions that spawned them. For those who practice from the perspective of technical inte- gration, there is no necessary connection between conceptual foundations and tech- niques. Therapists have a variety of tools in their toolkit to use with clients. One of the best-known forms of technical integration, which Lazarus (2008a) refers to as technical eclecticism, is the basis of multimodal therapy. Multimodal therapists bor- row from many other therapeutic models, using techniques that have been demon- strated to be effective in dealing with specific clinical problems. Whenever feasible, multimodal therapists employ empirically supported techniques.

In contrast, theoretical integration refers to a conceptual or theoretical cre- ation beyond a mere blending of techniques. This route has the goal of producing a conceptual framework that synthesizes the best aspects of two or more theoretical approaches under the assumption that the outcome will be richer than either the- ory alone. This approach emphasizes integrating the underlying theories of therapy along with techniques from each. Examples of this form of integration are dialectical

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430 CHAPTER FIFTEEN

behavior therapy (DBT) and acceptance and commitment therapy (ACT), both of which are described in Chapter 9.

Emotion-focused therapy (EFT), introduced in Chapter 7, is another form of theoretical integration. This approach is informed by the role of emotion in psy- chotherapeutic change. Greenberg (2011), a key figure in the development of EFT, conceptualizes the model as an empirically supported, integrative, experiential approach to treatment. Emotion-focused therapy is rooted in a person-centered philosophy, but it is integrative in that it synthesizes aspects of Gestalt therapy, experiential therapy, and existential therapy. Emotion-focused therapy blends the relational aspects of the person-centered approach with the active phenomenologi- cal awareness experiments of Gestalt therapy.

The assimilative integration approach is grounded in a particular school of psychotherapy, along with an openness to selectively incorporate practices from other therapeutic approaches. Assimilative integration combines the advantages of a single coherent theoretical system with the flexibility of a variety of interventions from multiple systems. An example of this form of integration is mindfulness-based cognitive therapy (MBCT), which integrates aspects of cognitive therapy and mindful- ness-based stress reduction procedures. As you may recall from Chapter 9, MBCT is a comprehensive integration of the principles and skills of mindfulness that has been applied to the treatment of depression (Segal, Williams, & Teasdale, 2013).

The common factors approach searches for common elements across differ- ent theoretical systems. Despite many differences among the theories, a recogniz- able core of counseling practice is composed of nonspecific variables common to all therapies. Lambert (2011) concludes that common factors can be a basis for psycho- therapy integration:

The common factors explanation for the general equivalence of diverse therapeu- tic interventions has resulted in the dominance of integrative practice in routine care by implying that the dogmatic advocacy of a particular theoretical school is not supported by research. Research also suggests that common factors can become the focal point for integration of seemingly diverse therapy techniques. (p. 314)

Some of these common factors include empathic listening, support, warmth, developing a working alliance, opportunity for catharsis, practicing new behaviors, feedback, positive expectations of clients, working through one’s own conflicts, understanding interpersonal and intrapersonal dynamics, change that occurs outside of the therapy office, client factors, therapist effects, and learning to be self-reflective about one’s work (Norcross & Beutler, 2014; Prochaska & Norcross, 2014).These common factors are thought to be far more important in account- ing for therapeutic outcomes than the unique factors that differentiate one theory from another. Specific treatment techniques make relatively little difference in outcome when compared with the value of common factors, especially the human elements (Elkins, 2016). Among the approaches to psychotherapy integration, the common factors approach has the strongest empirical support (Duncan, Miller, Wampold, & Hubble, 2010).

Of all of the common factors investigated in psychotherapy, none has received more attention and confirmation than a facilitative therapeutic relationship (Lambert, 2011). The importance of the therapeutic alliance is a well-established

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AN INTEgRATIVE PERsPECTIVE 431

critical component of effective therapy. Research confirms that the client–therapist relationship is central to therapeutic change and is a significant predictor of both effectiveness and retention of therapy outcomes (Elkins, 2016; Miller, Hubble, & Seidel, 2015).

Advantages of Psychotherapy Integration An integrative approach provides a general framework that enables practi- tioners to make sense of the many aspects of the therapy process and provides a map giving direction to what practitioners do and say (Corey, 2015). One reason for the movement toward psychotherapy integration is the recognition that no single theory is comprehensive enough to account for the complexities of human behav- ior, especially when the range of client types and their specific problems are taken into consideration. Because no one theory contains all the truth, and because no single set of counseling techniques is always effective in working with diverse client populations, integrative approaches hold promise for counseling practice. Norcross and Wampold (2011b) maintain that effective clinical practice requires a flexible and integrative perspective. Psychotherapy should be flexibly tailored to the unique needs and contexts of the individual client. Norcross and Wampold contend that using an identical therapy relationship style and treatment method for all clients is inappropriate and can be unethical.

The 11 systems discussed in this book have evolved in the direction of broad- ening their theoretical and practical bases and have become less restrictive in their focus. Many practitioners who claim allegiance to a particular system of therapy are expanding their theoretical outlook and developing a wider range of therapeu- tic techniques to fit a more diverse population of clients. There is a growing recog- nition that psychotherapy can be most effective when contributions from various approaches are integrated (Goldfried, Glass, & Arnkoff, 2011). Although to date the bulk of psychotherapy integration has been based on theoretical and clinical foundations, Goldfried and colleagues suggest that evidence-based practice will increasingly become the organizing force for integration. Empirical pragmatism, not theory, will be the integrative theme of the 21st century.

Practitioners who are open to an integrative perspective will find that several theories play a crucial role in their personal counseling approach. Each theory has its unique contributions and its own domain of expertise. By accepting that each theory has strengths and weaknesses and is, by definition, “different” from the oth- ers, practitioners have some basis to begin developing a theory that fits for them and their clients. It takes considerable time to learn the various theories in depth. It is not realistic for any of us to expect that we can integrate all the theories. Instead, integration of some aspects of some theories is a more realistic goal. Developing an integrative perspective is a lifelong endeavor that is refined with clinical experience, reflection, reading, and discourse with colleagues.

The Challenge of Developing an Integrative Perspective A survey of approaches to counseling and psychotherapy reveals that no common philosophy unifies them. Many of the theories have different basic phi- losophies and views of human nature (Table 15.1). As the postmodern therapists

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432 CHAPTER FIFTEEN

TAbLe 15.1 The basic Philosophies

Psychoanalytic therapy

Human beings are basically determined by psychic energy and by early experiences. Unconscious motives and conflicts are central in present behavior. Early development is of critical importance because later personality problems have their roots in repressed childhood conflicts.

Adlerian therapy

Humans are motivated by social interest, by striving toward goals, by inferiority and superiority, and by dealing with the tasks of life. Emphasis is on the individual’s positive capacities to live in society cooperatively. People have the capacity to interpret, influence, and create events. Each person at an early age creates a unique style of life, which tends to remain relatively constant throughout life.

Existential therapy

The central focus is on the nature of the human condition, which includes a capacity for self- awareness, freedom of choice to decide one’s fate, responsibility, anxiety, the search for meaning, being alone and being in relation with others, striving for authenticity, and facing living and dying.

Person-centered therapy

Positive view of people; we have an inclination toward becoming fully functioning. In the context of the therapeutic relationship, the client experiences feelings that were previously denied to awareness. The client moves toward increased awareness, spontaneity, trust in self, and inner-directedness.

Gestalt therapy The person strives for wholeness and integration of thinking, feeling, and behaving. Some key concepts include contact with self and others, contact boundaries, and awareness. The view is nondeterministic in that the person is viewed as having the capacity to recognize how earlier influences are related to present difficulties. As an experiential approach, it is grounded in the here and now and emphasizes awareness, personal choice, and responsibility.

Behavior therapy

Behavior is the product of learning. We are both the product and the producer of the environment. Traditional behavior therapy is based on classical and operant principles. Contemporary behavior therapy has branched out in many directions, including mindfulness and acceptance approaches.

Cognitive behavior therapy

Individuals tend to incorporate faulty thinking, which leads to emotional and behavioral disturbances. Cognitions are the major determinants of how we feel and act. Therapy is primarily oriented toward cognition and behavior, and it stresses the role of thinking, deciding, questioning, doing, and redeciding. This is a psychoeducational model, which emphasizes therapy as a learning process, including acquiring and practicing new skills, learning new ways of thinking, and acquiring more effective ways of coping with problems.

Choice theory/ Reality therapy

Based on choice theory, this approach assumes that we need quality relationships to be happy. Psychological problems are the result of our resisting control by others or of our attempt to control others. Choice theory is an explanation of human nature and how to best achieve satisfying interpersonal relationships.

Feminist therapy

Feminists criticize many traditional theories to the degree that they are based on gender-biased concepts, such as being androcentric, gendercentric, ethnocentric, heterosexist, and intrapsychic. The constructs of feminist therapy include being gender fair, flexible, interactionist, and life-span-oriented. Gender and power are at the heart of feminist therapy. This is a systems approach that recognizes the cultural, social, and political factors that contribute to an individual’s problems.

Postmodern approaches

Based on the premise that there are multiple realities and multiple truths, postmodern therapies reject the idea that reality is external and can be grasped. People create meaning in their lives through conversations with others. The postmodern approaches avoid pathologizing clients, take a dim view of diagnosis, avoid searching for underlying causes of problems, and place a high value on discovering clients’ strengths and resources. Rather than talking about problems, the focus of therapy is on creating solutions in the present and the future.

Family systems therapy

The family is viewed from an interactive and systemic perspective. Clients are connected to a living system; a change in one part of the system will result in a change in other parts. The family provides the context for understanding how individuals function in relationship to others and how they behave. Treatment deals with the family unit. An individual’s dysfunctional behavior grows out of the interactional unit of the family and out of larger systems as well.

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AN INTEgRATIVE PERsPECTIVE 433

remind us, our philosophical assumptions are important because they influence which “reality” we perceive, and they direct our attention to the variables that we are “set” to see. A word of caution, then: Beware of subscribing exclusively to any one view of human nature. Remain open and selectively incorporate a framework for counseling that is consistent with your own personality and belief system and that validates clients’ belief systems as well.

Despite the divergences in the various theories, creative syntheses among some models are possible. For example, an existential orientation does not necessarily pre- clude using techniques drawn from behavior therapy or from some of the cognitive theories. Each point of view offers a perspective for helping clients in their search for self. I encourage you to study all the major theories and to remain open to what you might take from the various orientations as a basis for an integrative perspective that will guide your practice.

In developing a personal integrative perspective, it is important to be alert to the problem of attempting to mix theories with incompatible underlying assumptions. Examine the key concepts of various theories as you begin to think about integra- tion (Table 15.2). By remaining theoretically consistent, but technically integrative, practitioners can spell out precisely the interventions they will employ with various clients, as well as the means by which they will select these procedures.

TAbLe 15.2 Key Concepts

Psychoanalytic therapy

Normal personality development is based on successful resolution and integration of psychosexual stages of development. Faulty personality development is the result of inadequate resolution of some specific stage. Anxiety is a result of repression of basic conflicts. Unconscious processes are centrally related to current behavior.

Adlerian therapy

Key concepts include the unity of personality, the need to view people from their subjective perspective, and the importance of life goals that give direction to behavior. People are motivated by social interest and by finding goals to give life meaning. Other key concepts are striving for significance and superiority, developing a unique lifestyle, and understanding the family constellation. Therapy is a matter of providing encouragement and assisting clients in changing their cognitive perspective and behavior.

Existential therapy

Essentially an experiential approach to counseling rather than a firm theoretical model, it stresses core human conditions. Interest is on the present and on what one is becoming. The approach has a future orientation and stresses self-awareness before action.

Person-centered therapy

The client has the potential to become aware of problems and the means to resolve them. Faith is placed in the client’s capacity for self-direction. Mental health is a congruence of ideal self and real self. Maladjustment is the result of a discrepancy between what one wants to be and what one is. In therapy attention is given to the present moment and on experiencing and expressing feelings.

Gestalt therapy

Emphasis is on the “what” and “how” of experiencing in the here and now to help clients accept all aspects of themselves. Key concepts include holism, figure-formation process, awareness, unfinished business and avoidance, contact, and energy.

Behavior therapy

Focus is on overt behavior, precision in specifying goals of treatment, development of specific treatment plans, and objective evaluation of therapy outcomes. Present behavior is given attention. Therapy is based on the principles of learning theory. Normal behavior is learned through reinforcement and imitation. Abnormal behavior is the result of faulty learning.

(continued)

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434 CHAPTER FIFTEEN

One of the challenges you will face as a counselor is to deliver therapeutic ser- vices in a brief, comprehensive, effective, and flexible way. Many of the theoretical orientations addressed in this book can be applied to brief forms of therapy. One of the driving forces of the psychotherapy integration movement has been the increase of brief therapies and the pressures to do more for a variety of client populations within the limitations of 6 to 20 sessions. Short-term and very-short-term therapies are increasing (Norcross et al., 2013). Time-limited brief therapy refers to a variety of time-sensitive, goal-directed, efficiency-oriented methods. These methods can be incorporated in any theoretical approach (Hoyt, 2015). Lambert (2011) believes the future direction of theory, practice, and training will see (1) the decline of single- theory practice and the growth of integrative therapies, and (2) the increase in short- term, time-limited, and group treatments that seem to be as effective as long-term individual treatments with many client populations.

An integrative perspective at its best entails a systematic integration of underly- ing principles and methods common to a range of therapeutic approaches. The strengths of systematic integration are based on its ability to be taught, replicated, and evaluated (Norcross & Beutler, 2014). To develop this kind of integration, you will eventually need to be thoroughly conversant with a number of theories, be open to the idea that these theories can be connected in some ways, and be willing to continually test your hypotheses to determine how well they are working. Neukrug (2016) reminds us that “the ability to assimilate techniques from varying theoretical perspectives takes knowledge, time, and finesse” (p. 139).

Cognitive behavior therapy

Although psychological problems may be rooted in childhood, they are reinforced by present ways of thinking. A person’s belief system and thinking is the primary cause of disorders. Internal dialogue plays a central role in one’s behavior. Clients focus on examining faulty assumptions and misconceptions and on replacing these with effective beliefs.

Choice theory/ Reality therapy

The basic focus is on what clients are doing and how to get them to evaluate whether their present actions are working for them. People are mainly motivated to satisfy their needs, especially the need for significant relationships. The approach rejects the medical model, the notion of transference, the unconscious, and dwelling on one’s past.

Feminist therapy

Core principles of feminist therapy are that the personal is political, therapists have a commitment to social change, women’s voices and ways of knowing are valued and women’s experiences are honored, the counseling relationship is egalitarian, therapy focuses on strengths and a reformulated definition of psychological distress, and all types of oppression are recognized.

Postmodern approaches

Therapy tends to be brief and addresses the present and the future. The person is not the problem; the problem is the problem. The emphasis is on externalizing the problem and looking for exceptions to the problem. Therapy consists of a collaborative dialogue in which the therapist and the client co-create solutions. By identifying instances when the problem did not exist, clients can create new meanings for themselves and fashion a new life story.

Family systems therapy

Focus is on communication patterns within a family, both verbal and nonverbal. Problems in relationships are likely to be passed on from generation to generation. Key concepts vary depending on specific orientation but include differentiation, triangles, power coalitions, family-of-origin dynamics, functional versus dysfunctional interaction patterns, and dealing with here-and-now interactions. The present is more important than exploring past experiences.

TAbLe 15.2 Key Concepts (continued)

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AN INTEgRATIVE PERsPECTIVE 435

Integration of Multicultural Issues in Counseling Multiculturalism is a reality that cannot be ignored by practitioners if they hope to meet the needs of diverse client groups. I believe current theories, to varying degrees, can and should be expanded to incorporate a multicultural dimension. I have consistently pointed out that if contemporary theories do not account for the cultural dimension, they will have limited applicability in working with diverse cli- ent populations. For some theories, this transition is easier than for others.

Clients can be harmed if they are expected to fit all the specifications of a given theory, whether or not the values espoused by the theory are consistent with their own cultural values. Rather than stretching the client to fit the dimensions of a single theory, practitioners need to tailor their theory and practice to fit the unique needs of the client. This calls for counselors to possess knowledge of various cultures, to be aware of their own cultural heritage, and to have skills to assist a wide spectrum of clients in dealing with the realities of their culture. Psychotherapy integration stresses tailoring interven- tions to the individual client rather than to an overarching theory, making this approach particularly well suited to considering cultural factors and the unique perspective of each client. Comas-Diaz (2014) believes that cultural competence enables counselors to work effectively in most clinical settings. Practitioners demonstrate their cultural com- petence by becoming aware of their own and their clients’ worldviews, and by being able to use culturally appropriate interventions to reflect their cultural beliefs, knowledge, and skills. This is a good time to review the discussion of the culturally skilled counselor in Chapter 2 and to consult Tables 15.7 and 15.8, which appear later in this chapter.

In your role as a counselor, you need to be able to assess the special needs of clients. The client’s ethnicity and culture and the concerns that bring this person to counseling challenge you to develop flexibility in utilizing an array of therapeutic strategies. Some clients will need more direction and guidance; others will be hesitant to talk about themselves in personal ways, especially during the early phase of the counseling process. What you may see as resistance could be the client’s response to years of cultural conditioning and respect for certain values and traditions. Basically, it comes down to your familiarity with a variety of theoretical approaches and your ability to employ and adapt your techniques to fit the person-in-the-environment. It is not enough to merely assist your clients in gaining insight, expressing suppressed emotions, or making certain behavioral changes. The challenge is to find practical strategies for adapting the techniques you have developed to enable clients to exam- ine the impact their culture continues to have on their lives and to make decisions about what, if anything, they want to change.

Being an effective counselor involves reflecting on how your own culture influ- ences you and your interventions in your counseling practice. This awareness is critical in becoming more sensitive to the cultural backgrounds of the clients who seek your help. Using an integrative perspective, therapists can encompass social, cultural, spiritual, and political dimensions in their work with clients.

Integration of Spirituality and Religion in Counseling The counseling process can help clients gain insight into the ways their core beliefs and values are reflected in their behavior. Current interest in spiritual and religious beliefs has implications for how such beliefs might be incorporated in

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436 CHAPTER FIFTEEN

therapeutic relationships (Frame, 2003; Johnson, 2013; Young & Cashwell, 2011a). Survey data from members of both the American Psychological Association and the American Counseling Association indicate that spiritual and religious matters are therapeutically relevant, ethically appropriate, and potentially significant topics for the practice of counseling in secular settings (Delaney, Miller, & Bisono, 2007; Young, Wiggins-Frame, & Cashwell, 2007).

Worthington (2011) asserts that the increasing openness of therapists to cli- ents’ spiritual and religious concerns and interests has been fueled by the multicul- tural evolution. The emphasis on multiculturalism has empowered people to define themselves from a cultural perspective, which includes their spiritual, religious, and ethnic contexts. Johnson (2013) views spiritually informed therapy as a form of mul- ticultural therapy. The first step is for the therapist to be sincerely interested in the client’s spiritual beliefs and experiences and how he or she finds meaning in life. Johnson believes that a client-defined sense of spirituality can be a significant avenue for connecting with the client and can be an ally in the therapeutic change process. However, the emphasis is on what the client wants, not on the therapist’s spiritual experiences or agenda for the client.

Clients who are experiencing a crisis situation may find a source of comfort, support, and strength in drawing upon their spiritual resources. For some clients spirituality entails embracing a religion, which can have many different meanings. Other clients value spirituality, yet do not have any ties to a formal religion. What- ever one’s particular view of spirituality, it is a force that can help the individual to find a purpose (or purposes) for living. Spiritual or religious beliefs can be a major sustaining power that supports clients when all else fails. Other clients may be affected by depression and a sense of worthlessness due to guilt, anger, or sadness created by their unexamined acceptance of spiritual or religious dogma. Counselors must remain open and nonjudgmental in conversations about religion or spiritual- ity. Furthermore, counselors cannot ignore a client’s spiritual and religious perspec- tives if they want to practice in a culturally competent and ethical manner (Johnson, 2013; Young & Cashwell, 2011a, 2011b). It is essential for counselors to be aware of and understand their spiritual or religious attitudes, beliefs, values, and experiences if they expect to facilitate an exploration of these issues with clients.

Common Goals Spiritual values have a major part to play in human life and struggles. Exploring these values has a great deal to do with providing solutions for clients’ struggles. Because spiritual and therapeutic paths converge in some ways, integration is possible, and dealing with a client’s spirituality will often enhance the therapy process. Themes that have healing influences include loving, caring, learning to listen with compassion, challenging clients’ basic life assumptions, accepting human imperfection, and going outside of self-oriented interests (social interest). Both a spiritual perspective and counseling can help people ponder questions of “Who am I?” and “What is the meaning of my life?” Pursuing these existential questions can foster healing.

Implications for Assessment and Treatment Traditionally, when clients come to a therapist with a problem, the therapist explores all the factors that contributed to the development of the problem. A background of involvement in religion can be

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AN INTEgRATIVE PERsPECTIVE 437

part of a client’s history, and thus it can be a part of the intake assessment and can be explored in counseling sessions. Frame (2003) presents many reasons for including spirituality in the assessment process: understanding clients’ worldviews and the contexts in which they live, assisting clients in grappling with questions regarding the purpose of their lives and what they most value, exploring religion and spirituality as client resources, and uncovering religious and spiritual problems. This information will assist the therapist in choosing appropriate interventions. Young and Cashwell (2011a) maintain that counselors must assess whether clients’ spiritual or religious beliefs may be exacerbating or helping clients’ psychological problems.

Your Role as a Counselor It is critical that counselors not be judgmental when it comes to their clients’ beliefs and that counselors create an inviting and safe climate for clients to explore their values and beliefs. There are many paths toward fulfilling spiritual needs, and it is not your role as a counselor to prescribe any particular pathway. By conducting a thorough assessment on a client’s background, you will obtain many clues regarding personal themes for potential exploration. If you remain finely tuned to clients’ stories and to the purpose for which they sought therapy, clients’ concerns about spiritual or religious values, beliefs, and practices will surface. It is critical that you listen for how clients talk about existential concerns of meaning, values, mortality, and being in the world. Remain open to how your clients define, experience, and access whatever helps them stay connected to their core values and their inner wisdom (Johnson, 2013).

If you are to effectively serve diverse client populations, it is essential that you pay attention to your training and competence in addressing spiritual and religious concerns your clients bring to therapy. Ethically, it is important to monitor yourself for subtle ways that you might be inclined to influence clients to embrace a spiritual perspective or to give up certain religious beliefs that you think are no longer func- tional for them. It is important to keep in mind that clients, not therapists, should determine the specific values they want to retain, replace, or modify.

From my vantage point, the emphasis on spirituality will continue to be impor- tant in counseling practice, which makes it imperative that you prepare yourself to work competently with the spiritual and religious concerns that your clients bring up. For further reading on the topic of integrating spirituality and religion into counseling, I highly recommend Integrating Spirituality and Religion into Counseling: A Guide to Competent Practice (Cashwell & Young, 2011) and Spirituality in Counseling and Psychotherapy: An Integrative Approach That Empowers Clients (Johnson, 2013).

Issues Related to the Therapeutic Process Therapeutic Goals

The goals of counseling are almost as diverse as are the theoretical approaches (Table 15.3). Some possible goals include the following:

ŠŠ Restructuring the personality ŠŠ Uncovering the unconscious ŠŠ Creating social interest

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ŠŠ Finding meaning in life ŠŠ Curing an emotional disturbance ŠŠ Examining old decisions and making new ones ŠŠ Developing trust in oneself ŠŠ Becoming more self-actualizing

TAbLe 15.3 Goals of Therapy

Psychoanalytic therapy

To make the unconscious conscious. To reconstruct the basic personality. To assist clients in reliving earlier experiences and working through repressed conflicts. To achieve intellectual and emotional awareness.

Adlerian therapy

To challenge clients’ basic premises and life goals. To offer encouragement so individuals can develop socially useful goals and increase social interest. To develop the client’s sense of belonging.

Existential therapy

To help people see that they are free and to become aware of their possibilities. To challenge them to recognize that they are responsible for events that they formerly thought were happening to them. To identify factors that block freedom.

Person-centered therapy

To provide a safe climate conducive to clients’ self-exploration. To help clients recognize blocks to growth and experience aspects of self that were formerly denied or distorted. To enable them to move toward openness, greater trust in self, willingness to be a process, and increased spontaneity and aliveness. To find meaning in life and to experience life fully. To become more self-directed.

Gestalt therapy

To assist clients in gaining awareness of moment-to-moment experiencing and to expand the capacity to make choices. To foster integration of the self.

Behavior therapy

To eliminate maladaptive behaviors and learn more effective behaviors. To identify factors that influence behavior and find out what can be done about problematic behavior. To encourage clients to take an active and collaborative role in clearly setting treatment goals and evaluating how well these goals are being met.

Cognitive behavior therapy

To teach clients to confront faulty beliefs with contradictory evidence that they gather and evaluate. To help clients seek out their faulty beliefs and minimize them. To become aware of automatic thoughts and to change them. To assist clients in identifying their inner strengths, and to explore the kind of life they would like to have.

Choice theory/ Reality therapy

To help people become more effective in meeting all of their psychological needs. To enable clients to get reconnected with the people they have chosen to put into their quality worlds and teach clients choice theory.

Feminist therapy

To bring about transformation both in the individual client and in society. To assist clients in recognizing, claiming, and using their personal power to free themselves from the limitations of gender-role socialization. To confront all forms of institutional policies that discriminate or oppress on any basis.

Postmodern approaches

To change the way clients view problems and what they can do about these concerns. To collaboratively establish specific, clear, concrete, realistic, and observable goals leading to increased positive change. To help clients create a self-identity grounded on competence and resourcefulness so they can resolve present and future concerns. To assist clients in viewing their lives in positive ways, rather than being problem saturated.

Family systems therapy

To help family members gain awareness of patterns of relationships that are not working well and to create new ways of interacting. To identify how a client’s problematic behavior may serve a function or purpose for the family. To understand how dysfunctional patterns can be handed down across generations. To recognize how family rules can affect each family member. To understand how past family of origin experiences continue to have an impact on individuals.

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ŠŠ Reducing maladaptive behavior and learning adaptive patterns ŠŠ Becoming grounded in the present moment ŠŠ Managing intense emotions such as anxiety ŠŠ Gaining more effective control of one’s life ŠŠ Reauthoring the story of one’s life

This diversity can be simplified by considering the degree of generality or speci- ficity of goals. Goals exist on a continuum from specific, concrete, and short term on one end, to general, global, and long term on the other. The cognitive behavioral approaches stress the former; the relationship-oriented therapies tend to stress the latter. The goals at opposite ends of the continuum are not necessarily contradic- tory; it is a matter of how specifically they are defined.

Therapist’s Function and Role In working toward an integrative perspective, ask yourself these questions:

ŠŠ How do the counselor’s functions change depending on the stage of the counseling process?

ŠŠ Does the therapist maintain a basic role, or does this role vary in accor- dance with the characteristics of the client?

ŠŠ How does the counselor determine how active and directive to be? ŠŠ How is structuring handled as the course of therapy progresses? ŠŠ What is the optimum balance of