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Notes for tutors - Theoretical integration (1)

Submitted by counsellor Fiona Ballantine Dykes


Developing the skills of integrating theory and practice within a core theoretical model is challenging and demanding. Trainees need a great deal of help in making links between their understanding of theoretical concepts and what they actually do in the session and why. Evidence from external assessment suggests that this is an area of weakness for many candidates. Even those who are able to conduct a safe, well held taped session can sometimes be at a loss when asked to explain how their use of skills, understanding of process/relationship links with their theoretical model. The increasing focus on evidence-based practice within all psychological therapies places further emphasis in the need to be able to integrate theory and practice.

The challenge for centres running integrative courses is even greater and more attention needs to be given to helping the trainees develop a comprehensive and digestible model that not only gives candidates a sound practitioner basis, but also prepares them for the requirements of accreditation with a professional body. Sue Wheeler makes it clear that BACP expects integration to be “clarified by the staff offering the training rather than left to the students.” She acknowledges that counsellors will evolve and develop their own integrative style over time “but the initial training should provide clear guidelines about how pieces fit together.” (Wheeler p. 134)

CPCAB values all theoretical approaches. Individuals think, function and experience themselves, their personal history and their relationships in different ways and every approach has something valuable to offer. It is important for the profession that this wide range of approaches continues to be available. It is also important that training centres ensure that whatever theoretical approach is being delivered it is made relevant to the workplace.

Integrating theory and practice
A coherent counsellor training needs to consider and LINK the following elements in relation to the centre’s theoretical model:
• What are the underlying assumptions about human nature and the nature of the self?
• How does the approach explain how psychological problems/difficulties and/or explicit and implicit patterns of relating (past and present) develop?
• How does the approach define the nature of the therapeutic relationship and the role of the therapist?
• How does the approach address a range of presenting issues?
• What kinds of therapeutic skills/techniques and interventions are associated with this approach?
• How does the approach define and explain the idea of therapeutic change and how does this link with the counselling process?

The following descriptions offer a “taster” of the kinds of themes to be explored within a range of theoretical approaches. They are not intended to cover every example systematically.

What are the underlying assumptions about human nature and the nature of the self?
Different approaches have fundamentally different beliefs about human nature. Tutors need to explore what beliefs about humans underpin the centre’s approach. For examples:
• Human capacity for growth (humanistic belief in actualising tendency)
• Individuals have the ability to make healthy choices (TA).
• Behaviour is the product of learning and can be “unlearned” (behavioural).
• Predetermined nature of human difficulties (psychodynamic focus on unconscious drives both negative and positive).
• Individuals are the authors of their lives and have the capacity for freedom, responsibility and self-determination (existential).

Different approaches have different frameworks for looking at the structure of the self. For examples:
• Configurations of self, organismic self and self concept (person-centred).
• Id, ego, superego (psychodynamic).
• True self and false self (Winnicott).
• Parent, Adult, Child (TA).
• Top dog, underdog (Gestalt).

How does the approach explain how psychological problems/difficulties develop in an individual’s personal history?
Each model/approach offers a language and framework for looking at what “goes wrong”. This is usually connected with the individual’s relationships with significant others (parents, siblings, friends, teachings). For examples:
• A person-centred approach might explore the concept of “conditions of worth” and how this effects the development of the self concept and loss of contact with the organismic self.
• A TA approach might explore the development of ego states and early script messages and how these are perpetuated by “games”.
• A cognitive/behavioural approach might look at the individual’s development of irrational beliefs or early conditioning which directly affect an individual’s emotional response.
• A psychodynamic approach might explore how people develop an early model of relationships which then forms the foundation for all future relationships.

How does the approach define the nature of the therapeutic relationship and the role of the therapist?
The nature of the therapeutic relationship and what is “helpful” to the client is directly linked with what “went wrong”. For examples:
• In the person centred approach the reason that the “core conditions” are so important is because this relationship offers a felt contrast to the formative relationships based on judgement, non acceptance and lack of authenticity.
• The psychodynamic relationship offers an opportunity to explore and work with transference and to repeat the failure of the ‘significant other’ with a better resolution and therefore less neurosis with the emphasis in making links between past and present. The therapist may offer interpretations.
• A cognitive therapeutic relationship offers a collaborative and interactive approach to tackling irrational beliefs, with a view to changing behaviour or the consequence emotional response. There are likely to be homework tasks.
• A Gestalt therapist works with the here and now relationship to bring awareness and more immediate experiencing or conflict to resolve unfinished business. The focus is on “What” and “How”, rather than “Why”.

How does the approach address a range of presenting issues?
What might your theoretical model suggest as the reasons for the client’s presenting issue - e.g. a repeating pattern of poor relationships or depression? For examples:
• A person-centred approach might look at where the client’s locus of evaluation is (external or internal) or how in touch the client is with their “organismic self” as a possible cause of depression.
• A TA approach might look at how early script messages are being replayed and familiar transactions being repeated in unsuccessfully relationships.
• A CBT approach might explain depression as the result of unrealistically high expectations of oneself and inevitable failure.

What kinds of therapeutic skills/techniques and interventions are associated with this approach?
The theoretical approach and the nature of the relationship directly affect the therapeutic interventions that the counsellor uses in the session. All approaches now place importance on establishing a sound working alliance and building empathy, but different approaches will suggest the use of different techniques and therapeutic interventions. For examples:
• The person-centred approach is focussed on entering the client’s felt emotional world and conveying empathy and acceptance. The skill of accurate heart-felt reflection of both spoken and unspoken communication is vital; the ability to track and follow (rather than lead) the client are central; the ability to use immediacy sensitively and congruently is paramount
• A psychodynamic approach will actively seek to find out about the client’s past history and may offer interpretations of the client difficulties or what is going on in the relationship. The use of immediacy will be very important for understanding any transference issues. The session is likely to be less client-led and there is less emphasis on equality in the relationship.

How does the approach define and explain the idea of therapeutic change and how does this link with the counselling process?
Each approach has its own language and framework for describing “change” within the therapeutic relationship and how this can be facilitated and noticed in the counselling work. For examples:
• The person-centred approach suggests that if the therapist can truly create the core therapeutic conditions in the relationship then the client will start to become more in touch with his organismic self (less bound by his self-concept), more able to grow and develop in healthy ways, more accepting of those unwanted aspects of self (be less dependent on other’s conditions of worth), more able to rely on himself to make choices (i.e. to develop an internal rather than an external locus of evaluation).
• The Gestalt approach suggests that if the client is given the opportunity (e.g. offered in empty chair work) to work through conflict in the here and now it leads to increased awareness, movement from environmental support to self-support, resolution of unfinished business.
• A behavioural approach suggests that by using a variety of techniques – e.g. behavioural rehearsal, relaxation methods, recording and monitoring behaviour – the client will eliminate maladaptive behaviours and learn new and more effective ways of relating.

Integrating theory into practice is a life long process of change and development as counsellors develop their own unique style and understanding of their work. However, by diploma level candidates are expected to be able to present and reflect upon their counselling within a coherent theoretical framework. It is therefore not enough to say (in answer to a question about theory ):
“I offered my client the core conditions which enabled her to trust me, to open up and to go deeper into her feelings.”

Candidates need to be able to comment on why the core conditions are important in the person-centred approach and why going deeper into feelings is helpful. They need to be aware of this how the ability to show empathy and acceptance impacts on the client’s formative experience (conditions of worth, creation of the self-concept, external focus of evaluation). They need to be able to comment on the process of change in relation to this theoretical model. They need to be aware that no human being can offer the core conditions throughout the entire 50 minutes of a session and that the counsellor’s own internal process impacts on their ability to be present for the client.

Suggested exercise for TC-L4 tutors:
• Ask your students to list the key concepts of their theoretical approach as a group activity.
• Create a “map” of the likely theoretical process of the counselling relationship if the counsellor successfully creates a relationship where the core conditions are present for much of the time.
• Watch a video of a counselling session . Ask students to “map” the counselling session onto the theoretical “blueprint”, identifying key moments when counsellor interventions (attitudes) lead to change.
• Experiment with making a process “map” using a different theoretical framework.
• Discuss how the language/relationship/skills/description of change/therapeutic goals differ.

Suggested exercise 2:
Invite trainees to add a specific field to their counselling skills proformas/feedback sheets called “theoretical links”. Encourage trainees to include discussion of the theoretical links in skills feedback.

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