Monthly Archives: June 2019

What does therapy mean to you?

Compiled by Bethany Bray June 11, 2019

What does therapy mean to you?

Jessica Ferrence, a licensed professional counselor (LPC) in Fayetteville, North Carolina, was a little taken aback when a client posed this question to her in a session. However, it sparked Ferrence’s interest and led to some self-reflection.

Therapy is what counselor practitioners do – but it means something different to each professional. It’s a place for the client to heal, grow, be vulnerable, set goals, get to know themselves and many, many more things.

For Ferrence, therapy is a place to uncouple oneself from pain and find strength.

“Therapy puts people in a vulnerable position because we trust clinicians with our deepest, darkest, most painful secrets; things we haven’t shared with our partners or family members or best friends for various reasons. When we feel safe enough to let down our walls — when we share the burden we’ve been shouldering for years or relive the experiences that haunt us in our dreams — we find the strength to find our voice,” says Ferrence, who considered the topic both as a practitioner and recipient of therapy. “Confronting our pain and reclaiming our lives, without fear of judgment or ridicule, can be extremely cathartic. We feel validated, understood and accepted for the first time in a long time — and maybe even ever. And that’s when healing truly begins. That’s when we realize that the power to break free from the grip of our past lies within us. That our vulnerabilities are no longer vulnerabilities, but rather areas of strength that we draw from. [It’s] where the image of our best self has come into focus, and more importantly, that we have the courage to turn that image into a reality.”

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CT Online asked a sampling of American Counseling Association members to consider the question “What does therapy mean to you?”

Read their thoughts below, and add your voice to the conversation in the comment section at the bottom of this page.

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As a therapist, to me, therapy is…

An honor and privilege. I continue to be humbled by the fact that my clients share with me their most sacred stories. Often these are trauma stories, in which their deepest pain and vulnerabilities lie in the details they have shared with very few, or only with myself.
A collaboration between the client and myself. My clients bring their expertise about themselves and their experiences. They bring their stories. They also bring their strength, resiliency and all of themselves – shadow and light. As a therapist, I bring years of clinical experience and education. It is my responsibility to provide a safe, non-judgemental and compassionate space for us to work in. As appropriate, I will offer clients my perspective, as well as evidence-based interventions and information, which they have the right to accept or decline freely, based on what fits for them.
An opportunity to support clients in reaching their goals. These goals might involve learning how to cope with the aftermath of loss or trauma, or learning how to manage distress related to stress and/or a mental/physical illness. Sometimes we are working together to adjust their understanding and expectations regarding healthy relationships and boundaries.
Often focused on helping clients to recognize that they deserve to be loved, respected, cherished and protected — and that in life they don’t need to be perfect to be “good enough,” but rather they only need to be perfectly themselves – with all of their disappointments, triumphs, strengths and vulnerabilities. Frequently, I find [therapy] is about helping clients learn to view themselves from the perspective of their wisest and most compassionate selves.
A place to educate and normalize my client’s reactions and/or symptoms, so that they can get a handle on what it is they are dealing with, what they might expect and strategies they might wish to consider to help them to better manage their distress.
A place in time where clients do not have to wear masks or say they are “OK” when they are not. A refuge. A place where their distress will be heard and witnessed by another human being, who will not judge, but rather will reflect back their distress without minimizing, and will also hold up a mirror to their strength, courage and tremendous resiliency.

Shirley Porter, a registered psychotherapist and a registered social worker in London, Ontario, Canada

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To me, therapy is for everyone. It is the opportunity for individuals to get the most out of life.

Though traditionally viewed as a medium for helping someone work through a particularly challenging issue or mental health disorder, therapy offers much more. The reality is that, yes, everybody struggles at various points throughout life and may benefit from some additional assistance. People need not wait, however, until life becomes challenging to seek therapy. That is, effective therapy may help people go well beyond attaining life satisfaction to the point of thriving.

Accordingly, the lens through which counselors view clients should be one that extends well beyond problem resolution. By resolving an issue, a person may shift from a bad place to a neutral one. Pushing beyond this is where we really begin to witness existential growth. This is the place where life satisfaction increases, interpersonal relationships improve, goals are achieved and one begins living a life that — until therapy — seemed unattainable.

As counselors we make the unattainable attainable. While I have yet to meet a new client who comes into the office under the premise of “My life is great, and I am here to make it even better,” counselors have the tools to do just that! When working with clients, then, my thought process is to first help address the presenting problem, then facilitate a personal growth process that exceeds previously thought of expectations.

This is one way, of many, that we may continue to destigmatize the therapeutic process. Therapy is not just for individuals with mental illness or problems—it is for everyone.

Matt Glowiak, a licensed clinical professional counselor (LCPC), certified advanced alcohol and other drug counselor, full-time clinical faculty member at Southern New Hampshire University and co-founder/co-clinical director of counseling speaks in Chicago, Park Ridge and Lake Forest, Illinois.

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By definition, therapy is sitting in a room with an essential stranger and discussing your inner most intimate memories, feelings and traumas. Sounds fun right?

No.

So, if therapy isn’t always fun, why do so many people continue to go and find such benefit from the process?

Everyone’s answer to the above question is going to be a bit different but being a therapist myself, and a client within therapy throughout my life and currently; I would like to share my current perspective on what therapy is and why everyone should go.

To me, therapy is a helpful tool to use in order to get to know myself on a deeper, more authentic level.

Within our bodies and minds we all hold the answers to our presenting concerns, but the protective factors and defense mechanisms we’ve built up over the years tend to get in the way of effectively working through our life’s difficulties alone. Therefore, we rely on our coping skills and our loved ones to assist us in times of need. But what happens when your go-to coping skills are no longer working? For a lot of people, it means that you now have to adapt your life and accept the fact that you are now anxious, depressed, alone…fill in the blank — and that’s just the way it is. Fortunately, though this doesn’t have to be the case.

Therapy can be a great way to adapt or change your learned way of life in order to gain a better understanding of your inner workings and what happens when your internal and external worlds collide.

By nature, the process of therapy forces you to be vulnerable. And with vulnerability being the key component to experiencing all emotions (the good, the bad and the ugly) the therapeutic process can assist in the education, understanding, integration and execution of your complex emotions. Therefore, allowing you to take what is learned within the therapeutic hour out into the world and apply it to your life in order to reach our full potential.

In summary, I think that everyone should have access to, and be a client within the therapeutic process sometime throughout their life. It is not something I think people should be in forever, because I do think one of the goals of therapy is teaching clients how to be their own therapists. But I do think everyone should be able to experience the benefits that the unique relationship between client and therapist can have.

Shannon Gonter, a licensed professional clinical counselor (LPCC) in Louisville, Kentucky who works with young adults and specializes in men’s issues

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To me, therapy or counseling is the space in which counselors are able to promote, encourage and support clients in achieving wellness. This space is where clients go to seek out the assistance that they need to improve areas of their lives that contribute to their overall sense of wellness. These areas may include but are not limited to social, cultural, emotional, psychological, spiritual, relational and/or physical.

Therapy is this safe space where I can explore where I am in life, what obstacles I may be facing and what I need to feel whole again. To me, wellness is the experience of wholeness.

Ashley C. Overman-Goldsmith, an LPC and doctoral student at North Carolina State University and owner and lead therapist at Sea Change Therapy in Williamsburg, Virginia. Her current research centers on honoring the lived experiences of terminally ill clients while helping these clients resolve issues that affect their end-of-life experience.

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As a veteran and mental health professional, I often find myself conducting community presentations in order to reduce the stigma against clinical mental health counseling. Often, I find myself having discussions about what therapy is and what it means.

During these conversations, I draw the line between therapy and Therapy. Many find things helpful and calming that they consider “therapeutic,” like gardening, physical exercise, cooking, art, etc. I have clients that say “_____ is my therapy” and that’s great. The meaning in that context is anything that is emotionally soothing or helpful to them.

The other one, though, is Therapy. It is a formal interaction with a licensed mental health professional that is bound by a set of ethical principles, licensure regulations and expectations of professional conduct. I typically use the term clinical mental health counseling, which is more cumbersome but also clearer than just the word “therapy.”

During Therapy, in the clinical sense, a client identifies areas in their life that are not functioning as well as they would like. They then work with a trained professional to develop and work towards goals that will improve that functioning. The professional does not only have training in therapeutic interventions, but they also have training in evidence-based practices that research has proven can help the client resolve their concerns.

Unfortunately, many of the clients I see do not engage in Therapy until the things they have been using to try and manage their problems don’t seem to work. I often describe it this way: if I were a medical doctor, I would be an emergency room doc. The veterans I see come in to my office either right before a crisis, during a crisis, or after a crisis has occurred. Clinical mental health counseling is often seen as a last-ditch effort, a final resort to try before the wheels fall off the wagon.

Instead, I try to encourage clients to consider clinical mental health counseling as a resource to use in order to prevent a crisis, rather than reaching out in response to a crisis. To use Therapy in conjunction with things they consider therapeutic, rather than thinking they are two separate things. For my clients, I have seen this combination help them live the post-military life they both desire and deserve.

Duane France, a U.S. Army noncommissioned officer (retired), combat veteran and LPC who practices in Colorado Springs, Colorado. In addition to his clinical work, he also writes and speaks about veteran mental health on his blog and podcast at veteranmentalhealth.com

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To me, therapy is an opportunity. It seems that with any kind of client, in any type of situation, using any option of modalities, therapy is a gateway to a field of possibilities. I believe one of my greatest gifts to my clients is helping them to facilitate possibilities of thought, feeling and action. With possibilities, clients can see opportunity. Two important words come to mind when I think of opportunity: awareness and empowerment.

Clients come to counseling, voluntarily or involuntarily, but most come with some desire to figure out something. Clients may be looking for specific techniques or just a way to be able to communicate with their partners. They may be court ordered for addictions treatment or just feel like something is not right. Whatever the concern, figuring it out seems to bring insight and peace on some level. Being a licensed professional counselor, certified yoga instructor and an artist has allowed me to provide multiple strategies to foster clients’ inquiry into their presenting concerns. But strategy aside, therapy provides clients opportunities for self-awareness and insight about the world around them.

Additionally, opportunity begets empowerment. One of the key principles of counselor identity is empowerment of our clients to help themselves. I remember working in a community mental health center years ago. Then I was working with children and families who did not have a lot and who had experienced violence, abuse and insecurity in their living situations. I wondered what good could I do in one 60-minute session, and with one meeting per week for each client, especially when I was working in the context of highly distressing situations. Therapy was the act of empowering my clients to find options in how they reflected on themselves and responded to their environments.

With options available, clients can find freedom to choose. Feeling free to make decisions – intentional decisions – is one of the most empowering experiences for anyone. Being able to foster opportunity for my clients means that they have a chance to feel their personal power to make their own choices.

I would say that my primary job as a counselor and counselor educator is being an options-maker or a possibilities-creator! I believe it is in therapy where opportunities are born!

Megan M. Seaman, an LPC, certified yoga instructor and assistant professor in the Counseling and Art Therapy Department at Ursuline College in Pepper Pike, Ohio. She also maintains a private practice in Beachwood, Ohio where she works with children, youth and families using creative arts healing and yoga therapy strategies.

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To me, therapy is providing an open space for people to have the opportunity to discuss life events or problems that are impacting their daily lives. This is a place where someone feels heard. Our lives are often so busy that we don’t listen.

Counseling provides this safe place for someone to “unpack” life problems and look at them with someone who is truly listening and is available for unbiased support. Therapy offers the opportunity for people to discuss and explore ways to improve their lives and find resources to enhance their quality of life. Thus, they find the strength to manage difficult life events such as trauma, illness and adjustment to disability.

Therapy is also the passionate pursuit of learning and effectively using practice-proven and evidence-based practices to help with the healing process. But, it also requires a counselor to have the courage to question, redirect, and, yes, confront a client to keep them on the path to wellness and wholeness.

This is hard work! But it is an honor to be trusted by someone who doesn’t know us to listen, care and support them during their most vulnerable times.

Judy A. Schmidt, a certified rehabilitation counselor (CRC), licensed professional counselor associate (LPCA) and clinical assistant professor in the Clinical Rehabilitation and Mental Health Counseling program in the Department of Allied Health Sciences, School of Medicine, University of North Carolina at Chapel Hill. She is the rehabilitation counselor for the acute inpatient rehabilitation unit for UNC Hospital in Chapel Hill.

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To me, therapy is a communion of two souls who make an agreement to walk alongside each other for a part of this journey. Therapy calls us to bear witness to another person’s healing process by helping them to come back home to their true and authentic self. It reminds us of our wholeness and asks us to remove any barriers that prevent us from seeing this wholeness.

Therapy reminds us that we cannot have the shadow without the light and that the shadow only exists because of the light. It is about quieting the ego and the mind in order to get us out of our heads and into our hearts and bodies.

Therapy involves being truly seen and heard by another person to help us remember that we are not alone on this journey. It is about accepting someone for who they are (battle scars and all) while also seeing their infinite potential.

Jessica Smith, an LPC, licensed addiction counselor, yoga teacher and owner of Radiance Counseling in Denver, Colorado

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Bethany Bray is a senior writer for Counseling Today. Contact her at bbray@counseling.org

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at facebook.com/CounselingToday.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Bringing evidence-based processes into the therapy room

By Boyd Eustace and John Donahue June 5, 2019

By way of introducing ourselves as the co-authors of this article and providing a little context for what follows, John Donahue is a clinical psychologist, an assistant professor at the University of Baltimore, and a practicing psychotherapist. Boyd Eustace is a licensed counselor and a lead therapist at a hospital-based outpatient mental health clinic in Baltimore, in addition to maintaining a private counseling practice in the city. The University of Baltimore’s graduate program in counseling psychology and the outpatient clinic in which Boyd works partner in the training and professional development of the university’s graduate students. Colleagues on both sides of this partnership share an interest in fostering collaboration between graduate-level training programs and clinicians in practice settings. A primary focus of the partnership is bridging the gap between academia and clinical practice.

At this point, it has been well-established that a science–practice gap exists in the field of mental health. In 1996, in an article for BMJ, David L. Sackett and colleagues suggested that evidence-based practice reflects clinical decision-making on the basis of three components:

1) Research evidence

2) Clinical expertise and judgment

3) Client values, preferences and characteristics

Later, the American Psychological Association adopted this “three-legged stool” approach when it defined evidence-based practice in psychology as “the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences.”

One way the separation between science and practice can be witnessed is in the varying weights that mental health practitioners tend to apply to the different legs of the evidence-based practice stool. For example, research has found that prior clinical experiences exert the strongest influence on treatment decisions. Additionally, mental health practitioners almost universally report incorporating client expectations and values into treatment planning and strive to establish strong working alliances with their clients. However, when it comes to the first leg of the stool, clinicians have frequently reported hesitancies about factoring in empirical research findings when assessing and treating their clients. This contrast may in part stem from negative perceptions toward empirically supported treatments (ESTs) (see Michael E. Addis et al., 1999) and from confusion among community mental health providers concerning the differences between ESTs and evidence-based practice (see Michelle A. DiMeo et al., 2012).

The EST movement has expanded our understanding of many psychotherapy protocols that are efficacious in the treatment of specific diagnostic categories. With that said, ESTs certainly have not become a panacea for treating distinct disorders, and a few serious issues have hampered widespread dissemination of research-backed treatments to community-based clinics. Among these issues are concerns that:

Efficacy studies generally include samples that are not representative of the modal, multiproblem patient/client with several comorbidities
Treatment manuals result in rigid and mechanistic applications of psychotherapy
Studies often fail to attend to mechanisms of change that underlie variance in outcomes
Primary outcomes of randomized controlled trials (i.e., symptom reduction) are not necessarily the primary outcomes of interest for patients/clients in the community

In addition to these stated concerns about treatment protocols, there is substantial evidence that the targets of ESTs — individual Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnoses — are themselves invalid. Since the DSM introduced the categorical model of psychopathology in 1980, research has generally supported the conclusion that the diagnostic system is plagued by comorbidity, heterogeneity of symptoms within diagnoses, lack of adequate symptom coverage (resulting in excessive “not otherwise specified” diagnoses), and diagnostic thresholds that appear quite arbitrary.

Given these findings, the National Institute of Mental Health has stated that it is moving away from DSM-based diagnoses as its outcome of interest and has instead introduced the Research Domain Criteria (RDoC) initiative, which articulates a group of putative mechanisms of psychopathology that can be studied at varying levels of analysis. However, the RDoC approach, which is still in its nascent stages, has been critiqued for its emphasis on the biological level of analysis. It is currently a framework for research rather than a classification system that demonstrates clinical utility.

Fostering evidence-based care in light of obstacles

Although ESTs have been helpful in furthering scientifically informed mental health practice, the preceding section demonstrates that they possess numerous limitations and do not represent the compendium of effective counseling methods or stand for our full understanding of evidence-based practice in clinical settings. They have also too often contributed to the proliferation and endorsement of brand-name treatment approaches and trademark interventions, creating further divisions between orientations and increasing resistance to evidence-based practice. Moving beyond the era of prescriptive treatment protocols for specific disorders may therefore be helpful in expanding the use of evidence-based practice in the clinic.

In this spirit, we embraced a recent book by Steven Hayes and Stefan Hofmann titled Process-Based CBT: The Science and Core Clinical Competencies of Cognitive Behavioral Therapy. Rather than outline yet another protocol, or describe the techniques important for x disorder, the purpose of this text is to describe the “core processes that are common to many empirically supported treatments,” regardless of tribal theoretical identities and disregarding the confines of illusory diagnostic boundaries. Because of this approach, we thought it might be a particularly valuable vehicle in disseminating evidence-based practice into the community clinic.

As a lead therapist at this particular outpatient clinic, Boyd organized five monthly seminars focused on evidence-based practice and process-based cognitive behavior therapy (CBT) during the summer and fall of 2018 with the hospital’s mental health staff. We (John and Boyd) collaborated on curriculum content and co-led the seminars. The goals of these meetings were to increase the participants’ overall knowledge related to clinical research, broaden their understanding of evidence-based decision-making, and help identify various ways for them to incorporate science into their everyday practice. Participants included licensed practitioners, students-in-training and clinical supervisors.

Each monthly seminar was approximately 90 minutes in length, was offered around midday during a period that would conflict less with client sessions, and focused on specific chapters and topics from Process-Based CBT. Specifically, topics included:

1) The history of ESTs and problems with the “protocols for syndromes” approach

2) Evidence-based practice and some drawbacks with over-reliance on clinical judgment

3) Benefits and obstacles implementing ESTs in the clinic

4) Core cognitive, behavioral and emotion regulatory processes

5) Cognitive restructuring, cognitive defusion, exposure and psychological acceptance

Each seminar included brief didactic presentations on agenda items followed by group discussion. In essence, we did not want to teach another protocol. Instead, we sought to engage the mental health team in a discussion about specific processes and techniques that are empirically validated.

What did we learn?

At the conclusion of the seminar series, team members were offered an opportunity to complete a questionnaire designed to provide feedback concerning the pertinence and usefulness of the information presented in the educational workshops. The questionnaire included three items rated on a Likert scale ranging from strongly disagree to strongly agree, plus one open-ended question. Eight of 12 practitioners chose to complete the questionnaire. All of these practitioners were either licensed clinical social workers or licensed professional counselors with prior clinical experience ranging from four to 18 years. General outcomes were as follows:

All practitioners either agreed or strongly agreed that the seminars provided information that might help them integrate science into their everyday practice in the clinic.
Most practitioners either agreed or strongly agreed that the seminars broadened their understanding of counseling outcome studies, ESTs, randomized controlled trials, and some of the problems related to treatment-construct validity and generalizing findings to practice settings. (Two participants responded that they were undecided.)
All practitioners either agreed or strongly agreed that the seminars delineated the advantages and challenges of using evidence base to inform
clinical decisions.

Additionally, practitioners were asked about the ways in which the seminar modified their views on evidence-based practice. Illustrative of the possible benefits of this program, several practitioners noted that evidence-based practice is beneficial because it helps clinicians select interventions that have been proved to work. One respondent wrote, “The seminar made me aware of the disconnect between research and practice … that we are still trying to find ways to connect research and practice.” Another wrote, “It is important to also consider clients’ preferences and values along with research.”

In conducting this seminar, we also arrived at some revelations. One is that, sometimes, clinicians are regularly using evidence-based techniques but are unaware that they are doing so. For example, in our discussion on exposure procedures, one clinician noted that she did not conduct exposure therapy, and this statement was then endorsed by several other members of the group. However, when the clinicians were prompted to consider ways in which their work with clients facilitated emotional willingness and tolerance of difficult experiences, it became clear that this procedure was a significant part of their practice. When the emphasis is on protocols, we may be more inclined to say, “I don’t do that.” But when the conversation shifts to processes, we can more easily notice the instances in which specific empirically supported procedures are useful, thus bringing additional intentionality to the use of these techniques.

In connection to our own work, this seminar series has reminded us of the importance of assessing and monitoring changes in processes, not just changes in outcomes. When we track a process in session and use procedures in the service of modifying that process, we should also close the loop and assess this change (or lack thereof). This can be done in a variety of ways, including self-report, behavioral tests and self-monitoring. It is important that we share these findings with our peers and continue to test and refine our practices.

This seminar series also helped solidify our view that practice-based research may be critical in reducing the science–practice gap. Information must flow in both directions — from the laboratory to the clinic, and from the clinic back to the laboratory. We hope that our discussions over these five months have helped lay the groundwork for practice-based research that will contribute to this noble task.

Concluding comments

We (John and Boyd) practice acceptance and commitment therapy and rational emotive behavior therapy, respectively. Both of these evidence-based models are theoretically grounded in the CBT tradition and are transdiagnostic, and they overlap substantially in their approaches. Our view of counseling is aligned with the process-based approach advocated by Hayes and Hofmann, which highlights the advantages of therapists using testable models to employ a versatile range of evidence-based interventions. This approach reflects the complexity and situational specificity of presenting problems and implies a nondogmatic, nuanced, multimodal strategy.

The process-based approach takes to heart Abraham Maslow’s cautionary observation: “I suppose that it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail.” In other words, with a predetermined armamentarium in hand, we might be tempted to rigidly and reductively treat diagnostic labels instead of treating our individual clients/patients and their idiosyncratic problems.

Similarly, Arnold Lazarus, cognitive therapist and founder of multimodal therapy, advised therapists to have a variety of tools in their toolbox so that they could “offer a broad-spectrum versus narrow-band treatment approach.” Taking this broad-spectrum approach improves outcomes and prevents future behavioral and emotional problems for our clients.

In keeping with the aforementioned frame of reference, our goals in this seminar series were to:

Use Hayes and Hofmann’s influential text as a method of engaging an eclectic group of mental health practitioners on the topic of evidence-based practice
Begin to move away from the specific protocols and techniques linked to brand-name therapies for diagnostic syndromes
Initiate a conversation about how to effectively target the precise processes that appear to be important across different psychotherapy orientations

Given the overall good receptivity to the seminar series across clinicians, we believe we took steps toward those goals.

Furthermore, we think that this approach is one that is transportable to other clinics. Reflecting on the successful aspects of this seminar series, we recommend:

Organizing sessions at a time that is minimally disruptive to the busy schedules of mental health practitioners (for us, that was around lunchtime, but this will vary across settings)
Tailoring each session to a specific topic or set of topics
Including out-of-session readings that participants can review prior to
each session

We also hope to extend this work with further trainings, which then may stimulate research questions and encourage practice-based research relevant to the process of therapy. In this effort, we may plant the seeds for the upward dissemination of evidence that will help to answer Gordon Paul’s great question: “What treatment, by whom, is most effective for this individual with that specific problem, under which set of circumstances, and how does it come about?” Or, as is stated in the Process-Based CBT text, “What core biopsychosocial processes should be targeted with this client given this goal in this situation, and how can they most efficiently and effectively be changed?”

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Boyd Eustace, a licensed clinical professional counselor and clinical supervisor, sees clients and supervises therapists in a hospital-based mental health clinic and in his private counseling practice in Baltimore. He received training in rational emotive-cognitive behavior therapy at the Albert Ellis Institute and specializes in brief solution-focused individual and couple counseling at LB Counseling Services. Contact him at lbcounseling90@gmail.com or via his website at pcc-mentalhealth.com.

John Donahue is a licensed clinical psychologist and assistant professor of psychology at the University of Baltimore. His clinical and research interests involve mechanisms underlying psychopathology that cut across traditional diagnostic boundaries and the application of mindfulness and acceptance-based approaches to psychotherapy. Contact him at jdonahue@ubalt.edu.

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Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

The miscommunication model and the WDEP system

By Barbara A. Mahaffey June 4, 2019

Helping clients keep or revitalize loving relationships are long-term goals for those who specialize in couples counseling. Those goals get derailed when one or both clients storm out of the room during the middle of a heated debate during an intake session. Therapeutic ruptures and divorces can happen if counselors fail to quickly mediate couples’ arguments, especially if the counselor has not yet established credibility and an alliance with the clients.

Success in couples counseling sometimes depends upon gaining a therapeutic alliance with both partners while simultaneously preventing or resolving emotional outbursts. However, simply teaching couples polite ways to communicate will not keep them together, according to John Gottman. Another technique or approach is warranted. Couples who come to counseling are seeking relief from anger, tension and communication breakdowns, so it makes sense for us to offer them a new way of relating to each other.

I developed a technique to help couples communicate and self-disclose in a nonthreatening way and used this technique as my intake in private practice starting in 1996. What is different about this creative technique? The secret may be the miscommunication model. I found the missing key to helping couples alter communication patterns was engaging them in creating a drawing that contained the reasons they struggled to keep calm and communicate their needs and wants. While completing this drawing, people gained insight into the ways they had been miscommunicating.

What is lacking for many couples is the ability to debate, relate and communicate without blame, shame and anger. While drawing the miscommunication model, each person recognizes that communication is difficult and that everyone struggles with multiple barriers. For most, the drawing is a cathartic exercise that can shift the common blame-game conflicts to goal setting and nonthreatening communication opportunities.

Most people come to counseling with the expectation of a tell-all session focused on disclosing problem after problem, or they complete a checklist of problems before a session begins. Unfortunately, intervention strategies specific to preventing or defusing negative or emotionally charged situations is a skill gap in counselor education. This raises an important question: How do counselors gain trust simultaneously with two strangers, provide tools to promote their affective connection, and prevent outbursts and ruptures during a volatile first session?

Establishing multiple therapeutic alliances

As is the case with individual counseling, a therapeutic alliance is the most important factor in successful couples counseling. Gaining a therapeutic alliance with two people simultaneously is a multifaceted challenge, however, especially when these individuals are trying to describe relationship concerns and upsets to a stranger.

Conflict resolution for couples begins after a counselor establishes ground rules and structure during the intake session. The first important rule is to establish how clients can have a calm session. If a first session is filled with anger and centered on problems, counselors will find it more difficult to form a bond with these individuals. Establishing a nonthreatening review of couple challenges is one way to provide catharsis, encourage openness and set ground rules. Sessions should also end with goal setting to keep a calm home environment in between sessions.

I developed the miscommunication model during years of intake assessments to deescalate anger and promote a working relationship among all people in the counseling room. As part of the effort to establish an alliance with both people simultaneously, the model provides counselors with a way to demonstrate barriers to a satisfying relationship while establishing nonthreatening goals and tasks. The first tasks are to provide the mechanism through which each client will participate in counseling, learn about barriers to healthy communication, and gain awareness of ways that relationships can be derailed. In demonstrating the miscommunication model, counselors can then help couples learn to express what they want.

Clients may not come to counseling with a set of rules for governing appropriate self-disclosure. Therefore, counselors can introduce the tenets of choice theory’s WDEP (want, do, evaluate, plan) system concurrently with the miscommunication model to add a directive structure to counseling sessions, according to internationally known choice theorist Robert Wubbolding. The purpose of combining the WDEP system and the miscommunication model is to first outline how common traits, past experiences, barriers, learned patterns, language and its meanings, emotional reactions, life interference and family rules contribute to a breakdown in couple communication, and then to introduce a way to build a happier relationship.

The miscommunication model approach to intake interviews

The miscommunication model was developed to help clients understand and conquer the many barriers to an improved relationship. One potential helpful insight is that people can and often do have different “wants” or needs in a relationship. Choice theory’s WDEP system provides structure when integrated in this model.

In some cultures, relationship conflict begins when one of the partners in a couple believes that both partners should share common wants. Counselors can provide conflict-resolution templates to help couples thwart power struggles (for example, by getting the couple to focus on helping each other attain goals rather than focusing on whose wants are more important). Guiding couples to learn aspects of negotiation and acceptance are additional ways that this model promotes a healthy relationship.

What has been missing in previous approaches to couples counseling is engaging couples in a conversation about the ways that anyone can be misunderstood when trying to communicate. One way to engage clients in intake sessions is to draw a diagram denoting two people communicating and then to explain the common barriers to and complexities of relationships. Framing this information in a way that suggests that interpersonal communication can be improved adds hope for couples with relationship ruptures.

Miscommunication barriers vary, and the model illustration on page 39 shows only a small sampling of these barriers. Clients can be encouraged to come up with more examples that fall under headings such as personal characteristics, past experiences, brain lies, family rule books, rate of talking versus rate of thinking, life event disruptions, and words and definitions. Counselors who draw a miscommunication model — with clients’ input — can integrate the goal-setting WDEP system tenets of “what are our wants,” “what will we do,” “evaluate” and “plan for and create a quality world.” This is a refreshing new way to engage clients in a nonthreatening conversation.

People who come for couples counseling typically have not been able to resolve their differences and are seeking assistance to do so. Learning that people miscommunicate many times a day helps to remove some of the blame, shame, guilt and anger that are often present in these relationships. These negative emotions can be the underlying cause of a ruptured relationship. Learning about the many ways that miscommunication has disrupted their relationship also serves to add skills to the couple’s toolbox. It is important for counselors to normalize the frequency of miscommunication by pointing out that everyone differs in some way and that disagreements are commonplace, not the exception.

Personal characteristics

Discussing the barriers that hinder relationships can be tricky business. People depend on counselors to lead conversations about problem-solving though, and the place to begin is by talking about the “elephants in the room.”

The first barrier to communication in the miscommunication model is each person’s differing characteristics. Each person has different traits, cultural influences, coping and defense mechanisms, learned behaviors, circumstances and life predicaments that can hinder relationship harmony. Some clients can easily list other attributes that differ, including age, race, religion, education, interests, abilities, sibling status, and work or military experience. Others may note differences in body language, personalities, parental influences, relationship histories, likes and dislikes, communication habits and health issues. A few clients might disclose traumatic experiences, medical histories and pre-existing thoughts about counselors or the counseling process.

This extensive list can be developed over several sessions if warranted. Counselors can explain that many of the barriers will be unspoken and unconscious. It is sometimes appropriate for counselors to note that barriers can be kept secret to protect the emotional safety of the clients. One example of this is that clients are not pressured to disclose childhood abuse. Significant others or spouses may not realize that certain topics are “off limits” for the other person in the room.

Preventing session blowups and engaging clients in a calm conversation about what has changed in their relationship involves helping couples gain insights into their communication skills. At some point in their couplehood, their ability to discuss what they want/need and how to share problems changed.

Sometimes the differences or discrepancies in how people relate to one another are obvious and sometimes not. When discussing relationship barriers, it is wise to point out how a person’s past or lived experiences can create a block to understanding another person’s actions, decision-making, problem-solving abilities, and likes or dislikes. For example, a couple might argue about going to a certain restaurant without being able to talk about a past negative experience that is influencing the thinking, emotions or actions of one of the partners. The miscommunication model would focus attention on this important discussion topic by adding it as a conversation bubble for one of the communicators in the drawing.

Talk about family rules

One way to introduce the “family rules” miscommunication barrier is to discuss the family-learned communication styles that Virginia Satir wrote about in Peoplemaking. Her communication styles and “family rule books” of placater, distractor, computer, blamer and open communicator can be added between the two people in the miscommunication model drawing. This is the counselor’s judgment call and depends on how volatile the couple’s relationship can be.

Another Satir concept, “can of worms,” illustrates the complicated communication patterns in families and can be added in a future session should it become a hot button issue. If a client points out that the other person’s family has a rule book of open warfare and verbal onslaughts, I recommend noting this as a topic for a future session.

Another family rule book example that can be noted for future discussion is the concept of “life expectations.” Many times, derailed personal goals connected to children, work, education or bill paying can be hidden aspects behind relationship dissatisfaction. Although understanding a client’s values, morals and beliefs is an important part of establishing trust and a therapeutic alliance, an intense discussion around these topics can derail the focus on issues during the first session. It may be beneficial for counselors to be directive and to suggest that such topics be developed in future sessions, after the therapeutic alliance has been well-established among everyone involved.

Normalize individual differences

Yet another barrier to communication is our personal brain differences. Part of the benefit of the miscommunication model drawing is the catharsis clients feel when they realize that many other people have struggled to keep a relationship thriving. Counselors might point out the many possible differences between people in learning styles, intelligences, interests, values/morals and perceptual acuities/filters. Also, people “screen” in and retain information differently, yet they may not realize these differences.

In the miscommunication model, these differences can be demonstrated by drawing two brains and pointing out the different ways, speeds and processing pathways for each person. For example, Person A may process and filter by using cognitions or thoughts first. Person B may process by filtering feelings first. Yet another person can believe that they verbalized a thought even when they didn’t because we think faster as humans than we speak. Drawing the two brains can aid in emphasizing that each person in the relationship has unique qualities. Note that people have different processing speeds and rates of speech too. This provides clients with an opportunity to gain awareness and new insights.

Some counselors who draw the miscommunication model use the phrase “our brain lies to us” to describe another barrier: conceptualizations. To help clients grasp the concept that the brain sometimes “lies,” counselors can offer the examples of optical illusions or mistaken perceptions by witnesses. Some clients may resist the notion that their brain isn’t always a dependable source of accurate perceptions. The knowledge that information is not always perceived, interpreted, processed and retained correctly can be unsettling. Counselors may wish to ask permission to point out inconsistent communication to highlight instances when the “brain lies.”

When drawing the miscommunication model, counselors can also add the ways that people differ genetically, developmentally and stage/age wise, and then discuss those aspects.

The miscommunication model next leads to introduction of the Do tenet from the WDEP system. This helps clients shift to a discussion about how to resolve or respect individual differences.

Daily life barriers

Daily life disruptions are constant sources of miscommunication. Any number of new or co-occurring outside events can affect a person’s relationship and communication quality. Family, work, environment, health issues, money issues and other stressors can add to a person’s strife and grief. In the miscommunication model, the importance of these variables could be added or symbolized as a conversation bubble that is drawn or attached to the second person in the couple interaction. The risks involved in second marriages, deaths in the family, and child rearing are common topics within this barrier. During this discussion, counselors may engage clients in ideas about evaluating their situations, establishing their plans and setting goals.

Words and language as relationship barriers

Words are one of the biggest hindrances to successful couple communication. How a person defines a word or phrase can cause grave misunderstandings, especially when there is a lack of clear definition related to emotions. I would caution counselors not to ask clients, “What is your definition of love?” because that query can result in a storm-filled diatribe in session. Conversely, pointing out that emotion-laden words such as love may be defined in many ways can be a healing approach.

Miscommunication also happens in cultural and historical contexts. Newly created terms used in texting, social media and alternative forms of communication (such as meta communication) only sometimes have shared meanings. For example, one couple split their household over the phrase, “I am done.” One spouse interpreted this as the intent to divorce, whereas the other spouse interpreted it as meaning their conversation had ended.

Another couple’s rupture was healed after talking about how one of them expressed love through behaviors rather than verbally. The husband realized he had learned about love from watching John Wayne movies and had internalized a belief that “I don’t have to say I love you, I just do.” He also learned an important evaluation skill — that challenging a learned reaction and confronting a prior belief could benefit both him and his wife. His wife benefited from learning that he was not intentionally dismissing the words that would typically be used to express an affective connection. She also started observing the favors and actions he did to show his caring for her between counseling sessions. This problem resolution happened because of her request to “receive the gift of a verbal love commitment — the statement of ‘I love you.’”

I have seen couples benefit from discussing throughout the counseling process words that have different meanings or definitions. Some examples of words that often have different contexts or descriptors include committed relationship, separation, affective connection, friendship, change and going steady.

Integrating WDEP’s problem-solving steps

The final aspect of the miscommunication model and the integrated WDEP system is the creation of a plan. (While the evaluation aspect of WDEP is not elaborated on in the model, it is part of the ongoing discussion orchestrated by the counselor in the room.) The plan can have three goal sections — one for each member of the couple and one for the couple as a unit. Each person is given a chance to state one goal that will facilitate the creation of their “quality world.” This is an important aspect to goal attainment and success, according to Wubbolding and his associate, John Brickell.

Typically, the couple goal is a fun and easy task or set of tasks. One of these might be to plan an activity in which both individuals create a new interest together and then report back to the counselor about what was accomplished. The plan should include a timeline and should feature positive, mutually agreed upon and doable activities, according to Mark Young, a counselor educator at the University of Central Florida.

One of the skills that counselors can model during the session termination phase is to frame plan changes in positive ways. For instance, instead of wording a goal with terms such as “unmet expectations,” counselors can help clients set goals that are “gifts for each other” that lead to relationship improvement.

Drawing the miscommunication model and integrating the WDEP system on a piece of paper that the couple can take home is a great way to assist them in recalling homework, goals and barriers to future interpersonal communication. It also is an unexpected presentation method. One benefit to drawing the dynamics of interpersonal communication is that couples can come to future sessions better prepared to diagram their miscommunications. This paves the way to increased insights about their conflicts and arguments.

When counselors try to teach clients different or accepted ways to communicate without first gaining their trust and, more importantly, their insights into barriers to communication, they often fail to help couples improve and stay in committed relationships. Relationships can improve, but it involves a process of learning how communication can go in a wrong direction. People can more easily change their attitudes and opinions about each other if they are given information that empowers positive change. The miscommunication model is a tool that couples can use to discuss their individual wants, intentions, behaviors and plans.

Simultaneously conducting an intake assessment and providing education about how to navigate relationships has been successful in helping me prevent couples counseling ruptures and storm-filled counseling sessions. Counselors can combine the miscommunication model with the WDEP system for a directive approach that leads to problem resolution.

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Helpful resources

“Applying reality therapy’s WDEP tenets to assist couples in creating new communication strategies,” by Barbara A. Mahaffey and Robert Wubbolding, The Family Journal, 2016
“Couples counseling directive technique: A (mis)communication model to promote insight, catharsis, disclosure and problem resolution,” by Barbara A. Mahaffey, The Family Journal, 2010
“Therapeutic alliance: A review of sampling strategies reported in marital and family therapy studies,” by Barbara A. Mahaffey and Paul F. Granello, The Family Journal, 2007

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Barbara A. Mahaffey is the executive director of the Scioto Paint Valley Mental Health Center, an agency that serves clients in five counties in Ohio with outpatient and residential facilities. Contact her at bmahaffey@spvmhc.org.

Letters to the editor: ct@counseling.org

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Voice of Experience: Invisible people, Part 3: The homeless

By Gregory K. Moffatt June 3, 2019

He was the only student in my class who didn’t turn his papers in on time. He was constantly late and regularly fell asleep in class. I felt insulted by his seeming lack of respect for my classroom, for me and for our discipline. If I could have dropped him from the class, I would have. I almost resented the days he showed up.

But he wasn’t truly lazy, and he wasn’t intentionally disrespectful. Instead, he was a struggling member of the third group of invisible people I am highlighting in this series. It had never occurred to me that this student might be homeless, but a conversation with one of my colleagues opened my eyes to his situation. What I learned totally changed the way I saw him. I had been so blind.

The student was the eldest of three siblings who had been living with their mother in a homeless shelter. Mom had married young and had no job skills. When her husband left her, she had no money to pay the rent for their meager apartment. After months of eviction notices, the movers came in and swept everything in the apartment to the curb in less than an hour.

His mother spent the rest of that morning trying to find a place for them to stay. In the meantime, thieves helped themselves to their unsecured possessions on the curb. An afternoon rain had soaked their clothes, bedding and personal belongings. Much of what they owned was ruined. When my student and his siblings came home from school, they found their mother sitting on a broken dresser — dropped by a member of the eviction team — guarding what possessions they had left.

My student slept on a cot in a large room with several other families in the shelter. There was no place to store things other than under their cots, and things put there were often pilfered by other residents. Even an old pair of shoes might be better than those someone was already wearing.

Common bathrooms meant lines, especially in the mornings as my student tried to ready himself, wearing one set of clothes one day and his second set the next. Like others in the shelter, he washed out what he could in the sink, hoping the clothes would dry on the end of his cot by the next day.

This family was homeless because of divorce and a thoughtless ex-husband. Divorce happens to almost half of the U.S. population, so there was nothing unusual in that circumstance alone. My attitude toward my student made it clear I hadn’t even considered that there might be much more to his story.

Many of the people who are homeless in our nation struggle with addiction. Others are seriously mentally ill. To save money many years ago, my home state decided to get out of the mental health business. Mental health patients who were deemed not to be a risk to self or others were sent home or let out on the street, and the facilities closed. Some families couldn’t care for their family members who were mentally ill, and these individuals became nomads.

But there are also many people who are homeless who have merely fallen on hard times. Some men and women travel from one state to the next in search of job opportunities that might enable them to settle down with their families. They spend their nights in shelters, doorways, alleys or their cars.

Those who want to pull themselves out of the abyss of homelessness are met with barriers at every turn. Businesses don’t want them warming themselves in their shops. Cynical pedestrians cross the street to avoid saying, “I don’t have any money for you.” Esteem is further eroded by words such as, “You’ll just spend it on drugs.”

Services for those who are homeless are often inaccessible. For example, in Atlanta, the labor pool (where men and women go to find work) was many blocks away from where most shelters were located. It was smarter to sleep under a nearby bridge, thus possibly being first in line the next morning. Better that than to sleep in a shelter and not being allowed to leave until 7 a.m., thus risking being at the end of long lines and having less chance of securing a job for the day.

People who are homeless can also be stalled by people like me — a college professor and professional counselor who should have known better. My student had no place to study at the shelter, no place to keep his homework, and no money to buy his books. With limited transportation options, he was perpetually tardy. And he was exhausted all of the time from caring for his family, working when and where he could, and getting insufficient sleep in the crowded shelter.

Our clients who are homeless need transportation, food, clothing and jobs. I know that we aren’t social workers, but those who work with the homeless have to think pragmatically.

I’m glad that I learned about this student’s story — which has a happy ending. He and his family got back on their feet, he graduated from college, and life is better. It frightens me to think how many other people I might not have seen clearly, however, because of my cultural blindness.

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Dear readers: I would value hearing from you if you found this series on cultural awareness (invisible people) helpful. My primary writing goal is always to help us do our jobs better. You help me do that with your comments, questions and ideas.

Previous articles in this series:

Voice of Experience: Invisible people, Part 1: Native Americans

Voice of Experience: Invisible people, Part 2: The incarcerated

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Gregory K. Moffatt is a veteran counselor of more than 30 years. His monthly Voice of Experience column for CT Online seeks to share theory, ethics and practice lessons learned from his diverse career, as well as inspiration for today’s counseling professionals, whether they are just starting out or have been practicing for many years. His experience includes three decades of work with children, trauma and abuse, as well as a variety of other experiences, including work with schools, businesses and law enforcement. Contact him at Greg.Moffatt@point.edu.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.