15. 整合方法帮助个人改变

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An integrative approach to helping a person change As discussed in Chapter 13, there are a number of different therapeutic models of counselling practice in use today. These are each based on particular theoretical foundations. Models of practice can broadly be grouped as follows: 1 psychoanalytic 2 humanistic/existentialist 3 co gn iti ve—beha vio u ral 4 constructivist (narrative and solution-focused) 5 integrative. The various approaches to counselling which fit into the above groupings are described in some detail by Feltham and Hortori (2012). We ourselves prefer to use an approach that fits into the last group; this is an integrative approach. This approach integrates and makes use of theoretical concepts, skills and strategies taken from a number of the different counselling approaches which belong in groups one to four in the above list. As a new counsellor or counsellor in training, you may be curious about our reasons for choosing to use an integrative approach, so we will consider this now. WHY USE AN INTEGRATIVE APPROACH? We have noticed that there is currently a strong movement among many practitioners within the counselling profession towards the use of integrative or eclectic approaches in preference to single-theory approaches. There is a considerable body of literature supporting an integrative approach, including an established professional journal devoted entirely to the discussion of integrative counselling (the Journal of Psychotherapy Integration). Clearly, integrative counselling is now recognised as useful by many practising counsellors. An important reason for this is that none of the individual counselling approaches has sufficient explanatory, technical or conceptual power to help all of those Who seek help (Beitman, 1994). Further,. in our experience, the individual approaches, when used exclusively, are often insufficient to effectively help some people to address emotional issues, to make useful changes to their thinking, and to start to use new behaviours which are more adaptive. Prochaska and DiClemente (2005) point out that both in the research literature and in clinical experience it has become clear that no single system of therapy adequately addresses what to do, when to do it, with whom, in what way and with which problem. We agree that this has generally been the situation and believe that these difficulties can be minimised by using an integrative approach which involves a systematic but flexible process, as described in the next chapter. Such an integrative approach enables a skilled counsellor to choose skills and strategies that are most suitable for addressing a person’s needs at each stage in the counselling process. Additionally, the counsellor can focus more strongly on the use of the approach or approaches that suit a particular person with particular problems. When using an integrative approach we need to recognise that the strategies we use come from various models of counselling and that these depend on differing theoretical frameworks. However, this does not need to be a problem. As pointed out by O’Brien and Houston (2007), what the integrative therapist does is to call on the practical wisdom that has evolved in whatever theoretical camp seems relevant to the work at hand. I* .1. - B fa a. 4 E fa I 4 J I. I. 4.4 u k I J a ■ L 4. 4 ■ i. 1 4 4 k. I .1. 4 HELPING PEOPLE CHANGE As we have stated previously, a major goal of counselling is to help a person change. Usually people come to counsellors at times of crisis and emotional distress, when they do not know how to change so that they can feel better and be able to live more comfortable, satisfying and adaptive lives. If we are to be effective as counsellors in helping those who come to see us to change, then we need to have some understanding of the change processes that can occur as a consequence of counselling. We need to recognise that although some people with emotional, psychological and behavioural problems are able to spontaneously change so that they feel better and behave more adaptively, others may have difficulty changing without the benefit of counselling. Consider the question ’What is the value of counselling?’ Beitman (1994) suggests that, rather than seeing counselling as a specific agent of change, we need to recognise that counselling can be a facilitator or accelerator of the self-change process which occurs naturally within people. In our experience this is true. When people come to see us as counsellors, we notice that they are often confused and overwhelmed by their problems and cannot recognise ways to change which would be helpful for them. By coming to counselling they are usually able to engage in a process that relatively quickly helps them deal with their emotions, change their thinking, and make decisions regarding future behaviours. The facilitative nature of the counselling process speeds up what might occur naturally over time without counselling. Research findings show that positive change occurs regardless of the model of counselling used (Prochaska, 1999). Further, research suggests that the relationship between a person and their counsellor may be a more important factor in producing change than the model of counselling used (Howe, 1999). While respecting these conclusions, in our experience, the effectiveness of counselling in producing change can be maximised if we recognise that the skills that are most useful in producing

change to a person’s emotional state are not necessarily the same as those that are most helpful in facilitating change to thinking processes, or those that are most appropriate for addressing behaviour. Additionally, we believe that we need to recognise that it is important to match the skills we use with particular stages of the counselling process. In order to lead satisfying and comfortable lives, human beings need to feel good emotionally, to be free from troubling thoughts and to engage in behaviours which lead to positive outcomes. Many people come for counselling because they are experiencing troubling emotions and thoughts and are engaged in behaviours that are unhelpful for them. It therefore follows that to be most useful, counselling should address emotions, thoughts and behaviours. Now it is tme that most, if not all, single-theory7 counselling approaches do have the goal of bringing about change in a person's emotions, thoughts and behaviours. However, when we examine the strategies used in specific counselling approaches we find that most approaches tend to focus more heavily on either emotions, thoughts or behaviours. Additionally, in our view, most single-theory7 counselling approaches do not significantly adjust their strategies to match stages in the counselling process, or the particular needs of individual people. In most single-theory approaches there is an assumption that if change occurs in one of emotional feelings, thinking processes or behaviour, then change will spontaneously7 occur in the others. Although we recognise that this may often happen, in our opinion it will not necessarily occur. We therefore think that it is important for counsellors to be skilled in making use of the different strategies that directly address emotions, thoughts and behaviours. In our view, strategies that are most effective in directly addressing each of these are different from each other and come from different theoretical models of counselling. In order to assist the understanding of change processes, we will discuss methods counsellors use to promote emotional change, changes in thinking (cognitive change) and changes in behaviour. While pointing out differences in the ways that these three attributes can be addressed, we recognise that changing one of them may sometimes spontaneously7 produce change in the others. . .. . b a. «. 4 a. «. 4. j . hB. 4 d 1.4. 4 a i.> FACILITATING EMOTIONAL CHANGE As we know, most people come for counselling help when they are experiencing a level of emotional distress. For some people, their emotions are clearly expressed, either verbally or non-verbally. For others, although they may exhibit some level of emotional distress, their emotional expression is more contained. From our experience as counsellors, we recognise that some people have difficulty7 clearly7 identifying the emotions they are experiencing. Sometimes a person’s emotions are so repressed that in the early7 stages of counselling it may be impossible for them to get in touch with their emotions.

As human beings our experience is that when we release our emotions we tend to feel better and to enter into a calmer state. For example, if we are grieving and very sad, our experience is that if we let our emotions out by crying, afterwards we will feel better. We may not feel happy, but we are likely to be less distressed and more comfortable. In a similar way, if a person is very angry, they may need to release their anger in some way. This may be by shouting, punching a pillow or engaging in a symbolic ritual. Clearly, one way in which a counsellor may help a person to feel better is to help them to achieve catharsis through emotional release. Many counsellors who use Person-Centred Counselling place a significant emphasis on reflection of emotional feelings. As a consequence of this, the people they help are likely to get in touch with strong emotions. When this occurs usually the counsellor will allow the person to fully experience the emerging emotion (subject to safety when dealing with people who are very angry). Generally, if a person starts to cry, the counsellor will allow7 the crying to continue until it naturally abates. Consequently, emotions are released and catharsis occurs. With regard to other emotions, such as frustration, anger and despair, the Person-Centred counsellor will usually encourage the person, through reflection of content and feelings, to verbally express the emotions rather than avoid dealing with them. The reflective skills used by these counsellors are clearly very useful in helping a person to deal effectively with emotional feelings. Counsellors who use an experiential counselling approach such as Gestalt Therapy have a different way of helping a person release emotions. The person may be encouraged to release emotions in a role-play by dialoguing in an imaginary way with someone who is, in their view, behaving in ways that make them feel bad. During the role-play they may be encouraged to act out their feelings by shouting, or they may be invited to physically express their emotions, for example by punching a beanbag. Counsellors using a Gestalt Therapy approach directly seek to achieve catharsis by encouraging the person to act out emotional feelings with consequent emotional release. We have explained how skills used in both Person-Centred Counselling and Gestalt Therapy can be extremely useful in dealing with emotions. As integrative counsellors we are able to choose whether to use a reflective Person-Centred Counselling approach or an experiential Gestalt Therapy approach when counselling. We recognise that what suits one person will not necessarily suit another. Although we have all trained in the use of Gestalt Therapy we recognise that some people do not like to be involved in experiential counselling strategies, whereas others find experiential work extremely useful. For people who are not comfortable with an experiential approach, we will choose to use reflection to deal with emotions. Additionally it should be recognised that early in a counselling process, when joining with the person seeking help is paramount, use of the less confronting Person-Centred Counselling skills is likely to be more appropriate than the use of an experiential approach. Can you see the advantage of using a flexible integrative counselling style, where the skills can be deliberately selected so that they are most appropriate for the particular person and the particular stage of the counselling process? You might ask, ‘Is emotional release sufficient in itself?' In their book Emotional Expression in Psychotherapy, Pierce, Nichols and Du Brin (1983) are clear in their belief that when feelings are expressed fully they lead to new ways for people to view themselves and the world, in other words, the person’s thinking changes. 1 he authors go on to say that the new ways of thinking and viewing the world then lead to more satisfying behaviours. However, they do recognise that this process does not happen automatically. Unfortunately, it may not necessarily happen at all. Although we believe that emotional release is a very important component of the change process, we do not believe that it is sufficient in itself. In our experience many people who release emotions in counselling are unable to make significant changes to their thinking and behaviour without receiving more direct help to deal with their thoughts and behaviours. Unfortunately, those people who are unable to make changes in their thinking and behaviours are quite likely' to re-experience ongoing problems in the future as troubling situations arise. FACILITATING COGNITIVE CHANGE (CHANGES IN THINKING) Skills from a number of therapeutic approaches can be used to bring about changes to a person’s thinking. These skills include focusing on the person’s strengths, challenging self-destructive beliefs, externalising, reframing, normalising, exploring polarities and using the ‘here and now’ experience, These skills are described in subsequent chapters. We will now discuss their origins, and their usefulness in promoting change. FOCUSING ON THE PERSON'S STRENGTHS Focusing on the person’s strengths will be discussed in Chapter 22. This approach helps the person to think more positively and start to recognise that they have the ability to cope with difficult situations. This strategy has its origins in Solution- Focused Counselling as discussed by Macdonald (2011). CHALLENGING SELF-DESTRUCTIVE BELIEFS The idea of directly challenging a person’s self-destructive beliefs conies from Rational Emotive Behaviour Therapy as developed by Albert Ellis (2001). Ellis believed that people can be helped if what he called their 'irrational beliefs’ were challenged and replaced by more ‘rational’ beliefs. As will be discussed in Chapter 20, Rational Emotive Behaviour Therapy theory suggests that changing thoughts automatically results in changing emotions and behaviours. Although this may sometimes happen, we don’t believe that it will necessarily happen, because, as pointed out by Greenberg (2002), the interactions between emotions, cognitions and behaviour are complex and do not follow a simple linear sequence. In other words, changing one of these attributes will not necessarily change the others. However, strategies from Rational Emotive Behaviour Therapy can be extremely useful in helping to change self-destructive thoughts. EXTERNALISING Externalising is a strategy used in Narrative Therapy as developed by Michael White (2007). The value of externalising is that it can help a person to have more control over their problem by separating the problem from the person, as will be described in Chapter 21. REFRAMING This skill has its origins in Neuro-Linguistic Programming as discussed by O’Connor and Seymour (2003). This skill is particularly useful for those people who think within the constraints of a very narrow and negative view of their world. By using refraining, the counsellor may be able to help such people to take a wider and more positive view, changing the way they think about their situation. NORMALISING Normalising, as will be explained in Chapter 17, involves giving a person information that helps them to understand that their feelings, reactions or situation are normal and to be expected, rather than unusual. I he expectation is that after normalising their situation the person will usually be able to think about the situation differently and hopefully more positively. This is likely to affect not only their thinking but also their emotional state, enabling them to move forward and make useful decisions. Although normalising may have an effect on behaviour, it does not directly target behaviour, so behavioural change will not necessarily occur. EXPLORING POLARITIES As will be explained in Chapter 23, exploring polarities is a Gestalt Therapy strategy". While the Gestalt Therapy intention is to target a person’s experience as a whole, we believe that this particular strategy is most useful in changing the way a person thinks about, values and manages particular personal attributes. This Strategy is most useful in helping to change the thinking of those people who are focusing on what they perceive as negative aspects of themselves. USING THE 'HERE AND NOW' EXPERIENCE Using the immediacy of the 'here and now’ experience is a Gestalt Therapy approach. The aim is to raise a person’s awareness of what is happening in the present moment in the interaction between themselves and the counsellor. By raising the person’s awareness of this, they get more fully in touch with what is happening within themselves, and what may be happening in their relationships with others. The aim is to bring about change in the whole of the person’s experience including emotions,

thoughts and behaviours. However, we believe that focusing on the immediacy of the counselling process is initially most likely to impact on a person’s thoughts. USING DIFFERENT STRATEGIES FOR DIFFERENT PURPOSES Can you see how we can use a number of different strategies, taken from different therapeutic approaches, for different purposes in addressing the way a person thinks? Some theorists from single-model counselling approaches believe that changing thoughts automatically leads to emotional and behavioural change. Although we agree that changing thought processes may to varying extents influence the emotions and behaviours of people, as integrative therapists we believe that it is more useful to target emotions and behaviours by using specific strategies which address these. FACILITATING BEHAVIOUR CHANGE V / Until now in this chapter we have discussed ways of helping a person by using methods that involve emotional release and changes in thinking. For some people, this may be sufficient to produce behavioural change, but for others the counselling process needs to be more strongly directed towards addressing behaviours. As explained in Chapters 25 and 26, we can use particular strategies to help a person explore their options for the future and make decisions about their future behaviour. 1 his can be done by using either a problem-solving approach or a Gestalt Therapy approach. When using a problem-solving approach, questions as described in Chapter 9, particularly those from Solution- Focused Counselling, can be used. If a Gestalt Therapy experiential approach is used, the person can be invited to engage in experiential practical experiments related to behavioural change. CHANGE OCCURS IN COUNSELLING THROUGH A PROCESS OF EXPLORATION AND SELF-DISCOVERY A good model to illustrate the usefulness of the process of self-discovery m counselling is the Johari window. 1 he Johan window was devised by Joseph Luft and Harry Ingham at a workshop in 1955 and is shown in Figure 15.1. According to Luft (1969) the name 'Johari’ is pronounced as if it were Joe’ and 'Harryh which is where the name comes from: Joe-Harry7. However, most counsellors do not pronounce the word this way. 1 he window has four panes as shown. Each pane in the window contains information about the particular person who is represented by the window. The two panes on the left-hand side contain information that is known to the person, whereas the two panes on the right-hand side contain information that is unknown to the person. The two panes at the top contain information that is known to others and the two panes at the bottom contain information that is unknown to others. Information in the top left-hand pane (the open pane) is openly recognised by both the person and other people. For example, if David were to use his own personal window as an example, he might recognise that he gets satisfaction from writing textbooks and other people are aware of this information. Consequently this information is in his open pane. Information in the bottom left-hand pane, labelled hidden, is known, to him alone and unknown to others. He can possibly think of some characteristics and beliefs of his that would fit into this pane, but if he doesn’t tell anyone else they stay hidden. Information in the top right-hand pane labelled blind is known to others but not to David. For example, other people may know that he has some special qualities that he may not recognise, information in the bottom right-hand pane, labelled unknown, is totally unseen and is locked in David’s subconscious.

Figure 15.1 The Johari window Known to selfUnknown to self Known to othersOpenBlind Unknown to othersHiddenUnknown The Johari window from: Group Processes: An introduction to Group Dynamics, by Joseph Luft © McGraw-Hill Education

THE INFLUENCE OF COUNSELLING ON THE JOHARI WINDOW 1 he likely influence of successful counselling on the Johari window is shown in Figure 15.2. When a person comes to talk with a counsellor, it is quite likely that at first they will talk about information in the open pane. However, if a trusting relationship develops, the person may take the counsellor into their confidence and self-disclose information from the hidden pane, in turn enlarging the open pane. Additionally, as counselling proceeds the counsellor may give the person feedback or ask questions. As a result of the feedback and questioning, the person may discover information that was unknown to them but may, or may not, have been recognised by the counsellor. Once again the open pane is enlarged. As a consequence of the counselling process, the person may gain insight (to use a psychoanalytic term), or gain awareness (to use a Gestalt Therapy term), or discover previously unknown

possibilities (to use a Solution-Focused or Narrative Therapy description). As shown in Figure 15.2, the person’s self-knowledge is likely to increase during ail effective counselling process, allowing for personal growth which will inevitably result in some level of change in either emotional affect, thinking processes or behaviours. We believe that this change process is enhanced when the counsellor uses an integrative approach that specifically includes skills to address emotions, thoughts and behaviours, as explained in the next chapter.

Figure 15.2 The effect of counselling on the Johari window Insight Known to self Open feedback Known to others Unknown to self Blind Self-disclosure Unknown to others Hidden Unknown

IN CONCLUSION As discussed at the beginning of this chapter, the counselling style described in this book is integrative; it draws on strategies and skills taken from a number of differing counselling models. As counsellors, if we are to be effective in helping those who come to see us, we need to be skilled in enabling them to make changes. If we help them to .... release emotions they will feel better in the short term. However, if our counselling help is to be of long-term value, after emotions have been released we also need to help them to change their thoughts and behaviours. If we do this, it is likely that they will be able to deal with future problems in more adaptive ways.

Learning summary • • • • • • • • Many counsellors now prefer to use an integrative approach, drawing theories, strategies and skills from individual counselling approaches to suit the immediate needs of the person seeking help. Changing one of emotions, thoughts or behaviours does not necessarily change the others because the interaction between emotions, thoughts and behaviours is complex. Integrative counselling can directly address emotions, thoughts and behaviours. Counselling facilitates and accelerates the natural processes of change. A person seeking help will generally feel better if they are able to talk about and express their emotions. A number of approaches can be used to facilitate changes in thinking. These include reframing, challenging self-destructive beliefs, normalising, exploring polarities, focusing on strengths, and using the Mere and now' experience. As described by the Johari window, human beings naturally have information about themselves, some of which is hidden from others and some of which is hidden from themselves. If a person can accept the hidden parts of themselves, they are likely to be better able to deal with these parts, and consequently are able to lead more adaptive and satisfying lives. References and further reading London. Greenberg, L.S. 2002, 'Integrating an emotion-focused approach to treatment in psychotherapy integration’, Journal of Psychotherapy Integration, 12(2): 154—89. Howe, D. 1999, ‘The main change agent in psychotherapy is the relationship between therapist and client', in C. Feltham (rd*), Controversies in Psychotherapy in Counselling, SAGE, London, pp. 95—103. Luft, J. 1969, Of Human Interaction, National Press, Palo Alto, GA. Macdonald, A. 2011, Solution-Hocused Therapy: Theory, Research & Practice, 2nd edn, SAGE, London. O’Brien, M, & Houston, G. 2007, Integrative Therapy: A Practitioner's Guide, 2nd edn, SAGE, London* O'Connor,!. & S ey m o u r, J. 2003, Introducing NLIJ Ac uro-Linguistic I hogra mining, 2nd edn, Th o rso ns, London. Pierce, R.A., Nichols, M.P. & Du Bnn, M.A. 1983, Emotional Expression in Psychotherapy, Garner, New York. Prochaska, J.O. 1999, 'How do people change, and how can we change to help more people?’, in M.A. Hubble, B.L. Duncan & S.D. Miller (cds), I he Heart and Sou! of Change: What ITbrG in t herapy, American Psychological Association, Washington, DC. Prochaska, J.O. & DiClemente, C.C. 2005, 'The transtheoretical approach’, in J*C. Norcross & M.R. Goldfricd, Handbook of Psychotherapy Integration, Oxford University Press, New York, pp. 147-71. White, M. 2007, Maps of Narrative Practice, Norton, New York.