Counseling Today, Member Insights

A ‘problem’ of perception

By Thomas Hofmann June 24, 2015

Many counselors now identify themselves as having a strength-based counseling approach, often as part of an eclectic theory base. Yet how do we know we are thinking within a strength-based model and operating with strength-based strategy? Most of our historical theory base developed from a Westernized medical model worldview, and many writers of strength-based literature distance themselves from that paradigm. Most of our agency forms, as well as the Diagnostic and Statistical Manual of Mental Disorders (DSM), demand a problem-focused, labeling-oriented view of our clients. Is it even possible to be a strength-based counselor in our current practice environment?

In a 2006 edition of the journal Psychotherapy, Joel Wong proposed a strength-centered therapy model that is both social constructionist in its philosophical background and virtues based. Social constructionism argues that complaints are based solely on client worldview, as described by Steve Turtle_smallde Shazer in his 1985 book Keys to Solution in Brief Therapy. A virtues-based perspective originated with philosophers such as Aristotle and St. Thomas Aquinas and was amplified by positive psychologists Christopher Peterson and Martin Seligman. Aristotle emphasized the care and nurturing of human virtue; Peterson and Seligman developed a taxonomy of virtues in their 2004 book Character Strengths and Virtues: A Handbook and Classification.

The DSM is itself a handbook and a classification. Reported pathology must be classified by behavior and client self-reports. To be given a pathological diagnosis, the client must meet certain criteria. Yet what are these criteria? Normal human behaviors and internal subjective states include a bit of anxiety, depression, loss of appetite or binge eating, as examples. The majority of symptoms for most diagnoses stem from prevalent human states that have become a significant detriment to a client’s quality of life or to those around them. Aristotle argued for moderation in virtues rather than extremes. Could we identify codependency as a misuse to the extreme of the human virtues of persistence, love and hope?

Wong argued for a philosophical use of moderate constructivism. Perhaps it is not only client perspective that creates problems, as de Shazer contended. As opposed to radical constructivism, positivist philosophy contends that everything can eventually be measured and then operationally defined so that everyone can give it the same meaning. As we become more sophisticated with evidence-based treatment and our advancing knowledge of biological causes of internal states and behavior, we can explain client complaints as consisting of more than just client worldview. Schizophrenia was once thought to be triggered by a schizophrenogenic mother, but recent fMRI (functional magnetic resonance imaging) data show the presence of abnormal brain structure and activity. However, even cognitive behavior therapy, current champion of the evidence-based model using clear clinical pathways and treatment manuals for each diagnostic category, still depends on challenging client worldview to a very large degree.

Counseling simultaneously in both worlds

How can we use a strength-based approach while diagnosing our clients to provide them with the accurate and appropriate classification to report to other professionals and insurance companies? Now that I have a smartphone I constantly hear, “We have an app for that!” As counselors, we can choose to use reframing as a kind of translation app, translating the pathological information in our heads to strength-based verbalizations for clients.

My definition of reframing is providing a perspective that is equally true or more true to the client than the view that she or he currently holds. Can we argue that diagnoses, made up of human internal states and behaviors, are very often coping mechanisms? Generalized anxiety keeps a person hyperalert to danger. Over time, with hyperalertness as the predominant choice of reaction, the limbic system does not function as well, nor does the client.

Motivational interviewing suggests that one way to reduce client defenses is to respect all client choices. We can argue that most choices have a positive intention. Underlying the choice is a virtue, or multiple virtues, that often is expended in vain efforts. Generalized anxiety shows a person ever watchful for danger. Remember that our frame of codependency is as an overzealous use of the virtues of persistence, hope and love, which turns the effort to counterproductive ends. We would not begrudge a turtle its shell. Yet we sometimes look at a person with depression and forget to honor the protective mechanism of retreat. Substance abuse is a means of seeking escape from what the client perceives to be an intolerable internal state, which is not a bad intention in itself.

When we find a way to first honor the client’s coping behaviors, the associated positive intention behind them and the virtues that propel them, we can enhance our chances of also having conversations about the problematic parts of the condition and encourage the client to be more forthcoming. Counseling students are often taught to view ego defenses as pathological when doing client assessment. But for a young child who is trapped in a horrific situation with no way to escape, dissociation is a brilliant way to escape. Children who are browbeaten with repeated verbal abuse can introject that belief (take it on as their own) to survive a childhood in which fighting for their self-esteem might be quite dangerous. In certain situations, denial helps us all to live a more calm and happy life.

In a nutshell, strength-based counseling theories proceed from an immediate view of clients possessing their own answers. Solution-focused therapy focuses on solution talk from an imagined future in which the problem does not exist. Motivational interviewing engages clients in a very honest dialogue in which they face their own ambivalence while the counselor stays out of the way. Narrative therapy takes the same story content and, by externalizing pathology as an oppressive outside force, reframes that content in a way that is just as true, yet more empowering, for the client.

So, how can we follow a strength-based approach even as our agencies require problem-focused assessments and insurance reimbursement requires a diagnosis? One way, right out of the gate, is to perceive the positive intentions behind our clients’ inefficient behaviors and the virtues that drive them in wasted directions. Clients have a harder time dismissing enduring virtues as their own when the positive intentions are pointed out to them.

We also need to ask if we are sure of the client’s goal. James Prochaska and Carlo DiClemente proposed that counselor awareness of a client’s level of motivation to make a certain change is critical in the success of the client actually making that change. Assessing the client’s motivation helps us ensure that the client is fully engaged when it is time to take action. Until then, work can consist of enhancing motivation or determining a goal with which the client is genuinely engaged.

In the July 2002 Journal of Mental Health Counseling, Victoria E. White adapted the groundbreaking work of Michael White and the narrative therapy technique of externalization to suggest a method for presenting a DSM diagnosis to a client in a nonpathologizing way. She proposed working with the client to externalize the diagnosis so that it is perceived as an oppressive force “outside” of the client rather than as a pathological label with which the client identifies.

Assessing pathology within strength-based approaches

In their 2009 book Solution-Focused Substance Abuse Treatment, Teri Pichot and Sara A. Smock discuss the dilemma of obtaining necessary problem-focused assessment data while utilizing a solution-focused approach. They contend that the normal tools and approach of solution-focused therapy do allow counselors to infer problems through inconsistencies in statements and reports, objective evidence and use of scales for assessment, among other ideas. And if there are missing data that are needed, the counselor can ask. This may briefly interfere with the purity of the approach. However, the counselor’s skill at redirecting toward solution talk is important.

How we conceptualize cases in our heads and how we talk to clients can often occur from different frames. But as we become more experienced at framing the pathological as strengths and virtues that are used with good intentions, it is possible that our own inner and outer frames will begin to merge. And by assertively and immediately pursuing a strength-based approach from the get-go with our clients, they might be more motivated to open up and honestly discuss their situations, while simultaneously feeling empowered by our approach.

 

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Thomas Hofmann is a full professor in the master’s in clinical mental health counseling program at Hodges University in Florida and also teaches in the certified addiction professional track in the undergraduate program. He has experience in both mental health and substance abuse settings across the continuum of care. Contact him at thofmann@hodges.edu.

Letters to the editor: ct@counseling.org

 

 

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