Advanced Counseling Skill

Introduction

1.1. Defining Counseling

Counseling is a word that everyone seems to understand, but it is known that

no two individuals understand it exactly in the same way .There are a number
of ways to define counseling. However, even professional counseling
associations, like American counseling Association and British association for
counseling find it difficult to come up with one precise definition. .
Dictionary Meaning: advice, psychological support/service offered to people.
However, in the real sense counselors have no right to advice others. Instead,
counselors provide/show alternative rather than advice. In the process of
counseling, counselors bring alternatives with maximum benefit and
minimum risk.

The following are of some of the different definitions by different individuals.

 Counseling is an interactive exchange process between counselors and

clients to help clients confidentially explore their problems and enhance
their capacity to solve their own problems.
 Counseling is process in w/c a person with a special competence assists
other person to better understanding of themselves and their
environment.

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  Counseling is confidential communication between two persons in w/c
one assists the other to make personal decisions or to take responsibility
for his decision.
There have been many attempts to differentiate psychotherapy from
counseling. Traditionally, the term psychotherapy has been associated with
psychiatrists and medical settings, whereas the term counseling has been
associated with educational and, to some extent, social-work settings.
Although there is much overlap, theories developed by psychiatrists often use
the word psychotherapy, or its briefer form, therapy, more frequently than
they do counseling. Some writers have suggested that counseling is used with
normal individuals and psychotherapy with those who are severely disturbed.
The problem with this distinction is that it is difficult to differentiate severity
of disturbance, and often practitioners use the same set of techniques for
clients of varying severity levels.
In spite of their differences, both Psychotherapy and counseling are
interactions between a therapist/counselor and one or more clients/patients.
The purpose is to help the patient/client with problems that may have aspects
that are related to disorders of thinking, emotional suffering, or problems of
behavior. Therapists may use their knowledge of theory of personality and
psychotherapy or counseling to help the patient/client improve functioning.
The therapist’s approach to helping must be legally and ethically approved.

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 Counseling is both a science and an art. As a science it requires
knowledge and skills and as an art it calls for some talent and creativity.
Moreover, it needs a lot of work and experience to be effective counselor.
COUNSELING IS NOT Telling or directing, A conversation, An
interrogation, A confession or Praying.
1.2. Aims of Counseling
Counseling helps clients take charge of their lives by:
 developing their ability to make wise and realistic decisions
 assisting them to alter their own behavior to produce desirable results
 providing information for informed decision making
1.3. Target groups for counseling
Generally, the objective of counseling related earlier shows that every human
being; be it the so called “abnormal” “normal” and “ subnormal” should
benefit from professional counseling information. Counseling is offered to all
age groups: Children, adolescence, adults and the old.
 To all level of educational programs
 To the sociality and economically ,disadvantage;
 The minority
 Women
 The disabled etc
1.4. Fields of Counseling
1. Personal counseling: a field of counseling that deals with clients who are
suffering from emotional distress and behavioral difficulties. E.x.

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 individuals with anxiety disorder, mood disorder, lack of assertions,
social problems etc..
2. Vocational Counseling/ career counseling
Interpreting an occupational interest
assisting teenager to make proper decision about their future career
job interview preparation
helping individuals how to assimilate them with a new job environment
3. Crises counseling
A sub-field of counseling especially designed for functionally debilitated/
weakened individuals. It helps individuals to change their perception, and
adjust themselves with dangerous situations like suicidal thought, family
problem, unwanted pregnancy, chronic health problem, etc..
4. HIV/AIDS counseling
A branch of counseling that emerged with the occurrence of HIV. It is
designed for providing pre -test and post-test counseling for individuals.
Its main intention is to create awareness about the disease, how to
prevent, or minimize the risk, and how to live friendly with the virus.
5. Educational Counseling/ school counseling
It renders counseling service to pupils who need assistance in making
decisions regarding important aspects of their academic life (e.g. choosing
field of study, interest, potential).
6. Rehabilitation counseling
It provides counseling service for individuals with special needs.

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 To empower their potential
Dealing about the cause and extent of the problem
how their personality is affected by their disability and vice versa
helping them how to live friendly with their disability
helping them to accept their problem as a challenge and as an
opportunity
2. The World of the Counselor
2.1. Qualities of an Effective Counselor
In order to help the client and achieve the desired outcome, counseling must
offer clients a new and fresh experience in their life. Especially counselors
have greater responsibility for ensuring that the counseling process is valuable
and therapeutic to the client.

However, the degree of helpfulness of counseling activity found in the person

of the counselor. That means a helper personal qualities can enhance or
detract the process. And it is essential than specific skills or knowledge.
Therefore, effective counselor needs to have the following qualities.
A. Self-awareness: - self exploration
It is a good starting place for most counselors because it enables them to know
what exactly they are doing, which problems are theirs, and which belongs to
the client. One such difficulty is projection.
E.g. A counselor who had been very happy at home might say "I had a very
funny client today", instead of " I felt excited today at home"
B. Good psychological health:

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 Counselors are more helpful to clients when they are psychologically intact
and not distracted by their overwhelming problems. They are models of good
behavior, whether they choose to be or not. Every counseling session is a
period of intense tutoring in good behavior. When they are not healthy,
causes even more anxiety in the other person (client).
C. Open-mindedness:
Being free from fixed or preconceived ideas, or being flexible. A
counselor should be free from dogmatic beliefs, and attitudes. It allows
counselors to accommodate clients feeling, attitude, behaviors that may be
different from their own.
- it allows counselors to interact with a wide range of clients.
- it is a prerequisite for honest communication.
D. Respect:- Being non-judgmental . It is the belief that every person is a
worthy being.
E. Confidentiality: Even though confidentiality is burdensome to the
counselor, in counseling,
confidentiality is non-negotiable. It is burdensome because it is not easy to
differentiate which bit of information is secret and which one is not. It is found
in the code of ethics. A counselor may under no circumstance loss information
to any body without the consent of the client.
2.2. Skills of an Effective Counselor
◆ Attention giving – there was a range of skills which clearly indicated to
you that the person was giving you their full attention.

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Be prepared! Before we engage in any sort of listening to another person we
can convey that we are attending by being ready. We can prepare both the
setting and ourselves. When you were thinking about the good (or bad)
interview you had earlier, did the setting affect your perception? It is not
always possible to create the ideal setting for listening to someone, but we can
demonstrate attention giving by making the best of the environment, even
when this involves a compromise between what we need and what is
available. Firstly we can eliminate as many distractions as possible. We can,
for example, ask people not to interrupt us for an agreed amount of time. In
some circumstances, we can make sure that there are no telephone calls; we
can certainly ensure that mobile phones are switched off. If we are lucky
enough to have a choice, we can arrange to be in a room that is quiet and
private, but this is often a luxury.
◆ Observing – the person was able to pick up ‘clues’ about how you were
feeling.
Good observation skills are very helpful in active listening. Attending is
evidenced primarily by our non-verbal behaviour and the obverse of this is
that we, as listeners, can sensitively observe the talker’s non-verbal behaviour
and helpfully make use of what we observe. Observation of a speaker can
yield a wealth of information to which we can respond with greater depth than
if we respond only to what we hear. At the same time, we have to be careful
not to see only what we want to see. This is what links observation to
suspending value judgements – if we judge by what we see, we could be

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making serious mistakes. What are your thoughts about a young person who
comes to work or college in a heavy coat regardless of the weather, and seems
reluctant to take if off even in a comfortably warm room? It might suggest any
number of things. The young person is too poor to buy more suitable clothes.
S/he is living somewhere where there are inadequate washing facilities. S/he
is attention seeking and winding you up.S/he is ‘going through a phase’. S/he
is hiding something. Any or none of these may be accurate, but if we have not
even noticed we are not really listening to all the messages this young person
is sending.
◆ Listening – you really felt that both what you said, and how you felt about
it, had been heard.
How many people do you know who are prepared simply to listen to you –
without offering advice, without saying ‘I know what you mean because
I . . .’, or ‘When that happened to me . . .’? People who can really focus on the
speaker, whilst setting their own concerns aside and accepting that their
experiences may be of no interest to the speaker, are rare. Perhaps these are
the genuine ‘good listeners’?
Active listening operates at several levels, and even the first level demands a
degree of self discipline.
◆ Responding – the other person made a comment or responded in some
way, indicating that they were ‘alongside’ you. Responding sensitively and
appropriately, assures speakers that what they said and how they are feeling
have been heard. Being listened to is a novel experience for many and for

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some can even feel threatening. We need to keep this in mind and make our
responses carefully. The basic responding skills which are essential for every
listener’s ‘tool kit’ are:
◆ appropriate questioning
◆ paraphrasing
◆ reflecting
◆ summarizing.

PARAPHRASING AND REFLECTING

These two responding skills are often described as if they are the same,
because both involve a sort of ‘playing back’ to the speaker what they seem to
be communicating. To some degree, too, their purpose is the same – to convey
to the speaker that we have heard and understood what was said. Perhaps this
idea of ‘playing back’ has given rise to the myth that this kind of response is
just repeating the last four words a person says, as if the listener were some
kind of echo. You may have heard the old joke about this type of echoing.
Speaker: I feel awful.
Listener: You feel awful.
Speaker: Yeah, my life isn’t worth living.
Listener: Your life isn’t worth living.
Speaker: Right, I may as well jump in the river.
Listener: You may as well jump in the river.
(Person leaps into the river, is swept away and seen no more!)

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Paraphrasing
Paraphrasing focuses on the fact(s) or content of what is said. It involves
rephrasing, in the listener’s own words, what was said. This not only allows
the speaker to know that they are being listened to accurately, but can help to
clarify thinking. If the listener plays back the gist of what was said – adding
no inferences and leaving nothing out – the speaker can feel sure that the
listener is getting things right.
Reflecting
Paraphrasing relates to content, whereas reflecting relates to feelings.
Reflecting is the ability to pick up and play back the emotional content of
what is said, rather than the factual content. This skill is closely related to
empathy; by communicating that we have heard feelings as well as content,
we demonstrate that we are really trying to understand the speaker’s emotions.
These skills – and we’ll look at each cluster in greater detail – are usually
thought of as the skills of active listening. The phrase ‘a good listener’ is used
very frequently, but rarely is it clearly or accurately defined. The difference
between a listener and a good listener is that the latter really lets the talker
know that they are listening. If we are at a lecture, or in the theatre or cinema,
we may be listening avidly to what we are hearing, but on the whole the talker
has very few clues as to whether we are, or are not. In small groups and,
especially, in one-to-one interactions, speakers need to know that they are
being heard and if we develop and enhance the skills appropriate to active
listening this will happen. Our interactions will be that much more

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meaningful, because if we are actively listening we are fully engaged with the
other person and with the process.
2.3. The Counseling Relationship
Counseling relationship is a process of forming a relationship between the
client and the counselor. It is different from other social relationship.
Counseling relationship is;
1. Established and continuous voluntarily by the counselor and counselee
2. It is formal and structured. To have specified duration, confidentiality,
objective etc.
3. Is limited by therapeutic time limit and range of techniques limited only
for professional relationship.
4. Is closers and deeper in its relationship
5. Is effective and powerful because it uses effective human relationship
skills purposefully and consciously.
5. Approaches in Counseling

There are two approaches of counseling on the bases of the number of

counselee and counselors. These are: Individual counseling approach, and
Group counseling approach
Individual Counseling Approach:It involves a one-to-one, or face to face
encounter between the counselee and the counselor. It is mostly used with the
remedial role of counseling and used by most counselors.
Group counseling Group refers to aggregated or interdependent individuals
whose interaction is aimed to some shared goal. Group counseling is an

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approach that involves a situation where one counselor handles a group of
clients simultaneously.
What all group counselors share in common is recognition of the benefits of
working with more than one client at a time. If clients can be placed in a group
on the basis of relatively similar problems, work can be done more efficiently
than it can in one-to-one counseling. In most groups, benefits occur from
interactions among group members, not from working with the counselor per
se. With therapeutic groups, the group counselor is more a facilitator than an
active participant or leader.

Therapeutic factors of group work as distinct from individual work

A. Group support
Clients can gain huge solace sensing that they are ‘not the only one’ to have
felt a certain way or to have struggled with a certain problem. The simple
interchange of support, compassion and understanding from peers – the
hallmark of effective therapeutic work – is usually reported as the most valued
aspect.
B. Group learning
Clients can learn a great deal from one another in a therapeutic group, both in
gaining new ideas on how other people have coped with problems and from

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the interpersonal interaction and the feedback group members provide one
another. In addition, in psycho-educational groups, the process of learning
new ideas can be greatly enhanced with a supportive peer group.
C. Group optimism
In groups, clients witness other people who are solving or who have solved
problems similar to their own and this can give them great hope that such
change is also possible in their lives. Groups literally provide a sense of there
being ‘hope in numbers’.
D. Opportunity to help others
The opportunity to help others in groupwork gives members a chance to be of
value and to contribute meaningfully to the group and thus be valued
themselves. It also gives members a distraction from self-absorption in their
own problems, and thus can give a new perspective.
E. Group empowerment
Group members with common experiences bound together in a common
purpose can feel empowered to take on outside forces and to address the
community and societal issues that they may not have been able to do alone.
In addition, by being in a group with complementary resources, they can have
much greater impact than as single individuals operating alone.
Selecting and assessing groups

In good preparation, you need to think through the membership of the group
to ensure that the group mix will work well and that individual clients won’t
feel excluded. Essentially, this is about ensuring that clients have similar

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enough concerns and experiences and are from similar enough backgrounds
and cultures so that they can feel accepted and connect with one another. For
example, if you run a group that is mainly composed of middleclass, middle-
aged couples, a young single parent may feel quite excluded in that group and
be at risk of dropping out. Clients generally stay in a group if they feel a
connection or identity with one or more of the other group members. In
concrete terms, this means making sure someone is not the ‘only one’ from a
significant minority, such as the only father, the only black person, or the only
person
with a child in care. If this is unavoidable, then you should discuss these
issues openly with this client and prepare with them how to deal with it.
Preparing clients for membership

Giving clients time and space to decide about and prepare for a group is
generally a good idea. Just as ample preparation benefits the facilitator, so
ample preparation benefits the client and helps ensure that the group is a
success for them. This preparation can include giving out advance information
on the group, revealing some of the teaching content in advance (if a psycho-
educational group) and/or preparatory group or individual meetings. The aim
of the preparatory meetings is to help clients articulate their personal goals
and understand these in relation to the group goals, to ensure that they are
well-informed of the group method (and accustomed to it), to anticipate any
potential problems.
The role of group leaders or group facilitators

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The terms ‘group leaders’ and ‘group facilitators’ capture some of the extra
responsibilities that face professionals running therapeutic groups.
Professionals need to lead the group in establishing boundaries, such as the
finishing and starting times, ensuring that rules are kept, chairing and
moderating group discussion and ensuring that each group member is heard
and gets a fair share of group time. While many of these roles can be
delegated to the other group members, and the mark of a mature and well-
functioning group is shared leadership, the professional generally needs to be
able to take a strong leadership role in the initial stages when rules are being
established and at later times if problems in the group occur. For example, if
one member became extremely distressed or if there was a personal attack
between group members, then the group leader would have a special
responsibility to take some control to resolve the situation. Professionals also
act as leaders to therapeutic groups in other subtle ways. How they interact
with group members, the attitude they take and what they reveal about
themselves all have profound influences on the group culture. For example, if
a leader is confrontational or a ‘detective of pathology’ towards individual
group members, then group members are likely to relate to each other in a
similar manner (Yalom, 1995). Alternatively, if the facilitator is supportive
towards group members and always seeks to highlight strengths and
possibilities, then this will influence group members to act likewise. Potential
group facilitators should acknowledge and own this influence and make sure
they are a ‘role model’ for the desired group culture.

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Counseling skills within groups

Group formation Skills

 Identify the purpose of the group, the commonalities of potential
participants and anticipated outcomes prior to organizing the practical
aspects of the group.
 Ensure the environment for meeting is comfortable and without hazards.
 Consider the duration of the group to maximize the likelihood of
reaching goals in the context of resource concerns.
Leadership skill
Leadership style needs to be attuned to the needs of the group.
 Some flexibility towards less directive stances as groups progress can
facilitate increased ownership and feelings of confidence for group
members.
 Consistency is required for group members to feel emotionally safe.
 Chaotic or overly passive leadership styles can increase feelings of
anxiety for group members.
 Social work practitioners have a responsibility to manage the behavior
of group members and thus need to attune their leadership style in
groups accordingly.
Goal Setting
Once the beginnings of a working alliance or working relationship are
formed, and after the service user feels they have heard enough to explore
desired outcomes for the work, specific goals can be agreed upon by the two
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parties, i.e. social worker and service user. The purpose of goal setting is to
assist motivation for change through incentives and to keep a focus on the
work, which facilitates the brief nature of the approach. To set goals using this
approach, an emphasis is made upon the language of questions used. Goals
need to be achievable, specific and well-defined. They need to be generated
from the ideas of the service user and not the worker to be successful.
This requires workers to have a belief in the abilities of the service user and an
acceptance of their definition of what needs to change. Some examples of
goal-setting questions that can be incorporated into a first meeting with a
service user are taken from O’Connell and Palmer (2003).
 How will you know that coming here has been worthwhile for you?
 What are your best hopes for this session?
 How do you think coming here might help you?
 How will you know when things are getting better?
 What is the first sign for you?
 What is your main concern?
Having helped the person to devise a goal, which meets the criteria, it is then
useful to help them look at what might help, or hinder, the achievement.

GOAL
FACILITATING FORCES HINDERING FORCES
(INTERNAL WORLD) ( EXTERNAL WORLD)
skills, resources, strengths Limitations
1. 1.
2. 2.
3. 3.
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etc. etc.

FACILITATING FORCES HINDERING FORCES

EXTERNAL WORLD) ( (INTERNAL WORLD)

people, places, opportunities etc people, places, rules etc

1. 1.
2. 2.
3. 3.
etc. etc.

6. Family, Marital and Divorce Counseling

6.1. Concepts of Family, Marital and Divorce Counseling
Couples or marital counseling/ therapy can be defined as a format of
intervention involving both members of a dyad in which the focus of the
intervention is the dysfunctional and displeasing interactional patterns of the
couple. Only the spouses usually attend marital therapy sessions, although the
children may be invited during the initial assessment or later for specific issue.
In general, even if therapy is behaviorally focused, it must attend particularly
to the feeling level, having as its goal creating more positive feelings between
the partners as well as more reasonable behavior.

Family counseling on the other hand focuses on issues involving the behavior
of a child or adolescent and the interactions between parents and children. In
family counseling /therapy, one can discern triangles involving various family
members. Family therapy … looks at problems within the system of
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relationships in which they occur, and aims to promote change by intervening
in the broader system rather than in the individual alone. the animating idea of
family therapy is that because most human behavior is interactive, problems
can often best be addressed by helping people change the way they interact.
one belief which is shared by family therapists is that the focus of concern
should be mainly on what occurs between people rather than on what occurs
inside an individual. Family therapy is distinguished from other
psychotherapies by its conceptual focus on the family system as a whole. In
other words, a person’s thoughts, feelings, and behaviors are seen as
multidetermined and partly a product of significant interpersonal
relationships. From the family systems perspective, alterations in the larger
marital and family unit may therefore have positive consequences for the
individual members as well as for the larger system.

Marital and family treatment can be defined as a systematic effort to produce

beneficial changes in a marital or family unit by introducing changes into the
pattern of family interactions. Its aim is the establishment of more satisfying
ways of living for the entire family and for individual family members.
6.2. Processes That Characterize Functional
Families
 What do you comment on the belief that “functional
family is the one that does not experience conflict”?

1. Connectedness and commitment of members as a caring, mutually supportive

unit
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2. Respect for individual differences and autonomy, fostering the development
and well-being of members of each generation, from youngest to eldest
3. For couples, a relationship characterized by mutual respect, support, and
equitable sharing of power and responsibilities
4. For nurturance, protection, and socialization of children and caregiving to
other ulnerable family members, effective parental/ executive leadership and
authority
5. Organizational stability, characterized by clarity, consistency, and
predictability in patterns of interaction
6. Adaptability: flexibility to meet internal or external demands for change, to
cope effectively with stress and problems, and to master normative and non-
normative challenges and transitions across the life cycle
7. Open communication characterized by clarity of rules and expectations,
pleasurable interaction, and a range of emotional expression and empathic
responsiveness
8. Effective problem-solving and conflict-resolution processes
9. A shared belief system that enables mutual trust, problem mastery,
connectedness with past and future generations, ethical values, and concern for
the larger human community
10. Adequate resources for basic economic security and psychosocial support in
extended kin and friendship networks and community and larger social systems
6.3. Traditional phases of family development
 Couple formation (love, cohabitation or engagement, marriage)

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  The childbearing family (birth of the first child, oldest child under 5
years old)
 The family with schoolchildren
 The family with teenagers
 The family as a launching center (the offspring begin their own adult life
structure, usually but not always moving away from home)
 The family in its middle years (which may include one or both spouse’s
retirement and often includes grandparenthood)
 The couple as part of a three-generation family (includes eventual
death of a spouse)
6.4. Family Tasks
Families can be viewed as laboratories for the social, psychological, and
biological development and maintenance of family members. In providing this
function, couples and families must accomplish vital tasks, including the
provision of basic physical needs (food, shelter, and clothing), the development
of a marital coalition and the socialization of children, and the resolution of
crises that can arise in relation to illness and other life changes.
6.4.1.Provision of Basic Physical Needs
Therapists working with economically disadvantaged families immediately
recognize the fundamental requirement of addressing the basic physical and
material needs of families. All of the more complex functions of the family
are affected by the extent to which these needs are met.
6.4.2. Rearing and Socialization of Children

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For the purposes of this discussion, we define personality as each person’s
adaptation to the biological characteristics that he or she inherits at birth and
that interact with the demands of the family and the external world. Although
much of children’s essential temperaments are inborn, their ultimate stance in
relation to the world, their knowledge of cultural norms, and their attitudes
toward men and women are developed within the family and the
neighborhood, as well as through the media (especially television). Early
neglect, trauma, or chaotic upbringing can permanently damage brain
structure and function.

Children learn from who their parents are as well as from what they do. For
this reason, some aspects of learning cannot be controlled by education. An
anxious parent will communicate some anxiety to the child, regardless of the
parent’s skill in communicating. However, we know that certain basic
parenting skills are necessary for optimal child development.
6.4.3. Use of Age-Appropriate Child-Rearing Techniques
Parents need to understand the child’s capacities at different ages in order to
parent adequately. For example, expecting a 1-year-old to demonstrate
patience and self-control or trying to reason with a 3-year-old having a temper
tantrum will result in rage and confusion for both the child and the parent. In
addition, some parents may have particular difficulty with a certain phase
because of what they experienced in their own families of origin. For
example, a parent who was very sexually promiscuous as an adolescent may

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become frightened when his or her child reaches the same age and may be
untrusting and overly controlling.
6.4.4.

Maintenance of Parental Coalition and Generational Boundaries

It is beneficial for both parents and children for the parents to be clear that
they are functioning as a team to parent the children and that adult roles are
different from child roles. Although parents cannot agree on everything, there
should be some sort of mutual, consistent child-rearing guidelines. Even when

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parents disagree, the child should know that the parents will find a way to deal
with the disagreement rather than leave the child in limbo. Problems arise
when the parents are so much in conflict that one or both turn to the child for
support, leaving the child either with a loyalty conflict (“If I side with Dad,
Mom will not love me”) or in a “parentified,” caregiving role.
6.4.5. Support of a Sibling Coalition
The history of developmental theory has largely neglected the roles of siblings
in families. A key issue concerns the microenvironment of the siblings, or the
world of the siblings as opposed to that of their parents. Research in the 1990s
(Reiss et al. 1991) found that siblings display a small degree of similarity in
personality, but this appears to result mostly from shared genes rather than
from shared experience. There are obviously other factors that go into how
siblings turn out differently—the so-called nonshared environment— such as
life events, each child’s perceptions about parents, different attitudes of
parents to different siblings, and the friends that they develop (Reiss et al.
1991). Family theory has stressed the important role that siblings play in
normal family functioning. Each sibling has a crucial role in the maintenance
of homeostasis for that particular family system. Siblings often work together
when their parents are continually at odds or have divorced or when one or
both parents have severe mental illness. That bond is often the link to keep
afamily functional when one or both parents cannot carry out parental roles.
Family therapists believe that issues of loyalty, attachment, and bonding are
important and useful in changing dysfunctional patterns. Dysfunctional

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families often have dysfunctional sibling relationships. For example, siblings
may mimic the parental relationship by always bickering in the same way in
which the parents bicker or by one sibling’s being dominant. The bottom line
for the family therapist is that each sibling should be seen as a separate
individual. Interventions focused on siblings may be included in family
treatment models. Treatment can use older siblings as change agents, or focus
on sibling conflict. When one parent has died, siblings are important in
maintaining the family system in coping with the parental loss. When one
sibling has a mental disorder, the others can be active sources of support. In
addition, siblings need to know very specific information about Axis I
disorders, such as schizophrenia, particularly its prognosis and the resultant
difficulties in communication and problem solving with their siblings
(Landeen et al. 1992).

6.5. Goals in Family Counseling

One convenient way to conceptualize types of treatment goals is to distinguish
final goals (the ultimate results desired) from the mediating (or intermediate)
goals that must precede the final results. Although one would conceptualize
unique and specific goals for each individual family, more general mediating
and final family therapy goals are presented here.
5.5.1. The most common mediating goals
1. Establishment of a working alliance. Patients and families size up therapists
very quickly, and these early attitudes are likely to persist. Thus, the early
connection between the family therapist and each family member is crucial to

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the ultimate outcome of the work. Setting up such an alliance in individual
therapy seems relatively simple in comparison with setting up an alliance with
the multiple members of a family, who themselves often do not get along with
each other. The therapist also must find a way to connect with each person
rather than favoring certain family members.
2. Specification of problem(s). Specifying problems includes a detailed
delineation of family members’ feelings and behaviors around the symptoms
or problems that brought the family to
treatment.
3. Clarification of attempted solutions. Many families have attempted
solutions to their problems before concluding that they need outside
intervention. Because almost invariably these solutions have failed, the
therapist should determine what did not work (as, indeed, some would say that
many problems are simply ordinary situations to which poor solutions were
applied).
4. Clarification and specification of individual desires and needs. Each family
member’s desires and needs must be clarified and specified as they are
expressed, mediated, and met in the total
family/marital environment and network of relationships. It is the lack of
clarity and conflict (either overt or covert) around such needs and desires that
leads to or constitutes family pathology itself.
5. Modification of individual expectations or needs. The therapist must help
each family member to understand that individuals can change only so much,

26
but that even small individual changes can produce profound family changes.
Over the course of treatment, members of the family may modify their
expectations. Greater appreciation of the family’s contributions may occur, as
well as increased reliance on oneself or sources outside the family.

6. Recognition of mutual contributions to the problem(s). Therapists differ in

how much they think recognition of family members’ mutual contributions to
problems must come early in the therapy or how explicit it must be. However,
the very acceptance of the family intervention format (most or all family
members coming to most sessions) implies some recognition of mutual
contribution to the problem or at least to solutions.
7. Redefinition of the problem(s). Redefining a problem completely or
redefining it into various parts, some of which are problematic and others not,
are all steps to possible solutions. By way of an example, the therapist might
say, “You are not bad people; you are responding to stress with anxiety or
anger.”
8. Improvement of communication skills. Communication skills include
listening and expressive skills, diminution of coercive and blaming behavior
with an increase in reciprocity, and effective
problem-solving and conflict resolution behaviors.
9. Shifting disturbed, inflexible roles and coalitions. Changing roles and
coalitions may include helping to improve the autonomy and individualization
of family members, fostering the more flexible assumption of leadership by

27
any particular family member as circumstances require, and facilitating
general task performance by one or more members.
10. Increasing family knowledge about psychiatric illness. In families that
have one or more members with serious Axis I pathology, such as
schizophrenia or recurrent affective illness, a common mediating goal is to
increase family information about the illness, its course, and its
responsiveness to environmental, including familial, stresses.
11. Fostering insight into historical factors related to current problems or
into current interaction patterns. This mediating goal may be relatively
important in psycho dynamically oriented family or marital work and may be
absent in other orientations. However, other orientations may reframe
particular stories about the family’s history as a way of changing interactions.
6.5.2. The most common final goals
1. Reduction or elimination of symptoms or symptomatic behavior in one or
more family members.
2. Resolution of the problem(s) as originally presented by the family 3.
Increased family/marital intimacy
4. Role flexibility and adaptability within the family matrix
5. Toleration of differentness and differentiation appropriate to age and
development level
6. Balance of power within the marital dyad and appropriate sharing of input
and autonomy for the children
7. Increased self-esteem

28
8. Clear, efficient, and satisfying communication
9. Resolution of neurotic conflict, inappropriate projective identification, and
marital transference phenomena
6.6. Phases of family counseling
6.6.1. Early Phase
During the early phase of treatment, the therapist comes to a better
understanding of the life of the family, making contact and promoting
empathy and communication. Some major nonproductive patterns are
spotlighted, and scapegoating is neutralized. A process is begun in which the
focus is moved away from the identified patient and attention is directed to the
entire family system. (See Table 8–1 for the objectives of treatment in the
early phase.)
Objectives of the early phase
1. Detail the primary problems and nonproductive family patterns.
2. Clarify the goals for treatment.
3. Solidify the therapeutic contract.
4. Strengthen the therapeutic relationship.
5. Shift the focus from the identified patient to the entire family system.
6. Decrease guilt and blame.
7. Increase the ability of family members to empathize with one another.
8. Assess the family’s strengths.
9. Assess the family’s preferred style of thinking and working.
10. Define who is in the family.

29
11. Obtain a clear idea of what ethnic and cultural issues are part of the
family’s functioning.
12. Determine the life cycle phase for each individual and for the family.
_ 5.6.2. Middle Phase
The middle stage is often considered to be the one in which the major work of
change takes place. What the therapist does during the middle stage varies
depending on the goals that have been singled out as being of primary
importance. Common examples of persistent, nongratifying interpersonal
patterns and attitudes, preferably drawn from recent or here-and-now
interactions, are repeatedly discussed. Old nonfunctional coalitions, rules,
myths, and role models are challenged, and the possibility of alternative
modes is presented. New habits of thinking, feeling, and interacting take time
to develop, and much repetition is often required. At the same time, resistance
to change comes to the fore and must be dealt with accordingly. The initial
focus may be on the identified patient, but the focus then moves to the family.
Often the identified patient may improve before the family does. A crisis often
develops when problems that have been hidden away or have been too painful
to face are brought to the conscious awareness of the family members
6.6.3 Termination Phase
In the closing phase, the therapist reviews with the family which goals have
and have not been achieved. It is often useful to review the entire course of
therapy, including the original problems and goals. A useful technique is to
ask each family member to state what he or she would have to do to make the

30
situation the same as it was at the onset of treatment. For example, the father
would have to yell at the mother, who would have to yell at the daughter, who
would have to stop going to school. In essence, the family reconstructs the
sequences leading to the pathology. Videotape playback may be helpful at this
time so that the family can see what it looked like at the start of treatment
compared with its present stage. It is important to acknowledge that some
behavior cannot be altered and that life will continue to change—that is, to
have unexpected and periodic problems. The family should be provided with
the skills for solving future conflicts and challenges. What are the criteria for
suggesting termination of therapy? If the original goals have been achieved,
the therapist may consider stopping. When the treatment has been successful,
new coping patterns and an enhanced empathy by family members for one
another will have been established. There will be recognition that the family
itself seems capable of dealing satisfactorily with new situations as they arise.
There may be little to talk about during the sessions and little sense of
urgency. Nonproductive quarreling and conflict will have been reduced; the
family members will be freer to disagree openly and will have methods of
living with and working out their problems.
6.7. Theories/Models of Family Counseling
Family therapy schools and traditions may be classified in terms of their
central focus of therapeutic concern. That is they may be classified with
respect to their emphasis on problem-maintaining behavior patterns;

31
problematic and constraining belief systems; and historical, contextual and
constitutional predisposing factors.

6.7.1. The Mental Research Institute Mri Brief Therapy

The central organizing idea of the MRI approach is that ineffective attempts to
solve problems eventually come to maintain these problems, and so are aptly
called ‘ironic processes’. Assessment should therefore focus on tracking
repetitive behaviour patterns involving problems and ineffective attempted
solutions. Treatment, in turn, should disrupt paradoxically (or counter-
intuitively) inviting clients to stop trying to solve their problems. For example,
Watzlawick et al. (1974) describe how a wife’s concern about her husband’s
lack of openness led her to continually enquire about his whereabouts, his
thoughts and feelings and his plans. However, he perceived his wife’s concern
as overly intrusive and became secretive. In turn his wife became more
inquisitive. Assessment focused on clarifying this vicious cycle of demanding
and withdrawing behaviour. Treatment aimed to disrupt the cycle and replace
it with the seeds of a behavior pattern that would become a virtuous cycle of
mutually satisfying encounters.

The MRI approach does not entail a well-articulated model of the functional
and dysfunctional family, but does involve the view that families who
repeatedly use ineffective solutions for problems will be less well adjusted
than those that show greater flexibility and avoid becoming trapped in cycles
that involve doing ‘more of the same’.

32
Assessment and the MRI Approach
Assessment is typically conducted by interview, and it is only essential for the
‘customers’ – that is, the people who most wants change to occur – to be
present. The MRI model distinguishes between ‘customers’ who are
committed to resolving the problem and ‘window-shoppers’ who are attending
treatment to satisfy someone else. For example, a person with a drink problem
who denies the diffi culty but attends therapy at their spouse’s request is a
‘window-shopper’. There is no requirement for the whole family to attend
brief therapy. Indeed, MRI brief marital and family therapy is often conducted
with individuals, but the conceptual framework for this individual work
involves identifying others who are trapped in a repetitive cycle of interaction
around a specifi c clearly defi ned presenting problem.

During the assessment process, the emphasis is on developing a step-by-step

description of the way episodes begin, progress and conclude. Such accounts
clarify the nature of problem-maintaining factors and these typically involve
ineffective solutions. Ineffective solutions, or ironic processes, fall into four
main categories:
1. Attempts at making the self or others deliberately be spontaneous. For
example, trying to force another family member to spontaneously feel love or
respect towards oneself.
2. Using solutions that do not entail risk when some risk taking is inevitable.
For example, trying to cope with anxiety by avoiding the anxiety-provoking
situation.

33
3. Trying to resolve confl ict through oppositional arguing.
4. Confi rming an accuser’s suspicions by defending oneself. When accused
of being distant, a spouse who responds defensively confirms the accuser’s
suspicions that the spouse is being distant.
Treatment and the MRI Approach
The overall aim of MRI brief therapy is to help clients resolve their presenting
problems. MRI brief therapy is not concerned with restructuring the
organisation of the family or facilitating personal growth. Furthermore, brief
therapy sessions are a forum within which clients and therapists work towards
developing and reviewing tasks that are carried out between sessions. It is
these intersession tasks that are the main avenue through which change
occurs. The process within the therapy sessions is of less importance in
promoting change. Where clients’ attempted solutions involve trying to make
others behave spontaneously, effective MRI interventions involve arranging
for the client to agree that when the other person agrees to do the required act
voluntarily in response to a request, the problem has shown the fi rst sign of
improving.

For example, a man who wants his partner to express love spontaneously may
be invited to consider, as a minimum treatment goal, his partner agreeing to
take a daily walk with him voluntarily, in response to an open request. That is,
the minimum goal is not, ‘She wants to go for a walk with me’, but rather
‘She agrees voluntarily to go for a walk with me’.

34
6.7.2. STRATEGIC FAMILY THERAPY
A central underlying theme of strategic family therapy is that families are
ambivalent about change, usually because family problems serve some
important interpersonal protective function for some family members, and so
therapists must carefully design specific directives to undermine this
ambivalence or resistance and so help families resolve their presenting
problems, while also providing the family with an opportunity to deal with the
complex interpersonal problem that the symptom was designed to solve. For
example, the misbehavior of a depressed unemployed father’s son may
distract the father from his depression. Managing the misbehaviour gives the
father a focus for his attention and in this senseserves the function of keeping
the father from sinking into depression. In this instance, requesting both
parents to spend exclusive private time with each other planning how best to
manage the son, would address both the father’s need for support and the
boy’s need for security and structure.
The Healthy Family and Strategic Therapy
Within strategic therapy it is assumed that healthy families have clearly
defined intergenerational hierarchies, so that it is quite clear that for important
issues, parents are in charge and have the final veto on major family decisions.
It is also assumed that when healthy families move from one stage of the
family lifecycle to the next, they are flexible enough to modify their rules,
roles and routines suffi ciently to meet the demands of the new lifecycle stage.
For example, when families move from having preadolescent children to

35
having adolescents, there is usually a requirement for the teenager to have
increased autonomy and privacy, and also to take on more age-appropriate
responsibilities. Healthy families manage such changes flexibly, solving
problems and negotiating new arrangements as required and without excessive
difficulty. A third assumption of strategic therapy is that within family
relationships there is a mix of complementary and symmetrical transactions
(which have been defined in Chapter 2). A final assumption is that healthy
families select love rather than violence as the central value and distribute
love within the family in a non-intrusive, non-violent way.

Assessment in Strategic Therapy

Assessment in strategic therapy involves identifying the specifi c problem
with which the family want help; clarifying the pattern of interaction around
the problem; and clarifying the role of hierarchical incongruities, lifecycle
stage ‘stuckness’, and exclusive reliance on symmetrical or complementary
transactions in this cycle. The way the family manage the issues of power, the
need to be loved, to love and protect, and to repent and forgive is also
addressed.
Treatment in Strategic Family Therapy
Treatment in strategic family therapy involves conceptualizing or formulating
problems within the therapeutic team; reframing problems for clients; and
giving directives to clients that will disrupt the pattern of interaction which
maintains the presenting problem. Therapy sessions are largely devoted to

36
reframing, giving directives and reviewing progress. Therapeutic change in
strategic therapy is assumed to arise from responding to directives between
sessions, since it is between sessions that problem-maintaining behaviour
patterns occur. These problem maintaining behaviour patterns, as has been
noted, often involve hierarchical incongruities
6.7.3. STRUCTURAL FAMILY THERAPY
The central idea underlying structural family therapy is that problematic
family organisational structures may compromise their capacity to meet the
demands of lifecycle changes or unpredictable interfamilial or extra familial
stresses. Structural family therapists join with families, come to understand
their structure and the demands that the family are having difficulty meeting;
facilitate enactment of their problem-solving attempts; and, through
unbalancing and boundary making, help the family use its own latent
resources to modify its structure so that it can meet the demands it faces. For
example, in helping families with anorexic children, Minuchin noted the lack
of parental coalitions and the diffuse intergenerational boundaries. He
unbalanced these family systems by asking the parents to feed their daughters
in the early stages of therapy and later once weight gain had begun by inviting
the girls to take control of their own weight. He drew boundaries by insisting
that, once out of the danger zone, the girls’ weight be monitored away from
the parents, and the parents engage in joint problem solving and decision
making about managing routine aspects of family life.
Healthy and Unhealthy Families and Structural Family Therapy

37
Within structural family therapy, healthy families are assumed to have a
structure that permits them to meet lifecycle demands which is characterized
by clear intergenerational boundaries between parent and child subsystems.
These should be neither rigid nor diffuse and entail neither
rigid nor chaotic family functioning. In terms of emotional closeness, they are
neither enmeshed nor disengaged.

In contrast, family structures characterized by diffuse or rigid boundaries and

extreme enmeshment or disengagement, and excessively weak or rigid and
arbitrary hierarchies make it diffi cult for families to respond to environmental
or developmental stresses. Disengaged families are slow to mobilize support
when needed, whereas enmeshed families have difficulty permitting the
development of autonomy. Both disengagement and enmeshment are
strategies for conflict avoidance. They allow couples to avoid the pain entailed
by conflict resolution, which would lead to modification of the rules
governing the family structure. Disengaged parents avoid conflict by cutting
off conversations about change.
Assessment and Treatment in Structural Family Therapy
Assessment and treatment occur concurrently in structural family therapy.
Those members of the family and wider social system thought to be most
relevant to the resolution of the problem are invited to the fi rst session.
Where schools and other agencies are involved, staff from these
settings may be invited. The process of assessment and therapy begins with
joining, when the therapist and clients unite to form a therapeutic system.

38
During the joining process, the therapist develops a working alliance with
family members. The therapist tracks each person’s description
of the problem in a blow-by-blow manner and notes differences between
differing accounts. Through enactment, the therapist encourages family
members to jointly attempt problem solving in the consultation room.

The therapist may coach family members to persist with particularly difficult
transactions or try different ways of discussing the problem during an
enactment. The enactment reveals the family structure and also its strengths
and flexibilities. These structural problems and strengths are continually fed
back to the family in sessions through the process of reframing. For example,
the therapist may say to an enmeshed parent who answers for a teenager, ‘You
have become your daughter’s voice’.
6.7.4. COGNITIVE-BEHAVIOURAL MARITAL AND FAMILY
THERAPY
The central assumption of cognitive behavioral family therapy is that
problematic behavior and cognitions are learned and maintained by particular
types of repetitive patterns of interaction. These patterns of interaction may
involve imitation, operant conditioning, classical conditioning, or some
combination of these. Cognitive-behavioural marital and family therapists
help clients disrupt problem-maintaining interaction patterns by coaching
them in the skills required to shape and reinforce non-problematic behaviours
in other family members and by challenging their negative cognitions. For
example, in behavioural parent training, parents learn to positively reinforce

39
prosocial behaviour and to extinguish antisocial behaviour by arranging for
the child to have time-out from reinforcement when it occurs. In traditional
behavioural marital therapy, couples learn to reinforce each other for engaging
in positive rather than negative interpersonal behaviour.
Differences between Distressed and Non-distressed Family Relationships
Compared with non-distressed family relationships, family members in
distressed relationships engage in more negative interpersonal behaviour
patterns, which are mutually reinforcing and view each other in more negative
terms Negative cognitive schemas dominate the thought processes of family
members in distressed relationships. Negative cognitive schemas underpin
negative selective attention, and involve particular types of attributions,
expectancies, assumptions and standards concerning family relationships that
maintain negative family-based behaviour patterns.
Negative cognitive schemas are associated with selectively attending to
negative aspects of others; making personal attributions for negative
behaviour and situational attributions for positive behaviour; holding negative
expectations of other family members; holding assumptions about how to
conduct family relationships that fi t with those of other family members; and
holding standards of conduct which other family members do not accept
Assessment in Cognitive-behavioral Marital and Family Therapy
Assessment in cognitive behavioral marital family therapy begins with
conducting a functional analysis in specifi c problematic domains. This
involves monitoring the duration, frequency and intensity of problematic or

40
positive behaviours and their antecedents, related cognitions and
consequences. In addition, behavioural checklists may be used to assess
overall patterns of positive and negative behaviors. Psychometric
questionnaires may be used to evaluate cognitive aspects of family
relationships. Typically, goals are framed in terms of increasing positive and
reducing negative interactions, behaviours, feelings and cognitions.
Treatment in Cognitive-behavioural Family Therapy
In behavioural family therapy for children, a range of procedures based on
social learning theory are used to help parents modify their children’s
behaviour. These include using reward systems, such as star charts and token
economies, to increase positive behaviour and time-out procedures to reduce
the frequency of negative behaviour. With adolescents and in couples therapy,
contingency contracts are used for the same purposes. These involve an
agreement between parents and adolescents or members of a couple about the
consequences of specifi c behaviours. With couples a distinction is made
between quid pro quo and good faith contracts. With quid pro quo contracts,
the consequences for both parties of engaging in target positive behaviours are
specifi ed and linked. For example, ‘If you make dinner, I’ll wash up the
dishes afterwards’. With good faith contracts, the consequences for both
parties of engaging in target positive behaviours are specifi ed but are not
linked. For example, ‘If you make dinner, you may go sailing; if I do the
shopping, I may go out with friends’. Good faith contracts are more
commonly used.

41
Cognitive restructuring is the principal intervention used to challenge negative
cognitions. Family members are invited to monitor and record the antecedent
situations which gives rise to particular cognitions, and their subsequent
impact on mood and interpersonal behaviour. When negative cognitions are
identifi ed in this way, clients are coached in challenging these by fi nding
tangible evidence to support or refute them. When negative cognitions are not
supported, clients are invited to revise them so that the new cognitions fi t the
evidence. They are also invited to record the impact of revised cognitions on
mood and interpersonal behaviour.

6.7.5. TRANSGENERATIONAL FAMILY THERAPY

Transgenerational family therapy rests on the assumption that clients’ family-
of-origin relationships and events, which occurred and continue to occur in
clients’ families of origin, predispose them to developing current life
problems in their families of procreation. All transgenerational therapists are
united by their belief that family problems are multigenerational phenomena
and that often this is because patterns of family interactions or relationships
are replicated from one generation to the next.
6.7.6. Emotionally-Focused Couples Therapy
Within emotionally-focused couples therapy (Greenberg & Johnson, 1988;
Johnson, 1996, 2002a, 2003a; Johnson & Denton, 2002; Johnson & Whiffen,
2003), it is assumed that marital confl ict arises when partners are unable to
meet each other’s attachment needs for safety, security and satisfaction. That

42
is, marital distress represents the failure of a couple to establish a relationship
characterised by a secure attachment style. Members of the couple do not
view each other as a secure base from which to explore the world. Initially,
partners’ failure to meet each other’s attachment needs gives rise to primary
emotional responses of fear, sadness, disappointment, emotional hurt and
vulnerability. These primary emotional responses are not fully expressed and
the frustrated attachment needs are not met within the relationship. The
frustration that occurs leads these primary emotional responses to be
supplanted by secondary emotional responses such as anger, hostility and the
desire for revenge or to induce guilt. These secondary emotional responses fi
nd expression in attacking or withdrawing behaviour. Couples become
involved in rigid repetitive attack–withdraw or pursuer–distancer behaviour
patterns.

These may eventually evolve into attack–attack or withdraw–withdraw

patterns. These rigid mutually reinforcing patterns of confl ict-maintaining
behaviour persistently recur because partners desperately want their
genetically programmed attachment needs to be met. Unfortunately their
behavioural attempts to elicit caregiving from their partners is (mis-) guided
by internal working models based on insecure attachment styles.
Consequently, they inadvertently prompt their partners to relate to them in
ways that ensure that their attachment needs will be persistently frustrated.
These problematic internal working models for self and others in close

43
relationships have derived from insecure attachments to primary caregivers in
early life.

Emotionally-focused couples therapy aims to help couples fi nd ways to meet

each other’s attachment needs and develop a relationship based on a secure
attachment style. Thus, the goal of therapy is for partners to be able to declare
their needs for safety, security and satisfaction in ways that predictably elicit
caregiving within the relationship. Emotionally-focused couples therapy
begins by asking couples to identify the issues over which they have confl icts
and to describe their rigid patterns of interaction around these which involve
attacking and withdrawing.
6.7.7. PSYCHOEDUCATIONAL FAMILY THERAPY
Psychoeducational family-based interventions have developed from a tradition
of empirical research, which has shown that certain individuals are genetically
or constitutionally predisposed to developing psychological problems, such as
schizophrenia or mood disorders, and the course of these disorders is affected
by the levels of stress and support available in the immediate psychosocial
environments of such vulnerable individuals.
Psychoeducational family-based interventions help family members
understand the factors that affect the aetiology and course of a particular
psychological problem faced by a family member, and train family members
in the skills required to offer their vulnerable child or spouse an optimally
supportive home environment Psychoeducation involves making
psychological difficulties of patients understandable to them and their family

44
by providing a coherent theoretical framework; giving families a coherent
action plan to follow by training them in problem solving, communication,
and medication management skills; and providing social support by arranging
for families who face similar problems to meet and discuss common concerns.

7, Religious counseling @@@

8. Drug Addiction Counseling

8.1. Concepts of Drug Addiction
Lay definition

One such popular lay definition, adapted from Nakken (1996), states that
addiction is an abnormal love and trust relationship with an object or event in
an attempt to control that which cannot be controlled. What makes addiction an
abnormal relationship? First, the relationship is between a person and an object
or event (e.g., alcohol, sex, cocaine, food, spending). This kind of relationship
involves twisted concepts of respect, love, and trust: People come to love and
trust the object or event to meet their needs and push away anyone or anything
that interferes with that bond. Similarly, this unilateral relationship consists of
efforts to satisfy one’s personal needs to the exclusion of family, friends, and

45
loved ones, while at the same time demanding painful sacrifice from these same
relationships.

2 Addiction is an increasing desire for something with an accompanying

decreasing ability to satisfy that desire.

Clinical Definitions

The fourth edition (text revision) of the Diagnostic and Statistical Manual for
Mental Disorders (DSM-IV-TR) (APA, 2000) categorizes these addictive
disorders into abuse and dependence.
Substance abuse
Substance abuse is defined by the Diagnostic and Statistical Manual for
Mental Disorders (DSM-IV-TR) (APA, 2000) as a maladaptive use of
chemicals that occurs over time and that impacts major life domains and
responsibilities. Individuals meeting criteria for substance abuse will likely
experience one of the following over the course of 12 months:
(a) role failure—avoiding responsibilities (with detrimental consequences) in
such areas as home, school, or work;
(b) chemical use during dangerous situations— for example, while driving a
car or operating heavy machinery;
(c) legal-related issues—for example, expulsion from school; and/or
(d) continue to abuse chemicals even when doing so significantly deteriorates
important relationships or impacts social concerns.

46
 Substance dependence
When an individual continues to abuse substances compulsively, despite
significant negative consequences, substance dependence is likely. In this
case, the DSM-IV-TR notes that individuals meeting criteria for substance
dependence will likely exhibit three or more of the following
over the course of 12 months:
(a) tolerance—they will need for markedly increased amount or intensity of
the behavior to achieve the desired effect and /or markedly diminished effect
with continued involvement in the behavior at the same level or intensity.
(b) physical or psychological withdrawal when they stop using (or lower the
amount of) the chemical;
(c) more chemical use than planned, or over a longer time period than was
intended;
(d) a persistent desire or unsuccessfully attempts to control, cut back, or stop
chemical use;
(e) excessive amounts of time spent in obtaining the chemical, using their
chemical, or recovering from the chemical’s effects (i.e., hangovers);
(f) Important social, occupational, or recreational activities are given up or
reduced because of the behavior
(g) continued abuse of the chemical even upon recognizing that it
significantly impacts
their physical or psychological health
TERMS TO NOTE

47
Compulsive use of drugs generally means that a person uses drugs
automatically and habitually without thinking about the consequences of the
behavior. Three important aspects related to compulsive drug use include
reinforcement for substance use, cravings for the substance, and habit.
Loss of control has been described as an inability to predict when or how
many drugs will be consumed. Some drug users describe loss of control as
powerlessness, meaning that the desire for substances controls their behavior.
Psychological dependence is defined by beliefs: A person thinks he or she
needs the substance in order to cope.
Physical dependence, on the other hand, is defined by actual physical changes
related to drug use that may result in withdrawal symptoms and tolerance.

8.2. The Costs of Drug Addiction

Addiction is similar to a virus—it infects and spreads into every aspect of the
individual’s life, including the spiritual, emotional, physical, psychological,
familial, social, recreational, and vocational domains. Rather than improving
with time, untreated addictive disorders are like untreated heart conditions—
given enough time and stress, the individual will suffer an “attack,” usually
impacting one of the aforementioned domains. Unlike other chronic and yet
manageable disorders (e.g., diabetes), the addictive disorder impacts not only

48
the individual addict but also just about every individual who comes in contact
with the addict.

Given the prevalence of addictive disorders, it is no wonder that millions of

individuals are directly and indirectly affected. In order to recognize the extent
of these impacts, we now turn to the discussion of the tangible and intangible
costs attributed to addictive disorders. We recognize the ambiguity of the term
cost: Do we view cost in terms of national dollars spent on treatment?
Do we look at economic losses caused by addicted individuals’ behaviors?
What about the personal expenditures by individuals, big business, and
insurance companies?
How about the connection between crime and addiction?
We believe that in order to accurately describe the severity of these disorders,
each of these questions must be addressed and answered. One mustn’t forget
about the individual and familial damage done by both chemical and process
addictions.
The costs are related to
 Treatment and Prevention society spends significant monies on
preventing and treating addictive disorders.
 Health Costs Foreign chemicals (i.e., alcohol, cocaine, tobacco, ecstasy,
etc.) ingested in mass quantities cause significant trauma and damage to
the human body.

49
  Job Productivity Losses related to substance abuse can be devastating
and sometimes permanent for individuals and families. e.g., employee
absenteeism, decreased productivity, job-related injury
 Crime and Punishment It should come as no surprise that alcohol and
drugs play a major role in crime rates, particularly violent crime and
billions of dollars as a result of motor vehicle crashes.
 List related costs of drug abuse in your area?

8.3. Theories/ Models of Addiction of Drug addiction counseling

8.3.1. The Moral Model of Addictive Disorders “Why Don’t They Just
Stop?”

The theory views addiction as a choice, “the result of willful overindulgence

and moral degradation [that] can be cured with willpower and a desire to
abstain” (Erickson, 2005, pp. 87–88). Addictive disorders are viewed as
sinful practices, reserved for the morally weak, solved only by one’s decision
to stop drinking/drugging. Other tenets of this model include
(a) the emphasis on personal choice as the basis of addiction,
(b) individual and obstinate violation of societal norms (from whence the term
“acting out”
originates), and

50
(c) the idea that individuals lack spiritual direction and need to “get right with
God” for abstinence to occur.
8.3.2. The Physiological Theory of Addiction “I Can’t Help It—I Have a
Disease:”

Physiological Theory actually encompasses many different theoretical

principles, most notably the Disease/Medical Model and Genetic
Predisposition Theory. Scientists believe that they have discovered the
“addiction” gene, or rather a group of chromosomes that contribute to the
development of chemical dependency (Crabbe, 2002). These genes can
therefore be passed along to children like any other genetic characteristic.
Evidence that contributes to the influence of genetics on the development of
addictive disorders includes adoption and twin studies, alcohol sensitivity
studies, and neurobiological research. It is no mystery that addiction runs in
families. For example, some studies have noted that 50 percent of alcoholics
had fathers who were alcoholics (Craig, 2004).

8.3.3. The Psychological Theory of Addictive Disorders

The Psychological Theory of addiction explains addiction in terms of

conscious and unconscious processes that lead to the escape from existential
suffering (Ventegodt, Morad, Kandel, & Merrick, 2004). This makes intuitive
sense: If you could lessen your pain by taking an aspirin, most would do so.
Further, if someone can have a drink to help de-stress after a tough day, why
not? But for those who turn to the addictive use of chemicals or behaviors, the

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stress that drives them to such use is usually greater than a simple headache or
hard day. For example, the tremendous amount of childhood abuse that our
addicted clients report is beyond the common “I’m having a hard week” kind
of stress. Similarly, due to the lack of developed and healthy coping
mechanisms found with addicted individuals, escaping through chemical or
behavior use has little in the way of checks or balances.

The Self-Medication Hypothesis attributes addictive use of chemicals or

behaviors to the lessening of psychological pain/ In this context, individuals
use such things as sex, alcohol, eating, work, or cocaine to self-medicate their
distress or as an escape from a painful reality.
The Influence of the Environment on Addictive Disorders
Sociocultural Theory Sociocultural Theory centers on how culture can affect
addictive tendencies. For example, Fisher and Harrison (2005) noted how
one’s culture can inhibit the development of alcoholism. Take the Jewish
culture: Low rates of alcoholism are reported in this group, largely due to their
moderate use of alcohol
Social Learning Theory

First, individuals learn/model specific behaviors by observing others

(particularly those whom they admire) and maintain those behaviors that are
both attractive and reinforced
8.4. Drug Addiction Counseling strategies

8.4.1. Behavior-Modification Strategies

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Therapy must address the drug habit before a client with a drug problem can
change the behavior. Habit implies a pattern of behavior that may be rote and
automatic. Your role as a counselor or therapist is to increase clients’
awareness. These behavioral changes can be addressed in therapy by the use
of selfmonitoring, shaping and contingency management, cue exposure and
response prevention, and skills training and psychoeducation
Teaching Your Client to Monitor and Change Drug-Use Behavior Chains

To begin with, the therapist or counselor helps the client understand the
context, function, and reinforcement history of his or her drug use behavior.
The therapist or counselor will want to identify how behaviors, thoughts, and
emotions link together (or interact) in the client’s pattern of drug use. As the
therapist discusses the behavior chains leading to drug use with the client,
effort is made to identify each link in the chain and how it leads the client one
step closer to using drugs.

For example, imagine that your client tells you about the following behavior
chain for her drug use. She tells you that she uses Xanax (alprazolam) right
before her partner arrives home from work. You ask her about that, and
discover that she feels anxious about her partner’s arrival because the partner
tends to yell at her about something immediately upon arrival home. So she
looks at the clock to see what time it is, and at around 5:00 p.m., when her
partner gets off work, she takes her first Xanax, followed by another one when
she hears the garage door opening a bit later, signaling the arrival of the

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partner. Her behavior chain includes the links of a behavior (looking at the
clock) and of an emotional response (anxiety about being yelled at), and
particular cues (5:00 p.m. and the garage door’s going up, as well as the
partner’s presence) that lead to the use of Xanax.

By raising the awareness of the client to this chain of events, you have armed
her with knowledge that may allow her to circumvent the use of drugs in this
situation, if you teach her how to respond differently at each link in the chain.
For example, changing her behavior (not looking at the clock or not being
available to be yelled at), changing her response to her anxiety, or changing
her beliefs that Xanax somehow manages her anxiety or diminishes the bad
feelings about being yelled at, will allow her many different ways and points
of opportunity to respond in other ways rather than using drugs.

In order to understand the details about these behavior chains, the client will
need to monitor her behavior, including what she does, when and why she
may do it, what she thinks, how she feels, and, eventually, how she can
respond differently. This requires the ability to self-monitor, which you as a
therapist will want toteach to her.
Weekly Drug Use Diary

Date and time you What kind of What happened right

started using: drug(s)?— before you used (the
(list time you used situation, your thoughts,
each type) and your feelings)?

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Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7

A sample self-monitoring form.

Shaping Behavior
Shaping client behavior in session can be a powerful tool to promote behavior
change. Especially in the beginning of therapy, you may want to shape your
client’s behavior by the use of reinforcement and sometimes by use of
punishment.
Reinforcement makes it more likely that the client will repeat a certain
behavior in the future. Generally speaking, client movements toward changing
a drug problem should be rewarded. The rewards may include giving the
client more attention or time in a session, or perhaps giving praise or offering
a compliment. The point is to make sure that you reward (positively reinforce)
the client when she or he is making progress toward changing drug use.

On the other hand, there may be times when you will want to use punishment
with a client. Punishment can be misunderstood, since in some cases it is
linked with authoritarian behavior and used in an attempt to control others
rather than with the goal of changing behavior. It goes without saying that the
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use of an authoritarian kind of punishment is not a wise idea for developing a
therapeutic alliance, and the research suggests it may be harmful for clients.
So when discussing punishment in the context of psychotherapy, it is not
talking about
control or harshness.

In therapy, punishment can be accomplished simply by ignoring what the

client is doing or saying (therapeutic neglect), or by expressing disapproval
about the behavior. If the therapeutic alliance is well developed, the client will
care about the relationship with the therapist or counselor, and will be
dismayed if you disapprove of or ignore what he or she is doing in session.
Another good example of punishment involves spending time discussing
things in session that the client has been actively trying to avoid. For example,
if the client has not completed his or her homework from the last session, and
you see this behavior as avoidant, then the punishment might be to use the
whole session completing the homework together. You will know whether
this use of session time is punishing to the client if she or he hesitates about
complying or complains about the use of time.
Teaching Your Client Seek Alternative Activities

Since the goal is to change the behavior patterns that contribute to drug use, it
will be important to incorporate new behavior patterns, or activities, into the
life of your client to replace the old. Helping the client develop alternative
activities that do not involve the possibility of drug use is one recommended

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way of doing this. Alternative activities simply means that the behavior is new
and provides an alternative to old behavior that may be linked in some way
with past drug use. Alternative activities should be interesting, stimulating,
and relevant in order to fully engage the client — for example, career and
vocational training, newhobby development, exercise routines or challenging
and vigorous recreational activity, spiritual or traditional cultural practices, or
development of new social support networks and involvement in new social
activities. Alternative activities also structure your client’s time in order to
prevent the risk of boredom and fill up the time voids left when drug-using
patterns are extinguished.

Moving From Extrinsic Reinforcement to Intrinsic Reinforcement

Therapists and counselors should remember that permanent change is more
likely to occur if the client finds the new behavior reinforcing inside and
outside session. Although learning a new behavior in therapy relies a great
deal upon reinforcement (e.g., praise or shaping) by you, eventually the client
will need to rely less on your reinforcement and more on his or her own. After
all, you will not be around to encourage the new behaviors in your clients
after treatment or therapy has ended. Part of encouraging a movement from
extrinsic (coming from outside) to intrinsic (arising from within the client).

8.4.2. Cognitive-Modification Strategies

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Therapy also needs to address client beliefs that contribute to drug use
behavior if a client is going to successfully change that behavior. Because of
the power of thoughts and beliefs to influence future behavior, cognitive
modification strategies should be used to address thoughts, perceptions, and
emotions related to drug use. This would include modifying positive
expectancies by use of expectancy challenges; thinking about the natural
consequences of drug use behavior before actually engaging in it; learning
how to problem solve and plan ahead; and altering distorted perceptions and
thoughts through the use of other strategies such as imagery, meditation, urge
surfing, and thought stopping.

Thought Stopping
Sometimes the client faces ruminative or obsessive thought processes that
hinder progress. The client may find his or her mind wandering, spinning, or
racing out of control with negative thoughts that are not helpful. Sometimes
the thoughts may be related to regrets or past shortcomings, and in other
instances the thoughts may be related to self-inflicted put-downs or doubts.
Counselors and therapists should teach clients how to stop such destructive
thoughts in their tracks.
Modifying Thinking Errors
Other kinds of misperceptions and errant beliefs cause trouble for people with
drug problems.
A/ Anticipating a Negative or Poor Outcome

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When engaging in this thinking error, people believe that an event will likely
have a lousy outcome most of the time. Anticipating a negative outcome can
be expressed in three different ways. First, clients may engage in what
cognitive therapists call fortunetelling, which means that they believe they
know for certain what the outcome of an event will be (and it is usually not
good). You may wish to use the following strategies to modify this type of
error.

First, you can ask the client to determine how often he or she has been in the
situation in the past, and then how often the outcome has been negative.
Second, you may wish to challenge the client to tell you how she or he knows
the outcome (the future), then perhaps have the client test the assumption of a
poor outcome. This may have the effect of challenging him or her to move
forward in spite of the prediction of doom by collecting personal data on a
real-life outcome rather than simply guessing that the future will be
unpleasant. Some cognitive therapists call this hypothesis testing, which
means teaching clients to test their assumptions about outcomes just as
scientists do. Second, the client can expect a negative outcome by engaging in
what cognitive
therapists call catastrophizing, which means expecting that the worst possible
thing that can happen, will happen. To combat catastrophizing, therapists and
counselors want to ask clients what they imagine is the worst thing that can
happen, in order to get the worst possible outcome on the table. That question

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should be followed by, “What is the best possible outcome?” This question
allows clients to view a range of outcomes for perspective, rather than merely
focusing on the negative. Finally, ask the client, “What is the most realistic
outcome?” which of course usually falls somewhere in the middle.
b/ Discounting the Positive
A third type of thinking error that may interfere with changing a drug problem
is called discounting the positive. When clients engage in this type of thinking
error, they generally ignore or refute evidence that supports the idea that
positive events or changes are happening to them. Frequently this type of
thinking error can be detected in a client’s language. You as a therapist may
point out something positive to your client in session, but a client engaging in
this thinking error may respond by saying, “Yes, but. . . .”

To counter this thinking error, ask the client to come up with alternative
explanations (other than one discounting the experience) for how he or she
could interpret the compliment or the event. If the client has trouble doing
this, ask how another person might interpret the compliment, the positive
outcome, or the reinforce being discounted.
c/ Emotional Reasoning
Emotional reasoning, may hinder changing a drug problem, occurs when a
person decides something must be true simply because it feels like it must be
true. Emotional reasoning places intuition above evidence, and the client often

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uses circular reasoning to perpetuate these types of errors. Sometimes a
client’s language will be a tip-off.
8.4.3. Skills Training
Of course, behavior and cognitive modification are not meant to be mutually
exclusive endeavors in therapy. Using various combinations of behavior- and
cognitive-modification strategies to change drug use patterns helps you
develop sophisticated and relevant individualized treatment plans for your
clients.

Skills training begins with assessing the current level of client skills to
determine whether he or she has the skills necessary to successfully cope with
a particular situation or successfully complete a particular task without drug
use. Obvious clues that a client may not have good skills in a particular area
may include evidence that your client may have failed in the past under
similar conditions, or that the client may have avoided coping with such a
situation in the past. A second set of clues may be within session evidence,
failure to cope well in session with you during a role-play, or problems in
interpersonal behavior while interacting with other treatment clients. Finally,
as mentioned in Chapter 4, the client may show signs of skill deficits during
an assessment, such as the Situational Competence Test, or may respond
slowly and vaguely when attempting to solve a particular problem in session
8.4.4. Support Groups

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Many therapists and counselors like to refer their clients to support groups
outside therapy in order to maximize the amount of social support available to
a client as he or she tries to change a drug problem. In addition to the social
support mentioned, support groups often will include program activities
intended to prevent or reduce drug use, including psycho education to help
their members. Support groups also may sponsor events such as dances,
picnics, or other drug free entertainment or recreational events that can help to
structure clients’ out of- session time with enjoyable social activities with
peers.

8.5. Relapse Prevention

Critical to client success after treatment is the ability to cope successfully with
high-risk situations without resorting to drug use. Counselors and therapists
work very hard during therapy with their clients to prevent relapse and to
make certain they reach their personal goals regarding behavior change.
Differentiate between slip, lapse and relapse?

 A slip is like a trip, when people make a small mistake and they realize,
“Oh, I made a mistake”, and they immediately regain control and do
not continue using. They may think about the benefits and the costs of

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 what they have just done. They may think, “Why did I do that? I will
lose all these things if I go back to drugs again.”
 A lapse is like a stumble; it takes longer for them to regain control.
Maybe they will use a few times, and then decide it is not worth it, and
stop.
 A relapse is like a fall. They think, “I have no control”, and they
continue using and return to their previous intensity of use.

Many clients do not know that their drug use during recovery can be
categorized in these three
types of behaviors. After using heroin again on one occasion, they are not yet
addicted again.
Note - it is not possible to say for all individuals whether following their first
reuse of heroin
they will be addicted again. There are many factors that contribute. If they do
have a slip, they
can learn from it to prevent a lapse or relapse. As a counselor, you can use that
lapse to talk
about preventing relapse.

Relapse prevention is an integral part of therapy and treatment for drug

problems. Relapse prevention as a therapy relies on cognitive and behavioral
modification techniques and skills training to avoid relapse. Relapse
prevention includes educating the client about warning signs for high-risk
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situations and for behavior that may result in subsequent drug use, as well as
training in new skills that help the client avoid a slip back into old behavior.
Another aspect of relapse prevention addresses how to respond if a slip back
into old behavior occurs, and how to return clients to healthy behaviors in the
event of such a slip. Although the origins of relapse prevention are cognitive
behavioral, its strategies fit nicely with many other models, including the
Minnesota model, which has incorporated relapse prevention into its treatment
and aftercare protocols. In addition, family and friends can be involved in
helping their loved ones stay the course after treatment. The rest of this
chapter will focus on relapse and its prevention, and on strategies that may
shorten or manage the course of a relapse if it occurs.

Vulnerabilities for Relapse

Research has found that certain vulnerabilities can place a client in a high-risk
situation for a relapse (Marlatt & Donovan, in press; Marlatt & Gordon,
1985). The first of these vulnerabilities is called lifestyle imbalance. Lifestyle
imbalances occur when a person spends too much time in one life domain,
such as working too much without a balance of recreation, or having too much
free time and not enough structure. There are several life activities that seem
important for lifestyle balance, including eating healthy and exercising,
spirituality, intellectual endeavors, healthy emotional expression, social
activities and relationships, private time, work, and play.

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The second vulnerability that can place clients in high-risk situations is a
desire for indulgence. Many times a client will feel like he or she should be
rewarded with something pleasurable for his or her strong efforts in
overcoming a drug problem, but sometimes the rewards that are sought place
the client in an awkward
situation that tempts him or her to use drugs. Other times the client may
experience stress or a poor mood and may want to alter the stress or mood
with an indulgence. Sometimes the desire for indulgence constitutes an
attempt to compensate for lifestyle imbalances.

A third vulnerability can arise when the client experiences cravings or urges
to use. As mentioned in Chapter 1, cravings can be triggered by social cues as
well as physical cues. Obviously, cravings or urges to use can place a client in
a high-risk situation for drug use, sometimes before the client is aware of the
danger.
In other cases, a client may cause a high-risk situation (e.g., a fight with a
loved one) out of frustration related to a craving or urge, or in some instances
as a pretext to using drugs again. The client may be unaware that the
discomfort caused by a craving or urge has contributed to the interpersonal
conflict.
Relapse Prevention Strategies

Restoring Lifestyle Balance Counselors and therapists need to develop

continuing-care and posttreatment plans with lifestyle balance in mind. Make

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sure you suggest to clients how to provide for a more balanced lifestyle in
these plans.

Will your client be doing things to improve her or his physical, spiritual,
emotional, and intellectual health and well-being during and after treatment,
aftercare, or therapy? Does the plan balance work with play? Does it include
serious and challenging activities with pleasurable returns? Is there a balance
of alone-time with social interactions? Determine whether the client is
spending too much time in one area of her or his life, and if so, suggest ways
to correct that imbalance. Suggest activities that fit into the client’s schedule
and are attractive to the client, and evaluate over time how well the client’s
activities remain balanced and whether the plans are effective at maintaining
such a balance.
Substitute Indulgences
In addition, teach the client to seek out substitutes for drugs or behaviors/
situations that were related to drug use in the past. Substitute indulgences are
activities that are pleasurable but not related to past drug use behavior. These
behaviors and practices are meant to respond to the vulnerability that a client
may experience when desiring to indulge in something pleasurable. Substitute
indulgences also are meant to be healthy alternatives. One example is safe sex
with a willing partner. Another example might be self-soothing behavior such
as a warm shower or a massage. The sky is the limit when determining what
constitutes a substitute indulgence for a client. Suggest indulgences that are
enjoyable and relevant for the individual. Try to find indulgences that fit

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easily into his or her lifestyle, that are affordable and accessible, and that are
not too complicated for the client to generate or achieve.
Coping Imagery
In order to prepare a client for facing high-risk situations during or after
treatment, aftercare, or therapy, a counselor or therapist can teach a client to
use imagery as a tool to improve his or her ability to cope. The counselor or
therapist may use guided imagery , describing the situation and the successive
steps of how the client successfully copes with that situation while he or she
sits and listens, maybe with eyes closed. The goal is to suggest a skillful
course of action in that situation that will lead to positive outcome while
illustrating how the client can succeed in using this particular coping strategy.

In addition, the imagery also tends to imaginally enhance the client’s

selfefficacy. The client succeeds at coping in the imagery; the skills training
that occurs by the use of this imagery increases his or her competence to cope
with that situation; while the imagery also enhances confidence in his or her
ability to succeed under these circumstances. Eventually the client learns how
to take control of his or her own imagery experience, first by describing it in
session, then eventually using the technique in vivo outside of session to
mentally guide him or herself through the situation in real life.
Stimulus Control and Cue Exposure
In addition, stimulus-control and cue-exposure techniques can be used
effectively as relapse prevention strategies. Stimulus control means that the

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client learns how to control her or his level of exposure, and under what
conditions, to a particular cue that had been associated with drug use. Cue
exposure, as you may remember, uses exposure and response-prevention
strategies in session to reduce the power of a drug-use cue to trigger cravings
or urges to use.

Cue exposure should be the strategy of choice if the cue cannot possibly be
avoided in the real world. For example, it is likely that a client who used to
abuse heroin will not be able to avoid seeing spoons in the real world, so you
should definitely consider cue exposure to spoons in session, probably with a
flame involved to increase the realism of the exposure. However, it may be
possible for a client who abuses marijuana to avoid exposure to bongs. Under
these circumstances, you may want to suggest a stimulus-control strategy
instead of cue exposure, and have your client dispose of his or her bongs
during treatment, in aftercare, or in session (or perhaps have a loved one
dispose of these, which controls the stimulus exposure even further). Then
have your client avoid driving by or entering paraphernalia shops and
interacting with friends who have bongs in the future.
Self-Monitoring
Self-monitoring can be used to assess for potential high-risk relapse situations.
You can assign your client to keep track of stress related to high-risk cues
(e.g., relationships or work) or to track mood changes or emotions. Teach the
client to track these stressors on a sliding scale so that he or she can see

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fluctuations in the amount of stress or in the strength of moods or emotions
experienced. Sometimes counselors or therapists like to teach clients to rate
stress and moods/emotions on a scale of 1 to 100, and to link each rating to a
situation or thought. You may even want your client to identify any thinking
error he or she is making and include alternative ways of responding to and
thinking about the situation. Review the self-monitoring every session to see if
there are any signs of problems, and help the client to respond accordingly.
Relapse Rehearsal

Relapse rehearsal is a way to plan ahead for how your client will successfully
negotiate a lapse or relapse, should one occur. The goal is to circumvent the
duration and severity of the lapse or relapse event by practicing for how to
respond to such an event ahead of time. In addition, the relapse rehearsal can
include a plan for circumventing the relapse chain of events before a client
slips. The relapse rehearsal also can reduce the risk of a poor coping response,
or even a slip or relapse should the chain progress that far. The goal is to
develop a “stay-safe” plan for the client before he or she is even at risk, in
hopes that the plan can be implemented quickly if needed when the risk arises,

Relapse Contracts

If a client does slip or relapse, it does not mean that progress is arrested or that
treatment has not succeeded. Remember, lapses and relapses provide
opportunities for clients to grow and for recovery plans to be improved. In
addition, there are strategies that can be used to reduce the duration and

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severity of a lapse or relapse. The first intervention upon a lapse or relapse
occurs well before it happens, when you and your client develop a relapse
plan and use relapse rehearsal in session. In this way, you teach the client to
respond to a lapse or relapse by actively seeking help and by doing something
differently.

When your client contacts you after a lapse or relapse, make sure that she or
he comes in to see you if possible (although a contract can be made on the
phone or online, too). During this contact, you can use a relapse contract to
control the severity or duration of the lapse or relapse. A relapse contract is an
agreement that you negotiate with your client on the limits of the relapse
behavior. First, you want to try to negotiate with the client to get an agreement
on stopping the lapse or relapse as soon as possible.

Cognitive Restructuring
Cognitive restructuring includes reframing the lapse so that the client views it
in a more positive manner. For example, clients often associate a lapse with
personal failure on their part, and the guilt and shame associated with goal
violation relates to this sense of failure. As a counselor or therapist, you want
to challenge your client’s perceptions of failure by normalizing the
experience. After all, relapse is part of the change process and tends to happen
commonly among people learning something new. For example, how many
people learn how to ride a bike perfectly the first time they get on one?
Chances are there will be at least one fall, with perhaps a few scrapes or
bruises from the experience. If falling off a bike is not an unexpected
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experience while learning how to ride, then it follows that a lapse would not
be an unexpected experience when a person attempts to overcome a drug
problem. Arguably, overcoming a drug problem is more difficult than riding a
bike, too.

9. Sexual Offenders Victim Counseling

Sexual Offenders and Victims Counseling

A sex offense is any sexual behavior with a child, a non-consenting adult, or

anyone who is unable to give consent due to physical condition (e.g.
intoxication) or mental capacity (e.g. developmental disability). It includes
crimes of penetration with a body part or other object, crimes of contact (like
fondling), and crimes of noncontact (like exhibitionism). It can also include
crimes related to the production and consumption of certain types of
pornography, especially child pornography.

A sex offender (sexual offender, sex abuser, or sexual abuser) is a person who

has been criminally charged and convicted of, or has pled guilty to, a sex
crime.

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 Types of Sexual Violence

Rape: forced sexual intercourse, including vaginal, anal, or oral penetration.

Penetration may be by a body part or an object. Rape victims may be forced
through threats or physical means. In about 8 out of 10 rapes, no weapon is
used other than physical force. Anyone may be a victim of rape: women, men
or children, straight or gay.
Child Sexual Abuse: sexual contact by force, trickery, or bribery where there
is an imbalance in age, size, power, or knowledge.
Drug facilitated assault: when drugs or alcohol are used to compromise an
individual's ability to consent to sexual activity. In addition, drugs and alcohol
are often used in order to minimize the resistance and memory of the victim of
a sexual assault.
Incest: sexual contact between persons who are so closely related that their
marriage is illegal (e.g., parents and children, uncles/aunts and
nieces/nephews, etc.). This usually takes the form of an older family member
sexually abusing a child or adolescent. Incest is considered by many experts to
be a particularly damaging form of sexual abuse because it is perpetrated by
individuals upon whom the victim trusts and depends. In addition, support can
also be lacking and pressure to keep silent powerful as fear of the family
breaking up can be overwhelming to other family members.
Partner Rape is defined as sexual acts committed without a person's consent
and/or against a person's will when the perpetrator is the individual's current
partner (married or not), previous partner, or co-habitator.

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Sexual harassment: unwelcome sexual advances, requests for sexual favors,
and other verbal or physical conduct of a sexual nature in which submission to
or rejection of such conduct explicitly or implicitly affects an individual's
work or school performance or creates an intimidating, hostile, or offensive
work or school environment. is when someone: touches you or asks you to
touch them in private parts even if it is over the clothing; shows you sexual
pictures or objects that make you feel uncomfortable; talks about sexual things
or tells you dirty jokes; makes you feel uncomfortable at school, work, or at
play; doesn’t stop when you ask them to.

 What do you think are the motives for sexual offense?

 What Self-protective measures do you think victims need to take?
 If a victim does not say “no” or does not “fight back,” it is not sexual
assault. Do you agree? Why?
 Share any experiences of sexual offense that you heard or faced?
 Share any advise you would like to give to fellow friends about dangers
of sexual offense.
Treatment

Sex offender therapy is challenging regardless of the nature of the clients, and
other factors also come into play. There exists the constant issue of resistance
to treatment, particularly when treatment is a condition of experimentation.
Criminogenic thinking pervades the scene, and counselors must be on guard
for the often-subtle signs of that mind-set. For instance, individuals convicted
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of sex offenses can be calculating, not only with their therapist but also with
others in their therapy groups. Power plays, deflection, grooming and lying
are a few examples of the criminal thinking that may be evident. Many
offenders will also present with a virtual encyclopedia of thinking errors.
Often topping the cognitive distortion list are victim stance (“This label is
unfair”), minimization (“All I did was grope her”), justification (“We’d had
sex before and she didn’t complain”) and entitlement.
In addition to the cognitive distortions and potential for criminogenic
behavior, counselors may also have to contend with other factors such as
addictions, co-occurring disorders and, of course, shame, guilt and incredibly
demeaning self-talk.. But when all of these factors are thrown into the mix, the
counselor is often faced with denial on several levels: denial of facts (“It
wasn’t me”); denial of intent (“I was drunk”); denial of impact (“She didn’t
seem to mind”); and denial of the need for treatment.
Goals of treatment
1/ Accepting responsibility and modifying cognitive distortions. Offenders are
masters of deceit—even of themselves. The treatment process will confront
thinking errors and attempt to correct them so that the offender will accept
responsibility for his actions.
To modify cognitive distortions and cause an offender to accept responsibility,
treatment might include—
 Education about denial;
 Support for incremental steps toward accountability;

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  Making the acceptance of some responsibility a prerequisite for
admission into treatment, and full acceptance a prerequisite for
successful completion;
 Confronting denial and other cognitive distortions by challenging
discrepancies between different versions of the events, educating the
offender about the relationship of cognitive distortions to sex offense
behavior, and modeling accountability.
2/ Developing victim empathy. Part of the denial and deceit that sex offenders
employ is that the victim is somehow complicit in the activity, did not really
mind, and—at least—was not really harmed. Being able to understand the fear
and trauma experienced by the victim is an important goal of therapy.
To develop victim empathy, treatment might include
 Psychoeducation on the effects of abuse on victims;
 Opportunities for an offender to develop an emotional understanding of
the impact of sexual abuse, such as role playing or writing exercises;
 Teaching empathy skills, such as recognizing emotional distress and
communicating empathy;
 In some instances, an offender may meet with his victim(s) face to face.
3/ Controlling sexual arousal. Treatment will focus on sexual arousal as a part
of the offense cycle, along with methods of controlling or rechanneling
arousal toward acceptable partners and activities.
To control sexual arousal, treatment might include

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  Education about deviant sexual fantasy and its relationship to sexual
behavior;
 Cognitive-behavioral interventions that help offenders:
A/ Develop, maintain, or increase appropriate sexual arousal patterns;
B/ Interrupt deviant sexual fantasies and urges;
C/ Help reduce deviant sexual fantasies and urges. Some techniques include
aversion therapy (association of inappropriate sexual stimuli with a foul odor
or other unpleasant sensation), orgasmic reconditioning (the gradual
substitution of appropriate stimuli for inappropriate stimuli during
masturbation), covert sensitization (the reinforcement of the relationship
between inappropriate behavior and ensuing negative consequences), and
satiation (compulsory repetition of a paraphilic fantasy to the point of
boredom);

 Providing methods for practicing arousal control in everyday situations;

 Psychopharmacological interventions to manage sexual arousal. Drugs
can be helpful for a percentage of sex offenders in the context of a
comprehensive treatment program, particularly where deviant sexual
arousal is particularly intense, frequent, or lengthy. The two primary
categories of medication are:
4/Improving social competence. Difficult social situations may generate the
type of anxiety that is a precursor to re-offending. Treatment will help
offenders identify those situations and develop skills to address them.
Treatment to improve social competence can include—
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  Using the group setting to model, practice, and rehearse appropriate and
effective social interactions. Social deficits that can afffect sexual
offending behavior include, but are not limited to: anger management,
assertiveness, conflict resolution, leisure time skills, problem solving,
stress management, conversational skills, parenting, and substance use;
 Referral to specialized treatment, such as marriage and family therapy,
substance abuse treatment, or anger management; and
 Involvement of significant others in treatment, if appropriate

4/Developing relapse prevention skills. Treatment will help offenders

understand the sequence of events that leads to their offense behavior.
Offenders will then be helped to interrupt that cycle or chain of events in order
to prevent future victimization.

5. Relapse prevention The ultimate goal of sex offender therapy is relapse

prevention, based first upon accountability and assumption of responsibility
for offensive behavior. Relapse prevention is a self- control program that
provides the offender with a variety of cognitive, behavioral, and social skills
training tools for assuming responsibility for their behavior. Essentially, a
focus of relapse prevention is learning to identify the factors that increase risk
for sexual offending and developing adaptive coping skills for minimizing or
eliminating those risks, as well as identifying and escaping lapses to exit from
the build up phase of the deviant cycle before victimization.

Focus/strategies of treatment
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It is important to note that underlying this treatment program are several
concepts and ideas that preclude the acceptance of any deterministic theories
of behavior and personality.
1/ Methods of treatment are designed around Cognitive/Behavioral
theory(that addresses dysfunctional core beliefs as well as current thoughts
that promote maladaptive behavior) and the philosophy of Personal
Responsibility (taking responsibility for one’s own decision and
consequences ) is absolutely essential to progressing through treatment. Sex
offending is a choice; it is not a direct consequence of abuse or other feature
of the offender’s developmental make up. 
2/ Research supports the best practice of sex offender therapy being
conducted in groups whenever possible. The peer support, which includes
challenging denial and other thinking errors, is invaluable in treatment and
also lends itself to generally better outcomes. Part of the reason for this is that
so many sex offenses are based in secrecy. Bringing offenses out into the open
is generally conducive to discussion and to the cognitive elements that are so
important to reducing recidivism.
Of course, group therapy adds still other elements for the therapist to
consider, including properly populating groups (for example, matching risk
factors, genders and ages) and building and maintaining effective group
dynamics. Sex offenders don’t want to talk about their “stuff” in front of
others. Consequently, providing a safe environment and building trust are
staples of effective sex offender therapy groups. While this represents a

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formidable enough battlefront on its own, sex offender therapists are faced
with another perhaps even more challenging front — that of our society,
including our lawmakers.
3/The Sex Offenders are encouraged to raise and process personal issues
as necessary. They are to report to the group any deviant impulses they have
experienced, and any high-risk situations they may have experienced.  They
are to inform the group how they conducted their behavior to avoid
reoffending.  Transfer-In Sex Offenders, who have completed treatment or
have been court ordered, will be enrolled in this Phase. 
There are definitive differences in treating sex offenders than other
clinical populations.
1) We are often directive and have definitive expectations for our clients. We
set treatment
goals that are contrary to the offender’s wishes.
2) We are often confrontative. Traditional psychotherapy seeks to reduce
feelings of anxiety and inadequacy, while sex offender therapy seeks to
confront the offender with his thinking errors and to bring him to accept
accountability for his actions.
3) We are prohibitive, e.g., we tell our clients where they can go, who they
can see, where
they can work, and similar.
4) We work with clients who have denial of the problem. We want
verification of our

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client’s behavior and may subject them to polygraph evaluations. We doubt
self-report,
especially in the early phase of treatment.
5) We place a high value on the rights and needs of others before the rights
and needs of the
offender. We are victim and community safety advocates.
6) We require waivers of confidentiality in order to facilitate community
supervision and
communication among involved professionals.

We believe that offenders, in general:

1) Oppose treatment efforts initially. They are not going to like limits. Initial
motivation
varies and must be cultivated.
2) Have an initial poor recognition of problems. Initial insight is often limited
and distorted.
3) Act out in many ways that harm others.
4) Are initially dishonest to us and themselves.
5) Hold secrets and hide themselves from you.
6) Will blame others for their problems and see their victimization in terms of
their own
personal needs,” I was only trying to reach out to her”.

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7) Will do anything to avoid your scrutiny or involvement in their life. They
will try to be your best client.
 I do not want to talk to my children about sexual abuse, because I do not
want to frighten them. Is this really the right thing to do?

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