Counseling Techniques: A Comprehensive Resource for Christian Counselors

By Zondervan

Counseling Techniques provides a useful resource for any type of counseling practitioner. Presenting a wide variety of the most effective and commonly used techniques associated with various diagnoses, theoretical bases, and client populations, it offers experienced therapists and students alike a single, trustworthy resource for clinical reference and guidance.

Each chapter includes a user-friendly, step-by-step explanation of the techniques covered. Sections survey the following:

• Basic types of techniques (cognitive, behavioral, experiential, and more)

• Techniques for children, adolescents, adults, couples, and families

• Techniques for a wide variety of individual and family issues, including emotional dysregulation, shame, loss, sexual abuse, trauma, domestic violence, attachment wounds, and much more

Featuring a lineup of top-notch, highly experienced counselors and thoroughly integrated with a Christian worldview, Counseling Techniques will equip therapists and students in various helping disciplines for the frequent clinical issues that arise in all forms of counseling.

• Language: English
• Publisher: Zondervan
• Release date: Oct 16, 2018
• ISBN: 9780310529453

Book preview

Acknowledgments

This book is the culmination of dreams and ideas to put forth a practical, conversational, and professional book that presents strategies, interventions, and techniques that work with a multitude of clinical issues. The creation of this book is the result of the work of many dedicated and encouraging individuals. Having my name on the cover is humbling and is a privilege when so many others have contributed to its completion in various ways.

First and foremost, I want to express my gratitude to Zondervan for taking a risk on me and providing me a platform to voice my say. Zondervan has been a delight to work with in the editing, designing, and marketing of this book. My editor, Madison Trammel, has especially been a joy to work with and a fountain of feedback and stimulation, without which this project would have been impossible. He has been extraordinarily patient with me, tolerating all the inconveniences the completion of this book has caused. I was also blessed similarly by the assistance of Bob Hudson of Zondervan, who carried the project through to completion. Finally, Zondervan blessed me with an incredible copy editor, Laura Weller, whose attention to detail is extraordinary.

I owe a debt of gratitude for the assistance of those whose contributions helped me achieve this milestone. Tim Sosin, thank you for volunteering to be my assistant. You worked tirelessly in coordinating the project, communicating with contributors, and keeping me from insanity. Chelsea Breiholz, your willing and humble spirit coupled with invaluable comments and suggestions not only blessed me but will also bless those who use this book. Nils Juarez Palma, your contributions to this project have been meaningful to me. And Dr. David Jenkins, I am very appreciative of your providing me with insightful thoughts.

A special friendship has developed out of this project. I have personally been enriched by Dr. Fred DiBlasio. Fred, your goodwill, amicable spirit, and calming presence provided enjoyment and encouragement. I look forward to our new relationship growing.

Where would any of us be without prayer support? This project would have been unbearable without the pledges of a cadre of praying brothers and sisters in Christ. They provided both shade from the oppressive heat of this project and sunshine to move forward. Among those people are my LifeGroup, Live with Purpose, and family members whose prayers girded me through obstacles and frustrations.

A host of students and friends provided invaluable help with the indexing of this enormous manuscript. I wish to acknowledge each of them for rising to the occasion to bear my burden: Krista Clifton, Mary Katie Blevins, Nils Juarez Palma, Kay Griffith, Donna Fitch, Katie Thomas, Kelly Carapezza, Yatpor Lau, Dr. Sally Goh, Eric Kananen, Linda Kananen, Cayli Snipes, Patrice Parkinson, Bradleigh Thomassian, Yulia Gray, Kevin King, Dr. Patricia Kimball, Katie Thomas, and Denise Thomas.

I would not have embarked on this venture without the wholehearted support of my wife, Denise. Throughout our marriage she has never wavered in encouraging me to pursue my aims. I’ve also benefited by the warm presence of my three dogs: Eli, Buster, and Nellie. Their companionship, snuggling, and playfulness furnished enjoyable respite during writing blocks and wearisome editing.

A final expression of heartfelt gratitude goes to my Lord and Savior, Jesus Christ. He provides a firm foundation and sustenance for my life. He has blessed me beyond my ability and, I know, will use this work to further the kingdom and continue his mission of binding the brokenhearted and setting the captives free.

Truly, I am among all men most richly blessed.

John C. Thomas

Lynchburg, Virginia

February 19, 2018

CHAPTER 1

Laying the Groundwork

JOHN C. THOMAS, PHD, PHD

The Spirit of the Lord is upon me; he has appointed me to preach Good News to the poor; he has sent me to heal the brokenhearted and to announce that captives shall be released and the blind shall see, that the downtrodden shall be freed from their oppressors, and that God is ready to give blessings to all who come to him.

LUKE 4:18–19 TLB

As a counselor educator and clinical supervisor, I’ve heard a recurring request from students and supervisees: How do I _______? Novice counselors want a how-to description to apply a strategy, intervention, or technique (SIT) to therapeutic situations. Experienced counselors who attend clinical workshops want to see SITs taught and enacted. As Bandura’s (1977) research affirmed, we learn by observing those we consider models of clinical prowess.

As the field of counseling continues to grow and develop, the diversity and complexity of SITs also progresses. Concomitantly, innovative and effective SITs have been developed to leverage the process of change and promote soul transformation. While many of these SITs are easy to implement, others require a sufficient knowledge of the theory to effectively employ.

The pursuit of a graduate degree launches us into a new frontier of providing professional services to clients. Though supervised throughout the residency requirements of our states, we can collect only a selective sampling of SITs during that time. This book seeks to address that space between training and practice and to prepare students with a wider range of ideas prior to the start of their professional career. Furthermore, this book provides the experienced clinician with opportunities to learn and grow. It is a useful resource for the novice and seasoned counselor.

Consider the scenario wherein numerous leading Christian mental health clinicians agree to provide their expert supervision or consultation to develop your counseling prowess. Through this improbable gift, you are afforded the opportunity to learn how they interact with particular clientele and client issues. You are able to digest the intricacies of their counseling theory, conceptualization, and use of SITs. Most importantly, you gain understanding of how they integrate the Christian worldview into their clinical work both explicitly and tacitly. Imagine what you could take away from that privilege and incorporate into your own work to enhance your therapeutic outcomes.

Thanks to the graciousness of these seasoned Christian counselors, you gain the opportunity to ingest their knowledge, skill, and experience. The chapters in this volume bring together wisdom and insight from hundreds of years of clinical experience. Throughout the book you will absorb theoretical and relevant underpinnings for specific classes of SITs, learn about effective SITs used with their clients, read how their knowledge and SITs apply to relevant case studies, and even peer through the office door to discover clinical dialogue. Skilled in their areas of expertise, these contributors offer a treasure chest of understanding and tools.

Because counseling is a complex enterprise with seemingly infinite nuances, every therapist can grow—and needs to grow—in their work. For this book to be useful, you must apprehend their concepts, be receptive to them, and believe that you can discover new ways of conducting therapy. No matter where you are on your professional journey, the experiences of colleagues and experts in the field can benefit you. This notion has been articulated by Jeffrey Kottler (2012): These [counselors] are constantly questioning what they do and why, being brutally honest with themselves about their work and its outcomes. . . . They are always soliciting feedback from their clients and colleagues, begging for the most frank assessments about what is working and what is not. Most of all, they are often so humble that they don’t seek attention or the limelight but just quietly go about their extraordinary commitment to helping others (as cited in Shallcross, 2012).

Over the course of my editing, I’ve incorporated a number of SITs into my own clinical practice. I told one of the contributors that I am the first to have profited from this project. As they say in Alcoholics Anonymous, people must be humble, open, and willing (HOW) to change.

Moreover, mastering particular SITs requires repetition and quality feedback through clinical supervision or consultation. While supervision is a vital method for learning how to apply or improve clinical skill, it isn’t always practical or affordable. Nevertheless, the knowledge and expertise of accomplished clinicians in this volume provide a treasure chest of ideas and strategies to skillfully address sundry clinical presentations.

THE TECHNIQUE CONTROVERSY

Most counselors advocate for the judicious use of interventions and techniques, believing that they are vital to therapeutic effectiveness (e.g., J. S. Beck, 2011; Burns, 2008; Conte, 2009; Corey, 2005; Ellis & MacLaren, 2005; Leahy, 2003, 2015; Satir, 1987; Thompson, 2003). Conte (2009), for instance, captures both the benefits and beauty of using SITs: If theoretical orientations constitute the canvases of therapy, then techniques are the brushes that paint counselors’ work into something memorable for clients (p. 1). When the art (SITs and skills) and science (theories) of counseling are merged in a masterful way, clients experience the transforming impact of the work. While many of these clinical necessities are taught in graduate programs, others are acquired and developed through clinical practice experiences. Once a competence has developed, practitioners can naturally exhibit basic counseling skills, establish goals, construct treatment plans, and focus a session. Such therapists have self-awareness, monitor potential countertransference while using it therapeutically, and are in tune with God’s leading.

However, the use of interventions and techniques in counseling is not without dispute. Other theorists and clinicians oppose or caution the use of SITs (e.g., Elkins, 2007, 2009; Mahrer, 2004; Mozdzierz & Greenblatt, 1994; Orlinsky, 2010; Schneider & Krug, 2010). Unsurprisingly, existential psychotherapist Yalom (2003) asserts that counseling is a relationally driven enterprise rather than theory or technique driven. For instance, Yalom believes that the healing strategy is entering into a close relationship with clients. Consistent with existential thought, it might be fair to say that Buber (2010) would consider counseling to be an I-Thou experience, while an I-it experience is more closely aligned with SITs.

A newer train of thought is that of determining the best approach based on practice-based evidence (Miller, Duncan, & Hubble, 2004). Advocates are neither for nor against the use of SITs. Evidence-based practice is unpacked in chapter 2. Regardless of one’s viewpoint on SITs, fostering a therapeutic relationship always requires the use of a SIT. Focusing on the therapeutic relationship as the vehicle of client change and healing is using a SIT. Being authentic, though it springs from the person of the therapist’s own growth, is at its core a strategy in counseling practice. I contend that the use of SITs is critical to produce true and lasting change in clients. When a therapist is attuned with the client in such a way that the client feels cared for and accepted, the freedom to choose the most effective and appropriate SITs for addressing relevant client issues is apparent.

TECHNIQUES AND TARGETS

SITs and counseling skills are arrows used to hit an identified target (Thomas & Sosin, 2011). If you are aiming at the wrong target, it doesn’t matter how well you choose and employ a SIT; it will be misguided and ineffective. Even if you have identified the right target but poorly align the arrow, the outcome is a miss. What are some identifiable targets?

SITs often target problematic emotional processes. Barlow and colleagues (Barlow et al., 2011) have identified eight protocols for treating emotional disorders that span the entire mental health system: (1) motivational enhancement, (2) understanding emotions and monitoring and tracking emotional responses, (3) emotional awareness, (4) cognitive appraisal and reappraisal, (5) emotional avoidance, (6) emotionally driven behavior, (7) awareness and tolerance of physical sensations, and (8) interoceptive and simultaneous emotional exposure. These protocols, or targets if you will, can have an array of SITs to address them.

An additional target is the spiritual dimension. Hook, Worthington, Aten, and Johnson (2013) proposed that mental health practitioners, specifically Christian counselors, should be able to use various techniques to facilitate deep-level sanctifying transformation in clients’ relationships with God, others, and themselves (p. 123). While Christian counselors often work with non-Christians, an integrative approach can be expressed in how you exemplify Christ-incarnate with the client—for example, being present and counseling in such a way that the client witnesses the adorable attributes (e.g., love, gentleness, longsuffering) of God as evidenced in the person of Jesus Christ embodied in you and your clinical work (Thomas & Sosin, 2011). The heart of a Christian counselor is to see transformation at all levels in their clients—not just in psychological outcomes but in God-centric outcomes as well.

The bottom line is that the measuring stick for counseling efficacy is client outcome, which is defined ultimately by the client (Thomas & Sosin, 2011). Client outcome can include whether the client feels less distressed, feels more in control, has improved relationships, possesses a better sense of self, and is no longer impaired, deviant, dangerous, or dysfunctional. Thus, skill development aids in implementing strategies and employing techniques and processes that facilitate effective change in the lives of clients.

STRATEGIES, INTERVENTIONS, AND TECHNIQUES

Most people do not differentiate between the terms technique, strategy, and intervention. Though the terms are often used interchangeably without violating the therapeutic gospel, they do represent different aspects of clinical work. Strategies are modi operandi, or plans of action customized to meet a particular goal. In essence, they are a procedural plan to get from point A to point B (Cormier & Cormier, 1985); they represent the overall target, or the forest instead of the trees. Interventions, on the other hand, refer to a clinician’s aim at disrupting and/or alleviating client problems. To further our analogy, interventions represent the trees within the forest or a specific arrow to fire at the chosen target. I consider techniques as the branches on the tree or aiming for the bull’s-eye. In sum, Thompson (2003) offers a slightly different perspective of the terms: Fundamentally, a counseling technique is presented as a strategy. A strategy is an intervention. An intervention is a counselor or therapist’s intention to eliminate or illuminate a self-defeating behavior (p. xi).

The starting place is to formulate a path forward that addresses the client’s concerns and issues. Then the counselor can customize the strategies based on the assessment data and the desired outcomes or targets. Interventions are best understood as functions of goals and outcomes. In other words, an intervention is determined for each concern or issue in the treatment plan that is aimed at the client’s targets. Though techniques can be linked to theory, they are the actual therapeutic action that corresponds to an intervention and strategy.

Figure 1.1 illustrates the differences between strategy, technique, and intervention. Other strategies would include motivational interviewing, systemic work, behavior modification, self-awareness, sobriety, normalizing, referral for psychiatric evaluation, reducing frequency of maladaptive behaviors, taking a sexual history, and even spiritual growth. After settling on the strategy, the basis is set for selecting an intervention, such as addressing core beliefs. Others could include considering evidence for a belief, assigning homework, putting a filter on one’s computer, and learning self-enhancement training. Finally, examples of techniques include learning about distorted beliefs, using the cognitive downward arrow, or using the antecedent-belief-consequence model (ABC). Other techniques that are associated with various strategies and interventions could include systematic desensitization, self-monitoring, reframing, cognitive restructuring, relaxation training, response prevention, sculpting, enactment, the empty chair, genogram, sensate focus, and a host of others.

A prerequisite of an effective intervention or technique is timing. Cormier and Cormier (1985) suggested five criteria to consider prior to implementing SITs: (1) the therapeutic relationship is established, (2) the problem has been thoroughly assessed, (3) goals have been mutually agreed upon, (4) the client is ready and committed to change, and (5) baseline measures have been created. For example, if a client is uncertain of whether to deal with a problem, a therapeutic strategy might be to address client readiness. The intervention might be to address a discrepancy between the client’s future desires and current behavior, and the technique might be to side with the negative (explore motivational interviewing for deeper understanding of these concepts).

Figure 1.1. Relationship between strategy, intervention, and technique

Figure 1.1. Relationship between strategy, intervention, and technique

Because client problems are multidimensional, are controlled by diverse variables, and are the targets of change, treatment is often implemented in combination. Recall the famous question by Paul (1967): Which treatment strategy or combination of strategies will be most effective for the client with these desired outcomes? (p. 111). In sum, it is necessary to select and sequence a variety of strategies, interventions, and techniques to address the complexity and range of problems presented by a single client.

TECHNIQUES AND THE PERSON OF THE COUNSELOR

In this profession, the person of the counselor is the instrument and the tool by which therapy happens (Thomas & Sosin, 2011). Corey (2005) contends that the person of the counselor is the main technique of counseling. When it is used, everything about the therapist is dynamically present in everything that occurs in the session. Famed family therapist Virginia Satir (1987) said, Therapy is a deeply intimate and vulnerable experience, requiring sensitivity to one’s own state of being as well as to that of the other. It is the meeting of the deepest self of the therapist with the deepest self of the patient (p. 17). Raines (1996) asserts that when we meet people who have suffered malignant deprivations and losses . . . only the provision of an authentic person will suffice (p. 373).

While the counseling profession does attract healthy individuals, it also has a notorious reputation of being a magnet for the impaired and unhealthy (Thomas & Sosin, 2011). Diane Langberg eloquently articulated this truth:

If it is true that those who seek us out are broken, needy, and vulnerable, and if it is true that you and I are called by God to shepherd such people, then we must learn how to shepherd fitly. Furthermore, if it is true that such a task is so serious and awesome because of its potential impact for good or evil in the lives of others, and if it is also true that shepherding selfishly and unfitly grieves the God who has called us, then we had better learn to counsel according to the Master’s own heart. (as cited in Clinton & Oschlager, 2002, p. 75)

Because of this fact, many counselors harm rather than help. Whereas general ethical codes hold that the foundation of the code is to do no harm, as Christians our foundational ethic is to love as Christ loves. That mandate necessitates careful monitoring of our own hearts.

The effectiveness of counseling hinges on the person of the counselor (Wampold, 2001) and his or her ability to draw from God. The apostle Paul scribed in his letter to the Corinthian congregation: Our conscience testifies that we have conducted ourselves . . . in our relations with you, with integrity and godly sincerity (2 Cor. 1:12). Wisdom, compassion, and integrity cannot be taught in a classroom, seminar, or book. Openness and curiosity are essential to cultivate self-awareness.

Therapeutic skill is important, but the person of the therapist subsumes any ability, theory, or technique (Thomas & Sosin, 2011). If honoring God through your work is your desire, then you will not become complacent where you are; rather, you will continue to press toward excellence (cf. Phil. 3:13–14; Col. 3:23). Be committed to a life of spiritual and psychological growth. The past is the blueprint for a person’s present and future life. It will dictate one’s life unless that person intentionally chooses to do something about it. Just as we advocate for clients in their struggles, we must choose to face our own issues (Thomas & Sosin, 2011). If lack of spiritual vigor characterizes your heart, seek renewal.

One indication that the person of the counselor is not being sufficiently emphasized is when the therapist fails to communicate his or her values. Therapist values will be manifest in and through the work of and approach toward counseling. Seasoned therapists creatively use strategies, interventions, and techniques that are consistent with their value system, personality, theory, and the client’s issues (Thomas & Sosin, 2011). Giving novice counselors a how-to list that covers every scenario is simply not possible. But if I had to try, the person of the counselor would be at the top. Crabb (1977) aptly described it this way: Counselors who value technique above conviction and theory above character will not adequately shepherd their clients (p. 15). Because we are the tool with which God engages our clients, we must be well-maintained three-dimensionally—body, soul, and spirit. A dull machete cuts very little.

STRATEGIES, INTERVENTIONS, TECHNIQUES, THEORY, AND SCHOOLISM

Even though techniques emerged out of particular schools of counseling (e.g., Gestalt, Adlerian, Jungian, classical behaviorism), most are applicable to clinical situations regardless of the school. Colleague Dr. Gary Sibcy (personal communication, October 14, 2016) says that schoolism is dead. He coined the term schoolism to denote the idea that one theoretical system is correct and all other systems are incorrect, inferior, and/or irrelevant. Sibcy says that trans-theoretical integration and metatheory as well as various forms of eclecticism have replaced schoolism. Presently the view that different modalities provide a separate level of analysis or lens into human functioning is a preferred framework. This shift is toward understanding how disorders/spectrums of problems develop and maintain across various levels of functioning (cognitive, behavioral, emotional, interpersonal/social, and even spiritual).

Consequently, several meta-theories such as developmental psychopathology and interpersonal neurobiology have been created. The evidence-based treatment (EBT) movement has developed out of and parallel to this evolution of theory, promoted by experts such as Barlow, Linehan, and McCullough. Clinicians are to consider the spectrum of emotional disorders and, based on the current science about those disorders, develop unified treatment protocols or treatment packages that target specific processes that underlie the broad range of emotional disorders that play a role in the maintenance of the problematic emotions. Treatment packages draw from a variety of treatment approaches (e.g., cognitive, behavioral, emotional, relational) or theoretical perspectives (e.g., emotional-focused therapy, cognitive behavioral therapy, Adlerian, Gestalt). The common factors movement has also linked into this evolution. This movement looks at various components involved in all or most of the effective treatments and incorporates these into the treatment packages. Research has found nonspecific factors and core competences, or common factors that are foundational to counseling and span all theories and schools of psychotherapy (cf. Drisko, 2004; Russell, Jones, & Miller, 2007; Stuart, Levy, & Katzenstein, 2006).

As a result, therapists have come to classify themselves as eclectic. This is typically code for their practice of borrowing SITs from many schools of psychotherapy. Gladding (2006) associates techniques with specific theories, such as the empty chair technique with Gestalt theory. Without consideration of the purpose and function of the SITs in these schools of therapy, eclectic therapists fall into the trap of using what they think might work for the problem at hand. Yontef (1993b), for example, challenges the notion of separating techniques from their theoretical schools of thought. His rationale is that each technique functions to accomplish a clearly relevant outcome; for example, the empty chair technique is a means to the client resolving unfinished business, a key point in Gestalt. As an existentially based theory, the empty chair moves a client from dialogue about a person or issue toward the present moment experience in a fuller and more holistic form. It allows clients to get in touch with their felt experiences. This technique would be unhelpful, therefore, for emotional and dramatic clients who are overly connected with an emotional part of self.

This doesn’t mean, however, that non-Gestalt therapists can’t still use techniques associated with this school of clinical thought. For example, a counselor might consider himself a cognitive behavioral therapist but employ the empty chair since it is appropriate to the strategy and intervention. If the cognitive behavioral counselor believes that a client needs to connect with the whole of self and express latent emotions (strategies), he can incorporate it into his stated approach. If the later strategy is the focus, the intervention might be to express feelings associated with particular beliefs, and the technique the empty chair.

The conclusion is that techniques can be responsibly or effectively used without considerations of relationship and overall methodology and philosophy (Yontef, 1993a, p. 84). For example, a counselor might consider himself a cognitive behavioral therapist but employ the empty chair since it is appropriate to the intervention and strategy. Yet the empty chair technique arose out of an existential theory, specifically Gestalt. The empty chair was a means of working through unfinished business, such as integrating disowned parts of self and promoting catharsis.

BENEFITS OF THERAPEUTIC STRATEGIES, INTERVENTIONS, AND TECHNIQUES

A number of writers have proposed a rationale for the use of techniques in counseling (Conte, 2009; Jacobs, 1992; Rosenthal, 1998; Sobell & Sobell, 2008). They agree that the use of counseling techniques can improve therapeutic outcomes. For example, Conte (2009) says that techniques help therapists to construct effective communication with clients. Using techniques can increase client understanding of self, the world, God, and how he or she interacts with others. In addition, Rosenthal (1998) offers six benefits of using techniques: (1) they allow the client to surmount an impasse or sticking point; (2) they can renew the client’s interest in therapy; (3) they offer an escape from the humdrum experience of doing the same thing session after session by adding variation and creativity; (4) they can be used as an adjunct to any brand or modality of therapy; (5) they are often what clients insist are responsible for their improvement; and (6) they can be highly efficacious when applied to a given symptom, difficulty, or disorder.

Likewise, Jacobs (1992) offers seven benefits of techniques: (1) they make concepts more concrete; (2) they heighten awareness; (3) they dramatize a point; (4) they speed up the counseling process; (5) they enhance learning because people are visual learners; (6) they enhance learning because people learn through experience; and (7) they give focus to the session.

MULTICULTURALISM AND STRATEGIES, INTERVENTIONS, AND TECHNIQUES

Cultural competence is a staple of any counselor’s toolbox. The uniqueness of the individual as well as his or her cultural group membership needs to be respected at all times. The counselor needs to be knowledgeable regarding culturally competent psychological evaluations and other types of assessment and regarding treatment planning and choosing and implementing SITs. This volume does not specifically discuss how to adapt SITs for specific cultures nor which ones might be contraindicative for a specific culture. Though I have decided not to detail the cultural issues of a specific SIT that is discussed, that does not mean, however, that multicultural discussion of it is unimportant. I defer to your cultural competency in making prudent decisions concerning each SITs cultural appropriateness.

THE LIMITATIONS OF STRATEGIES, INTERVENTIONS, AND TECHNIQUES

Over the course of my lifetime, I’ve heard thousands of sermons, each having a different level of impact. Some were exceptional and inspirational. Others were challenging, nourishing, and illuminating. Sadly, I’ve heard messages that were scripturally unsound, heretical, and shaming. In spite of the fact that a sampling of the ministers had constructed a homiletic masterpiece, their messages had as much positive spiritual impact as a pew.

As part of my undergraduate degree, I enrolled in a homiletics class. I preached a semester of assigned sermons and learned the central factor in a good sermon. But after my first message, I was taken aback by my low grade. While the message was technically sound, it lacked impact. Though I adhered to all the guidelines for writing a quality message and my hard work led to a well-crafted sermon, I failed to pray and commit the process to the work of the Spirit. In my case, I consulted the commentaries without consulting the Holy Spirit. With prayer, even a sermon that does not adhere to homiletical guidelines can have a positive spiritual impact far beyond these deficits.

While the use of techniques is woven into the fabric of counseling, reducing counseling to a collection of techniques is misguided. Leitner (2007) articulated this point well, saying that counseling is not about assembling a bag of tricks or incorporating a formula. A counselor who has acquired many techniques is merely a technician skilled in a gimmick. According to Thompson (2003), The counseling experience is much more than the counselor’s use of technique; the human dimension of the relationship as well as the readiness and responsiveness of the counselee are also very important (p. xii; as cited in Thomas & Sosin, 2011, p. 92). As Thomas and Sosin (2011) remind us, Helping someone is not a procedure but a healing relationship. It is through the interaction of the counselor and counselee, with the work of the Holy Spirit that produces real change (p. 64).

DISTINCTIVENESS OF SPIRIT-INFUSED COUNSELING

A unique feature of Christian counseling is that the therapist and client(s) are never the only presences in the office. Indwelling within believers in Christ and operative within the office walls is the powerful Holy Spirit. The apostle John recorded Jesus’s words that he would ask the Father to give us the Holy Spirit as our advocate. He said, You know him, for he lives with you and will be in you (John 14:17; see also 6:13; 1 Cor. 3:9, 16–17; 6:17, 19; 1 John 2:27). Since the Holy Spirit is already within us, we are responsible to connect with and draw awareness and discernment from him. As we share our hearts with the Holy Spirit, we engage in dialogue; we speak to him and he speaks to us. As we linger in his presence, he will abide with us during therapy. He not only transforms the therapist personally but also supernaturally empowers the counseling. This process is not limited to therapy with clients who consider themselves Christians, but can be used with anyone. Spirit-infused counseling can take place even if no faith issue is ever discussed.

A counselor who seeks to work distinctively from his or her Christian center must be sensitive to the Holy Spirit’s leading. He is our sixth sense, the most important sense that we can have since he is the Spirit of truth. We must grow in grace and truth ourselves, holding tightly to the Word of God. Employing a psychotherapy theory or SIT without it being well formed in you is impossible. The theory and therapy must be formed well in your mind to be effectively used. Knowing a Bible verse and having it well formed in your mind and heart are quite different.

The clinician’s cleverness in choosing SITs or prowess in employing them will not promote true transformation in the client. Rather, transformation will come from the counselor’s willingness and ability to be fully present with the client and fully engaged with the Spirit of God. SITs are simply tools that can help us as we are already spiritually present and engaged.

GENERAL GUIDELINES FOR EMPLOYING SITS

The collection of SITs in this book are not meant to be a cookbook approach to clinical work. The intent is to provide you with a sampling of effective means of addressing particular problems, issues, or populations. It is not expected that all of the SITs will work for every client. The selection of them, however, should be purposeful (Mozdzierz, Peluso, & Lisiecki, 2011). While EBTs are considered to displace the need for schools of psychotherapy (e.g., Barlow, 2011; Luborsky et al., 1999; Nathan & Gorman, 2002), it is still important to have a theoretical orientation that encompasses how humans function and come to dysfunction, and what it takes to move the maladaptive patterns, improvised life themes, distressful emotions, problematic cognitions, spiritual impairment, and pathological disorders to healthy functioning. Always remember, however, that SITs are founded on an accurate and thorough assessment of the client(s), client motivation and readiness, the quality of the relationship, the therapist’s experience, and the whisper of wisdom from the Holy Spirit into the therapist’s mind. Following are seven guidelines to keep in mind when selecting and implementing SITs.

GUIDELINES

First, determine whether the SITs are consistent with a Christian worldview. As I noted in Therapeutic Expeditions: Equipping the Christian Counselor for the Journey (Thomas & Sosin, 2011), A skill is a skill; the philosophy upon which counseling is built matters greatly. For this reason we contend that a biblical worldview aptly anchors the counseling techniques and skills in God (p. x). Christian counselors consider whether the SITs can and should be used given their philosophical underpinnings and their targets.

For example, mindfulness is used to assist clients with slowing down their stress-filled, hurried pace of life that feeds rumination and anxiety (Garzon & Ford, 2016). When mindfulness is conceptualized from its roots in Buddhism, it involves an emptying of the mind. Mindful meditations, however, focus attention. The work of mindfulness is not working; it is a kind of surrender. From a Christian standpoint, clients are to maintain a nonjudgmental and present acceptance of awareness based on divine grace. Garzon and Ford (2016) view mindfulness from the biblical idea of a conscious connection with a present and relational Godhead. Garzon and Ford advance such adaptations as using meditation to support self-acceptance and self-compassion by focusing on God’s grace and goodness. Additionally, mindfulness can be explained by likening it to being watchful of unruly thoughts and feelings in the present moment through the peace of the Spirit (Gal. 5:22). It is a way to lasso those wayward thoughts and feelings that enter the mind, no matter how godly an individual lives. The mindful Christian observes what is happening, maintains distance by avoiding those thoughts, collects them, and then corrals them, while resting in Christ.

Since the foundation and scaffolding of a Christian worldview is truth, wise counselors choose and employ SITs that are also based in truth. Standard of care requires the use of EBTs (Thomason, 2010; Worthington & Johnson, 2013), though its prudence is questioned (Mozdzierz et al., 2011): When mainstream counselors seek to build their approach upon evidence-based treatments they are advocating that counselors employ strategies that are based on ‘truth.’ . . . Christians committed to honoring God’s Word realize that while evidence-based treatments are worthy of being utilized, the philosophical underpinnings of one’s entire approach should also be ‘evidence-based’; that is, based on truth (Thomas & Sosin, 2011, p. 21).

Garfield and Bergin (1986) stated that progress in developing new and more effective techniques of psychotherapy has obscured the fact that subjective value decisions underlie the choice of techniques, the goals of change, and the assessment of what is a ‘good outcome’ (p. 16).

Often the use of SITs does not pose an issue for a Christian therapist. For example, while the empty chair technique has existential and humanistic origins, it is based on the Gestalt notion of internal polarization, which makes it easily adaptable to use in Christian counseling, given that Christians have their own reasons to appreciate the internal complexity of human beings, since we are made in God’s image. The purpose behind using the technique is generally far more critical than the technique itself (Thomas & Sosin, 2011, p. 23). In sum, a Christian worldview doesn’t mean that we have to throw the technique out with the humanism bathwater.

The second guideline is to ensure that the SITs are consistent with you, the therapist. The more naturally a SIT can be carried out, the more authentic and poignant it will be. Any SIT that makes you uncomfortable or is discordant with your person needs to be avoided. Allow what is inside you to flow into the client. Part of what emanates from you, as well as being infused in you, should be the Holy Spirit (John 14:26; 16:12–13) and his bestowed fruit (Eph. 5:22–23). More importantly, just as God actively enters the world, the counselor enters into the world of the counselee. The counselor exists outside of her work and outside of the therapeutic helping relationship (Thomas & Sosin, 2011, p. 23). Be aware of your beliefs, attitudes, values, and feelings.

Third, ensure that the SITs are germane to how you conceptualize healthy and problematic functioning. While schoolism might be dead, as counselors we still need to have a robust and coherent understanding of human behavior in order to make sense of client behavior. Additionally, clients also have reactions to our derived SITs based on our conceptualization. Some clients will outright reject an intervention or technique that they believe is not going to help them, violates their values, or will make them uncomfortable. Other clients may passively go along with it but will likely not return, citing that the therapist was a poor match. For very disturbed clients, it is best to avoid using any interventions and techniques that might be viewed as contrived, rote, repetitive, or impersonal. Many may feel humiliated by the suggestion or will be unable to engage with the intervention or technique. The best strategy is offering them a strong and stable safe haven so they can face their issues and behavior with a clear sense of warmth and acceptance.

The fourth guideline is consideration of client welfare. Most SITs pose no risk for clients, especially when context, demographics, timing, and skill level are accounted for in the decision making. A selective few SITs, however, may pose a risk for certain clients. Clearly any SIT that the client feels uneasy about should be explored and an acceptable alternative used instead. Certain SITs might be unwarranted and harmful based on the nature of the client’s disorder or issue, or due to the phase of treatment. Consider an individual who has been traumatized and is susceptible to abreactions. Employing a technique with such an individual is contraindicated if there is concern for decompensation. If uncertainty exists that the client might not weather a SIT due to inadequate ego strength and coping skills, don’t use it. Additionally, exposure techniques are effective with anxiety disorders, but the client might not be able to tolerate them. Examples are those clients who have co-occurring disorders that mitigate standard techniques or those who are too fragile for a technique such as flooding. Paradoxical techniques are very effective but pose the risk of confusing clients, shutting them down, or making them feel attacked.

Fifth, the SIT should be suitable for the issue. Rather than thinking about particular interventions or techniques, begin with knowing what it is you want to accomplish. This is counselor intentionality. By knowing what you want to do or need to do, you can have a clearer sense of how the session should proceed and how to accomplish what is necessary to bring change.

Sixth, be flexible. Because of the diversity of populations that counselors serve, one size does not fit all (Thomas & Sosin, 2011, p. 63). A seasoned counselor knows how to adapt and apply a particular SIT to a particular client. Additionally, speak the client’s language. Though SITs will be expressed through each therapist in a unique way, skilled clinicians have the ability to adapt them to each client.

Finally, when choosing to implement a particular SIT, first explain its purpose. Consistent with informed consent is the client’s understanding and willingness to experience the course of action. Connect the SIT with a sound rationale for using it. To do so is not only ethical but demonstrates respect for the client’s freedom and autonomy. Becoming proficient at the use of SITs takes time, but it begins with understanding their nature and purpose and learning to effectively communicate this to your clients.

THE HEART OF THIS BOOK

This book is designed to be a clinical resource in your educational training and practice. It contains an impressive roster of accomplished and skilled contributors. The volume is composed of well-known authors, speakers, and faithful workers who desire to love and minister to others in the name of Christ. Other contributors will be introduced to you, and although they may not have established a platform to have name recognition, they, too, bring a wealth of knowledge and extensive experience. We all are fortunate to be able to learn from the expertise of these esteemed colleagues. I am both honored and pleased to be able to share and disseminate their clinical wisdom. This book is a testament to the quality and depth of the field of Christian counseling.

The chapters in this book are designed to include particular features: an introduction; a theology and psychology of the topic; at least one case study; and then exemplary strategies, interventions, and techniques. Every contributor also provided a recommended reading list to deepen your knowledge, abilities, and skills on that given topic.

Every attempt is made by the contributors and myself to create a conversational volume that will benefit advanced graduate students with relevant conceptual and practical clinical information to enrich their counseling. The main purpose of the informational section of each chapter is to provide a foundational platform and conceptual bridge to wisely applying the therapeutic tools of clinical work. Contributors were asked to share their thoughts and experiences in their own manner, following the broader chapter guidelines.

In the twenty-seven chapters that follow, the contributors and myself address a wide range of practical strategies, interventions, and techniques that can augment more effective counseling. Arguably, one volume cannot adequately address all the factors that comprise the complex and holistic aspects of helping all clients and addressing every clinical presentation. We have, however, attempted to provide you with a broad perspective based on various theoretical strategies and a range of clinical issues with which therapists are presented. I pray that these chapters will renew your interest in learning and growing in your clinical expertise and/or build on your interest to further develop and mature your knowledge and skills. Readers with more extensive knowledge of some of these strategies, interventions, and techniques can expect to broaden their understanding and obtain additional knowledge and tools to augment their practice.

As you work with the wounded, broken, lost, and exploited, take with you the words of psychologist, philosopher, and physician William James, Act as if what you do makes a difference. It does.

CONCLUSION

The debate over the value of SITs will likely never be settled. The effectiveness of using them, however, cannot be dismissed as invaluable. All would agree that counseling is an interpersonal process, meaning that it is the active engagement of two or more participants. As providers of clinical service, counselors who walk in the Spirit are often prone to avoid a technical approach. Interventions and techniques are only a vehicle to accomplish the objective of change. The nature of counseling lends itself to equifinality; many paths can be taken to reach the desired destination. Seasoned therapists have knowledge of numerous passages and believe they are competent to negotiate them. This book is one means of learning the tools to guide and help others achieve their aim.

The armamentarium of available and viable SITs is far beyond the scope of this book. Including even the lion’s share suitable for every client issue or from a particular theoretical model is impossible. If a reader finds his or her favorite SIT not discussed, it is likely due to space limitations. I am delighted to be a part of this volume with gifted contributors who provide outstanding insights into clinical presentation.

I end this introduction with the Prayer of St. Francis, a prayer that captures the heart of counseling:

Lord, make me an instrument of your peace:

where there is hatred, let me sow love;

where there is injury, pardon;

where there is doubt, faith;

where there is despair, hope;

where there is darkness, light;

where there is sadness, joy.

O divine Master, grant that I may not so much seek

to be consoled as to console,

to be understood as to understand,

to be loved as to love.

For it is in giving that we receive,

it is in pardoning that we are pardoned,

and it is in dying that we are born to eternal life.

Amen.

RECOMMENDED READING

Barlow, D. H., Farchione, T. J., Fairholme, C. P., Ellard, K. K., Boisseau, C. L., Allen, L. B., & Ehrenreich-May, J. T. (2011). Unified protocol for transdiagnostic treatment of emotional disorders: Therapist guide (1st ed.). New York, NY: Oxford University Press.

Garzon, F. (2013). Christian devotional meditation for anxiety. In E. L. Worthington Jr., E. L. Johnson, J. N. Hook, & J. D. Aten (Eds.), Evidence-based practices for Christian counseling and psychotherapy (pp. 59–78). Downers Grove, IL: IVP Academic.

Satir, V. (1987). The therapist story. Journal of Psychotherapy and the Family, 3(1), 17–25.

Shallcross, L. (2012). The recipe for truly great counseling. Counseling Today. Retrieved from http://ct.counseling.org/2012/12/the-recipe-for-truly-great-counseling/

PART 1

Theory-Based Strategies

CHAPTER 2

Evidence-Based Counseling

DAVID LAWSON, PSYD

Dear children, let us not love with words or speech but with actions and in truth.

1 JOHN 3:18

Most of the time I struggle with chapters that address evidence-based therapies (EBTs), and I have been known to skim or skip the chapter altogether. For me, EBT chapters just do not have the glamour of other chapters that discuss theories, skills, and pathologies. For many, the idea of another chapter that addresses numbers, statistics, and research can feel unnecessary in a field dominated by relationships. Who wants to read another chapter highlighting cognitive or behavioral approaches as the two clear victors in the Who has the most effective therapy? game when working with clients? I believe this mentality has slighted the field at a time when other theoretical approaches are becoming more prominent in studying strengths through the evidence-based approach.

Another difficulty is the connection of EBTs to insurance companies and reimbursements. Many of my students, when I lecture on the topic of EBTs, interpret the attempts by insurance companies to contain costs as attempts by companies who have little to no heart for the client or profession to mandate behaviors and therapeutic modalities. Although the bottom line of any business plays a role in the development of limits and directives, one positive feature of EBTs is that they continue to refine and define the profession, helping us make adjustments in certain areas, changing the emphasis in others, and honing the skills of our practice and trade. And so, despite the challenges of working with institutions like insurance companies, EBTs have provided valuable evidence to balance the overemphasis on business and expediency in finishing therapy.

Add into the mix the weakness of the classes on research and statistics that are generally offered in master’s level counselor training programs, and you have a setup for disaster. Most of the graduate classes at my university and others are designed to help counselors be critical consumers of research. Although this is good for the many who struggle with math and numbers, a lack of critical understanding of research has weakened our ability to effectively understand and apply, and thus benefit from, EBTs. So although EBTs have significantly gained influence in the counseling and therapy cultures, many practitioners are incapable of reaping their benefits because of a lack of training. And many are dependent on others to interpret the significant movements of EBT.

Moreover, much of our mental health curriculum highlights ways in which research done well can further the knowledge base. Yet a poor understanding of research can cause problems for counselors and guide them to incorrect answers. We often teach students to be highly critical consumers without reminding them to balance the weaknesses with the strengths found in the research being criticized. I fear we have created more doubt in the value and strength of our students’ research. This weakness in our training programs sets up many consumers of research to marginalize what is being accomplished in EBT versus informing or getting counselors excited about the field and its research.

Finally, this chapter benefits the reader in multiple ways, even if your therapy of choice is not the prescribed EBT found in the literature. First, EBTs not only give insight into what therapeutic modalities work but also provide guidance for use of what techniques might work with specific populations. So, even if you are not a supporter of a specific therapeutic modality, any therapist can benefit from integrating techniques that work with the given problem. Second, EBTs are a constant reminder of the changing field that we work within. Therapists can easily become complacent about their work, comfortably repeating the same styles and techniques even if better and more effective techniques are available. By staying connected to the research and EBTs, we not only stay current but provide the best services to our clients who desperately need the best from us.

Although some readers may hope this chapter provides reading lists of therapies that work with specific populations or pathologies, I, however, focus on the concept of EBTs and provide a summary of their strengths and weaknesses. Many other great books connect diagnosis to the specific EBT. For readers who would like more formulaic approaches, Practitioner’s Guide to Evidence-Based Psychotherapy, edited by Fisher and O’Donohue (2006), is an exhaustive volume, covering the field of EBT and the approaches that work based on research. Also, the series Treatments That Work, edited by David Barlow and colleagues, takes a more specific approach to EBTs, highlighting therapeutic choices and techniques for specific cases, such as anxiety, depression, and other emotional disorders. Many books and articles provide these resources, and it is beyond the scope of this chapter to unpack the therapies that work and why. We will begin by understanding how and why EBT began, then the benefits and hopes of EBTs. Finally, I will conclude by addressing the weakness found within EBT.

HISTORICAL FOUNDATIONS OF EBTS

Although the current iteration of EBTs sounds very new or novel, for many authors the foundation of EBTs began in the 1970s and continued through the 1990s with the advent of health management organizations (HMOs). In one sense, however, EBTs are as old as the profession itself. From the moment Sigmund Freud began working with patients, other professionals and the culture in general doubted that his work had meaning (Masson, 1984). Freud worked diligently to create an intrapsychic framework to model counseling after the acceptable EBTs of the time, which were structures in medicine, that is, the body. Freud therefore created a map of the intrapsychic body, and developed a theory around how that system functioned, how it became sick, and how to move that body to health. Thus, Freud’s emphasis on the id, ego, and superego, as well as his drive theory were all attempts at constructing a model that was consistent with the knowledge and understanding of his time; he medicalized the inner world to fit the medical (EBT) needs. Freud’s emphasis on making therapy fit the accepted medical models of the time was simply his way of creating an EBT. Without this extensive theory building, others in the professional community would have rejected his work outright, and the field would have died.

Although many modern counselors, particularly those who research EBTs, struggle with Freud’s ideas today, we cannot ignore the fact that Freud not only created the process for modern therapy but also started the process through which we study it and, in the case of EBTs, how we currently evaluate the field. And while the field of therapy continued to grow and develop, it wasn’t until Freud’s death that therapy branched out into the various theories we have today.

Throughout therapy’s brief history as a profession, we have needed to constantly defend ourselves from naysayers who argue that therapy is ineffective (e.g., Eysenck, 1992; Maloney, 2013). Although small pockets of cynics existed in both the medical and psychological communities, it wasn’t until the 1960s that a true attack on therapy began from the very system we are now discussing—research. One such researcher, Hans Eysenck, is one of the most quoted psychological researchers in the twentieth century. His interests ranged from the nature of intelligence, pathologies and the effectiveness of therapy, to the eccentric, parapsychology and astrology. He is best known for his psychological tests that are still in print today; however, one of the grandest claims he made during his life was that therapy was a fraud and ineffective. He researched people going to therapy for problems and compared them to a control group who were not in therapy and discovered that the therapy group didn’t get better, and shockingly to him, many got worse (Eysenck, 1992). This only confirmed his belief in the falseness of therapy, and like Nietzsche before him declaring that God is dead, he declared that the therapy field was dead. Although nearly everything about his research was discredited, his work was cited for years as the critical study proving/debunking the myth of therapy. When I took Introduction to Psychology in the 1980s, his works were still being presented as having validity despite the criticisms of his research.

From the 1960s to the 1980s, the number of therapeutic styles and theories ballooned. Many of these newer modalities stretched the boundaries of what was acceptable and even socially accepted. From nude encounter groups to scream therapy, the field exploded into a myriad of ideas and techniques. During this time, costs for therapy also skyrocketed, with many clinicians charging hundreds of dollars to insurance companies for an hour of therapy. And, since insurance companies began researching cost comparisons of all medical services around the United States, they decided to evaluate the cost of mental health services. Consequently, the field began to move toward HMOs, and given the various and sometimes extreme variance of costs and charges around the country, the development of cost controls began to even the playing field among multiple and at times extreme variance in payments.

As insurance companies were evaluating costs, they also realized that many health professionals were using various and at times conflicting forms of therapies to help their patients and clients. It is from this awareness that insurance companies, as well as many researchers, began asking the question about what actually works. Although it may seem like there has been an inordinate amount of emphasis on counseling and psychotherapy, in truth the whole medical profession has gone through an evaluation of what works and what does not. EBT is a key component of how nearly every medical community currently evaluates what they do and why.

EVIDENCE-BASED PRACTICE DEFINED

Defining EBTs has been a difficult and at times polarizing process. Many continue to struggle with how and why we define EBT, and as the field grew, so did the challenges. Although there are many who disagree on an exact definition, most agree on one key principle. The following quote accurately summarizes the principle behind EBT and gives us a starting place for defining it: The unknown is unacceptable; evidence is a human safety net (Smith, James, Lorentzon, & Pope, 2004, as cited in Ross, 2012, p. 5). One of the great difficulties confronted in medicine and even in the mental health community is the common reliance on lore and tradition over evidence from our field. Although often benign, therapies without valid evidence did at times both weaken the trust of our communities in their providers and deeply harmed clients to the point of death (Josefson, 2001). Thus, one of the challenges confronting our field is to validate the practices used in therapy to protect our clients and serve them in their healing.

Sackett, Rosenburg, Muir-Gray, Haynes, and Richardson (1996) define EBT as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research. Simply put, EBT is the best way for therapists to research what works in therapy and what does not. In his definition of EBT, Sackett has identified three key components of the decision process for therapy with clients.

First, the clinical expertise of the clinician is key. One of the great challenges when working with a client is the general level of complexity. Not every depressed client who walks into a room expresses depression in the same way. Therefore, one of the more central functions of the counselor is to gain enough training and to have enough practice to know the various ways a problem can manifest itself. Culture, family styles, religious traditions, as well as various other factors impact expression of an issue. Thus, a clinician needs to know about an issue and its various expressions. Humbly placing yourself in supervision with other clinical experts or entering a supportive training group where you can collaboratively learn to diagnose and case conceptualize is key to developing your skills. Entering personal counseling as a method to understand yourself, your biases, and your blind spots is another effective way to grow that skill.

Second, clinicians must evaluate what evidence is available in best practice and treatments. Evidence does exist in nearly every area of medicine and mental health for which practices are effective. Constantly reading literature in your area is a key component to staying abreast of current trends, theories, and practices in the field. Taking advantage of continuing education classes in a specific area as well as supervision, consultation, or therapeutic groups in which you can share your ideas and your knowledge is also beneficial.

Finally, every client is unique and requires a uniquely different way of engagement and relational process. Even if you have studied and developed the requisite skills necessary to diagnose and treat a client, and even if you are current on the most effective therapies available, if you do not account for the individuality of the client and his or her style of engaging, the best therapies will be rendered ineffective due to a lack of social, cultural, and relational awareness. Counselors have been taught for years that every client is a unique cultural experience, and this is exceptionally true when utilizing EBTs with clients. Effective therapists learn to balance themselves and their training with the most effective EBTs alongside the uniqueness of the client. This exceptionally complex process may explain why many clinicians struggle to engage in EBTs after they graduate and might help us identify ways of moving forward to help encourage young clinicians to keep developing, growing, reading, and utilizing the best practices for clients.

BENEFITS OF EBT

Using EBTs has many benefits. Probably the greatest benefit within the EBT framework is the greater care provided to clients. Best practices are not just a process of following rules and regulations. The real benefit of developing best practices occurs in the healing and potential as our clients get better. Often therapists may help their clients, and although research indicates that being present with clients can cause change, by utilizing EBTs, the hope of greater success in therapy exists, as well as quicker alleviation of symptoms. This is particularly relevant with clients who are overwhelmed or nonfunctional because of their pain. By integrating EBTs into practice, a professional knows she is providing the best treatment available. And if the client is nonresponsive to the treatment, the counselor can still feel confident that she provided the best of her profession to the client.

The second benefit of prescribing EBTs is the movement away from eclecticism and toward a more cogent theoretical framework. The last few decades have seen an increase in atheoretical approaches to treatment (Duncan, 2010). This increase has grown as more technique-focused or technique-driven approaches dominate graduate programs versus developing and utilizing a grounded theory from which to use EBTs. Although theory is not the panacea to any problem, therapists who use techniques without a clear understanding of the theories behind them run the risk of using techniques inappropriately or ineffectively. The adage holds true that when you discover the benefits of using a hammer, everything looks like a nail. Further, the integration of EBT forces mental health providers back into a theory’s development and integration, particularly when therapy is not going well. Problems or complications in a client or with a disorder