Integrated Counseling: A Personal Theoretical Orientation

Introduction: A Skeptic Enters the Field

There are many ways to skin a cat, as the old saying goes. But when it comes to one's own theoretical approach to counseling, a practitioner had better have a routine — a system grounded in sound theory and vetted by practical experience — that leads to positive, empirical results. Those good old days of supposition and speculation are gone. No longer can therapists and counselors rely solely on their own fabrications and interpretations to administer treatment. Thanks to social media, the Internet, cutting-edge research, and evidence-based treatment models, therapists and counselors must learn to align personal theoretical predilections with pragmatic, results-driven tools, techniques, and approaches. In essence, the public is demanding results, and it is up to therapists and counselors everywhere to integrate all available resources and information to devise a theoretical orientation to counseling and therapy that is, ideally, optimally effective. It is the purpose of this paper to discuss the integrated seedlings of my own approach to counseling.

I was born a skeptic, a contrarian of sorts. If a teacher told me a polar bear's fur was white, I would argue immediately and say, "No, it's not." It's translucent — a pro-survival adaptation that allows sunlight to absorb into the polar bear's black skin on subzero days. My teacher would scowl at me as though I were a criminal, while the rest of the fourth-grade class, bristling from disillusionment, would have furrowed brows and fidgety fingers. My point is that I never accepted things at face value. I learned that things that are ostensibly simple are usually inherently complex. For example, the amount of human brainpower it takes to differentiate between the sounds of "p" and "b" is utterly jaw-dropping (Gelso & Fretz, 2001, p. 355). As this relates to psychology — specifically counseling and therapy — I knew that something that seemed so commonsensical could not be without its own complexities and uncertainties. It turns out I was right.

The first thing one must recognize about therapy and counseling is that it is an imperfect science. As much as practitioners who work in the field and make a living applying its theories and principles would like to believe in the impact these disciplines have on human behavior, one must inevitably confront the fact that there is no perfect model or golden rule that works for all people all of the time. Humans are innately mysterious and complex. That is not to say science will never find a way to address all ailments and disorders, but rather it is to acknowledge that when one counsels a patient, one does so not with the clinical certitude of a Dr. Frankenstein, but with the hope that methodology, directives, and the application of theory are going to work. Much of what one does in counseling is predicated on faith in one's own ability, in one's own understanding of the literature, and, of course, in one's preconceptions about human nature.

Obviously, the more one trains, studies, and accumulates experience, the more confidence one will have in one's abilities. Yet all of this acquired knowledge and training will not eliminate the truth that counseling is an imperfect science. Knowing this tenuous status underscores that what one does to counsel a client is inherently subjective and hinged to a faith-based — faith as in hope, not to invoke religion — paradigm. It is an "I hope that what I am doing will work," rather than an "I know what I am doing will work" position that most counselors, therapists, and psychologists take toward their clients, and I am no exception.

Counseling as an Imperfect Science

This humble and self-aware approach is difficult for people to understand, particularly nascent counselors, as it implies a certain ambiguity toward one's own self-confidence. People ask: how can someone who makes a living counseling be so unsure about the efficacy of counseling? The key is to be, as John Keats would say, comfortable in uncertainty (1970). There are gaps in what we know about human nature, yet that is not to say I am not confident — I am extremely confident in my abilities as a counselor. I am simply keenly aware of the imperfect art form that is counseling. It is my belief that because I acknowledge the fallibility of counseling, I am a better counselor. Knowing the limits is just as important as knowing the tricks of the trade.

To explicate this position — that a great counselor must be self-aware and acknowledge the limitations of counseling and pharmaceuticals — consider the uncertainty and confusion counselors and psychologists confront on a daily basis, specifically with regard to depression.

Louis Menand writes in his essay "Head Case" about this confusion: "However you go about making this decision [whether to take prescription meds], do not read the psychiatric literature. Everything in it, from the science (do the meds really work?) to the metaphysics (is depression really a disease?), will confuse you. There is little agreement about what causes depression and no consensus about what cures it" (2010).

These are telling words. If experts cannot agree on what causes depression and, more importantly, what cures it, what is a psychologist or counselor supposed to do? This is not biology, where one has the luxury of foolproof evidence. In psychology, there is nothing analogous to the Modern Evolutionary Synthesis that unifies Mendelian genetics with Darwinian evolution.

If this is not daunting enough, consider the low self-awareness that many psychologists and therapists frequently exhibit. Mick Cooper of Therapy Today writes: "The reality is, therapists do get it wrong. For instance, ninety per cent of therapists put themselves in the top 25 per cent in terms of service delivery. So therapists' perceptions, experiences or beliefs that their therapies are effective do not necessarily make them so" (2008).

An over-inflated ego and a superficial appreciation for the complexity of the job is a recipe for disaster. This typically translates into poor patient care and treatment, and a lower success rate.

Choosing a Therapeutic Foundation: Cognitive Behavioral Therapy

So if this is the current climate of the counseling arena, how does a counselor combat these obstacles — self-aggrandizement and a poor appreciation for complexity — and deliver high-quality, results-oriented patient care? As previously posited, it is really about integration. For me, this means integrating what I refer to as my rational skepticism and my high tolerance for the ambiguous nature of human beings with a sound, results-driven therapeutic model.

Before addressing the question of which therapeutic models I employ, it is worth clarifying the issue of therapeutic utility. For as much as we do not know about counseling and therapy, we do know that it works. As Cooper writes, "Does therapy work? Fortunately there is a simple answer to this question: yes. Studies which look at clients' behaviors, feelings or psychological functioning before and after therapy nearly always find that, on average, they are better off by the end of it" (2008).

If we know that therapy and counseling work, the next dilemma is which therapeutic model or models one should adopt and integrate. The answer that forms the fundamental basis of my work in the field is cognitive behavioral therapy (CBT). However, like most therapists and psychologists, I also take an à la carte approach to other popular therapeutic models, borrowing methodology, theory, and practices and integrating them into my standard CBT approach.

What is CBT? Like many terms and phrases in psychology, the answer seems to evolve over time due to new developments and findings that alter the overall concept. But the basic idea can be traced all the way back to the Stoic philosopher Epictetus, who wrote in The Enchiridion: "Men are disturbed not by things, but by the view which they take of them" (NACBT, 2008). A more modern rendition: CBT is a form of psychotherapy that emphasizes the important role of thinking in how we feel and what we do.

A rather comprehensive definition states that "cognitive-behavioral therapy integrates the cognitive restructuring approach of cognitive therapy with the behavioral modification techniques of behavioral therapy. The therapist works with the patient to identify both the thoughts and the behaviors that are causing distress, and to change those thoughts in order to readjust the behavior" (Free Dictionary). CBT works because it addresses the maladaptive thoughts that create maladaptive behavior. It integrates theoretical tenets of psychotherapy with practical behavior-modification exercises, which in turn creates real, tangible results. As Cooper writes, "if, on the one hand, you look at the particular therapies that have been shown to be effective for particular psychological problems — as advocates of empirically supported treatments have done — there is no question that the evidence base is strongest for CBT. While, for instance, there are scores of high-quality controlled trials demonstrating the effectiveness of CBT for depression, there are just a handful of studies demonstrating the same thing for person-centred therapy. And while CBT has been shown to be effective for numerous psychological difficulties — such as phobias, panic, PTSD, bulimia, sexual problems and deliberate self-harm — there is little equivalent evidence for the vast array of non-CBT practices" (2008).

CBT has been empirically proven to be successful at helping clients, but is it more effective for some populations than others? Is there a relationship between socioeconomic status, race, or gender and the efficacy of CBT? In a literature review published in the American Journal of Psychotherapy, this issue was addressed: the authors found that "CBT-trained therapists work with individuals, families, and groups. The approach can be used to help anyone irrespective of ability, culture, race, gender, or sexual preference. It can be applied with or without psychopharmacological medication, depending on the severity or nature of each patient's problem" (Gelso & Fretz, 2001). In my experience, CBT is indeed a universally effective approach, whether in a one-on-one, group, or familial setting.