Therapist Techniques

While many theories of psychotherapy and counseling develop specific techniques to fit their assumptions and concepts, many techniques cut across theories. Furthermore, many mental health practitioners make use of different theoretical frameworks and interventions at different times, and these practitioners sometimes combine techniques and interventions from a variety of sources.

Positive therapeutic outcomes depend upon components (often termed common factors) that are found in many theoretical orientations. Hence, no one form of therapy is clearly superior to all the others. Successful therapy requires the integration of a positive therapeutic relationship with a set of common factors or techniques. These common factors have been classified in a number of ways, but there is consensus regarding the critical importance of two factors, the presence of a facilitative therapeutic relationship and of positive expectations for success on the part of clients.

Nevertheless, the selection of specific techniques is still important to the individual therapist when designing and implementing a treatment plan to ameliorate problems involving the client’s thoughts (cognitions), feelings (affect), or actions (behavior). Most therapists are trained in a wide variety of theoretical orientations and techniques and they have many options for interventions. Psychologists consider both the usefulness of the techniques at their disposal for addressing the client’s concerns and their appropriateness in terms of the client’s cultural background (e.g., race, ethnicity, gender, sexual orientation, and ability status). Ethical and legal requirements mandate that the psychologist maintain a current knowledge of the empirical literature pertaining to the overall efficacy of therapeutic techniques and the appropriateness of interventions for use with clients from specific cultural backgrounds.

This entry describes the most widely used therapeutic techniques. In this review these techniques have been classified as supportive or relationship-building techniques and confrontational techniques, including cognitive techniques, behavioral techniques, and experiential techniques. Although some techniques fit in more than one category, each technique has been assigned to its dominant category.

Relationship-Building Techniques

Carl Rogers minimized the importance of techniques per se. Instead, he regarded unconditional positive regard (i.e., a nonjudgmental appreciation of the client’s worth as a person), accurate empathy (i.e., understanding the client’s feelings), and genuineness (i.e., being “who you are” instead of “acting a part”) as therapist behaviors that are both necessary and sufficient for the development of a positive therapeutic relationship. Many theorists and researchers have specific techniques for building a positive therapeutic relationship, and training strategies have been developed to teach doctoral trainees how to establish a facilitative relationship. At least 12% of the success of psychotherapy is determined by the quality of the therapeutic relationship.

Reflection

Reflection is one way that therapists communicate accurate empathy to their clients. Reflection requires the therapist to identify the client’s feelings and then respond to the client with words that communicate understanding and (sometimes) put the feelings into context. Common feelings expressed by clients include happiness, concern, depression, hurt, fear, anger, loneliness, confusion, guilt, shame, and inadequacy. Reflection mirrors the client’s feelings without evaluating them or adding content. Reflecting the essence of the clients’ experience allows clients to overcome distortions and denial, validates clients’ feelings, and encourages both therapists and clients to focus on the affective or feeling part of clients’ lives. Some therapists regard reflection as the most critical skill in counseling.

Paraphrasing

Paraphrasing is another relationship-building skill that consists of the therapist repeating back to the client a usually shortened version of what the client said. Effective paraphrases are brief, natural, well timed, tentatively expressed, focused on important topics, and used in balance with other skills. Accurate paraphrasing communicates to the client the therapist’s interest and that the therapist is paying close attention. It also provides a check on the accuracy of the therapist’s understanding and an opportunity for the client to correct the therapist if the therapist has misunderstood.

Minimal Encourages

Also called minimal verbal responses, these verbal equivalents of a head nod are small verbal expressions such as “uh-huh,” “yes,” and “mm-hmmm.” These verbalizations create little interruption, communicate that the therapist is listening, and encourage the client to continue.

Summarization

Summarization is used at various points during a therapy session, at the end of a session, and at the termination of therapy to integrate the therapeutic work. Summarization may integrate a number of paraphrases that are connected by a broad theme to organize information and help the client see patterns. It also communicates that the therapist is interested and attentive, thereby building a positive therapeutic relationship. In addition, summarization can be used to reinforce client progress and plan for future directions in which therapy might proceed.

Encouragement

This technique provides a sense of support to clients and increases hope so clients begin to believe in themselves. Encouragement focuses on solutions and optimism. Useful therapist skills include focusing on strengths, communicating respect, increasing awareness of options and humor in difficult situations, and being enthusiastic. Encouragement has also been used in family therapy to focus on solutions and family strengths rather than weaknesses or problems.

Confrontation Techniques

Successful psychotherapy requires the “therapeutic paradox” of supporting the client and communicating caring, while at the same time confronting the client’s blind spots, faulty logic, misperceptions, and problematic behaviors. Clients may enjoy counseling and feel valued but make little progress if the therapist focuses exclusively on support. Conversely, focusing on confrontation and giving insufficient attention to support and relationship building often results in the client leaving therapy. Effective therapy requires the development and maintenance of a delicate balance of support and confrontation.

Confrontations may be gentle and tentative or very direct and powerful. The type of confrontation used may vary by theoretical framework or the therapist’s personality. Nevertheless, all confrontations are intended to encourage cognitive or affective insights or behavior change. The interventions described in the remaining sections may be primarily confrontational or a combination of confrontational and supportive.

Cognitive Techniques

Many cognitive techniques can be traced back to Alfred Adler’s and Albert Ellis’s theoretical assumptions that most problems are caused by irrational beliefs or mistaken thoughts. Irrational beliefs are exaggerations (i.e., an event is “awful,” or “catastrophic,” or “terrible”), whereas more rational beliefs are more moderate (i.e., an event is regrettable or unfortunate). Ellis postulated that the most effective change results from actively and directly disputing clients’ faulty thinking and teaching clients to dispute their flawed beliefs. This may include homework in which the client analyzes the activating event (A), the irrational belief (iB), and the emotional and behavioral consequences (C), then disputes (D) the irrational belief and substitutes a rational belief (rB). The therapist may ask questions (e.g., “What is your evidence?”) or give directives (e.g., “Stop ‘shoulding’ on yourself”). The goal is to make clients aware of their self-talk so they can change the internal dialogue and problematic self-talk and the resulting feelings and behavior. The therapist may also challenge the discrepancies between the clients’ words and behavior, thereby confronting the self-defeating behavior.

Other views assume that emotional disturbance is a result of early decisions a child makes based on problematic early learning. These decisions result in dysfunctional life scripts. Injunctions (e.g., don’t be important, don’t succeed, don’t be sane) that children learn impose limits on who they can be or what they can do that carry into adulthood. These are challenged to create a healthier, more positive life script. Other cognitive theorists may label irrational beliefs as dysfunctional thoughts, cognitive distortions, automatic thoughts, and cognitive schema. Many cognitive techniques have been developed to confront clients to create awareness and change.

Thought Stopping

Thought stopping is used to stop intrusive, repetitive, self-defeating thoughts. When an unwanted thought comes to mind, the client is instructed to say “stop” either silently or out loud. A physical reminder such as snapping an elastic band on the wrist may also be incorporated. After repeated practice of accessing a thought and then stopping it during therapy sessions, the client is instructed to practice outside therapy.

Thought Scheduling

An alternative technique is scheduling the intrusive thought for a particular time. For example, a client who is disturbed by intrusive thoughts of a former love may be taught to think, “I’ll save those thoughts for a particular time each day,” whenever the thoughts arise. In this fashion, the clients learn they have control over their intrusive thoughts.

Catastrophizing

In catastrophizing, the therapist asks the client to imagine the worst possible event, explore the consequences, and consider possible coping strategies. This intervention interrupts irrational thoughts that create distress and helps the client consider more logical and rational possibilities. Clients generally discover that the worst is not the catastrophe they imagined, and fears are relieved.

Gender Role Analysis

Feminist therapy postulates that part of an individual’s problems result from rigid gender role expectations that restrict the person’s development. This technique entails analyzing the messages the client has received from multiple sources (e.g., family, school, religion, peers, and the media), discerning their impact, and deciding which messages work and which should be discarded. For example, a young man may realize that his difficulties in relationships are related to learning from his family and peers that men are not supposed to express tender emotions. He can choose to discard that gender role expectation and express more emotions.

Consciousness Raising

Consciousness raising involves clients developing an awareness of the biases and discrimination they have suffered due to their social identities (e.g., race, ethnicity, gender, sexual orientation, and ability status). For example, a client of color may face particular problems based upon stereotypes originating in the dominant culture. Consciousness raising helps clients understand how the dominant culture has shaped their self view so that effective change can occur. Strong emotions often accompany consciousness raising, so it is both a cognitive and an experiential/emotional technique.

Bibliotherapy

Bibliotherapy involves assigning clients written materials to read to help them learn about the problems that concern them. Bibliotherapy can help clients explore their thoughts and feelings about their concerns and gain new insights. It can also help them realize they are not alone in their experiences and reactions. Bibliotherapy assignments are carefully chosen and clearly focused on client issues, and in one survey 96% of psychologists reported that they assigned reading self-help books to clients occasionally or more often.

Cognitive Restructuring

Cognitive restructuring is another term for helping clients identify irrational beliefs and automatic negative interpretations. Logical questions are used to help clients consider alternative attributions for the behavior of others and to seek evidence for the original assumptions. For example, the assumption that a friend no longer likes the client because the friend was recently abrupt is only one explanation for the friend’s behavior. An alternative explanation is that the friend was stressed and distracted.

Redecision

This technique involves helping the client examine the faulty learning that lead to a faulty life script and redecide on a new life script. For example, a client can decide that she has worth and will no longer always put her needs last. Her script will change to reflect her as a person of value.

Miracle Question

The miracle question, sometimes called the magic question, asks the clients, if a miracle occurred that solved all of their problems, what would be different. This question emphasizes a problem-solving mindset, and it helps clients develop therapy goals.

Push-Button Technique

The client is asked to think about and focus on a positive, pleasant experience and to note the feelings that result. This teaches clients that thoughts and feelings are connected. Clients learn that focusing on particular thoughts can create particular feelings and that they can use the “push button” to stop unwanted, negative feelings and create positive ones.

Behavioral Techniques

Behavioral techniques focus on changing the client’s behavior. Behavior therapies assume that maladaptive behaviors are learned and therefore new, more functional behaviors can be learned to replace them. Principles of learning are emphasized. Behavior changes may be preceded by cognitive interventions that help the client decide what behavioral changes are desirable.

Counterconditioning/ Systematic Desensitization

These strategies inhibit and countercondition anxiety. Systematic desensitization generally uses deep relaxation to inhibit anxiety. After teaching the client to relax, the therapist has the client imagine anxiety-provoking material that is paired with relaxation. Systematic desensitization is used to treat concerns such as phobias, fear of flying, test anxiety, and public speaking anxiety.

Assertiveness Training

Practicing assertive behaviors to overcome social anxiety and passivity is another example of counter-conditioning. Interpersonal difficulties such as fear of complaining about poor service, inability to speak up in group situations, and inability to say no to requests from others can be ameliorated by assertiveness training. During assertiveness training, clients learn the differences among passivity, assertiveness, and aggression. Then role-playing and feedback are used to teach them to express their needs and feelings honestly and directly in a constructive manner. They practice direct and effective verbal ways of responding to situations both in therapeutic settings and later, as anxiety decreases, in their real lives. Assertive behaviors are practiced in situations that will likely lead to success so that these successful experiences will reinforce their continued practice of assertive behavior.

Shaping

In shaping, therapists reinforce behaviors that represent successive approximations of the agreed-upon goal. For example, if a woman who suffers from agoraphobia manages to leave her house and walk to the mailbox, the therapist would reinforce that behavior as getting her closer to being able to leave home. As she becomes comfortable with that behavior, however, the therapist might require that she walk around the block to be reinforced. In gradual steps, the therapist helps the client engage in behaviors that are closer and closer to the ultimate goal.

Social Skills Training

Some clients are unable to display appropriate social behaviors because they have never learned or even witnessed them. In such cases, the first therapeutic task may be teaching new skills. This can be done using instruction, demonstration, practice, role-playing, and homework assignments. For example, a young man who is afraid to ask a woman for a date could first be taught ways to begin a conversation. Then he could role-play these techniques in imaginary situations during therapy sessions. At a later stage, he would try these behaviors in social situations and discuss his experiences with the therapist during therapy.

Modeling

Therapists sometimes help clients learn new behaviors by modeling those behaviors or helping clients find appropriate role models outside the therapy or counseling sessions. For example, the therapist might act out the role of a job seeker in an interview during therapy to model job interview behavior for the client.

Shame-Attacking Exercise

An important source of emotional disturbance is self-blame. Therapists sometimes attempt to reduce self-blame by assigning clients to behave in ways they consider shameful or humiliating. Clients generally discover during the course of the assignment that other people are not nearly as aware of them as they thought, and are much less critical or disapproving than anticipated. This discovery lessens their feelings of shame, thereby making it easier for them to discard self-consciousness and behave more freely.

Role-Playing

Role-playing provides an opportunity for clients to try out new behaviors and expand their self-awareness. For example, a client may role-play a difficult conversation with a family member to rehearse an approach and learn about the emotional reactions stimulated by that approach.

“Acting as If”

“Acting as if” is an Adlerian technique useful with clients who wish they had behaviors and feelings that they believe are not in their repertoire. Instead of trying to convince clients that they do possess these characteristics, the therapist seems to agree with clients and therefore suggests they just “act as if” they are confident, outgoing, assertive, or whatever is lacking. Because the new behaviors are “acting” and not “real,” clients feel less threatened by trying the new behaviors. In a sense, this technique creates a self-fulfilling prophecy because clients adopt the behaviors as their own as they become more comfortable performing them.

“Spitting in the Soup”

When the therapist challenges client behaviors in such a way that hidden motivation, denial, or rationalization are uncovered, it makes it difficult for the client to continue the behavior. For example, a therapist may confront a wife about her tendency to start arguments with her husband to avoid intimacy. The realization of the hidden or denied motivation makes it difficult to continue. In other words, the therapist explains the payoff for the behavior to the clients. Henceforth, clients can no longer engage in that behavior without realizing their ulterior motive. The behavior becomes less appealing, just as spitting in soup would make it unappetizing.

Catching Oneself

Adlerian therapists use this technique to interrupt their clients’ bad habits and self-defeating behavior patterns. Clients may start by regretting something they have done regularly. At each occurrence, the therapist helps clients anticipate the behavior earlier until the clients learn to “catch themselves” before engaging in the undesirable behavior or habit. Catching oneself can be an important prerequisite for the thought stopping described earlier, because clients must be able to anticipate the onset of an unwanted thought in order to stop it.

Political Advocacy

A tenet of feminist therapy is that “the personal is political.” Therefore, engaging in political advocacy can be empowering and healing for the client. Working for any social justice cause that has meaning for the client can be effective. For example, a woman who has been a victim of domestic violence may empower herself and cement the power of her survivor status by working for changes in laws related to spousal abuse.

Imagery

Imagery involves visualizing in the imagination (as used in systematic desensitization mentioned earlier). Intrusive, unwanted images of traumatic events can be modified by changing the images of what happened. For example, an attacker can be visualized as smaller in size to reduce the client’s feeling of powerlessness. Imagery can be used to express or explore emotions that are difficult to communicate in words and can create a here-and-now troubling experience during the therapy session.

Experiential Techniques

Experiential techniques are used to get clients more in touch emotionally with their authentic selves, which is the most real expression of all feelings and the willingness to live in the moment. Fritz Perls developed a number of specific experiential techniques but believed that any experiential intervention that emerges in the moment can be therapeutic. Interventions are limited only by the creativity of the therapist. Some of his interventions involved dialogues between personal polarities to create experiential understanding. Whenever an individual recognizes a particular aspect of self, its opposite is implicit. Perls postulated that individuals are a never-ending sequence of polarities or opposites that aim for integration.

Top Dog/Underdog

The top dog represents a person’s conscience. The underdog is the part of the personality that goes along with the bullying demands of the top dog but also displays passive resistance. For example, if a client’s top dog demands that the underdog work an extra 2 hours every day to feel worthwhile, the underdog might appear to acquiesce to the top dog but sabotage the work by feeling sleepy and being unproductive. An experiential way to resolve the conflict between these two aspects of the personality is to create a dialogue between them.

Empty Chair

This technique provides a classic way to create a dialogue between personal polarities or between the client and other people. The therapist arranges two chairs facing each other, then clients act out the dialogue between the two people or the two parts of their personality by occupying each chair in turn and saying what that person or aspect of personality would say. This intervention allows clients to say all of the things to the empty chair that they have been unable to express to another person or to express the two sides of an internal conflict. This intervention provides a cathartic experience that allows for greater self-awareness and understanding.

Exaggerating Movement

Another technique to uncover deeper emotion entails exaggerating a client’s movement. For example, if a client is jiggling a foot, the therapist might ask the client to exaggerate the motion. Exaggerating the motion typically increases the underlying emotion. The therapist might even ask the client what the foot is saying.

Dream Work

Perls postulated that each character and object in a dream represents some part of the client. Asking each character and object in the dream to speak illuminates the meaning of the dream.

Hot Seat

Perls believed that confrontation is often necessary to help clients recognize their incongruities. By agreeing to work, the client enters the hot seat. Sometimes the therapist intentionally frustrates the client to liberate hidden feelings and experiences and release the authentic self. This creates a “safe emergency” in which the client is challenged to experience disturbing personal material in a safe environment.

Assuming Responsibility

Experiential therapy requires clients to take personal responsibility. This technique requires clients to end every sentence with the statement “and I take responsibility for it.” Furthermore, clients may be asked to change words such as can’t to won’t or but to and. For example, a client might be instructed to change the sentence “I can’t remember friends’ birthdays” to “I won’t remember friends’ birthdays.” Such changes underscore the clients’ responsibility for the behavior. Another responsibility technique requires the client to change every question into the statement behind it. For example, a client asking many questions about the therapist’s credentials may be anxious about beginning therapy.

Playing the Projection

When a client complains about or is critical of another person, the therapist suggests that the client is really critical of the part of self that has the same characteristics. The client may be asked to try on and play that part. For example, a client who complains excessively about a friend’s anger may be asked to role-play that anger. The client’s disturbance at the friend’s anger may be a projection of the client’s discomfort with personal anger.

Reversals

In reversals, clients are asked to act out the opposite of their usual behavior. This experience helps get clients in touch with the hidden polarities within. For example, a loud and boisterous client is asked to act out a quiet side.

May I Feed You a Sentence?

If the therapist perceives that the client is close to experiencing something but it is not quite there in awareness, the therapist may ask permission to feed the client a sentence. The sentence expresses this hidden material so that the client can try it on to see if it fits. This technique requires deep and accurate empathy on the part of the therapist. While an interpretation would only lead to intellectual understanding, the goal here is experiential awareness.

Flooding

Flooding is a technique used to treat fear. The client is presented fear-evoking stimuli continuously either in vivo or via imagery. Flooding assumes that eventually the client will discover that there is no basis for the fear—nothing awful happens. In vivo flooding might be used for concerns such as fear of flying or riding in elevators. Imagery could be used as an initial strategy to address fear of flying or for a fear that is difficult or dangerous to experience in vivo, such as fear of spiders or snakes. Flooding has been successfully used with obsessive-compulsive disorders, agoraphobia, panic disorder, posttraumatic stress disorder, and other phobias.

Conclusion

As stated at the beginning, therapists choose from a myriad of possible techniques depending on the personality and theoretical orientation of the therapist and the personality and concerns of the client. Research has demonstrated that therapeutic success is determined more by the common factors that create a strong and positive therapeutic alliance than any particular techniques. However, the use of particular techniques can make the therapy experience more comfortable for both the therapist and the client, depending on their personalities.

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