ESBT: Eclectic Structural Brief Therapy
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Eclectic Structural Brief Therapy (ESBT)
Self-Esteem Seekers Anonymous -
The SEA's Program of Recovery
By James J. Messina, Ph.D.
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A Therapy Truism:
How many therapists does it take to change a light bulb?
Just one, but the light bulb has to want to be changed.
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Introduction to Eclectic Structural Brief Therapy (ESBT)
How do therapists motivate clients to overcome their resistance to change within the therapeutic process, has taxed therapists for years. Research says that clients stay in treatment for from six to ten sessions and that they report maximum gains after three to six sessions and that brief therapy models have been found to have no significant difference in their effectiveness than those of long term therapy models (Budman & Gurman, 1988; Cummings, 1986; Budman & Stone, 1983). Budman and Gurman (1988) emphasize that brief therapy’s pragmatism and eclectism make it effective. Therapists who hold to a brief therapy model have values and beliefs about what can and cannot be accomplished in therapy. Brief therapy advocates believe that effective therapy results in the resolution of the current problems and not in the major modification of personality or character structure. Brief therapists believe that their job is to fix leaks rather than build a custom designed house form the ground up. Gelso and Johnson (1983) emphasize that short-term therapists exhibit behavior which reflects confidence in the efficacy of the brief therapy model, establish challenging but limited goals for treatment, work toward insight but also facilitate behavior change, and believe that their primary goal is to initiate a healing process that can continue throughout the clients’ lives.
Eclectic Structural Brief Therapy (ESBT) developed over thirty years by this author (Messina, 2001), is a model of brief therapy defined by the collaborative attitude of both the therapist and the “light bulbs” that are seeking such therapy. Most people do not engage counselors and therapists because they desire a lengthy process to uncover all subconscious and conscious drives which affect their mental health. They seek out therapy because they are in some form of crisis, which affects their mental well, being. They want to find coping strategies, which will assist them to alleviate their currently experienced pain. The ESBT model of therapy helps clients identify whether or not they are “light bulbs” wanting to be changed and if a match exists in temperament and personality style with the therapist. If there is the right mix of motivation and simpatico between clients and therapist then a change can occur in a brief period of time. If there is not a match, therapists need to encourage their clients to not pursue therapy at this time until they recognize they have a readiness and willingness to do what it takes to change so that they can become “turned on light bulbs.”
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Characteristics of Eclectic Structural Brief Therapy (ESBT)
1. Theoretical Basis
The Eclectic Structural Brief Therapy (ESBT) Model of therapy is based on the Model of Recovery from Low Self-Esteem (Messina, 1999-2001) which details:
- The causes of low self-esteem
- What are the behavioral consequences of low self-esteem
- A model of healthy adult self-esteem
- A recovery plan for adults to follow to overcome their low self-esteem
- A detailed explanation of the personality traits of low self-esteem which are involve the cognitive, emotional and behavioral consequences of experience low self-esteem
- Ways to overcome the introjected scripts which induce low self-esteem
- Therapeutic model of establishing and maintaining healthy boundaries in interpersonal relationships
2. Length of Session
ESBT is based on a flexible length of time. Their model does not rigidly adhere to the traditional 50-minute hour. Some therapists might utilize 15, 30, 45 or 60 minutes per session and then others might utilize whole day sessions with a family or group of clients to achieve the desired therapeutic goal. The length of time for each session is determined by the needs of the clients.
3. Frequency and Regularity of Sessions
Scheduling of sessions is flexible for better use of resources. The traditional weekly session, which was thought to help reduce resistance, is not needed in the ESBT model. Sessions might be daily, once or twice a month, or at longer intervals depending on the needs of the clients. In between sessions the clients would be encouraged to maintain contact with the therapist by use of email in which homework and reading assignments would be discussed. Also any problems which come up which the clients would like a third person perspective can be shared through such emails. There is no standard or predictable regularity and frequency of sessions in the ESBT model.
4. Duration of Treatment
Treatment length is flexible based on the needs of the clients. Some clients can be seen for just one session. Others might need up to 12 or more sessions within a year. The traditional length of treatment of from 1 to 3 years might be the same in this model but the number of sessions is not as important as the work being done by the clients to achieve the goals set out in therapy. In the ESBT model sessions could be scheduled at an as needed basis over many years and a longer time span because of the nature of the structured tasks which the clients takes on as part of the clients’ therapeutic plan.
5. Location of Therapy
ESBT clinical sessions are located where the clients can gain the most benefit. This could be in the office, the clients’ home, the hospital, a church, an agency, by email, on the phone, or in a therapeutic setting for desensitization purposes e.g. mall, airport, automobile, elevator, or airplane.
6. Initiation of Therapy
In the ESBT model clients are immediately engaged in taking responsibility for their own progress. This is done by clarifying immediately what brings the clients into treatment at this time by asking clients: “Why now?” questions to clarify the focus for the treatment, which is most responsive to their needs. This model emphasizes Nicholas Cummings’ (1988) caveat that a strong therapeutic alliance between the therapist and client must be established during the first contact to offer the client a sense of hope that relief from suffering is possible. As Cummings (pp. 312-313) explains: “In making a therapeutic contract with the client, we want to make clear that we are there to serve as a catalyst, but the client is the one who will do the growing. The contract is stated as follows: "I will never abandon you as long as you need me, and I will never ask you to do something until you are ready. In return for this, I ask you to join me in a partnership to make me obsolete as soon as possible."
7. Termination of Therapy
In the ESBT model the concept of termination is redefined as an interruption. The therapist informs the clients that further treatment is always available through the clients’ life cycle on an as needed, and usually intermittent, basis. In a traditional therapy model, therapy is concluded with the clients being viewed as a “completed product” never to return. In contrast, the clients in the ESBT model are introduced to the concept of “relapse” and are made aware that there are transitional times in people’s life, which might induce relapse. At those times the clients are encouraged to return for treatment to get “back on track” as soon as possible.
8. Goals of Therapy
The goal of ESBT model treatment is to assist clients to achieve greater insight and understanding on how they are contributing to their current problems by their own thoughts, emotions and actions. The intervention of the therapist might assist the clients to experience an emotional release of painful emotions, reinforcement of healthy coping skills, desensitization of fear-inducing stimuli, or confrontation and altering of personal problem behaviors.
9. Therapeutic Process
The ESBT model is a flexible therapeutic process based on a theoretical integration of a number of therapeutic models and perspectives:
- Limited and collaboratively set realistic goals similar to Reality Therapy (Glasser 1965 & 2000)
- Collaborative relationship between therapist and clients similar to Person Centered Therapy (Rogers, 1961)
- Rapid and early assessment done by therapist utilizing techniques from Systemic Family Therapy (Bowen, 1978; Haley, 1985; Minuchin & Fishman, 1981; Satir, 1983; Whitaker, 1976)
- Focused interventions similar to the Multi-model Behavioral Therapy (Lazarus, 1995)
- Staying centered in the “here and now” with the clients similar to Existentialist Therapy (May & Yalom, 1995)
- Directed activity accomplished by the clients similar to Cognitive Therapy (Beck, 1976; Ellis & MacLaren, 1998; Meichenbaum, 1997)
- Ventilation of emotions similar to the Gestalt Therapy (Perls, 1969)
- Teaching how to identify and refute irrational thinking similar to Rational Emotive Behavior Therapy (REBT) (Ellis & Harper, 1997; Ellis & MacLaren, 1998)
- Identifying, challenging and confronting psychological defenses similar to Psychodynamic Therapy (Freud, 1955)
- Encouraging personal responsibility taking and accepting the social consequences for one’s actions similar to Adlerian Therapy (Adler, 1930, 1931, 1938)
- Creative and efficient use of time
- Selection process by which suitable clients who are “light bulbs ready to be turned on” are enrolled in this treatment model (Budman & Gurman, 1988)
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How does Eclectic Structural Brief Therapy (ESBT) differ from long-term therapy?
There is now a vast literature on brief psychotherapy. Leaders in brief therapy include: Bennett (1983, 1986); Budman (1988); Cummings (1986, 1988); de Shazer (1982, 1985, 1988); Haley (1985); the MRI Group of Weakland, Fisch, Segal, and Watzlawick (1974, 1978, 1982); Strupp & Binder (1984); Talom, (1990); and Wells (1990). Reviews of the research (Bloom, 1992; Rosenbaum, Hoyt & Talmon, 1990; Hoyt, 1995; Rosenbaum, 1994) repeatedly have found brief therapy as effective as time-unlimited traditional therapies, regardless of diagnosis or duration of treatment.
Eclectic Structural Brief Therapy ESBT is a form of Brief Psychotherapy. Budman and Gurman (1988) pointed out that contrary to the romanticized beliefs about "long term" therapy, and the negative views of brief therapy that exist among many psychotherapists that there is very little research on the efficacy of long term therapy and hardly enough to justify the claims of its advocates. They go on to state that the efficaciousness of brief psychotherapy is based on outcome and process research. They point out that many consumers of psychotherapy benefit substantially from therapy experiences that last "only" between 2-5 months.
Budman and Gurman (1988) emphasize what makes brief therapy effective, is that it is pragmatic and eclectic. This comes from values of the brief therapists about what therapy can and cannot accomplish. Brief therapists believe that therapy results in the resolution of the current problem and not in the major modification of character structure. The metaphor would be comparing the building of a custom designed house from the ground up (long term therapy) or the fixing of a leaking sink (brief therapy).
To clarify the differences between long-term and short-term therapists, Budman and Gurman (1988) compare the values of the two types of therapists:
A. A Long-Term Therapist:
1. Seeks change in basic character
2. Believes that significant psychological change is unlikely in every day life.
3. Sees presenting problems as reflecting more basic pathology.
4. Wants to "be there" as clients make significant changes.
5. Sees therapy as having a "timeless" quality and is clients and willing to wait for change.
6. Unconsciously recognizes the fiscal convenience of maintaining long-term clients.
7. Views psychotherapy as almost always benign and useful.
8. Sees clients being in therapy as the most important part of clients’ life.
B. A Short-Term Therapist:
1. Prefers pragmatism, parsimony and least radical intervention and does not believe in notion of "cure."
2. Maintains an adult developmental perspective from which significant psychological change is viewed as inevitable.
3. Emphasizes clients’ strengths and resources; presenting problems are taken seriously (although not necessarily at face value).
4. Accepts that many changes will occur "after therapy" and will not be observable to the therapist.
5. Does not accept the timelessness of some models of therapy.
6. Fiscal issues often muted, either by the nature of the therapist's practices or by the organizational structure for reimbursement.
7. Views psychotherapy as being sometimes useful and sometimes harmful.
8. Sees being in the world as more important than being in therapy.
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Critical Factors in the Eclectic Structural Brief Therapy Model
A. Assumptions about clients held by therapist using the ESBT model:
1. The clients have experienced "faulty learning at some point in early life.
2. The clients and their/her environment interact and influence each other reciprocally.
3. The interpersonal environment of the clients is never neutral. It influences the clients positively or negatively.
4. Although personality, character, social supports etc. are all very important in people’s life patterns, chance encounters and chance events are also prominent factors in shaping life's course.
5. People understand experience, at least in part, on the basis of their stage of development.
6. There will be little to no therapy achieved until the clients are ready to change.
B. Therapist Factors in Eclectic Structural Brief Therapy Model
Critical factors concerning therapists in ESBT are:
1. The therapist must maintain a clear, specific focus and structure in the therapeutic process.
2. The therapist must maintain an active therapeutic role by suggesting activities or insights, collaborating and problem solving with the clients, using tasks and homework assignments and by asking questions.
3. The therapist must remain aware of the value of "time" in the process and that each session be valued as vital to the desired outcomes.
4. The therapist must make sure that the time between sessions is spent in carrying on the therapeutic process. This is done by liberal use of homework assignments. These assignments include readings, journal writing, practice of new behaviors such as exercise, joining self-help groups, public speaking, volunteering and trying new interactional patterns in the family, marriage and work or school setting if applicable.
5. The therapist must be willing to try new strategies and do something different and novel in order to move the clients to be motivated and challenged to deal with the presenting problems successfully.
6. The therapist must be willing to be flexible and eclectic in using a variety of treatment modalities for individual, couple, family and group therapies.
7. The therapist must be willing to use innovative session duration and re-scheduling.
8. The therapist must see end of treatment as interrupting vs. terminating and encourage the clients to recognize that therapy is a process over the whole life cycle and that he/she can return in the future on an as needed basis.
9. The therapist must be clear with the clients that relapse is a part of recovery and that to return to therapy is not failure but rather good common sense.
10. The therapist must be clear what the disincentives for brief therapy such as ESBT are so that they do not fall into the trap of unnecessarily lengthing therapy. Some disincentives are the bias of training programs against training therapists in the brief model, the current over supply of therapists competing for the same clients population and the financial survival need in the fee for serviced basis private practice.
C. Clients factors in Brief Psychotherapy
Although there is a common belief that 85% to 90% of all clients are appropriate for brief therapy Koss and Shiang (1994) indicate that individuals who appear to benefit most from brief therapy are those whose problems had a sudden or acute onset, were previously reasonably well-adjusted, could relate well with others and had high initial motivation when entering the therapeutic process. They went on to suggest that brief therapy may be inappropriate for individuals whose personal characteristics are in contrast to those noted above and for some types of psychological disturbances such as substance abuse, psychosis, and personality disorders. That being said, the factors, which seem to make clients good candidates for ESBT are:
1. The clients must have an average intellectual ability and capable of understanding the issues in involved. They must be able to read and write in order to many of the assignments given.
2. The clients must be psychologically minded and open to psychologically oriented insight, interpretations and suggestions.
3. The clients must have some social support system in place where they can turn for support and understanding during their time in the therapeutic process.
4. The clients must be motivated for change. They need to be the light bulbs that are ready.
5. The clients must have a social orientation and be able to relate their problems in a social context.
6. The clients must have a clear present problem or principle complaint, which can be identified in therapy.
7. The clients must have an ability to collaborate with the therapists in the process.
8. The clients in their past must have been able to have established at least one meaningful relationship in their lives.
9. The clients must have the capacity for rapid emotional involvement and equally rapid emotional separation.
10. The clients must have good ego strength.
11. The clients must have the ability to express feelings.
12. The clients must have the expectation that ESBT therapy will be successful. Their is possible by having family and friends who have experienced successful similar brief therapy, their own successful experience in previous similar therapy, if they are in a helping profession and if they have heard in the media the benefits of such brief therapies.
13. Those people who are not candidates for any psychotherapy and considered untreatable are excluded from ESBT based on the belief that therapists do not try to treat the untreatable.
14. In order to determine if this is so, therapists need to think of all therapy as "trial therapy" for 3 sessions and then they either: transfer inappropriate clients, use an alternative or adjunctive modality of treatment, or offer no treatment at all.
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What are some techniques to be used in ESBT?
Techniques are often considered the "art" of the science of psychotherapy, research has shown that tasks, such as homework, assignments and Bibliotherapy, strengthen treatment gains, generalize or carry over learning from session to real experience, and actually allow for the learning of a new skill or enhancing of an old skill. In ESBT, the goal of the use of techniques is to empower clients who have come for therapy demoralized, wounded and often feeling like outcasts. The techniques enable the clients to personalize their experience in therapy so that the outcomes are uniquely theirs. This helps them to own the outcomes of therapy as something, which they have done on their own with the facilitation of the therapist. They are able to view themselves as competent self-healers who can use therapeutic tasks to gain new coping skills and enhance old ones. Their experience enables them to have renewed self-confidence, increased self-worth and enhanced self-esteem. They begin to recognize that they are their own best "helpers" and that therapist becomes seen as teachers of the self-help therapeutic process.
Techniques in ESBT are rooted in the TEA System of Recovery as identified by James J. Messina (Self-Esteem Seekers Anonymous, The SEA'S Program Manual). The TEA system is as follows:
T - Thoughts
E - Emotions
A - Actions.
T - Thoughts
The first goal of ESBT techniques is to help clients to analyze their thoughts or thinking about their lives and to identify the irrational, unrealistic or unhealthy beliefs, self-scripts or ideas which are the roots of their identified problem. Once clients have identified the "sick" thoughts, then they need to replace them with healthier, more rational, and realistic thinking, beliefs, self-scripts and ideas,
E - Emotions
The second goal of ESBT techniques is to identify the "sick" emotions and feelings which were based and influenced on the old "sick" thinking and once clients have identified new "healthier" thoughts to integrate them into new "healthier" emotions and feelings. Their enables clients to have a healthier, rational and realistic emotional response to life so that they can begin to feel better about themselves and their ability to handle their own problems. As clients become able to think and feel more positively about overcoming their presenting problems they experience feelings of self-confidence, self-worth and self-deservedness.
A - Action
The third goal of ESBT techniques once clients have altered their "sick" thoughts and "sick" emotions is to change their "sick" actions and behaviors. Once clients have developed a healthier, more rational and realistic way of thinking and feeling about themselves and their lives, they can take actions to change their old behaviors. This enables them to exhibit new behaviors, which are healthier, more rational and result in improved self-esteem and increased coping capacity.
The TEA system caveat is that clients cannot change their behaviors or actions before they have changed their emotional and feeling response to life. When people change their actions because they have read or been told about it and know that it is the "correct" thing to do without the changed emotions and feelings which need to go along, their new change falls flat and dies. People need to change their thoughts and emotions before their actions become "authentic" and have greater "staying" power.
The techniques used in ESBT fall into three categories: A. Initiating, which are aimed at exploring clients' presenting problems so as to gain better understanding. B. Challenging, which are aimed at assisting clients to change their thoughts, emotions and actions. C. Concluding, which are aimed at evaluating clients' progress and degree of change.
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A. Initiating Techniques
The initiating techniques begin at the first contact from potential clients. These techniques help to screen clients for appropriateness for treatment. They are used to educate them about the goals of brief therapy. They are a way for the therapist to identify what are the identified and unconscious presenting problems. They are aimed at identifying the explicit contract of clients as to the "Why now" for seeking help. They are aimed at identifying the implicit contract of clients as to what they at the subconscious or unspoken level want the therapist to do for them.
Some of the ESBT Initiating techniques are:
1. Conduct a Pre-session telephone call to assess what the presenting problem is and to determine the motivation of the clients to be sure they are light bulbs wanting to be changed. Talom (1990) recommends giving clients an initial assignment in their pre-session call, which is to be completed prior to the initial session.
2. Mail out psycho-social-medical history forms in advance to be filled out prior to the first session so as not to take up valuable time getting history and data, which can be gotten in more efficient ways.
3. Ascertain in the initial session if clients are ready for treatment or if someone else is pressuring them into treatment. Giving homework in the first session, which is to be completed, by the second session is one way to test motivation and readiness of clients.
4. Ask clients how soon they expect to be helped and what they see to be the obstacles, which will get in the way of resolving the problem. Make sure the clients are part of the treatment team immediately placing the responsibility on them to have a say in treatment outcome.
5. Train clients in problem analysis and goal setting. Have them define the presenting problem and help set the recovery goals.
6. Explain the length and nature of ESBT treatment so that they are educated up front about the therapy experience. This helps set realistic expectations about what is possible and not possible in ESBT treatment.
7. Keep clients in the "here and now" and help they recognize that only "in the present is change possible." To help clients recognize their reality, Messina (1999-2001) in the Tools for Coping Series introduces each book with this caution: “Our parents did the best they could knowing what they did at the time. We, as adults, must now take responsibility for our own lives and learn what "normal" is so that we can have healthier, more productive lives.”
8. Operate with the assumption that the length of treatment will only be 1 session and fall back to the assumption that treatment will stop by the third session. Their keeps the focus of the work sharp and helps ascertain if the "light bulb is ready."
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B. Challenging Techniques
The goal of the challenging techniques in ESBT are to assist clients to have a better understanding of the unhealthy thinking and emotions underlying their presenting problems so that they can change them so as to alter their behaviors and actions. In order for this to happen ESBT therapists must have a thorough clinical understanding of the presenting problem, which can be obtained by a clinical interview and supportive homework assignments with assessment orientation such as the Growing Down Assessment, which are five family assessment activities, which clients can complete prior to their second appointment. Once there is better understanding of clients then therapists in ESBT focus on the presenting problems with a goal to create change in and out of the sessions.
Challenging techniques in ESBT are based on a philosophy similar to the ALERT system developed by Messina (Self-Esteem Seekers Anonymous - The SEA'S Program Manual). Clients use the ALERT system when they are confronted with a fear, challenge, pressure, or crisis, which causes anxiety, panic or stress.
A - Assess
L - Lessen
E - Ease
R - Relax
T - Take Action
A - Assess
Clients and their therapists in ESBT must first assess and identify the fear, challenge, pressure or crisis that is creating their anxiety, panic, or stress. Then they need to identify the "sick" irrational and unrealistic thoughts and feelings, which are at the root of the presenting problem, which is causing the discomfort.
L - Lessen
Clients then need to lessen the impact of the "sick" thinking and emotional response by countering it with new, more rational and reality-based beliefs and feelings. The clients with the help of their therapists are expected to identify "healthier" alternative self-scripts, beliefs, attitudes and ideas about their presenting problem. This enables them to picture their presenting problems as manageable, workable and potentially fixable.
E - Ease
Clients are then expected to ease their anxiety, panic or stress by "self-talk" based on their new rational and reality based beliefs and feelings. Clients visualizing themselves handling the current fear, challenge, pressure or crisis in a successfully healthy way augments these new self-scripts and self-affirmations.
R - Relax
Clients are then expected to relax once they have begun to counter their fear, challenge, pressure or crisis with healthier, more rational and realistic thoughts and emotions and self-talk. They are asked to let go of the tension, tightness and knots in their bodies while attending to a state of calmness, warmth and relaxation which comes from releasing the stress in their bodies.
T - Take Action
Once clients are more relaxed they are ready to take action to confront the fear, challenge, pressure or crisis with healthier, more rational and realistic thoughts and emotions. They are expected to take steps to relieve their anxiety, stress and panic by changing behaviors, response patterns and actions. They are encouraged to act in a calm, confident, relaxed, less anxious, less panicked and more rational manner. By taking action on their own to change their presenting problems they grow in greater self-confidence, self-worth and self-esteem.
Challenging techniques in ESBT are used to encourage clients to take on their own problems to resolve and change. The challenge being to prove to themselves that they indeed are the "light bulbs will to be changed." What follow next are some ESBT challenging techniques:
1. Use homework, tasks, practice assignments and prescriptions. Have the clients prescribe their own assignments or assist them to identify what they need to complete prior to their next session. Make future sessions contingent on completion of their assignments. The Tools for Coping Series contains 150 homework chapters or ESBT tools in ten specific categories:
1. Self-esteem development (Family Systems: Satir, 1983, 1988)
2. Life style of recovery (Reality Therapy: Glasser, 1965, 2000)
3. Family of origin behavioral introjected scripts (Gestalt: Perls, 1969) and irrational beliefs (REBT: Ellis & Harper, 1997),
4. Handling loss (Existential: May & Yalom, 1991),
5. Personal growth (Behavioral: Lazarus, 1995, 1997; REBT: Ellis & Harper, 1997; Cognitive: Beck, 1976 & Meichenbaum, 1997),
6. Handling relationships (Family Systems: Satir, 1983, 1988),
7. Communications (Person Centered: Rogers, 1961),
8. Anger work-out (Gestalt: Perls, 1969),
9. Handling control issues (Reality Therapy: Glasser, 1965, 2000; Adlerian: Adler, 1930, 1931, 1938 & Dreikurs, 1964),
10. Healing the inner child for self healing (Psychodynamic: Freud, 1955; Family Systems: Bowen, 1978; Haley, 1985; Minuchin, 1974, 1981; & Whitaker, 1976)
These materials encourage clients to keep a personal journal in which they respond to the "steps to change" section in each chapter. In their journal they are also encouraged to record the following:
1. An incident or issue that has come up for you today or their week.
2. How you dealt with the incident or issue.
3. What you’re thinking and feeling at the time of the incident or issue.
4. What you would have done differently to handle the incident or issue in a "healthier" way.
5.What your plans are to improve your handling of the same or similar incidents and issues in the future.
Clients are encouraged to use their journal and homework writing as a self-healing experience, opening up emotions and feelings long repressed, suppressed, ignored, non-identified or unknown. They are encouraged in the "steps to change" journal work to identify their irrational (Ellis, 1997, 1998), non-reality-based and unhealthy thinking which has been keeping them stuck and unproductive. The Tools for Coping journal work becomes an action-planning tool in which clients write their own books of personal recovery to chart new actions and behaviors based on healthier and more rational thoughts and emotions.
2. Have the client envision change. Gibson (1989, p. 35) provides the following instructions for this vision: "Suppose that some months from now you and I were to meet and I would show you two one-minute video clips of yourself. One would come from yesterday, when your problem was bothering you. The other one would come from a time in the future after you have solved your problem. If nobody told you which was which, how would you know which one was "before" and which one was "after"?"
3. Use novelty, uncommon therapy, do something different with clients, which catches them off guard and excites them to change, similar to the approach of Whitaker (1976) in his experiential therapy model.
4. Use a one-down position, using the "Columbo" technique, recommended by Cummings (1979), where you let it be known that you do not fully understand or comprehend the clients’ complaints and need for them to more fully explain what is going on concerning their presenting problems.
5. Use humor in treatment. Hoyt (1990) encouraged humor and hyperbole as shown in this example. He used the following comment with a man about to turn 40. The man had been complaining that he was feeling old, and that life was rushing by despite that fact that he was in a "Type A" frenetic fit. He complained about his inability to make commitments. Hoyt then asked him to be specific, "What commitment?"
Client: Well, my girlfriend wants to get married, but I'm not sure.
Therapist: How long have you been together?
Client: Eight years.
Therapist: Oh, I see. Well, you certainly don't want to rush into it. Why don't you wait to see how she handles menopause and retirement? You certainly don't want to get stuck with a crotchety old lady, do you?
The client laughed, first at Hoyt's gentle mockery, then harder, at himself. "It is crazy, isn't it?” he said. Hoyt tried to keep a straight face but added: "Well, I don't know. You can't tell what's going to happen in the future." Many months later the client telephoned Hoyt to let him know that he had gotten married and was happy. He offered Hoyt thanks for "bringing me to my senses." Hoyt told him he was glad to hear that the client was happy but the credit was his own because "you're the one who got the joke."
6. Focus on clients' roles in their past and current family lives. Teach the clients to do genograms (Bowen, 1978) so that they can have a clearer understanding of the dynamics of their past and present interpersonal environments. This helps clients to understand the impact of their families of origin on their current behaviors. In Laying the Foundation (Messina, 1999-2001) provides a tool for clients to assess their families and themselves as to the presence of 9 behavioral patterns or roles developed in dysfunctional families. These behavioral patterns or roles are: looking Good, Acting Out, Pulling In, Entertaining, Troubled Person, Enabler, People Pleaser, Rescuer and Non-feeling. Clients are helped to recognize that the past roles they played in their families of origin were necessary for survival then but are not adaptive or functional in their "here and now" adult lives. Once clients have a good understanding of various roles in family life, have them sculpt (Satir, 1983, 1988) their families of origin and current families to recognize the feelings and emotions involved in the roles they play so as to motivate their desire to change out of their unhealthy role scripts.
7. Utilize metaphor or paradox. An example of extensive use of metaphor is in Growing Down: Tools for Healing the Inner Child (Messina, 1999-2001). It uses the metaphor of inner child to mean the "inner part" of clients, their inner spirit or inner voice, which they have too long neglected, ignored or forgotten. The metaphor of child opens up clients to begin to re-parent and love themselves through: letting go of shame and guilt self-forgiveness, getting in touch with their feelings (Perls, 1969), unconditional self-acceptance, overcoming invisibility, having fun (Glasser, 2000) and establishing healthy boundaries (Minuchin, 1974).
8. Use the Crystal Ball Technique (DeShazer, 1984) to project the clients into a future through visualization. The four steps of the Crystal Ball Technique are:
Step 1: Have the clients visualize and fully experience an early, pleasant memory. Have them picture what other people are doing, what they are doing and then have them return to "where it has been." Goal: Encourage the idea that forgotten things can be remembered and remembered things can be forgotten. Repeat several times until clients are trained.
Step 2: Repeat the above task this time to retrieve a "surprisingly forgotten memory and picture some success. Goal: To awaken feelings of success.
Step 3: Now have the clients picture "returning to tell me about your successful resolution of the problem." Goal: To orient clients to the future and their success in the future with their presenting problem.
Step 4: Have the clients remember the manner in which their problems were resolved.
9. Ask challenging questions of clients (Gibson, 1989).
Ask: Why aren't you worse? This question prompts clients to take informal inventory of their coping skills.
Ask: What keeps you from applying your past solutions to this problem? This question helps clients to recognize that they can competently handle problems since they have done so in the past. If they have been successful in the past they can be successful in the present and future.
10. Encourage Bibliotherapy. Assigning reading to supplement therapy assist therapists to validate with clients what is being talked about in sessions. Getting other perspectives about the same topic from authors helps some clients to gain trust in the goals and work of their therapy sessions.
11. Teach clients to work out their anger. Tools for Anger Workout presents a system for overcoming resistance and obstacles to expressing anger; reducing depression; eliminating silent anger withdraw; overcoming pessimism, hostility, negativity, cynicism; getting out hatred, resentment, rage; eliminating jumping to negative assumptions and passive aggressiveness; stopping self-destructive anger responses and eliminating revenge seeking. The system is ANGER:
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B. Challenging Techniques
The goal of the challenging techniques in ESBT are to assist clients to have a better understanding of the unhealthy thinking and emotions underlying their presenting problems so that they can change them so as to alter their behaviors and actions. In order for this to happen ESBT therapists must have a thorough clinical understanding of the presenting problem, which can be obtained by a clinical interview and supportive homework assignments with assessment orientation such as the Growing Down Assessment, which are five family assessment activities, which clients can complete prior to their second appointment. Once there is better understanding of clients then therapists in ESBT focus on the presenting problems with a goal to create change in and out of the sessions.
Challenging techniques in ESBT are based on a philosophy similar to the ALERT system developed by Messina (Self-Esteem Seekers Anonymous - The SEA'S Program Manual). Clients use the ALERT system when they are confronted with a fear, challenge, pressure, or crisis, which causes anxiety, panic or stress.
A - Assess
L - Lessen
E - Ease
R - Relax
T - Take Action
A - Assess
Clients and their therapists in ESBT must first assess and identify the fear, challenge, pressure or crisis that is creating their anxiety, panic, or stress. Then they need to identify the "sick" irrational and unrealistic thoughts and feelings, which are at the root of the presenting problem, which is causing the discomfort.
L - Lessen
Clients then need to lessen the impact of the "sick" thinking and emotional response by countering it with new, more rational and reality-based beliefs and feelings. The clients with the help of their therapists are expected to identify "healthier" alternative self-scripts, beliefs, attitudes and ideas about their presenting problem. This enables them to picture their presenting problems as manageable, workable and potentially fixable.
E - Ease
Clients are then expected to ease their anxiety, panic or stress by "self-talk" based on their new rational and reality based beliefs and feelings. Clients visualizing themselves handling the current fear, challenge, pressure or crisis in a successfully healthy way augments these new self-scripts and self-affirmations.
R - Relax
Clients are then expected to relax once they have begun to counter their fear, challenge, pressure or crisis with healthier, more rational and realistic thoughts and emotions and self-talk. They are asked to let go of the tension, tightness and knots in their bodies while attending to a state of calmness, warmth and relaxation which comes from releasing the stress in their bodies.
T - Take Action
Once clients are more relaxed they are ready to take action to confront the fear, challenge, pressure or crisis with healthier, more rational and realistic thoughts and emotions. They are expected to take steps to relieve their anxiety, stress and panic by changing behaviors, response patterns and actions. They are encouraged to act in a calm, confident, relaxed, less anxious, less panicked and more rational manner. By taking action on their own to change their presenting problems they grow in greater self-confidence, self-worth and self-esteem.
Challenging techniques in ESBT are used to encourage clients to take on their own problems to resolve and change. The challenge being to prove to themselves that they indeed are the "light bulbs will to be changed." What follow next are some ESBT challenging techniques:
1. Use homework, tasks, practice assignments and prescriptions. Have the clients prescribe their own assignments or assist them to identify what they need to complete prior to their next session. Make future sessions contingent on completion of their assignments. The Tools for Coping Series contains 150 homework chapters or ESBT tools in ten specific categories:
1. Self-esteem development (Family Systems: Satir, 1983, 1988)
2. Life style of recovery (Reality Therapy: Glasser, 1965, 2000)
3. Family of origin behavioral introjected scripts (Gestalt: Perls, 1969) and irrational beliefs (REBT: Ellis & Harper, 1997),
4. Handling loss (Existential: May & Yalom, 1991),
5. Personal growth (Behavioral: Lazarus, 1995, 1997; REBT: Ellis & Harper, 1997; Cognitive: Beck, 1976 & Meichenbaum, 1997),
6. Handling relationships (Family Systems: Satir, 1983, 1988),
7. Communications (Person Centered: Rogers, 1961),
8. Anger work-out (Gestalt: Perls, 1969),
9. Handling control issues (Reality Therapy: Glasser, 1965, 2000; Adlerian: Adler, 1930, 1931, 1938 & Dreikurs, 1964),
10. Healing the inner child for self healing (Psychodynamic: Freud, 1955; Family Systems: Bowen, 1978; Haley, 1985; Minuchin, 1974, 1981; & Whitaker, 1976)
These materials encourage clients to keep a personal journal in which they respond to the "steps to change" section in each chapter. In their journal they are also encouraged to record the following:
1. An incident or issue that has come up for you today or their week.
2. How you dealt with the incident or issue.
3. What you’re thinking and feeling at the time of the incident or issue.
4. What you would have done differently to handle the incident or issue in a "healthier" way.
5.What your plans are to improve your handling of the same or similar incidents and issues in the future.
Clients are encouraged to use their journal and homework writing as a self-healing experience, opening up emotions and feelings long repressed, suppressed, ignored, non-identified or unknown. They are encouraged in the "steps to change" journal work to identify their irrational (Ellis, 1997, 1998), non-reality-based and unhealthy thinking which has been keeping them stuck and unproductive. The Tools for Coping journal work becomes an action-planning tool in which clients write their own books of personal recovery to chart new actions and behaviors based on healthier and more rational thoughts and emotions.
2. Have the client envision change. Gibson (1989, p. 35) provides the following instructions for this vision: "Suppose that some months from now you and I were to meet and I would show you two one-minute video clips of yourself. One would come from yesterday, when your problem was bothering you. The other one would come from a time in the future after you have solved your problem. If nobody told you which was which, how would you know which one was "before" and which one was "after"?"
3. Use novelty, uncommon therapy, do something different with clients, which catches them off guard and excites them to change, similar to the approach of Whitaker (1976) in his experiential therapy model.
4. Use a one-down position, using the "Columbo" technique, recommended by Cummings (1979), where you let it be known that you do not fully understand or comprehend the clients’ complaints and need for them to more fully explain what is going on concerning their presenting problems.
5. Use humor in treatment. Hoyt (1990) encouraged humor and hyperbole as shown in this example. He used the following comment with a man about to turn 40. The man had been complaining that he was feeling old, and that life was rushing by despite that fact that he was in a "Type A" frenetic fit. He complained about his inability to make commitments. Hoyt then asked him to be specific, "What commitment?"
Client: Well, my girlfriend wants to get married, but I'm not sure.
Therapist: How long have you been together?
Client: Eight years.
Therapist: Oh, I see. Well, you certainly don't want to rush into it. Why don't you wait to see how she handles menopause and retirement? You certainly don't want to get stuck with a crotchety old lady, do you?
The client laughed, first at Hoyt's gentle mockery, then harder, at himself. "It is crazy, isn't it?” he said. Hoyt tried to keep a straight face but added: "Well, I don't know. You can't tell what's going to happen in the future." Many months later the client telephoned Hoyt to let him know that he had gotten married and was happy. He offered Hoyt thanks for "bringing me to my senses." Hoyt told him he was glad to hear that the client was happy but the credit was his own because "you're the one who got the joke."
6. Focus on clients' roles in their past and current family lives. Teach the clients to do genograms (Bowen, 1978) so that they can have a clearer understanding of the dynamics of their past and present interpersonal environments. This helps clients to understand the impact of their families of origin on their current behaviors. In Laying the Foundation (Messina, 1999-2001) provides a tool for clients to assess their families and themselves as to the presence of 9 behavioral patterns or roles developed in dysfunctional families. These behavioral patterns or roles are: looking Good, Acting Out, Pulling In, Entertaining, Troubled Person, Enabler, People Pleaser, Rescuer and Non-feeling. Clients are helped to recognize that the past roles they played in their families of origin were necessary for survival then but are not adaptive or functional in their "here and now" adult lives. Once clients have a good understanding of various roles in family life, have them sculpt (Satir, 1983, 1988) their families of origin and current families to recognize the feelings and emotions involved in the roles they play so as to motivate their desire to change out of their unhealthy role scripts.
7. Utilize metaphor or paradox. An example of extensive use of metaphor is in Growing Down: Tools for Healing the Inner Child (Messina, 1999-2001). It uses the metaphor of inner child to mean the "inner part" of clients, their inner spirit or inner voice, which they have too long neglected, ignored or forgotten. The metaphor of child opens up clients to begin to re-parent and love themselves through: letting go of shame and guilt self-forgiveness, getting in touch with their feelings (Perls, 1969), unconditional self-acceptance, overcoming invisibility, having fun (Glasser, 2000) and establishing healthy boundaries (Minuchin, 1974).
8. Use the Crystal Ball Technique (DeShazer, 1984) to project the clients into a future through visualization. The four steps of the Crystal Ball Technique are:
Step 1: Have the clients visualize and fully experience an early, pleasant memory. Have them picture what other people are doing, what they are doing and then have them return to "where it has been." Goal: Encourage the idea that forgotten things can be remembered and remembered things can be forgotten. Repeat several times until clients are trained.
Step 2: Repeat the above task this time to retrieve a "surprisingly forgotten memory and picture some success. Goal: To awaken feelings of success.
Step 3: Now have the clients picture "returning to tell me about your successful resolution of the problem." Goal: To orient clients to the future and their success in the future with their presenting problem.
Step 4: Have the clients remember the manner in which their problems were resolved.
9. Ask challenging questions of clients (Gibson, 1989).
Ask: Why aren't you worse? This question prompts clients to take informal inventory of their coping skills.
Ask: What keeps you from applying your past solutions to this problem? This question helps clients to recognize that they can competently handle problems since they have done so in the past. If they have been successful in the past they can be successful in the present and future.
10. Encourage Bibliotherapy. Assigning reading to supplement therapy assist therapists to validate with clients what is being talked about in sessions. Getting other perspectives about the same topic from authors helps some clients to gain trust in the goals and work of their therapy sessions.
11. Teach clients to work out their anger. Tools for Anger Workout presents a system for overcoming resistance and obstacles to expressing anger; reducing depression; eliminating silent anger withdraw; overcoming pessimism, hostility, negativity, cynicism; getting out hatred, resentment, rage; eliminating jumping to negative assumptions and passive aggressiveness; stopping self-destructive anger responses and eliminating revenge seeking. The system is ANGER:
A - Accept
N - Name
G - Get It Out
E - Energize
R - Resume
A - Accept
Therapists need to help their clients accept that they are feeling anger. Clients need to be given permission to not deny they are angry and to face it head on. This may be difficult if their past experience with anger has been painful, hurtful or disastrous.
N - Name
Next clients need to name and identify what has them angry. They need to name the stimulus, which is triggering the anger. They need to identify not only their current anger but also if they can the old unresolved anger, which their current anger stimulus is triggering.
G - Get It Out
Clients, once they are able to accept and name their anger, are encouraged to get it out by expressive emotional anger workout in a private place on inanimate objects and not on people. Anger workout is aggressive ventilation of anger such as:
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Yelling in a car with windows closed
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Yelling with a towel in mouth
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Hitting a punching bag or weight bag
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Beating on pillows, cushions or mattress
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Yelling in a vacant part of the house
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Writing letters to the stimulus, which are never sent
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Making lists of what the stimuli do to provoke anger
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Journal writing of anger ventilation
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Whatever works for clients to ventilate anger
OR
Use the Read, Write and Burn technique (DeShazer, 1988):
Step 1: Set a time for one hour, alone, same time every day Example: 8-9 p.m. (maximum of 1.5 hours)
Step 2: On odd numbered days, during their time, write all the "good-bad" memories/all obsessive and anger thoughts. You must write for one hour, even if you repeat the same statement over and over.
Step 3: On even numbered days, read the previous days notes with gusto and lots of anger expression and then burn them.
Step 4: If any unwanted anger thoughts come up at other times you must "table" them until the daily scheduled one hour time. Write a brief note to remind yourself what was on your mind at the time so you can write about it during your “Scheduled Time.”
This technique is effective because it objectifies the clients’ anger. It does not allow the clients’ intrusive angry thoughts to continue throughout the day. It allows and permits the clients to express all negative thoughts and feelings. It facilitates catharsis (Perls, 1969) by "burning up" problems, watching them "go up in smoke." It helps the clients to eventually realize that there are better things to do than obsess over the negative.
E - Energize
Once clients have aggressively ventilated and experienced emotional release of the anger this will energize them to feel calmer, less depressed, more relaxed, less tense or less stressed. Clients report that through anger workout they are freed up to feel a whole range of healthy positive emotions, which had been previously blocked, or unknown to them.
R - Resume
Now that they are energized by their anger workout, clients are encouraged to resume involvement with the people who were the stimuli of their anger and to use healthy assertive confrontation to let them know how their behaviors made them feel in a cool, calm, relaxed and rational manner.
12. Predict relapse. Utilize the RELAPSE system (Self-Esteem Seekers Anonymous - SEA's Program Manual). In this system help clients to recognize that relapse of old behaviors is a reality. The goal of the RELAPSE system is to help clients have fewer incidences of relapse and have a greater time span between each relapse and to lessen the intensity of each relapse over time. The system is:
R - Recognize
E - Escape
L - Learn
A - Act
P - Protect
S - Support
E - Evaluate
R - Recognize
Clients are taught to recognize when they are in relapse. They are encouraged to admit that they have fallen back into old patterns of thoughts, emotions and actions, which are unhealthy, irrational or unrealistic. They are encouraged to use the TEA system to identify what thoughts, emotions and actions are "sick" in their relapse event.
E - Escape
Clients are then encouraged to use the ALERT system to assess, brainstorm healthier alternatives, organize, relax and take action to escape from their current relapse into "sick" thoughts, emotions and actions.
L - Learn
Once clients have escaped from their relapsing thoughts, emotions and actions they then need to learn what were the variables, which led to their relapse. There needs to do an honest appraisal of how thoroughly they have integrated their healthy, rational and realistic thinking with their emotions and feelings. They need to identify how authentic their changed actions and behaviors were. They need to identify if their change was a "faked wellness" because they changed their behaviors based on knowing what was correct or healthy but had not changed their emotional response to the needed change. They need to identify if their feelings are not in synch, harmony or congruent with their changed thoughts and actions. They need to be able to use the TEA system to figure what was out of step leading to the relapse event.
A - Act
Once clients have learned what went wrong to lead to the relapse event they need to make plans and act to modify their current efforts at recovery. They need to fine-tune their thoughts, emotions and actions so that they are consistent, healthier, more rational, more realistic and supportive of their efforts to grow and be healthy.
P - Protect
Once clients have developed new plans of action to alter their healing process they need to protect themselves from a repeated relapse by developing new self- talk which recognizes that it is human to fall back into old habits of thoughts, emotions and actions. They need to be realistic with themselves and not fall victim to the need to be "perfect" in recovery. They need to protect themselves from the beliefs, which are dangerous traps, that "since I have already failed or fallen short, there is no sense in going on," and "If I can't be perfect in my recovery - why try?" They need to remind themselves that relapse is an expected part of recovery. They can protect themselves from repeated relapse by self-forgiveness, self-acceptance and self-loving.
S - Support
As added protection to help them through the process of getting "back on the wagon" of recovery, clients are encouraged to seek out support from their existing support networks. They are encouraged to ask their support people to help protect them from quitting their recovery program as a result of the recent relapse. They are encouraged to give their support people permission to "call them on it" if they see them regressing into old "sick" patterns of thoughts, emotions and actions which led to their recent relapse event. This will help them to prevent a repeat of their relapse event.
E - Evaluate
Once clients are back on the wagon of their recovery, they need to continuously evaluate their thoughts, emotions and actions for any signs of the old "sick" patterns. They need to closely monitor their self-scripts, feelings and behaviors for any signs of potential relapse so that they can rectify them immediately. Clients are encouraged to believe that to recover is a life long process because old habits are hard to change and that as humans they will fall back into old "sick" ways unless they keep vigilant and alert for the signs of potential relapse.
To assist clients develop a life style built on the belief that relapse will occur at transition points in life, the ESBT program offers the Self Esteem Seekers Anonymous-The SEA's Program Manual which is a 12 step program and program for a life style of recovery in. In the manual is presented directions for therapists to conduct a 12-step program in their own practices or agencies to provide mutual support system for their clients to lessen the impact of relapse in the future.
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C. Concluding Techniques
The goal of the Concluding Techniques in ESBT is to assist clients to recognize the progress they have made in their lives while they were in therapy.
1. Post-treatment sculpting in which clients sculpt their current environment to recognize changes they have made in their role definitions and relationship rules.
2. Journal review in which clients review what they have been recording in their journal since initiation of therapy. Their helps them to recognize the distance they have come due to the changes apparent in the thoughts, emotions and actions recorded in their journals.
3. Encourage clients to conduct a therapy session with themselves so that they can assess the progress they have made in alleviating the presenting problems they brought originally into therapy. Encourage them to have a pre-session with themselves and prepare themselves with journal writing. Then encourage them to have a post-session with themselves to process over what happened in the session.
4. Draw up a contract with clients about their willingness to try it on their own without therapy for a time to see if the changes they have made are long lasting or just a form of "faked wellness."
5. Take an inventory of where the clients are at their time. Their inventory will assist both therapists and clients to recognize the progress attained and what if anything still needs therapeutic attention within the context of direct therapy.
6. Give clients a progress report on which they can rate themselves in regards to their progress in overcoming their presenting problems. What follows is a sample Progress Report.
CLIENT’S PROGRESS REPORT
These questions are to help you measure your progress in therapy. Consider a specific problem and rate your progress.
Specific problem:
1. How important is their problem (on a 1-10 scale)?
2. On a 1-10 scale, with 1 being where you were at your worst, where would you say you are today on their problem? (Do not compare yourself with where you want to be or where other people are. Do not make social comparisons).
3. How much progress did you expect to make? (1-10)
4. On a 1-10 scale, with 1 being no effort at all, how hard are you working to deal with their problem?
5. How difficult was it to make their effort? (1-10)
6. What percentage of your improvement would you say is the result of what you have done voluntarily? (Do not rate what percent was the result of luck or chance).
7. How much (in percent) did the sessions help?
8. How much (in percent) of the improvement would you say is permanent?
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A Final Word
Haley (1985) gives all therapists who do brief psychotherapy some cautions on how to fail in therapy. Their tips for how to consistently fail in brief therapy are:
1. Do not attend to the presenting problem of the clients.
2. Assume dealing with the clients’ past is essential so deal with it extensively.
3. Focus only on symptoms.
4. Predict a worsening of the symptoms or symptom substitution.
5. Over focus on the clients’ diagnosis and the various criteria necessary for coming up with their diagnosis.
6. You must use only ONE theoretical framework.
7. Don't be directive.
8. Assume change must be observable to be real change.
9. Insist on years of treatment to bring about change.
10.Evoke guilt in the clients.
11.Ignore the clients’ wanting quick results.
12.Don't define goals in therapy.
13.Don't collaborate with your clients.
14.Assume all responsibility for the success or failure the clients in therapy.
15.Don't evaluate your effectiveness.
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