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The Efficacy of Pullout Programs in Inclusion Classrooms CONJOINTLY DEFINING 20 Professional Issues in Counseling 2016, Volume 15, Article 2, p. 20-26 Conjointly Defining a Therapeutic Direction Conjointly Defining a Therapeutic Direction Joshua M. Gold University of South Carolina The rationale for the use of therapeutic conversations to generate “collaborative intentionality” in clinical service are presented. This treatise is exemplified by a sample case study. In addition, implications for graduate education, clinical supervision, and future research are provided. Keywords: Common factors, intentionality, therapeutic direction Conjointly Defining a Therapeutic Direction The efficacy of counseling is well-confirmed; however questions as to which specific therapeutic dynamics promote successful therapy remain under debate (Laska & Wampold, 2014; Shadish & Baldwin, 2009; Tschacher, Junghan & Pfammatter, 2014). Such uncertainty does not seem to hamper the impetus to provide clinical services. One basic premise of counseling is that doing anything is better than doing nothing, so therapist activity, as compared to passivity, seems a cornerstone of efficacious clinical service. However, clinicians still contemplate exactly what will “work” with which clients and which conditions for which presenting issues (Leibert & Dunne-Bryant, 2015). Graduate students, beginning counselors, and perhaps even those with extensive experience, ruminate about the process of creating a clinical directionality for, or with, their clients (McAleavey & Castonguay, 2014). The professional literature provides a diversity of answers, offering scholarly discussions about the strengths and limitations of “common factors” approaches, theoretical purity, eclecticism and theoretical integration. The practice of counseling seems to oscillate between the orthodoxy of theoretical implementation, without divergence, and the spontaneous enactment of a counselor’s unique expression of eclecticism (Laska, Gurman & Wampold, 2014). The first practice seems based on the principle that divergence from theory leads to clinical confusion; while the second practice reflects the principle that adherence to theory leads to clinical stagnation. In the mid-range of this dilemma seem to lay those scholars advocating eclecticism or integrationist approaches, with little guidance about which aspects of which theory complement each other than perhaps other combinations toward more efficacious clinical service for which clients. However, perhaps, there is an approach that alleviates the responsibility for these decisions solely from the counselor and provides a framework to share that accountability with all those individuals invested in the success of the therapeutic Joshua m. Gold, Department of Counselor Education, University of South Carolina. Correspondence concerning this article should be addressed to Joshua M. Gold, 253 Wardlaw College, University of South Carolina, Columbia, SC 29708. Email: [email protected] CONJOINTLY DEFINING 21 relationship (Harris, Kelley, Campbell & Hammond, 2014; Weinberger, 2014). However, before this approach can be presented, much akin to a common factors recommendation (Lambert & Ogles, 2014), the question must be addressed: given the multiplicity and diversity of client presenting issues, on what aspects of client’s case perceptions can such an intervention be founded? Rationale It is the thesis of this proposed approach that the term “common factors” can be applied to epistemological patterns across clients’ presenting issues. This notion implies that the meaning-making focus expressed by each client seems to represent client perceptions that transcend each problem but also which are characteristic of that individual. For example, a client who “believes in” a medical model searches for a biological roots of all personal suffering, with the attendant belief that an appropriate pharmacological intervention will alleviate one’s pain. As a second example, an individual presenting with issues of continual blame believes that other persons are responsible for the client’s pain and ought to change their actions accordingly. In each case the counselor’s focus of insight development, goal setting, and appropriate interventions would be distinctly different. However it can also be thought that clients’ are unaware of their problem orientations and that the orientation itself serves to render the problem unsolvable. In addition, it could be held that the client and counselor begin counseling with divergent views on what exactly is the problem. It can be extrapolated that, perhaps, the common elements within a client’s perspective provide a starting point for counseling. Relationship variables (Lambert & Ogles, 2014, p. 501) “repair alliance ruptures and increase motivation by reengaging clients through renegotiation of the therapeutic contract to increase patient participation and collaboration” (p. 502). This discussion is less about client change than an overt, counselor-led exploration of “providing information to patients themselves that appears to improve the quality of service” ((Laska & Wampold, 2014, p. 522). This investigation addresses those same questions of which the counselor has already made professional “sense” and the answers to which direct one’s clinical approach. However, rather than impose those answers on clients or assume that clients share or are willing to accept the counselor’s decisions, these matters are integrated into the first three sessions (Leibert & Dunne-Bryant, 2015) to foster rapport; to create a template for therapeutic conversations; and to co-author an initial direction for counseling (Brooks- Harris, 2008; Harris, Kelley, Campbell & Hammond, 2014). There seem to be four commonalities in a client’s issues: a) the client feeling defeated or hopeless, while client actions to solve the problem are congruent with the conceptualization of the problem and somehow are repeatedly unsuccessful; b) that clients have learned, through self-study, previous counseling, psycho-diagnosis and/or personal meaning-making, the stories to explain and or justify their circumstance in life; c) that those stories are repeated usually to those who support its content and become anchored into the client’s life perception; and d) clients come for therapy as they feel frustrated at not being able to effect meaningful change in their lives around the presenting issue, usually seeking behavioral direction as to how to quickly improve their lot. Across these four domains of commonality, it seems as though the client story echoes repeatedly and permeates all client perceptions. In addition to recognized patterns of client expression, attention has been directed as well to those relational and therapeutic techniques proven efficacious regardless of the clinician’s theoretical orientation (Davis, Lebow & Sprenkle, 2012; McAleavey & Castonguay, 2014). As Laska and Wampold (2014) asserted [these practices] “...are based on the science of how people heal in social contexts and describe specific factors that yield conjectures about what should be observed under CONJOINTLY DEFINING 22 various conditions” (p. 519). There are multiple listings of such factors, stemming from the work of Rosenzweig (1936); examples of which include Frank (1961), Garfield (1980), and Norcross and Lambert (2011). The thrust of these writings seems to emphasize the equivalence of differing therapeutic approaches, differing change factors and perhaps the most salient beneficial factors. It is in the identification of similarity, as compared to difference based on theoretical preference, client diagnosis, and/or presenting issue; and/or cultural factors etc., that the current proposed notion is hypothesized. As Lambert and Ogles (2014) offered, the identification of potentially common elements across theoretical orientations offers a foundational approach. While such a trans-theoretical approach would allow counselors to work across a spectrum of clients, it can be wondered whether a modification of these common factors could serve to direct counselor attention with each client. However the counselor approaches the intake session with a decidedly-distinct agenda. The clinician’s case analysis usually attends to the following issues: Specific aspects of the client history, in what areas and how much emphasis versus a focus solely on the present; The balance of psycho-diagnostics and developmental theory in understanding the client’s issues and symptoms; The relevance of cultural factors to each client which influence how the issue is perceived, the range of acceptable solutions and one’s referent group(s) of social support; The client prioritizing of affect, behavior, and cognition relative to the presenting issue; and The client’s adherence to a bio-psycho-social hierarchy of problem understanding and amelioration. The conceivable answers to these controversies are ones to which counselors were introduced in their graduate training programs; enacted through their post-degree licensure supervision; and honed through their professional clinical practice. These solutions direct which questions, insights and interventions the counselor deems as viable and comprise their “therapeutic toolbox.” While the clinician is versed in the discussion of each issue, the client may be wholly unaware of the “process” impact of the resolution of each question. Yet the answers to each of these questions would seem germane to how clients are making sense of the presenting issue (McAleavey & Castonguay, 2014). Therefore, client and counselor
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