A Comprehensive Resource for Christian Counselors

Counseling

Techniques

A Comprehensive Resource

for Christian Counselors

John C.

editor

Thomas

general

INSTRUCTOR MANUAL

Introduction

The purpose of the instructor manual for Counseling Techniques is to

present individuals with resources for teaching a course on practical counseling

techniques, as the name suggests. The manual is divided into three sections.

The first section is divided by chapter, covering each of the 28 chapters from

the book. Each chapter includes key terms, key points, student learning objectives,

a chapter summary, pedagogical suggestions, and a 25-question quiz. Key terms

and key points provide the reader with a quick overview of the chapter. Student

learning objectives delineate the general goals a student should have for mastering

the information in the chapter. Chapter summaries provide a brief summary of the

chapter, and pedagogical suggestions provide ideas for teaching the chapter’s

material to students. Finally, the chapter quizzes consist of 25 questions in the form

of fill-in-the-blanks, true/false, and multiple choice, with the answers bolded. In

the volume Counseling Techniques, every chapter is unique in its content and

length, and therefore the length for each part in this manual (key terms, points,

chapter summary, etc.) varies according to the chapter it reflects.

The second section consists of both a midterm exam and a final exam. Each

exam contains fifty questions taken from the chapter quizzes, with the answers

bolded. Study guides for both exams are available but not physically included in

this manual.

Finally, the third section contains two sample syllabi, one for a

Mon/Wed/Fri course and one for a Tue/Thurs course. Each syllabus includes a

short description, student learning objectives, and a sample schedule with

suggested readings, assignments, and quiz/exam dates.

It has been a joy and an honor to create these resources for Counseling

Techniques. I hope that this manual will be of help in teaching the valuable

information compiled in this volume.

Chelsea M. Breiholz

Table of Contents

Chapter overviews and components………………………………………………4

Midterm and final exams………………………………………………………...215

Sample syllabi……………………………………………………………………225

Chapter 1

Laying the Groundwork by John C. Thomas, PhD, PhD

Key Terms: SITs (strategies, interventions, and techniques), the technique

controversy, techniques, targets, practice-based evidence, client outcome, timing,

the person-of-the-counselor, schoolism, evidence-based treatment (EBT), Spirit-

infused counseling

Key Points:

• Research has shown SITs to be highly effective, but they are not without

controversy, as some prefer to focus on the counseling relationship over the

SITs.

• The purpose of SITs is to address the client’s particular goals, or targets.

• Although the terms strategies, interventions, and techniques are used

interchangeably, they technically have slightly different meanings, with

strategies being the most broad and techniques being the most specific.

• SITs are important, but the person of the counselor is more important.

• SITs are beneficial, but the therapeutic relationship and the Holy Spirit are

the gateways through which real, lasting change occurs.

Student Learning Objectives:

• To understand the potential arguments for and against the use of SITs

• To comprehend the purpose of SITs and to delineate the differences between

the terms strategies, interventions, and techniques

• To be able to explain the value of SITs, the value of the person of the

counselor, and the value of the Holy Spirit’s involvement in the counseling

process

Chapter Summary:

The use of strategies, interventions, and techniques (SITs) in the counseling

process is endorsed by the majority of counselors, according to current research;

some of them are learned in graduate school and others are learned out in the field.

However, research also suggests that there is still some controversy over the use of

SITs, mostly on the basis of philosophical stances. Famous existential icon Irvin

Yalom, for example, prefers to emphasize the personal, healing relationship with a

client as the main aspect of counseling rather than SITs. Others take a stance of

indifference towards SITs, wanting to merely follow whatever the current research

states as evidence-based practice. The author of this chapter, John Thomas, asserts

that the therapeutic relationship is not only a SIT in and of itself, but it is also the

gateway through which the use of all other SITs can be effectively employed.

The purpose of SITS are to address the myriad emotional processes and

issues that are the goals, or targets, of counseling. It is important to match the

appropriate SIT with the appropriate goal, just like correctly aiming an arrow at a

particular target. For Christian counselors, it is important to remember the target of

spiritual transformation and to be competent in various SITs related to this area.

The desired outcome of therapy, determined by the client, will serve as a guidepost

in helping the counselor consider which SITs would be most helpful for the client’s

particular goals.

Strategies, interventions, and techniques can and usually are used

interchangeably, but there are some differences among them. Strategies represent

the big picture, or the overall plan to achieve a certain goal, such as motivational

interviewing or self-awareness. Interventions are the specific plans to address

specific aspects of the goal(s), such as assigning homework or examining a client’s

beliefs. Techniques are the specific action steps taken within those interventions,

such as writing down maladaptive, untrue thoughts and replacing them with

healthy, true thoughts. It is important to consider the issue of timing as well, and

determine which particular SITs would be most effective for each client during

different times throughout the counseling process.

No discussion of SITs would be complete without discussing the person of

the counselor. Competence with SITs is important, but the person of the counselor

is more important, as the counselor is the gateway through which SITs enter into

the counseling process. The counseling profession does attract healthy individuals,

but it attracts unhealthy individuals as well, so it is crucial to pay attention to one’s

own psychological health as well and face any issues of our own when we become

aware of them. One’s values will come through in the counseling process both

implicitly and explicitly, so remembering to emphasize working on your own

person is necessary.

Although strictly adhering to particular schools of thought when it comes to

counseling has mostly gone out of style, it is still wise to have a solid, theoretical

base for conceptualizing the counseling process in a way that reflects one’s values.

The common factors movement has resulted in taking the “common factors”

among effective treatment modalities and incorporating them into practice when

appropriate; this is also referred to as being “eclectic,” a word which many

counselors today choose to describe their approaches. Although many techniques

originated from particular schools of thoughts, they themselves have potential to be

effective regardless of one’s personal theoretical inclinations. Specific

multicultural considerations are not often formally addressed in this book, but it is

wise for the reader to keep them in mind when studying and employing SITs as

well.

Research reveals a myriad of benefits to using SITs, but there is a

limitation—by themselves, they cannot create real change. This is similar to the

concept of preaching a technically well-crafted sermon that has no impact on the

audience. Between the action and the impact are the person of the counselor and

the person of the client, and for the Christian, also the Holy Spirit. SITs are empty

without the power of the therapeutic relationship and the power of the Holy Spirit.

The Holy Spirit works supernaturally in us, our clients, and in the counseling

process itself, and this sets Christian counseling apart. These elements all serve as

the foundation on which the use of the SITs is built.

There are six recommended guidelines to follow when considering the use of

SITs. As a Christian counselor, one must always evaluate them in light of a

Christian worldview and in light of truth to determine whether they are

appropriate, using both the Bible and current research. For example, mindfulness is

sometimes a controversial SIT, with some associating it with Buddhism only, and

others recognizing it as perfectly compatible with Christianity. One must also

determine if SITs are compatible with one’s own values; if they are not, they will

not be authentic and should not be used. It is also necessary to determine if SITs

align with your own theoretical views of counseling and conceptualizing human

functioning. One should always prioritize the well-being of the client, and make

sure the SIT is appropriate for the particular issue(s) being addressed. Finally, it is

wise to be flexible in one’s approach and to always explain the rationale behind

SITs to your clients, similar to the process of explaining informed consent.

In conclusion, although the different ways of viewing and employing SITs

may not always be shared by every counselor or researcher, research shows that

SITs are incredibly helpful and effective. Yet it is important to remember that SITs

are only tools, and the person of the counselor (and the Holy Spirit) is the gateway

through which they can create lasting change in the lives of clients.

Pedagogical Suggestions

• Have students either as a whole class or in groups discuss the pros and cons

of using techniques in therapy.

• Ask students to discuss or write about the differences between strategies,

interventions, and techniques as discussed in the book and to create their

own examples of each one.

• Ask students to discuss or write about ways in which their values, or a

counselor’s values, could be implicitly or explicitly expressed in the

counseling process; ask them to give specific, detailed examples to the best

of their abilities.

• Ask students which benefits of using SITs stand out to them the most (see p.

21 for a list of benefits and rationales) and why they view them as the most

important. Ask if they can think of any other possible benefits not listed in

the text.

• On page 23, the author states, “Knowing a Bible verse and having it well

formed in your mind and heart are quite different.” Have students discuss or

write about how these two things are different and to give specific examples

from their own lives.

• Discuss as a class if anyone feels there are any techniques not consistent

with Christian values and why.

• Have students discuss or write about the differences between Buddhist

mindfulness and Christian mindfulness, using their own current knowledge

and the information from the text on pages 23-24.

Chapter 1 Quiz (25 questions)

Fill in the blank

1. In opposition to the use of SITs, existentially-minded _________________

“asserts that counseling is a relationally driven enterprise rather than theory

or technique driven” (p.15). (Yalom)

2. _______________ are the big picture, the “modus operandi,” or plans of

action customized to meet a particular goal. (strategies)

3. ___________________ are the specifics of the plans used to address a

particular goal. (interventions)

4. ____________________ are the particular action steps used in working

towards a particular goal. (techniques)

5. Therapeutic skill is important, but _____________________ subsumes any

ability, theory, or technique. (the person-of-the-therapist)

6. ___________________ is the idea that one theoretical system is correct and

all other systems are incorrect, inferior, and/or irrelevant. (schoolism)

7. _________________________ looks at various components involved in all

or most of the effective treatments and incorporates these into the treatment

packages. (the common factors movement)

8. When mindfulness is conceptualized from its roots in _______________, it

involves an emptying of the mind, which is different from Christian

mindfulness. (Buddhism)

9. _________________________ involves knowing what you want to do or

need to do, so that you can have a clearer sense of how the session should

proceed and how to accomplish what is necessary to bring change.

(counselor intentionality)

10. The intended audience of this book is _________________. (graduate

students and/or counselors)

True or False

1. The therapeutic relationship itself is not considered a SIT. (T/F)

2. The measuring stick for counseling efficacy is client outcome, which is

defined ultimately by the counselor. (T/F)

3. A prerequisite of an effective intervention or technique is timing. (T/F)

4. The person of the counselor is the instrument and the tool by which therapy

happens. (T/F)

5. “Eclectic” is typically code for borrowing SITs from many schools of

psychotherapy. (T/F)

6. Techniques cannot be used appropriately and effectively unless they are

used within exclusive schools of psychotherapy only. (T/F)

7. Counseling is best defined as a collection of techniques. (T/F)

8. The collection of SITs in this book are meant to be a “cookbook” approach

to clinical work. (T/F)

9. Christian mindfulness is about maintaining a nonjudgmental and present

acceptance of awareness based on divine grace. (T/F)

10. Any SIT that makes you feel uncomfortable or is discordant with your

person should still be at least attempted if you feel it would be helpful. (T/F)

11. Each chapter of this book will include: a theology and psychology of the

topic; at least one case study, and then exemplary strategies, interventions,

and techniques. (T/F)

12. Counseling is an interpersonal process, meaning that it is the passive

involvement of two or more participants. (T/F).

13. The poem at the end of this chapter was written by St. Andrews. (T/F)

Multiple Choice

1. The analogy for SITs and goals used in the text involved using

______________ to hit targets

a. Balls

b. Darts

c. Knives

d. Arrows

2. Guidelines for using SITs, as discussed in the text, include all but ONE

of the following:

a) Ensuring that the SITs are consistent with you, the therapist

b) Determining if the SITs are consistent with a Christian worldview

c) Ensuring you have at least three Bible verses that support the SIT

you are planning to use

d) Considering the welfare of your client

Chapter 2

Evidence-Based Counseling by David Lawson, PsyD

Key Terms: EBT (evidence-based therapies), confirmation/selection bias,

health-management organizations (HMOs), Sigmund Freud, Hans Eysenck,

Sackett, eclecticism, diagnostic ability, self-care, Jeffrey Kottler, cognitive

behavioral therapy (CBT)

Key Points:

• Although for some EBTs have a poor reputation, research has shown they

are highly effective and necessary for the welfare of clients and the

validation of the counseling field.

• The genesis of the EBT movement is attributed to Freud, as he modeled his

own theory of psychotherapy after the medical model of his time.

• A research study by Eysenck, a 1960s researcher, was cited for many years

as evidence that therapy was ineffective, although this research has since

been discredited.

• EBTs are beneficial for the counseling field, as they help ensure the best

client welfare and allow the clinicians to create more effective treatment

plans due to the emphasis on accurate diagnosis.

• Lack of prevention, such as self-care, and inconsistency among therapists

are two problems that the EBT movement hopes to address in the future.

• However, EBT is not without its challenges in the research world, including

issues with validity, the use of secondary data, and regression towards the

mean.

• Evidence-based techniques and evidence-based therapists are two other EBT

movements worth paying attention to in the research.

Student Learning Objectives:

• To understand the reasons EBTs have a poor reputation and why they are

often poorly understood

• To be able to explain the origins of the EBT movement and the key

researchers/therapists involved

• To comprehend the benefits and value of EBTs

• To be able to list and explain the problems the EBT movement hopes to

address in the future and the three current challenges EBT faces in the

research world

• To develop a basic understanding of the other two EBT ideas mentioned in

this chapter, evidence-based techniques and evidence-based therapists

Chapter Summary:

The topic of evidence-based therapies (EBTs) is often viewed by both

authors and readers alike as unnecessary and uninteresting, in comparison to other

counseling-related topics; EBTs can have a reputation among graduate students

and young counselors as being “all about the money” and “heartless” due to their

association with insurance companies and limiting session numbers for clients.

Additionally, most counseling graduate programs provide poor research training,

leaving students unable to fully understand EBTs. Students are typically taught to

criticize research without looking for the strengths, and hence are primed to have a

rather negative, skeptical attitude towards it. However, there are actually many

benefits to EBTs and being able to study and understand them; these benefits will

be delineated and explored in this chapter, along with possible limitations.

The creation of the first EBT is attributed to Freud, simply because he

worked to make his model of therapy resemble the medical model that was

subscribed to by researchers during his time. EBTs are the way in which we are

able to study the field of counseling, and Freud’s contribution to their beginning

must be acknowledged, regardless of one’s feelings about his actual work. EBTs

also serve as evidence to defend the counseling field against those who claim it is

ineffective. One of the most famous examples is that of Hans Eysenck, a

psychological researcher in the 1960s who claimed that therapy did not work. He

said this based on a study he conducted where people who went to therapy were

compared to people who did not. The results of his study suggested that people

who went to therapy did not improve more than the control group and actually

even became worse. Today his research and methodologies have completely been

discredited, but his work was still referenced for many years as “evidence” that

therapy did not work.

Today, EBTs are beneficial for the field of counseling as well as for

insurance companies because they provide evidence for what is actually effective

in therapy. The medical world is based on EBTs as well, and this helps us avoid

reliance on tradition and word-of-mouth, one of the problems that attempts to

discredit our fields. When using EBTs in order to avoid this problem, Sackett and

colleagues (1996) recommend following three guidelines in the process of therapy:

developing your own clinical expertise, examining the evidence by reading current

research journals, and remembering that every client and situation are going to be

different and in need of unique relational approaches. Possibly the most important

benefit, however, is that clients will receive better care through the use of EBTs.

EBTs help counselors to focus more on theoretical frameworks behind different

treatments, and aid in the development of more effective treatment plans due to

greater focus on diagnostics. Furthermore, EBTs can help counselors and clients to

remain within the boundaries of the therapy and not develop unhealthy or

inappropriate relationships.

Students leaving graduate school often face obstacles to pursuing knowledge

of EBTs, such as being in debt, exhausted by reading, and state licensing

requirements for continuing education. However, proponents of EBTs hope that

instilling students with a hunger for knowledge and effective practice will help

motivate them to continue examining current research in the field. Emphasizing the

great need for prevention and the need for self-care, both in the medical world and

the psychological world, is also a way to help students recognize the importance of

understanding EBTs. There is much data on self-care, but it is rarely employed in

real life, and it is hoped that as EBTs continue to grow, more individuals will

utilize this important data. Yet another hope of EBT proponents is that EBTs will

help reduce the great amount of inconsistency that seems to be found in the

counseling world. This improvement in consistency could help counselors to avoid

using SITs that have no research support and may harm their clients, as in the case

of the rebirthing technique debacle where a client actually died.

Despite all the benefits previously described, David Lawson acknowledges

that the EBT world has its challenges. The first challenge is that therapy is still

primarily a relational experience, and thus forcing something so human and

dynamic into a research study is difficult; to use research terms, there are

challenges to internal and external validity. One cannot always be one-hundred-

percent sure that what is seen in research will actually translate to real life therapy.

The second challenge is that the counseling field uses secondary data rather than

primary data. This means that outcomes cannot be measured as objectively as

measuring the amount of a bacteria in the medical field. Most outcomes are

measured through questionnaires, and although consumer-response questionnaires

are helpful and do usually show that therapy is effective, those measures don’t

exactly tell us how, objectively, the therapy was effective. Finally, regression to

the mean is another challenge to EBTs. This concept simply means that over time

and repeated testing, numbers tend to gather towards a center point called the

mean. Mean regression interferes with statistical interpretation of study results,

thus making it even more difficult for us to know if the results are objectively,

certainly accurate in and of themselves.

Concerning the current state of EBT research, there are two issues that are

worth noticing: evidence-based techniques and evidence-based therapists. The idea

of evidence-based techniques is that with any certain type of therapy there are

specific techniques that are more effective than others. However, it can be argued

that this idea ignores the relational aspect of counseling and its impact on client

change. The idea of evidence-based therapists, a term coined by author David

Lawson himself, is that techniques alone are not enough, and different therapists

can have different results even if using the same technique for the same issue.

In conclusion, despite their reputation, EBTs are highly beneficial, and their

proponents are hopeful that they will continue to inspire students and counselors to

increase their research knowledge, consider prevention and self-care, and improve

counseling consistency in the field. Although there are challenges of validity, data,

mean regression, and personal opinions, EBTs have ultimately been shown to be

effective, and we should continue to immerse ourselves in research with an attitude

of curiosity and wonder.

Pedagogical Suggestions:

• As a class or in groups, have students discuss the reasons people are usually

reluctant to learn about or appreciate EBTs as stated in the beginning of the

text; ask if they relate to any of these reasons and if they have any

preconceived ideas or expectations about EBTs themselves.

• Using the text or even other resources as well, have students discuss or write

about all the possible pros and cons of EBTs and to make a text-supported or

research-supported argument for the side they lean towards most.

• On page 34, the text reads, “One of the great difficulties confronted in

medicine and even in the mental health community is the common reliance

on lore and tradition over evidence from our field.” Ask students to discuss

or write about any examples of this they have seen or experienced.

• Have students share with the class any personal examples of self-care and

how they have benefitted from it, either medically or psychologically. Also

ask if they have seen or experienced any examples of “self-care” that

actually did more harm than good (ex., Netflix binging) or ask if anyone

would like to make an argument for the benefits of these behaviors instead.

• Ask students as a class or in groups to give examples of

confirmation/selection bias from their own lives, things they have witnessed

or experienced, or even make up examples to illustrate this concept.

• Ask students to list multiple examples of primary and secondary data, and

ask if they have any ideas on how to help the counseling research field with

its secondary data problem.

• Have students write about or discuss the three challenges to EBTs listed in

the text and their views on each one, using the text to support their opinions.

Chapter 2 Quiz (25 questions)

Fill in the blank

1. Typical graduate research classes in counseling programs emphasize

criticizing the _______________ and downplaying the strengths of research

studies. (weaknesses)

2. One of the great difficulties confronted in medicine and even in the mental

health community is the common reliance on ______________ and

________ over evidence from our field. (tradition, lore)

3. One of the benefits of EBT is the way in which it

emphasizes_______________, which is the key to developing an effective

plan and an effective technique. (diagnosis or diagnostic ability)

4. A benefit of prescribing EBTs is the movement away from ____________

and towards a more cogent theoretical framework. (eclecticism)

5. The _______________ technique is listed in the text as an example of a

treatment unsupported by research that has therefore resulted in the death of

a client, illustrating the importance of EBTs and research-supported therapy.

(rebirthing)

6. _____________________ bias is the idea that we are all likely to see the

world from our own framework and deny or attack any other model that

challenges its ideas. (confirmation and selection)

7. This form of EBT, ___________________, highlights the fact that often

effective therapies have specific techniques that are more effective than

other techniques within the modality. (evidence-based techniques)

8. This form of EBT, ___________________, a term coined by

_______________, emphasizes the idea of the evidence-based therapist, as

therapists using the same technique for the same issue can produce

completely different results. (evidence-based therapists, Lawson)

True/False

1. EBTs give insight into what therapeutic modalities work, but they don’t

provide any guidance for use of what techniques might work with specific

populations. (T/F)

2. Sackett and colleagues define EBTs as the conscientious, explicit, and

judicious use of current best evidence in making decisions about the care of

the individual patient. (T/F)

3. The greatest benefit within the EBT framework is the greater care provided

to clients. (T/F)

4. EBTs create very little emphasis on diagnosis. (T/F)

5. One of the easiest, least concerning parts of therapy is preventing the

development of unhealthy relationships with clients and/or their unhealthy

dependence on the therapist. (T/F)

6. Although great volumes of data exist on self-care, the vast majority of

Americans rarely utilize it. (T/F)

7. The text lists binging on Netflix as a beneficial example of self-care. (T/F)

8. One challenge to EBTs is that the counseling field measures outcomes using

secondary data rather than primary data. (T/F)

9. Psychoanalytical studies are listed in the text as an example of why

regression towards the mean is a challenge for EBTs. (T/F)

10. EBT, while useful, is not the best way for therapists to research what works

in therapy and what does not. (T/F)

11. One limitation of EBT is that it negatively impacts psychotherapy’s

challenge of inconsistency and the often extreme variance found between

therapists. (T/F)

12. Internal validity and external validity are research challenges associated

with EBTs. (T/F)

Multiple Choice

1. According to the text, people are reluctant to read about or advocate for

EBTs because:

a) EBT study can feel unnecessary to those who work in such a relational

field.

b) EBTs sometimes have a bad reputation for “being all about money.”

c) Poor training in understanding research

d) Poor training in counseling

e) A, B, and C

2. The individual said to have initiated the EBT movement was:

a) Eysenck

b) Freud

c) Nietzsche

d) Sackett

3. This individual’s work, although currently discredited, was used for many

years to support the claim that therapy was ineffective:

a) Freud

b) Eysenck

c) Kotler

d) Rosenburg

4. Which of the following is NOT one of Sackett’s three key components of the

decision process for therapy with clients?

a) Clinicians must evaluate what evidence is available in best practice and

treatments.

b) Clinicians must know that the clinical expertise of the clinician is key.

c) Clinicians must remember that every client is unique and requires a

uniquely different way of engagement.

d) Clinicians must remember the importance of subscribing to current

research journals in the field.

5. Which of the following, if any, is NOT one of the challenges to EBT

proposed in the text by Lawson?

a) The active, dynamic process of therapy cannot be forced into a research

study.

b) In EBT research, we do not see or evaluate primary data.

c) Scores on outcome measures tend to regress towards the mean over time.

d) Tradition and lore are still effective in both the medical and

psychological fields, and therefore create doubt over the necessity of

EBTs.

Chapter 3

Cognitive-Based Strategies by Gary Sibcy, PhD, & John

C. Thomas, PhD, PhD

Key Terms: cognitions, cognitive behavioral therapy (CBT), schema, cognitive

rule, discovery, deconstruction/deactivation, development, socratic questioning,

goal setting, daily mood log, subjective units of distress (SUD) scale, magic button

technique, cognitive restructuring, discrimination training, downward

arrow/vertical arrow technique, experimental technique, cognitive-behavioral

analysis system of psychotherapy (CBASP), situational analysis (SA), Sibcy river

technique, the slice of time technique, the cost-benefit technique, externalization of

voices technique, problem-solving technique, survey technique, the reattribution

technique, the defining terms technique, the semantic method technique, the role

reversal technique

Key Points:

• Research has demonstrated that Cognitive Behavioral Therapy (CBT), based

on the philosophy that all problems are rooted in maladaptive cognitions, is

positively correlated with client outcomes, and many of the SITs utilized in

CBT have been shown to be highly effective.

• The psychology behind CBT is the idea that we all view the world through

filters called schemas, developed mostly through our early life experiences.

Cognitive rules, which utilize compensatory strategies, are the rules we

make up to protect our schemas from being triggered.

• This therapy fits very well with a Christian worldview, and the use of

Scripture as a basis for objective truth allows for a unique and deeper

impact.

• Cognitive SITs can be split into two main groups: traditional and third-wave.

The traditional group consists of the first two waves of cognitive therapy.

The first wave focuses mostly on behavior and the second wave focuses on

disputing cognitive distortions.

• The third wave of cognitive therapy focuses not on the content of a client’s

thoughts but how the client relates to his or her thinking, or the process. This

wave mainly consists of three methods, or stages: discovery,

deconstruction/deactivation, and development.

• Discovery is similar to assessment, and simply involves assessing the

cognitions of the client, particularly the maladaptive ones. Example

techniques include inventories, socratic questioning, goal setting, daily mood

logs, agenda setting, and the magic button technique.

• Cognitive restructuring is a common technique that can be used for all three

D stages; it helps clients to identify maladaptive cognitions, examine their

validity, and replace them with adaptive ones.

• Another type of cognitive restructuring is known as cognitive behavioral

analysis system of psychotherapy (CBASP), which analyzes triggering client

situations in a detailed manner.

• Deconstruction and deactivation techniques are aimed at helping to weaken

the client’s faulty or unhelpful cognitions.

• After faulty cognitions have been discovered and deactivated, they must be

replaced by developing healthy and truth-based cognitions.

Student Learning Objectives:

• To understand the psychology and theology behind CBT

• To be able to describe the differences between traditional and third-wave

CBT and the main people associated with them

• To comprehend the three different stages/methods of third-wave CBT and

gain a basic understanding of the variety of SITs associated with them

• To be able to explain the processes of cognitive restructuring and the therapy

of CBASP

Chapter Summary:

Cognition is a very broad term, referring generally to all the phenomena that

happen inside the mind. Research has demonstrated that Cognitive Behavioral

Therapy (CBT), based on the philosophy that all problems are rooted in

maladaptive cognitions, is positively correlated with client outcomes, and many of

the SITs utilized in CBT have been shown to be highly effective.

To understand the basics of CBT, it is important to consider both the

psychology and theology behind it. CBT holds to the assumption that all cognitions

are filtered; that is, rather than seeing the world the way it objectively is, we see

the world the way we are. We all interpret and experience the environment in

different ways. Clinically, this is known as having schemas. Schemas are core

beliefs learned through life experiences, particularly experiences during an

individual’s early life. Schemas are responsible for how we remember, how we pay

attention, and how we translate our experiences. The text cites the work of Young

(1998) who has created a list of eighteen basic schemas, a list commonly used as a

reference today. Although not exhaustive, the list includes schemas such as

emotional deprivation, self-sacrifice, abandonment/instability,

defectiveness/shame, and dependence/incompetence. Schemas generate associated

emotions and beliefs, such as “I am undeserving of respect.” Schemas also

generate cognitive rules, which usually go to the opposite extreme of the schema in

an attempt to protect the schema from being activated—for example, “I will

present myself in ways to get respect from others.” Cognitive rules then generate

compensatory strategies, which are the specific coping mechanisms one uses to

support the cognitive rule and ultimately the schema. In addition to the psychology

it is also important, as Christian counselors, to consider the theology behind CBT.

This therapy fits very well with a Christian worldview, and the use of Scripture as

a basis for objective truth allows for a unique and deeper impact. Scripture reveals

that our cognitions are tainted by sin from the Fall, but also that our cognitions can

be redeemed, beginning at salvation and continuing on in the process of

sanctification.

Cognitive SITs can be split into two main groups: traditional and third-wave.

The traditional group consists of the first two waves of cognitive therapy. The first

wave focuses mostly on behavior and the second wave focuses on disputing

cognitive distortions. The second wave is exemplified in two different ways in the

works of Ellis and Beck, two therapists who worked in the 1970s; Ellis emphasized

logic and examining maladaptive thoughts such as “should be” and “must be,”

while Beck highlighted cognitive distortions and correcting them. The third wave

of cognitive therapy focuses not on the content of a client’s thoughts but how the

client relates to his or her thinking, or the process. This wave mainly consists of

three methods, or stages: discovery, deconstruction/deactivation, and development.

Discovery is similar to assessment, and simply involves assessing the

cognitions of the client, particularly the maladaptive ones. Example techniques

include inventories, socratic questioning, goal setting, and daily mood logs, which

ask the client to record distressful events, rate their distress on a subjective units

(feelings) of distress (SUD) scale, and examine the thoughts behind their feelings.

Another discovery technique is agenda setting, which can actually be used in

all three D stages. The text discusses the ISTOP acrostic proposed by Burns to

delineate the steps: 1) invitation, which invites the client to make a change 2)

specificity, asking the client to be specific 3) troubleshooting, examining the

problem itself, and 4) openness, which examines the degree to which the client

wants to change. In regards to openness, there are two different types of resistance:

process resistance and outcome resistance. In process resistance, the client simply

doesn’t want to do the work a specific change requires. In outcome resistance, the

client does not want to face the consequences that changing the behavior or

cognition might create. Finally, the P in ISTOP refers to Plan, which involves

conceptualizing the problem into one of four categories: mood/anxiety, unwanted

habit or addiction, relationship problem, or no problem. After the problem is

conceptualized, the appropriate treatment plan and SITs can be considered.

Yet another discovery SIT is the magic button technique, also known as the

paradoxical cost-benefit analysis, which is a helpful way to address resistance. This

technique involves having clients imagine there is a magic button that would make

their problem disappear, and asking if they would press that button. Usually the

client will say yes, and so the counselor can then ask them to consider if there are

any disadvantages to pressing the button. According to the text, 90 percent of the

time clients say there are no disadvantages, and the counselor can gently make

suggestions.

Cognitive restructuring is a common technique that can be used for all three

D stages; it helps clients to identify maladaptive cognitions, examine their validity,

and replace them with adaptive ones. The technique begins with educating clients

about the nature of cognitions, schemas, and CBT, as described in the beginning of

this chapter. The counselor can use a cognitive distortion checklist to then help the

client examine his or her cognitions, and can also use Scripture as a basis for truth.

Through this process, the counselor can assist the client in identifying faulty

cognitions on their own, also known as discrimination training. The downward

arrow/vertical arrow technique and the experimental technique are two ways of

helping the client learn how to do this.

The downward arrow technique involves asking the client to temporarily

assume a particular cognition is true, and to ask a series of “if…then” questions,

such as “If ______ is true, what does that mean?” Judith Beck emphasizes that

asking what the thought means about the client rather than to the client will

ultimately lead to the underlying schema. The experimental technique involves

asking the client to conduct an experiment to examine the validity of a particular

cognition. If the client does find that a cognition is not true, it is then replaced with

a thought that is based on truth, and the counselor must help the client to turn the

new thought into an internalized habit through repetition and practice.

Another type of cognitive restructuring is known as cognitive behavioral

analysis system of psychotherapy (CBASP), which analyzes triggering client

situations in a detailed manner. Based on contemporary learning theory, CBASP

has been shown to be highly effective with mood problems and is the only current

EBT for chronic depression. Situational analysis (SA) is a helpful CBASP

technique in which clients examine their roles in relationships and determine if

their thoughts in a particular situation were helpful or unhelpful.

Deconstruction and deactivation techniques are aimed at helping to weaken

the client’s faulty or unhelpful cognitions. In the double-standard technique, the

counselor asks the client what they would say to someone they love who was in the

same situation they are. In the Sibcy river technique, clients learn that just because

they have a thought doesn’t mean that it’s true or that they even believe it. Clients

learn to visualize their thoughts, feelings, images, and sensations (TFIS) as floating

down a river while they stand on the bank and observe them. The slice of time

technique involves looking at a particular time/situation and examining the client’s

narrative during that time. The cost-benefit technique is self-explanatory and

involves examining the costs and benefits of a belief or thought. Other helpful

techniques include the survey technique, the reattribution technique, the defining

terms technique, the semantic method technique, and the role reversal technique,

which are explained in more detail in the text.

After faulty cognitions have been discovered and deactivated, they must be

replaced by developing healthy and truth-based cognitions. This process involves

problem solving. One example is the externalization of voices technique, where

you and the client take turns role-playing the dysfunctional thoughts. Another

example is a basic problem-solving technique in which the problem is identified

clearly, previous attempts to solve the problem are examined, a list of all possible

solutions are made and investigated, and a solution is ultimately chosen by the

client.

This chapter discussed a myriad of techniques that fall under the broad

spectrum of cognitive-behavioral therapy (CBT), typically seen as being divided

into three stages or methods of discovery, deactivation, and development, although

techniques can overlap among them. What all these techniques have in common is

that they belong to a methodology that has been shown to be evidence-based and

highly valuable in the counseling field; as Christians, it is especially important to

identify these unhealthy or untrue thoughts and replace them with the truth,

especially truth found in Scripture, as this is part of our lifelong process of

sanctification.

Pedagogical Suggestions:

• To illustrate the concept of schemas, provide the list of 18 schemas given by

Young in the text (pp. 45-46) and ask students to come up with a related

emotional statement (“showing sadness is a sign of weakness”) cognitive

rule (“I will present myself in ways to get respect from others”) and

compensatory strategies (“don’t reveal any vulnerable information that

might cause someone to disrespect you”) for each schema. Assign each

student a group of schemas to write about, or have the students break into

groups for discussion and assign a set of schemas to each group.

• Have students visit the website www.schematherapy.com and become

familiar with it. Free sample schema inventories are available, and students

may practice taking them if desired.

• Ask students to write about or discuss the similarities and differences

between Christian CBT and “secular” CBT, using information from the text,

other sources, the Bible, and life experiences, both real and/or hypothetical.

• Have each student, using the text, create a flow chart illustrating all the

different categorizations and techniques discussed in the chapter and how

they relate to each other. Encourage them to personalize it however their

brain understands the information best and to use colors or pictures or

whatever system they would like to illustrate CBT.

• Break students into pairs, and have students pick three techniques from the

chapter. Then each student will explain those three chosen techniques to

their partner, using as much detail as possible, as if their partner were a

client who had no prior knowledge of the techniques.

• Choose an imaginary faulty cognition such as “I am worthless because I got

a low grade on my exam at school” and have the class brainstorm and

explain different ways to address that cognition, using any technique or

combination of techniques from the text.

Chapter 3 Quiz (25 Questions):

Fill in the blank

1. _________ is a strategy for recognizing automatic thoughts, improving

problem solving, and developing emotional regulation skills. (Daily

mood log)

2. The ________________ technique involves asking the client to assume a

cognition is true and to then ask a series of “if….then” questions to

ultimately uncover an underlying core belief or schema. (downward

arrow/vertical arrow)

3. __________________ is recognized as the only evidence-based

treatment for chronic depression and is highly useful in helping clients

walk through many mood issues. (CBASP)

4. In the __________ technique, the therapist asks the client if or she would

use the same negative, perfectionistic, black-and-white patterns of

thinking to relate to a dear friend, e.g. “What would you say to a friend

who is in the exact same situation as you?” (double-standard

technique)

5. The _____________ technique is a role-play exercise whereby you

verbalize the client’s dysfunctional thoughts as accurately as possible

while the client attempts to counter your verbalizations with healthier and

more adaptive responses. (externalization of voices)

True/False

1. Maladaptive patterns of thinking are considered to be the root of all

problems, according to CBT. (T/F)

2. A.T. Beck’s approach to CT emphasized the functionality of thoughts,

and he was famous for creating the river metaphor. (T/F)

3. Ellis’s approach to CT was largely philosophical and examined client

logic, including maladaptive thoughts such as “I must be ______ in order

to be happy.” (T/F)

4. The third wave of CT is less concerned about the content of how a client

thinks and instead focuses on the relationship the client has with his or

her thinking. (T/F)

5. The river metaphor teaches clients to observe thoughts, feelings, images,

and sensations and then attach themselves to these experiences. (T/F)

6. Discovery involves activities aimed at gathering cognitive data from

clients. (T/F)

7. The first step in a daily mood log requires that the client describe a

distressful event in detail and then record the negative affect associated

with the event using the SVU scale. (T/F)

8. The second step in a daily mood log is for clients to explore the negative

thoughts associated with the identified afflicted feelings. (T/F)

9. The magic button technique is also known as paradoxical cost-benefit

analysis. (T/F)

10. Cognitive restructuring is a technique that should only be used in the

Development phase. (T/F)

Multiple Choice:

1. Which of the following are examples of cognitions, according to the text?

a) Attention

b) Beliefs

c) Expectations

d) Categorization of stimuli

e) All of the above

f) Only A and D

2. Techniques aimed at cognitions are directed primarily at which of the

following?

a) Building cognitive regulation skills

b) Correcting biases, errors, and distortions in information processing

c) Modifying problematic core beliefs and schemata

d) All of the above

e) None of the above

3. The main methods of third-wave cognitive therapy include all of the

following except:

a) Deconstruction/deactivation

b) Dissemination

c) Discovery

d) Development

4. Examples of discovery SITs include:

a) Goal setting

b) Inventories

c) Socratic questioning

d) Daily mood log

e) All of the above

f) Only A and D

5. The text uses the following acrostic to explain agenda setting:

a) ICANT

b) ISTART

c) ISTOP

d) IKNOW

e) IPHONE

6. Openness refers to a client’s willingness to address a problem. Which of

the following are types of resistance a client can have?

a) Outcome resistance

b) Consequence resistance

c) Process Resistance

d) A and C

e) B and C

f) None of the above

7. During the planning stage, a problem can be conceptualized as fitting into

one of four categories. Which of the following is NOT one of those

categories?

a) An unwanted habit or addiction

b) A relationship problem

c) No problem

d) A first-world problem

e) A mood or anxiety problem

8. _____________ distinguishes between asking what the thought means to

the client, which elicits an intermediate belief, and asking what it means

about the client, which usually uncovers the core belief.

a) A.T. Beck

b) Judith Beck

c) Burns

d) Leahy

e) None of the above

Chapter 4

Emotion-oriented Strategies by Todd Bowman, PhD

Key Terms: emotion, attachment, still-face experiment, relational soothing,

primary and secondary emotions, emotional awareness, attention to emotion,

emotional clarity, shame, guilt, connect and redirect, name it to tame it, SIFT,

specificity, sensitivity, empathy

Key Points:

• Bowman posits that our relationships with God and with our human primary

attachment figures determine our abilities to journey through our emotional

worlds.

• The “still face experiment” by Ed Tronick in the 1970s illustrates how a

primary attachment figure’s engagement affects an infant’s emotions. In this

experiment, the mother emotionally engages with the infant through

relational synchrony and then later becomes unresponsive, causing the infant

to scream in distress and eventually turn away in shame.

• Unhealthy behaviors, such as addictions and other harmful coping

mechanisms, emerge as individuals grow older and seek ways to assuage

distressful emotions that are too overwhelming for them to regulate on their

own; these behaviors are attempts at self-soothing, and they are aimed at

disconnecting people from the emotional experiences that feel too intense

for them to bear.

• Behaviors with “high primitiveness and high potential for novelty”

(Bowman, 2018) are prioritized by the brain, and hence the popularity and

highly addictive quality of sex, food, drugs, and media.

• However, human connection is still the most powerful form of emotion

regulation.

• Plutchik divides emotions into two categories of primary and secondary.

• Primary emotions are joy/sorrow, anger/fear, acceptance/disgust, and

surprise/expectancy, and sit on a spectrum that ranges in intensity.

Secondary emotions are combinations of primary emotions with other

emotions, and consist of love, submission, awe, disapproval, remorse,

contempt, aggressiveness, and optimism.

• The two aspects of emotional awareness are attention to emotion and

emotional clarity.

• Guilt refers mainly to remorse over one’s actions whereas shame refers to a

feeling that the self itself is defective and worthless.

• Another model of conceptualizing emotion is proposed by Jaak Panksepp,

who describes seven systems of neural circuitry: seeking, fear, rage, lust,

care, panic (separation distress), and play.

• Connect and Redirect is a part of Siegel and Payne Bryson’s model of

emotions; it is the idea that human connection, particularly in right-brain,

nonverbal ways such as facial expressions and touch, helps individuals to

“feel felt” and tune into their own emotional experiences.

• Another intervention by Siegel and Payne Bryson is called Name It to Tame

It, which is somewhat self-explanatory and involves using story to process

one’s emotions.

• The SIFT—sensations, images, feelings, and thoughts—model by Siegel is a

method of examining bodily sensations to help one identify one’s emotions

more accurately.

Student Learning Objectives:

• To understand attachment, the still-face experiment, the reasons for turning

to unhealthy behaviors and the power of human connection in emotion

regulation

• To be able to describe the emotional processing models (and associated

terms and SITs) of Plutchik, Panksepp, and Siegel and Payne Bryson

• To comprehend the differences between Shame and Guilt and provide

biblical examples

Chapter Summary:

Emotion comes from a Latin word meaning “to move” and is part of our

Imago Dei. In an attempt to examine the psychology and theology of emotion, one

must address the idea of attachment. In the beginning, God declared that it was

“not good for the man to be alone” (Genesis 2:18). God also is the ultimate secure

attachment relationship, as he reveals through his relationship with the Israelites

throughout the Old Testament. Bowman posits that our relationships with God and

with our human primary attachment figures determine our abilities to journey

through our emotional worlds.

The “still face experiment” by Ed Tronick in the 1970s illustrates how a

primary attachment figure’s engagement affects an infant’s emotions. In this

experiment, the mother emotionally engages with the infant through relational

synchrony involving eye-contact, prosody of speech, and exploring the

environment together. After this engagement, the mother “stills” her face and

becomes emotionally and physically unresponsive to the infant. At first the infant

is immediately distressed and makes repeated attempts to communicate and get the

mother’s attention. When the mother remains unresponsive, the infant’s cries of

distress escalate, until finally he turns away and hides his face, a physical gesture

embodying the emotion of shame. This response shows how shame, an emotion of

feeling deficient and defective, is from the beginning rooted in feeling

psychologically and emotionally cut-off from one’s primary attachment figure.

Unhealthy behaviors, such as addictions and other harmful coping

mechanisms, emerge as individuals grow older and seek ways to assuage

distressful emotions that are too overwhelming for them to regulate on their own;

these behaviors are attempts at self-soothing, and they are aimed at disconnecting

people from the emotional experiences that feel too intense for them to bear.

Behaviors with “high primitiveness and high potential for novelty” (Bowman,

2018) are prioritized by the brain, and hence the popularity and highly addictive

quality of sex, food, drugs, and media. However, human connection is still the

most powerful form of emotion regulation. Bowman provides the example of Jesus

on the cross telling his mother and his disciple John to turn to each other in John

19:26-27 to illustrate this concept of turning to another person when facing

difficult emotions. When we do this, we engage in a process known as relational

soothing, “in which shame is replaced with acceptance, fear is exchanged for a

deep sense of safety, sadness is lifted through the gift of presence, and pain is

soothed away by the outstretched arms of comfort” (Bowman, 2018). In the

counseling office, we as therapists have the opportunity to provide this experience

to our clients.

Once attachment is understood, it is important to find a definition of

emotion. Referring back to its Latin roots, Bowman (2018) offers the following:

“[emotion is] the psychological experience of being moved by a feeling toward

something the individual deems important” (p. 74). Bowman refers to Plutchik’s

1958 model as a way of conceptualizing emotion; Plutchik divides emotions into

two categories of primary and secondary. Primary emotions are joy/sorrow,

anger/fear, acceptance/disgust, and surprise/expectancy, and sit on a spectrum that

ranges in intensity. Secondary emotions are combinations of primary emotions

with other emotions, and consist of love, submission, awe, disapproval, remorse,

contempt, aggressiveness, and optimism. In order to regulate emotions effectively,

one must be aware of and be able to accurately identify the emotion, as well as feel

the emotion to the appropriate degree of intensity. The two aspects of emotional

awareness are attention to emotion and emotional clarity.

However, the emotion of shame is missing from Plutchik’s list, and

Bowman postulates that shame should be considered a primary emotion, and that it

is the opposite of attachment, highlighting the social nature of it. He also

differentiates shame from guilt, stating that guilt refers mainly to remorse over

one’s actions whereas shame refers to a feeling that the self itself is defective and

worthless. He illustrates this concept biblically with two stories: the story of Adam

and Eve eating the forbidden fruit in Genesis 3 and the story of Nathan using a

hypothetical story to confront David’s murder of Uriah in 2 Samuel.

Another model of conceptualizing emotion is proposed by Jaak Panksepp,

who describes seven systems of neural circuitry: seeking, fear, rage, lust, care,

panic (separation distress), and play. These are primitive emotions located near the

bottom of the brain in the limbic system and brainstem, similar to other instinctual

survival behaviors such as eating, implying they are perhaps of similar importance.

Concerning SITs that are helpful when working with emotions, a book by

Siegel and Payne Bryson entitled The Whole-Brain Child suggests a SIT called

Connect and Redirect, where Redirect refers broadly to client outcome. This is

simply the idea that human connection, particularly in right-brain, nonverbal ways

such as facial expressions and touch, helps individuals to “feel felt” and tune into

their own emotional experiences. Another intervention is called Name It to Tame

It, which is somewhat self-explanatory and involves using story to process one’s

emotions. This is simply where the client tells the story of his or her experiences

and externally processes with the counselor.

Finally, the SIFT—sensations, images, feelings, and thoughts—model by

Siegel is a method of examining bodily sensations to help one identify one’s

emotions more accurately. This is especially helpful when clients have difficulty

with emotional awareness, specificity, and sensitivity. Learning to tune into their

own emotional experience will help clients to increase their ability to empathize.

Pedagogical Suggestions:

• Have students write about or discuss biblical examples of attachment as

discussed in the text and how these examples build a case for God’s desire to

be a primary attachment figure for his people.

• Have students write about or discuss the still-face experiment and how it

relates to emotion regulation, unhealthy behaviors/addictions, and self-

soothing.

• Have students either in groups or as a class discuss the differences and

similarities between the Plutchik and Panksepp models of emotional

processing.

• Ask students to discuss or write about the differences between shame and

guilt and provide biblical examples, using the text, the Bible, and/or other

sources. Ask if they had thought of shame and guilt this way before reading

this chapter, and discuss how society often confuses the two and what the

implications are.

• Ask students to list the seven systems of neural circuitry proposed by

Panksepp and describe examples of each one for both infants and adults.

• Ask students to describe the Connect and Redirect technique, and the Name

It to Tame It technique, and to reflect on their own life experiences of these

dynamics in their relationships and how/if these experiences affected them.

• Ask students to come up with examples of bodily sensations that could

indicate certain emotions, according to the SIFT model.

Chapter 4 Quiz (25 questions)

Fill-in-the-blank

1. Emotion lies at the heart of ____________, the driving force inherent

within our most important human relationships. (attachment)

2. Our ability to navigate the wide range of emotions contained within the

human experience is shaped by the quality of our connection to

________ and to our primary attachment figures. (God)

3. ________________ is a process in which shame is replaced with

acceptance, fear is exchanged for a deep sense of safety, sadness is lifted

through the gift of presence, and pain is soothed away by the outstretched

arms of comfort. (relational soothing)

4. _______________ is defined as how much attention one gives their

affective state. (attention to emotion)

5. ________________ is defined as the extent to which one understands his

or her emotional experiences. (emotional clarity)

6. ____________ is a primary emotion, absent from the primary/secondary

emotions model, that could be considered as a gatekeeper emotion,

meaning its presence has the potential to overshadow other, less primitive

emotional states. (shame)

7. Bowman cites the story of Nathan and __________ in 2 Samuel as an

example of dealing with the emotional experience of guilt in the Bible.

(David)

8. _____________ is a SIT from Siegel and Payne Bryson’s model that

emphasizes the importance of nonverbal, right-brain connections in

identifying and eventually managing our emotional experiences.

(Connect and Redirect)

9. The ___________ model involves looking to the bodily sensations for

emotions that might be housed there. (SIFT)

True/false

1. The “still face experiment” begins with mothers and infants placed in a

room together, interacting with natural, connective behaviors known as

synchrony. (T/F)

2. The birth of shame manifests in the experience of becoming

psychologically cut off from one’s primary attachment figure, leading to

a sense of deficiency and inherent lack of worth. (T/F)

3. Bowman defines emotion as the psychological experience of being

moved by a feeling toward something the individual deems important.

(T/F)

4. Specificity is defined as identifying the emotion accurately. (T/F)

5. Sensitivity is defined as a synonym for sympathy. (T/F)

6. Strategies for emotion regulation depend on specificity as well as

sensitivity. (T/F)

7. Parker and Thomas (2009) write, “with shame, the self was pronouncing

judgement on its activity; with guilt, the self pronounced a more

summary judgement on the inadequacy of the self itself.” (T/F)

8. Panksepp’s model is a “bottom-up” model of emotional processing in the

brain, as opposed to a “top-down” model. (T/F)

Multiple Choice

1. The individual responsible for the “still face experiment” was:

a) Tronick

b) Plutchik

c) Panksepp

d) Lopez

e) None of the above

2. Our neurobiology is designed to prioritize stimuli with:

a) High potential for novelty

b) Greater familiarity

c) High primitiveness

d) A and C

e) A and B

3. An example of a stimulus that serves as an agent of self-soothing

mentioned in the text:

a) Food

b) Drugs

c) Sex

d) Money

e) A through C

f) All of the above

4. _______________’s 1958 model of emotion classifies emotions as

primary and secondary.

a) Lopez

b) Plutchik

c) Tronick

d) Panksepp

e) None of the above

5. Which of the following is NOT one of the four pairs of primary

emotional experiences?

a) Joy/sorrow

b) Trust/disapproval

c) Anger/fear

d) Acceptance/disgust

e) Surprise/expectancy

6. Emotional awareness is a valuable variable in accessing adaptive

emotion-regulation strategies and is comprised of two features:

a) Specificity and sensitivity

b) Attention to emotion and emotional clarity

c) Vulnerability and the therapeutic alliance

d) None of the above

7. Parker and Thomas identify the following as affective dimensions of

shame:

a) Anger

b) Lack of empathy

c) Aggression

d) Regret

e) A through C

f) None of the above

8. ______________ provide(s) a model for understanding neural circuitry

and its predisposition for emotional processing, namely, through seven

distinct yet interrelated systems.

a) Plutchik

b) Panksepp

c) Parker and Thomas

d) Bowman

e) None of the above

9. Which of the following is NOT one of the seven systems for

understanding neural circuitry and its predispositions for emotional

processing?

a) Seeking

b) Rage

c) Care

d) Trust

e) Play

Chapter 5

Emotional Dysregulation Strategies by Todd Bowman,

PhD

Key Terms: emotion regulation, alexithymia, externalizing behaviors, auto-

regulation, cognitive reappraisal, guided therapeutic imagery/visualization,

diaphragmatic breathing, autogenic phrases, progressive muscle relaxation,

expressive writing, relational regulation

Key Points:

• Bowman divides emotions into two categories: antecedent-focused, which

can be implemented before distressing emotions are experienced, and

response-focused, which can be utilized after the emotions are experienced.

• Neurobiology has a direct impact on one’s ability to regulate emotions.

• Two challenges to emotion regulation are alexithymia, lacking either

awareness and/or ability to verbalize emotional experiences, or externalizing

behaviors, using external stimuli to assuage distressful emotions.

• Alexithymia can be divided into categories, affective and cognitive.

• It is important to keep age and gender differences in mind when assessing

and teaching emotion regulation strategies with clients.

• A healthy way of assuaging distressful emotions, as opposed to externalizing

behaviors previously discussed, is known as auto-regulation, defined by

Bowman as “the organismic experience of adaptively and effectively

regulating emotion by drawing on the collectivity of internal resources,

including resiliency, strengths, and internal representations of primary

attachment figures” (Bowman, 2018, p. 93).

• Activating a person’s internal representation of God as a secure attachment

figure through spiritual exercises such as prayer and Scripture is one

beneficial way to help clients with auto-regulation skills.

• Cognitive reappraisal involves interpreting a situation in an alternative way

that could lead to a different emotional experience.

• Guided therapeutic imagery/visualization is another SIT that can be used for

auto-regulation, in which the counselor instructs the client to focus on

images intended to relax both the brain and body.

• Breathing exercises such as diaphragmatic breathing, autogenic phrases, and

progressive muscle relaxation are another beneficial set of SITs, increasing

emotional awareness, blood flow, and oxygen to the brain.

• Expressive writing is another SIT for emotion regulation, and involves free-

association writing, and typically involves a prompt concerning a situation

or experience.

• All of that being said, relational regulation is still the strongest form of

coping with emotions, “especially comforting, nonsexual touch, and gentle

tone of voice paired with affirming words” (Bowman, 2018, p. 108).

Student Learning Objectives:

• To understand the challenges and considerations involved with emotion

regulation, and its relationship to neurobiology

• To comprehend the relationship between auto-regulation and attachment

• To be able to describe the various SITs associated with auto-regulation

Chapter Summary:

In this chapter, Todd Bowman describes multiple SITs that are useful for

helping clients learn and improve their emotion regulation abilities. Emotions are a

gift from God, but they are meant to be stewarded well. Bowman divides them into

two categories: antecedent-focused, which can be implemented before distressing

emotions are experienced, and response-focused, which can be utilized after the

emotions are experienced.

Neurobiology has a direct impact on one’s ability to regulate emotions.

Ginot proposed that emotions are mainly housed in the right side of the brain, an

area that attachment strongly influences. Research shows that there is now strong

support for the idea that the brain and many of its functions are significantly

influenced by attachment and early life experiences.

Two challenges to emotion regulation are alexithymia, lacking either

awareness and/or ability to verbalize emotional experiences, or externalizing

behaviors, using external stimuli to assuage distressful emotions. Examples of

externalizing behaviors include alcohol, sex, drugs, media, and eating disorders,

among others. However, these externalizing behaviors provide short-term relief by

repressing emotions with a stronger stimulus and create long-term problems.

Stronger attachment bonds, however, are associated with less externalizing

behaviors and more adaptive emotion regulation abilities.

Alexithymia can be divided into categories, affective and cognitive. In the

therapeutic environment, the counselor can follow a three-step strategic process to

help clients who are struggling with alexithymia. This process involves helping the

client verbalize their situations, help them with cognitive appraisal, and help them

discuss their emotional responses. Psychoeducation can be helpful.

Before examining some alternatives to these common and maladaptive

externalizing behaviors, there are some preliminary considerations. Firstly, the

alternatives must be effective and contribute to an individual’s well-being both

short-term and long-term. Age and gender should also be considered, as research

has shown that young adults are more likely to use maladaptive coping strategies

than older adults. Additionally, one study found that teen boys and teen girls

scored differently on using emotion regulation strategies; boys scored higher for

positive thinking, cognitive restructuring, and acceptance, and the girls scored

higher for problem-solving, emotional expression, and rumination. It is important

to keep age and gender differences in mind when assessing and teaching emotion

regulation strategies with clients.

A healthy way of assuaging distressful emotions, as opposed to externalizing

behaviors previously discussed, is known as auto-regulation, defined by Bowman

as “the organismic experience of adaptively and effectively regulating emotion by

drawing on the collectivity of internal resources, including resiliency, strengths,

and internal representations of primary attachment figures” (Bowman, 2018, p.

93). Activating a person’s internal representation of God as a secure attachment

figure through spiritual exercises is one beneficial way to help clients with auto-

regulation skills. Prayer is one of the strongest ways that we can connect to God to

cope with emotional struggles; it can help us tune in to our internal representation

of him, if our attachment with him is secure. Scripture is also a helpful way of

connecting with God about our emotions, and can be particularly helpful if clients

do not yet have a secure internal representation of him. Scripture also allows us to

do our own form of cognitive restructuring, helping us base our thoughts on truth

and consider our emotional experiences in new ways.

Other SITs that can be used for auto-regulation include cognitive and

mindfulness-based exercises, which both seem to affect similar areas of the brain.

Cognitive reappraisal involves interpreting a situation in an alternative way that

could lead to a different emotional experience. The maladaptive opposite of this

technique is called excessive suppression, which involves the suppression of

emotional expression, as in putting on a “poker face.” Suppression, however, keeps

the emotion inside, whereas healthy regulation is able to release it.

Guided therapeutic imagery/visualization is another SIT that can be used for

auto-regulation. This technique is somewhat self-explanatory, and the counselor

instructs the client to focus on images intended to relax both the brain and body.

Bowman refers to Hall, Hall, Stradling, and Young (2006), who recommended five

considerations when using this guided imagery: client expectations/assumptions,

client readiness, timing, the physical environment, and any additional items that

may be needed such as paper. It is also important that the counselor informs the

client that he or she can stop the exercise anytime. Guided imagery can be a

beneficial coping method to replace externalizing behaviors that are harmful,

whether those behaviors were aimed at up-regulating or down-regulating.

Breathing exercises such as diaphragmatic breathing, autogenic phrases, and

progressive muscle relaxation are another beneficial set of SITs, increasing

emotional awareness, blood flow, and oxygen to the brain. As the most basic

breathing exercise, diaphragmatic breathing simply involves slowing down one’s

breath. Individuals who are chronically stressed and anxiety-ridden tend to breathe

fast and shallow, depriving their brains of oxygen, and this exercise can help their

bodies and brains relax. However, this may create a feeling of light-headedness or

dizziness for some who have not breathed slowly and deeply in a long time, so the

counselor should educate the client about these potential feelings in advance, and

also explain how diaphragmatic breathing can help with emotion regulation. This

slow breathing calms the sympathetic nervous system, the system responsible for

fight or flight emotions, and activates the parasympathetic nervous system, which

assists in relaxation. Autogenic phrases are a series of relaxing phrases focusing on

warmth and heaviness, repeated by the counselor to help clients regulate their

emotional state. Finally, progressive muscle relaxation involves repeatedly tensing

and relaxing each muscle group, helping individuals locate areas of tension and

release them.

Expressive writing is another SIT for emotion regulation, and involves free-

association writing, and typically involves a prompt concerning a situation or

experience. James Pennebaker is one of the researchers most associated with

expressive writing, his studies showing that the writing exercises resulted in higher

self-reported levels of emotional and physical well-being among undergraduate

college students. Bowman suggests that clients can use the SIFT model proposed

by Dan Siegel during the writing process to examine any sensations, images,

feelings, and thoughts that arise.

All of that being said, relational regulation is still the strongest form of

coping with emotions, “especially comforting, nonsexual touch, and gentle tone of

voice paired with affirming words” (Bowman, 2018, p. 108). Bowman provides a

story of the birth of his son to illustrate this concept, in which his son recognized

his voice and grew calm and quiet just minutes after being born. In the context of

the therapeutic relationship, the counselor can help the client regulate their

emotions through the power of relational connection.

Pedagogical Suggestions:

• Ask students to list as many examples of externalizing and internalizing

behaviors as possible and discuss ways in which they are maladaptive over

the long term; ask them to come up with a healthy behavior that is similar

and could be effective enough to replace each unhealthy one.

• Have students break into pairs and role-play a counselor and a client with

alexithymia, being sure to illustrate all five prominent features of

alexithymia and both the cognitive and affective factors. Have a few pairs

perform their dialogue in front of the class, and have their classmates write

on a piece of paper each time they notice one of the five features.

• Using the text and any other sources, have students discuss as a class or in

groups different ways to potentially incorporate the spiritual exercises of

prayer and Scripture into the counseling process.

• Have students break into pairs or triads and role-play counseling situations

involving cognitive reappraisal.

• Using the text and other sources, ask students to discuss any pros and cons

of guided imagery, diaphragmatic breathing, autogenic phrases, progressive

muscle relaxation, and expressive writing; ask students to brainstorm

potential counseling situations in which each exercise could be helpful.

• Ask students to discuss how they would go about assessing and increasing

relational regulation with their future clients.

Chapter 5 Quiz (25 questions):

Fill-in-the-blank

1. Emotion regulation is described as a family of emotion regulation

strategies that may be differentiated into _____________, when the

strategy intervenes before emotional responses are displayed, and

2. _____________, when the strategy intervenes after emotional response

patterns have appeared. (antecedent-focused, response-focused)

3. One’s capacity to regulate one’s emotional experiences well is directly

tied to one’s _______________. (neurobiology)

4. Alexithymia can be placed onto two dimensions: a(n) ____________

factor

5. and a(n) _______________ factor. (affective, cognitive)

6. ______________ can be conceptualized as the organismic experience of

adaptively and effectively regulating emotion by drawing on the

collectivity of internal resources, including resiliency, strengths, and

internal representations of primary attachment figures. (auto-regulation)

7. _______________ can be seen as the behaviors that increase the

individual’s perception of closeness in relationship with God and serve to

enhance their internal representation of him. (spiritual exercises)

8. Bowman uses the story of ___________ in the Bible to illustrate secure

attachment with God. (Hagar)

True/false

1. Emotional processing mostly involves left-brain experiences. (T/F)

2. The function of internalizing behaviors can be defined as “the use of

external stimuli to escape one’s current unpleasant emotional state.”

(T/F)

3. Emotion regulation can best be defined as “all of the processes, intrinsic

and extrinsic, through which individuals manage their emotions to

accomplish their goals.” (T/F)

4. The idea of an internal representation is of critical importance in the

process of auto-regulation. (T/F)

5. Prayer is the primary mechanism by which we spiritually connect to

emotionally redirect. (T/F)

6. When there is a healthy internal representation that can be drawn on in

times of stress, we are more inclined to manage our distress adaptively

and effectively. (T/F)

7. Cognitive-based and mindfulness-based approaches to emotional

regulation do not share overlapping regions of the brain. (T/F)

8. Cognitive reappraisal is defined as “interpreting a potentially emotion-

eliciting situation in a way that changes its emotional impact.” (T/F)

Multiple Choice

1. Examples of externalizing behaviors include:

a) Viewing pornography

b) Ruminating on situations

c) Disordered eating

d) Video games

e) All except B

f) All except C

2. Healthier attachment styles lead to:

a) Increased emotion regulation strategies

b) Reduction of externalizing behaviors

c) Increased coping

d) All of the above

e) None of the above

f) Only A

3. _______________ have a greater tendency to use acceptance as a strategy

for managing emotional situations, as opposed to maladaptive strategies.

a) Young adults

b) Older adults

c) Teen boys

d) Teen girls

e) Toddlers

4. ______________ scored statistically significantly higher in the use of

positive thinking, cognitive restructuring, and acceptance, whereas

______________ scored higher on problem-solving strategies, emotional

expression, and rumination.

a) Teen boys, teen girls

b) Teen girls, teen boys

c) Older adults, young adults

d) Young adults, older adults

5. Which of the following are listed as prominent features of alexithymia?

a) The reduced capacity for analyzing emotions

b) Difficulty verbalizing emotional experiences

c) Emotionalizing, or reduced ability to determine origins of emotions

d) Diminished fantasy life

e) All of the above

f) Only A and C

6. The spiritual SIT of __________ offers the individual an opportunity to

make a different meaning of her experience of emotion and to frame her

response in a different way.

a) Prayer

b) Scripture

c) Meditation

d) Mindfulness

e) All of the above

7. Which of the following are some results associated with cognitive

reappraisal?

a) Increased interpersonal functioning

b) Increased emotional well-being

c) Increased mood

d) Increased physical energy

e) A through C

f) All of the above

8. Perhaps the most foundational exercise that one can participate in to regulate

one’s emotional state is _____________

a) Progressive muscle relaxation

b) Diaphragmatic breathing

c) Guided imagery/visualization

d) Autogenic phrases

e) None of the above

9. _________________ is a series of phrases that have a degree of

suggestibility, with the goal of helping the client reach a state of deep

relaxation by adhering to the directions indicated in each progressive phrase.

a) Progressive muscle relaxation

b) Autogenic phrases

c) Diaphragmatic phrases

d) Visualization phrases

e) Auto-regulation phrases

Chapter 6

Behavioral Strategies by John C. Thomas, PhD, PhD

Key Terms: behavior therapy, behavior modification, behavioral regulation,

behavioral deficits/excesses, modeling, self-monitoring, shaping, successive

approximation, chaining, overlearning, the “act as if” technique, role-playing,

behavioral rehearsal, imaginal rehearsal, counterconditioning, exposure and

response prevention (ERP) techniques, behavioral contingencies, contingency

management, rewards, token economy, negative reinforcement, punishment,

penalty, extinction, extinction burst, aversion therapy, response cost, covert

sensitization

Key Points:

• Behavioral therapy, or behavior modification, addresses external behaviors

rather than internal processes, with the goal of assisting clients to develop

healthier actions.

• There are two types of maladaptive behaviors that this type of therapy seeks

to address, known as behavioral regulation and behavioral deficits/excesses.

• According to the Bible, our actions matter, but we are also more than our

actions.

• Modeling involves observing the behavior in another and imitating it, can be

divided into three categories—covert (imagining), symbolic or in vivo

(video, etc), and participant (real life)—and can also be accomplished

through role play.

• Self-monitoring is a way to keep track of behavioral progress, and involves

two steps: observing one’s behavior and then recording it using paper, an

app, or whatever form one desires to use.

• Shaping, or successive approximation, involves breaking a task or behavior

into smaller pieces that can be learned step by step.

• Chaining is a similar concept, but used for complex behaviors as opposed to

the more simple behaviors that can be learned through shaping.

• Overlearning can be used as a way to help clients master the new behavior

through repetition.

• The “act as if” technique is self-explanatory, and involves the client acting

as if the new behavior were already learned and mastered.

• Role-play is a broad term that includes such aspects as insight and attitude,

and behavioral rehearsal is a specific term that emphasizes learning a

particular skill.

• Altering existing behaviors can be addressed through counterconditioning,

exposure and response prevention (ERP) techniques, behavioral

contingencies, rewards, negative reinforcement, punishment and penalty,

and extinction.

Student Learning Objectives:

• To comprehend the Bible’s stance on actions/behavior, and how they are

important, but we are more than our actions

• To understand the different types of behavioral SITs that can be used to

address behavioral deficits and learn new skills

• To be able to explain the various behavioral SITs that can be used to alter

existing behaviors

Chapter Summary:

Behavioral therapy, or behavior modification, addresses external behaviors

rather than internal processes, with the goal of assisting clients to develop healthier

actions. There are two types of maladaptive behaviors that this type of therapy

seeks to address, known as behavioral regulation and behavioral deficits/excesses.

According to Thomas, deficits are defined as “behaviors or skills that are

underdeveloped in terms of frequency, intensity, or effectiveness” (Thomas, p.

111). Examples include poor hygiene and poor emotional intelligence. Excesses

are the opposite of deficits and include overeating, oversleeping, and compulsivity,

among others.

As Christians, it is necessary to consider the theology of behavior. The Bible

does state that our actions matter, and God commands us to engage in certain

actions and not engage in others. Yet, the Bible also tells us that we are more than

our actions. We are made in God’s image, we are connected to each other and our

environments, and we were created with agency and free will. Additionally, we

were made with complexity, and our behavior has potential to display on the

outside what is happening inside of us, as the Bible states that our heart is the

center of everything we do. Behavior can reflect our fallenness and can also be

deceptive, yet we also have the ability to control it.

One broad area of behavioral therapy is the learning of new behaviors,

which can be accomplished through a variety of methods. Modeling involves

observing the behavior in another and imitating it. Firstly, you as the counselor are

a model for your client. It is also helpful to help the client find another model in his

or her life, anyone who seems to model the target behavior well. Modeling can be

divided into three categories—covert (imagining), symbolic or in vivo (video, etc),

and participant (real life)—and can also be accomplished through role play.

Self-monitoring is a way to keep track of behavioral progress, and involves

two steps: observing one’s behavior and then recording it using paper, an app, or

whatever form one desires to use. There are many benefits to self-monitoring,

including establishing a baseline, increased external and internal awareness, and

efficiently tracking progress over time. Beforeusing this SIT, consider the client’s

readiness and ability to self-monitor effectively. Then, educate the client on the

details of the exercise.

Shaping, or successive approximation, involves breaking a task or behavior

into smaller pieces that can be learned step by step. Chaining is a similar concept,

but used for complex behaviors as opposed to the more simple behaviors that can

be learned through shaping. When implementing shaping, choose the target

behavior or goal, be sure not to under or over reinforce, and develop a list of

successive approximations and conduct a task analysis. A task analysis is also

known as a behavioral hierarchy, in which steps towards developing the target

behavior are written out in staircase form. During chaining, the same procedure is

followed for each small unit that makes up the complex behavior, and then each

time a new unit is learned, all previous units up to that point are reviewed.

Overlearning can be used as a way to help clients master the new behavior through

repetition.

The “act as if” technique is self-explanatory, and involves the client acting

as if the new behavior were already learned and mastered. Role-playing and

behavioral rehearsal are two other acting techniques that can be helpful for

learning new behaviors. Role-play is a broad term that includes such aspects as

insight and attitude, and behavioral rehearsal is a specific term that emphasizes

learning a particular skill. There are five stages involved in these SITs: informed

consent, choosing a goal, deciding the roles, playing the roles, and evaluating what

happened. Imaginal rehearsal is similar to behavioral rehearsal, and simply

involves the client imagining the behaviors occurring.

Altering existing behaviors can be addressed through counterconditioning,

exposure and response prevention (ERP) techniques, behavioral contingencies,

rewards, negative reinforcement, punishment and penalty, and extinction.

Counterconditioning involves creating a new emotional response, usually in

response to a feared or disgust-inducing stimulus, to replace an existing,

maladaptive emotional response. Exposure and response prevention (ERP)

involves repeated exposure to the unwelcome stimulus while preventing the usual

maladaptive response of fear, escape, disgust, or avoidance. This technique can be

very difficult and stressful for clients, and usually requires more time than the

standard therapy hour. Informed consent must also be discussed in detail as well.

Then, the counselor will teach the client relaxation techniques, create a hierarchy

of situations that are triggering for the client, and ask the client to rate the

situations on a subjective units of distress (SUD) scale, usually from 1 to 100.

After the actual treatment, it is also important to work on relapse prevention and

help the client practice the new behavior.

Behavioral contingencies, or contingency management, is a contract

between the counselor and client, where the counselor rewards the desired

behavior and punishes the undesirable behavior. The counselor can use a reward

system, such as a token economy, where a token is given to the client each time the

desired behavior is exhibited, and later the tokens can be exchanged for another

type of reward. Similarly, negative reinforcement can be used, which involves

strengthening a behavior by removing or avoiding an undesirable outcome. This is

commonly confused with the concept of punishment, which involves an unpleasant

consequence for the behavior one desires to weaken. Also similar, a penalty

involves meeting the target behavior with an uncomfortable consequence. These

types of therapy are also called aversion therapy. One type of aversive therapy

known as covert sensitization asks the client to imagine the behavior being met

with the unpleasant consequence. Extinction occurs when the behavior no longer

occurs, although it is not often recommended as a therapy technique because of the

difficulty level and length of time required, and is more effective if used in

combination with other techniques. Sometimes extinction occurs spontaneously

without an intervention as well.

Pedagogical Suggestions:

• Have students list as many examples as possible of behavioral deficits and

excesses; make it a competition to see who can list the most.

• Have students write an essay on the theology of behavior using the

information in the text, the Bible, and other sources.

• Have students break into pairs and choose one of the case studies from the

text. Then have them act out the case and its associated SITs as discussed in

the text as a way of practicing them. Students can also do this in triads so

that one of them can observe and give feedback.

• Ask students as a class or in groups to describe the differences between

shaping and chaining, and to provide examples of how each could be used in

a counseling context.

• Ask students in groups or as a class to come up with a hypothetical issue and

create a task analysis/behavioral hierarchy for addressing it.

• Have students break into pairs, one as the “counselor” and one as the

“client,” and have the “counselor” teach the “client” about role-play and

behavioral rehearsal. Then, have them actually walk through the process for

a hypothetical issue as practice.

• Have students study the ERP process, break into pairs or triads, and role-

play a counselor-client scene with a hypothetical issue to practice the

intervention.

• Ask students to break into pairs and secretly choose a SIT from the text.

Then have each pair role-play their SIT in front of the class and have the

students guess which SIT is being illustrated. Make it a competition and see

how quickly the audience can identify the SIT.

• Negative reinforcement, punishment, penalty, extinction, aversion therapy,

and response cost can be easily confused with each other. Ask students to

come up with creative ways to describe their differences, using examples if

desired. Make it a competition and have students vote on who came up with

the most creative descriptions.

Chapter 6 Quiz (25 Questions):

Fill-in-the-blank

1. Another generic term for behavioral therapy is ________________.

(behavior modification)

2. Problematic behaviors that can be addressed with behavioral therapy are

evident in two primary forms: ___________________ and

3. ___________________. (behavioral deficits/excesses, behavioral

regulation)

4. The ______________ technique involves learning new behavior by

considering the behavior a reality and anticipating it as expected. (act as if)

5. ___________________ is a technique used either to link aversive

consequences associated with the target or to perform target behaviors

through imagining them occurring. (imaginal rehearsal)

6. __________________ involves repeatedly facing one’s fear until it subsides

via the process of habituation. (exposure)

7. __________________ involves inhibiting the typical avoidance or escape

behaviors when in the presence of the negative stimulus. (response

prevention)

8. ___________________, a form of extinction, is a process by which the

behavior dissipates over time without intervention. (spontaneous recovery)

True/False

1. Behavioral deficits describe behaviors or skills that are underdeveloped in

terms of frequency, duration, intensity, or effectiveness. (T/F)

2. Whereas chaining is appropriate for learning simple behaviors, complex

behaviors require shaping. (T/F)

3. A behavioral hierarchy involves constructing a staircase outlining the

situations that can lead to skill development, and ranking the items to move

from least complex to greater complexity. (T/F)

4. Overlearning occurs by taking a repetitive and multifaceted approach to

mastering a new behavior. (T/F)

5. People often use the terms role playing and behavioral rehearsal

interchangeably, though they are different. (T/F)

6. Behavioral contingencies, or contingency management, is a behavioral

contract between you and the client who wishes behavioral change or needs

to be changed. (T/F)

7. One use of rewards is called contingency management, which rewards

clients when they display desired behaviors. (T/F)

8. Extinction is more effective when combined with other techniques that

stimulate and simultaneously reinforce alternative appropriate actions such

as positive reinforcement. (T/F)

9. Whereas penalty applies pain and unpleasantness, punishment applies loss of

comfort. (T/F)

Multiple Choice

1. Which of the following statements is mentioned by Thomas when describing

the theology of behavior?

a) We are interconnected with the environment around us.

b) We were created with moral freedom and personal agency.

c) Behavior is soul language.

d) All of the above

e) Only b and c

f) None of the above

2. Categories of modeling include all of the following except:

a) Participant

b) Observer

c) In vivo/symbolic

d) Covert

e) None of the above

3. Benefits of self-monitoring include:

a) Decreasing or increasing a behavior due to enhanced awareness

b) Becoming aware of internal experiences

c) Measuring change over time

d) All of the above

e) None of the above

f) Only a and c

4. Which of the following is NOT a stage involved in role-playing?

a) Choice of scenario and identification of the goal

b) Informed consent and client motivation

c) Evaluation and feedback

d) Assessment and catharsis

e) None of the above

f) All of the above

5. Substituting a new response (unconditioned response) for a previous

response (conditioned response) and helping a client lessen anxiety by

relating to a stimulus of anxiety differently is known as:

a) Imaginal rehearsal

b) Covert sensitization

c) Counterconditioning

d) Covert behavioral rehearsal

e) None of the above

6. ____________________ occurs when a behavior or response is strengthened

by removing, stopping, or avoiding an aversive stimulus or unpleasant

outcome.

a) Behavioral contingency

b) Negative reinforcement

c) Punishment

d) Penalty

e) None of the above

7. ____________________ occurs when the consequences of a behavior

decrease the likelihood that the behavior is repeated; that is, it weakens the

behavior.

a) Negative reinforcement

b) Punishment

c) Penalty

d) Response cost

e) None of the above

8. A form of aversive therapy, ___________________, requires that clients

imagine scenes that pair the undesired behavior with a highly unpleasant

consequence.

a) Covert sensitization

b) Response cost

c) Imaginal rehearsal

d) Negative reinforcement

e) None of the above

Chapter 7

Behavioral Dysfunction Strategies by Stephen P. Greggo,

PsyD

Key Terms: behavioral dysfunction, self-control, dysfunctional behavior,

behavior, sins of commission, sins of omission, motivational dialogue, change

conspiracy, unconditional positive regard, motivational interviewing, change

partnership, CATs, informational support, emotional support, instrumental support,

Celebrate Recovery, Alcoholics Anonymous, behavioral assessment, the A-B-C

assessment technique, mindfulness, Acceptance and Commitment Therapy (ACT),

willingness, FSD, rapid assessment instruments (RAIs), self-monitoring, reciprocal

inhibition, systematic desensitization, skill deficit, performance deficit

Key Points:

• The purpose of behavioral dysfunction strategies is to address maladaptive

and entrenched habitual behavior patterns.

• From a biblical perspective, the spiritual fruit of self-control is central to

dealing with unhealthy behaviors.

• Greggo (2018) defines self-control as “a series of small, nearly involuntary,

rapid-fire, life-affirming decisions” (p. 136).

• The SITs discussed in this chapter are compatible with a Christian view of

dysfunctional behavior and are also the building blocks for addressing these

issues in an evidence-based way.

• Motivational dialogue involves combining the unconditional positive regard

concept from Rogers with a technique known as motivational interviewing

(MI), for the purpose of partnering with the client in a change-conspiracy.

• Motivational interviewing was developed by William Miller and Stephen

Rollnick, and is a way of asking questions and creating dialogue where the

clients can talk themselves into making the changes they desire.

• It is also important to consider social support as clients are moving towards

making changes. There are three types of support: informational, emotional,

and instrumental, which concerns the ability of others to help with coping

and moving forwards in life.

• Behavioral assessment most commonly involves the A-B-C technique,

where the counselor helps the client to identify the antecedent (A), behavior

(B), and consequence (C) so that the problem can be analyzed in detail.

• Learning mindfulness techniques can help clients build self-awareness to

assist in the recording of behaviors.

• Willingness, a skill borrowed from Acceptance and Commitment Therapy

(ACT), involves being willing to let the distressing emotions happen instead

of trying to avoid them or deny them.

• Rapid assessment tools (RAIs) are extremely useful for assessing behavioral

struggles; they are brief, research-supported questionnaires, and many of

them are available for free in section 3 of the DSM-5 or on the DSM’s

website.

• Reciprocal inhibition is the idea that a maladaptive behavior pattern can be

decreased by learning a healthy, competing behavior pattern.

• Systematic desensitization is one technique that can be used for a wide

variety of struggles including anxiety and anger, teaching the client to relax

his or her muscles at will and thereby decrease arousal.

• It is paramount that the counselor discover and affirm the client’s own

personal motivation for making changes and help him or her to be patient

and cultivate self-control, as lasting change takes time.

Student Learning Objectives:

• To be able to explain the biblical view on self-control and dysfunctional

behaviors, referencing Scripture

• To understand the processes and concepts involved in motivational dialogue,

particularly the role of motivational interviewing (MI)

• To comprehend behavioral assessment and its associated techniques

• To be able to describe reciprocal inhibition and the concept it is based on

Chapter Summary:

The purpose of behavioral dysfunction strategies is to address maladaptive

and entrenched habitual behavior patterns. From a biblical perspective, the spiritual

fruit of self-control is central to dealing with unhealthy behaviors, for as Proverbs

25:28 states, “like a city whose walls are broken through is a person who lacks

self-control.” However, self-control is not willpower or strong internal fortitude, as

many believe it to be. Greggo (2018) defines self-control as “a series of small,

nearly involuntary, rapid-fire, life-affirming decisions” (p. 136). These little

decisions eventually add up to the big changes or actions that are typically

associated with having self-control.

Sins can be divided into acts of commission or acts of omission, and using

broad, generic language when discussing behavioral dysfunction is helpful because

it can include both types of sin. Additionally, the use of broad language allows the

strategies to be applied at any developmental stage, and can include a very wide

range of behaviors. The SITs discussed in this chapter, therefore, are compatible

with a Christian view of dysfunctional behavior and are also the building blocks

for addressing these issues in an evidence-based way. The particular SITs that are

recommended in this chapter are motivational dialogue, assessment, and reciprocal

inhibition.

Motivational dialogue involves combining the unconditional positive regard

concept from Rogers with a technique known as motivational interviewing (MI),

for the purpose of partnering with the client in a change-conspiracy. Although

extremely basic, it is important for the counselor to remember that showing

empathy and understanding towards the client is crucial for the client to start

believing that change is possible, which is the goal of motivational interviewing.

Motivational interviewing was developed by William Miller and Stephen Rollnick,

and is a way of asking questions and creating dialogue where the clients can talk

themselves into making the changes they desire. The counselor asks questions such

as “What is awakening in you to want to make this change at this point in your

life?” teasing out the client’s own values and motivations for change. The Holy

Spirit’s influence can be discussed as well, if the clients are Christians. The Bible

discusses the importance of putting on new, healthy behaviors and putting off

destructive ones. The counselor can do this by using MI and pointing out to the

client anything he says that supports commitment, activation, or taking steps,

known as CATs. When clients hear themselves speaking about CATs out loud,

they are more likely to put their words into actions and start putting off the old and

putting on the new.

It is also important to consider social support as clients are moving towards

making changes. There are three types of support: informational, emotional, and

instrumental, which concerns the ability of others to help with coping and moving

forwards in life. The counselor can provide these types of support, but the client

will need other people as well. Different types of therapy groups or self-help

groups can be considered, as well as recovery groups like Alcoholics Anonymous

(AA) or Celebrate Recovery (CR), a Christian step group that is similar to AA but

addresses a wide range of struggles from eating disorders to self-hate.

Another SIT is behavioral assessment for the purposes of increasing

awareness, intervention, and prevention. Most commonly, an A-B-C technique is

used, where the counselor helps the client to identify the antecedent (A), behavior

(B), and consequence (C) so that the problem can be analyzed in detail. It is also

important to use this technique to find exceptions to the problem, or situations

when the problematic behavior does not occur, to help ignite hope that change is

possible. In order to do this, it is wise for the client to spend a few weeks recording

the behavior to gain more information.

Learning mindfulness techniques can help clients build self-awareness to

assist in the recording of behaviors. In addition to recording external information

on frequency, severity, and duration (FSD), clients can learn to record internal

information on their emotions as well. Willingness, a skill borrowed from

Acceptance and Commitment Therapy (ACT), involves being willing to let the

distressing emotions happen instead of trying to avoid them or deny them. Then,

the client is able to make a decision to act according to his or her values rather than

reacting to their inner turmoil. Additionally, rapid assessment tools (RAIs) are

extremely useful for assessing behavioral struggles; they are brief, research-

supported questionnaires, and many of them are available for free in section 3 of

the DSM-5 or on the DSM’s website. These mini assessments are usually criterion

referenced rather than norm referenced, meaning that they reveal information about

the client himself rather than the client compared to the general population. All of

these techniques can help clients prepare for making changes in their lives.

Finally, reciprocal inhibition is the idea that a maladaptive behavior pattern

can be decreased by learning a healthy, competing behavior pattern. This is based

on the concept that two competing behaviors or states cannot exist at the same

time, such as physiological tension and relaxation. Systematic desensitization is

one technique that can be used for a wide variety of struggles including anxiety

and anger, teaching the client to relax his or her muscles at will and thereby

decrease arousal. Sometimes clients may simply be struggling with skill deficits,

such as a lack of adequate social skills, that make it difficult to cease a

dysfunctional behavior. In these cases, psychoeducation and support can be

extremely beneficial as the counselor helps the client learn new skills. Sometimes a

client does possess the appropriate skills but does not use them in every situation

where they are needed; in these cases, following all three SITs discussed in this

chapter in order—MI, assessment, and reciprocal inhibition—is recommended.

Throughout this process, it is paramount that the counselor discover and affirm the

client’s own personal motivation for making changes and help him or her to be

patient and cultivate self-control, as lasting change takes time.

Pedagogical Suggestions:

• Have students as a class list as many behavioral dysfunctions as possible for

which they think the techniques in this chapter would be helpful.

• Ask students in pairs or as individuals to create their own imaginary case

study illustrating one or several of the techniques discussed in the chapter;

students may role-play their case studies for the class, if desired, and the

class could provide thoughts and feedback.

• Have students write a brief essay, or a few paragraphs, describing the

Bible’s view on behavior and self-control, using the text, Scripture, and/or

other sources.

• Ask students to divide into triads and role-play the case study mentioned in

the text to better understand the associated SITs, or discuss the case study as

a class; have students create two columns for the SITs used with Alex and

with Bernice, and then explain the rationale for each one. Ask students if

they can think of any additional SITs that could be useful for this case.

• Have students break into pairs or triads (if an observer is desired) and

research motivational interviewing online. Then, have them practice

motivational interviewing questions on each other.

• Ask students to list concrete examples for each type of social support

mentioned in the text to better understand each one: informational,

emotional, and instrumental. Ask them how they would go about helping a

client locate and utilize each type of support, and how they could also

provide each type themselves as a counselor.

• Assign students to visit a local Alcoholics Anonymous, Celebrate Recovery,

or other similar support group and write a report about what they learned.

Discuss as a class.

• Have students break into pairs and play the roles of counselor and client.

Have the “client” create an imaginary issue and the “counselor” practice

using the A-B-C assessment technique, then switch roles and repeat.

• As homework, have students choose a behavior from their own life that is

relatively mundane (such as watching too much NetFlix or drinking too

much coffee) but that the student would like to change, and use the A-B-C

model (and other behavioral assessments discussed in the chapter if desired)

to track and record the behavior over the course of a week or two. Then,

have them share any insights they gained with the class, or write about them

in a report or essay.

• Have students familiarize themselves with section 3 of the DSM-5 and the

DSM website (the RAIs). Have students break into pairs and role-play

giving the assessments to each other as counselor and client (and interpret

the results afterwards), for the purposes of becoming comfortable with them

and understanding how they work.

• Ask students as a class to think about reciprocal inhibition and come up with

a list of potential competing behaviors for various dysfunctional behavior

patterns.

Chapter 7 Quiz (25 questions):

Fill-in-the-blank

1. ___________ is described as a series of small, nearly involuntary, rapid-fire,

life-affirming decisions. (self-control)

2. When clinicians use the term ___________, they mean observable, overt

action as well as covert happenings, that is, internal activity. (behavior)

3. In ______________, a change partnership is formed with the client by

locating and surfacing what the client currently values, desires, and is ready

to do. (motivational interviewing)

4. _______________ support describes how the involvement of others

increases coping skills, endurance, or the momentum to push forward.

(instrumental)

5. ______________ support is guidance from others about resources,

perspectives, or practical opportunities. (informational)

6. In the A-B-C assessment technique, the A stands for ________________.

(antecedents)

7. _____________ entails accepting and letting inner states, even drastically

uncomfortable ones, occur instead of avoiding them in various ways.

(willingness)

8. _____________ is a term carried over from the first wave of behavior

therapy, denoting two contradictory or incompatible physiological

responses. (reciprocal inhibition)

True/False

1. This chapter aims at helping therapists foster change in deep-seated and

troublesome habits. (T/F)

2. Motivational interviewing (MI) is a style of dialogue in which the counselor

talks the client into change. (T/F)

3. The abbreviation CAT stands for commitment, activation, or taking steps.

(T/F)

4. Celebrate Recovery is a step group for Christians that bears little

resemblance to other step groups such as Alcoholics Anonymous. (T/F)

5. When using assessment techniques, a deliberate effort should be made to

notice exceptions or breaks in the ordinary unwanted behavioral chain. (T/F)

6. Rapid assessment interventions (RAIs) are norm based rather than criterion

based. (T/F)

7. The treatment principle based on reciprocal inhibition is that it is feasible to

decrease undesired behavior by increasing a competing one. (T/F)

8. Anger management protocols often make use of systematic desensitization,

because anger is often accompanied by a physiological state of arousal.

(T/F)

9. Counselors strive to affirm and fortify a client’s own recognition and

motivation that change is possible. (T/F)

Multiple Choice

1. Greggo discusses the spiritual fruit of ____________, and in Proverbs the

lack of it is compared to a city whose walls are broken through.

a) Patience

b) Self-control

c) Peace

d) Faithfulness

e) None of the above

2. Benefits of using generic behavioral language, according to the text, include:

a) Strategies can be applied nicely across the full developmental lifespan.

b) Behaviors can be captured theologically as sins of commission or

omission.

c) Personal interpretations and applications can be utilized by the counselor.

d) All of the above

e) Only A and B

f) Only A

3. Motivational interviewing (MI) was developed by:

a) Miller and Rollnick

b) Greggo and Egan

c) Rogers

d) Saddleback Church

e) Alex and Bernice

4. Which of the following is a type of social support mentioned in the text?

a) Informational support

b) Technical support

c) Emotional support

d) Instrumental support

e) Physical support

f) A, C, and D

g) A, C, and E

h) All of the above

5. Becoming aware of fluctuating inner states so that a more deliberate course

of action can be taken is known as:

a) Acceptance and Commitment Therapy (ACT)

b) Mindfulness

c) Willingness

d) The A-B-C technique

e) Magic

6. ______________ is an example of reciprocal inhibition in action.

a) Acceptance and Commitment Therapy (ACT)

b) Progressive muscle relaxation

c) Systematic desensitization

d) Mindfulness training

e) All of the above

f) None of the above

7. When a client possesses a skill but does not use it in every situation in which

it is needed, this is known as:

a) Skill deficit

b) Skill excess

c) Performance deficit

d) Action deficit

e) None of the above

8. When a client possesses a skill but does not use it in every situation in which

it is needed, the best approach, according to the text, is:

a) Motivational dialogue followed by assessment and reciprocal

inhibition

b) Motivational dialogue followed by reciprocal inhibition

c) Psychoeducation and support

d) Psychoeducation, motivational dialogue, and assessment

e) None of the above

Chapter 8

Experiential Strategies by John C. Thomas, PhD,

PhD

Key Terms: experiential strategies/techniques, ordeal therapy, sculpting,

process, parables, metaphors, phototherapy, sand tray, psychodrama, equine

therapy, wilderness and adventure therapy, props, provocation, exaggeration,

paradox, jesting, life and trauma egg, angel egg, rituals, experiential writing

techniques, insight journaling, experiential vocalizing technique, voice therapy

Key Points:

• The purpose of experiential strategies is to draw out deep inner issues and

emotions, and to thereby help clients grow in self-awareness.

• In 1984, Haley created ordeal therapy, in which an inconvenient, difficult,

and undesirable ordeal is constructed for the client to perform every time the

issue emerges. The intent is for the ordeal to be so irritating that the client

gives up or decreases the frequency or severity of the issue in order to avoid

the ordeal.

• Thomas (2018) points out that both God and the prophets use various

“ordeals” or other experiential techniques throughout the Bible as a way of

addressing maladaptive behaviors.

• There are many benefits to using experiential strategies, and they can be

used with all populations and with all types of therapeutic methodologies.

• It is important to be willing to ethically move outside one’s comfort zone

when considering or using these techniques, as many of them are bold and

different from the norm.

• Examples of experiential strategies include parables and metaphors, writing

activities, phototherapy, poetry, music, art, sand trays, dance, sculpting,

psychodrama, equine therapy, wilderness and adventure therapies, using

props, using directives, and using ordeals.

• Metaphors and parables can be created by either the counselor or the client,

and they can be spoken or written. There are two types of metaphors: story-

telling and process-depicting.

• Provocation involves using unconventional techniques to “provoke” a client

to discover/reveal a deeper issue that is outside the client’s conscious

awareness.

• Examples of prevocational techniques include playing devil’s advocate,

siding with the client’s assertions, exaggeration, paradox, jesting, sarcasm,

putting the client in a crucible, and suggesting ridiculous ideas or solutions.

• The life and trauma egg originates from Murray’s and Carnes’s 1997 work,

and involves drawing an egg with symbols inside of it to represent different

traumatic events in a client’s life.

• There are also expressive experiential techniques such as creative writing,

journaling, insight journaling (in which the client journals about himself),

letter writing, and poetry.

• Additionally, the experiential vocalizing technique, or voice therapy, was

developed by Firestone in 2001, and helps clients to vocalize their inner

critic and thereby release internal emotions.

• Music and art can also be helpful experiential techniques, and younger

generations in particular seem to desire these types of nonverbal expression.

Student Learning Objectives:

• To understand the purpose, benefits, hesitations, and preparatory skills

involved in experiential strategies

• To be able to explain the use of experiential strategies throughout the Bible

and to provide scriptural examples

• To be able to describe the various experiential strategies discussed

throughout this chapter and any steps, guidelines, or benefits involved

Chapter Summary:

The purpose of experiential strategies is to draw out deep inner issues and

emotions, and to thereby help clients grow in self-awareness. Other words that are

sometimes used interchangeably with experiential include unconventional,

nontraditional, creative, and prevocational. Experiential strategies address

experience, which includes both internal and external, and are well-supported by a

Christian worldview.

In 1984, Haley created ordeal therapy, in which an inconvenient, difficult,

and undesirable ordeal is constructed for the client to perform every time the issue

emerges. The intent is for the ordeal to be so irritating that the client gives up or

decreases the frequency or severity of the issue in order to avoid the ordeal.

Thomas (2018) points out that both God and the prophets use various “ordeals” or

other experiential techniques throughout the Bible as a way of addressing

maladaptive behaviors. Moses, Jacob, and Abraham all received experiential

treatment from God, as did Elijah and Naaman. Jesus used several experiential

techniques through his miracles and teachings. Worship itself can also be seen as

an experiential activity.

There are many benefits to using experiential strategies: (1) they engage all

of the senses at once; (2) the client’s experience can be directly observed in the

session; (3) experience is the best way to learn; (4) abstract concepts can be made

concrete for clients; (5) they create greater self-awareness and insight; (6) they can

clearly emphasize a point; (7) they foster healing by increasing intensity; (8) they

work beneath the surface of conscious awareness, decreasing resistance; and (9)

they can foster spiritual growth. They can be used with all populations and with all

types of therapeutic methodologies.

It is important to be willing to ethically move outside one’s comfort zone

when considering or using these techniques, as many of them are bold and

different from the norm. Cultivating creativity and versatility are necessary, as well

as furnishing one’s office with several types of props such as cups, shields, paper,

or extra chairs. Timing is important, but the client’s willingness to engage with

experiential strategies is more important. It is also recommended to focus on

staying with the client during experiences and identifying/discussing the process of

the experience rather than simply the content. Noticing what the client is not

saying and observing the client’s body language, or asking the client where he

feels particular experiences or emotions in his body, can be helpful ways to discuss

the process. Video recording a session can also be helpful, so that the client can

observe himself.

Examples of experiential strategies include parables and metaphors, writing

activities, phototherapy, poetry, music, art, sand trays, dance, sculpting,

psychodrama, equine therapy, wilderness and adventure therapies, using props,

using directives, and using ordeals. Metaphors and parables can be created by

either the counselor or the client, and they can be spoken or written. There are two

types of metaphors: story-telling and process-depicting. Story-telling metaphors,

like parables, tell stories to illustrate a particular point or truth. Process-depicting

metaphors can be constructed by counselor or client as well, and can be analogies

for a client’s emotional experiences.

Props are a way to help clients learn, as props tend to be even more

memorable than words. Anything can be used as a prop, and it provides a visual

way to explain a concept. In phototherapy, clients can bring in photos that illustrate

their lives. Often clients will initially bring photos that represent difficult times.

Clients can also use photos to illustrate their stories or explain ideas. Sand tray

therapy involves a tray of sand and a wide variety of miniatures, which the client

can use to depict their experiences. Though typically a part of play therapy for

children, they are also effective and fun for adults.

Provocation involves using unconventional techniques to “provoke” a client

to discover/reveal a deeper issue that is outside the client’s conscious awareness.

Examples of prevocational techniques include playing devil’s advocate, siding

with the client’s assertions, exaggeration, paradox, jesting, sarcasm, putting the

client in a crucible, and suggesting ridiculous ideas or solutions. Provocation can

hurt emotionally in the moment, but one must remember to always do no harm, as

is stated in the ethical codes. When employing these techniques, there are six

guidelines one should follow: (1) make sure the technique is consistent with one’s

view of behavior; (2) explain and obtain informed consent from clients to use these

types of techniques; (3) ensure that the therapeutic bond is strong; (4) ensure that

there is respect for the client; (5) explain the particular technique to clients and

ensure the client’s permission; and (6) receive supervision.

More structured experiential techniques include the life and trauma egg, and

rituals. The life and trauma egg originates from Murray’s and Carnes’s 1997 work,

and involves drawing an egg with symbols inside of it to represent different

traumatic events in a client’s life. This can also be done for positive events instead.

Then, the client will create outside of the egg a list of family rules, family roles, a

list of words to describe his mother, and a list of words to describe his father. This

is often assigned as homework but can also be completed in a session. Rituals can

also be assigned as homework or in session to provide insight into relational

dynamics; this technique is particularly used with families.

There are also expressive experiential techniques such as creative writing,

journaling, insight journaling (in which the client journals about himself), letter

writing, and poetry. Additionally, the experiential vocalizing technique, or voice

therapy, was developed by Firestone in 2001, and helps clients to vocalize their

inner critic and thereby release internal emotions. Five steps are recommended by

Firestone to guide the counselor through the use of this technique, and involve

identifying destructive thoughts and behaviors, obtaining insight from them,

assisting the client in countering or speaking back to the critical inner voice, and

brainstorming positive ways to address these destructive thoughts or behaviors.

Music and art can also be helpful experiential techniques, and younger generations

in particular seem to desire these types of nonverbal expression.

Pedagogical Suggestions:

• Have students list (or act out) as many characters and stories from the Bible

they can think of that illustrate experiential strategies; make it a competition

and see who can list the most.

• The text mentions several benefits and hesitations involved with using

experiential strategies. Have students as a class or in groups discuss their

thoughts and feelings associated with experiential work in light of this

information.

• Have students break into groups, choose one of the case studies discussed in

the text, and role-play it for the class; ask the class for feedback, and discuss

the SITs that were illustrated. This can also be assigned as homework so that

students can better familiarize themselves with the cases and SITs.

• Have students break into pairs or triads, pick one or two (or several) of the

experiential techniques listed on page 164 of the text, and create a role-play

to illustrate them. If done in triads, the third person can be an observer and

provide feedback.

• Ask students as a class to create a master list of potential props that could be

helpful and creative ways they could be used.

• Ask students as a class to list various issues that they think could be

addressed with any of the techniques mentioned in the text and explain their

rationales. Perhaps write them all on the board and create a master list.

• Have students practice phototherapy by creating a short photo presentation

on something positive from their own lives. These can be photos that

represent happy memories or photos that represent favorite scenes or places,

etc.

• Have students break into pairs or triads and role-play using provocation

techniques as listed in the text to help them grow more comfortable with

how uncomfortable some of these techniques may feel.

• To illustrate the concept of the life and trauma egg, but without triggering

any trauma, ask students to create their own “angel eggs” depicting all the

positive, happy events that have happened throughout their lives. This can be

done in class or assigned as homework. Then, have them write a few short

paragraphs about their experience and potential ways they could use this

exercise with future clients.

Chapter 8 Quiz (25 questions):

Fill-in-the-blank

1. When the bodies of clients are placed in postures that can activate self-

awareness into their functioning within a system, this technique by Virginia

Satir is known as _____________. (sculpting)

2. ______________ can be used as visual analogies to represent concepts.

(props)

3. _______________ is an expressive and projective technique whereby the

client creates a psychological representation of his inner and outer life using

objects and miniatures. (sand tray therapy)

4. _______________ involves “calling out” various aspects of the client’s

experience through a number of particularly nontypical techniques.

(provocation)

5. “If you don’t study for your upcoming math test, we will have a better idea

of what would happen if you actually fail” is an example of

______________, a provocation technique. (paradox)

6. “Perhaps changing is too much work” is an example of _____________, a

provocation technique. (playing devil’s advocate)

7. “It sounds like you must be awfully special. Everyone else is allowed to be

human and make mistakes, but not you” is an example of ______________,

a provocation technique. (sarcasm)

8. Murray and Carnes are known for developing ____________________. (the

life and trauma egg)

True/False

1. Experience consists only of the external (relationships and environment)

world. (T/F)

2. Experiential techniques cannot be used with all populations and therapy

formats. (T/F)

3. Processes are experienced viscerally. (T/F)

4. There are two types of metaphors: storytelling and those that depict client

processes. (T/F)

5. Sand tray therapy is typically considered a play therapy activity for children

only and is not effective with adults. (T/F)

6. Insight journaling is a type of journaling that focuses on exploring the self.

(T/F)

7. Firestone developed voice therapy, or the experiential vocalizing technique,

in 2001. (T/F)

8. Younger generations seem to find meaning in art forms more than in words.

(T/F)

9. Experiential work bridges the heart-head divide. (T/F)

Multiple Choice

1. _____________ is the creator of ordeal therapy.

a) Haley

b) Thomas

c) Firestone

d) Murray

e) None of the above

2. The text mentions that the following individuals were involved with

experiential strategies in the Bible except:

a) Abraham

b) Moses

c) Mary

d) Jesus

e) Elijah

3. Which of the following is NOT one of the benefits of experiential

techniques?

a) Provides a holistic, multisensory approach

b) Provides in-moment observation

c) We learn through experience

d) Counseling becomes more concrete

e) None of the above

4. Which of the following is NOT listed as one of the recommended

preparations for experiential work?

a) Supply your office with necessities.

b) Be versatile.

c) Be brave.

d) Develop creativity.

e) None of the above

5. Which of the following is NOT listed as one of the recommended in-session

considerations for experiential work?

a) Stay with

b) Identify client processes

c) Assess the selection of client material

d) Train the client in mindfulness or relaxation techniques

e) None of the above

6. Which of the following is NOT listed as a provocation technique?

a) Putting the client in a crucible

b) Sarcasm

c) Paradox

d) Exaggeration

e) Minimizing

f) None of the above

7. Which of the following is NOT one of the conditions necessary for using

provocation techniques?

a) You must possess deep respect for the client.

b) The techniques must be consistent with how you understand behavior.

c) Informed consent

d) Obtain supervision

e) Obtain insurance approval

f) None of the above

8. Which of the following is NOT one of the steps mentioned by Firestone

involved in the process of voice therapy?

a) Identify negative thought patterns and processes.

b) Respond to and resist the voice.

c) Glean insights into the origins of the negative thoughts.

d) Collaborate on ideas to address the negative patterns.

e) None of the above

f) All of the above

Chapter 9

Spiritual Strategies by Fernando Garzon, PsyD

Key Terms: Scripture, Christian meditation, worship, solitude and silence,

forgiveness, Christian inner healing prayer (CHP), the Immanuel approach,

spiritual assessment, informed consent

Key Points:

• Spiritual strategies discussed in this chapter include Scripture, Christian

meditation, Bible reading and memorization, worship, solitude and silence,

forgiveness, and Christian inner healing prayer.

• In past decades, those in psychological circles often debated whether

spirituality was good or bad. Currently, the psychology world is trying to

investigate how spirituality can be beneficial and also how it can cause

harm.

• Informed consent and spiritual assessment are imperative.

• Typical hesitations/misconceptions about meditation include believing that

meditation originates from Eastern religions and is therefore not Christian,

meditation is New Age because it involves using the imagination, and

meditation empties one’s mind and opens one up to demonic influence.

• Worship is a spiritual strategy that is rarely mentioned in the clinical

literature and rarely employed by counselors, perhaps because of the

variability among denominations or fear of the client looking to the

counselor as his main spiritual leader.

• Forgiveness is highly supported in the clinical literature, but many clients

misunderstand it, and therefore an assessment for and a discussion of these

misconceptions is imperative before suggesting this strategy.

• The Enright model of forgiveness is emphasized in this chapter, involving

four non-linear phases known as uncovering, decision, working, and

deepening.

• Christian inner healing prayer (CHP) models aim to help the client process

traumatic memories by facilitating a conversation between the client and

God.

• Most CHP programs require formal training and supervised practice hours,

so this strategy should not be employed without such training, especially if

the client is struggling with PTSD, dissociation, or substance abuse.

• The Immanuel approach was developed by Karl Lehman, and is based on

attachment theory, eye-movement desensitization and reprocessing therapy

(EMDR), and neuroscience.

Student Learning Objectives:

• To be able to explain the differences between psychology’s definitions of

spirituality and Christianity’s definitions of spirituality

• To understand the processes and steps involved with the spiritual strategies

of Scripture, Christian meditation, Bible reading and memorization, worship,

solitude and silence, forgiveness, and Christian inner healing prayer.

Chapter Summary:

Spiritual strategies discussed in this chapter include Scripture, Christian

meditation, Bible reading and memorization, worship, solitude and silence,

forgiveness, and Christian inner healing prayer. Before examining these

techniques, it is helpful to define spirituality according to the world of psychology

and according to Christian theology.

In past decades, those in psychological circles often debated whether

spirituality was good or bad. Currently, the psychology world is trying to

investigate how spirituality can be beneficial and also how it can cause harm.

Spirituality is broadly defined as the search for something beyond the self. While

there are many different types of spirituality, they have two things in common: (1)

they all believe that the spirit exists, and (2) they all possess a heterogeneous

nature, or are all different. In the world of Christianity specifically, spirituality is

multi-factorial, and Garzon (2018) refers to Tan’s descriptions to illustrate the

concept. Tan asserts that Christian spirituality is based on a desire for God and a

relationship with him founded on love, which results in worship, obedience,

surrender, being filled with the Holy Spirit, engaging in sin less as one grows in the

process of sanctification, and communal and individual spiritual disciplines.

Christian spirituality is eternal, not temporary, and includes phenomena such as

spiritual warfare and mystical experiences.

Before using any spiritual strategies, it is necessary and ethical to explain

and obtain a thorough informed consent, both orally and in written form. A helpful

way to do this is to include a paragraph describing one’s training in these spiritual

interventions and/or one’s Christian history in the standard informed consent form.

It is also necessary to conduct a spiritual assessment, assessing for elements such

as denomination, spiritual activities such as prayer and reading Scripture, and

church attendance. Questions about these elements can easily be slipped into the

standard assessment of a client’s cultural background in the beginning stage of

counseling. If desired, short, formal questionnaires can be used, such as the

Religious Commitment Inventory or the Theistic Spiritual Outcome Survey.

Because Christians can sometimes tend to use the word “should” a lot—“I

should read my Bible more”—and experience religious self-condemnation and

shame, all spiritual strategies employed in counseling must be conducted with an

attitude of grace. The counselor can discuss the concept of grace explicitly with the

client in order to assess the client’s current understanding of it and to examine the

truth about grace as displayed in Scripture, which is a spiritual strategy itself. The

counselor can use Scripture in the session itself or assign readings or verses as

homework between sessions. However, there are a few key points one must keep in

mind when using this spiritual SIT: (1) the counselor must know the Bible well; (2)

the counselor must embody the spiritual concepts being discussed in the session to

illustrate them implicitly for the client; (3) it is important to connect the truths

learned through Scripture to situations in the client’s life, and (4) realistic Scripture

readings or verses are to be assigned to the client as homework.

Christian meditation is another spiritual SIT that can be useful, but Christian

clients may have some hesitations when the word “meditation” is mentioned.

Typical hesitations include believing that meditation originates from Eastern

religions and is therefore not Christian, meditation is New Age because it involves

using the imagination, and meditation empties one’s mind and opens one up to

demonic influence. Therefore, Christian meditation must be accurately explained

by the counselor. The Bible has many references to Christian meditation, and many

prominent figures in church history across denominations are known for practicing

meditation. Christian meditation is different from Eastern religious meditation in

that Christians believe in the immanence of God; it focuses on thinking about

God’s character or dwelling on verses of Scripture rather than emptying one’s

mind. If clients are worried that imagery is only a New Age tool, it can be helpful

to explain different ways we use our imagination every day, and also talk about

how our imaginations can be yielded to God. When demonic influence is a

concern, the counselor can discuss authority in Christ and prayer for protection

before meditating.

Meditating on the truths of Scripture can help clients to quietly reflect

without distractions, and involves the following steps, although they can be

tailored individually: (1) ask the client to choose a verse or biblical phrase; (2)

instruct the client to sit in a comfortable position; (3) ask the client to close his

eyes or find a spot in the room to look at; (4) instruct the client to breathe in and

out slowly while repeating the verse or phrase a few times; (5) repeat this process;

(6) ask the client to think about the verse or phrase and how it could apply to his

life; (7) remind the client it is normal for his mind to become distracted during this

exercise; and (8) ask the client if he would like to write down or discuss any of the

insights he gained during the exercise. The stress break technique can also be used,

in which the client writes the verse or phrase on an index card or in his phone and

pulls it out to read during stressful times in his day. Scripture can also be discussed

in session as part of cognitive restructuring, or the counselor can help the client

learn strategies for Scripture memorization. When doing this, it is helpful to be

creative, examine the client’s typical day for areas of time where memorization

could be practiced, utilize technology if desired, and ask the client to involve other

people in his life.

Worship is a spiritual strategy that is rarely mentioned in the clinical

literature and rarely employed by counselors, perhaps because of the variability

among denominations or fear of the client looking to the counselor as his main

spiritual leader. These concerns can be addressed by careful assessment during all

stages of the counseling process and during/after the spiritual exercises, as well as

openly addressing them if they arise. Silence and solitude are also helpful

strategies, involving shutting out all distractions to focus on God’s presence and

action in one’s life. However, diagnostic features should always be considered

before using this strategy. Those with borderline personality disorder, post-

traumatic stress disorder (PTSD), or poor coping skills are usually reactive to being

alone and should not be considered for these exercises.

Forgiveness is highly supported in the clinical literature, but many clients

misunderstand it, and therefore an assessment for and a discussion of these

misconceptions is imperative before suggesting this strategy. The counselor can

discuss how forgiveness does not mean reconciliation or saying that the other

person’s actions should be excused or tolerated. There are two empirically

supported forgiveness models in the literature, one by Enright and one by

Worthington. The Enright model is emphasized in this chapter, involving four non-

linear phases known as uncovering, decision, working, and deepening. In the

uncovering phase, the client learns to analyze the defense mechanisms he is using

to deal with the pain and ask himself whether these are helping him or hurting him.

In the decision phase, the client learns that the defense mechanisms are hurting him

and considers forgiveness as a possibly better alternative. In the working phase, the

client learns to see the situation and offender in a different way through the eyes of

compassion, perhaps using Gestalt techniques. Finally, in the deepening phase, the

client learns to consider suffering and humanity in general and reflect on

forgiveness for both himself and others in the world. The counselor should watch

for spiritual bypass, a phenomenon in which clients over-spiritualize in order to

avoid pain, particularly in the working and deepening phases.

Finally, Christian inner healing prayer (CHP) is another helpful strategy, and

many different models exist. Typically, they all aim to help the client process

traumatic memories by facilitating a conversation between the client and God.

Most CHP programs require formal training and supervised practice hours, so this

strategy should not be employed without such training, especially if the client is

struggling with PTSD, dissociation, or substance abuse. Additionally, the

counselor must always be nondirective when using this strategy so as not to

implant any false memories. The text discusses the Immanuel approach as an

example to illustrate the strategy. The Immanuel approach was developed by Karl

Lehman, and is based on attachment theory, eye-movement desensitization and

reprocessing therapy (EMDR), and neuroscience. The client begins by visualizing

a positive memory and inviting God’s presence into the memory. The counselor

can ask the client what he is seeing, feeling, or experiencing. Then, the client asks

God which memory he would like him to address in the session, and it is usually a

painful one. The counselor guides the client through the same process used with

the positive memory, and the client can ask God what he wants to show him about

the memory. The counselor then ends the session by asking the client to return to

the positive memory. Sometimes this process takes only one session, but it can be

used across multiple sessions as well. After a session, the counselor can ask the

client what the process was like for them and if they have any questions or

concerns they would like to discuss.

Pedagogical Suggestions:

• Have students break into pairs and practice verbally explaining informed

consent for spiritual strategies to a hypothetical client. Ask them to write a

sample paragraph or two that they can use in their own future informed

consent forms concerning spiritual strategies, following but not copying the

example given in the text.

• Have students break into pairs and practice using spiritual assessment

questions in a hypothetical intake session. Ask them to also do an online

search for spiritual assessment questionnaires other than the two mentioned

in the text and share their findings with the class. If the questionnaires are

available in the public domain, have students practice giving them to a

hypothetical client through role-playing.

• Have a class discussion on the definitions and common misconceptions of

grace, using Scripture and other sources. Ask students to each come up with

their own personal definition of grace and write it out in their own words.

Ask students to describe ways they could practically display their definition

of grace with their future clients.

• Have students discuss as a class or in groups their own views on Christian

meditation and how or if those views have changed since reading the

chapter. Ask them to discuss any personal experiences they have had with

meditation and if there are any common misconceptions they can think of

that are not listed in the text.

• Have students practice the stress break technique by writing down a verse or

biblical phrase on an index card or in their phone and reading it throughout

their days during times of stress or anxiety. Ask students to take the

suggestions for helping busy clients memorize Scripture in the text and

apply them to their own lives for one week as if they were their own client.

At the end of the week (or two), have students discuss or write a report on

their experiences and how they could use such strategies with future clients.

• Discuss the concept of forgiveness as a class or in groups. Ask students if

they identify with any of the misconceptions mentioned in the text and why.

Ask that they support their opinions with Scripture.

• Assign students to research the forgiveness models mentioned in the text and

to write a paper or discussion board post describing the similarities and

differences.

• Assign students to research Christian inner healing prayer models and to

write a paper or discussion board post describing the similarities and

differences. Have each student pick one model to describe in detail and

explain the training procedures and concepts involved.

Chapter 9 Quiz (25 questions):

Fill-in-the-blank

1. __________ , in the psychological sense, has been defined as the search for

that which transcends the self, or the search for the sacred. (spirituality)

2. Cashwell and Giordano (2014) propose the following common link between

spiritualities: _________ exists. (spirit)

3. Before employing spiritual strategies, the counselor ethically must utilize

informed consent and spiritual _______________. (assessment)

4. Two forms of Christian meditation supported by Scripture involve

meditating on small portions of Scripture and meditating on

_________________. (God’s character)

5. Variability among denominational expression and fear of the client viewing

the counselor as his main spiritual leader are associated with the hesitancy

many counselors may have prescribing the spiritual strategy of _________.

(worship)

6. There are two empirically supported models of forgiveness, one developed

by ________________ (Enright)

7. and one developed by ___________________. (Worthington)

8. The psychiatrist Karl Lehman developed the Christian inner healing prayer

strategy known as __________________. (the Immanuel approach)

True/False

1. In the physical and mental health fields, the question has shifted from

understanding the conditions in which spirituality promotes health and those

conditions in which it may harm well-being to whether spirituality is good or

bad. (T/F)

2. The Religious Commitment Inventory and the Theistic Spiritual Outcome

Survey are examples of spiritual assessment measures. (T/F)

3. When using the Bible in session or as client homework, it is not necessary

for the counselor to know the Bible well himself. (T/F)

4. Meditation is clearly mentioned in Scripture. (T/F)

5. Christian meditation involves emptying the mind. (T/F)

6. Research suggests that mental health professionals often recommend

worship as a practice for their clients. (T/F)

7. Individuals who struggle with borderline personality disorder and post-

traumatic stress disorder (PTSD) are excellent candidates for silence and

solitude. (T/F)

8. Forgiveness means excusing the actions of the offender. (T/F)

Multiple Choice

1. Which of the following is NOT listed in the chapter as a spiritual strategy?

a) Solitude and silence

b) Communion

c) Forgiveness

d) Scripture

e) None of the above

2. Which of the following is NOT one of Tan’s factors in Christian spirituality?

a) A response of worship and desire to obey God’s good will

b) Being filled with the Holy Spirit

c) The nonlegalistic practice of the spiritual disciplines

d) A deep hunger for God

e) None of the above

3. According to the text, Christians can be vulnerable to living in the land of:

a) Would

b) Could

c) Should

d) Can’t

e) Milk and honey

4. Which of the following is listed as a recommended consideration when using

the Bible in session or as homework?

a) Small, realistic homework assignments

b) Connecting the biblical concepts to the client’s life situations

c) Knowing the Bible well yourself

d) Implicitly embodying biblical concepts such as grace and compassion

e) All of the above

f) Only A and B

g) Only A through C

5. Which of the following is NOT listed as a concern that many clients may

have about meditation?

a) Meditation is from Eastern religions and is not Christian.

b) Meditation involves guided imagery and is therefore New Age.

c) Meditation opens one up to demonic influence.

d) Meditation is “too hard” and “ain’t nobody got time for that.”

e) None of the above

6. Which of the following is NOT one of the recommendations for using Bible

reading and memorization with “busy” clients?

a) Ask the client to involve others.

b) Be creative.

c) Assess the client’s daily routine.

d) Use technology and simple props.

e) Teach the client discipline and motivation skills.

f) None of the above

7. Which of the following is NOT listed as a common misconception about

forgiveness?

a) Forgiveness means reconciliation.

b) Forgiveness means tolerating the offender’s behavior.

c) Forgiveness means excusing the offender’s behavior.

d) Forgiveness means condoning the offender’s behavior.

e) None of the above

f) Only B through D

8. Which of the following is listed as one of the phases in Enright’s forgiveness

model?

a) Deepening

b) Quickening

c) Identifying

d) Locating

e) All of the above

f) None of the above

9. The ______________ phase in Enright’s forgiveness model involves

reframing the incident and exploring the larger context in terms of the

offender and the situation.

a) Deepening

b) Working

c) Exploration

d) Quickening

e) Identifying

f) Locating

g) None of the above

Chapter 10

Christian Formation of the Self Strategies by Ian F.

Jones, PhD, PhD

Key Terms: Descartes, Forster, Vande Kemp, Delitzsche, Clebsh and Jackle,

healing, sustaining, guiding, reconciling, Maslow’s hierarchy of needs, Rogers,

person-centered psychotherapy, Cooley, looking-glass self, Mead, the imitative

stage, the play stage, the game stage, Goffman, Webb-Mitchell, individualism,

universalism, Fowers, Barna, character development, Levinson, the young-old

polarity, the destruction-creation polarity, the masculine-feminine polarity, the

attachment-separateness polarity, soul growth, prayer, meditation, spiritual

disciplines, cognitive disciplines, behavioral disciplines, interpersonal disciplines,

worship disciplines, healing disciplines, McMinn, Leaf, Garner

Key Points:

• According to the Bible, a biblical view of the self is based on the foundation

of the self being made in the image of God and possessing a body, a spirit,

and a soul.

• Descartes, a seventeenth century philosopher, brought the self to the center

of philosophical inquiry. Descartes postulated that God is not personally

involved in human lives.

• Jonathan Langstaff Forster emphasized the idea of taking a biblical view of

the self and the soul in 1873, standing in contrast to other philosophers of his

time who viewed the body and the soul as separate, unrelated, and opposite

elements.

• In 1912, Fletcher emphasized the idea of biblical psychology and stated that

the foundation of this view is God’s role in our original and current

existence.

• Concerning biblical counseling, there are four historical elements, as

suggested by Clebsch and Jackle in 1964: healing, sustaining, guiding, and

reconciling.

• In the 1960s, counseling and psychology began to focus on the self from a

humanistic perspective.

• Cooley (1902) coined the term “looking-glass self” to illustrate how the self

is formed and seen through the responses of others.

• Mead (1934) also believed that the self cannot develop apart from social

interactions, and divides the self into two parts known as “I” and “me.” The

“I” is the raw material of the self, and the “me” is the part that is formed

socially. The full self develops through interactions between the “me” and

the “I.”

• According to Levinson (1978), there are four polarities involved in the

midlife-crisis: (1) the young-old polarity, (2) the destruction-creation

polarity, (3) the masculine-feminine polarity, and (4) the attachment-

separateness polarity.

• Some spiritual SITs that can help with Christian formation and development

of the self include various prayers, such as prayers of thanksgiving;

confession; seeking God’s blessing, peace, and protection; petition;

intercession; asking God for words and opportunities to speak them;

contemplation; and listening.

• Spiritual disciplines such as reading, meditation, suffering, community,

worship, confession, forgiveness, godly actions, and many others can be

helpful as well.

• It can also be beneficial to help the client develop a godly attitude towards

life and self, particularly through helping him examine and evaluate his

beliefs and thoughts.

Student Learning Objectives:

• To understand the various biblical, historical, and social views of the self

and human nature

• To comprehend the differences between modern developmental views of the

self and biblical views

• To be able to explain the different SITs and spiritual disciplines that can be

used in the counseling process to help the client move towards healthy

development of the self and healthy spiritual growth

Chapter Summary:

In this chapter, Jones discusses various biblical, historical, and social views

of the self and human nature, how they relate to the counseling field, and how

counseling can facilitate development of the self and Christian spiritual growth.

According to the Bible, a biblical view of the self is based on the foundation

of the self being made in the image of God and possessing a body, a spirit, and a

soul. Original Hebrew thought views the self as a whole person possessing all three

aspects. Humans are seen as unique from other living beings because humans are

made in God’s image, can communicate with him, and were chosen by God to be

responsible for handling his creation. Additionally, the human self is not

independent of the social context, with a need for community with God and others.

The self has free will and the ability to choose, but the self is also fallen, and can

make sinful choices solely in the interest of the self. The self also has the ability to

regulate itself, and the Bible is replete with commands to cultivate self-control and

discipline. We are repeatedly told to put off our old self, or destructive behaviors,

and put on the new self, or healthy behaviors, as we grow and are transformed in

Christ.

To describe a historical view of the self, Jones mentions Descartes, a

seventeenth century philosopher who brought the self to the center of philosophical

inquiry. Descartes postulated that God is not personally involved in human lives.

Yet there were other philosophers that held the opposite view, such as Vande

Kemp and Delitzsch, who both investigated biblical ideas relating to the self based

on Scripture. Jonathan Langstaff Forster in particular emphasized the idea of

taking a biblical view of the self and the soul in 1873, standing in contrast to other

philosophers of his time who viewed the body and the soul as separate, unrelated,

and opposite elements. Later, in 1912, Fletcher also emphasized this idea of

biblical psychology and stated that the foundation of this view is God’s role in our

original and current existence. Concerning biblical counseling, there are four

historical elements, as suggested by Clebsch and Jackle in 1964: (1) healing,

including physical aspects such as medication but also spiritual aspects; (2)

sustaining, in which the counselor assists the client to endure and grow through

suffering and difficulty; (3) guiding, in which wisdom and insight are provided;

and (4) reconciling, in which the counselor helps the client to grow in relationship

with God and others. Yet during this same time period, the 1960s, counseling and

psychology began to focus on the self from a humanistic perspective. For example,

Maslow’s hierarchy of needs placed self-actualization as the greatest need, rather

than a need for God or for others. Additionally, Rogers created person-centered

psychotherapy, in which the self’s own experience was considered the highest

authority.

As previously mentioned, the self has been considered to not be independent

from others, both biblically and from a secular perspective. Cooley (1902) coined

the term “looking-glass self” to illustrate how the self is formed and seen through

the responses of others. He divided self-development into three stages: (1) how we

think others see our behaviors; (2) how we think others interpret our behaviors; (3)

the feelings we have about ourselves based on the previous two stages. Similarly,

Mead (1934) also believed that the self cannot develop apart from social

interactions, and divides the self into two parts known as “I” and “me.” The “I” is

the raw material of the self, and the “me” is the part that is formed socially. The

full self develops through interactions between the “me” and the “I.” Mead

describes three developmental stages through which the self proceeds: (1) the

imitative stage, involving imitating others; (2) the play stage, involving taking on

the attitudes and behaviors of others; and (3) the game stage, where the “me” and

the “I” come together and form the full self. Goffman (1959) provides another way

of conceptualizing the self by comparing our lives to performing in a theater.

All these views of the self are helpful and insightful, although they do not

address the relationship with our Creator in the process of self-development.

Modern developmental theories of the self, according to Webb-Mitchell, possess

the following five characteristics: (1) individualism; (2) opposition to authority; (3)

the centrality of the mind; (4) natural religion, in which religion is considered a

social construct; and (5) universalism. He also created a list of characteristics

possessed by a biblical developmental theory of the self: (1) community and its

story, (2) obedience to authority, (3) we are mind/body/spirit in Christ, (4) God in

Christ, and (5) a particular people of a particular God: a kind of universal.

Character-development and maturity in Christ are two other theories of self-

development that contrast the modern developmental views, and are advocated by

Fowers (2005) and Barna (2011).

Jones presents the case of Ben, who is having identity issues, particularly

concerning his identity in Christ, and is having a midlife crisis of the self.

According to Levinson (1978), there are four polarities involved in the midlife-

crisis: (1) the young-old polarity, (2) the destruction-creation polarity, (3) the

masculine-feminine polarity, and (4) the attachment-separateness polarity. Ben

must work through these polarities, as well as working on his spiritual growth and

identity development in Christ. Roberts (2001) suggests three steps that can be

taken in counseling to assist in the spiritual growth process. The first step is to

assess the personality of the believer. Then, clarify the gospel and teach therapeutic

agency. Another counseling tool is to teach the client self-assessment skills and

emotional honesty, which will help him to “put off” unhealthy behaviors and “put

on” healthy ones. Some spiritual SITs that can help with Christian formation and

development of the self include various prayers, such as prayers of thanksgiving;

confession; seeking God’s blessing, peace, and protection; petition; intercession;

asking God for words and opportunities to speak them; contemplation; and

listening. Spiritual disciplines such as reading, meditation, suffering, community,

worship, confession, forgiveness, godly actions, and many others can be helpful as

well. If desired, one could separate the various disciplines into categories of

cognitive and behavioral, or interpersonal, worship, and healing.

It can also be beneficial to help the client develop a godly attitude towards

life and self, particularly through helping him examine and evaluate his beliefs and

thoughts. There are several approaches to changing thoughts and beliefs, including

a six-step approach by McMinn and a five-step approach by Leaf. Garner proposed

an approach of repetition to originally help musicians conquer stage fright, and

Pearce lists seven steps that can be followed to help a client develop healthy

thought patterns.

Pedagogical Suggestions:

• Have students write an essay or discussion board post describing their own

biblical view of the self, using information from the text, the Bible, and

other sources.

• Ask students to make a timeline and describe the historical and social views

of the self discussed in the chapter. Ask them how they think these views

compare to the current secular views of the self in our culture today, and

what some of the reasons could be that people hold to these views.

• On page 207, Barna lists 10 stages of maturity in Christ. Ask students to

have a class/group discussion or write a discussion board post on whether

they agree or disagree with the list and why. If they disagree, ask them to

create a list of their own stages of maturity in Christ.

• Ask students to break into pairs/triads and to create/present their own case

study report or role play illustrating an issue of the self and strategies or

theories discussed in the chapter. Make it a contest to see whose is most

creative and educational.

• Have students list all the spiritual activities discussed in the text and discuss

as a class or in groups how they could incorporate them into counseling with

future clients, what issues they could be helpful for, etc. Ask students if they

have ever used any of the activities/disciplines themselves and what their

experiences were like.

• In the text, Leaf lists five steps to changing thoughts and behavior. Ask

students to follow the steps over the course of 21 days (choosing a thought

or behavior they would like to change but that is also small and not

extremely serious) and write a short paper/discussion board post on their

experience with the exercise and how they could use it to help future clients.

Chapter 10 Quiz (25 questions):

Fill-in-the-blank

1. ___________________ shifted the focus of philosophy to the self and

believed that God is not actively engaged in our lives. (Descartes)

2. In his person-centered therapy, ____________ replaced God with “personal

experience” as the highest authority. (Rogers)

3. Cooley referred to our individual identity as the reflected or

_______________: a self that develops through our perception of how

others respond to our behavior. (looking-glass self)

4. ______________ believed that social interaction leads to the development of

the self and divided the self into the “I” and the “me.” (Mead)

5. ______________, in his dramaturgical theory, likened our lives to

performances in a theater. (Goffman)

6. _______________ is one of Webb-Mitchell’s five characteristics of modern

developmental theories, and is the view that the individual is primary,

existing for the self, without regard for God or others. (individualism)

7. _________________ proposed that character traits make it possible to

pursue the good life, a concept also known as virtue ethics. (Fowers)

8. _________________ disciplines address disordered thought life and include

meditation, listening, Scripture, study, prayer, and discernment. (cognitive)

True/False

1. According to a biblical view of the self, the self has freedom of choice. (T/F)

2. According to a biblical view of the self, the self is fallen and sinful. (T/F)

3. According to a biblical view of the self, the self has the capacity to self-

regulate. (T/F)

4. “Experience a profound compassion and love for humanity” is listed as the

final stage in Barna’s ten stages of maturity in Christ. (T/F)

5. The lost-found polarity is listed as one of Levinson’s four polarities affecting

a midlife crisis. (T/F)

6. The destruction-creation polarity is listed as one of Levinson’s four

polarities affecting a midlife crisis. (T/F)

7. Healing disciplines help repair and restore broken spiritual and interpersonal

relationships. (T/F)

8. Gathering the thoughts and actions that you want to change and looking for

the underlying motivations is the first step in Leaf’s five steps for changing

thoughts and behavior. (T/F)

9. Giving back and saying thanks are listed by Pearce as practical treatment

tools that can assist clients in challenging distorted thinking and developing

healthy biblical thinking. (T/F)

Multiple Choice

1. According to the text, a biblical view of self involves:

a) People have a body, soul, and spirit.

b) Humans reflect the image of God.

c) Humans have the unique ability to communicate with God.

d) Humans are tasked with responsibility for God’s creation.

e) All of the above

f) Only A through C

g) None of the above

2. Clebsch and Jaekle identified the following as historical functions of

pastoral care and counseling:

a) Healing

b) Sustaining

c) Guiding

d) Reconciling

e) Caring

f) All except E

g) All except B and C

3. Which of the following is NOT one of the stages in Cooley’s development

of the self?

a) We imagine or interpret how others judge our behavior/appearance.

b) We imagine or observe how our behavior appears to others.

c) We have self-feelings about the perceived judgements of others.

d) Both A and C

e) None of the above

4. Which of the following is NOT one of Mead’s three developmental stages of

the self?

a) The game stage

b) The play stage

c) The imitative stage

d) The mimicry stage

e) None of the above

5. _______________ is one of Webb-Mitchell’s five characteristics of modern

developmental theories.

a) Community and its story

b) The centrality of the mind

c) Obedience to authority

d) We are mind/body/spirit in Christ

e) None of the above

6. Which of the following is NOT one of Roberts’ three steps to counseling for

transformation and soul growth?

a) Assessing the personality of the believer

b) Clarifying the gospel

c) Teaching therapeutic agency

d) Teaching spiritual agency

e) None of the above

7. Celebration and hospitality are examples of:

a) Worship disciplines

b) Interpersonal disciplines

c) Healing disciplines

d) Behavioral disciplines

e) None of the above

8. Which of the following is one of McMinn’s six steps for challenging

thoughts and beliefs?

a) Help client dispute automatic thoughts

b) Find underlying core beliefs

c) Help client dispute core beliefs

d) Help client maintain gains

e) All of the above

f) Only B and C

Chapter 11

Coping Skills Strategies by Amanda M. Blackburn, PsyD,

and E. Nicole Saylor, PsyD

Key Terms: coping skills, cognitive appraisal, stress, hippocampus, adrenaline,

cortisol, psychodynamic coping skills, cognitive coping skills, appraisal-focused

coping, problem-focused coping, emotion-focused coping, deep breathing

exercises, progressive muscle relaxation, guided imagery, psychological coping

skills, intrapsychic coping skills, self-compassion, mindfulness, cognitive

restructuring, pro-con lists, goal setting, interpersonal/social coping skills,

interpersonal effectiveness skills, cultural rituals, religious coping, lament

Key Points:

• Coping skills aim at reducing, removing, or surviving emotional, physical,

and psychological pain.

• The view one takes of one’s suffering is known as cognitive appraisal, which

consists of two steps. In the first step, the individual labels the experience as

good, bad, or challenging, and the second step involves decidingwhat to do

about the newly labeled event.

• Research has shown that stress has a significant impact on the body,

including faster breathing, tense muscles, higher blood pressure, and a

release of adrenaline, noradrenaline, glucose, glutamate, and cortisol.

• Stress can also create difficulties in memory and new learning due to

changes in the brain.

• Coping skills can also be divided into psychodynamic—focusing on ego

strength development and relationships—and cognitive, which help with

specific symptoms and emotional regulation.

• Coping can additionally be divided into adaptive and maladaptive, as well as

appraisal-focused, problem-focused, emotion-focused strategies,

physiological, psychological, interpersonal, and religious.

• Physiological coping, or physiological management, includes breathing

exercises, progressive muscle relaxation, and guided imagery to calm the

overactive nervous system.

• Psychological and intrapsychic coping skills focus on an individual’s

internal experiences such as emotions and thoughts, and include self-

compassion, mindfulness, cognitive restructuring, pro-con lists, and goal

setting.

• Interpersonal, or social, coping skills are beneficial because emotion

regulation is significantly easier when one has someone trustworthy to help

him, and include interpersonal effectiveness skills training and cultural

rituals.

• Religious coping focuses on meaning-making and finding purpose in the

midst of suffering, and is especially helpful when the suffering cannot be

alleviated or lessened.

• Positive religious coping includes helping others, utilizing one’s faith

community for support, believing that one’s higher power or God will use

suffering for the strengthening of faith, and lament.

Student Learning Objectives:

• To understand the purpose and classifications of coping skills discussed in

the chapter

• To be able to describe the misconceptions associated with suffering and the

impact stress has on the body and brain

• To comprehend the various SITs associated with each category of coping

skills

Chapter Summary:

Coping skills aim at reducing, removing, or surviving emotional, physical,

and psychological pain. When reducing or removing the pain is not an option,

meaning-making becomes paramount, searching for answers to the questions of

“why, how, and what now” (p. 221).

The view one takes of one’s suffering is known as cognitive appraisal, which

consists of two steps. In the first step, the individual labels the experience as good,

bad, or challenging, and the second step involves deciding what to do about the

newly labeled event. People generally view suffering as an unexpected experience,

believing that suffering will not and should not happen to them. Another common

misconception is that if God loved us, he would keep us from suffering, and

therefore if we do suffer, God must not love us or must be punishing us for some

reason. Scripture clearly contradicts all of these misconceptions, informing us that

suffering is to be an expected part of life. However, these misconceptions, or

appraisals, of suffering, create stress.

Research has shown that stress has a significant impact on the body,

including faster breathing, tense muscles, higher blood pressure, and a release of

adrenaline, noradrenaline, glucose, glutamate, and cortisol. Struggles with memory

and new learning can also occur as various changes in the hippocampus and grey

matter in the brain take place. Certain enzymes are also released that can drive an

individual to socially withdraw. These physiological phenomena are adaptive and

helpful in life threatening situations. However, when not in a life-threatening

situation, they are detrimental and cause distress. Clients typically come to

counseling because these symptoms are occurring in the absence of a life-

threatening event or after a life-threatening event has ended. In these situations, it

can be best to begin with physiological coping skills, then move to cognitive,

social, and religious ones.

In general, coping skills can also be divided into psychodynamic—focusing

on ego strength development and relationships—and cognitive, which help with

specific symptoms and emotional regulation. Coping can additionally be divided

into adaptive and maladaptive, as well as appraisal-focused, problem-focused, and

emotion-focused strategies. Appraisal-focused involves learning to think about the

stressful situation in a different way that lessens the distress. Problem-focused

involves focusing on healthy ways to influence or change the stressful situation,

and emotion-focused involves learning ways to lessen or tolerate the emotions

elicited by the stressful situation, typically used first when the situation appears to

be out of the client’s influence or control. Emotion-focused is also known as

secondary coping. Finally, coping skills can be divided into physiological,

psychological, interpersonal, and religious.

Physiological coping, or physiological management, includes breathing

exercises, progressive muscle relaxation, and guided imagery to calm the

overactive nervous system. The most simple breathing exercise involves breathing

in through the nose for two counts and breathing out through the mouth for four

counts. When clients are resistant to learning physiological coping skills, educating

them about the nervous system and normalizing their feelings of anxiety and

awkwardness can be helpful.

Psychological and intrapsychic coping skills focus on an individual’s

internal experiences such as emotions and thoughts, and include self-compassion,

mindfulness, cognitive restructuring, pro-con lists, and goal setting. Self-

compassion consists of treating oneself kindly, recognizing that one is an imperfect

human just like everyone else, and learning to be in the present moment; from a

Christian perspective, this can also include learning to give and receive grace.

Mindfulness, also sometimes called grounding, involves learning to be aware of

the present moment, and consists of asking oneself questions about the current

moment relating to one’s senses. Cognitive restructuring involves recognizing

errors in thinking and learning how to replace them with healthy thought patterns

based on truth. This process begins with identifying the triggering situation or

event, identifying the resulting emotions, and identifying the resulting thoughts.

Then, one looks for evidence to support or contradict the thoughts, and replaces the

thoughts with healthy, more accurate alternatives. Pro-con lists and goal setting are

fairly self-explanatory.

Interpersonal, or social, coping skills are beneficial because emotion

regulation is significantly easier when one has someone trustworthy to help him.

Enhancing relationship abilities through interpersonal effectiveness skill training

can be helpful. According to Marsha Linehan, creator of dialectical behavioral

therapy (DBT), the three types of interpersonal effectiveness in a social exchange

are objective (the goal of the social exchange), relational (a relationship without

conflict), and self-respect (the ability to say no, have boundaries, and other self-

respecting relational abilities). Cultural rituals can also be considered as

interpersonal coping skills.

Finally, religious coping focuses on meaning-making and finding purpose in

the midst of suffering, and is especially helpful when the suffering cannot be

alleviated or lessened. Positive religious coping includes helping others, utilizing

one’s faith community for support, believing that one’s higher power or God will

use suffering for the strengthening of faith, and lament. Helping clients to engage

with God in the midst of their pain, lament is a powerful form of coping when one

has no control over the suffering. A five-step process for lamenting, based on many

of the biblical psalms, was created by Hall in 2016, and can be followed either

formally or informally. In this process, one invites God’s presence into the

suffering, expresses the pain, asks for his intervention, meditates on God’s

character and why he should intervene, and then praises God for who he is as an

expression of trust in him.

Pedagogical Suggestions:

• Ask students to describe the common beliefs/misconceptions people tend to

have about suffering, including those mentioned in the text and any others

they can think of. Ask them to articulate and analyze their own beliefs about

suffering, and ask how they would go about assessing these types of beliefs

in future clients. This can be done in a class discussion format, an essay

format, or a discussion board post.

• Ask students to create a case study illustrating either appraisal-focused,

problem-focused, or emotion focused coping skills. This can be done in a

presentation format or a written format.

• Have students break into pairs or triads and practice teaching each other

deep breathing and progressive muscle relaxation techniques, including

psychoeducation on the nervous system and how these techniques are

beneficial. If in triads, have the third person offer feedback.

• Assign students to practice the concept of self-compassion, or grace,

described in the text over the course of one week; they can be creative in

how they choose to apply this concept to their lives. Then, have them write a

report or discussion board post on their experience and how they could

potentially use this intervention with future clients.

• Have students break into pairs/triads and role-play imaginary scenarios of

using/teaching cognitive restructuring in a counseling setting.

• Assign students to practice the goal-setting technique described in the

chapter on themselves with a small, measurable, achievable goal. Have them

write up a brief report or discussion board post on their application process

and whether it was effective or not. Have them write about how this

technique could be used with future clients.

• Ask students to research interpersonal effectiveness skills (in legitimate,

peer reviewed, scholarly journals) and how to teach them in the counseling

setting. Students may create presentations, brief papers, or discussion board

posts to present their information.

Chapter 11 Quiz (25 questions):

Fill-in-the-blank

1. The ___________ appraisal process occurs in two steps: primary appraisal

and secondary appraisal. (cognitive)

2. The structure in the brain that can be affected by stress is the

_____________, resulting in struggles with learning and memory.

(hippocampus)

3. Coping skills derive from two main schools of therapeutic intervention:

________________ and cognitive behavioral approaches. (psychodynamic)

4. _________________ coping involves changing how one thinks about a

problem or stressor in order to reduce anxiety. (appraisal-focused)

5. ________________ assists in minimizing the common “thinking errors” that

occur when we cope by identifying and confronting these distortions.

(cognitive restructuring)

6. ________________ is the process of identifying, outlining, and pursuing

steps to solve a problem. (goal-setting)

7. _________________ coping attempts to better understand and create

meaning during stress and suffering. (religious)

8. __________________ provides a process for clients to engage with God in

relationship, to increase their comfort with discomfort. (lament)

True/False

1. The misconceptions about suffering include the commonly held assumption

that stress or the unexpected is “bad” and that “bad things won’t happen to

me.” (T/F)

2. Stress can activate certain enzymes that literally result in individuals being

less social, avoiding their peers, and having increased difficulty in

comprehension and memory. (T/F)

3. Some research has shown that mindfulness is as effective as taking

medication to prevent relapse of major depression symptoms. (T/F)

4. Cultural rituals are mentioned as a type of religious coping. (T/F)

5. Positive religious coping includes believing that God or one’s higher power

will use the experience to strengthen one’s faith. (T/F)

6. Volunteerism and charity are NOT examples of positive religious coping.

(T/F)

7. Interpersonal effectiveness skills are used to create and attend to healthy

relationships, which include any skill or behavior that improves our social

interactions. (T/F)

8. Identifying potential obstacles is NOT a part of the goal-setting process.

(T/F)

9. One limitation to cognitive restructuring is that acute emotional discomfort

can interfere with activating the higher order thinking that it requires. (T/F)

Multiple Choice

1. The process in which an event is labeled as good/beneficial, a challenge, or a

threat of possible harm is known as:

a) Secondary appraisal

b) Primary appraisal

c) Psychological coping

d) Problem-focused coping

e) None of the above

2. Which of the following is NOT a physiological effect of stress?

a) A release of glucose

b) A release of glutamate

c) A release of noradrenaline

d) Slowed digestion

e) All of the above

f) None of the above

3. The four categories of coping set forth by Pargament do NOT include:

a) Interpersonal

b) Psychodynamic

c) Physiological

d) Psychological

e) Religious

f) None of the above

4. In the basic breathing exercise to calm the nervous system, one should

breathe in for two counts and breathe out for ___________ counts.

a) Two

b) Three

c) Four

d) Five

e) Two and a half

5. Self-compassion involves all of the following EXCEPT:

a) Self-kindness

b) Mindfulness

c) Common humanity

d) Self-awareness

e) None of the above

6. Pro-con lists, while helpful, can often fall victim to common cognitive

distortions or errors of thinking, such as:

a) Mental filters

b) Emotional reasoning

c) Should statements

d) Overpersonalizing

e) All-or-nothing thinking

f) All of the above

g) Only A through C

7. The types of effectiveness within an interpersonal exchange as described by

Linehan include all of the following EXCEPT:

a) Objective

b) Relational

c) Intrapsychic

d) Self-respect

e) None of the above

8. All of the following are stages in Hall’s lament process EXCEPT:

a) Confidence in God

b) Complaints

c) Request

d) Motivation

e) Expression

f) Address to God

g) None of the above

Chapter 12

Attachment-Oriented Strategies by Gary Sibcy, PhD

Key Terms: secure base, the SECURE model, the secure base system,

attachment style, the attachment system, the exploration system, internal working

model (IWM), secure attachment, avoidant attachment, preoccupied attachment,

fearful-avoidant attachment, Bowlby, James McCullough, Siegel, therapeutic

attunement, attachment-informed counseling, significant other history, transference

hypothesis, interpersonal situation analysis, discipline personal involvement,

interpersonal discrimination exercises, interpersonal neurobiology, narrative

strategies

Key Points:

• God is a relational God, he created us as relational beings, and his

transcendence and immanence provide an unfailing secure base system for

us.

• The secure base system, or SECURE model, is comprised of the exploration

system and the attachment system; the exploration system is activated when

one feels secure, and the attachment system is activated when one feels

threatened.

• Over time, a child’s secure base system becomes the filter through which he

views himself and others, and is known as his internal working model

(IWM).

• There are four different types of attachment: secure, avoidant, preoccupied,

and fearful-avoidant.

• The Bible is replete with examples that illustrate these relational patterns,

and it is important to be aware of them as we engage with our clients,

especially of the ways in which Jesus is described as the ultimate secure base

for us.

• It is important to remember that not all pathology can be attributed to

attachment styles.

• Individuals with an avoidant attachment style tend to struggle with

perfectionism and a fear of failure, as well as a poor ability to tolerate

negative emotions. They often engage in both experiential and relational

avoidance.

• Those with a preoccupied attachment style tend to focus on relational issues

such as abandonment or rejection. Preoccupied individuals also struggle

with emotionally driven behaviors, behaviors that are exhibited in response

to negative affective experiences, such as compulsions.

• Those with a fearful-avoidant attachment style utilize both avoidant and

preoccupied features, longing for intimacy but engaging in relational

avoidance. They also fear abandonment and rejection, and are most likely to

engage in tension reduction behaviors such as cutting and purging.

• The best way for the counselor to connect with the client for the purposes of

influencing attachment is by targeting the right hemisphere of the brain, as

this is where attachment models are thought to be stored.

• Sibcy (2018) describes the SECURE model, built on past research by

Bowlby, in which there are six tasks of attachment-informed counseling:

safety, education, containment, understanding, restructuring, and

engagement.

• Other methods for attachment-informed counseling, developed by James

McCullough, include significant other history, transference hypothesis (a

hypothesis on how the client could be transferring past attachment patterns

onto the counselor), interpersonal situation analysis, discipline personal

involvement, and interpersonal discrimination exercises.

• Another attachment-informed method is known as interpersonal

neurobiology (IPNB), which is based on the work of Siegel and focuses on

the relationship between the mind/brain and one’s relationships.

• Narrative strategies can help the client learn to both tell and reframe his

story while learning how to self-soothe and grow from negative experiences.

Student Learning Objectives:

• To be able to describe the biblical examples of attachment mentioned in the

chapter and the ways in which God provides himself as a secure base

• To understand the four different attachment styles, associated tendencies for

pathology, and associated models such as the SECURE model and IWMs

• To comprehend the various methods described in the chapter for attachment-

informed counseling

Chapter Summary:

Attachment theory, a meta-theory that provides a lens through which to view

and understand other types of counseling theories, reflects God’s design for

humans to be completely dependent upon other humans when they are first born

into the world. God is a relational God, he created us as relational beings, and his

transcendence and immanence provide an unfailing secure base system for us.

The secure base system, or SECURE model, is comprised of the exploration

system and the attachment system; the exploration system is activated when one

feels secure, and the attachment system is activated when one feels threatened.

Both systems cannot be active at the same time. Over time, a child’s secure base

system becomes the filter through which he views himself and others, and is

known as his internal working model (IWM). Attachment is considered to be

generally stable across a person’s lifetime, and can be compared to a physical

immune system in terms of how it is believed to affect one’s psychological health.

There are four different types of attachment: secure, avoidant, preoccupied,

and fearful-avoidant. In secure attachment, a child believes he is capable and

worthy of love, and others are also capable and can be counted on to meet his

needs; in other words, he has a positive view of himself and others, and can move

easily between the attachment and exploration systems. As an adult, he is

comfortable with both intimacy and independence. A child with an avoidant

attachment style has a positive view of himself but a negative view of others. He is

not able to operate well out of his attachment system, and instead operates out of

excessive exploration. This usually develops as parents are emotionally

unresponsive when the child seeks security and instead emphasize independence,

even when the child is very young. As an adult, the individual may struggle with

intimacy. In preoccupied attachment, the child has a negative view of himself but a

positive view of others. Typically this develops as parents discourage or prevent

the child from using his exploration system, are unreliable about meeting the

child’s needs, and can sometimes even rely on the child to meet their own needs.

Individuals with this attachment style may have difficulty feeling relief or love

from others even when others are responsive to them, and they may also feel that

their emotions must be intense in order to get others to respond. Finally, a child

with a fearful-avoidant attachment style has a negative view of both self and

others, and often occurs when parents are abusive. The child is dependent on the

parent to meet his needs, but the parent is also causing the child pain. In response,

the child may learn to dissociate, and as an adult may struggle with both intimacy

and independence. These individuals may also be drawn to relationships that repeat

this abusive dynamic.

The Bible is replete with examples that illustrate these relational patterns,

and it is important to be aware of them as we engage with our clients, especially of

the ways in which Jesus is described as the ultimate secure base for us. Jesus urges

those who are in pain and in need to come to him for comfort and safety. He also

encourages the exploration system by telling us to “go and make disciples” in

Matthew 28:18-30, reassuring that his presence will always be with us as a secure

base. Additionally, Paul writes in Philippians 4:4-7 that God is always near to us,

and that when we feel anxious or fearful, we can turn to him through prayer and

find safety. Attachment patterns are also illustrated in the Old Testament, with

King Saul exhibiting a preoccupied attachment style and David displaying a secure

style, feeling confident in God’s love for him.

Concerning the counseling context, it is first necessary to note that not all

pathology can be attributed to attachment styles, as there are myriad other factors

involved. Research suggests that temperamental traits of neuroticism, negative

affectivity, inhibition, and avoidance also play a role, as well as environmental

factors, general and specific psychological vulnerabilities. However, there are

several ways in which attachment does influence pathology, and there are several

ways in which this knowledge could be useful for the counselor.

Individuals with an avoidant attachment style tend to struggle with

perfectionism and a fear of failure, as well as a poor ability to tolerate negative

emotions. They tend to engage in both experiential and relational avoidance,

meaning that they attempt to avoid any negative affective experience and any

opportunity to let another person know about said experience, respectively. Such

avoidance is a known factor in depressive and anxiety disorders. Similarly, those

with a preoccupied attachment style also engage in experiential avoidance,

although rather than being concerned with self-related issues such as

perfectionism, they tend to focus on relational issues such as abandonment or

rejection. Preoccupied individuals also struggle with emotionally driven behaviors,

behaviors that are exhibited in response to negative affective experiences, such as

compulsions. Finally, those with a fearful-avoidant attachment style utilize both

avoidant and preoccupied features, longing for intimacy but engaging in relational

avoidance. They also fear abandonment and rejection, and are most likely to

engage in tension reduction behaviors such as cutting and purging.

Because attachment style does influence pathology, therapeutic attunement

is critical. The best way for the counselor to connect with the client for the

purposes of influencing attachment is by targeting the right hemisphere of the

brain, as this is where attachment models are thought to be stored. The counselor’s

own emotions, expressions, eye contact, and body language are essential in

conveying empathy and connecting with the client, especially when the client is

experiencing intense or negative emotions. Additionally, Sibcy (2018) describes

the SECURE model, built on past research by Bowlby, in which there are six tasks

of attachment-informed counseling: safety, education, containment, understanding,

restructuring, and engagement. Safety involves helping the client develop a sense

of hope, as well as helping him explore his reason for coming to counseling, his

past history, and current goals. Education involves helping the client understand

his problems or situations and developing skills to cope with them, such as

spiritual formation skills. With containment, the counselor must find the balance

between challenging and supporting the client, or the therapeutic window, and with

understanding the counselor helps the client understand how his past relationships

may be affecting his present, possibly through attachment assessment measures.

Finally, restructuring helps clients to see their lives and problems in new ways,

also known as schema reconstruction.

Other methods for attachment-informed counseling, developed by James

McCullough, include significant other history, transference hypothesis (a

hypothesis on how the client could be transferring past attachment patterns onto

the counselor), interpersonal situation analysis, discipline personal involvement,

and interpersonal discrimination exercises. The interpersonal discrimination

exercises help a client to recognize how her current relational experiences, perhaps

with the counselor, are different from the negative ones in his past. Interpersonal

situation analysis is a method of examining a current situation in the client’s life to

help the client first become aware of his behavior and its effects and then to find a

way to change his behavior in a way that is more conducive to achieving his

desired outcomes. Another attachment-informed method is known as interpersonal

neurobiology (IPNB), which is based on the work of Siegel and focuses on the

relationship between the mind/brain and one’s relationships. It can be helpful for

clients to understand how their physical brain impacts and is impacted by their

relationships throughout their lives. Furthermore, narrative strategies can also be

employed in the counseling process to help the client learn to both tell and reframe

his story while learning how to self-soothe and grow from negative experiences.

Pedagogical Suggestions:

• Using the examples and verses listed in the text as well as the Bible and/or

other sources, have students discuss or write a discussion board post on all

the specific ways they can think of that God/Jesus provides a secure base for

us. Ask how this information could be used directly or indirectly in a

counseling setting, both Christian and secular.

• Ask students to independently research “God attachment” using scholarly,

peer-reviewed journals and write up a report, discussion board post, paper,

or PowerPoint presentation to reveal their findings. Ask how this

information could be used in future counseling.

• The chapter discusses both experiential avoidance and relational avoidance.

Ask students to discuss as a class or in groups ways in which these issues

could be addressed for future clients in counseling.

• Have students break into pairs or triads and practice role-playing each

attachment style in a counseling setting. Have the “counselor” or the

observer try to guess the “client’s” attachment style, and have the “client”

try to make it difficult for them to guess while still being true to the style.

• Have each student write up a brief report on a hypothetical client with one of

the attachment styles, trying to make it difficult to guess but also being true

to the style, and have their classmates guess the style as they present their

report. This can be done in pairs or triads as well for the sake of time.

• Have students break into pairs or triads and practice conducting a significant

other history, then forming a transference hypothesis based on one of the

four types mentioned in the text. Students can take turns role-playing an

imaginary client.

• Have students break into pairs or triads and practice an interpersonal

situation analysis, taking turns role-playing counselor and client. Before

beginning the exercise, have them summarize in their own words or list the

seven steps involved on an index card or piece of paper that they can

reference throughout the role-play, as well as any questions they may want

to remember to ask the client. Students may also write a hypothetical role-

play illustrating this technique as homework.

• Ask students to research interpersonal neurobiology as homework and write

up a report, paper, discussion board post, or PowerPoint presentation on

their findings and specific ways that this field can be helpful to their future

counseling work, particularly in relation to attachment. Ask for details and

practical ideas.

• Similarly, have students research narrative strategies as homework and write

up a report, paper, discussion board post, or PowerPoint presentation on

their findings and specific ways that these strategies could be helpful for

counseling, particularly in relation to attachment.

Chapter 12 Quiz (25 questions):

Fill-in-the-blank

1. Attachment theory is a ____________ theory, which is a theory that helps us

make sense of other theories. (meta)

2. When parents push their children to become independent and autonomous

even when the children do not feel a sense of security, the children would be

most likely to develop __________________ attachment style. (avoidant)

3. Attachment security is equated to emotional and psychological health like

the body’s _________________ is to our physical health. (immune system)

4. Those with _________________ attachment style tend to be concerned

about problems centering on self-definition such as perfectionism and fear of

failure. (avoidant)

5. ____________________ involves the person actively attempting to push out

of their awareness negative thoughts, feelings, and images related to

stressful life events. (experiential avoidance)

6. ____________________ behaviors are extreme forms of emotionally driven

behaviors and include cutting, burning, binging, purging, extreme forms of

sexual acting out, and excessive drug and alcohol use. (tension-reduction)

7. The ______________ phase of the SECURE model involves finding the

therapeutic window, or the balance between supporting and challenging.

(containment)

8. ________________ is a field that studies the interaction between relational

experiences and the developing mind. (interpersonal neurobiology)

True/False

1. In the SECURE model, the exploration system and the attachment system

can both be operating at the same time. (T/F)

2. For those with an avoidant attachment style, the attachment system is

underactivated and the exploration system is overactivated. (T/F)

3. In the Bible, David is an example of having a preoccupied attachment style

with God. (T/F)

4. Attachment is considered relatively stable across the lifespan. (T/F)

5. Those with a preoccupied attachment style tend to get flooded by and

entangled in their internal experiences. (T/F)

6. Therapeutic relationships are best established by targeting a client’s left

hemisphere of the brain. (T/F)

7. The restructuring phase of the SECURE model involves helping clients

develop coherent narratives that help them make sense of their existence in

light of God’s redemptive story in their lives, also known as schema

reconstruction. (T/F)

8. Interpersonal situation analysis helps clients understand how they handle

relationship conflict. (T/F)

9. Narrative strategies in attachment therapy can help clients learn to self-

soothe and to reframe their stories. (T/F)

Multiple Choice

1. When the secure based system is internalized by the individual, it is known

as the _________________.

a) Internal working model (IWM)

b) External working model (EWM)

c) SECURE model

d) Schema

e) None of the above

2. The following statement is an example of ______________ attachment: I’m

not worthy of love, and I desperately need others to take care of me, but I

must be in great need in order for her to respond to my emotions.

a) Secure

b) Avoidant

c) Preoccupied

d) Fearful-avoidant

e) None of the above

3. Which attachment style is thought to be the “genesis of dissociation”?

a) Secure

b) Avoidant

c) Preoccupied

d) Fearful-avoidant

e) None of the above

4. Known factors other than attachment style involved in psychological

pathology include:

a) Temperament traits such as neuroticism

b) Environmental risks

c) General psychological vulnerability

d) Specific psychological vulnerability

e) All of the above

f) Only A through C

g) None of the above

5. Individuals with ________________ attachment style desperately long to

merge themselves with another person while at the same time employing

avoidance strategies to keep others at a distance.

a) Secure

b) Avoidant

c) Preoccupied

d) Fearful-avoidant

e) None of the above

6. Which of the following is NOT one of Sibcy’s six tasks of the SECURE

model?

a) Safety

b) Education

c) Containment

d) Understanding

e) Assessment

f) None of the above

7. Transference hypothesis and interpersonal situation analysis are strategies

from _______________’s model of therapy that can be used in attachment-

informed counseling.

a) Bowlby

b) Sibcy

c) McCullough

d) Siegel

e) Cindy

f) None of the above

8. ______________________ help(s) clients differentiate past toxic

relationships from the present therapeutic relationship through asking the

client a series of questions.

a) Significant other history

b) Interpersonal situation analysis

c) Interpersonal discrimination exercises

d) Transference hypothesis

e) None of the above

Chapter 13

Child-focused Strategies by Kevin B. Hull, PhD

Key Terms: Self-awareness, self-agency, self-continuity, Harter, safety, active

listening, confidentiality, play therapy, sand tray therapy, computer/video/tablet

games, Gestalt, Perls, “I” language, empty chair technique, two chair technique,

Adler, individual psychology, systematic desensitization, cognitive therapy,

rational-emotive behavioral therapy (REBT), cognitive behavioral therapy (CBT),

solution focused brief therapy (SFBT)

Key Points:

• Self-awareness, self-agency, and self-continuity are three main categories of

childhood self-development identified by Harter in 2012.

• When establishing a therapeutic relationship with a child client, it is

important to focus on safety, active listening, identifying the problem, and

confidentiality.

• Play therapy is especially helpful for children, as play is said to be the main

way in which children express and make sense of their world. Sand tray

therapy, one aspect of play therapy, is helpful for similar reasons, and

involves a sand tray, miniatures, and access to water so that the child can

create whatever she wishes in her tray of sand.

• Computer games, video games, and tablet games can be used to help the

child bond with the counselor through mutual play or to provide analogies

for various life situations, as many games involve conflict and themes of

overcoming, relying on others for help, and improving or growing.

• Other SITs that can be useful with children include Gestalt techniques such

as “using I-language, substituting ‘won’t’ for ‘can’t’, taking responsibility,

and . . . . the empty chair technique” (Hull, 2018, p. 278).

• Individual psychology also contributes several SITs to child therapy, based

on Adler’s idea that negative behaviors have four possible goals: attention,

power, revenge, and inadequacy.

• Understanding the child’s motives behind their negative behavior patterns is

critical, as it allows the counselor and parents/caregivers to create reward

systems that are most beneficial and help the child feel in control of herself.

• Systematic desensitization techniques can be helpful with fear and anxiety.

• Techniques from cognitive therapy, rational emotive behavioral therapy

(REBT), and cognitive behavioral therapy (CBT) have also been shown in

the research to be helpful.

• Solution-focused brief therapy (SFBT) helps children to create new ways of

thinking and addressing problems through techniques such as the miracle

question, scaling, reinforcement, and identifying exceptions.

• One particular issue that often brings children to counseling is the issue of

loss, grief, or trauma. Children can have difficulty processing negative

emotions and can interpret these emotions as negative reflections of

themselves due to their ego-centric view of the world.

Student Learning Objectives:

• To be able to describe the unique developmental challenges faced by

children (and those counseling them) and what the Bible says about children

and their value

• To comprehend the ways in which a solid therapeutic relationship can be

developed with a child client in a counseling setting

• To understand the various SITs that can be helpful with children and the

particular issues with which they work well

Chapter Summary:

Children are a unique population, dependent upon others to meet their basic

needs and constantly immersed in developmental growth and challenges. Self-

awareness, self-agency, and self-continuity are three main categories of childhood

self-development identified by Harter in 2012. The Bible is also descriptive of the

developmental process, discussing the importance of nurturing, training, and

valuing children. Furthermore, it provides examples of what happens when

children are not nurtured, trained, or valued, or become wayward for other reasons,

such as Eli’s sons, David’s son Absalom, or King Ahaz. Yet there is also the story

of the prodigal son, which provides an illustration of hope and restoration.

When establishing a therapeutic relationship with a child client, it is

important to focus on safety, active listening, identifying the problem, and

confidentiality. For the child to feel a sense of safety, she must feel that both the

counselor and the counseling room are safe. Physically getting on the child’s level,

eye contact, clear explanations, and a calm voice are essential. Having child-sized

furniture, open spaces, and toys can also help the child feel comfortable in the

environment. Active listening involves open-ended questions, paraphrasing,

summarizing, and verbal and nonverbal encouragement to help the child feel heard

and understood. It is helpful to identify the current problem, or reason for

counseling, from the perspective of both the parent/caregiver and the child, and to

identify what has been done to address the problem so far. With confidentiality,

custody situations can be difficult, and it is always best to obtain permission from

both parents before proceeding with counseling for the child. Asking the parents to

waive their confidentiality rights, within the usual limits of course, can be helpful

towards establishing trust in the child’s therapeutic relationship with the counselor.

Children often struggle with self-related issues due to their developmental

journey such as shame, guilt, control, and autonomy, and there are a variety of

therapeutic approaches that can be beneficial for them. Play therapy is especially

helpful for children, as play is said to be the main way in which children express

and make sense of their world. Sand tray therapy, one aspect of play therapy, is

helpful for similar reasons, and involves a sand tray, miniatures, and access to

water so that the child can create whatever she wishes in her tray of sand.

Computer games, video games, and tablet games can also be helpful, as many

children are familiar with and fond of them. They can be used to help the child

bond with the counselor through mutual play or to provide analogies for various

life situations, as many games involve conflict and themes of overcoming, relying

on others for help, and improving or growing.

Other SITs that can be useful with children include Gestalt techniques such

as “using I-language, substituting ‘won’t’ for ‘can’t’, taking responsibility, and . . .

. the empty chair technique” (Hull, 2018, p. 278). Similar to the empty chair

technique, the two-chair technique can be used, in which the child acts out both

parts while moving from chair to chair. Puppets or stuffed animals can also be used

for this technique. Gestalt techniques for children line up very well with Scripture,

as the Bible also supports taking responsibility and changing negative thought

patterns through renewal of the mind.

Individual psychology also contributes several SITs to child therapy, based

on Adler’s idea that negative behaviors have four possible goals: attention, power,

revenge, and inadequacy. The encouragement technique involves accepting the

child for who she is and encouraging her efforts, and the logical consequences

technique involves helping her experience and understand how her actions have

natural consequences. Adlerian play therapy can also help children develop a

healthier sense of self, for example, using miniatures or puppets to reenact times

when she was able to help others or times when others were there for her.

For more specific problems, behavioral approaches tend to work well for

children as well as for the parents or caregivers, involving rewards/punishments

and token economies. Understanding the child’s motives behind their negative

behavior patterns is critical, as it allows the counselor and parents/caregivers to

create reward systems that are most beneficial and help the child feel in control of

herself. Systematic desensitization techniques can be helpful with fear and anxiety.

Techniques from cognitive therapy, rational emotive behavioral therapy (REBT),

and cognitive behavioral therapy (CBT) have also been shown in the research to be

helpful. Scripture verses and memorization can be useful with Christian children to

help them learn basic CBT skills and learn how to identify “truth.” When time is

limited, solution-focused brief therapy (SFBT) is an excellent option, based on the

idea that poorly defined goals are the main reason for problems. SFBT helps

children to create new ways of thinking and addressing problems through

techniques such as the miracle question, scaling, reinforcement, and identifying

exceptions. Art, sand trays, and other play therapy modalities can be used with

SFBT as well.

Finally, one particular issue that often brings children to counseling is the

issue of loss, grief, or trauma. Children can have difficulty processing negative

emotions and can interpret these emotions as negative reflections of themselves

due to their ego-centric view of the world. Therapy can be helpful in such

processing and learning to view their situations differently, creating a healthier

view of self as well. Play therapy can be used to address these difficult issues, and

prescriptive play therapy is a beneficial option in which the counselor chooses

certain toys or materials based on the particular loss or trauma experienced by the

child. Scriptures and Bible stories can be woven in to the process for Christian

children through art, writing, story-telling, or any other creative avenue.

Pedagogical Suggestions:

• Using not only the verses and information mentioned in the text but also

others, have students research the topic of children in the Bible and write a

discussion board post, brief and creative PowerPoint presentation, or brief

report on their findings and how this information should impact their future

counseling work.

• Have students break into pairs or triads and role-play one of the case studies

(and associated SITs) mentioned in the text to practice the techniques.

• Have students break into pairs or triads and write down the elements of

active listening on a piece of paper or index card. Then, have them practice

it on each other while the other person tells a story from their childhood as if

they themselves were a child. Have the third person, if in triads, be an

observer to make sure the “counselor” utilized all the elements of active

listening effectively.

• Bring in trays, sand, miniatures, and water (if possible) and have students

practice being creative with sand tray therapy. They may construct their own

sand tray worlds, either freely or in response to various prompts, or break

into pairs and role-play with one person playing a child client.

• Bring in (or have students bring in) various art supplies such as papers,

colored pencils, crayons, markers, stencils, clay, play-doh, etc. Assign

students to role-play a child struggling with a particular problem or situation

while another student practices using the art materials as a counselor.

Students may also experiment and be creative with the materials themselves,

responding to an issue/situation in their own lives, and can then share in

groups or with the class (or write a discussion board post or report later) on

their experience, what they learned, and how they could use art and

creativity in future counseling with children.

• Alternatively, ask students to create their own art project as homework using

any creative materials they desire, responding to an issue/situation in their

own lives, and then present their work to the class along with a report on

how the activity affected them and how such activities could be used in

future counseling.

• Bring in a few puppets or stuffed animals, and have students break into

pairs/triads to role-play a variation of the empty-chair or two-chair

technique. One student will role-play a child client and one will role-play the

counselor. Encourage creativity while getting students used to using these

props with hypothetical child clients.

• In pairs/triads, have one student role-play a child with negative self-beliefs

and an external locus of control. Have another student role-play the

counselor, and use CBT techniques and even Scripture (incorporated in a

creative way that a child would understand and enjoy) to help the child. The

observer could offer suggestions if the counselor gets stuck at any point, and

can also offer feedback. You can also role-play this as an example for the

class, with one of the students role-playing the child client and you as the

counselor.

• Have students break into pairs/triads and role-play to practice solution

focused brief therapy with a hypothetical child client. They may write down

the elements of SFBT on a card or paper to use as a guide.

• The text discusses at length the ways in which each type of therapy is

compatible/incompatible with Scripture and a biblical worldview. Divide

students into groups and assign each group a therapy or theory from the text,

then have them create a brief presentation to teach the class how their

assigned theory/therapy is compatible or incompatible with

Scripture/Christianity. Ask them to include the information provided in the

text but to also add original thoughts/verses/research of their own. Have

them make it their goal to construct the most creative, entertaining

presentation possible, and have the class vote on the best one.

Chapter 13 Quiz (25 questions):

Fill-in-the-blank

1. Open-ended questions, paraphrasing, summarizing, and verbal and

nonverbal encouragement are all aspects of __________________. (active

listening)

2. Parents can waive their confidentiality rights through _____________, a rule

that allows the therapist to ensure that the regular restrictions to

confidentiality will be observed, to help their children fully bond with the

therapist and embrace the therapeutic process as theirs alone. (HIPPA)

3. “I” language, substituting “won’t” for “can’t,” and taking responsibility are

all examples of ____________ therapy. (Gestalt)

4. The ___________ technique is a back-and-forth process in which the child

acts one part and then moves to another chair to act out what another part or

person may say or do. (two-chair)

5. ___________________ is based on the basic idea that the main problem

usually stems from poorly defined goals. (solution focused brief therapy)

6. __________________ is the sense of having control over one’s thoughts and

actions, and is critical as the child develops the idea that his behaviors

impact others and situations around him. (self-agency)

7. The parable of _______________ in the Bible is an example to provide

parents of wayward children with hope. (the prodigal son)

8. ________________ is credited with developing Gestalt therapy. (Fritz

Perls)

9. Rewards/punishments, consequences, and a token economy are all

techniques associated with the ______________ approach. (behavioral)

True/False

1. The two key elements of safety for the child in the counseling process are

the therapist as a safe presence and the counseling room as a safe place.

(T/F)

2. According to the text, children may struggle with shame, guilt, control, and

autonomy, typical issues of self-representation that arise during their

development. (T/F)

3. Play therapy is not compatible with Christianity. (T/F)

4. The individual psychology technique of unconditional affirmation involves

accepting the child as she is and noticing her effort as opposed to the

outcome. (T/F)

5. A behavioral approach to counseling children is inconsistent with Scripture.

(T/F)

6. It is important to understand the child’s motives in order to create an

effective reward/consequence system and help her feel that she can control

herself. (T/F)

7. CBT has been shown to be particularly effective in helping children with

depression. (T/F)

8. Solution focused brief therapy is effective but not compatible with

expressive forms of play therapy such as art and the sand tray. (T/F)

Multiple Choice

1. The three categories of child self-development identified by Harter include

all of the following except:

a) Self-continuity

b) Self-agency

c) Self-congruency

d) Self-awareness

e) None of the above

2. When creating a therapeutic relationship with a child client, all of the

following are listed as essential techniques except:

a) Establishing a sense of safety

b) Active listening

c) Confidentiality

d) Identifying the problem

e) None of the above

3. Elements of sand tray therapy must include all of the following except:

a) A tray of sand

b) Water

c) A collection of miniatures

d) Paper and pencils

e) None of the above

4. Individual psychology identifies which of the following as one of the four

goals of misbehavior?

a) Inadequacy

b) Attention

c) Revenge

d) Power

e) All of the above

f) None of the above

5. When dealing with a child who struggles with fear and anxiety about a

particular issue, such as going to school, the text suggests that ___________

could be helpful.

a) Systematic desensitization

b) Emotion-focused trauma therapy

c) Gestalt techniques

d) Individual psychology

e) None of the above

f) All of the above

6. Solution focused brief therapy (SFBT) includes all of the following

techniques except:

a) Scaling

b) The miracle question

c) Identifying exceptions

d) Assessing attachment style

e) None of the above

7. The “wow and how” technique, part of solution focused brief therapy

(SFBT), was developed by:

a) Nims

b) Homeyer

c) Adler

d) Perls

e) None of the above

8. _______________ is a technique in which the therapist constructs a play

environment to deal with a specific type of loss, strategically offering toys

that will be suited for the child’s specific situation.

a) Prescriptive play therapy

b) Descriptive play therapy

c) Artistic play therapy

d) Creative play therapy

e) None of the above

Chapter 14

Adolescent-focused Strategies by Andi J. Thacker, PhD

Key Terms: adolescence, differentiation, identity, prefrontal cortex, dopamine,

creativity, unconditional positive regard, grace, patience, parental consent, parent

consultations, developmental history, confidentiality, creative expression, choice

giving, contract setting, activity therapy, open-ended questions, metaphor, feeling

felt

Key Points:

• Adolescents face many developmental challenges such as differentiation,

identity formation, peer connections, physiological changes in the brain, and

the emergence of puberty and sexual identities/attractions.

• God created us with the ability to make choices and have a sense of agency,

and the stage of adolescence is a strong reminder of those abilities.

• When seeking to establish a therapeutic relationship with an adolescent

client, it is imperative that we present with unconditional positive regard, or

grace, patience, and attentive listening skills, as adolescents usually do not

choose to come to counseling voluntarily.

• It is recommended to conduct the first session with the parents only,

obtaining this written consent as well as a developmental history of the

client, and providing the parents with a chance to talk with the counselor

about the problems and their expectations.

• Consultations with the parents can be held after every three or four sessions,

and including the adolescent in these consultations is recommended to help

foster trust in the therapeutic relationship.

• Sometimes it is helpful to provide parents with education and parenting tools

that they could use as options to help them with their adolescent child, such

as choice giving and contract setting.

• Similar to play therapy for children, activity therapy makes use of

metaphors, symbols, and a wide variety of craft supplies or expressive

activities such as pencils, paper, markers, photography, and music.

• Concerning the structure of the actual sessions, Thacker (2018) recommends

“to allot five minutes for instruction about the activity, twenty to twenty-five

minutes for the activity, and ten to fifteen minutes for processing” (p. 301).

Student Learning Objectives:

• To be able to describe the various challenges faced by adolescents and the

best ways to establish a therapeutic relationship with them

• To understand the intricacies of adolescent therapy, including parental

involvement, legal concerns, confidentiality, group therapy options, and

session structure

• To comprehend the nature of activity therapy, the benefits of creative

expression, and the role of the counselor in using this method

Chapter Summary:

God created us with the ability to make choices and have a sense of agency,

and the stage of adolescence is a strong reminder of those abilities. Adolescents

ages thirteen to eighteen are learning to make decisions for themselves, to forge

strong connections with their peers, and to differentiate from their parents while

still remaining connected in some ways. To use Erikson’s language, they are facing

the challenge of identity versus identity confusion, trying to figure out who they

are, and connections with their peers are especially important for navigating this

challenge successfully. Additionally, their prefrontal cortex is developing, and

their brain is experiencing a lower level of baseline dopamine, prompting them to

engage in novelty-seeking behaviors to increase the levels. They tend to focus on

the positive possibilities of risk-taking rather than the negative ones, and they are

also experiencing the physical changes of puberty and developing sexual identities

and attractions. It is therefore helpful to keep their developmental struggles and

needs for peer connection in mind when entering into a counseling relationship

with adolescents.

When seeking to establish a therapeutic relationship with an adolescent

client, it is imperative that we present with unconditional positive regard, or grace.

Adolescents usually do not choose to come to counseling, so it is important to be

patient and move at the client’s pace. Listening well is essential, reflecting both

content and feeling, and helping the client to feel that you truly understand her.

Parents or caregivers are also a part of the counseling process, although they may

not be in the actual sessions with their adolescent child, and the counselor must

establish strong communication with them as well. Adolescents are considered

minors, and most states require written parental consent for minors to receive

counseling. Research and seek advice about legal considerations, especially when

blended families or custody disputes are present. It is recommended to conduct the

first session with the parents only, obtaining this written consent as well as a

developmental history of the client, and providing the parents with a chance to talk

with the counselor about the problems and their expectations. Consultations with

the parents can be held after every three or four sessions, and including the

adolescent in these consultations is recommended to help foster trust in the

therapeutic relationship. In situations where the adolescent does not share her

parents’ faith values, it is wise to let her alone lead any discussions of spirituality,

although the counselor can assure the parents that he will implicitly counsel from

his Christian worldview.

Sometimes it is helpful to provide parents with education and parenting tools

that they could use as options to help them with their adolescent child, always

being respectful of their thoughts and feelings as parents. One such tool is choice

giving, in which parents provide the adolescent with opportunities to make their

own decisions, helping them learn to make wise choices and exercise their

autonomy in a responsible way. Adolescents can also be given the opportunity to

have a voice in their own disciplinary process, helping them learn how their

choices have consequences and desire to take personal responsibility for their

behavior. One way of doing this is contract setting, in which identified behaviors

and consequences are agreed upon, written out, and posted in a public area of the

house.

Similar to play therapy for children, activity therapy for adolescents utilizes

a variety of props and creativity. Creative approaches have been found to be

especially effective with adolescents, as they are able to move beyond the realm of

simply talk therapy into the realm of transformative experience. Because God is a

Creator himself, and he created us with the ability to create also, we serve as a

reflection of him when we use our creative abilities in therapy with our clients.

Activity therapy makes use of metaphors, symbols, and a wide variety of craft

supplies or expressive activities such as pencils, paper, markers, photography, and

music. Therapy can be conducted in a directive way, in which the counselor

chooses the activities, or a nondirective way, in which the client chooses. New

activities or materials do not have to be used every session, and the client should

be free to use whatever materials she feels most drawn to as many times as she

would like. Stay within the metaphor she creates the entire time if that is most

developmentally appropriate for the client’s age, as this can sometimes make

processing issues in her life feel less threatening. The counselor should also

experience the activities himself before using any of them in therapy with a client;

this will help the counselor understand the client’s experiences and also provide

personal growth in self-awareness.

Concerning the structure of the actual sessions, Thacker (2018) recommends

“to allot five minutes for instruction about the activity, twenty to twenty-five

minutes for the activity, and ten to fifteen minutes for processing” (p. 301). It is

crucial that the counselor not attempt to interpret the client’s creation, touch it, or

provide feedback, even if the client herself does not assign meaning to it. Asking

open-ended questions about the creation and about the client’s experience of

creating is a wiser approach. Concluding the session in a logical, cognitive way can

help the client not feel emotionally exposed when she leaves. Group therapy is

another effective option for adolescent clients, as peer relationships are crucial for

them during this stage. However, when conducting groups, it is wise to remember

to keep confidentiality of each member, especially if parents begin to ask about

other children in their child’s therapy group.

Pedagogical Suggestions:

• Have students research adolescent brain development in depth as homework

using scholarly, peer-reviewed sources and write a brief paper or discussion

board post on their findings. Have them focus on addressing how these brain

challenges can impact an adolescent and how she experiences the world, as

well as how these changes could be utilized to create both positive

experiences and negative experiences such as the development of distress

and pathology. Conduct a class discussion on their research findings after

the homework assignment as well, if desired.

• Discuss as a class or in groups: what, if any, experience do you have

interacting with adolescents, either clinically or otherwise, and what has

helped you to connect with them? What makes it more difficult to connect?

• Have students independently research activity therapy and different types of

activities, consulting a wide variety of sources other than the text, and write

a paper or discussion board post on their findings. Instruct them to search for

insights and details that are new and not provided in the text. Discuss

findings as a class or in groups if desired.

• Have the students gain experience with a variety of activities used in activity

therapy. Have them break into pairs or triads and role-play a counseling

scenario with an adolescent client, using an activity and structuring the

session as recommended in the text. The third person could role-play a

parent, if desired.

• Bring in, or have students bring in, various mediums for activities including

paper, pencils, markers, clay, coloring books, etc. and have students each

create a variety of therapeutic activities they could use in future work with

clients. Then, have the students experience for themselves the activities they

created. This could also be done as homework, with a different activity each

week (or several at once, if confined to one week), either randomly assigned

or chosen by the student. Have students write a brief paper or discussion

board post on each experience, how it impacted them, and how they could

use it in future counseling (what issues it could be helpful with, etc.).

• Have students choose an expressive therapy—music, poetry, drama,

photography, movement, etc.—and create a therapeutic activity, then

experience it personally and write about their experience in a paper or

discussion board post. This can be done in class or as homework.

Chapter 14 Quiz (25 questions):

Fill-in-the-blank

1. According to Erik Erikson, the major developmental task of adolescence is

___________________________. (identity vs. identity confusion)

2. When adolescents are aware of the risks of behaviors yet place more

emphasis on the possible positive outcomes of such risky behavior, this is

known as _____________________. (hyperrationality)

3. The concept of unconditional positive regard is akin to the theological

concept of _____________________. (grace)

4. Parents should provide their adolescent children with age-appropriate

opportunities to make decisions in order to encourage independence. This is

known as ____________________. (choice giving)

5. ___________________ therapy is to adolescents as play therapy is to

children. (activity)

6. Because of the social engagement aspect of adolescence, ______________

activity therapy is uniquely suited to meet their developmental needs.

(group)

7. Increased novelty seeking for adolescents is due in part to changes within

the brain that lead to neural activity utilizing ____________. (dopamine)

8. Some research has indicated that _________________ therapies allow a

client to access different aspects of their personal experience that might not

be readily accessible with exclusively talk therapy. (expressive)

True/False

1. The need for superficial, shallow bonds with peers is absolutely crucial to

healthy adolescent development. (T/F)

2. Adolescent clients do not typically present for counseling on their own

volition. (T/F)

3. Clinicians do not need to obtain written parental consent to provide

treatment to a minor client. (T/F)

4. Parent consultations throughout the therapy process can be conducted with

or without the adolescent present, although it is recommended to include the

adolescent to foster trust. (T/F)

5. Due to the nature of activity therapy, metaphors and symbols in creative

expression provide a nonthreatening manner for the client to express self.

(T/F)

6. Maintaining photographic records of the adolescent client’s created work

during activity therapy is not helpful and is frowned upon. (T/F)

7. Concerning the structure of a session for adolescent activity therapy, one

should allot a maximum of ten minutes for the activity and twenty to twenty-

five minutes for processing. (T/F)

8. When processing the client’s created work in activity therapy, do not touch

the client’s creation or give evaluative feedback about the product. (T/F)

9. The counselor should always gain personal experience utilizing each artistic

medium prior to incorporating the medium into therapeutic practice. (T/F)

Multiple Choice

1. The acronym ESSENCE, meaning “emotional spark, social engagement,

novelty seeking, and creative expression” was coined by ______________

to describe the key features of adolescence.

a) Siegel

b) Thacker

c) Erikson

d) Yarhouse & Hill

e) None of the above

2. The main structure in the brain going through major changes during

adolescence, according to the text, is:

a) Prefrontal cortex

b) Amygdala

c) Hypothalamus

d) Temporal lobes

e) None of the above

3. ___________________ is the experience in which clients perceive that you

truly understand their experience and “get them.”

a) Grace

b) Unconditional positive regard

c) Feeling felt

d) Therapeutic alliance

e) None of the above

4. All of the following tasks should be accomplished in an initial session with

an adolescent’s parents except for:

a) Obtain a detailed developmental history

b) Discuss the parents’ expectations for therapy

c) Allow parents opportunity to speak candidly about the problem

d) Informed consent

e) None of the above

f) All of the above

5. A ___________________ therapy approach occurs when you allow the

adolescent client to lead and select specific activities.

a) Directive

b) Non-directive

c) Self-directed

d) Choice giving

e) None of the above

6. Examples of expressive activities that can be used in activity therapy include

all the following except:

a) Poetry

b) Drama

c) Music

d) Movement

e) None of the above

7. Which of the following is NOT one of the recommendations to remember

when building a therapeutic relationship with an adolescent client?

a) Reflecting feelings

b) Reflecting content

c) Patience

d) Unconditional positive regard

e) None of the above

f) Only A and B

8. Which of the following is NOT an aspect of contract setting?

a) Posting the contract in a public area of the home

b) Deciding on consequences together

c) Parents identifying the top 2-3 adolescent behaviors to be addressed

d) Adolescents deciding on the top 2-3 parental behaviors to be

addressed

e) None of the above

Chapter 15

Couple-focused Strategies by Frederick A.

DiBlasio, PhD

Key Terms: cognitive behavioral therapy (CBT), integrative behavioral couple

therapy (IBCT), emotion-focused therapy (EFT), neuroplasticity, firing, plastic

changes, limbic system, amygdala, adrenaline, cortisol, amygdala moment,

hippocampus, automatic implicit reactions, oxytocin, neurobiological-integrated

couple therapy, personality disorder (PD), emotional and interpersonal dyslexia

(EID), forgiveness, checking behavior, improving the fit, accepting and tweaking

personality, negotiation, compromise, William James, stroke-kick technique,

relationship restoration skills

Key Points:

• Research has shown that cognitive behavioral therapy (CBT), integrative

behavioral couple therapy (IBCT), and emotion-focused therapy (EFT)

approaches are most effective when counseling couples, promoting calming

during moments of conflict and increasing empathy and acceptance.

• Similar to the Christian concept of growing in one’s capacity to love,

research has shown that the brain does grow in different ways throughout

one’s lifetime, a concept known as neuroplasticity.

• The amygdala is triggered during conflict, activating a person’s survival

instincts or “fight/flight/freeze” system. Cortisol and adrenaline are released,

causing one’s energy to focus on survival at the expense of high brain

functions such as empathy or logical thinking.

• Clients can be taught to recognize when they are emotionally triggered,

having an “amygdala moment,” and to calm their amygdala for a few

moments before trying to solve a conflict.

• The amygdala also is responsible for releasing oxytocin, considered to be the

love/bonding hormone and essential for a marriage relationship; this

hormone can be released through touch, kissing, sex, petting an animal, or

experiencing empathy, among other ways.

• Both negative and positive experiences are believed to be stored in the

hippocampus, and the amount of either one can influence the intensity of the

amygdala’s reaction to a situation.

• Those with a personality disorder (PD) tend to repeat the same relational

errors and don’t appear to learn from them, a concept known as emotional

and interpersonal dyslexia (EID).

• Another useful technique for couples counseling is the clinical use of

forgiveness, which must be willingly decided upon by the couple.

• “Improving the fit” is a technique in which couples are provided a metaphor

of two geometrical angles that (ideally, but don’t always have to) add up to

180 degrees, in which each person is an angle in a particular area.

• 50/50 compromise is actually not often the best ratio for marriage.

• Additional techniques include assessing and tweaking personality, the

stroke-kick technique, and relationship restoration skills.

Student Learning Objectives:

• To be able to describe the nature of neuroplasticity, the ways in which our

brains respond during times of stress and conflict, and how this influences

relationships

• To understand how EID, PD, and forgiveness issues impact relationships

and the various interventions that can help

• To comprehend the use of oxytocin, compromise, improving the fit,

assessing and tweaking personality, the stroke-kick technique, and

relationship restoration skills and how these techniques can be applied to

couples counseling

Chapter Summary:

Research has shown that cognitive behavioral therapy (CBT), integrative

behavioral couple therapy (IBCT), and emotion-focused therapy (EFT) approaches

are most effective when counseling couples, promoting calming during moments

of conflict, and increasing empathy and acceptance. These types of therapy address

the physical calming of the brain and creation of new neural pathways, similar to

the Christian concepts of renewing the mind and growing in one’s capacity to love

throughout the lifespan. Secular approaches tend to emphasize following one’s

heart, but Christian counselors recognize that Scripture describes the heart as

deceitful and that happiness is not the goal of marriage.

Similar to the Christian concept of growing in one’s capacity to love,

research has shown that the brain does grow in different ways throughout one’s

lifetime, a concept known as neuroplasticity. DiBlasio (2018) defines

neuroplasticity as “the ability of the human brain to grow stronger through use and

stimulation, much like muscles and bodies do when adapting to physical demands

like exercise” (p. 313). New pathways, or plastic changes, are formed through

repetition and old pathways weaken due to lack of use, although they are usually

permanent.

Concerning the structure of the brain, an area of the limbic system

considered to be mainly responsible for emotions called the amygdala plays a

significant role in relational conflict. The amygdala is triggered during said

conflict, activating a person’s survival instincts or “fight/flight/freeze” system.

Cortisol and adrenaline are released, causing one’s energy to focus on survival at

the expense of high brain functions such as empathy or logical thinking. Over time,

this release of cortisol can lead to health problems such as depression, sleep

deprivation, and migraines, among many others. It is highly beneficial to begin

couples counseling by educating the couple about the brain and the amygdala in

particular, and then encouraging them to voluntarily form a contract with each

other for treatment. Clients can be taught to recognize when they are emotionally

triggered, having an “amygdala moment,” and to calm their amygdala for a few

moments before trying to solve a conflict.

The amygdala also is responsible for releasing oxytocin, considered to be the

love/bonding hormone and essential for a marriage relationship; this hormone can

be released through touch, kissing, sex, petting an animal, or experiencing

empathy, among other ways. Oxytocin can “increase contentment,

mellowness/calm, security, bonding and attachment, positive social interaction,

empathy, loving behaviors, growth, and healing” (DiBlasio, 2018, p. 320). When

conducting neurobiological-integrated couple therapy, educating clients on the

nature of oxytocin is beneficial, as they can then learn how to increase their own

and each other’s oxytocin levels especially during times of stress or conflict.

Educating the couple about the hippocampus is also helpful, as it is highly

connected to the amygdala. Both negative and positive experiences are believed to

be stored in the hippocampus, and the amount of either one can influence the

intensity of the amygdala’s reaction to a situation. This happens when people are

“triggered” and react in a way that is out of proportion to the actual situation,

because the situation is reminding their amygdala to relive at lighting speed past

negative situations in the hippocampus that are similar to the current one. Another

name for these instances is automatic implicit reactions. When couples are aware

of this, they can learn to recognize how their hippocampus is influencing their

current emotions and learn to see their current situations more clearly after calming

the amygdala.

In addition to brain education, another important area of education in

couples therapy is personality disorders. According to 2008 and 2005 statistics

reported in the chapter, respectively, 9 percent of the general population and 46

percent of the clinical population have a personality disorder (PD). Research has

shown that those with a PD have physiological differences in brain structure,

function, and connectivity. Additionally, those with a PD tend to repeat the same

relational errors and don’t appear to learn from them, a concept known as

emotional and interpersonal dyslexia (EID). Several techniques can be used to help

address EID, such as providing a diagnosis and explanation in a strengths-based

way, seeking support from the spouse, teaching the individual to build new brain

pathways and not always trust his emotions, and helping him establish

accountability with others.

Another useful technique for couples counseling is the clinical use of

forgiveness, which must be willingly decided upon by the couple. It can be done in

a five-hour session either at the beginning, middle, or end of counseling, although

it can be most beneficial to do it at the beginning. There is a long list of steps

involved in this process, but it begins with discussing definitions of forgiveness

and explaining the treatment process; each spouse then takes turns walking through

the steps of forgiveness with the other. The offender is given the opportunity to

explain the offense and to make a plan for not repeating it in the future.

“Improving the fit” is a technique in which couples are provided a metaphor

of two geometrical angles that (ideally, but don’t always have to) add up to 180

degrees, in which each person is an angle. Clients can rate each other’s perceived

angles as well as their own in any given area, and they often are in agreement

about the amount of influence each person has on an issue. Using this visual,

couples can decide on which areas each would like to change to create different

angles. This can lead into learning about compromise and negotiation techniques,

the first of which is letting clients know that 50/50 compromise is actually not

often the best ratio for marriage.

When faced with a conflicting issue, first ask each client to rate their

position on a scale of 1 to 10 to provide a visual, and then discuss the compromise,

which becomes a drastically different conversation when both individuals learn to

drop the 50/50 expectation. Related to addressing expectations, couples tend to

have idealistic, unrealistic expectations for what a good marriage “should” look

like, and helping them realize this can be helpful.

Finally, some additional techniques include assessing and tweaking

personality, the stroke-kick technique, and relationship restoration skills. Assessing

and tweaking personality is a technique in which clients are taught to celebrate the

positive aspects of the other person while also working on the negative aspects in

their own personalities. The stroke-kick technique involves preceding a negative

statement with a positive one, and usually ending with another positive statement

as well so that the negative statement will be better received. Similarly,

relationship restoration skills involve helping the other person feel valued and

loved in the midst of conflict or relational stress.

Pedagogical Suggestions:

• Have students research CBT, IBCT, and EFT in relation to couples therapy

and write a paper or discussion board post on their similarities and

differences. Have them research specific techniques associated with each

type of therapy and provide a clear explanation of how to use these

techniques in therapy with couples.

• Have students discuss (or write a paper or discussion board post) how the

concepts of neuroplasticity and neurobiology described in the chapter reflect

truths from Scripture, and how this could impact future counseling.

• Have students break into pairs or triads to role-play and practice explaining

the neurobiological concepts from the chapter in an easy-to-understand way

to a hypothetical client.

• Have students choose a topic from the chapter (such as oxytocin,

neuroplasticity, adrenaline, cortisol, etc.) and write a paper or discussion

board post, utilizing new information from scholarly sources not presented

in the text. Alternatively, students could create PowerPoint presentations for

the class. Have them discuss how this new in-depth knowledge could impact

their future counseling work, particularly with couples.

• Have students research an aspect of personality disorders or EID and write a

discussion board post or paper on their findings, being sure to write about

information not provided by the text. Ask them to also write about how this

information could influence future counseling.

• Have students break into triads and role-play to practice using DiBlasio’s

model of forgiveness with a hypothetical couple. Ask them to also discuss

how this model is similar to or different from previous forgiveness models

discussed in other chapters, and their opinions on them.

• In role-play triads, have students practice explaining improving the fit,

accepting and tweaking personality, and negotiation/compromise techniques

to hypothetical clients. They can also practice reducing expectations, the

stroke-kick technique, and relationship restoration skills.

Chapter 15 Quiz (25 questions):

Fill-in-the-blank

1. ____________________ is the ability of the human brain to grow stronger

through use and stimulation. (neuroplasticity)

2. Repetitive stimulation in the brain, creating an increased protein synthesis of

neurons, is known as _____________. (firing)

3. In neurology, the adaptive changes in the brain throughout life are known as

_______________________, because the brain can be shaped to almost any

form that it is purposed to become. (plastic changes)

4. ___________________ is meant to dull the signaling from the amygdala to

the higher order cognitive structures so that the person stays in an instinctual

survival mode, thus inhibiting logical cognitive thought that can get in the

way of fighting or fleeing danger. (cortisol)

5. ____________________ is a hormone released in the brain that is known to

increase contentment, mellowness/calm, security, bonding and attachment,

positive social interaction, empathy, loving behaviors, growth, and healing.

(oxytocin)

6. When those with personality disorders continue to repeat the same mistakes

over and over without learning from them, this is known as

____________________. (emotional and interpersonal dyslexia, EID).

7. The ____________________ is a brain structure not just for negative and

hurtful memories, but also for positive and pleasurable ones. (hippocampus)

8. One of the purposes for the ___________________ is to provide an

automatic, autonomic, conscious, and unconscious mechanism for

instinctual self-protection, including emotional and psychological survival.

(amygdala)

True/False

1. One of the problems with secular couple counseling is that many approaches

do not encourage humans to find happiness and follow their hearts. (T/F)

2. In emotional conflict, the amygdala calls for the release of adrenaline and

cortisol. (T/F)

3. Research has shown that depriving couples of sleep during conflicts has

detrimental effects on the couples’ ability to manage conflict. (T/F)

4. The more negative experiences stored in the hippocampus, the greater the

intensity of the perceived danger of the current threat. (T/F)

5. One key function of the amygdala is to activate the secretion of adrenaline,

an attachment/love hormone, between husband and wife that bonds them

together in a deep neurobiological way. (T/F)

6. 46 percent of the general population are believed to have one or more

personality disorders (PD). (T/F)

7. Those with personality disorders have been shown to have brain structures

that are smaller, with grey and white matter being less in volume. (T/F)

8. Compromise in marriage should always be 50/50, or close to it. (T/F)

9. Couples often come to therapy with a mind-set of how far short their

marriage is from the way a marriage should be. (T/F)

Multiple Choice

1. Which of the following is NOT listed as one of the therapies that is effective

with couples?

a) Cognitive behavioral therapy

b) Integrative behavioral couple therapy

c) Emotion-focused therapy

d) Psychoanalytic couple therapy

e) None of the above

f) All of the above

2. At the center of the limbic system are two small brain structures called the

________________, each about the size of an almond, which are thought to

create feelings modern society refers to as “the heart.”

A) Hippocampi

B) Amygdala

C) Prefrontal cortex

D) Temporal lobes

E) None of the above

3. When humans are emotionally hurt or under emotional threat, the

______________ is activated much like it is when under physical threat.

a) Amygdala

b) Hippocampus

c) Temporal lobe

d) Prefrontal cortex

e) None of the above

4. Which of the following problems is NOT associated with chronic release of

cortisol?

a) Depression

b) Sleep deprivation

c) Migraines

d) Chronic fatigue

e) None of the above

f) All of the above

5. When couples are given the geometrical metaphor of supplementary angles

and are asked to rate themselves and each other across a wide array of

subjects, this technique is known as:

a) The supplementary angle technique

b) Improving the fit

c) Accepting and tweaking personality

d) Improving the angle

e) None of the above

6. __________________ is credited with creating the concept of happiness as a

ratio of perceived reality divided by expectations, a useful formula in

couples therapy.

a) William James

b) DiBlasio

c) Hippocrates

d) Zimmerman

e) None of the above

7. _______________________ involve(s) the direct intent to do or say

something during tense moments to show the other that he or she is valued

and loved.

a) The oxytocin technique

b) Relationship restoration skills

c) The stroke-kick technique

d) Assessing and tweaking personality

e) None of the above

8. Which of the following is NOT one of DiBlasio’s first three steps of

forgiveness?

a) The focus on each person having the opportunity to seek forgiveness for

his or her wrongful actions is established.

b) Definitions of forgiveness are discussed.

c) The treatment process is introduced, and the couple decides whether to

participate.

d) The couple completes a ceremonial act to celebrate the forgiveness

decisions made.

e) None of the above

Chapter 16

Family-Focused Strategies by Frederick A. DiBlasio,

PhD, and Amanda G. Turnquist, MSW

Key Terms: functional family therapy (FFT), systemic family therapy (SFT),

brief strategic family therapy (BSFT), multisystemic therapy (MST), hierarchy,

reciprocity, Murray Bowen, John Weakland, Gregory Bateson, Jay Haley, Milton

Erikson, Virginia Satir, Salvador Minuchin, structural family therapy, Harry

Aponte, Cloe Madanes, strategic family therapy, enactments, directives,

boundaries, enmeshed boundaries, nurturance, process, outcome, peripheral parent,

parent coaching, time-out

Key Points:

• DiBlasio (2018) defines systemic family therapy as focusing on “how the

system created by the family through healthy and unhealthy dynamics

impacts the emotional and relational health of the family members” (p. 334).

• Historically, official counseling work with families did not begin until the

1950s when several famous individuals attempted to seek a cure for

schizophrenia by postulating that whole families needed to undergo therapy;

in these times, schizophrenia was thought to originate from dysfunctional

family patterns.

• Scripture provides a template for family therapy by describing the ideal

hierarchy and structure of the Christian family, with the parents at the top of

the hierarchy and children below them.

• The counselor can use a wide variety of techniques from a systems-oriented

perspective when dealing with family situations in therapy; these techniques

include enactments, inducing enactments, using directives, interrupting

dysfunctional patterns, setting healthy boundaries, using nurturance to

elevate hierarchy, empowering parents to win the process and outcome,

staying focused on the present problem, increasing involvement of the

peripheral parent, and parent coaching.

Student Learning Objectives:

• To comprehend the nature and history of family therapy, including the

different pioneers and their contributions

• To understand the Bible’s views on family, including dynamics and structure

• To be able to describe the various techniques that can be used in therapy to

address family dynamics, patterns, and struggles

Chapter Summary:

Many different types of therapy have been shown to be effective with

families, including functional family therapy (FFT), brief strategic family therapy,

multidimensional family therapy (MDFT), multisystemic therapy (MST), and

systemic family therapy (SFT), but all of them have in common a systems-oriented

approach. This is based on the idea of reciprocity, or the idea that one family

member’s behavior affects and is influenced by the behavior of all other family

members. DiBlasio (2018) defines systemic family therapy as focusing on “how

the system created by the family through healthy and unhealthy dynamics impacts

the emotional and relational health of the family members” (p. 334).

Historically, official counseling work with families did not begin until the

1950s when several famous individuals attempted to seek a cure for schizophrenia

by postulating that whole families needed to undergo therapy; in these times,

schizophrenia was thought to originate from dysfunctional family patterns.

Therapists involved in this work included Murray Bowen, John Weakland,

Gregory Bateson, Jay Haley, Virginia Satir, Salvador Minhuchin, Harry Aponte,

and Cloe Madanes. Jay Haley in particular, influenced by Milton Erikson, is

known for directing the Mental Research Institute (MRI) and being the first editor

of the journal Family Process. Minuchin and others developed structural family

therapy, while Madanes and Haley developed strategic family therapy. Both types

of therapy involved a team of counselors watching a family session through a one-

way mirror and sharing ideas live with the counselor in the other room.

Scripture provides a template for family therapy by describing the ideal

hierarchy and structure of the Christian family, with the parents at the top of the

hierarchy and children below them. This is supported by several verses that

illustrate how parents are to love and discipline their children, as well as the

famous Ephesians 5:22-6:4, which discusses the relationship between husband and

wife and the concepts of unity and self-sacrifice among family members.

Additionally, the body of Christ metaphor can be used to help illustrate a healthy

family dynamic where each member is valued and both unity and uniqueness are

present. With these scriptural illustrations in mind, the counselor can use a wide

variety of techniques from a systems-oriented perspective when dealing with

family situations in therapy; these techniques include enactments, inducing

enactments, using directives, interrupting dysfunctional patterns, setting healthy

boundaries, using nurturance to elevate hierarchy, empowering parents to win the

process and outcome, staying focused on the present problem, increasing

involvement of the peripheral parent, and parent coaching.

Enactments are family dynamics or patterns naturally occurring in the

present moment, easily observable by the counselor. Sometimes the counselor can

choose to induce an enactment, which simply consists of asking the family to

discuss an issue or engage in an activity that the counselor suspects will illustrate

the family’s dynamics and patterns in the therapy session. After the counselor is

able to observe such patterns, there are several options for intervention. Directives

can be used, which are tasks or assignments for the family to complete either in

session or at home that help them to establish healthier dynamics and patterns. The

counselor can also interrupt dysfunctional patterns, which usually involves

explaining the observed dysfunctional pattern to the family and then subtly finding

ways to interrupt it when it happens in session. It is also important to pay attention

to boundaries, as sometimes they can be too close (enmeshed) or too rigid. A child

and parent reversing roles is typically the most common type of boundary issue,

and it is necessary to address this so that the parent can be established at the top of

the hierarchy.

One way of helping the family establish a healthy hierarchy system is by

using nurturance. When parents provide nurturance to children, they are naturally

creating a hierarchy where the parents are at the top. This can be helpful in role-

reversal situations because the child is not the one nurturing the parent. Nurturance

also releases oxytocin and helps the parent bond with the child. Empowering

parents to win the process and outcome is another technique that can be beneficial

when children are challenging the hierarchy of the parent; process refers to all the

behaviors and exchanges in a given interaction and outcome refers to the end result

of the given interaction. Often parents will use yelling, threats, or force to win the

outcome, but this results in losing the process. Educating parents on the difference

between process and outcome can help them learn to win both rather than just the

outcome, improving their relationship with their child and establishing the proper

family hierarchy.

However, education alone is not enough, and sometimes direct education is

not helpful, so it is important for the counselor to remember this. Relatedly,

another technique that can help is staying focused on the presenting problem; by

doing this, rather than pointing out dysfunctional family patterns or educating the

family, counseling can create tangible results and also create a better relationship

between the parents and counselor. In cases where there is a peripheral or

underinvolved parent, there is also usually an overinvolved parent, and usually the

overinvolved parent is the mother. When this occurs, it is beneficial to help the

parents learn to balance each other out, and this often solves many family issues as

well as the dynamics change.

Finally, parent coaching is often a useful approach for most mild or

moderate child-related problems. For this approach, it is recommended to meet

first with only the parents, and then continue to meet with only the parents unless it

becomes necessary to include the other family members. Teaching the time-out

technique is one aspect of parent coaching that is especially important. Before

beginning this teaching process, it is essential to explain to the parents the

philosophy behind the technique and how its goal is to help foster a godly family

environment of love. Then, the parents are to also explain this rationale to their

children in an initial family meeting to explain the new technique to the children.

The parents can also use this time to apologize and seek forgiveness for past

discipline experiences in which they were overly angry, if necessary. Then the

parents explain the procedure for the technique, practice it, utilize it when an

offense occurs, and then discuss afterwards the child’s thoughts about the offense

and have the child ask for forgiveness.

Pedagogical Suggestions:

• Have students research functional family therapy (FFT), systemic family

therapy (SFT), brief strategic family therapy (BSFT), multidimensional

family therapy (MDFT), and multisystemic therapy (MST) and write a paper

or discussion board post on the similarities and differences. Have a class

discussion on the students’ opinions on these therapies after their research.

• Have students write a paper on (or have a class discussion on) their own

philosophies of parenting and family, and how these views could affect their

future counseling. Ask them to discuss the biblical support for family

structure and dynamics presented in the text, and how they would handle a

client who has a different view of family either different from theirs or

different from that described in the Bible.

• Divide students into groups and have them choose one of the case studies

from the text to role-play to practice the associated family therapy

techniques.

• Divide students into groups and have them role-play any of the family

therapy techniques from the text.

• Have students break into groups and practice teaching the time-out approach

to hypothetical clients. Then, have the “clients” practice implementing the

approach with the “child.” Switch out roles and/or change group members so

that students get a chance to practice different roles.

• As a class, watch a brief episode of a family-friendly, family-focused

television show, and then discuss the family dynamics and patterns they

noticed in the TV family members. Discuss techniques from the text that

could be helpful in different situations from the show. This can also be

assigned as homework, and each student can write a paper or discussion

board post.

• Have students break into groups and create PowerPoint presentations on one

of the pioneers of family therapy, discussing how this person contributed to

the field and how the information learned from this assignment could be

helpful in future counseling. Make it a competition to see who can make the

most creative, impactful presentation.

Chapter 16 Quiz (25 questions):

Fill-in-the-blank

1. _________________ is the concept that human behavior does not occur in a

vacuum but instead is highly influenced as a response and

interconnectedness to others. (reciprocity)

2. __________________ focuses on how the system created by the family

through healthy and unhealthy dynamics impacts the emotional and

relational health of the family members. (systemic family therapy)

3. ________________ are tasks that the counselor asks a family to do in

session or to accomplish at home for the purpose of building a healthier

pattern of behavior between family members. (directives)

4. Boundaries that are too close are known as _______________. (enmeshed)

5. The ______________ of an interaction is all of the behavioral sequences that

occur within the parent-child interaction. (process)

6. _________________ usually works for mild to moderate child-related

problems, meeting only with the parents rather than the whole family.

(parent coaching)

7. When the counselor asks the family to do or discuss something that is likely

to evoke the family dynamics in the session, this is called

_________________. (inducing an enactment)

8. Salvador Minuchin, along with others, is known for developing

_________________ therapy, having come to the United States with the

systemic ideas of family dysfunctional structure and patterns. (structural

family)

True/False

1. One of the classic principles of family therapy is realigning family hierarchy

so that parents are in charge of their children. (T/F)

2. In a family session, pointing out the dysfunctional pattern before interrupting

it is not necessary. (T/F)

3. The most common boundary intrusion occurs when a child becomes a

parental child and/or a parent becomes more childlike. (T/F)

4. A by-product of the parent giving nurturance is an elevation of hierarchy.

(T/F)

5. It is unusual for children to systematically step into the role of absent parent

while also filling the single parent’s need for companionship. (T/F)

6. Parents coming in for family treatment usually do not fear that counselors

will blame them for the child’s problem. (T/F)

7. When there is an acting-out child or child with a presenting problem, often

one parent is more involved than the other. (T/F)

8. Fathers tend to be overly involved in child problems, and mothers tend to

take on more peripheral roles. (T/F)

9. Minuchin and Haley were against the idea of having a team of people in one

room calling in instructions during a live family session in the adjacent

room. (T/F)

Multiple Choice

1. Which of the following is NOT one of the therapies listed as being effective

with families?

a) Multidimensional family therapy (MDFT)

b) Functional family therapy (FFT)

c) Systemic family therapy (SFT)

d) Brief strategic family therapy (BSFT)

e) None of the above

f) All of the above

2. _____________________ was a pioneer and leader in the family field, a

director of the Mental Research Institute (MRI), and the first editor in the

1950s of the prestigious Family Process journal.

a) Murray Bowen

b) Jay Haley

c) Milton Erikson

d) John Weakland

e) None of the above

3. Strategic family therapy was created by:

a) Haley and Madanes

b) Madanes and Satir

c) Haley and Weakland

d) Haley and Satir

e) None of the above

4. __________________ refer to manifestations of patterns and behavioral

sequences that are occurring live so that they can be observed by the

counselor, and thereby predisposed for direct intervention to address them.

a) Directives

b) Enactments

c) Live observations

d) Live behavioral windows

e) None of the above

5. When the parent controls negative emotions and behaviors, and maintains

loving authority during a conflict, this is known as:

a) Winning the process

b) Winning the outcome

c) Using a directive

d) Staying focused on the present problem

e) None of the above

6. ________________ and Madanes emphasized that therapy should start by

keeping the focus on the presenting problem and choosing a treatment

strategy to resolve it in as brief a time as possible.

a) Minuchin

b) Haley

c) Satir

d) Bowen

e) None of the above

7. Which of the following is NOT one of the steps involved in the time-out

procedure?

a) Set a private pretend practice time for each child

b) When a child commits a violation, calmly request that the child go to the

time-out chair or mat

c) After the time-out, discuss the violation and why the child thinks the

violation was wrong

d) If the child refuses to go to the chair or mat, sit on the chair or mat

with the child and talk to him throughout the time-out

e) None of the above

8. The concept of professional work with families began in:

a) The 1940s

b) The 1950s

c) The 1960s

d) The early 1900s

e) None of the above

Chapter 17

Family-of-origin-focused Strategies by Frederick A.

DiBlasio, PhD

Key Terms: family of origin therapy, counselor self-development, James Framo,

Harry Aponte, the person-of-the-therapist model, Freytag, introduction, rising

action, climax, falling action, denouement, inertia effect, enthusiasm, perceptions,

self-accountability segment, forgiveness, personality disorder (PD), emotional and

interpersonal dyslexia (EID)

Key Points:

• Family of origin therapy involves a counseling session, or several, with

one’s family of origin, usually to address past issues from one’s childhood,

work through forgiveness, and hopefully restoration of relationships.

• Adults, including counselors themselves, can still be heavily influenced by

their family of origin, either in their current relationships with others or their

own internal struggles.

• A pioneer in the field of family of origin therapy, James Framo

recommended family of origin counseling to take place in a one-time

session, spread out over two days for about four hours each day with both a

male and female counselor present.

• Harry Aponte’s model focuses on the person of the counselor, how the

counselor can be affected by family of origin in his professional work, and

how working through such issues can result in better care for clients.

• Counseling sessions can be compared to the five stages of a dramatic

production proposed by Freytag, and the inertia effect can explain why long

counseling sessions can be beneficial.

• It is important for the counselor to be enthusiastic and to personally invite

potentially unwilling family members to a family of origin session.

• Steps to a productive family of origin session include educating the family

on respecting each other’s perceptions, sharing positive family memories,

self-accountability, resolution, and seeking the spiritual value from past

difficulties.

Student Learning Objectives:

• To understand the purpose and benefits of family of origin therapy

• To be able to describe the two models of family of origin therapy presented

by Framo and Aponte

• To comprehend the structure, challenges, and various steps involved with

conducting family of origin sessions

Chapter Summary:

Family of origin therapy involves a counseling session, or several, with

one’s family of origin, usually to address past issues from one’s childhood, work

through forgiveness, and hopefully restoration of relationships. Benefits include

potential reconciliation in one’s familial relationships, improvement in one’s

marital and other relationships, and improvement in one’s own internal struggles

such as self-esteem. Scripture is replete with illustrations of a healthy family, as

well as the value of family, such as Jesus’s care for his mother and the story of the

prodigal son. Also illustrated in Scripture are examples of family tragedy, such as

situations where an adult child rejects God or other evil behavior occurs, such as in

the family of Joseph.

Concerning the psychology of family of origin issues, adults can still

experience emotional abuse from their families through their family members’

current treatment of them, through unconsciously being drawn to similar

dysfunctional relationships, or through internalizing the abusive voices. Issues with

one’s spouse can often be influenced by past family of origin issues. One’s work as

a counselor can also be affected by past family of origin issues, as certain

populations or issues can be triggering of childhood struggles.

Two pioneers in the field of family of origin therapy, James Framo and

Henry Aponte, are worth studying for their useful contributions of SITs. Framo

recommended family of origin counseling to take place in a one-time session,

spread out over two days for about four hours each day. He prescribed that both a

male and female counselor conduct the session, so that both gender dynamics can

be experienced and the chances of a counselor being caught up in the family’s

issues is reduced. The counselors begin by building rapport, then move into the

working phase of the session. To conclude, the counselor summarizes the themes

of the session and helps the family end on a positive note. Aponte, however,

focused his model on the person of the therapist and how difficulties in their

profession can stem from their own family of origin. Gaining awareness of the

family of origin’s influence is the first step, and then supervision or personal

counseling can be sought to help address past unresolved issues.

DiBlasio suggests that there are several benefits to Framo’s idea of long

sessions with families, citing the work of Freytag who described the counseling

session as similar to a dramatic production with five stages: introduction, rising

action, climax, falling action, and the denouement, which is the conclusion. The

inertia effect is another reason that long sessions can be helpful, as the “climax” is

considered the most productive stage of a session and more momentum can be

theoretically achieved with more time.

When considering family of origin sessions, there can be several concerns

that must be navigated. Most considerations begin during individual or couples

therapy when the counselor notices that past family issues on one or both sides

may be affecting current relationships or life situations. DiBlasio notes that it is

important for the counselor to display enthusiasm about family of origin sessions,

as this can help clients be more willing to participate. It is also important to

mention that the sessions will be only for the family of origin and spouses or in-

laws are not to be included, as they were not part of the original family unit.

Clients often report that various family members would likely not be willing to

come to such a session, and DiBlasio recommends that the counselor can ask

permission to personally call and invite the other family members himself. People

tend to be more willing to say yes when the counselor invites them personally and

uses a positive, strength-based communication style in the invitation.

When conducting family of origin sessions, the first step is often to help the

family members learn to respect each other’s perceptions. The counselor can

educate them on reasons why no two people will ever have the exact same

perception of a situation, such as personality differences, gender differences,

differences in developmental stages, neurobiological differences in memory

storage, and individual differences. Then, the counselor can ask each person to

share a positive family memory to help begin dialogue and ease anxiety. This can

be followed by a period of self-accountability where each person chooses a

negative behavior he can take responsibility for and seek forgiveness from other

family members. The counselor should remember that this part may be difficult for

any family members who have a personality disorder. Additionally, it is important

to help the family stay focused on resolution and making a plan to not repeat each

offense in the future. Towards the end of the session, the counselor can help the

family to find the spiritual value in their past, to notice how God can or did use

past pain for good.

Pedagogical Suggestions:

• Have students do additional research on Framo and Aponte and their

perspectives on family of origin therapy; they can present their findings with

a PowerPoint presentation, discussion board post, or class discussion.

• Ask students to choose a family scenario in the Bible and to write a brief

discussion board post or paper on how the family illustrates either the

importance/value of family or one of the other family issues described in the

chapter under the theology section.

• Framo is quoted in the text as saying, “Then there are some things that

women go through that only men can understand, and some things men go

through that only women can understand.” Ask students to break into groups

or have a class discussion (or write a discussion board post) on this quote,

what they think it could mean, how it could impact counseling, and what

some examples could be.

• Have students break into groups and role-play to practice a short-version of

Framo’s family of origin session, going through the three stages described in

the text. They can take turns playing the counselor.

• Ask students to list any populations or issues that they feel are or could be

difficult for them in their future counseling work, and to examine or discuss

in pairs if or how they feel their family of origin influences these struggles.

Talk with each pair and help them through any questions they might have.

Then ask them to do the opposite and examine if or how their family of

origin could have influenced their strengths as a counselor and

issues/populations they feel drawn to or work well with.

• Have students break into triads and role-play a counselor working with a

client who claims their family members would probably be unwilling to

come to a family of origin session. Have the “counselor” move through the

steps listed on page 363 of the text for personally inviting reluctant family

members to a session. The third student can role-play each family member.

• Have students break into groups and role-play a DiBlasio style family of

origin session as described in the text, moving through all the steps such as

explaining to the family the importance of respecting each other’s

perceptions, discussing pleasant memories, etc.

• Have students role-play in groups the same previously described family

scenario, with one of the family members having a personality disorder.

Chapter 17 Quiz (25 questions):

Fill-in-the-blank

1. _______________ was a pioneer in advocating that intense short-term

therapy with family of origin members can produce lasting positive results.

(Framo)

2. _________________ was instrumental in providing a theoretical framework

for helping practitioners to think about intergenerational patterns. (Bowen)

3. Aponte’s model, the _________________ model, involves a focus on family

of origin influence on counselors’ practices. (person-of-the-therapist)

4. DiBlasio cites ________________’s work to describe counseling sessions as

similar to dramatic productions. (Freytag)

5. The second stage of a dramatic production or counseling session is called

________________. (rising action)

6. DiBlasio states that a family of origin session should begin with sharing

___________________. (positive family memories)

7. The section of a family of origin session where each family member takes

personal responsibility for an offense or negative behavior is called the

______________________. (self-accountability segment)

8. When family members are struggling with the pain from the past, DiBlasio

urges them to ________________ the past and focus on how God can or has

used their pain for good. (spiritually embrace)

True/False

1. Current attachment issues with one’s spouse can be related to past issues

with one’s family of origin, according to research. (T/F)

2. One of the reasons that Framo recommended both a male and female

counselor be present for family of origin sessions is that when alone a

counselor can be easily and unknowingly drawn into family dysfunction.

(T/F)

3. One of the reasons that Framo recommended both a male and female

counselor be present for family of origin sessions is that “there are some

things that women go through that only men can understand, and some

things men go through that only women can understand.” (T/F)

4. The second portion of a Framo family of origin session involves building

rapport with the family members and reducing their anxiety. (T/F)

5. There are four stages of a dramatic production or counseling session. (T/F)

6. If counselors are enthusiastically convinced about the treatment they

provide, clients are more willing to attempt and to benefit from treatment.

(T/F)

7. The family of origin session is open to spouses and other family friends, if

desired. (T/F)

8. It is unusual for clients to have a negative viewpoint regarding whether a

family member would agree to come in for a family of origin session. (T/F)

9. Those with personality disorders do especially well with self-accountability.

(T/F)

Multiple Choice

1. All of the following are benefits of family of origin therapy EXCEPT:

a) Improving current family interactions

b) Improving interactions with others

c) Addressing internal difficulties

d) Providing a space for venting and catharsis

e) None of the above

2. Adults can continue to experience emotional abuse from their family of

origin through all of the following EXCEPT:

a) Internalizing the abusive treatment

b) A propensity to find others who continue the abusive pattern

c) Present dysfunctional treatment from family members

d) Poor self-efficacy and low self-worth

e) None of the above

3. Framo originally recommended that a one-time family of origin session be

split up between two days, with a total of approximately ______________

hours.

a) 4

b) 6

c) 8

d) 10

e) None of the above

4. The term for a counseling session’s success due to momentum is:

a) The rising action

b) The falling action

c) The inertia effect

d) The momentum effect

e) None of the above

5. Which of the following is NOT one of the three ways in which family of

origin sessions usually come about, according to the text?

a) During an individual therapy session, unresolved issues come to light

b) Families call directly once the therapist has a reputation

c) Issues come up during couples therapy

d) Issues come up during inpatient hospitalization

e) None of the above

6. All of the following are reasons that family members can have different

perceptions EXCEPT:

a) Gender differences

b) Personality differences

c) Implicit reactions in the brain’s hippocampus

d) Difference in developmental stages

e) None of the above

f) All of the above

7. DiBlasio states that there are 7 reasons for why he believes family of origin

therapy is effective, particularly towards the end of a session. Which of the

following is NOT one of those reasons?

a) The inertia effect

b) Much prayer has been involved

c) More client motivation due to self-accountability and a non-defensive

environment

d) God is pleased to have his children “speak the truth in love.”

e) None of the above

f) All of the above

8. One particular group of disorders one should always assess for when doing

family of origin therapy is:

a) Personality disorders

b) Anxiety disorders

c) Depressive disorders

d) Cognitive disorders

e) None of the above

Chapter 18

Family Conflict-Focused Strategies by Linda Mintle,

PhD, LCSW, LMFT

Key Terms: conflict, family development, system theory, content, process,

social learning theory, modeling theory, emotional security theory (EST), cognitive

contextual theory, Bowlby, attachment, Gottman conflict styles, avoidant style,

volatile style, validating style, hostile style, Thoman-Kilman conflict styles,

avoider style, competitive style, collaborative style, compromising style,

accommodating style, conversational orientation, conformity orientation,

authoritarian parenting style, authoritative parenting style, permissive parenting

style, dialectical behavior therapy (DBT), emotion-focused family therapy (EFFT),

emotion-focused therapy (EFT), the Maudsley approach, structural and Bowenian

family therapy, triangulation, the Gottman method, the four horsemen, Gottman’s

sound relationship house theory, peacemaker

Key Points:

• Conflict, believed to be driven by a search for resources and/or power, is a

normal part of family life, and can be especially prominent during various

stages of a family’s development such as marriage, having young children,

or having teenagers.

• There are several theories to explain how conflict is learned, influenced by

various factors, and how it impacts children, including social learning

theory, modeling theory, emotional security theory, cognitive contextual

theory, attachment theory, and cultural factors.

• The Gottman conflict styles can be divided into four categories: avoidant,

volatile, validating, and hostile. A mismatching of styles is the most likely to

create frequent conflict.

• The Thomas-Kilman conflict styles are divided into five categories: avoider,

competitive, collaborative, compromiser, and accommodator. A

questionnaire developed by Thomas and Kilman examines the factors of

assertiveness and cooperation to classify individuals into one of the five

categories.

• Families can be rated high or low on two orientation types: conversational

and conformity.

• Parenting styles can be divided into three types according to Baumrind:

authoritarian, authoritative, and permissive.

• Effective treatment methods for family conflict discussed in this chapter

include Dialectical Behavior Therapy (DBT), the Maudsley approach,

structural and Bowenian family therapy, emotion-focused family therapy

(EMFT), emotion-focused therapy (EFT), and the Gottman Method, as well

as teaching a few extra skills such as self-efficacy, mastery, and utilizing

one’s voice.

• Giving structured conflict practice assignments to families/couples and

discussing the biblical position of peacemaker can be beneficial.

Student Learning Objectives:

• To be able to describe the impact of, theories related to, and factors that

contribute to family conflict and one’s experience of it

• To understand the different methods of assessment for family conflict issues

• To comprehend the myriad treatment methods recommended for working

with family conflict

Chapter Summary:

Conflict, believed to be driven by a search for resources and/or power, is a

normal part of family life, and can be especially prominent during various stages of

a family’s development such as marriage, having young children, or having

teenagers. Conflict behavior that is maladaptive, especially concerning anger and

avoidance, has been shown to correlate with multiple long-term health problems,

but research has actually shown that experience with healthy conflict and

resolution can be beneficial. Systems theory, often used in family therapy

approaches to conflict, recommends that families be assessed as a whole, and the

parts that make up the whole should be assessed as well. Additionally, both the

process and content of the family members’ interactions during conflict should be

attuned to and assessed by the counselor. Based on these general guidelines, this

chapter examines influencing factors, assessment protocols, treatment methods,

and relevant biblical values to address conflict in family therapy sessions.

There are several theories to explain how conflict is learned, influenced by

various factors, and how it impacts children. According to social learning theory

and modeling theory, children learn patterns of behavior for handling conflict from

their parents. The emotional security theory (EST) and the cognitive contextual

theory both provide explanations for how conflict between parents affects the

family. Children are thought to draw their sense of emotional security from the

meaning they derive from parental conflict, according to EST. Similarly, cognitive

contextual theory illumines the ways in which children ascribe meaning to conflict

based on past experiences and personal interpretations. It is also necessary to

remember that cultural factors can influence these ascriptions of meaning, as

cultures interpret conflict in a wide variety of different ways. The ability to cope

and thus handle conflict well is influenced additionally by attachment style,

divided by Bowlby into secure, avoidant, ambivalent, and fearful/disorganized.

Beneficial assessment models are available, including the Gottman conflict

styles and the Thomas-Kilman conflict styles. The Gottman conflict styles can be

divided into four categories: avoidant, volatile, validating, and hostile. A

mismatching of styles is the most likely to create frequent conflict, although two

people with the same style can have conflict as well. The avoidant style involves

focusing on the positive aspects of the relationship at the expense of the negative,

choosing not to address conflictual issues and let the passage of time solve any

problems. Those with a volatile style are the opposite, aware of their opinions and

expressive, often with intense or dramatic verbiage; they emphasize honesty, but

they are not emotionally cruel. The validating style is seen as the most effective,

healthiest style, focusing on compromise, listening, and empathy while also being

assertive. As can be inferred from the name, the hostile style is the most unhealthy,

involving criticism, blaming, and emotional attacks on the other person.

The Thomas-Kilman conflict styles are similar, but also different, and are

divided into five categories: avoider, competitive, collaborative, compromiser, and

accommodator. A questionnaire developed by Thomas and Kilman examines the

factors of assertiveness and cooperation to classify individuals into one of the five

categories. The avoider category is the same dynamic as described in the Gottman

model. The competitive category prioritizes being right and getting what one wants

no matter what. The collaborative style is similar to Gottman’s validating style,

utilizing assertiveness and cooperation. The compromiser style is self-explanatory,

and the accommodating style involves putting aside one’s needs in favor of the

other person’s.

It is also valuable to assess a family’s orientation and parenting styles, as

well as be aware of the stages of conflict—prior conditions, frustration, active

conflict, solution or non-solution, follow-up, and resolution—in order to guide the

family through them in a healthy way. Families can be rated high or low on two

orientation types: conversational and conformity. Conversational is the degree to

which family members can freely share their thoughts and opinions, and

conformity is the degree to which family members are implicitly required to agree.

Parenting styles can be divided into three types according to Baumrind:

authoritarian, authoritative, and permissive. Authoritative is considered to be the

most effective style, involving both nurturance and parental control. The

authoritarian style uses little nurturance and a high degree of control, and the

permissive utilizes strong nurturance but weak control. Families often find the

results of these assessments to be insightful and incredibly beneficial. After the

assessment process, a treatment method can be selected based on the family’s

needs and goals. Effective treatment methods for family conflict discussed in this

chapter include Dialectical Behavior Therapy (DBT), the Maudsley approach,

structural and Bowenian family therapy, emotion-focused family therapy (EMFT),

and the Gottman Method, as well as teaching a few extra skills such as self-

efficacy, mastery, and utilizing one’s voice. Furthermore, giving structured conflict

practice assignments to families/couples and discussing the biblical position of

peacemaker can be beneficial.

Dialectical Behavior Therapy (DBT) involves learning a wide variety of

skills that assist in emotion regulation and interpersonal interactions, such as

mindfulness, interpersonal effectiveness skills, and tolerating distress. Each skill

involves a series of “how to” steps and are learned through repeated practice. The

Maudsley approach was created to help the families of young adults living at home

or adolescents with eating disorders. Parents actively help their child recover while

displaying a unified front, and problematic family conflict styles are shifted to

more healthy ones. Structural and Bowenian approaches are based on the idea that

families are composed of triangles, and work to de-triangulate children who have

ended up in an unhealthy position. Emotion-focused family therapy (EMFT)

asserts that dysfunctional family behavior is based on attachment and emotion

regulation issues, and seeks to create healthier relationships among family

members by changing interactional patterns during conflict.

When focusing on couples and the marital relationship, there are two

methods that have been shown to be especially helpful. The Gottman Method

teaches couples to control their arousal through self-soothing and reduce criticism,

defensiveness, contempt, and stonewalling, also known as the “four horsemen.”

Controlling arousal during conflict is essential, as Gottman found that when one’s

heartrate rises above 100, one becomes flooded with emotion and finds it more

difficult to listen to others. Couples also learn to increase positive affect during

conflict and focus on having positive relational experiences when conflict is not

occurring, an aspect of Gottman’s sound relationship house theory. Six steps can

also be taught to the couple to help them process conflict: “sharing feelings,

describing each partner’s subjective reality, sharing attachment issues, checking

emotional arousal (flooding), acknowledging responsibility, and problem solving a

way to make the fight better” (Mintle, 2018, p. 394).

Another effective approach with couples is emotion-focused therapy (EFT),

similar to the emotion-focused family therapy (EFFT) described in brief

previously. This approach focuses on helping the clients view each other as a safe

haven where they can emotionally engage and empathize together. They are taught

to make repairs after conflict via apologies and forgiveness, and to focus on

strengthening their bond of friendship.

Finally, Mintle provides a ten-step process that can be taught to families to

help them practice conflict well at home; this process includes evaluation questions

at the end to help family members determine if the steps were helpful or not.

Additionally, she discusses the biblical concept of peacemaker, stating that people

often mistakenly believe that being a peacemaker means avoiding conflict. It is

important to explain this false idea and the correct definition of a peacemaker to

Christian families or couples as they struggle with conflict. In a seven-step process,

Mintle suggests that peacemakers make a decision to address the conflict, begin

with prayer, listen to the other person’s viewpoint, take responsibility, speak the

truth in love, forgive, and work towards solutions.

Pedagogical Suggestions:

• Using both the Gottman conflict styles and the Thomas-Kilmann styles, have

students identify their own preferred conflict style from each, as well as the

conflict styles of their family members while they were growing up. Ask

them to note any mismatches, matches, or ways in which the style of a

parent was passed down to a child. Have a class discussion, or break into

groups to discuss their findings and reactions. Ask students to explain how

they and their family members exemplified certain styles. Ask them how, if

at all, they think their personal conflict style could affect their counseling

work.

• Choosing either the Gottman styles or the Thomas-Kilmann styles (or both),

write the names of each style on a slip of paper and put them in a bowl or

other container. Have each student draw a piece of paper, keeping it to

themselves. Then have the students come up two at a time and role-play a

conflict or argument, illustrating their conflict styles. The class could offer

up ideas or vote on what the conflict should be about. After the brief role-

play, have the class guess which conflict styles were being demonstrated.

• Have students break into groups and role-play a family counseling scenario,

choosing either dialectical behavioral therapy, the Maudsley approach,

emotion-focused family therapy, or structural and Bowenian family therapy.

Students may research these approaches in more detail the week before the

role-play exercise as homework, if desired, or during class before the role-

play if resources are available.

• Have students conduct further research on both the Gottman Method and

Sue Johnson’s emotion-focused therapy (EFT), then construct a paper,

discussion board post, or PowerPoint presentation on the similarities and

differences between the two, as well as a detailed description of each and

how one could go about becoming trained in them as a counselor.

• After studying Mintle’s ten-step process for structured practice with conflict,

have students break into “family” groups and role-play working through a

conflict while following these steps. Before practicing, have one student

volunteer to teach the other group members the steps as if he or she were

their family counselor.

• Have students break into pairs and practice teaching each other the seven

steps of Mintle’s peace process, with one student role-playing the client and

the other role-playing the counselor. Then, have them switch roles. The goal

is for the students to be able to teach the process without looking at the text

or any other resource. Ask students to discuss their thoughts about these

steps after the role-play.

Chapter 18 Quiz (25 questions):

Fill-in-the-blank

1. Family conflict is influenced by resources and __________________.

(power)

2. ___________________ theory posits that it is the meaning of interpersonal

and family conflict that relates to a child’s assessment of emotional security.

(emotional security)

3. ___________________ theory states that the way people make sense of

conflict is influenced by experiences, recollections, and interpretations.

(cognitive contextual)

4. The Thomas-Kilmann assessment instrument measures individuals on two

factors, assertiveness and ____________________. (cooperativeness)

5. ____________________ is a family based treatment developed for

adolescents with eating disorders and young adults living at home. (the

Maudsley approach)

6. _______________________ theory stresses the importance of knowing your

partner through friendship, expressing fondness and admiration, turning

toward the partner, and building a positive relationship when conflict is not

present. (Gottman’s sound relationship house)

7. Families often confuse making peace with __________________.

(avoidance)

8. ___________________ is the fourth step in the seven steps to help families

address the peace process when family conflict occurs. (take responsibility)

True/False

1. Research has shown that there are no long-term health consequences

associated with family conflict. (T/F)

2. Conflict activates attachment style. (T/F)

3. Those with a volatile conflict style are clear about their opinions and have no

problem arguing and persuading. (T/F)

4. A validating conflict style is superior to other styles in terms of couple

satisfaction and stability. (T/F)

5. Baumrind (1973) categorized parenting styles into three basic types:

authoritarian, authoritative, and permissive. (T/F)

6. The last stage of family conflict, according to Galvin, Braitwaite, and

Bylund (2016), is the follow-up stage. (T/F)

7. Structural and Bowenian family therapy include the technique of

detriangulation. (T/F)

8. When a person’s heartrate rises above 100, he is flooded with emotion,

inhibiting listening. (T/F)

9. According to Gottman’s research, healthy couples have a five-to-one ratio of

positives to negatives in their relationship. (T/F)

Multiple Choice

1. Both social learning theory and ____________________ posit that children

learn behavior patterns in their families, and parents are the models for

conflict behavior.

a) Modeling theory

b) System theory

c) Cognitive contextual theory

d) Family conflict theory

2. Which of the following is NOT one of the Gottman conflict styles?

a) The competitive style

b) The avoidant style

c) The volatile style

d) The validating style

e) None of the above

3. Which of the following is NOT one of the Thomas-Kilmann conflict styles?

a) The competitive style

b) The compromising style

c) The validating style

d) The collaborating style

e) None of the above

4. All of the following are examples of dialectical behavioral therapy (DBT)

skills EXCEPT:

a) Interpersonal effectiveness skills

b) Mindfulness

c) Tolerating distress

d) Emotional regulation

e) None of the above

f) All of the above

5. The goal of _________________ is to reestablish connection between

family members by creating new emotional and interactive experiences.

a) Emotion-focused family therapy

b) The Gottman Method

c) The Maudsley approach

d) Bowenian family therapy

e) None of the above

6. In ____________________, couples are coached to manage their arousal

and interactional patterns.

a) The Gottman Method

b) The Maudsley approach

c) Emotion-focused couples therapy

d) Structural family therapy

e) None of the above

7. Which of the following is NOT one of the steps in the Gottman Method?

a) Build positivity during nonconflict times

b) Physically soothe self and partner

c) De-escalate conflict

d) Reduce the four horsemen

e) None of the above

8. All of the following are aspects of emotion-focused therapy EXCEPT:

a) Make repairs

b) Build friendships

c) Create a safe haven

d) Teach constructive alternatives to ineffective patterns of interactions

e) None of the above

Chapter 19

Domestic Violence-Focused Strategies

by Lynne M. Baker, PhD

Key Terms: domestic violence, Walker, cycle of violence, assessment, safety,

worldview, the ABC’s of providing support, coping, forgiveness, marriage,

reconciliation, person-centered approach, repentance, remorse, divorce, separation,

self-awareness

Key Points:

• Domestic violence centers on a desire for power, control, intimidation, or

coercion, and is a pattern of behavior rather than a single incident. Behavior

is not exclusive to physical abuse and also includes sexual, emotional,

psychological, and even spiritual abuse.

• Assessment of a client’s safety and her children’s safety is critical.

• Baker provides an “ABC” guide to help counselors as they work with

Christian clients who are in domestic violence situations. The “A” stands for

“Acquire knowledge (and with it understanding)” and involves the process

of getting to know the client, how she views the world, her faith, and God, as

well as her coping style.

• The “B” stands for “Identify blocks or barriers” and concerns becoming

aware of any issues, such as specific religious beliefs concerning forgiveness

or marriage, that may be keeping the client from changing her current

situation.

• The “C” stands for “Clarify theological understandings” and involves

investigating any misconceptions about such religious beliefs through gentle

discussion.

• Forgiveness, marriage, and reconciliation are three common issues that are

influenced by one’s religious beliefs, and misconceptions can contribute to

the continuance of the abuse cycle.

• When working with domestic violence issues, counselors need to develop

self-awareness and examine their own beliefs about such topics as

forgiveness, marriage, and reconciliation.

Student Learning Objectives:

• To understand the definition and cycle of domestic violence, the Bible’s

stance on it, and how to assess for a client’s safety

• To be able to describe Baker’s “ABC” process for working with women in

domestic violence situations

• To comprehend the common misconceptions about forgiveness, marriage,

and reconciliation that one may encounter with domestic violence and to

also be aware of and examine one’s own beliefs on such concepts

Chapter Summary:

Domestic violence centers on a desire for power, control, intimidation, or

coercion, and is a pattern of behavior rather than a single incident. Behavior is not

exclusive to physical abuse and also includes sexual, emotional, psychological, and

even spiritual abuse. The most popular way of defining this pattern or cycle of

behavior are the three fairly self-explanatory stages developed by Walker in 1979:

tension, explosion, and loving contrition/honeymoon period. The Bible is very

clear on God’s opinion of such violent behavior, addressing multiple aspects and

principles.

Firstly, Scripture provides a myriad of verses denouncing violence and being

ruled by anger and corrupt speech. Instructions are also given on how spouses

should treat their partners with mutual submission and love, and how responses of

love should be given to others in general. Additionally, Jesus treated women in a

caring, attentive way that was countercultural to the way men of his time treated

women, illustrating the respect and love with which women should be treated.

Assessment of a client’s safety and her children’s safety is critical, and

asking questions such as “How safe do you feel in going home?” and “What do

you think might happen if…?” can be helpful. The goal is to encourage her to think

about her situation and assess it for herself. One of the first steps women in

domestic violence situations can take is realizing that the abuse is not their fault, as

many women tend to believe that they are somehow doing something to deserve

the perpetrator’s treatment. Gentle questions can be an effective way of helping her

take steps towards this realization. It is also important to get to know her

worldview, her faith, and how these views affect her thoughts about her current

situation.

Baker provides an “ABC” guide to help counselors as they work with

Christian clients who are in domestic violence situations. The “A” stands for

“Acquire knowledge (and with it understanding)” and involves the process of

getting to know the client, how she views the world, her faith, and God, as well as

her coping style. For example, some women turn heavily to prayer and others like

to have something else other than the abuse to focus on such as a routine. She may

also view God or the Bible as a strong source of comfort, or may find refuge in

journaling, art, or reading inspirational stories. It is recommended to use a person-

centered approach to counseling when trying to understand her world, validating

her feelings, experiences, and efforts to make her relationship work, for it is likely

she has never talked about her situation of domestic violence to anyone before.

The “B” stands for “Identify blocks or barriers” and concerns becoming

aware of any issues, such as specific religious beliefs concerning forgiveness or

marriage, that may be keeping the client from changing her current situation. Many

abusers hide behind Scripture to excuse their abusive behavior, taking verses out of

context and twisting them to fit their world. They may use these verses to tell the

woman why she deserves the abuse, why she should forgive him no matter what he

does, or why she cannot leave the marriage no matter what he does. Other times

the woman uses Scripture or what she has been told by others to justify why she

either deserves or must forever endure the abusive behavior. With good intentions

and a desire to please God, she may believe that it is her duty to always forgive,

and forgiveness means to stay in her current situation hoping one day her abuser

will stop or change his behavior.

Finally, the “C” stands for “Clarify theological understandings” and involves

investigating any misconceptions about such religious beliefs through gentle

discussion. One should be careful to avoid criticism of the client’s thoughts and the

verses she uses, and to instead help her critically examine these verses in context or

any statements she believes and help her to think about them in a deeper way.

Talking her into a belief or interpretation will not work, and she must come to a

conclusion by herself that she can own and fully believe.

Forgiveness is a common issue for Christian women in domestic violence

situations, and discussing definitions of forgiveness is a good place to start.

Examining the difference between repentance and remorse is also relevant, as well

as whether the client believes that forgiveness means continuing to receive abuse.

It is helpful to let her know that forgiveness is a process, and do not push her

towards forgiving the perpetrator, as this must be her own choice when she is

ready. Marriage is another common issue, and the counselor can use gentle

questioning to find out whether the client believes divorce or separation are

options. It can be useful to discuss with her when she believes the covenant of

marriage is broken, and whether it is broken when divorce papers are signed or

when the spouse repeatedly abuses and uses violence, behaviors that are not

consistent with love and God’s plan for marriage. Reconciliation may also be a

common issue if the client has already left her abuser, as she may be feeling

pressure from her own religious beliefs, from others, or from her abuser himself to

reconcile. In general, reconciliation is often harmful and dangerous, as genuine

change in these types of situations requires a long period of time. It is necessary to

discuss issues of safety with the client, including the safety of her children, if she is

considering reconciliation.

When working with domestic violence issues, counselors need to develop

self-awareness and examine their own beliefs about such topics as forgiveness,

marriage, and reconciliation. One should investigate the origins of one’s beliefs

and the original context of any relevant Scripture, being aware of how these beliefs

could affect one’s counseling work in this area. Working through one’s own beliefs

and asking questions will help equip one to go through this same process with a

client as well, learning which questions are helpful or unhelpful. Baker, the author

of this chapter, has written a book called Counseling Christian Women on How to

Deal with Domestic Violence that may be beneficial to read as well as to

recommend to clients who are in domestic violence situations and struggling with

these issues.

Pedagogical Suggestions:

• Have students each choose an aspect of domestic violence to address using

the verses and topics discussed under the biblical perspectives section of the

chapter. Have them write a discussion board post, brief paper, or

presentation on their topic, utilizing creativity and focusing on how this

biblical perspective can influence any future counseling work with domestic

violence situations.

• Have students break into pairs and role-play to practice assessing the safety

of a client in a domestic violence situation. Ask them to conduct further

research outside of the text on how to assess for safety and utilize this

information in their role-play, if possible.

• Have students break into pairs or triads and role-play to practice using

Baker’s ABC guide for working with domestic violence, then discuss their

experience and thoughts on using this guide.

• Have a class or group discussion on possible beliefs future clients might

have about forgiveness, marriage, and reconciliation, and how they would

help such clients explore their beliefs in a non-judgmental, empathic way.

Using the text or their own creativity, have students create a list of possible

questions to ask that could be helpful, and think about how they would react

if a client’s beliefs were different from their own.

• Ask students to cultivate self-awareness and write a paper about their beliefs

on forgiveness and marriage, especially in the context of domestic violence.

Ask them to use critical thinking and to ask themselves where their beliefs

came from, any expectations they have related to these beliefs, and how

these beliefs could impact their future counseling work. Issues such as

repentance, remorse, and reconciliation can also be examined.

Chapter 19 Quiz (25 questions):

Fill-in-the-blank

1. The three stages of the cycle of violence identified by _________________

include the building up of tension, the explosion, and a stage of loving

contrition. (Walker)

2. When exploring the worldview and faith of the client in a domestic violence

situation, it is important to avoid any apparent ________________.

(criticism)

3. The “A” in Baker’s ABC guide stands for _______________. (acquire

knowledge)

4. The “B” in Baker’s ABC guide stands for identify ________________.

(blocks or barriers)

5. The “C” in Baker’s ABC guide stands for ________________ theological

understandings. (clarify)

6. During the “A” stage, it is helpful to use a ______________ approach,

utilizing congruence, unconditional positive regard, and empathic

understanding. (person-centered)

7. During the ____________ stage, it is important to not dismiss the Scripture,

ideas, and explanations offered by the client but rather explore those ideas as

a process of discovery and contextual understanding. (C)

8. When discussing forgiveness, it can be helpful to explore with the client the

difference between repentance and ________________. (remorse)

True/False

1. One of the most significant steps toward healing comes from the realization

that domestic violence is not the fault of the victim. (T/F)

2. Significant coping mechanisms reported by women in one of Baker’s studies

included maintaining a strong relationship with God and praying. (T/F)

3. Some women in domestic violence situations find it helpful to focus on

something specific to continue functioning, such as a daily routine. (T/F)

4. Christian women in domestic violence situations may commonly cite “the

marriage covenant is forever binding” as a reason for why they cannot leave

their abusive spouse. (T/F)

5. When a client is considering reconciliation, the most important issue is the

physical, mental, and emotional safety of both the client and her children.

(T/F)

6. In cases of domestic violence, reconciliation is extremely difficult, often

impossible. (T/F)

7. Careful examination of one’s own beliefs regarding religious concepts,

including issues around forgiveness and marriage, is recommended when

considering work with domestic violence. (T/F)

8. Baker wrote a book in 2010 called Counseling Christian Women on How to

Deal with Domestic Violence that can be helpful for both counselors and

clients when working through domestic violence issues. (T/F)

9. In the majority of cases, women who are or have been victims of domestic

violence want to be able to tell their stories. (T/F)

Multiple Choice

1. Which of the following is NOT one of the driving forces behind domestic

violence?

a) Power

b) Control

c) Intimidation

d) Domination

e) None of the above

2. The _____________ stage of Baker’s ABC guide involves exploring the

client’s worldview, faith, and ways of coping.

a) A

b) B

c) C

d) D

e) None of the above

3. According to the text, Christian women in domestic violence situations may

believe that forgiveness includes:

a) Forgetting or excusing the offense

b) Engaging in mediation

c) Seeking reconciliation

d) All of the above

e) None of the above

4. According to Baker, forgiveness is best presented as:

a) A process

b) A magical event

c) A one-time event

d) An event that can take place on command

e) None of the above

5. Common beliefs and/or misconceptions that can commonly keep Christian

women from leaving (or keep them returning to) abusive situations center on

the following concepts EXCEPT for:

a) Forgiveness

b) The concept of marriage as indissoluble

c) Pressure for reconciliation

d) None of the above

e) All of the above

6. Christian women in domestic violence situations may feel pressure to

reconcile from all of the following EXCEPT:

a) Foundational beliefs about marriage and/or forgiveness

b) Well-meaning friends

c) Members of the clergy

d) The perpetrator

e) All of the above

f) None of the above

7. Types of religious coping that can be helpful for women in domestic

violence situations, according to the text, include:

a) Journaling or letter-writing

b) Drawing or art

c) Reliance on Scripture

d) Prayer

e) All of the above

f) None of the above

8. Forgiveness topic questions that can be helpful when counseling women in

domestic violence situations include all of the following EXCEPT:

a) Exploration of the client’s experiences of forgiveness

b) Any expectations that may have been placed on her by others

c) Any concerns she may have regarding forgiveness

d) Any possible roadblocks that may hinder her ability to extend forgiveness

e) None of the above

f) All of the above

Chapter 20

Forgiveness-Focused Strategies: The REACH

Forgiveness Model by Everett L. Worthington Jr., PhD,

Steven J. Sandage, PhD, and Jennifer S. Ripley, PhD

Key Terms: divine forgiveness, interpersonal forgiveness, responsible self-

forgiveness, Worthington, REACH forgiveness model, decisional forgiveness,

emotional forgiveness, injustice gap, reconciliation, hope-focused couple therapy,

lectio divina, empty chair dialogue, the Trait Forgiveness Scale, the Decision to

Forgive Scale, the Transgression-Related Inventory of Motivations, stabilization,

the four planks (decisions, discussions, detoxifying, devotion), leveling

intervention, triangulation, detriangulation, grief, empathy

Key Points:

• Worthington created a five-step model that has been shown to be effective

throughout the past two decades in a wide variety of settings. This model has

been consistently examined through randomized controlled trials, is

considered evidence-based, and there are myriad reasons as to why REACH

is effective, including its availability to be used in both Christian and secular

settings.

• Decisional forgiveness is a decision to forgive, to not act on seeking

revenge, and emotions of empathy, love, or peace towards the offender are

not necessary. Emotional forgiveness, on the other hand, does involve

experiencing those emotions of empathy, love, and peace towards the

offender.

• While the Bible does clearly address the importance of forgiveness, it does

not describe how to specifically forgive.

• The “R” stands for “Recall the hurt,” and participants take turns explaining

to their partners the offenses they are working to forgive.

• The “E” stands for “Emotionally replace negative with positive emotions,”

and involves helping participants find new perspectives.

• The “A” stands for “Altruistic gift of forgiveness,” and participants are

invited to reflect on past times they themselves were forgiven and how this

made them feel.

• The “C” stands for “Commitment to the forgiveness experience,” and the

commitment can be made in a variety of ways, such as writing a personal

contract, stating their commitment to another person or the group, or going

through a ritual.

• The “H” stands for “Hold on to forgiveness when doubt occurs,” and

encourages the commitment to decisional forgiveness even when emotional

forgiveness is not present.

Student Learning Objectives:

• To be able to describe the types of forgiveness discussed in this chapter, as

well as what forgiveness is not

• To comprehend Worthington’s REACH model of forgiveness

• To understand the intricacies of using the REACH model in

psychoeducational groups, hope-focused couples therapy, and family

therapy as described in the text

Chapter Summary:

Research has repeatedly shown, through over a thousand studies, that

forgiveness leads to better physical, mental, and spiritual health. To help people

move through the process of forgiveness, Worthington created a five-step model

that has been shown to be effective throughout the past two decades. This model

has been consistently examined through randomized controlled trials, is considered

evidence-based, and there are myriad reasons as to why REACH is effective,

including its availability to be used in both Christian and secular settings.

Before examining the REACH forgiveness model, it is necessary to define

the different types of forgiveness. Divine forgiveness is based on God’s

forgiveness of us through Jesus’s work on the cross. Interpersonal forgiveness

involves humans forgiving each other, and responsible self-forgiveness involves

taking responsibility for one’s offenses and forgiving oneself. Worthington’s

model provides two different categories of forgiveness: decisional and emotional.

Decisional forgiveness is a decision to forgive, to not act on seeking revenge, and

emotions of empathy, love, or peace towards the offender are not necessary.

Emotional forgiveness, on the other hand, does involve experiencing those

emotions of empathy, love, and peace towards the offender.

While the Bible does clearly address the importance of forgiveness, it does

not describe how to specifically forgive. Based on the exegesis of certain verses,

Worthington believes that the forgiveness required of us is decisional forgiveness,

rather than emotional forgiveness, although God does desire emotional forgiveness

as well. Secular science tends to view forgiveness through a stress-and-coping

model, where forgiveness is a possible coping response to the stress of being

wronged. When offenses occur, this is said to create an injustice gap, and the

greater the offense, the greater the gap. It is also helpful to discuss what

forgiveness is not, as it is often misunderstood. For example, forgiveness is not

physically saying the words “I forgive you,” nor is it equivalent with reconciliation

or justice.

While the REACH model of forgiveness can be used in a wide variety of

settings, this chapter examined the model’s utilization in psychoeducation groups,

hope-focused couples therapy, and family therapy. As mentioned previously, the

REACH model is effective for both Christians and non-Christians. Christian

psychoeducational groups are merely different in the language and concepts they

use, such as prayers for the offender or the Scriptural reasons why one should

forgive. The groups can be led by almost anyone, as the individuals partner up with

someone else in the group whom they do not know and walk through most of the

process by talking through it with their partner. If group work is not an option,

individuals can work through the process with a therapist, or use web-based

interventions or do-it-yourself workbooks that are available for free online.

The leader begins a group by asking participants to choose an offense to

work through forgiving, rate their current level of forgiveness, and complete a

series of self-scored questionnaires. Then the group participates in an icebreaker

that also serves to bring up the topic of forgiveness, followed by a lectio divina

exercise in which the leader reads relevant scriptures and each person in the group

responds to the reading with a word or two. The leader explains the two types of

forgiveness that will be used in the model, decisional and emotional, and also

provide a list of twelve other incorrect forgiveness definitions. Participants discuss

the definitions with their partners.

It is important not to push an individual towards committing to forgive if he

or she is not ready or does not want to make such a commitment. The group leader

is to simply offer participants an invitation to engage in decisional forgiveness. He

uses an analogy by having participants stand and stretch out their hands while he

talks at length about the burden of carrying around a grudge, and then instructs

them to drop their arms and sit down; he explains that the relief they feel

physically in this moment is an analogy for the relief and lightness they could feel

when they engage in forgiveness. Then, the leader can teach the group the five

steps of the REACH model, and participants will begin the work in their pairs.

The “R” stands for “Recall the hurt,” and participants take turns explaining

to their partners the offenses they are working to forgive. The “E” stands for

“Emotionally replace negative with positive emotions,” and involves helping

participants find new perspectives. Common ways of doing this are using empty

chair dialogue, imagining that the offender wrote them a letter explaining their

behavior, or imagining what kind of pain the offender must have experienced in

life to drive them to commit the offense. If empathy is not possible, there are other

options to work towards, such as sympathy. Next, the “A” stands for “Altruistic

gift of forgiveness,” and participants are invited to reflect on past times they

themselves were forgiven and how this made them feel. At this stage, individuals

can revisit the questionnaire results from the beginning of the group and state how,

if any, their degree of forgiveness has shifted so far. The “C” stands for

“Commitment to the forgiveness experience,” and the commitment can be made in

a variety of ways, such as writing a personal contract, stating their commitment to

another person or the group, or going through a ritual. Finally, the “H” stands for

“Hold on to forgiveness when doubt occurs,” and it can be helpful to remind

participants that even if they do not feel the emotions of forgiveness, they are to

hold on to their decisional forgiveness and know that the emotions are not required

for it to be considered real. After completing the process, participants write

personal answers to a series of twelve questions to customize their experience and

complete their questionnaires for a final time so they can view their progress.

Hope-focused couples therapy is another platform in which the REACH

model can be used, and is made up of two acronyms: HOPE and FREE. The

acronym HOPE stands for Handling Our Problems Effectively, and FREE stands

for Forgiveness and Reconciliation through Experiencing Empathy. In the hope-

focused approach (HFA) to couples therapy, it can be helpful to begin by assessing

the clients’ strengths, weaknesses, current struggles, and relationship patterns.

Often they are not open to forgiveness at the beginning of therapy, but it can be

helpful to assess interactive patterns surrounding offenses and forgiveness, both in

the present and in the past. These assessments can be done through questionnaires,

and the counselor then writes a report of the results to discuss with the couple.

If the couple are still emotionally struggling over an offense, stabilization is

important, and teaching them coping mechanisms such as time-outs can help them

learn to calm down and regulate their strong emotions more effectively. Also,

talking about their experiences with forgiveness before they began their

relationship with each other, including God’s forgiveness of them, and asking what

God may want them to learn from such experiences can be a helpful indirect way

to make progress when emotions are tense. Such an indirect approach can take

months, but is often effective at spontaneously bringing about forgiveness between

the two individuals. If this does not happen spontaneously and the couple desires it,

the counselor can teach the REACH model to them using an example from each

partner’s past before the current relationship began. Then, the model can be

applied to the current issues. Forgiveness can lead to reconciliation, an act that can

only happen when both parties are trustworthy. Worthington lists four planks that

build a metaphorical bridge to reconciliation: decisions, discussions, detoxifying,

and devotion. The planks can be discussed with the couple to help them understand

this process, as well as help the counselor conceptualize progress.

Finally, the REACH model can also be applied in a family therapy setting in

similar ways to the settings described previously, but with its own unique

considerations. The process can begin by asking each family member to state his or

her goals for forgiveness and familial relationships. Normalizing both differences

and anxiety is important so that family members do not expect the counselor to

give them a magical solution that everyone will agree on and cause them to no

longer have conflict or tensions. Leveling interventions can be used, encouraging

them to empathize with each other. Lastly, it is important to remember that once

the family starts moving towards forgiveness, grief over time lost due to grudges

and conflict may be experienced by the family members; it can be beneficial to

help them feel empathy towards each other as they navigate through such

emotions.

Pedagogical Suggestions:

• Have students discuss all the different definitions of forgiveness and what

forgiveness is not, as mentioned in the text. Do they agree or disagree, and

why or why not? Ask them to each write their own definition of forgiveness

in their own words, and reflect on how they learned their interpretation of

forgiveness.

• On pages 420-421, there is a list of things that forgiveness is not. Have

students break into groups and discuss how they would respond to each one,

if they had a client who held to that definition.

• Have students visit www.EvWorthington-forgiveness.com to view the

forgiveness workbooks for free and to learn more about the REACH model.

• Have students break into groups and role-play to practice leading a

psychoeducational group through the REACH model. Have students switch

out the leader role at each new stage so that everyone gets a turn to practice

leading a part of the model.

• Have students break into groups and role-play to practice either hope-

focused couples therapy or family therapy with the REACH model, based on

the information provided in the text.

Chapter 20 Quiz (25 questions):

Fill-in-the-blank

1. ___________________ is a behavioral intention to refrain from seeking

revenge and to treat an offender as a valued and valuable person. (decisional

forgiveness)

2. ____________________ involves emotionally replacing unforgiving

emotions with positive, other-oriented emotions like empathy, sympathy,

compassion, or love for the offender. (emotional forgiveness)

3. Scientifically, forgiveness is usually understood using a _______________

model. (stress-and-coping)

4. A(n) ____________________ is the perceived difference between the way a

person would like a situation resolved and the way it is now. (injustice gap)

5. During the E phase of a psychoeducational reach group, the leader can

introduce the technique of ___________________ to help group members

gain a new perspective on their offenders. (empty chair dialogue)

6. The two halves of the hope-focused approach to couples counseling, as

expressed in acronyms, are _________________ and FREE. (HOPE)

7. _______________ is defined as restoring trust in a relationship, which

requires mutually trustworthy behavior. (reconciliation)

8. In ________________ forgiveness, God the Father forgives on the basis of

the finished work of Jesus the Son’s restorative justice on the cross. (divine)

True/False

1. Person-to-person forgiveness is considered to be intrapersonal rather than

interpersonal. (T/F)

2. The randomized controlled trial is considered the highest standard of

empirical evidence. (T/F)

3. Forgiveness means physically saying the words, “I forgive you.” (T/F)

4. Forgiveness means reconciliation and restoring trust. (T/F)

5. Forgiveness means turning the matter over to God for divine justice. (T/F)

6. Forgiveness means accepting and moving on with life. (T/F)

7. The Bible does specify how to forgive. (T/F)

8. During the A phase of a psychoeducational REACH group, the leader asks

group members to reflect on a time when they offended someone who

forgave them. (T/F)

9. Clients often carry a fantasy that there may be some way for all to “get on

the same page” so they will not have to manage the differences that create

relational anxiety. (T/F)

Multiple Choice

1. Which of the following is NOT one of the seven findings of the meta-

analysis on REACH discussed in the text?

a) Decreases depression and anxiety and increases hope

b) Available in Christian and secular versions

c) It is an evidence-based practice in psychology

d) Can be applied to forgiving both others and oneself

e) None of the above

f) Only B and C

2. Settings in which REACH can be used include all of the following

EXCEPT:

a) Do-it-yourself workbooks

b) Psychoeducational groups

c) Couples counseling

d) Family counseling

e) None of the above

f) Only A and D

3. The questionnaires used in the REACH model include all of the following

EXCEPT:

a) The Trait Forgiveness Scale

b) The Forgiveness Readiness Scale

c) The Transgression-Related Inventory of Motivations

d) The Decision to Forgive Scale

e) None of the above

4. In a group setting of REACH, “the leader reads one of six scriptural

passages about forgiveness, then whips around the group, and each member

reacts with a word.” This part of the group is called:

a) Creating a working definition

b) Lectio divina

c) Icebreaker

d) Inviting decisional forgiveness

e) None of the above

5. In one part of the REACH group, “the leader keeps time as pairs take turns

sharing their ‘objective’ accounts of the harm.” This is known as:

a) The R

b) The E

c) The A

d) The C

e) None of the above

6. When emotions are “hot” and forgiveness cannot be approached directly in

hope-focused couples counseling, all of the following are ways that

forgiveness can be indirectly addressed EXCEPT:

a) Have both partners talk about offenses and forgiveness in their lives prior

to their relationship.

b) Talk about God’s forgiveness.

c) Work through offenses and forgiveness with a successful relationship in

the past.

d) Ask each person to examine how he or she contributed to the

presenting problem.

e) None of the above

7. Which of the following is NOT one of Worthington’s four planks in the

bridge of reconciliation?

a) Devotion

b) Detoxifying

c) Detriangulation

d) Discussions

e) None of the above

8. Which of the following is NOT one of the techniques or issues associated

with using the REACH model in family therapy?

a) Normalizing differences and anxiety

b) Ask each family member to state his or her goals

c) Detriangulating

d) Facilitating grief and empathy

e) None of the above

f) Only A and B

Chapter 21

Shame-Focused Strategies by John C. Thomas, PhD, PhD

Key Terms: shame, guilt, shame-based identity, healthy/functional shame,

unhealthy/dysfunctional shame, internalized shame, externalized shame,

attunement, family of origin, knowing, genogram, the time-machine elevator,

neuroplasticity, the shame box technique, the truth box technique, the “parts are

parts” technique, vulnerability, self-compassion, the two-chair critic: criticized

dialogue technique, the three-chair soothing: self-dialogue technique, letter

techniques, the radical acceptance technique, mindfulness, mentalization, the

opposite-action technique, the acting “as if” technique, spiritual formation,

spiritual disciplines

Key Points:

• Shame is different from guilt in that guilt focuses on behavior, whereas

shame focuses on personhood.

• There are a few different types of shame—shame-based identity, healthy or

functional shame, unhealthy or dysfunctional shame, internalized shame, and

externalized shame.

• Shame usually develops during one’s first few years as a result of

dysfunctional attachment relationships.

• The first therapeutic task is to establish a therapeutic bond with the client.

• The second therapeutic task involves entering the client’s story.

• The third task is to recognize, explore, and label shame.

• The fourth task is processing and treating shame.

• Finally, the fifth task is spiritual formation.

Student Learning Objectives:

• To be able to describe the difference between shame and guilt, and the

various types of shame

• To comprehend the origins, effects, and outcomes of shame

• To understand the five therapeutic tasks recommended by Thomas for

working with clients who struggle with shame

Chapter Summary:

Shame, a “negative self-conscious emotion that shapes and maintains a

person’s identity,” (Thomas, 2018, p. 438) exists in many forms, but it can often be

confused with other emotional experiences, so it is important to first discuss what

shame is not. The most common confusion occurs between the concepts of shame

and guilt. Shame is different from guilt in that guilt focuses on behavior, whereas

shame focuses on personhood. Additionally, shame is thought to emerge before

language, whereas guilt does not occur until a later stage of a child’s development.

Research has shown that shame contributes to psychological disorders more than

guilt does.

There are a few different types of shame—shame-based identity, healthy or

functional shame, unhealthy or dysfunctional shame, internalized shame, and

externalized shame. While a person can feel temporary shame over an event or

situation, the most pervasive and harmful type of shame is shame-based identity,

expressed through “I am” statements such as “I am bad,” “I am defective,” “I am

incompetent,” “I am unworthy,” or “I am unlovable.” This is an example of

unhealthy or dysfunctional shame, which is always based on identity. In contrast,

healthy or functional shame concerns a temporary event or weakness in character,

and it can be a positive source of motivation for change. Relatedly, internalized

shame concerns said weakness in character or personality, whereas externalized

shame focuses on an event or situation.

Shame usually develops during one’s first few years as a result of

dysfunctional attachment relationships. It can result in emotional reactions that are

out of proportion to what is actually happening in the moment, and the individual

who struggles with shame usually develops self-fulfilling prophecies in which his

behaviors perpetuate the shame-infused beliefs he holds about himself. Most often

he will construct a variety of defenses to protect himself from being known so that

others will not find out how “shameful” he really is. Shame bypasses logic because

it is a right-brain experience, responding to emotions rather than objective

evidence and making it difficult for an individual to even recognize its presence.

Most individuals are also very aversive to admitting the presence of shame, due to

its nature, and therefore this is one of the most difficult issues to be treated.

Thomas outlines 5 therapeutic tasks that can be beneficial when working with

shame, as well as some pre-requisite work that the counselor can engage in before

addressing shame work with clients. The pre-requisite work involves learning to be

aware of one’s own shame, as one’s shame can usually be felt by clients if it

emerges in session. It is important to work through one’s own issues surrounding

personal shame, and also to remember that sometimes self-disclosure about one’s

own shame can be helpful for clients as well.

The first therapeutic task is to establish a therapeutic bond with the client.

The bond is critical, because those who struggle with shame believe that other

people hold the same devaluing beliefs about them as they hold about themselves.

The counselor should focus on attunement, empathy, presence, and reflection, and

hyperfocus on being non-shaming to help the client have an experience counter to

what he is expecting. This hyperfocus is necessary, as a client who struggles with

shame will tend to interpret even the most innocent of words as shaming in some

way, filtering everything through their shame-infused beliefs. Techniques to help

with this challenge include monitoring the communication, checking in, not

“talking the client out of it,” being human, and keeping no secrets. It can also help

to let the client know that the usual rules of social interactions do not apply in

counseling, to be prepared for the client to test you, and to let the client know

ahead of time that she will probably feel shame and anxiety after opening up

during a counseling session.

The second therapeutic task involves entering the client’s story. Sharing his

story will help the client to come to new realizations about his life, connect with

his right-brain by bringing emotions into the story, and experience being mirrored

and attuned to by the counselor, a healing experience in and of itself.

The third task is to recognize, explore, and label shame. This task may

involve the greatest amount of “work.” The origins and intricacies of the client’s

feelings of shame are crucial, so the counselor should begin by assessing family of

origin experiences including how conversations, emotions, vulnerability,

expression of needs, and emotional closeness were handled. It is also important to

examine what is missing, as “children feel shame when what they need to feel

human is withheld” (Thomas, 2018, p. 451). Usually, attunement from the parents

is what was missing for those who struggle with shame. Other techniques include

genograms, eliciting and facing the shame, being aware that the client will likely

have an escape plan to avoid the shame, and drawing them out anyway. Those with

preoccupied attachment styles, however, usually do not need to be drawn out, as

they often pour out their stories as if under pressure; it is wise to provide

containment for them. Thomas presents a list of many more techniques that can

also be used during this task: exploring feelings, exploring events, focusing, using

journaling, using the time-machine elevator technique, listening for longings,

voicing the pain, using the empty chair, finding a hole in the armor, and

understanding the implications of the gospel of Jesus Christ.

The fourth task is processing and treating shame. Helping clients feel and

verbalize their feelings of shame is important, building up their tolerance and

ability to regulate such emotions. Cognitive and affective strategies can be useful,

teaching clients that they are not what they feel and that they are capable of

regulating and expressing their emotions in a healthy way. Psychoeducation on the

neuroplasticity of the brain can foster a sense of hope. One particular technique,

taken from the work of Sanderson in 2015, involves having the client create a

shame box and a truth box, writing down the shaming messages he believes for the

shame box and countering each with a truth for the truth box. He then can

participate in an impact exercise in which he writes down how the shame-infused

beliefs have impacted his life. Other techniques include: the parts are parts

technique, the practice of vulnerability technique, self-compassion, the meeting

with Jesus technique, the two-chair critic: criticized dialogue technique, the three-

chair soothing: self-dialogue technique, letter techniques, radical acceptance

technique, mindfulness, mentalization, the opposite-action technique, the acting

“as if” technique, the negative affect tolerance technique, the finding exceptions

technique, the pros and cons list technique, setting boundaries, rebuilding a new

identity, the universal limitations intervention, and enriching and using the client’s

support system.

Finally, the fifth task is spiritual formation. It is wise to help the client build

a biblically-based theology of the self so that he can believe not just with his mind

but with his emotions, as the two tend to hold different beliefs. The counselor can

then teach the client to turn to God for effective soothing, accepting his

weaknesses in a healthy way. It can also be helpful to teach the client spiritual

discipline strategies such as worship, prayer, and solitude, as these can be excellent

ways for him to connect with God and continue the healing process.

Pedagogical Suggestions:

• Have each student stand up in front of the class and role-play a quick

imaginary client story (1-2 mins) illustrating a type of shame, then have the

rest of the class guess which type(s) of shame (or guilt) is being

demonstrated.

• Have students break into pairs or triads and role-play to practice each

therapeutic task described in the chapter. Each task consists of a wide variety

of techniques that can be chosen, so one task could take a lot of time, if

desired.

• Have students break into pairs or triads and role-play to practice the third

therapeutic task, focusing on assessing the client’s family of origin and early

experiences to help students learn the relevant questions to ask and how to

think through the results.

• Have students break into pairs or triads and role-play to practice using the

time-machine elevator technique or the shame box technique.

• Have students personally practice the shame box technique on their own as

homework, followed by the impact exercise and the truth box exercise. Then

have them write a discussion board post or brief paper on their experience,

how it impacted them, and their thoughts on using it in their future as

clinicians.

• Ask students to personally participate in the practice of vulnerability

technique as homework, choosing an experiential activity that they believe

will make them feel uncomfortable. Then have them write a discussion

board post or brief paper on their experience and how they could use this

technique in the future with clients. Open the next class with a discussion of

the exercise, if desired.

• Have a class discussion on how spiritual formation could be used with

clients who struggle with shame, referencing the text but also asking

students if they can think of any other ways not mentioned that spiritual

formation could be incorporated to address feelings of shame.

Chapter 21 Quiz (25 questions):

Fill-in-the-blank

1. Healthy or functional shame is primarily __________________ based,

whereas unhealthy or dysfunctional shame is identity based. (event and

character)

2. ________________ shame is associated with one’s personality disposition

and character rather than a specific situation. (internalized)

3. When working with shame, the third therapeutic task involves exploring,

recognizing, and ______________ shame. (labeling)

4. __________________ refers to understanding how another feels, being in

contact with another’s subjective world, and having a right-brain connection.

(knowing)

5. Children feel ___________ when what they need to feel human is withheld.

(shame)

6. Parental _______________ is what is often missing in the history of shame-

prone clients. (attunement)

7. The _________________ technique involves writing down one’s shame-

infused beliefs on pieces of paper and putting them in a box, followed by

reflection/journaling about the beliefs while learning to tolerate feelings of

shame. (shame box)

8. The “practice of _________________” technique involves assigning clients

homework that challenges them to do an agreed-upon activity (or activities)

that pushes them into the “horror zone” such as going to restaurants by

oneself or speaking in public. (vulnerability)

9. The _________________ soothing: self-dialogue technique involves having

the client talk to the critic and shamed self, speaking truth and showing

compassion. (three-chair)

True/False

1. Shame is behavioral focused, whereas guilt is identity focused. (T/F)

2. Guilt is considered developmentally pre-verbal, but shame is learned later.

(T/F)

3. The shamed person develops behavioral patterns that are consistent with the

defective beliefs about self. (T/F)

4. Shame is a right-brain experience. (T/F)

5. Often when you experience shame, so does your client. (T/F)

6. How parents regulate their child’s emotions has a profound impact on a

child’s internal experience of shame. (T/F)

7. The fifth and last therapeutic task when working with shame is spiritual

formation. (T/F)

8. The “meeting with Jesus” technique involves imaging a conversation with

Christ (non-Christians can image a mature and wise-person). (T/F)

Multiple Choice

1. When working with shame, the first therapeutic task (bonding with the

client) involves all of the following techniques EXCEPT:

a) Hyperfocus on being nonshaming

b) Practice attunement

c) Check in

d) Avoid attempting to “talk clients out of it”

e) None of the above

f) Only A and C

2. When working with shame, transformation through story and addressing

right-brain language and connection are part of which therapeutic task?

a) Task 1

b) Task 2

c) Task 3

d) Task 4

e) Task 5

3. Eliciting unexpressed/avoided shame and facing the avoidance is a technique

used in which therapeutic task?

a) Task 1

b) Task 2

c) Task 3

d) Task 4

e) Task 5

4. Shame-prone clients with a(n) ________________ attachment style

continually pour out stories as if a water pipe exploded with the incredible

force of pressure from painful emotions, and need containment more than

exploration.

a) Secure

b) Avoidant

c) Fearful/disorganized

d) Preoccupied/ambivalent

e) None of the above

5. The time-machine elevator technique and journaling are techniques that are

used in which therapeutic task (when working with shame)?

a) Task 1

b) Task 2

c) Task 3

d) Task 4

e) Task 5

6. ________________ is the process by which people make sense of the world

by imaging how other peoples’ state of mind can influence behavior.

a) Mindfulness

b) Mentalization

c) Radical acceptance

d) Mirroring

e) None of the above

7. The universal limitations intervention, rebuilding a new identity, and

enriching/using the client’s support system are all techniques used during

which therapeutic task?

a) Task 1

b) Task 2

c) Task 3

d) Task 4

e) Task 5

8. The pros and cons list technique, setting boundaries, and acting “as if” are

all techniques used during which therapeutic task?

a) Task 1

b) Task 2

c) Task 3

d) Task 4

e) Task 5

Chapter 22

Trauma-Focused Strategies by Heather Davediuk

Gingrich, PhD

Key Terms: trauma, post-traumatic stress disorder (PTSD), complex trauma

(CT), safety and symptom stabilization, processing of traumatic memories,

consolidation and resolution, rapport, empathic reflection, boundaries,

confidentiality, intrusive reexperiencing symptoms, exposure and response

prevention (ERP) techniques, relaxation techniques, mindfulness, dissociation,

“parts of self” language, dissociative identity disorder (DID), containment,

ideomotor signaling, Braun’s BASK model, grounding techniques, eye movement

desensitization and reprocessing (EMDR)

Key Points:

• There are two types of trauma—event trauma, typically resulting in post-

traumatic stress disorder (PTSD), and chronic relational trauma, typically

resulting in complex trauma (CT).

• Complex trauma (CT) is considered especially severe because of the

vulnerable stage during which the trauma occurs, and because it is usually at

the hands of someone the child trusts, someone who is supposed to protect

and love him.

• There is a three-phase process that is typically followed when working with

CT, although the phases are known by different names; Gingrich refers to

the first phase as safety and symptom stabilization, the second as processing

of traumatic memories, and the third as consolidation and resolution.

• The first phase, safety and symptom stabilization, usually takes many years

due to the relational nature of the severe trauma experienced by those with

CT; this process primarily focuses on providing containment for distressing

symptoms and building safety.

• The second phase focuses on processing traumatic memories, and the

counselor can move towards this work when the client has learned sufficient

coping mechanisms.

• The third phase emphasizes consolidation and resolution, and helping clients

learn new coping strategies, as at this point they probably can no longer

dissociate to the extent they could previously.

Student Learning Objectives:

• To be able to describe the unique nature of complex trauma (CT) and the

concerns that can arise when working with such clients

• To comprehend the role of dissociation in complex trauma (CT)

• To understand the three phases of treating complex trauma (CT) according

to Gingrich and how some of these techniques can also be helpful with post-

traumatic stress disorder (PTSD)

Chapter Summary:

There are two types of trauma—event trauma, typically resulting in post-

traumatic stress disorder (PTSD) and chronic relational trauma, typically resulting

in complex trauma (CT). CT is considered especially severe because of the

vulnerable stage during which the trauma occurs, and because it is usually at the

hands of someone the child trusts, someone who is supposed to protect and love

him. CT and PTSD share many of the same symptoms, but CT usually involves

several more, including identity and attachment issues. In this chapter, Gingrich

addresses strategies mainly used with CT, although both CT and PTSD can greatly

benefit from mindfulness, grounding, ideomotor signaling and parts work. She

delineates a three-phase process that is typically followed when working with CT,

although the phases are known by different names. Gingrich refers to the first

phase as safety and symptom stabilization, the second as processing of traumatic

memories, and the third as consolidation and resolution.

The first phase, safety and symptom stabilization, usually takes many years

due to the relational nature of the severe trauma experienced by those with CT.

This process primarily focuses on providing containment for distressing symptoms

and building safety, beginning by ensuring safety within the therapeutic

relationship. Developing rapport is critical, and techniques such as empathic

reflection, using appropriate genuineness and self-disclosure, having a

nonjudgmental attitude, and being emotionally present can help. It is crucial that

the counselor actually be a safe person by remembering that every client is unique,

warning clients of any impending change, keeping appropriate boundaries, and

keeping confidentiality. Working with CT is often intense and replete with crises,

and therefore the counselor must always monitor his own mental health and

competencies, seeking supervision or personal therapy when needed. It is also

important to ask questions about others in the lives of one’s client to assess

whether the client is safe from others, and that others are safe from the client,

including the client herself.

Intrusive trauma symptoms can be especially distressing for clients, and

containing and stabilizing those symptoms as much as possible can greatly help

with safety. Some techniques that can be beneficial include exposure therapy or

prolonged exposure therapy, relaxation techniques, and mindfulness. Clients who

suffer from CT also typically have rates of dissociation, defined as

“compartmentalization, or disconnection among aspects of self and experience”

(Gingrich, 2018, p. 475). There are helpful techniques that make use of this

tendency to dissociate, such as using “parts of self” language, as most CT clients

can identify with having different parts of themselves even if they do not have

dissociative identity disorder (DID). Other names for working with different parts

of self, whether the client has DID or not, include parts work, ego state therapy,

and self-states. Viewing symptoms as attempts at coping is another technique, as

well as making contact with dissociated parts, if applicable. One way of doing this

is ideomotor signaling, a hypnotherapy technique in which the counselor teaches

the client how to use finger signals for yes, no, and stop as a way for the

dissociated parts to communicate.

The second phase focuses on processing traumatic memories. The counselor

can move towards this work when the client has learned sufficient coping

mechanisms, is able to ground herself, can manage her trauma symptoms between

sessions, and agrees with the counselor that she is ready to begin phase two. It is

critical not to ask leading questions or make suggestions, and to ask open-ended

questions instead. The counselor should begin by asking the client where she

would like to begin, and invite the part of self that holds the memory to allow

access to it. During the process, it is necessary to keep the client connected to the

here and now, which helps dissociated parts become integrated. The BASK model

by Braun is one way of conceptualizing this concept. Other techniques that are

beneficial for this phase include grounding techniques, pacing the trauma

processing, monitoring the frequency and speed, and processing emotions.

Finally, the third phase emphasizes consolidation and resolution, and helping

clients learn new coping strategies, as at this point they probably can no longer

dissociate to the extent they could previously. It is also important to help clients

grieve any losses, establish new and healthy relationships, and examine issues of

forgiveness. EMDR (eye movement desensitization and reprocessing) is an

additional treatment protocol that can be helpful for some CT clients, although for

most its use is not recommended. CT clients with high levels of dissociation should

not engage in EMDR, as this can make dissociative symptoms worse. Gingrich

recommends using the Dissociative Experiences Scale-II, available for free online

in the public domain, to assess for dissociation prior to treatment. Explicit spiritual

resources such as prayer and Scripture can of course also be useful during the

treatment process for Christian clients.

Pedagogical Suggestions:

• Have a class discussion, or have students write a discussion board post, on

the biblical stories/verses cited in the text along with Langberg’s six

principles and how they can influence future counseling work.

• Assign students to research an aspect of CT (using scholarly sources outside

of the text) and create a PowerPoint presentation or paper on their chosen

aspect.

• Ask students how they would go about assessing whether a client has

experienced PTSD or CT.

• Have a class or group discussion on boundaries in counseling and how one

could stay on top of one’s own mental health if working with CT clients.

• Have students break into pairs or triads and role-play to practice using “parts

of self” language as a counselor. The “client” does not need to make up a

trauma story or talk about any traumatic details since this is a phase one

role-play. The purpose is simply for the “counselor” to practice using parts

language out loud with a hypothetical dissociative client. Students will take

turns playing the counselor.

• Ask students to brainstorm examples of open-ended questions and grounding

techniques that could be used during phase two of CT treatment, as well as

new coping strategies that could be learned in phase three.

• Ask students how explicit spiritual resources could be incorporated when

working with CT clients.

Chapter 22 Quiz (25 questions):

Fill-in-the-blank

1. While single event trauma is most associated with post-traumatic stress

disorder (PTSD), chronic relational trauma is associated with

_______________. (complex trauma, or CT)

2. Gingrich refers to the first phase of CT treatment as

____________________. (safety and symptom stabilization)

3. Gingrich refers to the second phase of CT treatment as

_____________________. (processing of traumatic memories)

4. Gingrich refers to the second phase of CT treatment as

_____________________. (consolidation and resolution)

5. _____________________ uses finger signals as a way to communicate with

parts of self of which the CT survivor may not be aware. (ideomotor

signaling)

6. The BASK model, a way of conceptualizing dissociation, was developed

originally in 1988 by ___________________. (Braun)

7. In phase three of CT treatment, clients need to develop new

________________, as they can no longer as easily compartmentalize an

overwhelming feeling. (coping strategies)

8. ______________ has good research support for single-incident trauma but

should not be used with highly dissociative clients such as those with CT.

(EMDR)

9. The brief screening instrument recommended by Gingrich to screen for

dissociation, particularly prior to considering EMDR, is available for free

online and is called ______________________. (the Dissociative

Experiences Scale-II).

True/False

1. The added complexity of complex trauma (CT) is in large part due to CT

occurring during a particularly vulnerable stage of psychological

development when relational attachments are formed. (T/F)

2. Recommended treatments for PTSD are primarily behavioral and cognitive

behavioral techniques. (T/F)

3. CT survivors often experience PTSD symptoms along with many other

symptoms. (T/F)

4. The first phase of CT treatment usually takes not months but years. (T/F)

5. Therapeutic work with CT survivors is often intense and punctuated by one

crisis after another. (T/F)

6. CT survivors are usually motivated to seek counseling because of intrusive

reexperiencing symptoms. (T/F)

7. Even those with CT who do not have DID often experience some degree of

personality fragmentation. (T/F)

8. Grounding techniques involve engaging the senses of clients to help them

stay in the present. (T/F)

Multiple Choice

1. Examples of chronic relational trauma that could result in (CT) include all of

the following EXCEPT:

a) Child physical abuse

b) Child sexual abuse

c) Child spiritual abuse

d) Child neglect

e) None of the above

f) Only A and B

2. In addition to PTSD symptoms, those with CT also usually experience:

a) Intense feelings of shame and guilt

b) Impairment in identity formation

c) Difficulty trusting people

d) Problems with affect regulation

e) All of the above

f) Only A through C

3. Which of the following is listed as a strategy for helping the counselor be

and remain a safe person during phase one CT treatment?

a) Remember that every client is unique

b) Warn of impending change

c) Know your limitations

d) Keep appropriate boundaries

e) All of the above

f) Only C and D

4. When encountering one’s limitations as a counselor during work with CT

survivors, one should:

a) Read in the field

b) Get trauma-sensitive supervision

c) Seek out appropriate training opportunities

d) Refer out to an expert if necessary

e) All of the above

f) A through C only

5. Things you should warn your CT clients about include:

a) Missing a session for a conference

b) Putting a new picture on your wall

c) Changing appointment times

d) Any major issues going on in your life

e) All of the above

f) A through C only

6. Techniques that can be used during phase one of CT treatment include all of

the following EXCEPT:

a) Mindfulness

b) Exposure and response prevention (ERP)

c) Relaxation techniques

d) Using “parts of self” language

e) None of the above

f) A through C only

7. Working with personality fragmentation in CT survivors often goes by a

variety of names, including all of the following EXCEPT:

a) Parts work

b) Ego state therapy

c) Working with self states

d) Fragmentation therapy

e) None of the above

8. Indicators that it may be appropriate to begin phase two work with a CT

survivor include all of the following EXCEPT:

a) When the client is able to ground herself

b) When the client is able to manage trauma symptoms between sessions

c) When the client agrees it is a good time to begin

d) When the techniques used in phase one are not helping

e) None of the above

Chapter 23

Nonsuicidal Self-Injury-focused Strategies by David

Lawson, PsyD

Key Terms: non-suicidal self-injury (NSSI), suicidality, borderline personality

disorder (BPD), cutting, shame, physical grounding, control, the silent scream,

self-punishment, depersonalization, derealization, dissociation, trauma, online

communities, obsessive compulsive disorder (OCD), substance abuse, systems or

family therapy, cognitive behavioral therapy (CBT), psychoanalytic/relational

therapy, transference, countertransference, yoga, meridian points, dialectical

behavior therapy (DBT)

Key Points:

• Self-injury has a long history, as almost all religions have utilized it at some

point in time for the purpose of self-punishment, purging, cleansing, or

becoming more “spiritual” by harming the flesh.

• Contrary to previous beliefs, self-injury is now considered to be its own

phenomenon, not a suicide attempt, and the DSM-5 refers to it as non-

suicidal self-injury (NSSI).

• Self-injury is reported most often in adolescent populations, although some

studies show it is also becoming common in college populations.

• There are four main reasons that tend to be behind non-suicidal self-injury:

grounding, control, the silent scream, and self-punishment.

• According to Lawson, there are three treatment methods that can be helpful

with self-injury: systems therapy or family therapy, cognitive behavioral

therapy, and psychoanalytic/relational therapy.

• In addition to these three main treatment methods, there are a variety of

other techniques that have been shown to be effective with those who self-

harm, particularly intransigent cutting: yoga, meridian points, ice, rubber

bands, and drawing on the skin.

Student Learning Objectives:

• To understand the diagnostic and assessment issues surrounding self-injury

• To be able to describe the most common motivations behind self-injury

• To comprehend the three main treatment methods for self-harm, as well as

the additional techniques that can be beneficial

Chapter Summary:

Self-injury has a long history, as almost all religions have utilized it at some

point in time for the purpose of self-punishment, purging, cleansing, or becoming

more “spiritual” by harming the flesh. However, Jesus bears the scars so that we do

not have to; those who struggle with self-injury may find solace in knowing that

Jesus experienced wounds too, and kept his scars to show us that he understands

pain.

Psychologically, self-injury was previously considered either suicidal or

evidence of borderline personality disorder (BPD), two very heavy issues that

therapists often tended to avoid due to their intensity. As a result, many individuals

who engage in self-injury often feel very stigmatized, even by those in the mental

health field, and therefore feel intense shame and a desire to hide their behavior.

Contrary to previous beliefs, self-injury is now considered to be its own

phenomenon, not a suicide attempt, and the DSM-5 refers to it as non-suicidal self-

injury (NSSI).

Self-injury is reported most often in adolescent populations, although some

studies show it is also becoming common in college populations. Females appear

to engage in self-injury more than males, but this could also be due to

underreporting or definition differences. People tend to believe that self-injury is

driven by a desire to seek attention, a desire to commit suicide, or by borderline

personality disorder as previously mentioned, and while most of the time this is not

the case, it is still important to keep these issues in mind when first presented with

a self-harming client. In a case where the self-harm is actually driven by a desire

for attention, this is often due to borderline personality disorder. Suicide

assessment both at the beginning of therapy and throughout the entire process is

critical and also serves to normalize suicidality assessment, letting the client know

that self-harm and suicidality are not always related. It is also essential to assess for

trauma history, as this can be common among those who self-harm. Yet another

area for assessment is the client’s participation in online communities such as

social media sites or forums. These online communities can be a source of positive

emotional support and encouragement to recover, but they can also be a source of

triggers and encouragement to continue self-harming. Counselors should use open-

ended questions and ask clients about their online experiences, if applicable.

Counselors should consider assessing for other diagnoses as well, particularly

obsessive compulsive disorder (OCD) and substance disorders; there are some who

believe that self-harm is simply an expression of one of these disorders, and while

sometimes it could be, often it is not, so accurate assessment is essential.

There are four main reasons that tend to be behind non-suicidal self-injury:

grounding, control, the silent scream, and self-punishment. Those who self-harm

for grounding purposes state that they feel disconnected from their bodies, similar

to the concepts of depersonalization, derealization, and dissociation. Because they

cannot feel their physical bodies, they feel as if they are dead, but cutting helps

them feel alive and connected to their bodies again. Those who self-harm for

control purposes usually feel their lives are out of control and use cutting as a way

of regaining their sense of control. When this occurs in adolescents, the parents

may be overly controlling or have overly high expectations. The silent scream

refers to the expression of pain; these individuals may have difficulty expressing

their emotions in words or even labeling them, and they turn to cutting as a way of

releasing and communicating their pain. Finally, in the self-punishment category,

those who engage in self-harm have intense emotions and thoughts, usually of

shame and/or guilt, and cutting is their way of purging themselves of their

“badness” by punishing themselves through pain. Also, although not necessarily its

own category, some individuals engage in self-harm because the process of taking

care of their wounds afterwards makes them feel loved and cared for, so it is

important to assess for this dynamic as well.

According to Lawson, there are three treatment methods that can be helpful

with self-injury: systems therapy or family therapy, cognitive behavioral therapy,

and psychoanalytic/relational therapy. System therapy can be advantageous

because of its emphasis on family pathology and how the family relationships

influence the client’s own struggles with self-harm. Sometimes clients may

subconsciously hold themselves back from changing out of a sense of loyalty to

their family, unconsciously worried about how their recovery might affect family

members. It is important to learn how the family’s relationships relate to the

client’s self-harm behaviors, if at all. Cognitive behavioral therapy (CBT) is

beneficial because it can help clients learn about the thoughts, emotions, and

behaviors that are connected to their self-harm. Those who self-harm often think in

black and white and experience very intense emotions, which is why CBT is an

excellent choice. CBT can help them to be aware of maladaptive thoughts and to

replace them with adaptive ones, as well as gain insight into their self-harm, for

clients can be confused about why they are engaging in such behavior. Finally,

psychoanalytic/relational therapy is useful because it centers on the client’s

relationship with the therapist as a catalyst for healing, moving away from the past

notions of drives and more towards the importance of the present relationship. In

this modality, the counselor should create a “holding” environment for the client

and can help clients gain insight into their relational patterns as they surface in the

therapeutic relationship. As could be expected, transference and

countertransference are still important concepts in this type of therapy.

In addition to these three main treatment methods, there are a variety of

other techniques that have been shown to be effective with those who self-harm,

particularly intransigent cutting. Yoga is particularly helpful for those who struggle

to feel connected to their bodies. Meridian points, places on the body where one

can press to create a sense of grounding and pain, can also be helpful for such

purposes. Other techniques, borrowed from dialectical behavior therapy (DBT),

include using ice, rubber bands, or drawing on the skin as ways to satisfy the urge

to cut without actually cutting.

Pedagogical Suggestions:

• The text lists a quote by Dr. John Thomas: “The world is full of people with

wounds looking for those with scars.” Ask students to reflect on the

meanings and implications of these words, either in a class/group discussion

or a discussion board post; how does this concept influence counseling?

• The text lists multiple reasons behind self-harm behavior. Ask students if

they can think of any other possible reasons not listed.

• Ask students how they would go about assessing the reasons behind a

client’s self-harm, particularly if the client claimed she did not know why

she engaged in the behavior. This can be a class/group discussion or a

discussion board post.

• Beyond the additional techniques listed, ask students if there are any other

techniques they can think of that could be useful with different types of self-

harm. Ask them to research this question and see what the literature has to

say.

• Have students write their own paper on conceptualizing non-suicidal self-

injury, illustrating the importance of using scholarly research and

comprehensive/multiple conceptualizations. Spiritual and/or reflection

sections can also be included if desired.

• Have students break into pairs and choose one of the therapies from the text

to further research and teach to the class, in relation to the treatment of self-

harm. They can do this through PowerPoints, role-play, or whatever creative

way they choose. Have the class vote on the most creative, accurate, and

helpful presentation.

Chapter 23 Quiz (25 questions):

Fill-in-the-blank

1. The four main reasons described in the literature as to why people engage in

self-harm are: __________________, (physical grounding)

2. ______________________, (control)

3. ______________________, (the silent scream)

4. and ______________________. (self-punishment)

5. The phrase “I don’t feel things in my body” would be associated with the

literature-supported self-harm motivation of _________________. (physical

grounding)

6. The literature-supported self-harm motivation of ___________________

(the silent scream) is connected to the expression of pain; people struggle to

effectively find words to describe what their lives have been like because

their emotional distress seems to stifle their abilities to communicate.

7. The literature-supported self-harm motivation of ______________ (self-

punishment) could involve the thought, “I am bad or did something bad,

therefore I must suffer/be punished to make things right again.”

8. The strength of _____________ therapy when working with those who self-

injure is found in the awareness of the connection to family as a participant

in the pathology. (family or systems)

9. _______________ is a technique in which a client is directed to put pressure

on the upper lip just below the nose as a way to assuage the urge to cut.

(meridian point)

True/False

1. Many who engage in self-injury feel stigmatized by the mental health

community. (T/F)

2. Only one or two major religions have some form of self-punitive process to

help cleanse, purge, or limit the flesh’s impact on spiritual and religious life.

(T/F)

3. Most prominent among all definitions of self-injury is the idea that the self-

harm cannot be a suicide attempt. (T/F)

4. The greatest number of reported cases of self-harm consistently occurs

during childhood. (T/F)

5. Many believe that individuals who self-injure are attention seeking or are

doing it as an explicit threat of suicide, but neither of these ideas captures the

actual issues of those who self-injure. (T/F)

6. Self-injurious behavior can produce the sense of being powerful and

autonomous for those who feel out of control. (T/F)

7. Although some clients can describe the day and time the first self-injury

incident occurred in detail, others cannot remember the details. (T/F)

8. Pairing yoga with any form of therapy when working with self-injury can be

an effective way for clients to feel more grounded in their bodies. (T/F)

Multiple Choice

1. Cutting could be viewed as all of the following but is MOST COMMONLY:

a) Suicide attempts

b) Evidence of borderline personality disorder

c) Its own phenomenon not associated with suicidality, BPD, or OCD

d) Evidence of obsessive compulsive disorder (OCD)

e) None of the above

2. Self-injury can take the form of all of the following EXCEPT:

a) Cutting

b) Burning

c) Bruising

d) Picking at one’s skin or scabs

e) None of the above

f) Only C and D

3. The main methods for treating self-harm, according to Lawson, include all

of the following EXCEPT:

a) Cognitive behavioral therapy

b) Systems or family therapy

c) Psychoanalytic/relational therapy

d) Trauma-focused cognitive behavioral therapy

e) None of the above

4. Which of the following is NOT one of the four ways in which

psychodynamic/relational therapy sets itself apart from the traditional

psychoanalytic approach?

a) The relationship is key to the therapy.

b) There has been a movement away from drives.

c) There is a balance between the past and the present.

d) The unconscious still plays a role, but only in as much as the client is

confused by behaviors.

e) None of the above

f) Only C and D

5. The “holding” environment is mainly a part of which type of therapy?

a) Psychoanalytic/relational therapy

b) Cognitive behavioral therapy

c) Systems therapy

d) Family of origin therapy

e) None of the above

f) All of the above

6. Other techniques that can be helpful with self-harm include all of the

following EXCEPT:

a) Meridian point

b) Yoga

c) Ice

d) Rubber bands

e) None of the above

f) Only D and A

7. The use of ice for intransigent cutting is a technique borrowed from:

a) Cognitive behavioral therapy

b) Dialectical behavior therapy

c) Systems therapy

d) Play therapy

e) None of the above

8. Which of the following is NOT one of the dynamics that can be involved

with online communities and self-harm?

a) Normalizes the behavior/helps them feel less alone

b) Unintentional contagion effect

c) Copycat effect

d) Encouraging one another to get well and have hope

e) None of the above

f) All of the above

Chapter 24

Loss-focused Strategies by Eric Scalise, PhD

Key Terms: grief, H. Norman Wright, unspeakable losses, frequent losses,

gradual losses, accumulated losses, final losses, identity losses, threatened losses,

mourning, Elizabeth Kubler-Ross, stages of grief, complicated grief, the Inventory

of Complicated Grief, developmental trauma disorder (DTD), complex trauma,

resiliency, bereavement, compassion, empathy, compathic response, Grief Pattern

Inventory, instrumental orientation, intuitive orientation, blended orientation,

Martin, experiential interventions, emotion-focused therapy (EFT), psychodrama,

empty chair technique, rituals, equine-assisted therapy, creative-expressive

therapies, life timelines, memorials collages, journaling, daily examen

Key Points:

• Grief is defined as a normal process of pain that occurs when one loses

someone or something one values or loves.

• H. Norman Wright, an expert in the field of grief, has created a list of

different types of losses: unspeakable losses, frequent losses, gradual losses,

accumulated losses, final losses, identity losses, and threatened losses.

• Another famous grief expert, Elizabeth Kubler-Ross, has created a list of

grief stages: (1) shock and denial stage; (2) pain and guilt stage; (3) anger

and bargaining stage; (4) depression, reflection, and loneliness stage; (5) the

upward turn; (6) accepting and hope stage; (7) reconstruction stage.

• Complicated grief can occur when the grieving is experienced over a long

period of time with little movement towards closure, and symptoms are

usually severe, such as suicidal ideation or substance abuse.

• However, one of the greatest protectors from complex trauma is the concept

of resilience, defined as the ability to “bounce back” after loss or trauma.

• The Grief Pattern Inventory, developed by Martin, assesses for three basic

grieving orientations: instrumental, intuitive, and blended.

• There are a wide variety of strategies that can be effective with grieving

clients, including experiential interventions and emotion-focused therapy

(EFT).

• Other techniques that have been shown to be effective with grief include

psychodrama; the empty chair technique; rituals; equine-assisted therapy and

other pet therapies (canine, feline, etc.); creative/expressive therapies; life

timelines; memorials; collages; journaling; writing letters or psalms; and the

daily examen, an exercise in which one prayerfully examines the day for the

influence of God’s presence.

Student Learning Objectives:

• To be able to describe the nuances of grief, including types, stages, and

orientations

• To understand the nature of complicated grief, complex trauma, and

resiliency

• To comprehend the various SITs that can be effective when working with

grieving clients

Chapter Summary:

Grief is defined as a normal process of pain that occurs when one loses

someone or something one values or loves. For healing to occur, one must work

“through” grief rather than “out of” it, although this requires courage and is very

difficult. When working with clients who have experienced a loss, desiring to help

them in this process of working “through” it, it can first be helpful to learn about

the different types of losses, the various stages of grief, and relevant issues such as

complex trauma, developmental concerns with children and teens, and resiliency.

H. Norman Wright, an expert in the field of grief, has created a list of

different types of losses: unspeakable losses (such as miscarriage or infertility that

are not often talked about), frequent losses (losing mobility or friends due to old

age or illness), gradual losses (children leaving the house), accumulated losses

(medical or financial problems), final losses (a loss occurring during a late stage,

such as losing a spouse after decades of marriage), identity losses (losing a sense of

purpose), and threatened losses (waiting for the results of a medical test). These

losses can be real, anticipated, or imagined, but they all usually result in asking the

most common questions of “why?” and “why me?”

Another famous grief expert, Elizabeth Kubler-Ross, has created a list of

grief stages: (1) shock and denial stage; (2) pain and guilt stage; (3) anger and

bargaining stage; (4) depression, reflection, and loneliness stage; (5) the upward

turn; (6) accepting and hope stage; (7) reconstruction stage. Her stages are fairly

self-explanatory, and it is important to note that her stages were written for the one

who is dying or experiencing the loss, not the survivors.

Complicated grief can occur when the grieving is experienced over a long

period of time with little movement towards closure, and symptoms are usually

severe, such as suicidal ideation or substance abuse. There are several factors that

can contribute to the development of complicated grief, such as the individual

being in an environment where expression of grief is not acceptable or the “mode

of the loss is considered incomprehensible, senseless, tragic, or preventable”

(Scalise, 2018, p. 514), among others. A helpful instrument called the Inventory of

Complicated Grief was developed in 2001 by Prigerson and Jacobs, among the first

to delineate complicated grief, defining the process as having symptoms that

persist for over six months along with an increased negative mood. Similar to

complicated grief are the concepts of developmental trauma disorder and complex

trauma, discussed in a previous chapter. This is especially relevant to children and

teens who experience loss, as they have greater neurobiological activation, more

intense emotions, and a decreased ability to regulate them because of their young

age.

However, one of the greatest protectors from complex trauma is the concept

of resilience, defined as the ability to “bounce back” after loss or trauma.

Resilience is developed over time through skills related to thoughts and behaviors,

and there are many factors that increase resilience such as secure relationships,

self-care, and faith-integration, among others. The presence of God’s Word and

Spirit are also critical, as they bring “light” into the darkness of the loss. Relatedly,

it can also help to remember that the pain of loss is the evidence of love; if we

didn’t love, we wouldn’t grieve, but we must choose to take the risk if we want to

be fully alive.

When beginning the counseling process with those who are grieving, it is

imperative to remember this phrase: “everyone has a story to tell, and everyone

needs that story” (Scalise, 2018, p. 519). Helping clients to tell their story is a

critical part of working with loss. While working through this process, one should

be aware that there are three relevant terms—bereavement, grief, and mourning—

that are similar but also different. Bereavement is the state one enters when one

experiences a loss, grief is the emotional pain associated with the bereavement, and

mourning is the expression of the grief. Certain qualities, such as compassion and

empathy, are essential. Scalise (2018) refers to the combination of the two as

displaying a compathic response, modeled after Christ’s tenderhearted compassion

for us. One should also keep cultural differences in mind, as different cultures can

experience or express grief in different ways.

Different people also experience and express their grief in different ways.

The Grief Pattern Inventory, developed by Martin, assesses for three basic grieving

orientations: instrumental, intuitive, and blended. Those with an instrumental

orientation are more cognitive, and tend to seek out activities and problem-solve.

Those with an intuitive orientation are more focused on emotions, experiencing

them as intense and needing to express their feelings rather than problem-solve.

Those with a blended orientation are a combination of both instrumental and

intuitive. Assessing for the client’s grieving orientation before beginning

counseling work can be very beneficial.

There are a wide variety of strategies that can be effective with grieving

clients, including experiential interventions and emotion-focused therapy (EFT).

Experiential interventions focus on helping clients tell their stories in experiential

ways rather than simply “talking”; this can be especially helpful for children and

teens who may prefer non-verbal types of expression. These methods have been

shown to be highly effective and to result in significant symptoms reduction.

Emotion-focused therapy (EFT), developed by Sue Johnson and Les Greenberg, is

an experiential intervention that combines multiple methods from other

experiential types of therapy. With a focus on the present, this therapy can be

effective when working with grief, although appropriate training is necessary

before its utilization. Finally, other techniques that have been shown to be effective

with grief include psychodrama; the empty chair technique; rituals; equine-assisted

therapy and other pet therapies (canine, feline, etc.); creative/expressive therapies;

life timelines; memorials; collages; journaling; writing letters or psalms; and the

daily examen, an exercise in which one prayerfully examines the day for the

influence of God’s presence.

Pedagogical Suggestions:

• After reading the text, have students write out their own definition of grief.

Share with the class or discuss in groups if desired.

• Have a group or class discussion and ask students how they might go about

discerning whether a client was experiencing complicated grief.

• Ask students how grief might be experienced and expressed differently in

children and adolescents.

• In the text, Scalise says, “We grieve because we love, and love often speaks

of relationship—being connected to someone or something that we value

and cherish. . . . People can choose to love and risk loss or simply isolate

themselves with loneliness in an attempt to avoid anything painful” (p. 517).

Have students discuss this quote, either as a class, in groups, or in a

discussion board post, reflecting on their thoughts about it and how their

view might influence their future counseling work. How might their view of

love and grief/pain specifically affect their work with grieving clients?

• Ask students if they can think of any examples of how cultural differences

might affect the way an individual experiences and expresses grief. See page

521 for more information on cultural considerations.

• Have students research the Grief Pattern Inventory and study the three

orientations. Then have them break into pairs or triads and role-play to

practice assessing a client’s grief orientation; they can use either the actual

inventory or simply ask questions, or both. Then have them practice

explaining the results to the client and how this information could be helpful.

• Have students each choose one type of therapy or technique from the text

and create a PowerPoint presentation to teach it to the class. Emphasize that

they must use other outside scholarly sources other than just the text. Instruct

them to focus on how to use the method or technique specifically with grief

work.

• Have students visit the websites mentioned on page 530 of the text, which

provide lots of helpful information on the Elizabeth Kubler-Ross Foundation

and multiple resources for those who are grieving or helping. Students can

write a summary of their website explorations and their reflections on them

in a discussion board post or simply discuss them in class.

Chapter 24 Quiz (25 questions):

Fill-in-the-blank

1. Grieving ______________ the loss is the only way to heal, as opposed to

attempting to work “out of” it. (through)

2. The four types of losses were delineated by grief expert

__________________. (H. Norman Wright)

3. Miscarriage, infertility issues, postabortion consequences, etc. where the

issues are not identified, shared, or discussed are referred to as

_______________ losses. (unspeakable)

4. An array of growing medical, financial, or stress-related problems and

conditions are examples of ___________________ losses. (accumulated)

5. Grief expert ____________________________is credited with creating the

stages of grief. (Elizabeth Kubler-Ross)

6. When grief remains unresolved and without reasonable closure over a

significant period, it is known as _____________________. (complicated

grief)

7. One of the best moderators of complex trauma is the capacity for and

development of ___________________, also referred to as buoyancy or

“bounce back” ability. (resiliency)

8. _______________ is a psychic state or condition of mental anguish or

emotional suffering as a result or in anticipation of bereavement. (grief)

9. The _____________________ is a time of reflection and prayer at the end of

the day to allow the Holy Spirit to give wisdom and insight in “examining”

the day to detect God’s presence and discern his direction. (daily examen)

True/False

1. Kubler-Ross’s model does not address the stages of grief for survivors but

for the person dying, although similarities exist. (T/F)

2. Complex trauma results in a protracted overactivation (sensitized neural

responses) of an individual’s autonomic nervous system. (T/F)

3. During the process of complicated grief, secondary loss, or loss of control,

actually rarely leads to increased control behaviors. (T/F)

4. In the text, bereavement, grief, and mourning are considered to be

interchangeable terms for the same concept. (T/F)

5. Experiential work with grief includes constructing a world of meaning

through narrative storytelling, therapeutic writing, metaphorical language,

and visualization. (T/F)

6. The empty chair technique involves utilizing elements of theater such as

dramatization and role-playing to reenact real-life and past situations in the

present. (T/F)

7. Music is experienced in all areas of the brain and can have a profound and

positive impact on neurological functioning. (T/F)

8. Animal-assisted therapies can be helpful with grief work by increasing

levels of oxytocin, a bonding hormone that has a calming effect. (T/F)

Multiple Choice

1. The loss of children to graduation, marriage, and other empty-nest events are

examples of:

a) Frequent losses

b) Gradual losses

c) Accumulated losses

d) Final losses

e) None of the above

2. When the griever becomes more functional and seeks new and realistic

solutions to life and problems posed, this is known as which stage of grief?

a) Accepting and hope stage

b) Reconstruction stage

c) The upward turn

d) Anger and bargaining stage

e) None of the above

3. The Inventory of Complicated Grief was developed by:

a) Kubler-Ross

b) H. Norman Wright

c) Prigerson and Jacobs

d) Perper and Lobb

e) None of the above

4. All of the following are contributors to resilience, according to the text,

EXCEPT:

a) A positive outlook

b) The presence of caring relationships

c) The ability to set reasonable goals

d) Impulse control

e) None of the above

5. Which of the following is NOT one of the counselor qualities mentioned by

Scalise as important when working with grieving clients?

a) Compassion

b) Empathy

c) Unconditional positive regard

d) A compathic response

e) None of the above

6. The Grief Pattern Inventory was developed by:

a) Prigerson and Jacobs

b) Perper and Lobb

c) Martin

d) Kubler-Ross

e) None of the above

7. When most grief “energy” is focused on problem-solving and planned

activities as an adaptive strategy, this is known as which grief orientation?

a) Instrumental

b) Intuitive

c) Blended

d) Activity-based

e) None of the above

8. Which of the following is NOT one of the techniques for grief work

mentioned by Scalise in the text?

a) Memorials

b) Life timelines

c) Collages

d) Journaling

e) None of the above

Chapter 25

Sexual Addiction-Focused Strategies by Mark. R. Laaser,

MDiv, PhD

Key Terms: Pat Carnes, sexual addiction, pornography, unmanageability,

neurochemical tolerance, erototoxins, dopamine, serotonin, oxytocin, vasopressin,

adrenaline, endorphins, glucose, catecholamines, escalation, medication, mirror

neurons, the Sexual Addiction Screening Test (SAST), David Delmonico, the

Sexual Dependence Inventory (SDI), masturbation, authority rape, the sexual

addiction cycle, invasion trauma, neglect, addiction interaction disorder, Ginger

Manley, abstinence contract, yada sex, Virginia Satir, iceberg model, post-

traumatic growth (PTG), fantasy inventory

Key Points:

• Although there are a wide variety of definitions, one of the pioneers in the

sex addiction field, Carnes, has provided a useful list of five characteristics

to describe the nature of sexual addiction: unmanageability, neurochemical

tolerance, escalation, medication, and sex as a reward.

• When working with sexual addiction, accurate assessment is essential. There

are two specific instruments that have been created for this purpose: the

Sexual Addiction Screening Test (SAST) and the Sexual Dependence

Inventory (SDI).

• There are four basic beliefs found among sex addicts: (1) I am a bad,

unworthy person; (2) If you knew me, you would hate me and leave me; (3)

No one will take care of my needs but me; and (4) Sex is my most important

need.

• The sexual addiction cycle, created by Carnes, begins with trauma, either

invasion trauma or neglect, which produces shame-filled core beliefs about

the self. Then “preoccupation” or fantasy begins, in which the individual

becomes preoccupied with sexual thoughts. Rituals follow, which involve

the individual preparing to act out sexually. The acting out stage is self-

explanatory, followed by the stage of despair, which drives the individual to

repeat the cycle all over again in an effort to cope with feelings of shame.

• Concerning SITs that are effective with sexual addictions, in addition to the

clinical interview, Ginger Manley created a model of healthy sexuality

consisting of five dimensions: physical, behavioral, relational, emotional,

and spiritual.

Student Learning Objectives:

• To be able to describe the five characteristics of sexual addiction, as well as

the cycle of sexual addiction and the two main screening instruments used to

measure sexual addiction in clients

• To comprehend the core beliefs and cognitive distortions associated with

sexual addiction

• To understand the various SITs described by Laaser in each of the five

dimensions of healthy sexuality

Chapter Summary:

Pornography use is considered to be a widespread issue, with male use

estimated at 50-66 percent and female use at 25-33 percent; it is especially

increasing among those in the Christian population, possibly due to individuals

being raised in strict religious homes. Although there are a wide variety of

definitions, one of the pioneers in the sex addiction field, Carnes, has provided a

useful list of five characteristics to describe the nature of sexual addiction:

unmanageability, neurochemical tolerance, escalation, medication, and sex as a

reward.

Unmanageability is the idea that the individual feels he cannot control his

behavior. This is similar to the first step in Alcoholics Anonymous, where it is

admitted that one’s life has become unmanageable due to the addiction. Individuals

may be angry with God for not “taking away” their desire for sinful activities,

believing that if they could just stop engaging in the activities their problem would

be fixed, although this is not the case. Neurochemical tolerance means that over

time the brain becomes tolerant of the chemicals released during sexual activities

such as pornography use or fantasy, chemicals that mimic the effects of heroin and

addictive drugs; some studies even suggest that this is even more powerful than the

effects of addictive drugs. Neurochemicals involved in this process include

dopamine, serotonin, oxytocin, vasopressin, adrenaline, endorphins, glucose, and

catecholamines. These chemicals are sought after either to calm or excite the brain.

Escalation is the idea that the more one engages in the addiction, the more one

engages in the addiction. Frequency increases with a kindling-like effect, and the

individual has to increase the intensity of stimuli being used in order to get the

same effect due to neurochemical tolerance; an example of this would be

progressing from basic pornography to illegal pornography with children and

adolescents. Medication is the idea that the individual uses the addiction to cope

with distress, either by seeking to calm down or to create a high of pleasure, using

the sexual stimuli to escape from their painful or out of control emotions. Finally,

sex can be considered a reward, as many who are addicts feel that sex is one of

their basic needs in life and they are entitled to it either to simply survive or as a

reward for abstaining from it for a certain amount of time.

When working with sexual addiction, accurate assessment is essential. There

are two specific instruments that have been created for this purpose: the Sexual

Addiction Screening Test (SAST) and the Sexual Dependence Inventory (SDI).

Created by Carnes, the SAST is the most convenient and useful, as it is only 25

questions and available for free online. Also developed by Carnes, along with

David Delmonico, the SDI consists of over 500 questions and is expensive. Simply

asking the client questions such as “When did you choose sex as a solution to your

emotional pain?” is also essential. To help organize the results of assessments and

interviews, Carnes provided three levels of sexual activities to consider, although

he later updated to ten types. Level one includes activities such as masturbation

and fantasy, level two illegal activities, and level three actual sexual offenses such

as incest and sexual harassment.

The counselor should also assess throughout the counseling process for the

client’s underlying beliefs and cognitive distortions. There are four basic beliefs

found among sex addicts: (1) I am a bad, unworthy person; (2) If you knew me, you

would hate me and leave me; (3) No one will take care of my needs but me; and (4)

Sex is my most important need. These beliefs address the areas of self-image,

relationships, needs, and sexuality. Cognitive distortions that are common include

Nothing will help, I can stop if I really wanted to, I just need to control it better,

and It really doesn’t hurt anyone.

Being knowledgeable about the sexual addiction cycle and the role of trauma

in sex addiction is also important. The sexual addiction cycle, created by Carnes,

begins with trauma, either invasion trauma or neglect, which produces shame-filled

core beliefs about the self. Then “preoccupation” or fantasy begins, in which the

individual becomes preoccupied with sexual thoughts. Rituals follow, which

involve the individual preparing to act out sexually. The acting out stage is self-

explanatory, followed by the stage of despair, which drives the individual to repeat

the cycle all over again in an effort to cope with feelings of shame. One should

keep in mind that many of those with sexual addictions also engage in other

addictions, with alcohol addiction being the most common. It is not uncommon to

turn to another addictive behavior in an attempt to cope with the shame as well. In

addition to assessing for other addictions, one should also assess for other mental

health disorders. ADHD is the most common co-occurring mental health disorder

among those with sexual addictions.

Concerning SITs that are effective with sexual addictions, in addition to the

clinical interview, Ginger Manley created a model of healthy sexuality consisting

of five dimensions: physical, behavioral, relational, emotional, and spiritual.

Laaser uses these five dimensions to guide the treatment process using a

multifactorial, comprehensive approach.

The physical dimension includes techniques such as the abstinence contract,

teaching yada sex, referring to sex therapists, and medical interventions. The

abstinence contract is way for a client to commit to sobriety from any sexual

activity for a certain period of time, in order for the brain to detox. Detox can occur

in seven to twenty-one days, but ninety days is recommended for an abstinence

contract so that the client has sufficient time to work through issues in therapy and

in his marriage, if applicable. Yada sex, for married clients only, helps them to

develop deeper spiritual and emotional intimacy with their spouse. Often sex

addicts experience sex as purely physical, but the concept of yada sex teaches them

to experience it multidimensionally, the way God intended it. If specific sexual

disorders are present, such as those listed in the DSM-5, a referral to a sex therapist

may be warranted, particularly if the counselor is not trained in these issues.

Referral to an inpatient or intensive outpatient program should also be considered

if issues are severe, life-threatening, or outpatient counseling is ineffective.

Medical interventions may also be necessary if physical issues are contributing to

sexual problems, such as the presence of STDs and nutritional deficiencies.

The behavioral dimension includes support groups, accountability, and

commitment to recovery programs. Support groups such as Sexaholics

Anonymous, SexAddicts Anonymous, and Sex and Love Addicts Anonymous

follow the same twelve-step process as Alcoholics Anonymous and can be highly

effective components of treatment. Accountability, which can also be found in

such groups or elsewhere, is critical; the accountability process must not simply

focus on “not doing” the additive behaviors but must also focus on creating

positive behaviors to replace them. Furthermore, the individual needs not one

accountability partner but many, which is why groups are so beneficial. Whatever

recovery program the individual has chosen, he must also commit to it, and

understand that it is a lifelong commitment, not a temporary one.

The relational dimension consists of couples’ counseling (for those who are

part of a couple) and managing disclosure. The spouses should also receive help

through their own counseling and/or support groups, as talking with others who

have been through the same experience is very helpful. Spouses should also be told

that their partner’s infidelity and addiction is not their fault, as they are often

blamed or blame themselves. The addict must also disclose to his spouse about the

addiction and where he is at in his recovery in order to re-build trust, although

graphic details should be left out. One helpful tool for this is Virginia Satir’s

iceberg model, which helps individuals examine their emotions, perceptions,

expectations, and yearnings beneath their behaviors.

The emotional dimension focuses on reclaiming thoughts and fantasy,

fantasy inventory, and healing communities. As trauma is often involved with

sexual addiction, it is important to grieve the trauma and work through the process

to post-traumatic growth, which happens through the changing of one’s thoughts.

Clients can learn to reclaim their thoughts and fantasy life by learning to control

them. A fantasy inventory is one way of doing this, involving examining the

fantasies in detail and asking what they are trying to say. Fantasies can often be the

brain’s way of trying to heal something from the past, so details are critical for

achieving such insight. Community is also important, and can meet many of the

unmet needs that were driving the addiction.

Finally, for the spiritual dimension, Laaser lists seven goals that one can use

with clients to help them through the spiritual aspect of their recovery. The first

goal is for the client to be willing to change, followed by discovering what the

client is truly searching for in his life. The next few goals are for the client to

become sacrificial, to develop a daily meditation program, and to develop a

theology of suffering. Lastly, the client should cultivate an attitude of forgiveness

and develop a vision for his life.

Pedagogical Suggestions:

• Class or group discussion: The text states that repressive religious homes

may be one reason for the high percentages of Christians using pornography.

What might other reasons be? What might other reasons for pornography

addiction in general be that are not mentioned in the text?

• Have students go to Dr. Carnes’s website and become familiar with it and

the resources he offers: www.sexhelp.com. Then, have them obtain a copy

of the Sexual Addiction Screening Test available for free on the website and

become familiar with the questions and how to score it. If desired, have them

break into pairs and practice explaining hypothetical results of this

questionnaire to a hypothetical client in a tactful way.

• Have students brainstorm ways to assess for and address the common core

beliefs and cognitive distortions involved in sexual addiction. This could be

a class/group discussion or discussion board post.

• Have students research and compile a list of support groups or other services

for sexual addiction in the area (or the area in which they plan to practice

therapy in the future) so that they are aware of which kinds of services are

available for future clients. They may also research intensive outpatient or

inpatient services for sexual addiction.

• Have students each choose a topic from the chapter and engage in further

research, creating a PowerPoint presentation, paper, or discussion board post

on their findings to teach the rest of the class. Students should use sources

other than the text that are scholarly and peer-reviewed.

• The text discusses helping clients develop vision and mission statements for

their lives. Have students break into pairs and practice walking each other

through the process of creating these statements as practice.

• Have students research Virginia Satir’s iceberg model, then break into pairs

and role-play to practice teaching this model to a client and using it in a

hypothetical therapeutic context.

Chapter 25 Quiz (25 questions):

Fill-in-the-blank

1. The five characteristics of sex addiction, according to Carnes, are

________________, (unmanageability)

2. _________________, (neurochemical tolerance)

3. ___________________, (escalation)

4. ____________________, (medication)

5. and _______________________. (sex as a reward)

6. The Sexual Addiction Screening Test is available for free online on Dr.

Carnes’s website __________________. (www.sexhelp.com)

7. Masturbation, pornography, fantasy, prostitution, and affairs are considered

level _________ of Carnes’s nonprogressive levels of sexual addiction.

(one)

8. There are two kinds of trauma/abuse: invasion and ______________.

(abandonment or neglect)

9. The most frequent comorbid condition for sex addiction is ___________.

(ADHD)

True/false

1. Common for addicts is the belief that not acting out or sinning is the answer

to the problem. (T/F)

2. Research suggests that pornography triggers chemicals in the brain that

create a euphoric experience similar to that of heroin. (T/F)

3. The brain is so charged by sex that adrenaline is both released and increased

with sexual thoughts such as fantasy. (T/F)

4. Often addicts unwittingly or intentionally shut down oxytocin release to

avoid bonding with any sexual partner. (T/F)

5. The most common form of escalation in sexual addiction is to graphic

underage material. (T/F)

6. Early in their acting out, addicts learned that without sex they feel like their

basic needs are unmet. (T/F)

7. Addicts can remain sober with only one accountability partner. (T/F)

8. In sex addiction treatment, ask clients to tell you about their fantasies, but let

them know that details should always be avoided. (T/F)

Multiple Choice

1. Which of the following is NOT one of the neurochemicals listed as being

involved in sex addiction tolerance?

a) Dopamine

b) Oxytocin

c) Vasopressin

d) Adrenaline

e) None of the above

f) Only A and B

2. Which of the following is NOT one of the screening instruments for sexual

addiction mentioned in the text?

a) The Sexual Addiction Screening Test (SAST)

b) The Sexual Addiction Inventory (SAI)

c) The Sexual Dependence Measure (SDM)

d) The Sexual Dependence Assessment Protocol (SDAP)

e) None of the above

f) B through D

3. All of the following are listed as core beliefs associated with sexual

addiction EXCEPT:

a) I am a bad, unworthy person.

b) If you knew me, you would hate me and leave me.

c) No one will take care of my needs but me.

d) If I do not engage in sexual activities, I will die.

e) None of the above

4. All of the following are stages in the sexual addiction cycle EXCEPT:

a) Preoccupation or fantasy

b) Rituals

c) Acting out

d) Despair

e) None of the above

f) Only C and D

5. The most common co-addiction with sex addiction is:

a) Cocaine

b) Heroin

c) Alcohol

d) Gambling

e) None of the above

6. Which of the following is NOT one of Ginger Manley’s five dimensions of

healthy sexuality?

a) Physical

b) Biological

c) Emotional

d) Relational

e) None of the above

7. The abstinence contract is a part of which dimension of healthy sexuality in

sex addiction treatment?

a) Physical

b) Biological

c) Emotional

d) Spiritual

e) None of the above

8. Which of the following is NOT one of the seven goals listed to help you

assist your clients with spiritual formation during sex addiction treatment?

a) Develop a theology of suffering.

b) Determine what the addict is truly searching for in his life.

c) Cultivate an attitude of forgiveness.

d) The addict must become entirely willing.

e) None of the above

f) Only C and D

Chapter 26

Infidelity-Focused Strategies by Michael Sytsma, PhD,

and Douglas Rosenau, EdD

Key Terms: infidelity, unfaithfulness, wounded spouse, offending spouse, affair

partner, self-of-the-therapist, inception, pre-discovery, discovery, recovery,

resolution, complex trauma, post-traumatic stress disorder (PTSD), grief,

expectations, hope, risk assessment, structured separation, modeling, active

listening, systemic understanding, second-order change, sexually transmitted

infection (STI), penance, punishment, resolution phase, relapse prevention

Key Points:

• Infidelity is defined in this chapter as any type of unfaithfulness.

• There are several relevant concepts that counselors should be aware of when

working with infidelity: the competence of the self-of-the-therapist, the

complexity of infidelity, the complex trauma involved in infidelity, and the

view of infidelity as sin.

• There are some specific strategies recommended for the first three sessions

when working with infidelity; the first session should be with the couple, the

second with the offending spouse, and the third with the wounded spouse.

• After these first three sessions, some general SITs that can be beneficial

include setting expectations for healing, providing hope, risk

assessment/structured separation, laying out the “rules,” and modeling/active

listening.

• Other SITs include healing the wound before attacking the disease,

rebuilding trust/full disclosure, penance and examining roles, rebuilding

sexual intimacy and examining the possibility of an STI, and

resolution/relapse prevention.

Student Learning Objectives:

• To be able to describe the relevant concepts counselors should be aware of

when working with infidelity

• To comprehend how to conduct the first three sessions with a couple facing

infidelity

• To understand the various SITs described in this chapter that are beneficial

when working with infidelity

Chapter Summary:

In 1989, infidelity, defined in this chapter as any type of unfaithfulness, was

listed as the number one reason for divorce in 160 countries. Today, it seems to

still be fairly common, and younger women and men appear to engage in infidelity

at the same rate. Some statistics suggest that 65 to 70 percent of those who have

this experience choose to stay married, however, and good therapy may be

significant in helping couples through this type of trauma. There are several

relevant concepts that counselors should be aware of when working with infidelity:

the competence of the self-of-the-therapist, the complexity of infidelity, the

complex trauma involved in infidelity, and the view of infidelity as sin.

Working with infidelity can involve lots of painful emotions and erotic

details that can be difficult to tolerate; it is critical that the counselor be able to

tolerate such dynamics in order to help clients tolerate them as well. It is also

critical for the counselor to become educated on infidelity-related therapy as well

as the common phases of the infidelity process: inception, pre-discovery,

discovery, recovery, and resolution. The counselor should also be aware that

infidelity is complex and can occur in a wide variety of ways, not only sexually.

Infidelity can also cause complex trauma, and some research has shown that many

wives who have been betrayed developed symptoms of post-traumatic stress

disorder (PTSD). Grief is also a part of the process for both the wounded and the

offending spouse, and clients must move through the stages of grief, a process that

can take not months but years. The counselor should also remember that according

to Scripture, infidelity is a sin, an offense against God and against the spouse.

There are some specific strategies recommended for the first three sessions

when working with infidelity. The first session should be with the couple rather

than just one of the spouses, as this lets both individuals know they cannot attempt

to form an alliance with the counselor against their spouse. In this first session, the

wounded spouse tells his or her story, and even if the offending spouse tries to

interject, respectfully draw the attention back to the wounded spouse’s story. The

second session should be with the offending spouse, letting him or her unpack the

affair. The third session should be with the wounded spouse, letting him or her

process the pain as the counselor assesses how committed the wounded spouse is

to the marriage and what he or she knows about the actual affair.

After these first three sessions, some general SITs that can be beneficial

include setting expectations for healing, providing hope, risk assessment/structured

separation, laying out the “rules,” and modeling/active listening. Many couples

have unrealistic expectations about healing and the length of time it will take, so it

is important to let them know from the beginning that the healing process typically

takes three to five years. It is wise to also let them know that the offending partner

will probably heal first, and the wounded partner will generally need more time,

but complete healing is possible, even though life will be different. This can lead

into providing hope for the couple, and helping them recognize ways in which they

have cared for each other even in the midst of the trauma can be beneficial. The

counselor should also assess for any safety risks, as infidelity is one of the most

prominent factors in marriage violence.

Structured separations can be helpful or necessary if violence is suspected or

simply if the couple really needs some space for the emotions to settle. Whether

separated or not, one of the most effective strategies for couples involves laying

down the “rules” which can help them feel more stable, hopeful, and protected.

The first rule is that there must be absolutely no contact with the affair partner. The

second rule is to be truthful in all things, especially if the affair partner does make

contact, and the offending partner must immediately stop the communication and

involve the spouse to restore a sense of control and honesty. Regardless of the SITs

used, modeling and active listening should be utilized by the counselor throughout

therapy; many couples simply lack the skills of active listening, and learning them

in counseling is a very helpful strategy for strengthening their relationship.

Other SITs include healing the wound before attacking the disease,

rebuilding trust/full disclosure, penance and examining roles, rebuilding sexual

intimacy and examining the possibility of an STI, and resolution/relapse

prevention. It can be easy to focus on the “why” of the infidelity and to get

sidetracked or stuck rather than focusing on the issue at hand—healing the

marriage. One strategy the counselor must employ is to ensure this does not

happen by helping the couple stay focused on the goal. Rebuilding trust is a part of

that goal, and it involves the wounded spouse learning to trust and the offending

spouse being completely open and transparent as a way of learning to be

trustworthy. The offending spouse should engage in full disclosure, or confession,

of the infidelity as one way of doing this. It is better to disclose all the information

at one time, rather than in pieces over time, and to focus on the process rather than

the details so as not to unnecessarily further traumatize the wounded spouse.

Healthy penance, as opposed to punishment, on the part of the offending spouse

can also help with rebuilding trust. Examining their roles can be helpful as well;

for example, the wounded spouse may be falling into the role of detective or the

offending spouse may be falling into the role of defensive blamer.

Additionally, one of the most effective strategies is to help the couple rebuild

sexual intimacy. Part of this does include acknowledging the possibility of an STI

and getting the proper tests, if sexual infidelity occurred, as most STIs can have no

symptoms. The couple should also attend to the trauma, make needed changes, and

find new meaning in their sex life. For example, it can be helpful to ask the couple

what they would like to express through their sexual intimacy with each other.

Eventually, couples will be able to enter the resolution phase. In this phase, the

couple should monitor themselves for any signs of a potential relapse while

continuing to prioritize their intimacy and their marriage.

Pedagogical Suggestions:

• On page 559, the authors list common myths that counselors believe about

infidelity. Discuss these myths in a class/group discussion, asking students

to share their thoughts on these myths and their own beliefs about infidelity.

This can also be a discussion board post.

• Ask students to reflect on and discuss the question “What are some ways a

counselor could provide hope while also managing realistic expectations for

a couple who has experienced infidelity?”

• In practice, how might one differentiate penance from punishment in regards

to infidelity? Ask students to discuss this question either in groups or

discussion board posts.

• Have students each choose one topic from the text to further research and

create a PowerPoint, paper, or demonstration to teach the rest of the class.

The standard rules for using scholarly, academic sources apply.

• In regards to infidelity, the text mentions that “hearing the stories can be

very painful to highly erotic for the counselor” (p. 559). Have students

reflect on their ability to tolerate such intense emotions in a counseling

room, how this might affect their future work with clients facing infidelity,

or how they might improve their abilities in this area if they desire to work

with infidelity someday.

Chapter 26 Quiz (25 questions):

Fill-in-the-blank

1. When establishing the “rules” for the couple after infidelity, the first rule is

___________________________________________. (absolutely no

contact with the affair partner)

2. When establishing the “rules” for the couple after infidelity, the second rule

is _________________________________. (be truthful in all things)

3. When confessing or giving a full disclosure of infidelity, the offending

spouse should focus on _______________ rather than details. (process)

4. As opposed to punishment, __________________ can mean investing time,

money, and energy to rebuild the marital intimacy that has been so damaged

by infidelity. (penance)

5. After counseling for infidelity, avoiding conflict and stockpiling anger can

be a warning sign that the couple is in danger of ______________. (relapse)

6. One strategy for infidelity discussed in the text is to focus on

________________ (healing) the wound before attacking the

7. ________________. (disease)

8. The most important core concept is the recognition of infidelity as a kind of

complex _______________. (trauma)

True/False

1. Infidelity can also be defined as a fantasy. (T/F)

2. According to research, very few wives have responded to disclosure of

infidelity with post-traumatic stress disorder (PTSD) symptoms. (T/F)

3. The normal healing process after infidelity is about 1 to 2 years. (T/F)

4. The wounded partner will typically heal long before the offending partner.

(T/F)

5. Infidelity is one of the leading causes of violence in marriage. (T/F)

6. Keeping the couple focused on the current wound is a strategy that our

experience has shown facilitates a more complete healing. (T/F)

7. Sexually transmitted infections are rarely asymptomatic. (T/F)

8. Trickle disclosure is the most helpful kind of disclosure. (T/F)

9. Infidelity is varied and complex. (T/F)

Multiple Choice

1. Which of the following is NOT an example of infidelity?

a) Addictive/compulsive sexual acting out

b) Brief or more casual sexual hookups

c) Online romantic relationships

d) Emotional affairs that never culminate in physical sex

e) None of the above

f) Only A and B

2. Which of the following is NOT one of the phases of infidelity?

a) Inception

b) Pre-discovery

c) Discovery

d) Pre-recovery

e) None of the above

3. The first session when working with infidelity should be with:

a) The offending spouse

b) The wounded spouse

c) The couple

d) The affair partner

e) None of the above

4. The second session when working with infidelity should be with:

a) The offending spouse

b) The wounded spouse

c) The couple

d) The affair partner

e) None of the above

5. The third session when working with infidelity should be with:

a) The offending spouse

b) The wounded spouse

c) The couple

d) The affair partner

e) None of the above

6. Which of the following is NOT one of the strategies mentioned in the text

for working with infidelity?

a) Rebuilding trust

b) Guide a full disclosure (confession)

c) Healthy penance

d) Helping them choose their role

e) None of the above

f) Only A and C

7. For the wounded spouse, common corrosive roles can include all of the

following EXCEPT:

a) The detective

b) The accountability partner

c) The manager

d) The insurance agent

e) C and D

f) A and D

8. For the offending spouse, common corrosive roles can include all of the

following EXCEPT:

a) The defensive blamer

b) Guilt-ridden “infidel”

c) Impatient victim

d) Happy camper

Chapter 27

Betrayed Spouse-Focused Strategies by Debra Laaser,

LMFT

Key Terms: the trauma model, twelve-step model, codependent/co-addict, post-

traumatic stress disorder (PTSD), post-traumatic growth (PTG), relationship

betrayal, genogram, trust, sexually-transmitted disease (STD), space/separation,

the ampersand, black and white thinking, anger, sexual addiction, truth,

boundaries, bottom lines, accountability partners, safe community, distorted

beliefs, cognitive restructuring, forgiveness, vision

Key Points:

• Often women are told they are codependents or co-addicts who need to work

on themselves or powerless victims of trauma, one extreme or the other.

Laaser states that both of these approaches are counterproductive, and

instead advocates for a post-traumatic growth (PTG) model in which women

are able to express their pain without learning to feel like powerless victims.

• Laaser states that firstly clients need to be able to express their pain, tell their

story, and be heard and validated immediately, and thus lets them do this in

the very first session instead of asking various assessment questions.

• Laaser recommends that the second and third sessions be guided by the

client, empowering her to initiate talking about whatever she needs and

desires to talk about.

• Timing is imperative, and encouraging a woman to “work on” herself at the

wrong time can be damaging. Often counselors do this too quickly. It must

be done at the right time and in the right way, empowering her to make

choices for a better life rather than making her feel like she is at fault for her

husband’s infidelity.

• There are many topics that Laaser addresses at various points in the

counseling process: physical health, needing space/separation, making

decisions, the roller coaster ride, the ampersand, managing anger, education

about sexual addiction, living in the truth, rebuilding trust, boundaries and

bottom lines, accountability partners, safe community, reframing distorted

beliefs, knowing whether to stay or leave, forgiveness, and overriding old

associations.

Student Learning Objectives:

• To be able to describe the common approaches to counseling betrayed

women and why they are not typically effective

• To understand Laaser’s recommendations for the first three sessions with a

betrayed woman

• To comprehend the various helpful topics to be discussed during the

counseling process with a betrayed woman, as recommended by Laaser

Chapter Summary:

This chapter focuses on women who have been betrayed in marriage by the

infidelity of their spouse. Unfortunately, many women are counseled in unhelpful

or even damaging ways; often they are told they are codependents or co-addicts

who need to work on themselves, or powerless victims of trauma, one extreme or

the other. Laaser states that both of these approaches are counterproductive, and

instead advocates for a post-traumatic growth (PTG) model in which women are

able to express their pain without learning to feel like powerless victims.

While there are not particular SITs that can be methodically applied to every

woman’s situation, Laaser recommends several general guidelines that have been

shown to be effective in her experience. She states that firstly clients need to be

able to express their pain, tell their story, and be heard and validated immediately,

and thus lets them do this in the very first session instead of asking various

assessment questions. She also states that it is imperative to let clients know

immediately that their husband’s infidelity was not their fault. Additionally, Laaser

asks clients if they have any safe people in their lives they can talk to who can also

be impartial. She describes characteristics of safe people to the client, and suggests

joining a support group of other women who have also experienced being betrayed.

Often women have been told they are “crazy” and have learned not to trust

themselves or the Holy Spirit inside of them, accustomed to their experience being

invalidated. It is important for the counselor to talk to the client about trusting

herself (and the Holy Spirit), acknowledging how this is difficult for her because

others, including her husband, did not validate her reality. The counselor can

provide a healing place for her by validating her experiences and assuring her that

she is actually not “crazy.” Inquiring about whether her husband is seeking help

and providing words on hope are also necessary components of the first session.

Laaser recommends that the second and third sessions be guided by the

client, empowering her to initiate talking about whatever she needs and desires to

talk about. A five-question check-in is suggested, in which the counselor can

obtain a lot of useful information about the client’s self-care and the way she sees

herself. Genograms and learning about the client’s early life experiences are also

useful, although this information is meant to bring insight rather than focus the

sessions on the past. Timing is imperative, and encouraging a woman to “work on”

herself at the wrong time can be damaging. Often counselors do this too quickly. It

must be done at the right time and in the right way, empowering her to make

choices for a better life rather than making her feel like she is at fault for her

husband’s infidelity.

As previously mentioned, there is no cookie-cutter approach to counseling

betrayed women, as every woman’s situation is different. However, there are many

topics that Laaser addresses at various points in the counseling process: physical

health, needing space/separation, making decisions, the roller coaster ride, the

ampersand, managing anger, education about sexual addiction, living in the truth,

rebuilding trust, boundaries and bottom lines, accountability partners, safe

community, reframing distorted beliefs, knowing whether to stay or leave,

forgiveness, and overriding old associations.

Asking about physical health from the beginning is highly beneficial. Issues

to inquire about include sleep, nutrition, fatigue, stress, anxiety, and sexually-

transmitted diseases (STDs), among others. Sometimes women feel shame and do

not even want to think about the possibility of an STD or get tested, and the

counselor should gently encourage her to consider it. The issue of space/separation

should also be discussed, being sure to listen to what a woman feels she needs and

desires instead of pushing one’s own opinion on her. Clients need to feel

empowered to make decisions about their lives, as they typically have many that

need to be made. Helping them slow down and listen to themselves, even simply

having another person encourage them to trust themselves, can be very effective.

The counselor should educate her that her healing journey will be more like a roller

coaster rather than a smooth ride. This will help her not to have unrealistic

expectations and to not lose hope in the midst of the ups and downs.

The ampersand is a technique in which the client learns the concept of

“both/and” as opposed to “or,” a way of helping her to break away from black and

white, extreme thinking. This concept can help her acknowledge the fullness of her

reality and feel less confused, including seemingly opposite thoughts and feelings

that can co-exist. Teaching the client to manage anger is fairly self-explanatory, as

well as educating her about sexual addiction.

Laaser states that many women are the ones who found out about their

husband’s infidelity rather than him initiating a confession; however, unless the

truth is offered freely, there will always be doubt about whether they know the full

truth and it will be difficult to feel like they are “living in the truth.” The counselor

can help them feel validated for feeling this way, as well as educate her on what

the husband needs to do in order to start rebuilding trust. Laaser provides a list of 7

behaviors that the husband must display in order to show he is working on

becoming trustworthy. Offering daily updates on his sobriety is important. It is also

important for women to continue learning to trust themselves and trust God in new

ways, as previously mentioned. Many women are not used to trusting themselves

and are not even aware that they have their own needs and desires, neither are they

used to speaking up about them if they are aware. The counselor can encourage

women to learn about their needs and to voice them, learning to set boundaries and

bottom lines. Bottom lines are simply boundaries that are non-negotiable needs.

One of the boundaries that often needs to be set is the boundary of

accountability, for often the woman says that she is her husband’s accountability

partner. This is often problematic, as it creates a parent-child dynamic in the

relationship. The husband needs to find other men to be his accountability partners.

The woman also needs to find safe community, which can be found in group

settings, particularly other women who have been through the same experience.

Finally, cognitive restructuring via reframing distorted beliefs, discussing

whether a woman wants to stay or leave the marriage, examining the issues of

forgiveness, and overriding old associations are other helpful strategies. Helping a

woman create vision for moving forward with her life can be very beneficial.

Although every woman is unique and every situation different, using the

previously mentioned suggestions and simply being a safe person to come

alongside her can be an invaluable part of her journey towards healing.

Pedagogical Suggestions:

• Have students research post-traumatic growth (PTG) and related counseling

models, choosing an aspect of it to teach to the class through a presentation

or a discussion board post. Then specifically discuss how this aspect could

relate to counseling betrayed women.

• Laaser (2018) states that “the trauma of betrayal is like that of individuals

struggling with post-traumatic symptoms from other life crises” (p. 579).

Why would this be so? Discuss as a class or in groups.

• On page 582, Laaser gives 5 examples of the most unhelpful advice betrayed

women reported receiving. Why would each of these examples be unhelpful

or even damaging? Discuss as a class or in groups.

• Laaser discusses the importance of timing in relation to introducing a

betrayed woman to “working on herself.” Based on information provided in

the text, how would you be able to tell when the timing is right? How would

you be able to tell when the timing is not right? Discuss as a class or in

groups.

• Laaser discusses many characteristics of safe people. Are there any other

characteristics you would add? Discuss as a class or in groups. Have

everyone describe a safe person in their own words. Break into pairs and

role-play to practice teaching the characteristics of safe people to a

hypothetical client.

Chapter 27 Quiz (25 questions):

Fill-in-the-blank

1. According to Laaser, when wives were counseled, it was often from the

___________________ model that suggested she was a co-addict and a

codependent and had just as much to “work on” as the addict. (twelve-step)

2. A second model, which Laaser also deems to be ineffective, is the

_____________ model, which validates the trauma of being betrayed but

leaves the woman feeling like a powerless victim. (trauma)

3. _________________________ is the positive personal change that is

possible after experiencing a very traumatic event in one’s life. (post-

traumatic growth, or PTG)

4. A violation of an expectation of emotional and/or physical exclusivity with

one’s partner is called a _______________________. (relationship

betrayal)

5. Laaser uses Ecclesiastes 7:18, “It is good to grasp the one and not let go of

the other. Whoever fears God will avoid all extremes,” to illustrate the

concept of _________________, a way to help clients move away from

black and white thinking. (the ampersand)

6. ______________ are simply needs or desires we have. (boundaries)

7. ________________ are boundaries that are absolutes. (bottom lines)

8. In Laaser’s research, betrayed women stated that the worst advice they were

given was to __________________ immediately. (forgive and forget)

True/False

1. The trauma of betrayal is like that of individuals struggling with post-

traumatic symptoms from other life crises. (T/F)

2. Laaser recommends letting the client know in the very first session that her

husband’s betrayal was not her fault. (T/F)

3. Betrayed women should be introduced to “working on themselves”

immediately in the counseling process. (T/F)

4. Many betrayed women expect their healing journey to be like a roller coaster

ride, so it is important for counselors to let them know this is not the case

and that their journey to healing will be smooth and quick. (T/F)

5. Most women know about infidelity because they found it. (T/F)

6. The husband’s offering daily information about his sobriety is extremely

helpful in building trust. (T/F)

7. Expressing needs and desires is often a new experience for women. (T/F)

8. A woman should always be her husband’s main accountability partner. (T/F)

9. One should never advise a woman about staying or leaving. (T/F)

Multiple Choice

1. Laaser gives a description of safe people that can be given to clients. She

states that a safe person has all of the following characteristics EXCEPT:

a) Doesn’t give a lot of uninvited advice or judgement

b) Doesn’t pry for more information than you want to share

c) Won’t over-spiritualize your situation

d) Won’t just try and “fix” you

e) None of the above

f) Only A and C

2. Which of the following is NOT one of the recommendations Laaser has for

the first session with a betrayed woman?

a) Asking her about safe people in her life

b) Talking about her husband getting help if he hasn’t

c) Letting her know her husband’s betrayal was not her fault

d) Including some words of hope

e) None of the above

f) Only A and B

3. Laaser lists seven desires that are common to both men and women. Which

of the following is NOT one of them?

a) To be heard and understood

b) To be affirmed

c) To be chosen or desired

d) To be included

e) None of the above

f) Only B through D

4. The best accountability partner for a man is:

a) His wife

b) Other men

c) His parents

d) His pet cat or dog

e) None of the above

5. Which of the following is NOT one of the topics Laaser suggests to discuss

with a betrayed woman during counseling?

a) Boundaries and bottom lines

b) Living in truth

c) Managing anger

d) The importance of serving others

e) None of the above

6. Laaser recommends asking about all of the following physical health issues

EXCEPT for:

a) Sleep

b) Nutrition

c) Panic and anxiety

d) Sexually transmitted disease (STD)

e) None of the above

f) Only C and D

7. According to Laaser, the second and third sessions with a betrayed woman

should be

a) Led by the client’s initiative

b) Structured specifically for the purposes of assessment

c) Led by the counselor’s initiative

d) Mostly psychoeducational in nature

e) None of the above

8. According to a research study cited by Laaser in the text, post-traumatic

growth can:

a) Create greater appreciation for life

b) Create richer interpersonal relationships

c) Increase personal strength

d) Create new priorities

e) All of the above

f) Only A and B

Chapter 28

Couple Sexual Problems-Focused Strategies by Michael

Sytsma, PhD

Key Terms: sexual problems/issues, Masters and Johnson behavioral model,

self-of-the-therapist preparation, sexual attraction, disease, dysfunction,

discomfort, aging, gender differences, pregnancy, childbirth, fatigue, stress,

anatomy, physiology, communication, attributional errors, trauma, distress, the

DEC-R model: dialogue, education, coaching, and referral, sexual dance, active

listening, modeling, brakes and accelerators, models of sexual response,

bibliotherapy, acceptance, grieving

Key Points:

• In this chapter, Sytsma discusses self-of-the-therapist preparation work, an

overview of different types and sources of sexual problems, a general

strategy, and the DEC-R, a model of therapy specifically designed for use

with couple sexual problems.

• Sytsma posits that preparation of the self-of-the-therapist is more important

for working with sexual issues than with any others.

• Sytsma recommends categorizing a sexual problem as either a disease,

dysfunction, or discomfort.

• One common cause of sexual problems is a lack of knowledge about myriad

topics: basic anatomy and physiology, effects of aging, pregnancy and

childbirth, gender differences, and fatigue and stress.

• Other causes of sexual problems include poor sexual communication,

attributional errors related to sexual issues, trauma, physiological issues, and

divergent, distractive, or destructive sexual goals.

• Although many theories and models can be effective with sexual issues,

Sytsma’s number one recommended strategy is the DEC-R, an acronym

standing for Dialogue, Educate, Coach, and Refer.

Student Learning Objectives:

• To comprehend the necessary preparation and self-of-the-therapist work the

counselor must engage in prior to counseling couples with sexual issues

• To be able to describe the common types and sources of sexual issues

• To understand general strategy recommended by Sytsma for counseling

couples with sexual issues, in addition to the various techniques involved

with the DEC-R model

Chapter Summary:

Sexual problems are highly common, especially among couples who seek

counseling, and therefore it is imperative that one become knowledgeable about

the basics of working with sexual issues. In this chapter, Sytsma discusses self-of-

the-therapist preparation work, an overview of different types and sources of

sexual problems, general strategies, and the DEC-R, a model of therapy

specifically designed for use with couple sexual problems. In general, the goal of

such counseling is simply to help couples develop a healthy sexual life the way

God created it to be.

Sytsma posits that preparation of the self-of-the-therapist is more important

for working with sexual issues than with any others. Sexual attraction either

towards a client or from a client will certainly happen at some point in this type of

work, and the counselor should expect it in advance so as not to be surprised.

Although counselors are often tempted to avoid or deny such attraction, it is

important to realize that it is normal and to deal with it either through supervision,

consultation, or personal therapy. Counselors should also prepare themselves to

manage direct or graphic talk about sexual issues, stories of intense brokenness and

shame, and stories that may even sound offensive such as those involving

attraction towards underage individuals. If the counselor feels he cannot handle

such issues, it is necessary to be humble and to make appropriate referrals.

Accurately identifying sexual issues is critical, as many couples often are not

accurate in their own assessment of the problems; this requires the counselor to be

knowledgeable about a wide range of sexual issues. The counselor should also

learn how to gauge the severity and distress level associated with the identified

problems during the assessment process. Sytsma recommends categorizing a

sexual problem as either a disease, dysfunction, or discomfort. A disease by nature

cannot be treated directly through counseling, but the distress can be, and

counseling also provides a place to safely problem-solve. Dysfunctions include

those mentioned in the DSM-5 or the ICD-10 such as erectile dysfunction or

female orgasmic disorder. Although medical reasons could be the source of some

of these dysfunctions, the relational aspects can certainly be treated through

counseling. A discomfort may not meet criteria for a disease or dysfunction but

may cause significant individual and relational distress. Examples of discomforts

include disagreements about sexual positions, frequencies, and particular

behaviors.

One common cause of sexual problems is a lack of knowledge about myriad

topics: basic anatomy and physiology, effects of aging, pregnancy and childbirth,

gender differences, and fatigue and stress. Clients may not be aware that the

clitoris is the female equivalent of the male penis, that sexual difficulties are

normal during the aging process, or that women take much longer to climax than

men. Other causes include poor sexual communication; attributional errors related

to sexual issues; trauma; physiological issues; and divergent, distractive, or

destructive sexual goals. Regardless of the reason for the problem, it is crucial to

help both partners take responsibility for it and to strive for a big-picture

perspective rather than blaming each other and getting defensive.

A general strategy suggested by Sytsma is to attend to the symptoms or the

distress rather than to the problem itself. This can be especially helpful if the

problem has a medical cause, and clients can still achieve a successful outcome by

finding ways to decrease their levels of distress even if the problem does not

change. Although many theories and models can be effective with sexual issues,

Sytsma’s number one recommended strategy is the DEC-R, an acronym standing

for Dialogue, Educate, Coach, and Refer. This model was developed by Rosenau,

Sytsma, and Taylor in 2002, and the DEC-R stages are not sequential, able to be

used in any order at any point throughout therapy. That being said, it can be very

helpful to use the stages sequentially at first to help lay a foundation.

Dialogue involves dialogue with the counselor and dialogue within the

couple. The counselor must use dialogue to accurately identify the problem,

severity, and distress level, as previously mentioned. Common marital assessments

and standard intake forms can be helpful as well, as sometimes it may be easier for

a client to bring up sexual issues through a form. It is critical that the counselor be

at ease with asking direct questions about sexual issues, and he should specifically

ask the couple to describe their sexual “dance” or usual routine of what happens

when they decide to engage in sex. Couples rarely ever discuss this, which in and

of itself can be a common source of sexual issues, and so discussing this with the

couple in counseling can be highly beneficial. This is a great opportunity to help

the clients move from dialogue with the counselor to dialogue with each other. The

counselor should model good communication and active listening skills, another

area in which couples are often lacking, and teach them to use these same skills

when dialoging with each other. Other strategies for encouraging dialogue within

the couple about sexual issues include asking them to read a book about sexual

issues out loud together, make lists of their sexual brakes and accelerators,

schedule “coffee time” (an agreed-upon time to review previous sexual

experiences), and learn to identify sexual expectations and goals.

Education may need to occur at multiple times throughout therapy, and the

counselor should be prepared to teach clients about myriad sexual topics. This

means that the counselor should be constantly reading the latest research on sexual

issues and current treatments, as the field is always changing. Timing is also

critical in the education process, and the counselor should always seek to learn

what the client already knows before jumping in to share knowledge too quickly.

Tone is also critical, as the counselor should strive to sound curious, explorative,

proposing, and accepting. The most common topics the counselor ought to learn

about in advance include basic sexual anatomy and physiology, effects of aging,

gender differences, and different models of sexual response, among others.

Finally, the Coaching aspect focuses on helping couples actually engage in

building a healthy sexual life and engage in homework assignments that can be

helpful. Because homework can have negative connotations, it is important for the

counselor to create a non-threatening setting and let the couple know that it is

impossible to fail; even if they do not complete their homework, valuable

information is still obtained by examining why this occurred. The counselor should

also make sure the model of intervention he chooses is ethical and empirically

supported for the client’s situation. Some coaching strategies recommended by

Sytsma include bibliotherapy, helping the couple with acceptance and grieving,

helping couples try any new techniques in session (ethically and within reason,

such as a technique where the couple are assigned to caress each other’s hands for

fifteen minutes), and to refer if necessary, as previously mentioned.

Pedagogical Suggestions:

• Ask students to reflect on their current perceived abilities to handle sexual

flirting, direct sexual statements, reflexive sexual responses, educating on

sexual topics, hearing stories of great brokenness, and hearing sexual stories

that may be offensive. Also have them consider their current thoughts on

working with couples in general in the future. Ask them to write a brief

paper summarizing their conclusions, including how they might grow in

these abilities or if they feel that they should plan to always refer instead.

• Ask students to each choose one of the areas of sexuality couples are

commonly lacking in knowledge of, as listed in the text, and to conduct

further independent research using other scholarly, peer-reviewed sources.

Have students create a PowerPoint presentation, paper, or discussion board

post on their chosen topic, and teach it to the rest of the class if time allows.

• Have students research common marital assessments such as the Dyadic

Adjustment Scale or the Gottman Sound Relationship Scale that include

specific questions about sexual functioning and become familiar with them.

• Have students research current educational resources and bibliotherapy that

could be helpful for future clients who are struggling with sexual issues in

their marriage. Have them become familiar with these resources and compile

a list, as well as develop a plan for how to continue staying up to date with

current research and treatments for sexual issues.

Chapter 28 Quiz (25 questions):

Fill-in-the-blank

1. The first strategy one should always employ when working with sexual

issues is ___________________. (preparation)

2. The three broad categories Sytsma recommends for categorization of sexual

issues are: _________________, (disease)

3. ____________________, (dysfunction)

4. and ______________________. (discomfort)

5. _____________________ are beliefs regarding the causes of an event.

(attributions)

6. One valuable strategy suggested by Sytsma for counseling couples with

sexual issues is to attend to the _________________ rather than the problem

itself. (distress)

7. The D in DEC-R stands for ____________________. (dialogue)

8. The C in DEC-R stands for ______________________. (coach)

9. The R in DEC-R stands for _________________. (refer)

True/False

1. Most couples who seek counseling will not present with sexual issues. (T/F)

2. Possibly more than any other type of counseling, working with sexual

problems requires you to prepare yourself for the work. (T/F)

3. At some point in your career, sexual attraction toward clients and from

clients will happen and is normal. (T/F)

4. While the problem might seem obvious, couples often wrongly identify it.

(T/F)

5. Couples often are used to discussing each step of their lovemaking with each

other. (T/F)

6. Childbirth is typically considered a positive event but is often the cause of

sexual problems. (T/F)

7. All medications have the potential for side effects, but sexual problems are a

very rare negative side effect. (T/F)

8. Couples develop a sexual routine early in their sexual relationship that tends

to remain fairly habitual. (T/F)

Multiple Choice

1. When preparing oneself to work with sexual issues, one should prepare

oneself to:

a) Handle sexual flirting and direct sexual statements

b) Hear great brokenness and shame

c) Hear stories that may be offensive to you

d) All of the above

e) Only A and B

f) None of the above

2. Examples of problems that would fall into the category of “discomfort”

include all of the following EXCEPT:

a) Disagreements over sexual positions

b) Erectile dysfunction

c) Differing opinions on sexual frequency

d) Opposing views on sexual practices

e) None of the above

f) All of the above

3. Lack of knowledge about all of the following EXCEPT

_________________ is a common reason behind sexual issues, according to

the list provided by Sytsma.

a) Basic anatomy and physiology

b) Effects of aging

c) Sexual positions

d) Gender differences

e) All of the above

4. Physiological issues that can effect sexual functioning include all of the

following EXCEPT:

a) Disability

b) Aging

c) Body size/shape

d) Fatigue

e) None of the above

f) A through C

5. The E in DEC-R stands for:

a) Engage

b) Educate

c) Enlist

d) Ensure

e) None of the above

6. Strategies mentioned by Sytsma that encourage dialogue among couples

struggling with sexual issues include:

a) Reading out loud together

b) Listing brakes and accelerators

c) Scheduling “coffee time”

d) Identifying sexual expectations and goals

e) All of the above

f) Only A, B, and D

7. When providing clients with information on sexual issues, the counselor

should:

a) Inquire about what the clients already know first

b) Propose information rather than definitely provide

c) Use a curious, exploring tone

d) Convey acceptance in his/her tone rather than rejection

e) All of the above

f) A through C only

g) None of the above

8. When counseling couples with sexual issues, the most common topics the

counselor should be prepared to teach on include all of the following

EXCEPT:

a) Gender differences

b) The effects of aging

c) Basic sexual anatomy

d) Basic sexual physiology

e) Only C and D

f) None of the above

Midterm Exam (50 questions)

Fill-in-the-blank (16)

1. _____________________ bias is the idea that we are all likely to see the

world from our own framework and deny or attack any other model that

challenges its ideas. (confirmation and selection)

2. The ________________ technique involves asking the client to assume a

cognition is true and to then ask a series of “if….then” questions to

ultimately uncover an underlying core belief or schema. (downward

arrow/vertical arrow)

3. In the __________ technique, the therapist asks the client if he or she would

use the same negative, perfectionistic, black-and-white patterns of thinking

to relate to a dear friend, e.g. “What would you say to a friend who is in the

exact same situation as you?” (double-standard technique)

4. ________________ is defined as the extent to which one understands his or

her emotional experiences. (emotional clarity)

5. The ______________ technique involves learning new behavior by

considering the behavior a reality and anticipating it as expected. (act as if)

6. ___________________ is a technique used either to link aversive

consequences associated with the target or to perform target behaviors

through imagining them occurring. (imaginal rehearsal)

7. In the A-B-C assessment technique, the A stands for ________________.

(antecedants)

8. _____________ is a term carried over from the first wave of behavior

therapy, denoting two contradictory or incompatible physiological

responses. (reciprocal inhibition)

9. “If you don’t study for your upcoming math test, we will have a better idea

of what would happen if you actually fail” is an example of

______________, a provocation technique. (paradox)

10. There are two empirically-supported models of forgiveness, one developed

by ________________ (Enright)

11. and one developed by ___________________. (Worthington)

12. The psychiatrist Karl Lehman developed the Christian inner healing prayer

strategy known as __________________. (the Immanuel approach)

13. Cooley referred to our individual identity as the reflected or

_______________: a self that develops through our perception of how

others respond to our behavior. (looking-glass self)

14. _________________ coping involves changing how one thinks about a

problem or stressor in order to reduce anxiety. (appraisal-focused)

15. ________________ assists in minimizing the common “thinking errors”

that occur when we cope by identifying and confronting these distortions.

(cognitive restructuring)

16. Attachment theory is a ____________ theory, which is a theory that helps

us make sense of other theories. (meta)

True/False (18)

1. The therapeutic relationship itself is not considered a SIT. (T/F)

2. The measuring stick for counseling efficacy is client outcome, which is

defined ultimately by the counselor. (T/F)

3. A prerequisite of an effective intervention or technique is timing. (T/F)

4. One challenge to EBTs is that the counseling field measures outcomes using

secondary data rather than primary data. (T/F)

5. Emotion regulation can best be defined as “all of the processes, intrinsic and

extrinsic, through which individuals manage their emotions to accomplish

their goals.” (T/F)

6. Whereas chaining is appropriate for learning simple behaviors, complex

behaviors require shaping. (T/F)

7. Sand tray therapy is typically considered a play therapy activity for children

only and is not effective with adults. (T/F)

8. Younger generations seem to find meaning in art forms more than in words.

(T/F)

9. The destruction-creation polarity is listed as one of Levinson’s four

polarities affecting a midlife crisis. (T/F)

10. One limitation to cognitive restructuring is that acute emotional discomfort

can interfere with activating the higher order thinking that it requires. (T/F)

11. In the SECURE model, the exploration system and the attachment system

can both be operating at the same time. (T/F)

12. For those with an avoidant attachment style, the attachment system is

underactivated and the exploration system is overactivated. (T/F)

13. Adolescent clients do not typically present for counseling on their own

volition. (T/F)

14. Clinicians do not need to obtain written parental consent to provide

treatment to a minor client. (T/F)

15. The counselor should always gain personal experience utilizing each

artistic medium prior to incorporating the medium into therapeutic practice.

(T/F)

16. Individuals who struggle with borderline personality disorder and post-

traumatic stress disorder (PTSD) are excellent candidates for silence and

solitude. (T/F)

17. Behavioral deficits describe behaviors or skills that are underdeveloped in

terms of frequency, duration, intensity, or effectiveness. (T/F)

18. A behavioral hierarchy involves constructing a staircase outlining the

situations that can lead to skill development, and ranking the items to move

from least complex to greater complexity. (T/F)

Multiple Choice (16)

1. The individual said to have initiated the EBT movement was:

a) Eysenck

b) Freud

c) Nietzsche

d) Sackett

2. Which of the following are examples of cognitions, according to the text?

a) Attention

b) Beliefs

c) Expectations

d) Categorization of stimuli

e) All of the above

f) Only A and D

3. The individual responsible for the “still face experiment” was:

a) Tronick

b) Plutchik

c) Panksepp

d) Lopez

e) None of the above

4. Our neurobiology is designed to prioritize stimuli with:

a) High potential for novelty

b) Greater familiarity

c) High primitiveness

d) A and C

e) A and B

5. Which of the following are listed as prominent features of alexithymia?

a) The reduced capacity for analyzing emotions

b) Difficulty verbalizing emotional experiences

c) Emotionalizing, or reduced ability to determine origins of emotions

d) Diminished fantasy life

e) All of the above

f) Only A and C

6. Perhaps the most foundational exercise that one can participate in to regulate

one’s emotional state is _____________.

a) Progressive muscle relaxation

b) Diaphragmatic breathing

c) Guided imagery/visualization

d) Autogenic phrases

e) None of the above

7. Becoming aware of fluctuating inner states so that a more deliberate course

of action can be taken is known as:

a) Acceptance and Commitment Therapy (ACT)

b) Mindfulness

c) Willingness

d) The A-B-C technique

e) Magic

8. _____________ is the creator of ordeal therapy.

a) Haley

b) Thomas

c) Firestone

d) Murray

e) None of the above

9. According to the text, a biblical view of self involves:

a) People have a body, soul, and spirit.

b) Humans reflect the image of God.

c) Humans have the unique ability to communicate with God.

d) Humans are tasked with responsibility for God’s creation.

e) All of the above

f) Only A through C

g) None of the above

10. The three categories of child self-development identified by Harter include

all of the following except:

a) Self-continuity

b) Self-agency

c) Self-congruency

d) Self-awareness

e) None of the above

11. Elements of sand tray therapy must include all of the following except:

a) A tray of sand

b) Water

c) A collection of miniatures

d) Paper and pencils

e) None of the above

12. Individual psychology identifies which of the following as one of the four

goals of misbehavior?

a) Inadequacy

b) Attention

c) Revenge

d) Power

e) All of the above

f) None of the above

13. The acronym ESSENCE, meaning “emotional spark, social engagement,

novelty seeking, and creative expression” was coined by ______________

to describe the key features of adolescence.

a) Siegel

b) Thacker

c) Erikson

d) Yarhouse & Hill

e) None of the above

14. The main structure in the brain going through major changes during

adolescence, according to the text, is:

a) Prefrontal cortex

b) Amygdala

c) Hypothalamus

d) Temporal lobes

e) None of the above

15. ______________________ help(s) clients differentiate past toxic

relationships from the present therapeutic relationship through asking the

client a series of questions.

a) Significant other history

b) Interpersonal situation analysis

c) Interpersonal discrimination exercises

d) Transference hypothesis

e) None of the above

16. The following statement is an example of ______________ attachment:

I’m not worthy of love, and I desperately need others to take care of me, but

I must be in great need in order for her to respond to my emotions.

a) Secure

b) Avoidant

c) Preoccupied

d) Fearful-avoidant

e) None of the above

Final Exam (50 questions)

Fill-in-the-blank (16)

1. ____________________ is the ability of the human brain to grow stronger

through use and stimulation. (neuroplasticity)

2. When those with personality disorders continue to repeat the same mistakes

over and over without learning from them, this is known as

____________________. (emotional and interpersonal dyslexia, EID).

3. ________________ are tasks that the counselor asks a family to do in

session or to accomplish at home for the purpose of building a healthier

pattern of behavior between family members. (directives)

4. Aponte’s model, the _________________ model, involves a focus on family

of origin influence on counselors’ practices. (person-of-the-therapist)

5. DiBlasio cites ________________’s work to describe counseling sessions as

similar to dramatic productions. (Freytag)

6. The “C” in Baker’s ABC guide stands for ________________ theological

understandings. (clarify)

7. ___________________ is a behavioral intention to refrain from seeking

revenge and to treat an offender as a valued and valuable person. (decisional

forgiveness)

8. _______________ is defined as restoring trust in a relationship, which

requires mutually trustworthy behavior. (reconciliation)

9. Children feel ___________ when what they need to feel human is withheld.

(shame)

10. Parental _______________ is what is often missing in the history of shame-

prone clients. (attunement)

11. The _________________ technique involves writing down one’s shame-

infused beliefs on pieces of paper and putting them in a box, followed by

reflection/journaling about the beliefs while learning to tolerate feelings of

shame. (shame box)

12. Gingrich refers to the first phase of CT treatment as

____________________. (safety and symptom stabilization)

13. The four main reasons described in the literature as to why people engage in

self-harm are: __________________, (physical grounding)

14. ______________________, (control)

15. ______________________, (the silent scream)

16. and ______________________. (self-punishment)

True/False (18)

1. Those with personality disorders have been shown to have brain structures

that are smaller, with grey and white matter being less in volume. (T/F)

2. One of the classic principles of family therapy is realigning family hierarchy

so that parents are in charge of their children. (T/F)

3. A by-product of the parent giving nurturance is an elevation of hierarchy.

(T/F)

4. The family of origin session is open to spouses and other family friends, if

desired. (T/F)

5. Those with a volatile conflict style are clear about their opinions and have no

problem arguing and persuading. (T/F)

6. A validating conflict style is superior to other styles in terms of couple

satisfaction and stability. (T/F)

7. In cases of domestic violence, reconciliation is extremely difficult, often

impossible. (T/F)

8. In the majority of cases, women who are or have been victims of domestic

violence want to be able to tell their stories. (T/F)

9. During the A phase of a psychoeducational REACH group, the leader asks

group members to reflect on a time when they offended someone who

forgave them. (T/F)

10. The first phase of CT treatment usually takes not months but years. (T/F)

11. Even those with CT who do not have DID often experience some degree of

personality fragmentation. (T/F)

12. Most prominent among all definitions of self-injury is the idea that the self-

harm cannot be a suicide attempt. (T/F)

13. The greatest number of reported cases of self-harm consistently occurs

during childhood. (T/F)

14. In the text, bereavement, grief, and mourning are considered to be

interchangeable terms for the same concept. (T/F)

15. In sex addiction treatment, ask clients to tell you about their fantasies, but

let them know that details should always be avoided. (T/F)

16. According to research, very few wives have responded to disclosure of

infidelity with post-traumatic stress disorder (PTSD) symptoms. (T/F)

17. The normal healing process after infidelity is about 1 to 2 years. (T/F)

18. Most couples who seek counseling will not present with sexual issues. (T/F)

Multiple Choice (16)

1. When humans are emotionally hurt or under emotional threat, the

______________ is activated much like it is when under physical threat.

a) Amygdala

b) Hippocampus

c) Temporal lobe

d) Prefrontal cortex

e) None of the above

2. Strategic family therapy was created by:

a) Haley and Madanes

b) Madanes and Satir

c) Haley and Weakland

d) Haley and Satir

e) None of the above

3. Which of the following is NOT one of the steps involved in the time-out

procedure?

a) Set a private pretend practice time for each child.

b) When a child commits a violation, calmly request that the child go to the

time-out chair or mat.

c) After the time-out, discuss the violation and why the child thinks the

violation was wrong.

d) If the child refuses to go to the chair or mat, sit on the chair or mat

with the child and talk to him throughout the time-out.

e) None of the above

4. The goal of _________________ is to reestablish connection between

family members by creating new emotional and interactive experiences.

a) Emotion-focused family therapy

b) The Gottman Method

c) The Maudsley approach

d) Bowenian family therapy

e) None of the above

5. According to the text, Christian women in domestic violence situations may

believe that forgiveness includes:

a) Forgetting or excusing the offense

b) Engaging in mediation

c) Seeking reconciliation

d) All of the above

e) None of the above

6. Settings in which REACH can be used include all of the following

EXCEPT:

a) Do-it-yourself workbooks

b) Psychoeducational groups

c) Couples counseling

d) Family counseling

e) None of the above

f) Only A and D

7. In a group setting of REACH, “the leader reads one of six scriptural

passages about forgiveness, then whips around the group, and each member

reacts with a word.” This part of the group is called:

a) Creating a working definition

b) Lectio divina

c) Icebreaker

d) Inviting decisional forgiveness

e) None of the above

8. When working with shame, the first therapeutic task (bonding with the

client) involves all of the following techniques EXCEPT:

a) Hyperfocus on being nonshaming

b) Practice attunement

c) Check in

d) Avoid attempting to “talk clients out of it”

e) None of the above

f) Only A and C

9. ________________ is the process by which people make sense of the world

by imaging how other peoples’ state of mind can influence behavior.

a) Mindfulness

b) Mentalization

c) Radical acceptance

d) Mirroring

e) None of the above

10. Which of the following is listed as a strategy for helping the counselor be

and remain a safe person during phase one of CT treatment?

a) Remember that every client is unique.

b) Warn of impending change.

c) Know your limitations.

d) Keep appropriate boundaries.

e) All of the above

f) Only C and D

11. Things you should warn your CT clients about include:

a) Missing a session for a conference

b) Putting a new picture on your wall

c) Changing appointment times

d) Any major issues going on in your life

e) All of the above

f) A through C only

12. Cutting could be viewed as all of the following but is MOST COMMONLY:

a) Suicide attempts

b) Evidence of borderline personality disorder

c) Its own phenomenon not associated with suicidality, BPD, or OCD

d) Evidence of obsessive compulsive disorder (OCD)

e) None of the above

13. When the griever becomes more functional and seeks new and realistic

solutions to life and problems posed, this is known as which stage of grief?

a) Accepting and hope stage

b) Reconstruction stage

c) The upward turn

d) Anger and bargaining stage

e) None of the above

14. All of the following are stages in the sexual addiction cycle EXCEPT:

a) Preoccupation or fantasy

b) Rituals

c) Acting out

d) Despair

e) None of the above

f) Only C and D

15. The best accountability partner for a man is:

a) His wife

b) Other men

c) His parents

d) His pet cat or dog

e) None of the above

16. The E in DEC-R stands for:

a) Engage

b) Educate

c) Enlist

d) Ensure

e) None of the above

Sample Syllabi

Counseling Techniques

Syllabus (Mon/Wed/Fri)

I. Course description

This course will provide students with both theoretical and practical

information on a wide variety of counseling strategies, interventions, and

techniques (SITs) divided into three categories: theory-based strategies,

population-based strategies, and clinical issue-based strategies.

II. Intended learning outcomes:

At the end of this course, students will be expected to:

1. Comprehend the psychology and theology behind a wide variety of

effective counseling techniques for a wide variety of issues and

populations as mentioned in the text;

2. Be able to describe the various nuances, research findings, and related

issues surrounding the strategies, interventions, and techniques (SITs)

discussed in the text;

3. Understand the myriad strategies, interventions, and techniques (SITs)

presented in the text for each stated population and/or issue.

III. Outline of the weekly course schedule:

Week 1

• Mon – Class intro/syllabus/assignment overview

• Wed – Laying the Groundwork

o Read Ch. 1 (pp. 13-27)

o Quiz #1

• Fri – Evidence-Based Counseling

o Read Ch. 2 (pp. 31-43)

o Quiz #2

Week 2

• Mon – Cognitive-Based Strategies

o Read Ch. 3 (pp. 44-68)

• Wed – Cognitive-Based Strategies (cont’d)

o Quiz #3

• Fri – Emotion-Oriented Strategies

o Read Ch. 4 (pp. 69-85)

o Quiz #4

Week 3

• Mon – Emotional Dysregulation Strategies

o Read Ch. 5 (pp. 86-109)

o Quiz #5

• Wed – Behavioral Strategies

o Read Ch. 6 (pp. 110-133)

• Fri – Behavioral Strategies (cont’d)

o Quiz #6

Week 4

• Mon – Behavioral Dysfunction Strategies

o Read Ch. 7 (pp. 134-152)

o Quiz #7

• Wed – Experiential Strategies

o Read Ch. 8 (pp. 153-176)

• Fri – Experiential Strategies (cont’d)

o Quiz #8

Week 5

• Mon – Spiritual Strategies

o Read Ch. 9 (pp. 177-196)

• Wed – Spiritual Strategies (cont’d)

o Quiz #9

• Fri – Christian Formation of the Self Strategies

o Read Ch. 10 (pp. 197-220)

o Quiz #10

Week 6

• Mon – Coping Skills Strategies

o Read Ch. 11 (pp. 221-240)

• Wed – Coping Skills Strategies (cont’d)

o Quiz #11

• Fri – Attachment-Oriented Strategies

o Read Ch. 12 (pp. 241-265)

o Quiz #12

Week 7

• Mon – Child-Focused Strategies

o Read Ch. 13 (pp. 269-289)

o Quiz #13

• Wed – Adolescent-Focused Strategies

o Read Ch. 14 (pp. 290-309)

o Quiz #14

• Fri – Activity/Play-Therapy Day

Week 8

• Mon – Review for the mid-term exam

• Wed – Review for the mid-term exam (cont’d)

o Mid-term exam

• Fri – Couple-Focused Strategies

o Read Ch. 15 (pp. 310-331)

o Quiz #15

Week 9

• Mon – Family-Focused Strategies

o Read Ch. 16 (pp. 332-350)

o Quiz #16

• Wed – Family of Origin-Focused Strategies

o Read Ch. 17 (pp. 353-373)

o Quiz #17

• Fri – Family Therapy Practice Day

Week 10

• Mon – Family Conflict-Focused Strategies

o Read Ch. 18 (pp. 374-399)

• Wed – Family Conflict-Focused Strategies (cont’d)

o Quiz #18

• Fri – Domestic Violence-Focused Strategies

o Read Ch. 19 (pp. 400-416)

o Quiz #19

Week 11

• Mon – Forgiveness-Focused Strategies: The REACH Forgiveness Model

o Read Ch. 20 (pp. 417-437)

o Quiz #20

• Wed – Shame-Focused Strategies

o Read Ch. 21 (pp. 438-465)

• Fri – Shame-Focused Strategies (cont’d)

o Quiz #21

Week 12

• Mon – Trauma-Focused Strategies

o Read Ch. 22 (pp. 466-487)

o Quiz #22

• Wed – Nonsuicidal Self-Injury-Focused Strategies

o Read Ch. 23 (pp. 487-509)

• Fri – Nonsuicidal Self-Injury-Focused Strategies (cont’d)

o Quiz #23

Week 13

• Mon – Loss-Focused Strategies

o Read Ch. 24 (pp. 510-530)

o Quiz #24

• Wed – Sexual Addiction-Focused Strategies

o Read Ch. 25 (pp. 531-555)

• Fri – Sexual Addiction-Focused Strategies (cont’d)

o Quiz #25

Week 14

• Mon – Infidelity-Focused Strategies

o Read Ch. 26 (pp. 556-576)

• Wed – Infidelity-Focused Strategies (cont’d)

o Quiz #26

• Fri – Betrayed Spouse-Focused Strategies

o Read Ch. 27 (pp. 577-597)

o Quiz #27

Week 15

• Mon – Couple Sexual Problems-Focused Strategies

o Read Ch. 28 (pp. 598-620)

• Wed – Couple Sexual Problems-Focused Strategies (cont’d)

o Quiz #28

• Fri – Presentations

Week 16

• Mon – Presentations

• Wed – Presentations/Review for final exam

• Fri – Review for final exam

o Final exam

Counseling Techniques

Syllabus (Tues/Thurs)

I. Course description

This course will provide students with both theoretical and practical

information on a wide variety of counseling strategies, interventions, and

techniques (SITs) divided into three categories: theory-based strategies,

population-based strategies, and clinical issue-based strategies.

II. Intended learning outcomes:

At the end of this course, students will be expected to:

1. Comprehend the psychology and theology behind a wide variety of

effective counseling techniques for a wide variety of issues and

populations as mentioned in the text;

2. Be able to describe the various nuances, research findings, and related

issues surrounding the strategies, interventions, and techniques (SITs)

discussed in the text;

3. Understand the myriad strategies, interventions, and techniques (SITs)

presented in the text for each stated population and/or issue.

III. Outline of the weekly course schedule:

Week 1

• Tues – Laying the Groundwork

o Read Ch. 1 (pp. 13-27)

o Quiz #1

• Thurs – Evidence-Based Counseling

o Read Ch. 2 (pp. 31-43)

o Quiz #2

Week 2

• Tues – Cognitive-Based Strategies

o Read Ch. 3 (pp. 44-68)

o Quiz #3

• Thurs – Emotion-Oriented Strategies

o Read Ch. 4 (pp. 69-85)

o Quiz #4

Week 3

• Tues – Emotional Dysregulation Strategies

o Read Ch. 5 (pp. 86-109)

o Quiz #5

• Thurs – Behavioral Strategies

o Read Ch. 6 (pp. 110-133)

o Quiz #6

Week 4

• Tues – Behavioral Dysfunction Strategies

o Read Ch. 7 (pp. 134-152)

o Quiz #7

• Thurs – Experiential Strategies

o Read Ch. 8 (pp. 153-176)

o Quiz #8

Week 5

• Tues – Spiritual Strategies

o Read Ch. 9 (pp. 177-196)

o Quiz #9

• Thurs – Christian Formation of the Self Strategies

o Read Ch. 10 (pp. 197-220)

o Quiz #10

Week 6

• Tues – Coping Skills Strategies

o Read Ch. 11 (pp. 221-240)

o Quiz #11

• Thurs – Attachment-Oriented Strategies

o Read Ch. 12 (pp. 241-265)

o Quiz #12

Week 7

• Tues – Child-Focused Strategies

o Read Ch. 13 (pp. 269-289)

o Quiz #13

• Thurs – Adolescent-Focused Strategies

o Read Ch. 14 (pp. 290-309)

o Quiz #14

Week 8

• Tues – Review for the mid-term exam

o Mid-term exam

• Thurs – Couple-Focused Strategies

o Read Ch. 15 (pp. 310-331)

o Quiz #15

Week 9

• Tues – Family-Focused Strategies

o Read Ch. 16 (pp. 332-350)

o Quiz #16

• Thurs – Family of Origin-Focused Strategies

o Read Ch. 17 (pp. 353-373)

o Quiz #17

Week 10

• Tues – Family Conflict-Focused Strategies

o Read Ch. 18 (pp. 374-399)

o Quiz #18

• Thurs – Domestic Violence-Focused Strategies

o Read Ch. 19 (pp. 400-416)

o Quiz #19

Week 11

• Tues – Forgiveness-Focused Strategies: The REACH Forgiveness Model

o Read Ch. 20 (pp. 417-437)

o Quiz #20

• Thurs – Shame-Focused Strategies

o Read Ch. 21 (pp. 438-465)

o Quiz #21

Week 12

• Tues – Trauma-Focused Strategies

o Read Ch. 22 (pp. 466-486)

o Quiz #22

• Thurs – Nonsuicidal Self-Injury-Focused Strategies

o Read Ch. 23 (pp. 487-509)

o Quiz #23

Week 13

• Tues – Loss-Focused Strategies

o Read Ch. 24 (pp. 510-530)

o Quiz #24

• Thurs – Sexual Addiction-Focused Strategies

o Read Ch. 25 (pp. 531-555)

o Quiz #25

Week 14

• Tues – Infidelity-Focused Strategies

o Read Ch. 26 (pp. 556-576)

o Quiz #26

• Thurs – Betrayed Spouse-Focused Strategies

o Read Ch. 27 (pp. 577-597)

o Quiz #27

Week 15

• Tues – Couple Sexual Problems-Focused Strategies

o Read Ch. 28 (pp. 598-620)

• Thurs – Presentations

o Quiz #28

Week 16

• Tues – Presentations/review for final exam

• Thurs – Review for final exam

o Final exam