Theoretically Speaking…
To follow up on an earlier blog post about the core conditions in therapy, we will be taking a look at specific theories of counseling and how they impact therapy. We will also go over the theoretical approaches you are most likely to notice at Companioning Your Journey.
What Role Do Counseling Theories Play in Therapy?
An important thing to note when talking about multiple theories is that there is not a single theory which has been found to be the most effective. There are however evidenced based practices which are theories that have been rigorously studied and been found to show consistent results. This is likely less to do with the theory itself being more effective than a theory not deemed an evidenced based practice and more to do with a clinician using specific clinical skills and tracking measurable outcomes. Therapy however often does not fit inside of a medical model and there is no direct connection between “X” number of contact hours equals “Y” result. People are unique and the therapeutic relationship is unique. The most effective agent of change has been found time and again to be the relationship itself, more than a technique or theory.
That being said, theories can be extremely helpful in a variety of ways, but for the purpose of today’s post we will focus on what I believe to be the primary reason therapists should know their theoretical approach - Conceptualization. Conceptualization is the way that we come to create a framework of the client, the presenting problem, and what might alleviate this concern. Although every client is unique, if you adhere to a specific framework, your theory can help you begin putting pieces together of what the client would benefit from in your work together. To give you an example of what this might look like, I am going to give you a brief case study and then use that case study to provide an example of each theoretical orientation and how they might conceptualize this client.
Bryce: (Mock Case Study… with a nugget of truth)
Bryce presents to therapy expressing that they have been struggling to complete their blog posts in a timely matter and that they are often caught rushing the clock on a Sunday night. Bryce expresses enjoying his work but often feels drained and fatigued at the end of the day, leaving little energy for personal projects/passions. Bryce notices that there are pockets of time when they feel motivated and have enough energy to complete tasks, but often feels bogged down by the amount of things needing to be done. Bryce would like to find a way to maintain momentum and get things like their blog completed earlier, because they often beat themselves up for not doing enough/getting enough done earlier in the week.
Common Theories
Cognitive Behavioral Therapy (CBT)
Premise: One of the dominant evidenced based practices expected to be in a clinician’s tool belt is CBT. For a brief rundown, let’s reference a CBT concept called, the cognitive triangle: Thoughts - Feelings - Behaviors. Each of the three points of the triangle can influence one another and if a person would like to change one of the three, they must work to influence the other two.
Conceptualization: Bryce is having the thought that their blog posts are a lot of work, this leads them to feel overwhelmed, which then leads to avoiding working on it. If Bryce were to break down their posts into manageable tasks and start with an easier task, they may regain momentum and feel less overwhelmed.
Dialectical Behavioral Therapy (DBT)
Premise: DBT is a type of co that is effective for many populations, but was designed with the intention of treating individuals with borderline personality disorder. DBT is often a more intensive form of treatment where individuals are involved both in groups and in individual sessions weekly. DBT works to support individuals in building skills to ground themselves in the moment, build distress tolerance, and to build healthy relationships.
Conceptualization: Bryce is having a hard time holding onto the distress presented when they think about their blog post coming due. If Bryce were to gain some experience in mindfulness they might be able to ground themselves in the present moment and more effectively balance this routine stressor.
Acceptance and Commitment Therapy (ACT)
Premise: ACT is also similar to CBT and DBT in the sense that it works towards building mindfulness and getting into the present moment. Some of the shift in focus is adding the component of leaning into our values and also of accepting what is, especially things we wish we could change but can not. I often think of ACT with the image of a tidal wave coming at you. The wave is coming, it does us no good to stamp the ground or shout at the skies, we must accept that this wave will hit. Now that we are facing this inevitable event, we can decide how we might brace ourselves and best take the hit to help us survive..
Conceptualization: Bryce is noticing that the deadline for their blog post is coming up and they would like to put it off, but they made a commitment to themselves that they would post weekly on Sundays. Knowing that Bryce values their word, even a commitment they made to themselves, how might he be able to prepare differently for this upcoming deadline in the future so that he can support well-being.
Solution Focused Brief Therapy (SFBT)
Premise: This theory is often misunderstood as a coaching model, but this is not the case. In solution focused therapy, the therapist works with the client to assess what they want, what they have, and what might be a step to get closer to their preferred future. The “brief” portion is not necessarily saying that this model of therapy provides faster results or that the treatment will be in-and-out as quickly as possible, what it does mean is that when we meet, we are doing what is clinically necessary. If the client has an area where they wish to see change in their life, that is what we need to hold a session. Once a client feels they have reached their goals, we can put treatment on pause until the client returns with another goal.
Conceptualization: Bryce wants to get their posts completed on time and they know that they always feel better once they hit post, especially on the days that he has written the post in advance and is able to just login and submit. He does have days that he sets aside for different tasks in his practice, so maybe some of this time could be allocated towards that. Bryce is able to use their strength in delegating tasks to overcome procrastination and get their posts done on time.
Narrative Therapy
Premise: Narrative therapy is a unique and very powerful theory that I enjoy tapping into from time to time. For as long as we have been on this earth, storytelling has been a critical part of how we connect with others, tell epic tales, and pass on knowledge. There are some situations that someone may not be able to put into words or be able to find a way through, but if you are able to support them in building an image they may be able to take an inescapable situation and turn it into describing themselves at a bottom of a well. When we look around, if we see dirt, perhaps we can start to tunnel out, what would that look like if you could find a different way out? If we see bricks, maybe there are some gaps in-between that we can use to help pull ourselves up?
Conceptualization: Perhaps Bryce could imagine this task as their own scaled down version of the heroes journey and the sirens trying to pull them into a shipwreck are the distractions that help him procrastinate. What might Bryce envision when they feel uncertain of what to right? Does it feel like complete darkness or is there a light somewhere? How might he move closer to it?
Other Theories Not Expanded on in this Post
This is an incomplete list, but here are some of the other theories of counseling. I chose to expand on the theories which are focused on in graduate programs and of theories that I have practiced with and/or know other clinicians who use the theory. The others listed below are not as common, but do have great ideas within them.
Adlerian Therapy
Brieft Dynamic Theraoy
Existential Therapy
Feminist Therapy
Gestalt Therapy
Psychoanalysis
Rational Emotive Behavior Therapy
Reality Therapy
How I Uses Theory In My Practice
One of the most important images that I gained from a training on theories was that although there is not a dominant theory which is found to be most effective, it is important to be “wearing the same pair of shoes”. This means that if you are using one theory to conceptualize and treat a client, maintain that theory while you are in session. If you are continuing to jump around between modalities, your treatment will not be targeted or as effective. I tend to lean into solution focused therapy as it supports clients in assessing what they want, what they have, and how they can get closer to their goal. Although this theory can be used for grief, it is not always my go to for work around loss. I first see what the client is receptive to and individualize the treatment to make sure I am meeting them where they are at.
Ideas to Consider
As many therapists move closer to an eclectic approach, it is important to make sure that providers are still using therapeutic tools and conceptualizing the client in meaningful ways. We can not only be an empathetic person in the room, we must continue using directed treatment to support clients towards their goals.
Are there theories that you are familiar with that work well or did not work well for you? Do you feel like it is important to know your therapist’s theoretical orientation? Feel free to leave some thoughts below!
