CFN9885 - SECTION 12: INTERVENTIONS
Types of Interventions
All counseling theories agree that the primary goal of counseling is identify presenting problems and to help clients to initiate and facilitate the desired changes. However, how the problems are conceptualized and how the changes are to be accomplished will differ depending upon the characteristics of the clinician, the counseling theory or approach that is being utilized, the characteristics of the client, and any limits that are placed on the counseling process (i.e., type and number of sessions, etc.).
Interventions need to be designed jointly between the client and the clinician. A first step in this process is to ask clients about times in their lives when the issues or problems they have identified have not existed or have been less severe and what are some the reasons why these issues or problems were not as significant as they are now.
In this regard, clients can be asked what they have tried in the past to address these issues or problems and what has worked and what has not worked and why some of the things they have tried have worked or not worked. This process helps both the client and the clinician identify the types of personal and interpersonal resources or strengths the client possesses and how existing resources or strengths can be better utilized or help the client find new resources or strength to address their problems or issues.
What resources or strengths will be used will depend upon the client’s strengths or weaknesses and the types of problems or issues they want to address.
Interventions may include the following:
- Affective interventions: help clients to control or change their affect, feelings, or emotions surrounding the problem.
- Cognitive interventions: help clients to control or change their thoughts, beliefs, and attitudes about the problem.
- Behavioral interventions: help clients control or eliminate existing behaviors and/or develop new behaviors or skills.
- Systemic interventions: help clients to address relationship patterns, that is, help clients to change or better utilize their social environment.
With most clients, interventions would involve addressing a number of these areas.
Factors that Influence Types of Interventions
Choosing the most appropriate intervention involves adaptation. It is important to approach selection of interventions judiciously and be prepared to change or modify interventions when they are not working. Clinicians need knowledge, practice, and supervision in using specific interventions with clients with particular characteristics, paying particular attention to the client’s reaction to the intervention.
In considering which interventions to use, the clinician may want to consider the following factors:
- A description of all relevant and potentially useful treatment approaches
- A rationale for each procedure that will be used
- A description of the clinician’s role in each intervention
- A description of the client’s role in each intervention
- Possible discomforts or risks that may occur as a result of the intervention
- Expected benefits that will occur as a result of the intervention
- The estimated time and cost of each intervention
- The client’s expectations and preferences
- The client’s previous attempts to solve the problems
- The client’s characteristics and resources. (Cormier & Nurius, 2003)
Finally, clinicians need to be willing to admit when the approach they are using is not working with a client. There needs to be good fit between the clinician and the client. Most books on working with clients discuss methods for reducing client resistance or noncompliance. However, such discussions assume that clinicians always know what is best for their clients and it is the responsibility of the clinician to confront and try to overcome client resistance.
Another way to look at resistance is that it is the way in which clients are telling clinicians that they do not like what is being done in counseling. It is also possible that the therapy is not working because you are the wrong clinician for this client or you are doing a poor job with this client. If this happens, then clinicians need to discuss with clients why they feel the counseling is not working and what each of them can do to improve it.
You may also want to consult with your supervisor or another clinician to get their insight on the situation. If this is not successful then clinicians need to refer clients to another clinician.
The type of counseling relationship we have with our clients and the types of interventions we use may depend on the client’s level of functioning or competence. Much of the work in this area comes from Beavers and Hampton (1990) and their analysis of family functioning. They have developed assessment tools that classify families from successful or healthy family functioning to severely dysfunctional family functioning.
Some individual and family clients want and need a clinician who will - at least initially - take a more authoritative and guidance style of doing counseling. I have found that this is particularly true with clients who are experiencing a significant crisis in their lives or with clients who have trouble taking control of their lives.
With other clients or with some clients after we have established some stability in their lives, I may adopt a more partnership style of doing therapy. I have found that I do not want to have a style of therapy where my clients become dependent upon me. Basically, I want to work myself out of a job. While initially I may be directive with some types of clients, with all of my clients I ultimately see my job as empowering them to live their own lives in a way that is meaningful for them.
Because most clients come to therapy to address a content area, I have found that I need to be able to show them early signs that their presenting problems are being addressed. I can help them better understand and express their feelings and learn some of the reasons why they do certain things, but if I do not help them solve their presenting problems, they will typically see counseling as not very useful.
A client gains little if they merely have a better intellectual understanding of their problem, but they are not able to make meaningful changes in their life. Clients need to be able to put these new insights and understandings into constructive action that improves their life.
I remember a single mother and her 10 year-old son came for therapy because the son, while very bright, was not doing well in school and there was a great deal of conflict between them over his school performance. My colleague and I immediately decided to emphasize process (the mother’s relationship with her son) over content (practical ways to help him do better in school and practical ways to help their relationship).
While we made some improvements in the relationship between the mother and the son, his school performance declined and the mother was questioning the value of therapy. We decided to pay more attention to practical ways to help the mother and the son’s relationship and practical ways to improve the son’s school performance. When we paid more attention to the content areas, the mother and her son responded very positively, they were more responsive in therapy, and their relationship improved.
On the other hand, if we had only focused on content areas without addressing the process areas, the improvements might have been short lived. For the change to be sustained, the process areas needed to be addressed as well.
It is important for us to be flexible in the ways in which we work with our clients. I learned these lessons with one of my early traineeship clients. He was a single man in his mid-40s who had developed agoraphobia primarily around driving on freeways. Since he lived a significant distance from our office, I began doing therapy with him over the phone and sending him materials to read and complete.
I did therapy this way with him for three months until he began to lose some of his fears of freeway driving and he was able to come to my office for therapy. Initially, therapy was primarily cognitive-behavioral since I felt this orientation would work best with his initial presenting problem of agoraphobia. However, as the therapy progressed and he began to work on, and address, his agoraphobia, we began paying more attention to the underlying sources of his anxiety using primarily an object relations perspective.
It is my belief that too many clinicians and therapists feel they need to have one theoretical orientation, become an expert in that orientation, and use it on all of their clients. I have found that the problem with this approach is similar to the problem of the little boy with a hammer who is constantly looking for things that “need” hammering.
Because of their personality, life experiences, and clinical training, most clinicians will likely be naturally more attracted to some theories and orientations than others. However, I feel it is the characteristics and needs of my clients that should be the primary determining factor in what theory or orientation I use with them.
Below you will find information on the major models of treatment that are most frequently used.
Core Foundational Knowledge: Cognitive Behavioral Approaches
Major Theoretical Models for Cognitive Behavioral Therapy
• Cognitive Therapy (CT)
• Rational Emotive Therapy (RET)
• Cognitive Behavioral Therapy (CBT)
• Dialectical Behavioral Therapy (DBT)
• Acceptance and Commitment Therapy (ACT)
• Brief Cognitive Behavioral Therapy (BCBT)
• Problem Solving Therapy
Other Models within the Cognitive Behavioral Schema
• Systematic Rational Restructuring (SRR)
• Self-instructional Training (SIT)
• Anxiety Management Training (AMT)
• Stress Inoculation Training (SIT)
Key Principles Underlying Cognitive Behavioral Therapy
• Cognitive activity affects behavior
• Cognitive activity may be monitored and altered
• Desired behavior change may be effected through cognitive change
(Source: Dobson, K and Dozois, D, Handbook of Cognitive Behavioral Therapies)
Key Focal Points for Cognitive Behavioral Therapy
• Focus on current behaviors and thoughts and the conscious processing of information
• Attempts to uncover the underlying assumptions and personal schemas of the client
• Identification and correction of automatic thoughts and cognitive distortions
• Coping skills improvements, including improvements in problem solving abilities
• Desensitization through graduated exposure to feared stimulus
• Best applications are for “neurotic” conditions: anxiety, depression, anger control problems, self-control problems, and problem solving difficulties
Construction of Cognitive Schemas
• Cognitive schemas are structures that organize and process incoming information.
• Schemas represent the organized thought patterns that are acquired early in a person’s life and develop over the lifetime with accumulated experiences.
• The schemas of maladjusted individuals result in distorted perceptions, faulty problem-solving and psychological disorders
• The principal goal of cognitive therapy is to replace the client’s distorted appraisals of life events with more realistic and adaptive appraisals
Essential Behavioral Techniques
1. Establish behavioral targets for behaviors the client wishes to modify
2. Create a mechanism to expose the client to a feared stimulus so it can be confronted and mastered
3. Develop a ladder or hierarchy of feared responses or situations to be used in exposure
4. Model a desired action in response to a feared situation
5. Invite the client to imitate the modeled behavior
6. Support the client rehearsing and practicing the behavior to be enacted
7. Engage the client in relaxation training
8. Direct the client to engage in activity scheduling and tracking in which actions during the day are rated for pleasure, mastery, anxiety, sadness, fear or other feelings or sensations.
9. Help the client create and follow through on a plan for engaging in behaviors that create pleasure or a sense of mastery.
10. Facilitate the development of assertiveness skills that can be planned, rehearsed and implemented to create interpersonal effectiveness.
11. Support the development of improved communication and listening skills.
12. Teach the client to utilize self-praise or concrete rewards to reinforce desirable behaviors.
(Source: Leahy, R, Practicing Cognitive Therapy: A Guide to Interventions)
Essential Cognitive Techniques
• Teach the client to identify and monitor negative thoughts.
• Inform the client about the relations among cognition, affect and behavior.
• Direct the client to rate the degree of belief in the thought and the degree and intensity of emotion associated with the thought.
• Educate the client in categorizing the negative thought according to the kind of cognitive distortion exemplified by the thought.
• Assist the client in identifying and altering the underlying beliefs, assumptions, or schemas that predispose him/her to engage in faulty thinking patterns.
• Engage the client in vertical descent, exploring the actual consequences that would ensue from the negative thought being true.
• Explore the underlying assumptions and rules connected to the negative thought.
• Identify the costs and benefits, or advantages and disadvantages, of the thought.
• Examine the evidence for the negative thought in order to test the validity of the negative thought.
• Place the event in perspective, grading the event on a continuum from 0 to 100 in terms of what the client would still be able to do even if the event occurs.
• Address whether the client would apply the same rules and standards to other people.
• Have the client take the role of the person arguing against the negative thought.
• Ask the client to engage in a logical analysis of the negative thought and the conclusions that have been drawn from it.
• Explore the degree of completeness of information that the client is using to reach his/her conclusions.
• Seek out one or more alternative explanations for the event in question.
• Help the client to view the event as a problem to be solved and assume the position of a problem solver.
(Source: Leahy, R, Practicing Cognitive Therapy: A Guide to Interventions)
Common Cognitive Distortions
• Mind reading
• Fortune telling
• Control fallacies
• A Fallacy of Change
• Discounting positives
• Negative Filter
• Dichotomous (all or nothing) thinking
• “Shoulds” instead of “ares”
• Unfair comparisons
• Regret orientation
• “What if” thinking
• Inability to disconfirm
• Judgment focus
• Emotional Reasoning
(Source: Leahy, R, Practicing Cognitive Therapy: A Guide to Interventions)
Core Foundational Knowledge: Psychodynamic Approaches
Foundations of Psychodynamic Theory
• People experience and act on unknown wishes and fears
• Early experiences shape personality and interpersonal relationship schemata
• During the first 2 ½ years of life, brain growth is primarily in the right hemisphere, where memories are stored in the form of perceptual-representational experiences
• These perceptual-representational memories are stored in the right brain as implicit memory that is preconscious and holds procedural knowledge, reflecting learning with motor, perceptual and other embodied systems
• Early attachment experiences begin the process of creating the capacity to regulate emotions, first through interactive emotional engagement, then with support for independence
• After the first 2 ½ years, the predominance of brain growth begins to move to the left hemisphere, where declarative memory begins with the acquisition of verbal and symbolic capabilities
• Declarative memory allows for the verbal stating of memory and allows memories to be consciously known and recalled through symbolic representation, i.e., language
• Perceptual disturbances are ubiquitous, since experiences occur before the capacity exists to evaluate using conscious assessment capabilities
• If excessively challenging events occur, over-activation of the amygdala from the trauma response can shut down important areas of the brain responsible for information processing and verbalization, inhibiting the ability of the person to process the challenging experience
• The need to ward off and contain extremely disruptive feelings = traumatic memory not being accessible
• Defenses and resistances occur to help contain the emergence of disruptive feelings, but also prevent the ability to connect the feelings with other cognitive resources
• People repeat unhelpful behavior in an attempt to master enduring conflict or trauma (repetition compulsion)
• These repetitive actions can evolve into increasingly large and pervasive behavioral schemata
• Intrapsychic conflict is created when objectionable wishes, thoughts, drives and instincts meet forces that experience or anticipate the presence of guilt, shame or punishment
• People seek to resolve intrapsychic conflict through the creation of compromise formations
• Compromise formations without the presence of the person’s highest level, conscious evaluative capabilities, will often lead to the development of secondary problems or symptoms
• Transference and countertransference are key components of treatment by clarifying where the key conflicts lie
• Dynamic therapy restructures intense implicit memories within the context of an attuned relationship
• Repetitive feelings, styles of interaction, and intrapsychic conflicts can be brought into consciousness and undergo a process of clarification, allowing for restructuring of neural circuits in stored implicit memory and re-organization of the structures into more complex and more adaptive ways of experiencing and behaving
• Clarification comes from making linkages between the arrested emotional schemata and higher level structures of organization (conscious thought, insight) in a process called supervenience
• The process of re-organizing mental structures, narratives and psychological and behavioral schemata into much more complex states is called emergence
• To achieve emergence, the patient must be helped to reach a place where the defensive structures are brought to a state of disequilibrium where re-organization and restructuring can occur, a place called the bifurcation point
• The bifurcation point is a make or break moment, and to reach it there must be a combination of pressure to move through the defenses and support so the disequilibrium doesn’t overwhelm the patient’s adaptive capacities, a combination called the holding environment
Key Focal Points for Psychodynamic Counseling
• Focus on affect and the expression of emotion
• Expectation of attempts to avoid distressing thoughts and feelings
• Identification of recurring themes and patterns
• Discussion of past experience (developmental focus)
• Focus on interpersonal relationships (and attachment)
• Focus on the therapy relationship
• Exploration of fantasy life
(Source: Sadler, Jonathan, The Efficacy of Psychodynamic Psychotherapy)
Theoretical Models for Psychodynamic Psychotherapy
• Ego psychology
• Attachment theory
• Object relations theory
• Process-experiential therapies, e.g., Emotion Focused Therapy, Body Work
Essential Psychodynamic Techniques
1. Listen and observe
2. Assume everything is transference
3. Be aware of your tone and how it changes in response to the patient
4. Watch for qualifying remarks and interruptions in the flow of narrative
5. Resist the patient’s desire to case you in a more social role
6. Be “stupid” – use naïve sounding, simplistic requests for more information about the patient’s thoughts, feelings, and behaviors
7. Meet the patient where he is
8. Closely follow the affect – focus less on the facts of a narrative than on how the patient feels about it
9. Confront the patient about repetitive behaviors
10. Interpret in order to put behaviors in the context of deeper truths about what drive the patient to behave in the way he does
(Source: Sublette, ME, Novick, J, Essential Techniques for the Beginning Psychodynamic Psychotherapist)
Two Modes of Knowing
• Declarative knowledge (left brain): information that can be verbally stated and is available for conscious recollection
• Procedural knowledge (right brain): information represented implicitly, as embodied knowledge, reflecting learning with motor, perceptual and other systems
Construction of Emotion Schemes
• Emotion schemes are complex, integrative structures of experience that create motivations for behavior and/or inhibition
• Emotion schemes include: situations/memories, bodily sensations/expressions, symbolic representations, wishes/action tendencies, emotions and integrative feelings (“felt sense”)
• Different forms of experiencing (such as thought and feeling) are interwoven and linked
• Emotion themes are being continuously reshaped
• Emotions can generate other emotions and be secondary to other emotions
• Emotion schemes are unique to each person
Emotion Schemes and Self-regulation
• Too little or too much emotional arousal is dysfunctional (non-adaptive)
• The ability to regulate one’s emotions and level of emotional arousal is necessary for adaptive functioning
• Self-regulation of emotion depends upon a combination of successful attachment experiences and the construction of key executive function skills
• Effective self-regulation requires the ability to access, heighten, and/or tolerate emotion combined with the ability to contain or distance emotion
Theories of Emotional Dysfunction
• Inability to access and utilize all components of emotion schema system leads to impulsive or maladaptive actions
• Experiencing vestigial emotion schemes that are incongruent with current realities
• Substitution of less useful secondary reactive emotional responses for primary emotions
• Over-arousal from flooding of painful emotion
• Under-arousal or excessive emotional containment leading to emotional dysregulation
• Different aspects of self place multiple emotion schemes in conflict with one another, leading to emotional restriction or paralysis and inability to apply appropriate emotion to circumstance
Dysfunctional Schemata, Coping Styles and Modes
• Dysfunctional schemata are self-defeating life patterns of perception, emotion, and physical sensation.
• Coping styles are our behavioral responses to the schemas in hopes of making things better, but in fact they very often wind up reinforcing the schema.
• Modes are mind states that we can shift into quickly or more stably that cluster schemas and coping styles into a temporary "way of being."
• If basic emotional needs are not met in childhood, dysfunctional schemas, coping styles, and modes can result
Adaptive Strategies for Accessing Emotion
• Attending to emotion-related bodily sensations
• Remembering prior experiences of emotion
• Availing oneself of effective emotional cues, such as words, ideas or images
• Enacting emotional expression and behavioral tendencies
• Monitoring levels of arousal in order to maintain an overall sense of safety and security
Adaptive Strategies for Containing Emotion
• Seeking support, soothing, comfort or nurturance from others
• Using language, ideas or images that contain or distance emotional arousal
• Removing oneself from emotionally arousing cues
• Distracting oneself from emotion material with other activities
• Emotional clarification work
• Holding attention on the gradual expression of emotion with use of emotional and behavioral inhibition tools
The Core Defenses
• Acting Out
• Reaction Formation
Next Most Primitive
Level I: Pathological
These defenses are almost always are severely pathological, permitting one to effectively rearrange external experiences to eliminate the need to cope with reality.
• Delusional Projection
• Extreme projection
• Superiority Complex
• Inferiority Complex
Level II: Immature
• Acting out
• Passive aggression
• Projective identification
Level III: Neurotic
• Reaction formation
• Upward and Downward Social Comparisons
Level IV: Mature
• Thought suppression
Established Systems Models and Techniques
Theoretical Systems Models
• Bowenian or Intergenerational Therapy
• Structural Family Therapy
• Strategic Family Therapy
Premises of Social Systems Theory
• The whole is equal to more than the sum of its parts
• Systems are highly organized
• Boundaries are important
• Patterned interactions are important
• The behavior of the individual cannot be understood without reference to the system to which s/he belongs
Practical Application of Systemic Therapy
• Practical rather than analytical
• Does not work to determine causes nor diagnose people
• Looks for problematic patterns of behavior in groups of people
• It addresses those interactional patterns directly
• Therapist does not have power to change people or systems
• Therapist serves as a guide to help systems change themselves through the us of creative gentle pokes
• The basic structure of a session usually moves through three stages: initial complaints, transition to resourceful emphasis, and a homework assignment to maintain momentum.
Established Systems Therapy Techniques
• Use genogram to show intergenerational patterns
• Use joining to engage client system through tracking the content of family facts. Joining is accomplished through mimesis, whereby the therapist becomes more like the family in style or content of communication; confirmation by using a feeling word to reflect an expressed or unexpressed feeling of a family member; and accommodation through therapist’s personal adjustments in order to achieve a therapeutic alliance.
• Help client system strive for balance, achieving self-definition but not losing spontaneous emotional expression.
• Dismantling triangles as a way to dilute anxiety
• Use family mapping to depict structures and patterns in the family system
• Therapist determines alignments and power within the family unit
• Reframing, which involves explaining a perception from a different context in order to change the meaning without changing the facts
• Enactment, whereby families play out problematic behavioral sequences into the counseling session
• Spontaneous interaction allows the therapist to point out the sequencing and dynamics of observed behaviors while focusing on process rather than content.
• Restructuring the family roles through suggested role reversals or changes
• Use family communication style to determine feelings of self worth in members
• Family sculpting is used to experientially allow family members to understand and feel how they are perceived by others within the family
• Use of ambiguous or indirect worded directives to foster resistance and subsequent change
• Therapist uses paradoxes to lower or eliminate resistance to change by restraining, prescribing, redefining troublesome actions.
• Cultural grams and ecomaps are used as pictorials to show the influences and connections systems have to their nurturing and sustaining cultures.
Social Constructionist Models and Techniques
Established Theoretical Social Constructionist Models
• Solution Focused Therapy
• Narrative Therapy
• Collaborative Therapy
Premises of Social Constructionism
• The idea of objective knowledge and universal absolute truths is viewed skeptically
• Truths are not out there waiting to be discovered
• Knowledge and social realities are linguistically and communally constructed
• Language is the vehicle through which people know and attribute meaning to their world…
Practical Application of Social Constructionism to Clinical Therapy
• Therapy is non-pathological and non-judgmental
• The client’s uniqueness is appreciated, respected, and utilized
• Avoids blaming and labeling
• Therapy is more transparent with information and biases
Established Social Constructionist Techniques
• Miracle question is used to help the client visualize and construct own solution
• Scaling question is used to give the client the opportunity to evaluate his/her progress
• Homework assignments are focused on seeing positive changes
• Externalization of a problem separates the problem from the client’s identity
• Exceptions are used to draw the client’s attention to the times when the problem didn’t or doesn’t exist
• Dialogical inquiry is used as a way of engaging the client in collaborative or shared inquiry
Reasons for Using a Technique
1. A new technique can help a client get unstuck or move past an obstacle to change.
2. A new technique can re-invigorate the therapeutic process and renew the client’s interest in therapy.
3. A technique can incorporate and integrate more than one model of treatment.
4. A technique can be used flexibly on an as needed basis to whatever modality or process is being applied.
5. A new technique may be more effective in addressing a specific symptom or problem than what is found in the overall treatment modality being used.
Principles for Using a Technique
1. The technique must founded in evidenced based theory and practice.
2. The technique must fit the specific client’s needs.
3. The technique must fit your style and strengths.
4. The technique must be user ready at the automatic stage of skill acquisition.
5. If a technique is not working, stop using it.
6. Techniques may need to be adapted to each individual client.
7. There are instances where the use of a new technique is contraindicated.
Cautions in Using a Technique
1. Don’t use a technique unless you have investigated its clinical effectiveness and understand its limitations and contraindications.
2. Don’t use a technique unless you understand its theoretical underpinnings well enough to apply it with knowledge and modify it - as necessary - for use with each unique individual.
3. Don’t use a technique unless you can apply it fluidly and with confidence.
4. Don’t continue to use a technique if it is not working.
5. Keep clear that there will be times when specific techniques will not be effective.
Self-disclosure as a Technique
There are several important reasons why the clinician may want to use self-disclosure in the course of clinical work with clients. There are also situations in which self-disclosure is clearly contraindicated.
In this section, we will spend some time looking at both of these important issues. We will begin with a look at some of the important benefits of self-disclosure.
There has been a substantial amount of research to indicate that self-disclosure has the ability to enhance the therapeutic relationship and engender client disclosure. To begin with, under the right circumstance self-disclosure can help decrease client anxiety. This occurs because clinician self-disclosure may help normalize the client’s feelings, give them perspective, and allow them to realize that others have had similar experiences.
Secondly, several studies have found that self-disclosure can further the therapeutic relationship by increasing client trust and by encouraging personal disclosure by the client.
Thirdly, many clients enter therapy without good models for how to engage in personal discussions about important issues and problems. Clinician self-disclosure can provide the client with these alternative role models, as well as models of alternative ways of thinking and behaving.
Fourthly, a well-timed, relevant self-disclosure not only displays empathy, but also is a clear indicator for the client that the clinician has both heard and understood.
The choice to use self-disclosure should be purposefully aligned with an understanding of these benefits, and carefully evaluated to make sure that the benefits outweigh any potential risks associated with self-disclosure. These risks are related to the contraindications for using this kind of intervention.
- The “dyadic effect”: openness from the clinician supports openness from the client.
- Self-disclosure contributes an experiential component to the corrective emotional experience, improving emotional attunement through the use of mirroring and responding.
- Self-disclosure provides behavioral and social feedback that helps the client see him/herself more clearly and situate him/herself in relation to others.
- Self-disclosure models effective affect management and interpersonal effectiveness skills.
(Source: Karen Maroda, (2012) Psychodynamic Techniques: Working with Emotion in the Therapeutic Relationship.)
A purposeful alignment of the intervention with the client's needs also involved understanding the overall purposes for the self-disclosure in line with the overall treatment goals. This means that the clinician needs great clarity about why and how this intervention is being selected.
- The self-disclosure must be for the therapeutic benefit of the client, not the personal need of the clinician.
- The disclosure of emotion must contain real emotion.
- The clinician must feel comfortable in making the disclosure.
- The choice to apply self-disclosure should be under the control of the clinician at the time when it is being considered.
- The technique of self-disclosure must align with the larger style of the clinician and his/her authentic way of relating.
- Self-disclosure should only be used if the client wants it, if the therapeutic relationship is solid and strong, and if both the clinician and client are able to engage usefully about what is occurring in the treatment at the time of the disclosure.
Contraindications for Self-disclosure
There are a number of circumstances that contraindicate the use of self-disclosure. Some of these emanate from the 1) clinician’s assessment of the client, while others emanate from 2) the clinician’s assessment of his/her own feelings.
Careful attention should be paid to the existence of these two circumstances when determining if self-disclosure is appropriate. We will look at these contraindications in the brief section that follows.
Contraindications for Self-Disclosure based on Client Issues
Self-disclosure should not be used with the following:
- Clients who have problems with boundaries or reality testing and tend to idealize the clinician. These clients are likely to distort the meaning of the disclosure.
- Clients who are seeking inappropriate closeness.
- Clients who tend to focus on other’s needs rather than their own.
- Clients who are very self-absorbed or narcissistic and would experience the disclosure as an annoyance.
- Clients who make demands for personal information meant to disrupt or resist the therapy.
- Clients who are trying to avoid or distance themselves from their own emotional feelings.
- Clients who are severely mentally ill, or who present with serious substance abuse problems.
Contraindications for Self-Disclosure based on Clinician Issues
Self-disclosure should be used with caution when clinicians:
- Feel coerced by the client to disclose.
- Feel emotionally vulnerable.
- Are concerned that the client may misuse the information or share it with others.
- Have intense positive or negative feelings about the client.
- Disagree strongly with the client’s point of view.
- Believe the disclosure will burden the client.
There are also a few other circumstances where self-disclosure may be an appropriate action to take in the context of an overall therapeutic relationship. These are show below, with commentary to follow:
Other Indications Summary:
- When the client asks directly for a response.
- When the client is repetitively stuck in an emotional scenario from the past that stimulates a strong emotion in the clinician.
- When the clinical work is at an impasse that cannot be resolved simply by focusing on the client’s emotional experience.
- When a client expresses the notion that their feelings, thoughts, or experiences are strange or abnormal and the clinician knows the contrary to be true.
- When the client engages in all or nothing thinking.
- When the client believes he/she is the only one to have experienced something.
- When the client has been struggling to achieve a particular goal and seems to be losing confidence.
- When your clinical ability is diminished or affected by illness, pre-occupation with thoughts or worries, or other internal or external factors – but only if the client’s response to that information would be useful emotional clarification about the circumstances occurring.
- If the diminishment of clinical ability is too serious, or if the client would be harmed by the diminishment of ability, it may be preferable to reschedule the session.
(Source: Karen Maroda, (2012) Psychodynamic Techniques: Working with Emotion in the Therapeutic Relationship.)
Self-disclosure can serve as another vehicle for normalizing a client's experience and/or providing a more human response to client concerns that their difficulties place them outside the boundaries of normal human experience. Because there are deep concerns that all human being experience about being abnormal and unacceptable, the use of self-disclosure, used correctly and in a well-targeted way, can bridge the gap between the client's experience and the world of normal social experience.
It must also be noted that clients may have an experience of emotional distance from a clinician if that clinician comes into the treatment session not operating at their optimal capacity for attunement and emotional connection to the client. Left unaddressed, the client may worry that the cause of the emotional distance may be attributable to a disruption to the therapeutic relationship caused by the client. Honesty from the clinician about not being at their best may be preferable to the client's tendency to assume blame for or become angry at the disruption to the attuned relationship.
With certain clients or with a degree of impairment that is too high, it may also be preferable to reschedule the session to avoid problems with this consideration. Clinicians must be prepared to understand which approach takes better care of the client in this area.
For trainees who wish to study this technique in more detail, you might consider taking yourceus.com's course, THERAPIST SELF-DISCLOSURE: USES & MISUSES - AN OVERVIEW FOR MENTAL HEALTH CLINICIANS.