Models and Frameworks of Therapy
By: David Lechnyr, LCSW
What follows are some brief descriptions of different models of therapy available in counseling, including the most common, Cognitive-Behavioral Therapy (CBT).
Cognitive-Behavioral Therapy (CBT)
Cognitive-Behavioral Therapy (CBT) is, perhaps, the most often requested type of therapy for dealing with difficult behaviors and beliefs. Ironically, when it was first introduced, it was ridiculed as being overly simplistic and inappropriate for clinical use. Over time, it has become the de-facto standard of choice for clinical treatment by therapists and insurers alike.
CBT relies heavily on the Socratic method of questioning, does not involve external beliefs by the therapist and often includes homework assignments to assist with change. CBT has been shown to be extremely effective with depression, anxiety and feelings of worthlessness/guilt.
As a therapeutic model, CBT assumes that behavioral variables are specifically influenced by the type of cognitions, or thinking styles, that are utilized by the patient. Dysfunctional cognitions, distorted cognitions, including negative and positive automatic thoughts and attributional styles (attributing negatives events to themselves and their actions), are seen as having a major impact on the ways in which the patient functions and responds.
Negative cognitions, and cognitive distortions, are seen as directly related to depressed functioning. The cognitive-behavioral therapist is more active in assisting, and challenging, the patient to examine the various negative cognitive distortions which impact functioning. The patient is challenged to check out issues in their environment, such as asking others not involved in the problem about how they perceive the situation. The goal is not only to change cognitions, but to make the patient an active participant in their own healing.
It is understood that examining negative cognitions may by itself not be enough to bring about a change. The lack of positive cognitions, and experiences, is seen as influencing maladaptive emotions. The cognitive-behavioral approach also involves issues of Rational Emotive Behavioral Therapy (REBT), relaxation, biofeedback, Eye Movement Desensitization and Reprocessing (EMDR), and similar techniques, all directed at specific active things that the patient can involved in doing and receiving various forms of feedback, or reinforcement, from accomplishing.
Non-depressed patients are seen as having more positive cognitions and autonomic thoughts. Research into the use of cognitive behavioral therapy supports its significant value in treating depression. The results of Cognitive-Behavioral Therapy are initially equal to the results of utilizing anti-depressant medications. However, the long-term results provide for superior sustainable outcomes for the cognitive behavioral approach to therapy.
Cognitive Behavioral Therapy (CBT) has been around since the 1950’s in one form or another and was pioneered by several individuals. Of worthwhile note are the contributions of George Kelly (1905-1967), Albert Ellis (1913-2007) and Aaron Beck (1921-Present). Before this, most psychotherapy consisted of variations on Freud’s Psychoanalysis, wherein past issues were considered to be the root cause of many of our problems.
In 1955, George Kelly proposed that anxiety, depression, anger and paranoia were the result of how we each interpret these feelings. Beck’s position and status in the field of academic medicine gave the additional credibility to CBT. Beck considered that our automatic thoughts often contained what he called cognitive distortions where our misguided interpretation of our own feelings and events were the primary cause of our issues. CBT continues to be developed and refined, however it is very popular with both clinicians and health insurance companies.
Ego Psychology Model of Therapy
This model of therapy admits that the patient does have pathology. However, this model looks to the Ego Strengths possessed by the patient. The focus is on how to build on these strengths. It avoids focusing on the pathology and the many problems that would be nice to solve. The focuses is on how to help in the here and now. It is a psychodynamic model of treatment that encourages, supports, directs and reinforces strength development. It focuses on behavioral shaping of even minor approximations of positive behaviors in order to increase their occurrence and frequency.
Managed Care Model of Therapy
The idea of a managed care provider focuses on the need to direct and focus the type of care provided. It includes the idea that only the most appropriate care is provided. It is concerned with cost-efficient, cost- effective, limited services. It has as its center a knowledgeable provider who manages and guides the patient in obtaining the desired goals. The provider is suppose to be aware of what may be the most effective way of finding a solution to the patient’s problem without over-utilizing other unnecessary services. The provider’s job is to educate the patient about their condition, the realistic alternatives, what they should expect from treatment, how to realistically obtain their goal, and help the patient make realistic choices about alternatives for treatment and obtaining the desired outcome(s).
Neuro-Linguistic Programming (NLP) assumes there is a connection between the mind’s processes (neuro), language (linguistic) and behavioral patterns learned through experience (programming) and that these can be changed to achieve specific goals. A neuro linguistic therapist analyzes the detail of the patient’s words and phrases used to describe their presenting issues in order to understand the underlying cause. The goal is to help remodel the patient’s thoughts and associations in order to re-order their thought process for a better outcomes.
Object-Relation Model of Therapy
The Object-Relation model suggests that the pattern of early parent-child interactions dramatically influences the individual’s capacity for intimacy. Adult relating patterns are established in early childhood. Distortions in relating to other objects (people) early in life results in dysfunctional relating later in life. Understanding early life relating patterns can help the professional understand, and predict, how the patient will relate in the present and future.
The model suggests that the therapist must be aware of the patient’s tendency towards the pathological use of psychological splitting. The tendency is to split good and bad parents in a negative dysfunctional manner. It is understood that this is an expected part of all interactions with the patient. The patient will tend to split one staff member, or therapist, against another, therefore recreating similar dysfunctional childhood relating patterns in the present.
Such splitting can result in one therapist being seen as the good parent and the other as the bad parent. Such splitting can happen in the relationship with just one therapist. It is important for the therapist, or staff members, to be alert to such splitting in order to stay united in their approach to the patient. The model suggests that there are specific stages of therapy which can be seen in the context of short-term or long-term therapy.
The Engagement Stage is the first stage and vital to the establishment of an effective relationship. If the patient is not engaged early and quickly in a relationship of trust, it is doubtful that therapy will continue for long. The Projective Identification Stage suggests that not only are certain feelings projected onto the person of the therapist, but that the patient induces the professional to react behaviorally in specific ways. Therapist have to be aware of vague feelings that something is not right. They may find themselves becoming irritated, angry, rejecting, aroused, overly-caring, or doubt their abilities as therapists. One must use their own countertransference in a positive diagnostic manner to understand the meta-communication presented in the projective identification. The Confrontation Stage is an important stage that can take place within a short period of time. It is important to remember that the goal of therapy is to help the patient to admit to the specific goal of their relational pattern.
Though the patient may not readily admit to their use of projective identification, they need help in understanding how they are impacting others. The therapist also needs to understand, and respond appropriately, to the projective identifications utilized by the patient. It is a time to utilize gentle confrontation techniques whereby the therapist can help the patient realize that there may be better ways of handling the situation in order for them to accomplish their goal. The therapist refuses to respond to the meta-communication demands. It is hard to not rush in to save a needy and dependent patient. The confrontation takes place as part of the interactional process. The therapist must only refuse to give into the patient’s demands, while all the time reaffirming the relationship with the patient. The patient needs to confront what they fear most, i.e., the loss of human contact with others.
The Separation Stage is where the therapist must realize that an important part of the therapeutic process, from the beginning, is to assist the patient in separating and becoming independent. It is a stage where the therapist recognizes that they must be constantly aware of the mixed feelings about separation experienced by the patient. Many times the patient’s angry responses, or relapses, are related to their fears of leaving the therapist and being on their own.
The patient needs help in attaching to social supports and experiences which can allow them to separate and be able to handle their problems in a more competent manner. The therapist must be aware that they need to guide and direct the patient towards this stage of therapy rather than focus on keeping them dependent in treatment too long. It may help to start, toward the end of treatment, to start to stretch out the time intervals between treatment sessions in order to facilitate the patient relying more on themselves before all supports are removed.
It is important to know that in order for the patient to receive the maximum benefit from therapy the therapist must continue the focus on the therapy relationship. Patients are rarely aware of the kind of messages they have conveyed in their projective identifications. The vital goal of this last stage of therapy is for the patient to be provided information about the way they are perceived by others. It is important to remember that the significant issues for the patient revolve around fears of abandonment, rejection, and splits between good and bad people and feelings.
Rational Emotive Behavior Therapy
Rational Emotive Behavior Therapy (REBT) is a subtype of Cognitive-Behavioral Therapy developed by Albert Ellis in 1962. The additional focus is on critical thinking wherein problems were thought to be the result of irrational interpretations of events (e.g., I should be…, This is awful…). This additional refinement to CBT can be an important asset in CBT.
Reframe Model of Therapy
This model of therapy does not rely on insight. It is a model that helps the person see the world somewhat differently. It is based on understanding things in the here and now. It is just a different way of looking at things. It’s use is a surprise to the patient, giving them something to think over. It does not look for the individual to acknowledge or admit to the reframe.
The reframe is promoted to fit with the patient’s experience and functioning. The reframe is not meant to change the patient, but only to help the patient see the world differently. The reframe model accepts the patient as they are in the present time, not as they could be. It accepts that patients will get what they want to get from therapy in the end, not what the therapist wants them to get.
This model is designed to assist the patient in seeing things in psychological terms in order to assist them in continuing to find psychological explanations in their daily experiences. The psychological reframe is seen as an early part of the therapeutic process which needs to start in the first session with the patient. If done in the first session it can help the patient to bond to, and be more productive in, therapy.
Reframing is used less and less as therapy continues, with a focus being an encouragement of the patient finding their own psychological reframe of problems they encounter. This helps to empower the patient in dealing with problems in their lives, as long as the therapist is subtle in the encouragement of the patient being able to reframe, and find solutions, to their own problems.
The therapist avoids any hint of criticism, or a well you should know by now response to patients who ask for help in the middle of therapy. The focus is to help the patient feel good about learning to explore solutions. It encourages the excitement of exploration.
Scanning Model of Therapy
As humans mature and develop, the initial tendency is to focus on small details. As one grows, gains experiences, knowledge, and meets more people, the individual slowly becomes aware of a greater horizon to be seen. With maturity and experience the effective therapist learns how to scan the patient’s environment to understand the total bio-psycho-social-cultural- vocational implications that relate to the patient’s current life and reality.
The experienced therapist scans the larger picture asking questions upon questions about the vocational, social, family, marital, motivational, along with the practical here and now issues of what will help to return this patient to total functioning as soon as possible. The experienced therapist is aware of the tendency in therapy for one to focus on small details of the patient’s psychological reality while ignoring the larger picture of reality in which the patient resides.
Scanning the larger patient reality helps to keep the therapy, therapist, and patient, aware of the need to see all aspects of the patient’s functioning and life. Such scanning allows the therapist to comment, push, and point out areas of problems, or avoidance, presented by the patient. The scanning model also requires that the therapist always has an understanding the beginning, middle, and ending points of therapy so that they are constantly aware of where they are going in the treatment process.
Task-Centered/Focused/Outcome Model of Therapy
This model is active, focused and directed. It is concerned with the task at hand. It keeps a focus on the bottom line. It keeps the patient responsible for their own life and their own natural and logical consequence of their actions. It is time-limited, problem-limited, task-centered, and is limited to a specific outcome.
This model keeps the focus of treatment related to the outcome(s) desired and needed. It requires an active, verbal, directing therapist. It keeps a focus on the beginning, middle, and ending phases of therapy within a time-limited framework. It sees the initial Phase of therapy as developing a relationship, defining goals and directions for therapy and establishing an agreement, or contract, for how therapy will proceed within a time-limited period. This helps to focus therapy in a quick active manner.
The second phase of therapy is seen as assisting the patient in self-exploration until an understanding of psychological realities is established. Once this is accomplished the therapy quickly shifts to assisting the patient in finding alternative coping strategies rather than becoming stuck in resolving all problems through in-depth therapy.
The third phase of therapy is designed to assist the patient in disengaging from therapy. There is a realization that symptoms may worsen as the patient moves towards termination. The therapist focuses on the patient taking risks, becoming more assertive, dealing, and managing, the realities of their world. The goal of therapy is to assist the patient in learning how to manage their world, and others, rather than having the patient wish that the others will change on their own. This step empowers the patient in dealing with their fears of the world. In all of this the therapist is very active, directive, and focused on moving the treatment process forward.
Separation-Individuation Model of Therapy
This model understands that the organism is always growing, dividing and changing into a distinct human being. The model suggests that the therapist searches for experiences that will help the individual move from a dependent to an independent person. It sees the person’s need to separates and be his/her own person. It sees the need to be a separate individual. It creates experiences that force and focus the individual on being, growing, and having experiences that allow the patient to cope and feel confident in their own abilities.
It looks to push the individual into taking risks. It blocks the individual from avoiding problems or issues. The focus is instead on avoiding anything that will keep the patient in a dependent relationship. This model allows the therapist to be aware that the patient needs to struggle between the normal issues of dependence versus independence.
At times the patient will need to find fault with the parent/therapist in order to fully separate and find their own independent identity. This struggle can be minimized if the therapist works to establish experiences that allows the patient to move out on their own. Additionally, the struggle is minimized if the therapist, and others, do not react to the normal developmental struggles, adolescent fault finding, and normal psychological splitting between good and bad parents/therapists.
It acknowledges the fact that as the patient matures they will find therapy to be less and less helpful, or necessary, in their lives for a particular developmental phase. They may even tend to minimize the helpfulness of the process of therapy to their development. It acknowledges that as the patient nears termination there is a tendency for symptoms to worsen, for the patient to become more dependent, and for parents, and therapists, to question whether the patient is really ready to leave home. It accepts the termination regression period as not being a sign of a lack of being ready to leave home. It understands that separation brings out our fears of surviving on our own.
Solution-Focused Brief Therapy
Solution-Focused Brief Therapy (SFBT) is another subtype of Cognitive-Behavioral Therapy. SFBT focuses on what patients would like to achieve through therapy rather than on their troubles or mental health issues. By envisioning a desirable future, the goal of SFBT is to help you map out the specific changes necessary in order to achieve your desired outcome. With this technique, it is very important to focus on successful experiences in order to promote encouragement rather than dwell on problems or limitations. SFBT is important in that it focuses on goals and outcomes rather than in endlessly dwelling on the past.
Winnicott Good-Enough Model of Therapy
A good-enough therapist is much like what Winnicott defines for a good-enough mother. The good-enough mother seeks to provide for the child’s needs. She works hard initially to gratify needs that the child cannot meet for themselves. As the child slowly becomes able to do more on their own, the mother does less and less for the child. The mother slowly frustrates the need for full gratification, allowing the child to learn from their own experiences through logical and natural consequences.
The parent/therapist is still good-enough as she does less and less for the child (patient), though she stays in close supportive proximity to the child. The parent/therapist constantly is aware of what will help the child (patient) grow, and promotes more independent functioning. The parent/therapist sees the importance of the child (patient) needing to be an active doer rather than solely a passive receiver.
The therapist’s job is to promote growth, independence and action, avoiding any promotion of dependence after the initial brief beginning of the first few sessions. The promotion of independence by parents, and therapists, requires an active approach where the therapist works, and comments, on tasks that encourage growth and change designed to fit specific psychological developmental levels.