Discussion 6

complete the two questions from the document, use only the textbook for reference. The work must have two paragraphs at minimum. EX: One paragraph for each question .Must also include on more intext citation. Use opinions and examples in the work.

Chapters 11& 12. Module 6.

1. What are three differences between motivational interviewing and motivational enhancement therapy? What are three similarities? Discuss some macro-issues or social justice issues, such as perceived age, gender, or class discrimination, that clients may lack the motivation to address. How can motivational interviewing be helpful for resolving their ambivalence?

2. Think about the kinds of clients seen by social workers for whom narrative interventions would and would not be appropriate. What is the difference? Can narrative interventions be incorporated into other clinical interventions without violating the essence of the approach?

According to Walsh (2015), “The purpose of motivational enhancement therapies is to assist clients reach a certain objective, whereas motivational interviewing is a collection of techniques for talking with clients to help them overcome their ambivalence and reaching a goal.” (pg. 255). The similarities of motivational interviewing and motivational enhancement therapy consists of both providing change to individuals,

JOSEPH WALSH
Virginia Commonwealth University

Theories for Direct Social
Work Practice

T H I R D E D I T I O N

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Brief Contents

PREFACE xv

ABOUT THE AUTHOR xix

1 Thinking about Theory 1

2 A Social Work Perspective on Theory and
Practice 18

3 Person-Centered Theory 33

4 Ego Psychology 55

5 The Relational Theories, with a Focus on Object
Relations 85

6 Family Emotional Systems Theory 113

7 Behavior Theory 146

8 Cognitive Theory 171

9 Structural Family Theory 202

10 Solution-Focused Therapy 233

11 Motivational Interviewing and Enhancement
Therapy 255

12 Narrative Theory 278

13 Crisis Theory and Intervention 306

iii
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some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially
affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

REFERENCES 333

AUTHOR INDEX 369

SUBJECT INDEX 382

iv B R I E F C O N T E N T S

Contents

PREFACE xv

ABOUT THE AUTHOR xix

1 Thinking about Theory 1

What Is a Theory? 2

What Is a Practice Theory? 3

The Relationship Between Theory and Intervention Techniques 4

The Functions of Theory 6

Curative Factors in All Practice Theories 7

Selecting Theories for Practice 8

Eclecticism: Pro and Con 9

The Effect of Agency Culture on Theory Selection 9

Critical Thinking 10

Social Work Research on Theory and Practice Evaluation 11

Evidence-Based Practice 12

Ways to Improve Theory and Practice Research 15

Summary 16

Topics for Discussion 16

Idea for Class Activity 17

2 A Social Work Perspective on Theory and Practice 18

Defining Direct Social Work Practice 19

The Value Base of Social Work Practice 19

Strengths-Oriented Practice 20

v
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A Risk and Resilience Framework for Practice 22

Diversity and Multiculturalism 24

Client Empowerment 25

Limitations to Empowerment Practice 27

Empowerment and Research 27

Spirituality in Direct Practice 28

Incorporating Spirituality into Direct Practice 30

Summary 31

Topics for Discussion 31

Ideas for Assignments 32

3 Person-Centered Theory 33

Origins and Social Context 34

Major Concepts 37

Concepts Related to the Actualizing Tendency 37

Concepts Related to the Self 38

Congruence and the Fully Functioning Person 39

The Nature of Problems and Change 40

Assessment and Intervention 40

Assessment 40

Intervention 41

General Features 41

The Process of Intervention 41

Ending the Intervention 42

Spirituality and PCT 42

Attention to Social Justice Issues 43

Case Illustrations 44

The Premed Student 44

The Support Group 47

Evidence of Effectiveness 48

Specific Research on Client-Centered Theory and Therapy 48

Research on the Significance of the Practitioner/Client
Relatinship 49

Criticisms of the Theory 50

Summary 51

Topics for Discussion 53

Ideas for Classroom Activities/Role-Plays 53

Person-Centered Theory Outline 54

vi C O N T E N T S

4 Ego Psychology 55

Origins and Social Context 56

Major Concepts 58

The Drives 59

The Significance of Emotional Life 59

The Ego and Its Functions 60

The Defense Mechanisms 61

The Complexity of Defenses: Denial 64

The Nature of Problems and Change 64

Assessment and Intervention 65

Assessment 65

Intervention 66

The Social Worker/Client Relationship 66

Transference and Countertransference 67

Intervention Strategies 68

Exploration/Description/Ventilation 68

Sustainment 69

Person-Situation Reflection 69

Advice and Guidance (Direct Influence) 69

Partializing (Structuring) 70

Education 70

Developmental Reflection 70

Endings in Ego Psychology 71

Spirituality and the Psychodynamic Theories 71

Attention to Social Justice Issues 72

Case Illustrations 73

The Angry Attorney 73

The Post-Traumatic Stress Survivor 75

Evidence of Effectiveness 78

Criticisms of the Theory 80

Summary 81

Topics for Discussion 81

Ideas for Classroom Activities/Role-Plays 81

Appendix: Ego Psychology Theory Outline 82

5 The Relational Theories, with a Focus on Object
Relations 85

Origins and Social Context 86

C O N T E N T S vii

The Effects of Early Nurturing 87

Attachment Theory 88

Contemporary Object Relations Theory 89

Major Concepts 89

Relational Theory 91

Developmental Concepts 93

Donald Winnicott 94

Margaret Mahler 95

The Nature of Problems 96

The Nature of Change 97

Assessment and Intervention 98

The Social Worker/Client Relationship 98

Assessment 99

Intervention 100

Ending Intervention 100

Attention to Social Justice Issues 101

Case Illustrations 101

The Wild Child 101

The Group Therapy Intervention 104

Evidence of Effectiveness 106

Criticisms of the Theory 108

Summary 108

Topics for Discussion 108

Ideas for Classroom Activities/Role-Plays 109

Appendix: Object Relations Theory Outline 110

6 Family Emotional Systems Theory 113

Origins and Social Context 115

Analytic Theory 115

Systems Theory 115

Bowen’s Career 116

Major Concepts 117

The Multigenerational Perspective 117

Differentiation of Self 117

Triangles 118

Anxiety and the Nuclear Family Emotional System 119

Parental Projection 120

viii C O N T E N T S

Fusion and Emotional Cutoff 120

Other Concepts 121

The Nature of Problems and Change 122

Assessment and Intervention 122

The Social Worker/Client Relationship 122

The Genogram 123

Detriangulation 124

Increasing Insight 125

Education 126

Working with Individuals 126

Endings in Family Emotional Systems Theory 126

Spirituality and Family Emotional Systems Theory 127

Attention to Social Justice Issues 128

Case Illustrations 128

The Reeves Family 128

The Charles Family 131

Evidence of Effectiveness 139

Criticisms of the Theory 141

Summary 141

Topics for Discussion 142

Ideas for Role-Plays 143

Appendix: Family Emotional Systems Theory Outline 143

7 Behavior Theory 146

Origins and Social Context 147

Major Concepts 149

The Nature of Problems and Change 149

Classical Conditioning 150

Operant Conditioning 151

Modeling 151

Assessment and Intervention 153

Assessment 153

The Social Worker/Client Relationship 153

Intervention 155

Applied Behavior Analysis 156

Spirituality and Behavior Theory 156

Attention to Social Justice Issues 157

C O N T E N T S ix

Case Illustrations 158

Mama’s Boy 158

The Smart Shopper 161

Evidence of Effectiveness 164

Criticisms of the Theory 166

Summary 167

Topics for Discussion 167

Ideas for Role-Plays 168

Appendix: Behavior Theory Outline 168

8 Cognitive Theory 171

Origins and Social Context 172

Pragmatism and Logical Positivism 172

Information Processing Theory 173

Personal Construct Theory 173

Albert Ellis and Aaron Beck 174

Cognitive Theory in Social Work 174

Major Concepts 175

The Nature of Problems and Change 177

Assessment and Intervention 179

The Social Worker/Client Relationship 179

Assessment 180

Intervention 181

Cognitive Restructuring 181

Cognitive Coping 183

Problem-Solving Skills Development 185

Spirituality and Cognitive Theory 186

Attention to Social Justice Issues 187

Case Illustrations 188

Problem Solving and the Adolescent Girls Group 188

Cognitive Restructuring and the Single Parent 189

Managing Family Friction with Communication Skills
Development 190

Combining Cognitive and Behavioral Interventions 192

Improving Cognitive Capacity 193

Improving Behavioral Skills 193

Dialectical Behavior Therapy 194

x C O N T E N T S

Evidence of Effectiveness 195

Criticisms of the Theory 196

Summary 197

Topics for Discussion 198

Ideas for Classroom Activities/Role-Plays 198

Appendix: Cognitive Theory Outline 199

9 Structural Family Theory 202

Origins and Social Context 203

Major Concepts 205

Executive Authority 205

Subsystems 205

Boundaries 206

Rules 206

Roles 206

Alliances 207

Triangles 207

Flexibility 207

Communication 208

Other Concepts 208

The Nature of Problems and Change 212

Assessment and Intervention 214

The Social Worker/Client Relationship 214

Assessment 214

Intervention 215

Ending Structural Family Interventions 217

Spirituality in Structural Family Theory 218

Attention to Social Justice Issues 219

Case Illustrations 219

The Dalton Family 219

The Family Drawings 224

Evidence of Effectiveness 225

Criticisms of the Theory 227

Summary 228

Topics for Discussion 228

Ideas for Role-Plays 229

Appendix: Structural Family Theory Outline 230

C O N T E N T S xi

10 Solution-Focused Therapy 233

Origins and Social Context 233

Major Concepts 235

The Nature of Problems and Change 236

Assessment and Intervention 237

The Social Worker/Client Relationship 237

Assessment and Intervention Strategies 238

Ending the Intervention 242

Spirituality and Solution-Focused Intervention 243

Attention to Social Justice Issues 243

Case Illustrations 244

The Journalist 244

The Adolescent Mother 246

Evidence of Effectiveness 248

Criticisms of the Therapy 251

Summary 251

Topics for Discussion 251

Ideas for Classroom Activities/Role-Plays 252

Appendix: Solution-Focused Therapy Outline 252

11 Motivational Interviewing and Enhancement
Therapy 255

Origins, Social Context, and Major Concepts 256

The Summary Principles of Motivational Interviewing and
Enhancement 258

The Nature of Problems and Change 259

Assessment and Intervention 259

The Social Worker/Client Relationship 259

Assessment 260

Intervention 260

Motivational Enhancement Therapy 264

Spirituality in Motivational Interviewing and Enhancement 267

Attention to Social Justice Issues 268

Case Illustrations 268

The Man at the Medical Shelter 268

The School Brawler 270

Evidence of Effectiveness 272

xii C O N T E N T S

Criticisms of Motivational Interviewing and Enhancement
Therapy 273

Summary 274

Topics for Discussion 275

Ideas for Class Role-Plays 275

Appendix: Motivational Interviewing and Enhancement
Outline 275

12 Narrative Theory 278

Origins and Social Context 279

Existentialism 279

Postmodernism 280

Social Constructivism 281

Michael White and David Epston 282

Major Concepts 283

The Personal Narrative 283

Deconstruction 284

Reconstruction, or Reauthoring 284

Celebrating/Connecting 285

The Nature of Problems and Change 285

Assessment and Intervention 287

The Social Worker/Client Relationship 287

Assessment 287

Intervention 288

Normalizing and Strengthening 288

Reflecting (Deconstructing) 289

Considering Cultural and Political Issues 289

Enhancing Changes (Reauthoring or Reconstructing) 289

Celebrating and Connecting 290

Spirituality and Narrative Theory 292

Attention to Social Justice Issues 292

Case Illustrations 293

The Hospice Client 293

Juvenile Sex Offenders 295

Evidence of Effectiveness 297

Outcome Studies 297

Process Studies 299

C O N T E N T S xiii

Criticisms of the Theory 300

Summary 301

Topics for Discussion 302

Ideas for Role-Plays 302

Appendix: Narrative Theory Outline 303

13 Crisis Theory and Intervention 306

Origins and Social Context 307

Major Concepts 309

Stress 309

Crisis 309

Coping and Adaptation 310

Social Support 312

Assessment and Intervention 313

Overview 313

Assessment 314

A Word about Suicide Assessment 315

Intervention 316

Clinical Case Management 316

From Ego Psychology 317

From Behavior Theory 318

From Cognitive Theory 319

From Structural Family Theory 321

From Solution-Focused Therapy 323

From Narrative Theory 325

Spirituality and Crisis Theory 326

Attention to Social Justice Issues 327

Evidence of Effectiveness 327

Criticisms of the Theory 329

Summary 329

Topics for Discussion 330

Ideas for Role-Plays 330

Appendix: Crisis Theory Outline 331

REFERENCES 333

AUTHOR INDEX 369

SUBJECT INDEX 382

xiv C O N T E N T S

Preface

T heories for Direct Social Work Practice includes concise but comprehensive cov-
erage of 11 major clinical practice theories that social workers commonly use

in their assessment, planning, and intervention tasks with individuals, families,
and groups. The purpose of this book is to provide Master of Social Work
(MSW) course instructors and students (as well as practicing professionals) with
a single volume that incorporates the major theories and intervention strategies
used in a variety of direct practice settings. The Theories book is a resource that
students will be able to use long after they finish school.

APPROPRIATE COURSES FOR USE

Most MSW programs include a clinical or direct practice concentration and
require students to take at least one, and more often several, courses on topics
related to direct practice. Textbooks that cover practice theories, most of which
have been developed outside the social work profession, must be faithful to their
sources but also true to the values of social work and its appreciation of the en-
vironmental context of client systems. A challenge to instructors is selecting a
reasonable number of theories to include in those courses: not so many as to
allow for little more than an overview, and not so few that students acquire a
limited repertoire of practice skills. The scope of theories covered in Theories for
Direct Social Work Practice is intended to provide a fairly broad view of the prac-
tice field while allowing students to learn the material in depth.

This book may be appropriate for foundation and second-year courses in
MSW programs. It provides current, practical information about social work
practice theories and techniques that can be used at both beginning and ad-
vanced levels of practice. The Theories book also may be suitable for a variety
of direct practice electives (such as community mental health practice, crisis

xv
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intervention, and health care social work) because the material is not setting-
specific. The relatively small number of included theories should appeal to in-
structors, as the entire book can be covered in one or two semesters.

COVERAGE AND ORGANI ZAT ION OF THE BOOK,

INCLUDING TH IRD EDIT ION UPDATES

As noted earlier, Theories for Direct Social Work Practice covers 11 major theories;
more specifically, it covers 10 theories and a practice model. A model, described
more thoroughly in Chapter 11, is a set of techniques for working with certain
types of clients. I have included one model in the book (motivational interview-
ing) because of its tremendous popularity and influence in direct practice today,
as well as its applicability across many practice theories. (Another model from the
second edition, interpersonal therapy, has been removed.)

The book begins with two chapters that are intended to orient readers to the
importance of theory-based direct practice and the elements of theory that are
central to the mission of the social work profession. These elements include values,
attention to strengths, client empowerment, spirituality, and the ability to evaluate
one’s practice. The following 11 chapters are organized with a historical perspec-
tive, presenting the theories roughly in the order they were developed. Chapter 3
(new to this edition) is focused on person-centered theory, which, while not often
practiced in its pure form today, establishes the importance of the social worker/
client relationship and has practice implications across all theoretical perspectives.
Chapters 4–6 are devoted to psychodynamic theories, including ego psychology;
object relations theory (with a greater emphasis on relational theory); and Bowen’s
family systems theory (which, while not analytic, derives from an analytic base).
Chapters 7–9 are devoted to the cognitive-behavior theories, including behavior
theory, cognitive theory, and structural family theory (which I argue is consistent
with cognitive-behavioral methods). Chapters 10–12 focus on several “newer”
theories or approaches, including solution-focused therapy, motivational inter-
viewing, and narrative theory. The final chapter of the book, devoted to crisis in-
tervention, is integrative, in that it draws on techniques from the previous chapters
in the book to organize a rapid response to clients in crisis.

Each of the theory chapters is organized according to the following outline:

The focus of the theory

Its major proponents (past and present)

Its origins, including the social context

Perspective on the nature of the individual

Intrapersonal or interpersonal structural concepts (if applicable) and other
major concepts

Human development concepts (if applicable)

xvi P R E F A C E

Nature of problems

Nature of change

Intervention goals

Assessment and intervention strategies (including the nature of the worker/
client relationship)

How the client’s spirituality can be addressed

Attention to social justice issues

Case illustrations

Evidence of effectiveness and utility

Criticisms

Questions for discussion and class activities

Appendices (including an outline of each theory)

The theory outlines that conclude each chapter may be particularly useful to
instructors and students for systematically comparing the theories.

To bridge human behavior in the social environment–direct practice con-
nection, each chapter focuses on how the theory addresses issues of human de-
velopment within a context of human and cultural diversity. In addition to this
organizing theme, there is an exploration of how the theories address issues of
spirituality and social justice. A summary of the research on each theory’s effec-
tiveness and utility concludes each chapter.

Graduate students are almost always highly motivated to learn practice methods.
They have invested significant time and money in their professional development
and have only a few years to develop some mastery of the complex material. They
are also involved in field placements in which they are expected to provide direct
practice interventions competently. As an instructor of such students for many years,
I know that they are invariably excited at the prospect of acquiring a broad repertoire
of practical intervention techniques. My hope is that this book will be a resource that
satisfactorily meets their needs, and that its format brings the material to life.

I am a longtime direct service practitioner who has always enjoyed reading
about and experimenting with various approaches to direct intervention. I like to
think that as I try to master theories and models, as well as selecting methods that
seem to work well with different client populations, I am developing an ap-
proach to practice that is personal, but is nonetheless based in the traditions of
our profession. My hope is that this book will help social work students to un-
dertake the same developmental journey.

AUTHOR’S ACKNOWLEDGMENTS

I owe a great debt of gratitude to Jacqui Corcoran, a colleague and friend who
helped me significantly with several chapters. My outstanding former students

P R E F A C E xvii

R. J. Arey, Erica Escalante, Linda Fowler, Valerie Holton, and Cynthia Lucas
provided material for five of the case illustrations. Amy Waldbillig and Mary
Stebbins served reliably as my research assistants for the first and third editions.
I am grateful to them all.

The following professionals read drafts of the book and offered excellent
suggestions for improvement: Gerald Matthews, Ferris State University; Gary Pa-
quin, University of Cincinnati; Jody Gottlieb, Marshall University; Charles
Joiner, Arkansas State University, Jonesboro; and Deborah Rougas, University
of West Florida. I wish to acknowledge the reviewers of the second edition:
Shelly Cohen Konrad, University of New England; Daniel Coleman, Portland
State University; and Gary L. Villareal, Western Kentucky University. I also
wish to acknowledge the reviewers of the third edition: Gemma Beckley, Rust
College; Elizabeth Cramer, Virginia Commonwealth University; Ruby Gour-
dine, Howard University, School of Social Work; Sylvie Graziani, Laurentian
University, School of Social Work; Maureen V. Himchak, Kean University;
Linda Love, Virginia Commonwealth University; Andridia Mapson, Howard
University; and Betsy Vonk, University of Georgia.

xviii P R E F A C E

About the Author

Joseph Walsh is a professor of social work at Virginia Commonwealth Univer-
sity (VCU). He has been a direct service practitioner in the field of mental health
for many years, first in a psychiatric hospital and later in community mental
health center settings. He has worked with older adult and general outpatient
populations, but has mostly specialized in providing services to persons with seri-
ous mental illness and their families. Since 1993, Joe has been at VCU, teaching
courses in generalist practice, clinical practice, human behavior, research, and so-
cial theory. He continues to provide direct services to clients at the university’s
Center for Psychological Services and has worked in area shelters, clubhouses,
and group homes. He has published widely in social work and other human ser-
vices journals on topics related to clinical practice, and is the author of seven
other books, three of which were published by Brooks/Cole: Generalist Social
Work Practice Intervention Methods (2008), Clinical Case Management with Persons
Having Mental Illness: A Relationship-Based Perspective (2000), and The Social Worker
and Psychotropic Medication Toward Effective Collaboration with Mental Health Clients,
Families, and Providers (fourth edition 2013, co-authored with Kia J. Bentley).

xix
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Thinking about Theory

I taste a liquor never brewed,
From tankards scooped in pearl;
Not all the vats upon the Rhine

Yield such an alcohol! *

Each August, as my graduate students begin another year of study in the class-
room and field, I give an assignment to help them become oriented to their

field agencies. “Ask the direct social work practitioners in your agencies about
the theoretical basis of their practice. In other words, what theory or theories
do they use in working with clients?” I also ask my students to inquire whether
their agency has an “official” theory, or if staff work from a variety of perspec-
tives. I am always curious to learn from students what is going on in the field and
whether social workers who serve different types of clients (such as hospice cli-
ents, persons with mental illnesses, children with behavioral problems, and legal
offenders) gravitate toward certain practice theories.

Students bring a variety of responses to the classroom. Some students are
placed in agencies that subscribe to a particular theory such as object relations
or dialectical behavior theory, but this is unusual. Most agencies support a range
of theoretical perspectives for their staff as long as practitioners can produce pos-
itive outcomes (and outputs, as in numbers of clients seen, intakes, terminations,
and contact hours). What concerns me, however, are the not-infrequent remarks
that “they don’t operate with any theory. They just do what they have to do to
get results.” (Of course, allegiance to purely evidence-based practice models may
be consistent with this position.) I understand that direct practitioners may not
actively dwell on issues of theory after they leave graduate school and that this

* Dickinson, E. (1927). The Pamphlet Poets. New York: Simon and Schuster.

1
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may have no bearing on their effectiveness. I once worked at a mental health
agency for four years with little clinical supervision and would have been hard
pressed to articulate how I worked with clients. What upsets me, though, is the
occasional response from a student that his or her supervisor “has no use for aca-
demic types who waste time talking about abstractions rather than getting things
done” or that theoreticians “have no idea what goes on in the real world.”

It may be that universities include a fair number of faculty members who
seem to function in a realm apart from the “real world.” But I have always
been a practitioner as well as a professor and am convinced that all direct social
work practitioners operate from a theoretical basis. They may not always be able
to articulate their perspectives, but they have “automatically” learned, absorbed,
and revised ideas about how to work with clients. They orient themselves with
assumptions and presumed knowledge about human behavior, including beliefs
about the nature of problems and the nature of change. From this, they develop
strategies for how to help various types of clients resolve their difficulties. So I
worry about practitioners who actually feel hostile toward the idea of theory. It
seems to me that a practitioner’s methods of working with clients, if left unex-
amined, will become overly influenced by his or her moods, attitudes, and per-
sonal reactions. At the least, adherence to one or several theoretical perspectives
encourages the practitioner to be systematic in approaching clients. A practitioner
who is more reactive than proactive with clients may behave in ways that are less
effective, less efficient, and perhaps even dangerous to the client’s welfare.

Of course, the social work profession’s push toward evidence-based practice
(EBP) does promote a process of systematically choosing interventions without
adherence to a particular theoretical base. We will consider this issue more fully
later in the chapter.

The purpose of this chapter is to introduce several definitions of a practice the-
ory, describe its functions, consider elements common to all theories, and consider
how practitioners may evaluate the worth of a practice theory. We will then be in a
position to review the many practice theories described in the coming chapters.

WHAT IS A THEORY?

Several years ago I taught a doctoral seminar in social science theory in which I
used a different opening exercise. I challenged students to, between the first and
second class sessions, find one or several definitions of theory that were both com-
prehensible and not boring. This was always a daunting task, and students inevita-
bly failed, at least with regard to the second criterion. I have always felt that the
idea of theory in social work practice should be rather simple, but apparently I
am wrong. It is often defined in ways that are alienating and overly abstract and

2 C H A P T E R 1

impractical for social workers, who must be able to operationalize theory in
practice. Perhaps it is no wonder that some practitioners become hostile to the
idea. Listed below is a sample of definitions that my students have produced,
from least to most complicated. A theory is:

An attempt to explain something that is beyond factual understanding

An orderly explanation of confusing experiences

A systematic but speculative explanation for an event or behavior

A set of propositions linked by a logical argument that is put forth to explain
or predict some area of reality or type of phenomenon

A set of statements about relationships among variables that presents a
systematic understanding of a behavior, event, or circumstance, and offers an
explanation for why it occurred

A set of variables or characteristics that have been hypothesized, presumed,
or demonstrated to bear a relationship with one another

I will admit that the last definition loses me. Later in this chapter we will ex-
amine the components of social work practice theories. But with regard to the
above definitions, it is helpful to recall that there are several types of theories
(Bisman & Hardcastle, 1999). Case theories explain the behavior of one person
(for example, an individual spouse abuser). Social workers routinely develop theo-
ries about the causes of the behavior of their individual clients. Mid-range theories
explain a set of cases or events (for example, the behavior of unemployed alcoholic
men who abuse their spouses). Practitioners also develop these theories as they
become experienced working with certain types of clients over time. Grand theories
attempt to explain all sets of events and cases (such as Freud’s theory of psychosex-
ual development or Piaget’s theory of the stages of cognitive development). With
regard to their explanatory power, grand theories have fallen out of favor in the
social sciences in the past 30 years or so. The universal theories of human behavior
developed by Freud, Erickson, Gilligan, Kohlberg, Piaget, Skinner, and others are
still taught in schools of social work, and they are still useful to a practitioner’s
general understanding of what accounts for human behavior over the life span.
Still, there is a greater appreciation nowadays for human nature’s infinite diversity
and the idea that no principle of human development can be applied to everyone.

WHAT IS A PRACT ICE THEORY?

Practice theories represent a subset of theories, as defined above, and are limited to
perspectives on intervention with individuals, families, and groups. One useful defi-
nition of a practice theory is a coherent set of ideas about human nature, including
concepts of health, illness, normalcy, and deviance, which provide verifiable or es-
tablished explanations for behavior and rationales for intervention (Frank & Frank,
1993). Many other definitions are available, but this one is suitable as a basis for re-
flecting on theories and their relevance to social work intervention. There are, of

T H I N K I N G A B O U T T H E O R Y 3

course, many theories that may be used in direct practice, and social workers should
feel challenged to decide which one or several ones will serve their clients well. The
value of utilizing any theory (with conviction) in clinical practice is that it provides
the social worker with a framework to (a) predict and explain client behavior,
(b) generalize among clients and problem areas, (c) bring order to intervention activ-
ities, and (d) identify knowledge gaps about practice situations.

Despite its uses, there is also potential harm in rigid adherence to a practice
theory. Because all theories necessarily simplify human behavior (they all select a
limited number of variables from a seemingly infinite number that can possibly
affect a client’s life), they are reductionist and can become dehumanizing. Adher-
ence to a theory may create self-fulfilling prophecies (the practitioner will tend
to see what he or she is looking for) and blind the practitioner to alternative
understandings of behavior.

How does a social worker choose a theory to use in practice? One’s choice may
be influenced by a variety of rational and irrational factors, including (Turner, 2011):

The theory’s research support (i.e., documented evidence of its effectiveness)

A belief that the theory produces positive results (perhaps, in the context of
agency demands, with the least expenditure of time and money)

Its provision of useful intervention techniques

Its consistency with the practitioner’s values, knowledge, skills, and worldview

Personal habit

Its use by co-workers or supervisors

It was mentioned earlier that some practitioners cannot articulate their theory
base. They may be effective practitioners (what was once a deliberative process
may have become automatic), but all practitioners benefit from thinking critically
about their work.

The Relationship Between Theory and Intervention Techniques

It is important to emphasize that theories and intervention techniques are not the
same thing. Theories are abstract, and include concepts that suggest to the social
worker which intervention strategies may be effective with clients. Intervention
strategies are the concrete actions taken by social workers to help clients achieve
their goals. There should be consistency, however, between a practitioner’s
working theory and interventions. For example, the theory of ego psychology
purports that it is often useful for clients’ goal achievement to develop insight
into their manner of addressing life challenges. One intervention strategy that
derives from this concept is “person-situation reflection,” a process by which
the social worker asks questions to stimulate the client’s self-reflection. In con-
trast, behavior theory suggests that client change occurs when the person’s be-
havioral reinforcers are adjusted. An intervention strategy might include
designing an environmental plan (in a classroom or household, for example) to
reward (encourage) some behaviors and punish (extinguish) others.

4 C H A P T E R 1

The relationship between theory and intervention becomes complicated,
however, because there is overlap among the intervention strategies suggested
by different theories. That is, not every theoretical perspective includes a unique
set of intervention strategies. This point is often confusing to students (so please
read this paragraph twice). An ego psychologist and a behaviorist might both use
relaxation skill training with a client, although their rationales for using this tech-
nique would be different. The ego psychologist may hope to enhance the client’s
ability to reflect, whereas the behaviorist may be helping the client manage task-
related anxiety. The reader will readily see this overlap among intervention
strategies throughout this book. How the same technique can have a different
purpose will be discussed in each chapter.

The point above can be clarified in another way (see Figure 1.1). In my
view, most social workers tend to adopt a primary theory for the purpose of
assessment. That is, if ego psychology, cognitive theory, or some other theory
“fits” a practitioner’s assumptions about human nature, he or she will tend to
assess clients from that perspective. For example, if I believe that unconscious
processes influence mental functioning, it will be hard for me to completely
ignore that assumption even if I set out to practice from a behavioral perspec-
tive. My practice model (guiding strategy for working with certain types of cli-
ents), however, may rely heavily on behavioral methods when I work with
substance abuse clients. I may believe that these clients are not capable of ef-
fectively responding to “reflective” interventions due to their denial and need
for strict limits, and thus I put my “preferred” theoretical perspective aside. My
model may include the teaching of behavioral techniques for abstinence. I may

“Primary” Practice Theory (for Assessment)
(Fits the practitioner’s assumptions about human nature)

Practice Model
(A guiding strategy for working with certain types of clients)

Practice Strategy
(A guiding strategy for approaching a specific client)

Interventions
(The implementation of practice strategies; what we

actually do to facilitate the change process)

F I G U R E 1.1 The Relationship of Theory to Practice
©

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ng

ag
e

Le
ar

ni
ng

T H I N K I N G A B O U T T H E O R Y 5

hope to undertake reflective interventions with those clients following their ter-
mination of substance use, but I may not assume that this is necessary for their
recovery. My practice strategy for an individual client will be based on my model,
but individualized as I take into account that person’s particular personal and
environmental characteristics. One client may be receptive to self-help interven-
tions while another is not. Finally, my specific intervention will consist of activities
undertaken by the client and myself to achieve his or her goals.

To summarize, the nature of our clients and agency settings may guide our
practice strategies and interventions as much as our theoretical preferences, even
though we can never put those preferences completely aside.

THE FUNCT IONS OF THEOR Y

Theory is important because it has a direct influence on how the social worker
approaches his or her practice. It serves the functions of (Nugent, 1987; Polansky,
1986; Tzeng & Jackson, 1991):

Simplifying complex phenomena, and focusing the practitioner’s attention
on thoughts, feelings, behaviors, and events in a client’s life that are relevant
to explore

Helping the social worker to establish causal relationships and thus predict
what will influence a client’s future behavior

Simplifying the task of selecting attainable intervention outcomes

Guiding the social worker’s choices among potentially effective intervention
options

Protecting against irrational procedures, because the commitment to a body
of thought “greater than oneself” bolsters professional self-discipline

Mobilizing sound interprofessional practice, as the ability to effectively
coordinate the work of several service providers depends on understanding
one’s own theoretical base and that of others

Making the social worker’s development of knowledge cumulative from one
practice situation to the next, and promoting some level of generalization
among clients

One of my former students developed a useful illustration of the functions
of theory with reference to music. She wrote that the elements of music the-
ory include notes, keys, intervals, chords, and time. The musician uses this
knowledge to select notes and put them together in chords with different
rhythms to explore musical ideas including harmonies, dissonance, and impro-
visations. Yet, music theory is not the music. The theory is a way to describe
the music and gain an understanding of how it can be performed. It explains
why some combinations of notes and chords seem to work well while others
do not, and gives the music student ideas for writing new songs. So, too, in

6 C H A P T E R 1

social work, theories provide lenses through which the practitioner can
describe and understand the world, facilitating insights into what might happen
next and how the practitioner might enter the client’s world to assist in the
process of positively changing that world.

CURAT IVE FACTORS IN ALL PRACT ICE THEORIES

This book describes 10 theories and a practice model, and many others are used
by social workers. Why are there so many? Are they all fundamentally different?
Some authors have attempted to identify the “curative” factors that are common
to all effective interventions. Their starting point is the assumption that because
there are so many practice theories, and all of them seem to be helpful with at
least some clients, effectiveness may be less dependent on particular theories and
techniques than the practitioner’s personal qualities and approach to the work.
We will consider several of these here. In one worldwide study of professional
helpers, the following common characteristics of effective interventions were
found (Frank & Frank, 1993):

The client enters into an emotionally charged, confiding relationship with
the practitioner, and perceives that the practitioner is competent and caring.
This relationship is an antidote to alienation, enhances the client’s morale,
and promotes the client’s determination to persist in the face of difficulties.

The formal or otherwise “special” setting of the intervention helps the client
feel safe and arouses the expectation of help.

Interventions are based on an understandable (to the client) rationale and
procedures that include an optimistic view of human nature. The practi-
tioner’s explanations are compatible with the client’s view of the world and
thus help the client make sense of his or her problems.

Interventions require the active participation of the practitioner and client,
both of whom believe them to be a valid means of improving functioning.
The client is given new opportunities for learning and successful experiences
so as to enhance his or her sense of mastery.

These authors conclude that a practitioner’s ability to be effective with clients is
largely due to having confidence in whatever theories and interventions he or she
uses. They also emphasize that a client’s emotional arousal (experiencing a moderate
amount of anxiety) is a prerequisite for all behavioral and attitudinal change.

The more recent work of Miller, Duncan, and Hubble (2005) is consistent
with the above assertions about common elements of effective practice. These
researchers conclude from their studies of direct practice that the two elements
of (a) the therapeutic alliance and (b) the practitioner’s ongoing attention to the
client’s perspective about the intervention account for positive outcomes more
than anything else. They write that client characteristics (the nature of problems,
motivation, and participation) account for forty percent of the outcome, and the

T H I N K I N G A B O U T T H E O R Y 7

quality of the therapeutic alliance accounts for an additional thirty percent. The
practitioner’s guiding theory or model accounts for fifteen percent, and the
remaining fifteen percent is a placebo effect. These researchers state that the pres-
ence of shared goals, a consensus on methods used, and the emotional bond are
most predictive of positive client outcomes. As a part of this process the practi-
tioner should regularly solicit feedback and input from the client about the inter-
vention process. Further, the practitioner’s allegiance to some model of practice,
but not any particular model, is associated with positive outcomes. This last finding
supports the social worker’s use of a theoretical perspective or intervention model
toward which he or she feels comfortable and committed.

In the early 2000s a task force of the American Psychological Association set
out to empirically evaluate the significance of the practitioner/client relationship in
determining intervention effectiveness (Norcross & Wampold, 2011). A panel of
experts concluded after a series of meta-analyses that several relationship variables
were demonstrably effective (the alliance in individual, youth, and family therapy;
cohesion in group therapy; empathy; and collecting client feedback), and others
were probably effective (goal consensus, collaboration, and positive regard). Three
other relationship elements (congruence/genuineness, repairing alliance ruptures,
and managing countertransference) were deemed promising, but there was insuffi-
cient evidence to demonstrate effectiveness. The task force felt strongly enough
about these findings to recommend that all practice research studies explicitly ad-
dress practitioner behaviors and qualities because the relationship clearly acts in
concert with discrete interventions in determining effectiveness.

SELECT ING THEORIES FOR PRACT ICE

If a particular theory does not determine clinical outcomes, how do social
workers—or, how should social workers—select theories for use in their practices?
There is no single answer to this question, no uniformly accepted criteria to apply.
I do not propose a particular set of criteria for theory selection or evaluation in this
book, because any criteria are biased toward the assumptions inherent in some the-
ories and not others. Some social workers believe that a theory needs only to be
useful for organizing their work with clients, whereas others feel that it should pro-
vide intervention strategies with empirically demonstrable effectiveness for a range
of clients. It is widely accepted, however, that a “good theory” for practice should
be (Goldstein, 1990; Payne, 2005; Polansky, 1986; Witkin & Gottschalk, 1988):

Coherent (internally consistent)

Useful with the practitioner’s current clients

Comprehensive (able to direct practice activities across a range of clients)

Parsimonious (relatively uncomplicated for use)

Testable, and able to withstand scrutiny (there are a variety of methods for
doing this)

8 C H A P T E R 1

Another important criterion for social workers is that the theories they use
should facilitate, or at least allow, the pursuit of social justice activities with cli-
ents. This issue will be discussed in detail in Chapter 2.

Eclecticism: Pro and Con

Many social workers describe themselves as “eclectic,” which means they draw on
a variety of theories, depending on the client’s presenting situation. It may be said
that there are three kinds of eclecticism (Borden, 2009a). Technical eclecticism is
the application of procedures solely on the basis of their prior demonstrated effi-
cacy, as in evidence-based practice (discussed later). These practitioners are not pri-
marily interested in theory, but apply certain interventions to certain kinds of
presenting problems. Common factors approaches are based on a social worker’s as-
sumption that all theories exert their effects through similar underlying processes.
These practitioners focus on core elements shared by the major schools of thought,
as discussed earlier. Finally, theoretical integration represents the efforts of some prac-
titioners to utilize a range of theories based on the particular presenting issues of
their clients. Although such flexibility is a positive aspect of one’s practice, it may
be difficult to achieve real mastery in the use of more than three or four theories
(Turner, 2011). Further, some theories contain assumptions that are incompatible
with one another (object relations and narrative theory, for example).

Payne (2005) has summarized arguments for and against eclecticism in theory
selection. Its positive aspects are that clients stand to benefit from a range of ideas
about managing a problem issue; effectiveness is not directly related to theory selec-
tion; several theories may contain common elements; and some theories do not apply
to all practice situations. The negative aspects of eclecticism are that a practitioner
who attempts to use many theories may lack mastery of any of them. The process
may result in the practitioner’s loss of a common core of practice, and his or her cli-
ents may suffer. The approach in this book is that a social worker will be well served
by the mastery of several theories with which he or she comes to feel comfortable.

The Effect of Agency Culture on Theory Selection

All practitioners live in professional “cultures” represented by their schools, agen-
cies, and professional associations. Following graduation from a professional pro-
gram and employment in an agency, a social worker’s ideas about theory and
practice are likely to change to resemble those of immediate colleagues.
Research in the field of health administration has shown that the intervention
behavior of professionals is significantly accounted for by their conformity to
prevailing practices in their employing agencies (Westert & Groenewegen,
1999). That is, they tend to act in ways that produce or maintain positive peer
reinforcement. For example, at one point in my own career, I went from being a
cognitive practitioner to an object relations devotee after taking a new job.

In some settings the practitioner may be encouraged to seek new knowledge
about theory and practice, but in others he or she will lack the time (all that
paperwork to do!) and incentives to look beyond the status quo. Agency

T H I N K I N G A B O U T T H E O R Y 9

characteristics that have an effect on a social worker’s choices about theory in-
clude the supervisor’s preferences, exposure to some theories but not others, the
level of administrative support for professional development, the extent to which
risk taking by staff is encouraged, and the agency’s emphasis on program evalua-
tion and client outcome research.

Faced with the choices of many possible perspectives, and being subject to
agency cultural factors, social workers should ideally rely on critical-thinking
skills to guide their use of theory.

CRIT ICAL THINKING

Critical thinking can be defined as thinking that is purposeful, reasonable, goal-
directed, and evaluative of its outcomes (Gambrill & Gibbs, 2009). The ability to
engage in critical thinking is essential for social workers, because the use of theory
and intervention strategies includes a reliance on many assertions that cannot be
“proven” true or false. A practitioner must have confidence in the validity of his
or her theories, because hard facts are difficult to come by in social work practice.

Critical-thinking qualities are important for clinical social workers to develop
because they are immersed in unstructured problem areas every day in which goals,
the relevance of information, and the effects of decisions they make are unclear. The
social worker must reflect on the assumptions that underlie a theory and be open to
contemplating alternative ways of thinking and working. He or she must be flexible,
persistent when solutions are not obvious, and willing to self-correct when conclu-
sions run contrary to usual practice. Other characteristics of the critical thinker
include (Bromley & Braslow, 2008; Sharp, Herbert, & Redding, 2008):

A willingness to question one’s basic assumptions about theory and practice

Making an effort to work toward (an elusive) objectivity (looks for opposing
as well as supporting evidence for procedures)

An ability to imagine and explore alternatives

An understanding of the importance of social and cultural contexts to hu-
man behavior

An ability to distinguish between questions of fact and questions of value
(facts can be resolved with testing; values are based on beliefs and cannot be
tested)

Cautiousness when inferring causality or making generalizations

Critical thinking may seem self-evidently beneficial, but it has costs as well.
Its benefits include a means of clarifying the assumptions underlying one’s work,
increased accuracy in decision making, shared understanding among practi-
tioners, colleagues, and clients, and guidance in clarifying the influences of
one’s values on practice. Its costs are that it takes time (rarely a resource in the
practice world) and effort, requires a tolerance for doubt, and may negatively
affect one’s self-worth when acknowledging mistakes. Critical thinking requires

10 C H A P T E R 1

courage, too, as it may result in disagreements with peers and agency practice
guidelines.

The principles of critical thinking suggest that a clinical social worker should
always be open to examining his or her use of theory and intervention strategies.
If a social worker feels somewhat limited by agency culture from engaging in this
process, he or she may use other resources such as books and research-based
journals (for self-development), external supervision, informal support systems
with practitioners from other agencies, contact with former professors, and in-
volvement with professional associations.

SOCIAL WORK RESEARCH ON THEORY

AND PRACT ICE EVALUAT ION

We now consider more formally what is known about the effectiveness of social
work practice. These findings do not always directly pertain to theory but to
intervention methods that may not be specific to one theory. In each chapter
of this book, we will review the efforts of practitioners and researchers to dem-
onstrate the effectiveness of particular theoretical perspectives.

The methods by which social work interventions, as well as those offered by
other professionals, are tested for effectiveness have evolved during the past 50
years. During the 1950s and 1960s, non-specific theories and strategies were ap-
plied to heterogeneous client populations and examined for evidence of impact
(Conte, 1997). Case studies were common in the professional literature. Though
informative, they were rarely based on structured research designs.

So what is known about effective social work practice? Two literature re-
views published 40 years ago by Fischer (1973, 1976) created a stir within the
profession by concluding that there was no evidence for the effectiveness of case-
work. A later analysis of 44 studies concluded that effectiveness was difficult to
determine because of a lack of rigor in research methods (Reid & Hanrahan,
1982). The researchers recommended that social workers increase the structure
of their interventions (that is, better specify the components and steps) so that
effectiveness studies could be better developed.

Thomlinson (1984) made a contribution to this issue with a broad review of
the social work literature. He did not set out to determine whether any general
intervention strategies were effective, but to identify particular components of
effective practice. He found that effective social workers were able to adjust their
theories and practice to fit with the client’s presenting problem, properly orient
the client to intervention, specify the purposes of selected interventions, and at-
tend to time limits (not necessarily short-term).

Corcoran and Videka-Sherman (1992) later noted that in outpatient mental
health settings, effective social workers tended to provide active interventions fo-
cused on exploration, modeling, advice, reinforcement, and task assignments.
They concluded that adherence to a particular theory did not seem to be related
to effectiveness; what mattered was the social worker’s intervention, not the

T H I N K I N G A B O U T T H E O R Y 11

theory behind the action. They admitted that much remained to be learned
about practice effectiveness and called for more studies using comparison groups,
unbiased samples, and long-term clients.

Another meta-analysis of outcome research in social work included 45 stud-
ies conducted between 1990 and 1994 (Gorey, Thyer, & Pawluck, 1998). The
researchers attempted to compare the effectiveness of practice by the social
workers’ theoretical orientation. The researchers found no overall differences in
outcomes by theoretical orientation, which were primarily cognitive/behavioral
but also included psychosocial, psychoanalytic, problem-solving, task-centered,
and systems approaches. They did find, however (rather obviously), that theoret-
ical frameworks focusing on individual client change were most effective at
changing client behaviors, and that systems and structural frameworks were
most effective at changing target systems beyond the individual client. The
authors echoed sentiments voiced by many practice researchers—that greater
specificity in social workers’ intervention procedures was needed to facilitate use-
ful future studies of outcome effectiveness.

The field of psychology has specified rigorous practice effectiveness criteria.
A task force of the American Psychological Association put forth a list of recom-
mendations for evaluating direct practice (Crits-Cristoph, 1998). The goal of this
project was not to endorse certain interventions, but to facilitate the education of
practitioners by identifying interventions with empirical support. The criteria for
“well-established” treatments include (a) at least two group comparison experi-
ments that demonstrate efficacy in terms of superiority to pill, placebo, or other
treatment, or that are experimentally equivalent to another established treatment;
or (b) a series of at least nine single-subject experiments demonstrating efficacy in
comparison with a pill, placebo, or other treatment. Additional criteria are (c) the
use of treatment manuals (structured protocols that direct the practitioner’s ac-
tions and the duration of intervention) to maximize specificity; (d) clearly de-
scribed sample characteristics; and (e) the demonstration of effects by at least
two different investigators.

The American psychological association’s criteria for determining best practices
include two experiments that show an intervention to be more effective than
waiting-list control group outcomes, one or more experiments that meet all of
the above criteria except for that of replication, or at least three single-subject
designs using manuals and clear sampling procedures. Somewhat less rigorously,
an intervention is considered probably efficacious when there is only one study
meeting the criteria for “well-established”; all investigations have been con-
ducted by one researcher or team; or the only comparisons have been to no-
treatment control groups (this requires two studies by independent investigators).

Evidence-Based Practice

In the past two decades it has become imperative for clinical social workers to
demonstrate their practice effectiveness. This movement toward evidence-based
practice (EBP) is related to social work’s increased emphasis on accountability to
clients and third-party payers and its desire to further the knowledge base of the

12 C H A P T E R 1

profession. EBP means that treatment outcome studies justify a certain treatment
approach for a particular disorder (Cournoyer & Powers, 2002; Roberts &
Yeager, 2004). Thyer and Wodarski (2007) feel so strongly about this issue that
they advocate for the Code of Ethics to emphasize social workers’ responsibility
to use only empirically validated interventions.

In social work, EBP refers to the process of using a variety of research data-
bases to guide interventions that foster client change (Vandiver, 2002). Put simply,
the social worker is faced with the question of “What evidence do you have that
your proposed intervention will be effective with your client?” There are three
approaches to operationalizing EBP in practice, including (in order of preference)
the social worker’s use of formal practice guidelines, expert consensus guidelines,
and, when appropriate guidelines are not available for certain client problems, a
self-directed approach. Practice guidelines have the purpose of providing social
workers with organized knowledge based on some degree of evidence as to its
effectiveness in reaching relevant outcomes (Rosen & Proctor, 2002).

The following hierarchical model in EBP includes six “levels” of knowledge
(Rosenthal, 2004):

Systematic reviews or meta-analyses (summaries and critiques of all available
research on a topic) of well-designed controlled studies

Well-designed individual experimental studies

Well-defined quasi-experimental studies

Well-designed non-experimental studies

Series of case reports or expert committee reports with critical appraisal

Opinions of respected authorities based on clinical experiences

For social workers intent on using EBP, the steps involved in using practice
guidelines include assessment, diagnosis, and the selection of diagnostic-specific
practice guidelines for goal development, intervention planning, outcome mea-
sure establishment, and evaluation.

All social workers want to use interventions that have been shown to be effec-
tive, but efforts to identify evidence-based practice models have been controversial
for a number of reasons (Beutler, Forrester, Gallagher-Thompson, Thompson, &
Tomlins, 2012; Chambless, 1998; Rosenthal, 2004). Most research methodologies
have not been able to examine relationship factors in clinical intervention, and
these are considered fundamental in many theories (Miller, Duncan, & Hubble,
2005). Likewise, personal characteristics of social workers are often overlooked,
such as their experience with particular problem areas and overall competence in
carrying out particular interventions. With regard to research methods, there is a
bias toward cognitive and behavioral strategies. Stewart and Chambless (2009)
note, however, that while a majority of demonstrably effective interventions to
date are cognitive or behavioral, this is due in part to an underrepresentation of
other interventions in research studies. Further, qualitative researchers are distrust-
ful of efforts to generalize intervention outcomes because of the complexities in-
volved in every instance of clinical intervention (O’Connor, 2002).

T H I N K I N G A B O U T T H E O R Y 13

Another criticism of EBP is that the use of intervention manuals (written
practice directives used in many research studies) may limit the natural respon-
siveness of practitioners to their unique client situations (Stewart, Stirman, &
Chambless, 2012). In fact, it is not always clear how closely practitioners follow
these procedures, as they may respond differentially to challenges that emerge in
the course of intervention. In a related criticism, it is not always practical to rep-
licate research protocols in agency environments. Perhaps most important, the
studies of diagnostic categories (major depression, generalized anxiety disorder,
etc.) are rarely precise in capturing the essence of a client’s condition. EBP has
been adapted from the medical model of care, but in the social sciences, practi-
tioners must be very cautious in assuming that two clients are “alike,” even if
they share the same diagnosis. Variables such as a client’s social support, socio-
economic status, distress level, motivation, and intelligence may be more impor-
tant predictors of response than diagnosis.

So what is the relationship between evidence-based and theory-based prac-
tice? Some proponents of EBP argue that theory is superfluous, as the social
worker needs to be concerned only with what interventions are most likely to
provide desired outcomes. Others emphasize that EBP is reductionistic, simplify-
ing the personality of the client, nature of diagnosis, skill level of the practitioner,
the range of interventions that a practitioner actually provides, and the role of
theoretical orientation in determining outcomes (Miller, Duncan, & Hubble,
2005). Issues related to incorporating EBP into mental health practice do point
to its limitations, and to the importance of theory:

Social workers must be skilled in person-in-environment assessment and di-
agnosis so the interventions they select appropriately match the identified
problem. (Assessment is always theory-based.) (Gambrill, 2010)

EBP must be adapted and personalized for clients based on their culture,
interests, and circumstances (Zayas, Drake, & Jonson-Reid, 2011).

The perspectives of both consumers and professionals must be taken into
account in developing practice agendas so that real-world issues of resources,
service access, and consumer uniqueness are all considered (Gambrill, 2010).

The prevalence of co-occurring disorders, and the array of settings in which
intervention may be provided, indicate that EBP must take these complex
presentations and settings into account. (EBP does not address co-occurring
disorders as much as “single” disorders, and theory is needed to sort out the
many issues that these kinds of clients face.) (Corcoran & Walsh, 2010)

Knowledge of interventions must be broader than being able to implement
specific evidence-based interventions. (This “knowledge” must be based at
least in part on practitioner judgment, which may be formed by adherence
to a theoretical orientation.) (Nevo & Slonim-Nevo, 2011)

To summarize on a constructive note, the differing attitudes among practi-
tioners who follow and are skeptical of the findings of EBP may represent a mis-
understanding of the concept. Thyer and Pignotti (2011) differentiate between

14 C H A P T E R 1

evidence-based practice and process, and argue that the latter, more appropriate
concept requires a social worker’s integration of best research evidence, along
with his or her practice expertise and collaborative attention to client values.
Their term best research evidence refers to clinically relevant research. Practice exper-
tise refers to the social worker’s reliance on his or her accumulated skills in asses-
sing each client’s unique presentation and the risks and benefits of potential
interventions. Client values refers to the preferences and expectations that each
client brings to the professional encounter. Regehr and Glancy (2010) add that
the evidence-based process should include the social worker’s attention to
agency mandates and constraints and the resources available in the broader social
environment. Thus, the systematic literature reviews used in evidence-based
practice need not be seen as recommendations about what social workers should
or should not do, but as summaries of what the research says about an interven-
tion so the social worker can take the information into account, along with other
factors, when making practice decisions.

Ways to Improve Theory and Practice Research

With the above factors in mind, there are practical ways for clinical social work-
ers to participate in research regarding their practice effectiveness. Most of these
opportunities derive from a principle of collaboration between researchers and
practicing social workers ( Jackson & Feit, 2011). Such strategies might include
developing university/agency relationships in which social workers are given
control of the intervention being provided and the researcher functions as the
design expert. Further, disentangling the “practitioner versus intervention strat-
egy” conundrum may be achieved by assessing the personal characteristics of the
social worker, as well as what that person does. Many social workers have had
the experience of being told, “You have the perfect personality to work with
this type of client!” or “Perhaps you shouldn’t work with that type of client,
given your temperament.” We all have gifts and limitations that we bring to
our practice. Monitoring the social worker/client relationship might be a pro-
ductive way to take this variable into account. Horvath’s (1994) Working Alli-
ance Inventory provides one example of doing so. The client and the social
worker complete this 36-item instrument at various intervals to provide compar-
ison data on their perceptions of bonding, goal orientation, and task focus.
Finally, in evaluation research, strategy (an approach to intervention that consid-
ers a range of client and practitioner factors) may be a more relevant variable to
study than theory or specific intervention technique (Beutler et al., 2012). Char-
acteristics dictating a practitioner’s therapeutic strategy include such factors as the
client’s set of strengths and limitations, levels of social support, and problem
severity. These variables might be important to include in research studies
when client homogeneity is sought.

Regarding self-directed practice, evaluating one’s own interventions through
the application of single-system or pre-experimental designs can be implemented
in most agency settings. All that is required is a social worker with a background
in basic research methods as taught in all undergraduate and graduate programs.

T H I N K I N G A B O U T T H E O R Y 15

Any theoretical perspective, strategy, or intervention can be evaluated through
these methods. Doing so can help the social worker go a long way toward estab-
lishing the quality of his or her intervention practice with clients, supervisors, and
administrators.

SUMMARY

The purposes of this chapter have been to define theory, discuss its relevance to
social work practice, consider how social workers select theories for practice, and
review current thinking in the profession about theory and practice evaluation.
We close with some thoughts about who is best suited to develop theory for
social work practice.

It is likely that practice-relevant theory can best be developed and advanced
by agency social workers who are directly engaged with clients (Polansky, 1986).
Direct practitioners are immersed in the “trenches” of the profession every day.
Trying to bring about change with challenging clients always prods one to ques-
tion and improve ideas and practices that sometimes do not seem adequate to
meet those challenges. Once the social worker achieves a certain level of exper-
tise, the main source of useful new ideas becomes one’s clientele. Universities
may be better equipped to be repositories of knowledge in professions like social
work than the creators of such knowledge. Partnerships between practitioners
and researchers for testing theory in the field can be a constructive means of de-
veloping knowledge for social workers who are committed to theory and the
advance of its applications.

Our “thinking about theory” in a general sense is not quite complete. In the
next chapter we will consider several issues that are specifically important to the-
ory as used by social workers and that are distinct from those addressed by mem-
bers of other professions.

TOPIC S FOR DISCUSSION

1. Think of a time in your own life that a friend or other acquaintance has
helped you with a personal problem. What was it about that person’s
approach that was helpful to you (validation, confrontation, active listening,
concrete advice, or something else)? What does that tell you about your
own problem-solving process? Compare what is helpful to you with what
is helpful to your classmates.

2. Social workers tend to emphasize the importance of the worker–client rela-
tionship in clinical practice, but not all practice theories give this factor equal
emphasis. What elements of a helping relationship, if any, do you think are
universally important?

16 C H A P T E R 1

3. Social workers often work in agency settings that are quite modest, or even
drab. Some practitioners do not have offices at all, but work out of cubicles
or even their cars. Given this, what do you think about the assertion in this
chapter that the nature of the intervention “setting” is a curative factor for
clients?

4. Should clinical intervention be evaluated beyond asking clients to state
whether they achieved their goals, and to what degree? Can intervention
outcomes ever be generalized across clients and client populations?

5. Material in this chapter suggests that not all social workers engage in critical
thinking. Assuming that critical thinking is a good thing to do, how can it be
supported in agencies, both formally and informally?

IDEA FOR CLASS ACT IV ITY

As described on the first page of this chapter, ask a variety of clinical staff in your
field agencies about the theoretical basis of their practice. What theory or theo-
ries do they use in working with clients? Why? Has it changed over time? Does
the agency have an “official” theory, or do the staff work from a variety of
perspectives?

T H I N K I N G A B O U T T H E O R Y 17

A Social Work Perspective

on Theory and Practice

The show is not the show,
But they that go.
Menagerie to me
My neighbor be. *

Most of the practice theories described in this book have been developed
outside of the social work profession. They are used as much by practi-

tioners from other professions as they are by social workers. The manner in which
these theories are used may be somewhat different among professional groups,
however, depending on the client population served, the practice setting, and,
most important, the value perspective of the profession. In fact, it is sometimes
said that professions are distinguished more by their value bases than by any other
defining characteristics (Dolgoff, Loewenberg, & Harrington, 2008).

This is a book for social workers, of course, so it is important for us to con-
sider how the material presented in the upcoming chapters is, or should be, used
by social workers in ways that are true to their professional mission and values. In
this chapter we will review several defining characteristics of the social work pro-
fession, including its value base, respect for diversity and multiculturalism, emphasis
on strengths and empowerment perspectives, attention to risk and resilience mechan-
isms in clients’ lives, and attention to the spiritual concerns of clients. Throughout
the book each theory will be considered (and, in part, evaluated) for the ways in
which it promotes or detracts from these professional concerns.

* Dickinson, E. (1927). The Pamphlet Poets. New York: Simon and Schuster.

18
Copyright 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights,

DEF IN ING DI RECT SOCI AL WORK PRACT ICE

Direct social work practice can be defined in a variety of ways. The definition
presented here, developed by the author and other faculty from Virginia
Commonwealth University’s School of Social Work, represents an effort to capture
the profession’s broad scope. Direct social work practice is the application of social
work theory and methods to the resolution and prevention of psychosocial problems
experienced by individuals, families, and groups. These problems may include
challenges, disabilities, or impairments, including mental, emotional, and
behavioral disorders. Social work practice is grounded in the values of the social
work profession and, as such, promotes social and economic justice by empowering
clients who experience oppression or vulnerability to problem situations. Direct
practice is based on an application of human development theories within a
psychosocial context and is focused on issues of human diversity and multicultur-
alism. Social workers help clients to enact psychological and interpersonal change,
increase their access to social and economic resources, and maintain their achieved
capacities and strengths. Assessment always incorporates the impact of social and
political systems on client functioning. Interventions may include therapeutic,
supportive, educational, and advocacy activities.

With this working definition, we can now consider the concepts of values,
strengths, risk and resilience, multiculturalism, and empowerment more fully.

THE VALUE BASE OF SOCIAL WORK PRACT ICE

All professions espouse distinct value bases that are intended to define their pur-
poses and guide the actions of their members. Values are principles concerning
what is right and good, while ethics are principles concerning what is right and
correct, or rules of conduct to which social workers should adhere in order to
uphold their values (Dolgoff, Loewenberg, & Harrington, 2008).

People may adhere to several sets of values in their different life roles, which
may be generally consistent with each other or sometimes in conflict. Personal
values reflect our beliefs and preferences about what is right and good for people.
Societal values reflect a consensus among members of a group about what is right
and good that has been reached through negotiation, often politically. Professional
values specifically guide the work of a person in his or her professional life. Pro-
fessional ethics are the obligations of social workers in relationships with other
persons encountered in the course of their work, including clients, other profes-
sionals, and the general public. Social work’s values and ethics are intended to
help practitioners recognize the morally correct way to practice, and to decide
how to act correctly in specific professional situations. Social workers routinely
experience ethical dilemmas—for example, around issues of confidentiality and
participating in mandated interventions.

The National Association of Social Workers (NASW) Code of Ethics (2008)
is “intended to serve as a guide to the everyday professional conduct of social

A S O C I A L W O R K P E R S P E C T I V E O N T H E OR Y A N D P R A C T I C E 19

workers.” The primary mission of the social work profession, according to the
Code, is “to enhance the human well-being and help meet the basic human
needs of all people, with particular attention to the needs and empowerment of
those who are vulnerable, oppressed, and living in poverty” (p. 1). The six core
values of the profession relate to service, social justice, dignity and worth of the person,
the importance of human relationships, integrity, and competence. The Code of Ethics
further states that social workers should challenge social injustice, and that they
should “pursue social change, particularly with and on behalf of vulnerable and
oppressed individuals and groups of people” (p. 6). This can be done through
social change activities, particularly with vulnerable and oppressed individuals
and groups, around such issues as poverty, unemployment, and discrimination.
Social workers can help their clients develop the external resources required for
a fulfilling life. They should strive to ensure clients’ access to needed information,
services, and resources, equality of opportunity, and meaningful participation in
decision making.

The social work profession’s first great advocate for social justice activities
among direct service providers was Bertha Reynolds (1885–1978), one of
the pioneers of the profession. As a direct practitioner, she developed a con-
viction that social workers should advocate for the working class and other
oppressed groups, which went beyond the young profession’s concern with
individuals and families. She suffered for her convictions, losing a prestigious
faculty position at Smith College in 1938 when she advocated for social
work unionization and political activity, and showed an overt concern
with civil rights. However, her perspective is now commonplace in the
profession.

The major implication of the social worker’s obligation to uphold profes-
sional values with regard to theory selection is that the practitioner’s activities
should promote the mission of the profession. We will refer to the core values
in that context throughout the book.

STRENGTHS-OR IENTED PRACT ICE

Strengths-oriented practice implies that social workers should assess all clients in
light of their capacities, talents, competencies, possibilities, visions, values, and
hopes (Saleebey, 2008). This perspective emphasizes human resilience, or the
skills, abilities, knowledge, and insight that people accumulate over time as they
struggle to surmount adversity and meet life challenges. It refers to the ability of
clients to persist in spite of their difficulties.

Dennis Saleebey, the profession’s foremost writer on this topic, asserts that
social workers (and other helping professionals) have been historically guided
by a deficits perspective, one that exists in opposition to humanistic values.
This “problem orientation” encourages individual rather than ecological ac-
counts of psychosocial functioning, which is contrary to social work’s person-
in-environment perspective. Saleebey adds that several negative assumptions

20 C H A P T E R 2

need to be adjusted toward the development of a more “balanced” strengths per-
spective, including notions that:

The person is the problem (rather than person-in-environment interactions).

There are fixed, inevitable, critical, and universal stages of development.

Childhood trauma invariably leads to adult psychopathology.

There are social conditions, interpersonal relationships, and institutional
relationships so toxic that they invariably lead to problems in functioning
for people, families, groups, and communities.

The disease model and its linear view of causes and solutions should be
followed.

In this writer’s view, Saleebey is overly harsh in his statements about how social
work practitioners approach their clients. Further, the problem-driven focus of
social work (and other professions) is perpetuated in part by managed care and
insurance company reimbursement criteria. Still, his work is constructive in
offering positive concepts for social workers to use that will more adequately
identify client strengths. The major principles of strengths practice include the
following:

Problems can be a source of challenge and opportunity.

Practitioners can never know the “upper levels” of clients’ growth
potentials.

There should be collaboration between practitioners and clients rather than
adherence to the traditional worker/client hierarchy.

Every environment includes resources (many of them informal) that can be
mobilized to help clients change.

One way that a social worker can focus on client strengths is by paying at-
tention to the following issues during the assessment process (Bertolino &
O’Hanlon, 2002):

Treatment history. What was helpful and not helpful in the past.

Personal history. Physical, psychological, social, spiritual, and environmental
assets; how the person has coped with stresses and challenges.

Family history. Supportive relationships.

Community involvement. Cultural and ethnic influences, community
participation, spiritual and church involvement, neighborhood assets, and
other social supports.

Employment and education. Achievements, skills, and interests.

By the time some clients seek help from a social worker, the problem may
have preoccupied them to an extent that they have lost sight of their resources.
When working from the strengths perspective, the social worker, regardless of
theoretical orientation, develops an awareness of strengths and openly conveys

A S O C I A L W O R K P E R S P E C T I V E O N T H E OR Y A N D P R A C T I C E 21

them to clients. For example, if a client seems to have a solid social support
system, he or she needs to be reminded that this strength is critical to adjustment.
One could take this intervention a step further and ask about the resources that
clients have used to develop these strengths. The client could be asked, “What
would your husband say makes you a good partner?” or “Why do your friends
like to be around you?” The social worker must further be alert to the strengths
that clients bring to other contexts, such as work settings, their hobbies, and pas-
times. The social worker can also ask directly about strengths: “What do you do
well?” “What are your best qualities?” “What would other people say you do
well, or that is good in you?”

When clients talk about the challenges and problems they face, their full
range of thoughts and feelings need to be validated. Only then should they be
asked about the resilient qualities they may possess. The social worker can
inquire about the aspects of the client’s life that are still intact despite the
problem, and explore for resources that were drawn upon in these areas. Ques-
tions can further center on personal or family qualities or strengths that have
developed as a result of dealing with the presenting problem. A recent research
review found that when people are able to find and articulate their resources
after a major stressor, they experience less depression and a greater sense of
well-being (Helgeson, Reynolds, & Tomich, 2006).

A RISK AND RESIL IENCE FRAMEWORK

FOR PRACT ICE

The risk and resilience framework provides a basis for social workers to identify
and bolster client strengths and reduce risk influences. This framework, first
developed in other disciplines (such as psychology and education), considers the
balance of risk and protective mechanisms that interact to determine a client’s
ability to function adaptively despite stressful life events (Gest & Davidson,
2011). Risks can be understood as hazards in the individual or the environment
that increase the likelihood of a problem occurring. The presence of a risk influ-
ence does not guarantee a negative developmental outcome, but it increases the
odds of one occurring. Protective influences involve the personal, social, and insti-
tutional resources that foster competence and promote successful development.
They decrease the likelihood of experiencing problem situations and increase
the likelihood of a client’s rebounding from stress (Fraser, 2004). Resilience refers
to the absence of significant developmental delays or serious learning and behav-
ior problems, and the mastery of developmental tasks that are appropriate for
one’s age and culture, in spite of exposure to adversity (Werner & Altman,
2000).

Social work researchers have expanded the risk and resilience framework,
organizing it into a “risk and resilience biopsychosocial framework” (Greene,
2008). Relevant influences are considered with regard to the client’s biological
constitution, psychological status, and social environment. More specifically,

22 C H A P T E R 2

Corcoran and Nichols-Casebolt (2004) state that both of these influences can be
assessed with respect to a client’s individual characteristics, family, neighborhood,
social support networks, spirituality, school, income and employment status, and
the presence or absence of discrimination and segregation. This framework fits
well with social work’s emphasis on empowerment and the strengths-based
perspective. The strengths perspective underlies the concepts of protective influ-
ences and resilience, in that people are not only able to survive and endure but
can triumph over difficult life circumstances.

In the risk and resilience conceptualization, the presence of a certain risk or
protective influence may increase the likelihood of other risk and protective in-
fluences. For example, an aversive parenting style with poor monitoring increases
the risk of children socializing with deviant peers (Ungar, 2004). If parents are
overwhelmed by environmental stresses, such as unemployment, a lack of trans-
portation and medical care, or living in an unsafe neighborhood, their ability to
provide consistent warmth and nurturing may be compromised. This phenome-
non also operates for protective influences. Adolescents whose parents provide
emotional support and structure the environment with consistent rules and
monitoring tend to associate with peers who share similar family backgrounds.
Supportive parenting, in turn, affects the characteristics of the child in that he
or she learns to regulate emotions and develop cognitive and social competence.
Systems interactions also play themselves out from the perspective of a child’s
characteristics. If a child has resilient qualities, such as social skills, effective
coping strategies, intelligence, and self-esteem, he or she is more likely to attract
quality caregiving. Another example of this process is seen in the attachment
patterns formed with early caregivers in infancy. The attachment pattern persists
into other relationships—for example, those with teachers.

Although the exact nature of how risk and protective mechanisms work
together is unknown, different mechanisms are hypothesized. Two primary
models are the additive and the interactive models (Pollard, Hawkins, & Arthur,
1999). In the additive model, protective influences exert a positive effect to coun-
terbalance the negative influences of risk. In an interactive model, protective in-
fluences enact a buffering function against risk when it is present. At times, risk
and protective mechanisms are the converse of each other. For instance, at the
individual level, difficult temperament is a risk influence and easy temperament is
a protective influence for problems in social functioning. Even though it is not
easy to use knowledge of risk and protective mechanisms with specificity in as-
sessment and intervention, the social work practitioner’s attention to these bal-
ancing factors can sustain an orientation to strengths and possibilities for client
change.

While precise mechanisms of action are difficult to specify, data has begun to
accumulate that four or more major risk influences may overwhelm an individual
and represent a threat to adaptation (Epps & Jackson, 2000). Further, risk seems to
have a stronger relationship to problem behavior than does protection. Although
some have found that the more risks there are, the worse the outcome (Appleyard,
Egeland, van Dulmen, & Sroufe, 2005), others have argued that risk does not pro-
ceed in a linear, additive fashion (Greenberg, Speltz, DeKlyen, & Jones, 2001).

A S O C I A L W O R K P E R S P E C T I V E O N T H E OR Y A N D P R A C T I C E 23

Neither are all risk factors equal in weight. The association between risk and
protection and outcomes are complex and involve changing conditions across
the life span.

DIVERS ITY AND MULT ICULTURAL ISM

A hallmark of the social work profession is its commitment to working with di-
verse, underserved, and marginalized populations. In the early 1900s both Mary
Richmond and Jane Addams developed principles for working with impover-
ished, inner-city populations, although with different methods (Specht & Court-
ney, 1994). It was only in the 1960s and 1970s, however, that the social work
literature featured an increase in the numbers of articles about practice with cli-
ents from minority cultures (Harper & Lantz, 2007). This literature was
prompted by two social developments. Population changes in the United States
indicated that people of color, including African Americans, Native Americans,
Latinos, and Asians and Pacific Islanders, would eventually comprise a larger seg-
ment of the population than Caucasian Americans. This trend has certainly con-
tinued. Social globalism also brought attention to the international nature of
professional practice. Members of the social work profession are well aware that
some traditional practice methods were not helpful for minority clients, and
might in fact be damaging to them.

Multiculturalism, or a social worker’s ability to understand and work from the
perspective of a variety of client cultures, represents an advance from the more
generic “self-awareness” that has always been a feature of the profession. The
development of culturally competent perspectives is based on the principle that
minority clients (including persons of different racial and ethnic groups, gender,
age, immigrant status, geographic background, sexual orientation, and disability)
have their own ways of seeking and receiving assistance, and these should be
respected (Fong & Furuto, 2001).

Cultural competence demands an approach to clients in which “assumptions
are few and are held only until the truth becomes known” (Dorfman, 1996,
p. 33). In Lee’s (2002) model of social work education, two dimensions of com-
petence, including cultural knowledge and cultural sensitivity, are the primary
factors involved in providing effective transcultural intervention. Cultural knowl-
edge refers to the practitioner’s ability to acquire specific knowledge about his or
her clients’ cultural backgrounds, racial experiences, historical experiences,
values, spiritual beliefs, worldview beliefs, resources, customs, educational
experiences, communication patterns, thinking patterns, coping practices, and
previous help-seeking experiences. Cultural sensitivity refers to a social worker’s
attitudes and values about cross-cultural direct practice and his or her ability to
intervene effectively with members of different cultures.

Members of some cultures experience barriers to treatment due to providers’
“lack of awareness of cultural issues, bias, or inability to speak the client’s lan-
guage, and the client’s fear and mistrust of treatment” (U.S. Department of

24 C H A P T E R 2

Health & Human Services, 2001). In addition, although there is a movement
among the helping professions toward evidence-based practice (EBP), there is a
shortage of research on treatment outcome for mental disorders for people from
different ethnic groups. This is changing through the thoughtful efforts of
some scholars and practitioners to adapt culturally what is known about EBP
(Bernall & Rodriguez, 2012; Zayas, Drake, & Jonson-Reid, 2011), but as of
yet, relatively few models of culturally sensitive services have been tested.

Social workers must realize that it is impossible to “know” another culture.
A social worker’s competent responses to transcultural helping situations, how-
ever, include high levels of cultural knowledge and sensitivity. In addition to
acquiring considerable culture-specific knowledge about diverse clients, the
competent practitioner must demonstrate openness, empathy, and care with
those clients and be able to maintain an informed and empathic response to
them. When a social worker has developed a competent response to the trans-
cultural helping situation, he or she can make sound practice judgments from an
informed point of view, be open and sensitive in the cross-cultural helping
situation, connect with clients at an individual empathic level, and maintain aware-
ness of his or her own personal experiences, which might distort judgment.

We now turn to a discussion of client empowerment in social work practice,
a process by which clients can be helped to utilize their existing strengths to
work toward the achievement of their goals.

CL IENT EMPOWERMENT

In keeping with the profession’s values and mission, social work practitioners at
all levels desire to enhance the capacity, or power, of clients to address their life
concerns. Power can be understood as including (Lee, 2001):

A positive sense of self-worth and competence

The ability to influence the course of one’s life

The capacity to work with others to control aspects of public life

An ability to access the mechanisms of public decision making

Many clients do not—or perceive that they do not—have power, either
over themselves, their significant others, or the agencies and communities in
which they reside. This sense of powerlessness underlies many problems in liv-
ing. It can be internalized and lead to learned helplessness and alienation from
one’s community. An empowerment orientation to practice represents the social
worker’s efforts to combat the alienation, isolation, and poverty of substantive con-
tent in clients’ lives by positively influencing their sense of worth, sense of mem-
bership in a community, and ability to create change in their surroundings.

Clients may be empowered at a personal level (changing patterns of thinking,
feeling, and behaving), an interpersonal level (managing their relationships more
effectively), or an environmental level (changing their manner of interacting with

A S O C I A L W O R K P E R S P E C T I V E O N T H E OR Y A N D P R A C T I C E 25

larger systems) (Gutierrez, Parsons, & Cox, 2003). Direct practitioners are gener-
ally more inclined to address a client’s personal and interpersonal concerns.
Empowerment at the individual level is a process by which clients gain mastery
and control over their lives and a critical understanding of their environment.

Empowerment incorporates three themes (Parsons, 1991). It is a developmen-
tal process that can be experienced along a continuum from individual growth to
social change. Second, it is a psychological state that includes a client’s beliefs about
his or her competence, efforts to exert control, and understanding of the social
environment. Third, it may involve a client’s liberation from oppression, a process
that begins with education and politicization of his or her presenting problems.
In a sense, empowerment is a political concept, though the extent to which this
is apparent to clients and practitioners depends on their approach to intervention.
Payne (2005) argues that empowerment at the direct practice level tends not to
address social structure inequities.

Social workers may perceive this concept to be more relevant to practice
with large systems (organizations and communities), but in fact it has implications
for intervention at all levels. From the person-in-environment perspective, even
the most “individual” of problems, such as physical and mental illness, have in-
tervention implications that may include helping the client create an environ-
ment conducive to recovery. In every case of empowerment practice, the social
worker helps clients become aware of the conflicts within themselves and their
surroundings that oppress or limit them, and helps clients become better able to
free themselves from those constraints.

With their person-in-environment perspective on human functioning, social
workers are well positioned to promote client empowerment. For the process to
be effective, social workers must possess theoretical knowledge about how orga-
nizations function, and they must be empowered themselves in ways that give
them the competence to act with clients. The sources of power over social
workers in an agency (administrative or interprofessional) may create client/
worker power disparities that undermine the goals of empowerment practice.

Aspects of the empowerment process that social workers should assess in
their clients include the nature of the client’s goals and, related to those goals,
the client’s self-efficacy, knowledge, competence, ability, and willingness to
take action (Cattaneo & Chapman, 2010). The social worker’s specific actions
toward empowerment are less important than the general orientation toward
helping clients become more involved in their communities (however defined)
and feeling more capable of exerting control there. The concept of perceived con-
trol has been found to be related to reduction in psychological stress and in-
creased social action (Zimmerman, 2000). Empowerment can be achieved
through the use of any of the practice theories described in this book, although
some are more conducive to the process than others.

Direct social work practice is empowering to the extent that it helps people
develop skills to become independent problem solvers and decision makers. Toward
this end, the practitioner must establish a positive relationship with the client and
help him or her to manage the presenting problem. The social worker should strive
for collegiality, which means abandoning the expert role and developing a more

26 C H A P T E R 2

egalitarian relationship with clients so that they have the “final say” in decisions
that affect their lives. The practitioner must be willing to teach clients the
knowledge and skills necessary to enact interventions for themselves. The practi-
tioner must also be willing to help clients learn skills to secure external resources
and participate in social change activities if they so desire. Not all clients should
receive interventions targeted toward all of these areas, but the social worker
should have the capacity to initiate these change activities if requested.

Limitations to Empowerment Practice

Empowerment has become a major practice concept in the social work profes-
sion, but it may be difficult to operationalize in practice for the following reasons
(Payne, 2005; Richardson, 1994):

Some clients prefer the social worker to be an “expert,” and rely on his or her
guidance in seeking solutions for their problems.

Social workers may be uncomfortable with its call for client/worker partnerships and
the education of clients in change activities that go beyond their presenting
problems. In fact, some practitioners believe that it is unethical to suggest goals
and activities for clients that do not directly relate to their presenting problems.

Social workers cannot empower their clients unless they themselves also have power
(respect and influence) among their peers in the service professions. The status
of the profession with respect to furthering the interests of clients has histori-
cally been a topic of concern among academic scholars (Ehrenreich, 1985).

The values on which empowerment is based may conflict at times.
Self-determination, distributive justice, and collaborative participation
sometimes may be in conflict with each other (Carroll, 1994). For example,
the sense of self-determination of one interest group (such as disabled
students at a university) may result in initiatives to usurp power from
university administrators. Empowerment is not necessarily a win-win
proposition for members of different social groups.

Some practitioners may empower through coercive intervention. As an example,
practitioners at one agency worked from the assumption that empowerment
depends on a person’s level of functioning, and thus coercion was said to be
empowering when persons with severe mental illness (and poor judgment)
were forced to take medication to improve their clarity of thought (Strack,
Deal, & Schulenberg, 2007). Coercion may or may not be justified in this
particular example, but it points to the challenge of determining which
actions are indeed empowering and which may be disempowering.

Empowerment and Research

Practice research from the empowerment perspective is conducted differently
from traditional methods in which the professional is the “expert” and in control
of the process. Empowerment research involves doing “with” rather than doing

A S O C I A L W O R K P E R S P E C T I V E O N T H E OR Y A N D P R A C T I C E 27

“to” and emphasizes social worker/client collaboration (Cattaneo & Chapman,
2010). From this perspective, practice research uses clients as participants rather
than “subjects” in the areas of research design, accountability, implementation,
and utilization. An example of empowerment research might be a social worker’s
meeting with members of a drop-in center for persons with mental illness to
discuss possible ways of evaluating the center’s effectiveness. Members would
be invited to participate in the design of the project, data-gathering activities,
and decisions about how the results are used. At present, empowerment research
is not often done in social work except in the context of narrative therapy
(see Chapter 12), which is openly collaborative in nature.

Several qualitative research studies illustrate the challenges that social workers
face in using empowerment practice. In a study of 28 clients and social workers
(including administrators) in a community-based service setting, frontline work-
ers were interviewed about their perceptions of the empowerment process
(Everett, Homstead, & Drisko, 2007). The researchers found that social workers
sometimes experienced role conflicts in the process of helping clients become
more involved in their own problem-solving activities, moving back and forth
from the roles of “expert authority” to “collaborator.” They were often
challenged by the apparent powerlessness of their clients to make changes in
their lives, and they felt the same sense of powerlessness at times in dealing
with organizational barriers and limited job roles. The authors concluded that
for empowerment practice to be effective, the process must be formally valued
and articulated at all levels of an organization. In another study of 145 clients and
professionals, it was found that the two parties sometimes had different perspec-
tives on empowerment practice (Boehm & Staples, 2002). Clients were more
interested in the practical, tangible outcomes of empowerment activities, while
social workers were more interested in the process of empowering clients, with
less focus on specific outcomes.

To summarize, the concept of empowerment is useful for guiding social
work practice at all levels. Despite its limitations, it has the potential to help
client groups develop more secure lives through substantive interpersonal and
community connections. The actions of social workers can always be produc-
tively driven by a concern with clients’ capacities to take control of their lives.

SP IR ITUAL ITY IN DIRECT PRACT ICE

The term spirituality has many definitions, but can be generally understood as a
person’s search for, and adherence to, meanings, purposes, and commitments that
lie outside the self (Barker & Floersch, 2010). It may be said that there are two
contrasting perspectives on this idea (Frankl, 1988). One is that we create what is
meaningful in our lives; that is, there are no “objective” or external sources of
meaning that we must observe. Meanings emerge within us and reflect our in-
terests and values. An example is the person who chooses to devote her life to
working with abused children, having realized that doing so fulfills a personal

28 C H A P T E R 2

preference that is also important to society. The second perspective holds that at
least some meanings reflect a reality that exists independently of us. It becomes
our challenge to discover meanings that exist objectively. Some religious groups
believe that there is a divine plan and a correct set of beliefs about a supreme
being and codes of conduct, and that persons should live in accordance with
this plan. It is possible to hold both views simultaneously, as we may consider
some purposes objective and others based on our preferences.

Spiritual (or existential) meanings can be summarized into four categories,
which may overlap (Frankl, 1988). Belief systems may be religious or secular.
One can believe in the teachings of the Baptist faith because of its divine origins,
or in the Golden Rule (act toward others as you want them to act toward you)
because of purely humanitarian concerns. Social concerns include commitments to
social causes. One can demonstrate such a commitment, for example, in volun-
teer service of various types, commitments to bettering the quality of life for cer-
tain oppressed groups, or environmental concerns. Creative pursuits include art,
music, and literature, but may also include approaches to one’s work (for exam-
ple, the development of innovative agency programs). Also included in this
category is the experience of creative pursuits that bring meaning to one’s life.
Some persons feel most alive, for example, when responding to a piece of music.
Hope includes the defiance of suffering. This comes to the forefront of existence
at times when one experiences great self-doubt or despair, but recognizes that he
or she values life enough to persist in overcoming the adversity.

Spiritual concerns help people manage anxieties produced by confrontations
with death, isolation (or being alienated from others), and freedom (and the re-
sponsibilities involved in making choices), as well as concerns about their place in
the world (Yalom, 1980). Coming to terms with these issues is a challenge for all
people. Although we may not deal with these concerns daily, they influence
how we organize our lives.

Some emotions provide signals that we are struggling with existential con-
cerns (Lazarus & Lazarus, 1994). Most prominently, anxiety results from uncertain
threats to one’s identity, future well-being, or life-and-death concerns. Anxiety is
fueled by the struggle to maintain a sense of connection to others, and we often
feel threatened by the fragile nature of life. The emotion of guilt results from
thoughts or actions that we perceive as violations of important social standards
of conduct. Guilt results from a perceived “moral flaw” when we have not be-
haved in accordance with an important value. A religious person who sins may
feel guilt, and a social worker (who is not necessarily religious) who provides
poor service to a client also may feel guilt. The emotion of shame is similar to
that of guilt, but refers more specifically to the failure to live up to a personal
(rather than social) ideal. A Caucasian person who believes in equality of oppor-
tunity may feel shame when he reacts negatively to an African-American family
moving into his neighborhood. It is also important to emphasize that persons
experience positive emotions such as happiness and joy when they behave in
ways that affirm the spiritual self. A client who performs well as a Habitat for
Humanity volunteer may experience great joy from making a contribution to
the community.

A S O C I A L W O R K P E R S P E C T I V E O N T H E OR Y A N D P R A C T I C E 29

Incorporating Spirituality into Direct Practice

Spiritual issues are not appropriate to address with clients in all practice situations
(Coates & Schiff, 2011). Such concerns may not be appropriate to raise with
clients who are absorbed in immediate problem situations for which they are
seeking practical assistance. On the other hand, purpose-in-life issues may be
appropriate for intervention when the client is troubled by anxiety, guilt, and
shame, or demonstrates inclinations to look beyond the self and immediate
situation in understanding and resolving personal dilemmas. Spiritual issues
should be included as part of a multidimensional assessment with all clients, as
it is always possible that a person’s present problems and needs may contribute
to, or result from, struggles with a broad life concern.

With regard to utilizing spiritual themes in clinical practice, challenges to
social workers are fourfold:

To understand his or her own existential issues and their impact on practice

To consider client functioning within a broad context of meaning (that is, to
bring consistency to the client’s present and ultimate concerns)

To encourage client disclosure of existential concerns, when appropriate

To help clients identify meanings and purposes that can guide them in
making growth-enhancing decisions

Spiritual, theory-guided interventions can increase the client’s attention to
three issues. They can encourage the client’s investment in constructive life activity
(rather than passivity), encourage the client to look externally for solutions to pro-
blems (rather than be preoccupied with internal emotions), and encourage the
client to care about something outside the self (Lantz & Walsh, 2007).

Interestingly, social work practitioners have tended to feel uncomfortable or
unqualified to address issues of spirituality with clients. This may be due in part
to a reluctance to risk imposing one’s values on clients. Fortunately, this reluc-
tance is less prevalent today than in the recent past. In a 1992 random survey of
Virginia social workers, psychologists, and counselors (Sheridan, Bullis, Adcock,
Berlin, & Miller, 1992), it was found that respondents valued religious or exis-
tential dimensions in their own lives. Though they addressed these issues to vary-
ing extents in their practices, many expressed reservations about the potential
abuse of doing so, particularly with regard to imposing their beliefs. A recent
national study, however, examined social workers’ attitudes and behaviors about
religion and spirituality in practice with children and adolescents and came to a
different conclusion (Kvarfordt & Sheridan, 2007). The majority of respondents
regarded religion and spirituality as relevant to this population and used a wide
variety of spiritually based interventions. In a recent literature review, however,
Sheridan (2009) learned that a majority of practitioners do not rely on specific
ethical guidelines in this regard, and they report that religious or spiritual issues
were rarely addressed in their social work education.

Still, spirituality, as defined here, is a natural part of every person’s life, and
is receiving a greater focus from social workers and other practitioners

30 C H A P T E R 2

(Crisp, 2010). Although it is not overtly addressed in all practice theories, it can
always be incorporated into the processes of assessment and intervention. The
feasibility of the social worker addressing issues of spirituality with clients will
be discussed throughout the text in the context of each theory.

SUMMARY

This chapter has highlighted aspects of direct practice that are central to the per-
spective of the social work profession, including attention to professional values,
a strengths orientation, risk and resilience influences, diversity and multicultural-
ism, empowerment, and spirituality. We will see that all of the practice theories
presented in the coming chapters can potentially be used in ways that are consis-
tent with the social work perspective, but each practitioner must discover for
himself or herself how well they seem to work in particular settings. These the-
ories were largely developed outside the social work profession, so one of our
tasks will be to consider how they can be implemented to fit with the values
and priorities of social work practice.

TOPICS FOR DISCUSSION

1. Compare the characteristics of social work practice to direct practice as
carried out by several other professions, such as psychology, psychiatry, and
nursing. How is social work similar to, and different from, these other pro-
fessions? What do the differences suggest about the values of the social work
profession (and those of the other professions)?

2. Discuss a variety of ways in which a social worker might, accidentally or
purposely, address a client’s spiritual or religious life that are not ethically
appropriate. How can these pitfalls be avoided? Conversely, describe
situations in which a social worker might constructively engage these aspects
of a client’s life.

3. What are some specific areas of a client’s life that a social worker can inves-
tigate to assess his or her strengths? What are some questions you might ask,
or observations you might make, toward that end?

4. Consider a variety of types of clients who may come to an agency for
intervention. Speculate about the risk and resilience factors that may be
operating in the clients’ (or families’ or group’s) lives, at the biological,
psychological, social, and perhaps spiritual levels. How might you
incorporate these into an intervention plan?

5. Toward the goal of empowerment, some social workers believe that the
worker and client should be equal partners in the intervention process. What
does this mean to you? Do you agree? Are there circumstances in which the
notion of partnership might not apply?

A S O C I A L W O R K P E R S P E C T I V E O N T H E OR Y A N D P R A C T I C E 31

IDEAS FOR ASSIGNMENTS

(Students can write papers or prepare discussion points on the following topics.)

1. Consider an adolescent client who is referred for counseling because of
oppositional behavior in school, characterized by a failure to do homework
or even attend class on a regular basis. The client lives in low-income
housing with a single, unemployed mother and aging grandmother. What
kinds of social justice activities might the social worker incorporate into the
intervention plan? What portion of the intervention would be devoted to
individual and family counseling, compared to any possible social
interventions?

2. Many Asian-American clients observe traditional family norms in which the
mother is in charge of raising the children and the father is responsible for
earning money to support the family. Further, wives generally defer to the
opinions and decisions made by the husband. What biases, if any, might you
experience in working with this type of couple? How might you use
cultural sensitivity and cultural awareness to control your biases and
effectively work with such a woman and her family?

32 C H A P T E R 2

Person-Centered Theory

His labor is a chant,
His idleness a tune;

Oh, for a bee’s experience
Of clovers and of noon! *

Person-centered theory (PCT) incorporates a perspective on human nature
and development that is probably more optimistic and strengths-focused

than any other theory presented in this book. It was developed by the psycholo-
gist Carl Rogers during the mid-20th century and has been followed since then
by many other theorists and, especially, direct practitioners. PCT postulates that
all people have an innate drive toward self-actualization; in other words, there is
a tendency for their self-images to seek and maintain congruence with their or-
ganically derived potentials. Further, the more self-actualized a person becomes,
the more harmoniously he or she will live with others. PCT is clearly consistent
with the values of social work, which is why it maintains a position of high re-
gard in the profession even though its assumptions are open to criticism.

PCT proposes that all people have the means to grow beyond the limita-
tions of their experiences and work toward greater self-actualization when facili-
tated by a consistent and reliable relationship with an empathic, accepting
practitioner. In its practice the social worker does not offer a set of structured
interventions to a client, but rather creates a relationship in which the client feels
affirmed and encouraged to find his or her own solutions to problems or life
challenges. The social worker accepts and affirms the subjective realm of the cli-
ent’s experience rather than trying to interpret it. As we will see, PCT includes
relatively few concepts because Rogers believed that human potentialities are too

* Dickinson, E. (1927). The Pamphlet Poets. New York: Simon and Schuster.

33
Copyright 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights,

vast to be classified. From this perspective, anytime a practitioner adopts a formal
set of theoretical principles, he or she limits the possibilities of being open to the
complex range of human experiences. While needing to possess specific knowl-
edge and interpersonal skills, the practitioner is never an “expert” with regard to
any client’s situation.

PCT includes positive assumptions about people, respect for the absolute
uniqueness of human experience, and an apprecation for the social worker’s
need to listen to and empathize with clients. It is clearly a humanistic perspective.
Still, PCT is criticized by some for providing “necessary, but not sufficient” con-
ditions for intervention (Carmin, 1995), because it is not at all directive. Further,
in this age of time-limited and evidence-based practice (EBP), PCT is said to be
difficult to research because it is ambiguous about what the social worker does to
facilitate client change.

The adherents of PCT say that it is appropriate for use with many types of
client problems and challenges. For example, in addition to persons who have
general growth concerns, clients with psychosis, who feel marginalized and mis-
understood in their symbolic worlds, often respond positively to the approach
(Traynor, Elliott, & Cooper, 2011; Prouty, 1998). Lesbian, gay, bisexual, and
transgendered clients are largely receptive to the approach as well because of its
affirming nature (Livingstone, 2008; Davies, 2000). The theory has also been in-
corporated into a variety of expressive arts interventions for persons of all ages
who may not be capable of verbal interaction (Luke, 2011).

ORI GINS AND SOCIAL CONTEXT

Carl Rogers developed PCT during the 1940s and 1950s in four major books
on the topic: The Clinical Treatment of the Problem Child (1939), Counseling and
Psychotherapy: New Concepts in Practice (1942), Client-Centered Therapy (1951),
and Psychotherapy and Personality (Rogers & Dymond, 1954). With On Becoming
a Person (1961), Rogers entered a new career phase in which he began apply-
ing his theory to issues beyond direct practice, including education, commu-
nity group development, conflict resolution, and social justice activities.
Rogers’s approach stood in stark contrast to the prevailing psychodynamic
thinking of his time, in which people were considered to be essentially in con-
flict with themselves and others and the focus of intervention was helping peo-
ple adjust as best they could to a social world where cooperation, though not
the natural state of affairs, was necessary for survival. Rogers believed that peo-
ple, as self-actualizing beings, had a natural propensity to be in harmony with
themselves and their environments.

Rogers was born into a Chicago family with strict Christian religious values
(Thorne, 1992; Rogers, 1961). As a child he developed an interest in scientific

34 C H A P T E R 3

agriculture, but he eventually majored in history at the University of Wisconsin.
After marriage, however, he decided to enter the ministry. Rogers objected to
the conservative Christianity of his childhood, though, and sought a liberal edu-
cation at the Union Theological Seminary in New York. Still, his difficulties
accepting prevailing Christian orthodoxy led him to transfer to nearby Columbia
University after two years to study clinical and educational psychology. He de-
veloped an interest there in working with children, and after receiving his Ph.D.,
he worked for 12 years (from 1928 to 1940) in the Child Study Department of
Rochester’s Society for Prevention of Cruelty to Children.

In the 1920s and 1930s psychotherapy in the United States was dominated
by psychoanalytic thought, which stressed the use of specific techniques to main-
tain control of client interviews and direct them toward therapist-chosen objec-
tives. Few practitioners paid attention to the “here and now” relationship of the
client and therapist. Rogers was initially among those who favored interpretive
therapy, the major goal of which was to help clients (both children and their
parents) achieve insight into their past and present behavior and motives. While
working in Rochester, however, Rogers became sensitized to the importance of
a facilitative environment for positive psychological growth. His evolving ideas
were greatly influenced by his social work colleagues Elizabeth Davis and Fre-
derick Allen, who had studied under Jessie Taft at the “functional” school of
social work at the University of Pennsylvania. Rogers was later influenced by
the ideas of “renegade” psychoanalyst Otto Rank (also working at the University
of Pennsylvania) and the educational philosophy of John Dewey. Each of these
influences is described in some detail below.

Jessie Taft was the director of the University of Pennsylvania School of So-
cial Work. The functional school emerged in the 1930s under her leadership as a
reaction to psychodynamic theorists of the time, who tended to view people as
being prey to dark forces of the unconscious and the harsh restrictive influences
of early caregivers (Dorfman, 1996). The functionalists adopted an optimistic
view of people, asserting that they were not the end products of their pasts but
were capable of continually re-creating themselves in the context of here-
and-now environmental resources. Functional theory held that the social
worker/client relationship provided the context in which a client’s growth could
be fostered. Treatment was not something a social worker did to a client, but with
a client, and the processes of diagnosis, exploration of the client’s past, and inter-
pretation were de-emphasized.

Otto Rank, after being banished from Freud’s inner circle because of his
radical ideas, had a major influence on the development of psychotherapy in
the United States (Kramer, 1995). Rank postulated that each person has an
innate “creative will” and that the essence of life is ceaseless progress toward
self-development. The “will” was the subjective experience of life, which could
be either expressed in creative living or lost in neurotic symptoms. Anxiety was a
neccessary component of living and was the basis for all human choices. Rather
than setting out to eradicate pain, the purpose of therapy was to help clients
make deeper contact with themselves and their ambivalences and anxieties.
They could be helped to “own” the previously unacknowledged parts of their

P E R S O N – C E N T E R E D T H E OR Y 35

suffering rather than displace or project it onto others. Intervention helped cli-
ents become more aware of and accepting of themselves, and evaluate and clarify
more thoughtfully the meaning of their existence. All emotions—positive and
negative, constructive and destructive—were considered to be expressions of
the person that must be confronted, worked through, accepted, and integrated
into the development of a whole person. Rogers acknowledged that these ideas
resonated deeply with him when he invited Rank to lead a seminar in Rochester
in 1936.

A third major influence on Rogers’s theory was the pragmatic and educa-
tional philosophy of John Dewey (Westbrook, 2010). Dewey’s ideas about co-
operation helped Rogers develop his position that self-actualized people live in
harmony with others, rather than conflict. Dewey maintained that people are
inherently social beings, and that attention to social problems must utilize the
guidance of human action toward the achievement of ends that produce satisfy-
ing lives for them. Appropriate methods for solving social problems should al-
ways be empirical, tied to an examination of the problem, the gathering of
relevant facts, and the imaginative consideration of possible solutions.

Regarding the nature of a satisfying life, Dewey wrote of the harmonizing of
experience (the resolution of conflicts both within the individual and society),
the release from tedium in favor of the enjoyment of variety, and the expansion
of meaning (an enrichment of the individual’s appreciation of his or her circum-
stances within a culture). The social condition necessary for this kind of human
advancement was the democratic form of life, founded on habits of cooperation,
public spiritedness, and an organized, self-conscious community creatively re-
sponding to needs. Toward this end Dewey rejected the notion that a child’s
education should merely be preparation for civil life. Schools should instead be
viewed as extensions of civil society, with students encouraged to function as
community members, pursuing their interests in cooperation with others. Educa-
tion should facilitate self-directed learning, guided by cultural resources provided
by teachers.

During his years in Rochester, then, and during his subsequent academic
appointments at Ohio State University (1941–1945), the University of Chicago
(1945–1957) and the University of Wisconsin (1957–1962), Rogers developed
his theory of self-actualization and the role of practitioners in supporting this
process. Three periods of development of Rogers’s psychotherapy ideas can
roughly be summarized as follows (Zimring & Raskin, 1992):

1940s—An emphasis on feelings versus content in a client’s statements, and
the importance of accepting those feelings without interpretation

1950s—Accepting the client’s perspective on his or her situation as valid and
bringing concreteness, genuineness, and unconditional positive regard to the
encounter

1960s—Extraclinical applications of person-centered theory and therapy

The name of Rogers’s approach to therapy evolved over the years as well. First,
it was “relationship therapy” (1939), then “non-directive therapy” (1942), then

36 C H A P T E R 3

“client-centered therapy” (1951), and finally “person-centered therapy” (the
1970s). It is significant that Rogers was the first human services practitioner to
use the term “client” versus “patient” in his promotion of a demystified, egali-
tarian relationship between client and practitioner.

Ironically, while Rogers’s ideas were readily embraced by practicing profes-
sionals during his lifetime, and he served as president of the American Psycho-
logical Association in 1946–1947, person-centered theory and therapy never
enjoyed a wide respect among academic psychologists. His ideas were considered
to be vague, and his therapy unsystematic, and his disdain for theory worked
against him in the academy as well. Still, person-centered theory and therapy
remain extremely popular with the counseling and social work professions,
with a steady stream of conferences and publications, and even a journal
(Person-Centered and Experiential Psychotherapies) dedicated to its ideas.

MAJOR CONCEPTS

Person-centered theory was derived from person-centered therapy; that is,
Rogers’s development of the intervention preceded its theoretical justifications in
human behavior. For that reason we will first explore the theory of human behav-
ior that Rogers developed over a period of years (Maddi, 1996), and later in the
chapter, in the section “Intervention,” we will discuss his therapy concepts.

Concepts Related to the Actualizing Tendency

Every human being is a unique biological organism, born with inherent, organi-
cally based potentials and ideally striving to lead a life in which his of her sense of
“self” is consistent with those potentials. Put another way, all people are born
with a genetic blueprint to which specific substance is added as their lives prog-
ress, depending on social and environmental circumstances. The core tendency
of all people is to actualize their inherent potentials, which Rogers calls striving
toward self-actualization. (This concept, with a range of meanings, was also pres-
ent in the writings of Kurt Goldstein and Abraham Maslow.) Further, all poten-
tials serve the maintenance and enhancement of life. Still, the actualizing
tendency is not consciously known to a person until the self-concept emerges.
Thus, many people often find it difficult to appreciate their actualizing tendency
on the intuitive bases of their own experiences.

Rogers intentionally did not formulate any categories of organic potentials,
believing that they were limitless and emphasizing that any attempts at doing
would amount to an inappropriately narrow view of human nature. It is impos-
sible to truly know another person, so making assumptions about one’s range of
potentials is reductionistic. Still, to the extent that a person’s behaviors express his
or her preferences and competencies, one can say that those behaviors clarify the
nature of his or her potentials. Remember that Rogers was skeptical of theoreti-
cal systems, and thus it makes sense that his theory of human development
would represent an “open” system of thought.

P E R S O N – C E N T E R E D T H E OR Y 37

If a person grows up surrounded by significant others who provide him or
her with unconditional positive regard (warm acceptance regardless of his or her
thoughts, feelings, and behaviors), even if the significant others do not always
agree with them, the person will have a context in which to develop innate po-
tentials. On the other hand, if a person is surrounded by others who provide
conditional positive regard (that is, indications of disapproval and rejection of
some of those natural strivings), the person may develop a sense of self that is
inconsistent with his or her basic nature. In the latter situation the person inter-
nalizes conditions of worth—the sense that he or she will be accepted by others
only when acting, feeling, and thinking in certain ways that may not be consis-
tent with natural strivings. The two defenses that such a person might develop in
this case are denial (of the validity of one’s thoughts, feelings, and behaviors) and
distortion (modifying an unconscious impulse into a form that is more acceptable
to oneself and others). PCT asserts that conditional positive regard represents so-
ciety’s failure to promote the conditions for optimal human development.

As a simple example of this process, a person may possess an inherent striving
toward (and talent for) certain types of nurturing relationships, and eventually
decide on a career in social work. (It is important to emphasize here that one’s
potentials have nothing to do with specific career choices; rather, they reflect
inclinations toward broad lifestyles.) If that person’s significant others (including
parent figures, certainly, but also friends and teachers) and environmental condi-
tions (for example, the community and culture) support this striving, the individ-
ual may in fact become a social worker and in that way experience a fulfilled
sense of self. If the person’s strivings are not supported because significant others
hold strict values that oppose the individual’s preferred lifestyle, the person may,
in order to satisfy those conditions of worth, move into another type of career
that leaves her feeling unfulfilled.

PCT is extremely positive in its view of human nature, in that the actualiz-
ing tendency and the process of self-actualization do not inevitably place one in
conflict with others. What is consistent with the maintenance and enhancement
of life is also consistent with the maintenance and enhancement of the lives of
others. When people accept themselves, they gain an enhanced appreciation and
acceptance of others. Disagreements and misunderstandings will certainly arise,
but when they are addressed directly, suspicion decreases and people can live
together cooperatively. It is important to emphasize, however, that the actualiz-
ing tendency does not aim to reduce tension. On the contrary, the forward thrust
of life continuously pushes one into challenging environments that create anxiety
and increase tension. PCT has a constructive view of anxiety, however, as the
feeling provides the impetus for the person’s working through obstacles that, if
managed successfully, will lead to greater self-actualization.

Concepts Related to the Self

People develop a conscious sense of who they are, which is called a self-concept.
PCT defines the self rather simply as “the self which I currently concepualize
myself as being” (Thorne, 1992, p. 29). It is a conscious, fluid, and unfolding

38 C H A P T E R 3

Mobile User

self, one that is experienced and defined differently throughout one’s life. (In
fact, it closely resembles the concept of self that is presented by narrative theory,
which will be discussed in Chapter 12.) Inherent potentials are genetically deter-
mined, but the self-concept is socially determined, and its substance is based in
part on the person’s experience of approval or disapproval from others. Positive
regard refers to the person’s satisfaction at receiving approval from others; positive
self-regard is a more internalized version of this concept, representing one’s sense
of personal satisfaction with his or her actions. The need for positive regard and
positive self-regard are offshoots of the striving for self-actualization. The core
tendency of personality, then, is the inherent attempt of the organism to actual-
ize or develop its potentials in ways that will serve to maintain and enhance life,
including actualizing the self-concept, which is a psychological manifestation of
the total person. The self-concept consciously promotes the specific ways in
which the self-actualizing tendency is expressed.

Congruence and the Fully Functioning Person

Congruence, which characterizes a fully functioning person, is experienced when the
self-concept embraces all of one’s potentials. In the state of congruence, people
respect and value all manifestations of themselves, are conscious of all there is to
know about themselves, and are flexible and open to new experiences. They
function in a manner that is free of defensiveness. Characteristics of the ideal life-
style include:

An openess to experience, featuring the qualities of emotionality and
reflection

Living life in accordance with one’s values and capabilities, featuring flexi-
bility, adaptability, spontaneity, and inductive thinking

Organismic trusting (letting decisions come to oneself rather than basing
them on the opinions of others)

Experiencing oneself as functioning freely

Creativity (the ability to produce new and effective thoughts, actions, and
things in response to environmental challenges)

In contrast, the non-ideal lifestyle is characterized by defensiveness, living ac-
cording to a preconceived plan, disregarding one’s physical and psychological self,
feeling manipulated, settling for conforming to the expectations of others, and living
with conditions of worth. The non-ideal lifestyle may be characterized by the word
incongruence, a mismatch between the self-concept and the actualizing tendency.

PCT’s description of congruence and the fully functioning person represents
an ideal state, of course, which few can fully achieve. It is likely that most people
experience conditions of worth rather than unconditional positive regard among
many of their closest friends, relatives, and peers, and thus live in a state some-
where between the ideal and non-ideal lifestyles. However, PCT holds that it is
always a sign of psychological and organismic health when one actively strives for
conditions that promote self-actualization.

P E R S O N – C E N T E R E D T H E OR Y 39

THE NATURE OF PROBLEMS AND CHANGE

Problems or life challenges are caused by a discomforting incongruence that exists be-
tween a person’s self-concept and his or her inherent potentials. In other words, one’s
natural strivings are stunted by living with restricting conditions of worth. Such chal-
lenges are ubiquitous, but some persons will choose to seek the assistance of a human
services professional in resolving them. The client is aware of a problem but may not
have a clear sense of its sources and possible solutions. Change occurs when the person
develops greater congruence, which can result from professional intervention,
personal reflection, the use of personal supports, or changing external circumstances.

ASSESSMENT AND INTERVENT ION

The purpose of person-centered therapy (which we’re terming “PC therapy” to
avoid confusion with the theory that supports it) is to enhance the client’s con-
gruence relative to a presenting challenge. This therapy is highly compatible with
social work’s person-in-environment approach and can be used with clients who
seek help with, or are referred for, a variety of presenting emotional and behav-
ioral problems. It would probably not be appropriate for persons who are only
seeking physical or material assistance of some kind, although those persons may
also be experiencing psychosocial incongruity. Neither would it be appropriate
for clients who are not intellectually capable of receiving the three essential con-
ditions of empathy, unconditional positive regard, and practitioner congruence
(see the section “Intervention,” later in this chapter, for more about this topic).
Some social workers may decide that the approach can be utilized in part,
primarily as a relationship-development strategy with all types of clients, but
doing so in such a case would not truly qualify as PC therapy.

Assessment

The PC therapy practitioner first needs to assess whether a client is capable of
engaging in the approach (Wilkins & Gill, 2003). Rogers asserted that if two
people are in psychological contact, the client experiences incongruence, and
the client can at least minimally perceive the practitioner’s empathy, conditions
are sufficient for constructive change. PC therapy is inherently relational, so the
client must be assessed to be capable of mutual relating. (This would also be true
with children in person-centered art therapy.) Beyond this, PC therapy does not
feature a formal assessment protocol. The social worker begins the intervention
by telling the client that he or she is there to try to help with whatever issues the
client is experiencing. The social worker listens and responds with acceptance
and empathy, and does not set out to diagnose, judge, direct, attempt to solve,
profess to know precisely what is “wrong,” or claim to have clear answers to the
client’s concerns. (It is understood, of course, that in many settings social workers
are required to record a diagnosis to qualify the client for services.)

40 C H A P T E R 3

Mobile User

Intervention

General Features The “person of the therapist” is the most important ingredi-
ent in person-centered intervention. Its articulation of the appropriate nature of
the worker/client relationship is, of course, considered by many to be the most
enduring contribution of the theory. Throughout their interaction, the social
worker focuses on respecting, nurturing, and fostering the fragmented aspects
of the client’s notion of self, while modeling an integrated sense of wholeness.
More specifically, the social worker demonstrates the characteristics of (Rogers,
1957):

Empathy. The practitioner does his or her best to understand the problem
from the client’s perspective at both the cognitive and emotional levels, and
to reflect that understanding accurately to the client. The social worker ac-
cepts the client’s formulation of the problem and affirms the validity of his or
her subjective experience without interpretation.

Unconditional positive regard. The social worker demonstrates a valuing of the
person of the client and his or her situation, without reservation. This stance
runs counter to the client’s expectations of significant others in his or her life
(who provide conditions of worth). The social worker sees the client as
striving toward self-actualization and places no conditions on that striving.

Congruence, or genuineness. By demonstrating genuineness, the social worker
conveys a message of sincerely wanting to understand and work with the
client. The social worker models congruence to the client when he or she
consistently communicates feelings, thoughts, and behaviors. Further, the
social worker responds to questions honestly and non-defensively. All of
these qualities demand that the social worker has a high degree of self-
awareness and self-confidence, and does not hide behind a mask of profes-
sionalism or expertise. If any of these elements is missing, the social worker
sends a message to the client that may be inconsistent and confusing.

The Process of Intervention The practitioner does not incorporate specific
intervention techniques in PC therapy, but by establishing the above conditions
provides a facilitative setting where the client can engage in more open and au-
thentic reflection to achieve greater congruence. The process, when successful,
unfolds as follows (Rogers, 1986a).

The client and social worker come together purposefully to address a con-
cern of the client. The client is in a state of incongruence characterized by trou-
bling thoughts, behaviors, and feelings. The social worker is congruent in the
relationship. This means, in addition to the qualities listed earlier, that the social
worker can be objective (not falling prey to subjective moral judgments) and
possesses a high level of psychological knowledge (regarding human behavior
and its physical, social, and biological determinants).

Throughout their interactions, the social worker demonstrates unconditional
positive regard and empathic understanding of the client, and accepts the client’s

P E R S O N – C E N T E R E D T H E OR Y 41

perspective of the presenting situation as valid. The social worker is not directive
and does not verbally dominate the interactions. The client perceives these con-
ditions, and as a result, feels increasingly free to express his or her thoughts and
feelings. The most significant feelings expressed are about the self in relation to
others. In response to feeling accepted and affirmed, the client is increasingly able
to more clearly differentiate the significant objects of his feelings and perceptions.
The client is able to experience feelings that in the past have been denied or
distorted, and these feelings increasingly bring to the surface an awareness of his
or her potentials and the incongruity between them and the self-concept. The
client’s self-concept begins to reorganize to become more congruent with his or
her experiences. The client then reacts to his or her life experiences less in terms
of conditions of worth and more in terms of valuing the innate strivings toward
self-actualization. The evolving self becomes more congruent with the ideal self.

As the client becomes more congruent, he or she is more open to experi-
ence, less defensive, more realistic, and more objective. The client perceives
others more realistically, and his or her behavior becomes more expressive and
creative. He is perceived by others as more mature and socialized.

Ending the Intervention Consistent with its unstructured nature, there are no
formal ending protocols in PC therapy. If the experience is successful, the client
will reach a point where he or she feels satisfied with the current state of affairs
and raises the topic of ending with the practitioner. If the client is dissatisfied
with the process of therapy and raises the issue with the practitioner, the social
worker will respond in a manner consistent with his or her overall approach,
encouraging the client to process those feelings and make a decision about con-
tinuing or not. If the agency requires time-limited interventions, the social
worker will remind the client of this fact as the intervention progresses so that
the client understands that an ending is imminent.

SP IR ITUAL ITY AND PCT

The evolution of PCT is ironic in that, for most of his life, Rogers was opposed
to the idea of its incorporating any religious or spiritual implications. He did not
see a place for religion (defined as commitment to a particular dogma or belief
system) in PCT because he was at his core anti-dogmatic, both with regard to
religion and to the idea of “theory” in general. Rogers grew up with a Christia-
ninty that emphasized the innate sinfulness of human beings (“original sin”) and
rejected this perspective, even as he pursued his studies for the ministry. What
seems to have escaped Rogers until well into his adulthood is that self-
actualization as a basic organic drive is consistent with many notions of spiritual-
ity, defined as a person’s potential to transcend his or her state of incongruence
toward achieving some ideal. His phenomenological approach, which empha-
sized affirming the client’s reality, further recognizes the uniqueness of each
person and his or her need to find life’s meaning in unique ways. Surely

42 C H A P T E R 3

Rogers recognized that many of his clients would find self-actualization in spiri-
tual realms, perhaps “religious” ones, and surely Rogers would respect those
options.

PC therapy can in fact be seen as existential, with the client’s pursuit of
meaning and the transcendence of the self “as is” toward a self that becomes
something else. Rogers himself recognized this later in life, when he wrote: “I
realize that this account (of the therapeutic relationship) partakes of the mystical.
Our experiences, it is clear, involve the transcendent, the indescribable, and the
spiritual. I am impelled to believe that I, along with many others, have under-
estimated the importance of this mystical, spiritual, dimension” (Rogers, 1986b,
p. 200). In the words of one of his biographers, “The spiritual thread in Rogers’
work that remained covert and even denied for most of his professional life
eventually emerges not as a mysterious dimension but as the outcome of faith
in the actualizing tendency and in the power of the core conditions to bring
about transformation” (Thorne, 1992, p. 106).

Contemporary person-centered theorists have emphasized this point as well.
One author states that PC therapy is a philosophy of living, suited to those who
are in search of life’s meaning but not inspired by traditional religious thought
(van Kalmthout, 2008). Another writer notes that PC therapy incorporates four
distinct elements of existential theory, including its phenomenological explora-
tion of freedom and choice, its appreciation of the challenges of existence, an
understanding of human beings as fundamentally relational, and an understand-
ing of people as meaning-seeking creatures (Cooper, 2003). This author con-
cludes by observing that attention to its existential underpinnings can help PC
therapy practitioners develop deeper levels of empathy with their clients.

ATTENT ION TO SOCIAL JUST ICE ISSUES

Although PCT developed as a means of providing effective therapy to individuals,
its positive view of human nature and emphasis on client empowerment make
it consistent with the social work profession’s attention to social justice issues. It
does so by drawing on the natural striving of people to live in congruence with
their social environments, and by recognizing the need for people to deal with
the limitations imposed by the social environment that prohibit facilitative
living conditions. PCT has also had a significant influence of matters in the
fields of education, medicine, business, politics, the ministry, and other profes-
sions (Kirschenbaum & Henderson, 1989).

PC therapy has, for example, influenced the ongoing work of San Diego’s
Western Behavioral Sciences Institute, of which Rogers was an active member be-
tween 1963 and 1968 (Farson, 1965). The institute operates from the premise that
given the right conditions, people can be trusted, and it works to improve the en-
vironments that influence people’s lives. It has conducted research on developing
community leaders with the premise that all people have the potential to become
effective leaders when their potentials are tapped by a person-centered facilitator.

P E R S O N – C E N T E R E D T H E OR Y 43

The institute has also studied the conditions that can enable people to escape from
poverty, do better in school, and reduce racial tensions. It has organized media
dialogues between Islam and the West toward the goal of improving cross-
cultural relationships.

In short, PCT provides a basis for facilitating conditions whereby people can
enhance their innate desires to live congruently with others. Rogers explored
these possibilities during his affiliation with the Center for Studies of the Person
in La Jolla, California, which began in 1968 and continued until his death. His
last years were devoted to applying his theories to situations of political oppres-
sion and social conflict, and he traveled worldwide to help organize summits for
political leaders. For example, he brought together influential Protestants and
Catholics in Northern Ireland, blacks and whites in South Africa, citizens
moving from dictatorship to democracy in Brazil, and consumers and providers
in various health fields in the United States. His last trip, at age 85, was to the
Soviet Union, where he lectured and facilitated intensive experiential workshops
to enhance U.S.-Soviet relations.

PCT is by no means a “call to action” for social workers practicing with
individuals, groups, and families, but its positive assumptions about self-
actualization and the desire of people to live cooperatively provide a constructive
basis for clients and social workers alike to engage in problem-solving activities at
the macro level. Such activity is quite consistent with the theory’s perspective.

CASE ILLUSTRAT IONS

In the first of these two illustrations, the social worker struggles with his own
sense of congruence in working with a client who, for him, is quite challenging.
The second vignette tells the story of a social worker who leads a support group
from a person-centered perspective.

The Premed Student

Dan Lee was a 28-year-old single Chinese-American male student working to-
ward admission into medical school. He came to the university counseling center
to get help with his feelings of anxiety and tension related to that task, as well as
some ongoing family conflicts. Dan was having difficulty concentrating on his
studies and was in danger of failing a course that he needed to pass to stay on
track for medical school. Specifically, he was preoccupied with perceived per-
sonal slights from several friends, his sister, and his mother. Dan told the social
worker that he needed help learning how to get these significant others to be-
have more responsibly toward him so that he could focus more intensively on his
own work.

Dan was the older of two children (his sister was 22) born to a couple who
had grown up in Taiwan and moved to the United States before the children
were born. His father was a surgeon and his mother a homemaker, and they

44 C H A P T E R 3

divorced when Dan was 7 years old. He and his sister had lived with their
mother since then and had only occasional contact with their father. Dan had
internalized the values of his family and culture; he understood that he needed
to assume primary responsibility for the well-being of his mother and sister while
also achieving high social status for himself. He tried hard to be a good son and
brother but held a firm position that others should always yield to his directives.
He believed he was always “right” in decisions that he made about his mother
and sister (regarding where they lived, how his mother spent her time, and what
kinds of friends and career choices his sister should make). Regarding his friends,
Dan felt that whenever there was a conflict or misunderstanding, it was always
“their fault.” He gave one example of a friend who had arrived more than 20
minutes late on two occasions for scheduled social outings. The second time, he
demanded that the friend apologize for being insensitive, and when the friend
did not do so to Dan’s satisfaction, the relationship ended. These kinds of rela-
tionship disruptions were common in his life. Dan’s family and friends often did
not accept his admonitions, so he wanted to learn from the social worker how to
better help these other persons see that he was always “rational” and “correct” in
his decisions.

Spencer, the social worker, readily empathized with Dan and agreed to help
him address his concerns, although he did not take a position on the client’s spe-
cific goals. Spencer was a Caucasian male, several years older than Dan, but he
understood the value system in which Dan was raised. He liked Dan, appreciat-
ing his intelligence, motivation to get help, and ability to articulate his concerns,
but he soon observed that the client demonstrated a striking rigidity in his atti-
tude toward others. Still, he validated Dan’s perspective on the presenting issues.
Spencer easily engaged his client in substantive conversations each time they met,
reflecting back to Dan the difficulty of his competing demands and desire to help
his family lead safe and productive lives. Before long, however, Dan began chal-
lenging Spencer’s non-directive feedback: “I want to know what you think I
should do here.” “How can I approach my sister so she won’t be so defensive
about my input?” “I tell my mother she shouldn’t speak to my dad so often, but
she keeps doing it anyway. How can I get her to stop?”

Dan was clearly in a state of incongruence, having difficulty balancing his
desires for personal development with his desire to care for two adult family
members. He seemed to have internalized conditions of worth related to his
family responsibility and, possibly due to having done so at such a young age,
had become quite rigid in his approach to helping the family. His defensive pos-
ture involved distorting the motives of others as oppositional rather than expres-
sions of their own personal inclinations. In recognizing Dan’s rigidity as a
defense, Spencer helped him reflect on the possibility that the behaviors of others
toward him might not be intentionally oppositional, but rather reflective of
differences of opinion, and that perhaps Dan could reward himself for his well-
meaning efforts while recognizing that one’s influence over others cannot be
absolute. Spencer did so with non-directive feedback that included such state-
ments as “You believe that you know what’s best for your sister, but she tells
you that she has her own opinions, and it’s hard for you to let her go her way,

P E R S O N – C E N T E R E D T H E OR Y 45

and to credit yourself with having tried your best to appropriately guide her”; “You
wonder if your mother disrespects you when she says it should be up to her how
much time she spends with your father”; and “You are a highly responsible person,
and you want so much to be a good son and brother, and it’s hard for you to even
consider that your sister sees her career options differently than you do.”

Spencer was always patient in his responses to Dan, reminding him, “It’s a
very difficult situation you are in, and you’re trying your hardest to do the best
for your family, and it’s frustrating that you can’t find ways to help them under-
stand your concern for them”; “It hurts you to see other people move in direc-
tions you believe are not good for them”; and “You feel strongly that certain
people should do what you suggest even though they disagree.” Still, despite
these empathic, non-directive responses that Spencer believed reflected his posi-
tive regard, Dan became increasingly frustrated with the social worker. “I
thought you were a professional. I thought you were trained to help people.
Why can’t you come up with some new ideas for me to try?”

Over time Dan continued to keep his rigid perspective. The client tried to
consider his situation from others’ points of view, but he always came back to
the position that he was “rational” and others were “irrational.” He accused the
social worker of being incompetent for not answering his questions concretely
enough, and after six months of regular meetings, he brought up the idea of
terminating: “Maybe I should see another counselor.” Spencer himslf was frus-
trated with his inability to help Dan broaden his perspective on interpersonal
differences about what is “rational” or “correct” and address his inability to dis-
tinguish disagreement from disrespect. When the client raised the topic of termi-
nation, Spencer responded “It’s very hard for you to hear me say that I don’t
have concrete answers for you, and you wonder if another counselor could pro-
vide those. I can’t speak for other practitioners, but what I will say here again is
that your concerns about your family and friends are legitimate, and I’ll continue
to try to help you consider how you might engage with them in ways that are
true to your responsibilities and also your own goals.”

Spencer, while remaining non-directive, and using feedback from his own
supervisor to make sure he was doing so, hoped Dan would eventually perceive
that his influence over others was limited, and that they might respect and ap-
preciate him even as they did not agree with his advice, and, most basically, that
people have different ideas regarding what is best for them. Dan never articulated
openly that his ideas about the appropriate behavior of others were anything but
“correct,” but over time he reported fewer conflicts with his sister, mother, and
peers, and his study habits and grades improved to the point that he was admitted
to medical school. After a yearlong regimen of weekly intervention, Dan finally
decided to terminate because of his busy medical school schedule. During their
final session together, he said to Spencer, “I don’t know how much I’ve gotten
out of this, but I know you tried to help, and I appreciate that.”

Reviewing the intervention with his supervisor, Spencer believed that he
provided the three necessary conditions for PC therapy, although his own sense
of congruence was tested by the client’s strong defensiveness. Spencer regretted
that he had felt such frustration with the client, although he felt that he had

46 C H A P T E R 3

successfully contained his feelings. Further, despite Dan’s ongoing misgivings
about the quality of the intervention, he continued meeting with Spencer for a
full year and eventually demonstrated behaviors that were evidence of improve-
ment. It seemed that Dan had reached a higher level of congruence, even
though it wasn’t apparent to himself.

The Support Group

Allie and Sarah were social workers and also friends who worked at a commu-
nity mental health center in a large metropolitan city. They shared an interest in
working with persons who had severe mental illnesses and volunteered their time
to facilitating a support group for the family members of those persons through
the local chapter of the National Alliance for the Mentally Ill. The purpose of
the ongoing, open-ended meetings, held every Monday evening for 90 minutes
at a local church, was to provide participants with information about mental ill-
ness and its effects on family functioning, as well as a place where participants
could experience mutual support. Each week, 6 to 10 members came to the
meeting, with most being regular attendees. Referrals for the group came from
the assistant director of the local chapter. Allie and Sarah were notified in ad-
vance when a new member might be joining, but they never met the person
until he or she showed up for a meeting.

The support groups were conducted in an informal manner. Both Allie
and Sarah were person-centered practitioners; they reminded the group each
week that the members were in charge of the content, and that their roles as
leaders were to provide information about mental illness, bring in guest pre-
senters when requested, and facilitate communication so that each person was
given the opportunity to participate in discussions. From the person-centered
perspective, the members were experiencing incongruence due to their special
challenges in making personal and family adjustments to provide an environ-
ment of appropriate support to their ill members, but they also had a good
deal of experience with these situations, as well as many related strengths.
The participants needed information about mental illness (such as the meaning
of diagnoses, the roles of medication and other interventions, and risk and pro-
tective influences regarding recovery) and new ideas about how to take care of
themselves and their family members (including the difficult task of setting lim-
its). Still, they were the experts on their situations, as they were living the
experience. Neither Allie or Sarah, both in their early 30s, had direct experi-
ence with mental illness in their own families. They had no intention of artic-
ulating the concerns of the group in any other way than the members did
themselves, and they had no desire to “probe” for issues that might be “below
the surface.”

Either Allie or Sarah attempted to set a constructive tone for each meeting
with some introductory comments. “Once again, we are here to help you
address and work on your challenges in dealing with mental illness by providing
an atmosphere of mutual support. We have experience working with people
who have mental illnesses, but no special expertise as family members. We

P E R S O N – C E N T E R E D T H E OR Y 47

hope you will see us as facilitators, here to help you converse with each other in
ways you find helpful. We do have access to information about mental illness and
its treatment and will do our best to make those resources available to you.”

Group leadership, or facilitation, is always a challenging process. Allie and
Sarah attempted to gear their interventions to involving all members in group
participation, attending to their education and support needs, encouraging ex-
pressions of feelings, clarifying their concerns, and commenting on the group
process (the balance and tone of interactions among members). Their activities
were intended to enhance communication and interaction patterns and establish
a positive sense of cohesion. They were attentive to the roles that members
tended to assume in many types of groups (the placator, the monopolizer, the
isolater, and the negative member) and made observations to help all participants
feel that their contributions were relevant.

Group members tended to interact productively week after week, but the
co-leaders were always busy balancing their interactions. Some members were
openly pessimistic about the prognosis of their family members, and Allie and
Sarah, while acknowledging the special challenges of those persons, made sure
that others felt free to report on their more encouraging experiences. Some
members were quiet and the co-leaders tried to draw them out, especially if
they were new. Occasionally a member vented anger at Allie or Sarah; once a
member got upset about Allie’s empathic response to another participant by
shouting “How would you know what she’s up against? You don’t know what
our lives are like. You can’t possibly understand.” Allie responded non-
defensively, saying, “No, I don’t know exactly what your lives are like. I know
that you all struggle, though, and I know how frustrating it must be to live in
such stressful conditions.” Overall the members seemed to appreciate the experi-
ence of being understood, accepted, and affirmed, and they kept returning to the
group until they felt that their needs for support and education had been met.
There was no formal evaluation, other than asking the members on a regular
basis how well the group was meeting their needs.

EV IDENCE OF EFFECT IVENESS

Despite the relative absence of current research on client-centered theory and
therapy, it is widely acknowledged that Carl Rogers was revolutionary in his
dedication to psychotherapy research, beginning in the 1940s. Practice research
had rarely been undertaken before that time. In this section the research done by
Rogers and his colleagues will be discussed, and then the current research status
of PCT will be addressed.

Specific Research on Client-Centered Theory and Therapy

Research on PC therapy can be categorized into four periods (Bozarth, Zimring, &
Tausch, 2002). Initially, during the 1940s, Rogers became interested in comparing

48 C H A P T E R 3

the processes and outcomes of directive and non-directive interventions, using
judges to score practitioner and client comments based on observations of session
audiotapes and transcripts. In dozens of studies conducted during this period, it was
found that non-directive therapy was positively associated with clients’ increased
self-understanding, positive feelings, degree of self-exploration, and self-concept.
During the next decade (the second period), client-centered therapy (CCT) re-
search focused more directly on the client-centered relationship and the effective-
ness of practitioners working from the client’s internal frame of reference. Several
of these studies used control groups to determine whether differences could be
detected in client changes in self-perception based on counselor ratings, indepen-
dent observers, and self-reports. While the findings were largely positive, and this
use of control groups in psychotherapy research was novel, those studies were later
criticized for being methodologically unsound (e.g., lacking randomization and
using biased samples). Another major retrospective study at the time compared
the work of successful and unsuccessful therapists, finding that the differences lay
in the presence or absence of therapist warmth and efforts to subjectively under-
stand the client’s life.

Beginning in the late 1950s, and continuing for the next 30 years (the third
period), PCT researchers tested the impact of the three core practitioner attitudes
on client change. While much of this work focused on PC therapy itself, it
eventually included a variety of theoretical perspectives. As one example, Rogers
and his colleagues undertook an ambitious six-year study (from 1957 to 1963) of
the effect of PC therapy with psychotic clients. This was Rogers’s last major re-
search project on the intervention, and although it was not found to be signifi-
cantly different from other approaches, some positive outcome measures were
correlated with the core conditions (congruence and empathy). In the 1960s,
Rogers’s interests moved beyond psychotherapy, and his later research in the
United States tended to focus on studies of therapist-offered conditions in the
context of a variety of practice theories. PC therapy research was more extensive
outside the United States, however, and the relevance of the three condtions
continued to be supported.

By the 1990s (the fourth period) researchers became more interested in
studying the specific ingredients of different therapies that could account for their
effectiveness. In other words, there was a growing sentiment that the core con-
ditions may be useful or even necessary, but not sufficient, for client change. PC
therapy by itself was investigated in only a dozen or so outcome studies by this
time, focused on clients who experienced alcoholism, anxiety disorders, interper-
sonal difficulties, depression, cancer, and schizophrenia. The intervention was
consistently found to be effective.

Reaserch on the Significance of the

Practitioner/Client Relatinship

As described in Chapter 1, the American Psychological Association has syste-
matically evaluated the significance of the practitioner/client relationship in

P E R S O N – C E N T E R E D T H E OR Y 49

determining intervention effectiveness (Norcross & Wampold, 2011). The em-
phasis on treatment specificity put PC therapy as a “complete” intervention at a
disadvantage, as it was considered too general in its theoretical position. The task
force chose to emphasize the role of the therapist and his or her technique and
deemphasize the role of client variables. Still, a panel of experts concluded after a
series of meta-analyses that several relationship variables were demonstrably and
probably effective, and they were all consistent with the assertions of PCT (see
Chapter 1 for a discussion of these variables).

Some researchers who study relationship variables in therapy outcomes have
attempted to refine PC therapy’s three core conditions, as well as articulate new
relationship concepts (Kirschenbaum & Jourdan, 2005). It is said, for example, that
the concept of empathy is probably more complex than Rogers’s formulation, and
might look different with different kinds of clients and in different stages of inter-
vention. Further, the concept of congruence is widely believed to be Rogers’s least
well-developed idea (for example, with its implications for therapist self-disclosure)
and was integrated into other conceptual schemes (Cornelius-White, 2002). A
newer concept, that of the “therapeutic alliance,” has been developed, and while
it is inconsistently defined, it incorporates the client’s affective relationship with
the practitioner, the client’s capacity to purposefully work in therapy, the practi-
tioner’s empathic understanding and involvement, and client/practitioner agree-
ment on goals and objectives. There remains a consensus, however, that the
effective relationship makes a substantial contribution to intervention outcomes
independent of the specific type of treatment.

To summarize five decades of research on PCT and PC therapy, it has been
found that the relationship between the client and practitioner, in combination
with the resources of the client (extra-therapeutic variables), accounts for ap-
proximately seventy percent of the variance in successful intervention, with spe-
cific technique accounting for only fifteen percent of the variance (Miller,
Duncan, & Hubble, 2005). That is, effective intervention is predicated on the
nature of the client/practitioner relationship in combination with the resources
of the client, and technique may add relatively little to the outcome.

CR IT IC ISMS OF THE THEORY

PCT has been criticized on many grounds. Most directly, there is no way to test
its main assumption that all people have an innate self-actualizing tendency. In
fact, arguments for the self-actualization tendency seem to involve circular rea-
soning (Maddi, 1996). It is assumed that inherent potentials determine behavior,
although the existence of this unfolding process can be demonstrated only by
observing the behaviors of a person over time that promote his or her feelings
of congruence. PCT is also seen as overly simplistic in its postulating of only two
kinds of people: those who are fully functioning and those who are not. One
might assert that other personality types might fall along a continuum of these
poles, but PCT does not specify these middle points due to its desire to avoid

50 C H A P T E R 3

taking a reductionistic perspective on human behavior. Further, the notion that
one’s self-actualizing tendency, when shared openly with others, will lead to a
harmonious living environment is seen as naïve by some, who point to the per-
vasive existence of conflict in the world (May, 1982). For his part, Rogers did
not deny the presence of conflict (he even acknowledged the concept of “evil”)
in the world, but he believed that this was due to people living under arbitrary
conditions of worth that could change.

PC therapy is also criticized for being too simplistic. For example, while a
positive worker/client relationship may be essential for client success, the person-
centered practitioner does not analyze any relationship factors (spelled out in
other theories) such as transference, countertransference, and the role of the un-
conscious. Rogers countered that he did not deny the existence of any of these
phenomena (and others) but said that they naturally become part of the thera-
peutic interaction without a need for special conceptual status. Rogers had great
respect for the power of the unconscious, for example, but he felt (like the cog-
nitive theorists that we discuss in Chapter 8) that such influences gradually rise to
the surface in a person-centered relationship. Second, person-centered practi-
tioners may overlook inherent power differentials in the worker/client relation-
ship despite their desire to develop an egalitarian stance (van Belle, 1980). These
power imbalances may interfere with a client’s ability to experience a mutual
relationship and be truly open with the practitioner. Perhaps most significantly
with regard to social work, PC interventions do not actively attend to the specific
influences of external events on a client’s life or draw the client’s attention to the
need to address them (Masson, 1989). Non-directive PCT practitioners would
argue that it is not the place of therapy to focus attention on these factors, and
the self-actualizing client will become able to identify and manage external chal-
lenges on his or her own.

Several other criticisms of PC therapy suggest why it has fallen out of
favor during the past 30 years as a distinct therapeutic approach. It may be too
non-directive for many clients, who seek and need active feedback about their
feelings, thoughts, and behaviors. These persons may come from cultures that
respect and desire authority, and they may be confused by PCT. Further, the
realities of agency life and third-party payment for services often require prac-
titioners to impose limits on the length and course of intervention. Several
authors have offered possible solutions to this problem, stating that person-
centered practitioners should hold other theoretical perspectives and practices
in high regard and, when indicated, move clients into a complimentary inter-
vention approach when it seems more suited to their needs (Cooper &
McLeod, 2011).

SUMMARY

PCT has clearly had a major influence on the development of direct social work
practice and the field of psychotherapy in general. The intervention persists as a

P E R S O N – C E N T E R E D T H E OR Y 51

fully realized practice approach for some, and many of its elements have been
incorporated into other practice perspectives, sometimes so naturally that its in-
fluence is taken for granted. To summarize, PCT and PC therapy are responsible
for all of the following important developments in direct practice:

Articulating a view of the person as inherently resourceful and self-actualizing

Establishing the importance of the therapeutic relationship as a healing agent

Developing the art of listening and understanding, and demonstrating the
therapeutic effects of those qualities on the client

Introducing the term client as opposed to patient, to convey greater dignity,
respect, and power for the person seeking help

Demystifying the process of psychotherapy as an encounter between persons
that, while always challenging, does not require mastery of an array of con-
cepts and specific techniques

Initiating scientific research on the processes and outcomes of therapy

For contemporary adherents of PC therapy, there is a conflict between the pur-
ists, who believe that by nature, it cannot be refined, and those who have attempted
to make adjustments in the practice, primarily by adding points of focus. Process-
experiential practitioners believe that change occurs when the client’s level of affec-
tive experience within a session is high, and the practitioner should help the client
focus on bodily sensations at those times as a way to discover new meanings
(Haimeri, Finke, & Luderer, 2009). Efforts have also been made to integrate PC
therapy with solution-focused therapy, since the future-oriented techniques of the
latter approach may help raise a client’s awareness of his or her potentials (Cepeda &
Davenport, 2008). Additionally, it is well known that the popular motivational in-
terviewing and enhancement therapies are largely based on PCT, although they
have adopted additional directive techniques to help move a client toward a resolu-
tion of his or her ambivalence (Miller & Rollnick, 2013).

Whether or not one is a person-centered “purist,” Rogers’s distrust of or-
thodoxy is a useful quality for any social work practitioner to keep in mind. As
he wrote the year before his death: “We (person-centered practitioners) are un-
derrepresented partly because we constitute a threat to the academically minded.
We espouse the importance of experiential as well as cogntive learning. Such
learning involves the risk of being changed by the experience, and this can be
frightening to one whose world is intellectually structured” (Rogers, 1986b,
pp. 257–258). It is a worthwhile endeavor for all social workers to follow the
example of Carl Rogers in being curious and open-minded, and try to avoid
becoming limited in their client-centered thinking by allegiances to complex,
and possibly dehumanizing, dogmas.

52 C H A P T E R 3

TOPICS FOR DISCUSSION

1. Do you believe that people possess unique, biologically determined
potentials? If so, what might they include (even though PCT does not
specify any)?

2. Do you believe that the idea of a self-actualizing tendency is valid?

3. What kinds of clients do you think could benefit from PC therapy? What
kinds of clients might not? What do those differences tell you about the
general suitability of the approach for social work practice?

4. What are some limits, if any, to providing empathy and unconditional
positive regard to clients?

5. What, for you, is the major strength and major limitation of PCT?

6. Do you have any ideas about how the effectiveness of PC therapy might be
evaluated?

IDEAS FOR CLASSROOM ACTIV IT IES /ROLE -PLAYS

1. Develop a list of types of clients for whom students would have great
difficulty showing empathy. In small groups (and later in a class
discussion), develop some ideas about how the social worker might
maximize his or her ability to establish an empathic attitude toward these
clients.

2. Enact small-group role-plays (including a client, social worker, and observer)
of various clients that students have worked with in the field, with the
social worker’s task during the conversation being to try to identify one or
more potentials of the client. How are these potentials evident? How
confident is the social worker that they are real?

3. Role-play in small groups an interaction that is characterized by a client’s
anger, both at others and at the social worker. Utilize four participants in
these role-plays so that two observers can help the interviewer consider
ways of accepting the client’s perspectives and demonstrating positive
regard for the client during his or her experience of a strong negative
emotion.

4. Discuss in small groups the charactristics of congruence that a social worker
must bring to the relationship in PC therapy. How can this quality be de-
veloped? Compare each group’s observations with those of the others in a
large group discussion.

P E R S O N – C E N T E R E D T H E OR Y 53

Person-Centered Theory Outline

Focus Each person’s innate striving toward self-actualization

Major Proponents Carl Rogers, Natalie Rogers, James Bozarth, Eugene
Gendlin, David Cain

Origins and Social Context Otto Rank and will therapy
Jessie Taft and functional social work
John Dewey and education
Christianity

Nature of the Individual The ongoing striving of the self to achieve congruence
with organically based potentials

Major Concepts Organismic striving

Developmental Concepts Self-actualization
Potentials
Conditions of worth
The actualizing tendency
Positive regard
Positive self-regard

Nature of Problems Incongruence

Nature of Change Client gives up defenses and the self-image becomes
more congruent with inherent potentialities

Intervention Goals Established by the client; the social worker attempts to
help the client achieive greater congruence

Nature of the Worker/Client
Relationship

Worker empathy, congruence, and unconditional positive
regard
Client is able to receive the three abovementioned
conditions

Intervention Principles and
Techniques

Empathy
Unconditional positive regard
Congruence
Facilitation

Assessment Questions None specified

54 C H A P T E R 3

Ego Psychology

The Soul’s superior instants
Occur to Her alone,

When friend and earth’s occasion
Have infinite withdrawn. *

Ego psychology is the oldest practice theory discussed in this book, having
emerged in the United States by the 1940s. It is one of the psychodynamic

theories, along with psychoanalysis, relational and object relations theory (the
subject of Chapter 5), and self-psychology. All of the psychodynamic theories
emphasize the importance of stages of psychosocial (or psychosexual) develop-
ment and unconscious mental processes on human behavior. The psychody-
namic theories were dominant in the social work profession between the 1920s
and the 1970s. They have increasingly come under attack in the past 50 years by
proponents of newer theories, however, for allegedly being overly abstract, un-
structured, and impractical in today’s practice environment that encourages more
specific problem-solving processes (Hale, 1995). Proponents of psychodynamic
practice argue, in turn, that many newer theories are relatively superficial and
fail to appreciate the complexity of human behavior. Proponents also assert that
ego psychology has demonstrated flexibility in its adaptability to short-term in-
terventions (Schames & Shilkrit, 2011).

Both ego psychology and many of the relational theories are classified as psy-
chodynamic. Ego psychology, the focus on this chapter, is concerned with indi-
viduals in the context of their psychosocial environments, while the relational
theories, covered in the next chapter, have a stronger focus on interpersonal re-
lationships and their effects on individual functioning.

* Dickinson, E. (1927). The Pamphlet Poets. New York: Simon and Schuster.

55
Copyright 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights,

Psychodynamic theorists initially described the mind as consisting of three com-
ponents: id, ego, and superego (Fenichel, 1994). Put simply, the id represented innate
drives; the ego was the part of the mind that adapted the drives to socially acceptable
outlets; and the superego represented the conscience, or internalized value system.
Ego psychology developed as a theory of human behavior that focuses on the role
of the ego more than the mind’s other two components. Your “ego” is largely (but
not completely) your conception of “who you are.” It is the “you” who thinks, feels,
and acts in a reasonably consistent manner. It is everything you do to reflect, plan, and
act in ways that allow you to “fit in” more or less adequately with the environments
in which you live. More formally, the ego is the part of one’s personality that is re-
sponsible for negotiating between internal needs and the demands of social living (see
Figure 4.1). It is where cognition occurs, but unconscious mental processes also influ-
ence conscious thinking. Defense (or coping) mechanisms, which are unconscious dis-
tortions of reality, frequently come into play as we attempt to manage our
interpersonal and other conflicts. A client’s potential for personal growth or problem
resolution does not always require attention to unconscious processes, but giving
them that attention often maximizes his or her potential for change.

ORI GINS AND SOCIAL CONTEXT

Social work emerged as an occupation in the United States during the late 19th
century, as Chanty Organization Societies and “friendly visitors” attempted to
resolve the problems of poverty, illness, and crime that were becoming promi-
nent in the cities of the Northeast (Lubove, 1965). This was the Progressive Era,
characterized by a broad interest in the negative effects of urbanization and
industrialization on some citizens. As the new occupation of social work grew
in importance, many (although not all) of its members began to seek its

Conscious awareness

Unconscious mental processes

The Ego

F I G U R E 4.1 The Ego

ng
ag

e
Le

ar
ni

56 C H A P T E R 4

legitimacy as a profession. Toward that end, its pioneers tried to formulate a
knowledge base that would make it distinctive. The most famous early product
of this effort was Mary Richmond’s Social Diagnosis (1917), which detailed a sys-
tems approach to working with clients, with attention to both their personal and
environmental circumstances. It should be emphasized that other notable social
workers of the time, such as Jane Addams (1910), were by choice not invested in
the move to professionalization.

Social developments in the United States eventually led to the young profession’s
adoption of psychoanalytic theory in the 1920s as its basis for assessment and interven-
tion with individuals and families (Ehrenreich, 1985). Freud’s landmark work, The
Interpretation of Dreams, published in 1899, signaled the arrival of psychoanalytic theory.
Freud’s ideas, which he continued to develop until his death in 1939, were revolu-
tionary in their description of the importance of unconscious thought processes and
defense mechanisms in determining human behavior. His theory of childhood sexual-
ity (defined broadly) was both scandalous and intriguing in his repressive European
society. Analytic ideas were relatively little known in the United States until after
World War I. By then the country had become more politically conservative. The
prewar progressive faith in the possibilities of broad social engineering dissipated as
the country experienced dramatic economic growth. There was less interest in collec-
tive social movements and greater interest in individuals and their emotions and
pleasure-seeking activities. The nation was opening up to Freud’s ideas.

During the postwar years the “occupation” of social work was still trying to
professionalize in order to legitimize itself with clients and state legislatures, founda-
tions, and other sources of funding and institutional power. It has already been noted
that social work had been searching for an identified body of knowledge around
which to focus its activities. Analytic theory seemed ideally suited to the task. It of-
fered a comprehensive system of client assessment and was attractive to middle-class
persons (social workers and their funders). Its focus on relationship dynamics helped
social workers understand their roles in the intervention process more clearly.
Analytic theory also narrowed social work’s interest in environmental conditions
to issues within the family (though ego psychology later expanded this), which was
consistent with the broader retreat of social work from reform activities.

Psychoanalytic practice in the United States evolved to reflect changing so-
cial conditions and social work’s developing value base. The theory of ego psy-
chology emerged from psychoanalysis, beginning in the 1930s (Goldstein, 1995;
Fenichel, 1994). Its development was related to the desire of some theorists to
build a psychology of normal development, the influence of new humanistic
ideas in the social sciences that emphasized adaptive capacities rather than pathol-
ogy, and the American social value of pragmatism (or practicality).

Ego psychology was initially developed outside the profession (Hartmann,
1958), but reflected changes within the social work profession. “Pure” psychoanal-
ysis was represented in the diagnostic school of social work, in which assessment and
treatment planning, independent of the client’s preferences and environmental
constraints, was considered most appropriate. The newer functional school recog-
nized that intervention should be client-driven (collaborative) and that social
workers needed to mold their techniques to the realities (and limitations) of the

E G O P S Y C H OL OG Y 57

service environment, including time limitations (Furman, 2002). With ego psy-
chology, the social work profession shifted its thinking away from the role of the
unconscious in psychological activity toward a greater emphasis on client strengths
and adaptability. This was in part a reaction against Freud’s heavy emphasis on
drives, and highlighted the ego’s role in promoting healthy social functioning.

Gordon Hamilton was the first social work scholar to incorporate elements
of psychoanalytic theory (including transference, defense, and interpretation) into
casework practice. She eventually asserted that ego psychology was more consis-
tent with social work values than psychoanalysis because of its emphasis on the
healthy functioning of individuals (Hamilton, 1951). She also reaffirmed social
work’s traditional concern with the environment, demonstrating a commitment
not only to understanding the structure and dynamics of personality but also to
environmental or social therapy. Hamilton was the first to make use of the
phrase “person and situation” to define the distinguishing feature of social work
as a human services profession. She used the concept to highlight the interaction
between the “intrapsychic” and the “objective,” with the points of intersection
being the primary domain of the social worker.

Hollis (1964) later helped to expand social work’s understanding of the
interaction between the individual and the environment. While she limited her
understanding of the “situation” to an interaction between the client and client’s
significant others (families and friends), rather than broader socio-political con-
cerns, she did articulate some ways in which social workers could intervene in
the client’s environment. These included referring to other professional experts,
suggesting resources, preparing the client to make use of resources, enlisting so-
cial supports, influencing others on behalf of the client, and directly accessing
resources on the client’s behalf.

Ego psychology and other psychodynamic theories continue to be utilized in
the social work profession, although they have faced increasing theoretical “compe-
tition” during the past 40 years in light of new ideas about human nature, challenges
in providing quality services to diverse populations, and changing attitudes about the
mission of the profession. Goldstein (2008), among the most prominent recent
scholars of ego psychology, argues that the theory will continue to be useful for
social workers so long as it assumes a broad view of the impact of social realities on
clients’ lives, reduces the traditionally hierarchical relationship between the social
worker and client, fully embraces the strengths perspective, helps oppressed persons
develop a stronger sense of identity, and adapts to the needs of diverse populations.

MAJOR CONCEPTS

The following major assumptions underlie the concepts of ego psychology
(Hauser & Safyer, 1995):

Ego functioning includes both conscious and unconscious processes.

People are born with several innate drives.

58 C H A P T E R 4

People are born with an innate capacity to adapt to their environments, and
this capacity further develops through learning and psychosocial maturation.
This is the drive to mastery and competence.

Social influences on psychological functioning are significant, and many of
these are transmitted through the family unit.

Problems in social functioning can occur at any stage of development due to
person-environment as well as internal conflicts.

All of these points will be elaborated below.

The Drives

Ego psychology recognizes three innate human drives. These include drives
toward pleasure and aggression (when one’s well-being is threatened), from
psychoanalytic theory, and a drive toward mastery and competence (White, 1963).
Mastery refers to a person’s ability to influence his or her environment, and com-
petence is one’s subjective feeling about that ability. The drives toward pleasure
and aggression inevitably bring people into conflict with social norms. They
must be channeled into appropriate outlets for their fulfillment and thus may
be frustrated at times. The drive to mastery and competence, however, is consid-
ered conflict-free, representing an innate inclination to exist harmoniously in
one’s environment. It evolves throughout life from one’s talents, mastery of
developmental tasks, motivations that derive from personal goals, and innate
relationship-seeking orientation. Acknowledging this drive is consistent with
the strengths perspective of social work, because it assumes that all people have
talents that can be utilized as they seek functional competence.

The Significance of Emotional Life

The psychodynamic theories recognize the importance of emotional life and fo-
cus on its conscious and unconscious aspects. In ego psychology, some conscious
thinking is a product of the drives, from which emotions also spring. We are
pleasure seekers and “feelers” by nature, and thoughts are our means of deciding
how to gratify the drives. Defense mechanisms result from the need to manage
drives when we become frustrated, as we frequently do in the social world,
where impulses must always be converted into acceptable behaviors. Further,
personal growth is not always feasible when attending only to our conscious pro-
cesses. We need to explore our thoughts and feelings to better understand our
essential drives. Our capacity for change may be facilitated by uncovering ideas
and feelings that we typically keep out of consciousness. In that way, we can
better understand our impulses and direct them toward appropriate sources for
gratification.

Several theorists have elaborated on the processes of emotional life. Magai
(1996) asserts that emotional traits form the core of human personality, and that
all people possess five primary human emotions, originating in their neurophysi-
ology. Our personalities are organized around these “affective biases,” which

E G O P S Y C H OL OG Y 59

include happiness, sadness, fear, anger, and interest/excitement. These emotions
are instinctual and activate thinking and behavior in ways that are adaptive.
Thus, emotions influence cognition.

Two examples may help to illustrate these ideas. A person’s propensity to-
ward sadness may be elicited by the experience of a personal or material loss.
This leads to the person’s temporary physical slowing down, decrease in general
effort, and withdrawal in situations where efforts to recover the loss would likely
be ineffective. The sadness allows time for the person to reflect on her needs and
priorities, and regain energy for a more focused use of energy to achievable goals.
Her expressions of sadness are also a signal within her social network for others
to provide more support. As a contrasting example, a person’s anger tends to
increase energy and motivate behavior that is intended to overcome frustration.
Its expression is a signal to others to respond to the person with avoidance or
compliance so that she may resolve the problem confronting her.

Social theories of emotion assert that many other emotions are socially con-
structed to promote social cohesion. Mead (1934), the originator of symbolic
interaction theory, wrote that emotions develop as symbols for communication.
He believed that we are by nature more sensitive to visual cues than verbal ones.
Our emotional expressions are particularly powerful in that they are appre-
hended visually rather than verbally. Emotional expression is a signal to others
about how we are inclined to act in a situation, and others can adjust their
own behavior in response to our perceived inclinations. A young college stu-
dent’s lack of eye contact, tendency to look down, and physical distancing
from others may be manifestations of her sadness. Other persons, in response,
might choose to offer support, or avoid her if they interpret her expressions as
a desire for distance. All of us must interpret the emotional expressions of others,
and this process often takes place outside our conscious awareness. Practice the-
ories focused on emotional experience, such as ego psychology, help clients
become more aware of how they both express themselves and perceive others.

The Ego and Its Functions

The ego is not a physical structure, but a concept describing the part of person-
ality that negotiates between our internal needs and the outside world. It is pres-
ent from birth and is our source of attention, concentration, learning, memory,
will, and perception. The functioning of the ego is partly unconscious, or out of
our awareness. In ego psychology, both past and present experiences are relevant
in influencing our social functioning. The influence of the drives (toward plea-
sure and aggression) on emotions and thoughts is not dismissed, but conscious
thought processes receive greater emphasis. The ego mediates internal conflicts,
which might result from drive frustration, but it also mediates the interactions of
a person with stressful environmental conditions. If a client experiences sadness,
he or she may be having conflicts related to internal ambivalence or, on the
other hand, may be in conflict with other people. Ego psychology is a develop-
mental theory, so its principles support attention to ego development throughout
the life cycle.

60 C H A P T E R 4

What follows is a description of the major ego functions (Schamess &
Shilkrit, 2011; Goldstein, 2008; Marcus, 1999):

Awareness of the external environment refers to an accurate perception of the
external world. This includes orientation to time, place, and person, and the
absence of hallucinations, delusions, and loose associations.

Judgment is our capacity to choose behaviors that are likely to promote our
movement toward goals. The quality of our judgment may change in dif-
ferent circumstances.

The sense of identity is a reasonably coherent physical and psychological sense
of self. This includes our ability to maintain appropriate psychological
boundaries (balancing involvement and distance) from others.

Impulse control refers to our ability to distinguish between primary (drives or
impulses) and secondary (planned) mental processes, to control actions in
accordance with social norms, and to maintain control of behavior or emo-
tions to a degree that prevents significant problems in functioning.

Thought process regulation, related to the above function, is our ability to re-
member, concentrate, and assess situations so as to initiate appropriate action.
These reflect a shift to secondary process thinking, which is goal oriented
but also rational and reality focused.

Interpersonal (object) relations refers to two related functions: (a) the ability to
manage relationships appropriately toward personal goal attainment, and (b)
the ability to see other people as unique rather than replications of significant
others from our past. People often manage some types of relationships (such
as work or social relationships) more successfully than others (family or other
intimate ties). This concept is primary in object relations theory (discussed in
the next chapter) but is also of interest to ego psychology practitioners.

Defense mechanisms are distortions of reality that enable us to minimize anxi-
ety. They are experienced by all people and may or may not promote pro-
ductive social functioning. These will be discussed in more detail below.

Stimulus regulation is our ability to screen and select external stimuli to
maintain a focus on relevant life concerns. When ineffective, we may be-
come either overwhelmed or underwhelmed in situations.

Autonomous functions are the capacity to maintain attention, concentration,
memory, or learning. Any impairment of these functions must be assessed
for possible biological origin.

It should be evident that some ego functions are within our conscious awareness
and others are not.

The Defense Mechanisms

Ego psychology practitioners are sensitive to a client’s use of defense mechan-
isms, because the manner in which these are employed has a great influence on

E G O P S Y C H OL OG Y 61

one’s ability to manage challenges. Defenses are unconscious, automatic re-
sponses that enable us to minimize perceived threats or keep them out of aware-
ness entirely (Beresford, 2012; Gray, 2005). They are coping mechanisms used by
all people to protect themselves against becoming overwhelmed by anxiety.
Defenses distort reality to varying degrees, because they provide us with a con-
scious perspective on a particular situation that is biased toward our preserving a
sense of security.

People can use defenses in healthy (adaptive) and unhealthy (maladaptive)
ways. Defenses are used appropriately when they promote our adaptive func-
tioning and goal achievement and minimize internal and interpersonal conflicts.
The range of defense mechanisms is listed in Table 4.1.

T A B L E 4.1 Common Defense Mechanisms

Denial Negating an important aspect of reality that one may actually
perceive. (A woman with anorexia acknowledges her actual
weight and dieting practices, but believes that she is maintaining
good self-care by doing so.)

Displacement Shifting negative feelings about one person or situation onto
another. (A student’s anger at her professor, who is threatening
as an authority figure, is transposed into anger at her boyfriend,
a safer target.)

Intellectualization Avoiding unacceptable emotions by thinking or talking about
them rather than experiencing them directly. (A person talks to
her counselor about the fact that she is sad but shows no emo-
tional evidence of sadness, which makes it harder for her to
understand its effects on her life.)

Introjection Taking characteristics of another person into the self in order to
avoid direct conflict. The emotions originally felt about the other
person are now felt toward the self. (An abused woman feels
angry with herself rather than her abusing partner, because she
has accepted his belief that she is an inadequate caregiver. Be-
lieving otherwise would make her more fearful that the desired
relationship might end.)

Isolation of affect Consciously experiencing an emotion in a “safe” context rather
than the threatening context in which it was first unconsciously
experienced. (A person does not experience sadness at the
funeral of a family member, but the following week weeps
uncontrollably at the death of a pet.)

Projection Attributing unacceptable thoughts and feelings to others. (A man
does not want to be angry at his girlfriend, so when he is upset
with her, he avoids owning the emotion by assuming that she is
angry with him instead.)

Rationalization Using convincing reasons to justify ideas, feelings, or actions to
onself to avoid recognizing their true underlying motives. (A stu-
dent copes with the guilt normally associated with cheating on an
exam by reasoning that he had been too ill the previous week to
prepare for it.)

62 C H A P T E R 4

Some of the defense mechanisms are similar to each other. Displacement and
sublimation provide one example of this. In displacement, unacceptable feelings about
onepersonor situation are consciously directed toward anotherpersonor situation. It
is more “acceptable” to feel anger (for example) toward the substitute target than
toward the actual one. A graduate student may take out her frustrations on a room-
mate rather than the professor with whom she is angry. Sublimation is similar to
displacement but is considered more functional in that it directly enhances thequality
ofone’s social life. It involves the channeling (displacement)of unacceptable impulses
or feelings into socially acceptable outlets. One example is the aggressive adolescent
who becomes an effective member of the school debate team.

A client’s use of defenses can be evaluated in the following ways:

Flexibility versus rigidity. The behavior may or may not be appropriate to the
social context. For example, at times anger should be suppressed (toward the
boss during a staff meeting), and at other times it should be expressed (in a
close personal relationship when feelings have been hurt). A rigidly defensive
person will suppress—or express—angry feelings with insufficient regard for
the context, and thus the behavior is more likely to create conflicts.

Future versus past orientation. Defenses should promote adaptive behavior in
the present and future. When their use is based on past events that no longer
affect the client, they may be maladaptive. For example, a young, married

Reaction formation Replacing an unwanted unconscious impulse with its opposite in
conscious behavior. (A person cannot bear to be angry with his
boss, so during a conflict, he convinces himself that the boss is
worthy of loyalty and goes out of his way to be kind.)

Regression Resuming behaviors associated with an earlier developmental
stage or level of functioning in order to avoid present anxiety.
The behavior may help to resolve the anxiety. (A young man
throws a temper tantrum as a means of discharging his frustra-
tion when he cannot master a task on his computer. The startled
computer technician, who had been reluctant to attend to the
situation, now comes forward to provide assistance.)

Repression Keeping unwanted thoughts and feelings entirely out of aware-
ness (so that they are not expressed in any way).

Somatization Converting intolerable impulses into somatic symptoms. (A person
who is unable to express his negative emotions develops frequent
stomachaches.)

Sublimation Converting an impulse from a socially unacceptable aim to a so-
cially acceptable one. (An angry, aggressive young man becomes
a star on his school’s debate team.)

Undoing Nullifying an undesired impulse with an act of reparation.
(A man who feels guilty about having lustful thoughts about a
co-worker tries to make amends to his wife by purchasing
a special gift for her.)

T A B L E 4.1 Common Defense Mechanisms (Continued)

E G O P S Y C H OL OG Y 63

employee’s rationalization of keeping a low-paying job for fear of not being
able to find a better one may have been functional when he was just out of
college and had little experience. Ongoing use of the defense may no longer
serve the person once he has a master’s degree and more marketable skills.
The rationalization may be due to a fear of taking risks.

General reality adherence versus significant distortion. All defenses distort reality,
but people can distort reality to such a degree that they lose basic awareness
of their environment. A high school student, worried about an upcoming
term paper, may use the defense of somatization, and ask the teacher for an
extension due to illness. A more problematic use of the defense would be
the student’s becoming convinced that he has colon cancer and demanding
hospital admission for emergency tests.

The Complexity of Defenses: Denial Denial is defined in Table 4.1 as a per-
son’s negation (perhaps temporarily) of an important aspect of reality with which
he or she is confronted. It is among the most common defenses. Whether denial is
adaptive or maladaptive can be determined by several factors. First is the issue of its
timing. When we are faced with traumatic news, it is quite common to deny it
initially. This may be helpful, as it enables us to gradually come to terms with the
seriousness of the issue, avoid becoming overwhelmed, and more carefully con-
sider how to deal with it. If a man learns that he has potentially life-threatening
liver damage due to years of substance abuse, he may deny the truth of the medical
report for a period of time while he unconsciously works through the implications
of the news on his future. But if he continues to deny the truth of the medical
report for months, convinced of a misdiagnosis, he is using denial in a maladaptive
way because he is avoiding treatment and putting his life in danger.

Second, denial may be a positive coping strategy when doing something about
the event in question is not possible, but a dysfunctional strategy when rational action
might be productive. If the man described above has a terminal liver disease that can-
not be helped with treatment, his denial of its seriousness will not affect his mortality
and may help him to live out the rest of his life with greater serenity. If the disease is
treatable, however, his denial of its seriousness may unnecessarily lead to death.

Third, the adaptability of the defense depends on what aspect of an event is
denied. Keeping with the above example, the man’s ongoing denial of the fact of
his illness is not adaptive, but his denial of its implication (probable death) might
motivate him to seek out whatever treatments might prolong his life. It is not
unusual to hear about medical patients who were initially told that they would
probably die within several months, but who lived for years because of their de-
termination to prove the doctors wrong.

THE NATURE OF PROBLEMS AND CHANGE

In ego psychology, problems or challenges may result from conflicts within
the person or between the person and external world. That is, the stress a client

64 C H A P T E R 4

experiences may result from excess environmental demands (an external focus),
inadequate ego functioning (an internal focus), or reactions to normal life transi-
tions (such as age and work transitions, parenthood, separation from significant
others, and reactions to health problems). During ego-based intervention, the
social worker helps the client either to build new ego strengths or use existing
ego strengths more effectively. Change is manifested in the client’s ability to uti-
lize his or her ego functions to enhance self-understanding and achieve greater
mastery of challenges, crises, or life transitions. These are all empowering
activities.

The goals of intervention are to enhance the client’s inner capacities through
ego development (which includes greater self-understanding), modify or change
environmental conditions, or improve the fit between a person’s ego capacities
and environmental conditions by working on both areas. Clients are helped to
acquire new problem-solving and coping skills, and to achieve insight (self-
understanding) through reflection about their strengths, limitations, and potential
resources. Maladaptive defenses may be confronted and appropriate defenses
strengthened. Clients are empowered with knowledge or movement toward
more proactive stances with respect to their challenges. Insight can be empower-
ing to the extent that it strengthens clients’ sense of cohesion and focus. They
should emerge from the intervention process with an improved capacity for
self-direction.

ASSESSMENT AND INTERVENT ION

Assessment

The social worker evaluates the strengths and limitations of each of the client’s
ego functions through questioning the client and perhaps his or her significant
others, and reviewing any other available data sources. If possible, medical re-
cords or a medical evaluation should be sought to evaluate the possibility of
physiological impairments that may affect certain ego functions, particularly the
stimulus regulation and autonomous functions.

Assessment of a client’s psychosocial development requires a review of sig-
nificant past experiences. Ego psychology is a developmental theory; it assumes
that all of us move through certain physical and emotional stages as we grow.
Each new stage of personality development builds on previous stages. Any un-
successful transitions can result in the onset of abnormal behavior as evidenced by
problematic patterns of coping with new challenges. Such persons will experi-
ence difficulties mastering subsequent stages. In psychoanalytic theory, Freud
wrote about psychosexual stages (oral, anal, phallic, latency, and genital stages),
but ego psychology is more closely identified with stages that focus on environ-
mental as well as internal processes. The best known of these is Erikson’s (1968)
psychosocial stages of development (see Table 4.2).

As an example of this theory, many older adolescents struggle with the two
developmental stages of identity versus identity diffusion and intimacy versus isolation.

E G O P S Y C H OL OG Y 65

Common challenges in the first of these stages include resolving issues of self-
confidence (versus insecurity), positive role experimentation (versus ambivalence),
and anticipation of social and vocational achievement (versus social paralysis).
Challenges in the second phase include developing a capacity for intimacy as op-
posed to feeling socially empty or isolated within the family unit. The adoles-
cent’s successful transition into adult roles will depend on his or her successful
passage through the preceding developmental phases.

Gathering information about relevant history can help the social worker de-
termine whether the client may benefit from new skills associated with certain
stages. Other examples of developmental stage theories include Levinson’s
(1978) stages of male development, Kohlberg’s (1969) stages of moral develop-
ment, and Gilligan’s (1982) stages of moral development for women. Though all
of these may be useful for understanding the person in context, there is an ap-
preciation in the social work profession of developmental differences among all
people, especially members of different cultural, racial, and ethnic groups. Much
remains to be learned about human development across populations, and social
workers must be careful not to rigidly apply existing theories of development.

Intervention

The Social Worker/Client Relationship The quality of the worker/client
relationship is significant to intervention outcomes across theoretical perspec-
tives (Norcross & Wampold, 2011). The analytic theories are distinguished,
however, by the thoroughness of their attention to the nature of the worker/
client relationship. (They have developed more concepts about the relationship
than even the person-centered theorists.) In social work, Perlman (1979)
has vividly articulated the ways in which unconscious processes can distort
the social worker’s understanding of a client’s problems and their relationship,
and vice versa.

At a basic level, the working alliance should feature a positive emotional bond
characterized by collaboration, agreement on goals, and some level of mutual
comfort. For the social worker, it requires skills of empathy (the ability to perceive
accurately and sensitively the client’s feelings, and to communicate that under-

T A B L E 4.2 Erikson’s Stages of Psychosocial Development

Life Stage Psychosocial Challenge Significant Others

Infancy Trust vs. mistrust Maternal person
Early childhood Autonomy vs. shame and doubt Parental persons
Play age Initiative vs. guilt Family
School age Industry vs. inferiority Neighborhood
Adolescence Identity vs. identity diffusion Peers
Young adult Intimacy vs. isolation Partners
Adulthood Generativity vs. self-absorption Household
Mature age Integrity vs. disgust and despair Humanity

66 C H A P T E R 4

standing to the client) and authenticity (relating in a natural and sincere manner).
While this is similar to person-centered theory (discussed in Chapter 3), ego psy-
chology goes beyond this to include the social worker’s ongoing management of
the positive and negative aspects of the relationship. In fact, for some clients who
seek help with relationship problems, examining the worker/client relationship
over time may serve as the primary intervention! Client factors that influence the
nature of the relationship include voluntary status, level of motivation, ego stabil-
ity, and cultural factors (Sexton & Whiston, 1994). The social worker may be chal-
lenged, particularly in longer-term interventions, to maintain a controlled level of
emotional involvement with the client. The practitioner should also be alert to
transference and countertransference issues, as described below.

Transference and Countertransference The concepts of transference and
countertransference emerged within psychodynamic theory during its beginnings
(Harris, 2012). They call attention to subtle effects of the worker/client relationship
on all stages of the intervention. Transference was initially defined as a client’s uncon-
scious projection of feelings, thoughts, and wishes onto the practitioner, who comes
to represent a significant person from the client’s past such as a parent, sibling, other
relative, or teacher (Levy & Scala, 2012). The practitioner does not actually possess
those characteristics, but the client acts as if he or she does. The concept has gradually
expanded to refer more broadly to all reactions that a client has to the social worker.
These reactions may be based on patterns of interaction with similar types of people
in the client’s past or on the actual characteristics of the practitioner.

Countertransference was initially defined as a practitioner’s unconscious reac-
tions to the client’s projections (Walsh, 2011). This concept has also broadened
to refer to the effects of the practitioner’s conscious and unconscious needs and
wishes on his or her understanding of the client. It also refers to the conscious
attitudes and tendencies that the worker has about types of clients (such as being
drawn to working with children or having an aversion to older adults).

Transference and countertransference are not exotic ideas (despite the way
the terms sound). They exist in every relationship. We do not experience others
only in terms of an objective reality, but also in terms of how we wish them to
be, or fear that they might be. These reactions may be taken into account in
every practice encounter with regard to how they influence the social worker’s
perception of the client (and vice versa). The social worker’s awareness of his or
her emotional reactions facilitates the intervention process, as it helps the practi-
tioner better understand the rationales behind the decisions he or she is making.

Some common countertransference reactions that social workers may experi-
ence include dreading or eagerly anticipating seeing a client, thinking excessively
about a client during off hours, having trouble understanding a client’s problems
(they may be similar to the social worker’s own), being either bored or unduly
impressed with a client, feeling angry with a client for non-specific reasons, feeling
hurt by a client’s criticisms, doing things for the client that he or she is capable of,
and feeling uncomfortable about discussing certain topics (Hepworth, Rooney,
Rooney, Strom-Gottfried, & Larsen, 2012). These reactions are only problematic
when they cause the practitioner’s decision making to be based on his or her

E G O P S Y C H OL OG Y 67

feelings rather than the client’s goals. Practitioners who work from the theoretical
bases of ego psychology should monitor their own, and their clients’, transferences
throughout the intervention to make sure these reactions are not interfering with
the client’s movement toward goal attainment.

Intervention Strategies Ego psychology interventions are best understood as
general strategies rather than concrete directives. This is sometimes frustrating to
students and young practitioners who seek clearer guidance for intervention. So-
cial workers need to tailor these general strategies to the specific needs of clients.

Ego psychology incorporates two basic types of intervention strategies
(Woods & Hollis, 2000). The practitioner chooses ego-sustaining techniques after
assessing the client’s ego functions as relatively intact. These techniques help the
client to understand his or her motivations and behaviors more clearly and then
become mobilized to resolve present difficulties. They include sustainment (devel-
oping and maintaining a positive relationship), exploration/description/ventilation
(encouraging the client’s emotional expressions for stress relief and to gain a clearer
perspective about problems), and person-situation reflection (on solutions to present
difficulties). The practitioner may also provide education to the client, often about
environmental resources, and direct influence, particularly when the client is in crisis
and temporarily unable to exercise good judgment about self-care.

The major ego-modification technique, which is used when clients experience
maladaptive patterns of functioning that require an exploration of past experiences
and unconscious processes, is developmental reflection. The social worker facilitates
the client’s self-understanding by exploring his or her patterns of behavior over
time, providing new interpretations of relationship patterns, confronting maladap-
tive defenses, and guiding the client into corrective interpersonal experiences.

Each of these interventions is described in more detail below.

Exploration/Description/Ventilation The social worker elicits the client’s
thoughts and feelings about an area of concern and helps the client to express
and explore them. The practitioner keeps the client on the topic, but otherwise
allows the client to drive the process. As a result, the client is helped to:

Feel less alone and overwhelmed

Gain control of incapacitating emotions

See problems as more manageable

Become motivated to take action

Develop greater hope, confidence, motivation, and self-acceptance

More clearly recognize and understand his or her emotional reactions

Acquire greater insight

Reduce defensiveness

Develop a positive transference to the social worker

68 C H A P T E R 4

For some clients with considerable ego strength who are anxious or in crisis,
this intervention may be sufficient to resolve the problem.

Sustainment This is a deceptively difficult intervention strategy that becomes
more important over time in a worker/client relationship. The social worker lis-
tens to the client actively and sympathetically, conveys a continuing attitude of
goodwill (even when frustrated or angry), expresses confidence in the client,
nonverbally communicates interest, and realistically reassures the client about
his or her potential for goal achievement. This process can be challenging be-
cause the social worker must delicately balance supportive and confrontational
messages to the client. The purposes of the strategy are to:

Promote a confiding relationship

Instill a sense of the worker’s caring

Provide an antidote to alienation

Enhance the client’s morale and determination to persist

Inspire and maintain the expectation of help

Create a supportive atmosphere in which confrontation can be used
constructively

Person-Situation Reflection With this strategy the social worker first facili-
tates exploration/description/ventilation, and then guides the client into a fo-
cused, detailed review of thoughts and feelings related to the presenting issue.
The social worker:

Makes comments, asks questions, offers tentative explanations, and provides
nonverbal communications that promote the client’s reflective capacity

Leads discussions of the pros and cons of the client’s taking certain actions

Assumes a moderately directive and structured stance, perhaps including
confrontation

Provides here-and-now interpretations of client behavior

Through this process the social worker promotes the client’s abilities to
evaluate feelings, self-concept, and attitudes; understand others or some external
situation; develop insight into the nature of his or her behaviors and its effects on
others; and use better judgment for considering a wider range of problem-
solving options.

Advice and Guidance (Direct Influence) No practice theory advocates that
social workers routinely give advice to their clients. The values of the profession
mandate that clients should be empowered to resolve their own problems. Still,
social workers may occasionally need to give advice or make suggestions to a cli-
ent about ways of thinking, reviewing feelings, or behaving. This is always done
tentatively, and is reserved for situations in which the client is unable to exercise

E G O P S Y C H OL OG Y 69

good judgment, such as periods of crisis, psychosis, or self-destructive ideation. It
should always be done to meet the client’s needs rather than the worker’s desire
that the client act in accordance with the worker’s preferences.

The social worker’s interventions may include stating an opinion, emphasiz-
ing a course of action that the client is contemplating, or strongly cautioning the
client. If a client requests advice, the social worker should explore the client’s
reasons for doing so. The social worker may choose to deny the request, and
instead pursue a more reflective discussion. Even when provided, direct influence
is given in a context of reflective discussion, if possible, and the social worker
may guide the client to a decision rather than give direct advice. The social
worker should certainly avoid giving advice about major life decisions (whether
to get married, drop out of school, accept or leave a particular job, etc.) and
always review with the client the pros and cons of giving any advice.

Partializing (Structuring) Many clients benefit from a social worker helping
them break down presenting problems into discreet “units” that can be addressed
sequentially. This is particularly helpful for clients who feel overwhelmed or
have difficulty keeping focused on their concerns. The social worker’s actions
include focusing the client’s attention, perhaps initiating time limits on their
work, assigning (mutually developed) tasks for completion outside the session,
and outlining plans for using their time together. The social worker also engages
the client in reflective discussion of the above strategies as a means of improving
the client’s orientation to problem solving. These interventions can benefit cli-
ents by relieving the sense of being overwhelmed, providing an action focus, and
providing new opportunities for learning. Successes that result from partializing
strategies enhance the client’s sense of mastery and competence.

Education Most theories acknowledge that the practitioner will act as a client
educator for various purposes. In ego psychology the social worker may provide
information to clients about environmental resources and issues related to the
client’s biological, psychological, or social functioning (such as diet, relaxation,
the benefits of social interaction, or the actions of medications). The social
worker may also educate clients about the effects of their behavior on others,
and the needs and motivations of significant other people in their environments.
These interventions help clients by increasing their options for change, their
“fund of knowledge” for problem-solving activities, and their insight. The man-
ner in which education takes place in ego psychology is not fundamentally dif-
ferent from that of many other approaches, except that these practitioners may
be more likely to promote reflective discussion of educational resources.

Developmental Reflection This is the only strategy that is unique to the sec-
ond “level” of ego psychology intervention, ego modification. The social worker
engages the client in reflective discussions about his or her past life and relation-
ships. The goal is for the client to develop greater insight into the ways in which
his or her current sense of self and relationship patterns have their origins in past
experiences and relationships. This is the only ego psychology strategy in which

70 C H A P T E R 4

the social worker may intentionally arouse the client’s anxiety. Doing so is some-
times necessary to help the client face and experience troubling emotions that
may be suppressed and are associated with difficult interpersonal problems, so
that he or she can stop being affected by them. In developmental reflection,
the social worker:

Explores connections between the client’s present and past experiences with
comments, questions, and tentative explanations

Helps the client to better understand (interpret) past issues that may be
influencing the present problem, and then find ways of dealing with them

Confronts maladaptive ideas, feelings, and behaviors as appropriate

Refers to the nature of the clinical relationship as an example of the nature
of the client’s other significant relationships

This strategy helps clients identify longstanding patterns of functioning, in-
cluding defenses and their effectiveness; develop new ways of thinking about the
past and how it affects current behavior; develop insight into patterns of behavior
that stem from irrational feelings or interpersonal conflict; and experiment with
new ways of thinking and behaving.

Following a discussion of several more important issues in ego psychology,
these intervention strategies will be applied to two case examples.

Endings in Ego Psychology Given the abstract nature of ego psychology’s as-
sessment and intervention concepts, it should not be surprising that determining
an appropriate end point with a client is not always easy. Several ending princi-
ples are offered here. First, in addition to evaluating the extent to which the
presenting issue has been resolved, the social worker can review with the client
the status of each ego function that has been a focus of intervention (Walsh,
2007). It is important to communicate to the client that further strengthening
of ego functions is possible after the relationship ends. Second, the social worker
can help the client to devise strategies for continued self-reflection.

The client should be helped to review his or her past, present, and future
with regard to the presenting problem. The client’s recent past can be addressed
with a review of the intervention process. The present situation is reflected in the
client’s current status, focusing on the client’s new knowledge and skills. Looking
ahead to growth opportunities outside the clinical setting helps the client look
constructively toward the future.

SP IR ITUAL ITY AND THE PSYCHODYNAMIC

THEORIES

Clients’ spiritual or existential concerns can be addressed within the theories of ego
psychology and object relations (discussed in the next chapter). Both of these psycho-
dynamic theories assume the existence of drives, one of which is the drive to mastery

E G O P S Y C H OL OG Y 71

and competence. It follows from the existence of this drive that people strive to make
sense of their environments with the goal of finding satisfaction with, and seeking di-
rection for, their lives. Spiritual issues are at the heart of this drive.

Logotherapy is a useful existential/spiritual perspective that derives from the
psychodynamic theories (Frankl, 1988; Lantz & Walsh, 2007). In this practice ap-
proach, the will to meaning is conceptualized as an aspect of the drive to mastery. It
is a basic, enduring tendency to obtain what satisfies our nature. We all have this
innate drive to create or discover meaning and purpose in life beyond our physical
existence and survival. Many people do not often reflect on their spiritual selves,
because recognizing purposes beyond the self also includes an awareness of vulner-
ability, responsibility, and the potential for loss. A person’s experiences with suffer-
ing, guilt, and death, which are universal, can result in a suppression of this will.

Ego psychology and object relations theory assert that we utilize a variety of
defense mechanisms to minimize the impact of anxiety on our lives. The drive to-
ward mastery and competence is subject to the same defensive activities as other im-
pulses. Likewise, the will to meaning may be relegated to the unconscious, with the
result that we remain unaware of its influence while remaining consciously occupied
with less threatening ideas. This is not a satisfactory resolution of the problem of
anxiety, however, as we may then experience indirect symptoms of distress. For ex-
ample, a client’s depression may be related to the fact that he is avoiding making any
personal commitments because of a fear of subsequently losing those relationships.
Perhaps that client has experienced terrible losses and as a result has suppressed the
will to meaning, and cut himself off from new relationship opportunities.

The social worker using an ego psychology or object relations approach may
select from numerous strategies, including exploration and ventilation, education,
direct advice, life structuring, and reflection to help clients address their spiritual
concerns. The task of the practitioner should be to help the client become aware
of spiritual impulses that are being unconsciously avoided. Though growth-
enhancing, this may unfold as a painful process for the client, because spiritual
concerns can rarely be managed comfortably. Of course, it is always the client’s
decision whether such concerns are relevant to the intervention process.

ATTENTION TO SOCIAL JUST ICE ISSUES

The National Association of Social Workers (NASW) Code of Ethics (2008)
states that social workers should challenge social injustice. This can be done
through social change activities, particularly with vulnerable and oppressed indi-
viduals and groups. Ego psychology can be provided to families and groups, but
it is conceptually more focused on working with individuals. It attends to trans-
actions between client systems and their environments, but its most highly devel-
oped concepts are based on the characteristics of individuals. This reflects its roots
in psychoanalysis and appears to limit its facilitation of collective social change
activities. There is nothing that prohibits a social worker who practices ego
psychology from helping clients engage in larger system change activities, but
nothing within the theory itself encourages these interventions.

72 C H A P T E R 4

Still, ego psychology can be empowering for clients. Enhanced self-
understanding and greater awareness of one’s strengths, limitations, and resources
(enhanced mastery and competence) can be liberating for persons who have been
oppressed and feel powerless. Further, the short-term strategies of ego psychol-
ogy can be flexibly used to fit clients of varied backgrounds. Figure 4.2 sum-
marizes the environmental issues to which the social worker must be attuned in
attending to the special socio-cultural contexts of clients’ lives. Ego psychology,
then, is not outstanding in its orientation to social justice activities, but it can be
used to empower clients toward such ends.

CASE ILLUSTRAT IONS

The Angry Attorney

The following example describes Jacqui, a woman with a psychotic disorder. Ego
psychology is not typically considered suitable for persons with such disorders, as
these clients typically require concrete interventions such as medication, linkage,
education, and social skills training. But ego psychology’s emphasis on the im-
portance of the client/worker relationship makes it useful for working with per-
sons with thought disorders who characteristically have ambivalent attitudes
about intervention. In this case it made the difference between successful en-
gagement of the client and her refusal to participate in the process.

Jacqui had been released from a psychiatric hospital 45 days into her 90-day
probation, and was legally required to comply with intervention at the mental
health facility until her probation ended. She was a 40-year-old single
Lebanese-American woman with a degree in law, and had a diagnosis of de-
lusional disorder. This diagnosis is made when a person experiences non-bizarre

Focus on memberships and strengths; build
confidence, self-esteem, personal power;
provide options and choices; link client
with resources, connect to mutual aid and
peer groups, encourage collective and
political action

Person

Ego
Ego Functions

Coping Mechanisms
Mastery &

Competence

Sociopolitical Context
of Environment

Memberships
Race

Gender
Economic Status

Socialization
Health

Vulnerability to Trauma
Culture and Acculturation

Stigma

F I G U R E 4.2 The Ego and the Environment: Diverse Populations

ng
ag

e
Le

ar
ni

E G O P S Y C H OL OG Y 73

delusions (false beliefs involving real-life situations) but no hallucinations, and
functions well apart from events involving the delusions. Jacqui’s probation was
the result of her becoming paranoid and agitated, which severely disrupted her
ability to work. She needed to be forcibly taken by her family to a psychiatric
hospital after a series of confrontations with neighbors and police officers.

Jacqui’s impairments in ego functioning included poor reality testing and
judgment (behaving in ways that jeopardized her career and reputation), mal-
adaptive use of denial and projection (characteristic of paranoid persons), and
problems with impulse control (public arguments). Her strengths included a
sense of mastery (several graduate degrees and a law practice focused on minority
clients), good object relations (with a supportive family), and a coherent sense of
identity. Jacqui, clearly a reluctant client, was outraged that her physicians ex-
pected her to take medications. She was convinced of the reality of her percep-
tions and felt that most other people were her intellectual inferiors, unwitting
pawns in government conspiracies against her. She made it clear that she only
came to the agency because of the legal mandate. Further, she warned agency
staff to do nothing that might become the basis for a lawsuit.

Jacqui’s perception of her situation was one of forced compliance with an un-
just legal mandate. For that reason she felt she only needed to show up at her
scheduled meetings and accept the injectable medication for the remaining
45 days. She expected the social worker to try to convince her of the need for
treatment, as others at the hospital had done. Clearly, for her, the issue of unequal
power was a major constraint to her potential to develop a cooperative relation-
ship. It required that she subject herself to the will of the social worker and agency.

Nevertheless, within a month Jacqui and Tim, her social worker, developed
a solid working relationship. The social worker had relied on exploration/
description/ventilation, person-situation reflection, and sustainment to engage
the client. Understanding Jacqui’s negative attitude about the agency, Tim
encouraged her to ventilate her negative feelings about her incarceration and out-
patient commitment. He asked nothing of her except regular meetings. They
negotiated the details together, and agreed that they would meet biweekly, alter-
nating between the agency and her home. The social worker was eager to allow
Jacqui to remain on her “turf” so that she could relax and have more control of the
situation. In this way he could also meet her father and sister, and assess their
potential roles in Jacqui’s treatment. For their first three visits Tim did little more
than ask Jacqui to share stories of her exciting life. She was happy to do this, feeling
that she was being respected. Tim behaved in as non-threatening a manner as pos-
sible. Jacqui soon calmed down, stopped the angry tirades, and began to value this
new relationship, even as she continued to discount her need for services.

Tim avoided participating in her medication appointments so as not to be-
come involved in those power issues. He and the agency physician agreed for
the client’s benefit that the physician would assume the “bad guy” role by
himself, to the extent that he expected Jacqui to take her medicine. With
this strategy Jacqui could continue to see the social worker as supportive, and
maintain a positive transference. In the long run Jacqui worked well with both
staff members.

74 C H A P T E R 4

The social worker soon invited Jacqui to talk with him about some of her career
frustrations and how she might try to work them out. Tim listened attentively to her
descriptions of persecution from others, neither agreeing nor disagreeing about their
truth. He learned of her family relationships and how she planned to look for work
after the probation. Tim encouraged Jacqui to reflect on her current challenges in
the context of her goals to return to work. Jacqui began to feel that the social worker
sincerely wanted to understand her and had no intentions of using his power for
coercive interventions such as referrals for vocational counseling, as others had
done. He told her that when her probationary period ended he would report her
compliance with the legal mandates to the appropriate authorities.

Tim did not rush these interventions. He allowed this paranoid woman time
to get to know him (sharing general details about his own life), and to test the
validity of his interests in her. Tim continued encouraging ventilation and also
person-situation reflection regarding her family and career. He asked her to think
about what made others believe that she had a mental illness. Tim became a
trusted confidant, without being deceitful, and as a result Jacqui became willing
to share more personal concerns with him.

As Jacqui became comfortable with Tim, he began offering other interven-
tions, including education about job possibilities and partialization of her personal
goals into more focused units. He provided some direct influence tentatively, of-
fering opinions, for example, about how she might best prepare for job inter-
views. By the time her probationary period ended, Jacqui decided to stay
involved with the mental health agency. She was still paranoid but less so (due
in part to the medications), and became able to function well within a limited
social and occupational range. She used the social worker as a sounding board
for feedback when considering major life decisions (he gave no advice), and con-
tinued to take medications, which she perceived as useful for control of her anxi-
ety as she dealt with new challenges. Jacqui had always been a churchgoer, but a
new sense of spirituality emerged in her desire to become an advocate for other
Lebanese-Americans. She decided to work toward initiating a monthly supportive
discussion group for Lebanese professionals in the area. Jacqui eventually found
part-time work as a college instructor and tax examiner. Her frequency of meet-
ings with Tim gradually diminished to monthly. He transferred her to another
agency practitioner when he moved away several years later.

The Post-Traumatic Stress Survivor

Heidi was a 29-year-old married working mother (of a 12-year-old son) who
came to the mental health center requesting help dealing with stresses associated
with her job and marriage. Heidi, an assistant manager in charge of bookkeeping
at a grocery store, wanted to function more effectively at work and qualify for a
promotion. During her assessment the social worker, Jan, took note of Heidi’s
history of sexual acting out prior to her marriage and her patterns of obsessive-
compulsive behavior at work. She further noted Heidi’s tendencies to intellectu-
alize problems (a rigid defense). Jan was also impressed with the client’s strengths
of intelligence, motivation, and resilience.

E G O P S Y C H OL OG Y 75

In keeping with the client’s stated goals, Jan suggested a behavioral interven-
tion strategy based on coping skill development. They agreed that Heidi would
(a) secure a comfortable, secluded space for reviewing her day’s work once she
returned home; (b) develop a daily pattern of communication with her husband
(who was reluctant to come to the center) about their moods, mutual plans, and
parenting responsibilities; and (c) learn a set of relaxation activities. Jan set out to
implement these strategies through education and structure. She also encouraged
the client’s reflections about her emotional life, because Jan did not want to sup-
port Heidi’s tendencies to intellectualize. The social worker also helped Heidi
devise a regular exercise regimen (walking) to reduce her tension, and she en-
couraged the client to contact several friends more regularly as a social outlet
(Heidi was reluctant to reach out to others).

Jan estimated that Heidi would achieve significant improvement in 6 to 10
sessions (the agency permitted a maximum of 16 sessions, unless special permis-
sion was granted), and they agreed to review their work after six weeks. Heidi
made quick progress in her ability to manage her job responsibilities, as evi-
denced by her self-reports. The interactions with her husband were less success-
ful, even though the social worker spent much time helping her rehearse
strategies for better connecting with him. Jan noted that Heidi became more
relaxed in their sessions over time and shared personal information more freely,
which was evidence of their positive working alliance.

After their fourth session, however, Heidi’s depression and anxiety increased.
Jan observed that the more personal content the client shared, the more negative
feelings she experienced. Heidi eventually admitted that she was, in fact, a survi-
vor of long-term sexual abuse by her father, beginning at the age of five and
extending into her high school years. She added insightfully that she had learned
as a young girl to suppress her emotions as a means of coping with that trauma.
The present intervention had reawakened her range of emotions and she was
losing the ability to control them (poor stimulus regulation). Heidi was
experiencing insomnia, nightmares, and poor concentration. Most disturbingly,
she began to experience additional memories of abuse. She became more aware
of her father’s actions and was overwhelmed with anger, despair, shame, guilt,
and depression. She admitted to occasional suicidal wishes.

Jan felt that their work was at a turning point. Heidi had sought help to deal
with one set of problems, but another set of problems had emerged. Under this
new stress Heidi’s judgment was beginning to suffer and her sense of identity was
becoming confused (feeling the strong influence of her father, though he was not
physically present). The abuse memories made her less trusting of others, espe-
cially men, which negatively affected her everyday object relations. Jan recog-
nized that for Heidi to manage the effects of her abuse history, she would need
to explore her emotions rather than avoid them. In doing so Heidi would likely
become more distressed before developing new self-control. The social worker
suggested, and Heidi agreed, that they expand their work together and use the
ego psychology techniques of person-situation and developmental reflection in
addition to the behavioral interventions, so that the client could confront and
manage the negative emotions stemming from her abuse. Jan also offered to refer

76 C H A P T E R 4

Heidi at a later date to an abuse survivor’s group led by a social worker at an-
other agency.

The new, expanded set of goals included enhancing Heidi’s external social
supports (including communication with her husband), abuse history awareness,
feelings of self-control, anger management skills, ability to manage negative
emotions, and self-esteem. Jan first helped Heidi solidify her friendships and pos-
itive family supports as resources to draw upon when she felt overwhelmed. Jan
referred Heidi to the agency physician for a medication evaluation when she re-
quested medications, and an antidepressant was prescribed. The social worker
also presented this case to the agency’s peer review team for extended care and
was granted up to 16 additional sessions.

Together, Heidi and Jan balanced the client’s needs for nurturing and support
with her needs to face the facts of her abuse history and family trauma, and learn to
cope with them. From her ego psychology framework Jan encouraged a graduated
process of reflection, providing Heidi with guidance and suggesting limits to the
pacing of her self-exploration. Jan helped the client give up some defenses and
strengthen others, build on her personal strengths, and continue to develop
stress-coping skills. Recognizing the agency’s limits on service delivery, they met
three times monthly for six months. It was agreed that Heidi could phone Jan once
weekly when in distress to ask what she might do to calm herself.

The social worker needed to establish linkages with the agency psychiatrist,
staff at a local crisis facility (which Heidi attended three times), and staff at a psy-
chiatric hospital, where she was admitted once for suicidal ideation. Jan monitored
Heidi’s progress by charting the frequency of her self-reported anxiety attacks,
feelings of self-harm, phone calls and visits with friends, conversations with her
spouse, and productive workdays. The intervention contributed to Heidi’s greater
awareness of her needs, conflicts, and assets. It added to her stress at times; Heidi’s
psychological growth was erratic but continuous. She was able to make better de-
cisions about her life goals and relationships with family and friends.

Jan integrated family and group work into the interventions. She had observed
that Heidi increasingly avoided sharing her feelings with her husband. Also, Heidi
and her husband seemed to focus attention on their son rather intrusively at times,
largely to avoid a relationship with each other. Their son was experiencing normal
adolescent drives to separate from his parents, and he was frustrated with their re-
sistance to his changes. Three months into their clinical relationship, Heidi agreed
to Jan’s suggestion that her husband come for several marital sessions. Jan learned
that Heidi and her husband had developed avoidance patterns of dealing with in-
timacy. Heidi’s relationship with her husband improved in that they could talk
more openly in the supportive atmosphere of the clinic about their needs and feel-
ings. Heidi found her husband to be more supportive than she had expected. Still,
she made a decision near the end of her therapy to separate from him, allegedly as a
means of testing her ability to take care of herself, but also indicating that she was
questioning her commitment to the marriage.

Near the end of Heidi’s individual intervention she joined the group program
for survivors of sexual abuse, an open-ended group that met every two weeks. The
social worker who led the group organized it as a mutual support rather than an

E G O P S Y C H OL OG Y 77

insight-development experience for the 10 members. The leader provided educa-
tional material for members about the prevalence of sexual abuse and the normalcy
of their reactions to the trauma. Heidi still struggled with her need to face the reality
and consequences of her abuse history, but stated that the group helped her feel
much less alone. She developed additional supportive relationships there.

All of the interventions ended when Heidi made the decision to take a break
from therapy, after 24 total individual sessions. She had been confronting her abuse
history for six months, and learned that she could integrate those facts into her
sense of self without suppressing all of her emotions, losing herself in her work,
or looking for others to rescue her. Heidi was not completely at ease with herself
and her past, but she had learned much and now wanted to focus her energies on
other life pursuits, including her adjustment to living alone. Jan agreed that her
desire to end was indicative of Heidi’s growth. The client was ready to get on
with her life without the support of a practitioner. She had been following the
leads of others all her life, and now was ready to take control of herself.

EV IDENCE OF EFFECT IVENESS

The psychodynamic theories have a long tradition of the case study as a means of
evaluating intervention processes and outcomes (Lantz & Walsh, 2007). In case
studies, practitioners discuss the characteristics of a client, family, or group, their
own thoughts and actions, whether the client system improved, and whether the
process was conducted appropriately. These studies are usually interesting, in-
structional, and rich in detail. They also tend to lack external sources of valida-
tion, except, at times, from the client. The literature includes hundreds of
examples of ego psychology theorists and practitioners writing about single cases
or summarizing a series of cases drawn from their own practices. Many propo-
nents of ego psychology believe that this tradition provides a valid means of con-
sidering its effectiveness, and further maintain that many other theories overlook
the complexity of the intervention process in their own outcome studies.

It was noted in Chapter 2 that the case study method is unsatisfactory to some
practitioners, who feel that it is too subjective and not generalizable. Theories de-
veloped over the past half-century have relied more on experimental, quasi-
experimental, and structured single-subject evaluation methods. One challenge to
evaluating ego psychology is that its relatively non-specific intervention strategies
make it difficult to determine whether a practitioner is, in fact, working strictly
from the approach (although, as we shall see, this may be true of other theories
as well). Practitioners do not see this as a problem as much as an acknowledgment
that all clients are unique and deserve individualized interventions. It is interesting
to note that the newest theory presented in this book, narrative theory, also values
the case study as a primary method of theory description and evaluation.

Listed here are just a few examples of case study research in which ego psy-
chology was found to be effective with various client populations. They include
couples (Uhinki, 2001) and families (Nichols & Schwartz, 2007) in conflict;

78 C H A P T E R 4

clients with schizophrenia (Leffel, 2000); children of alcoholic mothers
(Dingledine, 2000); minority adolescents (Gibbs, 1998); African-American adults
(Manning, Cornelius, & Okundaye, 2004); adults experiencing grief reactions
(Meuser, 1997); persons with substance abuse disorders (Murphy & Khantzian,
1996); persons with borderline personality disorder, both individually (Clarkin,
Levy, Lenzenweger, & Kernberg, 2007) and in groups (von Held, 1987); persons
with mental illness in music therapy (Nolan, 1994); children with emotional and
conduct disorders (Perris, 1992); children experiencing sexual abuse (Lovett,
2007); incest survivors (Kramer & Akhtar, 1991); people in crisis (Sands, 1984);
and clients experiencing depression (Werner, 1983).

Still, a number of recent efforts have been made to test the effectiveness of
psychodynamic interventions using experimental designs. Falk Leichsenring and
his associates have conducted several meta-analyses of randomized controlled
therapy (RCT) and quasi-experimental trials of psychodynamic therapy, of
which ego psychology is a major derivative. In one project, Leichsenring
(2005) reviewed the empirical evidence for the efficacy of psychodynamic ther-
apy with specific psychiatric disorders. Studies published between 1960 and 2004
revealed 22 randomized trials, and these provided evidence for the efficacy of
psychodynamic therapy with depressive disorders (four trials), anxiety disorders
(one trial), post-traumatic stress disorder (one trial), somatoform disorder (four
trials), bulimia nervosa (three trials), anorexia nervosa (two trials), borderline per-
sonality disorder (one trial), Cluster C personality disorders (one trial), and
substance-related disorders (four trials).

Leichsenring, Rabung, and Leibing (2004) tested the efficacy of short-term
psychodynamic psychotherapy (STPP) in specific psychiatric disorders. They
identified 17 studies of STPP published between 1970 and 2004 that used ran-
domized controlled trials, treatment manuals (to ensure the integrity and consis-
tency of the interventions), experienced therapists, and reliable and valid
diagnostic measures. STPP yielded significant effect sizes for clients’ target pro-
blems, general psychiatric symptoms, and social functioning. Leichsenring and
Leibing (2007) later reviewed the efficacy of STPP in depression compared to
cognitive-behavioral therapy (CBT) or behavioral therapy (BT). Only studies in
which at least 13 therapy sessions were performed were included. Six studies met
the inclusion criteria, and in 58 of the 60 comparisons performed, there were no
significant differences between STPP and CBT/BT with regard to depressive
symptoms, general psychiatric symptoms, and social functioning. Thus, STPP
and CBT/BT seem to be equally effective methods in the treatment of
depression.

More recently, a group of researchers reviewed the efficacy of STTP rel-
ative to minimal treatment and non-treatment controls for adults with a range
of common mental disorders (Abbass, Town, & Driessen, 2012). They looked
at 23 studies involving 1,431 randomized clients with presenting problems that
included somatic, anxiety, depressive, and adjustment disorders. Outcomes for
most categories suggested significanty greater improvement in the treatment
groups that was maintained in medium- and long-term follow-up. Comment-
ing on these and other studies, Shedler (2010) noted a recurrent finding that

E G O P S Y C H OL OG Y 79

the benefits of ego psychological and related interventions not only endure
but increase with time relative to other interventions, an important trend
that has emerged in several independent meta-analyses.

While the above research is encouraging, ego psychology and other psycho-
dynamic interventions continue to be criticized for a lack of sufficient evidence
of effectiveness. Many professionals do not value the case study method of eval-
uation, and most practitioners would agree that more comparative research
should be done on these interventions. Shedler (2010), in his review of the liter-
ature, counterargues that considerable research supports the effectiveness of ego
psychology and related interventions, and the discrepancy between perceptions
and findings may relate to a negative bias stemming from a lingering academic
distaste for past psychoanalytic “arrogance.” Whether or not this is true, most
would agree that future process research should address the complex interactions
between ego psychology practitioners and their clients, as well as to concrete
outcome measures.

CR IT IC ISMS OF THE THEORY

Although it was once the social work profession’s most widely used practice the-
ory, ego psychology (and all of the psychodynamic theories) has been increasingly
criticized over the past 35 years (Rosen & Proctor, 2002; Goldfried & Wolfe,
1998; Conte, 1997; Myers & Thyer, 1997). Among the major criticisms are:

The theory focuses on concepts that are vague (such as the ego, drives, and
defense mechanisms).

The intervention strategies are abstract and difficult to operationalize.

Despite the drive to mastery and competence and its consideration of de-
fense mechanisms as adaptive, the theory still appears to be rather deficits-
oriented.

The developmental theories that are commonly used in ego psychology
(psychosexual, psychosocial, and moral, for example) do not adequately
respect human diversity.

Intervention strategies are open-ended and thus impractical in today’s time-
limited practice settings.

Outcomes are difficult to evaluate without more concrete indicators. Prac-
titioner reports of outcomes in case studies seem subjective. More controlled
studies of the type described earlier are needed.

Ego psychology may not adequately facilitate the pursuit of social change
activities.

In response to some of these criticisms, proponents of ego psychology have made
adjustments in recent years to address the changing face of direct practice, pnma-
rily by devising focused, short-term intervention approaches (Abbass, Town, &
Driessen, 2012; Goldstein & Noonan, 1999).

80 C H A P T E R 4

SUMMARY

Ego psychology has been in existence longer than any other practice theory in
this book. As a psychodynamic theory, it appreciates the effects of unconscious
mental processes on human behavior, and presents a comprehensive psychology
of human development. Many of its intervention techniques are geared toward
uncovering unconscious thought processes, but others maintain a concrete focus
on the “here and now.” Ego psychology is sensitive to the effects of the worker-
client relationship on the process of change, and emphasizes the importance of a
client’s reflecting on his or her thoughts and feelings as a means of developing
mastery and competence with regard to presenting challenges. The theory has
fallen out of favor somewhat in recent years because it has historically been an
open-ended, abstract approach that does not easily lend itself to empirical exam-
ination. Still, many social workers use its concepts to guide their assessments, and
many others find its intervention strategies useful for many types of clients.

TOPICS FOR DISCUSSION

1. Ego psychology considers that the quality of one’s present functioning is in
part the result of his or her mastery of prior developmental stages. Discuss
from the perspective of Erikson’s psychosocial theory how the manner in
which one has coped with a critical life stage in the past might affect present
behavior without one being aware of that influence.

2. One major contribution of ego psychology to analytic thought is the con-
cept of the drive to mastery and competence. Discuss what is implied by this
drive, and whether you agree that it exists.

3. Consider each of the defense mechanisms (or a subset of them) and describe
through examples how they can be utilized either as effective or ineffective
coping strategies.

4. Briefly describe two types of clients: one for whom person-situation reflec-
tion might be a sufficient intervention, and another for whom develop-
mental reflection might be needed in order to resolve the problem. What
are the differences in these types of clients?

5. The intervention strategy of advice and guidance (direct influence) appears to
run counter to ego psychology’s emphasis on reflective techniques. Discuss
examples of clinical situations in which this strategy might be appropriate.

IDEAS FOR CLASSROOM ACTIV IT IES /ROLE -PLAYS

1. Present a case scenario to the class, limiting the information to a description of
the client, his or her presenting problem, and type of agency. Divide the class

E G O P S Y C H OL OG Y 81

into role-play groups of three students—a client, a social worker, and an ob-
server. Assign to each group one, two, or three of the ego functions. Ask the
students/social workers to assess the client only from the perspective of their
assigned ego functions. Discuss afterward how the students sought information
from the client to accomplish this task. During the discussion, ask if students
from other groups have additional ideas for assessing the various ego functions.

2. List the ego psychology intervention strategies on the board. Ask students to
consider the types of clients for whom each technique, either alone or in
combination with one or more others, would be appropriate. Conversely,
ask students to discuss types of clients for whom the strategies may not be
suitable, either alone or in combination. What general themes seem to
emerge in the students’ perceptions of appropriateness?

3. Elicit from students a variety of presenting problem scenarios that might be
suitable for ego psychology intervention. Select one scenario and write the cli-
ent’s relevant background information on the board. Ask students in small role-
play groups (again with a client, one or more social workers, and one or more
observers) to attempt an intervention that focuses on some combination of in-
tervention strategies. Discuss the process afterward in the large group, including
thoughts about what worked, what didn’t work, and why. This activity can be
repeated for various client types and combinations of intervention strategies.

APPENDIX: Ego Psychology Theory Outline

Focus Ego: a mental structure that negotiates between a person’s internal
needs and the outside world

Ego functions

Unconscious thought

Past and present person-environment transactions

Major
Proponents

Hartmann, Erikson, Hollis, Goldstein

Origins and
Social Context

Reaction to Freud’s emphasis on instinct and his minimizing of ego
and reality functions

Efforts to extend psychoanalysis to build a psychology of normal
development

Development of the social and behavioral sciences

Interest in adaptive capacities (strengths perspective)

American culture (pragmatism)

The rise of functional theory in the social work profession

Nature of the
Individual

Ego contains all basic functions for adaptation: attention,
concentration, learning, memory, perception

Ego mediation of internal conflicts

Drive to mastery and competence

82 C H A P T E R 4

Stages of biopsychosocial development

Critical impact of life-cycle events

Major Concepts Ego and its functions:

– Reality testing

– Integration of internal and external stimuli

– Mastery and competence

– Direction of thought processes

– Drives (and their control)

– Defensive/coping functions

– Judgment

– Sense of the world and self

– Object (interpersonal) relations

– Superego: conscience

Developmental
Concepts

Maturation of conflict-free, autonomous ego functioning

Average expectable environment

Psychosocial stages (Erikson)

Object relations

Processes of coping and adaptation

Person-environment mutuality

Nature of
Problems

Life events

Heredity

Health factors

Ego deficits

Maladaptive defenses

Lack of fit between inner capacities and external conditions

Maladaptive interpersonal patterns

Nature of
Change

Ego mastery of developmental, crisis, transitional situations

Learning new problem-solving, coping skills

Emotionally corrective life experiences

Better person-environment fit

Conflict neutralization

Reflection and insight

Goals of
Intervention

Adjust defense mechanisms

Increase adaptive capacities for ego functioning

Modify maladaptive personality traits and patterns

APPENDIX: Ego Psychology Theory Outline (Continued)

E G O P S Y C H OL OG Y 83

Improve fit between individual capabilities and environmental
conditions

Nature of the
Worker/Client
Relationship

Genuineness, empathy, support

Cultivation of positive transference

Attention to countertransference

Use of the relationship to address developmental needs

Intervention
Principles and
Techniques

Ego sustaining

Exploration/description/ventilation

Sustainment

Person-situation reflection

Structuring

Education

Direct influence

Ego modification

Developmental reflection (and some of the above)

Focus first on conscious thoughts and feelings

“Use of self” in providing feedback

Use of the environment

Assessment
Questions

What defenses is the client utilizing?

How effective are the defenses?

How is the client managing relationships?

To what degree is the problem a matter of ego deficit versus conflict
with other people or the environment?

What circumstances are impeding the client’s ability to manage the
problem situation?

To what extent is the client’s stress a function of:

– Current life roles or developmental tasks

– A traumatic event

– A lack of environmental resources or supports

What inner capabilities and resources does the client have that can be
mobilized to improve functioning?

Based on Object Relations Theory and Self Psychology in Social Work Practice by Eda G. Goldstein.

APPENDIX: Ego Psychology Theory Outline (Continued)

84 C H A P T E R 4

The Relational Theories, with a

Focus on Object Relations

The soul selects her own society,
Then shuts the door;

On her divine majority
Obtrude no more. *

As described in the previous chapter, social workers have been using psycho-
dynamic practice theories for almost a century. Those theories have experi-

enced considerable evolution over the years in response to changing social values
and ideas about the nature of human functioning. Psychoanalysis was followed
by ego psychology, which in turn led to developments in object relations theory,
self psychology, and the contemporary relational theories. In this chapter we will
build upon the material presented on ego psychology and investigate the rela-
tional theories with a focus on object relations theory, a practice perspective
that is distinguished by its attention to the role of interpersonal relationships in
people’s lives.

Our first task is to clarify the meaning of the term object relations. It has
almost a mechanical sound, but in fact the word “objects” refers to people, or
parts of their personalities. The choice of that term is somewhat unfortunate for
social work, which is more humanistic in its references to people. Beyond this
issue, however, “object relations” has two meanings. Its general meaning is the
quality of our interpersonal relationships. Ego psychology includes object rela-
tions as one of the ego functions, referring to our ability to maintain productive

* Dickinson, E. (1927). The Pamphlet Poets. New York: Simon and Schuster.

85
Copyright 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights,

relationships with people in a variety of contexts. As a theory, however, object
relations refers more specifically to our internalized attitudes toward others and
the self, and how those attitudes determine our approach to new relationships.
Object relations theory focuses on the internal world of our relationships and
recognizes that these may be even more significant than relationships in the ex-
ternal world in shaping our lives. One theorist refers to this as “the power of the
situation in the person” (Goldstein, 2001, p. 131). The theory is concerned with
how what is “outside” (relationships) gets “inside” (ongoing attitudes about those
relationships) and how our needs are met or not met in relationships. Object
relations theory is also concerned with the effects of relationships on a person’s
ability to have a relationship with the self—that is, to perceive the self as stable,
feel good about the self, and be able to feel comfortable when apart from others.

Object relations theory provides a bridge between the study of persons and fam-
ily systems. It represents a shift in analytic thought from a focus on drives to a focus
on relationships, and the relative weight given to each. Core issues in the theory
include the nature of objects and how they become internalized (St. Clair, 1999).
Like ego psychology, it is a developmental theory, and views stages in terms of un-
folding object relations. The contributions of object relations theory to the science
of human behavior include understanding attachments, how one’s inner world be-
comes composed of representations of others, and the challenge of balancing being
alone and being with others (Goldstein, 2001). Like the social work profession, it
recognizes the influence of the environment on human development and social
functioning, and values interpersonal connections over notions of independence.

ORI GINS AND SOCIAL CONTEXT

The emergence of object relations theory was in large part a natural evolution of
psychoanalytic thought. No significant practice theory is static, of course. Theory
evolution is a positive thing, indicating that many practitioners have adopted the
theory and, through practice and research, discovered its areas of relative weak-
ness as well as strength with regard to certain client populations and problems. As
described in the previous chapter, psychoanalysis was initially focused on the
drives and a rather pessimistic view of human nature featuring ongoing, inevita-
ble conflict. Ego psychology represented an effort to build an analytic model of
healthy human development. Object relations theorists, although varied in their
particular contributions, attempted to correct the analytic focus on the individual
and his or her drives, and bring the importance of relationships to the fore
(Flanagan, 2011). There was so much enthusiasm among practitioners for these
developments that object relations became identified as a unique theory, rather
than a development within psychoanalysis. Other social influences on the devel-
opment of object relations theory are described below.

86 C H A P T E R 5

The Effects of Early Nurturing

There is a large body of research devoted to studying the links between early life
experiences and physical and mental health (Lally, 2011; Gerhardt, 2004). This
work demonstrates that negative infant experiences such as child abuse, family
strife, poverty, and emotional neglect correlate with later health problems rang-
ing from depression to drug abuse and heart disease. Relational elements of a
person’s early environments appear to alter the development of central nervous
system structures that govern physiological and psychological responses to stress
(Farmer, 2009). These findings tend to support the lifelong significance of spe-
cific relationship interactions.

Many of you may be familiar with the tradition of research on the nurturing
practices of rhesus monkeys, and research continues in this area (Suomi, 2005;
Webb, Monk, & Nelson, 2001). In some of these experiments, monkeys are
separated from their mothers at various intervals and raised in a group of other
monkeys with a different mother. The infants who are separated later in life (af-
ter three or six months) exhibit normal behavior in the new setting. Those sepa-
rated earlier, however, show a variety of abnormalities. The monkeys separated
at one month initially exhibit a profound depression and refusal to eat. Once
they recover, they show a deep need for attachments with other monkeys and
great anxiety during social separation. The monkeys separated at one week
showed no interest in social contact with other monkeys, and this did not change
as they grew older. Autopsies of these monkeys show changes in brain develop-
ment. The timing of separation from the primary caregiver seems to be signifi-
cant to their later development.

This research has clear implications for human development in the concept
of neural plasticity, or the capacity of the nervous system to be modified by ex-
perience (Bryck & Fisher, 2012). Humans may have a “window of opportunity,”
a critical period for altering neurological development, although this window
varies for different areas of the nervous system. Even through the second decade
of life, for example, external signals as well as internal biology influence neuro-
logical changes. Although stress can clearly affect brain development, any nega-
tive effects during the first three years of life are reversible (Nelson, 1999). A
study of 2,600 undergraduate students found that even in late adolescence and
early adulthood, satisfying social relationships were associated with greater auto-
nomic activity and restorative behaviors when confronting acute stress
(Cacioppo, Bernston, Sheridan, & McClintock, 2000). Higher levels of
cortocotropin-releasing hormone (CRH) characterized chronically lonely indivi-
duals. Secure emotional relationships with adults appear to be at least as critical as
individual differences in temperament in determining stress reactivity and
regulation.

In summary, secure attachments play a critical role in shaping the systems
that underlie human reactivity to stressful situations. At the time that infants be-
gin to form specific attachments to adults, the presence of caregivers who are
warm and responsive begins to buffer or prevent elevations in stress hormones,
even in situations that elicit distress in the infant. In contrast, insecure

T H E R E L A T I O N A L T H E O R I E S , W I T H A F O C U S O N O B J E C T R E L A T I O N S 87

relationships are associated with higher CRH levels in potentially threatening si-
tuations. Thus, one’s object relations are critically important in one’s develop-
ment. Still, it must be emphasized that there is much to be learned in this area.
Some people who have been subjected to serious early-life traumas become ef-
fective, highly functional adolescents and adults. Infants and children are resilient
and have strengths that can help them overcome early-life stresses.

Attachment Theory

Attachment theory offers a beneficial foundation for understanding the connec-
tions between biology and social experience. It may be useful for us to consider
one model of parent-child attachment here (Shorey & Snyder, 2006). All chil-
dren seek close proximity to their parents, and they develop attachment styles
suited to the types of parenting they encounter. Ainsworth, Blehar, and Waters
(1978) identified three infant attachment styles—secure, anxious-ambivalent, and
avoidant. A fourth attachment style has been identified more recently—the disor-
ganized type (Carlson, 1998; Malm, 1996).

Parents of secure infants are sensitive and accepting. Securely attached infants
act somewhat distressed when their mothers leave, but greet them eagerly and
warmly upon return. Securely attached children are unconcerned about security
needs, and are thus free to direct their energies toward non-attachment-related
activities in the environment. Insecure infants, rather than engaging in explor-
atory behaviors, must direct their attention to maintaining their attachments to
inconsistent, unavailable, or rejecting parents. Because these children are able to
maintain proximity to the parents only by behaving as if the parents were not
needed, the children may learn not to express needs for closeness or attention.

Anxious-ambivalently attached infants, in contrast, are distraught when their
mothers leave. Upon their mothers’ return, these infants continue to be dis-
tressed even as they want to be comforted and held. These children employ hy-
peractivation strategies. Their parents, while not overtly rejecting, are often
unpredictable and inconsistent in their responses. Fearing potential caregiver
abandonment, the children maximize their efforts to maintain close parental at-
tachments and become hypervigilant for threat cues and any signs of rejection.

Avoidantly attached infants seem to be relatively undisturbed both when
their mothers leave and when they return. These children want to maintain
proximity to their mothers, but this attachment style enables the children to
maintain a sense of proximity to parents who otherwise may reject them. Avoi-
dant children thus suppress expressions of overt distress, and rather than risk fur-
ther rejection in the face of attachment figure unavailability, may give up on
their proximity-seeing efforts.

The disorganized attachment style is characterized by chaotic and conflicted
behaviors. These children exhibit simultaneous approach and avoidance beha-
viors. Disorganized infants seem incapable of applying any consistent strategy to
bond with their parents. Their conflicted and disorganized behaviors reflect their
best attempts at gaining some sense of security from parents who are perceived as
frightening. When afraid and needing reassurance, these children have no

88 C H A P T E R 5

options but to seek support from a caregiver who also is frightening. The parents
may be either hostile or fearful and unable to hide their apprehension from their
children. In either case, the child’s anxiety and distress are not lessened, and one
source of stress is merely traded for another.

Although children with disorganized attachments typically do not attain the
sense of being cared for, the avoidant and anxious-ambivalent children do expe-
rience some success in fulfilling their needs for care.

Contemporary Object Relations Theory

Recent developments in object relations theory include the emergence of rela-
tional theories, which are distinctive in that they assign primary importance to
“real” interpersonal relationships and the primacy of social experience as the mo-
tivator and organizer of mental life, rather than the drives (Perlman & Brandell,
2010). These will be discussed in greater detail later in this chapter.

Now we turn to the major concepts of object relations theory, all of which
are considered in client assessment. These definitions are adapted from Flanagan
(2011), Goldstein (2001), and St. Clair (1999).

MAJOR CONCEPTS

Many of the concepts associated with ego psychology are also used in object rela-
tions theory. In this section we will emphasize only concepts that are either unique
to object relations theory or used in particular ways in the context of this theory.

The concept of attachment, described earlier, is central to object relations the-
ory. It assumes that all people have an inherent biological need to form attach-
ments with others in order to experience healthy development and to meet their
emotional needs. Satisfactory human development is dependent on healthy early
attachments. This is in contrast to earlier analytic theories, including ego psychol-
ogy, that are more focused on drives than on relationships. As implied in the
animal studies described earlier, there may be critical periods in which disruption
of a key relationship can have long-term adverse consequences.

The process of introjection is the psychological “taking in” of the characteris-
tics of other people. This is sometimes described as a defense mechanism in ego
psychology, similar to internalization. For example, if a child is fearful of an ag-
gressive parent, the child may take in (introject) characteristics of aggression so
that he can better identify, and feel safe, with the parent. Introjection more spe-
cifically describes the process by which we become able to carry images of other
people (our caregivers) within us when they are not physically present. We can
maintain the sense of a parent’s caring as we make our way through the limited
environment of the household or neighborhood. Keep in mind that the term
“introjection” refers to the process, not the content, of this activity.

A representation is the content, or result, of an introjection. It is a cognitive
construction with deep emotional resonance, something like a “mental picture.”

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It refers to the internal images of other people that we form and adhere to, per-
haps consciously, but often unconsciously. The quality of these images is crucial
to our development of stable or unstable object relations. They are accompanied
by affects, or strong feelings. An example is the individual who has a strong inter-
nal sense of a father figure, including the range of attitudes and behaviors (posi-
tive and negative) that such a person should display. The individual with that
representation will experience strong emotions when encountering a (probably
older) person with those qualities. People who develop frequent and significant
interpersonal problems have a limited capacity to manage consistent and accurate
representations of other people, and they tend to experience strong negative
feelings when in conflict with them. The individual who is drawn to father fig-
ures, and who generally experiences strong positive emotions in their presence,
may become extremely angry and rejecting when they feel disappointed by those
people.

Object relations, described earlier, are the set of a person’s internalized atti-
tudes toward other people and toward the self. These develop through real in-
teraction with significant other people in the context of facultative or
problematic environments. Our interactions with early caregivers are especially
significant in determining later object relations with others.

The term “object” can be used to refer to an actual person in the physical
world or one’s mental representation of a person or a part of the person. An
internal object is the same as a mental representation, but this is not true of an
external object. I have an internal representation of my deceased father, and also
of my living mother, but my living mother also exists as an external object. I
have a real, ongoing relationship with her, even though we live far apart. The
nature of an object and its emotional resonance is based in part on the actual
characteristics of the external person and in part on our ideas and feelings about
the individual.

A part object is one or several characteristics that we have internalized about a
person, but not the “total” person. A client might maintain an internal represen-
tation of part of an individual that tends to be one-dimensional (good or bad) yet
does not perceive the “total” person with both strengths and limitations. Early in
the developmental process, a client may internalize his or her mother’s caring
qualities, or her hostile qualities, as part objects. Splitting others into part objects
can help the child avoid feelings of disappointment and rejection, perceiving the
person as “bad.” This is normal in children, but if it persists, it can make the
person fragile in relationships with others and even cause what they fear (rejec-
tion). A whole object is the internalization of all aspects of another person. In this
instance the client is able to integrate experiences of gratification and frustration
with the mother, father, or other primary caregiver. This ability to internalize a
whole object represents a state of psychological maturity.

A self-object is an internal representation of one’s own self. That is, we inter-
nalize aspects of ourselves (in whole or in part), as well as our experiences of
others. We might internalize either a partial self-object or a whole self-object,
with implications that we may feel positively, negatively, or both (at times) about
ourselves. I may identify with my limitations (tending to be selfish at times, for

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example) and develop a negative self-object based on that characteristic, or I
might have a more well-rounded self-representation. A true self is a self-image (or
self-object representation) in which we recognize that we possess a variety of
characteristics and needs, and we work to meet those needs. In contrast, a false
self is a self-image in which one’s personal needs are devalued and suppressed in
deference to others. The person organizes his or her life around a desire to be
compliant with, and pleasing to, other people. The true self is subjugated, with
implications that the person never fulfils, or even consciously understands, his or
her own needs.

Finally, object constancy is a mature psychological state in which we are able to
maintain whole-object representations of significant people in our lives, even
when separated from them. The person who experiences object constancy can
maintain relationships even when separated from the other person for a long
time. (Consider close friends who see each other only every few years.) With
object constancy the person can balance being alone and being with others,
and in either case maintain an awareness that there are available (or potential)
people who care about them.

Relational Theory

In recent years there has been an integration of the psychodynamic, object rela-
tions, and interpersonal theoretical perspectives into what is broadly termed rela-
tional theory (Borden, 2009b). In relational theory, the basic human tendency (or
drive) is relationships with others, and our personalities are structured through
ongoing interactions with others in the social environment. Little or no attention
is paid to other possible drives. There is a strong value of recognizing and sup-
porting diversity in human experience, avoiding the pathologizing of differences,
and enlarging conceptions of gender and identity. It is assumed that all patterns
of human behavior are learned in the give-and-take of relational life, and thus
they are all adaptive, reasonable ways of negotiating our experience in the con-
text of our need to elicit care from, and provide care for, others. Consistent with
object relations concepts, serious problems in living are seen as self-perpetuating
because we all have a tendency to preserve continuity and familiarity in our in-
terpersonal worlds. Our problematic ways of being and relating, when they
emerge, are perpetuated because they preserve our ongoing experience of the
self. What is new is threatening because it lies beyond the bounds of our experi-
ence in which we recognize ourselves as cohesive, continuous beings. That is,
problematic interpersonal patterns are repeated because they preserve our con-
nections to significant others in the past.

The relational perspective provides a context of understanding for practi-
tioners in their efforts to connect biological, psychological, and social domains
and enlarge conceptions of persons in their environments. If this sounds to the
reader like social work’s longstanding focus on person-in-environment, it should!
It seems, in this sense, that the psychodynamic thinkers have finally caught up to
social work, although this connection is not often made in the literature. Still,
relational theory differs from social work’s overarching perspective in that it

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preserves analytic and object relations concepts while enlarging the scope of en-
vironmental concerns. Nonetheless, the similarity is striking, and relational prac-
titioners pursue a variety of activities familiar to social workers, including brief
intervention, case management, environmental development, and advocacy.

Regarding the therapeutic implications of the relational perspective, it is the
client’s subjective experience and sense of personal meaning that is always the
focus of intervention. Both the client and practitioner participate actively in
the helping process, and each influences the other in conscious and unconscious
ways. Relational theorists encourage the social worker’s natural, authentic man-
ner of engagement with the client. Such practitioners engage in self-disclosure
and encourage the client to regularly comment on the intervention process.
Contrary to traditional analytic notions, the relational social worker experiences
and freely expresses a wide range of thoughts and feelings in the moment with a
client to facilitate a sense of mutual connection (Freedberg, 2007). This does not
imply a neglect of appropriate boundaries, however. The mature practitioner
will be capable of maintaining a clear sense of self and flexible ego boundaries
to ensure the high level of emotional and cognitive integration necessary for em-
pathy to be effective.

The relational perspective enriches the concept of empathy by adding the
notion of mutuality. The ability to participate in a mutual relationship through
the use of empathic communication is seen as a goal for the client’s growth and
development, as well as a mechanism that allows for change in the worker/client
relationship. Current social work literature reflects different views regarding the
degree to which workers should beome emotionally involved with clients, but
the general consensus calls for the worker to maintain a neutral, objective per-
sona and a sense of separateness. In relational theory, the more the worker ex-
pends energy on keeping parts of herself or himself out of the process, the more
rigid, and less spontaneous and genuine, he or she will be in relating to the client
system. The worker/client relationship runs the risk of becoming organized into
dominant and subordinate roles.

Relational theory incorporates an object relations perspective with a greater
focus on the inter-subjective aspects of self-development (Perlman & Brandell,
2010). This inter-subjectivity is a mutual recognition of the self and the other
as people with unique experiences and differences. The client gradually becomes
able to recognize other people’s uniqueness, developing the capacity for sensitiv-
ity and a tolerance of difference. Through relational intervention, the social
worker is able to help the client see others as a distinct person, rather than repe-
titions of others from the past, and thus the client is freed from the “pull” of past
object relations.

With a relational cultural perspective the social worker continuously evaluates
the relational context with regard to diversity issues such as age, race, culture,
and gender, and their impact on the use of one’s self in the empathic process.
Comes-Diaz and Jacobsen (1991) have contributed greatly to social work’s ap-
preciation of these issues by analyzing the nature of ethno-cultural transference
and countertransference in direct practice (see Table 5.1). Building on relation-
ship concepts discussed in the last chapter, these shared reactions of the social

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worker and client are related to perceived differences and similarities between
the two parties. They are all assumptions, however, and only through an open
encounter can the parties become aware of the nature of their relationship and
come to understand each other.

Feminist perspectives have contributed greatly to the development of rela-
tional theory. Feminism, of course, refers to a wide-ranging system of ideas about
human experience developed from a woman-centered perspective (Lengermann &
Niebrugge-Brantley, 2000). Among the psychological theories are psychoana-
lytic and gender feminism (Tong, 1998), both of which begin from the position
that women and men approach relationships differently. Analytic feminists assert
that women’s ways of acting are rooted in their unique ways of thinking. These
differences may be biologically determined in part, but they are also influenced by
cultural and social conditions. Feminine behavior, as Western culture understands
it, features gentleness, humility, supportiveness, empathy, tenderness, nurturance,
intuitiveness, and sensitivity. Masculine behavior in turn is characterized by
strength of will, ambition, independence, assertiveness, rationality, and emotional
control. Analytic feminists assert that these differences develop from early child-
hood relationships. Because women are the primary caregivers in our society,
young girls tend to develop ongoing relationships with their mothers that promote
their valuing of relatedness and the other feminine behaviors described above. For
young boys, the mother is eventually perceived as fundamentally different, partic-
ularly as they face social pressures to begin fulfilling male roles. This pressure to
separate from the mother figure has long-range implications for boys, as they
tend to lose what could otherwise become a learned capacity for intimacy and
relatedness. Many object relations theorists have appeared to value separation
over relatedness in human relationships, and feminist thinkers are helping to coun-
terbalance this notion.

Gender feminists tend to be concerned with how values of separateness (for
men) and connections (for women) lead to a different morality for women.
Carol Gilligan (1982) elucidated a process by which women develop an ethic
of care rather than an ethic of justice, based on their relational values. Gender
feminists believe that these female ethics are equal to male ethics, although they
have tended in patriarchal societies to be considered inferior.

What follows are additional concepts from object relations theory that are
specific to human development and that may help to clarify some of the above
ideas.

DEVELOPMENTAL CONCEPTS

There are dozens of object relations theorists, and thus it is not easy to summa-
rize what “the” theory says specifically about human development. In this sec-
tion we will consider the ideas of two theorists who offer consistent but different
accounts of the process: Donald Winnicott and Margaret Mahler. Winnicott is
more closely associated with relational theory (less emphasis on drives), whereas
Mahler’s work is rooted in a stricter “stage” approach to human development.

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Donald Winnicott

Donald Winnicott was a British pediatrician who contributed much to the de-
velopment of object relations theory. He was by all accounts a compassionate
man, and his theoretical work features more of a strengths orientation than that
of some of his contemporaries. His ideas are consistent with a social work per-
spective on the dynamics of infant development (in fact, his second wife was a
social worker). His contributions include the following ideas (Winnicott, 1975):

A faciliative environment is one that flexibly adapts itself to the needs of the in-
fant, rather than expecting the infant to adapt to it. This environment is comprised
of people and resources that recognize the primacy of meeting the infant’s needs so
that he or she can develop in a healthy manner. This is an admittedly “fluid” con-
cept that does not specify exactly what should be present in such an environment.

Infant omnipotence refers to the infant’s first perceptions, in which there is no
perceived difference between the self and the world. This is a normal, functional
stage in which the infant lives in a world of fantasy where, in a facultative envi-
ronment, his or her needs are met when they arise.

Good-enough mothering is another general term in which the mother or primary
caregiver is described as having a primary preoccupation with the child’s welfare,
or being focused on meeting the needs of the child above all else. This is a tempo-
rary situation in a facultative environment, as the good mother will eventually re-
sume attending to her other life demands and needs. Winnicott did not speak to
the role of fathers, but we may suppose that the term good-enough parenting would
be applicable in today’s world of varied family constellations. Winnicott added that

T A B L E 5.1 Issues in Ethnocultural Transference and
Countertransference

Transference

Inter-ethnic Intra-ethnic

Over-compliance and friendliness Omniscient-omnipotent

Denial of ethnicity and culture The traitor

Mistrust, suspicion, hostility The auto-racist

Ambivalence Ambivalence

Countertransference

Denial Over-identification

Extreme curiosity Us vs. them

Guilt Distancing

Pity Cultural myopia

Aggression Anger

Ambivalence Survivor’s guilt

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parental care should include the activities of holding the child (to give the child a
sense of safety), handling the child (to develop his or her sense of uniqueness), and
presenting other people and material objects to the child (to promote object relat-
ing). One of Winnicott’s most famous contributions to object relations theory is
the concept of the holding environment, a haven of security from which the child can
begin to explore the world and take risks with a sense of confidence.

The transitional object is a physical object adopted by the child, representing
an intermediate step between internal and external object relations. The object
gives the child a sense of the parent being with him or her while being physically
separate from that person. A commonly cited example is the security blanket,
although a variety of materials associated with the mother or father can serve
such a function. Incidentally, transitional objects are not universal—they are spe-
cific to cultures that value independence (Goldstein, 2001).

Winnicott wrote that, in a facultative environment, the child gradually
moves from a position of dependence to one of independence. The stages in
this process include absolute dependence, in which the child is completely passive in
the relationship with the caregiver. The child moves into a state of relative depen-
dence as he or she becomes—partly due to physical maturation and mobility—
aware of his or her separateness. As the child develops social skills with family
members and peers, he or she begins moving toward independence. The term ego
relatedness refers to the child’s increasing capacity to be alone.

Winnicott did not attach clear timelines to his developmental stages. As a
contrast, the work of Margaret Mahler is described next.

Margaret Mahler

Margaret Mahler, born in Hungary, was trained as a pediatrician (like Winnicott),
although she began practicing psychiatry soon after receiving her medical degree.
She interacted with many of the original analysts in Europe prior to migrating to
England and then to New York. Mahler’s passion was working with children,
and in her career she focused on the processes that lead to children’s development
of a “self.” Her most famous work was The Psychological Birth of the Human Infant
(Mahler, Pine, & Bergman, 1975).

The twin concepts of separation and individuation describe the process by which
an infant develops from a state of complete dependence on outside caregivers to
one of object constancy, in approximately three years. The first two stages include
autism (birth to three months), in which the infant senses no difference between
the self and the external world; and symbiosis (one to five months), during which
the infant senses a difference between the self and “other,” but assumes that the
other exists only to meet his or her needs. The third and final stage of separation
and individuation occurs in the following four substages:

Differentiation (5–8 months) represents the infant’s awareness of his or her dif-
ference from the “other” and the capacity to function apart from that person.

Practicing (8–16 months) is the period in which the infant applies his or her
developing will to intentionally separate from the significant other for brief
periods by, for example, crawling away.

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In rapprochement (16–24 months), the child learns that he or she can exist
apart from the significant other, but that the other will be available to attend
to the child’s needs when the child returns or calls for help.

Object constancy (24–36 months) is the mature stage of development in which
the child has internalized the image of the significant other (object) and can
spend longer periods of time alone without feeling abandoned.

Object relations theorists differ in their ideas about the specific stages in-
volved in human development, but they tend to agree on the general process.
It may be apparent to the reader that it would be impossible for a practitioner
to assess the specific degree to which an adolescent or adult client’s infant and
early childhood environment was facultative, or to what extent his or her devel-
opment was healthy. This information would emerge from the family history
and perhaps records from other providers, but it will always depend to some de-
gree on the client’s emotional memories. The client’s needs will be discovered
further through the nature of his or her relationship with the practitioner.

We have already noted the influence of relational theories on the idea that a
person’s capacity for relationships may be more important than his or her ability
to separate or individuate. Further, these theorists believe that the biological ef-
fects of many significant interpersonal deprivations in early life are reversible. It is
accepted among object relations theorists that a healthy person always seeks and
maintains secure attachments, and that the process of becoming “independent” is
not meant to suggest otherwise (Mitchell, 1988). In fact, as we have seen, the
focus on the significance of relationships has become even more pronounced in
contemporary object relations theory.

THE NATURE OF PROBLEMS

The development of healthy object relations is not an all-or-nothing process. When
a person grows up with caregivers who are able to provide good-enough parenting,
and in a facilitative environment, he or she will develop relatively intact and inte-
grated object relations. The person will maintain the capacity throughout life to de-
velop and sustain productive, satisfying relationships. The person may develop
serious problems in living, and experience conflicted relationships, but will also
have the capacity to manage interpersonal problems. Another person may grow up
in an environment that is initially satisfactory, but becomes less so due to abrupt
changes in caregiving circumstances prior to the development of a stable internal
environment. That individual will have “intermediate” success with object relations,
developing problems with managing some relationships, but probably does not have
a major diagnosable disorder. A person who experiences early deprivation in both
caregiving and the environment, however, will become unstable, anxious and fear-
ful, and be at a greater risk of major emotional and character disorders.

Persons with poor object relations tend to utilize the defense mechanism of
splitting, which is a source of their chronic relationship conflicts. Splitting,
described earlier, characterizes how a person sees others as “good” or “bad” prior

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to seeing them as “whole” (capable of having a mix of characteristics) It is a uni-
versal defense (or coping) mechanism for young children. It is considered an
“immature” defense because it is usually resolved by the parent figure demon-
strating to the child that he or she can be loved without being gratified at all
times. Splitting is used in adulthood when a person is incapable of tolerating am-
bivalent or mixed feelings about other people. The client perceives a “good”
person as one who helps the client meet his immediate needs. The client cannot
tolerate any negative feelings about a person who is perceived as being “good.”
Conversely, the client transforms any person who frustrates or angers him or her
into a “bad” person. Thus, the client feels and believes that other people are
either all good or all bad. He or she tends to alternate between idealizing and
devaluing people. Once a person is devalued, it may be difficult for the client
to feel positively about that person again.

Splitting always becomes an issue in direct practice with persons who have
poor object relations. A “good” person (a social worker, for example) who dis-
appoints the client in some way (which is inevitable in anything other than a
superficial relationship) becomes a “bad” person. The client completely, and per-
haps for a long time, reverses his or her attitudes and actions toward that social
worker. It is also common for the client to “split” the self into categories of good
and bad, with an inability to integrate these perceptions of the self. As such the
client may present to the social worker one day as engaged in the intervention
process, and another day as detached or negative.

People with significantly impaired object relations, and who extensively uti-
lize the defense mechanisms of denial, projection, splitting, and projective identifica-
tion (discussed later in this chapter), are frequently in conflict with their significant
others. They cannot integrate the positive and negative aspects of those other peo-
ple, and thus alternately love or hate them. In severe cases these clients may be
diagnosed with personality disorders, enduring patterns of behavior with others
that are pervasive and inflexible, leading to interpersonal distress (American
Psychiatric Association, 2000). The association of poor object relations with
some personality disorders has been demonstrated in several studies (e.g., Diguer,
et al., 2004). Practitioners will often move their focus from the specific presenting
problem to general personality patterns once it has been diagnosed.

THE NATURE OF CHANGE

For clients who experience problems stemming from fundamentally impaired
object relations, change first requires that they develop insight into their repeti-
tive negative interpersonal patterns. Second, they must modify their internal
structures (objects) so that they can respond to others as unique human beings
rather than as representations of past relationships. This second task is addressed
through initiating new relationships, or addressing existing relationships in new
ways. The client must analyze and discuss his or her thoughts, feelings, and
behaviors regarding these relationships with the social worker until new, more
functional patterns become stable. For children and adolescents, insight is not a

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prerequisite for change. Young clients may be helped to change through envi-
ronmental adjustments and practicing new behaviors.

ASSESSMENT AND INTERVENT ION

The Social Worker/Client Relationship

The social worker’s careful, consistent monitoring of the practice relationship is
critical in object relations theory (Goldstein, 2001). Remember that a client’s on-
going problems are related to a rigid replaying of old relationship dynamics with
new people. The client will tend to act out his or her object relations patterns with
the practitioner. For example, the angry man who is oppositional with authority
figures will act the same way, sooner or later, toward the social worker. This is
facilitative toward goal achievement because the practitioner can point out and
discuss these dynamics with the client in a safe environment. It also ensures, how-
ever, that the social worker will experience a range of emotions in response to the
client’s behaviors that must be managed constructively. Thus there should be a
strong focus on transference and countertransference issues in the practice relation-
ship (Høglend et al., 2011). This can be stressful for both parties, requiring clear
structuring, limit setting, and occasional confrontation. The social worker will be
challenged at times to provide an accepting, “holding” environment for the client.

An example of this challenge is seen in many clients’ use of the coping/
defense mechanism of projective identification (Waska, 2007). This mechanism
provides a good example of how people may interact unconsciously (on a level
of affect) in addition to interacting on conscious levels. It can also be thought of
as a form of nonverbal communication.The client, when unconsciously
experiencing an unacceptable emotion or impulse (such as despair or anger),
will project that feeling onto the social worker, and behave in such a way that
provokes the social worker to consciously experience that same emotion. The
client then consciously (and verbally) identifies with the social worker’s feeling,
finally getting across his or her message.

A survivor of childhood sexual abuse, for example, may feel hopeless about
her chances to ever feel stable and have relationships with men in which she will
not be victimized. If the client is not verbally articulate, or is highly repressed, she
may behave in ways that make the social worker feel helpless to assist her. She may
speak with a quivering voice, express ambivalence, avoid eye contact, become
tearful, ask to leave the session, and in other subtle ways exude a sense of despair.
If the social worker acknowledges his or her own feeling of helplessness (and this
really is how the social worker feels), the client may be able to admit that she feels
the same way. The social worker needs to be alert to the possibility that his or her
emotional status in the session reflects the client’s emotional state, and be prepared
to respond to this occurrence toward the goal of helping the client to become
more self-aware and articulate. The social worker should also process these situa-
tions with the supervisor to differentiate between his or her own emotional reac-
tions and those that may be due to the client’s projective identification.

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Relationship management is central to intervention in object relations theory,
but now we will consider a range of other assessment and intervention principles.

Assessment

The process of assessing clients from an object relations perspective is similar to
that used in ego psychology, except for a closer focus on the ego function of
object relations. In order to maintain this focus, the social worker must provide
“therapeutic space” to the client (not push the client too quickly to confide de-
tails of sensitive relationships). The practitioner then assesses the separation-
individuation level of the client (as much as possible) from client reports and
perhaps family reports or other available information. He or she also assesses the
client’s use of specific defense mechanisms that are common to persons with ob-
ject relations problems. The social worker should also test the client’s openness
to interpretations, to find out whether he or she will be receptive to exploring
the nature of significant relationships that carry a risk of high emotional
reactivity.

The social worker should focus on the following types of questions in asses-
sing a client’s object relations:

Does the client maintain positive relationships with some significant others
(such as teachers, employers, and friends), or do most close relationships be-
come conflicted?

Regarding the client’s interpersonal conflicts, are they rooted in present re-
ality, or is an old relationship being repeated? Is the client tending to de-
velop conflicted interactions with significant others in the present as he or
she did with a significant figure from early life?

Do the client’s behaviors seem to repeat early experiences with parents? For
example, if the client felt neglected, is he establishing relationships today
with people who are likely to be neglectful?

Do the client’s problem behaviors represent efforts to master old traumas by
repeating them with other people? For example, if the client was abused by
a primary caregiver, is she becoming involved with abusive others, and then
trying unrealistically to demonstrate that she is worthy of affection?

To what degree are the client’s behaviors accurate renditions of what oc-
curred in childhood? Does the client possess distorted memories of his or her
past that need to be corrected?

What cultural or environmental conditions are affecting the client’s
relationship-seeking behavior?

When relationship conflicts are assessed, they can be described in terms of
three components: (a) the wishes, needs, or intentions expressed by the client,
(b) the expected or actual responses from others, and (c) the client’s own cogni-
tive, emotional, or behavioral responses to the behavior of others (Luborsky &
Crits-Christoph, 1990).

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Intervention

The intervention strategies used in object relations theory are similar to those
used in ego psychology, although there is a greater emphasis on sustainment
and developmental reflection. These two strategies are especially important be-
cause, in object relations theory, there is a need to explore the client’s inter-
personal history and developmental milestones. This requires the social worker
to be able to sustain a productive relationship through periods of the client’s
anxiety, resistance, feeling confronted, mood changes, and testing of formal
limits. If the practitioner is able to develop a “fund of empathy” with the cli-
ent, the relationship will survive these likely ups and downs. Both of these
strategies were introduced in the previous chapter, and the reader is referred
there to review them.

Several object relations theorists have identified stages of intervention
(Goldstein, 2001). In the early stage, the social worker provides a holding
environment to reproduce positive early parenting experiences for the client.
Whatever conflicts the client experiences in his or her life will be mirrored in
the intervention. The social worker can then begin to model a different way of
“being” with the client, which can help the client develop a more consistent,
integrated sense of self and sense of others.

The practitioner begins to interpret positive and negative patterns of inter-
action with people in various life contexts, suggesting their origins, intentions,
and effects. The social worker interprets the practice relationship in this way to
demonstrate to the client that relationships can survive periods of conflict and
negative interaction. In the middle stage, the social worker interprets the cli-
ent’s maladaptive defenses, such as splitting and projective identification, help-
ing the client to look inward to understand what feelings and attitudes he or
she is trying to disown and project. In the end phase, the client is helped to
resolve major interpersonal conflicts and overcome developmental arrests. The
client is guided into corrective experiences with people in his or her environ-
ment, using the success of the clinical relationship as a model for managing
them.

As a part of these interventions, the practitioner and client must agree on the
limits of their relationship. They must negotiate how often they will meet, what
the consequences are for any negative client behavior during or between ses-
sions, the frequency of phone calls, and how crises will be managed. This must
be done carefully because the social worker must enforce limits on the client’s
impulsive or demanding behaviors when they occur (which is likely). The prac-
titioner should also intervene in the environment by helping the client bring
structure to his or her daily life.

Ending Intervention

The process of ending intervention from the perspective of object relations theory
may include one component not present in ego psychology. If the social worker
has formed a constructive working relationship with a client who has had signifi-
cant relational deficits, the practitioner should openly explore with the client the

100 C H A P T E R 5

meaning of the ending (Schermer & Klein, 1996). Reviewing the client’s emotional
reactions and stressing the positive gains that the client has made should make the
transition out of the relationship less difficult for the client. The social worker
should not assume that the ending will be difficult for the client, but raise the issue
for discussion in order to minimize the possibility of difficulty.

ATTENT ION TO SOCIAL JUST ICE ISSUES

Object relations theory is more facilitative of clients’ pursuits of social justice-
related goals than ego psychology because it is relational, rather than individually
oriented. Within this theory the practitioner always attends to transactions be-
tween client systems and their environments, although the “environments” may
at times be limited to the family and other close interpersonal systems. Object
relations theorists in social work do not assume that clients who are vulnerable
or oppressed in various ways, and who must deal with problems related to pov-
erty, unemployment, and discrimination, experience those problems because of
poor object relations. Still, like ego psychology, object relations is focused on
small systems, and the social worker is not encouraged to look very far outward
(except in the relational-cultural perspective) for types of influences on client
functioning that tap into social justice issues. On the positive side, however, if
clients who experience difficulties related to poor object relations receive help,
they should develop an improved ability to manage important relationships in all
facets of their lives, and be better able to address any challenges related to the
environmental issues described above. One great challenge for object relations
practitioners is to understand how interpersonal processes unfold for members
of other cultures and ethnic backgrounds, so that those clients can be empow-
ered by the resolution of their interpersonal problems.

CASE ILLUSTRAT IONS

The Wild Child

Carolyn, a 15-year-old Caucasian adolescent, was “always in trouble,” according
to her mother. She had been referred to a social worker at the mental health
center for an assessment after getting caught with several friends setting fire to
dry brush along the side of a highway. No one had been hurt, but the blaze
became large and took several hours for the fire department to extinguish.
Carolyn faced legal charges for this incident, and was being considered for possible
incarceration by the juvenile court. In the past, Carolyn had been in legal trouble
for a series of petty theft incidents. Her mother had also become concerned that
Carolyn was engaging in promiscuous sex, and possibly prostitution.

Carolyn was the third and youngest child (with two brothers) born to a
middle-class couple from a large midwestern city. Her parents complained that

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“she has no reason to behave as she does—she always had everything she
needed.” Still, Carolyn had frequently been in trouble with her parents, school-
teachers, and other authority figures since the first grade. She tended to be argu-
mentative, moody, oppositional, and inconsistent in tending to her assigned
responsibilities. Her father said, “she’s an angry, unhappy, ungrateful kid.” On
the other hand, Carolyn was athletic, energetic, and had excellent social skills.
She had many friends, although many of them shared her negative attitudes
and were considered poor influences. Carolyn had average intelligence but did
poorly in school, with no evident motivation to study. She had no sense that she
should develop long-range goals.

The social worker’s role (Taneisha, a single African-American female) was to
make counseling recommendations to the court that would be taken into ac-
count regardless of her placement. She might have the opportunity to work
with Carolyn over time, but this depended on the outcome of the court hearing.
In conducting the assessment, the social worker learned that Carolyn’s parents
were both 50 years old and had been married for 30 years. Her father was an
equipment technician at a local television station, and her mother worked part-
time as a real estate agent. They reported that their marriage was stable, and that
they had tried to raise Carolyn to be a responsible person. Her mother, in par-
ticular, felt that she had spent more time with Carolyn than her other two chil-
dren, trying to help her develop appropriate values and interests. Carolyn was
seven and nine years younger than her brothers. She had cordial relationships
with them but, partly due to the age difference, they were not close. Carolyn
saw her siblings only during holidays and family celebrations.

Carolyn expressed a different view of the relationship with her parents. She
said her mother was overbearing and would never allow Carolyn out of her
sight. Carolyn accused her mother of trying to keep her home as much as possi-
ble for as long as she could remember. She said that her father was “okay,” but
distant. In her words, he worked long hours and was not very involved in her
life. Carolyn added that her father was not very involved in her mother’s life,
either. She complained that they stayed at home most of the time when not
working, and that they didn’t talk much.

Taneisha learned that Carolyn’s upbringing was affected by a critical event.
Her mother, who had wanted a daughter very badly, had given birth to a still-
born girl three years before Carolyn was born. This was a traumatic event for the
family. Her mother was depressed for a year after the event. When she became
pregnant with Carolyn, she was thrilled but apprehensive. She and her husband
learned of the baby’s gender early during the pregnancy, and she became
completely focused on having a safe pregnancy and delivery. She quit her job
and stayed home. When Carolyn was born, her mother was overjoyed, and
then became a devoted but overprotective parent. Her husband admitted that
his wife had been obsessed with Carolyn and wouldn’t let her out of his sight.
In fact, her husband was angry about his wife’s attitude, and withdrew emotion-
ally from her. This pattern of relationships seemed to characterize the family dur-
ing Carolyn’s life, up to this point. The social worker tentatively concluded that
Carolyn was angry about the perceived overprotection. She had not developed a

102 C H A P T E R 5

capacity to manage close relationships due to relational deficits stemming from
that experience.

Taneisha had no way of objectively knowing the conditions of Carolyn’s early
upbringing. However, as she got to know the client over time, she saw a pattern
emerge in which Carolyn was afraid of getting close to or trusting anyone for fear
of being consumed by them—of losing her identity completely. At the same time,
Carolyn felt empty and abandoned by caregivers and friends who would not provide
her with the security she needed. Carolyn often described a “hole” in her abdomen
that was painful to experience, and which she tried to fill with adventure, alcohol,
and, more recently, sex. That is, though many of Carolyn’s problem behaviors were
related to present circumstances and the influence of her friends, they were also
rooted in her inability to develop steady attachments, or stable object relations,
with others. She tended to see people as “good” when she was friendly with but
not close to them, and as “bad” when they became closer to her.

Interestingly, this pattern did not stem from a lack of parental attention—just
the opposite! Carolyn did not have opportunities for age-appropriate movement
toward independence because of her mother’s well-meaning but intrusive pres-
ence. Carolyn’s environment was positive in many ways but not facilitative of
her needs for separation. Carolyn came to equate closeness with suffocation.
Her defensiveness included a strong anger, with which she acted out her fears
with oppositional behavior.

Carolyn appeared to form a tentative attachment with Taneisha. The social
worker did not use the intervention technique of developmental reflection be-
cause the client was not reflective by nature. They instead focused on her current
life concerns. The technique of sustainment was important, however, as Carolyn
often became anxious, angry, and subversive of the intervention process as she
became closer to the social worker and was challenged to disclose sensitive infor-
mation about her life. Taneisha accommodated the client’s lability by being flex-
ible with their schedule. She also allowed Carolyn to take the lead in formulating
topics for their meetings, and she was confrontational only when it appeared that
the client would not react negatively.

With person-situation reflection Taniesha encouraged Carolyn to talk about
the emotions she experienced in her current life activities, rather than project
blame elsewhere. She helped Carolyn understand some of her relationship pat-
terns, and helped her grasp the issue of her ambivalence in relationships. The
social worker used their relationship to demonstrate how Carolyn tended to re-
act to others when issues of intimacy emerged. Taneisha provided many struc-
tured interventions as well. Knowing that Carolyn had little self-confidence and
was reluctant to take on any challenges, she encouraged the client to explore
some of her talents and interests, such as swimming and a school service club
that included visiting nursing homes.

The social worker met with the client and her parents together only a few
times. They were not requesting family intervention, and Carolyn had asked for
individual attention during this assessment for the courts. During their joint ses-
sions Taneisha was careful to maintain a positive atmosphere with the conflicted
family. She pointed out the caring of the parents and educated them about the

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nature of Carolyn’s interpersonal problems. The family was encouraged to talk
more openly among themselves, and the parents were encouraged to support
Carolyn’s healthy activities. Taneisha stated that she would like to provide regu-
lar family sessions if Carolyn remained at the agency.

The social worker formulated a set of recommendations for the professionals
who would be working with the client if she was placed in a residential facility
that reflected the spirit of object relations theory. Taneisha emphasized Carolyn’s
problems in relationships but also her strengths, and noted that she would likely
benefit from modeling by slightly older females, a combination of supportive and
confrontational interactions, and peer counseling. In short, corrective relation-
ships might help Carolyn break her “approach—threat—anger—acting out” cy-
cle. In the end Carolyn was sentenced to time in a residential facility. Taneisha
was disappointed, but believed that with appropriate interactions Carolyn might
become better able to understand that intimacy did not inevitably lead to a loss
of identity. With this understanding her relationships might improve and her
acting-out behaviors might decrease.

The Group Therapy Intervention

Jordan was a 34-year-old, single, and unemployed white male, living with his
mother, sister, and brother-in-law in the latter couple’s home. He complained
of depression, poor self-esteem, and extreme discomfort around other people.
Though he was intelligent, cared about others, and had a charming self-
deprecating wit, Jordan had difficulty making and then sustaining relationships,
and could not hold a job. During her assessment, the social worker (a married
woman of the same age named Tai) learned that Jordan entered into relation-
ships only if he felt he might receive unconditional positive regard. When he
perceived that this was not forthcoming, he felt betrayed, became angry, and
terminated the relationship. For these reasons he had no close friends and,
when working, became so anxious with interpersonal pressures that eventually
he quit. Jordan visited prostitutes to satisfy his sex drive, and was particularly
ashamed of this secretive practice. He was not comfortable with his living situa-
tion and sought counseling at the mental health center to see if he could become
more independent.

Tai diagnosed Jordan with dysthymic disorder and avoidant personality dis-
order. The client confided that his father had always been stern and critical, and
though his mother was more outwardly caring, she was passive in the family
unit. Jordan recounted many examples in his upbringing of his father forcing
him to engage in tasks that might have been age-appropriate for some children
but were beyond his developmental capability, such as giving a short presentation
at a Boy Scout meeting. At these times the child cried with fear, but his mother
stood by quietly. Jordan had felt insecure, inferior, and full of self-doubt his en-
tire life. He always doubted the goodwill of others and, in keeping with his fam-
ily pattern, assumed that other people looked down on him. From Jordan’s
perspective his older brother and younger sister seemed to be much better ad-
justed than he was.

104 C H A P T E R 5

For several months Tai intervened to help Jordan move toward his goal of
self-sufficiency as he sought better social skills, employment, and junior college
enrollment. She provided the interventions of sustainment, person-situation re-
flection, and, eventually, developmental reflection. She began challenging Jordan
to face up to his anger and to recognize his maladaptive defenses (particularly
splitting and projection). The social worker was careful not to be overly con-
frontational, however. She perceived that Jordan was always ready to reject
others before he was rejected, and she did not want the therapy to end for that
reason. Neither did she structure their time together or impose agendas on the
client. She wanted Jordan to be in control of the process and to move at his own
pace.

Jordan came to trust the social worker and became more comfortable in
general. Over a period of several months, he demonstrated progress by applying
for jobs, attending interviews, and visiting a regional college campus to investi-
gate part-time enrollment. Still, with each initiative he became incapacitated
with anxiety and the fear of failure. Tai referred him to an agency physician,
who prescribed a small dose of anti-depressant medication that helped Jordan
sleep better at night, stabilized his mood, and reduced his anxiety. Tai also re-
ferred Jordan to a therapy group that she co-led. The idea of talking in a group
was traumatic for the client, and only after several months of considering the
recommendation did he decide to participate.

It was in group therapy that Jordan made his greatest improvements. This
was an ongoing, relationship-oriented group that met weekly for 16 weeks. It
included four women and two other men. All of the members faced different
life challenges, but they shared difficulty with close relationships. Tai and her
female co-leader were nondirective in their leadership, asking questions and
making comments that promoted person-situation and developmental reflection.
They helped the group develop an atmosphere of mutual sustainment, but in the
spirit of developmental reflection also facilitated confrontations at times, generat-
ing anxiety in the members so that they faced up to their major defenses. Jordan
was not initially pushed to participate with the others, but soon after beginning
the group, he found that his interpersonal skills and comfort level were greater
than he had assumed.

The group followed Goldstein’s (2001) three-stage model. In the early stage,
the social workers provided a holding environment to reproduce positive early par-
enting experiences for the members. The co-leaders interpreted positive and nega-
tive patterns of interaction among the members, suggesting their origins, intentions,
and effects. The social workers tried to model for the clients through their own
behavior that relationships can survive conflict. In the middle stage, the practitioners
interpreted the members’ maladaptive defenses (splitting and projection), helping
them to understand the feelings they were trying to disown. In the end stage, the
social workers emphasized that each member’s relationships with the others repre-
sented corrective experiences to earlier patterns. The leaders also began to generalize
the members’ intra-group experiences to their other life conflicts.

During the course of attending the group, Jordan developed positive feelings
about most of the members and even became a friend of one other male

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member. At the time the group ended, he was taking classes at the community
college in preparation for a career as an electrician. Interestingly, he experi-
enced a “relapse” when the group ended. The end coincided with Tai’s unex-
pectedly leaving the agency to take another job. Jordan became upset and
accused his primary social worker of not caring about the members after all
their time together. It was an awkward final session for Jordan, but Tai felt
confident that the relapse would be short-term and that the client would be
able, with the support of others, to resolve his anger and turn his attention to
his remaining vocational work.

EV IDENCE OF EFFECT IVENESS

Some research efforts to test the effectiveness of psychodynamic theory, of which
object relations is a major type, were summarized in the last chapter. Here we
will review evidence of effectiveness of object relations theory more specifically.
Despite its limitations with regard to large-scale research validation, object rela-
tions theory has been successfully used with clients who face a variety of pro-
blems and challenges in meeting their goals. The literature indicates that its
interventions have been effective with samples of young adults (Lindgren,
Werbart, & Phillips, 2010); children with oppositional defiant disorder (Bambery
& Porcerelli, 2006); persons with depression (Van et al., 2008); adult daughters
of alcoholic mothers (Dingledine, 2000); persons in methadone treatment pro-
grams (Wood, 2000); persons struggling with chronic loneliness (Coe, 1999;
Feldman, 1998); children in foster care (Metzger, 1997); sexually abused inner-
city children (Josephson, 1997); survivors of child abuse (Ornduff, 1997); persons
with psychotic disorders in group settings (Takahashi, Lipson, & Chazdon, 1999);
juvenile delinquents (Loftis, 1997); women in groups who have been sexually
abused (Burns, 1997); and persons with borderline personality disorder (Levine,
2002). Interventions based on object relations theory have also been effectively
used in a multicultural context, with clients from Puerto Rico (Rosario, 1998).

Although a majority of reports about the effectiveness of object relations in-
terventions are based on client outcomes in case studies, some are based on re-
search designs that include larger numbers of clients. In a pretest/post-test study
of 23 clients with borderline personality disorder receiving transference-focused
psychotherapy for 12 months, client measures of suicidality, self-injury, and med-
ical and psychiatric service utilization dropped significantly (Clarkin et al., 2001).
Another pre-experimental study followed 20 clients receiving brief therapy to
investigate whether their quality of object relations (QOR) would increase during
clinical intervention (Schneider, 1990). Measures were taken at intake, termina-
tion, and six months later of the clients’ complexity of representations and capac-
ity for emotional investment. The finding of a significant correlation between
improved QOR and positive therapy outcome supported the hypothesis at all
data collection points. Another study investigated the relationship between the
mastery of maladaptive interpersonal patterns and the outcome of intervention

106 C H A P T E R 5

(Grenyer & Laborsky, 1996). Transcripts from 41 sessions were scored using a
content analysis mastery scale. Changes in mastery of interpersonal conflicts
over the course of therapy were significantly related to changes in observer, prac-
titioner, and clients’ reports of problem resolution. These results are consistent
with the object relations proposition that symptoms abate with the mastery of
core interpersonal conflicts.

Another study followed clients at 6- and 12-month intervals to investigate
the efficacy of both interpretive and supportive forms of short-term therapy,
and the interaction of each type of therapy with the client’s QOR (Piper,
McCallum, Joyce, Azim, & Ogrodniczuk, 1999). Clients receiving both forms
of therapy maintained intervention gains across both time intervals, although
there was a direct relationship only between QOR measures and favorable out-
come in the interpretive therapy that focused on patterns of the clients’ relation-
ships. The authors concluded that QOR was an important predictor of outcome
for persons receiving that intervention.

Several studies have focused on children and adolescents. Tuber (1992) re-
viewed the literature on the association between assessment of children’s object
representations and intervention outcomes. He concluded that accurate assess-
ment in this regard did tend to increase the likelihood of positive outcomes for
children. A study of 100 inner-city females between 8 and 16 years old con-
cluded that girls reporting more depression had significantly earlier develop-
mental levels of object relations than did girls reporting less depression,
regardless of their chronological ages (Goldberg, 1989). In a quasi-
experimental study of six families (three of which served as controls), the
potential for an object relations family intervention including components of
cognitive therapy to increase anger control in aggressive male adolescents was
investigated (Kipps-Vaughan, 2000). Program effectiveness measures were col-
lected over a five-month period from teachers, parents, and the adolescents.
Comparative measures indicated that the intervention had a positive effect on
the adolescents’ anger control, family relationships, problem-solving skills, qual-
ity of communication, and school grades, and that clients experienced a de-
crease in school suspensions. Changes in QOR were also studied among 90
adolescents in a long-term, psychodynamic inpatient program (Blatt & Ford,
1999). Clients were divided into two diagnostic categories based on their pa-
thology: disorders related to interpersonal relationships and disorders related to
the sense of self. Based on responses to projective tests, the researchers con-
cluded that the adolescents’ improvements were characterized by a decrease in
inaccurately perceived relationships with others.

Finally, in an unusual study conducted at a religiously oriented inpatient fa-
cility, an object relations intervention was evaluated with 99 primarily depressed
clients (Tisdale, Key, Edwards, & Brokaw, 1997). Effectiveness was measured by
changes in the personal adjustment and positive “God image,” with measures
taken at admission, discharge, and 6 and 12 months after discharge. The re-
searchers concluded that the hospital program had a significant positive impact
on both variables and that there was a positive correlation between object rela-
tions and the clients’ God image.

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CR IT IC ISMS OF THE THEORY

Relational theory has been subjected to many of the same criticisms as has ego
psychology. Johnson (1991) summarizes several of these. First, the theory features
concepts that many social workers believe are vague (such as objects, object rela-
tions, object constancy, and projective identification). Further, its intervention
strategies appear to some practitioners to be difficult to operationalize and sys-
tematically evaluate. Other social work authors have expressed additional con-
cerns. As examples, the theory focuses attention on processes of early
development that are often difficult to validate due to possible biases in client
or family reporting (Payne, 2005). Object relations theory may promote client
assessment from perspectives that do not reflect cultural diversity (Applegate,
1990). Practitioners working from this perspective may tend to see problems
only within people and their intimate relationships rather than in the context
of a larger environment. As a depth approach to intervention, it may not be use-
ful in many traditional social work settings (Cooper & Lesser, 2002). Finally, be-
cause the first wave of object relations theorists wrote in the 1950s and 1960s,
when the nuclear family was more prominent and gender roles were rigid, it is
seen as a parent-blaming approach to problems in living (Coleman, Avis, &
Turin, 1990). More recently, practitioners and theorists have attempted to apply
object relations interventions to members of diverse client populations. They
have also attended to issues of time limits in clinical practice (Goldstein &
Noonan, 1999).

SUMMARY

This concludes our review of two psychodynamic theories, ego psychology and
relational theory, each of which emphasizes the importance of the practitioner
attending (when possible) to clients’ unconscious mental processes as a means of
helping them resolve challenges and experience psychological growth. Few the-
ories in this book deny the possible existence of an unconscious (except behav-
iorism), but in these theories, it is given greater relevance as a determinant of
social functioning. For practitioners who value empirically based practice, these
two theories are problematic because they include concepts that are difficult to
operationalize. Still, the ego psychology and relational theories continue to be
used as the primary perspectives of many social work practitioners, who find
that they provide a basis for flexible interventions with a range of clients.

TOPIC S FOR DISCUSSION

1. It is not unusual for some people to have difficulty developing satisfactory
relationships with certain types of others, such as authority figures, members
of the opposite sex, or work peers. Yet these people may not have pervasive

108 C H A P T E R 5

relationship problems. Do these recurrent but specific problems represent
relational deficiencies, or something less fundamental? If these specific pro-
blems are different, what might be their sources?

2. Discuss what you perceive to be the characteristics of people who maintain
appropriate balances between “independent” and “relational” life. How do
different perspectives on this point reflect personal values or cultural
differences?

3. Discuss what is meant by the following abstract terms, and provide examples
of how they might “appear” in one’s life: introjection, representation, object, part
object, whole object, and self-object.

4. What do you perceive to be the characteristics of a facilitative environment
for an infant or young child? How might cultural differences lead to differ-
ent ideas about such an environment?

5. Consider the concept of projective identification. Try to recall if you
have been the recipient of this phenomenon at any time in your life,
with clients or otherwise. Describe the process and the feelings you
experienced.

IDEAS FOR CLASSROOM ACTIV IT IES /ROLE -PLAYS

Each role-play activity can be done with one set of students (and perhaps the
instructor) in front of the class or in small groups. The roles of social worker,
client, and observer should all be represented, and each role may include more
than one person.

1. Present a real (from a student) or hypothetical situation in which a client
with object relations deficits experiences conflict with the social worker.
Play out the session for some period of time (15 minutes should be suffi-
cient). Afterward, ask the observers in each group to describe any evidence
of the social worker’s frustrations with the interaction. Ask the social work-
ers how they tried to sustain the client, even when confrontation was nec-
essary. Finally, ask the clients how they experienced the behavior of the
social workers.

2. Present a situation featuring a client who has fundamental relational deficits,
and whose presenting problem is being fired from a series of jobs due to
interpersonal conflicts. Present as much information to the class as is available
(using students’ own cases is always preferable). Ask the students to devise a
guiding intervention strategy, and then act out a role-play in which that
strategy is implemented. Discuss afterward what worked well and what
didn’t work so well in each group.

3. Present a situation in which the identified client is a child or adolescent who
displays aggressive acting-out behaviors with other children at school. Ask
students to identify possible sources of information to determine whether the

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client has significant relational deficits, including specific questions the social
worker could ask the family, other primary caregivers, or school personnel.

4. Consider Comes-Diaz’s list of possible ethnocultural transferences and
countertransferences in the client/worker relationship. Identify issues from
the list that you have experienced with clients or other acquaintances. Try to
identify the sources of your (or the other person’s) feelings, and what you
did, or might have done, to process them with the other person. (This item
could be used as a written course assignment.)

APPENDIX: Object Relations Theory Outline

Focus Interpersonal relationship patterns

Internalized perceptions of the self and others

Reenactments of early relationships

Major Proponents Jacobson, Klein, Fairbairn, Mahler, Kernberg, Winnicott,
Bowlby, Ainsworth, Goldstein, Benjamin, Mitchell

Origins and Social
Context

Studies of early childhood deprivation and its effects

Interest in the role of early relationships
(attachment theory)

Studies of infant-mother interactions (1940s, 1950s)

Feminism

Nature of the
Individual

Healthy development requires a nurturing early
environment

People are relationship-seeking from birth

People internalize their early relationship patterns

Major Concepts Same as ego psychology

Attachment

Introjection

Object relations (whole, part, and self-objects)

Object constancy

Developmental
Concepts

Facilitative environment

“Good-enough” parenting

Holding environment (for safety and security)

Transitional objects

Stages of object relations development

Winnicott

Absolute dependence

Relative dependence

Toward independence

110 C H A P T E R 5

Mahler

Autism

Symbiosis

Separation/individuation (differentiation practicing rap-
prochement, object constancy)

Relationship differentiation (vs. separation/individuation)

Nature of Problems Internalization of “bad” self and object (other people)
perceptions

Extensive use of splitting and projection in relationships

Repetitive self-defeating interpersonal behavior

Nature of Change Insight

Modification of faulty “internalizations”

Development of positive internalized self and object
perceptions

Adjustment of defense mechanisms

Goals of Intervention Modification of internalized relationship patterns

Modification of defenses

Acceptance of new experiences as new, rather than as re-
petitions of older ones

Nature of
Worker/Client
Relationship

Emphasis on transference, countertransference

Emphasis on the present relationship and how it is af-
fected by the client’s interpersonal patterns

Provision of a holding environment

Inter-subjectivity

Intervention
Principles and
Techniques

“Here-and-now” reality testing

Set limits on impulsive and demanding behavior

Bring structure to the client’s life

Developmental reflection

Interpret the nature of relationships in new ways

Interpret transference

Confront primitive defenses

Provide a corrective relationship

Guide into corrective experiences

Assessment Questions Does the client maintain positive relationships with some
significant others, or are most close relationships
conflicted?

What old relationship is being repeated?

APPENDIX: Object Relations Theory Outline (Continued)

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Do behaviors repeat early experiences with parents?

Do problem behaviors represent efforts to master old
traumas by repeating them with others?

To what degree are the client’s behaviors accurate rendi-
tions of what occurred in childhood?

What cultural conditions are affecting the client’s
relationship-seeking behavior?

What environmental conditions are affecting the client’s
relationship-seeking behavior?

Based on Object Relations Theory and Self Psychology in Social Work Practice by Eda G. Goldstein.

APPENDIX: Object Relations Theory Outline (Continued)

112 C H A P T E R 5

Family Emotional

Systems Theory

There’s grief of want, and grief of cold, –
A sort they call “despair”;

There’s banishment from native eyes,
In sight of native air. *

Since its introduction in the 1960s, family systems theory has thrived as an influ-
ential and widely used theory of family assessment and intervention. The the-

ory provides a comprehensive conceptual framework for understanding how
emotional ties within families of origin (including extended family members) in-
fluence the lives of individuals in ways they often fail to appreciate and may tend
to minimize. The theory is sometimes called family emotional systems theory to
underscore this point, and to distinguish it from the generic “family systems”
term. This theory is unique in its attention to multigenerational family processes
and also in its prescriptions for working with individual clients in a family con-
text (Bowen, 1978; Kerr & Bowen, 1988). It is placed directly after the psycho-
dynamic theories in this book because its creator, Murray Bowen, was trained as
an analyst and, in my view, the theory can be understood as an extension of
some analytic ideas (such as unconscious mental processes) to the study of family
systems.

Bowen asserted that the nature of healthy human functioning includes one’s
acquisition of a balance between emotional and rational life. The concept of dif-
ferentiation characterizes one’s ability to achieve this balance. The concept also

* Dickinson, E. (1927). The Pamphlet Poets. New York: Simon and Schuster.

113
Copyright 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights,

describes one’s ability to function effectively both apart from and within the
family of origin. Differentiation is made possible by a facilitative family envi-
ronment in which the person can establish an identity related to, but also
separate from, the identity of the nuclear family. Within most cultures of
American society, people typically accelerate the processes of physical and
emotional separation from their families of origin during late adolescence.
This is a major life transition for those who leave and those who stay behind.
People who have achieved a high level of differentiation will be successful in
this transition, and those who have not will experience difficulty establishing a
stable sense of identity outside the family. Each person’s capacity to develop
positive relationships in adulthood is driven by his or her learned patterns of
managing family of origin relationships. That is, the influence of that family is
pervasive throughout life.

The concepts from family systems theory may be useful for social work
practice with all types of presenting problems as a means of assessing the nature
of family interactions. Understanding the subtle aspects of family relationships
may be significant in treatment planning regardless of the family’s specific
needs. The intervention strategies, however, are not appropriate for all prob-
lem situations. Family systems interventions are generally appropriate when the
focus will be on the quality of nuclear or extended family interpersonal pro-
cesses, and the desire for one or more family members to become more differ-
entiated. These families often appear to the outside observer to be functioning
well. It is their interpersonal lives that are the sources of their difficulties. Some
structural stability in the family is necessary for the social worker to help mem-
bers explore any patterns of behavior that may be contributing to problem
situations.

Titelman (1998) edited a book that includes examples of a range of problems
for which family systems interventions may be appropriate. These include family
problems related to marital fusion, emotional dysfunction in children, a child
with a medical problem, college students with adjustment problems, concerns
about elderly members, depression, phobias, obsessive compulsive disorder, alco-
holism, incest, divorce, and remarriage. More recently the theory and its inter-
ventions have been found useful for issues encountered with traumatized
children (Brown, 2011); families with an anorexic member (Krasuski, 2010);
families with a member at risk for cancer (Harris et al., 2010); adolescents with
substance abuse and other risky behaviors (Knauth, Skowron, & Escobar, 2006);
abused children (Skowron, 2005); homelessness (Hertlein & Killmer, 2004); cou-
ples violence (Walker, 2007; Stith, McCollum, Rosen, & Locke, 2003); and
even the training of clergy (Crimone & Hester, 2011).

114 C H A P T E R 6

ORIGI NS AND SOCI AL CONTEXT

Murray Bowen was a member of the first generation of family theorists who
emerged in the United States during the 1940s (Guerin & Guerin, 2002). He was
trained in psychodynamic theory, but he shared a concern with his peers (includ-
ing Nathan Ackerman, John Bell, Don Jackson, and Carl Whittaker) that existing
practices were not adequate to treat certain disorders such as schizophrenia. Also,
like his peers, Bowen was influenced by general systems theory (see below).

Analytic Theory

The field of psychoanalysis was slow to recognize the importance of family dy-
namics on individual functioning (Mullahy, 1970). Freud had never involved
families in treatment, but Alfred Adler stressed the importance of family constel-
lations (including birth order and sibling rivalry) on personality formation. Harry
Stack Sullivan, a mentor of Bowen, argued that people were the products of
their relatively enduring patterns of interpersonal interaction. He believed that
the role of the family during one’s transition to adolescence was especially signif-
icant, and his interpersonal theory of schizophrenia (Sullivan, 1962) was based on
the nature of those interactions.

Systems Theory

Bowen’s other influence was general systems theory. This way of thinking, so cen-
tral to the social work profession today, challenged prevailing attitudes in science
at the time that complex phenomena could be broken down into series of sim-
pler cause-and-effect relations. Systems theory argued instead for a circular cau-
sality, in which all elements of a system simultaneously are influenced by, and
influence, each other. During the 1940s, general systems theory was adapted to
phenomena at all levels—plant, animal, human life, and even inanimate phe-
nomena such as galaxies (Von Bertalanffy, 1968).

Systems theory had existed since at least the late 1800s, when economist
Herbert Spencer formulated his evolutionary perspectives on society (Buckley,
1967; Klein & White, 1996). Its concepts found practical applications in the
new science of information technology in the early 20th century, spurred by ob-
servations of the workings of the telegraph, telephone, and other inventions. This
new technology gave rise to such concepts as inputs, outputs, and feedback loops.
An even greater impetus for systems theory was the growth of information tech-
nology during World War II and the need for widely dispersed weapons systems
that could be coordinated. The new field of cybernetics focused on the analysis of
the flow of information in electronic, mechanical, and biological systems
(Wiener, 1948). The first family theorists were influenced by the communications
aspects of systems theory and sociologist Talcott Parsons’s concept of functional-
ism, which postulated that every social structure now or at one time performed a
necessary function for system maintenance (Ritzer & Goodman, 2004).

F A M I L Y E M O T I O N A L S Y S T E M S T H E O R Y 115

The basic principles of systems theory now seem rather simple, but they
were once quite innovative in the helping professions. One of these is connected-
ness, the principle that all parts of a system are interconnected, and changes in
one part will influence the functioning of all other parts. A second principle is
wholeness, the idea that any phenomenon can be understood only by viewing the
entire system. Finally, the feedback principle states that a system’s behavior affects its
external environment, and that environment affects the system. These ideas are
still evident in the social work profession’s person-in-environment, psychosocial,
and generalist practice concepts. Through the work of Bowen and his
contemporaries, they also became the basis for family systems theories.

Bowen’s Career

Bowen began his family research in 1948 at the Menninger Clinic in Kansas.
He observed the interactions of mothers and their children with schizophre-
nia, hoping to gain a better understanding of their symbiosis. This systems
term from biology describes a state of coexistence between two organisms
in which each is dependent on the other for a continuation of its existence.
In psychology, the term refers to a relationship in which the attachment is so
intense that physical or emotional separation compromises each party’s abilities
to function.

Bowen’s schizophrenia research in the late 1950s at the National Institute of
Mental Health focused on families that he studied for lengthy periods of six
months to three years (Bowen, 1959; Dysinger & Bowen, 1959; Howells &
Guirguis, 1985). Bowen concluded that the type of family anxiety that results
in one member’s developing schizophrenia required three generations to unfold.
In his sample, the first generation’s parents were relatively mature, but the child
acquired their combined immaturity, manifested as anxiety and fusion (similar to
symbiosis). The same process, repeated in the next generation, produced suffi-
cient emotional fusion for schizophrenia to develop. These observations were
the source of his recommended three-generation assessment of families.

Bowen is criticized for being one of a group of influential family theorists
who blamed the development of schizophrenia on parents’ behavior. It is now
known that schizophrenia is largely biological in origin. Still, Bowen’s work was
helpful to family theorists in understanding the manner in which anxiety can be
passed down through generations. Eventually, Bowen went to Georgetown
University, where he continued his work until his death in 1990.

It is ironic that family systems theory provides such a rich understanding of
the emotional lives of people within their families, because it emphasizes the im-
portance of rationality in the formulation of “health.” This is consistent with the
psychodynamic theory in which Bowen was trained. It is the function of the ego
to channel the drives into healthy outlets. Bowen felt that it was important for
one’s reasoning ability to develop, so that it could keep emotional experience
from becoming the only basis on which decisions are made.

The influence of systems thinking on Bowen’s theory will become more
evident as we consider its major concepts.

116 C H A P T E R 6

MAJOR CONCEPTS

What follows are the major concepts of family systems theory that are central
to the process of assessment. These are drawn primarily from Bowen (1978),
Comella (2011), and others as noted.

The Multigenerational Perspective

One of Bowen’s greatest contributions to the field of family theory was his
principle that individual personalities and patterns of interaction among family
members have their origins in previous generations. Additionally, he demon-
strated that extended family relationships might be as important to personal
development as nuclear family relationships. In these ways Bowen foreshadowed
recent developments in the field of family therapy, of moving beyond the
nuclear family unit into a consideration of other influences on family life. His
broad definition of “family” also accommodates diverse family forms.

Bowen recommended a three-generation assessment of families, partly be-
cause of realistic limits on the availability of information, and also because of
his early career work with families who included a member with schizophrenia
(Bowen, 1959; Dysinger & Bowen, 1959; Howells & Guirguis, 1985). Bowen’s
work of that time was helpful to family therapists in understanding the manner in
which anxiety can be passed down through generations. For example, McKnight
(2003) found in a study of 60 mothers that a cutoff of parents from the previous
generation has an impact on their parental functioning and the well-being of
their adolescent children. The more cut off a mother is from her own mother,
the less well she functions, and cutoff between a mother and father is likely to
result in a child who is cut off from his or her own father.

The social worker does not need information about three generations to ef-
fectively provide family interventions. Family structures are more diverse and
fragmented today than they have ever been in American life. Social workers ex-
perience reconstituted families, dissolving families, single-parent families, and gay
and lesbian families. Geographic mobility is such that many people have limited
awareness of their blood or territorial origins. It is always important to acquire as
much information as possible about nuclear, extended, and cross-generation fam-
ily relationships, but the practitioner can proceed with whatever data are avail-
able. In fact, the trend in family systems theory in the past 20 years has been to
develop strategies to work with families with a focus on only one or two gen-
erations (Titelman, 1998).

Differentiation of Self

Healthy or adaptive individual functioning is characterized by differentiation of self.
This is a key concept in family systems theory that has two meanings. First, it
represents a person’s capacity to distinguish between and balance his or her
thinking and feeling selves. Both aspects of experience are important. The think-
ing process represents one’s ability to detach from, or look objectively at,

F A M I L Y E M O T I O N A L S Y S T E M S T H E O R Y 117

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personal reactions or biases. Emotional processes provide important information
about the significance of the situation. The “total” human experience involves
both emotion and reason. While Bowen advocated for a balance of reason and
emotion, he thought this was really not an attainable condition because emo-
tional feeling, unlike intellect, was a pervasive life force. For that reason it must
also be emphasized that differentiation is an ideal that can never be fully attained.

The term differentiation also refers to the ability of an individual to physically
differentiate from his or her family of origin in a manner that preserves aspects of
those emotional ties while not being constrained by them. Differentiation is thus
a characteristic not of a person, but of a relationship. The person develops the
capacity to maintain a balance in being able to separate self and maintaining old
and new emotional ties. It will be shown later that this idea has been amended
by some feminist thinkers who perceive the self as being more connected than
separate in nature (e.g., Knudson-Martin, 2002).

In one major review of the literature, Bowen’s concept of differentiation
was supported, as a consistent relationship was found between differentiation
and chronic anxiety, marital satisfaction, and psychological distress (Miller,
Anderson, & Keala, 2004). Further, more differentiated persons experience
more intimate relationships with their parents. In a study of 23 men and women
over the age of 30, the more differentiated group’s greater intimacy resulted in a
deeper sense of loss during the initial grief response to a parent’s death, but also a
corresponding absence of regret and guilt in the months that followed (Edmon-
son, 2002). Higher levels of differentiation even have an effect on one’s response
to physical illness, as the severity of the symptoms of fibromyalgia have been
correlated with lower levels of differentiation and perceived stress (Murray,
Daniels, & Murray, 2006). The validity of the concept has been supported
more recently by factor analyses of a widely used differentiation of self-
inventory (Jankowski & Hooper, 2012).

Highly charged emotional interactions can cloud a person’s ability to appro-
priately separate his or her feelings from those of others and to have an indepen-
dent existence. Bowen felt that it was important for one’s reasoning ability to
develop so that it could keep emotional experience from becoming the only ba-
sis on which decisions are made. Still, a constructive critique of Bowen’s bias
toward individuation has been formulated by Knudson-Martin (2002). While
supporting Bowen’s general theoretical perspctive, she argues that people have
an innate propensity toward togetherness, and work toward degrees of separation
from that position, rather than assuming the opposite (as Bowen did), that indi-
viduation helps a person learn to develop appropriate relatedness. Knudson-
Martin notes that Bowen’s conceptualization reflects a male and Western bias
about the nature of social functioning.

Triangles

In family systems theory, the interpersonal triangle is the primary unit of analysis.
All intimate relationships are inherently unstable; they require the availability of
a third party to maintain their stability. On first glance this might seem like a

118 C H A P T E R 6

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paradoxical notion, but it makes common sense. The price of intimacy in any
relationship is the experience of occasional conflict. People cannot exist in har-
mony all the time. When in conflict, people usually rely on a third person (or
different third persons, depending on the circumstances) for mediation, ventila-
tion, or problem-solving assistance. (One author has written about the “pet-
focused” family, in which the pet can become a part of the triangle in these
same ways (Entin, 2001).) This is a natural, healthy process. Serious problems
related to one’s differentiation may develop, however, when he or she is drawn
into certain types of triangles within the family. When a “weaker” (undifferenti-
ated) person is drawn into a triangle in a way that does not facilitate the original
two persons’ resolution of their conflict, the person may be deprived of the op-
portunity to become a unique individual. He or she may assume the ongoing
role of helping the other two persons avoid their problems with each other.
For example, in one study of 150 families in Japan and the United States, it
was found that triangulated daughters in both cultures had lower scores on a
measure of ego development (Bell, Bell, & Nakata, 2001). Problematic triangu-
lation in families occurs when conflicted adults draw in weaker family members,
often the children, to maintain the stability of their relationship.

Anxiety and the Nuclear Family Emotional System

Anxiety is an unpleasant but normal and functional affect that provides people with
warning signs for perceived threats (Marks, 1987). Its symptoms include tension and
nervous system hyperactivity. An anxiety-producing situation may be perceived as
an opportunity for growth or as a threat to well-being. Anxiety becomes problem-
atic when it interferes with one’s capacity for problem solving. The concept of anxi-
ety is central to psychodynamic theory, and Bowen adapted it to family systems
theory. Family systems possess levels of anxiety, just as individuals do.

The nuclear family emotional system includes four relationship patterns that
may foster problem development (Georgetown Family Center, 2012). With mar-
ital conflict, each spouse projects his or her anxiety onto the other and attempts to
control the other. With the problematic emotional functioning of one spouse, the
other spouse makes accommodations to preserve relationship harmony, but may
develop heightened anxiety as a result. If one or more children exhibit a physical
or emotional functional impairment, the parents will focus their anxieties on that
child, who in turn may become emotionally reactive to them. With emotional
fusion, family members distance themselves from one another to reduce the inten-
sity of their relationships, and they may become isolated in the process.

A family system that is characterized by psychological tension for any of the
above reasons may produce an atmosphere of anxiety that is shared by all mem-
bers. As described earlier, this system anxiety can be passed on and increased
through generations. An individual who is not differentiated experiences rela-
tively high levels of tension in family relationships and will tend to be drawn to
friends, spouses, and partners with similar levels of anxiety. In fact, one study
concluded that anxiety is the best predictor of differentiation of self, emotional
reactivity, and emotional fusion (Cocoli, 2006).

F A M I L Y E M O T I O N A L S Y S T E M S T H E O R Y 119

Parental Projection

As described in Chapter 3, psychological defenses are processes by which people
protect themselves from intolerable anxiety by keeping unacceptable impulses
out of their awareness (Goldstein, 1995). Defenses are positive coping mechan-
isms when they help the person function effectively and do not significantly dis-
tort reality. Projection is a common defense mechanism in which one person
attributes to someone else his or her unacceptable thoughts and feelings. The
projector is not aware of having the feelings or thoughts, but believes instead
that the person on whom they are projected is experiencing them. For example,
a wife may feel anger toward her husband for spending too little time in the
household. If she is threatened by the idea of being angry with her spouse, she
may project that feeling onto a child. She may decide that the child is angry with
the father and report that “fact” to her husband.

Projection may involve significant distortions of others’ feelings, attitudes,
and behaviors. Parents often use the projection defense with their children as
“targets” because children are vulnerable family members. Children tend to ac-
cept and internalize the pronouncements, insights, and beliefs of their parents.
Within family systems, children may suffer if the parents project negative feelings
and ideas onto them. They may believe that they possess the negative thoughts
and feelings attributed to them, and behave as such. In family systems theory,
parental projection is a major source of transmitted family anxiety.

Fusion and Emotional Cutoff

Emotional cutoff is an instinctual process between generations. It deals with the
ways people separate themselves from the past in order to start their lives in the
present generation (Illick, Hilbert-McAllister, Jefferies, & White, 2003). Cutoff
may be manifested in physical distance, internal distance, or a combination of
both. While emotional cutoffs may be natural and healthy, emotional fusion is
the opposite of differentiation. It is a shared state involving two or more people,
the result of a triangulation in which one member sacrifices his or her striving
toward differentiation in the service of balancing the relationship of two other
people. When one person is emotionally fused with another, his or her emo-
tional reactivity to the other person becomes strong. The person does not
“think,” but “feels,” and does so in response to the emotional state of the other
person. The feelings of the mother, for example, become those of the son.
When she is happy, he is happy, and when she is sad, he is sad. The son does
not have an emotional life apart from that of his mother. Neither person is con-
sciously aware of this state because they lack the capacity to reason about or re-
flect on the situation. This happens because, for a significant length of time
during childhood and adolescence, prior to having an opportunity to differenti-
ate, the fused person began to serve an ongoing function within a triangle that
served the needs of two other family members.

People tend not to have insight into the fact that they are fused, but they
experience high levels of emotional reactivity to the other person and may

120 C H A P T E R 6

attempt to extricate themselves from the relationship. A common strategy is the
emotional cutoff, a person’s attempts to emotionally distance himself or herself
from certain members of the family or from the entire family. Emotional cutoff
is the result of a person’s inability to directly resolve issues of fusion, which in
turn prevents him or her from forming a unique identity or satisfying relation-
ships with others.

In situations where the family is living together, emotional cutoff may be
characterized by physical avoidance of another person or, more commonly, not
discussing emotionally charged topics. For example, a son in conflict with his
mother may be pleased to talk about what happened at school, but they may
avoid discussing how they feel about each other or the family. This pattern can
continue after the family member leaves home. The son and mother may enjoy
each other’s company to an extent, but they have superficial interactions. The
son may look for substitute families at work, at college, or at church.

Emotional cutoff is often seen in physical distance. Adolescents may be eager
to leave home as a solution to their family problems. Again, this may represent a
normal family transition. However, when distance alone is seen as a solution to
ongoing family tensions, the person may be disappointed. A first-year college
student may feel that he can at last become his own person, when in fact his
fusion with another family member prevents him from fully experiencing other
people. An important aspect of emotional cutoff is that the person experiencing
it is usually not aware of the strength of the pull of the primary relationship. The
process is denied or minimized.

Other Concepts

Bowen believed that sibling position within a nuclear family is a partial predictor
of a child’s personality development. For example, oldest children tend to be
more responsible and conservative, whereas younger children are more sociable
and rebellious. These differences are due in part to the constellations of triangles
that exist in families of different sizes. Research during the past 15 years, how-
ever, has tended to dispel the notion that personality types can be validly
predicted on the basis of family position alone (Steelman, Powell, Werum, &
Carter, 2002). Many other variables are considered, including gender, number
of years between siblings, innate temperaments, and the nature of external envir-
onments. Still, being alert to the different triangulation possibilities for each sib-
ling is useful in assessing family systems.

Societal emotional processes are the manner in which social systems can be con-
ceptualized as analogous to those of the family with regard to the rules that gov-
ern interpersonal behavior within and among them. Family systems concepts
may be helpful for understanding these other systems. For example, the social
service delivery system has been described as one-third of a triangle, along with
participating individual members and the family, with implications for the differ-
entiation and fusion of participants (Moore, 1990). The church congregation has
also been conceptualized as a family (Howe, 1998). Each member’s relationship
patterns acquired in the family of origin may be replicated with the

F A M I L Y E M O T I O N A L S Y S T E M S T H E O R Y 121

congregation, and it is this body from which the individual must strive for ap-
propriate differentiation. Although interesting, the concept of societal emotional
processes is not yet as well developed as those concepts that are specific to the
family unit.

THE NATURE OF PROBLEMS AND CHANGE

The nature of problems was discussed in the section above. The nature of change
involves an opening up of the family system (Kerr & Bowen, 1988). Presenting
problems may be quite varied but represent difficulties related to triangles, fusion,
and emotional cutoff. These emotional processes may be manifested either by
too much or too little investment in family activities among some or all mem-
bers. Change requires detriangulation and new alliance building among members
of the nuclear and extended family. The social worker attends to the following
goals:

Lowering the anxiety present in the family system

Increasing the reflective capacity (insight) of all members

Promoting differentiation of self by emotionally realigning the family system,
which includes identifying and adjusting symptomatic triangles and opening
up cut-off relationships

Instilling member sensitivity to the influences of multigenerational family
patterns on their present interactions

Improving the family’s ability to share their systemic concerns with each
other

Readdressing inequalities within the family by inhibiting members who are
behaving in inappropriately dominant ways

ASSESSMENT AND INTERVENT ION

Family systems therapists do not work with a set of explicit, concrete interven-
tion techniques. Like ego psychology, the theory offers broad intervention strat-
egies with which the social worker can design techniques in accordance with a
family’s particular concerns (Bowen, 1978; Kerr & Bowen, 1988). These strate-
gies are summarized below.

The Social Worker/Client Relationship

As a prerequisite to change, family members must experience the intervention
setting as safe, comfortable, and relatively free of the anxiety that tends to char-
acterize their natural environment. The social worker acts as a coach. He or she

122 C H A P T E R 6

remains on the sidelines of family interaction, asking questions and making sug-
gestions that the family members discuss and enact with each other. The practi-
tioner strives to be the focus of the family’s attention and to set the tone of their
exchanges. He or she must be calm, promote an unheated atmosphere, and
maintain professional detachment. The purposes of this posture are to avoid
emotional reactivity and negative triangulation with family members. The prac-
titioner also serves as a model for rational interaction.

In the early stages of intervention, the social worker may ask family mem-
bers to talk directly to him or her about sensitive issues, rather than to one an-
other, to minimize interpersonal tensions. If tensions are so high that productive
interactions cannot proceed, the practitioner can use displacement stories as a
means of taking the family’s focus off itself and giving it some distance from its
own concerns. This is a technique in which the practitioner provides an example
of a hypothetical family with processes and problems similar to those of the ac-
tual family. The social worker asks the actual family to share observations and
suggest interventions.

The Genogram

A major tool for both assessment and intervention is the multigenerational geno-
gram (see Figures 6.1 and 6.2). This is a visual representation on one sheet of
paper of a family’s composition, structure, member characteristics, and relation-
ships (Kerr & Bowen, 1988; McGoldrick, Gerson, & Petry, 2008). It typically
covers a span of three generations. Information provided on a genogram includes
basic facts about family members (such as dates of birth and death, marriages,
moves, and illnesses), the primary characteristics and levels of functioning of
each member (education, occupation, health status, talents, successes, and fail-
ures), and relationship patterns among members (closeness, conflicts, and cutoffs).

2025 24 19

M. 2000

M. 1972

= positive attachment

= enmeshment

= emotional cutoff

F I G U R E 6.1 The Reeves Family

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ag

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Le

ar
ni

F A M I L Y E M O T I O N A L S Y S T E M S T H E O R Y 123

Overall family characteristics that may be assessed include structure (roles, rules,
and boundaries) and the impact of life events, life transitions, and relationship
patterns across generations. The advantage of the genogram as an assessment
tool is its presentation of complex family data on one page. It is also an excellent
means of eliciting family medical information (Sawin & Harrigan, 1995).

By participating in the construction of the genogram, family members gain
insight into their family processes. They learn about interpersonal patterns and
how triangles operate within the family. With these insights, family members
learn to recognize that their behavior is related to larger system processes, and
the ways in which those processes support or inhibit member functioning. This
normalizes some family problems, particularly those related to transitions. With
the information provided, family members may be able to offer their own ideas
for enhancing family functioning. The genogram often stimulates a process of life
review among older adults. Another way in which the genogram serves as an
effective early intervention is that, during its construction, each member is phys-
ically observing a diagram, rather than each other. This brings a shared focus to
the discussion and displaces any negative feelings onto an object rather than onto
another person.

Some social workers may be reluctant to construct genograms at the level of
detail suggested by family systems theory because it is time consuming and may be
annoying to clients who are eager to move into problem resolution activities
(McGoldrick, 1996). Despite these concerns, it is important to understand that,
in the first session, genogram construction engages all family members in the dis-
cussion, and usually offers a new way for them to think about their family system.

Detriangulation

This represents any strategy by which the practitioner disrupts one triangle and
opens up the family members to new, more functional alliances or triangles.

M. 1985

44 40

M. 1955

D. 1988D. 1992

M. 1958

16 10

= positive attachment

= enmeshment

= emotional cutoff

F I G U R E 6.2 The Charles Family

ng
ag

e
Le

ar
ni

124 C H A P T E R 6

There are many ways in which the social worker can detriangulate the family
(Dallos & Vetere, 2012; Guerin, Fogarty, Fay, & Kautto, 1996). He or she can
shift alliances with tasks to be performed within the session or when members
are at home. Within the session, the social worker might encourage role rever-
sals, or situations in which members interact with each other in different ways. A
child who is accustomed to complaining to his mother about the annoying be-
havior of a sibling might be asked to confront the sibling. When a couple trian-
gulates a child with a child as a means of avoiding issues in their relationship,
they might be instructed to spend a certain amount of time together talking
about whatever is on their minds that day. If they need the assistance of a third
party to bring an issue to resolution, they might be encouraged to talk with a
different adult family member. In these ways members are guided into new at-
tachments with nuclear or extended family members. Any strategy that contri-
butes to members’ opening up the family to new attachments can be pursued.
The practitioner should always encourage the development of new attachments
that have the possibility of promoting a member’s differentiation.

Increasing Insight

Family systems theory holds that understanding can lead to change. The social
worker facilitates reflective discussions that promote insight about the effects of
relationships on one’s personality and behavior. Children and adolescents may
appear to have less capacity for reflection, but insight can be defined for them
simply as understanding that one person’s behavior always affects another per-
son’s feelings and behavior. Two techniques that promote insight are person-
situation reflection, focused on the present, and developmental reflection, focused on
the history of the family and its patterns (Woods & Hollis, 2000). These techni-
ques were discussed in Chapters 3 and 4 but will be summarized here with re-
gard to their family applications. With the first technique, the social worker
makes comments, asks questions, and offers tentative explanations that promote
the family members’ reflective capacity. For example, two family members in
conflict may be helped to carry on a calm discussion of their differences and mu-
tually decide how to resolve them. The social worker assumes a moderately di-
rective stance and provides here-and-now interpretations of behavior. The
technique improves the family members’ capacity to evaluate feelings and atti-
tudes, understand each other and the nature of their behaviors, and consider a
range of problem-solving options. With developmental reflection, the social
worker uses comments, questions, and tentative explanations to explore connec-
tions between the family’s present and past patterns of behavior. If an adolescent
is displaying oppositional behavior withm the family, the social worker may lead
a discussion of how this represents a pattern with all the children over time, and
the circumstances that perpetuate the pattern. The practitioner may intentionally
arouse anxiety to help the family face and confront their ingrained maladaptive
behaviors. The family may develop insight into patterns of behavior that stem
from irrational feelings and be able to consider new ways of thinking in the
present.

F A M I L Y E M O T I O N A L S Y S T E M S T H E O R Y 125

Two related techniques that the social worker might use are externalizing
the thinking (helping each member put into words what is generally kept inside)
and encouraging the “I” position. In the latter practice the social worker asks
each person to speak about his or her own feelings and label them as such, rather
than reacting to negative feelings with critical comments toward others. For ex-
ample, a father who generally accuses his son of being grossly insensitive might
be helped to say, “Dan, I feel angry when you walk away when I’m trying to
talk to you. I feel like you’re mocking me.” This works against the tendencies of
many family members to blame others for what they feel, and helps the recipient
of the comment be less defensive.

Education

Families often benefit from understanding that their patterns of interaction have
sources in the family’s history, and that improving family life may involve “going
backward” to revisit relationships with various extended family members. This
helps family members feel less confused and guilty about their behaviors. In teach-
ing families about family system processes, the social worker helps each member to
observe the self within triangles and to examine behavior in terms of family
themes. This also serves as a normalizing strategy for families who worry that
they are uniquely dysfunctional or beyond help. The social worker must decide
when to integrate teaching moments with other interventions. The practitioner
should always provide this information in terms that the family can understand.

Working with Individuals

One of the strengths of family systems theory is its utility for working with any
subset of a family or even with individual clients (McGoldrick & Carter, 2001).
Family systems intervention requires an awareness, but not necessarily the pres-
ence, of all family members. In individual practice the social worker can con-
struct a genogram with the client and examine the client’s behavior in terms of
emerging family themes. The practitioner helps the client observe the self in tri-
angles and then detriangulate by developing new or different relationships with
family members who are available. The social worker can also help the client
develop insight and use this knowledge of the effects of family relationships to
disrupt the repetitions of unsatisfactory relationship patterns with others.

Endings in Family Emotional Systems Theory

The major family emotional systems theorists do not clearly address issues related
to ending intervention. A review of the major concepts, however, suggests some
methods for determining an appropriate ending point (Walsh & Harrigan, 2003).
Several family assessment instruments are suitable as measures of change. The
genogram can be redrawn with the family at intervals to see if desired changes
are occurring, or the family can be asked at intake to draw two genograms: one
as they see themselves, and the other as they wish themselves to be. The

126 C H A P T E R 6

products can be reviewed at times to track progress. The Family Adaptability and
Cohesion Scale includes one subscale (of two) that provides a measure of family
cohesion (Walsh, 2003). A social worker might ask families to complete the co-
hesion scale from this instrument at intervals to help members see how they are
progressing toward emotional cohesion.

Lower observed system anxiety levels can serve as an indicator of positive
change. The social worker can informally monitor the family’s ability to communi-
cate without tension, interruptions, and defensiveness. He or she can also monitor
changes in anxiety outside the session by soliciting reports of the tone and content of
family interactions. Levels of emotional cutoff can be monitored as members’ extent
of interaction, the content of their interactions, and their ability to be physically
together without reported anxiety or conflict. Finally, because insight is important
for lasting change, a family’s ability to accurately articulate its relationship patterns,
potential problem areas, and options for creating change is significant. If a family
develops and sustains a constructive, shared understanding of its system dynamics,
the social worker and family may decide to end the intervention.

SP IR ITUALITY AND FAMILY EMOTIONAL

SYSTEMS THEORY

Children usually develop their early values and spiritual beliefs in the context of
family life. In fact, Lantz and Walsh (2007) write that the family is the major
source of meaning development for all people. Shared spirituality in family life
might be seen in religious activities, community service activities, and how the
members perceive appropriate ways to support each other’s personal and social
development. For these reasons, family systems interventions can (and should)
incorporate topics about spirituality, understood as the shared meanings that
members develop about the purposes of their lives, both apart and together.
These issues have great emotional resonance with all people. Some authors
(e.g., Lazarus, 2010) write that the multigenerational exploration of one’s family
is highly facilitative of a person’s developing deeper meaning-in-life issues.

Bowen did not write extensively about spirituality, but emotional connec-
tions among family members are often tied to issues of meaning and purpose.
During intervention, the social worker should encourage family members to dis-
cuss such topics when they arise. As family members strive toward differentiation,
they may develop different spiritual perspectives from their significant others, and
when these concerns are not addressed, the possibility of emotional cutoff may
increase (Rootes, Jankowski, & Sandage, 2010). Sharing spiritual concerns may
also present a fragmenting family with opportunities to find common ground.
About 20 years ago, I conducted a small study on this topic and found that fami-
lies in conflict related to the mental illness of one member were sometimes able
to preserve a sense of cohesion through attention to spiritual topics (Walsh,
1995). The second case illustration in this chapter also shows how a family used
its religious affiliation as a means of resolving some conflicts.

F A M I L Y E M O T I O N A L S Y S T E M S T H E O R Y 127

ATTENTION TO SOCIAL JUST ICE ISSUES

We have noted that effective intervention with family emotional systems theory
requires at least moderate structural stability within a family. Thus the theory’s
interventions may not be suitable with families who are experiencing problems
directly related to such issues as poverty, unemployment, discrimination, and in-
equality of opportunity. Still, as a systems perspective, it encourages the social
worker to consider external events that might be affecting family cohesion. Ego
psychology focused on individuals, object relations focused on relationships, and
family systems theory considers the entire multigenerational family and also its so-
cial context. The social worker’s professional detachment will prevent him or her
from being an advocate, but the possibility of family social action exists through
the social worker’s coaching of discussions of related topics when appropriate.

On one other point related to social justice, family emotional systems theory
has been criticized for not being sensitive enough to cultural and ethnic family
diversity (McGoldrick, 1998). This reasonable criticism is leveled against most
theories that profess uniform principles of development across populations. In
fairness, the theory’s current proponents have worked to expand its applicability
to diverse family forms (Rothbaum, Rosen, Ujiie, & Uchida, 2002).

CASE ILLUSTRAT IONS

Two examples of family systems intervention are described below. The first
involves a family with marital conflict and substance abuse, and represents a
two-generation intervention. The second, three-generation, example involves
emotional fusion, the functional impairment of an adolescent member, and issues
related to the adult children of elderly family members.

The Reeves Family

Though every family system is unique, some dynamics are common in families
characterized by the alcohol abuse of an adult member. There is often an en-
meshment, or codependency, of the adults. This pattern has its origins in the adults’
families of origin (Bowen, 1991a; Cook, 2007). Spousal interactions tend to be
characterized by fusion, control and defiance patterns, inadequate conflict resolution
habits, and tendencies for the negative triangulation of others (Scaturo, Hayes,
Sagula, & Walter, 2000). The non-alcoholic spouse may be over-responsible. The
term over-responsible refers to a form of pursuit that diverts the person away from his
or her own self by focusing instead on the behavior of another person. It features
boundary crossing and an avoidance of issues central to the relationship. The alco-
holism may keep the couple’s focus away from core relationship issues.

There are common patterns of triangulation in alcoholic families. One child
(typically the oldest one) becomes a hero. The hero stabilizes the family, as his or
her responsible behavior ensures that no additional problems occur in the system.

128 C H A P T E R 6

The hero becomes the pride of each parent and a refuge from their conflicts. Such a
child may be detached from his or her feelings, however. The scapegoat is the child
whose negative behaviors divert others in the family from the problem of alcohol-
ism. This person acts out and often gets in trouble. Substance abuse may be among
this child’s problems. The parents are often upset with the scapegoat, but they need
the negative behaviors to maintain their own facade of cohesion. The lost child copes
with family anxiety by separating himself or herself from the family, emotionally and
perhaps physically. While this may seem to be a healthy strategy, the lost child is
undifferentiated, and lacks a stable sense of self on which to build an independent
life. Finally, the mascot also diverts the couple’s attention from each other, but is
more of an entertainer or clown. This person is well liked in the family, but is super-
ficial and seems immature. The parents resist the mascot’s efforts to grow up.

Marcia was the identified client of the Reeves family. She was 22, Cauca-
sian, living at home, working part-time, and attending community college. She
was referred for individual therapy following a short-term hospitalization for de-
pression. Marcia had been anxious, crying frequently, and failing her courses. She
admitted to feelings of dread about finishing school, but added that it wasn’t
“right” to feel that way. Her stated goals (while general) were to finish school
and then get her own apartment and full-time job in the business field as an
executive secretary. Marcia was likable and had a good sense of humor. She
said her family had always been supportive of her. She got along particularly
well with her father, the only child to do so. She was assigned to work with
Joe, a 30-year-old, married Caucasian male.

The social worker, whose agency encouraged work with individuals, did not
meet with the family for several months, but he eventually came to know them
all (see Figure 6.1). Mr. Reeves, 53, owned Reeves Roofing Services, a success-
ful local business. The family was financially well off. He was an alcohol abuser,
with daily heavy drinking, and generally kept to himself. He verbally berated his
wife of 31 years when angry, often within earshot of the children. Mr. Reeves
was a domineering man who intimidated his family. Mrs. Reeves, 51, was attrac-
tive and sociable, but passive and prone to anxiety. She voiced no complaints
about the family. She was nurturing of the children and bought them gifts fre-
quently. She talked with them about anything but their emotional lives.

There were three other children. Carolyn, 24, was married and had a 2-year-old
daughter. She was in contact with the family mostly on formal occasions such as holi-
days, but also during family crises. She saw her role in the family as that of a peace-
maker. She became frustrated with her siblings and parents whenever conflicts
developed. Patrick, 20, worked for his father as a manager and lived with friends. He
had been the “problem child” in the past, engaging in substance abuse and opposi-
tional behavior. Dad had bailed him out of trouble many times. Patrick was loyal to
the family, but not close to any of them. He and his father were often in conflict, but
since he moved out of the house, they experienced less friction. Kathleen, 19, lived
with a cousin and attended modeling school. She was attractive and socially sophisti-
cated. She had been away from home for most of the past three years, attending
boarding schools. She was a favorite of her mother, who was impressed with her ca-
reer direction and personal style. Kathleen tended to be parental with her sister Marcia.

F A M I L Y E M O T I O N A L S Y S T E M S T H E O R Y 129

The social worker’s assessment of Marcia included an exploration of her
coping style, dependency issues, and the circumstances of her depression. He
suggested that Marcia keep a diary of her emotional experiences to help her
become aware of any patterns to her stresses and mood cycles. He helped
Marcia, through graduated tasks, to resume her previous level of part-time
school, part-time work, and social interaction with friends and family. A psychi-
atrist prescribed anti-depressant medications for Marcia, but supported counseling
as the primary intervention. Joe quickly developed a close relationship with
Marcia. The intervention intensified, focusing on developing Marcia’s insight
about her fears, lack of confidence, interpersonal patterns, and self-image.

When Marcia came to feel safe with the social worker, she admitted that her
“goals” of self-sufficiency were false, and that she wanted to maintain depen-
dence on her parents. She was strongly enmeshed. Marcia viewed her college
graduation as the end of an adolescence, beyond which she could not function.
She was reluctant to share these fears with anyone because, she said, she did not
want to be “found out.” The pull of the family system was enormous. Late ado-
lescent and early adult depression is frequently related to a lack of differentiation
and “sacrificial roles” fulfilled in triangulation with parents (Lastona, 1990). Joe
realized that he needed to slow down the pace of his interventions and initiate a
family focus.

Marcia’s parents and siblings reluctantly agreed to participate in family therapy.
Her father was particularly ambivalent, and seemed to attend primarily to make sure
that nothing negative was said about him. For these reasons, only six family meet-
ings were held, and at two of them, one or the other parent was not present. The
family’s conversations during the genogram process and other interventions tended
to be superficial and non-critical. Still, Joe came to understand that, because the
other children had left home, Marcia’s parents were dependent on her presence to
keep themselves in balance with each other. They sabotaged her initiatives toward
independence with critical comments. Marcia had previously revealed to the practi-
tioner that they were privately critical of his own interventions.

Despite this relatively short-term family intervention, Joe had an impact on the
system. He educated the family about systems influences by discussing in a positive
way their mutual roles in helping each other function. He did not directly confront
Mr. and Mrs. Reeves about their triangulation of the children, as this would have
been destructive to the intervention. He framed family conflicts in terms of stage-
of-life issues (empty nesting, children leaving home) to which the parents could re-
late and that also kept the focus off Marcia. He encouraged new functional alliances
and triangles by enforcing the value of sibling relationships. He encouraged Mrs.
Reeves to spend time together with Marcia and her oldest daughter. This might
weaken the triangle of Marcia and her parents and also allow Mrs. Reeves to have
time away from her husband. No members of the extended family lived in the area,
so Marcia was encouraged to join social groups as a structured means of developing
extra-family relationships. One of these was an Al-Anon group (Marcia had pri-
vately admitted to the practitioner her concern about her dad’s drinking).

None of these task activities included Mr. Reeves, but Joe was careful to
engage him in discussions, recognize his contributions to the family’s financial

130 C H A P T E R 6

stability, and suggest new ways for him to interact with his children outside the
home (to de-emphasize his dominance). Joe was not sure whether Mr. Reeves
did these things, as he continued to seem withdrawn. Neither did Joe assume
that he had any influence over Mr. Reeves’s drinking. Some of the practitioner’s
questions in family sessions gave opportunities for the issue of Mr. Reeves’s
drinking to be raised by the others, but it never was.

The social worker continued to see Marcia individually, and she made prog-
ress. She slowly adjusted her role within the family in response to Joe’s interven-
tions: She pursued her education, made small changes in her family interactions,
and developed relationships outside the family. Joe needed patience to give
Marcia the time she needed to work toward differentiation. Marcia never gradu-
ated from college, but she did move into an apartment with a friend from work
and thereafter spent less time in the company of her parents.

The Charles Family

Normal life transitions can create problems in functioning for individuals and
families. Among family systems theorists, Carter and McGoldrick (1999) have
identified six general stages of a family’s lifespan, including young adulthood (be-
tween families), the young couple, families with young children, families with
adolescents, families at midlife (including launching children), and families in
later life. As families enter each new stage, they may experience difficulty coping
with the challenges inherent in that stage. The following case provides an exam-
ple of a biracial family’s stresses related to two lifespan stages—adolescence and
the declining health of older members. Concepts from family systems theory are
useful for understanding the heightened anxiety and emotional tumult that creep
into a family with aging or dying members (Bowen, 1991b; Qualls & Williams,
2013). The illustration includes excerpts from the social worker’s dialogues with
the family, and indicators of many of the intervention strategies are included in
parentheses.

Dan Charles was a 16-year-old high school sophomore referred to the mental
health center because of poor grades, negative attitudes about school and his peers,
and reports by his parents of suicidal thinking. The Charles family (Figure 6.2) had
moved from Ohio to Virginia six months earlier when Dan’s father, Jeff (age 41),
accepted new employment. The Charles family was biracial, as Jeff was Caucasian-
American and his wife, Jinhee, was Japanese-American. This was not mentioned as
an issue with regard to the presenting problem. According to Dan and his parents,
Dan was unhappy about living in Virginia. He was irritable, argumentative, and in
persistent power struggles with them. Dan usually stayed in the house when he
was not in school and had made no friends. He complained about life in Virginia
and said he wanted to move back home. Dan complained about his classmates and
refused to participate in school activities. Dan’s two younger siblings (Adam, 10,
and Kim, 8) resented Dan’s anger and how he took it out on them. They enjoyed
living in Virginia and had made new friends.

During the assessment of the social worker (Cassandra, a 32-year-old single
Latina woman), however, other family issues emerged as significant to the

F A M I L Y E M O T I O N A L S Y S T E M S T H E O R Y 131

present situation. She learned that Jin (age 42), Dan’s mother, was concerned
about the health of her aging parents back in Ohio. Jin’s mother was in the mid-
dle stages of Alzheimer’s disease, and her father was physically limited by conges-
tive heart failure. For that reason, Jin felt guilty about moving away from Ohio.

Jeff was a middle-class native of a rural community in Ohio, where he learned
skills primarily related to hunting, farming, and construction. His interests and va-
lues reflected his outdoorsy upbringing, and his parents had not emphasized higher
education. Jeff was an only child born to parents who were nurturing but doting,
investing most of their energies into Jeff’s happiness. Jeff was a popular child and
adolescent, but he had never excelled at school. He stayed close to home and be-
came a successful unskilled laborer who worked a series of factory jobs.

Jin was the middle child and only daughter of a couple from California. Her
parents were first-generation Japanese natives who had moved to the West Coast
in the 1930s. Sadly, they had been interned as children with their own families
in a camp for Japanese persons during World War II, and spent two years in
confinement. When they were released at the end of the war, their families con-
tinued to live in the Oakland area. Jin’s parents met in high school and married
several years later. Jin’s father was an auto mechanic and eventually found work
at a truck production plant in Ohio, where Jin and her brothers grew up. Jin met
Jeff in high school, and they married after Jeff finished his technical school train-
ing. He had been a devoted husband, and while Jin was embraced by the Charles
extended family, her own parents had trouble accepting Jeff as a suitable husband
to their daughter. He was not Japanese and was not, in their minds, sufficiently
upwardly mobile.

Additional relevant family cultural dynamics will be described in the context
of the intervention.

Cassandra met with the family 10 times over a period of four months, focus-
ing on systems issues rather than the presenting problem of one member’s mal-
adjustment. She framed the family’s functioning in a context of everyone’s need
to better adjust to the move, and the family was agreeable to working on this.

SOCIAL WORKER Obviously, things have been tense in the home for all of you.

(REFRAMING): But consider that you’ve had to move several times in the last
few years, and there have been real worries about money and
health. Considering all that, you’ve done well in many ways. I
can see that you all care about each other, and that you’d all
like the atmosphere at home to improve.

JEFF: That’s not quite true, though. We’re not all trying. [he looks at
Dan]

SOCIAL WORKER: But you said he’s been a good kid in the past. I wonder if
you’re all clear about what this experience has meant to him.
Dan?

DAN: My folks should know.

SOCIAL WORKER: Maybe they do, and maybe they don’t. Perhaps you’ll become
able to tell them more about that.

132 C H A P T E R 6

One motivator for the family was that, because they were now rooted in a
new location, they had few choices but to support one another. The practitioner
introduced the theme of life-cycle stresses and complimented all of them on the
good decisions they had made in their transition. Dan was pleased to have the
focus taken off him.

SOCIAL WORKER

(EDUCATION):
All families go through transition periods. When there is a new
child born, when a parent dies, when a child goes to school or
moves away. Those things all have a big effect on everyone,
even though you may not be aware of it at first. I think that,
among other things, your family is in a transition period. Family
members have to take some responsibility for themselves, of
course, but I think you are all affected by these changes. Some
of what you’re concerned about is related to that. I hope you all
recognize that and can maybe make some decisions about how
to make this transition easier.

As they reviewed the genogram, the practitioner suggested that they could
help each other with their adjustment by dealing more directly with their feel-
ings and interacting with each other in new ways. She included attention to the
grandparents in this process. Recognizing the entire family’s concern for the ag-
ing couple, she integrated strategies to see that all of their needs were addressed.

SOCIAL WORKER

(EDUCATION,
LOWERING

SYSTEM

ANXIETY):

It’s clear to me that you share a sense of family, especially since
you’re all concerned about Jin’s parents. It has to be hard to be
this far away from them. Again, I’m not sure if you’re all aware of
what each other is experiencing, not only with this move, but
with other challenges over the past few years, like the family fi-
nances. With people close to us, if we don’t regularly ‘check in,’
we may begin to make assumptions that aren’t true. Or we may
decide that not talking is the easiest way to avoid stress.

Cassandra then asked the family if she could share some of her observations
about the genogram. She did so as a means of encouraging the family members
to consider the entire system, but she also wanted to raise the issue of their bira-
cial family, to see if this might reveal any underlying dynamics significant to the
presenting problem. The process was successful on both counts, and the follow-
ing story emerged.

The couple’s racial difference had several significant effects on their relation-
ship (Romanucci-Ross, De Vos, & Tsuda, 2006). In Japanese spousal relation-
ships, the wife takes on the mothering role toward the husband, and Jeff
admitted to having been attracted by this quality in Jin, given how his own par-
ents doted on him. And while father-and-child relationships in Japan are tradi-
tionally characterized as distant, parents in later life often rejoin their children’s
families to be cared for. This extended Jin’s caregiving role beyond that of her
current family, and created some adjustment challenges for all three generations.
This was complicated by the fact that Jin and her brothers had agreed that their
parents were too ill to move, even though Jin had acted as the primary caregiver.

F A M I L Y E M O T I O N A L S Y S T E M S T H E O R Y 133

Japanese family values are characterized by a focus on connection and a de-
sire to be part of the broad racial group. American family values, in contrast,
focus on the immediate family, a single generation, individual achievement, and
autonomy. This values conflict created some strain in the Charles family. Jeff, in
fact, viewed his parents-in-law’s desire to be near Jin to be related to their desire
to interfere with them. Further, in Japanese culture, communication patterns are
such that women are hesitant to discuss their emotions and are careful not to be
offensive to others. Jin did possess these characteristics, and thus had trouble ex-
pressing any frustrations she was feeling to Jeff and the children. Jeff was outspo-
ken in his negative reactions to what was happening in the family, but Jin was
not as expressive.

Further discussion revealed that Jin’s parents’ confinement in an internment
camp may have set up belief systems and patterns of interaction that affected Jin
negatively. During World War II, 120,000 Japanese persons were interned in
these camps, sixty percent of whom were United States citizens (Nagata, 1991).
They were abruptly removed from their homes and had to give up whatever
business and careers they had established. The emotional effects of such traumatic
experiences shaped the lives of their children. Common outcomes were inhibited
family communication, self-esteem problems, a lack of assertiveness, an emphasis
on the importance collective identity, and the belief that children (especially sons)
should “vindicate” the family’s honor thought external achievement. Parents who
had been interred usually maintained silence about their experiences in the camps,
inhibiting cross-generational communication and creating a sense of secrecy. The
messages that children tended to receive from their parents were that the children
must finish the unfulfilled dreams of the parents, to heal the pain of past loss.
A strong sense of living within Japanese culture was emphasized, which caused
those who married outside the race to feel guilty. Jin discussed these issues with
great difficulty, and Jeff appeared anxious as she spoke.

SOCIAL WORKER

(USE OF THE

GENOGRAM):

As we have just seen, genograms sometimes lay out family
relationships in a way that is more clear than just talking
about them. For example, Jin, it looks like your brothers
have put you in charge of your parents, even though they
live closer. Is that accurate?

JIN: Men aren’t as thoughtful that way. It’s my job to make sure
my folks get what they need and don’t become isolated. You
know what it’s like for older folks—if they get lonely, they
give up and die. My brothers need to be concerned about
their own careers. They want to do the family proud.

JEFF: Men aren’t thoughtful? You think I’m like your brothers?

JIN: Well, look. [pointing at the genogram] It was just you and your
parents. They took care of you. They died before you were
able to repay that.

SOCIAL WORKER: Since we’re all looking at the genogram, do any of you see
anything interesting?

134 C H A P T E R 6

JIN: Yes. I take care of my folks, and Jeff is used to being taken
care of. So now he expects me to take care of him. I want to
take care of him, but I can’t do everything. I have our own
children, too.

JEFF (DEFENSIVELY): Jin goes overboard worrying about her parents. She gives
them more attention than she gives the rest of us. Shouldn’t
we be number one now?

SOCIAL WORKER

(REDIRECTING THE

INTERACTION):

I suggest that all of you direct your comments to each other
rather than to me. You’re really speaking to each other.
Don’t worry about me, I’ll follow along and participate.

Jeff and Jin argued about this issue often. Jeff was the only child in his family
of origin. He was born when his parents, now deceased, were in their forties.
They had been quite doting, and Jeff was accustomed to being taken care of. Jeff
seemed to want Jin to attend to him in the ways she did for her parents. Jin, being
a natural peacemaker, tried to see Jeff’s side of the issue. Still, she resented his in-
sensitivity to her experiencing this midlife role reversal with her parents.

JIN: He just doesn’t know what it’s like for me.

SOCIAL WORKER

(USE OF “I”
STATEMENTS):

I don’t know if he does or not. It’s important for you to make
it clear to Jeff how you feel, Jin. In fact, all of you should try to
make it clear how the behavior of your parents and brothers
and sister makes you feel, both good and bad. You can best get
your feelings across by using what are called ‘I’ statements. That
is, always say, ‘I feel this way’ or ‘I feel that way’ when some-
thing happens.

ADAM: I don’t get it.

SOCIAL WORKER: For example, if your sister makes a lot of noise and keeps you
from getting your homework done, you might say, ‘I get mad
when you make such a racket because I can’t study,’ instead of
only saying something like, ‘Stop making such a racket!’

Cassandra suspected that Dan tended to be caught in a triangle with his par-
ents as a diversion from their conflicts. When they were angry with each other,
they found fault with Dan and vented their feelings at him.

JIN: He used to be a good kid. But now look. The rest of us are
trying our hardest to make all these adjustments, and he goes off
and sulks, not helping at all.

SOCIAL WORKER

(USE OF “I”
STATEMENTS):

Make sure you talk to Dan instead of to me. And tell him how
his behavior makes you feel.

JIN: Okay. Dan, I feel frustrated when you go off by yourself when
I’m trying to talk to you. I feel like you’re mocking me. [To the
social worker] Is that okay?

F A M I L Y E M O T I O N A L S Y S T E M S T H E O R Y 135

The social worker wondered if Dan willingly took on the role of trouble-
maker when his parents were in conflict. It was true that the recent move was
hard on Dan, more so than the other children, due to his stage of life. But the
combined family stress may have resulted in Dan’s increased efforts to divert his
parents’ attention from each other, his mother from her guilt about not fulfilling
her role in her nuclear family, and his father’s anger toward his in-laws and about
his unmet needs to be cared for.

SOCIAL WORKER

(DETRIANGULATION

DISCUSSION):

It’s normal that there would be a lot of tension in a house-
hold after a major move. Dan, I know your parents are
concerned about your welfare. I’m wondering, though, how
you see them reacting to, for example, a failing grade at
school or your staying in your room all day.

DAN: Well, they yell. They yell at me. It can go on for days.

SOCIAL WORKER: Are things pretty calm between them otherwise?

KIM: Oh, no.

SOCIAL WORKER: What’s that, Kim?

KIM: They yell at each other a lot.

SOCIAL WORKER: You think so? Adam, what do you observe?

ADAM: Yeah. That’s just the way it is. But it’s okay, it doesn’t bother
me much.

SOCIAL WORKER: So things can get tense in the house. That’s not necessarily a
problem unless you lose sight of what you are really upset
about.

JEFF: I don’t follow you.

SOCIAL WORKER: Sometimes people use each other as outlets when they’re
upset but maybe not sure what, exactly, they’re upset about.
With all that’s happened, is it possible you take out some
feelings on each other that might be related to your mixed
feelings about moving?

[AND LATER]
SOCIAL WORKER

(DISPLACEMENT):

Sometimes kids might become concerned about their parents
arguing and actually do things to take the parents’ attention away
from each other, or give them something to agree on.

While the younger children did not seem to be as obviously affected by the
family anxiety, Cassandra was concerned that their “staying out” of the situation
put them at risk for emotional cutoff.

KIM: I’m doing fine. Nobody seems mad at me, except Dan some-
times. I can get away from it. It doesn’t bother me, really. I can
go to my room.

SOCIAL WORKER: That helps, sure. And it’s okay to have your private space. But I
wonder if you are able to feel comfortable being around your
parents and brothers. I hope you do, most of the time.

136 C H A P T E R 6

The social worker eventually helped the family develop plans for groups of
them to travel to Ohio every three weeks to look after Jin’s parents. These re-
presented detriangulation exercises and an effort to open up the nuclear family to
the extended family system. This might also help Jeff’s relationship with his
parents-in-law, as it seemed their lack of full acceptance of him into their family
had produced an underlying resentment in him.

SOCIAL WORKER: Jin, you like to visit your parents. Have you considered taking
other family members along?

JIN: Not much. They’re all trying to get adjusted here, and it’s my
problem, really.

SOCIAL WORKER: But they might be interested in going along. Have you asked
them?

JIN: No. I’ve been preoccupied and … [hesitating] I thought Jeff
might get annoyed and think I was trying to keep the kids
from getting settled here.

JEFF: Oh, come on, I’d never say that!

JIN: You might think I was planning to get us all back home.

SOCIAL WORKER

(OPENING

UP THE SYSTEM

TO EXTENDED

FAMILY MEMBERS)

Jeff and Jin, if you agree that you’re going to live here, as you
said before, and make the best of it, perhaps you don’t have to
have such doubts. These short trips can be a good way for you
to connect with each other and stay connected to the
grandparents.

The family decided that Jin and two of the children might make one trip,
enabling them to spend two full days together. Jeff and two of the children might
travel to Ohio on another weekend. Jeff and Jin could not take long trips together
without the entire family, so Cassandra encouraged them to spend time together
close to home but away from the children. Their lives had centered on the chil-
dren for years. The couple reluctantly decided to meet once a week for lunch.

JEFF: I’m not sure that lunch together can help. It seems kind of trite.
We have most suppers together as it is.

SOCIAL WORKER: With the kids, though.

JIN: Jeff, there’s less of a chance we’ll get upset if the kids aren’t
around, sulking.

Jin felt good about this plan, and it lowered her anxiety. The social worker
helped the family appreciate Jin’s need to provide support to members of two
generations. In the spirit of developing new family tasks, Jeff and the children
decided that they could undertake minor home renovation projects during the
absences of the other members.

SOCIAL WORKER (COACHING): Jeff, you’ve mentioned that you and Dan don’t
spend time together anymore. What did you used
to do?

F A M I L Y E M O T I O N A L S Y S T E M S T H E O R Y 137

JEFF: We camped, played sports. I don’t know, he’s
getting older, he doesn’t do as much of that stuff
anymore.

DAN: There’s the carpentry stuff, too.

JEFF: Yeah, we used to work on the house some.
Sanding the floors, building cabinets.

SOCIAL WORKER: Might you enjoy sanding floors together again?

JEFF: Actually, there’s a lot to do in the new place. But
he won’t help.

DAN: I might.

Cassandra hoped that this would both enhance their sense of mastery and
positively change the nature of their relationships. In all of these strategies, she
was helping the family to form new alliances and to differentiate. The children,
with the encouragement of the social worker, spent some of their time in Ohio
talking with their grandparents about their mother’s and father’s lives when they
were younger. This strengthened their relationships with their grandparents. The
grandparents had been rather silent about certain traumatic aspects of their his-
tory, but, with Jin’s encouragement, became able to share more of those stories.
All three children were fascinated, and came to know their grandparents in a
very different light.

Another effective intervention strategy was Cassandra’s support of the family’s
following through with a vague desire to join a church in Virginia. The family had
not been active in their church in Ohio but was more interested in doing so now,
partly because of their relative social isolation. Jin had become more conscious of
her religious roots since her parents had become ill and were facing existential con-
cerns more directly. Interestingly, she had become more interested in Christianity
over the years, another issue which had disappointed her parents. She decided to
embrace her religion more openly, with her parents being farther away.

SOCIAL WORKER: I’m getting the feeling that there’s a lot of … intensity to what
happens in the house. Is there anything that you all do that
involves other people? I know you don’t have family in the
area.

JIN: We go to church. Sometimes. We haven’t spent much time
there, really.

SOCIAL WORKER: Did you ever? I mean, before you moved here?

JEFF: Sure. I volunteered on Sundays, too, to clean up after
services.

SOCIAL WORKER: Churches have family activities, too. Is there anything fun the
kids might do there?

Cassandra supported the idea, as it might provide the family with a bonding
experience. This activity could also help them consider family functioning within
a spiritual context. The family did participate in several church activity groups

138 C H A P T E R 6

that helped them to initiate social ties. In the past, their church had not provided
them with a basis for family-focused activity, but it became a bigger part of their
lives now.

By the time the intervention ended, the family had made a better adjust-
ment to life in Virginia. Relationships improved among the members, and Dan
was feeling better about his parents, his siblings, and his school. Jeff had helped
Jin confront her brothers about their need to be more attentive to her parents,
and Jeff and Dan continued to spend recreational time together. The family had
talked about possibly moving Jin’s parents to Virginia if their health continued to
deteriorate. They continued to make monthly trips to Ohio.

EVIDENCE OF EFFECT IVENESS

Evaluating the effectiveness of family theories is generally difficult, and family
systems theory is among the most difficult to operationalize. Bowen did not be-
lieve that empirical study was an appropriate way to determine the usefulness of
his theory (Georgetown Family Center, 2012). He believed that such methods
overlooked its richness in focusing on limited variables. Further, he believed that
what people say they do is not always the same as what they do, so he did not
put great faith in standardized clinical self-report measures.

Family systems theorists emphasize research on process rather than outcome,
and on single cases or small samples. Such studies have been conducted at the
Georgetown Family Center (2012) and include the topics of emotional processes
with adoption; families and cancer; families with substance-abusing adolescents;
family processes in immigrant families; relationships and physiology; relationship
processes and reproductive functioning; prayer, emotional reactivity, and differ-
entiation; and the workplace as an emotional system. Previous studies by the
center have focused on AIDS and the family (Maloney-Schara, 1990), aging
and the family (Kerr, 1984), family violence, and managing diabetes. The theory
is also used as a model for adolescent group work to promote member growth
through differentiation (Nims, 1998).

The literature includes many studies of the utility of the theory’s concepts,
and several are presented here. A study of 229 college students in the Midwest
found an association between emotional reactivity, emotional cutoff, and nega-
tive mood (Wei, Vogel, Ku, & Zakalik, 2005). Another researcher tested 125
college undergraduates to examine whether level of differentiation (i.e., levels
of autonomy and intimacy with the family of origin) was associated with life
stressors and social resources (Roberts, 2003). She found that higher levels of
differentiation correlated with lower levels of perceived life stress and more social
resources. Further, lower social class status was significantly associated with more
life stressors, but not with fewer social resources. A test of the association be-
tween the differentiation of self and depression revealed a negative association
among 60 racially diverse adults living in a rural community (Hooper & DePuy,
2010). Harris et al. (2010) surveyed 313 first-degree relatives of melanoma

F A M I L Y E M O T I O N A L S Y S T E M S T H E O R Y 139

patients and discovered that more cohesive families communicated more openly
about the issue. A study of 416 families with a young adolescent member re-
vealed that intra-family triangulation was negatively associated with perceived
support from friends (Buehler, Franck, & Cook, 2009). Kim-Appel (2003) ex-
amined the relationship between differentiation and psychological symptom sta-
tus (i.e., somatization, interpersonal problems, depression, anxiety, and hostility)
in persons aged 62 and older. Her hypotheses were confirmed, as measures of
differentiation correlated negatively with emotional reactivity and emotional cut-
off, and correlated positively with “I” position statements.

Other studies have supported the validity of the theory’s concepts with re-
gard to persons who have substance abuse problems. Adolescents who begin
using substances at age 13 or younger have significantly higher levels of emo-
tional reactivity than persons who start using at age 14 or older (Pham, 2006).
Among individuals in substance abuse treatment, those who report lower levels
of differentiation of self are more likely to report violence in their intimate rela-
tionships, while those who report more emotional reactivity (overwhelmed by
emotions of the moment) and greater emotional cutoff (threatened by intimacy)
are more likely to report at least one instance of violence in intimate relationships
during the past year (Walker, 2007). In another study using a similar sample,
higher levels of differentiation were related to lower levels of chronic anxiety
and higher levels of social problem solving. Higher chronic anxiety was related
to lower problem solving, indicating that differentiation influences social prob-
lem solving through chronic anxiety. Higher levels of social problem solving
were related to less drug use, less high-risk sexual behavior, and an increase in
academic engagement (Knauth, Skowron, & Escobar, 2006). A sample of 35
chemically dependent men and women in oupatient recovery from substance
dependence found that patterns of cut-off, triangulation, and the occupying of
at-risk sibling positions were evident in respondents (Cook, 2007).

Several studies have focused on family-of-origin influences on career deci-
sion making. Keller (2007) studied college students and found that differentiation
(and the ability to take an “I” position) were positively predictive of a student’s
proactive career exploration. Dodge (2001) investigated the effects of differentia-
tion (and, from another theory, the concept of personal authority) on career de-
velopment outcomes for 243 college students. Each concept was positively
associated with a sense of vocational identity and self-efficacy in career decision
making. Further, family of origin conflict was inversely associated with low self-
efficacy in career decision making, low individuation, and dysfunctional career
thoughts. The author concluded that addressing family conflict in therapy could
have a positive impact on career development in young adults. In another study
of this type, 1,006 college students were surveyed using measures of fusion, tri-
angulation, intimidation, anxiety, and career decision making (Larson & Wilson,
1998). Results indicated that anxiety (from fusion) inhibits career development,
but triangulation is not related to career decision problems.

A number of studies have considered the effects of family systems on a per-
son’s later degree of satisfaction with intimate relationships. In a study of 60 mar-
ried couples, it was found that higher-differentiated couples described higher

140 C H A P T E R 6

levels of marital satisfaction than lower-differentiated couples (Racite, 2001).
Couples who demonstrated different levels of differentiation reported more mar-
ital problems than couples who were similar in differentiation. In one research
project, men’s and women’s emotional cutoff scores were predictive of the na-
ture and quality of their relationships and related depressive episodes over time
(Glade, 2005). Larson, Benson, Wilson, and Medora (1998) studied the effects of
the intergenerational transmission of anxiety on 977 late adolescents’ attitudes
about marriage. The participants’ experiences of fusion and triangulation were
found to be related to negative opinions about marriage. Timmer and Veroff
(2000) studied the relationship of family of origin ties to marital happiness after
four years of marriage for 199 black and 173 white couples. One predictor of
marital happiness for wives, particularly those from disrupted families, was close-
ness to the husbands’ families of origin. When husbands’ or wives’ parents were
divorced or separated, closeness to the husband’s family reduced the risk of di-
vorce. Regarding parenting potential, Skowron (2005) found that greater differ-
entiation of self (lower reactivity, emotional cutoff, or fusion, and better ability
to take an “I” position) predicted lower child abuse potential.

CRIT IC ISMS OF THE THEORY

Family systems theory has been criticized for two related reasons (Bartle-Haring, 1997;
Knudson-Martin, 2002; Levant & Silverstein, 2001). First, it has not adequately at-
tended to variations in how men and women experience differentiation and fusion.
The theory has incorporated a male bias in its valuing of reason over emotion and
prioritization of separation over connection. Beginning with Gilligan (1982), develop-
mental theories about women have considered their relational and communication
styles to be different from those of men. Women are typically brought up to empower
others in the family—to respond to the thoughts and feelings of others and foster their
growth and well-being. Men are programmed to seek extra-familial success, while
women are programmed to nurture and support them, often at the expense of their
own development. While these are culturally supported roles, they may create a ten-
dency to see women as enmeshed. A gender-neutral family theory would place greater
emphasis on helping men increase their capacity for intimacy and balance their
achievement and relationship needs. Second, even with its attention to societal emo-
tional processes, the theory has not been sufficiently contextual in its identification of
males as the dominant cultural group and their uses of power in family systems
(Nichols, 2009). Although these criticisms are valid, they began to be addressed by
theorists in the 1990s, resulting in positive revisions of some of this theory’s concepts.

SUMMARY

Family systems theory is unique in its attention to the subtle emotional family
processes that develop over several generations. It is an appropriate guide to

F A M I L Y E M O T I O N A L S Y S T E M S T H E O R Y 141

assessment and interventions that focus on the quality of nuclear and extended
family relationships and the desire for members to become differentiated. A re-
cent survey of North American marriage and family intervention practitioners
found that it is one of their three most utilized theoretical perspectives (Bradley,
Bergen, Ginter, Williams, & Scalise, 2010). The theory provides a useful means
of working on issues related to boundaries, enmeshment, and emotional distance.
It is versatile in its applicability to individuals and subsets of families. Its
potential for use across cultures has been articulated, although not yet extensively
(Skowron, 2004).

Family systems theory interventions require that the client, whether an
individual or a family, have the capacity to interact in an atmosphere of rela-
tive calm, and be able to reflect on relationships. There must be a relatively
stable family structure that the majority of members are not in crisis. For these
reasons the theory might not be appropriate for families whose primary con-
cerns involve meeting basic material and support needs. The urgency of such
needs suggests interventions that do not require sustained reflection. Likewise,
families characterized by chaos from structural instability would require a
higher level of worker activity than is consistent with the family systems
perspective.

Family systems theory might be appropriate for intervention with the above
types of families after their initial problems are resolved. After a family acquires
access to basic needs, its members may struggle with issues related to enmesh-
ments or cutoff. A structural breakdown may be related to a triangulation in
which an adolescent accedes to an inappropriate position of power. The social
worker’s ability to assess those dynamics may be helpful in determining how to
help the family organize problem-solving activities, strengthen certain subsys-
tems, or plan for growth after the primary intervention ends.

TOPIC S FOR DISCUSSION

1. Think about your own family of origin, and try to identify one or two ex-
amples of “relationship patterns” that characterized that system. How did
these develop, and when? It might be interesting to talk with some other
family members about these patterns.

2. What are the characteristics of a person who is differentiated? As you con-
sider this question, think about any value biases that might be reflected in
your response.

3. The ideal position of the social worker in family emotional systems work
achieves both engagement and therapeutic distance. Think about clinical si-
tuations that might test your ability to assume or retain this ideal position.
How can you manage these challenges?

4. Describe a point of fusion that you have observed in your work with an
individual, family, or family subsystem. Describe how you might (or did)
proceed to modify that relationship.

142 C H A P T E R 6

5. Think of some ways that you could use displacement stories or activities as
part of an intervention. Try to be creative in how you select and implement
them.

IDEAS FOR ROLE-PLAYS

(The instructor or students should fill in the details of these vignettes however they deem
appropriate.)

1. A single mother, divorced two years ago, has ongoing conflicts with her ex-
spouse, and is also having trouble “letting go” of a supportive 19-year-old
daughter who is moving toward independence in a normal way. Two other
children, aged 14 and 10, are in the household (all the children live with
their mother). Focus the intervention on helping the mother to appropri-
ately “let go.”

2. An individual adult client is troubled by his inability to risk intimacy (how-
ever you define it) in relationships with significant others. The assessment
indicates that this person was the hero child in a family in which the father
was an alcohol abuser.

3. In a family that includes a father, mother, and two children, the mother is
dying of ovarian cancer. The father has withdrawn emotionally from her
because he does not perceive himself as having adequate caregiving capabil-
ities. He feels guilty about this withdrawal. The adult son and daughter
(living independently in the same city) have good relationships with both
parents and want to help reverse their father’s withdrawal.

APPENDIX: Family Emotional Systems Theory Outline

Focus The lifelong influence of nuclear family relationships

(“You can run, but you can’t hide”)

The “hearts and minds” of family members

Major Proponents Bowen, McGoldrick, Carter, Kerr, Guerin, Titelman

Origins and Social Schizophrenia research (family dynamics)

Context Cybernetics

Natural systems theory

Psychodynamic theory

Nature of the Individual A striving to balance intellectual and emotional
experience

Nuclear family processes influence functioning
throughout life

F A M I L Y E M O T I O N A L S Y S T E M S T H E O R Y 143

Major Concepts Multigenerational perspective (three generations)

Nuclear family emotional system

The triangle

Differentiation of self (in emotional and cognitive
functioning)

Fusion (of emotions and intellect)

Emotional cutoff

Parental projection

Sibling position

Anxiety

Family Development Stages Young adults leaving home

Couples

Families with children

Families with adolescents

Older members with young adults leaving home

Nature of Problems Triangulation (adults in conflict draw in “weaker” family
members to maintain stability, and thus elicit symptoms
in them)

Emotional fusion (anxious attachment)

Emotional reactivity

Too much or too little investment in family relationships

Nature of Change “Opening up” the family system

Detriangulation

Changing the relationship of primary couples

Going backward through the extended family to find
solutions

Less family anxiety

Goals of Intervention Lower family system anxiety

Identify and adjust the central symptomatic triangle(s)

Put problems in the context of the multigenerational
family system

Promote an awareness of the relevance of all family
members

Redress inequalities within the family

Emotionally realign the family system (includes opening
any “closed” relationships)

Promote differentiation (requires each member to have
relationships with all other family members)

APPENDIX: Family Emotional Systems Theory Outline (Continued)

144 C H A P T E R 6

Enhance habits of problem sharing

Increase the reflective capacity of all members

Nature of Worker/Client
Relationship

Worker as “coach”; professional detachment (to avoid
reactivity, triangulation)

Worker provides a calm atmosphere

Intervention Strategies Review of the multigenerational genogram (education)

Discuss behavior in terms of family themes

Externalize the thinking (increase quality of
communication)

Lead detriangulation conversations

Shift alliances within triangles with tasks

The displacement story

Guide members into functional attachments with
nuclear and extended family members

Increase insight (help each member observe the self
within triangles)

Person-situation reflection

Developmental reflection

Assessment Questions What are the current stresses? How are they expressed?

How has the family handled stresses historically?

What physical and emotional symptoms are evident in
the family?

How do the symptoms affect family relationships?

How does the nuclear family interact with the extended
family?

How well does the family manage anxiety?

How well differentiated are the family members?

What triangles exist? Which are primary?

Are any emotional cutoffs operating?

APPENDIX: Family Emotional Systems Theory Outline (Continued)

F A M I L Y E M O T I O N A L S Y S T E M S T H E O R Y 145

Behavior Theory

The heart asks pleasure first,
And then, excuse from pain;

And then, those little anodynes
That deaden suffering. *

In this chapter we will review a practice theory that is very unlike the reflective
theories described in the previous four chapters. Behavior theory consists of ideas

about how human actions and emotions develop, are sustained, and are extin-
guished through principles of learning. Behavioral practitioners are distinguished
by their relative lack of concern with a client’s internal mental processes and their
focus on physical, observable, “objective” behavior. Behavioral practice is also dis-
tinguished by a commitment to the principles of the traditional “scientific method”
for helping clients to eliminate unwanted behaviors or acquire desired behaviors.
Some behaviorists actually reject its status as a “theory” because of their distrust of
any concepts (abstractions) as explanations for thoughts, feelings, or behavior.
Behavioral practitioners have always been concerned with the empirical evidence
for the effectiveness of their interventions, and thus third-party payers value these
approaches. Because implementing behavioral strategies does not require that the
client be able to think abstractly, it is a popular practice approach with children
and persons with cognitive and developmental disabilities. But it can be used
with all client populations.

Three major approaches to behavior therapy include behavior analysis
(focused on the consequences of behavior), the stimulus-response model (focused
on environmental factors that elicit and maintain a behavior), and social learning
theory, which adds a concern with cognitive mediational processes (Wilson, 2000).

* Dickinson, E. (1927). The Pamphlet Poets. New York: Simon and Schuster.

146
Copyright 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights,

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This chapter will concentrate primarily on the first three approaches, as the
fourth is more closely related to cognitive theory (the subject of Chapter 8). Addi-
tionally, the intervention model of dialectical behavior therapy will be discussed in
the next chapter, as it includes some cognitive techniques.

ORIGI NS AND SOCI AL CONTEXT

Behaviorism has been prominent in the social sciences since the first half of the
twentieth century, and it became a popular theory among clinical practitioners
by the 1960s. Its rise was closely linked with the advance of logical empiricism,
first in the field of philosophy and later in the sciences (Thyer & Wodarski,
1998). Beginning with the French philosopher Descartes in the 17th century,
“empiricism” has referred to knowledge that is based on observation or sensory
experience. In the late 1800s, its definitions (there are several) were refined to in-
corporate the process of basing knowledge on evidence that is rooted in “objec-
tive” reality (it is now disputed that any such thing exists) and gathered
systematically by observation, experience, or experiment (Spiegler, 1993). A major
principle of behaviorism is that all claims to knowledge should withstand testing
and verification.

The first major innovator of behaviorism in psychology was Wilhelm
Wundt in Germany, the late-19th-century “father of experimental psychol-
ogy” (Taylor, 1972). He believed that laws of cognitive and emotional expe-
rience could be derived with the same research methods that were being used
to study human physiology. His thinking was influenced by developments in
the physical sciences that emphasized exact measurement of phenomena as
well as the importance of inter-subjective verification. Wundt set up the first
psychology laboratory for experiments with animals. In Russia, Pavlov’s (1927)
discovery of the laws of classical conditioning represented a major step for-
ward for this new science. American educational psychologist Thorndike
(1911) was another major contributor, inventing the “puzzle box” for ex-
periments with rats and developing the first principles of operant
conditioning.

Contemporary discussion of behaviorism begins with the work of Watson
(1924). He coined the term “behaviorism,” conducted experiments on humans,
and brought the approach into mainstream psychology. Watson set out to
establish psychology as a science. Protesting against what he viewed as the
subjectivism of introspective psychology, he urged the discipline to give up its
concern with understanding consciousness and to focus instead on observable
facts. He believed that psychology as a scientific enterprise should seek to predict
and control events, and that only “objective” methods, enabling two or more
scientists to observe the same objects and events, would further the achievement
of those goals. He reasoned that because states of consciousness are private,
observation of behavior alone was able to provide the clear data needed for
scientific activity. Watson felt that human behavior should be reducible to the

B E H A V I OR T H E OR Y 147

laws of physics, and that eventually psychologists would be able to explain be-
havior at the molecular level.

B. F. Skinner (1953) disagreed with Watson about the ultimate aim of be-
haviorism, arguing that the behaviorist should focus at the level of the person.
Skinner’s work advanced the field tremendously. He refined the principles of
operant conditioning, and his many publications, some of which were geared
toward general audiences, brought behaviorism into the public consciousness.
The radical behaviorists, including both Watson and Skinner, acknowledged the
existence of mental processes but were not concerned with them. Moderate
behaviorists, such as Tolman (1948) and Hull (1943), were interested in mental
processes as intervening variables between a stimulus and response. Bandura’s
(1977) social learning theory brought mental processes further into the realm of
behaviorism. A major learning principle that Bandura presented was that of
modeling: people learn not only by direct reinforcement, but also by seeing how
the behavior of others is reinforced.

Research on conditioning and learning principles became a dominant part
of experimental psychology in the United States following World War II, but
this research was largely confined to animal laboratories. Several studies of
humans, however, bolstered the belief that behaviorism could be an effective
therapy for humans. Wolpe (1958) was among the first to conduct research
that applied learning principles to the eradication of adult neurotic disorders.
In so doing, he developed the intervention method of systematic desensitiza-
tion. In London, Hans Eysenck also popularized behavior therapy as a means
of treating behavioral and emotional disorders (Eysenck & Rachman, 1965). In
1963, he founded the first journal devoted to behaviorism, Behavior Research
and Therapy, which remains a respected publication today.

Behavior theory and its related interventions are prominent in the social
work profession. The first social worker to extensively advocate for the
behavioral perspective in direct practice was Thomas (1974, 1968), who con-
ducted research on intervention with substance abusers and couples, among
other client populations. Bruce Thyer has advocated the philosophy of logical
positivism and its adoption by social work practitioners for more than three
decades (Thyer & Wodarski, 2007). While some social workers believe that a
focus on observable behavior runs contrary to the profession’s increasingly
holistic perspective, Thyer has eloquently demonstrated its utility for promot-
ing positive outcomes with a variety of client populations. He also argues that
the application of behavioral intervention is critical in the development of
evidence-based practice standards for social workers. Mattaini (2008) has
developed an ecobehavioral model of practice that he argues is fully consistent
with social work professional values. While his model is firmly rooted in
empirical practice, it encourages social workers to assess human behavior in
a broader context than some behaviorists would consider, including all rele-
vant social systems with which clients interact. The goal of the model is to
expose clients to new cultures, defined as family members, friends, organiza-
tions, and communities, that can provide ongoing support for the acquisition
of new behaviors.

148 C H A P T E R 7

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MAJOR CONCEPTS

The basic principles and assumptions of behavior theory are as follows (Gambrill,
1994; Wilson, 2000; Thyer & Wodarski, 2007):

Behavior is what a person does, thinks, or feels that can be observed.
Inferences about a person’s mental activity should be minimized because it
cannot be directly observed. Clinical assessment should focus on observable
events, with a minimum of interpretation.

People are motivated by nature to seek pleasure and avoid pain. They are
likely to behave in ways that produce encouraging responses, or positive
reinforcement. (It must be emphasized, however, that it is not always easy
to determine what constitutes pleasure and pain for a specific client.)

People behave based on their learning, by direct environmental feedback,
and also by watching others behave and interact.

Behavior is amenable to change. A prerequisite for change is that the
behavior of concern must be defined in terms of measurable indicators.

Intervention should focus on influencing reinforcements or punishments for
client behaviors. Consistent and immediate reinforcement produces change
most rapidly.

Thoughts and feelings are behaviors subject to reinforcement principles.

The simplest explanations for behavior are preferred. Practitioners should
avoid reification (giving “life” to esoteric concepts such as the “ego”) and
searching for “ultimate” causes of behavior.

Behaviorists do not offer a theory of human development. They do ac-
knowledge, however, that genetic and biological factors are relevant to a person’s
sensitivity to stimuli and attraction to certain reinforcers. Knowledge of the per-
son, however, is only relevant to intervention insofar as it helps to specify envi-
ronmental circumstances that serve as significant reinforcers.

THE NATURE OF PROBLEMS AND CHANGE

All behavior is influenced by the same principles of learning, which include clas-
sical conditioning, operant conditioning, and modeling. These are described below. No
behavior is considered inherently healthy or unhealthy, or normal or abnormal.
It is all developed and maintained because of a person’s unique reinforcement
schedules. Reinforcement can be understood as any environmental feedback that
encourages the continuation of a behavior. An aggressive adolescent’s fighting
behaviors may be reinforced by his enhanced status within a peer group. Punish-
ment is feedback that discourages the continuation of a behavior. That same ado-
lescent’s aggression may be discouraged by a loss of driving privileges. Put
simply, a person’s behaviors change when the reinforcements in his or her

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environment change and are consistently applied. Intervention always involves
the rearrangement of a client’s reinforcements so that more desirable or func-
tional behaviors will result.

Classical Conditioning

Conditioning is a process of developing patterns of behavior through responses
to environmental stimuli or specific behavioral consequences (Kazdin, 2000).
The earliest behavioral research involved classical conditioning, in which an
initially neutral stimulus comes to produce a certain response after being paired
repeatedly with another stimulus. In Pavlov’s famous research with dogs, the
sight of food (the conditioned stimulus) naturally produced salivation (an invol-
untary response). A bell (the unconditioned stimulus) initially failed to evoke
salivation. However, after the bell was paired with the food, over time the
dogs salivated when presented with the bell alone. The bell at this point at-
tained the status of a conditioned stimulus because it was capable of producing
a response by itself.

Classical conditioning plays a role in understanding many problems that cli-
ents experience. For example, previously neutral cues, such as certain places (res-
taurants or bars), people, or feeling states (e.g., boredom) may become associated
with problem behaviors. A person who is accustomed to abuse alcohol when in
the company of friends at a particular location will be inclined to drink when at
that location, whether or not other incentives are present. Many anxiety-related
disorders are classically conditioned. For instance, a bite by a dog might general-
ize to a fear of all dogs. A series of stressful classroom presentations in grade
school might generalize to a person’s longstanding fear of public speaking or so-
cial interaction.

During intervention, the principles of classical conditioning are reversed.
For example, a client struggling with a drug problem may experience urges
to use when experiencing a particular emotion, such as boredom. The condi-
tional pairing between boredom and drug use may eventually lose its associa-
tion if the person abstains from using drugs to counteract boredom over a
period of time, and learns instead to manage boredom in a new way (for ex-
ample, with exercise, reading, or listening to music). For anxiety, fear-laden
situations such as those involving public speaking are often rank-ordered by
the client and practitioner according to the level of fear they invoke. Clients
learn to face each event or item on the list, starting with the least anxiety-
provoking, by learning to pair relaxation exercises rather than anxiety with
the event. Relaxation processes might include deep breathing, deep muscle re-
laxation, and visualization. In this process of systematic desensitization, a form of
exposure, a conditioned stimulus that usually produces a negative response (anx-
iety) becomes paired with a new, incompatible response (relaxation). Clients
work their way through the rank ordering of fears until they are no longer
plagued by the most disabling anxiety.

An essential issue with any kind of conditioning, and one that presents a
major challenge to behavioral practitioners, is that all significant other persons

150 C H A P T E R 7

in the client’s life must consistently support new reinforcement contingencies
over a period of time in order to sustain a long-term effect. If the client’s behav-
ior changes are reinforced by some persons (family, teachers) but not others
(peers, co-workers), those new behaviors may fade.

Operant Conditioning

The main premise of operant conditioning is that future behavior is determined
by the consequences of present behavior (Gambrill, 1994). The practitioner also
pays attention to the antecedent, or prior, conditions that may trigger the behav-
ior. Two types of reinforcement are postulated in this model: positive and negative.
Both positive and negative reinforcement encourage the continuation of a be-
havior. Positive reinforcement encourages the continuation of a behavior pre-
ceding it. For instance, alcohol use is positively reinforced by the resulting
feelings of well-being and pleasant social interaction with others. Negative rein-
forcement is the process by which an aversive event is terminated by the indivi-
dual’s behavior and, therefore, the behavior is reinforced. Alcohol use, for
example, is negatively reinforcing if it leads to escape from feelings of boredom
or sadness. Compulsive behaviors, such as overeating or substance abuse, are re-
inforced positively by the feelings of well-being that are created and the social
interaction with others involving the food or substance. (Similarly, positive and
negative punishment is distinguished by either adding a negative consequence
that eliminates a behavior, or eliminating a reinforcer that then eliminates the
behavior.) In practice, clients are helped to seek out behaviors that offer alterna-
tive reinforcements (that is, other activities such as relationships, work, or hob-
bies), so they will not be as prone to indulge in the problem behavior.

Operant conditioning principles can also be enacted when people assume
environmental control over the behavior of others. Parenting skills development of-
fers one example of operant behaviorism for parents of children with behavior
problems. Parents are taught to reinforce their children’s pro-social behaviors
and extinguish negative behaviors through either ignoring them or using punish-
ments (providing adverse consequences for the target negative behavior). An ex-
tended example of parenting skills development is provided later in this chapter.

Modeling

People also learn behaviors by modeling, or watching others engage in behaviors
and be reinforced or punished for them (Bandura, 1977). Modeling is a pervasive
means of learning for all people, but especially children and adolescents. For in-
stance, children may learn to act appropriately in school by seeing classmates
praised for listening to the teacher and criticized for talking while the teacher is
lecturing. Adolescents may begin using alcohol or acting aggressively because
they have seen their parents and other relatives act this way and be positively
reinforced for doing so. Along with didactic instruction and discussion, modeling
is a chief method of behavior change. In modeling, the practitioner shows the
client how to enact a new behavior. The client then practices the new behavior

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(called behavioral rehearsal), receiving supportive feedback and suggestions for its
refinement.

Covert modeling can also be used for intervention purposes. In covert
rehearsal, the social worker guides the client through a process of imagining the
completion of steps toward a successful outcome (Beck, 1995). For example, an
anxious client who must give a formal presentation may imagine herself
approaching the public-speaking situation with ease, and with the expectation
that she will do well. She visualizes and feels herself speaking in a confident and
calm manner, and receiving a warm reception from the audience. The practi-
tioner “walks” the client through this process, and then the client rehearses it
herself prior to and during the actual event. Though artificial, this helps the
client anticipate and manage the anxiety that he or she will experience during
each step.

Practitioners tend to prefer coping (satisfactory progress) rather than mastery
(perfection) approaches to behavior change through modeling and rehearsal.
Coping more openly manifests the struggles that a person might expect when
performing the new behavior, including the free expression of anxiety, hesita-
tion, and making errors. Clients identify more easily with a coping model (Hep-
worth, Rooney, Rooney, Strom-Gottfried, & Larsen, 2012). The social worker’s
rehearsal of new skills with clients is important because confidence to carry out
tasks is enhanced by practice.

To summarize, all situations in which people find themselves (except for
truly novel ones), “cue” or prompt behaviors based on principles of classical con-
ditioning (paired associations with certain aspects of the setting), operant condi-
tioning (prior experiences in similar situations), or modeling (watching others
behave and receive feedback). During the first day of a new academic year at a
new school, for example, a student may be inclined to socialize with classmates
based in part on conditioned positive associations of the classroom setting with
other peer situations. She may respond eagerly to the instructor’s questions due
to her anticipation of positive reinforcement for doing so. Finally, she will watch
how students behave in this new school to learn what other classroom behaviors
are reinforced by other students and the instructor.

The goal of behavioral intervention can be stated rather simply: to change
behavior. This is accomplished through the use of reinforcers and punishments.
The social worker helps the client achieve new, desirable behaviors by manipu-
lating the environment to alter reinforcement patterns or by providing new op-
portunities for positive modeling. For example, returning to the above scenario,
if a child behaves in school in ways that are disruptive to the classroom process,
the practitioner can devise a plan in which those negative behaviors are extin-
guished (punished) and new, more acceptable classroom behaviors are reinforced.
One of the challenges in behavior therapy is to identify the specific antecedent
conditions and responses that are reinforcing to the client from among the nu-
merous influences on the client’s behavior. A teacher’s displeasure with acting
out behaviors might serve as punishment to some students, but as reinforcement
to others.

152 C H A P T E R 7

ASSESSMENT AND INTERVENT ION

Assessment

The Social Worker/Client Relationship Although behavior therapy is highly
structured, the importance of a positive social worker/client relationship should
not be underestimated. The social worker needs to be perceived as competent,
caring, and trustworthy, because he or she will be encouraging the client to en-
gage in some behaviors that will feel uncomfortable or threatening. Further, the
behavior of both parties in the practice relationship is subject to the same condi-
tioning principles described above (Wodarski & Bagarozzi, 1979). The client will
be initially attracted to the social worker if their interactions result in less anxiety
and the practitioner is perceived as having the ability to secure rewards for the
client. The practitioner’s empathic understanding will facilitate these conditions.
The social worker must be careful not to use punishing behaviors with the client,
at least initially, as these tend to be alienating and result in a loss of his or her
perceived reinforcing potential. The social worker must be collaborative with the
client as they devise intervention strategies because the client needs to have a
strong investment in change strategies. Over time, the client will evaluate the
relationship on the basis of its rewards and costs relative to alternative behaviors
(such as different intervention approaches, a different social worker, or no inter-
vention at all), and the perceived likelihood of future rewards and costs. Regular
discussions about how the client is reacting to the intervention help to sustain his
or her sense of reward for participation.

After orienting the client to the principles of behavioral intervention, the
practitioner can perform a comprehensive assessment through functional behavior
analysis. First, the client’s problem behavior is specified as clearly and concretely
as possible. Next, the environmental conditions (cues) that enhance or maintain
the behavior are identified. Finally, the consequences of the behavior are con-
sidered. The practitioner asks questions of the client about cues that may occur
in each of five life domains that may be related to the problem situation: the
environmental, social, physical, cognitive, and emotional domains (Carroll,
1995).

Listed below are examples of the types of questions the social worker asks
during assessment (Bertolino & O’Hanlon, 2002):

When do you experience the behavior?

Where do you experience the behavior?

Who are you with when the behavior occurs?

How long does the behavior typically last?

What happens immediately after the behavior occurs? That is, what do you
do, or what does someone else do to or with you?

What bodily reactions do you experience with the behavior?

How long do these reactions last?

B E H A V I OR T H E OR Y 153

How often does the behavior typically happen (hourly, daily, weekly)?

What is the typical timing (of the day, the week, the month, or the year)
of the behavior?

What do the people around you usually do when the behavior is happening?

Table 7.1 includes a more detailed list of cues, behaviors, and consequences to
investigate in each of the five domains.

The ecobehavioral assessment (Mattaini, 2008) is similar to functional behavior
analysis in that it considers the client’s behavior in a broad context. It is different,
however, in that it uses an eco-map to illustrate the particular domains with
which a client interacts and focuses more on systems that are external to the cli-
ent. Figure 7.1 provides a simple eco-map of a young woman who is having
problems adjusting to living away from home at college for the first time. The
circles represent her particular environmental contexts, and the lines indicate
whether she is having positive or negative exchanges within those domains.

T A B L E 7.1 Five Domains of Behavior Analysis

Domain Antecedents (Triggers, Cues) Consequences (Reinforcers)

Environmental What people, places, and things
act as cues for the problem?

What people, places, and things
have been affected by the
problem?

What is the level of the
client’s day-to-day exposure to
these cues?
Can some of these cues be
easily avoided?

Has the client’s environment
changed as a result of the
problem?

Social With whom does the client
spend most of his time?

Has the client’s social network
changed since the problem
began or escalated?

Does he have relationships with
people who do not have the
problem?
Does he live with someone who
is involved in the problem?

How have his relationships been
affected?

Physical What uncomfortable physical states
precede the problem occurrence?

How does the client feel
physically afterward?
How is her physical health
as a result?

Emotional What feeling states precede the
occurrence of the problem?

How does the client feel
afterward?
How does she feel about
herself?

Cognitive What thoughts run through the
client’s mind, or what beliefs
does he have about the problem?

What is he thinking afterward?
What does he say to himself?

154 C H A P T E R 7

From these behavior assessments the practitioner determines the reinforcers and
triggers that are maintaining the problem behavior. This assessment leads to the
planning step, in which the practitioner and client construct concrete target behaviors
(goals) that include attention to the antecedent conditions and contingencies
required to bring about desired new behaviors. The success of the process mandates
that the client (and perhaps other relevant persons, such as a spouse, friend, or
teacher) agree to task assignments in which these new conditions are applied.

Intervention

The process of intervention in behavior theory is systematic, and includes the
following steps:

1. The client’s problems are stated in behavioral terms.

2. Measurable outcomes related to problem reduction are developed.

3. The practitioner and client gather baseline data (its current occurrence)
on the problem behavior.

4. The steps required to reach problem resolution are specified.

Family

Social
worker

Dormitory
life

Academic
schedule

Roommate

Close friends
at school

Close friends
at home

Client

F I G U R E 7.1 Eco-Map for an Ecobehavioral Assessment

ng
ag

e
Le

ar
ni

B E H A V I OR T H E OR Y 155

5. The client’s personal and environmental resources for making changes are
specified. Any other people who will participate in the intervention are
identified and sought out for consultation (often to act as reinforcers).

6. Possible obstacles to goal achievement are identified in advance, and plans
are made to minimize them.

7. An appropriate intervention strategy is chosen with the participation of the
client and with an emphasis on positive consequences for new behaviors. As
a rule, behavioral practice focuses on rewarding positive behavior rather than
punishing negative behavior whenever possible.

8. The practitioner, client, or other persons collect data about the client’s
activities. The client’s behavior changes are documented regularly.

9. The client and practitioner evaluate the intervention process regularly,
comparing baseline conditions to current “counts” of desired behavior.

10. The intervention ends after the client achieves his or her goals and
demonstrates the likelihood of goal maintenance.

Ending intervention in behavior theory is a process of fading. That is, after an
intervention has been under way for some length of time and the client has
acquired the desired new behaviors, any artificial supports (including meetings
with the practitioner and the reinforcement schedule) are gradually eliminated.

Applied Behavior Analysis

It is worth emphasizing here that a form of behavioral intervention known as
applied behavior analysis (ABA) has become a standard intervention for social work-
ers and others who work with children who have autism spectrum disorders. ABA,
which is focused on basic skills training, begins with the examination of the
antecedents of a child’s problem behavior and its consequences. Any avoidable
antecedents for a problem behavior are removed, and desirable behaviors are bro-
ken down into their component parts and introduced to the child. Positive rein-
forcement is then provided for each successful performance of a behavior. This
intervention is further distinguished by its intensity. Comprehensive interventions
for persons with autism include small-group or one-on-one behavioral and educa-
tional interventions that are delivered for at least 10 to 15 hours per week for a
significant period of time, ranging from months to years (Shattuck & Grosse, 2007).
ABA has been shown to facilitate improvements in clients’ adaptive, cognitive, and
language skills, as well as to reduce problem behavior (Seida et al., 2009).

SP IR ITUAL ITY AND BEHAVIOR THEORY

Because behaviorism is focused on concrete observable events, it gives no
particular attention to ideas related to spirituality or purpose in life. These topics
are often abstract and refer to a person’s internal belief systems, which are out
of the realm of the practitioner’s concern. Remember that the behavioral

156 C H A P T E R 7

practitioner is not concerned with any aspects of mental life except as they are
represented in external behavior. Behavioral social workers would not deny the
significance of spirituality in clients’ lives, but spiritual matters are relevant only
to the extent that they may serve as antecedent conditions or reinforcers in the
context of a presenting problem. A social worker might operationalize aspects of
a client’s spirituality (such as the number of church services attended or the
amount of time spent on goal activities that are intended to enhance personal
fulfillment) if the client articulates goals related to it. But the social worker
would not otherwise explore these concerns with a client.

ATTENT ION TO SOCIAL JUST ICE ISSUES

Behavior theorists argue that their methodology can be used effectively to pro-
mote a range of social justice issues. Wodarski and Bagarozzi (1979) write that
the behavioral practitioner can determine “what reinforcers social workers and
their clients possess that can be utilized to manipulate other individuals who
distribute such reinforcers as housing, medical care, and other social services”
(p. 264). The authors note that social workers themselves possess important
collective reinforcers, such as knowledge and resources. If politicians, for example,
do not agree to secure more adequate social conditions for certain disadvan-
taged groups in return for political support (positive reinforcement), an inter-
vention strategy might include punishment contingencies, such as
demonstrations, negative advertising, or supporting other candidates. Wodarski
and Bagarozzi describe a number of behavioral interventions with individuals
and small groups that have targeted social justice issues, including efficient
household energy consumption, trash control, and comfort with racial integra-
tion. More recently, Thyer and Wodarski (2007, 1998) describe behavioral
interventions for a variety of social problems, such as child maltreatment,
children with educational disadvantages, school violence, adolescent sexuality,
HIV disease, substance abuse, crime, unemployment, marital conflict and
domestic violence, race, older adult issues, chronic medical problems, and
hospice care.

While the term “manipulation,” as used in behavioral therapy, has a negative
connotation for many social workers (compared with “collaboration”), Gambrill
(1994) argues that many practitioners misunderstand the philosophical basis of
behaviorism. She writes that “behavioral methods, if effective, increase clients’
skills in influencing their environment (a large part of which may be provided
by other people), but they do not teach them to manipulate this environment
in an insidious or unfair way” (p. 56). She provides examples of intervention
that focus on empowering clients, including enhancing advocacy skills, and notes
that social skills training helps clients acquire interpersonal skills that can enhance
their advocacy potential.

Behaviorism requires that social workers become familiar with the life
experiences of oppressed and culturally diverse groups because they need to
understand each person’s unique set of reinforcers. Behavioral practitioners also

B E H A V I OR T H E OR Y 157

routinely use outside resources, such as information about resources and oppor-
tunities for new activities, to help clients learn and to change their behavior.
Thus it can be argued that behaviorism can be used in service to the values of
the social work profession (Thyer & Wodarski, 2007).

CASE ILLUSTRAT IONS

There are many behavioral interventions that the practitioner might select de-
pending on the client’s presenting problem, the client’s preferences, and the
time and resources available. Described below are two examples of behavioral
interventions, each of which incorporates several target strategies.

Mama’s Boy

In the coercive cycle of aggressive children, children and adults get caught up in a
pattern that tends to increase undesired behavior. The adult makes a request, the
child reacts with hostility, the adult in turn acts with hostility and withdraws, and
the child averts the request. Parent training, or parenting skills development, is a
model of operant behavioral intervention that teaches parents to apply the prin-
ciples of reinforcement to change their children’s behavior and break these frus-
trating patterns. Parents learn to reinforce desirable behaviors in their children
and ignore or punish negative behavior. The interventions can be provided in
individual, family, or group formats. Successful parenting skills development in-
volves the following steps:

Parents select a priority goal related to the child’s behavior.

Goals are broken down into smaller, observable components, called tasks.

Tasks are specified to encourage the presence of positive behavior,
rather than the absence of negative behaviors.

A baseline measure of the desired behavior is determined (in numbers).

A target goal is established.

Ms. Rosman was participating in a parenting skills development program
because her 10-year-old son, Andy, would not do his homework, and he also
engaged in disruptive behaviors at bedtime. In order to determine a reasonable
target for the desired behaviors, the baseline, or current occurrence of the beha-
viors, must be determined. Its occurrence can be measured in different ways:
through its frequency (Ms. Rosman said that Andy never did his homework, so
his baseline would be zero) or duration (Ms. Rosman observed his behavior for a
week and said that Andy showed “appropriate homework behaviors” for only
two minutes at a time).

The behavioral term shaping refers to reinforcing successive approximations
of a desired behavior to eventually meet a goal that is initially out of reach for a
client. In parenting skills development, the practitioner may provide parents with

158 C H A P T E R 7

a handout on command giving, which includes the following points (Webster-
Stratton, 2001):

Only use commands that are necessary; giving too many different commands
may confuse, agitate, or alienate the child.

Issue only one command at a time.

Issue clear and specific commands (“Look both ways before you cross the
street”) rather than vague warnings (“Be careful” or “Watch out”).

Issue statements (“Please clean up your toys and put them in the box”)
rather than questions (“Why don’t you pick up your toys?”) or “Let’s”
commands (“Let’s clean up the toys”), unless the parent plans on being a
permanent part of the effort.

Phrase commands as to what the child should do (“Please play in the kitchen
rather than in the living room”) rather than on what the child should not
do (“Don’t play in the living room”).

Keep commands brief (do not lecture).

Praise compliance with a command.

Preferred reinforcement systems include the use of high-probability beha-
viors, social reinforcement, and token economies. High-probability behaviors are
those in which children frequently engage, such as playing outside, talking on
the phone, using the Internet, playing video games, and watching television. So-
cial reinforcements include interpersonal rewards such as praise, hugs, pats on the
shoulder, a smile, a wink, or a thumbs-up sign.

With Ms. Rosman, the social worker provided education on the benefits of
praising her child. They went down a list of “things to do” and “things not to do”
(Webster-Stratton, 2001) that demonstrated how Ms. Rosman could enact the
principles of praise with Andy. The list of “things to do” included the following:

Describe specifically what he does to deserve praise.

Pair verbal praise with eye contact, a smile, or physical affection.

Praise effort and progress rather than total achievement.

Praise his positive behavior immediately after it is performed.

The list of “things not to do” included:

Use unlabeled praise (global statements about Andy, such as “What a
good boy!”).

Couple praise and criticism (“You did a good job washing the dishes,
but why can’t you dry them right?”).

Wait too long after the behavior to praise him.

Take any feelings of awkwardness as a sign to stop praising.

Another type of reinforcement system to use with children involves token
economies (Barkley, 2000). A token economy involves the use of tangible

B E H A V I OR T H E OR Y 159

reinforcers, such as chips, coins, tickets, stars, points, stickers, or check marks, for
desirable behaviors that are earned, compiled, and then traded for an agreed-
upon reward.

Punishment involves the presentation of negative events (e.g., physical disci-
pline, harsh words, criticism) or the removal of positive events (e.g., privileges)
that decrease the occurrence of a response. These can be effective, although
parenting skills development experts recommend that positive reinforcements
be provided at three times the ratio of punishments (Barkley, 2000). The defini-
tion of extinction involves no longer reinforcing a behavior, resulting in a decrease
or eradication of the behavior. Kazdin (2000) states that before undertaking ex-
tinction, it is important to understand the reinforcer that is maintaining the be-
havior with some certainty, and whether it can be controlled. When applying
extinction to a particular behavior, one must first examine its function. In
Ms. Rosman’s situation, Andy engaged in disruptive behavior at bedtime to pro-
long his time awake and to get special attention from his mother. The social
worker told Ms. Rosman about the importance of being consistent, and to
ignore Andy’s behaviors every time they occurred. She was also asked to practice
in the session, after watching the practitioner model them, appropriate behaviors
during a child’s tantrum, such as looking away, maintaining a neutral facial
expression, and avoiding any verbal or physical contact.

Time-out, or isolation, is a form of punishment that involves physically re-
moving a child from the source of reinforcement for a brief period (Hodges,
1994). The time-out should be structured around a certain amount of time,
observing the general guideline of one minute per year of the child’s age. Its
purposes are to extinguish the negative behavior through punishment, help the
child calm down, and help the child understand why the behavior is unaccept-
able. It is important to follow a time-out with a time-in activity, which could be
either a supportive conversation with the parent or re-engagement in a previous
activity that the child enjoys.

The location for a time-out should be free from reinforcement; there should
be no activities available, and the child is to do nothing. Ms. Rosman said that
she could move a stool for Andy to the front hallway of their home for a time-
out, although he could see other family members in the living room from there
and might call out to them. The social worker reminded Mrs. Rosman that
Andy’s attempts to engage family members in annoying behaviors should be
ignored. If Andy’s disruptive behaviors escalated there, the time-out period
should resume only after he got his behavior under control. The time-out should
end with the child’s being reminded why he was punished, and with a resumption
of normal activities so that the child has an opportunity to feel good again and
perhaps show that he can behave appropriately.

Parents must be warned that they will likely experience an initial increase in
the undesirable behavior when they first begin employing extinction techniques.
The social worker advised Ms. Rosman to take the inevitable “extinction burst”
as a sign that the technique was working. She was assured that Andy’s behavior
would improve and that gains would last if Ms. Rosman consistently ignored any
recurrence of the undesirable behaviors. She was reminded to pair her extinction

160 C H A P T E R 7

behaviors with positive reinforcement for appropriate behaviors. Ms. Rosman
worried that ignoring “bad” behavior seemed to implicitly encourage it. The
social worker emphasized that refusing to give in to the behaviors would help
Andy learn over time that they had no effect. If reinforcement of desirable
behaviors and ignoring undesirable behaviors didn’t stamp out the problems,
then they would consider using punishments.

The technique of distraction, paired with ignoring negative behavior, can be
effective with young children (Webster-Stratton, 2001). For instance, if a young
child cries because he wants to play with the television remote control, then
rather than shouting at him, the parent could take the remote control away
and divert his attention to a brightly colored ball: “Here’s something else you
can play with. See if you can catch it!” Distraction helps to avoid arguments
about a parental command.

This example of parenting skills development incorporates a number of op-
erant behavior intervention principles, as well as modeling. Ms. Rosman was able
to help her son make some improvements in his homework behavior as a result
of their ongoing application, with occasional directives from the social worker.

Another common behavioral intervention with children and adolescents is
social skills development. It was not used in the illustration above, but is worth
summarizing here. Social skills development is simply a process of teaching clients
how to engage in socially appropriate behaviors. An assumption of the technique
is that the client is capable of improved social behavior, but, due to a lack of
learning or a reinforcement of antisocial behaviors, does not currently practice
it. It is associated with social learning theory, briefly mentioned earlier, because
of its use of modeling. Social skills development involves a series of steps, each of
which must be thoroughly addressed before moving to the next one:

1. Through assessment, determine what skill the client wants or needs.

2. Describe the skill and its utility to the client.

3. Outline all parts of the skill separately (there may be more parts than you
first think).

4. Model the skill for the client.

5. Role-play each part of the skill with the client.

6. Evaluate the role-plays.

7. Combine the parts of the role-plays into a full rehearsal.

8. Encourage the client to apply the skill in real-life formats.

9. Evaluate and refine the skill.

The following example of intervention with an older adult includes strate-
gies related to classical conditioning.

The Smart Shopper

Systematic desensitization was described earlier as a process by which a client
gradually overcomes his or her anxieties by confronting them in a series of steps,

B E H A V I OR T H E OR Y 161

from less to more challenging. It is a type of exposure therapy (another type is
flooding, in which the client is overwhelmed with a feared object or situation in
order to learn that he or she can tolerate it). This behavioral intervention
technique was helpful to Mr. Tucker, an older adult who had developed panic
disorder with agoraphobia. Mr. Tucker was a 72-year-old widower, living alone
in a small house that he had shared with his wife for more than 40 years prior to
her death three years previously. His son, living in a nearby city, had become
concerned about Mr. Tucker’s well-being, noticing that he was isolating himself
at home and not tending to his physical health. The previously robust man
appeared to be malnourished and physically weak, and his diabetes was going
unattended. His son initially thought that Mr. Tucker’s condition was related
to grieving the death of his wife, but his father had by now achieved a stable
mood, even as his avoidant behaviors were increasing.

Natalie, a middle-aged social worker born in Brazil, was assigned to work
with the client. She agreed to make home visits and assessed Mr. Tucker as
having an anxiety disorder, concluding that through a process of classical condi-
tioning, he had become fearful of being outside the house. Mr. Tucker had been
a healthy working man most of his adult life, putting in long hours at a printing
company and leaving most domestic responsibilities to his wife. Mrs. Tucker de-
veloped breast cancer in her mid-60s and experienced a slow decline until her
death four years later. Mr. Tucker dutifully cared for his wife during the illness,
assuming such responsibilities as grocery shopping and escorting his wife to her
doctor’s appointments.

As his wife’s condition worsened, Mr. Tucker understandably became more
upset. He came to associate his relatively new activities of going to the doctor’s
office and shopping with feelings of fear. After his wife’s death, as he adjusted to
living alone, Mr. Tucker continued to associate common activities of daily living
outside the home with his anxiety states. Mr. Tucker gradually stopped going
outside, except for rare instances when he felt it absolutely necessary to purchase
household supplies. He welcomed friends and family into his home, and was
clear-headed and personable there. But because he was an aging man who would
not attend to his physical needs, his health was suffering.

Natalie’s functional behavior analysis of Mr. Tucker’s anxiety revealed that
his avoidant behaviors were primarily related to environmental cues, and his re-
sponses featured physical symptoms such as nausea, dizziness, and mild hand
tremor. Following the social worker’s education of Mr. Tucker about the ratio-
nale underlying systematic desensitization, the client agreed to work toward
overcoming his panic disorder. It should be emphasized that Mr. Tucker’s
isolative lifestyle was also being reinforced through operant conditioning, as his
family and friends indulged his requests to visit him at his home rather than
expect him to venture outdoors. Still, Natalie identified the desensitization
strategy, to work against his classically conditioned panic reactions, as having a
strong potential for success.

The social worker invited Mr. Tucker to select specific activities as a focus of
their intervention. He chose grocery shopping and going to the doctor’s office
for check-ups, with the former activity as a starting point, thinking he would

162 C H A P T E R 7

have a better chance of success. Mr. Tucker articulated a goal of being able to go
shopping independently for all of his groceries once per week. He and Natalie
constructed a list of 10 tasks associated with grocery shopping. They included
making a shopping list, searching the day’s newspaper for coupons, getting into
the car and driving onto the road, driving to the outskirts of the neighborhood,
driving past the grocery store, driving into the lot and parking, walking from the
car to the store, selecting a pushcart and walking through the store, selecting
items for purchase, and paying at the cash register. Mr. Tucker opted to address
the tasks in sequence, beginning with the first task. Natalie suggested that Mr.
Tucker select a time of day when he felt most able to tolerate these tasks. The
client chose early morning, when there would be fewer people on the roads and
in the store. Natalie also suggested that Mr. Tucker consider asking his son to
go to the store with him during his first attempts. The client agreed that this
would be helpful.

Before Mr. Tucker addressed the first task on the list, Natalie taught him a
relaxation technique and rehearsed it with him at some length. A client needs to
feel calm when approaching a stressful activity, and must be able to relax during
the activity if anxiety escalates (Meichenbaum & Deffenbacher, 1988). If this
process is successful, the client will begin to dissociate the task from the anxiety
and fear that had been paired with it. Relaxation techniques are often used by
themselves to help clients manage certain types of anxiety, such as that which
contributes to insomnia. Natalie helped Mr. Tucker master a basic natural
breathing technique that includes the following steps (Davis, Eshelman, &
McKay, 2008):

1. Sit comfortably and close the eyes.

2. Breathe through the nose.

3. At a pace that is slow but comfortable, gradually inhale, concentrating in-
ternally on how the lower third, middle third, and upper third of the lungs
are filling with air.

4. When inhalation is complete, hold the breath for a few seconds.

5. Exhale slowly, pulling in the abdomen as the air leaves the lungs.

6. Relax the abdomen and chest.

7. Repeat the technique up to five times, to achieve mastery.

It is crucial that the client has mastery of the relaxation technique and be
able to use it in “abbreviated” form in public situations prior to confronting
anxiety-provoking situations. In the final step in preparation, the social worker
reminds the client not to expect complete success on the first attempts at task
completion (Thyer & Bursinger, 1994), as confronting one’s fears is never easy.
This helps prevent the client from becoming demoralized if he experiences diffi-
culty. The practitioner assures the client that he can terminate an activity at any
time if it seems overwhelming. If the client is unable to successfully complete a
task, the practitioner takes responsibility for the failure (due to initiating a step
prematurely or to inadequate preparation) and then moves to an easier task for

B E H A V I OR T H E OR Y 163

the client. Finally, the client is helped to identify rewards for successful task com-
pletion. This builds operant reinforcement into the process. Mr. Tucker, an avid
music listener, decided to treat himself to a CD from his mail-order music club
following his successful completion of two “repetitions” of a task.

Systematic desensitization interventions often work relatively quickly (Thyer &
Bursinger, 1994). Positive results often occur by the third or fourth session
(although each session may be several hours long, depending on particular cir-
cumstances). The social worker is intensively involved during the early stages,
in person or perhaps by phone, to “coach” the client and revise steps as neces-
sary. Mr. Tucker was able to achieve his goal of weekly shopping trips within
three weeks. He had the most trouble with the step of walking into the store
and selecting a pushcart. His son accompanied him to the grocery store three
times before Mr. Tucker was able to follow through with that step. Natalie
reviewed the client’s physiological reactions that accompanied those failures
and helped Mr. Tucker practice the relaxation technique until he felt relief
from those reactions. Mr. Tucker’s son was also present for the client’s first
two successful shopping trips before removing himself from the process.

Mr. Tucker accomplished his second goal of keeping doctor’s appointments
more quickly, his confidence bolstered by the earlier success. The social worker
then “faded” from Mr. Tucker’s life, gradually reducing the frequency of his
visits, and finally keeping contact with occasional phone calls until the client
was able to maintain his behaviors independently. Natalie felt that Mr. Tucker’s
achievements would generalize to other areas of his life outside the house, and
that he no longer experienced symptoms of an anxiety disorder.

EV IDENCE OF EFFECT IVENESS

Behavioral interventions maintain popularity among practitioners, administra-
tors, and third-party payers because their effectiveness is often supported by
quantitative research methodologies. We must recognize, however, that some
other theoretical perspectives do not lend themselves as easily to experimen-
tal, quasi-experimental, and single-subject research designs. Psychodynamic
practitioners, as we have seen, place a higher value on case studies and qual-
itative studies of outcome. Thus, though behavior theory cannot necessarily
claim superiority on this basis (although its proponents might do so), its ef-
fectiveness in many instances can be concretely demonstrated. In this section
we will review the findings of experimental and quasi-experimental research
studies.

In Chapter 1, we reviewed the American Psychological Association’s criteria
for well-established and probably efficacious clinical interventions. Chambless and
Ollendick (2001) have compiled a list of empirically validated behavioral treat-
ments using those criteria. Well-established interventions have been documented
for persons with agoraphobia, panic disorder, generalized anxiety disorder, post-
traumatic stress disorder, social anxiety, major depression, anorexia, sexual

164 C H A P T E R 7

dysfunction related to anxiety, behavioral problems related to dementia, behav-
ioral problems related to schizophrenia, family stress when one member has
schizophrenia, attention-deficit hyperactivity disorder, encopresis, and enuresis.
Probably efficacious behavioral interventions are documented for persons with
blood injury phobia, specific phobia, alcohol abuse and dependence, cocaine
abuse, opioid dependence, chronic pain, headache, smoking cessation concerns,
avoidant personality disorder, anger control problems, obesity, and other
conditions.

Other literature reviews add detail to the above findings. Two meta-
analyses concluded that the most effective treatment for ADHD in children is
medication in combination with behavioral interventions (specifically including
negative reinforcers) to improve the appropriateness of social behaviors
(Hinshaw, Klein, & Abikoff, 2002; Turchiano, 2000). A systematic review of
interventions for obsessive compulsive disorder in children and adolescents
found that behavioral methods were as effective as drugs (O’Kearney, Anstey,
von Sanden, & Hunt, 2006). As one example, a seven-week group interven-
tion for persons with the disorder, which focused on exposure and relaxation
for improved self-control, significantly improved participant ratings of obses-
sion, compulsions, and depression (Himle et al., 2001). A review of 24 studies
of intervention for social phobia concluded that exposure in combination with
cognitive restructuring (described in the next chapter) produced the best outcomes
compared to waiting list, placebo, and cognitive restructuring alone (Taylor,
1996). For persons who experience panic disorder, behavioral interventions were
as effective as anti-depressant medications in 23 randomized trials, although a
combination of the two strategies was even more effective (Furukawa, Watanabe,
& Churchill, 2007). A meta-analysis of treatments for sleep problems concluded
that behavior therapy produces greater sleep quality over time than drug therapy
(Smith et al., 2002). Similar results have been found with regard to insomnia in
older adults (Pallesen, Nordhux, & Kvale, 1999) and bedtime refusal and night
waking in young children using extinction and prevention strategies (Mindell,
1999).

Behavioral interventions are often used with children who demonstrate
problem behaviors. A review of 12 parenting skills development programs indi-
cates that these programs have short-term positive effects on antisocial behavior
in children, although long-term effects are not as clear (Furlong et al., 2012).
A meta-analysis of 32 treatment programs in Europe found that behavioral and
cognitive behavioral programs reduced the recidivism of juvenile and adult
offenders by twelve percent (Redondo, Sanchez-Meca, & Garrido, 1999). A sys-
tematic review of 11 studies demonstrated the effectiveness of media-based (self-
instructional manuals, DVDs, etc.) interventions for parents to use with children
with behavior problems (Montgomery, Bjornstad, & Dennis, 2006). Behavioral
interventions have also been found to be effective in reducing selective mutism
(Pionek-Stone, Kratochwill, Sladezcek, & Serlin, 2002).

To provide more details about what interventions may be used effectively in
behavior theory, we will look at four recent meta-analyses. In one such review of
51 studies of the treatment of insomnia, effective behavioral interventions included

B E H A V I OR T H E OR Y 165

relaxation strategies, improved sleep hygiene (implementing conducive lifestyle
habits), and sleep scheduling activities (learning to associate the bedroom with sleep,
and restricting the amount of daytime sleep) (Irwin, Cole, & Nicassio, 2006). A
review of 30 studies of behavioral marital therapy found that relationship improve-
ments were associated with the development of communication, problem solving,
emotional expressiveness skills, desensitization to negative emotional reactions,
and contingency contracting (each member agreeing to perform certain desired ac-
tivities for the other) (Shadish & Baldwin, 2005). A review of 30 studies of the use of
vouchers or money-based incentives for substance abusers, contingent on their
satisfying predetermined therapeutic goals (generally abstinence, staying in treat-
ment, medication compliance, and workplace productivity), found that modest
monetary incentives given immediately after completion of the desired behavior
were effective (Lussier, Heil, Mongeon, Badger, & Higgins, 2006). Finally, a review
of 194 studies about the effectiveness of HIV-prevention interventions (appropriate
use of condoms) found that active (behavioral) interventions were far more effective
than passive (informational) ones (Albarracìn et al., 2005). The most effective behav-
ioral interventions included role-plays, learning to apply condoms, regularly taking
HIV tests, and sexual self-management strategies.

CR IT IC ISMS OF THE THEORY

Behavior therapy has been described as empowering because it educates clients
about processes of change that can be generalized (Cooper & Lesser, 2002), but it
has been criticized for not adequately attending to the broad biopsychosocial-
spiritual perspective on human behavior (Nichols, 2009). It is sometimes seen as
dehumanizing, overlooking aspects of life that may be important to the client
(Payne, 2005). A second criticism of behaviorism is that its interventions rely
on a “controlled environment” in which a client’s reinforcements (or punish-
ments) must be consistently applied to create and sustain new behaviors (Allen-
Meares, 1995). It is often difficult for social workers to plan for and monitor such
consistency of reinforcement when a client interacts with many people in many
life domains. A child who demonstrates aggressive behavior may be reinforced
for alternative behaviors at home or at school, but with his friends, the aggression
may still be reinforced. Behavioral practitioners work hard to establish effective
reinforcement schedules but are rarely able to engage all relevant persons in the
process. Finally, it is difficult to isolate the significant antecedents and reinforcers
that surround many problem behaviors (Walters, 2000b). Is a man’s reluctance to
get out of bed in the morning a consequence of his wife’s verbal comments the
day before, his anticipation of his boss’s comments at work that day, or some-
thing else? We are commonly unaware of the range of stimuli and reinforcers
that govern our behaviors. At times these are discoverable, but they can also
remain unclear. For these reasons, behaviorism, while an effective intervention
for many client problems, has fallen short of its original goal to become a
generalizable science of human behavior.

166 C H A P T E R 7

SUMMARY

Behavior theory offers an approach to direct practice that focuses on observable,
concrete client behaviors and outcomes, rather than internal mental processes. It
provides a potentially effective basis for social work practice, particularly among
children and other client populations with a limited potential for abstract thought.
Some social workers do not consider behaviorism a practice “theory” because it is
purely focused on stimulus-response issues (Thyer & Wodarski, 2007). Though it
certainly has a “Spartan” conceptual basis, behaviorism does incorporate ideas
about the nature of problems and change. Behaviorism is preeminent among
practice theories in its attention to empirical research on its effectiveness. Though
often criticized by social workers for being overly reductionistic, its emphasis on
monitoring human action has been adapted within other theoretical perspectives.
When practiced by social workers, behavior theory is often combined with
cognitive theory, which is the focus of the next chapter.

TOPICS FOR DISCUSSION

1. Some behavioral practitioners argue that a major strength of their approach
is its not being a theory at all. That is, by limiting their focus to questions of
stimulus and response, they avoid abstractions inherent in other practice
approaches that lack validity. Review the definition of practice theory given
in Chapter 1 and decide whether, in your view, behaviorism qualifies as a
theory. As you discuss this topic, consider whether any conceptual processes
are required of a practitioner when identifying certain phenomena in clients’
lives as “stimuli” and “responses.”

2. Do you think that behavioral approaches are reductionistic—that they fail to
elicit aspects of social functioning that may be important to clients? Can a
behavioral practitioner organize his or her work to show an appreciation for
the “whole” person?

3. Behaviorists assert that interventions should focus, when possible, on rein-
forcing rather than punishing behaviors. Why is this? Think about client
populations such as substance abusers or aggressive children. How can social
workers develop interventions that reinforce certain client behaviors while
extinguishing others?

4. Recall any clients you have worked with or observed in the past in the
context of the five domains of behavior analysis in Table 6.1. How would
your client’s responses to the various questions have helped you to devise a
focused behavioral intervention?

5. What values, if any, are inherent in behaviorism? Do you think that it can be
used in the service of social justice? Discuss some clients you have worked with
who faced oppressive circumstances, and whether behaviorism could have
offered (or did offer) them the capacity to better confront those problems.

B E H A V I OR T H E OR Y 167

IDEAS FOR ROLE-PLAYS

(The instructor and students should fill in the details of these vignettes however they deem
appropriate.)

1. Role-play an intervention with a grade school or middle school student
who is frequently in trouble for aggressive behavior with peers and teachers
in the schoolyard before school, at recess, and after school. The student does
not behave aggressively in the classroom. Be specific in the assessment about
determining target behaviors and goals.

2. Select a type of client with one or more behavior problems that all students
can use for small group (or one large group) role-plays. As usual, include the
social worker, client, and observer roles in each group. Perform an assess-
ment that is based on the five domains of behavioral assessment. After the
role-plays, compare how the social workers were able to get the information
needed from the client, or perhaps the client’s significant others.

3. Select one or more examples from students’ field placements of clients
whose presenting problems are described as more “emotional” than behav-
ioral (such as depression, anger, guilt, or a desire for greater closeness with a
spouse or partner). Role-play the first session to see how a behavioral prac-
titioner would attempt to orient the clients to the behavioral approach, and
develop appropriate goals and objectives for intervention.

APPENDIX: Behavior Theory Outline

Focus Observable behavior

Reinforcements

Punishments

Principles of conditioning (modeling, classical, operant)

Major Proponents Pavlov, Watson, Skinner, Thomas, Thyer, Wodarski, Mattaini

Origins and Social Context Experimental psychology

Interventions with children and other non-cognitively-
oriented populations

Empiricism (emphasis on observable evidence)

Parsimony (simple vs. complex explanations)

Avoidance of “reification” (giving substance to abstract
ideas)

Distrust of “inferences” about mental activity

Nature of the Individual Genetic and biological factors are relevant

Trait theory

168 C H A P T E R 7

Human nature is to seek pleasure and avoid pain

All behavior is accounted for by contingencies of:

Survival

Reinforcement

Social evaluation

Thoughts and feelings are behaviors in need of
explanation

No behavior is pathological by nature; it is all influenced
by the same principles

Developmental Concepts None

Nature of Problems Reinforcement of negative behavior

Nature of Change Changing or adjusting reinforcers (reconditioning)

Concrete measurement of behavioral responses

Goals of Intervention Develop new, desirable behaviors via new reinforcement
patterns

Nature of Worker/
Client Relationship

Worker must be trustworthy, demonstrate positive
regard, be collaborative

Intervention Principles
and Techniques

State problems in behavioral terms

Establish clear, measurable objectives

Gather baseline data

Specify steps toward problem resolution

Specify personal and environmental resources

Identify relevant significant others for participation

Identify possible obstacles in advance

Interventions (emphasize positive consequences)

Modeling

Behavioral rehearsal (includes role-playing)

Reinforcement control (positive and negative)

Stimulus control (rearranging antecedents)

Systematic desensitization

Shaping

Overcorrection

Relaxation training

Collect data

Document changes over time

APPENDIX: Behavior Theory Outline (Continued)

B E H A V I OR T H E OR Y 169

Assessment Questions Is the client’s problem stated specifically?

Can the problem be translated into concrete behaviors?

Is the client motivated to work actively on the problem?

What reinforcers tend to be most influential in the
client’s life?

What persons are available to assist the client in problem
resolution?

What resources can the client mobilize to resolve the
problem?

How can the client’s behaviors be measured over time?

APPENDIX: Behavior Theory Outline (Continued)

170 C H A P T E R 7

Cognitive Theory

The brain is wider than the sky,
For, put them side by side,

The one the other will include
With ease, and you beside.

The brain is deeper than the sea,
For, hold them, blue to blue,
The one the other will absorb,

As sponges, buckets do.*

You are driving down the interstate, 10 miles over the speed limit. Suddenly
you see flashing lights and hear the siren of a police car behind you. How

do you feel? Scared! You pull over. The police car proceeds to follow the car
that was in front of you. Now you feel relieved, even happy. What changed?
The police car was always following the car in front of you. What changed
was the nature of your thoughts about what you had observed.

Many behavioral practitioners eventually turned their attention to clients’ inter-
nal interpretations of events as they respond to stimuli and reinforcers. Social learning
theory (Bandura, 1977) was instrumental in developing the concept of cognitive media-
tion, defined as the influence of one’s thinking between the occurrence of a stimulus
and response. Learned patterns of evaluating environmental stimuli help to explain
why each of us adopts unique behaviors in response to similar stimuli. This and other
developments in the cognitive sciences (described below) accounted for the devel-
opment of cognitive theory in social work practice. This approach is consistent with
behaviorism in many ways and, as we shall see, the two theories can be used together.

* Dickinson, E. (1927). The Pamphlet Poets. New York: Simon and Schuster.

171
Copyright 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights,

Cognitive theory for clinical practice emerged in the 1960s and continues to
be a popular and effective basis for intervention by social workers. It is quite
different from the ego and relational theories in its assertion that conscious thinking
is the basis for most human behavior and emotional experience. It is different
from behavioral theory in its focus on internal mental processes. Whereas some
of these processes might be categorized as unconscious (or preconscious), they are
presumed to maintain a minor influence on behavior and can readily be brought
to the surface with reflection or the social worker’s probing (Lantz, 1996).

Cognitions include our beliefs, assumptions, expectations, and ideas about the
causes of events, attitudes, and perceptions in our lives. Cognitive theory postulates
that we develop habits of thinking that form the basis for our screening and coding
of environmental input, categorizing and evaluating that experience, and making
judgments about how to behave. Emotions are defined within this theory as physi-
ological responses that follow our cognitive evaluation of input (Lazarus & Lazarus,
1994). Thus, thoughts occur prior to most emotions, and, in fact, produce them.

The relationship between thoughts, feelings, and behaviors can be summa-
rized as follows (Beck, 1995):

An activating event—produces a belief or thought—that produces an
emotion or action.

Cognitive interventions are focused on enhancing the rationality of a client’s
thinking patterns, the degree to which conclusions about the self and the world
are based on external evidence, and the linear connections among a person’s
thoughts, feelings, and behaviors.

ORI GINS AND SOCIAL CONTEXT

Cognitive theory is consistent with trends in American thought that have existed
since the late 1800s. It did not work its way into the helping professions, how-
ever, until the 1950s. Its influences included developments in American philoso-
phy, information processing theory in the computer sciences, and social learning
theory in psychology.

Pragmatism and Logical Positivism

American philosophers have always tended to evaluate ideas pragmatically, with
reference to practical applications, compared to their European cohorts (Kurtz,
1972). One example is John Dewey (1938), the most influential American prag-
matist of the early 20th century who, as described in Chapter 3, also influenced
the development of person-centered theory. He wrote that when a person’s
experiences present challenges to understanding, the natural response is to initiate
a process of problem solving, or “inquiry.” Dewey maintained that ideas are

172 C H A P T E R 8

arrived at through plans of action that are evaluated for “truth” by their expected
consequences. His work influenced the systematic procedures seen in the
problem-solving model, described later in this chapter. Logical positivism was an-
other major philosophical movement that became prominent in the United
States in the 1930s (Popper, 1968). Focused on language, the positivists per-
ceived the task of philosophy to be analysis and clarification of meaning, and
they looked to logic and the sciences as their models for constructing formally
perfect languages. The positivists’ verifiability principle maintained that a statement
was meaningful only if it was empirically verifiable. They were critical of ideas
that could not be tested, and these ideas influenced theorists from other fields
who became concerned with verifiability.

Information Processing Theory

The advance of computer and information technology was particularly influen-
tial on the development of a “science of cognition” in the social sciences (Bara,
1995). Human service practitioners became interested in how people processed
information and in correcting cognitive “errors.” In retrospect, these ideas may
seem like rather simplistic accounts of how the mind works, but they emerged at
a time when little was understood about the functioning of the nervous system.

Information processing theory maintains that there is a clear distinction be-
tween the thinker and the external environment (Ingram, 1986). People receive
stimulation from the outside and code this with sensory receptors in the nervous
system. The information is then integrated and stored for the purposes of present
and future adaptation to the environment. We develop increasingly sophisticated
problem-solving processes through the evolution of cognitive patterns that en-
able us to attend to particular inputs as significant. Information processing is a
sensory theory in that information from the external world flows passively inward
through the senses to the mind. The mind is viewed as having distinct parts,
including a sensory register, short-term memory, and long-term memory, which
make unique contributions to our thinking in a specific sequence.

Information processing theory eventually gave way to motor theories, in
which the mind is thought to play an active role in processing input, not merely
recording but also constructing its nature. This was augmented, in turn, by mod-
els of the mind as engaging in parallel processes, organizing multiple activities in
perception, learning, and memory while it receives external information. That is,
the mind is interactive with its environment.

Personal Construct Theory

The American psychologist George Kelly introduced a theory of personality in
1955 in which a person’s core tendency is to attempt to predict and control the
events of experience (Maddi, 1996). He described the essence of human nature
as the scientific pursuit of truth—an engagement in empirical procedures of for-
mulating hypotheses and testing them in the tangible world. This “truth” is not
absolute, but represents a state in which perceptions are consistent with our

C O G N I T I V E T H E OR Y 173

internal construct system. Constructs are interpretations of events arrived at
through natural processes of reasoning. Kelly asserted that the only important
difference between laypersons and professional scientists is that the latter are
more self-conscious and precise about their procedures.

Kelly’s model of the “person as empirical scientist” influenced the ideas of cog-
nitive theorists who followed him. These included Leon Festinger and cognitive dis-
sonance theory, Seymour Epstein’s hierarchical organizations of personal constructs, and
David McClellan’s explorations of motives, traits, and schemas. All of these theorists,
in turn, had direct influence on the psychotherapies of Albert Ellis and Aaron Beck.

Albert Ellis and Aaron Beck

Albert Ellis was the first cognitive therapist, publishing Reason and Emotion in Psy-
chotherapy in 1962. He believed that people can consciously adopt principles of
reasoning, and he viewed the client’s underlying assumptions about himself or her-
self and the world as targets of intervention. The major theme of Ellis’s work is that
our understandings of how we need to conduct ourselves to maintain security are
often narrow and irrational. Behind most distressing emotions, one can find irra-
tional beliefs about how things should or must be. Ellis’s therapy involved helping
people become more “reasonable” about how they approached their problems.
He was known to be a confrontational practitioner, actively persuading clients
that some of the principles that they lived by were arbitrary and unrealistic.

Cognitive therapy became a more prominent practice theory with the publica-
tion of Aaron Beck’s Cognitive Therapy and the Emotional Disorders in 1976. Beck had
been trained as a psychoanalyst and was interested in the problem of depression. He
initially attempted to validate Freud’s theory of depression as “anger turned toward
the self.” Instead, his observations led him to conclude that depressed people main-
tain a negative bias in their cognitive processing. He conceptualized this negativism
in terms of cognitive schemas—memory structures made up of three basic themes of
personal ineffectiveness, personal degradation, and the world as an essentially un-
pleasant place. Beck was less confrontational than Ellis, seeing clients as “colleagues”
with whom he examined the nature of “verifiable” reality.

In the past 50 years, many cognitive practitioners have integrated techniques
from cognitive theory with strategies from other approaches. As one prominent ex-
ample, Meichenbaum’s work (1977) combined cognitive modification and skills
training in a therapy model that is useful in treating anxiety, anger, and stress.

Cognitive Theory in Social Work

Social workers have been using cognitive theory extensively for more than
30 years. Reid and Epstein’s (1977) Task-centered Practice, while not strictly cogni-
tive in theoretical orientation, incorporated many elements of the structured,
rational, behavioral-outcome-focused intervention that characterize the approach.
The following year, Lantz (1978) published a comprehensive summary of cogni-
tive theory and its related interventions in Social Work. In 1982 Sharon Berlin
began her work integrating the theory with the unique perspective of the social

174 C H A P T E R 8

work profession, which culminated in her book Clinical Social Work Practice: A
Cognitive-Integrative Perspective in 2002. Berlin’s work addresses a gap in the litera-
ture on cognitive therapy that stems from its almost exclusive focus on personal
meanings and lack of attention to the ways people acquire information from their
social environments. That is, cognitive therapy approaches in social work must in-
corporate clients’ life conditions and interpersonal events, particularly those who
experience severe deprivation, threats, and vulnerability. More recently, Corcoran
(2005), in Building Strengths and Skills: A Collaborative Approach to Working with Cli-
ents, constructed an eclectic practice approach for social workers that interweaves
both strength-based and skills-based practice approaches through a creative inte-
gration of motivational interviewing, solution-focused therapy, and cognitive-
behavioral therapy.

MAJOR CONCEPTS

Within cognitive theory there are no assumed innate drives or motivations that
propel people to act in particular ways. We all develop patterns of thinking and
behavior through habit, but these patterns can be adjusted as we acquire new in-
formation. A central concept in cognitive theory is that of the schema, defined as
our internalized representation of the world, or patterns of thought, action, and
problem solving (Granvold, 1994). Schemas include the ways that we organize
thought processes, store information, process new information, and integrate the
products of those operations (knowledge). Schemas are the necessary biases with
which we view the world, based on our early learning. They develop through
direct learning (our own experiences) or social learning (watching and absorbing
the experiences of others). When we encounter a new situation, we either assimi-
late it to “fit” our existing schema, or accommodate it, changing the schema if, for
some reason, we can’t incorporate the experience into our belief patterns. A flexi-
ble schema is desirable, but all schemas tend to be somewhat rigid by nature.

Piaget’s (1977) theory of cognitive development is the most influential in so-
cial work and psychology. It describes the first schema that an infant possesses as a
body schema, because a small child is unable to differentiate between the self and
the external world. Cognitive development involves a gradual diminishing of this
egocentricity. In Piaget’s system, the capacity for reasoning develops in stages,
from infancy through adolescence and early adulthood. These stages are sequen-
tial, evolving from activity without thought to thought with less emphasis on activity. We
evolve from being toddlers who scream out when hungry, to adults who patiently
prepare our own meals. That is, cognitive behavior evolves from doing to doing
knowingly, and finally to conceptualization. Normal maturation in one’s physical
and neurological development is necessary for full cognitive development.

Figure 8.1 illustrates how our core beliefs (schemas) influence the manner in
which we perceive particular situations throughout life. Our internal perspectives
about the world, based on unique life experiences, lead to assumptions and related
coping strategies. These core beliefs have a direct influence on how we perceive
and react to life situations. Our assumptions and related strategies are not “correct”

C O G N I T I V E T H E OR Y 175

or “incorrect” as much as they are “functional” or “non-functional” for our ability
to achieve our goals. Schemas can change, but not always easily.

It was mentioned earlier that cognitive theory is a motor theory, asserting that
we do not merely receive and process external stimuli, but are active in constructing

Relevant Early Life Experiences
For example: Negative comparison of self with siblings

Core Beliefs/Schemas (pervasive and rigid, but changeable)
Fundamental assumptions regarding the self, others, the world, the future
When problematic, these involve themes of helplessness or unlovability

“I don’t have qualities that can attract other people.”
“I’m not capable of being successful.”

Coping Assumptions
May be constructive or destructive

“If I work hard, I can do well.”
“If I don’t do great, then I am a failure.”

Coping Strategies
For example: High standards, hard work, correct shortcomings (positive)

Over-preparation, manipulation, avoid seeking help (negative)

Specific Situations
(For example, performance in graduate school)

Thoughts and Their Meanings
(May be constructive or destructive)

“I can get through this if I go to every class and do all the reading.”
“I can’t do all this work. I don’t have the energy.”

Emotions
Pride, excitement
Depression, guilt

Behaviors
Organizing a study schedule

Cheating, quitting

F I G U R E 8.1 The Influence of Core Beliefs

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176 C H A P T E R 8

the reality we seek to apprehend. There is no singular way to perceive reality; still,
rational thinking can be understood as thinking that (Ellis & McLaren, 1998):

Is based on external evidence

Is life-preserving

Keeps one directed toward personal goals

Decreases internal conflicts

A person’s thoughts can accurately reflect what is happening in the external
world, or be distorted to some degree. These distortions, called cognitive errors, will
be described below.

Cognitive interventions are applicable to clients over the age of approximately
12 years because the person must be able to engage in abstract thought. Of course,
some adults with cognitive limitations, such as intellectual developmental disability,
dementia, and some psychotic disorders, may not be responsive to the approach. To
benefit from these interventions, clients must also be able to follow through with di-
rections, not require an intensely emotional encounter with the social worker, dem-
onstrate stability in some life activities, and not be in an active crisis (Lantz, 1996).

Other concepts that are central to cognitive theory will be introduced in the
section below.

THE NATURE OF PROBLEMS AND CHANGE

Many problems in living result from misconceptions—conclusions that are based
more on habits of thought rather than external evidence—that people have
about themselves, other people, and their life situations. These misconceptions
may develop for any of three reasons. The first is the simplest: The person has
not acquired the information necessary to manage a new situation. This is often
evident in the lives of children and adolescents. They face many situations at
school, at play, and with their families that they have not experienced before,
and they are not sure how to respond. This lack of information is known as a
cognitive deficit, and can be remedied with education. A child who has trouble
getting along with other children may not have learned social skills, and teaching
that child about social expectations may help to resolve the problem.

The other two sources of misperception are rooted in schemas that have be-
come too rigid to manage new situations. That is, the schema cannot accommo-
date the situation. An adolescent who can manage conflicts with his friends
suddenly realizes that he cannot use those same strategies to manage conflict
with his new girlfriend.

As a part of one’s schema, causal attributions refer to three kinds of assump-
tions that people hold about themselves in relation to the environment. First, a
person might function from a premise that life situations are more or less change-
able. (I’m unhappy with my job, and there is nothing I can do about it.) Second,
a person may believe that, if change is possible, the source of power to make
changes exists either within or outside the self. (Only my supervisor can do

C O G N I T I V E T H E OR Y 177

something to make my job better.) Finally, a person might assume that the im-
plications of his or her experiences are limited to the specific situation, or that they
are global. (My supervisor didn’t like how I managed that client with a substance
abuse problem. He doesn’t think I can be a good social worker.)

The final sources of misperceptions are specific cognitive distortions of reality.
Because of our tendency to develop thinking habits, we often interpret new si-
tuations in biased ways. These patterns are generally functional because many
situations we face in life are similar to previous ones and can be managed with
patterned responses. These habits become a source of difficulty, however, when
they are too rigid to accommodate our considering new information. For exam-
ple, a low-income community resident may believe that he lacks the ability to
advocate for certain medication benefits and, as a result, continues to live with-
out them. This belief may be rooted in a distorted sense that other people will
never respect him. The client may have had real difficulties over the years with
failure and discrimination, but the belief that this will happen in all circumstances
in the future may be arbitrary. Table 8.1 lists some widely held cognitive distor-
tions, also known as “irrational beliefs” (Beck, 1967), with examples.

T A B L E 8.1 Common Cognitive Distortions

Irrational Beliefs Examples

Arbitrary inference: Drawing a conclusion
about an event with no evidence, little
evidence, or even contradictory evidence

”I’m not going to do well in this course. I have
a bad feeling about it.”
“The staff at this agency seem to have a dif-
ferent practice approach than mine. They
aren’t going to respect my work.”

Selective abstraction: Judging a situation
on the basis of one or a few details taken
out of a broader context

“Did you see how our supervisor yawned
when I was describing my assessment of the
client? He must think my work is superficial.”

Magnification or minimization: Concluding
that an event is either far more significant,
or far less significant, than the evidence
seems to indicate

“I got a B on the first assignment. There is a
good chance I will fail this course.”
“I don’t really need to get to work on time
every day. My clients don’t seem to mind
waiting, and the administrative meeting isn’t
relevant to my work.”

Overgeneralization: Concluding that all
instances of a certain kind of situation or
event will turn out a particular way
because one or two such situations did

“My supervisor thinks that my depressed cli-
ent client dropped out because I was too
confrontational. I don’t have enough empa-
thy to be a decent social worker.”

Personalization: Attributing the cause,
or accepting responsibility for, an external
event without evidence of a connection

“The instructor didn’t say this, but our group
presentation got a mediocre evaluation be-
cause of my poor delivery.”

Dichotomous thinking: Categorizing
experiences as one of two extremes:
complete success or utter failure
(usually the latter)

“I didn’t get an A on my final exam. I blew it!
I’m not competent to move on to the next
course.”
“I got an A on the midterm. I can coast the
rest of the way through this course.”

178 C H A P T E R 8

Interventions within cognitive theory can help clients change in three
ways. Clients can change their personal goals to become more consistent with
their capabilities, adjust their cognitive assumptions (beliefs and expectations),
or change their habits of thinking (which includes giving up cognitive distor-
tions). Even when some of a person’s beliefs are distorted, the potential to
correct them in light of contradictory evidence is great. During assessment,
the social worker observes the client’s schema, identifies thinking patterns
with respect to the presenting situation, and considers the evidence supporting
the client’s conclusions about the situation. When those conclusions seem
valid, the social worker helps the client develop better problem-solving or
coping skills. When the conclusions are distorted, the social worker uses tech-
niques to help the client adjust his or her cognitive processes in ways that will
facilitate goal attainment.

ASSESSMENT AND INTERVENT ION

The Social Worker/Client Relationship

Cognitive intervention is always an active process. Intervention often resembles a
conversation between the social worker and the client. (I often tell students that
if they like to talk, this is a good theoretical perspective to adopt.) The social
worker serves as an educator in situations where clients experience cognitive def-
icits, and as an “objective” voice of reason (to the extent that this is possible)
when the client experiences cognitive distortions.

The practitioner is a collaborator—goals, objectives, and interventions are
developed with the client’s ongoing input. The client’s desired outcomes are
often written down so that they may be followed consistently over time or re-
vised. Beyond this, the social worker may serve as a model of rational thinking
and problem solving for the client, or as a coach, leading the client thorough a
process of guided reasoning. The social worker needs to demonstrate empathy
with the client’s problem situation, in part because confrontation is frequently
a part of the interventions. Confrontation involves the social worker pointing
out discrepancies between a client’s statements and actions (Hepworth, Rooney,
Rooney, Strom-Gottfried, & Larsen, 2012), which can sometimes be difficult for
a client to tolerate. The social worker’s perceived positive regard will help the
client understand that these confrontations are being presented constructively.

Cognitive interventions are highly structured, and it is the responsibility of
the social worker to establish and maintain that structure (Beck, 1995). The
structure of the first session includes the social worker’s setting an agenda, doing
a mood check, reviewing and specifying the presenting problem, setting goals,
educating the client about the cognitive model, eliciting the client’s expectations
for the intervention, educating the client about the nature of his or her problem,
setting up homework assignments, providing a session summary, and eliciting the
client’s feedback about the session. Subsequent sessions include brief updates and
checks on the client’s mood, the social worker’s linking issues between the

C O G N I T I V E T H E OR Y 179

previous and current session, setting the agenda, reviewing homework, discussing
issues on the agenda, setting up new homework tasks, providing a final session
summary, and eliciting the client’s feedback about the session.

The social worker must always be aware that his or her assessments are also
subject to cognitive biases. To minimize the possibility of his or her own distor-
tions when working with a client, the social worker should:

Consistently examine his or her own beliefs and attitudes about the client
through supervision

Generate and evaluate a variety of hypotheses about a client’s problem situation

Consider and “rank” the evidence for and against the “working hypotheses”
about a client

Use clear evaluation measures of client change (standardized or personalized)

Use various sources of feedback, including peers and supervisors

Assessment

The practitioner initially educates the client in the logic of cognitive theory and then
assesses the client’s cognitive assumptions, identifying any distortions that may con-
tribute to problem persistence. The rationality of a client’s thinking is assessed
through a process known as Socratic questioning (Boyle, Hull, Mather, Smith, & Farley,
2009). This term derives from the work of the philosopher Socrates, whose teaching
technique involved asking questions of his students until they came upon the answers
by themselves. The social worker assesses the validity of a client’s assumptions associ-
ated with a problem issue through detailed, focused questioning. After the client de-
scribes the presenting problem and some of the relevant history surrounding it, the
following types of questions guide the social worker’s assessment:

First, tease out the client’s core beliefs relative to the presenting problem
(“What were you thinking when…?” “How did you conclude that…?”
“What did it mean to you when…?”)

What is the logic behind the client’s beliefs regarding the significance of the
problem situation?

What is the evidence to support the client’s views?

What other explanations for the client’s perceptions are possible?

How do particular beliefs influence the client’s attachment of significance to
specific events? Emotions? Behaviors?

To maximize the reliability of the client’s self-reports during assessment and
intervention, the social worker should (Berlin, 2002):

Inquire about a client’s cognitive events of concern as soon as possible after
the event

Analyze the internal consistency of a client’s statements

180 C H A P T E R 8

Minimize the kind of probing that may influence a client’s ability to reflect
“objectively” on his or her thoughts and feelings

Help the client acquire cognitive retrieval skills (through imagery and
relaxation)

At the end of the assessment, the social worker helps the client to arrive at a
tentative conclusion about the rationality of his or her thought patterns, and, if
any distortions are apparent, examines the client’s willingness to consider alterna-
tive perspectives.

Intervention

When a client’s perceptions and beliefs seem valid, the practitioner intervenes by
providing education about the presenting issue and implementing problem-
solving or coping exercises. When the client exhibits significant cognitive distor-
tions, the practitioner and client must identify the situations that trigger the mis-
conceptions, determine how they can be most efficiently adjusted or replaced with
new thinking patterns, and then implement corrective tasks. Various specific inter-
vention strategies are presented below. Not all possible interventions are described
in this chapter (there are many), but what follows is representative of the theory.

Cognitive Restructuring Strategies for cognitive intervention fit into three
general categories. The first of these is cognitive restructuring. This technique is
used when the client’s thinking patterns are distorted and contribute to problem
development and persistence (Mueser, Rosenberg, & Rosenberg, 2009).
Through a series of discussions and exercises, the social worker helps the client
experiment with alternative ways of approaching challenges that will promote
goal attainment.

The ABC model (presented earlier in this chapter) is the basis of the cogni-
tive restructuring approach. “A” represents an activating event; “B” is the client’s
belief about, or interpretation of, the event; and “C” is the emotional and be-
havioral consequence of B. For example, if A is an event (a rainy day) and C, the
consequence, is the person’s feeling of depression, then the B (belief) might be:
“Everything looks so gray and ugly, and I wanted to go out. Nothing can go
well for me on a day like this.” If the same activating event (rain) occurs, but
the resulting emotion (consequence, or C) is contentment, the client’s belief
might be: “How peaceful. Today I can stay home and read. It’ll be really
cozy.” The ABC process occurs so quickly that clients often make the assump-
tion that A directly causes C, but except in certain reflexive actions (such as plac-
ing a finger on a hot stove and then abruptly pulling it back), there is always a
cognitive event, B, that intervenes.

In order to change a client’s belief systems, three steps are necessary. The first
is to help the person identify the thoughts preceding and accompanying the dis-
tressing emotions and non-productive action (“What was going through your
mind…?”). It is important to put the client into a frame of mind in which he
or she can reflect on thoughts and feelings as if the event is occurring at the present

C O G N I T I V E T H E OR Y 181

moment. Some clients may require assistance in grasping their thinking patterns.
The practitioner might engage the client in imagery (“Close your eyes, take a
deep breath, and see yourself in that situation. What are you doing? What are
you feeling? What are you thinking?”). The social worker may invite other cli-
ents to participate in role-plays toward the same end (“Let’s pretend we’re at
work, and I am your boss…”). By reenacting the problem situation, clients can
more accurately retrieve the thought patterns contributing to the problem.

The second step is to assess the client’s willingness to consider alternative
thoughts in response to the problem situation. One means of addressing this is
the point/counterpoint or cost/benefit analysis, in which the social worker asks
the client to consider the costs and benefits of maintaining his or her current
beliefs pertaining to the problem (Leahy, 1996). This can be accomplished
through simple conversation, but is often more effective with pen and paper.
Writing down the pros and cons of an argument can help the client visualize
whether his or her goals are being well served by the current perspective. It
must be emphasized that the mere number of pros and cons will not influence
the client’s thinking in one direction or the other, as some will carry more
“weight” than others.

The third step is to challenge the client’s irrational beliefs by designing nat-
ural experiments, or tasks, that he or she can carry out in daily life to test their
validity. For instance, if a college student believes that if she speaks out in class,
everyone will laugh at her, she might be asked to volunteer one answer in class
and observe the reactions of others. By changing clients’ actions, their cognitions
and emotions may be indirectly modified. The actions may provide new data to
refute clients’ illogical beliefs about themselves and the world.

The ABC Review This cognitive intervention technique requires a client to fill
out a form over a specified period of time (Hofmann & Reinecke, 2010). Its
purpose is to help the client become more aware of his or her automatic
thoughts and subsequently work toward modifying them so that emotions and
behaviors can become more productive. Following an assessment of the client’s
cognitive patterns, the social worker prepares a sheet of paper with four columns
(see Figure 8.2). The first column is headed “Situation that produces stress” (the
A component of the ABC process). The client is instructed to write down during
the course of a day the situations that produce the negative emotions or
behaviors for which he or she is seeking help. The next column is headed
“Automatic thought” (the B component), and here the client records the
thoughts that accompany the situation. This step is difficult and takes practice
for many clients. Some tend to overlook their interpretations that intervene
between situations and emotional and behavioral responses. Others tend to
record emotions rather than thoughts. During the intervention, the social
worker can help the client learn to distinguish between thoughts and feelings.
Next, the client is asked to think about and record in the third column the
assumptions that seem to underlie the automatic thought. For example, a client
who is rejected for a job (the situation) may think that he “will never get a good
job” (automatic thought) because “I am worthless” (the underlying assumption).

182 C H A P T E R 8

Finally, the client is asked to record the emotional response to the automatic
thought, such as depression or panic (the C component).

The social worker asks the client to fill out the form with some mutually
agreed-on frequency, depending on the nature of the problem and the ability
of the client to maintain a structured task focus. Often, the social worker will
ask the client to fill out the form every day between their meetings, when they
can review it together. Over time, the social worker helps the client clarify his or
her automatic thoughts and understand which of them are arbitrary. The social
worker then asks the client, with an expanded form, to experiment with alterna-
tive, more rational thoughts about his or her problem situation that might be
more constructive (see Figure 8.2 again). These alternative thoughts, and the
feelings that follow them, can be written in fourth and fifth columns on the
page. The client and social worker can then monitor how the client’s feelings
and behaviors change.

Cognitive Coping A second category of interventions is cognitive coping. The
practitioner helps the client learn and practice new or more effective ways of
dealing with stress and negative moods. All of these involve step-by-step pro-
cedures for the client to master new skills. (Here we begin to see the conver-
gence of the cognitive and behavior theories: combining new thinking patterns
with new situations that may provide reinforcement of new behaviors.) Cog-
nitive coping involves education and skills development that targets both co-
vert and overt cognitive operations, with the goal of helping clients become
more effective at managing their challenges. Clients can modify their cognitive
distortions when they experience positive results from practicing new coping
skills. That is, if clients develop good coping skills, they may elicit positive
reinforcement from the environment. Several interventions are presented here
in detail.

Situation that
produces stress Automatic thought

Assumption behind
automatic thought

Situation
that
produces
stress

Automatic
thought

Assumption
behind
automatic
thought

Feeling/
behavior

Alternative
thought

Feeling/
behavior

F I G U R E 8.2 The ABC Worksheets

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C O G N I T I V E T H E OR Y 183

Self-Instruction Skills Development This is a means of giving clients an internal cog-
nitive framework for instructing themselves on how to cope more effectively with
problem situations (Kunzendorf et al., 2004; Meichenbaum, 1999). It is based in
part on the premise that many people, as a matter of course, engage in internal
speech, giving themselves “pep talks” to prepare for certain challenges. For exam-
ple, one good friend of mine, a respected social worker, stands in front of the mir-
ror every morning and lectures herself about what she needs to do to manage the
most difficult parts of her workday. She feels energized by this practice.

Often, when people find themselves in difficult situations that evoke tension
or other negative emotions, their thinking may become confused, and their ability
to cope diminishes. Some people have a lack of positive cues in their self-dialogue.
Having a prepared internal (or written) script for problem situations can help a
client recall and implement a coping strategy. When using this technique, the so-
cial worker assesses the client’s behavior and its relationship to deficits in sub-vocal
dialogue. The client and social worker develop a self-instruction script, including
overt self-directed speech, following their plan for confronting a problem. Such a
script may be written down or memorized by the client. The social worker and
client visualize and walk through the problem situation together so the client can
rehearse its implementation. During rehearsal, the client gradually moves from
overt self-dialogue to covert self-talk. The client then uses the script in the natural
environment, either before or during a challenging situation.

As an example, Beth (who will be introduced later in more detail) felt guilty
about dropping her young son off at the day care center every morning on her way
to classes, believing that she was a poor mother for indulging herself at the expense
of time with her son. This negative feeling stayed with her much of the day. She
developed a self-instruction script with the social worker that included the follow-
ing statements: “My son will be well cared for. Many good parents take their chil-
dren to day care when they go to work every day. I spend every evening and every
weekend with my son. When I get my degree, I will be a better provider for my
son and myself. It is good for my son to learn to interact with other people. He has
a chance to play with other children while there. I will be a better parent if I take
care of myself as well as him.” Beth initially wrote down these statements, but
quickly memorized them. She recited them to herself internally every morning
and anytime during the day that she began to feel guilty about her son.

Communication Skills Development The teaching and rehearsal of these skills
cover a wide spectrum of interventions that includes attention to clients’ social,
assertiveness, and negotiation skills. Positive communication builds relationships
and closeness with others, which in turn helps improve mood and feelings about
oneself (Hepworth et al., 2012; Hargie, 1997). Social support is a source of posi-
tive reinforcement and buffers individuals from stressful life events. In addition,
when a person can articulate his or her concerns, other people may construc-
tively suggest how that person might adjust his or her attitudes and behaviors.

The components of communication skills development include using “I”
messages, reflective and empathic listening, and making clear behavior change
requests. (These were discussed in Chapter 6, as an intervention with family

184 C H A P T E R 8

emotional systems theory.) “I” messages are those in which a person talks about
his or her own position and feelings in a situation, rather than making accusatory
comments about another person. The basic format for giving “I” messages is: “I
feel (the reaction) about what happened (a specific activating event).” For exam-
ple: “I feel angry when you break curfew on Saturday night. I also worry about
you.” These statements help the speaker to maintain clarity about his or her own
thoughts and feelings. This is a clearer communication than saying, “How dare
you stay out so late!” which generally makes the other person feel defensive.

Listening skills include both reflective listening and validation of the other
person’s intent. The purpose of reflective listening is to ensure that one under-
stands the speaker’s perspective. It decreases the tendency of people to draw pre-
mature conclusions about the intentions and meaning of another’s statement
(Brownell, 1986). Reflective listening involves paraphrasing the feelings and con-
tent of the speaker’s message with the format: “What I hear you saying is…” or
“You seem to feel [feeling word] when I…” Beyond reflection, validation in-
volves conveying a message that, given the other person’s perspectives and as-
sumptions, his or her experiences are legitimate and understandable (“I can see
that if you were thinking I had done that, you would feel angry”).

A third component of communication skill development involves teaching
people to make clear behavior requests of others. Such requests should always be
specific (“Pick up your toys”) rather than global (“Clean up this room”), measurable
(“I would like you to call me once per week”), and stated in terms of positive behavior
rather than the absence of negative behavior (“Give me a chance to look at the
mail when I come home” rather than “Stop bothering me with your questions”).

Problem-Solving Skills Development The third intervention category is
problem solving. This is a structured, five-step method for helping clients who do
not experience distortions but nevertheless struggle with the problems that they
clearly perceive. Clients learn how to produce a variety of potentially effective
responses to their problems (Freeman, 2004). The first step is defining the problem
that the client wishes to overcome. As the poet Emerson (1958) wrote, “a prob-
lem well defined is a problem half solved.” Solutions are easier to formulate
when problems are clearly delineated. During the process, only one problem
should be targeted at a time.

The next step in problem-solving skills development involves the client and
social worker’s brainstorming to generate as many possible solutions to a presenting
problem as they can imagine. At this point, evaluative comments are not al-
lowed, so that spontaneity and creativity are encouraged. All possibilities are
written down, even those that seem impossible or silly. Some supposedly ridicu-
lous ideas may contain useful elements on closer examination. It is important in
this step for the social worker to encourage additional responses after clients de-
cide they are finished. Clients often stop participating when a list contains as few
as five alternatives, but when pressed they can usually suggest more.

The third stage of the problem-solving process involves evaluating the alterna-
tives. Any patently irrelevant or impossible items are crossed out. Each viable al-
ternative is then discussed as to its advantages and disadvantages. More

C O G N I T I V E T H E OR Y 185

information about the situation may need to be gathered as a result of the work
during this stage. For instance, information might be gathered about other agen-
cies and resources (including other people in the client’s life) that can assist in
making some of the choices more viable.

Choosing and implementing an alternative involves selecting a strategy for prob-
lem resolution that appears to maximize benefits over costs. Although the out-
come of any alternative is always uncertain, the client is praised for exercising
good judgment in the process, and is reminded that making any effort to address
the problem is the most significant aspect of this step. The social worker should
remind the client that there is no guarantee that the alternative will succeed, and
that other alternatives are available if needed.

During the following session, the social worker helps the client to evaluate the
implemented option. If successful, the process is complete except for the important
discussion about how to generalize problem solving to other situations in the
client’s life. “Failures” must be examined closely for elements that went well in
addition to those still needing work. If a strategy has not been successful, it can
be tried again with adjustments or the social worker and client can go back to
the fourth step and select another option.

Role-playing is an effective teaching strategy that can be used with all of the
above interventions (Freeman, 2004). This involves the social worker first modeling
a skill, then the worker and client rehearsing it together. Role-playing offers a
number of advantages for intervention. First, the social worker demonstrates new
skills for the client, which usually is a more powerful way of conveying information
than verbal instruction. Second, by portraying the client in a role-play, the social
worker gains a fuller appreciation of the challenges faced by the client. At the same
time, the client’s taking on the perspective of another significant person in his or her
life (family member, boss, or friend) allows the client to better understand the other
person’s position. Assuming the roles of others also introduces a note of playfulness
to situations that may have been previously viewed with grim seriousness.

SP IR ITUAL ITY AND COGNIT IVE THEORY

Unlike behavior theory, the concepts of cognitive theory can facilitate an under-
standing of clients’ spirituality and promote their reflections on the topic. Re-
member that spirituality refers here to a client’s search for, and adherence to,
meanings that extend beyond the self. Cognitive theory emphasizes each person’s
natural inclination to make sense of reality, and the idea that values can change
through reflection and action. The theory further asserts that we are active par-
ticipants in constructing our realities. Thinking represents our organized efforts
to create meaning from personal experience.

In the context of cognitive theory, then, spirituality can be understood as
the core beliefs (including values) that provide us with meaning and motivate
our actions. Effective social functioning depends on our developing patterns of
shared meaning with others, and thus we tend to seek out others who share our

186 C H A P T E R 8

deepest concerns. Cognitive deficits or distortions may contribute to a person’s
disillusionment in striving for spiritual goal attainment. Interventions relevant to
spirituality include Socratic questioning, which helps clients reflect on long-term
goals and the significance of problem situations in that context. Any cognitive
interventions that encourage a client’s reconsideration of ways of understanding
and acting on challenges may be relevant to his or her spirituality.

An example may help to clarify these points. Terri was a grade school
teacher with a clear commitment to helping children develop positive social
and academic skills. Her strong values about children were related in part to a
personal background in which she had felt unfairly demeaned. Along with this
core value went a belief that she was socially incompetent, less intelligent, and
less worthy of affection than other people. This core belief led to serious cogni-
tive distortions in which Terri believed herself to be untalented and inept profes-
sionally. Acting on these distortions, Terri received unsatisfactory evaluations
from the school principal and was at risk of losing her job. While the social
worker helped Terri address her distortions with cognitive intervention strate-
gies, he also helped her to maintain a focus on her ultimate value so that she
would persist toward her goal of success in the classroom.

ATTENT ION TO SOCIAL JUST ICE ISSUES

Cognitive theory includes many features that may facilitate the social worker’s pro-
motion of social justice activities with clients. The theory incorporates an empower-
ment approach, with its premise that people can be competent problem solvers, and
can be helped to generalize problem-solving strategies to other life challenges. In
examining core beliefs, the social worker will likely encourage the client’s examina-
tion of personal and social values. The concept of “social construction of reality”
underscores the social worker’s obligation to be sensitive to issues of cultural and
ethnic diversity. The theory is applicable to many client populations—actually, to
all people who have the capacity for cognition and reflection. The theory may
have particular appeal to members of diverse populations who seek concrete, practi-
cal approaches to problem solving, such as persons in lower socioeconomic groups,
Latino clients, and African-American clients (Balter, 2012).

On the other hand, cognitive theory focuses on individuals and tends to
limit its attention to the immediate rather than the macro environment. It does
not encourage the social worker to look outside the client, except to consider
environmental evidence for his or her beliefs about the world. In considering
the “rationality” of a client’s thinking, practitioners may be as likely to support
the acceptance of social conventions as to encourage social change activities
when working with vulnerable or oppressed client groups (Payne, 2005). Sec-
ond, though the theory encourages sensitivity to diversity, the social worker
must always make difficult judgments about the “rationality” of a client’s think-
ing. The less the social worker understands the client’s world, the more difficult
will be the task of assessing the client’s rationality.

C O G N I T I V E T H E OR Y 187

CASE ILLUSTRAT IONS

Problem Solving and the Adolescent Girls Group

Ridgedale High School was located in a lower-class section of a large city and
served neighborhoods that experienced much criminal activity. Drug dealing,
prostitution, grand and petty theft, and burglaries occurred frequently. As one
preventive measure, the school offered a number of coping skills groups for stu-
dents who were considered at risk for developing delinquent behaviors. One
such group was offered to female adolescents who demonstrated chronic school
truancy. This eight-week, time-limited group, like others at the school, was led
by a social worker. This “academic and personal success” group used the
problem-solving model as a basis for intervention.

Adrienne, a 26-year-old single African-American female, led the group. She
devoted the first meeting to the girls getting acquainted with each other and
generating topics for discussion. Subsequent meetings included structured discus-
sions among the girls about ways to problem-solve with regard to the topic for
that day. During one group session, the issue of safe sex was selected as a topic
for discussion. The girls agreed that they did not want to become pregnant, and
some were opposed to the idea of having sex, but all of them had faced difficulty
with boys who were sexually aggressive.

The social worker’s responsibilities each week included teaching and imple-
menting the problem-solving process to address a variety of problems in living.
She emphasized that engaging in this practice was often more effective when
done in the group setting, with the benefit of immediate input from others. In
the first part of this meeting, the girls were asked to specify a problem related to
the general topic of safe sex. They quickly agreed that they wanted to learn how
to reject the advances of boys who tried to talk them into sex. Adrienne asked
the girls to role-play several scenarios during the meeting to get a clearer idea of
the situations they had in mind. This was helpful and also provided the girls with
some amusement as they acted out the parts.

The girls next brainstormed possible solutions to the challenge. Because all
ideas are welcomed and none are censored, this task was fun for the girls. They
could laugh and be outrageous with each other while also sharing suggestions
about physically protecting themselves, making specific and assertive verbal
responses to boys, limiting their dates to certain kinds of settings, avoiding certain
topics of conversation, addressing their preferences before a date began, and deal-
ing with other situations.

In the group setting, it is not necessary for all members to choose the same
solution to implement. Each girl can select her own solution, and it is supported
as long as she can articulate reasons for the choice that represent a logical cost/
benefit thought process. Adrienne, whose goal was to teach generalizable
problem-solving skills, asked the girls to make a commitment to implement their
solutions if and when the problem situation arose. In this instance, the girls
agreed that greater assertiveness would help them maintain control of the situa-
tion when alone with a boyfriend. The girls could not all implement their

188 C H A P T E R 8

strategy in the context of a date situation during the next week, but they could
practice assertiveness skills in other contexts with boys.

The following week the girls shared their experiences in exercising asser-
tive behavior with boys at school and over the weekend, and stated whether
they considered these episodes successes or failures. Several of the girls had, in
fact, been on dates. One had specifically experienced the problem of aggressive
behavior with a boy and described how she had responded. The girls helped
each other evaluate their task implementation, and again were constructive in
their comments. As a final stage in this process, they helped each other refine
their approaches to assertiveness and consider new strategies for the coming
week.

Cognitive Restructuring and the Single Parent

Beth was a 26-year-old single Caucasian parent who was raising a 4-year-old son
while attending college to get a business degree. She maintained an apartment
with money acquired from a computer programming job she kept during school
breaks. Her parents, both of whom lived in town and were divorced, helped
Beth with occasional money and babysitting assistance. Her son attended a day
care center while Beth went to school. She had many friends, most of whom did
not have children. Beth sought counseling because she was overwhelmed with
stress related to managing her responsibilities. She had little time to relax, lived
on a tight budget, had an unsatisfying social life, and felt that she was a bad par-
ent because she was preoccupied with school and often lost her temper with her
son. She could not sleep well, was often irritable, and had trouble concentrating
on her schoolwork. Despite her goal of being a businesswoman, Beth wondered
if the material and emotional costs were worthwhile. Patrick, her 46-year-old,
Italian-American male social worker, acknowledged that this was a difficult
time in Beth’s life, but also pointed out her personal strengths of persistence,
resilience, and love for her child. Pat educated Beth about several community
agencies that might provide material assistance to her household.

Beth was a suitable candidate for coping skills development. Still, much of
her difficulty was rooted in her causal attributions and cognitive distortions. The so-
cial worker concluded after the assessment that Beth had a basic sense of power-
lessness to change any aspect of her life situation. Further, Beth had a tendency
to engage in overgeneralization, believing that any failures implied complete in-
competence on her part. She also personalized negative events in her life, believ-
ing that anything negative that happened was due to her own inadequacies, and
ignoring the parts that other people or circumstances played in those situations.

Patrick organized a cognitive restructuring intervention with Beth. He initially
educated Beth in the ABC sequence of cognitive operations. This helped her see
that her appraisal of life situations, based on core beliefs that were not always con-
sistent with external evidence related to the event of concern, played a role in pro-
ducing her emotional experiences. Like many clients, Beth was able to grasp this
point only after some discussion and reflection. She could see, for example, that

C O G N I T I V E T H E OR Y 189

her father’s high expectations of her as a child and adolescent resulted in her belief
that she should be competent to manage every aspect of her life.

It was more difficult for Beth to see that she might have the power to change
some of her problem situations. She had to cope with multiple stresses, but Patrick
eventually helped Beth see that there were some areas of life in which she could
proactively make adjustments. As one example, Beth had become reluctant to ask
her grandparents to babysit her son on weekends, thinking that they resented the
intrusion on their time. Beth had reported, however, both that the grandparents
loved her son and they seemed to feel lonely as they got older. Patrick explored
these contradictory statements with Beth and helped her work out a flexible
“schedule” of family babysitting requests so that she would call on her mother,
father, and grandparents every few weeks in rotation for that purpose. This worked
out well, providing Beth with more predictable time for study and even a few
hours for working. The process also taught Beth that she could have an effect on
her environment.

In the process of Socratic questioning, Patrick and Beth reviewed specific situa-
tions in her life that made her feel sad or upset and looked at alternative interpreta-
tions of those situations. It is important to understand in cognitive intervention
that some negative emotional responses to situations reflect a client’s accurate ap-
praisals. For example, Beth described her frustrations with several professors that
appeared to accurately reflect their insensitivity to her learning style. On the other
hand, Beth’s anger at her friends for their alleged unwillingness to understand her
limited availability for social outings seemed (to the social worker) to indicate an
oversensitivity to rejection. Beth believed that her friends did not want to spend
time with her anymore, and thus she tended not to seek them out. Through his
questioning, Patrick helped Beth see that there was limited external evidence for
her assumption. The practitioner suggested that, possibly, Beth’s friends were well
aware of her busy schedule, and called less often so as not to intrude.

Beth agreed to engage in the pen-and-paper ABC review for several weeks.
The social worker asked her to record for one week every situation in which she
felt rejected by her friends and to record her accompanying thoughts and feel-
ings. In a relatively short time, Beth was able to see that she quickly jumped to
self-denigrating conclusions whenever a friend was not available to spend time
with her (which, to Beth’s surprise, did not happen as often as she had supposed).
Patrick noted that many times people learn that they have made erroneous esti-
mates of the frequency of their problem situations when they record them. Beth
changed her thinking about her friends’ behaviors and resumed more comfort-
able relationships with several of them.

Managing Family Friction with Communication Skills

Development

Nigel and Nita Bourne sought family counseling because of conflicts that had
become more prominent since Nigel, a recovering alcoholic, had stopped drink-
ing six months previously. Nigel, age 50, was a successful businessman in his

190 C H A P T E R 8

community and had been married to Nita, 47, for 24 years. Three children lived
in the household: Diane, 22; Peter, 20; and Christina, 19. Whereas all members
of the family were pleased with Nigel’s decision to stop drinking, he had become
more tense and moody, and their longstanding but “subtle” communication pro-
blems had become prominent. Nigel tended to be authoritarian with his family,
and Nita tried to “make up” for his brusque manner by being overly agreeable
with the children, rarely disagreeing with or confronting them. The siblings
tended to be argumentative with each other. Nigel was receiving alcoholism
treatment in addition to seeking family counseling. Their goal was to become
able to air their feelings and process their disagreements without falling into ar-
guments. They agreed that a calmer atmosphere would also help their father to
maintain his sobriety.

Following his assessment, the social worker (Barry, a 37-year-old, married
Caucasian male) agreed that communication skills development would be an im-
portant intervention. He explained his rationale for this strategy, and the family
agreed to participate. Barry took control of a chaotic situation and modeled the
skills that he was trying to teach. He assured all family members that they would
have the opportunity each week to make their thoughts and feelings known to
each other. He set a “ground rule” that no one could be interrupted when ex-
pressing a thought or feeling. Barry did, however, reserve the right to intervene
if he perceived that communication was breaking down. This directive made a
significant difference in reducing escalating tensions during the family’s
interactions.

The social worker next taught listening skills by asking each person to repeat
back what someone had said to him or her each time, making sure the listener
had received the message accurately. The family members felt awkward follow-
ing this directive, but they were amazed to learn how often they misunderstood
each other. Barry pointed out that this represented a learned family pattern. The
receiver of a message began to defensively formulate a response for the sender
before the sender had completed the message.

When the family had made some progress in these ways, the social worker
taught the use of “I” messages. For example, Nigel, instead of angrily saying to
his son, “You need to get a job and get out of the house!” was asked to formu-
late the message as “I feel angry when you are not working because a young
man of your age should take on more responsibility.” His son was instructed to
say, even though Nigel would not agree, “Sometimes I feel uncomfortable living
here when I am not working, but I also think parents should always support
their kids.” These messages resulted in a clearer articulation of each member’s
assumptions about family life. The members had great difficulty learning to com-
municate in these ways, and Barry gave them homework assignments to practice
using “I” messages.

As a final component of this four-session intervention, the family members
were asked to role-play a variety of conflicted interactions that occurred in the
household. Members usually portrayed themselves in these role-plays, and other
members were asked to comment afterward on the quality of the communica-
tion and problem solving demonstrated and to make suggestions for more

C O G N I T I V E T H E OR Y 191

effective ways to interact. During the role-plays, members were helped to make
clearer and more specific requests of each other. For example, Diane tended to
be negative in her interactions with her younger sister, saying, “You are so con-
trolling all of the time. You’re never considerate of Peter or myself.” She was
encouraged to give the same message in a more constructive way, saying, “It
feels to me like you are ignoring my ideas when you make decisions for all three
of us. Peter and I would like to be considered more often. You know, we might
still agree with you.”

Barry had moderate success with this family. The level of tension in the
household did diminish, and each member seemed to acquire improved commu-
nications skills. Nita became able to confront her husband about his authoritarian
manner, which was one of her goals. Interestingly, this assertive behavior ran
counter to her family’s cultural value of women as passive, and it seemed that
she would be likely to “speak out” only occasionally. The family members re-
mained mutually supportive, although Nigel was having difficulty containing his
temper. He planned to get help for this problem from his substance abuse
counselor.

COMBINING COGNI T I VE AND BEHAVIORAL

INTERVENT IONS

Many social workers combine intervention approaches from cognitive theory
and behavior theory when working with clients. The two theories are often
compatible because cognitive interventions help clients develop alternative
ways of thinking, and behavioral approaches help reinforce clients’ new
thought patterns with effective new behaviors. In fact, “cognitive-behavioral”
interventions are probably much more common that primarily “cognitive”
approaches.

Consider Carrie, a new university student commuting from a small town in
Appalachian country, who felt depressed because she did not “fit in” to the large
campus environment. Through arbitrary inference, she concluded that the other
university students were not friendly because none of them ever approached
her in the crowded student commons. She also concluded that she would con-
tinue to be lonely and sad because she was a dull person. To help adjust her
thoughts, a social worker (Miriam, a 24-year-old graduate student from India)
helped Carrie learn to evaluate her external environment differently. She was
helped to change some of her beliefs and expectations about how to make
friends in an environment more impersonal than the one she came from. Carrie’s
thinking was adjusted through the techniques of education (about the typical
behaviors of college students on a large campus) and an ABC review of her
thoughts and feelings. She concluded that the commons was not an appropriate
place to meet people because it is crowded, and students tend to hurry through
lunch and off to classes. There might be more appropriate settings for Carrie to

192 C H A P T E R 8

meet people. She also learned that she would benefit from assertiveness in her
desire to make friends.

In addition to assessing and adjusting Carrie’s thought patterns, Miriam’s be-
havioral strategies of desensitization and behavioral rehearsal helped to adjust her
present reinforcers. Miriam and Carrie designed and practiced a series of steps
whereby the client approached a small group of students at a lunch table and
asked to join them. Positive reinforcers included the other students obliging her
and later asking Carrie to join them in other activities. Combining these inter-
ventions allowed Miriam to help Carrie cognitively (to assess and adjust her as-
sumptions about the behavior of college students) and behaviorally (to spend
increasingly long time periods in the crowded commons, and saying “hello” to
a certain number of students in her classes). In addition to all of these interven-
tion activities, Carrie benefited from working with a social worker whom she
perceived as having had to make a major adjustment herself to a new culture.

Carrie’s story features several aspects of a cognitive-behavioral approach
known as social skills training. This was described in the previous chapter, but its
cognitive aspects are presented here. The full range of its components is listed
below (Cook et al., 2008).

Improving Cognitive Capacity

Providing knowledge about relationships (what they are, why they are im-
portant, how they develop, social norms)

Enhancing perceptual skills (how to interpret the social world more
accurately)

Improving decision-making skills (when it is appropriate to approach others)

Improving assessment skills (how to consider a variety of explanations for the
observed behavior of others)

Improving Behavioral Skills

Self-presentation (to enhance the likelihood of positive responses)

Social initiatives (includes how to start conversations)

Conversation (talking, listening, turn-taking)

Maintenance (of relationships over time)

Conflict resolution (handling disagreements, disappointments)

Although cognitive interventions often include task assignments, true behav-
ioral interventions require the social worker to take a highly systematic approach
to organizing environmental activities and measure progress carefully. In a pure
sense, cognitive-behavioral interventions are generally more cognitive than
behavioral.

C O G N I T I V E T H E OR Y 193

Dialectical Behavior Therapy

Another example of combining cognitive and behavioral intervention is dialectical
behavior therapy (DBT). This intervention approach, often associated with the
treatment of borderline personality disorder but also used with other client po-
pulations, may be appropriate when the social worker determines that a client’s
core difficulty is affective instability (Robins, 2002; Linehan, 1993).

From the perspective of DBT, some persons develop pervasive problems in
social functioning due to a lack of interpersonal and self-regulation skills, and
their potential to acquire adaptive behavior skills is inhibited by both personal
and environmental factors. That is, certain internal and external stimuli trigger
their problem behaviors through learned associations. The practitioner utilizes a
behavior chain analysis in assessment, similar to the one discussed in Chapter 7,
to identify the affective, cognitive, behavioral, interpersonal, and environmental
triggers to problem behaviors. The intervention first targets a client’s life-
threatening behaviors, and then moves on to address behaviors that interfere
with the intervention itself and the client’s quality of life.

The components of DBT include individual therapy, a skills-training group,
a practitioner consultation team, and coaching (by telephone). The manualized
length of treatment must be at least six months, although one year is ideal. (This
is clearly a resource-heavy intervention.) The skills training group includes the
four modules of mindfulness (awareness of self and context through mindful ob-
servation, and the ability to control the focus of one’s attention on the present
moment), emotional regulation, interpersonal effectiveness, and distress toler-
ance. The individual sessions, conducted by the same practitioner who leads the
groups, address the client’s specific maladaptive behaviors related to group
themes while strengthening and generalizing his or her coping skills. Some
client-practitioner phone contact is permitted between sessions for support and
crisis intervention. An important component in DBT is the consultation team
that can help the practitioner maintain objectivity during the often-intensive in-
tervention process.

DBT incorporates five intervention stages. The first of these is actually a pre-
commitment stage, in which the social worker explains the model, orients the
client to its expectations, and requires the client to commit to three things, in-
cluding reducing self-harming behaviors, working on interpersonal difficulties,
and developing new skills. In stage 1, the social worker helps the client develop
new behavior skills to reduce life-threatening behaviors and any difficulties that
interfere with the client’s ability to consistently attend therapy. Quality-of-life
issues, including substance misuse and other impulsive behaviors, are addressed
once basic safety issues are secure. In stage 2, the client learns skills to make
them able to experience a full range of emotions and reduce post-traumatic stress
symptoms. This includes exposure to traumatic memories and the emotional
processing of past abuse experiences. Stages 3 and 4 focus on the development of
self-respect and attention to meaning-in-life issues.

Dialectical behavior therapy can be considered a well-established intervention
for clients with borderline personality disorder, based in part on seven randomized

194 C H A P T E R 8

clinical trials across four different research teams (Lynch, Chapman, Rosenthal,
Kuo, & Linehan, 2006). Another summary of studies comparing DBT to other
treatments indicated that DBT is more effective than less structured interventions
in reducing client suicidality, although overall differences are modest (Binks
et al., 2006). A more recent meta-analysis of 16 randomized studies also con-
cluded that DBT had a moderate effect on reducing participants’ self-injurious
and suicidal behaviors (Kliem, Kröger, & Kosfelder, 2010). The same study,
however, found a 27 percent dropout rate across the studies. A systematic review
of DBT provided for inpatients with borderline personality disorder (11 studies)
found that possitive treatment effects persisted months after discharge, even
though the duration of these programs was much abbreviated (Bloom, Wood-
ward, Susmarus, & Pantalone, 2012). Another review of the modality with per-
sons with eating disorders (13 studies, most of which were uncontrolled) found
that DBT had success in addressing eating disorder behaviors, although improve-
ments in emotional regulation were not always associated with behavior change
(Bankoff, Karpel, Forbes, & Pantalone, 2012).

EVIDENCE OF EFFECT IVENESS

A strength of cognitive theory is that its interventions lend themselves to empir-
ical research methods. Over a decade ago Chambless and Ollendick (2001) com-
piled a list of validated cognitive interventions using the American Psychological
Association’s criteria for well-established or probably efficacious interventions. (These
criteria were described in Chapter 1.) The authors note well-established cognitive
interventions for geriatric depression, major depression, anorexia, bulimia, and
conduct disorder, and well-established cognitive-behavioral interventions for ago-
raphobia, panic disorder, generalized anxiety disorder, post-traumatic stress disor-
der, social anxiety, chemical abuse and dependence, binge-eating disorder,
smoking cessation, avoidant personality disorder, schizophrenia, conduct disor-
der, ADHD, and childhood anxiety.

Probably efficacious cognitive interventions are described for obsessive compul-
sive disorder, and probably efficacious cognitive-behavioral interventions are in-
cluded for opiate dependence, irritable bowel syndrome, sickle-cell disease pain,
marital discord, geriatric caregiver distress, sleep disorders, and disorders of child-
hood and adolescence (depression and recurrent abdominal pain).

Another literature review by Butler and Beck (2001) provides a good sum-
mary of the research on cognitive interventions up to that time. They reviewed
14 meta-analyses that covered 9,138 subjects in 325 studies. The researchers
found that cognitive therapy was substantially superior to lack of treatment, wait-
ing list, and placebo controls for adult and adolescent depression, generalized
anxiety disorder, panic disorder (with or without agoraphobia), social phobia,
and childhood depressive and anxiety disorders. Cognitive interventions were
moderately superior in the treatment of marital distress, anger, childhood somatic
disorders, and chronic pain.

C O G N I T I V E T H E OR Y 195

During the past decade a number of meta-analyses and systematic litera-
ture reviews have provided further evidence of the effectiveness of cognitive-
behavioral interventions for a variety of social functioning problems. These
analyses support their use for post-natal depression (in groups) (Scope, Booth,
& Sutcliffe, 2012); major depression in older adults (Gould, Coulson, & Ho-
ward, 2012) and other adults (Jakobsen et al., 2011); adolescent non-suicidal
self-injury (Brausch & Girresch, 2012); insomnia (Mitchell, Gehrman, Perlis,
& Umscheid, 2012); the positive symptoms of schizophrenia (Wykes, Huddy,
Cellard, McGurk, & Czobor, 2011); bipolar diroder (Sylvia, Tilley, Lund, &
Sachs, 2008); HIV-infected persons’ mental health and immune system func-
tioning (Crepaz, Passin, & Herbst, 2008); obsessive-compulsive disorder (Pra-
zeres, de Souza, & Fontenelle, 2007); generalized anxiety disorder and panic
disorder (Siev & Chambless, 2007; Mitte, 2005); breast cancer pain control
(Tatrow & Montgomery, 2006); behavior disorders in children and adolescents
(Gresham, 2005; Gonzalez, Nelson, & Gutkin, 2004); major depression in
children and adolescents (Haby, Tonge, Littlefield, Carter, & Vos, 2004); and
task performance for persons with schizophrenia (Krabbendam & Aleman,
2003).

CR IT IC ISMS OF THE THEORY

Five criticisms have been made about cognitive theory, as discussed below.
Thought is prior to most emotional experience. All practitioners agree that both

cognition and emotion are essential to human functioning, but some give greater
importance to emotional life. Magai (1996), for example, asserts that emotional
traits form the core of human personality. She states that people possess five pri-
mary human emotions that originate in their neurophysiology: happiness, sad-
ness, fear, anger, and excitement. These emotions are instinctual and the
sources of one’s motivations. They activate cognition and behavior in ways that
are adaptive for survival. To illustrate, a person’s propensity toward sadness may
be elicited by the experience of personal loss. This leads to a temporary physical
slowing down, a decrease in general effort, and withdrawal in situations where
efforts to cope with the loss would be ineffective. The sadness allows the person
time to process his or her needs and regain energy for more focused application
to achievable goals. It also provides a signal to others in their social networks to
offer support. This idea that emotions influence cognition is antithetical to the
principle stressed in cognitive theory.

The emphasis is on conscious rather than unconscious thought. The content of con-
scious thought is certainly more readily accessible to people than their more subtle
ideas and emotions, but this does not imply that they are more relevant to social
functioning. Psychodynamic practitioners attribute great influence to unconscious
thought processes, and even some social theorists state that significant mental ac-
tivity may occur “beneath the surface” of conscious thought. Cognitive theorists
do attempt to locate a “core belief” in a client, but spend relatively little time on

196 C H A P T E R 8

the client’s past to do so. By ignoring what is less concrete and accessible, social
workers may never fully understand the basis of a person’s thoughts and emotions.

Cognitive theory has an “individual” rather than a relational focus. Cognitive the-
ory maintains an emphasis on the individual rather than on interpersonal pro-
cesses located within the family, group, or community. Relational theorists and
feminist thinkers, on the other hand, place greater value on the interpersonal
aspects of human experience (families, groups, and communities), and assert
that the essence of human life is most evident in relationship capacity. In fairness,
it must be acknowledged that some prominent cognitive theorists have devel-
oped strategies for marital intervention (e.g., Baucom, Epstein, Rankin, &
Burnett, 1996; Beck, 1988).

Cognitive theory overemphasizes objectivity and rationality. Cognitive practitioners
apply a “scientific method” to their direct practice. The philosophy of this posi-
tivist method (ideas about external reality, what can be “known,” and the “poli-
tics of knowledge”) has come under fire since the 1980s. Post-positivist thinkers
do not trust the value-free nature of this approach, and claim that all types of
“rational” knowledge, in fact, incorporate the perspectives of those in positions
of social power (Rodwell, 1998).

Cognitive theory employs overly structured approaches. Many cognitive interven-
tions include systematic procedures, and researchers sometimes require the use
of formal “manuals” for the appropriate provision of an intervention. Some
argue that standardized protocols represent a strength of cognitive theory, as
they bring great clarity to clinical practice. An alternative view, however, is
that highly systematized approaches dehumanize intervention and create a rigid-
ity that prohibits the social worker from attending to clients as unique people
(Payne, 2005).

SUMMARY

Cognitive theory focuses on conscious thought as the primary determinant of
most human emotions and behaviors. It has had great appeal to social work prac-
titioners because of its utility for working with many types of people and prob-
lem situations. For social workers who may have appreciated the systematic
nature of behavioral practice but were uncomfortable with its narrow focus,
cognitive theory initially offered a related but more humanistic alternative. Cog-
nitive interventions tend to be more systematic than those from the person-
centered, ego, and relational theories in helping a client explore his or her basic
assumptions, ideas, and values as they relate to a problem. The basic assumptions
of cognitive theory can be readily grasped by most clients, which facilitates a
practitioner’s desire for collaborative intervention. Cognitive theory has main-
tained relevance over the past 50 years by evolving from a position of seeking
“objectivity” in thought to incorporating ideas from social constructivism. Its
techniques also lend themselves to empirical validation, which makes the theory
attractive to third-party payers.

C O G N I T I V E T H E OR Y 197

TOPIC S FOR DISCUSSION

1. Describe two examples of (different) cognitive distortions that you have
observed in your clients. Discuss plausible intervention strategies for
changing them.

2. Depression is an unpleasant mood for anyone to experience, but we all
know people who seem to be depressed much of the time without evident
external stressors. Describe how a person might develop a cognitive pattern
that produces depressed moods.

3. Consider a client who, for you, would represent a special population (based
on age, race, gender, sexual orientation, disability, or socioeconomic status).
Note one cognitive pattern of the client that might be different from yours
but would not represent a distortion. How can a social worker guard against
mistakenly assessing such a pattern as a distortion?

4. Share examples of how a social worker’s own cognitive biases might become
problematic in working with clients. How might the social worker guard
against this?

5. How can cognitive/behavior theory guide a social worker’s intervention
with an otherwise well-adjusted client who spends three days in a hospital
recovering from a heart attack?

IDEAS FOR CLASSROOM AC TI V IT IES /R OLE -PLAYS

1. Organize role-plays featuring any type of client who has a presenting
problem that might be suitable for cognitive intervention. The social worker
should assess the client’s cognitive patterns, with the ultimate goal of
uncovering one or several core beliefs. Discuss afterward the kinds of
questions that seemed to facilitate this goal.

2. Organize a role-play featuring any kind of client (the same client may be
used from the previous exercise). Begin from the point of having identified a
cognitive distortion. The social worker should introduce and use the
pen-and-paper ABC intervention to help the client examine his or her
cognitive patterns and perhaps consider alternative interpretations of a
significant event. Students can share the challenges they faced in conducting
this intervention, which may (in the role-play) span several sessions.

3. Many agencies provide education and support groups for the families of
clients who have certain long-term disorders, such as schizophrenia, bipolar
disorder, and ADHD. Assign students to develop a brief psychoeducational
program for families of a client who experiences one such problem, based on
the principles of cognitive theory. Students must decide what material to
include that might correct cognitive deficits, help to confront cognitive
distortions, and assist in family problem-solving activities.

198 C H A P T E R 8

APPENDIX: Cognitive Theory Outline

Focus Cognition, including:

Structure (how thought processes are organized)

Propositions (“stored” information)

Operations (patterns of information processing)

Products (beliefs, attitudes, values)

Major Proponents Beck, Ellis, Lantz, Lazarus, Meichenbaum, Berlin, Corcoran

Origins and Social
Context

Development of the cognitive sciences

Pragmatism/logical positivism

Cognitive mediation in behaviorism

De-emphasis of the unconscious

Social learning theory

Emphasis on concrete goals and objectives in human services

Nature of the
Individual

Thought is the origin of most emotions and behaviors

Emotions result from cognitive evaluations

Human nature is neutral (neither good nor evil)

“Reality” as a human construction

Major Concepts Schemas (via direct and social learning)

Developmental
Concepts

Biological maturation of cognitive capacities

Core beliefs

Capacity for symbolization

Development of the self through self-talk

Conditioning

Cognitive pattern (schema) development

Nature of
Problems

Patterns of causal attribution

Life situations are more or less changeable

Internal versus external locus of control

Specific versus global implications of perceptions

Cognitive distortions (faulty information processing)

Arbitrary inference

Overgeneralization

Magnification

Minimization

Selective abstraction

Personalization

Dichotomous thinking

C O G N I T I V E T H E OR Y 199

Nature of
Change

Changing personal goals

Adjusting cognitive assumptions

Beliefs

Expectations

Meanings attached to events

Adjusting cognitive processes

Selection of input

Memory retrieval

Thought patterns

Goals of
Intervention

Promote the adjustments noted above

Increase self-regard

Enhance the sense of internal control

Nature of Worker/
Client Relationship

Positive regard

Social worker provides and enforces structure

Worker is:

A model

A coach (through guided reasoning)

A collaborator

Objective

Active

Intervention
Principles

General:

Socratic questioning

Reframing

More specific categories of intervention:

Cognitive restructuring

Self-instruction training

Triple column technique

Point/counterpoint (cost/benefit analysis)

Education (particularly for children and adolescents)

Cognitive coping

Problem solving

Communications skills development

Social skills development

Stress management skills development

APPENDIX: Cognitive Theory Outline (Continued)

200 C H A P T E R 8

Assessment Questions What is the logic behind the client’s beliefs?

What is the evidence to support the client’s views?

What other explanations for the client’s perceptions are
possible?

How do particular beliefs influence the client’s attachment of
significance to specific events? To emotions? To behaviors?

How strongly does the client believe that approval from others
is necessary to feel good about himself or herself?

APPENDIX: Cognitive Theory Outline (Continued)

C O G N I T I V E T H E OR Y 201

Structural Family Theory

Elysium is as far as to
The very nearest room,

If in that room a friend await
Felicity or doom.

What fortitude the soul contains,
That it can so endure

The accent of a coming foot
The opening of a door!*

S tructural family theory is a popular and useful perspective for organizing inter-
ventions with families. It offers an alternative and complementary perspective

to family emotional systems theory (discussed in Chapter 6). Structural family
practice is not quite as rich theoretically, but it includes more concrete interven-
tion techniques. Whereas interventions from family emotional systems theory
tend to be reflective in nature, those from structural theory demand action from
both the family and the social worker. In fact, this approach to intervention has
much in common with the cognitive and behavioral theories.

Structural family theory was developed by Salvador Minuchin in the 1960s,
and has continued to evolve through his ongoing work and that of others
(Minuchin, 1974; Minuchin, Lee, & Simon, 1996; Minuchin, Nichols, & Lee,
2007). The focus of the theory is family structure, a concept that refers to the in-
visible and often unspoken rules that organize how family members interact. During
assessment, the social worker evaluates these patterns of interaction for their sys-
tem utility. Structural family theory does not focus on the emotional lives of

* Dickinson, E. (1927). The Pamphlet Poets. New York: Simon and Schuster.

202
Copyright 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights,

family members as much as the external “architecture” of the family. Structural
practitioners assert that when a family establishes appropriate authority, rules,
subsystems, and boundaries, the emotional lives and behaviors of its members
will develop in ways that are mutually satisfactory.

Structural theory developed in response to a perceived need among practi-
tioners for interventions that could be used with families experiencing multiple
problems, including non-traditional, inner-city families dealing with poverty and
other issues contributing to family disruption. This flexible theory can be used
with any type of family, but its interventions seem particularly suitable for fami-
lies plagued by physical or mental illness, acting-out members, drug addiction,
crime, single parenthood, and violence.

ORIGI NS AND SOCI AL CONTEXT

We saw in Chapter 6 how family systems theories became popular among hu-
man service professionals in the years after World War II. Structural family the-
ory emerged several years after that first wave, in the mid-1960s. Its perspective is
derived from the influences of its founder’s background, social developments in
American society, and the status of structural theory in the field of sociology.

Salvador Minuchin maintained an interest in social action throughout his life
(Aponte & DiCesare, 2002; Nichols, 2009). He was born in Argentina in the
1920s and became a pediatric physician. Always interested in travel and public ser-
vice, Minuchin served as a physician in the Israeli army in the late 1940s. He later
came to the United States and studied child psychiatry with the noted family theorist
Nathan Ackerman. In 1954 he underwent training for psychoanalytic practice, and
was particularly influenced by Harry Stack Sullivan’s interpersonal theories.

In the major turning point of his professional life, Minuchin accepted a job
in the late 1950s as a psychiatrist at the Wiltwyck School for Boys in New York
State. At Wiltwyck, where he stayed for eight years, Minuchin worked with a
challenging population of institutionalized delinquent boys, many of whom were
African-American and Puerto Rican. He decided that family intervention was
the most useful way to help these adolescents, and thus became the first of the
major family theorists to work with multi-problem families. Throughout these
years he maintained contact with other notable family theorists of the time.
Minuchin left Wiltwyck in 1965 to become the director of the Philadelphia Child
Guidance Center for 10 years. His national reputation was established with the
publication of Families of the Slums (Minuchin, Montalvo, Guerney, Rosman, &
Schumer, 1967), which outlined his theory of structural family intervention in
detail. He continued to practice and write until his retirement in 1996.

Minuchin’s interest in working with children and multi-problem families
from poor urban areas was timely, given changing social conditions in the United
States during the 1960s. Those were years in which poverty, unemployment, de-
linquency, out-of-wedlock births, and discrimination in the cities emerged as

S T R U C T U R A L F A M I L Y T H E O R Y 203

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major public policy concerns (Reisch, 2000). The Kennedy and Johnson adminis-
trations attempted to address these social issues through such initiatives as the War
on Poverty and the Great Society (Day, 2000). Related programs included the
Economic Opportunity Act, Job Corps, VISTA, Upward Bound, Neighborhood
Youth Corps, and Head Start. The spirit of the times supported the efforts of hu-
man service practitioners to reach out to persons who experienced problems re-
lated to oppressive urban conditions. Minuchin’s theory was well suited to this
challenge. He was the only major family theorist of the time who had extensive
experience with these client populations, and there were underserved populations
in the cities that might benefit from his models of family intervention.

A third influence on Minuchin’s theory was the systems perspective in the
field of sociology known as structural functionalism (Parsons, 1977). Developed by
Talcott Parsons, this theory was dominant in American sociology from the 1940s
through the 1960s. It conceptualized societies as social systems featuring structures
(repetitive patterns of behavior) that should be evaluated in terms of their contri-
bution to the maintenance of the system. Structural functionalism emphasized
the importance of shared norms and values among actors in a system. The foun-
dations of any system were said to be motivated actors whose behaviors are held
in check by role expectations, the power of sanctions, and their shared desire to
uphold institutional values.

In structural functionalism, a social institution (such as the family) is defined as
an established order comprising rule-bound behavioral patterns of people guided
by shared values. Institutions are necessary in all societies for members to meet
their social needs and maintain social order. They tend toward self-maintenance
with boundaries, rules about relationships, and control of internal tendencies
to change. The purposes of the family institution are to regulate reproduction,
socialize and educate children, provide economic and psychological support to
members, transmit values, and care for sick and elderly persons. Minuchin was
aware of Parsons, and even called his own therapy structural (Kassop, 1987). His
outlook was compatible with many principles of structural functionalism. The
family is conceptualized as a social unit situated in a hierarchy composed of in-
dividuals and established social structures.

Minuchin’s work was influenced by social worker Virginia Satir (1964), whose
own family intervention methods were evolving during the 1960s. Satir’s family in-
tervention is most often called experiential, and goes beyond a focus on family struc-
ture. Still, her interventions required a high level of practitioner activity, and she was
particularly influential in her development of family communication interventions
and sculpting techniques, which will be described later in this chapter. Family struc-
tural interventions have been prominently featured in the social work literature
through the work of Harry Aponte, who has developed a model of multi-systemic
therapy that combines structural and larger systems interventions (Aponte, Zarski,
Bixenstine, & Cibik, 1991). This will be described later in the chapter.

Structural family therapy has also been expanded by contemporary practi-
tioners to incorporate ideas from solution-focused therapy (see Chapter 10), spe-
cifically the use of the “miracle question” (Ramisch, McVicker, & Sahin, 2009);
family-directed structural therapy, which utilizes group intervention methods

204 C H A P T E R 9

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(McLendon, McLendon, & Petr, 2005); and structural ecosystems therapy, which
maintains a major focus on environmental risk factors in working with persons
who abuse substances (Mitrani, McCabe, Burns, & Feaster, 2012).

With this brief introduction to the theory’s development, the logic behind
its major concepts that inform family assessment can be better understood.

MAJOR CONCEPTS

The family structure concept was described earlier. The other major concepts, all
of which make up that structure, are described below.

Executive Authority

Effective family structure requires that some person or persons assume a position
of primary decision-making power. This executive authority characterizes the per-
sons in that role. Structural theory asserts that in every family consisting of more
than one generation, adult members should exercise primary authority. As an ex-
ample of the appropriateness of such authority, a study of European-American
adolescents found a positive link between the nature of the parent-adolescent
\hierarchy and the capacity of both boys and girls to experience intimacy with
their best friends (Updegraff, Madden-Derdich, Estrada, Sales, & Leonard, 2002).
Other family members may share authority in some circumstances, such as in
deciding how to spend a weekend or what kind of restaurant to visit.

During assessment, the social worker should determine who has power,
whether power shifts depending on circumstances, and how decisions are
made. Regarding decision making, the social worker should assess the extent to
which the opinions and needs of all members are taken into account, the ability
of the family to problem-solve as a unit, and the family’s flexibility in adjusting
decisions when appropriate.

Subsystems

In any family that is composed of more than two people, some members
develop patterns of interaction in certain contexts that exclude other members.
Examples of these subsystems include parents, adult members, nuclear- versus
extended-family members, siblings, and some adult/child alliances. Subsystems
are normal and usually functional. For example, adult members need to act as a
subsystem in establishing behavioral standards for children, and siblings learn
social skills and ways of negotiating conflict through their own interactions. Sub-
systems may be problematic, however, when serious conflicts develop between
them (parents versus children, for example) or if they inappropriately exclude
certain other members. A problematic parent/child subsystem may develop as a
strategy by one parent to avoid interacting with, or dilute the influence of, the
other parent.

S T R U C T U R A L F A M I L Y T H E O R Y 205

Boundaries

Families are systems, but they must preserve some physical and emotional sepa-
rateness for each member in order to ensure their effective functioning. These
boundaries are both internal and external. Internal boundaries are the barriers that
regulate the amounts of contact that members or subsystems are expected to
have with each other. In some families, for example, each member is entitled
to the privacy of his or her own room, while in others, it is desired that the
members share rooms. Likewise, some families engage in many social activities
together; in others, the members interact infrequently. Boundaries may be rigid
(members being physically or emotionally isolated) or fluid (members being too
close to each other, and therefore denied privacy or separateness). A study of
adolescents from diverse ethnic backgrounds revealed that appropriate parent/
child boundaries promoted the young adolescents’ maturity and ability to
form coalitions and communicate well with peers (Madden-Derdich, Estrada,
Updegraff, & Leonard, 2002). External boundaries refer to the separation of the
family unit from outside systems such as other families and community groups.
Most families believe that much of their internal business (finances, conflicts,
illnesses, religious practices, child-rearing practices) should be kept private from
persons (and agencies) outside the family.

Rules

Rules are the behaviors and responsibilities to which each family member is ex-
pected to adhere. They are different for each member depending on life stage
and family position (parent, child, extended-family member, etc.) and are usually
established with reference to age-appropriate social norms. The executive au-
thority has primary responsibility for rule development, but all members may
participate in the process. A parent may decide rules about driving practices
among adolescent members, but the adolescent may be permitted to set rules
about his or her study and work routines. Rules may pertain to such issues as
curfew, household upkeep, academic standards, who is expected to work, how
money will be spent, and with which other people family members may interact.
Some rules are openly articulated, while others may be acquired through habit.
For effective family functioning, rules should be clearly understood by all
members.

Roles

A family member’s roles refer to his or her functions within the system. Each
family member must manage several roles. These may be assigned by the execu-
tive or some external source (usually reflecting social norms) or be assumed by
members because of particular family circumstances. Examples of typical roles
include the breadwinner, money manager, caregiver, housekeeper, and “social
director.” Other roles may include the family “hero” (who presents a positive
image of the family to the outside world) or “scapegoat” (the source of all family

206 C H A P T E R 9

problems). Roles change over time and in different contexts. The social worker
needs to assess how a family’s roles are defined, whether they seem appropriate,
how satisfied members are with their roles, and whether any members experi-
ence stress due to “role overload” or being responsible for a number of possibly
conflicting roles.

Alliances

Alliances are conditions in which two family members or subsystems interact
cooperatively. These are positive when they contribute to the overall well-
being of the persons involved and to the family unit. In families that include
two spouses, their alliance around child-rearing practices is positive if those prac-
tices contribute to the health of the children. Alliances are negative when they
are rigid, exclusionary, or otherwise contribute to family problems. Two siblings
can form an alliance against a third sibling or against a parent, with the purpose
of enhancing their power and the result being cruel or unfair treatment of the
third person. Two terms that reflect family problems in this regard are en-
meshment (two or more members behaving in collusion with one another to the
extent that they cannot function with autonomy) and disengagement (two mem-
bers being isolated from one another). You may recall that these terms are also
used in family emotional systems theory.

Triangles

Triangles were described in Chapter 6 and represent a type of alliance in which
two family members turn their attention to a third member for relief or support
when in conflict with each other. As examples, two adults in conflict may
choose to blame a child member for creating their problem (that is, scapegoat-
ing), or an adult and a child member may join forces to block the power of
another adult member. Negative triangles often develop outside of the parties’
awareness. Family emotional systems theory focuses on the emotional outcomes
for the most vulnerable member of a triangle, whereas structural theory focuses
on triangles’ long-term threats to family organization. Triangles are often a natu-
ral process of seeking relief from tension, but they may cause structural problems
if they become disruptive to other members in a family system.

Flexibility

For effective functioning, all families frequently need to adjust their structures to
accommodate the predictable and unpredictable changes in the lives of their
members and in the environment. Predictable changes may include the move-
ment of members into new life stages (childhood to adolescence, adulthood to
older adulthood) or the addition and loss of members through birth, death, com-
ing home, and moving away. Unpredictable changes may include a member’s
abrupt job loss, physical injury, illness, incarceration, pregnancy, or changed rela-
tionship with significant others in the external environment. Flexibility refers to

S T R U C T U R A L F A M I L Y T H E O R Y 207

the ability of the family system to make adjustments that preserve its positive
functions. Flexibility is not in opposition to structure. The opposite of structure
is chaos, which represents a family’s structural breakdown in the face of system
challenges.

Communication

The ability of people in relationships to engage in clear and direct communication,
the practice of conveying messages, is important in every practice theory. It re-
ceives extensive attention in structural family theory, however, because the prac-
titioner is interested in the structure of communication. Functional family
communications are characterized by verbal and nonverbal congruence and con-
sistently observed rules. The structural practitioner will assess and may help the
family to become aware of its “rules”; for example, who is permitted to talk to
whom about what issues, at what times, and in what tones of voice. Many family pro-
blems are caused or sustained by unclear or unbalanced communication, or by its
absence. If communication skills are enhanced, other restructuring activities are
facilitated.

Other Concepts

Other factors not specific to structural theory must also be taken into account
during structural family assessment. These include:

Cultural Considerations Diverse family cultures may feature differences in struc-
ture regarding communication style, family hierarchy and power structure, how
much authority the family wishes to grant the practitioner, member preferences
for formal or informal interaction (with each other and the practitioner), and the
issue of dual identity (the family’s relationship to the dominant external culture)
(Fong & Furuto, 2001). Social work practitioners need to be aware of cultural
norms when a family’s background is different from their own, so that the assess-
ment will not be biased. Structural family interventions have recently been found
to be effective with such populations as Hispanic (Becerra & Michael-Marki,
2012) and African-American youth (Santisteban et al., 1997), gay men (Long,
2004), Asian-Americans (Kim, 2003), and Chinese families (Sim & Wong, 2008),
among others.

As an example of how structural family theory can and should take into ac-
count the family’s cultural context, a review of the process with lesbian, gay,
bisexual, and transgendered (LGBT) families is presented here. Note that con-
cepts from family emotional systems theory (discussed in Chapter 6) are also in-
cluded in this example.

LGBT individuals are present in many families as partners, parents, or chil-
dren. The term “LGBT families” describes families in which one or both of the
adult heads of the family identify as lesbian, gay, bisexual, or transgender. In
many aspects, LGBT families, and the challenges that bring them to counseling,
are similar to most other families. LGBT families may seek counseling for

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assistance with communication issues, parenting issues, infidelity issues, acting-
out child behaviors, and substance abuse (Connolly, 2004). Additionally, these
families may seek intervention to deal with specific LGBT issues, such as coming
out or disclosure issues; problems relating to families of origin and their reactions
to the LGBT family; dealing with cultural oppressions, including homophobia,
transphobia, or heterosexism; and internalized homophobia or transphobia.
LGBT families of color or interracial families often face additional challenges,
including dealing with the intersecting oppressions of racism, homophobia, or
transphobia, and, in the case of interracial families, dealing with issues arising
from family members having differing cultural identities and expectations sur-
rounding family life (Green & Boyd-Franklin, 1996).

Family intervention for LGBT families is a relatively new focus in the prac-
tice literature. Prior to the 1980s, much of the literature regarding LGBT indi-
viduals in families focused on the alleged treatment of homosexuality, attempting
to shift individuals’ same-sex desires and behaviors to heterosexual desires and
behaviors (Spitalnick & McNair, 2005). Since then, more literature around the
treatment of LGBT families is focusing on positive and affirmative practices that
address the specific needs of the population. A number of family theory concepts
from structural family and Boweman theory can be used when these issues may
present themselves in LGBT families, including family and gender roles, bound-
aries, and differentiation of self.

Traditionally, roles within a family are strongly influenced by members’ cul-
tural backgrounds and personal histories. For LGBT families, the creation of roles
and division of tasks is not necessarily based on gendered divisions. Being com-
posed of two men or two women, a same-sex couple cannot rely on traditional
male-female role divisions to structure their interactional patterns (Green &
Mitchell, 2002). Instead, they must work to negotiate and develop family and
relationship roles that account for the desires, strengths, and preferences of all
involved. It is important to note that, despite the stereotype, only a small minor-
ity of LGBT couples divides relationship roles in a manner in which one mem-
ber plays the role of the “wife/mother” and the other plays the role of the
“husband/father.” Structural family practitioners working with LGBT families
need to be aware of issues surrounding family roles, as they are often working
to create roles without the aid of models (Coates & Sullivan, 2006). In-session
enactments (described later in this chapter) are a powerful tool for helping LGBT
families recognize the roles that they currently hold in the family, as well as iden-
tifying potential alternative family structures (Greenan & Tunnell, 2003).

Creating or maintaining healthy family boundaries is a significant issue in
LGBT families. Families of origin and society at large may devalue the commit-
ment that same-sex partners have made to one another, and their shared roles as
parents or stepparents to children. This can cause split loyalties, in which each
partner remains loyal and connected to her or his family of origin to the exclu-
sion of the partner, thus destabilizing the relationship and its boundaries
(Greenan & Tunnell, 2003). LGBT parents may also adopt alternative parenting
roles, such as having their children call them by their first names, in an attempt
to create a post-heterosexist family (Coates & Sullivan, 2006). Although

S T R U C T U R A L F A M I L Y T H E O R Y 209

well-intentioned, this parenting style can potentially lead to disengagement, as it
does not provide for well-defined boundaries between family members. Con-
versely, in LGBT families, as with other minorities who perceive their families
to be operating in an ambivalent or hostile social environment, a greater risk of
enmeshment exists. Social workers practicing with LGBT families need to be
aware of patterns of enmeshment or disengagement so that they can assist fami-
lies in developing appropriate boundaries among members and between the fam-
ily and outside systems.

The Bowen family systems concepts of differentiation of self and fusion are
often discussed in family practice with LGBT families, particularly with lesbian
couples. Beginning in the 1980s, family theorists looking at lesbian couples as-
serted that these dyads had high levels of fusion, leading to relationship problems
that were a primary cause of the termination of these relationships (Laird, 1993).
More recently, scholars such as Spaulding (1999) and Basham (1999) have as-
serted that the typification of lesbian relationships as pathologically fused stems
from sexist biases regarding appropriate levels of connection between partners.
In contrast, gay male couples are often perceived as more emotionally distant
from their partners. Within gay male couples, open or non-monogamous rela-
tionships are common, which has led some individuals to make the assumption
that gay couples are less committed and caring than other couples. In gay male
couples with negotiated open relationships, the meaning of sex with others is
viewed differently, as simply a pleasurable act rather than a betrayal of commit-
ment (Green & Mitchell, 2002). In working with LGBT families and couples,
social workers need to be conscious of potential fusion but at the same time rec-
ognize that heterosexist views about family relations may influence their assess-
ment of the family’s level of differentiation. The use of genograms with LGBT
families has been noted as an important tool that opens up space for dialogue
about issues such as the impact of homophobia and heterosexism on the family
(Swainson & Tasker, 2006).

Providing culturally competent social work practice is critical to working
with all minority or oppressed populations, including LGBT individuals and fam-
ilies. Wetchler (2004) suggests that all practitioners, regardless of sexual orienta-
tion and gender identity, are raised and live in a heterosexist society, which may
shape their values and attitudes toward LGBT couples. At times, a social worker’s
personal values may differ from those of his or her LGBT clients. A practitioner
may have strong values regarding the importance of fidelity and monogamy in
relationships, and thus be challenged in working with a family whose values re-
garding monogamy are different. Green (2007) states that the most important
prerequisite for helping same-sex couples is the practitioner’s personal comfort
with love and sexuality between two women or two men. Additionally, practi-
tioners working with LGBT families need to be aware of their personal beliefs
regarding LGBT people as parents, and its potential effects on family
intervention.

Particularly relevant to cross-cultural awareness with LGBT families is an
awareness of the many forms that families may take within the LGBT commu-
nity. This includes an understanding of the concepts of family of origin (or the

210 C H A P T E R 9

family in which LGBT individuals were raised) and family of choice, which can
encompass chosen biological family members and non-biological relations, in-
cluding partners, co-workers, neighbors, and friends (Green, 2007). In a sense,
LGBT people are bicultural. The majority of LGBT people were raised in the
dominant, heterosexual culture, but as part of the LGBT community, they may
have beliefs, values, and behaviors that may differ from those of the dominant
culture (Johnson & Keren, 1998). Social workers need to have knowledge re-
garding the LGBT community, and use practice techniques that demonstrate un-
derstanding and respect. Cross-cultural skills can range from following clients’
leads with regard to how they identify themselves and their relationships, to
openly and honestly discussing with clients how larger social oppression, such
as homophobia, may be affecting their relationship.

Family Goals Families do not always openly articulate a set of goals, but members
nevertheless tend to develop a sense of purpose regarding their place in the family
and how they can be mutually supportive of those goals (Hepworth, Rooney,
Rooney, Strom-Gottfried, & Larsen, 2012). Family goals may include raising re-
sponsible children, developing loving bonds, developing a shared sense of spiritu-
ality, or amassing material resources. The social worker should assess the family’s
awareness of and level of consensus about goals, as well as their functionality.

Family Life Cycle Stage The nature and quality of a family’s functioning varies
depending partly on its composition, which may include unattached adults, new
partners, young children, adolescents, adult children, or persons in later life. It
would be expected, for example, that a family with adolescents features more
ongoing tension than one composed only of new partners. Social work has
been significant in demonstrating the utility of the life model perspective
through the work of Gitterman (2009), whose ecological perspective focuses on
the complex relationship between people and their environmental systems dur-
ing predictable and unpredictable life transitions.

Family Myths This refers to shared family beliefs that evolve in a family’s effort
to define itself, set boundaries with the outside community, and perhaps protect
members from both internal and external conflict (Hepworth, Rooney, Rooney,
Strom-Gottfried, & Larsen, 2012). They are called myths because they are not
“true” in an objective sense, but reflect traditions and possibly cultural factors.
Examples of family myths are: “Outsiders are not to be trusted”; “People should
always stay close to home”; “Children should take care of their parents”; “Dad’s
violent behaviors are not to be questioned”; and “Mom doesn’t really abuse
drugs.” Myths tend to be problematic for outsiders (including social workers)
when they serve a defensive function.

External Systems Influences It has been noted that the family is a primary social
institution, but there are others with which families routinely interact, including
religious, educational, economic, and political institutions. Further, families exist
in the midst of other identifiable systems, such as the neighborhood and the

S T R U C T U R A L F A M I L Y T H E O R Y 211

larger community. All of these entities contribute to conditions that influence
a family’s structure and the quality of life of its members. Recall that structural
family theory developed in a context of serving the needs of families that
were socially disadvantaged by external systems. The social worker must al-
ways assess the effects of a family’s interactions with these other systems, and
possibly direct some of his or her interventions toward creating a more mutu-
ally facilitative environment. The social worker’s extra-family activities may
include linkage, referral, mediation, and advocacy activities. Meyer (1970)
brought attention to these processes in her development of the eco-map, a
graphic representation in which the family is placed within the context of
the larger social system.

THE NATURE OF PROBLEMS AND CHANGE

The above concepts direct the manner in which structural practitioners assess the
problems experienced by their clients. Many problem situations are on a “con-
tinuum of functionality,” however. It is not easy to conclude whether, for ex-
ample, a boundary is rigid or fluid.

Power imbalances describe situations in which the “wrong” (less mature or re-
sponsible) members have the most power in a family system. Perhaps young mem-
bers of the family can get adult members to acquiesce by throwing temper
tantrums or making threats. Young members may also assume power when the
adult members choose not to exercise it. Further, adult members in a family may
be inconsistent in their expectations of members or disagree about major decisions
and behavior limits. When the “wrong” family members have the most power, the
system often moves toward chaos (a lack of structure), because it lacks an executive
authority with reasonably mature judgment about family functioning.

Subsystem boundaries that are too rigid or too diffuse produce situations in which
some members are either emotionally or physically isolated from each other or
too involved in each other’s lives. Examples of problems related to diffuse
boundaries include the sexual abuse of a child by an adult and parental overin-
volvement that prevents adolescent members from developing age-appropriate
independent living skills. Adult and child subsystems may intrude into each
other’s personal affairs to the extent that none are assured of privacy, and as a
result they act out their frustrations with negative behaviors. Problems related
to rigid boundaries include adult members being unavailable to their children
and lack of communication and interaction among members of subsystems
(adults, children, extended family, etc.). When boundaries are rigid, members
may experience high levels of tension due to an inability to find support to man-
age their everyday challenges at school, with peers, or at work. Members of sub-
systems also fail to benefit from the learning that might otherwise come from
their interaction.

The following two sources of family problems are related to the boundary
issues described above, but refer to the behaviors of individuals rather than of

212 C H A P T E R 9

subsystems. Disengaged (isolated) members do not interact with other members or
with the family system in general. When one spouse is disengaged from the
other, each person may feel lonely or depressed. Another example is commonly
seen in an adolescent member “shutting out” the rest of the family and organiz-
ing her or his life around peer activities. This diminishment of the family’s influ-
ence prevents it from providing appropriate guidance and limits to the
disengaged member. Of course, the person may feel angry with or pushed
away by the family. On the other hand, enmeshed members rely too much on
one other for support and assistance, instead of developing their own life skills.
They may be at risk for failure to progress through expected stages of social de-
velopment and become unable to assume socially appropriate roles.

When members of a family lack good communication skills, they may develop
a family atmosphere of pervasive conflict or tension related to the avoidance of processing
conflict. It was noted earlier that good communication practices are an essential
component of successful family systems. Communication is the “currency” of family
interaction. Because conflict is also a natural part of interpersonal life, an inability to
process it sustains even small problems. For example, if a parent cannot resolve anger
with a child related to poor grades in school, the resulting tension may persist and
spiral into resentments that “blow up” at times into harsh physical punishments.

Family problems may derive from a failure of the system to realign (or resume
productive and cooperative individual and family roles) after a stressful event
such as the birth, death, injury, illness, or separation of a member. Although
making adjustments to change can be challenging for any family, rigid families
have particular trouble, essentially holding onto roles and rules that are no longer
functional. With the death of one parent, for example, the other parent may be
unable to make changes in his or her roles and routines to devote more time to
nurturing the children. The children may not be inclined to increase their sup-
port of the remaining parent by taking over some household responsibilities. This
failure to adjust may result in a variety of presenting problems, such as increased
tension, other emotional distress among members, substance abuse as a coping
strategy, and behavioral acting out.

Member resistance to normal family change processes is related to the issue above but
indicates a lack of flexibility in the family system to accommodate any changes.
This issue presents a challenge for many families: being able to recognize when
one member is moving into appropriate new roles and a changed relationship
with the family, and making adjustments in the rest of the family to accommodate
that change. Parents typically struggle with these change issues when considering
when to allow younger members to work, drive, stay out later, and spend more
time away from home. Siblings struggle to adjust to one member’s moving away,
and to the changing expectations for those remaining in the household.

The goals of intervention in structural family theory are to change the existing
family structure so that it becomes more functional. Change may also involve in-
creasing the available supports for members outside the family system. A basic prin-
ciple of structural family intervention is that action precedes understanding. One or
more family members must take action, with the guidance of the social worker,
to change the nature of family interactions, rather than simply talk about taking

S T R U C T U R A L F A M I L Y T H E O R Y 213

action. Through restructuring processes that include practicing new ways of inter-
acting and communicating, family members may experience permanent relief
from the presenting problem. Insight about the problem situation may occur after
the fact, but is not considered a necessary aspect of change. This perspective is con-
sistent with (but not identical to) those of the cognitive and behavior theories.

ASSESSMENT AND INTERVENT ION

The Social Worker/Client Relationship

The social worker is highly directive in structural family intervention. From the
first meeting, he or she must “take charge” and lead the family’s process of prob-
lem resolution. Minuchin felt that the practitioner was the “expert” in that he or
she, as a trained observer, was in the best position to understand a family’s struc-
ture. At the same time, the social worker must make efforts to connect with each
family member, be perceived as credible and empathetic, and promote an atmo-
sphere of family competence. Two studies of videotaped structural family ses-
sions revealed that empathy and collaboration were essential ingredients in
facilitating within-session change (Nichols, 2009; Hammond & Nichols, 2008).

Assessment

Prior to problem exploration, it is often useful for the social worker to conduct a
structured warm-up exercise to promote the family’s comfort. Such exercises
may include traditional “icebreakers,” such as having members introduce each
other, talk about their favorite hobbies, describe the figures from popular culture
they most admire, and so on (Barlow, Blythe, & Edmonds, 1999).

Structural family theory does not rely on a lengthy process of formal infor-
mation gathering. The social worker does ask all members of the family to de-
scribe the issue that brought them to the agency and give some details about its
background, but always in a conversational tone. The social worker then at-
tempts to get information about the following issues, not by asking the questions
specifically, but by observation and a non-threatening interchange:

What are this family’s patterns of interacting? Who spends time with whom,
what do they do together, and what do they talk about?

How does the family present itself structurally? What roles do the members
seem to occupy? How do these roles play out in the session?

Where does power lie in this family? Who makes decisions and who
enforces them? Is authority or decision making shared in any way?

What subsystems appear to be prominent? Which members appear to be
bonded, and for what reasons? Are alliances rigid or fluid?

Does the presenting problem appear to serve a function for the family? Does
one member’s, or several members’, behaviors absorb the family’s attention?

214 C H A P T E R 9

What are this family’s typical patterns of managing stress? How do they re-
spond as a unit to everyday stress, as well as to crises and members’ normal
life transitions?

How sensitive are family members to each other’s feelings and needs? Do
they listen to each other and take each other seriously? Are certain members
ignored?

What do members seem to expect from each other? What is their sense of
shared responsibility for any family functions?

Do members accommodate each other’s needs? Are they capable of flexi-
bility in their responses to each other?

Is the family involved with external systems? With what formal and informal
institutions do they interact, like churches, civic associations, recreational
centers, or perhaps legal and welfare agencies? Are they welcoming or sus-
picious of outsiders?

The social worker begins rather quickly to assess the family structure and
presenting issue by encouraging members to enact rather than merely describe their
significant interactions. This is facilitated through role-plays. During these enact-
ments the social worker focuses on the nature of member interactions with re-
spect to the questions listed above.

During enactments, the social worker identifies both positive and negative
patterns of interaction within the family. The practitioner alerts family members
to any observed problematic communication patterns and asks if they wish to
change them. The practitioner also identifies and articulates any structural char-
acteristics of concern such as weak bonds between spouses or others, conflicts
between subsystems, alienation or enmeshment of any members, and alliances
outside the family that contribute to internal problems. What follows next are
the strategies that help to promote the change effort.

Intervention

It must be emphasized that when implementing any of the interventions de-
scribed below, repetition is often necessary for structural changes to become inter-
nalized in a family system.

Supporting system strengths refers to the social worker providing compliments
about aspects of family functioning that are going well. This includes affirming
the dignity of the family with empathetic responses and nonjudgmental com-
ments about its behaviors.

Relabeling, or normalizing, a problem helps family members develop a new
perspective about themselves that is more constructive. Behaviors that are currently
problematic may have initially represented members’ caring for each other. For ex-
ample, a parent’s harsh verbal treatment of a child may now be a problem, but it
may also indicate that the parent cares about the child. When relabeling, the social
worker does not excuse behavior, but places it into a context that reduces defensive-
ness and the stigmatization of any member as “the problem.”

S T R U C T U R A L F A M I L Y T H E O R Y 215

Mobile User

Problem tracking encourages the family to track its target behaviors between
sessions so that members can more clearly identify their structural patterns and
get accustomed to working actively on problem resolution. A part of each family
meeting will include a review of these observations as well as reports of new
activities undertaken between sessions. At the same time, members are asked to
give up an exclusive focus on past events that have been problematic and look
toward their future family life.

Teaching stress management skills can enhance the self-control of members
prior to initiating any anxiety-provoking interactions. The most basic means of
supporting stress management is to find out what healthful means of relaxation
members already have and prescribe more of those activities. Other practices,
such as deep breathing and progressive relaxation, can help members manage
tensions that may emerge during family intervention. Several of these techniques
are described in the chapters on cognitive theory and behavior theory.

Helping the family modify its rules is achieved through discussion and mutual
decision making. The potential for a family to resolve its presenting problems is
usually high, particularly in the relatively formal environment of the social work-
er’s office, where interactions may be less emotionally charged. As a part of this
process, the social worker should help to correct any cognitive distortions or
myths regarding what family life should or should not provide for the
members.

Manipulating space, or assigning family members to stand or sit in certain con-
figurations, can highlight important structural characteristics. For example, adults
who lack power in setting limits on child behavior may be asked to sit closely
together so that they can provide support to each other. Likewise, two estranged
siblings might be instructed to sit next to and even face each other, as a means of
encouraging their interaction. Space manipulation, also known as sculpting, can
also be used to visually highlight family structural characteristics. This technique
was developed by social worker Virginia Satir (1964). The plight of a child who
feels ignored by his parents, for example, can be “illustrated” by the social
worker turning the child’s chair around while his parents talk among themselves
about the child. The goal of these activities is always to promote the develop-
ment of more functional structural arrangements.

In communication skills training, the social worker instructs families in methods
of clear speaking and listening to communicate their needs, ideas, and feelings. It
was stated earlier that the quality of communication is a primary determinant of
family functioning. Functional families are characterized by a shared understand-
ing of messages between senders and receivers and rules about communication
that are consistently observed (the range of topics that are appropriate to discuss,
when they can be discussed, and who can participate). Communication interven-
tion may include the following activities:

Pointing out confusing messages (“I don’t understand something. You tell
your son that he should spend time with his friends, but then you won’t let
him go out on weekends.”)

Teaching members to make clear requests of one another

216 C H A P T E R 9

Teaching members how nonverbal behaviors (expressions, tone of voice,
and physical distance) may enhance or disrupt communication

Disallowing interruptions, so that all members have the opportunity to be
heard

Helping clients learn to disengage from unproductive conflict (to stop its
escalation before reaching the point of negativity)

Directing role-plays, simulations of actual or possible family situations, is a
means of adjusting family interactions. During role-plays, the social worker asks
the entire family, or certain members, to act out a specific episode that has rele-
vance to them. For example, if a parent has difficulty setting limits with an ado-
lescent child, the social worker may ask the two members to role-play a
conversation in which the parent tries to establish a curfew agreement. After-
ward, the social worker and family members evaluate the exchange and make
suggestions about how the members might behave differently to be more consis-
tent with the family’s goals. Role-plays may be brief (less than a minute) or more
lengthy (10 to 15 minutes). In role reversals, members are asked to play the roles
of other persons in the family to sensitize them to the feelings of others with
whom they may be in conflict.

A major practice strategy in structural family theory is to assign tasks for
members to complete between sessions. These tasks are always intended to
strengthen or loosen alliances and subsystems in accordance with the family’s
goals. The practice ensures that the family works actively toward its goals in
the natural environment. As examples, two spouses who have become disen-
gaged may be asked to spend one evening together each week without other
family members. A sibling who is enmeshed with an adult may be asked to
undertake a household maintenance task with another sibling or adult. There
is much room for social worker and family creativity in devising such tasks.
The social worker should leave it to the family members to decide on the
specific elements of tasks so that they will be suitable to the persons involved.
At some point during the follow-up meeting, the social worker should assess
whether the tasks have been completed, whether they were helpful, and what
other tasks might be useful.

Ending Structural Family Interventions Structural interventions focus on be-
havioral change, and thus indicators that the process should end can be ascer-
tained through formal change measures, family member behaviors in sessions,
and family self-reports of activities between sessions.

Formal Instruments Several instruments have been designed to assess and measure
change in structural family therapy. One example of an established instrument
that is partially suitable as a change measure within this theory is the Family As-
sessment Device (FAD) (Franklin, Hopson, & Barge, 2003). This instrument in-
cludes six subscales, four of which (problem solving, communication, roles, and
behavior control) are consistent with the focus of structural intervention. These
four subscales, composed of between 6 and 11 items rated on a continuum, can

S T R U C T U R A L F A M I L Y T H E O R Y 217

be used independently of the other two subscales. A social worker can ask family
members to complete the FAD at intervals during the intervention process as a
measure of structural changes regarding the four variables. The instrument is
brief, practical, and valid. Another instrument that may help to assess the quality
of family interactions is the Structural Family Systems Ratings Scale (Mitrani,
Feaster, McCabe, Czaja, & Szapocznik, 2005).

Time Measures The social worker can use time measures to see how alliances
change among family members. For example, toward the goal of developing
rules for appropriate boundaries, a child may be asked to monitor how much
time she is permitted to spend alone in her room or out of the house with
friends without parental interruption. The issue of permanence of change can
be addressed by evaluating the consistency of these measures over some specified
length of time. At the end of the intervention, the practitioner can summarize in
concrete terms (time, frequency, and content) the manner in which various sub-
systems have changed.

Quality of Role-Plays As a family’s functioning improves, the social worker can
use role-plays more flexibly to help members anticipate possible future chal-
lenges. He or she can ask family members to respond to difficult situations that
they have not yet faced. Their ability to do so flexibly indicates that the family
has acquired the ability to respond to new challenges.

Monitoring External Interactions Throughout the intervention, the social worker
and family will be sharing their impressions of how well they are managing their
target behaviors related to task activities in the natural environment. When there
is consensus among the participants that they have mastered these behaviors, the
intervention can end unless the family sets additional goals.

SP IR ITUAL ITY IN STRUCTURAL FAMILY THEORY

Structural family theory is not as rich as family emotional systems theory with
regard to incorporating members’ spiritual issues because it is focused on orga-
nization rather than emotional life. Concepts such as authority, boundaries,
rules, power, subsystems, and roles do not encourage an exploration of the
belief systems of members, except as they relate to structural operations. For
example, one member’s decision to pursue a career in human services in a
family of businesspeople may create conflict related to this perceived values
difference, which may result in the “outside” member being restricted from
certain roles and alliances. However, in structural family intervention, the con-
tent of such a conflict would be less important than its effects on family struc-
ture. As far as considering the spirituality of individual family members, the
perspective described for cognitive theory in Chapter 8 is consistent with
structural theory.

218 C H A P T E R 9

ATTENT ION TO SOCIAL JUST ICE ISSUES

Structural family theory is clearly consistent with the professional value of social jus-
tice. In fact, Minuchin (1984) wrote that its interventions have little value without
the practitioner’s attention to macro-social issues that affect the family’s life. Al-
though the theory is useful with many presenting problems, the families for whom
it was initially developed included vulnerable and oppressed people. With the prin-
ciples of structural intervention, social workers can focus change efforts on issues re-
lated to poverty, unemployment, discrimination, and other forms of social injustice.
The earlier discussion about LGBT families provides one illustration of this point.

Some structural theorists have systematically enlarged the theory to include
attention to social structures so that families can gain access to external informa-
tion, services, and resources. For example, one community mental health center
implemented a structural family therapy program that features a two-tiered,
home-based intervention (Aponte, Zarski, Bixenstine, & Cibik, 1991). The
home-based therapy provides a viable means of intervention for families that
are not receptive to office-based counseling, either for cultural reasons or because
they do not have transportation resources. Families suited to this model of inter-
vention tend to be poor and underorganized, meaning that member roles are ill
defined and parental authority is either diffuse or overbearing. These families of-
ten become involved with social agencies and thus lose some control over their
own destiny. With the two-tiered approach, social workers help families resolve
their internal problems, and then help them address community problems that
they share with other families. The intervention persists for 12 to 16 weeks.

The first and primary focus in this program is the provision of structural family
intervention, so that family members can develop consensus about their roles and
responsibilities within the unit. The adults are helped to develop and enforce ap-
propriate controls over the younger members. The social workers attempt to pro-
vide practical solutions to the family’s concrete problems, which tend to be
initially centered on one child’s problem behavior, but are eventually accepted as
systemic problems. If the structural interventions are successful, the second tier of
intervention is introduced, and the family is invited to participate in a multiple-
family support group composed of other families who have completed the struc-
tural therapy. This open-ended group is conducted in a public community setting
by different staff members. The goals of the ongoing group are for participants to
increase their awareness of community factors that influence their lives and to em-
power themselves to take action toward enhancing their community lives.

CASE ILLUSTRAT IONS

The Dalton Family

Nita Dalton was a 42-year-old, Caucasian, married mother of three children liv-
ing in the rural outskirts of a large city. She was referred to the family agency
by a case manager at the county human services department who had been

S T R U C T U R A L F A M I L Y T H E O R Y 219

managing her requests for financial assistance. The referring worker was con-
cerned about Nita’s reports of family conflict that included emotional detach-
ment from her husband and acting-out behaviors from her two sons. Carrole, a
55-year old, Caucasian social worker, met with Nita at the mental health center
and decided that the client’s concerns could be best addressed if the entire family
came for a second appointment. All of the household members agreed to do so
except for Nita’s husband, who remained uninvolved throughout the five-session
intervention. The members who did participate included Nita, her two sons
(ages 22 and 20), their new wives (ages 20 and 19, respectively), and her
8-year-old daughter (see Figure 9.1).

The social worker quickly observed that the family was highly conflicted.
Nita’s husband was employed part-time as an auto mechanic, but was estranged
from the others, living several miles from the house and maintaining minimal
contact with them. He was also said to have a drinking problem. Nita was over-
functioning as the de facto head of the household, trying to manage it on the
limited income that her husband provided. As a result she was continuously
stressed, anxious, and depressed. She complained that her two sons were irre-
sponsible, working sporadically and always trying to borrow money from her.
It was hard for Nita to set limits with them; they were able to wear her down
with persistent cajoling. Carrole noticed that the older children were cheerful in
the session, seeming to feel entitled to the family resources, and having little sen-
sitivity to their mother’s distress. Nita felt close to her young daughter, and spent
most of her free time with her. She wanted to work outside the home (and had
done so in the past) but felt that she had no time to do so. She said that if her
sons would leave home and take care of themselves, she could get a job.

Nita and her family came from an Appalachian cultural background. In that
culture, women are expected to assume the role of household manager and sur-
vive with little material support, all for the good of the family. Men maintained
primary power, but were less involved in day-to-day family interactions. Marital
infidelity was common among members of their community. In fact, women

45 42

820 22

1920

F I G U R E 9.1 The Dalton Family Genogram

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220 C H A P T E R 9

often came to view themselves as “martyrs” (as Nita did), accepting that it was
their fate to suffer for the sake of the family.

The sons, feeling a need to defend themselves against their mother’s criticisms,
agreed to several sessions of family counseling. Carrole decided that the Daltons were
suitable for structural family intervention, and assessed them as outlined below.

Locus of Power Dad maintained absent, passive control over the family. He
maintained the authority to do what he wanted, which was usually to stay
away. He took the money he wanted out of his paycheck and gave the rest to
his wife. Nita could not predict how much of his pay would come into the
household each week, but she maintained it was too little. She was ambivalent
about whether she wanted the marriage to continue (they had been separated
several times in the past), and felt it was up to him. In Dad’s absence, the boys
were able to team up to exert power over Mom.

Problematic Boundaries Nita and her husband were disengaged. Nita and her sons
were enmeshed; that is, despite their conflicts, they seemed to need each other.
Nita’s relationship with her daughter was positive, but there was a potential for
enmeshment because of Mom’s reliance on the daughter for emotional support.
Living in a semi-rural area, the family was moderately isolated from its external
environment. This was typical of families in the region with Appalachian roots.
The children all had friends, but Nita was close only to a sister who lived nearby.

Relevant Subsystems There was an absence of an adult couple system and a re-
lated lack of partnership regarding parental authority. The brother subsystem was
strong, and the mother/daughter subsystem was also strong. Only the latter
seemed to be functional with regard to family structure. There did not seem to
be a daughter-in-law subsystem—these young women appeared to have a con-
genial but not close relationship. Nita’s own daughter seemed to be an outsider
sibling because of her age, although she enjoyed the presence of the others. The
social worker felt that Nita needed support from another adult (husband, close
friend, or other extended-family member) to strengthen the adult subsystem.

Relevant Triangles Three problematic triangles within the family were Mom/
Dad/daughter (Nita relied on her daughter to meet her needs for companionship
that she did not get from her husband); Mom/Dad/oldest son (Mom tried to rely
on this son for assistance with family management, although this was frustrating
for her); and new spouse/son/Mom (the older son’s spouse encouraged her hus-
band to make demands on Mom for money and other material resources).

Context This was an Appalachian family in which women were expected to fill
certain traditional roles. Nita accepted her caregiver role, and, despite her stress
level, got attention from her sons with the current arrangement. Additionally,
dad was attempting to recover from alcoholism, which may have accounted for
his desire to avoid internal family stresses. Another important issue was the fa-
mily’s poverty, as there were insufficient resources for maintaining the

S T R U C T U R A L F A M I L Y T H E O R Y 221

household. Even if Dad had invested his entire paycheck into the family, it
would have been difficult to cover the Daltons’ basic financial needs.

Family Stage As young adults, the sons should have been working and leaving
home, particularly to support their new wives. Nita and her husband wished to
begin relinquishing their day-to-day parenting roles so that they could attend to
some of their own interests.

Function of Nita’s Symptoms In her current role, in which the others blamed her
for being the “unstable” member, Nita served to absorb the family’s chaos. She
served a function for her husband as well by keeping the rest of the family’s focus
away from him.

Overall Nature of the Family Structure Carrole concluded that the Dalton family
had become chaotic, characterized by an absence of appropriate executive author-
ity, subsystem functions, and boundaries.

The social worker had moderate success with helping the Dalton family re-
structure itself into a more functional unit. Whereas the father’s refusal to partici-
pate was an initial concern, Carrole was encouraged by the motivation of the other
members. Several of them were angry with each other, but they shared an interest
in resolving their conflicts, if only for selfish reasons. Nita was in conflict with ev-
eryone but her daughter; the sons and older wife were in conflict with Nita; and
the daughter was angry with her brothers (for monopolizing Mom’s attention) and
her sisters-in-law (for not spending enough time with her). With this assessment,
the social worker provided the following interventions.

Reframing The social worker summarized Nita’s symptoms of anxiety and de-
pression, and her feelings of anger, as evidence that she was working too hard to
be a good parent, and perhaps caring too much about her adult children. Nita
accepted the reframe, which helped her feel affirmed, and also suggested to the
others that their mother was interested in their well-being. None of the children
challenged this perspective.

Developing a Shared Definition of “Family Challenges” After hearing each mem-
ber’s point of view about the family situation, Carrole summarized the problem
as a lack of sufficient emotional and material resources to go around the family. She
shared her belief that the family members had the capacity to work toward ex-
panding those resources. Those members who had few material resources might
make up for this with task contributions to the family unit. This problem defini-
tion was relatively nonthreatening to the children, so they agreed with it.

Practicing Clear Communication Skills with All Family Members The Daltons (ex-
cept for Nita) shared a habit of arguing with and interrupting each other. Even
the social worker had trouble containing their interruptions, so she formalized
their interactions during the first two visits. She called on members to speak in
turn, silenced any interruptions that occurred, and assured everyone that they
would have the opportunity to respond to others’ comments. Carrole was

222 C H A P T E R 9

authoritative but not abrupt in this task, and she was careful to repeatedly explain
her rationale for this controlling behavior. After a while, the Dalton children’s
interactions became more peaceful.

Positioning Family Members to Highlight Appropriate Alliances As examples, the
sons were separated from their wives at times (to break up a problematic alliance
or triangle), and the daughter (who idolized her sisters-in-law) was seated next to
them to encourage their relationship development. Nita was seated next to vari-
ous sons and daughters-in-law at times when the social worker wanted them to
carry on conversations to establish new household rules about money and per-
sonal responsibilities. Carrole supported the parental subsystem by sitting next to
Nita at times and taking her side (joining) in conversations about family author-
ity, roles, and rules. This was important because Nita was the only adult member
without an ally in the household. At these times the social worker shared her
concern that Nita was still on her own at home. Nita had mentioned that her
sister and two other friends always tried to be helpful to her. Carrole encouraged
her to collaborate with any of them when making household decisions.

Role-Playing to Practice New Styles of Family Interaction For example, Nita role-
played a hypothetical situation with her son (in which he was requesting money
that she could not afford to give) so the social worker could assess their behavior
and help them to improve their abilities to control anger and bring discussions to
constructive closure. During all role-plays, Carrole assigned the uninvolved
members to pay attention and comment on the participants’ behaviors. This tac-
tic brought all members into the process of problem solving and promoted their
sense of mutual participation in family activities. In role reversals, certain members
were instructed to take the role of another family member in discussions of spe-
cific problem situations so that they could perceive their own behavior more
clearly and better understand the point of view of the other person. As one ex-
ample, Nita was asked to portray her son and ask him (playing the role of Mom)
for money. Her son (as Nita) was assigned to reject her request and articulate the
reasons why she should not get any more of the family’s limited funds.

Task Assignments Between family meetings, task assignments were intended to
support the development of appropriate alliances and clarify boundaries between
family members and subsystems. Carrole assigned Nita (with her approval) to
spend two hours away from the family, two times during the coming week, doing
whatever she wanted. She assigned this same task each week, because it proved
difficult for Nita to disengage from the household. The sons were asked to spend
a certain amount of time alone with their spouses each week talking about future
plans. Carrole hoped that this activity would help the young couples to realize that
they might benefit from greater self-reliance. The daughters-in-law were asked to
include the daughter in one social activity each week, to strengthen that bond and
to reduce the potential enmeshment of Nita and her daughter.

The family made significant gains. Their communications became less con-
flicted, some new household rules were developed, and the roles of the children
expanded. Nita spent more time with her friends, the sons were looking for

S T R U C T U R A L F A M I L Y T H E O R Y 223

work more regularly, and the daughters-in-law assumed some responsibility for
taking care of the daughter. The level of tension was lower in the social worker’s
office and in the Dalton home. Carrole would have liked to see the family for
several more sessions, but the family (primarily the sons) wanted to terminate
because, in the social worker’s view, their motivation and interest had waned.
She was disappointed, but felt that they had made some progress.

The Family Drawings

Cynthia’s agency provided in-home intervention services to families identified as
being at risk for child emotional and behavioral problems. These were generally
single-parent families living in poverty. The families tended to lack strong au-
thority and consistency in the behavior of parent figures and have poor limit
setting on the behavior of the children. Cynthia, a 40-year-old, married, Cauca-
sian social worker raised in England, worked with the Paulson family for six
months. The family included Kendra, a 20-year-old single mother of
7-year-old, 5-year-old, and newborn twin boys. Her mother had moved in
with Kendra when the new babies were born, and the two adults often argued.
Grandmother tried to take on the traditional parent role because Kendra was
away working, sometimes at odd hours. Kendra was a strict parent when she
was home, but grandmother was permissive and set few limits with the kids.
Damon, the 5-year-old, began to develop behavior problems of aggression in
the home, neighborhood, and school.

After the assessment Cynthia decided to work with Kendra and her mother on
improving their relationship. She infrequently included the two older children in
the process. She felt that if the adults could get along better and agree on appropriate
parenting strategies, the children would respond with improved behavior. Cynthia
met with Kendra and her mother weekly for three months, and then twice monthly
when the situation began to improve. Her goal was system restructuring, as evi-
denced by both adults assuming appropriate roles of authority in the family. She
taught them how to communicate clearly, directly, and frequently with each other.
Cynthia also helped Kendra resolve the lingering anger she felt toward her mother.
Kendra was bitter about the lack of supportive parenting she had received as a child.
The pair was able to learn and practice a process for resolving their differences and
agreeing on household and child-rearing rules. Cynthia developed role-plays based
on possible conflict situations that the adults practiced during her visits. Occasionally,
the social worker brought in the older boys to talk about what they were doing and
to let the adults practice what they had learned with them.

One day when Cynthia was visiting, the children were behaving rambunc-
tiously. To calm them down, she suggested that the older boys draw a picture of
the family. To Cynthia’s surprise, the pictures portrayed the family’s problems.
They indicated where each child saw himself in relation to the others in the
size of the figures, their expressions, and their positions. Because the boys seemed
to enjoy drawing, it occurred to Cynthia that this might be a good way to mon-
itor the family’s changes over time. Every month or so, she asked the boys to

224 C H A P T E R 9

draw family pictures, and then discussed with them and the adults what the
drawings showed. As the weeks went by, the pictures demonstrated that the
family system was stabilizing. The figures of the family members, including
the babies, became more equal in size and closer to each other.

When Kendra and her mother became able to solve problems consistently
without the social worker’s assistance, and Damon’s behavior improved as well,
it was time to end the intervention. As a closing activity, Cynthia asked each of
the four family members (excluding the infant) to draw a picture of what he or
she wanted the family to be like. Afterward she used the pictures to review the
work they had done together during the previous six months. All of them had
made changes that the social worker felt were likely to persist. Cynthia took the
pictures and had them mounted together on a mat board. The family members
all agreed that the board should hang on the wall of their home.

EVIDENCE OF EFFECT IVENESS

The results of a PsycINFO® literature search on structural family intervention in-
cluded articles describing its applicability to families characterized by divorce, single
fatherhood, mental illness, multigenerational parenting, violence, and incest. It is
also used with families with children who experience autism, chronic pain, enuresis
and encopresis, chronic illness, cancer, learning disabilities, depression, anorexia,
brain injury, substance abuse, and school behavior problems. There are undoubtedly
many other types of presenting problems for which this theory has been used.

There is limited empirical evidence beyond single case studies, however, that
structural family interventions are more effective than other modalities. De-
scribed here are multi-client or comparison group studies that have been con-
ducted on the topic. Minuchin himself carried out several of these. The
theory’s founder and his colleagues tested the new structural approach with 11
families at Wiltwyck School, and compared outcomes to the standard fifty percent
success rate recorded at the facility (Minuchin, Montalvo, Guerney, Rosman, &
Schumer, 1967). Pre- and post-test measures on variables including leadership,
behavior control, and guidance statements indicated that 7 of the 11 families
improved (63.6%) after 6 to 12 months of intervention. The authors noted that
the families assessed as enmeshed developed clearer boundaries, whereas the
disengaged families showed no improvement.

In another study 10 years later, Minuchin, Rosman, Baker, and Liebman
(1978) summarized the findings from a variety of their studies of families that
included children with anorexia, diabetes, and asthma. They reported that 45
of 53 anorexic children (85%) were improved regarding target symptoms and
social functioning after a course of treatment including hospitalization and out-
patient family therapy. These positive results persisted after follow-ups over sev-
eral years. Their studies of 20 clients with psychosomatic diabetes (in which an
emotional condition worsened the medical symptoms) indicated that all clients

S T R U C T U R A L F A M I L Y T H E O R Y 225

(100%) were fully or moderately improved following family intervention. Of 17
families that included a child with psychosomatic asthma, 14 (84%) were said to
recover or improve moderately. The researchers concluded from these latter two
projects that a child’s psychosomatic symptoms may serve to moderate stress be-
tween parents.

A process study of structural family intervention demonstrated that the effec-
tiveness of the modality was dependent on the practitioner’s use of theoretically
appropriate intervention strategies (Walsh, 2004). It was hypothesized in this
100-participant study that when the practitioner focused on increasing parental
power in at least half of all sessions, more positive change in family organization
would be observed than if the practitioner did not maintain this focus in at least
half the sessions. The hypothesis was supported based on scores from the Control
and Organization subscales of the Family Environment Scale.

Two studies have focused on children with ADHD. Aman (2001) con-
ducted a nonequivalent pre-test/post-test control group study (62 families in
each group) to determine whether a multiple-family group model that included
structural interventions could produce positive outcomes regarding parenting
stress level and family satisfaction. Results indicated that the experimental families
experienced fewer home conflicts and reported improved family relationships.
Barkley, Guevremont, Anastopoulos, and Fletcher (1992) randomly assigned 61
adolescents (ages 12 to 18) to four intervention modalities, one of which was
structural family therapy, for 8 to 20 sessions. Families were assessed at pre-
treatment, post-treatment, and three months later. All four interventions (also
including behavior management, communications training, and problem solving)
resulted in significant reductions in negative communications, conflict, and an-
ger. Improvements were noted in school adjustment, ADHD symptoms, and
the mother’s depressive symptoms, but there were no significant differences in
outcomes among the four modalities. Most outcomes remained stable between
post-treatment and the follow-up measure.

A number of intervention studies have been conducted on the problem of
substance abuse. Another randomized study of substance abuse relapse preven-
tion that included more than 100 women found that those receiving structural
ecosystems therapy (featuring a major focus on environmental factors) were more
likely to seek services in response to relapse and spearate from other drug-using
household members (Feaster et al., 2010). A qualitative study of families from
ethnically diverse backgrounds investigated whether structural family interven-
tions that focused on adaptive capacity and boundary change would reduce or
eliminate alcohol abuse (Hunter, 1998). Three families (African-American,
Caucasian, and Hispanic) received structural family therapy for 6 to 10 weeks
after completing pre- and post-treatment measures of family stress and relation-
ships. All three families made changes in the two target domains, which resulted
in improved communication, age-appropriate child behavior, and decreased pa-
rental stress. In another study, with a pre- and post-treatment follow-up design,
structural interventions were provided to 122 African-American and Hispanic
youth, aged 12 to 14 years, as a preventive factor against drug use (Santisteban
et al., 1997). The interventions were intended to reduce behavior problems and

226 C H A P T E R 9

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enhance family functioning. It was found that the interventions were effective in
significantly modifying both high-risk factors. Further, both high-risk factors
were predictive of drug initiation nine months later. Drug use was also reduced
for the few study participants who were already using.

Cancrini, Cingolani, Compagnoni, Costantini, and Mazzoni (1988) studied
outcomes for 131 heroin addicts (aged 16 to 33) who were treated with either
structural or paradoxical family therapy in one agency during the same year.
Structural family therapy was found to be most effective with addicts who had
additional psychological problems. Zeigler-Driscoll (1979) compared the effec-
tiveness of structural family therapy for individuals in an inpatient drug treatment
program. No differences were found in abstinence or recidivism rates, but the
structural interventions improved the families’ coping abilities when an addicted
member returned to drug use. Stanton and Todd (1979) provided 65 families
with a heroin-addicted son with a family intervention that included structural
methods and compared outcomes with a control group of 25 non-addict fami-
lies. After intervention the structural families were more expressive than the con-
trols and better able to resolve disagreements, maintain solidarity during task
completion, and maintain clear subsystem boundaries.

Several empirical studies have focused on adolescents with behavior pro-
blems. A quasi-experimental study of structural family therapy provided in the
context of a three-day wilderness family camp found that the experimental fam-
ilies scored higher on measures of family cohesion after the intervention
(McLendon, McLendon, Petr, Kapp, & Mooradian, 2009). In another study,
the outcomes of structural and psychodynamic interventions (with a control
group) were compared for sixty-nine 6- to 12-year-old Hispanic boys with
behavioral and emotional problems (Szapocznik, Arturo, & Cohen, 1989). The
two treatment conditions were similarly effective in reducing the presenting pro-
blems and in improving psychodynamic ratings of child functioning. Structural
family therapy was more effective, however, in maintaining family cohesion at
one-year follow-up. Chamberlain and Rosicky (1995) conducted a literature
review of seven studies between 1989 and 1994 on the effects of structural family
intervention. Generally, the results were supportive of the intervention for
adolescent conduct disorders.

Finally, an interesting control group study of 30 families of persons suffering
recent loss of sight found that structural family intervention was useful as a com-
ponent of the rehabilitation process (Radochonski, 1998). The experimental
families demonstrated positive changes in the internal structure and functioning
of the families, with significant improvements in the personal functioning of the
members who had lost their sight.

CRIT IC ISMS OF THE THEORY

Structural family theory has been a popular approach to family intervention for
almost 50 years, but, like every theory, it can be criticized. First, in its focus on

S T R U C T U R A L F A M I L Y T H E O R Y 227

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the “external architecture” of a family system, the theory de-emphasizes a fa-
mily’s emotional life. Structural practitioners believe that functional family struc-
ture will result in an improved quality of life, including emotional life, for all
members. Still, it does not directly attend to this aspect of the human experience,
and thus some practitioners may overlook the nuances of family relationships that
influence structural characteristics. Family emotional systems theory (Chapter 6)
is more concerned with that aspect of human functioning.

Second, practitioners may mistakenly hold biases about “appropriate” family
structure. Structural theory was based on its founder’s recognition that many
multiproblem families lack strong executive authority and rules. In the 21st cen-
tury, with diverse family forms emerging in this country and around the world,
more egalitarian family structures may be appropriate. For example, some femin-
ists criticize structural theory for promoting patriarchal ideas about family life
(Dziegielewski & Montgomery, 1999).

Structural practitioners must be careful not to begin with specific assump-
tions about family structure prior to assessing a system and how well it works
for members. The practitioner must also engage in cross-cultural family study
to ensure that he or she does not impose a rigid perspective of appropriate family
structure. With these precautions in mind, structural family theory can be used
with diverse family forms. In fact, there are case studies in the literature indicat-
ing that it has been useful with Hispanic, Chinese, Vietnamese, Jewish, West
African, Native American, Mexican-American, and Italian-American families.

SUMMARY

Structural family theory provides a useful perspective for clinical social work
practice with diverse family forms. It is focused on the external “architecture”
of families—including their rules, boundaries, and subsystems—rather than on
the inner psychology of members and their interactions. A functional family
structure will result in a system that meets members’ basic material and emotional
needs. Structural family interventions were specifically developed to help the
kinds of families encountered by social work practitioners—those experiencing
multiple problems such as poverty, illness, unemployment, physical abuse, sub-
stance abuse, absent members, and acting out. With this theoretical approach,
social workers can also continue to provide the environmental interventions
(through case management) that make the profession distinctive.

TOPIC S FOR DISCUSSION

1. Structural theorists believe that an appropriate family structure will result in
positive emotional relationships among the members. Do you agree? If so,
can a social worker de-emphasize emotional issues in family assessment and
intervention?

228 C H A P T E R 9

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2. Observing member interactions can provide a great deal of information
about a family’s structure. Describe from your own professional or personal
experience examples of important elements of a family’s structure being
manifested in members’ behaviors.

3. Select one type of racial or ethnic group that, for you, would be an example
of family diversity. Consider three major concepts of structural family
theory, and describe how they might be different from that which is
common in your own ethnic/racial group, but still functional.

4. It is said in structural theory that “action precedes understanding.” What
does this mean? Do you agree? How does it compare with the intervention
stance in family emotional systems theory?

5. Consider a single female parent of two adolescent children who is
experiencing high stress because of pressing family responsibilities (work,
childcare, budgeting). Her children, in a normal way, have become less
interactive with her, not communicating as they once did. They are also
beginning to get into trouble at school for disruptive behavior. Discuss some
possible intervention strategies from structural theory that might enhance the
family’s quality of communication.

IDEAS FOR ROLE-PLAYS

(The roles of social worker, client, and observer should all be represented, and each role may
include more than one person.)

1. Consider a family unit that includes a maternal grandfather (58), mother
(37), daughter (18), and male cousin (17). The mother and daughter
experience angry outbursts, and sometimes physically fight with one
another. The school made a family referral to the social worker after the
mother and daughter, in the presence of the grandfather, got into a public
shouting match during a school activity. Select and implement intervention
strategies that might interrupt this family’s negative patterns of interaction.

2. Stan and Mike are gay men who recently moved in together, along
with Mike’s 7-year-old son (the boy’s mother died five years ago). They are
both concerned about the well-being of Mike’s son, and seek the social
worker’s assistance in helping them organize a “healthy household.” Select
and implement intervention strategies that might help them to accomplish
this goal.

3. A Latino father has been physically abusing the two older of his three
children (ages 11, 9, and 7), partly because he knows no other way to
discipline them. His wife is angry with him for ignoring her objections to his
behavior. He has been mandated to see the social worker alone to receive
parenting assistance. Select and implement intervention strategies that might
help to stop the abuse.

S T R U C T U R A L F A M I L Y T H E O R Y 229

APPENDIX: Structural Family Theory Outline

Focus Functional family structure (the organized patterns in
which members interact)

Executive authority in the family unit

Major Proponents Minuchin, Satir, Aponte, Colapinto, Szapocnik, Nichols

Origins and Social
Context

Expansion of family intervention to multiproblem families

Need for brief interventions

Rise in prominence of social learning, cognitive, and
behavior theories

Nature of the Individual Not specifically addressed, but concepts from cognitive
and behavior theory are consistent with it

Major Concepts Structure (an invisible set of rules that organizes how
members interact)

Executive authority

Power

Member roles

Subsystems

Boundaries (internal and external)

Transactional patterns

Rules

Flexibility

Family Development Accommodation and boundary making

Themes Adult, adult/child, and sibling subsystems

Structural adaptations to life transitions

Nature of Problems Disengaged family members or subsystems

Ineffective hierarchies

Rigid or diffuse boundaries

Excessive emotional distance

Enmeshed family members or subsystems

Triangles

System interference with normal development

Conflict avoidance

Failure to realign after stress

Nature of Change Action precedes understanding

Learning and practicing result in more effective problem-
solving, decision-making, and communication skills

230 C H A P T E R 9

Goals of Intervention Create structural change

Alter boundaries

Realign subsystems

Resolve immediate symptoms (short-term)

Increase/preserve mutual support of members

Nature of Worker/Client
Relationship

Worker as “stage director” (high level of worker activity)
Worker assumes a position of “shaping competence”

Clients are conceptualized as victims of circumstances

Worker joins with individuals or subsystems as needed
(adjusts personal style)

Intervention Principles Normalize symptoms

Join alliances as appropriate

In-session enactments

Structural mapping

Educate about structure

Manipulate space

Encourage tracking of problem behavior

Highlight and modify interactions*

Support strengths

Shape competence (build on strengths)*

Enhance self-control of members via relaxation and stress
management

Affirm sympathetic responses, nonjudgmental observations
of members

Realign boundaries*

Unbalance subsystems* (change behaviors within
subsystems)

Challenge unproductive member assumptions

*These strategies can be implemented through:

Teaching communication skills (speaking, listening
skills, managing conflicts)

Assigning tasks for implementation in the natural
environment

Role-plays, role reversals

Assessment Questions What are the family’s patterns of interacting?

How does the family present itself structurally?

Where does the power lie in this family? In what contexts?

APPENDIX: Structural Family Theory Outline (Continued)

S T R U C T U R A L F A M I L Y T H E O R Y 231

What subsystems appear to be prominent?

Does the presenting problem serve a function for the
family?

What are this family’s patterns of managing stress?

How sensitive are family members to each other?

What kinds of behavior do members seem to expect of
each other?

Do they accommodate each other’s needs?

Is the family involved with external systems?

APPENDIX: Structural Family Theory Outline (Continued)

232 C H A P T E R 9

Solution-Focused Therapy

I dreaded that first robin so,
But he is mastered now,

And I’m accustomed to him grown,
He hurts a little, though.*

S olution-focused practice is a short-term approach to intervention in which the
social worker and client attend to solutions or exceptions to problems more

so than to problems themselves (Franklin, Trepper, Gingerich, & McCollum,
2012; Elliott & Metcalf, 2009; Dejong & Berg, 2008; Corcoran, 2005). Its focus
is on helping clients identify and amplify their strengths and resources toward the
goal of finding solutions to presenting problems. Solution-focused therapy (SFT)
is one of only two intervention approaches in this book that does not represent a
single theoretical perspective (the other being motivational enhancement ther-
apy), but is a model of practice that draws from theories in psychology, social
work, and sociology. This model is clearly oriented toward the future, more so
than most of the practice theories discussed so far. From a practice perspective,
this shift in emphasis from problems to solutions is more radical than it might first
appear.

ORIGI NS AND SOCI AL CONTEXT

The principles underlying solution-focused therapy reflect a synthesis of ideas
drawn from the systems, cognitive, communication, and crisis intervention theo-
ries; the principles of brief therapy; and the social theory of constructivism.

* Dickinson, E. (1927). The Pamphlet Poets. New York: Simon and Schuster.

233
Copyright 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights,

We will review each of these influences except for the last one, which is de-
scribed in the context of narrative theory in Chapter 12.

Family systems theory, discussed in Chapters 6 and 9, has great relevance to
the solution-focused approach to practice (Andreae, 1996). It assumes that
human behavior is less a function of the characteristics of individuals than of
patterns of behavior they learn in their families of origin. General systems theory
takes an even broader view, emphasizing the reciprocal influences between peo-
ple and the environmental circumstances they encounter (Von Bertalanffy,
1968). Activity in any area of a system affects all other areas. The thoughts, feel-
ings, and behaviors of individuals in a given system, then, are malleable and
influenced by the behavior of other elements in the system. This is, of course,
consistent with social work’s person-in-environment perspective. One important
implication of systems thinking is that a client’s change efforts need not be
directly related to a presenting problem. Because any change will affect the entire
system, new actions will influence its elements in ways that cannot be predicted.
The social worker may thus consider creative strategies for change when work-
ing with a client system.

SFT was largely influenced by systems thinking as developed at the Mental
Research Institute (MRI) in Palo Alto, California (Weakland & Jordan, 1992).
The MRI brief therapy model views emotional and behavioral problems as de-
veloping because people by nature develop a limited range of response patterns
in relation to their life problems, some of which do not effectively resolve them.
These patterns may include underreacting, overreacting, avoiding, denying, and
even taking actions that worsen the situation. In a sense, the problem becomes
the sum of failed solution efforts. MRI interventions represent efforts to identify
and explore a client’s problem cycles and find new ways of interrupting them.
The focus of this work is on presenting problems, not underlying issues.

Cognitive theory has contributed to the development of solution-focused
practice principles with its accounts of how people create unique meaning in
their lives. The concept of schemas, described in Chapter 7, describes how we
develop habits of thinking that should ideally be flexible but can at times become
rigid, preventing us from assimilating new information that might enhance our
creative adaptability to life challenges. SFT can also be seen as an extension of
the problem-solving process as outlined in cognitive theory.

Communications theory and the study of language was of interest to the
developers of solution-focused therapy with regard to the impact of the words
people use about their attitudes toward the self and the world (de Shazer, 1994).
SFT proceeds from the assumption that language shapes reality, and thus it em-
phasizes the importance of word clarity in intervention. Solution-focused practi-
tioners maintain a distrust of the abstractions found in many other practice
theories. Such preoccupations are considered nonsensical and, worse, unproduc-
tive toward the goals of furthering a client’s welfare. The social worker tries hard
to understand the specific nature of a client’s concerns and goals, and supports
client initiatives toward change that are concrete as well.

Crisis theory (described more fully in Chapter 13) developed as human
service professionals in many settings faced demands to provide focused, effective

234 C H A P T E R 10

interventions for people in need of immediate relief. Crises may be developmen-
tal (leaving home, retirement), situational (natural disasters, death of a loved one,
loss of a job), or existential (meaning-of-life issues). Caplan (1990, 1989) devel-
oped one widely respected model of crisis theory, defining a crisis as a disruption
in a person’s physical or emotional equilibrium due to a hazardous event that
poses an obstacle to the fulfillment of important needs or life goals. Crises are
characterized by a person’s need to resolve problems while feeling overwhelmed.
Crisis intervention must be short term because, with its associated debilitating
physical effects, a crisis can persist for only four to eight weeks. All interventions
are time-limited, have a here-and-now focus, rely on tasks to facilitate change,
and feature a high level of practitioner activity (Gilliland & James, 2005). Like
systems theory, crisis theory recognizes that the environmental context influences
the severity of distress, as well as the availability of resources to meet its demands.

A final, more general influence on the development of solution-focused
practice was the proliferation of brief therapy models that emerged within the
human service professions in the 1980s (Corwin, 2002). Some of these ap-
proaches did not result from an evolution of ideas about appropriate practice
but were a reaction to external pressures, including the need to manage long
waiting lists in agencies and reduced insurance coverage for clinical services. Still,
it was discovered that these methods are effective, sometimes more so than
longer-term interventions. Brief treatment models have emerged within most
practice theoretical frameworks and tend to share the following elements:

A narrow focus on the client’s most pressing concerns

A belief that not all of a client’s presenting concerns need to be addressed

A focus on change, not a “cure”

An assumption that the origins of a client’s problems need not be
understood in order to help the client

Clients should lead the process of problem formulation, goal setting, and
intervention

Intervention should have a strengths orientation

Solution-focused therapy is distinct from some brief therapies in its strategies for
assessment, goal setting, and intervention, as we will see.

MAJOR CONCEPTS

Despite its roots in other theories, solution-focused therapy has become recog-
nized as a unique approach in direct practice. Its major principles are described
below.

“Grand theories” of human development—those that emphasize similarity
across populations and cultures—are no longer relevant to the world of social
work practice. For example, not all children and adolescents progress through
the same stages of cognitive, moral, and social development. This principle is

S O L U T I O N – F OC U S E D T H E R A P Y 235

shared with most other practice approaches that have emerged in the past several
decades.

Language is powerful in shaping one’s sense of reality. The words we use to
define ourselves and our situations influence the conclusions that we draw about
those situations. A drug abuser who “buys into” the language of addiction may
define himself as “diseased,” and thus less functional by nature than many other
people. Social workers need to be attuned to how clients use language to define
their challenges and their functioning. Is their language constructive or destruc-
tive? Interestingly, social workers may be tied to a professional language that
stigmatizes clients. If I use the language of the Diagnostic and Statistical Manual
of Mental Disorders (DSM; “major depression”), for example, I may conclude
that my client has a limited capacity to alleviate her depression without
medications.

Social workers must de-emphasize problem talk in an effort to shift the interven-
tion focus away from a search for the causes of a client’s difficulties. An emphasis
on solution talk represents a means of helping clients focus on solutions to problems
and to act or think differently than they normally do. This includes the social
worker’s cultivating an atmosphere in which strengths and resources are
highlighted. It is important to emphasize again that solutions do not need to be
directly related to a client’s presenting problem; a client’s decisions to act differently
in the future may emerge independently of any problem talk. This idea is consis-
tent with the systems perspective that any change reverberates through a system,
affecting every other element. The social worker thus does not need to feel con-
strained by “linear” thinking about problems and solutions. This non-linear perspec-
tive is quite different from that espoused in many other practice theories and
models, where it is assumed that there is a logical, systematic relationship between
problems and solutions, and that a solution should be directly related to the nature
of a problem. For example, a cognitive practitioner might conclude that a client’s
ongoing depression is a consequence of negative self-talk, and that the solution to
this problem should include changes in specific types of self-talk. A solution-
focused practitioner would be more open to a range of client-generated solutions.

Problems are real, but often not so ubiquitous in the lives of clients as they may
assume. It is through habits of selective attention that clients become preoccu-
pied with the negative aspects of their lives. An adolescent girl who feels hopeless
about her ongoing social rejection at school may benefit from recognizing more
clearly when this problem is not happening in her life—for example, when she is
participating in youth groups at church. The social worker’s role in a client’s goal
achievement is made more constructive with an exploration of problem excep-
tions (times when it is not happening).

THE NATURE OF PROBLEMS AND CHANGE

As we have seen, the solution-focused perspective includes few assumptions
about human nature. This supports its focus on the future and its de-emphasis
of lengthy assessment protocols. The perspective does assume, however, that

236 C H A P T E R 10

people want to change, are suggestible, and have the capability to develop new
and existing resources to solve their problems.

The nature of problems in SFT can be summarized through several princi-
ples (O’Connell, 2005). Many problems result from patterns of behavior that
have been reinforced. Our rigid beliefs, assumptions, and attitudes prevent us
from noticing new information in the environment that can provide solutions
to our problems. That is, we are often constrained from change by our habitual,
narrow views of situations. There is in fact no “correct” way to view any prob-
lem or solution.

Significant change can be achieved for most problems that clients present to
social workers in a relatively brief period of time (Elliott & Metcalf, 2009). This
is largely because change is constant in our lives—it is always happening,
whether we recognize it or not. There is no difference in SFT between symp-
tomatic and underlying change—all change is equally significant. Small changes
are important because they set ongoing change processes in motion in any
system. The process of change is facilitated in our favor by our learning to
reinterpret existing challenging situations and acquire new ideas and information
about them.

The goals of intervention in solution-focused therapy are for clients to focus
on concrete solutions to their problems or challenges, discover exceptions to
their problems (times when they are not happening), become more aware of
their strengths and resources, and learn to act and think differently.

ASSESSMENT AND INTERVENT ION

The Social Worker/Client Relationship

During the engagement stage, the social worker attempts to build an alliance by
accepting, without interpreting or reformulating, the client’s perspective on the
presenting problem in the client’s own language. The worker promotes a collab-
orative relationship by communicating that he or she does not possess “special”
knowledge about problem solving, but is eager to work with the client on de-
sired solutions. The practitioner builds positive feelings and hope within the cli-
ent with future-oriented questions, such as “What will be different for you when our
time here has been successful?”

With its emphasis on short-term intervention and a rapid focus on client
goals, solution-focused therapy is sometimes criticized for not adequately attend-
ing to the development of a positive worker/client relationship (Coyne, 1994).
That is, the rapid application of techniques may prohibit the development of a
sound working relationship, which in turn might decrease the effectiveness of
the intervention. In response to this concern, one study compared client percep-
tions of the “working alliance” at a university counseling center when receiving
either solution-focused or brief interpersonal therapy (Wettersten, Lichtenberg,
& Mallinckrodt, 2005). The working alliance was assessed after each session
with respect to the client’s sense of bonding, shared tasks, and shared goals.

S O L U T I O N – F OC U S E D T H E R A P Y 237

With approximately 30 clients in each treatment group, it was found that SFT
practitioners indeed develop a working alliance with their clients, although it is
not perceived as such by clients early in treatment.

Assessment and Intervention Strategies

Before beginning the discussion of the particulars of solution-focused thereapy,
we will outline the process as follows:

Problem articulation, including the client’s beliefs about the source of the
problem, how it affects the client, how the client has coped so far, and what
solutions the client has tried already

Developing goals within the client’s frame of reference

Then, during each session, the social worker:

Explores for exceptions

Participates in task development (jointly designed by the social worker)

Provides end-of-session feedback

Evaluates client progress

One of the unique characteristics of solution-focused therapy is the lack of a
major distinction between the assessment and intervention stages. Although a cli-
ent’s presenting issue does need to be investigated, many of the social worker’s
questions and comments made during that stage are intended to initiate change
processes. The reader should keep in mind, then, that distinctions between
“stages” of therapy are somewhat artificial. All of the techniques presented below
are drawn from Elliott and Metcalf (2009), DeJong and Berg (2008), Quick
(2008), Corcoran (2005), and de Shazer (1994, 1985).

The assessment stage is intended to gather information directly related to the
client’s presenting problem. The social worker also evaluates the client’s level of
motivation by discussing the value of resolving the problem. This can be done
informally with a scaling exercise, whereby the social worker asks the client to rate
his or her willingness to invest effort into problem resolution on a l-to-10 scale.
If the client’s motivation is low, the social worker raises the dilemma with the
client about how the problem situation can improve in that context. Of course,
there are several ways to formulate or partialize any problem, and the client may
be motivated to address some aspects more than others. Parents of an acting-out
adolescent, for example, may be more highly motivated to change his school
behavior than his related playground behavior.

Through refraining comments and actions, the social worker gives the client
credit for the positive aspects of his or her behavior relative to the presenting
problem. This strategy also introduces clients to new ways of looking at some
aspect of themselves or the problem. For example, a client who feels so stressed
about a family issue that he is unable to sleep or work can be credited with car-
ing so much that he is willing to sacrifice his own well-being. The social worker
might also suggest that the client is working too hard on the problem, and might

238 C H A P T E R 10

consider sharing responsibility for problem resolution with other family members.
The social worker’s goal is not to be deceptive, but to help the client feel less
overwhelmed and more capable of managing the issue. The practitioner must be
careful not to falsify the client’s reality through the use of exaggerated compliments
and reframes. Rather, he or she identifies genuine qualities of which the client may
be unaware but can realistically bring to bear on the problem situation.

The social worker asks strengths-reinforcing coping questions during the initial
session, such as “How have you been able to manage the problem thus far?” or
“What have you done recently that has been helpful?” Another pre-session change
question asks the client, “Has anything changed about the problem between the
time you made this appointment and now?” Questions designed for clients who
seem to be stuck in a pessimistic stance might be formulated as: “It sounds like
the problem is serious. Why is it not worse? What are you (or your family) doing
to keep things from getting worse?”

If appropriate, the social worker asks questions about the desired behavior of
other persons in the client’s life who are connected to the problem, such as:
“What will your son be doing when you are no longer concerned about his
behavior on the weekends?” If the client is reluctant to participate in the assess-
ment, the social worker asks questions that serve to promote collaboration, such
as: “Whose idea was it that you come here? What do they need to see to know
that you don’t have to come anymore? How can we work together to bring this
about? Can you describe yourself from the perspective of the person who re-
ferred you here?” The social worker thus attempts to engage the client by join-
ing with him or her against the external coercive source.

During exploration the practitioner externalizes the client’s problem, making
it something apart from, rather than within, the person. This gives the client a
reduced sense of pathology, and a greater sense of control. For example, with
depression, the practitioner focuses on aspects of the environment that create or
sustain the client’s negative feelings. In situations where the client must cope
with a physical illness or disability, the worker focuses on aspects of the environ-
ment that inhibit his or her ability to cope. The social worker often personifies
the problem (“How closely does depression follow you around? Does depression
stay with you all day long? Does it ever leave you alone?”), reinforcing the idea
that it is an entity separate from the essence of the person.

The practitioner then explores exceptions to the client’s presenting problems.
This is in keeping with the assumption in solution-focused practice that problems
are not so ubiquitous as clients tend to assume. These questions initiate the inter-
vention stage as they bring ideas for solutions to the client’s attention. The ques-
tions help clients identify their strengths, and the practitioner will often prescribe
that the client do more of what he or she does during these “exception” periods.
Exploring for recent exceptions is recommended, as these will be more salient to the
client’s sense of competenece. The following types of questions seek exceptions:

“What was different in the past when the problem wasn’t a problem?”

“Are there times when you have been able to stand up to, or not be
dominated by, the problem? How did you make that happen? What were

S O L U T I O N – F OC U S E D T H E R A P Y 239

you thinking? When did it happen? Where did it happen? Who was there?
How did they have a part in creating that? What did you think and feel as a
result of doing that?”

“What are you doing when the symptom isn’t happening?”

“What do you want to continue to happen?”

The client is encouraged to define his or her goals, and from that starting
point, the practitioner collaborates with the client to achieve them. The social
worker may present alternative perspectives regarding goals that are intended to
free the client from habitual patterns of thinking and consider new ideas. For
example, if a client wishes to “feel less depressed” or “experience more happy
moods,” the social worker might clarify that the client “wants to spend more
time with his interests” (if these have been identified as strengths) or “join the
civic association” (if that has been articulated as a possibility). All goals must be
articulated in ways that are concrete so that the client and practitioner will
know when they have been met. It is important for the social worker to par-
tialize goals, or break them down into discrete units that can be actively and
specifically addressed. For each identified goal the client is asked to scale its
importance with regard to his or her well-being in general and relative to the
other goals.

If the client has difficulty specifying the problem or any exceptions, inter-
vention tasks may be developed following responses to the miracle question
(Dejong & Berg, 2008). The client is asked to imagine that, during the night
while asleep, the presenting problem went away, but he or she did not know
that it had. What, then, would the client notice as he or she got up and went
through the next day that would provide evidence of problem resolution? The
social worker helps the client report specific observations of what would be
different, not settling for such global comments as “I would be happy” or
“My wife would love me again.” The client might reply that his wife greeted
him warmly, and that he got through breakfast without an argument with his
spouse and child.

It is important to emphasize here that at no time does the social worker sug-
gest specific tasks for the client to enact between sessions. The client always has
the responsibility for doing so. The social worker helps the client formulate task
ideas and alternatives, and supports certain tasks as appropriate, but it is always
left to the client to choose a task. This is an empowering process for the client
and is a core principle of the model.

The client’s answers to the “miracle question” (if utilized) provide indicators
of change that can be incorporated into tasks intended to bring about those in-
dicators in real life. These tasks can relate to the client’s personal functioning,
interactions with others, or interactions with resource systems. They are based
on existing strengths, or new strengths and resources that the client can develop.
Often, the client is encouraged to do more of what he or she was doing when
the problem was not happening. In every task assignment, the social worker
predicts potential failures and setbacks because these are always possible, are a

240 C H A P T E R 10

part of life in the best of circumstances, and should not be taken as indications of
total client failure.

All task interventions are intended to encourage the client to think and behave
differently with regard to the presenting problem than has been typical in the
past. Clients may still rely on their existing resources to a large degree, but
they will use them in new ways. It may seem paradoxical to note that in
many cases, the social worker encourages easier alternatives to prior attempts
at problem resolution. This is not to minimize the seriousness of the problems
people face, but to emphasize that people commonly react to failed problem
resolution ideas by applying the same (failed) ideas more intensively. For exam-
ple, a couple who argues each evening at home may decide, with the social
worker’s support, to take a walk through the neighborhood after supper, with
no expectation that they address their family concerns. Their rationale may be
that spending quiet time alone doing something new will reconnect them in an
important way.

Before ending this review of intervention strategies, two other techniques
need to be highlighted. First, the formula first-session task is an assignment given
to the client at the end of the initial visit. The social worker states: “Between
now and the next time we meet, I’d like you to observe things happening in
your life that you would like to see continue, and then tell me about them.”
This is an invitation to clients to act in a forward-looking manner, and the task
may also influence the client’s thinking about exceptions. Second, the surprise task
is an assignment (not necessarily limited to the intial session) whereby a client is
asked to do something before the next session that will “surprise” another person
connected with the problem (spouse, friend, child, other relative, employer,
teacher, etc.) in a positive way. The social worker leaves the nature of the sur-
prise up to the client. The rationale behind this technique is that whatever the
client does will “shake up” the client system from its routine, and perhaps initiate
new, more positive behavior patterns within the system.

Each session includes a segment in which the practitioner and client review
therapy developments and task outcomes. The client’s progress toward goal
achievement is measured by scaling changes on a l-to-10 continuum. During
goal setting, the social worker asks what point on the scale will indicate that
the client’s goal has been satisfactorily achieved. The practitioner asks the client
during each subsequent meeting to indicate where he or she is on the scale, and
what needs to happen for the client to advance to a higher point on the scale.

During all sessions following the initial visit, the social worker asks “What’s
better?” to again orient the client to thinking positively, although the client
should be encouraged to report both positive and negative developments.
When the client is able to identify improvements, the social worker asks:

“What needs to happen for these changes to continue?”

“What obstacles may get in your way, and how might you overcome them?”

“What have you learned so far from what you’ve been doing?”

“What have you learned not to do?”

S O L U T I O N – F OC U S E D T H E R A P Y 241

It should be evident from the previous description of assessment and inter-
vention strategies that solution-focused therapy is concerned with systems activity,
client strengths, quick intervention, a variety of task-oriented change activities,
and short-term work. It also encourages creative thinking on the part of social
workers—a challenge for some of us. Social workers have the opportunity to
develop unique, situation-relevant intervention activities with their clients.

Ending the Intervention

In solution-focused therapy, the practitioner focuses on the ending almost from
the beginning of intervention, as goal setting and solution finding orient the cli-
ent toward change within a brief time period. Progress is monitored each time
the social worker and client meet. In fact, the social worker should approach
each session as though it might be the last, and ask the client each time to think
about one thing he or she can do during the following week to continue prog-
ress toward goals.

Once a client has achieved his or her goals, new goals are set, or the inter-
vention ends. The ending focuses on helping clients identify strategies to main-
tain changes and the momentum to continue enacting solutions. Listed below
are examples of questions the practitioner may use during the end stage of inter-
vention (O’Connell, 2005).

“What will you do to make sure you do not need to come back and
see me?”

“How confident do you feel about following the plan of action? What help
will you need to persist with the plan?”

“What do you expect your hardest challenge to be?”

“What do you think the possible obstacles might be? How will you over-
come them?”

“What do you need to remember if things get difficult for you again?”

“What will be the benefits for you that will make the effort worth it?”

“Who is going to be able to help you? Who do you feel will remain a
problem?”

“How will you remind yourself about the things that you know help?”

“With all the changes you are making, what will you tell me about yourself
if I run into you at a supermarket six months from now?”

The practitioner must be careful to end the intervention collaboratively, be-
cause clients do not always perceive the process as such. In one study of couples
who had completed SFT, clients and practitioners gave different perspectives on
the status of the presenting problem (Metcalf & Thomas, 1994). Some clients felt
that the intervention ended too soon, and that the practitioner forced the pro-
cess. The researchers concluded that practitioners should not quickly assume the
quality of the collaboration, and ask routinely whether clients are getting what

242 C H A P T E R 10

they want. Social workers should also take care to present a comfortable enough
environment that clients will genuinely share their feelings about the process,
including the desire for a lengthier intervention.

SP IR ITUAL ITY AND SOLUT ION-FOC USED

INTER VENTION

Keeping in mind that solution-focused therapy does not subscribe to particular
concepts of human development, it should not be surprising that a client’s spir-
itual or existential concerns are not a focus of the social worker’s intervention
unless they are raised as such by the client. That is, a client’s appropriate goals
may include these concerns, just as they might include any others in this
future-oriented practice approach. In following the lead of the client, the social
worker should be prepared to address spiritual goals and help the client to
generate tasks for goal achievement relative to them. For example, a client
of Islamic faith may feel depressed because she has been “sinful,” and wish
to reconnect with Allah. The social worker should, as always, accept the
problem from the perspective of the client, and help the client set goals that
will result in her feeling more worthy of Allah’s grace and the mosque’s
fellowship. These goals might involve new, different, or increased activities
with people associated with the mosque, or different solitary behaviors to
enhance the client’s religious or existential well-being, such as prayer and
service work.

ATTENT ION TO SOCIAL JUST ICE ISSUES

An outstanding characteristic of solution-focused therapy is its client-centered
nature, which has positive implications for the social worker’s potential social
justice activity with clients. SFT highlights client strengths and the client’s po-
tential to access resources and enact change. Intervention is always composed
of tasks tailored to the client’s particular situation, and these tasks may address
a client’s social justice goals. The social worker must be prepared to help cli-
ents gain access to needed information, services, and resources, and to pursue
social change activities if those activities pertain to the client’s goals. The prac-
titioner will not initiate related activities, but will be responsive to the client’s
leads in that respect. The therapy has applicability for a broad range of
presenting issues that could include poverty, unemployment, discrimination,
and other forms of social injustice. Finally, with its emphasis on understanding
clients’ perspectives on themselves and their world, SFT interventions man-
date that the social worker become knowledgeable about issues of oppression
and cultural and ethnic diversity as they relate to a client’s problem
presentation.

S O L U T I O N – F OC U S E D T H E R A P Y 243

CASE ILLUSTRAT IONS

The Journalist

Felicia was a 23-year-old, single, Caucasian female recreation therapist who came
to see the social worker through her Employee Assistance Program. She had a
pressing request: She needed to overcome her inability to express her feelings
toward men. Felicia reported that her current boyfriend had asked to see her
during the coming weekend (four days away), and she suspected he was going
to break up with her. He had been complaining recently that she did not seem
to care about him when, in fact, Felicia was deeply invested in the relationship.

Felicia explained that she had had a lifelong problem of being unable to ex-
press feelings of affection to men. This had often ruined her chances for relation-
ships with young men. Whenever she cared about a man, she became tongue-
tied to the point of avoiding intimate conversations altogether. Because she was
so quiet by nature, the men interpreted her reticence as indifference, and did not
pursue the relationship. Felicia was devastated in these situations, but had never
been able to make any progress with the problem. On the other hand, Felicia
had many close female friends, and had no trouble communicating with them.
The social worker perceived nothing in Felicia’s appearance or manner that
would repel men or women. She was bright, interesting, stylish, and communi-
cated her feelings clearly.

Cristina, a 29-year old, married, Latina social worker, asked Felicia if she had
experienced any exceptions over the years to her inability to communicate with
potential boyfriends. She could not think of any, but she described what she
considered the source of her problem. Her father was a domineering, non-
expressive individual who punished his two daughters for any displays of emo-
tion. Felicia had learned to be more expressive with women through the exam-
ple of her mother. Cristina appreciated Felicia’s willingness to disclose this
information, but stated that it would have limited relevance to their work to-
gether. Her current strengths and resources should be sufficient for her goal
achievement.

Continuing with the theme of seeking exceptions, the social worker re-
minded Felicia that verbal communication was not the only way to express feel-
ings to others, and asked if she was able to be expressive in other ways. After
thinking about it, Felicia responded that she was a pretty good writer. She could
express herself well in writing because she was alone at those times, and could
think carefully about what she wanted to say. In fact, she had kept a journal for
several years. Cristina asked if Felicia ever sent letters or shared any of her writ-
ings with men. She had not done so, but the idea furthered her thinking about
her strengths as a writer.

Felicia decided that she might be able to discuss her feelings with her boy-
friend verbally if he learned in advance what they were. She could arrange this
by first writing her boyfriend a letter in which she expressed what she wanted to
say. She would end the letter by saying she wanted to keep their date on Friday
to discuss what was in the letter. The social worker supported Felicia’s plan and

244 C H A P T E R 10

praised her creativity in formulating this strategy. They agreed to meet one
week later to talk about the process. Cristina reminded Felicia that the letter
may or may not help achieve her goal, and that she should not consider the
plan a “sure thing.” There might be other ways to tap Felicia’s strengths to
achieve her goal.

A week later Felicia reported that the letter had worked perfectly. She had
felt comfortable writing the five-page document and only mildly anxious about
putting it in the mailbox. Her boyfriend called her after reading the letter to say
how much he appreciated it, and that he would be excited to see her the fol-
lowing day. The date went well, and their relationship was continuing. Felicia
added that since the ice had been broken with her boyfriend, it had become
easier to share her feelings verbally.

This was an excellent outcome for that task, and what Felicia said next sur-
prised the social worker. Feeling good about the incident with her boyfriend, she
had decided to write a letter to her father as well, expressing anger at how he
had treated her and her sister over the years, and asking that he talk with her
about this in person. He had agreed, and Felicia spent an afternoon with him.
Her father was quite upset by what Felicia had to say, but had responded with
empathy. Felicia said she planned to continue talking about family issues with
her dad. It seemed that within one week, she had tapped into an existing per-
sonal strength to become an effective communicator.

The social worker gave Felicia the option of coming back a few more
times so that they could monitor her progress, but she turned down the offer,
saying she had achieved her goals. As part of the ending process, Cristina asked
Felicia a series of questions to help her look ahead toward ways of sustaining
her achievements. Felicia was asked how confident she felt about continuing
with her strategy for improving her verbal expressiveness. The client responded
that, because the strategy had been effective, she would continue to use it
when she felt unable to communicate verbally. She also planned to regularly
reflect in her journal on her capacity for clear communication with men and
women.

Cristina next asked the client to consider any obstacles that she might expe-
rience relative to her ongoing interpersonal success, and how she might manage
them. Felicia quickly admitted that she was not sure how her “verbal confi-
dence” would hold up during and after arguments with her boyfriend and her
father. She planned to use letters in these instances because those had proven
successful, and she would also consult more openly with her good friends about
these concerns. Felicia also planned to read more books about relationships. She
framed verbal communication as a skill requiring practice.

The social worker’s final question was: “With the changes you are making,
what will you tell me about yourself if I run into you on the street in six
months?” Felicia would tell the social worker that she was continuing to work
on her communication skills, had more male friends (in addition to her boy-
friend), and was in regular contact with her parents. She would no longer be
feeling inadequate in her relationships, and would be able to resolve disagree-
ments with friends. Cristina congratulated Felicia on her success.

S O L U T I O N – F OC U S E D T H E R A P Y 245

The Adolescent Mother

Brenda had first come to the attention of the social worker at her school two
years ago. At that time she was a 15-year-old high school freshman who was
frequently truant. Her social worker, Shaniqua, a 23-year-old African-American
woman, learned then that Brenda was also in trouble with the police for several
misdemeanor violations, and was an occasional runaway. Her mother, Doris, a
single 33-year-old who worked in computer programming, noted that Brenda
would not follow minimal household rules, had parties when her mother was
away, lacked a sense of personal responsibility, and spent her time with a “bad
crowd.” The whereabouts of Brenda’s father were unknown. Shaniqua had lim-
ited success engaging the young woman in a relationship, but her mother had
been interested in working to resolve their problems. Shaniqua’s involvement
ended when Brenda began attending school more consistently.

At the time of the present intervention, Brenda was the 17-year-old single
mother of a newborn girl. Once pregnant, she again developed a truancy prob-
lem, and now she was under the supervision of the children’s services agency in
the county. Brenda had lived at home through her pregnancy, but since the birth
of the infant, Doris had become increasingly exasperated with her. Brenda loved
her baby, but showed little consistent concern about meeting the child’s basic
needs. She expected her mother to take care of the baby while Brenda main-
tained a social life. Doris believed that Brenda was again in danger of getting
into trouble with the law, although she wasn’t sure how her daughter spent
her time. Doris was so distressed about the situation that she lost her job due to
absenteeism and poor performance and now survived on public assistance bene-
fits. A member of the family’s church who had observed the deteriorating home
situation made the referral to the children’s services agency.

Despite being concerned about the infant’s welfare, Doris lacked the energy
to provide complete care for her. Further, she had thrown Brenda and the infant
out of the house four times in the past two months. She believed that mothers
need to care for their young children, and she would not provide a setting in
which Brenda could avoid responsibility for her own child. There was an ex-
tended family in the neighborhood, and Brenda and the baby stayed at the
homes of her aunts, uncles, cousins, and friends for brief periods. Doris eventu-
ally allowed Brenda to return home, but the cycle continued. Some members of
the church were pressuring Doris to keep Brenda at home until other suitable
arrangements could be made.

Doris was willing to participate in the interventions offered by the school
and children’s services agency, but was less enthusiastic than two years ago be-
cause of her depression and ongoing frustration with her daughter. Brenda
showed minimal willingness to invest in any interventions. She relied on her cir-
cle of friends and relatives for most of her emotional and maternal support.

Brenda agreed to a family meeting only after the school threatened legal ac-
tion in response to her not attending school. At the first meeting, Shaniqua, now
25, spent much time empathizing with the perspectives of each client. She
pointed out each person’s strengths, including Doris’s resilience as a single

246 C H A P T E R 10

mother, her concern for her daughter and granddaughter, a solid work history
and desire to work, and her good judgment about appropriate parenting. She
added that Doris had good coping skills but was perhaps trying to do too
much, more than one person could reasonably manage. She seemed to be ignor-
ing her own needs. In turn, Shaniqua noted that Brenda cared for her child, had
good social skills, was healthy, a good learner, and welcomed some assistance in
getting her life better organized. Brenda also seemed to have good judgment
about her baby’s needs when she was at home. Shaniqua shared her good feel-
ings about the social network of the family, including their friends at church and
in the neighborhood.

The social worker externalized the presenting problem by formulating a
theme that two new elements had entered their lives: a new baby and “chaos.”
She framed the new baby as the exciting change, and chaos as the draining one.
They all wanted to keep the baby, but needed to think of ways to use their
resources to get rid of “chaos.” When they discussed goals, Shaniqua asked
Brenda how she might be of help in getting the other agencies “off her back,”
and improving how she and her mother “got along,” which were Brenda’s pri-
orities. Doris’s goals for Brenda were more extensive, focusing on her assuming
more household and parenting responsibilities. Regarding her own goals, Doris
wanted to work and have some leisure time on the weekends.

The social worker’s request that Brenda and Doris “scale” their motivation
to work on their issues resulted in moderate to high scores. Shaniqua concluded
the assessment by asking Doris and Brenda what their lives would be like when a
social worker was no longer required to be a part of it. Doris said that she would
be working, always knowing where Brenda was, and having Brenda home for
part of each day. Brenda said that she would not have to deal with agencies,
not have to go to school, have a part-time job, and be able to see her friends
several evenings per week. Brenda added that she would be getting along better
with her mother. Shaniqua did not ask the miracle question in this case, because
the clients’ answers to the above questions presented many options for solution-
oriented tasks. Shaniqua told Doris and Brenda that, after this and all subsequent
sessions, she would ask them to identify a number of existing life situations in
which they did not experience their presenting problems. These conversations
helped them to focus on their capacities to interact without argument, Brenda
organizing her time around childcare more carefully, and Doris taking time for
herself.

During the third meeting, Brenda mentioned that she was interested in at-
tending a vocational school in preparation for a job as an alternative to attending
her high school. The client mentioned that she was interested in being a dental
assistant, but wasn’t sure if that was an attainable goal. Doris agreed to support
this goal if Brenda would agree to continue spending all weekday evenings at
home with the baby. Shaniqua offered to get information about vocational edu-
cation in the area to share with the family. On another topic, Doris reflected on
the possibility of her cousins and sisters helping with Brenda’s transition to par-
enthood so that she could look for work more regularly. Shaniqua suggested that
they might be willing to help if it could be done in a proactive rather than a

S O L U T I O N – F OC U S E D T H E R A P Y 247

reactive way. Doris agreed, and also said that they might also help connect her
(Doris) with job opportunities. Among Doris’s ideas for tasks was to seek out
several friends and her pastor to solicit their guidance in initiating job searches
and also some weekend social activities.

Over the next several weeks, the clients attended to these and other tasks
developed during the counseling sessions. Shaniqua asked the clients each week
to perform a “surprise task”—something unexpected that would please the other
person. The social worker’s assessment was that the pair shared a positive bond
beneath their anger, and that the surprise tasks might strengthen their bond. This
strategy proved useful. As examples, Brenda served her mother breakfast in bed
one day; Doris made Brenda a sweater.

The intervention ended after six meetings. Brenda was applying to voca-
tional schools in the area and attending high school regularly. She was assuming
some household tasks in return for her mother’s blessing in seeing her friends.
Her attention to parenting tasks was increasing. Doris was still not employed,
but was interacting more with her friends and looking for work. Brenda was
staying with relatives at times, but these visits, arranged in advance, did not in-
clude “chaos,” and thus were welcomed. Both clients expressed satisfaction with
their level of goal achievement.

EV IDENCE OF EFFECT IVENESS

A number of experimental, quasi-experimental, single-subject, and pre-
experimental designs provide evidence of the utility of solution-focused ther-
apy with a variety of client populations at the individual, couple, family, and
group levels. Most recently, Franklin, Trepper, Gingerich, & McCollum (2012)
have published a book arguing that SFT demonstrates effectiveness in its appli-
cations with court-mandated domestic violence offenders, couples experiencing
intimate partner violence, medication adherence for persons with mental
illness, child protection, school social work, pregnant and parenting adoles-
cents, and persons receiving alcohol treatment. SFT is also used with children,
and Taylor (2009) has reviewed its effectivenss when combined with sand tray
interventions.

A variety of other noteworthy evaluations of the modality have been done.
In an Australian child and adolescent mental health clinic, practitioners experi-
mented with a two-hour, single-session SFT intervention model (Perkins,
2006). The 216 study participants (5- to 15-year-olds) were diagnosed with
parent-child relational problems (26.6%), oppositional defiant disorder (17.9%),
anxiety disorder (8.7%), ADHD (8.2%), adjustment disorders (8.2%), disruptive
behavior disorder not otherwise specified (6.8%), and separation anxiety disorder
(3.9%). The clients received SFT featuring assessment, family education, an exam-
ination of previously attempted problem solutions, and an array of new tasks and
strategies. All outcome measures demonstrated significant improvement in clients
four weeks after treatment compared to the control group (wait-list) condition.

248 C H A P T E R 10

Data from one SFT private practitioner’s 277 clients, analyzed by an outside
researcher, indicated that clients presenting with mood disorders attended an av-
erage of 4.14 solution-focused therapy sessions, with 60.9% partially or mostly
resolving their presenting problems (Reimer & Chatwin, 2006). Those clients
who presented with relationship problems attended an average of 2.34 sessions,
with 76% partially or mostly resolving their presenting problems.

Gingerich and Eisengart (2000) conducted a major literature review of SFT
outcome studies, reviewing all 15 controlled studies available at the time. The
five “well-controlled” studies on depression, parent-child conflict, orthopedic in-
jury rehabilitation, prison recidivism, and antisocial adolescent offenders all
showed positive outcomes, with SFT being more effective than a comparative
intervention or no intervention in four studies, and equal to a comparison inter-
vention in the other study. The four “moderately controlled” studies, on
counseling high school students with academic, personal, and social problems;
groups for elementary and high school students; depression and oppositional be-
havior; and intervention with couples, included methodological limitations, but
produced results consistent with the utility of SFT. The other six “poorly con-
trolled” studies (on problem drinking, family environment with schizophrenia,
parent-child conflict, child welfare, school-age children with behavioral pro-
blems, and depression/substance abuse) also reported positive results.

At least three studies have focused on general adult outpatient populations,
without specifying the nature of the presenting problems. In a pre-test/post-test
study of 83 clients treated with SFT at a university counseling center, 82% re-
ported problem resolution, based on personalized scaling measures, with a mean
number of 5.6 sessions (excluding dropouts) (Beyebach et al., 2000). A one-year
follow-up of 36 mental health agency clients at another site revealed sustained
positive outcomes for 64% of participants (Macdonald, 1997). Researchers in an-
other outpatient setting reported that 80% of 129 clients treated with solution-
focused therapy reported between-session progress, which is a major focus of the
model (Reuterlov, Lofgren, Nordstrom, Ternston, & Miller, 2000).

Interventions have been effective with couples and families in groups. A
quasi-experimental study of a psychoeducational group for 12 HIV sero-
discordant couples that included solution-focused therapy as part of a broader
intervention package resulted in significantly less depression, less anxiety, and
greater marital satisfaction among participants (Pomeroy, Green, & Van Laningham,
2002). A single-subject design with multiple baseline measures for an SFT group
of five couples experiencing marital problems reported that 8 of the 10 participants
achieved greater marital satisfaction and various other individual goals (Nelson &
Kelley, 2001). A quasi-experimental control group study of 23 couples who par-
ticipated in a six-week SFT group focused on marital concerns found significant
improvements in members’ adjustments in a variety of problem areas, but not in
their likelihood of divorce (Zimmerman, Prest, & Wetzel, 1997). An experimental
study of a six-week SFT group for parents of adolescents (N = 530) found signifi-
cant participant gains in parenting skills (Zimmerman, Jacobsen, Maclntyre, &
Watson, 1996). Metcalf’s (1998) book on SFT in groups provides additional
examples of the modality’s applications.

S O L U T I O N – F OC U S E D T H E R A P Y 249

The following two studies included families seen outside of group modali-
ties. A study of a 10-session family therapy intervention (including 45 families
randomly assigned to three treatment groups) demonstrated the effectiveness of
solution-focused therapy’s “formula first-session task” in subsequent measures of
family compliance, clarity of treatment goals, and resolution of presenting pro-
blems (Adams, Piercy, & Jurich, 1991). There were no differences among the
groups after the intervention, however, on family outcome or optimism. An-
other experimental study of 22 clients with schizophrenia and their families,
which included solution-focused interventions provided in five sessions over a
10-week period, reported significant differences between groups on measures of
expressiveness, active-recreational orientation, moral-religious emphasis, and
family congruence (Eakes, Walsh, Markowski, & Cam, 1997).

Several studies have focused on children and adolescents. Using a single-
subject design, one group of researchers found that 5 to 10 sessions of solution-
focused intervention with seven children aged 10 to 13 with learning disabilities
and classroom behavior problems were effective in resolving their major behavior
problems (Franklin, Biever, Moore, Clemons, & Scamardo, 2001). A larger pre-
test/post-test study of 136 children (aged 5 to 17 years) referred from a school
system due to behavioral problems indicated that solution-focused interventions
produced improvements in learning, appropriate levels of activity, and self-image
(Corcoran & Stephenson, 2000). Results were mixed with regard to the clients’
conduct problems.

Two studies have been done with youths in protective settings. An experi-
mental study of 21 offenders in a detention center demonstrated that 10 sessions
of individual solution-focused intervention resulted in a lessening of clients’ chem-
ical abuse and antisocial tendencies, and increases in their levels of empathy, appro-
priate guilt, and problem-solving abilities (Seagram, 1998). SFT was introduced in
a residential center for 39 youths aged 7 to 18 years with mental and emotional
impairments, and those receiving the interventions demonstrated increases in adap-
tive behaviors and a decrease in maladaptive behaviors (Gensterblum, 2002).

Interesting results have also been found in studies of various special popula-
tions. Pre- and post-test data were collected on 74 older adults, aged 65 to 89
years, who received solution-focused outpatient mental health services for pro-
blems including depression, anxiety, marital distress, and stress related to chronic
illness. The compiled results showed significant improvements among clients
with regard to their self-ratings and global assessment of functioning scores
(Dahl, Bathel, & Carreon, 2000). A seven-stage crisis-intervention model that
included SFT was effective in working with three substance-dependent indivi-
duals in another setting (Yeager & Gregoire, 2000). A pre-test/post-test control
group study of 52 mental health agency clients with depression indicated that the
experimental clients acquired significantly greater levels of hope, but there were
no differences between groups in depression inventory scores (Bozeman, 2000).
In an orthopedic work adjustment program for adolescents, 48 clients were di-
vided into two groups, one of which was provided with solution-focused inter-
ventions. Client in both groups demonstrated an enhanced adjustment to their
condition (Cockburn, Thomas, & Cockburn, 1997).

250 C H A P T E R 10

CR IT IC ISMS OF THE THERAPY

The major criticisms of solution-focused therapy imply that the practice is super-
ficial, denying clients the opportunity to explore their presenting problems and
related emotions in greater depth (Lipchik, 2002). For example, its encourage-
ment of clients to “think positively” may induce a client’s denial or minimization
of problems. Clients who perceive the social worker’s de-emphasis of problems
may feel discouraged from sharing important information or negative feelings
about the presenting issue. Some clients may also feel strongly about working
on problems in ways that are not compatible with SFT (such as exploring their
family backgrounds and developing insight). Of course, proponents of SFT al-
ways encourage clients to consider alternative perspectives about human behav-
ior and the nature of change. Finally, some critics have concerns that the
principles of the approach may create a false impression for beginning practi-
tioners that intervention is “easier” than in fact it may be.

Many practitioners who do not subscribe to the SFT model nevertheless see
value in adopting some of its principles, suggesting that they can be incorporated
into, and not necessarily exist apart from, other modalities. Principles from solution-
focused therapy can prompt the social worker to reconsider the time spent discuss-
ing the client’s past, present, and future; encourage the use of scaling techniques
when “stuck” in problem exploration; attend to the client’s coping strategies as a
corrective against a problem bias; and be careful not to foster client dependency.

SUMMARY

Solution-focused therapy is a practice model that has steadily grown in popularity
since the 1980s. Its principles derive from the crisis, cognitive, systems, and com-
munications theories, as well as those of short-term practice. It is exceptionally
strengths-focused. Much work is being done at present to test the effectiveness of
SFT; in the future, its major concepts may become more fully refined, and its
range of applications more clearly articulated. Solution-focused therapy seems ide-
ally suited to the current economics of direct practice as one of a handful of ap-
proaches that are task focused and short-term by nature. Although SFT is an
effective intervention model for many types of clients, the social worker using it
must also possess the knowledge and skills to be able to connect with clients, assess
their motivation, streamline goals that are appropriate to the presenting situation,
and apply sound professional judgment in bringing about lasting solutions.

TOPICS FOR DISCUSSION

1. Solution-focused practitioners believe that a client’s solutions need not be
directly tied to his or her problems. Do you agree? Are interventions that are
tied to specific presenting problems more likely to be effective?

2. When externalizing a problem, does a social worker risk helping a client
avoid taking responsibility for it?

S O L U T I O N – F OC U S E D T H E R A P Y 251

3. How does the SFT skill of “not knowing” fit with the notion that social
workers should have expertise in understanding the nature of problems and
how they develop?

4. Why is there such an emphasis on giving compliments in SFT? Present three
“new” compliments that you might have given to a client on your caseload
prior to learning about SFT. Would these have enhanced your intervention?

5. Discuss various strategies that a practitioner might use to help clients find
(a) exceptions to their presenting problems, and (b) solutions that are based
on continuing certain behaviors. Use types of clients of interest to you and
your classmates as examples.

IDEAS FOR CLASSROOM AC TI V IT IES /R OLE -PLAYS

1. Students should pair off, with one playing a social worker, and the other
portraying a client. Each “client” should be assigned a different presenting
problem. After the social worker clearly ascertains the nature of the
problem, he or she asks the “miracle question,” and helps the client concretize
the response as much as possible. After the role-play, students can share
what was helpful in completing the task, and what goals the client articulated
as a result.

2. Describe how SFT might be used with a 10-year-old child (boy or girl) who
refuses to attend school (fourth grade) because she is worried about her
newly divorced single mother, who stays home to care for a younger
(2-year-old) child.

3. Using any type of client and presenting problem, ask students to
role-play a termination session in which the client is feeling uncertain
about his or her chances of avoiding a problem recurrence. The social
worker should use future-oriented questions to help the client resolve the
uncertainty.

APPENDIX: Solution-Focused Therapy Outline

Focus Solutions or exceptions to problems

Major Proponents Berg, Corcoran, de Shazer, Elliott, Metcalf, Lipchik,
Weiner-Davis

Origins and Social
Context

Developments in brief therapy

Crisis theory

Systems theory in social work

Communications theory (the uses of language)

A rise in the strengths perspective

Social constructivism

252 C H A P T E R 10

Nature of the Individual People create meaning out of their experiences

People want to change

People have sufficient resources to solve most problems

Major Concepts The power of language in shaping one’s reality

A de-emphasis on problem talk

An emphasis on solution talk

Developmental Concepts None

Nature of Problems Problems result from cycles of behavior that have been
reinforced

People are constrained by narrow, pessimistic views of
problems

There is no “right” way to view a problem or solution

Problems are not so ubiquitous as assumed

Problems can be resolved without understanding causes

Problems do not serve a function in a system

Rigid beliefs and attitudes prevent people from noticing new
information

Nature of Change Change is constant

Change occurs by reinterpreting situations and filling
information gaps

Change may be behavioral or perceptual

There is no distinction between symptomatic and structural
change

Change is subject to the self-fulfilling prophecy

Small change can snowball

Rapid change is possible

Goals of Intervention Focus on solutions to problems

Help clients to act or think differently

Highlight client strengths and resources

Recognize exceptions

Nature of Worker/Client
Relationship

Social worker is a collaborator

Clients define goals; the social worker helps clients select
goals and strategies that are achievable

Worker affirms clients’ rights to their perspectives on
problems and solutions

Worker communicates the possibility of change

APPENDIX: Solution-Focused Therapy Outline (Continued)

S O L U T I O N – F OC U S E D T H E R A P Y 253

Intervention Principles Normalize problems

Compliment (focus on positives)

Establish the worth of challenging the problem

Offer alternative perspectives on ways of thinking, feeling,
and behaving

Externalize the problem (reframe)

“Relative influence” scales

Ask the miracle question

Task interventions—to do more of what the client is doing
when the problem is not happening

Encourage the client to think and behave differently

Complaint patterns

Context patterns

The “surprise task”

The formula first-session task

Suggest easier alternatives to prior solution attempts

Predict setbacks

Assessment Questions
(May be used as
interventions)

How has the client tried to manage his or her concerns thus
far?

What are the client’s overall survival strategies?

How much, or how often, has the client been able to stand
up to, or not be dominated by, the problem?

How will the client know when the problem has resolved?

What was different in the past when the problem did not
exist?

What is the client doing when the symptom isn’t happening?

What does the client want to continue to happen?

What has changed since the client scheduled the first
appointment?

APPENDIX: Solution-Focused Therapy Outline (Continued)

254 C H A P T E R 10

Motivational Interviewing and

Enhancement Therapy

How still the bells in steeples stand,
Till, swollen with the sky,

They leap upon their silver feet
In frantic melody! *

Motivational interviewing and motivational enhancement therapy are client-
centered, directive methods for enhancing motivation to change problem

behaviors by exploring and resolving a client’s ambivalence (Miller & Rollnick,
2013; Wagner & Ingersoll, 2012). Motivational interviewing (MI) is a set of strate-
gies for talking with clients to help them resolve their ambivalence about addres-
sing a concern, while motivational enhancement therapies (MET) are complete
interventions that build on the client’s resolution of ambivalence toward the
achievement of a specified goal. Like solution-focused therapy, motivational
enhancement does not represent a single theoretical perspective, but uses con-
cepts from a variety of sources. It has become quite popular in the past 25 years
as a means of engaging clients who are either reluctant or unmotivated to address
problems that are considered to be serious by significant others, if not by the
clients themselves. Reluctant clients have presented human services practitioners
with special challenges for generations (Kindred, 2011; Rooney, 1992). Initially
developed for the treatment of substance abuse, MI and MET are now utilized
for other types of problems, such as eating disorders, behavioral problems of
adolescence, general health care issues, physical inactivity, cigarette smoking,

* Dickinson, E. (1927). The Pamphlet Poets. New York: Simon and Schuster.

255
Copyright 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights,

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diabetes, HIV high-risk behavior, medication adherence, family preservation, sex
offenses, and pain management. Motivational interviewing is a brief process (four
sessions or less), and motivational enhancement interventions, while sometimes
longer, are also time limited. We will focus on concepts related to motivational
interviewing for most of this chapter, and elaborate on the related enhancement
therapies in the section on intervention.

Because the motivational interviewing and enhancement therapies are rather
new and derived from several theoretical perspectives, their major concepts are
included in the following section.

ORIGINS , SOC IAL CONTEXT , AND MAJOR

CONCEPTS

Motivational interviewing emerged from the work of William Miller and some
colleagues in response to frustrations experienced by substance abuse practi-
tioners, who could not motivate many of their clients to change or see the
seriousness of their problems (Miller & Rollnick, 2013). At that time (the
1980s), intervention in the field tended to be highly confrontational. Practi-
tioners relied on a medical model for problem formulation and took authorita-
tive stances, arguing that the client had a problem and needed to change,
offering direct advice, and using punitive measures for noncompliance. Con-
frontation was said to be necessary to break through the clients’ denial, which
is pervasive in substance abuse. Even so, many clients did not benefit from
these interventions.

Miller derived the principles of motivational interviewing from his own
personal style of counseling (Draycott & Dabbs, 1998), person-centered therapy
(see Chapter 3), the theory of cognitive dissonance (Festinger, 1962), and the
trans-theoretical stages of change model (Connors, Donovan, & DiClemente,
2001; Prochaska & Norcross, 1994). Although both person-centered therapy (PCT)
and motivational interviewing rely on the practitioner’s use of empathy, there are key
differences between the two. Unlike PCT, which is non-directive and employs
empathy throughout the process, MI seeks to enhance the client’s motivation to
change and uses empathy in a selective way to achieve this goal. Further, PCT explores
the client’s feelings and conflicts “in the moment,” whereas MI fosters and amplifies
the client’s experience of dissonance so that motivation for change is tapped.

Cognitive dissonance theory maintains that a person is not capable of holding
two incompatible beliefs at one time (Cooper, 2012). When we are presented
with environmental input that contradicts a firmly held belief, we need to some-
how reconcile the discrepancy in order to avoid anxiety. For example, the pedo-
phile who cannot resist the urge to fondle a young child, but who also believes
that children should never be victimized, may resolve this dissonance by deciding
that the particular child “needs love.” The process of resolving dissonance usually

256 C H A P T E R 11

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occurs outside of a person’s awareness, although an “objective” outsider (such as
a social work practitioner) can often identify it.

Ambivalence can be understood as a mild form of cognitive dissonance, in that we
are unable to choose between two beliefs or goals that are in contrast to one another.
Few decisions that we make, major and minor, are completely free of conflicted
thoughts. We might experience agonizing ambivalence when deciding whether to
accept a particular job offer, but this sense of uncertainty may also be present as we
decide whether to accept an invitation to a party with people we don’t know well. In
motivational interviewing, the practitioner helps the client to resolve this ambivalence,
hopefully in a direction that strengthens the client’s desire to change (for example, to
get a certain kind of job). If this goal becomes a dominant cognition, the client’s other
thoughts and behaviors will be more easily brought into compliance with it.

Another major influence on motivational interviewing is the trans-
theoretical stages of change (TSOC) model, developed to recognize and address
the reluctance of many people with substance use disorders to change their
behaviors. TSOC offers an alternative to approaches that view clients as resistant,
in denial, or uncooperative if they express a lack of readiness or willingness to
change. It views motivation as a state of readiness to change and proposes that all
people follow a predictable course when changing behavior. The following six
stages of change have been formulated in the TSOC:

Precontemplation—The person does not believe that he or she has a prob-
lem and is unwilling to change, even though others suggest there may be a
problem.

Contemplation—The person is considering changing a behavior, seeing that
there are significant benefits to be gained by (for example) stopping alcohol
use, even as he or she continues to drink.

Preparation—The person is poised to change the problematic behavior
within the next month, and works on a strategy for doing so.

Action—The person implements a change in behavior (for example, going
to rehab).

Maintenance—Sustained change persists for six months.

Relapse—The person resumes the problem behavior.

The TSOC model may seem simple, but as a guide to approaching inter-
vention, it has advanced the process of treating substance abusers remarkably.
The model has also been tested with other kinds of presenting problems such
as dietary change (Armitage, 2006), male battering behavior (Scott & Wolfe,
2003), and smoking cessation and exercise adoption (Rosen, 2009), and has
been found to be a largely (but not completely) valid predictor of client change.
Motivational interviewing focuses mainly on clients in the first three stages of
change, while motivational enhancement therapies guide a client through the
fourth and fifth stages.

Collaboration, rather than confrontation, is a hallmark of motivational inter-
viewing and enhancement. Indeed, within this perspective, confrontation is

M O T I V A T I O N A L I N T E R V I E W I N G A N D E N H A N C E M E N T T H E R A P Y 257

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viewed as a tactic that only escalates client resistance. Motivational interventions
“sidestep” denial, and instead emphasize listening reflectively to clients’ concerns
and supporting change talk. This is defined as talk that emphasizes the:

Disadvantages of the status quo

Advantages of change

Optimism about change

Intention to change

Motivational interviewing also contrasts with the principles of Alcoholics
Anonymous (AA), a dominant treatment paradigm demanding that people label
themselves as alcoholic and admit their powerlessness over alcohol. MI down-
plays the use of labels, stressing more of a non-hierarchical collaboration between
the client and practitioner, as well as the development of self-efficacy so the
client can develop confidence for changing.

The Summary Principles of Motivational

Interviewing and Enhancement

The assumptions of motivational interviewing can be summarized as follows:

Motivation to change is elicited from the client, not imposed from the
outside.

A client’s motivation for enacting change relative to some problem is often
impeded by ambivalence.

It is the client’s task to articulate and resolve his or her ambivalence.

Direct persuasion is not an effective method for resolving ambivalence.

Readiness to change is a product of interpersonal interaction.

Practitioner comments are useful in examining ambivalence.

The principles of motivational interviewing, stated simply here and described
in detail later, include the following four practitioner interventions:

Express empathy, as acceptance facilitates honest dialogue

Develop discrepancies between how things are with the client and how they
should be (from the client’s perspective); let the client present arguments for
change

Roll with client reactance; avoid arguing

Support self-efficacy, the client’s belief in the possibility of change

One prominent social worker who has written about motivational inter-
viewing is Jacqueline Corcoran (2005). In response to a perceived lack of
strengths-based practice models in the profession, she developed an intervention
model incorporating solution-focused therapy, motivational interviewing, and
cognitive-behavioral therapy.

258 C H A P T E R 11

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THE NATURE OF PROBLEMS AND CHANGE

Motivational interviewing does not incorporate unique ideas about how pro-
blems develop. Because the approach does not emphasize unconscious mental
processes, however, its ideas about the nature of problems are consistent with
those of the cognitive and behavior theories, and solution-focused therapy. Its
attention is focused on how change occurs. In order to change, a client must
be willing (see the importance of changing), able (confident about changing),
and ready (to prioritize changing). Further, MI assumes that

Change can occur quickly.

The attributes of the social worker are significant to the change process.

A client’s arguing for change increases the likelihood that it will occur.

The major reason why change happens is that the client perceives that the
disadvantages of a problem behavior outweigh its advantages and, simulta-
neously, that the advantages of changing behavior outweigh the disadvantages.
The person whose wife complains about his smoking marijuana every weekend
may decide that his marriage is more valuable than his need to relieve stress in
that particular way. Also critical to change is that clients build a sense of self-
efficacy so that they believe they have the necessary resources to carry out a
change effort. This client may need to discover that there are other ways to man-
age his anxiety effectively.

In motivational interviewing, the initial intervention goal is to build clients’
motivation when they are not willing to change, rather than focusing on actual
behavior change. A client’s perception of the (alleged) problem is thus the focus
of the early part of the social worker’s attention. As the work moves into the
action stage of the TSOC model, client behavior becomes a target for interven-
tion with motivational enhancement therapies.

ASSESSMENT AND INTERVENT ION

The Social Worker/Client Relationship

Motivation is not a stable, internal quality of an individual, but is affected by the
interaction between the practitioner and client (Killick & Allen, 1997). The con-
text of the helping relationship is therefore emphasized. The social worker ini-
tially seeks to understand the client’s frame of reference about the presenting
issue with reflective listening. He or she affirms the validity of the client’s per-
spective and the client’s freedom of choice in dealing with the situation. The
practitioner then elicits and selectively reinforces the client’s own self-
motivational statements about the problem issue. The social worker seeks to
engage clients at their current stage of change to build their motivation, and to
enlarge upon the concerns and strengths they demonstrate. Given this emphasis,
client resistance is an invalid concept. A more appropriate term is client reactance,

M O T I V A T I O N A L I N T E R V I E W I N G A N D E N H A N C E M E N T T H E R A P Y 259

which is intended to capture a client’s normal, predictable reactions to uncertain-
ties about the purposes of the client/worker interaction (Hepworth, Rooney,
Rooney, Strom-Gottfried, & Larsen, 2012). “Reactance” can also be defined as
speech that signals movement away from a particular kind of change. It is charac-
terized by arguing, interrupting, negating, and ignoring. The presence of reactance
is a problem for the practitioner rather than the client, signifying that the practi-
tioner needs to adjust interviewing strategies to match the client’s position toward
change. The responsibility for how behavior change occurs is left to the client.

Assessment

Motivational enhancement practitioners have not delineated formal procedures for
client assessment (Agostinelli, Brown, & Miller, 1995). This is not an oversight but
a reflection of the nature of the approach, which does not make a clear distinction
between assessment and intervention. It is important to emphasize, however, that
when the social worker becomes aware of a client’s reason for referral, he or she
should not presume that the client will want to address that issue during the initial
meeting. The practitioner should allow the client to choose topics for exploration.
The social worker asks open-ended questions, listens reflectively, affirms the
client’s dignity, and summarizes the content of the client’s statements by linking
together what has been discussed related to some presenting situation. Further,
the social worker asks evocative questions related to ambivalence, change, and
motivation to encourage the client’s sustained reflection.

Intervention

The following guidelines help the practitioner to enact the four principles of
motivational interviewing described earlier.

Begin where the client is. The social worker should not assume that the client is
ready to engage in change.

Explore clients’ problem behaviors, and accept their perceptions as valid. The social
worker listens with empathy to clients’ concerns, and in this way can more
accurately assess the person’s relationship to the process of change.

Reinforce client statements about wanting to change. The social worker attends
selectively to client expressions about change. The social worker seeks to point
out discrepancies between the client’s values and goals, such as long-term
health, and how the problem may stand in the way of reaching them. Advice
and feedback are postponed until sufficient motivation to change has been built.

Affirm clients’ statements about their ability to change. In this way, the individual
feels empowered to take the first steps toward change.

Specific techniques of motivational interviewing include eliciting self-
motivational statements, strategies to handle resistance, the decisional balance,
and building self-efficacy (Miller & Rollnick, 2013).

260 C H A P T E R 11

Eliciting Self-Motivational Statements Self-motivational statements are statements
made by clients that indicate a desire to bring about a change. They emerge
from the client’s decision to change, but also his or her sense of competence,
confidence, and awareness of resources that will support change efforts. The
social worker elicits self-motivational statements by posing questions that the
client might answer in a way that favors change. The conversation will lead
into exploring the disadvantages of the status quo situation through:

Problem-recognition questions. “What things make you think that this is a
problem? In what ways do you think you or other people have been
harmed?”

Concern questions. “What worries you about your behavior? What can you
imagine happening to you? What do you think will happen if you don’t
make a change?”

Questions about extremes. “What concerns you the most about this in the long
run? How much do you know about what can happen if you continue with
this behavior, even if you don’t see this happening to you?”

Other types of questions encourage the client to explore the advantages of
changing. These questions involve:

Intention to change. “The fact that you’re here indicates that at least a part of
you thinks it’s time to do something. What are the reasons you see for making
a change? What would you like your life to be like five years from now?”

Optimism about change. “What makes you think that, if you decided to make
a change, you could do it? What do you think would work for you if you
decided to change? When else in your life have you made a significant
change like this? How did you do it? What strengths do you have that will
help you succeed? Who could offer you support in making this change?”

Questions about extremes. “What might be the best results you could imagine
if you make a change? If you were completely successful in making the
changes you want, how would things be different?”

These types of questions provoke the individual to consider change by
examining and contrasting views of the future (both with and without the prob-
lem), the functions the behavior serves, and its harmful consequences. The social
worker then asks the client to elaborate further on his or her comments that
favor change. Still, the motivational interviewer is encouraged to use questions
sparingly, selecting a few that will begin the conversation about change, and then
move on to statements that require the client to elaborate further on statements
that affirm and reinforce the client’s consideration of change.

Handling Reactance As discussed earlier, signs of reactance, such as the client’s
arguing, interrupting, denying, and ignoring certain issues, alert the social worker
to the need to switch interviewing strategies. In general, the new strategies
should involve reflective responses that diffuse potential power struggles and

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mobilize the side of the client’s ambivalence that is geared toward change
(Moyers & Rollnick, 2002). Strategies include simple reflection, amplified reflection,
double-sided reflection, shifting focus, agreement with a twist, reframing, clarifying free
choice, and using paradox. Each of these is illustrated below, using substance abuse
as the presenting problem.

Simple reflection is acknowledging a client’s feelings, thoughts, or opinions so
that the client continues to explore the presenting problem rather than become
defensive (“You have a lot of stress going on in your life right now. Do you
think this may not be the best time to change your behavior?”). The client,
given the freedom to decide where to go with the topic, might respond,
“I don’t know. Maybe it’s not a good time, but I’m not sure.” (Carroll, 1998).

Amplified reflection goes beyond simple reflection in that the client’s statement
is acknowledged, but in an extreme fashion. The purpose of such a statement is
to bring out the side of the client that wants to change. An amplified reflection,
such as the statement, “You say that you’re fine the way you are, so maybe there
is nothing that you should change,” typically has the effect of getting the client
to back down from an entrenched position and allow for the possibility of nego-
tiation about change. This strategy is similar to that of paradoxical intention. Par-
adox involves siding with the client’s defensiveness, which then causes the client
to take the other side of the argument for change. Sometimes clients who have
been entrenched in a negative position regarding change will start to argue from
the other side of their ambivalence, the part that wants to change, when the
practitioner joins their position. (For example, “Well, I don’t want to say there’s
nothing I can do to make my life better.”)

Double-sided reflection taps into both aspects of the client’s ambivalence. It
acknowledges that when people are exploring the possibility of change, they are
divided between wanting to change and wanting to hold onto the behavior that
has become problematic. Examples of this kind of comment are: “You’re not sure
your drinking is a big deal, yet your girlfriend left you because of how you acted
when you were drinking, and you’re upset she’s gone,” and “Your relationship
was very important to you, and your alcohol use caused problems in the
relationship.” Double-sided reflection can pull the client’s attention to the incon-
sistency between the problem behavior and his or her goals and values.

Shifting focus occurs when the social worker moves the client’s attention from
a potential impasse to avoid becoming polarized from his or her position. When
the client begins to argue against what the practitioner might feel is the best
course of action, the practitioner should immediately shift his or her position,
and redirect the focus (“I think you’re jumping ahead here. We’re not talking
at this point about you quitting drinking for the rest of your life. Let’s talk
some more about what the best goal is for you right now, and how to go about
making it happen.”). A guideline for shifting focus is to first defuse the initial
concern, and then direct attention to a more workable issue.

Agreement with a twist involves agreeing with some of the client’s message,
but in a way that orients the client in a change direction (“I agree there’s no need
for you to say you’re an alcoholic. I am hearing that there are certain aspects of
drinking that you enjoy, and that it’s also causing you some problems.”).

262 C H A P T E R 11

Reframing, a concept described in several other chapters of this book,
involves taking arguments that clients use against change and altering the mean-
ing of the information to promote change instead. A common example involves
the tendency of drinkers to consume large quantities without experiencing ill
effects and loss of control. This tendency is sometimes used as an excuse for
why the drinking is not a problem. This excuse can be reframed by the social
worker as tolerance of alcohol, which is actually symptomatic of problem drink-
ing (“You’re right, you don’t notice any effects from the alcohol. But that’s be-
cause you’ve been drinking so long your body is used to it. The alcohol is
affecting your body but not your mind.”)

Clarifying free choice involves communicating to the client that it is up to him
or her to make a change, rather than getting embroiled in a debate about what
the client should or must do (“You can decide to take this on now or wait until
another time.”). This is a useful intervention because when people perceive that
their freedom of choice is being threatened, they tend to react by asserting their
liberty. A good antidote for this reaction is to assure the client that in the end, it
is he or she who determines what happens.

Decisional Balance This is another motivational technique that involves weighing
the costs and benefits of the client’s problem behavior, and the costs and benefits
of change. The advantages and disadvantages of change are a continual focus of
motivational interviewing, but in this technique they are gathered together more
formally in a comparative “balance sheet.” This is similar to the “cost/benefit”
strategy used in cognitive therapy. The social worker should understand, how-
ever, that the relative number of costs and beneftts listed will rarely resolve a
client’s ambivalence, as each item carries different weight.

Supporting Self-Efficacy and Developing a Change Plan Techniques involved in
building self-efficacy, with examples, include:

Evocative questions. “How might you go about making this change? What
would be a good first step? What obstacles do you foresee, and how might
you deal with them?”

Ruler assessment. “How confident are you that you could stop your purging
behavior? On a scale from 0 to 10, where 0 is not at all confident and 10 is
extremely confident, where would you say you are? Why are you at 2 and
not 0? What would it take for you to go from 2 to [a higher number]?”

Reviewing past successes. “When in your life have you made up your mind to
do something challenging, and did it? It might be something new you learned,
or a habit that you quit, or some other significant change that you made.
When have you done something like that? What did you do that worked?”

Discussing personal strengths and supports. “What is there about you, what
strong points do you have, that could help you succeed in making this
change? What sources of support do you have? Are there others you could
call on for help?”

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Asking questions about hypothetical change. “Suppose you did succeed in stop-
ping your drug use, and are looking back on how that happened. What
most likely is it that worked? How did it happen? Suppose that this one big
obstacle weren’t there. If that obstacle were removed, then how might you
go about making this change?”

Brainstorming involves freely generating as many ideas as possible for how a
change might be accomplished, and as a result perceiving one or two ideas
that might work.

Giving information and advice. Social workers should be reluctant to give
advice to clients, because doing so takes responsibility for behavior away
from the client. Whenever advice is given, it should be done reluctantly,
tentatively, and on matters that are not likely to have negative consequences.
For example, if a client had success with maintaining sobriety in the past
because of involvement with AA, but relapsed after terminating that
involvement, a social worker may suggest that the client consider resuming
that program as one part of his or her desire to resume sobriety.

These MI interventions may result in a person’s readiness to consider a
change plan in which goals are set, options for change are considered, and a ten-
tative plan is formulated. We now turn to five examples of the more structured
motivational enhancement therapies.

Motivational Enhancement Therapy

Wagner and Ingersoll (2012) promote the use of MET in groups, and have
developed 10-session and 1-session intervention models. Both of these rely
extensively on the use of worksheets produced by the authors. The 10-session,
90-minute group is organized as follows, with a listing of topics and worksheets
utilized:

Week #1: Introduction to the group and an exploration of lifestyles (typical
day/lifestyle worksheet)

Week #2: The stages of change (the wheel model)

Week #3: Awareness: The good things and not-so-good things about the
problem behavior (the awareness window)

Week #4: Looking forward (the looking forward form)

Week #5: Decisional balance: Pros and cons of changing and staying the
same (the decisional balance worksheet)

Week #6: Exploring values (the exploring values worksheet)

Week #7: Supporting self-efficacy and change success stories (remembering my
successes)

Week #8: Supporting self-efficacy by exploring strengths (the coat of arms)

Week #9: Planning for change (the change plan worksheet)

264 C H A P T E R 11

Week #10: The importance of confidence and desire for change (the
importance, confidence, and desire forms)

The single-session motivational group attends to the following topics, pro-
cessed within a single three-hour session:

Lifestyles, stress, and substance use

Health and substance use

A typical day

The good things and the less-good things

Providing information

The future and the present

Exploring concerns

Helping with decision making

The authors have conducted comparative studies of the effectiveness of these
two groups and found that, while both produce positive changes in participants,
the longer group is more effective over the long term.

Numerous programs target marijuana use, and included here are two ran-
domized programs that sought to demonstrate how MET might be effective,
alone and in combination with other theory-based approaches, in addressing
the issue (Marijuana Treatment Project Research Group, 2004).

A two-session MET program was designed for self-referred marijuana
abusers (N = 146) who had an interest in reducing or terminating their substance
use. The program included two one-hour sessions for individual clients spaced
four weeks apart, so that clients would have time to implement any desired
changes before evaluating and discussing their outcomes. At the first session, the
practitioner and client discussed and completed a Personalized Feedback Review
(PFR) form that was intended to motivate the client to reduce his or her mari-
juana use and support the selection of appropriate goals and change strategies.
The PFR summarized the client’s recent marijuana use; problems, concerns,
and attitudes favoring and opposing change; and ratings of confidence about
change. During the second session, the parties reviewed the client’s efforts to
reduce use and perhaps make adjustments in change strategies. The client was
invited to bring any supportive significant others to the second session that they
wanted (which occurred 15% of the time). Results of the program indicated that
72% of participating clients came for both sessions and reported an overall 35.7%
reduction in days smoking marijuana from baseline. A nine-month follow-up
indicated an 8.6% abstinence rate among participants.

In another, more elaborate program utilized with the same population,
MET was combined with cognitive-behavioral therapy (CBT) and case manage-
ment in a three-month intervention that included eight weekly sessions and a
final session four weeks later (again, so that participants could review their
change strategies with the practitioner after a period without contact). The pro-
gram (N = 156) was structured as follows:

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Sessions #1 and #2 were devoted to MI and the PFR review, as in the earlier
example.

Sessions #3 and #4 were devoted to the practitioner’s case management
activities for identifying and reducing non–substance abuse problems,
identifying potential obstacles to abstinence (such as legal, housing, voca-
tional, psychiatric, and medical problems), setting goals, identifying resources
in the community, and developing a plan to address these challenges.

Sessions #5 to #9 provided CBT interventions for understanding marijuana
use patterns, coping with urges to use, managing thoughts about restarting
marijuana use, problem solving, and “marijuana refusal” skills.
In addition, five “elective modules” were available for practitioners to use if
any of them would be of particular benefit to their clients. When used, they
would substitute for one of the CBT sessions. These modules focused on
planning for emergencies and relapse, seemingly irrelevant decisions, man-
aging negative moods and depression, assertiveness, and anger management.

The results of this intervention indicated that the average number of sessions
attended was 6.5, and 47% of participants attended all sessions. There was an
overall 58.8% reduction in days smoking marijuana from baseline, with fewer
numbers of days of use, dependence symptoms, and abuse symptoms. More
than 20 percent (22.6%) maintained abstinence at nine-month follow-up, and
29% brought a significant other to at least one session. The authors of this com-
parative study concluded that both the two-session and nine-session METs were
effective in reducing marijuana use anong participants who had prior interest in
changing their use patterns.

As a final example, the Adapted Motivational Interviewing (AMI) program
for women with binge eating disorder is an MET intervention that was tested in
a randomized, controlled trial with 108 participants (Cassin, von Ranson, Heng,
Brar, & Wojtowicz, 2008). Experimental group participants (N = 54) were pro-
vided with a single-session, structured-group MI intervention as a prelude to
reading and utilizing a self-help book on recovering from binge eating. The
women in the control group (N = 54) used only the handbook. The AMI
session protocol, provided to individual clients in sessions that averaged 81 minutes,
included the following practitioner activities:

Elicit concerns about binge eating (its impact on physical and mental health,
finances, and relationships)

Explore ambivalence

Discuss stages of change and the client’s own stage

Write a decisional balance outline related to continuation of the behavior

Bolster self-efficacy; encourage recall of past experiences where the client has
shown mastery

Values exploration (dissonance between one’s actual and ideal lives)

Assess readiness and confidence for change

266 C H A P T E R 11

Elicit ideas for behavioral alternatives to binge eating

Collaboratively develop a change plan consisting of small steps

Once this process was complete, clients were left on their own to read the
21-page handbook Defeating Binge Eating. The contents of the book included the
following subjects:

What binge eating is

Learning to take small steps

Understanding hunger and food cravings

Beginning the work

Working with hunger and appetite

Working with food and feelings

Preventing relapse

Local and Internet-based mental health resources

The researchers collected symptom data from members of the two groups at
intervals of 4, 8, and 16 weeks. Significantly more women in the AMI group
abstained from binge eating than did those in the control group (27.8% versus
11.1%), and also no longer met the Diagnostic and Statistical Manual of Mental
Disorders (DSM) frequency criteria for binge eating disorder (87.0% versus
57.4%). Interestingly, a majority of women from both groups reported satisfac-
tion with their goal achievement relative to binge eating.

SP IR ITUAL ITY IN MOTIVAT IONAL I NTERVIEWI NG

AND ENHANC EMENT

Motivational interviewing and enhancement interventions are client-centered
techniques that focus on helping clients resolve ambivalence about their goals.
It is quite possible that clients will raise issues of spirituality as they struggle
with difficult life challenges. The questions used with MI are consistent with a
spiritual focus, as the social worker may ask about clients’ life goals and what is
most important and meaningful to them. Motivational interviewing and en-
hancement, however, does not assume any particular spiritual aspects of human
nature. To the extent that issues of meaning are motivating or contributing to
the ambivalence of a client, the social worker should ask questions about them,
just as he or she would any other topic. For example, if a substance abuser wants
to stop getting drunk because doing so “goes against my values as a parent—I’m
supposed to be with my family on the weekends, and take my children to tem-
ple,” the social worker should help the client reflect on this value as a basis for
deciding whether and how to change the drinking behavior. On the other hand,
the social worker should not raise the possibility of spirituality as a motivating
force; this must be left to the client.

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Mobile User

ATTENTION TO SOCIAL JUST ICE ISSUES

Motivational interviewing and enhancement works primarily at the individual
level of change, but can address a broad range of client concerns. Social workers
should always be alert to macro-issues that might be noted by clients as factors
affecting their motivation and self-efficacy. At the same time, motivational inter-
viewing is respectful of people’s ability to make choices that are right for them.
Clients are often ambivalent about initiating change efforts that involve con-
fronting other people or systems they perceive to be more powerful than they
are. For example, an employee may be considering bringing charges of discrimi-
natory practice against an employer, but fear that such an effort will result in
failure or long-term retribution. The social worker can certainly use motivational
interviewing questions to help the client resolve this dilemma. Of course, it must
be left to the client to decide whether to proceed and, if so, how a change plan
can be developed. Methods of change that might involve fighting against an
oppressive force are not suggested to the client in a predetermined way. The social
worker assumes that there may be some good reasons for the client to maintain the
problem behavior and instills confidence in the client, if change is warranted, to
design a plan that incorporates his or her best interests and strengths.

CASE ILLUSTRAT IONS

Several examples of motivational enhancement therapy were presented earlier. In
this section, two examples of motivational interviewing are presented. One fea-
tures a client with a substance abuse problem, and the other describes an adoles-
cent girl with behavior problems.

The Man at the Medical Shelter

Philippe was a 50-year-old Argentinean male recently admitted to a Virginia
hospital due to liver failure from a history of alcohol and drug abuse. He was
hospitalized shortly after discharging himself from a shelter against medical
advice. Philippe no longer had a place to live because he had lost his apartment
six months previously. The client, a high school graduate, had lived in the
United States for 30 years and was an American citizen. His family of origin lived
in New York State. Philippe’s wife was deceased, and his two children, who
lived in Tennessee, were not on speaking terms with him.

The medical shelter would not allow Philippe to return. The social worker’s
role now was to help him find a place to stay where staff would be available to
take care of his medical needs. Rather than being focused on this primary
agenda, though, Lyndon, a 35-year-old, first-generation Spanish-American
male, began the interview by inviting the client to share his general concerns.
After introducing himself, Lyndon said, “My job is to talk with you about how
you’re doing right now, and to help you figure out where you can go after

268 C H A P T E R 11

you’re discharged, so that you can continue to recover. You’ve been through
surgery, and that takes some time and rest to get over. But that might not be
what’s on your mind right now, so we can also talk about whatever concerns
you most at the moment.” This opening statement initiated a collaborative pro-
cess in which the client had an equal say in what was discussed.

The client’s priority was his physical pain. Philippe alluded to the fact that he
had a “nasty” scar, which he showed to the social worker. Lyndon provided
simple reflections about the way Philippe felt physically, to which the client re-
sponded by sharing details about his emotional state: “I just can’t believe I let my
life get like this. I have no one, and I have nothing.” Lyndon responded with
another simple reflection, “You’re feeling lonely and sad because of all you have
lost from alcohol,” which encouraged Philippe to explore the losses that he had
sustained due to alcohol use. Among other statements, Philippe said he had no
one to stay with, and his family wanted him “to get better first” before he went
to them. Lyndon responded with yet another simple reflection: “You seem to
understand why they’re taking this position.” With this, Philippe centered his
thoughts on the damage that he had caused to his family relationships. He said,
“Where I come from, family is everything.”

The social worker followed with an exploration of the discrepancy between
Philippe’s values—the importance of family—and his alcohol use: “Family is
everything to you, and you have alienated a lot of your family members with
your alcohol use.” Lyndon discovered in the ensuing discussion that Philippe
was feeling particularly alone since he made the choice six months ago not to
associate any longer with people who used drugs. Lyndon complimented him
on his ability to take such a bold step to beat his addiction.

At this point, Philippe said he “wasn’t doing so good,” admitting that he had
left the shelter to “have a beer.” The rule at the shelter was abstinence from
alcohol and drugs; as a result, he had not been allowed to return. His physical
condition had deteriorated, and he had returned to the emergency room. The
social worker reflected, “You have taken some steps to beat the alcohol—you
have stopped hanging around some people you used with—and you found it
hard to resist drinking when you were at the shelter.” Philippe said he had
done a good job in stopping his drug use, but alcohol was still hard for him.
Lyndon asked what might happen if he continued on the path he was on. He
said he would probably die soon, which he adamantly did not want to do before
he could reconcile with his family. Philippe concluded he would have to make a
change to get this to happen.

The social worker mentioned another medical shelter in the city, but the
rules were even stricter against substance use than the first shelter he had stayed
in. Philippe said he thought he “could do it this time.” Lyndon asked, “What
makes you think you can make a change right now?” Philippe responded that
he didn’t want to continue the way he had—he couldn’t keep cycling in and out
of the hospital; otherwise, he would never get better.

Lyndon asked Philippe if he had thought about a plan. The client said that
he would do what he had previously done to resist drugs; he would stay away
from people who drank and places that sold alcohol. He said praying helped,

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although he didn’t like AA—he had been made to go before, and preferred his
own Catholic God, rather than a “higher power.” He admitted he wasn’t sure
how long he could go without drinking, and that after he was better physically,
he might think about treatment. He had been mandated to do so previously; but
this time, he would go because he wanted to.

To summarize the social worker’s method of interviewing, Lyndon used a
collaborative approach, reflecting Philippe’s statements and getting him to argue
for his own change, rather than confronting him about his alcohol use and telling
him what he must do. This allowed Philippe to open up slowly rather than re-
maining guarded and defensive. As he revealed more, the social worker elabo-
rated on the discrepancy between his desire to reconcile with his family and the
impossibility of doing this if he was still drinking. Lyndon worked toward build-
ing Philippe’s self-efficacy by complimenting him on his ability to quit drugs and
stay away from people who used. Rather than lecturing him about how to stay
sober, Lyndon asked him for his own plan. He allowed Philippe to take some
referrals for treatment in the future, knowing that it would be the client’s choice
whether to follow through with them.

The School Brawler

This intervention took place in a school setting, where the social worker saw
a 12-year-old African-American girl named Bettina, who had been in trouble
for frequent fighting. Following a few minutes of introduction, Robyn, a
26-year-old Caucasian female, began by setting a brief agenda: “Bettina, you’ve
been sent to me to talk about some problems at school and what we can do
about those, but we can also talk about whatever else you think is important.”
In this way, Robyn directed the focus of the meeting, but allowed for flexibility
so that any or all of the client’s concerns could be given attention. Still, Bettina
chose to focus on the presenting problem.

The social worker listened with empathy as she tried to elicit statements
about change from the client. She asked Bettina, “What are some of the good
things about fighting?” and “What are some of the not-so-good things about
fighting?” Like many clients, Bettina was surprised at the former line of question-
ing. Robyn explained, “There must be some good things about it, otherwise
you wouldn’t keep doing it, right?”

As Bettina responded, the social worker probed for more information and
selectively reinforced the client’s statements about change. When reflecting on
why she liked to fight, Bettina said that it made her feel proud when she won.
It also ensured that her peers “respected” her. On the other hand, Bettina said
she didn’t want to get expelled from school or end up in juvenile hall. She was
also afraid of hurting people. For instance, she found herself pounding another
girl’s head against the sidewalk during one fight, and she didn’t want to do that
kind of thing. Rather than just allowing Bettina to list these reasons for not
fighting, Robyn explored with her the disadvantages of the status quo. For in-
stance, the social worker asked, “What worries you about getting expelled for
fighting? How will getting expelled for fighting stop you from doing what you

270 C H A P T E R 11

want in life?” Thus the social worker helped the client talk herself into changing
rather than using direct persuasion.

The social worker avoided challenging the client’s statements because direct
confrontation was likely to escalate resistance rather than reduce it. Any resistance
to change was sidestepped. For instance, when Bettina said, “If I don’t fight, I’ll get
disrespected,” the social worker used the technique of amplified reflection: “So the
only way to get people’s respect is to fight them.” Amplified reflection often results
in verbal backpedaling from the client, who attempts to soften the extreme posi-
tion reflected by the social worker. In this case, Bettina said, “No, sometimes I just
give them a look. I can give some pretty mean looks.”

As part of her motivational interviewing, Robyn picked up on what the cli-
ent held as important in her life. She then worked to enlarge the discrepancy
between the client’s values and her present problem behavior. Bettina valued
her friendships at the school, but her fighting was endangering those relation-
ships: “So on one hand, those friends are important to you, and on the other,
if you get expelled for fighting and get transferred to another school, you won’t
be able to see your friends like you do now.”

As the conversation continued, the social worker focused on instilling in
Bettina some optimism about change. For instance, when Robyn asked the
question, “What makes you think that if you decided to make a change, you
could do it?” Bettina said, “I can do it if I set my mind to it. I only wanted to
cut my fighting down a little bit before. But now I want it to stop.” Robyn
asked, “What personal strengths do you have that will help you succeed?” The
client answered, “I can talk. I know how to talk to people so they don’t mess
with me. I just lay them straight. No need to fight most of the time.” Robyn
further inquired about who could help Bettina make these changes. She identi-
fied her friends as a support system: “I can say to them, ‘you-all, talk me down,
because I can’t fight no more. I don’t want to get kicked out of school.’ So
when I’m in an argument, they’d probably say something like, ‘forget her—
she ain’t worth it.’ And they’d be right—she ain’t.”

The social worker assessed the client’s commitment to change, as well as her
confidence that she could make changes. To begin, Robyn used the commit-
ment ruler technique: “If there was a scale to measure your commitment, and
it went from 0 to 10, with 10 being totally committed—nothing could make
you fight—where would you say you are right now?” Bettina identified herself
at a “7,” and Robyn asked her to account for this value. Bettina said, “One more
fight, and I’m kicked out of school. They already told me that. They might
mean it this time.”

The social worker then asked Bettina to rate herself on a similar ruler in-
volving her confidence that she could change. Bettina gave herself a “5” ranking,
and said, “I already changed some. Like last year I got in trouble every day, but
this year I don’t get in trouble very often. I try to stay away from people I got a
problem with. Before, I wouldn’t think about it, and I would just fight people
and not think about what would happen. But now I think about it.”

Because Bettina’s confidence that she could change was lower than her
commitment, Robyn turned to a technique that would enhance the client’s

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self-efficacy, asking evocative questions: “How might you go about continuing
to make change? What would be a good first step?” Bettina answered that she
would continue to avoid people who bother her. She would also talk to her
friends about helping her “calm down.”

When asked about possible obstacles, Bettina admitted that it could be diffi-
cult if someone “got up in her face.” The social worker and client began brain-
storming about how to handle this obstacle. With some prompting and
suggestions, Bettina produced three options: making threats but not necessarily
following through, staying in public settings so that other people could intervene,
and telling the instigator, over and over again if need be, “You’re not worth it.”

In motivational interviewing, when the social worker offers information and
advice, it is phrased tentatively (“If it’s okay, I’m going to make a suggestion.
I don’t know if it will work for you or not. It’s worked for others who have
struggled with the same things you have.”). The social worker avoids struggling
with the client about what she must do. Instead, the social worker strategically
applies techniques so that the client’s motivation to change is bolstered. In this
way, during the course of a single session, Bettina decided that she was ready to
commit to a change plan. She met with Robyn for several more weeks, report-
ing on her progress in staying out of fights and getting feedback that helped to
maintain her positive direction.

EV IDENCE OF EFFECT IVENESS

Empirical research has been conducted on motivational interviewing and en-
hancement for the past 25 years, with promising but mixed results. Recently,
Smedslund et al. (2011) conducted a systematic review of randomized, controlled
trials of the effectiveness of motivational interviewing and enhancement therapy
with persons dependent on or abusing substances. They focused on studies that
included people with alcohol or drug problems, and randomly divided them into
an MI group or a control group that either received no treatment or some other
treatment. A total of 59 studies with 13,342 participants were included in the
review. The featured outcomes in these studies included extent of substance
abuse, retention in treatment, motivation for change, and repeat convictions.
Compared to no-treatment controls, MI showed a significant effect on substance
use, which was strongest at post-intervention and weaker at short- and medium-
term follow-up. There were no significant differences between MI and treat-
ment as usual for either post-intervention or follow-up. Overall, the results
show that people who have received MI have reduced their use of substances
more than people who have not received any treatment. However, it seems
that other active treatments can be as effective as motivational interviewing.
There was not enough data to conclude about the effects of MI on retention
in treatment, readiness to change, or repeat convictions.

Other studies have shown more positive findings. Dunn, Deroo, and Rivara
(2001) reviewed 29 studies that focused mainly on substance-abuse issues, but

272 C H A P T E R 11

also included problems related to smoking, HIV risk reduction, and diet and
exercise. They found generally moderate-to-large effects for the intervention’s
reduction of both substance abuse and substance dependence, with maintenance
of effects over time. MI was also found to promote client engagement in more
intensive substance abuse programs. Although studies to date have largely been
conducted on adults, adolescent substance use has also shown positive results
from motivational interviewing (Burke, Arkowitz, & Dunn, 2002). Some of
these effects are modest, however, and not necessarily superior to alternative
interventions, as found in one major review (Gates, McCambridge, Smith, &
Foxcroft, 2006). There is some indication that motivation intervention is most
effective with heavy substance abusers in moderating their substance use
(McCambridge & Strang, 2004).

In the Project MATCH Research Group (PMRG) study (1997, 1998), 952
individuals with alcohol problems from outpatient clinics and 774 from aftercare
treatment were provided with 12-step facilitation (12 sessions), cognitive/
behavioral coping skills therapy (12 sessions), or motivational enhancement ther-
apy (4 sessions). MET fared as well as the other two interventions that were three
times as long, both at post-test and three years later. Motivational interviewing has
also shown to be beneficial in reducing substance abuse among college students
(Michael, Curtin, Kirkley, Jones, & Harris, 2006); persons with dual (mental
health/substance abuse) diagnoses (Martino, Carroll, Nich, & Rounsavillle, 2006);
homeless adolescents (Peterson, Baer, Wells, Ginzler, & Garrett, 2006); regular am-
phetamine users (Baker et al., 2005); psychiatric inpatients (Santa Ana, Wulfert, &
Nietert, 2007); and gay men (Morgenstern et al., 2007). It must be noted again,
however, that in a majority of these studies, the intervention was not superior to
alternative interventions.

In addition to problems related to substance abuse and drug addiction, MI
has been found effective for health-related behaviors related to diabetes and
hypertension and eating disorders such as binge eating (Dunn, Neighbors, &
Larimer, 2006; Treasure et al., 1999). Only mixed findings, however, have
been reported with the use of motivational interviewing for quitting cigarette
smoking (Persson & Hjalmarson, 2006; Steinberg, Ziedoms, Krejci, & Brandon,
2004); increasing physical exercise (Jackson, Asimakopoulou, & Scammel, 2007;
Butterworth, Linden, McClay, & Leo, 2006; Brodie, 2005); and reducing HIV
risk behaviors (Burke, Arkowitz, & Dunn, 2002).

These reviews indicate that motivational interviewing and enhancement can
be helpful for a number of types of problems that social workers encounter, but
more needs to be learned regarding the scope of its utility.

CR IT I C ISMS OF MOTIVATIONAL INTERVIEWING

AND ENHANCEMENT THERAPY

Motivational interviewing and enhancement focuses primarily on one aspect of
the individual: motivation. It does not take into account other important aspects

M O T I V A T I O N A L I N T E R V I E W I N G A N D E N H A N C E M E N T T H E R A P Y 273

of client functioning, such as psychological development, intelligence, and skill
levels. Neither does it encourage proactive attendance to the influence of larger
social influences, such as discrimination and oppression, that may contribute to
problem situations. Motivational interviewing and enhancement are practical
approaches to intervention, but lack a clear theoretical basis that might generate
broader thinking about its implementation.

Two other criticisms of motivational interviewing are worth mentioning.
First, by selectively reinforcing reasons that the client may want to change,
practitioners may allow some possibly powerful influences for the client’s hold-
ing onto the problem behavior to go unchallenged. For instance, if a client
mentions that drinking improves her ability to manage social situations, practi-
tioners might raise ideas about how she could develop skills to improve her
ability to manage “trigger” situations. A social worker might also be more
effective if he or she spent time assessing for defense mechanisms and cognitive
distortions. A final criticism is that motivational interviewing and enhancement
is manipulative of clients. Though client choice is respected, the social worker
may favor one alternative (not drinking versus drinking) to an extent that his
or her questioning may be biased to help that result come about. This issue
may or may not be as controversial in the area of substance dependence,
where a client’s basic survival may be at stake, but in other problem areas
(for example, some types of relationship conflict), client self-determination
may be compromised. Keep in mind that motivational interviewing is openly
described as “directive” by its founders.

SUMMARY

Motivational interviewing and enhancement therapies are directive, client-
centered interventions that enhance motivation for change by helping clients to
clarify and resolve their ambivalence about behavior change associated with a
presenting problem. The approach has proven useful with many clients who
demonstrate little outward motivation to change behaviors identified by them-
selves or by others as problematic. Social workers may already be familiar with
some of the principles of motivational interviewing and enhancement, such as
empathy, the emphasis on collaboration and strengths, beginning where the cli-
ent is, and self-determination. The particular strategies associated with the tech-
nique are worth learning because social workers are often engaged with clients
who are reluctant to change, especially those who have been mandated to seek
assistance from social service agencies. Further, the use of motivational interview-
ing techniques does not preclude the social worker from using other intervention
methods as well. That is, it may be used as a stand-alone treatment, but also as a
way to prepare clients for other intervention approaches (including motivational
enhancement therapies but also strategies from other theoretical approaches)
once the client’s motivation is galvanized.

274 C H A P T E R 11

TOPICS FOR DISCUSSION

1. Share some difficult decisions you have made in life about which you
needed to resolve a great deal of ambivalence. Discuss the factors that
helped you make a decision, and how you moved through the
stages of change (understanding that you were not aware of the model
at the time).

2. What other strategies do you use, or know about, that can help clients de-
velop motivation to confront some problem issue other than those discussed
in this chapter? How successful do they seem to be?

3. Motivational interviewing discourages the social worker’s confrontation of
clients. In what situations do you now confront clients? How is it appro-
priate in those situations? In your opinion, does motivational interviewing
and enhancement offer a realistic alternative to confrontation?

4. What are three differences between motivational interviewing and motiva-
tional enhancement therapy? What are three similarities?

5. Discuss some macro-issues or social justice issues, such as perceived age, gender,
or class discrimination, that clients may lack the motivation to address. How can
motivational interviewing be helpful for resolving their ambivalence?

IDEAS FOR CLASS ROLE -PLAYS

1. Identify several types of clients or practice situations that may be appropriate
for motivational interviewing. Conduct a series of role-plays in which stu-
dents focus on each of the four major intervention strategies (elicit self-
motivational statements, handle “resistance,” promote decisional balance,
and support self-efficacy). Use the questions and comments presented in this
chapter when implementing the strategies. After the role-plays, discuss what
was helpful and what was difficult.

2. Design a motivational enhancement therapy program for a type of problem
for which it might be suitable. Provide a rationale for why the program
might be suitable for addressing the problem.

APPENDIX: Motivational Interviewing and Enhancement Outline

Focus Enhancing clients’ motivation to change by exploring and
resolving ambivalence about change, and supporting action
plans for change.

Major Proponents Allen, Carroll, Ingersoll, Killick, Metcalf, Miller, Moyers,
Rollnick, Treasure, Wagner, Ward, Corcoran

M O T I V A T I O N A L I N T E R V I E W I N G A N D E N H A N C E M E N T T H E R A P Y 275

Origins and
Social Context

Changing philosophy of substance abuse intervention

Person-centered theory

Cognitive dissonance theory

Trans-theoretical stages of change model

Nature of the
Individual

None specified, except ambivalence is a normal and ubiqui-
tous human condition

Major Concepts Motivation

All people are motivated to do some things

Appropriate motivation to change cannot be imposed
from outside

Motivation to change is often impeded by ambivalence

Ambivalence

Characterizes most human change processes

Must be articulated and resolved by the client

Resolution of ambivalence is a product of interpersonal
interaction

Developmental
Concepts

None specified

Nature of Problems Not specified, but problem perspectives are consistent with
the cognitive, behavioral, and solution-focused theories

Nature of Change Trans-theoretical stages of change model (precontempla-
tion, contemplation, preparation, action, maintenance,
relapse)

Goals of Intervention To resolve a client’s ambivalence so that motivation to
work toward certain goals is enhanced

Nature of
Worker/Client
Relationship

Collaboration

Empathy

Reflective listening

Worker elicits self-motivational statements

Reactance is the practitioner’s problem, not the client’s

Intervention
Principles

Explore client problem behaviors

Provide education

Reinforce client statements about wanting to change

Reinforce intention to change and optimism about change

Affirm client’s ability to change

APPENDIX: Motivational Interviewing and Enhancement Outline
(Continued)

276 C H A P T E R 11

Elicit self-motivational statements

Handle reactance

Reflective comments and questions (simple, amplified,
double-sided)

“Beyond” reflective comments and questions (shifting fo-
cus, agreement with a twist, reframing, decisional balanc-
ing, clarifying free choice)

Support self-efficacy and develop a change plan (evocative
questions, ruler assessment, review past successes, discuss
strengths and supports, ask about hypothetical change,
brainstorm)

Assessment
Questions

Do you think this might be a problem? Are there ways you
or other people have been harmed by this behavior?

What worries you about your behavior? What can you
imagine happening if you don’t make a change?

How much do you know about what can happen if you
continue with this behavior, even if you don’t see this hap-
pening to you?

What are reasons you see for making a change? What
would you like your life to be like five years from now?

What makes you think that if you decided to change, you
could do it?

What are the best results you could imagine if you make a
change?

APPENDIX: Motivational Interviewing and Enhancement Outline
(Continued)

M O T I V A T I O N A L I N T E R V I E W I N G A N D E N H A N C E M E N T T H E R A P Y 277

Narrative Theory

Much madness is divinest sense
To a discerning eye;

Much sense the starkest madness
’Tis the majority

In this, as all, prevails.*

N arrative theory is the newest approach to direct practice presented in this
book. Its major premise is that all people are engaged in an ongoing process

of constructing a life story, or personal narrative, that determines their understand-
ing of themselves and their position in the world (Payne, 2005; Abels & Abels,
2002; White & Epston, 1990). It holds that human development is inherently
fluid, and that there are no developmental “milestones” that people should expe-
rience to maximize their chances for a satisfying life. Instead it is the words we
use, and the stories we learn to tell about ourselves and others, that create our
psychological and social realities. These life narratives are co-constructed with
the narratives of significant other people in one’s family, community, and cul-
ture. Narrative theory is the most social theory presented in this book, as it gives
primary attention to the effects of culture on one’s narratives.

According to narrative theory, all personal experience is fundamentally am-
biguous, and thus we must arrange our lives into stories to give them coherence
and meaning. These stories do not merely reflect our lives—they shape them. As
we develop a dominant “story line” (and self-concept), our new experiences are
filtered in or out, depending on whether they are consistent with the dominant
life narrative. Many problems in living that we experience are related to life nar-
ratives that exclude certain possibilities for goal-oriented future action.

* Dickinson, E. (1927). The Pamphlet Poets. New York: Simon and Schuster.

278
Copyright 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights,

An ultimate value of narrative practice is empowering clients, or helping
them gain greater control over their lives and destinies. Narrative theory is un-
ique in its conceptualization of problems as (at least in part) by-products of cul-
tural practices that are oppressive to the development of functional life
narratives. In this sense, it is clearly a “therapy of advocacy” and is highly con-
sistent with social work’s emphasis on social justice. The practitioner actually
raises the possibility of oppressive cultural practices as part of the intervention.
While some argue that narrative interventions may not be well suited for client
problems related to basic needs such as food, shelter, safety, and physical health,
they are certainly suitable for issues related to self-concept, interpersonal rela-
tionships, and personal growth.

Narrative therapy is a process of understanding and deconstructing a client’s
stories through listening and reflection, and then constructing alternative life
stories. The client tells and explores his or her story along with the practitioner,
formulates a preferred reality, and develops an alternate life story supportive of
that reality. The interventions are generally far less structured than in most other
practice approaches.

ORIGI NS AND SOCI AL CONTEXT

Narrative theory integrates a variety of philosophical and sociological theories
into a perspective for social work practice. Some of its ideas are drawn from
the traditions of existentialism and symbolic interactionism. It also incorporates ideas
from multiculturalism (see Chapter 2). Most immediately, narrative theory has
emerged from the broad social theories of postmodernism and social constructivism.
These represent different approaches to the understanding of human behavior
and the nature of change than what we have considered thus far. Narrative the-
ory is also based on some traditional theories of social work practice, as we shall
see in the section on intervention later in this chapter.

Existentialism

Existentialism is not a coherent philosophical system, but rather a term that de-
scribes a refusal to subscribe to any particular system of thought that attempts to
summarize human experience (Cusinato, 2012). The early existential writers
influenced developments in art, music, and psychology throughout the 20th
century. Postmodernism incorporates much of what is central to existential
thinking.

Several themes characterize existential thought. One is the absolute unique-
ness of the individual (Kierkegaard, 1954). People discover their uniqueness in
the ways they relate to their subjective experiences of life, and they should be

N A R R A T I V E T H E OR Y 279

careful about identifying too closely with other persons and groups. Concepts
about human nature that postulate connections between individuals and larger
social systems (found in almost every chapter of this book) tend to delude people
into accepting stereotypes about themselves that serve to limit their unique po-
tentials. The essence of one’s existence can in fact never be fully apprehended by
another, because perception is internal to the perceiver rather than representing
an “objective” state of affairs. By extension, efforts to make generalizations about
people (which social scientists often do) reflect the subjective belief systems of
the architects of those statements. To the existentialist, they are dehumanizing.

Among existential thinkers, the possibility of choice is central to human na-
ture (Sartre, 1956). Choice is ubiquitous: All of a person’s actions imply choices.
We are always free to make choices, and there are no truly “rational” grounds
for choice, because any criteria that we use to make choices are themselves cho-
sen. People do tend to adopt criteria for making choices in their lives, just as the
author has made choices in this book about which theories to include and how
to evaluate them. Existentialist thinkers want us to understand that, though we
can choose to align ourselves with other people and ideas, there is nothing nec-
essary about those choices.

Whatever one’s view about the nature of individuals in the context of the
society, existential thinkers remind us that clients’ views of themselves and their
problems may be contaminated by an acceptance of external standards that are
arbitrary. The task of the existential social worker is to apprehend the essence
of each client’s life, and help him or her to create or discover new purposes for
living that may be more suitable to the client’s unique nature.

Postmodernism

Postmodernism is not a uniform social or philosophical theory either, but repre-
sents various developments in the social sciences, the arts, and architecture
(Keddell, 2009). It provides new ways of theorizing about the social world and
the people within it. It is a “top-down” perspective that analyzes how prevailing
ideologies affect people’s perceptions of their worlds. Postmodernism takes the
position that it is not possible to find broad, rational solutions to society’s pro-
blems. This is different from many other social theories that advance themes of
universalism and systematic problem solving. Postmodernists assert, following
the ideas of Foucault (1966), that any generalizations about people and societies
serve to reinforce positions of power among groups rather than represent objec-
tive truth. The prevailing ways in which a society is “understood” or explained
give some groups privilege at the expense of others.

For these reasons, postmodernists reject the idea of a “grand narrative.” They
are instead attracted to the perspectives of individuals and small groups, particu-
larly those that have been marginalized by privileged members of society. These
perspectives are considered to be valid as those of other social groups. Post-
modernism is clearly a manner of thinking that focuses on the “small.” It is
sometimes criticized by social activists for ignoring social problems and de-
emphasizing collective action (Atherton & Bolland, 2002).

280 C H A P T E R 12

The following aspects of postmodernism have influenced the development
of narrative theory (Brown & Augusta-Scott, 2007; Polkinghorne, 2004):

“Knowledge” represents beliefs that are rooted in social contexts (time,
place, and culture) and influence what people understand, see, and say.
Knowledge is not objective, but reflects the values of certain people at a
certain place in time.

Discourse (a conversation about ideas) tends to be based on prevailing
ideologies. There are many possible discourses; some ideologies are dominant
and others are subjugated. Some social workers argue, for example, that the
fields of psychiatry and medicine dominate the public discourse about
mental health and illness, and subjugate the alternative perspectives of other
professional and social groups who may strive to work with people more
holistically.

Knowledge is power, and those who control the nature of knowledge
preserve their situations of influence in a culture. For example, as men
occupy most positions of political power, their values tend to be prioritized
and perpetuated.

Personal narratives are reflections of a culture as much as of the lives of
individuals.

With its emphasis on individuals and small groups, postmodernism
encourages social workers to help clients understand how their narratives, or
beliefs about themselves, may be rooted in societal oppression.

Postmodernism is criticized by some theorists as lacking any coherent agenda
that might build consensus in a society around such issues as transcendent values
and shared priorities. In fact, its emphasis on the relativism of knowledge is anti-
thetical to the social work profession’s drive to establish generalizations in re-
search (Wakefield, 1995). Many practicing social workers may take issue with
postmodernism’s rejection of the possibility of people sharing common experi-
ences related to psychosocial development.

Social Constructivism

The theory of social constructivism maintains that there is no objective reality
that people might all apprehend and agree on (Rodwell, 1998). In comparison
to postmodernism, this is a “bottom-up” perspective that considers how indivi-
duals and groups “create” their social worlds. All of us experience an objective
physical reality (our bodies and the material world), but what that reality means to
us (including our perspectives on relationships, social situations, and ourselves) is
a mental creation. We apply our beliefs acquired from prior experiences to new
input received from the environment. This perspective is largely consistent with
cognitive theory (discussed in Chapter 8), although social constructivism incor-
porates fewer assumptions about human nature.

All of us are born with biological and temperamental qualities that influence
our abilities to integrate sensory perceptions, but we become active participants

N A R R A T I V E T H E OR Y 281

in the process of making sense of the world early in life. It is the interaction of
what we bring to social situations and what those situations present that produces
our evolving view of “reality.” These subjective processes shape our sense of self,
competence, and contentment. Whereas satisfactory interpersonal functioning
depends on maintaining many patterns of shared meaning with others, it is often
useful for us (and our clients) to remember that these perceptions do not reflect
absolute truths.

A major implication of social constructivism is that one’s presumed knowl-
edge about the self and others is wholly subjective. Social workers cannot make
generalizable assertions about the nature of the self and an “appropriate” social
world. In contrast, psychodynamic theories assume the existence of common
psychosexual or psychosocial stages, and social workers use that knowledge to
assess the “normalcy” of their clients’ functioning. Cognitive theorists maintain
that there are stages of cognitive and moral development that are relevant to
assessment and intervention. In social constructivism, the notion of a common
human nature is de-emphasized. Of course, these implications are the source of
some critiques of social constructivism (Nichols, 2009). With this perspective,
narrative practitioners do not rely on developmental stages as significant to prob-
lem development or intervention. Not relying on any such umversals may be
very difficult, however, for social workers who are educated to see all people as
sharing common experiences, such as identifiable life stages.

Michael White and David Epston

The originators of narrative therapy for direct practice are Michael White and
David Epston, who lived in Australia and New Zealand, respectively. They
began collaborating in the 1980s. Their best-known book is Narrative Means to
Therapeutic Ends, published in 1990. Michael White worked as an electrical and
mechanical draftsman in his early adulthood, but he eventually became disen-
chanted with that career, and with systems thinking in general. He became a
social worker in 1967. Early in his human-service career, he became frustrated
with traditional modes of intervention that he believed to be ineffective and de-
humanizing. White was drawn to the work of sociologists Michel Foucault and
Erving Goffman and the anthropologist (and communications theorist) Gregory
Bateson. He developed an interest in how people come to understand their
worlds, and his major ideas for narrative therapy emerged from this theme.
White went on to serve as co-director of a clinic in South Australia until his
death in 2008.

David Epston was initially a family therapist who, like White, had long-
standing interests in anthropology (and its concept of the narrative metaphor)
and literature. Epston was an excellent storyteller and is also known for the in-
novative narrative techniques of letter writing (which he felt had more lasting in-
fluence than conversations), resource collections (letters and tapes) that could be
passed from one client to another, and the development of supportive communities
for persons who are rewriting their personal narratives. Epston now serves as
co-director of a family therapy center in New Zealand.

282 C H A P T E R 12

MAJOR CONCEPTS

Narrative theory is premised on the idea that people’s lives and relationships are
shaped by their life stories and the ways of life they develop based on those stor-
ies (Payne, 2005). Their stories are always unique, but are shared to some degree
with others in their communities, and they reflect the value systems of those
communities. Narrative theory ignores the concept of systems in its prioritizing
of the life story told from the perspective of the individual. Each person’s notion of
identity, or the “self,” is inherently fluid. That is, identity is how we define
ourselves at particular points in time. Who we are is a matter of ongoing contra-
diction, change, and struggle; a dynamic process of “being” rather than some-
thing continuous. This is a very different position from many other theories in
this book that assume a changeable but more or less cohesive and continuous
“self.” From the narrative perspective, all people are capable of developing
new, empowering stories that include new senses of the self. There is variety in
how practitioners operationalize narrative theory. What follows is an effort to
summarize its major ideas.

The Personal Narrative

The concept of the personal narrative, so central to this theory, was described
earlier in this chapter. To elaborate, any personal narrative includes a process of
selective perception. Some story lines are dominant, establishing primary themes
in the person’s mind, and interpretations of experience that do not fit the domi-
nant story line may be suppressed. Thus, a narrative is always biased and selective.
The case of Martin provides an example of this.

Martin was a 30-year-old, single, white male with a good job in a furniture
company sales department. He was referred to the social worker by his proba-
tion officer to get help with controlling his violent temper. Martin had recently
been convicted of assault after fighting with and seriously injuring a neighbor at
a holiday barbecue. Martin had been arrested on several other occasions for
disturbing the peace and fighting in bars. A former girlfriend once invoked a
restraining order against him for alleged abusive behavior. Martin admitted that
he was quick to become upset and resort to fighting rather than using other
methods of working out conflicts. He actually resisted any observations from
others that he could be “soft” and “emotional” at times. Martin was an effec-
tive salesman, but his supervisors had told him that his presentation was some-
times too aggressive. They had advised him to learn to relax more with
customers.

Martin met with the social worker (Terrence, a 30-year-old Caucasian male)
10 times over the course of one year. The social worker was interested in
Martin telling the story of his life and where he saw himself at present with
regard to his personal goals. Terrence asked Martin how satisfied he was with
himself. The social worker could readily see that Martin’s identity was tied up
with images of the strong, athletic, dominant male. These seemed to have been
learned from and patterned after his father (an assembly-line worker) and older

N A R R A T I V E T H E OR Y 283

brothers, all of whom had similar perspectives on life. Terrence engaged Martin
in a process of analyzing his assumptions about himself and the role of men in
families and society. Martin admitted that he was not altogether comfortable
with his persona, but that he had always ignored his other inclinations because
he thought they would not be acceptable among his family and friends.

Martin’s example demonstrates how cultural values influence one’s per-
sonal narrative, and how they can contribute to problem behavior. As another
example, women in American society from certain socioeconomic classes were
once—and often still are—expected to be submissive to men. This cultural
norm contributes to the depression of many women (Kelley, 1996). More gen-
erally, people with low self-esteem may maintain that characteristic because
their thoughts and conversations feature themes of self-degradation (perhaps
with the language of “mental illness”). They continue to unwittingly construct
life narratives that portray themselves as having certain limitations. These stories
tend to be self-perpetuating because of their habits of language, and also be-
cause of the influence of cultural values that may impede alternative modes of
thinking.

Deconstruction

Another central concept in narrative theory is deconstruction, a term derived from
postmodernism. It refers to the social worker and client’s analysis of the client’s
claims to knowledge and understanding in order to discover the underlying as-
sumptions that are manifested in surface complaints. It is similar to the ego psy-
chology concept of insight, except that it refers more broadly to the client’s
awareness of social conditions and power relationships that contribute to his or
her personal assumptions about knowledge. Deconstruction involves exploring
ingrained cultural assumptions that contribute to the occurrence of a problem.
It is a process of uncovering and challenging assumptions about the way the
world should be, and thereby opening up new possibilities for how it can be.
This concept will be elaborated on later in this chapter.

Reconstruction, or Reauthoring

In essence, reauthoring is the term that summarizes the work of narrative interven-
tion. Sometimes called reconstruction, it refers to the process by which the client,
with the assistance of the social worker, develops a new personal narrative that is
consistent with his or her personal goals. The process is based on the client’s
enhanced awareness of, and liberation from, limiting cultural influences, explora-
tion of unique outcomes (aspects of one’s narrative that are not consistent with
the dominant problem-saturated story), exploration of “sparkling moments” (the
awareness of new personal truths that highlight strengths), and the consideration
of possibilities for a new story line. It is important to note that a reauthored per-
sonal narrative affects not only the client’s present and future sense of identity,
but also the client’s past, as events from the past are now seen from a new and
different perspective.

284 C H A P T E R 12

Celebrating/Connecting

The process of celebrating/connecting refers to the client’s reconnecting with others
in his or her familiar social world, and perhaps recruiting others in the celebra-
tion and acknowledgment of the new identity (Epston & White, 1995). To sup-
port the reconstructed life story, the social worker and client consider ways to
celebrate and substantiate the client’s new narrative. Three strategies for doing
this are described later in this chapter.

THE NATURE OF PROBLEMS AND CHANGE

From the perspective of narrative theory, problems that bring clients to seek pro-
fessional help are conditions of emotional or material suffering that result from
personal narratives saturated with self-denigrating beliefs. Through a process of
refocusing, social workers can help clients to construct different life narratives,
or stories, that portray them in a different light. Clients can formulate alternative
past and future stories, and devise unique outcomes for themselves. In this pro-
cess, the practitioner places great emphasis on the client’s use of language. He or
she is always alert to the elements of experience that a client chooses to express,
and the language or meaning that is given to that experience. It is important to
emphasize that narrative practitioners do not help clients ignore or wish away
problems by creating new “fictions.” Many problems that clients identify are
concrete and must be dealt with by concrete action. A family with insufficient
money to support itself must be helped to regain necessary resources. But life
narratives always influence the experiences that clients label as challenges, and
how they address them.

As a final point on this issue, the practitioner makes sure that the client un-
derstands that he or she is not the problem—the problem is the problem. This
refers to the process of externalization, noted earlier, which helps the client sepa-
rate his or her “core” self (although that concept is admittedly ambiguous) from
the presenting situation. For example, a social worker might discourage a client
from thinking of herself as an “insecure person,” and instead may refer to her as
being “pursued by insecurity.”

Returning to Martin, the client soon admitted that he was not satisfied
with himself. He was often getting into trouble and losing friends. The social
worker asked Martin to examine his lifelong relationship with anger—where it
had come from and why it was persistent in his day-to-day life. Martin even-
tually realized that anger was not a necessary component of his life, and he
could develop an alternative lifestyle and attend to other aspects of himself
and his world. Martin was a reflective man, and with Terrence’s encourage-
ment, he could see that he might develop a new identity from which to
make other choices and consider broader possibilities for his future. Martin
saw that he was locked into a rigid but not a necessary pattern of living. He
could reauthor his life narrative.

N A R R A T I V E T H E OR Y 285

In summary, the goals of narrative therapy are not so much to solve pro-
blems as to:

Awaken the client from a problematic pattern of living

Liberate the client from externally imposed constraints

Help the client author stories of dignity and competence

Recruit supportive others to serve as audiences to the client’s new life story

The nature of narrative therapy makes it appropriate for a variety of client
populations, but there are also some clients whose situations make them less
likely to benefit from the approach. What follows is a listing of clients from
both categories, compiled by graduate social work students. Clients who are
appropriate for narrative therapy include:

Survivors of all types (trauma, illness, abuse) because of their frequent desire
to engage in life reassessment

Gay, lesbian, and transgendered clients who struggle with identity issues
related to social oppression

Members of all oppressed groups, and self-described “outsiders”

Persons who carry “labels” (such as diagnoses) that are imposed from the outside

Immigrant and migrant families, as they struggle to meld their original and
new cultures

People experiencing life transitions of any type, as those events require adjust-
ments and lead to reflection and decision making about life goals and values

Juvenile sex offenders (who are faced with the challenge of developing new
identities)

Any client with a troubled sense of self, since this approach is focused on a
reformulation of personal identity

People with low self-esteem, who can be helped to reinterpret events in
their life stories toward a sense of greater competence

Older adults who may wish to engage in life review, including terminally ill
and hospice clients

Caregivers of cancer (and other long-term illness) patients

Children in foster care, who are in a process of authoring new stories of
identity and family

Children dealing with traumas, including those related to natural disasters

Narrative interventions by themselves may not be as useful for:

Persons for whom behavioral controls or monitoring are required, or who
are at risk for re-offending (such as pedophiles)

Single-issue clients, such as persons who are seeking assistance with
budgeting or time management

286 C H A P T E R 12

Persons in immediate crisis who require personal and material supports for
stabilization

Any client whose presenting issues are problematic to the social worker; that
is, the social worker’s own discourses (values) interfere with his or her ability
to engage in the narrative process (examples may include certain types of
criminals, but could really include any type of client, since all social workers
have biases)

Practice settings where the relatively informal process of narrative therapy
may be used include schools, hospice agencies, college counseling centers, in-
home counseling programs, residential settings, mentor/peer programs, prisons,
substance abuse rehabilitation facilities, and other in-patient settings.

ASSESSMENT AND INTERVENT ION

The Social Worker/Client Relationship

The role of the social worker is to help clients construct new life narratives that
portray them in a different, more positive light. The social worker adopts an
“archaeological” position, not to study the details of the client’s history so
much as to understand the “building blocks” of the client’s life stories (beliefs,
assumptions, and values).

The social worker/client relationship is different from that found in more
conventional theories because the practitioner relinquishes the role of expert
and functions as a collaborator. Toward this end the social work must reflect
on his or her own “preferred self-description” as a practitioner, and the ways in
which this might set up a power differential with the client (Richert, 2003). The
social worker demystifies the relationship by orienting clients to the narrative
therapy process and inviting them to ask questions or make comments about
the intervention as it unfolds. In this way, the client is given a shared responsi-
bility for shaping the counseling conversation. The client may be given the free-
dom to meet with the social worker as often or as seldom as desired, within
realistic limits of the social worker’s availability. The social worker further rejects
labeling the client as normal or abnormal, or “disordered,” as this is an oppressive
practice. In one study of six pairs of clients and practitioners, Grafanaki and
McLeod (1999) identified three appropriate categories of practitioner participa-
tion from the narrative perspective. These included the practitioner as audience
for the client’s telling of his or her life story, negotiator of a new story line, and
co-constructor of a new story line. In the examples provided below, the ways in
which these roles are operationalized will become clearer.

Assessment

Because narrative interventions are considered consultative rather than therapeu-
tic, the assessment stage is relatively brief (Brown & Augusta-Scott, 2007;

N A R R A T I V E T H E OR Y 287

Payne, 2005). The client is invited to share his or her presenting concerns. To
learn how they see themselves, the social worker asks clients to describe their
concerns and how they generally spend their time and deal with challenges.
The social worker asks clients about strengths, talents, and accomplishments as a
means of setting the stage for a constructive emphasis. There are no standard
diagnostic procedures (except as mandated by the social worker’s agency). In-
stead, the practitioner perceives clients as having individual, lived experiences to
share and build upon. Clients are encouraged to think of themselves as protago-
nists in their life stories rather than as victims. This approach to assessment has
much in common with person-centered therapy (Chapter 3), which also respects
each client as having unique lived experiences and potentials, and as deserving
positive regard and validation.

Elements of the assessment can be summarized as follows:

Use externalizing conversations (the person is not the problem)

Map the effects of the problem on the person

Map the effects of the person on the problem (strengths, exceptions,
competence)

Determine whether the client favors the present situation

Intervention

As noted above, the social worker tends to move quickly into the intervention
phase. We will consider intervention as fitting into the five stages described
below.

Normalizing and Strengthening

This first intervention overlaps with client assessment. The social worker en-
courages the client to describe how she understands and approaches the problem
situation. In a manner similar to solution-focused intervention, the social worker
helps the client to externalize the problem so that her entire self-image is not
affected by it. (Again, the client is not the problem; the problem is the
problem.) This helps the client avoid identifying herself as a victim or feeling
“consumed” by the problem issue. The social worker avoids engaging with the
client in a linear problem-solving process.

The practitioner next invites the client to describe other related challenges in
her life and how she is managing them. Using active listening skills, the social
worker asks the client about her most important life priorities and values. The
social worker encourages the client to conceptualize the problem as only one
aspect of her life, one that may be more contingent on external than internal
factors—some of which may be unknown to the client at the moment.
Throughout their conversations, the social worker is careful to validate the sig-
nificance of the presenting issue from the client’s perspective. As one example
of the variety of perspectives that people may have about a common issue,

288 C H A P T E R 12

Dalton (1997) studied the narratives of 23 new mothers and found that they
were all in a process of redefining mothering from their own points of view,
separate from traditional social roles assigned to women.

Reflecting (Deconstructing)

The social worker helps the client to analyze her assumptions about the self and
the world in order to uncover the fundamental ideas and social relationships re-
presented by the presenting problem. The practitioner helps the client challenge
assumptions about the way the world should be, and thereby open up new pos-
sibilities. This is similar to the concepts of cognitive restructuring (cogntive the-
ory) and insight development (in ego psychology and relational theory), except
that it emphasizes the client’s awareness of social conditions and power relation-
ships that contribute to assumptions about the self. The social worker helps the
client to identify values and biases that underlie her construction of problems.
This is done by asking questions about what the client’s behaviors and beliefs
seem to say about her as a person, and questions about what is most important
in her life.

Considering Cultural and Political Issues As the client’s narrative unfolds,
the social worker encourages the client to consider any social forces that might
influence her thinking, and to separate her life and relationships from knowledge
and stories that the client judges to be oppressive. These therapeutic interactions
do not fit with the client’s “preferred” story because the social worker refuses, so
to speak, to act as a receptive audience for the client’s typical story. The social
worker’s actions offer the client new ways of dialoguing, and the client’s story
begins to change.

Using the example of the violent client presented earlier, the social worker
suggested that Martin consider that one of the stressful aspects of his world might
be societal expectations of male dominance. This idea confused Martin at first,
but he eventually came to accept it as a part of his cultural learning, and by tac-
itly accepting it, he was closing himself off to other possible ways of interacting
with people.

Enhancing Changes (Reauthoring or Reconstructing)

The social worker helps the client to give up stories that are the result of rigid
narratives, and encourages the client to “envision,” or consider, alternate stories
about both the past and the future. This is sometimes termed “reconstruction,”
because the client makes decisions about the person that he or she wants to be
based on values that are more true to the self than those derived from arbitrary
external factors, such as traditional gender norms. The social worker helps the
client recognize parts of the life story that represent “exceptions” to the
problem-saturated story, and to identify “preferred outcomes” for the personal
narrative.

N A R R A T I V E T H E OR Y 289

This furthers the process of reflection begun in the previous stage, but the
social worker may actively help the client to recognize resources that he or she
can utilize to promote her new ways of thinking about her situation. These
resources (such as people, events, and practices) may exist in the client’s envi-
ronment but may also be recognized by watching videos or movies of persons
who have faced similar challenges, personal journaling, and letter writing to
significant others who might add to the client’s self-understanding. Each of
these practices can help clients reflect on their situations in novel ways. As
one example, Diamond (1997) found that for persons in treatment for
substance addiction, letter writing to friends, relatives, and even to the self
(journaling) about the recovery process helped them change their attitudes
about the problem and their relationships to others. Another study of 17 indi-
viduals receiving general psychotherapy services found that journaling helped
participants express emotions, increase their awareness of personal resources
and agency, separate their problems from themselves, decrease symptoms
and problem behaviors, and acquire a sense of empowerment (Keeling &
Bermudez, 2006).

Through discussion and these other techniques, the social worker en-
courages the client to reauthor her life story according to alternative and pre-
ferred stories of identity. The client is helped to consider life perspectives that
may be in conflict with the expectations of significant others. This process was
helpful with Lettie, a client who had been diagnosed with schizotypal personality
disorder and was considered “odd” and “unfit” to be a mother. When her es-
tranged husband died, Lettie’s mother-in-law sought custody of the young chil-
dren. Lettie had a limited ability for cognitive abstraction, but with the social
worker’s affirmation, she came to understand that her social status (unemployed
single mother) contributed to the assumptions of others (and herself) that she was
incapable of responsible parenting behavior. The social worker encouraged a
self-advocacy stance for the clent and supported her participation in legal pro-
ceedings. Lettie was eventually able to perceive and articulate her capabilities
that proved those social biases to be unfounded.

Spectator questions, in which the social worker asks the client to consider how
his or her changes may be perceived and evaluated by others, are helpful in the
client’s coming to feel secure in a new identity. There is no expectation that the
client will terminate involvement with these people, but she may want to let
them know about the changes that she has undergone. The client may also
want to expand her social interactions to include new groups of people. This
leads to the final stage of intervention.

Celebrating and Connecting

The social worker helps the client plan to sustain the new narrative, or the new
sense of self. This “new” person may be similar to the one who entered inter-
vention, but she may have made changes that she wants others to know about.
Attention to this issue is a part of the ending of narrative therapy.

290 C H A P T E R 12

In consultation, the social worker leads the client through reflective conversa-
tions and tasks that help her place her new life narratives into a broad context.
The client is helped to recognize her development of strengths and resources,
and to retrace her steps to new knowledge through a review of “historical ac-
counts,” such as therapy notes, videotapes, and audiotapes of sessions, or journals
that were written during the intervention (Bello, 2011). The social worker chal-
lenges the client to consider what new directions her life may take with this new
knowledge. The practitioner may invite the client to help other clients indirectly
by permitting the use of her story as an example in future clinical interventions.
Clients are often gratified to know that their journeys may be helpful to others.

Personal declarations involve the client’s circulation of pertinent written in-
formation with significant others about her arrival at a new status. The client
may choose to write letters to certain people for this purpose. In the spirit of
identifying audiences that bear witness to the client’s new self-understanding,
the client may join clubs or organizations that will be supportive of her new
position in life. Epston and White (1995) cite the example of some clients with
“mental illnesses” who choose to affirm their dignity by joining advocacy or-
ganizations to combat the public stigmas associated with their labels. Joining
activities may also include something as simple as a client who develops an
interest in literature (appreciating the stories of others) and becomes a member
of a book club.

Celebrations are any special commemorations of a client’s development of
new life narratives. These can take many forms, depending on the client’s partic-
ular circumstances. They may include prizes or awards given in ceremonies at-
tended by significant others. These commemoratives work especially well with
children and adolescents. The practitioner may or may not be a direct participant
in a celebration—his role may most prominently include assisting clients to de-
vise suitable celebrations. For example, Martin’s social worker suggested that he
try to think of ways to celebrate his accomplishments. The client gave the issue
some thought for a few weeks. He recalled seeing a football player after the Su-
per Bowl walking across the television screen and announcing, “I’m going to
Disney World.” Martin enjoyed the self-mocking idea of taking on the image
of that “macho” athlete and actually taking his parents and two brothers on a
trip to Disney World. He thought it would provide him with a pleasant way
to enhance his relationship with his family. He also wanted to use the time to
let his family get to see his new, more “patient” self.

Because narrative therapy is relatively structured, its ending is considered a
natural process of completing a consultation. Often, clients and practitioners do
not make a definitive decision to end their work. They may leave the door open
for occasional consultations without boundaries on time frames (Freedman &
Combs, 1996). Of course, as with any intervention, some clients may unexpect-
edly drop out of narrative therapy. At these times the practitioner may decide to
send a letter to the client in which he or she summarizes the process of their
work together, emphasizing what the client may have gained along the way
and enouraging a continued striving toward the goals that had been identified
(Laub & Hoffman, 2002).

N A R R A T I V E T H E OR Y 291

SP IR ITUAL ITY AND NARRATIVE THEORY

Narrative theory is particularly open to exploring issues of spirituality in clients’
lives. Recalling that spirituality is a person’s search for ultimate values, meanings,
and commitments, narrative theory’s desire to help people author life stories that
are consistent with their most personal aspirations almost always touches on spir-
itual issues. In relating their life stories, clients are encouraged to talk about and
explore the nature of their religious or secular belief systems, as well as their so-
cial concerns (including commitments to causes or social groups). Some existen-
tial thinkers assert that meaning can be found in creative pursuits such as art,
music, literature, and novel approaches to one’s work. A client’s spirituality gen-
erally becomes a focus of that person’s thinking at times of self-doubt or despair,
and the narrative social worker’s questions and comments encourage the client to
become more aware of, or consider how well his or her life is manifesting, these
personal ideals. The social worker does not attempt to direct the client’s thinking
in any particular direction, but is prepared to help the client come to terms with
his or her most basic beliefs about the self and its place in the world.

ATTENTION TO SOCIAL JUST ICE ISSUES

More than any other theory in this book, narrative theory can be classified as a
“theory of social justice.” The social worker always considers how the client sys-
tem may be vulnerable to cultural narratives that include forces of oppression,
such as racism, ageism, and sexism. That is, practitioners help clients to consider
problem-saturated stories as they relate to social conditions. In this way, they
may encourage the client to address social conditions and change through access
to new information, services, resources, equal opportunities, and greater partici-
pation in collective decision making. To provide narrative therapy effectively,
the social worker must be knowledgeable about oppression and cultural and eth-
nic diversity. When considering the source of problems, the social worker can
then attempt to give clients the opportunity to liberate themselves from certain
cultural assumptions. This helps clients identify and challenge commonly unex-
amined “life prescriptions” that permeate their societies. The social justice aspects
of narrative theory are further seen in its effort to promote communities of sup-
port for clients.

One example of a social justice issue that can be addressed with narrative ther-
apy is that of working with the children of Japanese Americans who experienced
internment during World War II (Nagata, 1991). Over sixty percent of those
incarcerated at the time were U.S. citizens, many of whom were given less than
a week’s notice of their removal and had to give up businesses, property, and per-
sonal possessions. These Japanese Americans lived an average of two to three years
in the camps, enclosed by barbed wire and watched by armed guards. These peo-
ple felt especially victimized, having been rejected by their own country of citizen-
ship. Such massive trauma came to serve as an unconscious organizing principle for

292 C H A P T E R 12

later generations of Japanese Americans. Virtually all of their children report that
their parents maintained a silence about their experiences in the camps, a silence
that inhibited communication within the family and created a sense of foreboding
and secrecy. Their children also felt a significantly greater sense of vulnerability
than those whose parents had not been interned.

The children of interned Japanese Americans tend to report deficits in family
communication, problems with self-esteem (as they are pressured to prove their
“worth” after their parents had been demeaned), limited vocational choices
(again, having internalizing a need to “prove” themselves to their parents and
to the broader American culture), problems with assertiveness (with their parents
modeling a self-protective passivity in the larger culture), and, finally, identity
problems. The children were raised to “stick with” their Japanese American
peers rather than move into the mainstream American culture.

In narrative therapy, exploring the above internment themes can be useful
with members of subsequent generations, as not all of them recognize the rele-
vance of their parents’ internment on their own life stories. These clients may in
fact either openly deny such a relationship or present a restricted life narrative
that omits this aspect of their cultural past. Social workers can help clients make
the latent themes of internment manifest by drawing attention to events and at-
tributes in the client’s lives not accounted for by their present narratives, or chal-
lenging the completeness of their stories as initially shared.

Now we will consider two examples of narrative intervention, one with a
specific client and the other focusing more generally on a type of presenting
problem.

CASE ILLUSTRAT IONS

The Hospice Client

Narrative theory, with its emphasis on reflection and the search for meaning, is
well suited to hospice patients seeking to construct their end-of-life stories. Ad-
ditionally, it is suited to using relatively few sessions spread over a long period of
time. For a hospice patient, the death-inducing illness may unfortunately become
the dominant story line (Young, 2010). As family and professional caregivers be-
come increasingly involved with the patient, the co-created reality is that the
patient is the illness, rather than the one afflicted by illness. Interventions that
reduce threat and enhance the individual’s sense of control over the process pos-
itively affect mental and physical health (Aldwin, 2007).

Mrs. Kelly, aged 86, was dying of ovarian cancer. She had been ill for seven
months, and was living at home with her husband of 60 years. The couple had
two daughters, one of whom lived in town and was often with her parents; the
other, who had a history of conflict with the family, lived farther away and was a
less frequent visitor. Mr. Kelly, also 86, was a caring but domineering provider
who was accustomed to making all major family decisions and taking care of his
wife and daughters. As Pam, the young social worker, came to know the family,

N A R R A T I V E T H E OR Y 293

she became aware that Mrs. Kelly wanted to take more charge of her life during
the final weeks. She wanted time to “prepare,” and her husband, despite his good
intentions, was somewhat intrusive in that process. Pam mediated this issue be-
tween the couple and helped diffuse Mr. Kelly’s feelings of helplessness and fear.

Through listening and reflective questioning, the social worker wanted to
help Mrs. Kelly assess her life and the “realities” of her situation, and mobilize
her underlying strengths to challenge the power of the illness. Rather than
teaching coping strategies, the social worker planned to listen for and identify
examples of Mrs. Kelly’s creative coping. Pam began the narrative process by
asking the client to “Tell me the story of your name.” This led to Mrs. Kelly’s
lengthy reminiscence of her family of origin. The social worker asked the client
to reflect on the special talents and qualities possessed by her family members.
Mrs. Kelly was quite verbal and became increasingly animated as she recalled
the important people and events in her life. The social worker later asked
Mrs. Kelly for a list of three things that once gave meaning and purpose to her
life. This led to a dialogue about work, love, art, nature, and other topics that
were quite personal to Mrs. Kelly. Later, Pam asked, “How has your illness
changed what’s meaningful in your life?” and again asked Mrs. Kelly to name
three things that were still beautiful and three things that still made her laugh.

At first, Mrs. Kelly had not seemed sure of the value of talking with anyone.
“Talk therapy” is not easily embraced by members of her generation. Before
long, however, the client was consistently interactive and appeared to enjoy the
invitation to reflect. With her description of each older family member, all of
whom had died, Mrs. Kelly seemed to become clearer about her identity and
more validated as a unique individual. One of nine children, she reported being
spoiled by her sisters and growing up timid and quiet. She had continued these
patterns when she was married by allowing her husband, and later her daughters,
to manage all family decision making. Mrs. Kelly did not regret this but was now
aware that she had been more capable of self-care than she was given credit for.

The social worker agreed that women of Mrs. Kelly’s generation were not
generally encouraged to function independently. She shared with Mrs. Kelly a
pattern she had noticed in women in their 70s and 80s. Their acceptance of be-
ing cared for by their spouses seemed to carry over into their assumptions of how
they coped with life’s challenges. They acknowledge that difficult events have
occurred in their lives but mistakenly conclude that they were sheltered from
them. They do not recognize their own part in surviving stressful times. This
theme became apparent to Mrs. Kelly in her review of the past.

During the reconstruction phase, the social worker asked Mrs. Kelly about
her hopes for the future. Even when hope for a cure has been lost, many criti-
cally important hopes remain, including the hope to live whatever time is left
with joy and purpose, and perhaps the hope to be remembered. Mrs. Kelly
wanted to become more active during her final months on Earth. Her daughters
had almost no contact with each other, and she wanted to meet with them to-
gether, to ask them to reconcile and recognize the importance of family ties. She
wanted to communicate with confidence to her husband that he would survive
her death and continue making a good life for himself and their daughters.

294 C H A P T E R 12

Pam affirmed these priorities and helped Mrs. Kelly arrange to have sufficient
private time with her family members. She congratulated Mrs. Kelly for making
these efforts, and the client said, “I like the way I feel when I do new things. It
makes me feel important.”

Following through with these tasks, Mrs. Kelly experienced a greater sense
of connection to other people and, perhaps more important, to something
greater than herself. She began to request more time alone, to think about her
spiritual nature as her illness worsened. Mrs. Kelly passed away five weeks after
her relationship with the social worker had begun. They had six meetings for
time periods ranging from 30 minutes to 2 hours. By the time of her death,
Mrs. Kelly had revised her life story to include episodes of strength and quiet
wisdom, and she had successfully brought the other three members of her family
closer together.

Although it did not pertain to this case, narrative therapy can empower cli-
ents to partner with the entire hospice team in fighting the effects of the illness.
There is often a disconnection between the main drivers of treatment (physi-
cians) and the recipients of treatment. Families and clients long for communica-
tion that is honest and provided with empathy, and that recognizes their unique
qualities (Farber, 1999). Physicians, in part because of time constraints and their
training, may appear insensitive and authoritarian, focused on survival rather than
on quality of life. They may find it difficult to promote the benefits of dying well
over living poorly. Narrative therapy can serve as a complement to traditional
medical services by encouraging the reciprocity and individualized attention de-
sired by patients and families.

Juvenile Sex Offenders

Daybreak is a residential juvenile sex offender treatment program that serves
11- to 17-year-old adolescents. Interventions focus on issues related to the
clients’ past traumas, past victimizations, behavior problems, cognitive distortions,
and defenses that are common among sex offenders. Treatments include individ-
ual and group therapy, family therapy, life skills instruction and activities, educa-
tional groups, music and drama therapy, academic educational programs, and
structured recreational activities.

Narrative therapy, which is one part of the intervention, helps the adoles-
cents separate themselves from their problem-saturated stories and open ave-
nues by which they can bypass the problems that have plagued them. This
approach allows the clients to reconstruct meanings and experiences in their
lives to produce a more constructive view of themselves and their futures.
This is especially important for youths who perceive only the negative aspects
of their life stories. Many of the clients at Daybreak have difficulty seeing past
their offending behaviors and the abuses that they have suffered. Clients often
say that they were abused because they are “bad” people. By exploring their
unique outcomes (evidence of “good” behavior), social workers can provide
the adolescents with opportunities to develop an alternative story, one not
dominated by abuse.

N A R R A T I V E T H E OR Y 295

Although Daybreak uses a largely cognitive-behavioral-based treatment
method, the narrative approach is present in a 14-objective treatment module
that begins with “My Life Story.” Completing the Life Story objective provides
an opportunity for offenders and their social workers to gain greater insight into
the offender’s past experiences and his or her interpretation of those experiences.
The Life Story objective serves as a non-threatening means of supporting the
client during his or her introductions to peers and the staff. It helps the client
identify significant life events that may have contributed to his or her offending,
and it helps the professionals understand the offender’s worldview, self-concept,
use of time, and coping styles. It acts as a beginning stage for the development of
a therapeutic relationship between the client and the therapist.

The treatment objectives that follow incorporate the narrative approach as
well. Juvenile sex offenders often exhibit qualities such as resilience, resourceful-
ness, and intelligence, which they are unable to see in themselves due to society’s
dominant negative constructs about their behaviors. Through the narrative ap-
proach, clients are confronted with their own self-assumptions and are encour-
aged to explore their beliefs and feelings more fully with the social worker who,
in turn, works to break down those cultural assumptions and the negative feel-
ings related to them.

One 15-year-old male client in the program named Jacob complained about
feeling depressed, having trouble sleeping, and being unable to focus in school
and on his treatment. He stated that no one on the unit liked him and that he
felt worthless. He also stated that those feelings move him into his cycle of abuse
because they remind him of the emotional abuse that he suffered at the hands of
his mother.

Jacob presented in the first session as lethargic and withdrawn, not wanting
to talk. His social worker, Renaldo, asked what he was feeling, and he stated that
he was sad and tired. The social worker asked him why he was feeling tired, and
Jacob replied that he was up all night reading. He related that one of the char-
acters in his book died and he “feels pain in his chest” because of it. They ex-
plored how passionate Jacob was about his reading. Jacob stated that he loves to
read to escape from his “hell.” He appeared to be in a better mood when talking
about the content of his readings.

Through the use of metaphors, Renaldo attempted to open Jacob up to ex-
ploring some of his emotions. He explained that the characters in the book pos-
sessed certain powers and were able to fly. Jacob wished that he could be like
them. The social worker questioned why he would want that, and Jacob replied
that with special powers, he could change things that have happened in the past,
and flying would make him feel free. Jacob and Renaldo talked about some of
the things that made the client feel that he could not fly, such as his sexual abuse,
his abuse of his sister, and the impact of his offending on the family. They used
the metaphor of flying to help Jacob talk about how he can change things in the
present that will help him to “grow wings.” Jacob stated that completing his
treatment successfully would enable him to return home and make his father
happy. They agreed that this would be his first step to growing wings and
decided to work on a list of “special powers” that Jacob might already possess

296 C H A P T E R 12

to keep him focused on his treatment. He appeared to enjoy the idea of the
metaphors.

In a subsequent session, Jacob stated that he had used some of his “special
powers,” which consisted of processing with his peers and staff the angry feelings
that perpetuate his feelings of sadness or incompetence, and going to bed early
instead of staying up reading all night, which causes him to think of sad things.
Jacob stated that these actions put him in a better mood, resulting in him being
approachable to his peers. The course of his intervention at Daybreak began to
improve from this point.

EVIDENCE OF EFFECT IVENESS

There are many descriptions in the literature of types of problems for which nar-
rative therapy has been found helpful. Though narrative practitioners resist label-
ing clients, the results of a PsycINFO® literature search included articles
describing the theory’s applicability to persons who experience attachment disor-
ders, eating disorders, body image disorders, post-traumatic stress disorder, depres-
sion, stuttering, substance abuse, panic disorder, adolescent behavior problems,
childhood adjustment issues (as a component of play therapy), life with violent
partners, general relationship problems, and mental illnesses. The interventions
are useful with families and groups as well as individuals. Much existing research
on narrative therapy is qualitative, featuring case studies and small convenience
samples. We will consider both types of research here.

Outcome Studies

Quantitative research methods are not incompatible with narrative theory, and
several examples are described here. One researcher applied a set of narrative
techniques (including externalization, relative influence questioning, identifying
unique outcomes and accounts, facilitating the circulation of new narratives, and
assigning between-session tasks) to six families experiencing parent-child conflicts
(Besa, 1994). Five of the six families reported improved relationships. In a
follow-up study of 49 clients discharged from a substance use treatment facility
who had participated in narrative therapy, it was found that the clients’ new life
narratives had been integrated into their post-discharge lives (Kuehnlein, 1999).

Two randomized studies have focused on persons adjusting to medical con-
cerns. In one study, 70 mothers of infants born with severe congenital heart dis-
ease were assigned to intervention and control groups, with the treatment group
receiving psychoeducation, parent skills training, and narrative therapy
(McCusker et al., 2010). The six-session group interventions included one
session devoted to personal narrative development, although the theme was
incorporated into several other sessions. Six months later, the mothers in the ex-
perimental group continued to demonstrate significant gains in feeding practices,

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anxiety, worry, and appraisal of the health situation. (Problematically, the sepa-
rate effects of each intervention could not be evaluated.) In another experiment,
234 adults with cancer were assigned to one of three treatment groups. One fea-
tured weekly narrative therapy (requiring written stories about how cancer af-
fected their lives), one involved completion of a pain questionnaire, and the
third was a no-treatment control group (Cepeda et al., 2008). Results of the
three-session program showed that pain intensity and well-being were similar
in all three groups before and after the intervention, but persons in the narrative
therapy group who demonstrated high emotional disclosure experienced signifi-
cantly less pain and higher levels of well-being than persons whose narratives
were less emotional.

Several outcome studies have been conducted with clients having post-
traumatic stress disorder. An experimental study randomly assigned 26 Rwandan
genocide orphans with that diagnosis into two groups, one of which received
narrative exposure therapy (focused on the traumatic incident) while the other
received interpersonal therapy (Schall, Elbert, & Neuner, 2009). Both interven-
tions consisted of four weekly sessions, and both concluded with a single group-
based guided mourning session. Although there were no significant differences
between the groups on outcome measures at the end of the interventions, the
experimental group demonstrated significantly fewer symptoms of post-
traumatic stress disorder at the six-month follow-up, and in fact few of them
met the criteria for the disorder. A systematic review of narrative exposure ther-
apies for survivors of mass violence with post-traumatic stress disorder (eight
studies including 482 participants) concluded that the intervention produced a
significant decrease in symptoms compared to other treatments, wait list controls,
or “treatment as usual” (McPherson, 2012). Among a more general population
of persons with post-traumatic stress disorder, researchers examined the narratives
of 20 clients after they had completed the intervention, attempting to find differ-
ences in narrative style between the 8 clients who improved and the 12 who did
not (van Minnen, Wessel, Dijkstra, & Roelofs, 2002). The clients who improved
showed a significantly greater decrease in “disorganizing thoughts” and an in-
crease in sensitivity to their internal events.

There have been many studies of the effectiveness of narrative therapy with
depression. In another study of the experience of cancer, 72 depressed and pre-
dominantly female adult clients were randomly assigned to two groups, receiving
either narrative therapy along with an anti-depressant medication or “usual care”
with the same medication (Vega et al., 2011). At the end of the intervention, the
experimental group showed significantly greater improvement in measures of
pain, global health, and global quality of life, but not depression. Treatment re-
tention was also higher in the experimental group. Another study of 47 adults
with major depression found that eight sessions of narrative therapy resulted
in symptom improvement, both at the end of treatment and three months
later (Vromans & Schweitzer, 2011). Two other comparison studies support the
effectiveness of narrative therapy with older adults experiencing depression.
A total of 106 older adults participated in a quasi-experimental study featur-
ing one group’s treatment with integrative reminiscence and narrative therapy

298 C H A P T E R 12

(Bohlmeijer, Westerhof, & Emmerick–de Jong, 2008). The eight-session inter-
vention featured weekly discussion topics of member responses to questions
about their past lives. It resulted in a decline of negative self-evaluation, an in-
crease in positive evaluation of social relations, a more positive evaluation of the
past, and a less negative evaluation of the future among experimental group
participants. Finally, a randomized, multi-site trial with 202 persons assigned to
treatment and control groups also evaluated the efficacy of life review and narra-
tive therapy as an early treatment for depression in late life (Korte, Bohlmeijer,
Cappeliez, Smit, & Westerhof, 2012). The narrative interventions were effective
in reducing symptoms at post-treatment and at a nine-month follow-up.

Process Studies

Presented next are examples of research on the narrative intervention process, all
of which included more than one client. A recent longitudinal study of 47 adults
with a variety of presenting problems examined evidence of personality change
during narrative therapy, as evidenced by the clients’ written accounts of the
process (Adler, 2012). Results indicated that across all participants, themes of
“agency” (taking action), more than a sense of “identity coherence,” were re-
lated to improvements in mental health. Two authors have written about the
significance of narrative interventions in the context of play therapy with chil-
dren. One study of six videotapes from play therapy sessions indicated that chil-
dren symbolize themes of traumatic events in play therapy, alternating happy/
neutral and angry stories (Kanters, 2002). In a study of 10 children receiving
sandplay therapy, Cockle (1993) noted that the five “coping” children viewed
their world as balanced and showed resourcefulness in dealing with adversity.
The five “difficult coping” children described their worlds as barren and danger-
ous, and their stories lacked elements of resourcefulness.

“Anger” narratives were investigated by Andrew and McMullen (2000),
who reviewed audiotapes of 109 stories of anger experiences told by 19 adult
clients in one psychotherapy center. The researchers identified five common an-
ger themes, and asserted that this confirmed earlier research about common
scripts in the lives of people with similar backgrounds. Regarding themes that
may be common to eating disorders, Von Wyl (2000) analyzed stories told dur-
ing interviews with seven anorexic and eight bulimic clients from inpatient psy-
chiatric centers, and concluded that the major conflicts represented in the two
disorders are different.

Barber, Foltz, DeRubeis, and Landis (2002) investigated the hypothesis that
psychiatric clients display consistent narrative themes when describing relation-
ships with mothers, fathers, same-sex best friends, and romantic partners. In the
study, 93 clients were asked to give narratives about each of those people, and
independent judges rated these with respect to intensity of wishes, responses of
others, and responses from self. They found substantial variability in interpersonal
themes across narratives, and concluded that client narratives are less predictable
than the researchers had imagined. This unpredictability in client presentation is
consistent with the assumptions of narrative theory.

N A R R A T I V E T H E OR Y 299

The “process” studies described previously illustrate how narrative theorists
have become interested in understanding within-session narrative activity by cli-
ents. Several researchers have developed instruments to help practitioners review
their own narrative processes with clients. The Narrative Process Coding System
is one example of a method for studying the narrative sequences of intervention
with individual clients (Angus, Levitt, & Hardtke, 1999). This is a manual that
guides researchers through a study of session transcripts to document topic shifts
and three types of narrative process, including references to a client’s external
events, internal events, and reflections. At a micro level, the coding system helps
to outline social worker/client interactions around narration, plot, and narrative
process style. At a macro level, it helps to show how specific narratives become
linked to a client’s life story. The structured understanding of within-session cli-
ent behaviors might eventually result in knowledge about the types of practi-
tioner comments that promote client storytelling and the types of narratives
that tend to be presented by different types of clients.

CR IT IC ISMS OF THE THEORY

Narrative theory is attractive to many social workers because of its focus on client
empowerment and social change activities. However, it has been subject to
several criticisms. First, narrative therapy may not be suitable as a primary inter-
vention with persons whose problems are related to basic needs acquisition
(Williams & Kurtz, 2003). These types of clients represent a large segment of
the social work profession’s traditional client populations. Narrative theory’s
relative lack of structure and emphasis on subjective impressions may not be
helpful with clients who face, for example, problems related to unemployment,
lack of health care, or inadequate housing. It might be used with these clients
once the initial problem is resolved to help them reconsider their life courses.

Other criticisms stem from narrative theory’s rejection of general theories of
physical, psychological, cognitive, and moral development. Some argue that it is
not possible for practitioners to help people change without such a guiding set of
principles (Nichols, 2009). Put another way, can a clinical social worker really
avoid any assumptions about the nature of people and how they change? A re-
lated criticism relates to narrative theory’s conceptualization of identify, or the
self (Zielke & Straub, 2008). Specifically, to what degree is the self autonomous,
as opposed to a fluid social construction? Most other theories in this book offer
more extensive ideas about human nature that can be used as guildes in the in-
tervention process.

Narrative theory rejects labeling clients because such labels arbitrarily impose
the persepctives of outside social groups. Many social workers are trained to concep-
tualize some client problems as “illnesses” or “disorders.” Narrative theory has been
criticized for encouraging practitioners to ignore these serious conditions. When
working with a client who has schizophrenia, for example, a narrative practitioner
might be less likely to encourage medication use and challenge “delusional” ideas.

300 C H A P T E R 12

The therapeutic neutrality of any practitioner may not be possible, and the
narrative practitioner risks imposing his or her own values, perhaps unwittingly,
to influence how the client shapes his or her story (Gottlieb & Lasser, 2001). The
social worker may tend to promote a story that represents one particular dis-
course and marginalizes the client’s inner voices that don’t fit the story. A femi-
nist practitioner, working with a client who has experienced repeated domestic
violence, may hope that the client reshapes her personal narrative in a way that
highlights lifestyle alternatives other than returning to the abusive spouse, and in
subtle ways act accordingly (Allen, 2012). Wyche (1999) further notes that the
validity of a social worker’s interpretations of client narratives may be limited in
situations in which the practitioner is a member of a different race, class, or gen-
der. Bias is a potential problem with any practice approach, but narrative theory
may be particularly open to it without principles that might serve as checks on
the social worker’s activities.

Narrative theory de-emphasizes systems thinking (White & Epston, 1990).
This minimization of the role of systems is particularly glaring in the profession
of social work, where the person-in-environment perspective gives great weight
to the reciprocal impact of families, groups, organizations, and communities.

A final criticism of narrative therapy is that its processes are at odds with
the emergence of managed care in clinical social work practice—a develop-
ment that occurred at the same time that narrative theory was emerging
(Kelley, 1998). Managed care demands DSM-V diagnoses and pre-approved
intervention plans based on empirically proven methods, whereas in narrative
therapy, the emphasis is on the social worker and client co-creating new reali-
ties through dialogue.

SUMMARY

The ideas that underlie narrative theory represent outgrowths of developments
in postmodern social thought, although they are also related to other, longer-
standing developments in the human service professions, such as multicultural-
ism, the strengths perspective, social justice, and client empowerment. The
impact of narrative theory on professionals engaged in direct practice has been
great, as it provides a useful alternative for intervention with many types of
presenting problems. Narrative therapy is even moving into the field of medi-
cine. Goodrich (2006) writes that by listening more closely to the stories of
patients and reflecting more deeply on their medical experiences, physicians
can more clearly understand each patient’s situation, adopt the patient and
family’s perspectives on an illness, and, as a result, provide more individualized
and comprehensive care.

A practitioner’s full embracing of narrative theory is not always possible,
however, because its relatively unstructured methods are incompatible with the
strict policies about structured service provision present in many agency settings.
A challenge for social workers in the future will be to identify the types of clients

N A R R A T I V E T H E OR Y 301

for whom the approach may be beneficial, consider ways of flexibly implement-
ing the theory into a variety of agencies, and establishing further evidence of its
effectiveness through both qualitative and quantitative methods.

TOPIC S FOR DISCUSSION

1. Narrative therapy is said to be consultative and informal in nature. Can it be
adapted for use in agencies that demand structure from practitioners with
regard to such matters as length of sessions and duration of intervention?

2. Think about the kinds of clients seen by social workers for whom narrative
interventions would and would not be appropriate. What is the difference?
Can narrative interventions be incorporated into other clinical interventions
without violating the essence of the approach?

3. Share examples of clients from field placement agencies whose problems may
be related to culturally oppressive values and practices. Discuss how the social
worker might proceed to help a client explore (deconstruct) these influences.

4. Related to the above point, discuss how these clients might be helped to
construct new life stories that do not reflect cultural oppression, and the role
of the social worker in that process.

5. What are some ways that various types of clients can be helped to
“celebrate” their new life stories at the end of narrative intervention?

IDEAS FOR ROLE-PLAYS

1. Divide the class into pairs. One member of each pair (the client) thinks of a
personal belief that has been highly influential in his or her development of an
identity. Choices may include race, education, religion, sexuality, social class,
lineage, or culture. The student portraying the social worker provides the client
with an opportunity to talk about the belief and its influence on the client’s
life. The social worker should listen with interest and curiosity, and encourage
the client to explore the effects of the belief on his or her life. The student
practitioner helps the client to focus on family, work, spirituality, relationships,
history, the future, and the client’s life position. In a follow-up class discussion,
the client should talk about the effects of the conversation on his sense of
identity, and what the social worker did that was useful to the process.

2. Practice the informal, nondirective type of assessment favored by narrative
practitioners with clients who have specific presenting problems, but are
willing to explore them in detail with the social worker.

3. Practice ways of externalizing clients’ problems without absolving them of
responsibility for their behavior, especially with client populations who tend
to blame others (such as adolescent legal offenders, substance abusers, and
spouse batterers).

302 C H A P T E R 12

4. Practice deconstruction interventions with a variety of types of clients.
Two examples that might provide interesting contrasts for follow-up class
discussion are women who have been battered and men who have been
batterers.

5. In separate role-play activities, practice reconstruction interventions with the
same clients as in the above exercise.

APPENDIX: Narrative Theory Outline

Focus Personal narratives that determine one’s understanding
of the self and the world

Major Proponents Abels and Abels, Crockett, Dickerson, Epston, Freedman,
Monk, Kelley, Payne, White, Zimmerman

Origins and Social Context Existentialism

Postmodernism

Social constructivism

Multiculturalism

Nature of the Individual Personal experience is fundamentally ambiguous

People arrange their lives into stories to give them
meaning

New experiences are filtered in or out of a story line
depending on their consistency with the dominant life
narrative

Narratives are co-constructed with significant others

Cultural norms contribute significantly to life narratives

Some story lines are dominant and others are
suppressed

People are capable of developing new, more
empowering stories

Major Concepts The personal narrative

Deconstruction

Reauthoring/Reconstruction

Celebrating/Connecting

Nature of Problems Conditions of emotional or material suffering that
result from narratives saturated with negative
assumptions

By-products of cultural practices that may be oppressive
to the person

N A R R A T I V E T H E OR Y 303

Nature of Change Awareness of arbitrary beliefs and assumptions about
the self and world

Examination of culturally reinforced assumptions that
may be limiting

Reauthoring one’s life and relationships

Goals of Intervention Awaken the client from a problematic pattern of
living

Free the client from externally imposed constraints

Help the client author stories of dignity and competence

Recruit supportive others as audiences (and supports)
for the client’s new life story

Nature of Worker/Client
Relationship

A collaborative atmosphere

Social worker relinquishes the “expert” position

The social worker as archaeologist

Labels and divisions of behavior into normal and
abnormal are rejected

Client is welcome to questions and comment about the
intervention process

Intervention Principles Acknowledge the problem

Normalize and strengthen

Externalize the problem

Encourage the client to explore his or her life story

Ask questions about personal meaning in the client’s life

Worker communicates to clients that they are
protagonists in their life stories

Reflect (deconstruct)

Identify values and biases that underlie problem
construction

Enable the client to separate his or her life from
knowledge and stories judged to be oppressive

Help the client give up problem-saturated stories

Encourage the client to reauthor the life story with a
preferred identity

Open up new possibilities with exceptions questions

Envision (discuss alternate futures)

Encourage the client to consider life perspectives that
may be in conflict with the expectations of significant
others

APPENDIX: Narrative Theory Outline (Continued)

304 C H A P T E R 12

Help the client make plans to sustain the new narrative

Help the client connect with others in a familiar social
world who will celebrate and acknowledge the new
narrative

Leave the door open for occasional future consultations

Assessment Questions Ask questions about how the client spends his or her
time in an effort to learn how he or she sees himself or
herself

Ask about strengths, talents, and accomplishments as a
means of setting the stage for a constructive emphasis

APPENDIX: Narrative Theory Outline (Continued)

N A R R A T I V E T H E OR Y 305

Crisis Theory and Intervention

I measure every grief I meet
With analytic eyes;

I wonder if it weighs like mine,
Or has an easier size.*

Studying crisis theory provides a means for us to integrate many of the theoreti-
cal perspectives described throughout this book. Crisis theory is sometimes

described as a theory of human behavior, and sometimes as a theory for clinical practice.
It can alternately pertain to the study of human reactions to highly stressful situa-
tions, or to the principles of intervention that can be used with clients experienc-
ing crises. In this final chapter, we will consider both aspects of crisis theory, but
focus more closely on intervention. These topics are important to study because
social workers of all theoretical backgrounds often work with people in crisis,
regardless of agency setting.

A crisis can be defined as the perception or experience of an event (genuine
harm, the threat of harm, or a challenge) as an intolerable difficulty ( James &
Gilliland, 2013). The crisis is an aberration from the person’s typical pattern of
functioning, and he or she cannot manage the event through the usual coping
methods. The person either lacks knowledge about how to manage the situation
or, because of feeling overwhelmed, lacks the ability to focus his or her energies
on it. All of us experience crises at times in our lives. A crisis often results when
we face a serious stressor with which we have no prior experience. The stressor
may be biological (a major illness), interpersonal (the sudden loss of a loved one),
environmental (unemployment or a natural disaster), or existential (inner con-
flicts regarding values and purpose in life).

* Dickinson, E. (1927). The Pamphlet Poets. New York: Simon and Schuster.

Crisis intervention can be used with a range of presenting problems, such as
sexual assault, medical illness, combat stress, post-traumatic stress disorder, migra-
tion, suicidal ideation, chemical dependence, personal loss, school violence, part-
ner violence, and family stress ( James & Gilliland, 2013; Lantz & Walsh, 2007).
It represents a strengths approach when it underscores the possibility of client
growth, even in horrible situations. The social worker must build upon clients’
strengths in order to help them adapt to, and grow from, the experience.

A strengths-based approach to crisis intervention is founded on the following
assumptions (Chazin, Kaplan, & Terio, 2000):

1. In a crisis event, each individual’s response is unique, and the helping process
should be individualized.

2. Each individual is the “expert” in his or her own recovery process. Social
workers facilitate what is already there—discovering strengths and coping
skills, and connecting with support resources.

3. The natural recovery process needs to occur without artificial interventions
disrupting the process as much as possible. “Help,” whether psychological
first aid or practical assistance, should fit seamlessly into one’s natural process.

ORIGI NS AND SOCI AL CONTEXT

Social workers have practiced crisis intervention since the profession’s earliest
years (Golan, 1987). In fact, the social work profession emerged in response to
socially identified needs to help growing numbers of citizens who experienced
high-stress situations. Smith College offered its first summer program in 1918
to train workers in skills for rehabilitating shell-shocked soldiers. Social workers
also provided services in the first suicide prevention center, the National Save-
a-Life League in New York City in 1906. Through the years, caseworkers
assisted families experiencing disruption during the Great Depression; homeless,
runaway, and impoverished people (through the Traveler’s Aid Societies); and
people dealing with life disruptions during World War II (through family service
agencies). Social workers generally preferred long-term interventions during
those years, but, as caseloads and waiting lists increased, they effectively adopted
short-term approaches to their work (Parad, 1965).

Formal crisis theory was developed in the fields of psychiatry, psychology,
and sociology. It emerged during the 1940s, primarily through the work of psy-
chiatrists Erich Lindemann and Gerald Caplan, both of whom had been affiliated
with Massachusetts General Hospital (Roberts, 2000). Lindemann and his associ-
ates developed concepts of crisis intervention in the aftermath of Boston’s Coco-
nut Grove nightclub fire, in which 493 people died. Their ideas were based on
observations of the grief reactions of survivors and the friends and relatives of
those who died. Lindemann identified common crisis (grief) reactions of somatic

C R IS I S T H E O R Y A N D I N T E R V E N T I O N 307

distress, guilt, anger, disrupted patterns of conduct, and preoccupation with
images of the deceased. He concluded that the length and outcome of a grief
reaction were dependent on the person’s having time to mourn, adjust to the
changed environment, and eventually develop new relationships.

Military psychiatrists have always tried to predict the behavior of soldiers in
field situations, and to quickly rehabilitate those who become overwhelmed.
Lindemann’s ideas were adapted to military intervention methods during World
War II. Crisis outcomes were found to be most positive when soldiers were trea-
ted close to the setting of the precipitating event (the front lines), when the psy-
chiatrist focused only on the immediate situation, and when the soldier was
returned to the combat situation in a relatively short time (Golan, 1987).

Caplan (1990) expanded on Lindemann’s work of the 1940s and 1950s. His
ideas were influenced by his work with immigrant mothers and children. Among
his major contributions to crisis theory was the idea that all people are vulnerable
to crisis reactions during developmental transitions, such as moving into adoles-
cence and adulthood. Caplan specified two types of crises: normal life transitions
and hazardous events. He was the first to relate the concept of homeostasis to crisis
intervention and to describe stages of a crisis reaction, which will be presented
later. It is noteworthy that developmental theorists, such as Erikson (1968), also
postulated the normalcy of psychosocial crises in human development during the
1950s and 1960s. Further, the field of sociology made important contributions to
crisis theory with studies on the effects of stressful family events such as marriage,
parenthood, and old age on family structure and member interaction.

In the 1960s, the social worker Lydia Rapoport wrote about the importance
of adapting various intervention modalities, such as ego psychology, learning
theory, and others, to crisis intervention. She emphasized the importance of
rapid assessment, and the practitioner’s ready access to the client. Later, Naomi
Golan (1978) emphasized that people were most receptive to receiving help dur-
ing the most difficult period of a crisis, and that intensive, brief interventions
were more successful when the client was motivated in this way.

The suicide prevention movement expanded greatly during the 1960s, ini-
tially with telephone hotlines. Between 1966 and 1972, the number of these
centers grew nationally from 28 to almost 200. The greatest boost to crisis inter-
vention programs came with the community mental health movement, for
which 24-hour crisis programs were a required component. The number of cen-
ters that included these units grew to almost 800 by 1980.

Social interest in providing crisis intervention services exploded during the
1970s for two major reasons (Myer, 2001). One was the increase in geographic mo-
bility in the United States and other modern countries, and many people’s conse-
quent lack of ties to nuclear families and other primary supports. Myer cites evidence
of 130 million situational crisis episodes occurring annually in the United States. A
second reason was the new awareness in science of links between psychological
trauma and long-term neurological disorders (Aupperle, Melrose, Stein, & Paulus,
2012). Today, crisis programs continue to be found in mental health centers and
hospitals. Most social workers receive training in crisis intervention in schools or
their agencies, as it is recognized that clients of all types may experience crises.

308 C H A P T E R 13

MAJOR CONCEPTS

Stress

Stress can be defined as an event in which environmental or internal demands tax
or exceed a person’s coping resources (Lazarus & Lazarus, 1994). The event may
be biological (a disturbance in body systems, such as the experience of a disease),
psychological (cognitive and emotional factors involved in the evaluation of a
stressor, such as the fear of an important relationship ending), or social (the dis-
ruption of a social unit; for example, the closing of a town’s major industrial
plant). Psychological stress, about which we are primarily concerned in this chap-
ter, can be summarized into three categories:

Harm refers to the effects of a damaging event that has already occurred.

Threat is probably the most common form of psychological stress. The per-
son perceives a potential for harm from an event that has not yet happened.

Challenge consists of events that a person appraises as opportunities, rather
than occasions for alarm. The person is mobilized to struggle against the
obstacle, such as a threat, but with a different attitude. Faced with a threat,
a person is likely to act defensively. In a state of challenge, the person is
excited and confident about the task to be undertaken.

The nature of a person’s experience of stress is related to biological constitu-
tion and previous experiences in managing stress (Pervanidou, 2008). Vulnerabil-
ity to stress is also related to one’s position in the social structure; some social
positions (including poverty, racism, and blocked opportunities) are exposed to
a greater number of adverse situations than others (McEwen, 2012). Although a
single event may pose a crisis for one person but not another, some stressors are
so severe that they are almost universally experienced as crises.

Traumatic stress refers to events that involve actual or threatened severe injury
or death to oneself or to significant others (American Psychiatric Association,
2000). These include natural (such as flood, tornado, and earthquake) and technolog-
ical (such as nuclear) disasters, war and related problems, and individual trauma, such as
being raped or assaulted (Aldwin, 2007). Many trauma survivors experience a set of
symptoms known as post-traumatic stress disorder (American Psychiatric Association,
2000). These symptoms include persistent reliving of the traumatic event, persis-
tent avoidance of stimuli associated with the traumatic event, and a persistently
high state of arousal. The symptoms of post-traumatic stress disorder may occur
as soon as one week after the event, or as long as 30 years after! Complete or partial
recovery from symptoms is possible, but not certain (almost 50% of survivors con-
tinue to experience some long-term symptoms), which supports the importance of
timely professional intervention (Bisson & Andrew, 2007).

Crisis

The term crisis was defined earlier in this chapter. To elaborate, the experience
of crisis occurs in three stages (Caplan, 1990). First, there is a sharp and sudden

C R IS I S T H E O R Y A N D I N T E R V E N T I O N 309

increase in the person’s level of tension. Second, the person tries but fails to cope
with the stress, which further increases tension, and contributes to the sense of
being overwhelmed. At this point the person is highly receptive to accepting
help. Third, within approximately four weeks, the crisis resolves, either nega-
tively (with an unhealthy coping solution) or positively (with successful manage-
ment of the crisis and perhaps an enhanced sense of personal competence). The
negative emotions most likely to emerge in a person’s experience of crisis include
anxiety, guilt, shame, sadness, envy, jealousy, and disgust (Zyskinsa & Heszen,
2009).

Crises can be classified into three types (Lantz & Walsh, 2007). Developmental
crises occur as events in the normal flow of life create changes that produce
extreme responses. Examples include college graduation, the birth of one’s child,
a midlife career change, and retirement from primary occupations in later life.
People may experience crises at these times if they have difficulty negotiating
the typical challenges outlined by Erikson (1968) and Gitterman (2009). Situa-
tional crises refer to uncommon, extraordinary events that a person has no way
of forecasting or controlling. Examples include physical injuries, sexual assault,
loss of a job, illness, and the death of a loved one. Existential crises are character-
ized by escalating inner conflicts related to issues of purpose in life, responsibility,
independence, freedom, and commitment. Examples include remorse over past
life choices, a feelings that one’s life has no meaning, and a questioning of one’s
basic values or spiritual beliefs.

A client in crisis may follow three general courses (James & Gilliland, 2013).
In the growth pattern, the client recovers from the event and then, often with the
help of a practitioner, develops new skills and strengths. In the equilibrium pat-
tern, the client returns to the pre-crisis level of functioning, but does not experi-
ence enhanced social functioning. In the frozen crisis pattern, the client does not
improve, but makes adjustments that involve harmful strategies (such as substance
abuse) that keep him or her in a chronically troubled state.

Whether a stress experience becomes a crisis depends on the person’s coping
capacities, so we now turn to a discussion of that concept.

Coping and Adaptation Coping represents a person’s efforts to master the
demands of stress (Folkman, 2009). It includes the thoughts, feelings, and actions
that constitute those efforts. Adaptation involves related, longer-term adjustments
the person makes in his or her lifestyle.

Biological Coping The biological view of stress and coping emphasizes the body’s
attempts to maintain physical equilibrium, or a steady state of functioning
(Koolhaas, de Boer, Coppens, & Buwalda, 2010). Stress results from any demand
on the body, specifically the nervous and hormonal systems, during perceived
emergencies. The body’s response to a stressor is called the general adaptation syn-
drome. It occurs in three stages. In the state of alarm, the body becomes aware of
a threat. During resistance, the body attempts to maintain or restore homeostasis.
This is an active response of the body in which endorphins and specialized cells
of the immune system fight off stress and infection. In the third stage, exhaustion,

310 C H A P T E R 13

the body terminates coping efforts because of its inability to physically sustain the
state of disequilibrium. The immune system is constructed for adaptation to
stress, but the cumulative wear and tear of stress episodes can gradually deplete
its resources. Common outcomes of chronic stress include stomach and intestinal
disorders, high blood pressure, heart problems, and some emotional disorders.

Psychological Coping The psychological aspect of managing stress can be viewed
in two different ways. Some theorists consider coping ability as a stable personal-
ity characteristic, or trait; others see it instead as a transient state—a process that
changes over time, depending on the context (Matthieu & Ivanoff, 2006;
Lazarus, 1993). Those who consider coping as a trait see it as an acquired defen-
sive style, a set of automatic responses that enable us to minimize perceived
threats. Those who see coping as a state, or process, observe that coping strategies
change depending on our perceptions of the threats. The context has an effect
on our perceived and actual abilities to apply effective coping mechanisms. The
two approaches can be integrated; that is, coping can be conceptualized as a gen-
eral pattern of managing stress that incorporates flexibility across diverse contexts.

A person’s coping efforts may be problem-focused or emotion-focused (Green,
Choi, & Kane, 2010). The function of problem-focused coping, which includes
confrontation and problem-solving strategies, is to change the stressful situation.
This method tends to dominate when we view the situation as controllable by
action. In emotion-focused coping (distancing, avoidance, and reappraisal of the
threat), the external situation does not change, but our behavior or attitudes
change with respect to it. When we view stressful conditions as unchangeable,
emotion-focused coping may dominate. People may productively use either of
these general approaches at different times. American culture tends to venerate
problem-focused coping and the independently functioning self, and to distrust
emotion-focused coping and what may be called “relational coping.” Relational
coping takes into account actions that maximize the survival of others—such as
families, children, and friends—as well as the self (Hardie, Kashima, & Pridmore,
2005). Feminist theorists propose that women are more likely than men to
employ the relational coping strategies of negotiation and forbearance. Further,
power imbalances and social forces such as racism and sexism affect the coping
strategies of individuals. Social workers must be careful not to assume that one
type of coping is superior to the other.

People exhibit some similarities in the ways they cope with crises and the
ways they cope with everyday stress, but there are several differences (Yeager &
Roberts, 2005). Because people tend to have less control in crisis situations, a
primary coping strategy is emotional numbing, or the constriction of emotional
expression. They also make greater use of the defense mechanism of denial.
Confiding in others takes on greater importance. The process of coping takes a
longer time, and reactions may be delayed for months. The search for ultimate
values and life meanings takes on greater importance, and personal identity trans-
formations are more common. Despite the many negative consequences of trau-
matic stress, however, it is important to recognize that survivors sometimes
report the experience as positive. In this “growth” pattern (Lantz & Walsh,

C R IS I S T H E O R Y A N D I N T E R V E N T I O N 311

2007), clients utilize their experience to discover new strengths, skills, behavioral
patterns, insights, and meaning potentials in their lives.

As described next, a strong system of social support helps a person to avoid
or recover from crises.

Social Support Social support can be defined as the interpersonal interactions
and relationships that provide people with assistance or positive feelings of
attachment (Hobfoll, 1996). A key function of crisis intervention should involve
the client’s linkage with formal or natural support resources. The utilization of
natural supports by clients is important because of limits in the scope and avail-
ability of formal services. Most important, natural supports promote normalcy in
clients’ lives. Many people perceive their support networks to be inadequate.
People who experience “marginalizing” problems, such as chronic mental and
physical disorders, tend to have smaller networks than people whose challenges
are more universal.

There are many possible sources of social support. Examples include the cli-
ent’s subjective perceptions of support from family and friends (Lakey & Orehek,
2011), and the availability of others who can provide listening, emotional sup-
port, reality confirmation, and personal assistance (Richman, Rosenfeld, &
Hardy, 1993). Supportive relationships often occur in clusters, distinct categories
such as the nuclear family, extended family, friends, neighbors, formal commu-
nity relationships, school peers, work peers, church associates, recreational
groups, and professional associations (Peralta, Cuesta, Martinez-Larrea, Serrano, &
Langarica, 2005). Having contacts in a variety of clusters is desirable, as it indicates
that a person is supported in many areas of life. A person’s support system should
ideally be able to provid material support (food, clothing, shelter, and other concrete
items), emotional support (all interpersonal supports), and instrumental support
(services provided by casual contacts, such as grocers, hairstylists, and landlords)
(Walsh & Connelly, 1996).

How Social Support Aids Coping The experience of crisis creates an emotional
arousal in a person that reduces the efficiency of his or her cognitive functioning
(Caplan, 1990). When under stress, a person becomes less effective at focusing
attention and negotiating the environment. Social supports help to compensate
for these deficits by:

Promoting an ordered worldview

Promoting hope

Promoting timely withdrawal and initiative

Providing guidance

Providing a communication channel with the social world

Affirming one’s personal identity

Providing material help

Containing distress through reassurance and affirmation

312 C H A P T E R 13

Ensuring adequate rest

Mobilizing other personal supports

There is no consensus about how social workers can evaluate a client’s level
of social support, but one useful model suggests gathering four types of informa-
tion (Walsh, 1994). The social worker asks the client to list all persons with
whom he or she has interacted in the past one or two weeks. Next, the social
worker asks the client to draw from that list the persons whom he or she perceives
to be supportive in significant ways. The client is then asked to describe specific
recent acts of support provided by those significant others. Finally, the social
worker asks the client to evaluate the adequacy of the support received from
each source. Based on this assessment, the social worker can identify the client’s
supports and target certain cluster areas for development.

ASSESSMENT AND INTERVENT ION

Overview

Crisis intervention requires the social worker’s attention to structured stages, as
listed below and adapted from Eaton and Roberts (2009) and Corwin (2002).

Rapid establishment of a constructive social worker/client relationship. The social
worker must connect quickly with the overwhelmed client through demonstra-
tions of acceptance, empathy, and verbal reassurance. The social worker must
convey a sense of optimism and hope to the client, as well as his or her compe-
tence to assist in the resolution of the crisis. The social worker must be active in
helping the client focus and make decisions, and the practitioner may also estab-
lish relationships in person or by phone with the client’s significant others, if
appropriate and available.

Eliciting and encouraging the client’s expression of painful feelings toward the goal
of helping the client feel calmer, gain greater mastery of his or her emotions, and
become better able to focus on immediate challenges.

Assessment must be rapid, but thorough enough to result in a well-crafted
intervention plan. The social worker investigates the full range of precipitating
factors, the meaning to the client of the hazardous event, the client’s existing
capacities for adaptive functioning, and the client’s potential and actual support
systems. Notice, however, that a thorough assessment is not the first stage in crisis
intervention because the client’s immediate needs are initially more pressing.
Some details about assessment will be described later.

Restoration of cognitive functioning. After the initial assessment, the social
worker shares his or her (possibly tentative) conclusions with the client
about the causes of the crisis and the meaning of the client’s reactions. This nor-
malizes the experience somewhat for the client and helps him or her to assume a
proactive problem-solving attitude in contrast to the initial avoidance strategies.

Planning and implementing interventions. Depending on the situation, the social
worker can draw from many intervention options. All of these must incorporate

C R IS I S T H E O R Y A N D I N T E R V E N T I O N 313

time limits, structure, a here-and-now orientation, and a high level of practi-
tioner activity. They must include the social worker’s continued reassurance
and encouragement of the client, enhancement of his or her ability to connect
current stress with patterns of past functioning, and promotion of improved cop-
ing methods. As the client regains a sense of safety, control, and support, the
social worker’s level of activity diminishes.

Environmental work secures and develops material and social supports for the
client, as needed. This involves referral and linkage and, if needed, the practi-
tioner’s advocacy for the client with other systems.

Ending and follow-up. To assist with anticipatory guidance, the social worker
may review the crisis episode and what the client learned from it as a means of
preventing future crises. There is some discouraging evidence, however, regard-
ing the efficacy of debriefing following trauma, based on the rationale that such
activity sensitizes the victim to the possibility of pathology (Yifeng, Szumilas, &
Kutcher, 2010; Rose, Bisson, Churchill, & Wessely, 2002). In contrast to this
evidence, one study found that “high-avoidance copers” appear to benefit from
post-trauma information provision, so, for at least some trauma survivors,
debriefing appears to be a useful strategy (Gist & Devilly, 2002).

Assessment

The purpose of crisis assessment is to gather information from the client and per-
haps his or her significant others about the crisis in order to help the client mobilize
resources as quickly as possible. Because it must be completed quickly and retain a
focus, it is less in-depth than assessments in other types of practice. The social
worker learns more about the client as the intervention proceeds, and the client’s
mental status stabilizes. The following questions should be a part of the assessment:

What factors can the client identify relative to the onset of the crisis?

What is the current quality of the client’s affective, cognitive, and behavioral
functioning? Which areas appear to be the most adversely affected?

Is the client self-destructive?

Does the client require immediate medical or psychiatric attention?

How does the client’s current level of functioning compare with pre-crisis
functioning?

Has there been significant trauma, illness, pathology, or substance abuse in
the client’s past?

What are the client’s strengths? Areas of life stability?

What are the client’s realistic alternatives for managing the distress?

What are the client’s formal, informal, and potential support systems?

Are there financial, social, or personal impediments to the client’s progress?

One example of a structured assessment process is the triage assessment model
(Myer, 2001). It assesses crisis reactions in the domains of affect, cognition, and

314 C H A P T E R 13

behavior. Each of these domains includes three types of possibly problematic
responses. In the affective domain, these include anger/hostility, anxiety/fear,
and sadness/melancholy. The cognitive domain includes the client’s perception
of the event as a transgression, threat, or loss. Reactions in the behavioral domain
include the client’s patterns of approach, avoidance, or immobility.

A Word About Suicide Assessment

Before moving into a discussion of crisis intervention, it is important to address
the topic of suicide prevention. Suicide is the tenth-leading cause of death in the
United States (American Foundation for Suicide Prevention, 2010). It has also
been reported that 1 in 20 adolescents meets the criteria for Major Depressive
Disorder (March, Franklin, & Foa, 2005). Depression is considered a leading
factor in suicidal behavior, and suicide is the third-leading cause of death for
adolescents ages 15 to 19 (Bertera, 2007).

There are numerous factors associated with the risk of suicidal behavior in
people of all ages (Bertera, 2007; James & Gilliland, 2013; Miller & Glinski,
2000). Women are more likely than men to attempt suicide, but men are more
likely to successfully complete the act. Older adults and adolescents are more
likely to attempt suicide than members of other age groups. Separated or di-
vorced people are more likely to attempt suicide than those who are married.
Persons suffering from serious medical illnesses, such as cancer, are more likely
to attempt suicide than healthy people. Others who are at risk of suicide are
people who experience chronic pain, suffer from chronic mental illness, have
previously attempted suicide, experience depression and wish to “end their
pain”, and are experiencing a crisis of any type.

A risk and protective factor model for suicide assessment includes the
social worker’s attention to the following five areas (Högberg & Hällstrom,
2008):

Historical information about the client—demographic, developmental,
mental health, and medical

Personal information—the client’s general cognitive, emotional, and ego
functioning

Specific symptoms of the client’s distress

Person-environmental interactions—the significance to the client of any life
transitions, loss episodes, developing isolation, or breakdowns in social
support

Protective factors—the client’s present social supports, occupational
supports, sense of purpose in living, social skills, and the need to care
for children

The social worker’s presentation to the client is key to a successful interven-
tion process (Högberg & Hällstrom, 2008). The social worker’s relationship with
the client is a powerful, respectful collaboration in which the social worker con-
veys an empathic understanding of the client and the meaning of the client’s

C R IS I S T H E O R Y A N D I N T E R V E N T I O N 315

suicidal ideation, and does not take a judgmental stance about the possibility of
suicide. The social worker assures the client that he or she will not take any
actions against the client’s will unless the danger of self-harm becomes imminent.
The social worker affirms the client’s feelings but helps the client separate those
feelings from their influence on self-destructive behavior. The social worker
promotes an atmosphere of safety and respect, and allows the client to proceed
at his or her own pace.

Intervention

The social worker’s specific intervention strategies for crisis intervention must be
adapted from other practice theories. That is, crisis theory does not suggest
unique interventions. The remainder of this section considers the social worker’s
intervention options, all of them drawn from theories presented earlier in the
book.

Two unique features of crisis intervention are the social worker’s short-term
but sometimes intensive involvement with the client and his or her significant
others, and the social worker’s active use of the environment in establishing lin-
kages and supports. For this reason it is important for us to review a commonly
recognized but underappreciated professional role: that of the clinical case
manager.

Clinical Case Management Case management is an approach to service deliv-
ery that focuses on developing growth-enhancing environmental supports for
clients, using resources that are spread across agency systems (Walsh, 2009). In
clinical case management, the social worker combines the interpersonal skill of
the clinical practitioner with the action orientation of the environmental archi-
tect. It includes the following 13 activities in four areas of focus (Kanter, 1996):

Initial phase—Engagement, assessment, and planning

Environmental focus—Linking clients with community resources, consulting
with families and caregivers, maintaining and expanding social networks,
collaborating with physicians and hospitals, and advocacy

Client focus—Intermittent psychotherapy, living skill development, and
psychoeducation

Client-environment focus—Monitoring the client’s activities and progress
within the service system

In addition to the relationship-building skills described earlier, the practice
skills needed for case management include the social worker’s ability to do the
following (Kanter, 1996, 1995):

Recognize a client’s fluctuating competence and changing needs

Develop a realistic view of the client’s strengths, limitations, and symptoms

Make ongoing judgments about the intensity of involvement with a client

316 C H A P T E R 13

Titrate support to maximize a client’s capacity for self-directed behavior

Differentiate the biological and psychological reactions to a crisis

Help the client’s significant others cope with the crisis situation

Appreciate the effects of social factors on a client’s sense of competence

Appreciate a client’s conscious and unconscious motivations for behavior

Maintain appropriate relationship boundaries during this often-
intensive work

With the assumption that the social worker will almost always provide case
management interventions in crisis work, we now consider a variety of specific
clinical interventions, drawn from six theories presented in this book, which may
be used as a part of that process. These interventions are not tied to specific types
of crises, as their use may reflect, at least in part, the practitioner’s preferences.

From Ego Psychology Ego-sustaining techniques (Woods & Hollis, 2000) can
help clients become mobilized to resolve their crises and to understand their
motivations and actions more clearly. These strategies are particularly useful for
clients who require a supportive relationship and an opportunity to process their
distress through ventilation and reflection. Specific strategies for the social worker
include sustainment (to develop and maintain a positive relationship), exploration/
description/ventilation (to encourage the client’s emotional expressions for stress
relief and for gaming objectivity about problems), and person-situation reflection
(toward solutions to present difficulties). The practitioner may also provide
education to the client, often about environmental resources, and direct influence,
particularly when the client is temporarily unable to exercise good judgment
about self-care. The practitioner will almost certainly use the technique of struc-
turing as a means of breaking down the client’s concerns into manageable units.

The Sexual Assault Mary Ellen, a 21-year-old emergency medical technician,
had a history of conflicted relationships with men. She had a low opinion of
herself and, despite her best intentions, often entered into relationships with
neglectful, verbally abusive men. At this time, Mary Ellen was living with a
female roommate and had been seeing a young man, Dale, for several weeks.
The relationship was pleasant but superficial. One evening, however, Dale
showed up at her apartment drunk. He was loud and threatening, and after a brief
argument, Mary Ellen told him to leave. Instead, he became angrier. Dale forced
Mary Ellen to have sex with him after making threats that he would physically
harm her otherwise. Afterward he abruptly left. Mary Ellen’s roommate returned
home, learned what had happened, and drove her distraught friend to the hospital.

Following a brief medical exam, Mary Ellen saw Laura, a social worker, for a
mental health assessment. In rape crisis situations Laura always intervened with
the ego psychology techniques of sustainment and exploration/description/
ventilation. She felt that it was important to initially communicate acceptance
and empathy to rape victims, who usually felt degraded after the event. The

C R IS I S T H E O R Y A N D I N T E R V E N T I O N 317

social worker also used the structuring techniques to narrow the focus of the
client’s thoughts if the ventilation of feelings proved overwhelming. Later on in
her interviews, Laura always educated clients about their options for self-care and
(possibly) perpetrator prosecution, and used direct influence to guide them
toward resources (such as supportive friends and medical and counseling profes-
sionals). Laura gave each client up to several hours of her time, and always made
arrangements for them to leave with a close friend or family member.

Mary Ellen was by nature a quiet person who had learned to suppress her
negative feelings as a coping strategy. Respecting this, Laura sat with her client
and made calm, affirming statements about her innocence in the event. Mary
Ellen gradually began to share feelings of fear and anxiety, but emphasized her
capacity to “deal with it.” The social worker acknowledged the client’s strengths,
but reminded her of some of the short- and long-term effects of rape that many
women face. She educated the client about the resources available to her. Mary
Ellen began to talk more freely, sensing Laura’s acceptance, and eventually
admitted to her anger at Dale and at all men. The client cried as she described
her frustration with relationships in general, and her fears of going back home.
Laura engaged in person-situation reflection with the client, who wanted to ex-
plore her pattern of destructive relationships with men. After Mary Ellen became
quiet again, Laura helped her focus on precautions that she could take to be safe.
She helped the client make plans to have friends and family nearby, and to prevent
future contact with Dale. Mary Ellen left with her roommate, agreeing to return
to the outpatient clinic in a few days for a more extended counseling session.

From Behavior Theory Behavioral interventions can be useful with clients
whose crises are related to problematic reinforcement patterns (rewards and pun-
ishments) in their lives (Thyer & Wodarski, 2007). The techniques are useful
when specific behaviors by the client (or significant others) are contributing to
the crisis episode, and thus need to be adjusted for problem resolution. The
social worker’s target behaviors may relate to life skills training, relaxation training,
coping skills training, assertion training, or desensitization. All behavioral interven-
tions are highly structured, which is helpful for people who feel overwhelmed
and out of control.

The Seizure Disorder One winter morning, fifth-grade student Scott Owens had
a seizure during math class. The teacher and other students watched in horror as
the grand mal episode left the 11-year-old boy writhing on the floor for several
minutes. Afterward, Scott was taken to the nurse’s station, where he rested,
recovered, and then went home with his mother. That first episode signaled
the onset of a seizure disorder that would require ongoing monitoring and med-
ication for Scott. While waiting for the results of the initial medical testing, Scott
had a second seizure at school two weeks later. Medical treatment would soon
eliminate seizures from Scott’s life. The onset of the disorder, however, precipi-
tated a crisis for him.

Scott felt humiliated about having the seizures at school. He was concerned
that his classmates considered him a freak, or a frail, dangerous kid. He was also

318 C H A P T E R 13

frightened about his health, wondering if he had a brain tumor (despite what
the medical tests revealed). His family and teachers were supportive, but Scott
became depressed, isolative (not even going to basketball practice), and preoccu-
pied. His fears were evident in his new tendency to become easily agitated
about everyday frustrations. Some of Scott’s peers did, of course, avoid and stig-
matize him. Like many 11-year-old boys, Scott did not talk about his feelings,
but the adults around him were concerned about the abrupt changes in his
behavior.

Chandra, the school social worker, promptly organized a behaviorally based
crisis intervention plan with Scott’s teachers and parents. Chandra felt that Scott
could be helped through this crisis if his engagement in healthy behaviors was
gently and consistently encouraged. These behaviors, as identified by the adults,
included talking (at least a bit) about his condition, participating in routine activ-
ities (including schoolwork and sports), spending time with friends, and partici-
pating in family meals (a major shared activity in the household) and weekly
church. The social worker had previously asked Scott about his own priorities,
but he had declined to respond. Chandra asked Scott’s parents and teachers to
document “target” (pre–seizure disorder) levels of these activities, and also the
level and quality of those behaviors since the seizures occurred. Chandra then
helped the parties determine how they might reinforce Scott’s efforts to resume
his previous activities. She emphasized that they should avoid punishing Scott’s
problem behaviors because that might worsen his feelings.

During the meeting, they all agreed to (a) provide Scott with information
about seizure disorder and its controllable nature; (b) ask the physician to provide
Scott with examples of patients with the disorder who lead normal lives;
(c) monitor his use of anti-seizure medications; (d) encourage Scott to resume
his sports activities; (e) enforce the importance of academic success, and expect
that he perform well in that regard; and (f) speak to the parents of Scott’s best
friends to inform them of Scott’s condition. Scott’s teachers and parents would
probably have focused on these activities without the social worker’s help, but
this structured approach helped their efforts be more quickly and consistently
applied. Afterward, Scott was invited into the room so that they could share
the plan with him. This was intended to confirm for Scott that they cared about
him and were confident that he could adjust to his medical condition.

Scott was a resilient child who responded positively to the behavioral inter-
ventions within several weeks. He felt cared about, and the information he
received about his disorder helped him develop a more balanced perspective.
He never shared many feelings about the condition but did resume his normal
activities. He had no further seizures, and his classmates eventually seemed to
forget about the few episodes from the fifth grade.

From Cognitive Theory Crises may be characterized by strong emotional
reactions that are precipitated by a client’s subjective, negative appraisals of a
life situation. Examples of such developmental crises include moving out of the
parental home, the loss of a close relationship, or the onset of post-college life.
Even when a crisis is clearly due to some material deprivation, a client’s core

C R IS I S T H E O R Y A N D I N T E R V E N T I O N 319

beliefs about the self and the world will influence his or her capacity to cope
with the crisis. For these reasons, cognitive interventions may be effective in
helping clients resolve crises. The steps involved in this type of cognitive inter-
vention are as follows (Beck, 1995):

Assess the client’s cognitive assumptions, and identify any distortions that
may contribute to the onset and persistence of the crisis

When a client demonstrates clear thinking patterns, educate the over-
whelmed client about ways of managing the crisis, and implement a
problem-solving process (the social worker will need to be more directive
than with clients who are not in crisis)

When the client exhibits significant cognitive distortions, identify situations
that trigger the critical misconceptions, determine how they can be most
efficiently replaced with new thinking patterns, and implement corrective
tasks

The social worker assesses the validity of a client’s assumptions associated
with the crisis issue through focused questions, such as “What is the logic behind
the client’s beliefs regarding the significance of the crisis situation?” “What is the
evidence to support the client’s views?” “What other explanations for the client’s
perceptions are possible?” “How do particular beliefs influence the client’s attach-
ment of significance to events, emotions, or behaviors related to the crisis?”

Strategies that may be used in cognitive intervention fit into three general
categories. The first is cognitive restructuring, used when the client’s thinking pat-
terns are distorted and contribute to problem development and persistence.
Some techniques include education, the ABC (event/thought/feeling) review, and
the point/counterpoint technique. The second category is problem solving, a struc-
tured means for helping clients who do not experience distortions but neverthe-
less struggle with certain life challenges. The third is cognitive coping. The
practitioner helps the client learn and practice new or more effective ways of
dealing with stress and negative moods. Some techniques include self-instruction
training and communication skills development.

Many social workers combine intervention approaches from cognitive the-
ory and behavior theory when working with clients in crisis. Cognitive interven-
tions help clients to develop new ways of thinking, and behavioral approaches
help reinforce clients’ new thought patterns with effective new behaviors.

Woman with a Gun Becky, a member of a mobile crisis intervention team,
accompanied four police officers to the home of Kate Carter, a 30-year-old
woman who was threatening to shoot herself. Kate had been abandoned earlier
that day by her fiancé after an argument and a physical altercation. She had called
the mental health center’s emergency number and said her fiancé was gone for
good. Kate felt desperate. She stated that she was weak, unattractive, and unlov-
able. Becky, who had talked to Kate, assessed that the client was in danger of
self-harm, but that her call was a constructive reaching out for help. Becky fur-
ther assumed, with her clinical experience, that people in such crises focus only

320 C H A P T E R 13

on their negative self-beliefs. Becky used cognitive intervention in these situa-
tions, gently pointing out the clients’ distortions and helping them recall positive
aspects of their lives.

Kate was inside the small house with a gun. She had fired several shots into
the ceiling while on the phone with Becky, and took one more such shot when
the police first arrived. She commanded all of them to stay outdoors, but was
willing to talk through the closed door. Becky kept a safe distance as she talked
with the client. The social worker was patient, calm, and conversational. She got
acquainted with Kate as much as the client would allow. She learned that Kate
had been in and out of several intensive relationships in her adult life and, in her
view, had always been abandoned. Becky also perceived that the client was
somewhat dependent and histrionic, but she did not attempt to make any formal
diagnosis.

Becky made comments and asked questions throughout the conversation to
challenge the distortions that underlay the client’s suicidal thoughts and feelings.
Examples included: “Your relationship has not worked out, Kate. That doesn’t
mean that your entire life is a failure” (overgeneralization). “You seem to believe
all the critical comments your fiancé made about you. But you were together for
two years. I’m sure he saw good qualities in you as well. Can you identify any of
them?” (selective abstraction). “Why do you assume that the breakup is all your
fault? Don’t you think he had anything to do with the problems?” (personaliza-
tion). “I don’t know anyone whose life is all good or all bad. You seem to think
it is all bad now” (dichotomous thinking).

The client eventually calmed down and agreed to go to a regional psychiat-
ric unit for an assessment. She was hospitalized for four days, and then released to
live with her older sister. Becky counseled Kate for several weeks until her mood
stabilized and she was able to make some short-term plans to resume her previ-
ous lifestyle. The social worker continued to support the client’s initiatives and to
challenge her distortions. Some of these had surfaced in reaction to the situation,
but others seemed to be rooted in core beliefs.

From Structural Family Theory Families can experience crises as well as
individuals with regard to such issues as housing, income, food, crime, violence,
and medical care, among others. Structural family interventions are often appro-
priate in these cases. Structural theory assumes that the establishment and main-
tenance of appropriate authority, rules, roles, and subsystems within families
facilitates productive behaviors among the members (Minuchin, Nichols, &
Lee, 2007). The social worker is concerned with strengthening the basic organi-
zation of the family unit so that its members can constructively address their
pressing concerns. Structural theory generally works well for families in crisis
because it focuses on concrete goals that can be pursued even in a context of
emotional turmoil.

During family assessment, the social worker must (in addition to providing
case management services) identify any problematic structural characteristics, such
as weak bonds between spouses or others, conflicts between family subsystems,
the alienation or enmeshments of any members, and alliances outside the family

C R IS I S T H E O R Y A N D I N T E R V E N T I O N 321

that may be contributing to the crisis. Subsequent interventions may include any
of the following:

Normalizing some aspects of the crisis so that family members can develop a
more confident attitude about the situation

Communication skills development, in which the social worker instructs family
members in methods of clear speaking and listening to better communicate
their needs, ideas, and feelings about the situation

Supporting the family system’s strengths, providing compliments about aspects of
family functioning that are going well during the crisis

Encouraging family members to enact (through role-plays) rather than de-
scribe their old and new approaches to managing the crisis

Helping the family to modify its rules through discussion and mutual decision
making, to better adapt to the crisis situation

Clarifying each member’s appropriate roles within the family

Assigning tasks for members to complete between meetings, to “practice”
making adjustments in family organization in response to the crisis.

The Emergency Shelter The Holton family faced immediate eviction from their
apartment because of failing to pay rent over a period of several months. The
family, consisting of mother Debra (31), father Donald (27), and children Sasha
and Scott (8 and 6), had nowhere to go. Under increasing financial and marital
stress during the preceding few months, Donald had been escaping to the com-
pany of his friends, leaving Debra to manage the household as best she could.
Donald was drinking heavily, and Debra was becoming verbally abusive to the
children. The children, in turn, were doing poorly in school, and getting into
fights in the neighborhood. In a panic about the eviction, Debra called 911,
and was quickly linked by phone with the Emergency Shelter (ES).

That same day, the shelter’s social worker, Valerie, met with the Holtons.
The shelter had an opening, and the family was offered placement there. Rel-
ative to structural family intervention, conditions of the placement were that
both parents would (a) attend ES parenting classes to learn more effective
means of establishing appropriate expectations of their children; (b) participate
in couples counseling with Valerie, to make decisions about their relationship
and roles within the family; (c) participate in job-search activities (the shelter
offered childcare); (d) ensure that their children were ready for school each
day; and (e) use appropriate discipline with the children. Additional expecta-
tions of the agency were that the family would visit the Department of Social
Services for a financial benefits and housing assessment, not use any substances,
observe curfew, and use psychiatric services if deemed appropriate by agency
staff.

The Holton family was greatly relieved to secure the ES placement. Once
the material crisis situation was relieved, all of them calmed somewhat, although
family tensions were still evident. Donald and Debra frequently argued, and,

322 C H A P T E R 13

though the children were well behaved, they seemed to avoid both parents.
Valerie noticed, as she often did in such situations, that once the family became
materially comfortable, their motivation to participate in growth activities at the
shelter diminished. She needed to be firm with Donald and Debra about attend-
ing their classes and counseling. The family stayed at the center for 60 days, at
which time a subsidized apartment became available for them. The relationship
between Donald and Debra was still conflicted, but Donald had found a job and
become more organized about budgeting income for the family. The couple had
made some important agreements about childcare strategies that did not involve
physical discipline. When the Holtons moved out of the shelter, Valerie was
concerned that major responsibility for the family’s cohesion would again fall to
Debra, but all of them had nonetheless made important gains.

From Solution-Focused Therapy In solution-focused crisis intervention, the
social worker and client attend to solutions or exceptions to problems, more so
than to the problems themselves (Corcoran, 2000). Its focus is on helping clients
identify and amplify their strengths, so that available resources can be better uti-
lized as solutions to the crisis. This approach is useful in crises when the client has
the capacity to organize and direct his or her thinking and behavior. In solution-
focused crisis intervention, the social worker:

Accepts the client’s perspective on the crisis

Builds positive feelings and hope within the client with future-oriented ques-
tions, such as “What will be different for you when our work has been
successful?”

Collaborates with the client to select specific, concrete, and prioritized goals

Credits the client for the positive elements of his or her behavior relative to
the crisis

Asks strengths-reinforcing coping questions (“How have you been able to manage
the situation this well so far?”)

Asks questions about the desired behavior of other people in the client’s life who are
connected to the crisis situation

Explores exceptions to the client’s negative feelings and behaviors in the crisis
situation (“Are there times when you think you can stand up to the prob-
lem? How so?”)

Asks the miracle question to determine indicators of change that can be
incorporated into solution tasks (“What if you woke up in the morning and
your problem was gone, but you didn’t know it? What would you notice
that was different?”)

Elicits solution-focused tasks from the client in which he or she applies strengths
to new and existing resources to test solutions to the crisis

The client’s progress toward crisis resolution may be measured by scaling
changes on a numerical continuum

C R IS I S T H E O R Y A N D I N T E R V E N T I O N 323

A Pregnancy Crisis Gordon and Adrienne, a married couple in their 20s, were
expecting their first child in three months. Although their marriage was strong,
Adrienne had schizoaffective disorder and was, in the words of her husband,
“psychologically fragile.” There had been two previous episodes (pre-
pregnancy) in which Adrienne became so anxious with paranoid delusions that
she was unable to go outside their apartment on her own. She usually responded
well to medications, but even so tried to minimize stress in her life by depending
on her husband for support and spending much time at home. The couple had
recently relocated near Gordon’s family. Adrienne had not yet received mental
health services in the new city.

The pregnancy had gone well until the seventh month, when Adrienne again
began to develop psychotic symptoms. Gordon brought her to the local mental
health agency for help, but after their assessment the doctor and social worker faced
a dilemma. It would be dangerous to the child to medicate Adrienne prior to deliv-
ery. Yet Adrienne’s symptoms worsened, and she begged for relief. She talked about
being frightened for her life, saying that there were intruders trying to break into her
house each afternoon while her husband was at work. She had called the police for
help, but they were no longer willing to respond to the “crazy” calls. Gordon was
trying to be supportive, but was stressed about his need to continue working. Sandy,
the social worker, called for a meeting of the couple, the physician, and the client’s
mother-in-law to work out an intervention plan.

Sandy felt that an intervention strategy was needed whereby the family and
agency staff could provide Adrienne with enough support that she could get
through the remaining months of her pregnancy without medication. Because
the couple had been able to successfully contain Adrienne’s symptoms in the
past (although with medication), Sandy developed a solution-focused approach
to the present crisis. He first reframed Adrienne’s anxiety, remarking that preg-
nancy was a difficult time, and all women need extra help when they get close to
delivery. He credited Adrienne and her family with having been able to manage
her symptoms in the past, and then asked coping questions such as “What did
you do to help Adrienne feel more secure in the past? What have you done
recently that has been helpful?”

Sandy and the physician learned that Gordon had been staying home every
evening, and he came home for lunch every day. Adrienne’s in-laws had been vis-
iting her each afternoon. The family acknowledged that this level of contact was
excessive, and they were all becoming emotionally drained. Sandy credited Adri-
enne with having good judgment about when she needed help. He instilled posi-
tive feelings in the distressed client with such comments as “Your family cares, and
wants to continue helping. We just need to figure out the best way to do this.”
The social worker asked about exceptions to the client’s feelings of stress in the
crisis situation, asking “Are there times when you have been able to stand up to
your anxieties? How did you make that happen?” Adrienne and Gordon agreed
that she was most comfortable in the afternoons when she was watching certain
television programs or, on pleasant days, when she could walk in the park.

Sandy acknowledged that it might not be feasible for her husband, sister-
in-law, mother-in-law, and counselor to be with her at all times. He facilitated

324 C H A P T E R 13

a discussion in which the family eventually agreed on a schedule of contacts. The
in-laws would take Adrienne along when they ran household errands (thereby
accomplishing tasks while providing her with support), Gordon would call
home at lunchtime each day, and the social worker would visit Adrienne at
home twice weekly and call her once per week. The physician agreed to take
Gordon’s calls if he had questions about symptoms or felt the need to reconsider
the medication option. Adrienne agreed to go for walks on sunny days if she had
enough energy to do so. These were all solution-focused tasks in which the fam-
ily utilized their existing resources to manage the crisis. Sandy agreed to meet
with Gordon and Adrienne weekly to review task implementation.

The plan was successful in that Adrienne delivered her child (a daughter)
without having to take psychotropic medication. It was a difficult process for
all involved, however, as Adrienne pushed the limits of the plan, particularly by
making many phone calls per day to the agency and to family members. As her
delusions persisted, Adrienne became more demanding, but with mutual support
the “team” maintained their situation. Adrienne was given appropriate medica-
tions immediately after delivery.

From Narrative Theory Narrative theory asserts that people arrange their lives
and self-understanding into a series of storieses to give themselves a sense coher-
ence and meaning (Goodson, 2013). As each person develops a dominant “story
line,” new experiences are filtered in or out, depending on whether they are
consistent with the ongoing life narrative. Many crises that people experience
during life transitions (divorce, children leaving home, death of loved ones,
etc.) may be complicated by life narratives that exclude certain possibilities for
self-understanding and future action. Narrative interventions, though not practi-
cal in most crisis situations because of their unstructured, slow-paced format, can
help people gain greater control over their lives during difficult transitions
through the development of a new narrative and, with it, a new identity.

Narrative therapy is a process of a client’s coming to understand his or her life
story through reflection, and then amending that story to include new possibili-
ties for future action. Interventions generally adhere to the following stages:

Normalizing and strengthening. The social worker encourages the client to
describe how he or she understands and approaches the crisis situation, and
affirms the client’s resources for dealing with it.

Reflecting (deconstructing). The social worker helps the client to analyze his or
her assumptions about the self and the world in order to uncover the fun-
damental ideas and social relationships that are affected by the crisis. The
social worker helps the client to identify values that underlie his or her
construction of the crisis and the social conditions that contribute to the
client’s assumptions about the self.

Enhancing changes (reconstructing). The social worker helps the client to “give
up” stories about the self that result from rigid narratives and consider alter-
nate stories about the past, present, and future, and to make decisions about
the person that he or she now wants to be.

C R IS I S T H E O R Y A N D I N T E R V E N T I O N 325

Celebrating and connecting. The social worker helps the client make plans to
sustain the new narrative, or the new sense of self, after crisis resolution
through new or adjusted connections with others.

The Empty Nest Wesley was a 42-year-old divorced watch repairman who lived
in a small house with his only child, Ben, age 21. Wesley had been divorced for
10 years. His wife had developed a serious substance abuse problem at that time,
and moved across the country to escape her problems with family, friends, and
employers. Wes was given custody of their son, and he was a devoted father.
The watch repairman had always felt guilty about the conflicted domestic situation
during his son’s youth and became highly involved in Ben’s life after the divorce.
Ben had been a good high school and college student, majoring in engineering.
Now he had accepted a job with a prestigious engineering firm in another part of
the country. Wes was proud of his son, and gave him a new car as a gift.

Wesley had been dreading the day his son moved away. He had organized
his life around the young man, and ignored his own needs for other companion-
ship. The day his son flew off to his new home Wesley became depressed. He
cried every day for a week, and could not sleep well. He did continue working,
and it was a customer who referred him for counseling at a local mental health
agency. A social worker, Brad, was assigned to work with Wesley, and he
quickly assessed that the client was in crisis. Wesley was not suicidal, but felt
empty and lacking in direction. Brad assumed a narrative stance with the client,
inviting Wesley to relate and explore the story of his marriage and parenting up
to the present time. Wesley seemed to connect well with Brad, who was not
much younger than he was. Brad encouraged Wesley to describe the person he
was and wanted to be. He encouraged the client to talk about a variety of areas
of his life. Wesley acknowledged that he had given up a number of personal
interests after his marriage, and he eventually decided to resume some of them.
Brad helped Wesley to understand that his age did not preclude him from devel-
oping relationships with women, something that Wesley had avoided after his
marriage ended. Over a period of weeks, Wesley began to define himself as
more than a parent. He was also a craftsman and outdoors enthusiast who had
a greater interest in people than he had realized for a while. He continued to
miss his son terribly, but felt more productively occupied, joining a hiking club
and teaching watch repair classes at a local community college.

SP IR ITUAL ITY AND CRIS IS THEORY

It should not be surprising that, in times of crisis, people tend to draw upon their
religious resources (if they have such beliefs and affiliations) or, in a more general
sense, reflect on their most deeply held values and commitments. Indeed, a crisis
may be spiritual (or existential) in nature, characterized by inner conflicts related to
issues of purpose in life and commitment (remorse over past life choices, feeling
that life has no meaning, and questioning basic values or spiritual beliefs). In every

326 C H A P T E R 13

case, clients’ worlds are turned upside down, and the clients may be either soothed
or confused as they face the implications of the crisis for their spiritual lives.

The social worker must be prepared to help clients in crisis articulate their
spiritual concerns, provide active listening, and perhaps link clients with appro-
priate resources to help them though the situation. For clients who have formal
religious affiliations, the social worker should provide empathic listening, but also
help the client connect with religious professionals for more formal assistance.
The social worker can help clients who struggle with existential values face the
facts of that dilemma, but also maintain hope for resolution. Periods of active
crisis may not be the time to engage clients in a critical reflection about their
spirituality unless the client expresses a desire to do so. Such an intervention
may be appropriate following the client’s stabilization.

As noted by Caplan (1990), the purposes of crisis support include the pro-
motion of hope, reassurance, and an affirmation of the client’s sense of identity,
and the mobilization of support from others. The first two directly touch on the
social worker’s ability to mobilize aspects of spirituality that will promote crisis
resolution. Most of the intervention strategies included in this chapter can
promote that goal.

ATTENT ION TO SOCIAL JUST ICE ISSUES

The social worker’s development of crisis intervention skills is very much in
keeping with the profession’s value of promoting social justice. This is because
all people, and all types of clients, are vulnerable to crises related to injustice
throughout their lives. Further, through the linkage, referral, and advocacy activ-
ities that are common to crisis intervention, social workers can initiate change
activities on behalf of vulnerable clients who experience crises related to such
issues as poverty, unemployment, and discrimination. These activities can
enhance clients’ access to relevant information, services, resources, and opportu-
nities about events critical to their lives. Social workers also have a responsibility
to develop knowledge about cultural and ethnic diversity, so that they can better
understand the unique ways in which clients from special populations experience
and recover from crises.

EVIDENCE OF EFFECT IVENESS

The effectiveness of crisis intervention across programs and types of clients is dif-
ficult to evaluate. Every crisis is different, and the nature of a crisis (the event, the
client’s perception of that event, and the client’s resources) is significant in deter-
mining its course and outcome. Evaluating crisis intervention is further compli-
cated by the absence of uniform theoretical and practice principles across
programs. Perhaps for these reasons, little large-scale outcome research has
been conducted on the topic. Some literature reviews have found that crisis

C R IS I S T H E O R Y A N D I N T E R V E N T I O N 327

intervention is effective for stabilizing people with severe mental illnesses (Joy,
Adams, & Rice, 2006), and enhancing medication adherence (Haynes, Ackloo,
Sahota, McDonald, & Yao, 2008).

Corcoran and Roberts (2000) conducted a meta-analysis of the literature and
acknowledge that, though clients consistently express satisfaction with crisis
intervention services, other outcome measures might better determine the
long-range impact of these services as well as their curative factors. Only four
areas of crisis intervention are represented in the evaluation literature more than
anecdotally: crime victimization, suicide prevention, psychiatric emergencies, and
child abuse. Two studies of victim assistance for child sexual abuse (including
counseling and material assistance) found that parents were satisfied with those
services and reported positive family changes. Three evaluations of police crisis
teams (including officers and mental health workers) responding to domestic
violence calls determined that the officers were able to make more arrests, and
a majority of victims expressed that the intervention was helpful to their adjust-
ments. In 14 studies, researchers found a consistently negative correlation
between the presence of suicide prevention centers and suicide attempts in a
variety of cities, particularly among persons aged 15 to 24 years. A recent system-
atic review of suicide prevention strategies revealed that a number of best prac-
tices have been established (van der Feltz-Cornelius et al., 2011). These include
training general practitioners to recognize and treat depression and suicidality,
improving the accessibility of care for at-risk people, and restricting access to
means of suicide.

In 10 studies, psychiatric emergency services were found to be effective with
regard to reduced client hospitalizations and perceived mental health benefits
from clients. The services were effective for depressed persons, especially those
who did not have co-morbid personality disorders. They further appeared to be
more beneficial for females, older persons, and those from higher socioeconomic
groups. A four-year follow-up of one crisis program determined that the only
clients who required further intervention were those with previous treatment
histories (Mezzina & Vidoni, 1996). In programs targeted to clients with severe
mental illnesses (schizophrenia, bipolar disorder, and major depression), fewer
clients were rehospitalized, and a majority expressed service satisfaction. A
short-term (three-day) inpatient crisis intervention program effectively relieved
symptoms, and prevented longer-term hospitalizations for clients with mental ill-
nesses (Ligon & Thyer, 2000). Programs for children and adolescents at mental
health centers have also resulted in fewer hospital admissions. Treatment compli-
ance and the presence of family support are often stated as important factors in
positive outcomes.

Family preservation services are intensive in-home programs of counseling
and case management for children who are at risk of abuse or neglect. The goals
of such services are to prevent out-of-home placements and improve family
functioning. In 11 evaluation studies of these programs, all of which included a
crisis intervention component, it was consistently found that fewer out-of-home
placements occur. Interestingly, it does not appear that the quality of family
functioning improved in all cases, and there is not always a positive correlation

328 C H A P T E R 13

between parent attitudes about the program and placement outcomes. These
findings are mixed, however, as a recent literature review found that relatively
few studies have been conducted on this topic (O’Reilly, Wilkes, Luck, &
Jackson, 2010). A study of a related type of program found that community-
based crisis intervention for children was successful in maintaining children in
the home and increasing family adaptability and cohesion, but only in the short
term (Evans et al., 2003). On a related topic, a meta-analysis found clear evi-
dence that early psychological intervention for children and adolescents who
have experienced a traumatic experience is helpful toward their positive adjust-
ment (Kramer & Landolt, 2010).

Because of the many uncontrollable factors involved in crisis intervention,
evaluating their relative effectiveness requires creative use of research designs
(Dziegielewski & Powers, 2000). One set of researchers, writing about mobile
crisis psychiatric programs, urges the development of evaluation strategies that
can control for program variability, types of referrals, and program philosophy
(Ferris, Shulman, & Williams, 2001). A more extensive use of service recipients
in the evaluation process might also be helpful in clarifying impact factors.

CRIT IC ISMS OF THE THEORY

Crisis intervention may include elements from many practice theories, and thus it
cannot be subject to the “thematic” criticisms raised with other theories in this
book. No practitioner disputes that crisis intervention is an essential practice
modality. What can be criticized, however, is crisis theory as a human behavior
theory, with its emphasis on uniform stages in the experience of crisis for all peo-
ple. What is needed is a greater application of cross-cultural knowledge to issues of
crisis experience and recovery. Related attributes that can productively guide the
work of the crisis practitioner include knowledge about the status and experiences
of different cultural groups, skills for implementing culturally appropriate crisis
interventions, and experience in crisis intervention with different types of clients
(Canada et al., 2007; Kiselica, 1998). Among the common assumptions that crisis
practitioners must always question are that individuals (rather than the family or
social group) should be the focus of crisis intervention, that a client’s dependence
on others is an undesirable trait, and that formal services are superior to a client’s
natural supports. The processes of assessment and planning in crisis intervention
will become more appropriately client-centered as social workers develop broader
guidelines for understanding the crisis experiences of different cultural groups.

SUMMARY

All social work practitioners must be prepared to provide crisis intervention ser-
vices, regardless of their client population or practice setting. Although some
agencies have special crisis programs, any client can experience a developmental,

C R IS I S T H E O R Y A N D I N T E R V E N T I O N 329

situational, or existential crisis. The social worker’s specific methods of crisis
intervention can be quite varied, but they must always fit the context of the
client’s level of distress and be characterized by rapid assessment, brief duration,
focus on few issues, and a high level of practitioner activity. Crisis intervention is
also unique for some social workers in that it often requires cooperative and in-
tensive work with other professionals and the client’s significant others. In this
chapter, the nature of stress, crisis, and coping has been discussed, as well as a
variety of strategies for crisis intervention, all of them drawn from the book’s
earlier chapters.

TOPIC S FOR DISCUSSION

1. Share examples of crises that you or people you know (not clients) have
experienced. What was the nature of the crisis? How did the person (or
group) respond, and what factors seemed to influence the response?

2. Psychological stresses can be categorized as involving harm, threats, or chal-
lenges. Identify examples of each of these stress perceptions as they are seen
in direct practice. How does the way in which the situations are perceived
influence clients’ reactions? Are client perceptions generally realistic in this
regard?

3. In this chapter, crisis intervention strategies are described from the perspec-
tive of six practice theories. Consider other examples of client situations that
would be suited to each of these intervention perspectives.

4. All crisis interventions feature rapid assessment, time limits, a focus on few
issues, and a high level of practitioner activity. Review the case illustrations
included in this chapter and identify how each of these features was evident.

5. Discuss some ways that a social worker can help a client in crisis process
issues of spirituality (when the client wishes to do so) while maintaining a
position of spiritual “neutrality.”

IDEAS FOR ROLE-PLAYS

Organize role-plays for each of the following scenarios in two parts. First, the social worker
and client are meeting for the first time. Second, the social worker and client have met twice
already, and are now engaging in their final conversation (the client may be terminating or
being referred to another provider for ongoing assistance). As usual, use the roles of social
worker, client, and observer/assistant, and include other details as desired.

1. A 52-year-old working mother with a spouse and two children (aged 25 and
20) learns that she has pancreatic cancer, and will probably not live through
another year.

330 C H A P T E R 13

2. A family of four (father, 46, mother, 45, and two daughters, 16 and 11) has
lost its home due to hurricane damage. They must break up temporarily to
occupy other living quarters (the homes of a friend and a relative, and a
shelter).

3. An adolescent learns that his single father is going to prison. He will be
living with an aunt in another city whom he knows, but is not close to.

After each role-play, discuss the actions of the social worker, their rationales, and their
apparent effectiveness.

APPENDIX: Crisis Theory Outline

Focus The nature and types of crises experienced in human life

Major Proponents Lindemann, Caplan, Parad, Rapoport, Golan

Origins and
Social Context

The effects of stress in urban environments

Formal studies of social disasters

Studies of the behavior of soldiers in combat situations

Suicide prevention movement

Community Mental Health Centers Act

Geographic mobility (separation from natural supports)

Awareness of links between trauma and neurological
functioning

Nature of the
Individual

Universality of crisis stages (event, failed coping, positive
or negative adjustment)

Major Concepts Crisis (developmental, situational, existential)

Stress (including the general adaptation syndrome)

Crisis response (growth, equilibrium, frozen)

Coping and adaptation (biological and psychological)

Problem-focused coping

Emotion-focused coping

Social support (material, emotional, instrumental)

Developmental
Concepts

Stress experiences

Acquired coping patterns

Nature of Problems Physical, psychological, and social events that exceed
coping capacities

Nature of Change Growth, equilibrium, “frozen crisis”

Goals of Intervention Restore the client to the pre-crisis level of functioning

Enhance the client’s pre-crisis coping skills

C R IS I S T H E O R Y A N D I N T E R V E N T I O N 331

Nature of Worker/Client
Relationship

Intensive (client is vulnerable, receptive to help)

Worker is active

Client and worker focus on concrete tasks

Worker may interact with client’s significant others, other
professionals

Intervention Principles Clinical case management

Ego psychology

Behavioral

Cognitive

Structural

Solution-focused

Narrative

Assessment Questions What factors can the client identify related to the onset of
the crisis?

What is the current quality of the client’s emotional,
cognitive, and behavioral functioning? Which areas
appear to be the most adversely affected?

Is the client suicidal?

Does the client require immediate medical or psychiatric
attention?

How does the client’s current functioning compare with
his or her pre-crisis functioning?

Has there been significant trauma, illness, pathology, or
substance abuse in the client’s past?

What are the client’s strengths? Areas of stability?

What are the client’s present alternatives for managing
the stress?

What are the client’s available support systems (both
formal and informal)? Potential supports?

Are there financial, social, or personal impediments to
the client’s progress?

APPENDIX: Crisis Theory Outline (Continued)

332 C H A P T E R 13

References

Abbass, A., Town, J., & Driessen, E.
(2012). Intensive short-term dynamic
psychotherapy: A systematic review
and meta-analysis of outcome
research. Harvard Review of Psychiatry,
20(2), 97–108.

Abels, P., & Abels, S. L. (2002). Narrative
social work with groups: Just in time.
In S. Henry, J. F. East, & C. L.
Schmitz (Eds.), Social work with groups:
Mining the gold (pp. 57–73). New
York: Haworth Press.

Adams, J. F., Piercy, F. P., & Jurich, J. A.
(1991). Effects of solution-focused
therapy’s “formula first-session task”
on compliance and outcome in family
therapy. Journal of Marriage and Family
Therapy, 17(3), 277–290.

Addams, J. (1910). Twenty years at Hull
House. New York: Macmillan.

Adler, J. M. (2012). Living into the story:
Agency and coherence in a longitudinal
study of narrative identity development
and mental health over the course of
psychotherapy. Journal of Personality and
Social Psychology, 102(2), 367–389.

Agostinelli, G., Brown, J. M., & Miller,
W. R. (1995). Effects of normative
feedback on consumption among
heavy-drinking college students.

Journal of Drug Education, 25,
31–40.

Ainsworth, M. S., Blehar, M. C., &
Waters, E. (1978). Patterns of
attachment: A psychological study of the
strange situation. Oxford, England:
Lawrence Erlbaum.

Albarracín, D., Gillette, J. C., Earl, A. N.,
Glasman, L. P., Durantim, M. P., &
Ho, M-H. (2005). A test of major
assumptions about behavior change:
A comprehensive look at the effects
of passive and active HIV-prevention
interventions since the beginning of
the epidemic. Psychological Bulletin,
131(6), 856–897.

Aldwin, C. M. (2007). Stress, coping, and
development: An integrative perspective
(2nd ed.). New York: Guilford Press.

Allen, M. (2012). Narrative therapy for
women experiencing domestic violence.
Philadelphia: Jessica Kingsley
Publishers.

Allen-Meares, P. (1995). Social work with
children and adolescents. White Plains,
NY: Longman.

Aman, L. A. (2001). Family systems multi-
group therapy for ADHD children
and their families. Dissertation Abstracts
International, 6i(10-B), 5548.

American Foundation of Suicide
Prevention. (2010). Facts and figures:
National statistics. www.afsporg/
understanding-suicide/facts-and-
figures. Accessed: September 1,
2012.

American Psychiatric Association (2000).
Diagnostic and statistical manual of mental
disorders (4th ed.). Washington, DC:
Author.

Andreae, D. (1996). Systems theory and
social work treatment. In F. J. Turner
(Ed.), Social work treatment (4th ed.)
(pp. 601–616). New York: Free Press.

Andrew, G., & McMullen, L. M. (2000).
Interpersonal scripts in the anger
narratives told by clients in
psychotherapy. Motivation & Emotion,
24(4), 271–284.

Angus, L., Levitt, H., & Hardtke, K. (1999).
The Narrative Process Coding System:
Research applications and implications
for psychotherapy practice. Journal
of Clinical Psychology, 55(10),
1255–1270.

Aponte, H. J., & DiCesare, E. J. (2002).
Structural family therapy. In J.
Carlson & D. Kjos (Eds.), Theories and
strategies of family therapy (pp. 1–18).
Boston: Allyn & Bacon.

Aponte, H. J., Zarski, J. J., Bixenstine,
C., & Cibik, P. (1991).
Home/community-based services: A
two-tier approach. American Journal of
Orthopsychiatry, 61(3), 403–408.

Applegate, J. S. (1990). Theory, culture,
and behavior: Object relations in
context. Child and Adolescent Social
Work Journal, 7(2), 85–100.

Appleyard, K., Egeland, B., van Dulmen,
M. H., & Sroufe, L. A. (2005). When
more is not better: The role of
cumulative risk in child behavior
outcomes. Journal of Child Psychology
and Psychiatry, 46(1), 235–245.

Armitage, C. J. (2006). Evidence that
implementation intentions promote
transitions between the stages of

change. Journal of Counseling and
Clinical Psychology, 74(1),
141–151.

Atherton, C. R., & Bolland, K. A. (2002).
Postmodernism: A dangerous illusion
for social work. International Social
Work, 45(4), 421–433.

Aupperle, R. L., Melrose, A. J., Stein, M.
B., & Paulus, M. P. (2012). Executive
function and PTSD: Disengaging
from trauma. Neuropharmacology, 62(2),
686–694.

Baker, A., Lee, N. K., Claire, M., Lewin,
T. J., Grant, T., Pohlman, S.,
Saunders, J. B., Kay-Lambkin, F.,
Constable, P., Jenner, L., & Carr,
V. J. (2005). Brief cognitive
behavioural interventions for regular
amphetamine users: A step in the
right direction. Addiction, 100(3),
367–378.

Balter, R. (2012). Using cognitive-
behavioral therapy with clients who
identify with more than one minority
group: Can one size fit all? In R.
Nettles & R. Balter (Eds.), Multiple
minority identities: Applications for
practice, research, and training
(pp. 117–140). New York:
Springer Publishing Co.

Bambery, M., & Porcerelli, J. H., (2006).
Psychodynamic therapy for
oppositional defiant disorder:
Changes in personality, object
relations, and adaptive function after
six months of treatment. Journal of the
American Psychoanalytic Association,
54(4), 1334–1339.

Bandura, A. (1977). Social learning theory.
Englewood Cliffs, NJ:
Prentice-Hall.

Bankoff, S. M., Karpel, M. G., Forbes, H.
E., & Pantalone, D. W. (2012). A
systematic review of dialectical
behavior therapy for the treatment of
eating disorders. Eating Disorders: The
Journal of Treatment & Prevention,
20(3), 196–215.

334 R E F E R E N C E S

Bara, B. G. (1995). Cognitive science: A
developmental approach to the simulation of
the mind. Hove, U.K.: Lawrence
Erlbaum.

Barber, J. P., Foltz, C., DeRubeis, R. J., &
Landis, J. R. (2002). Consistency of
interpersonal themes in narratives
about relationships. Psychotherapy
Research, 12(2), 139–158.

Barker, S. L., & Floersch, J. E. (2010).
Practitioners’ understanding of
spirituality: Implications for social
work education. Journal of Social Work
Education, 46(3), 357–370.

Barkley, R. A. (2000). Commentary:
Issues in training parents to manage
children with behavior problems.
Journal of the American Academy of
Child & Adolescent Psychiatry, 39(8),
1004–1007.

Barkley, R. A., Guevremont, D. C.,
Anastopoulos, A. D., & Fletcher,
K. E. (1992). A comparison of three
family therapy programs for treating
family conflicts in adolescents with
attention-deficit hyperactivity
disorder. Journal of Consulting and
Clinical Psychology, 60(3), 450–462.

Barlow, C. A., Blythe, J. A., & Edmonds,
M. (1999). A handbook of interactive
exercises for groups. Needham Heights,
MA: Allyn & Bacon.

Bartle-Haring, S. (1997). The relationships
among parent-child-adolescent
differentiation, sex role orientation,
and identity development in late
adolescence and early adulthood.
Journal of Adolescence, 20(5), 553–565.

Basham, K. K. (1999). Therapy with a
lesbian couple: The art of balancing
lenses. In J. Laird (Ed.), Lesbians and
lesbian families (pp. 143–177). New
York: Columbia University Press.

Baucom, D. H., Epstein, N., Rankin, L.
A., & Burnett, C. K. (1996).
Understanding and treating marital
distress from a cognitive-behavioral
orientation. In K. Dobson & K. Craig

(Eds.), Advances in cognitive-behavioral
therapy (pp. 210–236). Thousand
Oaks, CA: Sage.

Becerra, M. D., & Michael-Marki, S.
(2012). Applying structural family
therapy with a Mexican-American
family with children with disabilities:
A case study of a single-parent mother.
Journal of Applied Rehabilitation
Counseling, 43(2), 17–24.

Beck, A. T. (1967). Depression: Clinical,
experimental, and theoretical aspects.
New York: Hoeber.

Beck, A. T. (1988). Love is never enough.
New York: Harper and Row.

Beck, J. S. (1995). Cognitive therapy: Basics
and beyond. New York: Guilford
Press.

Bell, L. G., Bell, D. C., & Nakata, Y.
(2001). Triangulation and adolescent
development in the U.S. and Japan.
Family Process, 40(2), 173–186.

Bello, N. D. (2011). Narrative case study:
Using the client as her own witness to
change. Journal of Systemic Therapies,
30(2), 11–21.

Beresford, T. P. (2012). Psychological
adaptive mechanisms: Ego defense
recognition in practice and research.
New York: Oxford University Press.

Berlin, S. B. (2002). Clinical social work
practice: A cognitive-integrative
perspective. New York: Oxford
University Press.

Bernall, G., & Rodriguez, M. M. D.
(2012). Cultural adaptations: Tools for
evidence-based practice with diverse
populations. Washington, DC:
American Psychological Association.

Bertera, E. M. (2007). The role of positive
and negative social exchanges
between adolescents, their peers, and
family as predictors of suicide
ideation. Child & Adolescent Social
Work Journal, 24(6), 523–538.

Bertolino, B., & O’Hanlon, B. (2002).
Collaborative, competency-based

R E F E R E N C E S 335

counseling and therapy. Boston: Allyn &
Bacon.

Besa, D. (1994). Evaluating narrative
family therapy using single-system
research designs. Research on Social
Work Practice, 4(3), 309–325.

Beutler, L. E., Forrester, B., Gallagher-
Thompson, D., Thompson, L., &
Tomlins, J. B. (2012). Common,
specific, and treatment fit variables in
psychotherapy outcome. Journal of
Psychotherapy Integration, 22(3),
255–281.

Beyebach, M., Sanchez, M. S. R., de
Miguel, J. A., de Vega, M. H.,
Hernandez, C., & Morejon, A. R.
(2000). Outcome of solution-focused
therapy at a university family therapy
center. Journal of Systemic Therapies,
19(1), 116–128.

Binks, C. A., Fenton, M., McCarthy, L.,
Lee, T., Adams, C. E., & Duggan, C.
(2006). Psychological therapies for
people with borderline personality
disorder. Cochrane Database of
Systematic Reviews 2006, Issue 1.
Art No CD005652. DOI 10
1002/14651858. CD 005652.

Bisman, C. D., & Hardcastle, D. A. (1999).
Integrating research into practice: A model
for effective social work. Belmont, CA:
Wadsworth.

Bisson, J., & Andrew, M. (2007).
Psychological treatment of post-
traumatic stress disorder (PTSD). The
Cochrane Database of Systematic
Reviews, (3), CD003388.

Blatt, S. J., & Ford, R. Q. (1999). The
effectiveness of long-term, intensive
inpatient treatment of seriously
disturbed, treatment-resistant young
adults. In H. Kaley & M. Eagle (Eds.),
Psychoanalytic theory as health care:
Effectiveness and economics in the 21st
century (pp. 221–238). New York:
Routledge.

Bloom, J. M., Woodward, E. N.,
Susmaras, T., & Pantalone, D. W.

(2012). Use of dialectical behavior
therapy in inpatient treatment of
borderline personality disorder: A
systematic review. Psychiatric Services,
63(9), 881–888.

Boehm, A., & Staples, L. H. (2002). The
functions of the social worker in
empowering: The voices of
consumers and professionals. Social
Work, 47(4), 449–460.

Bohlmeijer, E. T., Westerhof, G. J., &
Emmerick–de Jong, M. (2008).
The effects of integrative
reminiscence therapy on meaning in
life: Results of a quasi-experimental
study. Aging & Mental Health, 12(5),
639–646.

Borden, W. (2009a). Comparative
theories. In A. R. Roberts (Ed.).
Social workers’ desk reference (2nd ed.),
pp. 259–263. New York: Oxford
University Press.

Borden, W. (2009b). Contemporary
psychodynamic theory and practice.
Chicago: Lyceum.

Bowen, M. (1991a). Alcoholism as viewed
through family systems theory and
family psychotherapy. Family
Dynamics of Addiction Quarterly, 1(1),
94–102.

Bowen, M. (1991b). Family reaction to
death. In F. Walsh & M. McGoldrick
(Eds.), Living beyond loss: Death in the
family (pp. 79–92). New York: Norton.

Bowen, M. (1978). Family therapy in clinical
practice. Northvale, NJ: Jason
Aronson.

Bowen, M. (1959). The family as the unit
and study of treatment: I. Family
psychotherapy. American Journal of
Orthopsychiatry, 31, 40–60.

Boyle, S. W., Hull, G. H., Mather, J. H.,
Smith, L. L, & Farley, O. W. (2009).
Direct practice in social work (2nd ed.).
Boston: Allyn & Bacon.

Bozarth, J. D., Zimring, F. M., & Tausch,
R. (2002). Client-centered therapy:
The evolution of a revolution. In

336 R E F E R E N C E S

D. J. Cain (Ed.), Humanistic
psychotherapies: Handbook of research and
practice (pp. 147–188). Washington,
DC: American Psychological
Association.

Bozeman, B. N. (2000). The efficacy of
solution-focused therapy techniques
on perceptions of hope in clients with
depressive symptoms. Dissertation
Abstracts International, 61(2–3), 1117.

Bradley, P. D., Bergen, L. P., Ginter, E. J.,
Williams, L. M., & Scalise, J. J.
(2010). A survey of North American
marriage and family therapy
practitioners: A role delineation
study. American Journal of Family
Therapy, 38(4), 281–291.

Brausch, A. M., & Girresch, S. K. (2012).
A review of empirical treatment
studies for adolescent nonsuicidal
self-injury. Journal of Cognitive
Psychotherapy, 26(1), 3–18.

Brodie, D. A. (2005). Motivational
interviewing to promote physical
activity for people with chronic heart
failure. Journal of Advanced Nursing, 50
(5), 518–527.

Bromley, E., & Braslow, J. T. (2008).
Teaching critical thinking in
psychiatric training: A role for the
social sciences. American Journal of
Psychiatry, 165(11), 1396–1401.

Brown, C., & Augusta-Scott, T. (Eds.).
(2007). Narrative therapy: Making
meaning, making lives. Thousand Oaks,
CA: Sage.

Brown, J. A. (2011). Restless bedfellows:
Taling Bowen theory into a child-
focused adolescent treatment unit in
Australia. In O. C. Bregman & C. M.
White (Eds.), Bringing systems thinking
to life: Expanding the horizons for Bowen
family systems theory (pp. 319–328).
New York: Routledge/Taylor &
Francis.

Brownell, J. (1986). Building active listening
skills. Englewood Cliffs, NJ. Prentice-
Hall.

Bryck, R. L., & Fisher, P. A. (2012).
Training the brain: Practical
applications of neural plasticity from
the intersection of cognitive
neuroscience, developmental
psychology, and prevention science.
American Psychologist, 67(2),
87–100.

Buckley, W. (1967). Sociology and modern
systems theory. Englewood Cliffs, NJ:
Prentice-Hall.

Buehler, C., Franck, K. L., & Cook, E. C.
(2009). Adolescents’ triangulation in
marital conflict and peer relations.
Journal of Research on Adolescence, 19(4),
669–689.

Burke, B., Arkowitz, H., & Dunn, C.
(2002). The efficacy of motivational
interviewing and its adaptations: What
we know so far. In W. R. Miller &
S. Rollnick (Eds.), Motivational
interviewing (2nd ed.) (pp. 217–250).
New York: Guilford Press.

Burns, M. J. (1997). The effectiveness of a
brief, inpatient group therapy
program with sexually abused
women. Dissertation Abstracts
International, 57(9-B), 5908.

Butler, A. C., & Beck, J. S. (2001).
Cognitive therapy outcomes:
A review of meta-analyses. Journal of
the Norwegian Psychological Association,
37, 698–706.

Butterworth, S., Linden, A., McClay, W., &
Leo, M. C. (2006). Effect of
motivational interviewing–based
health coaching on employees’ physical
and mental health status. Journal of
Occupational Health Psychology, 11(4),
358–365.

Cacioppo, J. T., Bernston, G. G.,
Sheridan, J. F., & McClintock, M. K.
(2000). Multilevel integrative analyses
of human behavior: Social
neuroscience and the complementing
nature of social and biological
approaches. Psychological Bulletin,
126(6), 829–843.

R E F E R E N C E S 337

Canada, M., Heath, M. A., Money, K.,
Annandale, N., Fischer, L., & Young,
E. L. (2007). Crisis intervention for
students of diverse backgrounds: School
counselors’ concerns. Brief Treatment and
Crisis Intervention, 7(1), 12–24.

Cancrini, L., Cingolani, S., Compagnoni,
F., Costantini, D., & Mazzoni, S.
(1988). Juvenile drug addiction: A
typology of heroin addicts and their
families. Family Process, 27(1),
261–271.

Caplan, G. (1990). Loss, stress, and mental
health. Community Mental Health
Journal, 26(1), 27–48.

Caplan, G. (1989). Recent developments
in crisis intervention and the
promotion of support services. Journal
of Primary Prevention, 10(1), 3–25.

Carlson, E. A. (1998). A prospective
longitudinal study of attachment
disorganization/disorientation. Child
Development, 69(4), 1107–1128.

Carmin, C. N. (1995). Necessary, but still
not sufficient. PsycCRITIQUES, 40(5),
459–460.

Carroll, K. (1998). A cognitive-behavioral
approach: Treating cocaine addiction.
http://www.drugabuse.gov/
TXManuals/CBT/CBTl.html.
Downloaded on August 28, 2001.

Carroll, K. M. (1995). Methodological
issues and problems in the assessment
of substance use. Psychological
Assessment, 7(3), 349–358.

Carroll, M. A. (1994). Empowerment
theory: Philosophical and practical
difficulties. Canadian Psychology, 35
(4), 376–381.

Carter, B., & McGoldrick, M. (Eds.).
(1999). The expanded family life cycle:
Individual, family, and social perspectives.
Boston: Allyn & Bacon.

Cassin, S. E., von Ranson, K. M., Heng,
K., Brar, J., & Wojtowicz, A. E.
(2008). Adapted motivational
interviewing for women with binge
eating disorder: A randomized

controlled trial. Psychology of Addictive
Behaviors, 22(3), 417–425.

Cattaneo, L. B., & Chapman, A. R. (2010).
The process of empowerment: A
model for use in research and practice.
American Psychologist, 65(7),
646–659.

Cepeda, L. M., & Davenport, D. S. (2008).
Person-centered therapy and solution-
focused brief therapy: An integration
of present and future awareness.
Psychotherapy: Theory, Research,
Practice, Training, 43(1), 1–12.

Chamberlain, P., & Rosicky, J. G. (1995).
The effectiveness of family therapy in
the treatment of adolescents with
conduct disorders and delinquency.
Journal of Marital and Family Therapy,
21(4), 441–459.

Chambless, D. L. (1998). Empirically
validated treatments. In G. P. Koocher,
J. C. Norcross, & S. S. Hill (Eds.),
Psychologists’ Desk Reference (pp. 209–
219). New York: Oxford University
Press.

Chambless, D. L., & Ollendick, T. H.
(2001). Empirically supported
psychological interventions:
Controversies and evidence. American
Review of Psychology, 52, 685–716.

Chazin, R., Kaplan, K., & Terio, S.
(2000). The strengths perspective in
brief treatment with culturally diverse
clients. Crisis Intervention & Time-
Limited Treatment, 6(1), 41–50.

Clarkin, J. F., Foelsch, P. A., Levy, K. N.,
Hull, J. W., Delaney, J. C., &
Kernberg, O. F. (2001). The
development of a psychodynamic
treatment for patients with borderline
personality disorder A preliminary
study of behavior change Journal of
Personality Disorders, 15(6),
487–495.

Clarkin, J. F., Levy, K. N., Lenzenweger, &
Kernberg, O. F. (2007). Evaluating
three treatments for borderline
personaity disorder: A multiwave

338 R E F E R E N C E S

study. The American Journal of
Psychiatry, 164(6), 922–928.

Coates, J., & Schiff, J. W. (2011). Special
issue on social work, spirituality,
and social practices: Conclusion.
Journal of Religion and Spirituality in
Social Work: Social Thought, 30(3),
320–323.

Coates, J., & Sullivan, R. (2006). Achieving
competent family practice with
same-sex parents: Some promising
directions. In J. J. Bigner (Ed.), An
Introduction to GLBT Family Studies
(pp. 245–270). New York: Haworth
Press.

Cockburn, J. T., Thomas, F. N., &
Cockburn, O. J. (1997). Solution-
focused therapy and psychosocial
adjustment to orthopedic
rehabilitation in a work hardening
program. Journal of Occupational
Rehabilitation, 7(2), 97–106.

Cockle, S. (1993). Sandplay: A
comparative study. International Journal
of Play Therapy, 2(1), 1–17.

Cocoli, E. (2006). Attachment dimensions,
differentiation of self, and social
interest: A structured equations
modeling investigation of an
interpersonal-maturational model.
Dissertation Abstracts International,
Section B: The Sciences and Engineering,
67(6-B), 3343.

Coe, J. E. (1999). Developmental
perspectives on women’s experiences
of loneliness. Dissertation Abstracts
International, 59(8-A), 3206.

Coleman, S. B., Avis, J. M., & Turin, M.
(1990). A study of the role of gender
in family therapy training. Family
Process, 29(4), 365–374.

Comella, P. A. (2011). Observing
emotional functioning in human
relationship systems: Lessons from
Murray Bowen’s writings. In O. C.
Bregman & C. M. White (Eds.),
Bringing systems thinking to life:
Expanding the horizons for Bowen family

systems theory (pp. 3–30). New York:
Routledge/Taylor & Francis.

Comes-Diaz, L., & Jacobsen, F. M. (1991).
Ethnocultural transference and
countertransference in the therapeutic
dyad. American Journal of
Orthopsychiatry, 61(1), 392–402.

Connolly, C. M. (2004). Clinical issues
with same-sex couples A review of
the literature. In J. J. Bigner & J. L.
Wetchler (Eds.), Relationship therapy
with same-sex couples (pp. 3–12). New
York: Haworth Press.

Connors, G., Donovan, D., &
DiClemente, C. (2001). Substance
abuse treatment and stages of change:
Selecting and planning interventions.
New York: Guilford Press.

Conte, H. R. (1997). The evolving nature
of psychotherapy outcome research.
American Journal of Psychotherapy, 51(1),
445–448.

Cook, C. R., Gresham, F. M., Kern, L.,
Barreras, R. B., Thornton, S, &
Crews, S. D. (2008). Social skills
training for secondary students with
emotional and/or behavioral
disorders: A review and analysis of the
meta-analytic literature. Journal of
Emotional and Behavioral Disorders,
16(3), 131–144.

Cook, L. (2007). Perceived conflict,
sibling position, cut-off, and
multigenerational transmission in the
family of origin of chemically
dependent persons: An application of
Bowen family systems theory. Journal
of Addictions Nursing, 18(3), 131–140.

Cooper, J. (2012). Cognitive dissonance
theory. In P. A. M. Van Lange, A. W.
Kruglanski, & T. E. Higgins (Eds.),
Handbook of theories of social psychology,
vol.1 (pp. 377–397). Thousand
Oaks, CA: Sage.

Cooper, M. (2003). Between freedom and
despair: Existential challenges and
contributions to person-centered and
experiential therapy. Person-Centered

R E F E R E N C E S 339

and Experiential Psychotherapies, 2(1),
43–56.

Cooper, M., & McLeod, J. (2011).
Person-centered therapy: A pluralistic
perspective. Person-Centered and
Experiential Psychotherapies, 10(3),
210–223.

Cooper, M. G., & Lesser, J. G. (2002).
Clinical social work practice: An integrated
approach. Boston: Allyn & Bacon.

Corcoran, J. (2005). Building strengths and
skills: A collaborative approach to working
with clients. New York: Oxford
University Press.

Corcoran, J. (2000). Brief solution-focused
therapy. In N. Coady & P. Lehman
(Eds.), Theoretical perspectives in direct
social work practice: An eclectic-generalist
approach (pp. 326–343). New York:
Springer.

Corcoran, J., & Nichols-Casebolt, A.
(2004). Risk and resilience ecological
framework for assessment and goal
formulation. Child & Adolescent Social
Work Journal, 21(3), 211–235.

Corcoran, J., & Roberts, A R. (2000).
Research on crisis intervention and
recommendations for future research.
In A. R. Roberts (Ed.), Crisis
intervention handbook: Assessment,
treatment, and research (2nd ed.)
(pp. 453–486). New York: Oxford
University Press.

Corcoran, J., & Stephenson, M. (2000).
The effectiveness of solution-focused
therapy with child behavior
problems. A preliminary report.
Families in Society, 18(5), 468–474.

Corcoran, J., & Walsh, J. (2010). Clinical
assessment and diagnosis in social work
practice (2nd ed.). New York: Oxford
University Press.

Corcoran, K., & Videka-Sherman, L.
(1992). Some things we know about
effective social work. In K. Corcoran
(Ed.), Effective practice for common client
problems (pp. 15–27). Chicago:
Lyceum.

Cornelius-White, J. H. D. (2002). The
phoenix of empirically-supported
therapy relationships: The overlooked
person-centered bias. Psychotherapy:
Theory, Research, Practice, Training,
39(3), 219–222.

Corwin, M. (2002). Brief treatment in clinical
social work practice. Pacific Grove, CA:
Brooks/Cole.

Cournoyer, B., & Powers, G. (2002).
Evidence-based social work: The
quiet revolution continues. In A. R.
Roberts & G. J. Greene (Eds.), Social
workers’ desk reference (pp. 798–807).
New York: Oxford University Press.

Coyne, J.C. (1994). Possible contributions of
“cognitive science” to the integration
of psychotherapy. Journal of
Psychotherapy Integration, 4(4), 401–416.

Crepaz, N., Passin, W. F., & Herbst, J. H.
(2008). Meta-analysis of cognitive-
behavioral interventions on HIV-
positive persons’ mental health and
immune functioning. Health
Psychology, 27(1), 4–14.

Crimone, M. W., & Hester, D. (2011).
Across the generations: The training
of clergy and congregations. In O. C.
Bregman & C. M. White (Eds.),
Bringing systems thinking to life:
Expanding the horizons for Bowen family
systems theory (pp. 197–207). New
York: Routledge/Taylor & Francis.

Crisp, B. R. (2010). Spirituality and social
work. Burlington, VT: Ashgate
Publishing Co.

Crits-Cristoph, P. (1998). Training in
empirically validated treatments: The
division 12 APA task force
recommendations. In K. S. Dobson &
K. D. Craig (Eds.), Empirically
supported therapies: Best practice in
professional psychology (pp. 3–25).
Thousand Oaks, CA: Sage.

Cusinato, M. (2012). Existentialism. In
L. L’Abate (Ed.), Paradigms in theory
construction (pp. 317–338). New York:
Springer.

340 R E F E R E N C E S

Dahl, R., Bathel, D., & Carreon, C. (2000).
The use of solution-focused therapy
with an elderly population. Journal of
Systemic Therapies, 19(A), 45–55.

Dallos, R., & Vetere, A. (2012). Systems
theory, family attachments, and
processes of triangulation: Does the
concept of triangulation offer a useful
bridge? Journal of Family Therapy,
34(2), 117–137.

Dalton, T. A. (1997). Listening to
maternal stories: Reconstructing
maternal-child relations to include
the voices of mothers. Dissertation
Abstracts International, 58(1-A),
0290.

Davies, D. (2000). Person-centered
therapy. In D. Davies & C. Neal
(Eds.), Therapeutic perspectives on
working with lesbian, gay, and bisexual
clients (pp. 91–105). Maidenhead,
England: Open University Press.

Davis, M., Eshelman, E. R., & McKay, M.
(2008). The relaxation and stress
workbook (6th ed.). New York: MJF
Books.

Day, P. J. (2000). A new history of social
welfare (3rd ed.). Boston: Allyn &
Bacon.

Dejong, P., & Berg, I. K. (2008).
Interviewing for solutions (3rd ed.).
Pacific Grove, CA: Brooks/Cole.

de Shazer, S. (1994). Words were originally
magic. New York: Norton.

de Shazer, S. (1985). Keys to solution in brief
therapy. New York: Norton.

Dewey, J. (1938). Logic: The theory of
inquiry. New York: Holt.

Diamond, J. P. (1997). Narrative means to
sober ends: Language, interpretation,
and letter writing. Dissertation Abstracts
International, 57(10-A), 4542.

Diguer, L., Pelletier, S., Hébert, É.,
Descôteaux, J., Rousseau, J., &
Daoust, J. (2004). Personality
organizations, psychiatric severity, and
self and object representations.

Psychoanalytic Psychology, 21(2),
259–275.

Dingledine, D. W. (2000). Standing in the
shadows: Adult daughters of alcoholic
mothers. Dissertation Abstracts
International, 61(5-A), 2037.

Dodge, T. D. (2001). An investigation
of the relationship between the
family of origin and selected career
development outcomes. Dissertation
Abstracts International, 62(2-B),
1140.

Dolgoff, R., Loewenberg, F. M., &
Harrington, D. (2008). Ethical decisions
for social work practice (8th ed.). Itasca,
IL: F. E. Peacock.

Dorfman, R. A. (1996). Clinical social work:
Definition, practice, and vision. New
York: Brunner/Mazell.

Draycott, S., & Dabbs, A. (1998).
Cognitive dissonance 2: A theoretical
grounding of motivational
interviewing. British Journal of Clinical
Psychology, 37, 335–364.

Dunn, C., Deroo, L., & Rivara, F. (2001).
The use of brief interventions
adapted from motivational
interviewing across behavioral
domains: A systematic review.
Addiction, 96, 1725–1742.

Dunn, E. C., Neighbors, C., & Larimer,
M. E. (2006). Motivational
enhancement therapy and self-help
treatment for binge eaters. Psychology
of Addictive Behaviors, 20(1),
44–52.

Dysinger, R. H., & Bowen, M. (1959).
Problems for medical practice
presented by families with a
schizophrenic member. American
Journal of Psychiatry, 116,
514–517.

Dziegielewski, S. F., & Montgomery,
D. H. (1999). Gender issues in family
therapy. In C. Franklin & C. Jordan
(Eds.), Family practice: Brief systems
methods for social work (pp. 321–340).
Pacific Grove, CA: Brooks/Cole.

R E F E R E N C E S 341

Dziegielewski, S. F., & Powers, G. T.
(2000). Designs and procedures for
evaluating crisis intervention. In A. R.
Roberts (Ed.), Crisis intervention
handbook: Assessment, treatment, and
research (2nd ed.) (pp. 487–511). New
York: Oxford University Press.

Eakes, G., Walsh, S., Markowski, M., &
Cam, H. (1997). Family-centered
brief solution-focused therapy with
chronic schizophrenia: A pilot study.
Journal of Family Therapy, 19(1),
145–158.

Eaton, Y. M., & Roberts, A. R. (2009).
Front-line crisis intervention.
In A. R. Roberts (Ed.),
Social workers’ desk reference (2nd ed.)
(pp. 207–215). New York:
Oxford University Press.

Edmonson, C. R. (2002). Differentiation
of self and patterns of grief following
the death of a parent. Dissertation
Abstracts International, Section B: The
Sciences and Engineering, 62(12-B),
5960.

Ehrenreich, J. H. (1985). The altruistic
imagination: A history of social work and
social policy in the United States. Ithaca,
NY: Cornell University Press.

Elliott, C., & Metcalf, L. (2009). The art of
solution-focused therapy. New York:
Springer.

Ellis, A. (1962). Reason and emotion in
psychotherapy. New York:
Stuart.

Ellis, A., & McLaren, C. (1998). Rational
emotive behavior therapy: A therapist’s
guide, vol. 2. Atascadero, CA: Impact
Publishers, Inc.

Emerson, R. W. (1958). Emerson: A
modern anthology. Boston: Houghton
Mifflin.

Entin, A. D. (2001). Pets in the family.
Issues in Interdisciplinary Care, 3(1),
219–222.

Epps, S., & Jackson, B. (2000). Empowered
families, successful children. Washington,
DC: APA.

Epston, D., White, M. (1995).
Termination as a rite of passage:
Questioning strategies for a therapy of
inclusion. In R. A. Neimeyer & M. J.
Mahoney (Eds.), Constructivism in
psychotherapy, (pp. 339–354).
Washington, DC: American
Psychological Association.

Erikson, E. (1968). Identity: Youth and crisis.
New York: W. W. Norton.

Evans, M. E., Boothroyd, R. A.,
Armstrong, M. I., Greenbaum, P. E.,
Brown, E. C., & Kuppinger, A. D.
(2003). An experimental study of the
effectiveness of intensive in-home
crisis services for children and their
families: Program outcomes. Journal
of Emotional and Behavioral Disorders,
11(1), 93–104.

Everett, J. E., Homstead, K., & Drisko, J.
(2007). Frontline worker perceptions
of the empowerment process in
community-based agencies. Social
Work, 52(1), 161–170.

Eysenck, H. J., & Rachman, S. (1965). The
causes and cures of neurosis: An
introduction to modern behavior therapy
based on learning theories and the
principles of conditioning. London:
Routledge & Kegan Paul.

Farber, S. (with Romer, A.). (1999). An
interview with Dr. Stuart Farber:
Living with a serious illness: A
workbook for patients and families
[Electronic version]. Innovations in
End-of-Life Care, 1, 2–13.

Farmer, R. L. (2009). Neuroscience and social
work practice. Thousand Oaks, CA:
Sage.

Farson, R. E. (1965). Science and human affairs.
Palo Alto, CA: Science and Behavior
Books.

Feaster, D. J., Mitrani, V. B., Burns, M. J.,
McCabe, B. E., Brincks, A. M.,
Rodriguez, A. E., Asthana, D., &
Robbins, M. S. (2010). A randomized
controlled trial of structural
ecosystems therapy for HIV

342 R E F E R E N C E S

medication adherence and
substance abuse relapse prevention.
Drug and Alcohol Dependence, 111(3),
227–234.

Feldman, E. L. (1998). Loneliness and
physician utilization in a primary care
population. Dissertation Abstracts
International, 59(1-A), 0322.

Fenichel, G. H. (Ed.). (1994).
Psychoanalysis at 100: An issues in ego
psychology book. Lanham, MD:
University Press of America.

Ferris, L. E., Shulman, K. L., & Williams,
J. I. (2001). Methodological
challenges in evaluating mobile crisis
psychiatric programs. The Canadian
Journal of Program Evaluation, 16(1),
27–40.

Festinger, L. (1962). A theory of cognitive
dissonance. Palo Alto, CA: Stanford
University Press.

Fischer, J. (1976). The effectiveness of social
casework. Springfield, IL: Charles C.
Thomas.

Fischer, J. (1973). Is casework effective? A
review. Social Work, 18, 5–20.

Folkman, S. (2009). Commentary on
the special section “Theory-based
approaches to stress and coping”:
Questions, answers, issues, and next
steps in stress and coping
research. European Psychologist,
14(1), 72–77.

Flanagan, L. M. (2011). Object relations
theory. In J. Berzoff, L. Flanaga, & P.
Hertz (Eds.), Inside out and outside in
(pp. 118–157). New York: Rowan
and Littlefield.

Fong, R., & Furuto, S. (Eds.). (2001).
Culturally competent practice: Skills,
interventions, and evaluations. Boston:
Allyn & Bacon.

Foucault, M. (1966). The order of things: An
archaeology of the human sciences. New
York: Vintage.

Frank, J. D., & Frank, J. B. (1993).
Persuasion and healing: A comparative

study of psychotherapy (3rd ed.).
Baltimore: Johns Hopkins University
Press.

Frankl, V. E. (1988). The will to meaning:
Foundations and applications of
logotherapy. New York: Meridian.

Franklin, C., Hopson, L., & Barge, C. T.
(2003). Family systems. In C. Jordan &
C. Franklin (Eds.), Clinical assessment
for social workers: Quantitative and
qualitative methods (2nd ed.)
(pp. 255–311). Chicago: Lyceum.

Franklin, C., Biever, J., Moore, K.,
Clemons, D., & Scamardo, M.
(2001). The effectiveness of solution-
focused therapy with children in a
school setting. Research on Social Work
Practice, 11(4), 411–434.

Franklin, C., Trepper, T. S., Gingerich,
W., & McCollum, E. E. (2012).
Solution-focused therapy: A handbook of
evidence-based practice. New York:
Oxford University Press.

Fraser, M. W. (2004). Intervention
research in social work: Recent
advances and continuing challenges.
Research on Social Work Practice, 14(1),
210–222.

Freedberg, S. (2007). Re-examining
empathy: A relational-feminist
point of view. Social Work, 52(1),
251–259.

Freedman, J., & Combs, J. (1996).
Narrative therapy: The social construction
of preferred realities. New York:
W. W. Norton.

Freeman, A. (2004). Clinical applications of
cognitive therapy. New York: Kluwer
Academic/Plenum Publishers.

Furlong, M., McGilloway, S., Bywater, T.
Hutchings, J., Smith, A. M., &
Donnelly, M. (2012). Behavioural
and cognitive-behavioral group-based
parenting programmes for early-onset
conduct problems in children
aged 3 to 12 years. Cochrance
Database of Systematic Reviews, 2,
CD008225.

R E F E R E N C E S 343

Furukawa, T. A., Watanabe, N., &
Churchill, R. (2007). Combined
psychotherapy plus antidepressants
for panic disorder with or without
agoraphobia. Cochrance Database
of Systematic Reviews, 1,
CD004364.

Furman, R. (2002). Jessie Taft and the
functional school: The impact of our
history. Canadian Journal of Social
Work, 4(1), 7–13.

Gambrill, E. (2011). Evidence-based
practice and the ethics of discretion.
Journal of Social Work, 11(1),
26–48.

Gambrill, E., & Gibbs, L. (2009). Critical
thinking for helping professionals:
A skills-based workbook (3rd ed.).
New York: Oxford University Press.

Gambrill, E. D. (1994). Concept and
methods of behavioral treatment. In
D. K. Granvold (Ed.), Cognitive and
behavioral treatment: Methods and
applications (pp. 32–62). Pacific Grove,
CA: Brooks/Cole.

Gates, S., McCambridge, J., Smith, L. A., &
Foxcroft, D. R. (2006).
Interventions for programs for
prevention of drug use by young
people delivered in nonschool
settings. Cochrane Database of
Systematic Reviews, 1,
CD005030.

Gensterblum, A. E. (2002). Solution-
focused therapy in residential settings.
Dissertation Abstracts International,
62(7-B), 3377.

Georgetown Family Center (2012).
http://www.georgetownfamily
center.org/index.html.

Gerhardt, S. (2004). Why love matters: How
affection shapes a baby’s brain.
Philadelphia: Routledge/Taylor and
Francis.

Gest, S. D., & Davidson, A. J. (2011). A
developmental perspective on risk,
resilience, and prevention. In M. K.
Underwood & L. H. Rosen (Eds.),

Social development: Relationships in
infancy, childhood, and adolescence
(pp. 427–454). New York:
Guilford Press.

Gibbs, J. T. (1998). African American
adolescents. In J. T. Taylor & L. N.
Huang (Eds.), Children of color:
Psychological interventions with culturally
diverse youth (pp. 171–214). San
Francisco: Jossey-Bass.

Gilligan, C. (1982). In a different voice.
Cambridge, MA: Harvard University
Press.

Gilliland, B. E., & James, R. K.
(2005). Crisis intervention strategies
(5th ed). Belmont, CA:
Brooks/Cole.

Gingerich, W. J., & Eisengart, S. (2000).
Solution-focused brief therapy:
A review of the outcome
research. Family Process, 39(4),
477–498.

Gist, R., & Devilly, G. J. (2002).
Post-trauma debriefing: The road
too frequently traveled. Lancet,
360(9335), 741–742.

Gitterman, A. (2009). The life model. In
A. R. Roberts (Ed.), Social workers’
desk reference (2nd ed.)
(pp. 231–235). New York:
Oxford University Press.

Glade, A. C. (2005). Differentiation,
marital satisfaction, and depressive
symptoms: An application of
Bowen theory. Dissertation
Abstracts International, Section B:
The Sciences and Engineering,
66(6S), 3408.

Golan, N. (1987). Crisis intervention. In
A. Minahan (Ed.), Encyclopedia of social
work (pp. 360–372). Silver Spring,
MD: NASW.

Golan, N. (1978). Treatment in crisis
situations. New York:
Free Press.

Goldberg, E. H. (1989). Severity of
depression and developmental levels
of psychosocial functioning in

344 R E F E R E N C E S

8–16-year-old girls. American
Journal of Orthopsychiatry, 59(2),
167–178.

Goldfried, M. R., & Wolfe, B. E. (1998).
Toward a more clinically valid
approach to therapy research. Journal
of Consulting and Clinical Psychology,
66(1), 143–150.

Goldstein, E. G. (2009). The relationship
between social work and
psychoanalysis: The future impact of
social workers. Clinical Social Work
Journal, 37(1), 7–13.

Goldstein, E. G. (2008). Ego psychology
theory. In B. A. Thyer, K. M.
Sowers, & C. N. Dulmus (Eds.),
Comprehensive handbook of social work
and social welfare, vol. 2: Human
behavior in the social environment
(pp. 135–162). Hoboken, NJ: John
Wiley & Sons.

Goldstein, E. G. (2001). Object relations
theory and self psychology in
social work practice. New York:
Free Press.

Goldstein, E. G. (1995). Ego psychology and
social work practice (2nd ed.). New
York: Free Press.

Goldstein, E. G., & Noonan, M. (1999).
Short-term treatment and social work
practice. New York: Free Press.

Goldstein, H. (1990). The knowledge base
of social work practice: Theory
wisdom, analogue, or art? Families in
Society, 11, 32–43.

Goodrich, T. J. (2006). A new
department. Family Systems & Health,
24(1), 218–219.

Gonzalez, J. E., Nelson, J. R., & Gutkin,
T. B. (2004). Rational emotive
therapy with children and
adolescents: A meta-analysis. Journal
of Emotional and Behavioral Disorders,
12(4), 222–235.

Goodson, I. F. (2013). Developing narrative
theory: Life histories and personal
representation. New York: Routledge/
Taylor & Francis Group.

Gorey, K., Thyer, B. A., & Pawluck, D.
(1998). The differential effectiveness
of social work interventions:
A meta-analysis. Social Work,
43(1), 269–278.

Gottlieb, M. C., & Lasser, J. (2001).
Competing values: A respectful
critique of narrative research.
Ethics and Behavior, 11(1),
191–194.

Gould, R. L., Coulson, M. C., & Howard,
R. J. (2012). Efficacy of cognitive
behavioral therapy for anxiety
disorders in older people: A meta-
analysis and meta-regression of
randomized controlled trials.
Journal of the American Geriatrics Society,
60(10), 1817–1830.

Grafanaki, S., & McLeod, J. (1999).
Narrative processes in the
construction of helpful and hindering
events in experiential psychotherapy.
Psychotherapy Research, 9(1),
289–303.

Granvold, D. K. (1994). Concepts and
methods of cognitive treatment. In D.
K. Granvold (Ed.), Cognitive and
behavioral treatment: Methods and
applications (pp. 3–31). Pacific Grove,
CA: Brooks/Cole.

Gray, P. (2005). The ego and analysis of
defense (2nd ed.). Northvale, NJ: Jason
Aronson.

Green, B., & Boyd-Franklin, N. (1996).
African American lesbians: Issues in
couples therapy. In J. Laird & R. J.
Green (Eds.), Lesbians and gays in
couples and families: A handbook for
therapists (pp. 251–271). San
Francisco: Jossey-Bass.

Green, D. L., Choi, J. J., & Kane, M. N.
(2010). Coping strategies for victims
of crime: Effects of the use of
emotion-focused, problem-focused,
and avoidance-oriented coping.
Journal of Human Behavior in the
Social Environment, 20(6),
732–743.

R E F E R E N C E S 345

Green, R. J. (2007). Gay and lesbian
couples in therapy: A social justice
perspective. In E. Aldarondo (Ed.),
Advancing social justice through clinical
practice (pp. 119–149). Mahwah, NJ:
Lawrence Erlbaum.

Green, R. J., & Mitchell, V. (2002). Gay
and lesbian couples in therapy:
Homophobia, relational ambiguity,
and social support. In A. S. Gurman &
N. S. Jacobson (Eds.), Clinical
handbook of couple therapy (3rd ed)
(pp. 546–568). New York:
Guilford Press.

Greenan, D. E., & Tunnell, G. (2003).
Couple therapy with gay men. New
York: Guilford Press.

Greenberg, M., Speltz, M., DeKlyen, M.,
Jones, K. (2001). Correlates of clinic
referral for early conduct problems:
Variable- and person-oriented
approaches. Development &
Psychopathology, 13, 255–276.

Greene, R. R. (2008). Risk and resilience
theory: A social work perspective. In
R. R. Greene (Ed.), Human behavior
theory and social work practice
(3rd ed.) (pp. 315–342).
Piscataway, NJ: Transaction
Publishers.

Grenyer, B. F. S., & Laborsky, L. (1996).
Dynamic change in psychotherapy:
Mastery of interpersonal conflicts.
Journal of Consulting and Clinical
Psychology, 64(1), 411–416.

Gresham, F. M. (2005). Methodological
issues in evaluating cognitive-
behavioral treatments for students
with behavioral disorders. Behavioral
Disorders, 30(1), 213–225.

Guerin, P. J., & Guerin, K. (2002).
Bowenian family therapy. In J.
Carlson & D. Kjos (Eds.), Theories
and strategies of family therapy
(pp. 126–156). Boston:
Allyn & Bacon.

Guerin, P. J., Fogarty, T. F., Fay, L. F., &
Kautto, J. G. (1996). Working with

relationship triangles: The one-two-three
of psychotherapy. New York: Guilford
Press.

Gutierrez, L., Parsons, R., & Cox, E. O.
(2003). Empowerment in social work
practice: A sourcebook. Pacific Grove,
CA: Brooks/Cole.

Haby, M. M., Tonge, B., Littlefield, L.,
Carter, R., & Vos, T. (2004). Cost-
effectiveness of cognitive behavioural
therapy and selective serotonin
reuptake inhibitors for major
depression in children and
adolescents. Australian and New
Zealand Journal of Psychiatry, 38(8),
579–591.

Haimeri, D., Finke, J., & Luderer, H.
(2009). Person-centered and
experiential therapy of depression.
International Journal of Psychotherapy,
13(2), 18–25.

Hale, N. G. (1995). The rise and crisis of
psychoanalysis in the United States: Freud
and the Americans, 1917–1985.
London: Oxford University Press.

Hamilton, G. (1951). Theory and practice of
social case work (2nd ed.). New York:
Columbia University Press.

Hammond, R. T., & Nichols, M. P.
(2008). How collaborative is
structural family therapy? The Family
Journal, 16(1), 118–124.

Hardie, E., Kashima, E. S., & Pridmore, P.
(2005). The influence of relational,
individual, and collective self-aspects
on stress, uplifts, and health. Self and
Identity, 4(1), 1–24.

Hargie, O. D. W. (Ed.). (1997). The
handbook of communication skills. New
York: Routledge.

Harper, K. V., & Lantz, J. (2007). Cross-
cultural practice: Social work with diverse
populations (2nd ed). Chicago:
Lyceum.

Harris, A. (2012). Transference,
countertransference, and the real
relationship. In G. O. Gabbard, B. E.
Litowitz, & P. Williams (Eds.),

346 R E F E R E N C E S

Textbook of psychoanalysis (2nd ed.),
(pp. 255–268). Arlington, VA:
American Psychiatric Publishing.

Harris, J. N., Hay, J., Kuniyuki, A., Asgari,
M. M., Press, N., & Bowen, D. J.
(2010). Using a family systems
approach to investigate cancer risk
communication within melanoma
families. Psycho-Oncology, 19(1),
1102–1111.

Hartmann, H. (1958). Ego psychology and
the problem of adaptation. New York:
International Universities Press.

Hauser, S. T., & Safyer, A. W. (1995). The
contribution of ego psychology to
developmental psychopathology. In
D. Cicchetti & D. J. Cohen (Eds.),
Developmental psychopathology, Volume
1: Theory and methods (pp. 555–580).
New York: Wiley.

Haynes, R. B., Ackloo, E., Sahota, N.,
McDonald, H. P., & Yao, X. (2008).
Interventions for enhancing
medication adherence. Cochrane
Database of Systematic Reviews, 2,
CD000011.

Helgeson, V., Reynolds, K., & Tomich,
P. (2006). A meta-analytic review of
benefit finding and growth. Journal of
Consulting and Clinical Psychology, 74,
797–816.

Hepworth, D., Rooney, R., Rooney, G.
D., Strom-Gottfried, K., & Larsen, J.
(2012). Direct social work practice:
Theory and skills (8th ed.). Belmont,
CA: Brooks/Cole.

Hertlein, K. M., & Killmer, J. M. (2004).
Toward differential decision-making:
Family systems theory with the
homeless clinical population. American
Journal of Family Therapy, 32(1),
255–270.

Himle, J. A., Rassi, S., Haghighatgou, H.,
Krone, K. P., Nesse, R. M., & Abelson,
J. (2001). Group behavioral therapy of
obsessive-compulsive disorder: Seven-
vs twelve-week outcomes. Depression
and Anxiety, 13(4), 161–165.

Hinshaw, S. P., Klein, R. G., & Abikoff,
H. B. (2002). Childhood attention
deficit hyperactivity disorder:
Nonpharmacological treatments and
their combination with medication.
In P. E. Nathan & J. M. Gordon
(Eds.), A guide to treatments that work
(2nd ed.), (pp. 3–23). London:
Oxford University Press.

Hobfoll, S. E. (1996). Social support: Will
you be there when I need you? In N.
Vanzetti & S. Duck (Eds.), A lifetime of
relationships (pp. 46–74). Belmont,
CA: Brooks/Cole.

Hodges, V. G. (1994). Home-based
behavioral intervention with children
and families. In D. K. Granvold (Ed.),
Cognitive and behavioral treatment:
Methods and applications
(pp. 90–107). Pacific Grove, CA:
Brooks/Cole.

Hofmann, S. G. & Reinecke, M. A. (Eds.)
(2010). Cognitive-behavioral therapy with
adults: A guide for assessment,
conceptualization, and intervention.
Boston: Cambridge University Press.

Högberg, G., & Hällstrom, T. (2008).
Active multimodal psychotherapy in
children and adolescents with
suicidality: Description, evaluation,
and clinical profile. Clinical Child
Psychology and Psychiatry, 13(1),
435–448.

Høglend, P., Hersoug, A. G., Bøgwald,
K., Amlo, S., Marble, A., Sørbye, Ø.,
Røssberg, J. I., Ulberg, R., Gabbard,
G. O., & Crits-Christoph, P. (2011).
Effects of transference work in the
context of therapeutic alliance and
quality of object relations. Journal of
Consulting and Clinical Psychology,
79(5), 697–706.

Hollis, F. H. (1964). Casework: A psychosocial
therapy. New York: Random House.

Hooper, L. M., & DePuy, V. (2010).
Mediating and mederating effects of
differentiation of self on depression
symptomatology in a rural

R E F E R E N C E S 347

community sample. The Family
Journal, 18(4), 358–368.

Horvath, A. O. (1994). Research on the
alliance. In A. O. Horvath & L. S.
Greenberg (Eds.), The working alliance:
Theory, research, and practice
(pp. 259–286). New York: Wiley.

Howe, L. T. (1998). Self-differentiation in
Christian perspective. Pastoral
Psychology, 46(5), 347–362.

Howells, J. G., & Guirguis, W. R. (1985).
The family and schizophrenia. New
York: International Universities Press.

Hull, C. (1943). Principles of behavior. New
York: Appleton-Century-Crofts.

Hunter, T. J. (1998). Naturalistic inquiry
of alcoholic families from ethnically
diverse backgrounds. Dissertation
Abstracts International, 59(1-B),
0418.

Illick, S. D., Hilbert-McAllister, G.,
Jefferies, S. E., & White, C. M.
(2003). Toward understanding and
measuring emotional cutoff. In P.
Titelman (Ed.), Emotional cutoff:
Bowen family systems theory perspectives
(pp. 199–217). New York: Haworth
Press.

Ingram, R. E. (Ed.). (1986). Information
processing approaches to clinical
psychology. Orlando, FL: Academic
Press.

Irwin, M. R., Cole, J. C., & Nicassio, P.
M. (2006). Comparative meta-
analysis of behavioral interventions
for insomnia and their efficacy in
middle-aged adults and in older adults
55+ years of age. Health Psychology,
25(1), 3–14.

Jackson, M. S., & Feit, M. D. (2011).
Connecting practice and research: A
social work paradigm of working
collaboratively with underserved
populations. Journal of Human Behavior in
the Social Environment, 21(7),
711–714.

Jackson, R., Asimakopoulou, K., &
Scammel, A. (2007). Assessment of

the transtheoretical model as used by
dietitians in promoting physical
activity in people with type 2
diabetes. Journal of Human Nutrition
and Dietetics, 20(1), 27–36.

Jakobsen, J. N., Hansen, J. L., Storebo,
O. J., Simonson, E., & Gluud, C.
(2011). The effects of cognitive
therapy versus “no intervention” for
major depressive disorder. PLoS
ONE, 6(12), 1–11.

James, R. K., & Gilliland, B. E. (2013).
Crisis intervention strategies (7th ed.).
Pacific Grove, CA: Brooks/Cole.

Jankowski, P. J., & Hooper, L. M. (2012).
Differentation of self: A validation
study of the Bowen theory
construct. Couple and Family
Psychology: Research and Practice, 1(3),
226–243.

Johnson, H. C. (1991). Theories of
Kernberg and Kohut: Issues of
scientific validation. Social Service
Review, 65(1), 403–433.

Johnson, T. W., & Keren, M. S. (1998).
The families of lesbian women and
gay men. In M. McGoldrick (Ed.),
Re-visioning family therapy: Race,
culture, and gender in clinical practice
(pp. 320–329). New York:
Guilford Press.

Josephson, L. (1997). Clinical social work
practice with young inner-city
children who have been sexually
abused: An object relations approach.
Dissertation Abstracts International, 58
(1-A), 0291.

Joy, C. B., Adams, C. E., & Rice, K.
(2006). Crisis intervention for people
with severe mental illnesses. Cochrane
Database of Systematic Reviews, 4,
CD001087.

Kanter, J. (1996). Case management with
long-term patients. In S. M. Soreff
(Ed.), Handbook for the treatment of
the seriously mentally ill
(pp. 259–275). Seattle, WA:
Hogrefe & Huber.

348 R E F E R E N C E S

Kanter, J. (Ed.). (1995). Clinical issues in case
management. San Francisco: Jossey-
Bass.

Kanters, A. L. (2002). Resolution of
symbolic play therapy narratives of
traumatic events: Exposure play
therapy. Dissertation Abstracts
International, 62(10-B), 4790.

Kassop, M. (1987). Salvador Minuchin: A
sociological analysis of his family
therapy theory. Clinical Sociology
Review, 5, 158–167.

Kazdin, A. (2000). Behavior modification in
applied settings (6th ed.). Pacific Grove,
CA: Brooks/Cole.

Keddell, E. (2009). Narrative as identity:
Postmodernism, multiple ethnicities,
and narrative practice approaches in
social work. Journal of Ethnic &
Cultural Diversity in Social Work:
Innovation in Theory, Research &
Practice, 18(3), 221–241.

Keeling, M. L., & Bermudez, M. (2006).
Externalizing problems through art
and writing: Experiences of process
and helpfulness. Journal of Marital
and Family Therapy, 32(4),
405–419.

Keller, B. D. (2007). Beyond individual
differences: The role of differentiation
of self in predicting the career
exploration of college students.
Dissertation Abstracts International,
Section B: The Sciences and Engineering,
68(1-B), 649.

Kelley, P. (1998). Narrative therapy in a
managed care world. Crisis
Intervention, 4(2–3), 113–123.

Kelley, P. (1996). Narrative theory and
social work practice. In F. Turner
(Ed.), Social work treatment (4th ed.)
(pp. 461–479). New York:
Free Press.

Kerr, K. B. (1984). Issues in aging from a
family theory perspective. In The best of
the family 1978–1983 (pp. 243–247).
New Rochelle, NY: Center for
Family Learning.

Kerr, M. E., & Bowen, M. (1988). Family
evaluation: An approach based on Bowen
theory. New York: W. W. Norton.

Kierkegaard, S. (1954). Fear and trembling
and the sickness unto death. Garden
City, NY: Double Day.

Killick, S., & Allen, C. (1997). “Shifting the
balance”: Motivational interviewing
to help behaviour change in
people with bulimia nervosa.
European Eating Disorders Review, 5(1),
35–41.

Kim, J. M. (2003). Structural family
therapy and its implications for the
Asian American family. The Family
Journal, 11(4), 388–392.

Kim-Appel, D. (2003). The relationship
between Bowen’s concept of
differentiation of self and
psychological symptom status in
individuals age 62 years and older.
Dissertation Abstracts International,
63(7-A), 2461.

Kindred, M. (2011). A practical guide for
working with reluctant clients in health and
social care. Philadelphia: Jessica
Kingsley Publishers.

Kipps-Vaughan, D. (2000). The
integration of object relations family
therapy and cognitive behavior
therapy: The development of a
treatment protocol for increasing
anger control in male adolescents
with externalizing behavior
difficulties. Dissertation Abstracts
International, 61(3B), 1639.

Kirschenbaum, H., & Henderson, V. L.
(Eds.). (1989). The Carl Rogers reader.
Boston: Houghton Mifflin.

Kirschenbaum, H., & Jourdan, A. (2005).
The current status of Carl Rogers and
the person-centered approach.
Psychotherapy: Theory, Research,
Practice, Training, 42(1), 112–124.

Kiselica, M. S. (1998). Preparing Anglos
for the challenges and joys of
multiculturalism. The Counseling
Psychologist, 26, 5–21.

R E F E R E N C E S 349

Klein, D. M., & White, J. M. (1996).
Family theories: An introduction.
Thousand Oaks, CA: Sage.

Kliem, S., Kröger, C., & Kosfelder, J.
(2010). Dialectical behavior therapy
for borderline personality disorder: A
meta-analysis using mixed-effects
modeling. Journal of Consulting and
Clinical Psychology, 78(6), 936–951.

Knauth, D. G., Skowron, E. A., &
Escobar, M. (2006). Effects of
differentiation of self on adolescent
risk behavior. Nursing Research, 55(5),
336–345.

Knudson-Martin, C. (2002). Expanding
Bowen’s legacy to family therapy: A
response to Home and Hicks. Journal
of Marital and Family Therapy, 28(1),
115–118.

Kohlberg, L. (1969). Stages in the
development of moral thought and action.
New York: Holt, Rinehart, &
Winston.

Koolhaas, J. M., de Boer, S. F., Coppens,
C. M., & Buwalda, B. (2010).
Neuroendocrinology of coping styles:
Towards understanding the biology
of individual variation. Frontiers in
Neuroendocrinology, 31(3),
307–321.

Korte, J., Bohlmeijer, E. T., Cappeliez, P.,
Smit, F., & Westerhof, G. J. (2012).
Life review therapy for older adults
with moderate depressive
symptomatology: A pragmatic
randomized controlled trial.
Psychological Medicine, 42(6),
1163–1173.

Krabbendam, L., & Aleman, A. (2003).
Cognitive rehabilitation in
schizophrenia: A quantitative analysis of
controlled studies. Psychopharmacology,
169(3–4), 376–382.

Kramer, D. N., & Landolt, M. A. (2010).
Characteristics and efficacy of early
psychological interventions in
children and adolescents after single
trauma: A meta-analysis. European

Journal of Psychotraumatology,
1, 1–24.

Kramer, R. (1995). The birth of client-
centered therapy: Carl Rogers, Otto
Rank, and the beyond. Journal of
Humanistic Psychology, 35(4), 54–110.

Kramer, S., & Akhtar, S. (Eds.). (1991).
The trauma of transgression:
Psychotherapy of incest victims.
Northvale, NJ: Jason Aronson.

Krasuski, T. (2010). Quality of life and
family relations in patients with
anorexia nervosa. Acta
Neuropsychologica, 8(3), 234–243.

Kuehnlein, I. (1999). Psychotherapy as a
process of transformation: Analysis of
posttherapeutic autobiographical
narrations. Psychotherapy Research,
9(1), 274–288.

Kunzendorf, R. G., McGlone, M.,
Huliman, D., Boulia, K., Portuese, J.,
Dinsmore, T., & Bramhill, E. (2004).
Reframing cognitive therapy to
integrate recent research on emotion,
imagery, and self-talk. Imagination,
Cognition, and Personality, 23(4),
309–323.

Kurtz, P. D. (1972). American philosophy.
In P. Edwards (Ed.), The encyclopedia
of philosophy, Vol. 1 (pp. 83–93). New
York: Macmillan.

Kvarfordt, C. L., & Sheridan, M. J. (2007).
The role of religion and spirituality in
working with children and
adolescents: Results of a national
survey. Journal of Religion & Spirituality
in Social Work, 26(1), 1–23.

Laird, J. (1993). Lesbian and gay
families. In F. Walsh (Ed.),
Normal family processes (2nd ed.)
(pp. 282–328). New York: Guilford
Press.

Lakey, B., & Orehek, E. (2011).
Relational regulation theory: A new
approach to explain the link between
perceived social support and mental
health. Psychological Review, 118(3),
482–495.

350 R E F E R E N C E S

Lally, J. R. (2011). The link between
consistent caring interactions with
babies, early brain development, and
school readiness. In E. Zigler, W. S.
Gilliam, & W. S. Barnett (Eds.), The
pre-K debates: Current controversis and
issues (pp. 159–162). Baltimore: Paul
H. Brooks Publishing.

Lantz, J. (1996). Cognitive theory and
social work treatment. In F. J. Turner
(Ed.), Social work treatment (4th ed.)
(pp. 94–115). New York: Free Press.

Lantz, J. (1978). Cognitive theory and
social casework. Social Work, 31,
361–366.

Lantz, J., & Walsh, J. (2007). Short-term
existential intervention in clinical practice.
Chicago: Lyceum.

Larson, J. H., & Wilson, S. M. (1998).
Family of origin influences on young
adult career decision problems: A test
of Bowenian theory. American Journal
of Family Therapy, 26(1), 39–53.

Larson, J. H., Benson, M. J., Wilson, S.
M., & Medora, N. (1998). Family of
origin influences on marital attitudes
and readiness for marriage in late
adolescents. Journal of Family Issues,
19(6), 750–769.

Lastona, M. D. (1990). A family systems
approach to adolescent depression.
Journal of Psychology and Christianity,
9(4), 44–54.

Laub, B., & Hoffmann, S. (2002).
Dialectical letters: An integration of
dialectical cotherapy and narrative
therapy. Psychotherapy: Theory,
Research, Practice, Training, 39(2),
177–183.

Lazarus, I. S. (2010). A transpersonal
feminist approach to family systems.
International Journal of Transpersonal
Studies, 29(2), 121–136.

Lazarus, R. S. (1993). Coping theory and
research: Past, present, and future.
Psychosomatic Medicine, 55, 234–247

Lazarus, R. S., & Lazarus, B. N. (1994).
Passion and reason: Making sense of our

emotions. New York: Oxford
University Press.

Leahy, R. L. (1996). Cognitive therapy Basic
principles and applications. Northvale,
NJ: Jason Aronson.

Lee, J. A. B. (2001). The empowerment
approach to social work practice: Building
the beloved community (2nd ed.). New
York: Columbia University Press.

Lee, M. (2002). Working with Asian
American populations: A treatment guide.
Columbus, OH: Asian American
Community Services.

Leffel, R. J. (2000). Psychotherapy of
schizophrenia. Dissertation Abstracts
International, 60(S–B), 4232.

Leichsenring, F. (2005). Are
psychodynamic and psychoanalytic
therapies effective? A review of
empirical data. International Journal of
Psychoanalysis, 86(1), 841–868.

Leichsenring, F., & Leibing, E. (2007).
Psychodynamic psychotherapy: A
systematic review of techniques,
indications, and empirical evidence.
Psychology and Psychotherapy Theory,
Research, Practice, Training, 80(1),
217–228.

Leichsenring, F., Rabung, S., & Leibing,
E. (2004). The efficacy of short-term
psychodynamic psychotherapy in
specific psychiatric disorders: A meta-
analysis. Archives of General Psychiatry,
61(12), 1208–1216.

Lengermann, P. M., & Niebrugge-
Brantley, J. (2000). Contemporary
feminist theory. In G. Ritzer (Ed.),
Modern sociological theory (6th ed.),
(pp. 307–355). Boston:
McGraw-Hill.

Levant, R. F., & Silverstein, L. B. (2001).
Integrating gender and family systems
theories The “both/and” approach to
treating a postmodern couple.
In S. H. McDaniel & D. D.
Lusterman (Eds.), Casebook for
integrating family therapy: An ecosystem
approach

R E F E R E N C E S 351

(pp. 245–252). Washington, DC:
American Psychological Association.

Levine, H. A. (2002). Intrapsychic and
symptomatic change in patients with
borderline psychopathology. Dissertation
Abstracts International, 62(12-B), 5969.

Levinson, D. J. (1978). The seasons of a
man’s life. New York: Knopf.

Levy, K., & Scala, J. W. (2012).
Transference, transference
interpretations, and transference-
focused psychotherapies.
Psychotherapy, 49(3), 391–403.

Ligon, J., & Thyer, B. A. (2000).
Community inpatient crisis
stabilization in an urban setting:
Evaluation of changes in psychiatric
symptoms. Crisis Intervention and
Time-limited Treatment, 5(3), 163–169.

Lindgren, A., Werbart, A., & Phillips, B.
(2010). Long-term outcome and
post-treatment effects of
psychoanalytic psychotherapy with
young adults. Psychology and
Psychotherapy: Theory, Research,
Practice, Training, 83(1), 27–43.

Linehan, M. M. (1993). Cognitive-behavioral
treatment of borderline personality
disorder. New York: Guilford Press.

Lipchik, E. (2002). Beyond technique in
solution-focused therapy: Working with
emotions and the therapeutic relationship.
New York: Guilford Press.

Livingstone, T. (2008). The relevance of a
person-centered approach to therapy
with transgendered or transsexual
clients. Person-Centered and Experiential
Psychotherapies, 7(2), 135–144.

Loftis, R. H. (1997). A comparison of
delinquents and nondelinquents on
Rorschach measures of object
relationships and attachment:
Implications for conduct disorder,
antisocial personality disorder, and
psychopathology. Dissertation Abstracts
International, 5S(5-B), 2720.

Long, J. (2004). Review of couples
therapy with gay men. Journal of

Feminist Family Therapy, 16(1),
83–84.

Lovett, B. B. (2007). Sexual abuse in the
preschool years: Blending ideas from
object relations theory, ego
psychology, and biology. Child &
Adolescent Social Work Journal, 24(6),
579–589.

Luborsky, L., & Crits-Christoph, P.
(1990). Understanding transference: The
CCRT method (the core conflictual
relationship theme). New York: Basic
Books.

Lubove, R. (1965). The professional altruist:
The emergence of social work as a career
1880–1930. Cambridge, MA:
Harvard University Press.

Luke, M. (2011). In S. Degges-White &
N. L. Davis (Eds.), Integrating the
expressive arts into counseliing
practice: Theory-based interventions
(pp. 157–182). New York: Springer
Publishing.

Lussier, J. P., Heil, S. H., Mongeon, J. A.,
Badger, G. J., & Higgins, S. T. (2006).
A meta-analysis of voucher-based
reinforcement therapy for substance
use disorders. Addiction, 101,
192–203.

Lynch, T. R., Chapman, A. L., Rosenthal,
M. Z., Kuo, J. R., & Linehan, M. M.
(2006). Mechanisms of change in
dialectical behavior therapy:
Theoretical and empirical
observations. Journal of Clinical
Psychology, 62(4), 459–480.

Macdonald, A. J. (1997). Brief therapy in
adult psychiatry: Further outcomes.
Journal of Family Therapy, 19(1),
213–222.

Madden-Derdich, D. A., Estrada, A. U.,
Updegraff, K. A., & Leonard, S. A.
(2002). The boundary violations
scale: An empirical measure of
intergenerational boundary
violations in families. Journal of
Marital & Family Therapy, 28(2),
241–254.

352 R E F E R E N C E S

Maddi, S. R. (1996). Personality theories: A
comparative analysis (6th ed.). Pacific
Grove, CA: Brooks/Cole.

Magai, C. (1996). Personality theory:
Birth, death, and transfiguration. In
R. D. Kavanaugh, B. Zimmerberg, &
S. Fein (Eds.), Emotion interdisciplinary
perspectives (pp. 171–202). Mahwah,
NJ: Lawrence Erlbaum.

Mahler, M. S., Pine, F., & Bergman, A. S.
(1975). The psychological birth of the
human infant. New York: Basic
Books.

Malm, M. (1996). Introduction to the
special section on attachment and
psychopathology: 2. Overview of the
field of attachment. Journal of
Consulting and Clinical Psychology,
64(1), 237–243.

Manning, M. C., Cornelius, L. J., &
Okundaye, J. N. (2004).
Empowering African Americans
through social work practice:
Integrating an Afrocentric
perspective, ego psychology, and
spirituality. Families in Society, 85(2),
229–235.

Maloney-Schara, A. (1990). Biofeedback
and family systems psychotherapy in
the treatment of HIV infection.
Biofeedback and Self-Regulation, 15(1),
70–71.

March, J. S., Franklin, M., & Foa, E.
(2005). Cognitive-behavioral
psychotherapy for pediatric obsessive-
compulsive disorder. In E. D. Hibbs &
P. S. Jensen (Eds.), Psychosocial
treatments for child and adolescent
disorders: Empirically based strategies for
clinical practice (2nd ed.) (pp. 121–142).
Washington, DC: American
Psychological Association.

Marcus, E. R. (1999). Modern ego
psychology. Journal of the American
Psychoanalytic Association, 47(3),
843–871.

Marijuana Treatment Project Research
Group. (2004). Brief treatments for

cannabis dependence: Findings from a
randomized multisite trial. Journal of
Consulting and Clinical Psychology,
72(3), 455–466.

Marks, I. M. (1987). Fears, phobias, and
rituals: Panic, anxiety, and their disorders.
New York: Oxford University Press.

Martino, S., Carroll, K. M., Kostas, D.,
Perkins, J., & Rounsaville, B. J.
(2002). Dual diagnosis motivational
interviewing: A modification of
motivational interviewing for
substance-abusing patients with
psychotic disorders. Journal of Substance
Abuse Treatment, 23, 297–308.

Martino, S., Carroll, K. M., Nich, C., &
Rounsaville, B. J. (2006). A
randomized controlled pilot study of
motivational interviewing for patients
with psychotic and drug use disorders.
Addiction, 101(10), 1479–1492.

Mattaini, M. A. (2008). Ecosystems
theory. In B. A. Thyer, K. M.
Sowers, & C. N. Dulmus (Eds.),
Comprehensive handbook of social work
and social welfare, Vol. 2: Human
behavior in the social environment
(pp. 355–377). Hoboken, NJ: John
Wiley & Sons.

Matthieu, M. M., & Ivanoff, A. (2006). Using
stress, appraisal, and coping theories in
clinical practice: Assessments of coping
strategies after disasters. Brief Treatment
and Crisis Intervention, 6(4), 337–348.

Masson, J. (1989). Against therapy. London:
Collins.

May, R. (1982). The problem of evil:
An open letter to Carl Rogers. Journal
of Humanistic Psychology, 22(3),
10–21.

McCambridge, J., & Strang, J. (2004). The
efficacy of single-session motivational
interviewing in reducing drug
consumption and perceptions of
drug-related risk and harm among
young people. Results from a multi-
site cluster randomized trial. Addiction,
99(1), 39–52.

R E F E R E N C E S 353

McCusker, C. G., Doherty, N. N.,
Molloy, B., Rooney, N.,
Mulholland, C., Sands, A., Craig, B.,
Stewart, M., & Casey, F. (2010). A
controlled trial of early interventions
to promote maternal adjustment and
development in infants born with
severe congenital heart disease. Child
Care, Health, & Development, 36(1),
110–117.

McEwen, B. S. (2012). Brain on stress:
How the social environment gets
under the skin. PNAS Proceedings of
the National Academy of Sciences of the
United States of America, 109(Suppl. 2),
17180–17185.

McGoldrick, M. (1996). The legacy of
unresolved loss: A family systems
approach. New York: Newbridge
Communications.

McGoldrick, M. (Ed.). (1998). Re-visioning
family therapy. New York: Guilford
Press.

McGoldrick, M., & Carter, B. (2001).
Advances in coaching: Family therapy
with one person. Journal of Marital &
Family Therapy, 27(3), 281–300.

McGoldrick, M., Gerson, R., & Petry, S.
(2008). Genograms: Assessment and
intervention (3rd ed.). New York: W.
W. Norton.

McKnight, A. S. (2003). The impact of
cutoff in families raising adolescents.
In P. Titelman (Ed.), Emotional cutoff:
Bowen family systems theory perspectives
(pp. 273–287). New York:
Haworth.

McLendon, D., McLendon, T., & Petr, C.
G. (2005). Family-directed structural
therapy. Journal of Marital and Family
Therapy, 31(4), 327–339.

McLendon, T., McLendon, D., Petr, C.
G., Kapp, S. A., & Mooradian, J.
(2009). Family-directed structural
therapy in a therapeutic wilderness
family camp: An outcome study.
Social Work in Mental Health, 7(5),
508–527.

McPherson, J. (2012). Does narrative
exposure therapy reduce PTSD in
survivors of mass violence? Research on
Social Work Practice, 22(1), 29–42.

Mead, G. H. (1934). Mind, self and society.
Chicago: University of Chicago Press.

Meichenbaum, D. (1999). Cognitive-
behavior modification: An integrative
approach. Cambridge, MA: Perseus
Publishing.

Meichenbaum, D. (1977). Cognitive-
behavior modification: An integrative
approach. New York: Plenum.

Meichenbaum, D., & Deffenbacher, J.
(1988). Stress inoculation training.
Counseling Psychologist, 16, 69–90.

Metcalf, L. (1998). Solution-focused group
therapy: Ideas for groups in private practice
and schools. New York: Free Press.

Metcalf, L., & Thomas, F. (1994). Client
and therapist perceptions of solution-
focused brief therapy: A qualitative
analysis. Journal of Family
Psychotherapy, 5(4), 49–66.

Metzger, J. W. (1997). The role of social
support in mediating the well-being of
children placed in kinship foster care
and traditional foster care. Dissertation
Abstracts International, 58(6-A), 2394.

Meuser, T. M. (1997). An integrative
model of personality, coping, and
appraisal for the prediction of grief
involvement in adults: A dissertation
study. Dissertation Abstracts
International, 57(8-B), 5336.

Meyer, C. H. (1970). Social work practice:
The urban crisis. New York: Free Press.

Mezzina, R., & Vidoni, D. (1996). Beyond
the mental hospital: Crisis intervention
and continuity of care in Trieste:
A four-year follow-up study in a
community mental health centre.
International Journal of Social Psychiatry,
41, 1–20.

Michael, K. D., Curtin, L., Kirkley, D. E.,
Jones, D. L., & Harris, R. (2006).
Group-based motivational

354 R E F E R E N C E S

interviewing for alcohol use among
college students: An exploratory
study. Professional Psychology Research
and Practice, 37(6), 629–634.

Miller, A. L., & Glinski, J. (2000). Youth
suicidal behavior: Assessment and
intervention. Journal of Clinical
Psychology, 56(9), 1132–1152.

Miller, R. B., Anderson, S., & Keala, D. K.
(2004). Is Bowen theory valid? A review
of basic research. Journal of Marital &
Family Therapy, 30(4), 453–466.

Miller, S. D., Duncan, B. L., & Hubble,
M. A. (2005). Outcome-informed
clinical work. In J. C. Norcross & M.
R. Goldfried (Eds.), Handbook of
psychotherapy integration (2nd ed.)
(pp. 84–102). New York: Oxford
University Press, 2005.

Miller, W., & Rollnick, S. (2013).
Motivational interviewing: Preparing
people to change addictive behavior (3rd
ed.). New York: Guilford Press.

Mindell, J. A. (1999). Empirically
supported treatments in pediatric
psychology: Bedtime refusal and
night waking in young children.
Journal of Pediatric Psychology, 24(6),
465–481.

Minuchin, S. (1984). Family kaleidoscope.
Cambridge, MA: Harvard University
Press.

Minuchin, S. (1974). Families and family
therapy. Cambridge, MA: Harvard
University Press.

Minuchin, S., Lee, W., & Simon, G. M.
(1996). Mastering family therapy:
Journeys of growth and transformation.
New York: Wiley.

Minuchin, S., Nichols, M. P., & Lee, W.
Y. (2007). Assessing families and couples:
From symptom to system. Boston:
Allyn & Bacon.

Minuchin, S., Montalvo, B., Guerney, B.,
Rosman, B., & Schumer, F.
(1967). Families of the slums.
Cambridge, MA: Harvard University
Press.

Minuchin, S., Rosman, B. L., Baker, L., &
Liebman, R. (1978). Psychosomatic
families: Anorexia nervosa in context.
Cambridge, MA: Harvard University
Press.

Mitchell, M. D., Gehrman, P., Perlis, M., &
Umscheid, C. A. (2012). Comparative
effectiveness of cognitive behavioral
therapy for insomnia: A systematic
review. BMC Family Practice, 13(1),
40–50.

Mitchell, S. A. (1988). Relational concepts in
psychoanalysis. Cambridge, MA:
Harvard University Press.

Mitrani, V. B., Feaster, D. J., McCabe, B.
E., Czaja, S. J., & Szapocznik, J.
(2005). Adapting the structural family
systems rating to assess the patterns of
interaction on families of dementia
caregivers. The Gerontologist, 45(4),
445–455.

Mitrani, V. B., McCabe, B. E., Burns, M.
J., & Feaster, D. J. (2012). Family
mechanisms of structural ecosystems
therapy for HIV-seropositive women
in drug recovery. Health Psychology,
31(5), 591–600.

Mitte, K. (2005). Meta-analysis of
cognitive-behavioral treatments for
generalized anxiety disorder: A
comparison with pharmacotherapy.
Psychological Bulletin, 131(5), 785–795.

Montgomery, P., Bjornstad, G. J., & Dennis,
J. A. (2006). Media-based behavioural
treatments for behavioural problems in
children. Cochrance Database of Systematic
Reviews, 1, CD002206.

Moore, S. T. (1990). Family systems
theory and family care: An
examination of the implications of
Bowen theory. Community
Alternatives: International Journal of
Family Care, 22(1), 75–86.

Morgenstern, J., Irwin, T., Wainberg, M.
L., Parsons, J. T., Muench, F., Bux,
D. A., Kahler, C. W., Marcus, S., &
Schulz-Heik, J. (2007). A randomized
controlled trial of goal choice

R E F E R E N C E S 355

interventions for alcohol use disorders
among men who have sex with men.
Journal of Counseling and Clinical
Psychology, 75(1), 72–84.

Moyers, T., & Rollnick, S. (2002). A
motivational interviewing perspective
on resistance in psychotherapy.
JCLP/In Session Psychotherapy in
Practice, 58, 185–193.

Mueser, K. T., Rosenberg, S. D., &
Rosenberg, H. J. (2009). Treatment of
posttraumatic stress disorder in special
populations: A cognitive restructuring
program. Washington, DC: American
Psychological Association.

Mullahy, P. (1970). The beginnings of
modern American psychiatry: The ideas of
Harry Stack Sullivan. Boston:
Houghton Mifflin.

Murphy, S. L., & Khantzian, E. J. (1996).
Addiction as a “self-medication”
disorder: Application of ego
psychology to the treatment of
substance abuse. In A M. Washton
(Ed.), Psychotherapy and substance
abuse: A practitioner’s handbook
(pp. 161–175). New York:
Guilford Press.

Murray, T. L., Daniels, M. H., & Murray,
C. E. (2006). Differentiation of self,
perceived stress, and symptoms
severity among patients with
fibromyalgia syndrome. Families,
Systems, & Health, 24(1),
147–159.

Myer, R. A. (2001). Assessment for crisis
intervention: A triage assessment model.
Belmont, CA: Wadsworth.

Myers, L. L., & Thyer, B. A. (1997).
Should social work clients have the
right to effective treatment? Social
Work, 42(1), 288–298.

Nagata, D. K. (1991). Transgenerational
impact of Japanese-American
internment: Clinical issues in working
with children of former internees.
Psychotherapy: Theory, Research,
Practice, Training, 28(1), 121–128.

National Association of Social Workers
(2008). Code of Ethics. Washington,
DC: Author.

Nelson, C. A. (1999). How important are
the first three years of life? Applied
Developmental Science, 3(4), 235–238.

Nelson, T. S., & Kelley, L. (2001).
Solution-focused couples group.
Journal of Systemic Therapies, 20(4),
47–66.

Nevo, I., & Slonim-Nevo, V. (2011). The
myth of evidence-based practice:
Toward evidence-informed practice.
British Journal of Social Work, 41,
1176–1197.

Nichols, M. P. (2009). The essentials of
family therapy (4th ed.). Boston:
Allyn & Bacon.

Nichols, M. P., & Schwartz, R. C.
(2007). Family therapy: Concepts
and methods (5th ed.). Boston:
Allyn & Bacon.

Nims, D. R. (1998). Searching for self: A
theoretical model for applying family
systems to adolescent group work.
Journal for Specialists in Group Work, 23
(1), 133–144.

Nolan, P. (1994). Therapeutic response in
improvisational music therapy: What
goes on inside? Music Therapy
Perspectives, 12(1), 84–91.

Norcross, J. C., & Wampold, B. E. (2011).
Evidence-based therapy relationships:
Research conclusions and clinical
practices. Psychotherapy, 48(1), 98–102.

Nugent, W. R. (1987). Use and evaluation
of theories. Social Work Research and
Abstracts, 23, 14–19.

O’Connell, B. (2005). Solution-focused
therapy (2nd ed.). Thousand Oaks,
CA: Sage.

O’Connor, M. K. (2002). Using
qualitative research in practice
evaluation. In A. R. Roberts & G. J.
Greene (Eds.), Social workers’ desk
reference (pp. 777–781). New York:
Oxford University Press.

356 R E F E R E N C E S

O’Kearney, R. T., Anstey, K., von
Sanden, C., & Hunt, A. (2006).
Behavioural and cognitive behavioral
therapy for obsessive compulsive
disorder in children and adolescents.
Cochrance Database of Systematic
Reviews, 4, CD004856.

O’Reilly, R., Wilkes, L., Luck, L., &
Jackson, D. (2010). The efficacy of
family support and family
preservation services on reducing
child abuse and neglect: What the
literature reveals. Journal of Child
Health Care, 14(1), 82–94.

Ornduff, S. R. (1997). TAT assessment of
assessment of object relations:
Implications for child abuse.
Bulletin of the Menninger Clinic, 61(1),
1–15.

Pallesen, S., Nordhux, I. H., & Kvale, G.
(1999). Nonpharmacological
interventions for insomnia in older
adults: A meta-analysis of treatment
efficacy. Psychotherapy: Theory,
Research, Practice, Training, 35(4),
472–482.

Parad, H. J. (Ed.). (1965). Crisis
intervention: Selected readings. New
York: Family Services Association of
America.

Parsons, R. J. (1991). Empowerment:
Purpose and practice principles in
social work. Social Work with Groups,
14(1), 7–21.

Parsons, T. (1977). On building social system
theory: A personal history. In T. Parsons
(Ed.), Social systems and the evolution of
action theory. New York:
Free Press.

Pavlov, I. P. (1927). Conditioned reflexes.
London: Oxford University Press.

Payne, M. (2005). Modern social work theory
(3rd ed). Chicago: Lyceum.

Peralta, V., Cuesta, M. J., Martinez-Larrea,
A., Serrano, J. F., & Langarica, M.
(2005). Duration of untreated
psychotic illness: The role of
premorbid social support

networks. Social Psychiatry and
Psychiatric Epidemiology, 40(5),
345–349.

Perkins, R. (2006). The effectiveness of
one session of therapy using a single-
session therapy approach for children
and adolescents with mental health
problems. Psychology and
Psychotherapy: Theory, Research,
Practice, Training, 79(1), 215–227.

Perlman, F. T., & Brandell, J. R. (2010).
Psychoanalytic theory. In J. R.
Brandell (Ed.), Theory and practice in
clinical social work (2nd ed.) (pp.
41–80). Thousand Oaks, CA: Sage.

Perlman, H. H. (1979). Relationship: The
heart of helping people. Chicago:
University of Chicago Press.

Perris, C. (1992). Integrating
psychotherapeutic strategies in the
treatment of young severely disturbed
patients. Journal of Cognitive
Psychotherapy, 6(1), 205–219.

Persson, L-G., & Hjalmarson, A. (2006).
Smoking cessation in patients with
diabetes mellitus: Results from a
controlled study of an intervention
programme in primary healthcare
in Sweden. Scandanavian Journal of
Primary Health Care, 24(1),
75–80.

Pervanidou, P. (2008). Biology of post-
traumatic stress disorder in childhood
and adolescence. Journal of
Neuroendocrinology, 20(5), 632–638.

Peterson, P. L., Baer, J. S., Wells, E. A.,
Ginzler, J. A., & Garrett, S. B. (2006).
Short-term effects of a brief
motivational intervention to reduce
alcohol and drug risk among homeless
youth. Bulletin of the Society of
Psychologists in Addictive Behaviors,
20(1), 254–264.

Pham, M. (2006). Differentiation and life
change events in a chemical dependent
population. Dissertation Abstracts
International, Section B: The Sciences and
Engineering, 67(4-B), 2237.

R E F E R E N C E S 357

Piaget, J. (1977). The development of thought:
Equilibration of cognitive structures. New
York: Viking Press.

Pionek-Stone, B., Kratochwill, T. R.,
Sladezcek, I., & Serlin, R. C. (2002).
Treatment of selective mutism: A
best-evidence synthesis. School
Psychology Quarterly, 17(1), 168–190.

Piper, W. E., McCallum, M., Joyce, A. S.,
Azim, H. F., & Ogrodniczuk, J. S.
(1999). Follow-up findings for
interpretive and supportive forms of
psychotherapy and patient personality
variables. Journal of Counseling and
Clinical Psychology, 67(2),
267–273.

Polansky, N. A. (1986). “There is nothing
so practical as a good theory.” Child
Welfare, 65, 3–15.

Polkinghorne, D. E. (2004). Narrative
therapy and postmodernism. In L. E.
Angus & J. McLeod (Eds.), The
handbook of narrative and psychotherapy:
Practice, theory, and research (pp.
53–67). Thousand Oaks, CA: Sage.

Pollard, J., Hawkins, D., Arthur, M.
(1999). Risk and protection: Are both
necessary to understand diverse
behavioral outcomes in
adolescence? Social Work Research,
23, 145–158.

Pomeroy, E. C., Green, D. L., & Van
Laningham, L. (2002). Couples who
care: The effectiveness of a
psychoeducational group intervention
for HIV senodiscordant couples.
Research on Social Work Practice, 12(1),
238–252.

Popper, K. R. (1968). Conjectures and
refutations: The growth of scientific
knowledge. New York: Harper and
Row.

Prazeres, A. M., de Souza, W. F., &
Fontenelle, L. F. (2007). Cognitive-
behavior therapy for obsessive-
compulsive disorder: A systematic
review of the 1st decade. Revista
Brasihena de Psiquiaatria, 29(3).

Prochaska, J., & Norcross, J. (1994).
Systems of psychotherapy: A
transtheoretical analysis (3rd ed). Pacific
Grove, CA: Brooks/Cole.

Project MATCH Research Group. (1998).
Matching alcoholism treatments to
client heterogeneity: Project
MATCH three-year drinking
outcomes. Alcoholism: Clinical &
Experimental Research, 22, 1300–1311.

Project MATCH Research Group. (1997).
Matching alcoholism treatments to
client heterogeneity: Project MATCH
posttreatment drinking outcomes.
Journal of Studies on Alcohol, 58,
7–29.

Prouty, G. (1998). Pre-therapy and pre-
symbolic experiencing: Evolutions in
person-centered/experiential
approaches to psychotic experience.
In L. S. Greenberg, J. C. Watson, &
G. Lietaer (Eds.), Handbook of
experiential psychotherapy
(pp. 388–409). New York:
Guilford Press.

Qualls, S. H., & Williams, A. A. (2013).
Foundations of caregiver family
therapy. In S. H. Qualls & A. A.
Williams (Eds.), Caregiver family
therapy: Empowering families to meet the
challenges of aging (pp. 11–43).
Washington, DC: American
Psychological Association.

Quick, E. K. (2008). Doing what works in brief
therapy: A strategic solution focused approach.
Burlington, MA: Academic Press.

Racite, J. A. (2001). Marital satisfaction
and level of differentiation in
distressed and non-distressed couples.
Dissertation Abstracts International,
Section A: Humanities and Social
Sciences, 62(2-A), 792.

Radochonski, M. (1998). Family therapy
following loss of sight in an adult
member. Polish Psychological Bulletin,
19(1), 167–171.

Ramisch, J. L, McVicker, M., & Sahin, Z.
S. (2009). Helping low-conflict

358 R E F E R E N C E S

divorced persons establish appropriate
boundaries using a variation of the
miracle question: An integration of
solution-focused theapy and
structural family therapy. Journal of
Divorce & Remarriage, 50(7),
481–495.

Redondo, S., Sanchez-Meca, J., &
Garrido, V. (1999). The influence of
treatment programmes on the
recidivism of juvenile and adult
offenders: A European meta-analytic
review. Psychology, Crime, and Law,
5(3), 251–278.

Regehr, C., & Glancy, G. (2010). Mental
health social work practice in Canada.
Ontario, Canada: Oxford University
Press.

Reid, W. J., & Epstein, L. (Eds.). (1977).
Task-centered practice. New York:
Columbia University Press.

Reid, W. J., & Hanrahan, P. (1982).
Recent evaluations of social work:
Grounds for optimism. Social Work,
27(4), 328–340.

Reimer, W. L., & Chatwin, A. (2006).
Effectiveness of solution-focused
therapy for affective and relationship
problems in a private practice context.
Journal of Systemic Therapies, 25(1),
52–67.

Reisch, M. (2000). Social policy and the
great society. In J. Midgley, M. B.
Tracy, & M. Livermore (Eds.), The
handbook of social policy (pp. 127–142).
Thousand Oaks, CA: Sage.

Reuterlov, H., Lofgren, T., Nordstrom,
K., Ternston, A., & Miller, S. D.
(2000). What is better? A preliminary
investigation of between-session
change. Journal of Systemic Therapies,
19(1), 111–115.

Richardson, M. S. (1994). Agency/
empowerment in clinical practice.
Journal of Theoretical and Philosophical
Psychology, 14(1), 40–49.

Richert, A. J. (2003). Living stories, telling
stories, changing stories: Experiential

use of the relationship in narrative
therapy. Journal of Psychotherapy
Integration, 13(1), 188–210.

Richman, J. M., Rosenfeld, L. B., &
Hardy, C. J. (1993). The social
support survey: A validation study of a
clinical measure of the social support
process. Research on Social Work
Practice, 3(3), 288–311.

Richmond, M. (1917). Social diagnosis.
New York: Sage.

Ritzer, G., & Goodman, D. J. (2004).
Modern sociological theory (6th ed.).
Boston: McGraw-Hill.

Roberts, A. R. (2000). An overview of
crisis theory and crisis intervention. In
A. R. Roberts (Ed.), Crisis intervention
handbook: Assessment, treatment, and
research (2nd ed) (pp. 3–30). New
York: Oxford University Press.

Roberts, N. H. D. (2003). Bowen family
systems theory and its place in
counseling psychology Dissertation
Abstracts International, 63(12S), 6105.

Roberts, A. R., & Yeager, K. R. (Eds.)
(2004). Evidence-based practice manual:
Research and outcome measures in health
and human services. New York: Oxford
University Press.

Robins, C. J. (2002). Dialectical behavior
therapy for borderline personality
disorder. Psychiatric Annals, 32(10),
608–616.

Rodwell, M. K. (1998). Social work
constructivist research. New York:
Garland.

Rogers, C. R. (1986a). A client-
centered/person-directed approach to
therapy. In I. Kutash & A. Wolf
(Eds.), Psychotherapist’s casebook (pp.
197–208). San Francisco: Jossey-Bass.

Rogers, C. R. (1986b). Carl Rogers on
the development of the person-
centered approach. Person-Centered
Reviews, 1(3), 257–259.

Rogers, C. R. (1961). On becoming a
person. Boston: Houghton Mifflin.

R E F E R E N C E S 359

Rogers, C. R. (1957). The necessary and
sufficient conditions of therapeutic
personality changes. Journal of
Consulting Psychology, 21, 95–103.

Rogers, C. R. (1951). Client-centered
therapy. Boston: Houghton Mifflin.

Rogers, C. R. (1942). Counseling and
psychotherapy. Boston: Houghton
Mifflin.

Rogers, C. R. (1939). The clinical treatment
of the problem child. Boston: Houghton
Mifflin.

Rogers, C. R. and Dymond, R. (Eds.).
(1954). Psychotherapy and personality
change. Chicago: University Press.

Romanucci-Ross, L., De Vos, G. A., &
Tsuda, T. (2006). Ethnic identity:
Problems and prospects for the twenty-first
century (4th ed.). Lanham, MD: Alta
Mira Press.

Rooney, R. H. (1992). Strategies for work
with involuntary clients. New York:
Columbia University.

Rootes, K. M. H., Jankowski, P. T., &
Sandage, S. J. (2010). Bowen family
systems theory and spirituality:
Exploring the relationship between
triangulation and religious questing.
Contemporary Family Therapy: An
International Journal, 32(2),
89–101.

Rosario, H. L. (1998). The descriptive
quality of object representation and
idealization in a clinical Puerto Rican
sample. Dissertation Abstracts
International, 59(8-A), 3212.

Rose, S., Bisson, J., Churchill, R., &
Wessely, S. (2002). Psychological
debriefing for preventing posttraumatic
stress disorder (PTSD). Cochrane
Database of Systematic Reviews, 2,
CD000560.

Rosen, A., & Proctor, E. K. (2002).
Standards for evidence-based social
work practice: The role of replicable
and appropriate interventions,
outcomes, and practice guidelines. In
A. R. Roberts & G. J. Greene (Eds.),

Social workers’ desk reference (pp. 743–
747). New York: Oxford University
Press.

Rosen, C. S. (2009). Is the sequencing of
change process by stage consistent
across health problems? A meta-
analysis. Health Psychology, 19(6),
593–604.

Rosenthal, R. N. (2004). Overview of
evidence-based practice. In A. R.
Roberts & K. R. Yeager (Eds.),
Evidence-based practice manual: Research
and outcome measures in health and
human services (pp. 20–28). New
York: Oxford University Press.

Rothbaum, F., Rosen, K., Ujiie, T., &
Uchida, N. (2002). Family systems
theory, attachment theory, and culture.
Family Process, 41(3), 328–350.

Saleebey, D. (2008). The strengths
perspective: Putting possibility and
hope to work in our practice. In B. W.
White, K. M. Sowers, & C. Dulmus
(Eds.), Comprehensive handbook of social
work and social welfare, Vol. 1: The
profession of social work (pp. 123–142).
Hoboken, NJ: John Wiley & Sons Inc.

Sands, R. G. (1984). Crisis intervention
and social work practice in hospitals.
Health and Social Work, 8(4), 253–261.

Santa Ana, E. J., Wulfert, E., & Nietert,
P. J. (2007). Efficacy of group
motivational interviewing (GMI) for
psychiatric inpatients with chemical
dependence. Journal of Consulting
and Clinical Psychology, 75(5), 816–822.

Santisteban, D. A., Coatsworth, J. D.,
Perez-Vidal, A., Mitrani, V., Jean-
Gilles, M., & Szapocznik, J. (1997).
Brief structural/strategic family
therapy with African American and
Hispanic high-risk youth. Journal of
Community Psychology, 25(5), 453–471.

Sartre, J. P. (1956). Being and nothingness.
New York: Philosophical Library.

Satir, V. (1964). Conjoint family therapy.
Palo Alto, CA: Science and
Behaviour Books, Inc.

360 R E F E R E N C E S

Sawin, K. J., & Harrigan, M. P. (1995).
Measures of family functioning for research
and practice. New York: Springer.

Scaturo, D. J., Hayes, T., Sagula, D., &
Walter, T. (2000). The concept of
codependency and its context within
family systems theory. Family Therapy,
27(1), 63–70.

Schall, S., Elbert, T., & Neuner, F. (2009).
Narrative expossure therapy versus
interpersonal psychotherapy.
Psychotherapy & Psychosomatics, 78(5),
298–306.

Schamess, G., & Shilkrit, R. (2011). Ego
psychology. In J. Berzoff, L. M.
Flanagan, & P. Hertz (Eds.), Inside out
and outside in: Psychodynamic clinical
theory and psychopathology in
contemporary multicultural contexts (3rd
ed.) (pp. 62–96). Lanham, MD:
Rowman & Littlefield.

Schermer, V. L., & Klein, R. H. (1996).
Termination in group psychotherapy
from the perspectives of contemporary
object relations theory and self
psychology. International Journal of
Group Psychotherapy, 46(1), 99–115.

Schneider, E. L. (1990). The effect of brief
psychotherapy on the level of the
patient’s object relations. Dissertation
Abstracts International, 51(4-A), 1391.

Scope, A., Booth, A., & Sutcliffe, P.
(2012). Women’s perceptions and
experiences of group cognitive
behaviour therapy and other group
interventions for postnatal depression:
A qualitative synthesis. Journal of
Advanced Nursing, 68(9),
1909–1919.

Scott, K. L., & Wolfe, D. A. (2003).
Readiness to change as a predictor of
outcome in batterer treatment. Journal
of Counseling and Clinical Psychology,
71(5), 879–889.

Seagram, B. M. C. (1998). The efficacy of
solution-focused therapy with young
offenders. Dissertation Abstracts
International, 58(10-B), 5656.

Seida, J. K., Ospina, M. B., Karkhaneh,
M., Hartling, L., Smith, V., & Clark,
B. (2009). Systematic reviews of
psychosocial interventions for autism:
An umbrella review. Developmental
Medicine & Child Neurology, 51(2),
95–104.

Sexton, T. L., & Whiston, S. C. (1994).
The status of the counseling
relationship: An empirical review,
theoretical implications, and research
directions. The Counseling Psychologist,
22(1), 6–78.

Shadish, W. R., & Baldwin, S. A. (2005).
Effects of behavioral marital therapy:
A meta-analysis of randomized
controlled trials. Journal of Counseling
and Clinical Psychology, 73(1), 6–14.

Sharp, I. R., Herbert, J. D., & Redding,
R. E. (2008). The role of critical
thinking skills in practicing clinical
psychologists’ choice of intervention
techniques. The Scientific Review of
Mental Health Practice: Objective
Investigations of Controversial and
Unorthodox Claims in Clinical Psychology,
Psychiatry, and Social Work, 6(1), 21–30.

Shattuck, P. T., & Grosse, S. D. (2007).
Issues related to the diagnosis and
treatment of autism spectrum
disorders. Mental Retardation and
Developmental Disabilities, 13, 129–
135.

Shedler, J. (2010). The efficacy of
psychodynamic psychotherapy.
American Psychologist, February–
March, 98–109.

Sheridan, M. J. (2009). Ethical issues in the
use of spiritually based interventions
in social work practice: What we are
doing and why. Journal of Religion and
Spirituality in Social Work: Social
Thought, 28(1–2), 99–126.

Sheridan, M. J., Bullis, R. K., Adcock, C.
R, Berlin, S. D., & Miller, P. C.
(1992). Practitioners’ personal and
professional attitudes and behaviors
toward religion and spirituality: Issues

R E F E R E N C E S 361

for education and practice. Journal of
Social Work Education, 28, 190–203.

Shorey, H. S., & Snyder, C. R. (2006).
The role of adult attachment styles in
psychopathology and psychotherapy
outcomes. Review of General
Psychology, 10(1), 1–20.

Siev, J., & Chambless, D. L. (2007).
Specificity of treatment effects:
Cognitive therapy and relaxation for
generalized anxiety and panic
disorders. Journal of Consulting and
Clinical Psychology, 75(4),
513–522.

Sim, T., & Wong, D. (2008). Working
with Chinese families in adolescent
drug treatment. Journal of Social Work
Practice, 22(1), 103–118.

Skinner, B. F. (1953). Science and human
behavior. New York: Macmillan.

Skowron, E. A. (2005). Differentiation of
self and child abuse potential in young
adulthood. The Family Journal, 13(1),
281–290.

Skowron, E. A. (2004). Differentiation of
self, personal adjustment, problem
solving, and ethnic group belonging
among persons of color. Journal of
Counseling & Development, 82(4), 447–
456.

Smedslund, G., Berg, R. C.,
Hammerstrøm, K. T., Steiro, A.,
Leiknes, K. A., Dahl, H. M., &
Karlsen, K. (2011). Motivational
interviewing for substance abuse.
Cochrane Database of Systematic
Reviews, 5, CD008063.

Smith, M. T., Perlis, M. L., Park, A.,
Smith, M. S., Pennington, J., Giles,
D. E., & Buysse, D. J. (2002).
Comparative meta-analysis of
pharmacotherapy and behavior
therapy for persistent insomnia
American Journal of Psychiatry, 159(1),
5–10.

Spaulding, E. C. (1999). Unconsciousness-
raising: Hidden dimensions of
heterosexism in theory and practice

with lesbians. In J. Laird (Ed.),
Lesbians and lesbian families (pp. 11–25).
New York: Columbia University
Press.

Specht, H., & Courtney, M. (1994).
Unfaithful angels: How social work has
abandoned its mission. New York: Free
Press.

Spiegler, M. (1993). Contemporary behavior
therapy (2nd ed.). Pacific Grove, CA:
Brooks/Cole.

Spitalnick, J. S. & McNair, L. D. (2005).
Couples therapy with gay and lesbian
clients: An analysis of important
clinical issues. Journal of Sex and Marital
Therapy, 31, 43–56.

Stanton, M., & Todd, T. (1979).
Structural family therapy with drug
addicts. In E. Kaufman & P. Kaufman
(Eds.), The family therapy of drug and
alcohol abuse. New York: Gardner.

St. Clair, M. (1999). Object relations and self-
psychology: An introduction (3rd ed).
Pacific Grove, CA: Brooks/Cole.

Steelman, L. C., Powell, B., Werum, R.,
& Carter, S. (2002). Reconsidering
the effects of sibling configuration:
Recent advances and challenges.
Annual Review of Sociology, 28,
243–269.

Steinberg, M. L., Ziedoms, D. M., Krejci,
J. A., & Brandon, T. H. (2004).
Motivational interviewing with
personalized feedback: A brief
intervention for motivating smokers
with schizophrenia to seek treatment
for tobacco dependence. Journal of
Consulting and Clinical Psychology,
72(4), 723–728.

Stith, S. M., McCollum, E. E., Rosen, K.
H., & Locke, L. D. (2003).
Multicouple group therapy for
domestic violence. In F. W. Kaslow
(Ed.), Comprehensive handbook of
psychiatry: Integrative/eclectic, Vol. 4
(pp. 499–520). New York: Wiley.

Strack, K. M., Deal, W. P., &
Schulenberg, S. E. (2007). Coercion

362 R E F E R E N C E S

and empowerment in the treatment
of individuals with serious mental
illness: A preliminary investigation.
Psychological Services, 4(1), 96–106.

Stewart, R. E., & Chambless, D. L. (2009).
Cognitive-behavioral therapy for
adult anxiety disorders in clinical
practice: A meta-analysis of
effectiveness studies. Journal of
Consulting and Clinical Psychology,
77(4), 595–606.

Stewart, R. E., Stirman, S. W., &
Chambless, D. L. (2012). A
qualitative investigation of practicing
psychologists’ attitudes toward
research-informed practice:
Implications for dissemination
strategies. Professional Psychology:
Research and Practice, 43(2), 100–109.

Sullivan, H. S. (1962). Schizophrenia as a
human process. New York: W. W.
Norton.

Suomi, S. J. (2005). Mother-infant
attachment, peer relationships, and
the development of social networks in
rhesus monkeys. Human Development,
48(1–2), 67–79.

Swainson, M., & Tasker, F. (2006).
Genograms redrawn: Lesbian couples
define their families. In J. J. Bigner
(Ed.), An introduction to GLBT family
studies (pp. 89–115). New York:
Haworth Press.

Sylvia, L. G., Tilley, C. A., Lund, H. G., &
Sachs, G. S. (2008). Psychosocial
interventions: Empirically-derived
treatments for bipolar disorder.
Current Psychiatry Reviews, 4(2),
108–113.

Szapocznik, J., Arturo, M. E., & Cohen,
R. (1989). Structural versus
psychodynamic child therapy for
problematic Hispanic boys. Journal of
Consulting and Clinical Psychology,
57(5), 571–578.

Takahashi, T., Lipson, G., & Chazdon, L.
(1999). Supportive-expressive group
psychotherapy with chronic mental

illness, including psychosis. In V. L.
Schermer & M. Pines (Eds.), Group
psychotherapy of the psychoses: Concepts,
interventions, and contexts (International
Library of Group Analysis, 2).
Philadelphia: Jessica Kingsley
Publishers.

Tatrow, K., & Montgomery, G. H.
(2006). Cognitive-behavioral therapy
techniques for distress and pain in
breast cancer patients: A metaanalysis.
Journal of Behavioral Medicine, 29(1),
17–27.

Taylor, C. (1972). Psychological
behaviorism. In P. Edwards (Ed.), The
encyclopedia of philosophy, Vol. 6 (pp.
516–520). New York: Macmillan.

Taylor, E. R. (2009). Sandtray and
solution-focused therapy. International
Journal of Play Therapy, 18(1),
56–68.

Taylor, S. (1996). Meta-analysis of
cognitive-behavioral treatment for
social phobia. Journal of Behavior
Therapy and Experimental Psychiatry,
27(1), 1–9.

Thomas, E. J. (Ed). (1974). Behavior
modification procedure: A sourcebook.
New Brunswick, NJ: Aldine
Transaction.

Thomas, E. J. (1968). Selected
sociobehavioral techniques and
principles: An approach to
interpersonal helping. Social Work,
13(1), 12–26.

Thomlinson, R. J. (1984). Something
works: Evidence from practice
effectiveness studies. Social Work, 29,
51–57.

Thorndike, E. L. (1911). Animal
intelligence: Experimental studies. New
York: Hafner.

Thorne, B. (1992). Carl Rogers. London:
Sage.

Traynor, W., Elliot, R., & Cooper, M.
(2011). Helpful factors and outcomes
in person-centered therapy with
clients who experience psychotic

R E F E R E N C E S 363

processes: Therapists’ persepectives.
Person-Centered and Experiential
Psychotherapies, 10(2), 89–104.

Thyer, B., & Pignotti, M. (2011).
Evidence-based practices do not exist.
Clinical Social Work Journal, 39(4),
328–333.

Thyer, B. A., & Bursinger, P. (1994).
Treatment of clients with anxiety
disorders. In D. K. Granvold (Ed.),
Cognitive and behavioral treatment:
Methods and applications (pp. 272–284).
Pacific Grove, CA: Brooks/Cole.

Thyer, B. A., & Wodarski, J. S. (Eds.).
(2007). Social work in mental health: An
evidence-based approach. Hoboken, NJ:
Wiley.

Thyer, B. A., & Wodarski, J. S. (Eds.).
(1998). Handbook of empirical social work
practice. Vol. 1: Mental disorders. New
York: Wiley.

Timmer, S. G., & Veroff, J. (2000). Family
ties and the discontinuity of divorce
in Black and White newlywed
couples. Journal of Marriage and the
Family, 62(1), 349–361.

Tisdale, T. C, Key, T. L., Edwards, K. J.,
& Brokaw, B. F. (1997). Impact of
treatment on God image and personal
adjustment, and correlations of God
image to personal adjustment and
object relations development. Journal
of Psychology and Theology, 25(1),
227–239.

Titelman, P. (Ed.). (1998). Clinical
applications of Bowen family systems
theory. New York: Haworth.

Tolman, E. (1948). Cognitive maps in rats
and man. Psychological Review,
189–208.

Tong, R. T. (1998). Feminist thought (2nd
ed.). Boulder, CO: Westview Press.

Treasure, J., Katzman, M., Schmidt, U.,
Troop, N., Todd, G., & de Silva, P.
(1999). Engagement and outcome in
the treatment of bulimia nervosa: First
phase of a sequential design comparing
motivation enhancement therapy and

cognitive behavioral therapy.
Behaviour Research and Therapy, 37,
405–418.

Tuber, S. (1992). Empirical and clinical
assessments of children’s object
relations and object representations
Journal of Personality Assessment, 58(1),
179–197.

Turchiano, T. P. (2000). A meta-analysis
of behavioral and cognitive therapies
for children and adolescents with
attention deficit hyperactivity and/or
impulsivity disorders. Dissertation
Abstracts International, 60(11-B), 5760.

Turner, F. J. (Ed.) (2011). Social work
treatment (5th ed). New York: Free
Press.

Tzeng, O. C. S., & Jackson, J. W. (1991).
Common methodological framework
for theory construction and
evaluation in the social and behavioral
sciences. Genetic, Social, and General
Psychology Monographs, 117(1), 49–76.

Uhinki, A. (2001). Experiences of
therapeutic assessment with couples.
Journal of Projective Psychology & Mental
Health, 8(1), 15–18.

Ungar, M. (2004). The importance of
parents and other caregivers to the
resilience of high-risk adolescents.
Family Process, 43(1), 23–41.

Updegraff, K. A., Madden-Derdich, D.
A., Estrada, A. U., Sales, L. J., &
Leonard, S. A. (2002). Young
adolescents’ experiences with parents
and friends: Exploring the
connections. Family Relations, 51(1),
72–80.

U.S. Department of Health and Human
Services (2001). Culture, race, and
ethnicity: A supplement to mental health:
A report of the surgeon general. Retrieved
2007, from http://www.surgeon
general.gov/library/mentalhealth.cre/.

Van, H. L., Henriksen, M., Schoevers, R.
A., Peen, J., Abraham, R. A., &
Dekker, J. (2008). Predictive value of
object relations for therapeutic

364 R E F E R E N C E S

alliance and outcome in
psychotherapy for depression: An
exploratory study. Journal of Nervous
and Mental Disease, 196(9),
655–662.

van Belle, H. (1980). Basic intent and
therapeutic approach of Carl Rogers.
Toronto: Radix Books.

van der Feltz-Cornelius, C. M.,
Sarchiapone, M., Postuvan, V.,
Volker, D., Roskar, S., Grum, A. T.,
Carli, V., McDaid, D., O’Connor,
R., Maxwell, M., Ibelshauer, A., Van
Audenhove, C., Scheerder, G., Sisask,
M., Gusmao, R., & Hergerl, U.
(2011). Best practice elements of
multilevel suicide prevention
strategies: A review of systematic
reviews. Crisis: The Journal of Crisis
Intervention and Suicide Prevention,
32(6), 319–333.

Vandiver, V. L. (2002). Step-by-step
practice guidelines for using evidence-
based practice and expert consensus in
mental health settings. In A. R.
Roberts & G. J. Greene (Eds.),
Social workers’ desk reference
(pp. 731–738). New York:
Oxford University Press.

van Kalmthout, M. (2008). Meaning in a
Godless universe: A challenge for
person-centered therapy. Person-
Centered and Experiential
Psychotherapies, 7(1), 56–69.

van Minnen, A., Wessel, I., Dijkstra, T., &
Roelofs, K. (2002). Changes in PTSD
patients’ narratives during prolonged
exposure therapy: A replication and
extension. Journal of Traumatic Stress,
15(1), 255–258.

Vega, B. R, Palao, A. Torres, G., Hospital,
A., Benito, G., Perez, E., Dieguez,
M., Castelo, B., & Bayon, C. (2011).
Combined therapy versus usual care
for the treatment of depression in
oncologic patients: A randomized
controlled trial. Psycho-Oncology,
20(9), 943–952.

Von Bertalanffy, L. (1968). General system
theory (rev. ed.). New York: George
Braziller, Inc.

von Held, H. (1987). Supportive group
therapy for outpatients with
borderline personality disorder. Praxis
der Psychotherapie und Psychosomatik,
30(5), 236–242.

Von Wyl, A. (2000). What anorexic and
bulimic patients have to tell: The
analysis of patterns of unconscious
conflict expressed in stories about
everyday events. European Journal of
Psychotherapy, 3(1), 375–388.

Vromans, L. P., & Schweitzer, R. D.
(2011). Narrative therapy for adults
with major depressive disorder:
Improved symptoms and interpersonal
outcomes. Psychotherapy Research, 21(1),
4–15.

Wagner, C. C., & Ingersoll, K. S. (2012).
Motivational interviewing in groups.
New York: Guilford Press.

Wakefield, J. C. (1995). When an
irresistible epistemology meets an
immovable ontology. Social Work
Research, 19(1), 9–17.

Walker, M. W. (2007). Differentiation of
self and partner violence among
individuals in substance abuse
treatment. Dissertation Abstracts
International, Section B: The Sciences and
Engineering, 67(12–B), 7393.

Walsh, F. (Ed.). (2003). Normal family
processes: Growing diversity and
complexity. New York: Guilford Press.

Walsh, J. (2011). Countertransference
with clients who have schizophrenia.
Families in Society, 92(4),
377–382.

Walsh, J. (2009). Clinical case
management. In A. R. Roberts (Ed.),
Social workers’ desk reference (2nd ed.)
(pp. 755–759). New York: Oxford
University Press.

Walsh, J. (2007). Endings in clinical practice:
Ensuring closure across service settings
(2nd ed). Chicago: Lyceum.

R E F E R E N C E S 365

Walsh, J. (1995). The impact of
schizophrenia on the client’s religious
beliefs: Implications for families.
Families in Society, 76(9), 551–558.

Walsh, J. (1994). Social support resource
outcomes for the clients of two
community treatment teams. Research
in Social Work Practice, 4, 448–463.

Walsh, J., & Connelly, P. R. (1996).
Supportive behaviors in natural
support networks of people with
serious mental illness. Health and Social
Work, 21(A), 296–303.

Walsh, J., & Harrigan, M. P. (2003). The
termination stage in Bowen’s family
systems theory. Clinical Social Work
Journal, 31(4), 383–394.

Walsh, J. E. (2004). Does structural family
therapy really change the family
structure? An examination of process
variables. Dissertation Abstracts
International: Section B: The Sciences and
Engineering, 64(12-B), 6317.

Walters, G. D. (2000a). Beyond behaviorism:
Construction of an overarching
psychological theory of lifestyles.
Westport, CT: Praeger.

Walters, G. D. (2000b). Behavioral self-
control training for problem drinkers:
A meta-analysis of randomized
control studies. Behavior Therapy,
31(1), 135–149.

Waska, R. (2007). Projective identification
as an inescapable aspect of the
therapeutic relationship. Psychoanalytic
Social Work, 14(2), 43–64.

Watson, J. B. (1924). Psychology, from the
standpoint of a behaviorist. Philadelphia:
J. B. Lippincott.

Weakland, J., & Jordan, L. (1992). Working
briefly with reluctant clients: Child
protective services as an example.
Journal of Family Therapy, 14, 231–254.

Webb, S. J., Monk, C. S., & Nelson, C. A.
(2001). Mechanismsof postnatal neuro-
biological development: Implications
for human development. Developmental
Neuropsychology, 19(1), 147.

Webster-Stratton, C. (2001). Incredible
Years parents and children training
series Available from Incredible Years,
Seattle, WA (www.incredibleyears.
com).

Wei, M., Vogel, D., Ku, T., & Zakalik, R.
A. (2005). Adult attachment, affect
regulation, negative mood, and
interpersonal problems: The
mediating role of emotional rectivity
and emotional cutoff. Journal of
Counseling Psychology, 52(1), 14–24.

Werner, C., & Altman, I. (2000). Humans
and nature: Insights from a
transactional view. In S. Wapner, J.
Demick, T. Yamamoto, & H.
Minami (Eds.), Theoretical perspectives
in environment-behavior research:
Underlying assumptions, research
problems, and methodologies (pp.
21–37). New York: Kluwer
Academic.

Werner, M. L. (1983). Ego activation on
the treatment of acutely depressed
outpatients. Journal of the American
Academy of Psychoanalysis, 10(A),
493–513.

Westbrook, R. (2010). The making of a
democratic philosopher: The
intellectual development of John
Dewey. In M. Cochran (Ed.), The
Cambridge companion to Dewey (pp.
13–33). New York: Cambridge
University Press.

Westert, G. P., & Groenewegen, P. P.
(1999). Medical practice variations:
Changes in the theoretical approach.
Scandinavian Journal of Public Health,
21, 173–180.

Wetchler, J. L. (2004). A heterosexual
therapist’s journey toward working
with same-sex couples. In J. J. Bigner &
J. L. Wetchler (Eds.), Relationship therapy
with same-sex couples (pp. 137–145).
New York: Haworth Press.

Wettersten, K. B., Lichtenberg, J., &
Mallinckrodt, B. (2005). Associations
between working alliance and

366 R E F E R E N C E S

outcome in solution-focused brief
therapy and interpersonal therapy.
Psychotherapy Research, 15(1–2),
35–43.

White, M., & Epston, D. (1990). Narrative
means to therapeutic ends. New York:
Norton.

White, R. W. (1963). Ego and reality in
psychoanalytic theory: A proposal
regarding independent ego entities. New
York: International Universities Press.

Wiener, N. (1948). Cybernetics. New
York: Wiley.

Wilkins, P., & Gill, M. (2003). Assessment
in person-centered therapy. Person-
Centered and Experiential
Psychotherapies, 2(3), 172–187.

Williams, N. R., & Kurtz, P. D. (2003).
Narrative family interventions. In A.
C. Kilpatrick & T. P. Holland (Eds.),
Working with families An integrative
model by level of need (pp. 174–195).
Boston: Allyn & Bacon.

Wilson, G. T. (2000). Behavior therapy. In
R. J. Corsini & D. Wedding (Eds.),
Current psychotherapies (6th ed.)
(pp. 205–240). Itasca, IL:
F. E. Peacock.

Winnicott, D. W. (1975). Collected papers:
From paediatrics to psycho-analysis. New
York: Basic Books.

Witkin, S., & Gottschalk, S. (1988).
Alternative criteria for theory
evaluation. Social Service Review, 62,
211–214.

Wodarski, J. S., & Bagarozzi, D. A. (1979).
Behavioral social work. New York:
Human Sciences Press.

Wolpe, J. (1958). Psychotherapy by reciprocal
inhibition. Palo Alto, CA: Stanford
University Press.

Wood, S. A. (2000). Object relations,
alexithymia, symptoms of
psychological distress, and
methadone treatment outcomes.
Dissertation Abstracts International,
61(5-A), 2043.

Woods, M. E., and Hollis, F. H. (2000).
Casework A psychosocial therapy (5th
ed.). New York: McGraw-Hill.

Wyche, K. F. (1999). Interpreting the life
narrative: Race, class, gender, and
historical context. Psychology of
Women Quarterly, 23(1), 323–326.

Wykes, T., Huddy, V., Cellard, C.,
McGurk, S. R., & Czobor, P. (2011).
A meta-analysis of cognitive
remediation for schizophrenia:
Methodology and effect sizes.
American Journal of Psychiatry, 168(5),
472–485.

Yalom, I. D. (1980). Existential
psychotherapy. New York:
Basic Books.

Yeager, K. R., & Gregoire, T. K. (2000).
Crisis intervention application of brief
solution-focused therapy in
addictions. In A. R. Roberts (Ed.),
Crisis intervention handbook: Assessment,
treatment, and research (2nd ed.) (pp.
275–306). New York: Oxford
University Press.

Yeager, K. R., & Roberts, A. R. (2005).
Differentiating among stress, acute
stress disorder, acute crisis episodes,
trauma, and PTSD: Paradigm and
treatment goals. In A. R. Roberts
(Ed.), Crisis intervention handbook:
Assessment, treatment, and research (3rd
ed.) (pp. 90–119). New York:
Oxford University Press.

Yifeng, W., Szumilas, M., & Kutcher, S.
(2010). Effectiveness on mental health
of psychological debriefing for
crisis intervention in schools.
Educational Psychology Review,
22(3), 339–347.

Young, E. (2010). Narrative therapy and
elders with memory loss. Clinical
Social Work Journal, 38(2),
193–202.

Zayas, L. H., Drake, B., & Jonson-Reid,
M. (2011). Overrating or dismissing
the value of evidence-based practice:
Consequences for clinical practice.

R E F E R E N C E S 367

Clinical Social Work Journal, 39(4),
400–405.

Zayas, L. H., Drake, B., & Jonson-Reid,
M. (2011). Overrating or dismissing
the value of evidence-based practice:
Consequences for clinical practice.
Clinical Social Work Journal, 39,
400–405.

Zeigler-Driscoll, G. (1979). The
similarities in families of drug
dependents and alcoholics In E.
Kaufman & P. Kaufman (Eds.), The
family therapy of drug and alcohol abuse.
New York: Gardner.

Zielke, B., & Straub, J. (2008). Culture,
psychotherapy, and the diasporic self
as transitoric identity: A reply to social
constructionist and postmodern
concepts of narrative psychotherapy.
In T. Sugiman, K. J. Gergen, W.
Wagner, W., & Y. Yamada, Y. (Eds.),
Meaning in action: Constructions,
narratives, and representations
(pp. 49–72). New York: Springer.

Zimmerman, M. A. (2000). Empowerment
theory: Psychological, organizational,
and community levels of analysis.
In J. Rappaport & E. Seidman (Eds.),
Handbook of community psychology

(pp. 43–65). New York: Kluwer
Academic/Plenum.

Zimmerman, T. S., Prest, L. A., & Wetzel,
B. E. (1997). Solution-focused
couples therapy groups: An empirical
study. Journal of Family Therapy, 19(1),
125–144.

Zimmerman, T. S., Jacobsen, R B.,
Maclntyre, M., & Watson, C.
(1996). Solution-focused parenting
groups: An empirical study.
Journal of Systemic Therapies, 15(4),
12–25.

Zimring, F. M., & Raskin, N. J. (1992).
Carl Rogers and client/person-
centered therapy. In D. K.
Freedheim, H. J. Freudenberger, J.
W. Kessler, S. B. Messer, D. R.
Peterson, H. H. Strupp, & P. L.
Wachtel (Eds.), History of
psychotherapy: A century of change
(pp. 629–656). Washington, DC:
American Psychological
Association.

Zyskinsa, J., & Heszen, I. (2009).
Resources, coping with stress,
positive emotions, and health.
Introduction. Polish Psychological
Bulletin, 40(1), 1–5.

368 R E F E R E N C E S

Author Index

A
Abbass, 79, 80
Abels, 278, 303
Abikoff, H. B., 165
Ackerman, N., 115, 203
Ackloo, E., 328
Adams, C. E., 328
Adams, J. F., 250
Adcock, C. R., 30
Addams, J., 24, 57
Adler, 299
Adler, A., 115
Agostinelli, G., 260
Ainsworth, 110
Ainsworth, M. S., 88
Akhtar, S., 79
Albarracín, D., 166
Aldwin, 293
Aldwin, C. M., 309
Aleman, A., 196
Allen, 275, 301
Allen, C., 259
Allen, F., 35
Allen-Meares, P., 166
Altman, I., 22
Aman, L. A., 226
American Foundation for Suicide

Prevention, 315
American Psychiatric Association, 97, 309
American Psychological Association, 8, 12,

37, 49–50, 97, 164, 195

Anastopoulos, A. D., 226
Anderson, S., 118
Andreae, D., 234
Andrew, 309
Andrew, G., 299
Angus, L., 300
Anstey, 165
Aponte, 230
Aponte, H. J., 203, 204, 219
Applegate, J. S., 108
Appleyard, K., 23
Arkowitz, H., 273
Armitage, 257
Arthur, M., 23
Arturo, M. E., 227
Asimakopoulou, K., 273
Atherton, 280
Augusta-Scott, 281, 287
Aupperle, 308
Avis, J. M., 108
Azim, H. F., 107

B
Badger, G. J., 166
Baer, 273
Bagarozzi, D. A., 153, 157
Baker, A., 273
Baker, L., 225
Baldwin, S. A., 166
Balter, 187
Bambery, 106

Bandura, A., 148, 151
Bankoff, 195
Bara, B. G., 173
Barber, J. P., 299
Barge, C. T., 217
Barker, 28
Barkley, R. A., 159, 160, 226
Barlow, C. A., 214
Bartle-Haring, S., 141
Basham, K. K., 210
Bateson, G., 282
Bathel, D., 250
Baucom, D. H., 197
Becerra, 208
Beck, A., 174, 199
Beck, A. T., 178, 197
Beck, J. S., 152, 172, 179, 195, 320
Bell, D. C., 119
Bell, J., 115
Bell, L. G., 119
Bello, 291
Benjamin, 110
Benson, M. J., 141
Beresford, 62
Berg, 252
Berg, I. K., 233, 238, 240
Bergen, 142
Bergman, A. S., 95
Berlin, S. B., 180
Berlin, S. D., 30, 174–175, 199
Bermudez, 290
Bernall, 25
Bernston, G. G., 87
Bertera, 315
Bertolino, 21
Bertolino, B., 153
Besa, D., 297
Beutler, L. E., 13, 15
Beyebach, M., 249
Biever, J., 250
Binks, 195
Bisman, C. D., 3
Bisson, 309
Bisson, J., 314
Bixenstine, C., 204, 219
Bjoenstad, 165
Blatt, S. J., 107
Blehar, M. C., 88
Bloom, 195
Blythe, J. A., 214

Boehm, A., 28
Bohlmeijer, 299
Bolland, 280
Booth, 196
Borden, 9
Borden, W., 91
Bowen, M., 113–119, 121–123, 127, 128,

131, 143
Bowlby, 110
Boyd-Franklin, N., 209
Boyle, 180
Bozarth, 48
Bozarth, J., 54
Bozeman, B. N., 250
Bradley, 142
Brandell, 89
Brandon, T. H., 273
Brar, 266
Braslow, 10
Brausch, 196
Brodie, D. A., 273
Brokaw, B. F., 107
Bromley, 10
Brown, 114, 281, 287
Brown, J. M., 260
Brownell, J., 185
Bryck, 87
Buckley, W., 115
Buehler, 140
Bullis, R. K., 30
Burke, B., 273
Burnett, C. K., 197
Burns, 205
Burns, M. J., 106
Bursinger, P., 163, 164
Butler, A. C., 195
Butterworth, S., 273
Buwalda, 310

C
Cacioppo, J. T., 87
Cain, D., 54
Cam, 250
Canada, 329
Cancrini, L., 227
Caplan, 327, 331
Caplan, G., 235, 307–308, 309
Cappeliez, 299
Capplan, 312
Carlson, E. A., 88

370 A U T H OR I N D E X

Carmin, 34
Carreon, C., 250
Carroll, 27
Carroll, K. M., 153, 262, 273, 275
Carter, 143, 196
Carter, B., 126, 131
Carter, S., 121
Cassin, 266
Cattaneo, 26, 28
Cellard, 196
Cepeda, 52, 298
Chamberlain, P., 227
Chambless, D. L., 13, 14, 164, 195, 196
Chapman, 26, 28
Chapman, A. L., 195
Chatwin, A., 249
Chazdon, L., 106
Chazin, R., 307
Choi, 311
Churchill, 165
Churchill, R., 314
Cibik, P., 204, 219
Cingolani, S., 227
Clarkin, 79
Clarkin, J. F., 106
Clemons, D., 250
Coates, 30
Coates, J., 209
Cockburn, J. T., 250
Cockburn, O. J., 250
Cockle, S., 299
Cocoli, 119
Coe, J. E., 106
Cohen, R., 227
Colapinto, 230
Cole, J. C., 166
Coleman, S. B., 108
Combs, 291
Comella, 117
Comes-Diaz, 92
Compagnoni, F., 227
Connelly, P. R., 311
Conners, G., 256
Connolly, C. M., 209
Conte, 10
Conte, H. R., 80
Cook, 128, 140, 193
Cooper, 34, 43, 51, 256
Cooper, M. G., 108, 166
Coppens, 310

Corcoran, 11, 14, 23, 275
Corcoran, J., 175, 199, 233, 238, 250, 252,

258, 323, 328
Cornelius, 79
Cornelius-White, 50
Corwin, M., 235, 313
Costantini, D., 227
Coulson, 196
Cournoyer, B., 13
Courtney, M., 24
Cox, 26
Coyne, J. C., 237
Crepaz, N., 196
Crimone, 114
Crisp, 31
Crits-Christoph, P., 12, 99
Crockett, 303
Cuesta, 312
Curtin, L., 273
Cusinato, 279
Czaja, S. J., 218
Czobor, 196

D
Dabbs, A., 256
Dahl, R., 250
Dallos, 125
Dalton, T. A., 289
Daniels, M. H., 118
Davenport, 52
Davidson, 22
Davies, 34
Davis, 163
Davis, E., 35
Day, 204
de Boer, 310
de Shazer, 252
de Shazer, S., 234, 238
de Souza, W. F., 196
De Vos, G. A., 133
Deal, 27
Deffenbacher, J., 163
DeJong, P., 233, 238, 240
DeKlyen, M., 23
Dennis, 165
DePuy, 139
Deroo, L., 272
DeRubeis, R. J., 299
Descartes, R., 147
Devilly, G. J., 314

A U T H OR I N D E X 371

Dewey, J., 35, 36, 54, 172–173
Diamond, J. P., 290
DiCesare, E. J., 203
Dickerson, 303
Dickinson, E., 1, 18, 33, 55, 85, 113, 146,

171, 202, 233, 255, 278, 306
DiClemente, C., 256
Diguer, 97
Dijkstra, T., 298
Dingledine, D. W., 79, 106
Dodge, T. D., 140
Dolgoff, R., 18
Donovan, D., 256
Dorfman, 35
Dorfman, R. A., 24
Drake, 14, 25
Draycott, S., 256
Driessen, 79, 80
Drisko, J., 28
Duncan, 50
Duncan, B. L., 7–8, 13, 14
Dunn, C., 272, 273
Dunn, E. C., 273
Dysinger, R. H., 116, 117
Dziegielewski, S. F., 228, 329

E
Eakes, G., 250
Eaton, 313
Edmonds, M., 214
Edmonson, C. R., 118
Edwards, K. J., 107
Egeland, B., 23
Ehrenreich, 27
Ehrenreich, J. H., 57
Eisengart, S., 249
Elbert, 298
Elliott, 34, 233, 237, 238, 252
Ellis, A., 174, 177, 199
Emerson, R. W., 185
Emmerick-de Jong, 299
Entin, 119
Epps, S., 23
Epstein, L., 174
Epstein, N., 197
Epstein, S., 174
Epston, 303
Epston, D., 282
Epston, D. E., 278, 285, 291, 301
Erickson, 3

Erikson, 82, 83
Erikson, E., 65, 308, 310
Escobar, M., 114, 140
Eshelman, 163
Estrada, A. U., 205, 206
Evans, M. E., 329
Everett, J. E., 28
Eysenck, H. J., 148

F
Fairbairn, 110
Farber, 295
Farley, 180
Farmer, 87
Farson, 43
Fay, L. F., 125
Feaster, 205
Feaster, D. J., 218
Feit, 15
Feldman, E. L., 106
Fenichel, G. H., 56, 57
Ferris, L. E., 329
Festinger, L., 174, 256
Finke, 52
Fischer, J., 11
Fisher, 87
Flanagan, 89
Flanagan, L. M., 86
Fletcher, K. E., 226
Floersch, 28
Foa, E., 315
Fogarty, T. F., 125
Folkman, 310
Foltz, C., 299
Fong, R., 24, 208
Fontenelle, L. F., 196
Forbes, 195
Ford, R. Q., 107
Forrester, 13
Foucault, M., 280, 282
Foxcroft, D. R., 273
Franck, 140
Frank, J. B., 3, 7
Frank, J. D., 3, 7
Frankl, 28, 29
Frankl, V. E., 72
Franklin, 233, 248
Franklin, C., 217, 250
Franklin, M., 315
Fraser, M. W., 22

372 A U T H OR I N D E X

Freedberg, S., 92
Freedman, 303
Freedman, J., 291
Freeman, 185, 186
Freud, S., 3, 57, 65, 82, 115
Fukukawa, 165
Furlong, 165
Furman, R., 58
Furuto, S., 24, 208

G
Gallagher-Thompson, 13
Gambrill, 14
Gambrill, E. D., 10, 149, 151, 157
Garrett, 273
Garrido, V., 165
Gates, S., 273
Gehrman, 196
Gendlin, E., 54
Gensterblum, A. E., 250
Georgetown Family Center, 119, 139
Gerhardt, S., 87
Gerson, R., 123
Gest, 22
Gibbs, 10
Gibbs, J. T., 79
Gill, 40
Gilligan, 3
Gilligan, C., 66, 93, 141
Gilliland, B. E., 235, 306, 307, 310, 315
Gingerich, 233, 248
Gingerich, W. J., 249
Ginter, 142
Ginzler, 273
Girresch, 196
Gist, R., 314
Gitterman, A., 211, 310
Glade, A. C., 141
Glancy, 15
Glinski, J., 315
Goffman, E., 282
Golan, 331
Golan, N., 307, 308
Goldberg, E. H., 107
Goldfried, M. R., 80
Goldstein, 58, 89, 120
Goldstein, E. G., 8, 57, 61, 80, 82, 86, 95,

98, 100, 105, 108, 110
Goldstein, K., 37
Gonzalez, J. E., 196

Goodman, 115
Goodrich, T. J., 301
Goodson, 325
Gorey, K., 12
Gottlieb, M. C., 301
Gottschalk, S., 8
Gould, 196
Grafanaki, S., 287
Granvold, D. K., 175
Gray, P., 62
Green, 311
Green, B., 209
Green, D. L., 249
Green, R. J., 209, 210, 211
Greenan, D. E., 209
Greenberg, M., 23
Greene, 22
Gregoire, T. K., 250
Grenyer, B. G. S., 107
Gresham, F. M., 196
Groenewegen, P. P., 9
Grosse, 156
Guerin, 143
Guerin, K., 115
Guerin, P. J., 115, 125
Guerney, B., 203, 225
Guevremont, D. C., 226
Guirguis, W. R., 116, 117
Gutierrez, 26
Gutkin, T. B., 196

H
Haby, M. M., 196
Haimeri, 52
Hale, N. G., 55
Hällström, T., 315
Hamilton, G., 58
Hammond, 214
Hanrahan, P., 11
Hardcastle, D. A., 3
Hardie, 311
Hardtke, K., 300
Hardy, C. J., 312
Hargie, O. D. W., 184
Harper, K. V., 24
Harrigan, M. P., 124, 126
Harrington, D., 18, 19
Harris, 67, 114, 139
Harris, R., 273
Hartmann, 82

A U T H OR I N D E X 373

Hartmann, H., 57
Hauser, S. T., 58–59
Hawkins, D., 23
Hayes, T., 128
Haynes, R. B., 328
Heil, S. H., 166
Helgeson, V., 22
Henderson, 43
Heng, 266
Hepworth, 184
Hepworth, D., 67, 152, 179, 211, 260
Herbert, 10
Herbst, J. H., 196
Hertlein, K. M., 114
Hester, 114
Heszen, 310
Higgins, S. T., 166
Hilbert-McAllister, G., 120
Himle, J. A., 165
Hinshaw, S. P., 165
Hjalmarson, A., 273
Hobfoll, S., 312
Hodges, V. G., 160
Hoffman, 291
Hofmann, 182
Högberg, G., 315
Høglend, 98
Hollis, 82
Hollis, F. H., 58, 68, 125, 316
Homstead, K., 28
Hooper, 118, 139
Hopson, L., 217
Horvath, A. O., 15
Howard, 196
Howe, L. T., 121
Howells, J. G., 116, 117
Hubble, 50
Hubble, M. A., 7–8, 13, 14
Huddy, 196
Hull, 180
Hull, C., 148
Hunt, 165
Hunter, T. J., 226

I
Illick, S. D., 120
Ingersoll, 255, 264, 275
Ingram, R. E., 173
Irwin, M. R., 166
Ivanoff, 311

J
Jackson, 329
Jackson, B., 23
Jackson, D., 115
Jackson, J. W., 6
Jackson, R., 15, 273
Jacobsen, 92
Jacobsen, R. B., 249
Jacobson, 110
Jakobsen, 196
James, R. K., 235, 306, 307, 310, 315
Jankowski, 118, 127
Jefferies, S. E., 120
Johnson, H. C., 108
Johnson, T. W., 211
Jones, D. L., 273
Jones, K., 23
Jonson-Reid, 14, 25
Jordan, L., 234
Josephson, L., 106
Journda, 50
Joy, C. B., 328
Joyce, A. S., 107
Jurich, J. A., 250

K
Kane, 311
Kanter, J., 316
Kanters, A. L., 299
Kaplan, K., 307
Kapp, 227
Karpel, 195
Kashima, 311
Kassop, M., 204
Kautto, J. G., 125
Kazdin, A., 150, 160
Keala, 118
Keddell, 280
Keeling, 290
Keller, B. D., 140
Kelley, L., 249
Kelley, P., 284, 301, 303
Kelly, G., 173–174
Keren, M. S., 211
Kernberg, 110
Kernberg, P. F., 79
Kerr, 143
Kerr, K. B., 113, 139
Kerr, M. E., 122, 123
Key, T. L., 107

374 A U T H OR I N D E X

Khantzian, E. J., 79
Kierkegaard, S., 279
Killick, 275
Killick, S., 259
Killmer, J. M., 114
Kim, J. M., 208
Kim-Appel, 140
Kindred, 255
Kipps-Vaughan, D., 107
Kirkley, D. E., 273
Kirschenbaum, 43, 50
Kiselica, M. S., 329
Klein, 110
Klein, D. M., 115
Klein, R. G., 165
Klein, R. H., 101
Kliem, 195
Knauth, D. G., 114, 140
Knudson-Martin, C., 118, 141
Kohlberg, 3
Kohlberg, L., 66
Koolhaas, 310
Korte, 299
Kosfelder, 195
Krabbendam, L., 196
Kramer, 35, 329
Kramer, S., 79
Krasuski, 114
Kratochwill, T. R., 165
Krejci, J. A., 273
Kröger, 195
Ku, 139
Kuehnlein, I., 297
Kunzendorf, 184
Kuo, J. R., 195
Kurtz, P. D., 172, 300
Kutcher, 314
Kvale, G., 165
Kvarfordt, C. L., 30

L
Laborsky, L., 107
Laird, J., 210
Lakey, 312
Lally, 87
Landis, J. R., 299
Landolt, 329
Langarica, 312
Lantz, 174, 199

Lantz, J., 24, 30, 72, 78, 127, 172, 177,
307, 310, 311

Larimer, M. E., 273
Larsen, J., 67, 152, 179, 260
Larson, 211
Larson, J. H., 140, 141
Lasser, J., 301
Lastona, 130
Laub, 291
Lazarus, 127, 199
Lazarus, B. N., 29, 172, 309
Lazarus, R. S., 29, 172, 309, 311
Leahy, R. L., 182
Lee, Dan, 44–47
Lee, M., 24, 25
Lee, W. Y., 202, 321
Leffel, R. J., 79
Leibing, E., 79
Leichsenring, F., 79
Lengermann, P. M., 93
Lenzenweger, 79
Leo, M. C., 273
Leonard, S. A., 205, 206
Lesser, J. G., 108, 166
Levant, R. F., 141
Levine, H. A., 106
Levitt, H., 300
Levy, 67, 79
Lichtenberg, J. W., 237
Liebman, R., 225
Ligon, J., 328
Lindemann, 331
Lindemann, E., 307–308
Linden, A., 273
Lindgren, 106
Linehan, M. M., 194, 195
Lipchik, E., 251, 252
Lipson, G., 106
Littlefield, 196
Livingstone, 34
Locke, L. D., 114
Loewenberg, F. M., 18, 19
Lofgren, T., 249
Loftis, R. H., 106
Long, J., 208
Luborsky, L., 99
Lubove, R., 56
Luck, 329
Luderer, 52

A U T H OR I N D E X 375

Luke, 34
Lund, 196
Lussier, J. P., 166
Lynch, T. R., 195

M
Macdonald, A. J., 249
MacIntyre, M., 249
Madden-Derdich, D. A., 205, 206
Maddi, 37, 50
Maddi, S. R., 173
Magai, C., 59, 196
Mahler, 110, 111
Mahler, M., 93, 95–96
Mahler, M. S., 95
Mallinckrodt, B., 237
Malm, 88
Maloney-Schara, A., 139
Manning, 79
March, J. S., 315
Marcus, 61
Marijuana Treatment Project Research

Group, 265
Markowski, M., 250
Marks, I. M., 119
Martinez-Larrea, 312
Martino, S., 273
Maslow, A., 37
Masson, 51
Mather, 180
Mattaini, 168
Mattaini, M., 148, 154
Matthieu, 311
May, 51
Mazzoni, 227
McCabe, 205
McCabe, B. E., 218
McCallum, M., 107
McCambridge, J., 273
McClay, W., 273
McClellan, D., 174
McClintock, M. K., 87
McCollum, 233, 248
McCollum, E. E., 114
McCusker, 297
McDonald, H. P., 328
McEwen, B. S., 309
McGoldrick, M., 123, 124, 126,

128, 131, 143

McGurk, 196
McKay, 163
McKnight, A. S., 117
McLaren, C., 177
McLendon, 205, 227
McLeod, 51
McLeod, J., 287
McMullen, L. M., 299
McNair, L. D., 209
McPherson, 298
McVicker, 204
Mead, G. H., 60
Medora, N., 141
Meichenbaum, D., 163, 174, 184, 199
Melrose, 308
Metcalf, 233, 237, 238, 249, 252, 275
Metcalf, L., 242
Metzger, J. W., 106
Meuser, T. M., 79
Meyer, C. H., 212
Mezzina, R., 328
Michael, K. D., 273
Michael-Marki, 208
Miller, 50, 52, 275
Miller, A. L., 315
Miller, P. C., 30
Miller, R. B., 118
Miller, S. D., 7–8, 13, 14, 249
Miller, W. R., 255, 256, 260
Miller, William, 256
Minuchin, S., 202–204, 214, 219,

225–226, 230, 321
Mitchell, 110, 196
Mitchell, S. A., 96
Mitchell, V., 209, 210
Mitrani, 205
Mitrani, V. B., 218
Mitte, K., 196
Mongeon, J. A., 166
Monk, 303
Monk, C. S., 87
Montalvo, B., 203, 225
Montgomery, 165
Montgomery, D. H., 228
Montgomery, G. H., 196
Mooradian, 227
Moore, K., 250
Moore, S. T., 121
Morgenstern, J., 273

376 A U T H OR I N D E X

Moyers, 275
Moyers, T., 262
Mueser, 181
Murphy, S. L., 79
Myer, R. A., 308, 314
Myers, L. L., 80

N
Nagata, 292
Nagata, D. K., 134
Nakata, Y., 119
National Association of Social Workers

(NASW), 19, 72
Neighbors, C., 273
Nelson, C. A., 87
Nelson, J. R., 196
Nelson, T. S., 249
Neuner, 298
Nevo, 14
Nicassio, P. M., 166
Nich, C., 273
Nichols, 230
Nichols, M. P., 78, 141, 166, 202, 203,

214, 282, 300, 321
Nichols-Casebolt, 23
Niebrugge-Brantley, J., 93
Nietert, P. J., 273
Nims, D. R., 139
Nolan, P., 79
Noonan, 80
Noonan, M., 108
Norcross, 8, 50, 66
Norcross, J., 256
Nordhux, I. H., 165
Nordstrom, K., 249
Nugent, 4

O
O’Connell, B., 237, 242
O’Connor, M. K., 13
Ogrodniczuk, J. S., 107
O’Hanlon, 21
O’Hanlon, B., 153
O’Kearney, 165
Okundaye, 79
Ollendick, 195
Ollendick, T. H., 164
Orahek, 312
O’Reilly, 329
Ornduff, S. R., 106

P
Pallesen, S., 165
Pantalone, 195
Parad, 331
Parad, H. J., 307
Parsons, R. J., 26
Parsons, T., 115, 204
Passain, W. F., 196
Paulus, 308
Pavlov, I., 147, 150, 168
Pavlov, I. P., 147
Pawluck, D., 12
Payne, 26, 166, 187, 278, 283, 303
Payne, M., 8, 9, 108, 197
Peralta, 312
Perkins, R., 248
Perlis, 196
Perlman, 89, 92
Perlman, H. H., 66
Perris, C., 79
Persson, L-G., 273
Pervanidou, 309
Peterson, P. L., 273
Petr, 205, 227
Petry, S., 123
Pham, M., 140
Phillips, 106
Piaget, 175
Piaget, J., 3
Piercy, F. P., 250
Pignotti, 14
Pine, F., 95
Pionek-Stone, B., 165
Piper, W. E., 107
Polansky, N. A., 6, 8, 16
Polkinghorne, 281
Pollard, J., 23
Pomeroy, E. C., 249
Popper, K. R., 173
Porcerelli, 106
Powell, B., 121
Powers, G. T., 13, 329
Prazeres, A. M., 196
Prest, L. A., 249
Pridmore, 311
Prochaska, J., 256
Proctor, E. K., 80
Project MATCH Research Group,

273
Prouty, 34

A U T H OR I N D E X 377

Q
Qualls, 131
Quick, 238

R
Rabung, S., 79
Rachman, S., 148
Racite, J. A., 141
Radochonski, M., 227
Ramisch, 204
Rank, O., 35–36, 54
Rankin, L. A., 197
Rapoport, 331
Rapoport, L., 308
Raskin, 36
Redding, 10
Redondo, S., 165
Regehr, 15
Reid, W. J., 11, 174
Reimer, W. L., 249
Reinecke, 182
Reisch, M., 204
Reuterlov, H., 249
Reynolds, 22
Reynolds, B., 20
Rice, K., 328
Richardson, 27
Richert, A. J., 287
Richman, J. M., 312
Richmond, M., 24, 57
Ritzer, G., 115
Rivara, F., 272
Roberts, 307, 311, 313
Roberts, A. R., 13, 328
Roberts, N. H. D., 139
Robins, C. J., 194
Rodriguez, 25
Rodwell, 197
Rodwell, M. K., 281
Roelofs, K., 298
Rogers, C., 33–44, 52, 54
Rogers, N., 54
Rollnick, 52, 275
Rollnick, S., 255, 256, 260, 262
Romanucci-Ross, L., 133
Rooney, 255
Rooney, G. D., 67, 152, 179, 211, 260
Rooney, R., 67, 152, 179, 211, 260
Rootes, 127

Rosario, H. L., 106
Rose, S. M., 314
Rosen, 128, 257
Rosen, A., 80
Rosen, K. H., 114
Rosenberg, 181
Rosenfeld, L. B., 312
Rosenthal, M. Z., 195
Rosenthal, R. N., 13
Rosicky, J. G., 227
Rosman, B., 203, 225
Rothbaum, 128
Rounsaville, B. J., 273

S
Sachs, 196
Safyer, A. W., 58–59
Sagula, D., 128
Sahin, 204
Sahota, N., 328
Saleebey, D., 20–21
Sales, L. J., 205
Sanchez-Meca, J., 165
Sandage, 127
Santa Ana, E. J., 273
Santisteban, D. A., 208, 226
Sartre, J. P., 279
Satir, 230
Satir, V., 204, 216
Sawin, K. J., 124
Scala, 67
Scalise, 142
Scamardo, M., 250
Scammel, A., 273
Scaturo, D. J., 128
Schall, 298
Schames, 55
Schammes, G., 61
Schermer, V. L., 101
Schiff, 30
Schneider, E. L., 106
Schulenberg, 27
Schumer, F., 203, 225
Schwartz, R. C., 78
Schweitzer, 298
Scope, 196
Scott, 257
Seagram, B. M. C., 250
Seida, 156
Serlin, R. C., 165

378 A U T H OR I N D E X

Serrano, 312
Sexton, T. L., 67
Shadish, W. R., 166
Sharp, 10
Shattuck, 156
Shedler, 79–80
Sheridan, J. F., 87
Sheridan, M. J., 30
Shilkrit, 55, 61
Shorey, 88
Shulman, K. L., 329
Siev, J., 196
Silverstein, L. B., 141
Sim, 208
Simon, G. M., 202
Skinner, 3, 168
Skinner, B. F., 148
Skowron, E. A., 114, 140, 141, 142
Sladezcek, I., 165
Slonim-Nevo, 14
Smedslund, 272
Smith, 165, 180, 299
Smith, L. A., 273
Snyder, 88
Socrates, 180
Spaulding, E. C., 210
Specht, H., 24
Speltz, M., 23
Spencer, H., 115
Spiegler, M., 147
Spitalnick, J. S., 209
Sroufe, L. A., 23
St. Clair, M., 86, 89
Stanton, M., 227
Staples, L. H., 28
Steelman, L. C., 121
Stein, 308
Steinberg, M. L., 273
Stephenson, M., 250
Stewart, 13, 14
Stirman, 14
Stith, S. M., 114
Strack, 27
Strang, J., 273
Straub, 300
Strom-Gottfried, 211
Strom-Gottfried, K., 67, 152, 179, 260
Sullivan, H. S., 115, 203
Sullivan, R., 209

Suomi, S. J., 87
Susmarus, 195
Sutcliffe, 196
Swainson, M., 210
Sylvia, 196
Szapocznik, J., 218, 227, 230
Szumilas, 314

T
Taft, J., 35, 54
Takahashi, T., 106
Tasker, F., 210
Tatrow, K., 196
Tausch, 48
Taylor, 248
Taylor, C., 147
Taylor, S., 165
Terio, S., 307
Ternston, A., 249
Thomas, 168
Thomas, E., 148
Thomas, F., 242
Thomas, F. N., 250
Thomlinson, R. J., 11
Thompson, 13
Thorndike, E., 147
Thorne, 34, 38, 43
Thyer, 14
Thyer, B., 148
Thyer, B. A., 12, 13, 80, 147, 149, 157,

158, 163, 164, 167, 168, 318, 328
Tilley, 196
Timmer, S. G., 141
Tisdale, T. C., 107
Titelman, 143
Titelman, P., 114, 117
Todd, T., 227
Tolman, E., 148
Tomich, P., 22
Tomlins, 13
Tonge, 196
Town, 79, 80
Traynor, 34
Treasure, J., 273, 275
Trepper, 233, 248
Tsuda, R., 133
Tuber, S. B., 107
Tunnell, G., 209
Turchiano, T. P., 165

A U T H OR I N D E X 379

Turin, M., 108
Turner, 4
Turner, F. J., 9
Tzeng, O. C. S., 6

U
Uchida, 128
Uhinki, A., 78
Ujiie, 128
Umscheid, 196
Ungar, 23
Updegraff, K. A., 205, 206
U.S. Department of Health & Human

Services, 24–25

V
Van, 106
van Belle, 51
van der Feltz-Cornelius, 328
van Dulmen, M. H., 23
van Kalmthout, 43
Van Lanningham, L., 249
van Minnen, A., 298
Vandiver, V. L., 13
Vega, 298
Veroff, J., 141
Vetere, 125
Videka-Sherman, L., 11
Vidoni, D., 328
Vogel, 139
Von Bertalanffy, L., 115, 234
von Held, H., 79
von Ranson, 266
von Sanden, 165
Von Wyl, 299
Vos, 196
Vromans, 298

W
Wagner, 255, 264, 275
Wakefield, J., 281
Walker, M. W., 114, 140
Walsh, 14, 30, 67
Walsh, J., 71, 72, 78, 126, 127, 307, 310,

311, 312, 313, 316
Walsh, J. E., 226
Walsh, S., 250
Walter, T., 128
Walters, G. D., 166

Wampold, 8, 50, 66
Ward, 275
Waska, 98
Watanabe, 165
Waters, E., 88
Watson, 168
Watson, C., 249
Watson, J., 147–148
Weakland, J., 234
Webb, S. J., 87
Webster-Stratton, C., 159, 161
Wei, 139
Weiner-Davis, 252
Wells, 273
Werbart, 106
Werner, 79
Werner, C., 22
Werum, R., 121
Wessel, I., 298
Wessely, S., 314
Westbrook, 36
Westerhof, 299
Westert, G. P., 9
Wetchler, J. L., 210
Wettersten, K. B., 237
Wetzel, B. E., 249
Whiston, S. C., 67
White, 59
White, C. M., 120
White, J. M., 115
White, M., 278, 282, 285, 291,

301, 303
Whittaker, C., 115
Wiener, N., 115
Wilkins, 40
Wilks, 329
Williams, 131, 142
Williams, J. I., 329
Williams, N. R., 300
Wilson, G. T., 146, 149
Wilson, S. M., 140, 141
Winnicott, 110
Winnicott, D., 94–95
Witkin, S., 8
Wodarski, J. S., 13, 147, 148, 149, 153,

157, 158, 167, 168, 318
Wojtowicz, 266
Wolfe, 257
Wolfe, B. E., 80

380 A U T H OR I N D E X

Wolpe, J., 148
Wong, 208
Wood, S. A., 106
Woods, M. E., 67, 125, 316
Woodward, 195
Wulfert, E., 273
Wundt, W., 147
Wyche, K. F., 301
Wykes, 196

Y
Yalom, I. D., 29
Yao, X., 328
Yeager, 311
Yeager, K. R., 13, 250

Yifeng, 314
Young, 293

Z
Zakalik, 139
Zarski, J. J., 204, 219
Zayas, 14, 25
Zeigler-Driscoll, G., 227
Ziedoms, D. M., 273
Zielke, 300
Zimmerman, 303
Zimmerman, M. A., 26
Zimmerman, T. S., 249
Zimring, 36, 48
Zyskinsa, 310

A U T H OR I N D E X 381

Subject Index

A
ABC model, 181, 182–183
Absolute dependence, 95
Actualizing tendency, 37–38
Adaptation, 310
Additive models, 23
ADHD, 165, 226
Adolescents. See also Families

cognitive therapy, 188–189
crisis therapy, 328
family emotional systems therapy,

131–139
motivational interviewing, 270–272
narrative therapy, 295–297
object relations therapy, 96,

101–104, 109
solution-focused therapy, 246–248, 250
structural family therapy, 225–226
suicide and, 315

Advice intervention, 69–70
Affective domain, 315
Affective instability, 194
Agency culture, 1–2, 9–10
Aggressive children case, 158–161
Agreement with a twist, 262
AIDS/HIV, 166, 249
Alarm stage, 310
Alcohol abuse. See Substance abuse
Alcoholics Anonymous, 258
Alliances, 122, 124–125, 207
Ambivalence, 257, 262

American Psychological Association (APA)
best practices, 12
direct practice evaluation, 8, 12
interpersonal distress, 97
practitioner/client relationship, 49–50
probably efficacious clinical

intervention, 164, 195
well-established clinical intervention,

164, 195
Amplified reflection, 262
Analytic theory, 57, 115
Anger, 73–75
Anger narratives, 299
Animal models, 87
Anorexia, 225, 299
Antecedents, 151, 154
Anxiety

behavior theory, 161–164
conditioning and, 150
ego psychology, 70, 71
existential concerns and, 29
family systems theory, 116–119,

127, 140
Anxious-ambivalent infant attachment

style, 88
Applied behavior analysis, 146, 156
Arbitrary inference, 178, 192
Assessment

behavioral, 153–155
cognitive, 180–181
crisis, 313–315

Assessment (continued)
ego psychology, 65–66
family emotional systems, 122–127
motivational interviewing, 260
narrative, 287–288
object relations, 99
person-centered, 40
solution-focused, 238–242
structural family, 214–215

Assimilation, 175
Attachment, 88–89
Attention deficit/hyperactivity disorder,

165, 226
Attributions, causal, 177–178
Authenticity, 67
Authority, executive, 205
Autism, 95
Autonomous functions, 61
Avoidant infant attachment style, 88

B
Baseline, 158
Behavior Research and Therapy, 148
Behavior theory, 146–170

assessment, 153–155
case illustrations, 158–164
cognitive theory and, 183, 192–195
criticisms of, 166
effectiveness evidence, 164–166
intervention, 4–6, 155–156, 318–319
major approaches, 146
major concepts, 149
nature of problems and change, 149–152
origins and social context, 147–148
overview, 146–147, 167, 168–170
social justice issues, 157–158
spirituality and, 156–157

Behavioral domain, 315
Behavioral rehearsal, 152, 193
Behavioral Therapy (BT), 79
Beliefs, 29, 175–176
Best practices criteria, 12
Best research evidence, 15
Biological coping, 310–311
Boundaries, 206, 212–213
Brainstorming, 185, 264
Brief therapy models, 234, 235
Building Strengths and Skills: A Collaborative

Approach to Working with Clients, 175
Bulimia, 299

C
Career decision-making and families, 140
Case study method, 11, 78–80, 106–107
Case theories, 3
Causal attributions, 177–178
Causality, circular, 115
CBT, 79
Celebration/connection, 285,

290–291, 326
Challenges as stress, 309
Change plans, developing, 263–264
Change talk, 258
Children. See also Families

abuse of, 328
behavior therapy, 164–165
crisis therapy, 328
narrative therapy, 299
object relations, 88–89, 94–96, 97, 109
solution-focused therapy, 248, 250
structural family therapy, 225–226

Choice, 280
Circular causality, 115
Clarifying free choice, 263
Classical conditioning, 147, 149, 150–151
Client empowerment, 25–28, 73, 279
Client values, 15
Client-centered therapies, 37. See also

Motivational interviewing;
Solution-focused therapy

Client-Centered Therapy, 34
Client-worker relationship

behavior theory, 153–155
cognitive theory, 179–180
crisis theory, 313
ego psychology, 66–67
family emotional systems

theory, 122–123
motivational interviewing, 259–260
narrative theory, 287
object relations theory, 92–93, 98–99,

100
solution-focused therapy, 237–238
structural family theory, 214

Clinical case management, 316–317
Clinical practice. See Direct social work

practice
Clinical Social Work Practice:

A Cognitive-Integrative Perspective, 175
Clinical Treatment of the Problem Child,

The, 34

S U B J E C T I N D E X 383

Clusters, 312
Code of Ethics, 13, 19–20, 72
Co-dependency, 128
Coercive cycle, 158
Cognitions, 172
Cognitive capacity, improving, 193
Cognitive coping, 183–185
Cognitive deficits, 177
Cognitive dissonance, 174, 256–257
Cognitive distortions, 178
Cognitive domain, 154, 315
Cognitive errors, 177
Cognitive mediation, 146, 171
Cognitive restructuring, 181–183,

189–190
Cognitive theory, 147, 171–201

assessment, 180–181
behavior theory and, 183, 192–195
case illustrations, 188–192
criticisms of, 196–197
effectiveness evidence, 195–196
intervention, 181–186, 319–321
major concepts, 175–177
nature of problems and change,

177–179
origins and social context, 172–175
overview, 171–172, 197, 199–201
social justice issues, 187
solution-focused therapy and, 234
spirituality and, 186–187
worker/client relationship, 179–180

Cognitive Therapy and the Emotional
Disorders, 174

Cognitive-behavioral therapy, 79
Cohesion scale, family, 127
Collaboration. See Client-worker

relationship
Collective reinforcers, 157
Communication

skills training, 184–185, 190–192,
216–217

solution-focused therapy, 234
structural family theory, 208, 213

Competence, 59, 71–72
Compulsive behaviors, 151
Conceptualization, 175
Conditional positive regard, 38
Conditioning, 147–148, 149, 150–151
Conditions of worth, 38
Confrontation, 179

Congruence, 39, 41
Connectedness, 116
Conscious thinking, 172. See also

Cognitive theory
Consequences, 154
Constructs, 174
Consultation in narrative therapy, 291
Coping, 152, 310–312. See also Defense

mechanisms
Coping, cognitive, 183–185
Coping defense mechanism, 62, 98
Core beliefs, 175–176
Corticotropin-releasing hormone (CRH),

87–88
Counseling and Psychotherapy: New Concepts

in Practice, 34
Countertransference, 67–68, 92, 94, 98
Covert modeling, 152
Creative pursuits, 29
Crises, 235, 306, 309–313
Crisis intervention. See also Crisis theory

behavioral, 318–319
clinical case management, 316–317
cognitive, 319–321
ego-sustaining, 317–318
narrative, 325–326
overview, 307, 313–314, 316, 329–330
solution-focused, 323–325
structural family, 321–323

Crisis theory, 306–332. See also Crisis
intervention

assessment, 314–315
case illustrations. See specific crisis

interventions
criticisms of, 329
effectiveness evidence, 327–329
major concepts, 309–313
origins and social context, 307–308
overview, 306–307, 329–330, 331–332
social justice issues, 327
solution-focused therapy and, 234–235
spirituality and, 326–327
worker/client relationship, 313

Critical thinking, 10–11
Cultural knowledge and sensitivity, 24
Cultures

behavior theory and, 148
crisis theory and, 329
defined, 148
multiculturalism, 24–25

384 S U B J E C T I N D E X

Cultures (continued)
narrative theory and, 283–284, 289, 293
structural family theory and, 208–211

Curative factors, 7–8
Cybernetics, 115

D
Decisional balance, 263
Decision-making in families, 140, 216
Deconstruction, 284, 289, 325
Defense mechanisms. See also specific defense

mechanism
cause, 56, 59
complexity of, 64
definition, 56, 61
evaluating, 63–64
examples of, 62–63, 64

Denial, 62, 64, 97
Dependence, 95
Depression

cognitive theory, 174, 195, 196
crisis theory, 315, 328
ego psychology, 72–73, 79
family emotional systems theory, 130
narrative theory, 298–299
object relations theory, 107
solution-focused therapy, 250

Description intervention, 68–69
Desensitization, 193
Detriangulation, 124–125
Developmental crises, 310
Developmental reflection, 68, 70–71, 100,

125
Developmental theories. See Ego

psychology; Object relations theory
Diabetes, psychosomatic, 225
Diagnostic school, 57
Dialectical behavior theory, 147
Dialectical behavior therapy (DBT),

194–195
Dichotomous thinking, 178
Differentiation

definition, 95
family emotional systems theory and,

113–114, 139–141
of self, 117–118

Direct influence intervention, 68, 69–70
Direct social work practice

best practices criteria, 12
client empowerment in, 25–28

definition, 19
evidence-based, 12–15
multiculturalism and, 24–25
risk and resilience framework, 22–24
spirituality in, 28–31
strengths-oriented, 20–22
value base of, 19–20

Disengagement, 207, 213
Disorganized attachment style, 88–89
Displacement, 62, 63
Distortions, 64, 177, 178
Distraction, 161
Domains, behavior analysis, 154
Double-sided reflection, 262
Drives, innate, 59, 71–72

E
Eating disorders. See Anorexia; Bulimia
Eclecticism, 9
Ecobehavioral assessment, 148, 154
Eco-maps, 154–155
Education (intervention), 68, 70, 126
Ego definition and functions, 56, 60–61
Ego psychology, 55–84

assessment, 65–66
case illustrations, 73–78
criticisms of, 80
effectiveness evidence, 78–80
endings, 71
intervention, 4–5, 64–65, 66–71,

317–318
major concepts, 58–64
nature of problems and change, 64–65
origins and social context, 56–58
overview, 55–56, 81, 82–84
social justice issues, 72–73
spirituality and, 71–72
worker/client relationship, 66–67

Ego relatedness, 95
Ego-modification technique, 68, 70
Ego-sustaining techniques, 68, 317–318
Emergency shelter case, 322–323
Emotional cutoff, 120–121
Emotional domain, 154
Emotional fusion, 120–121, 210
Emotional life, 59–60, 113, 120, 196
Emotion-focused coping, 311
Emotions in cognitive theory, 172
Empathy, 41, 66–67, 92, 100, 256
Empiricism, 147

S U B J E C T I N D E X 385

Empowerment, 25–28, 73, 279
Empty nest case, 326
Enmeshment, 128, 207, 213
Environment, 61, 95, 116
Environmental domain, 154
Environmental empowerment, 25
Equilibrium pattern in crises, 310
Ethnocultural transference and

countertransference, 92, 94
Evidence-based practice, 12–15
Executive authority, 205
Exhaustion stage, 310–311
Existential crises, 310
Existentialism, 279–280
Experiential intervention, 204
Exploration intervention, 68–69
Exposure therapy, 150, 162
External boundaries, 206
External interactions, 218
External systems influences on families,

211–212
Externalization of problem, 239, 285, 288
Externalization of thinking, 126
Extinction, 160
Eysenck, Hans, 148

F
Facilitative environment, 94
Fading, 156
False self, 91
Families. See also Family emotional systems

theory; Structural family theory
aspects, 211–212
cognitive therapy, 190–192
crisis intervention, 321–323, 328–329
narrative therapy, 297–298
solution-focused therapy, 250
stages, 131, 211, 213

Families of the Slums, 203
Family Adaptability and Cohesion Scale,

127
Family Assessment Device (FAD),

217–218
Family emotional systems theory, 113–145

assessment, 122–127
case illustrations, 128–139
criticisms of, 141
effectiveness evidence, 139–141
intervention, 122–127
major concepts, 117–122

nature of problems and change, 122
origins and social context, 115–116
overview, 113–114, 141–142, 143–145
social justice issues, 128
solution-focused therapy and, 234
spirituality and, 127

Family Environment Scale, 226
Feedback principle, 116
Feminism, 93, 118, 301, 311
Flexibility, 63, 205, 207–208
Flooding, 162
Formula first-session task, 241, 250
Frozen crisis pattern, 310
Fully functioning person, 39
Functional behavior analysis, 153
Functional school, 57–58
Functionalism, 115
Fusion, 120–121, 210
Future orientation, 63–64, 237

G
Gender differences, 141
Gender feminism, 93
General adaptation syndrome, 310–311
General reality adherence, 64
General systems theory, 115–116, 234. See

also Systems theory/thinking
Genograms, 123–124, 126
Genuineness, 41
Good-enough mothering, 94
Grand theories, 3
Group therapy case, 104–105
Growth pattern in crises, 310, 311–312
Guidance intervention, 69–70
Guilt, 29

H
Harm as stress, 309
Hierarchical organizations of personal

constructs, 174
High-probability behaviors, 159
HIV/AIDS, 166, 249
Holding environment, 95, 98, 100
Hope, 29
Hospice patients, 293–295
Hyperactivity, 88

I
“I” messages/position, 126, 184–185
Id, 56
Identity, sense of, 61

386 S U B J E C T I N D E X

Imagining, 152
Impulse control, 61
Incongruence, 39
Independence, 95–96
Individuation, 95
Infant omnipotence, 94
Infants, 87–89, 94–95. See also Families
Information processing theory, 173
Information technology, 115
Innate drives, 59, 71–72
Insecure infant attachment style, 88
Insight, increasing, 125–126
Insomnia, 165–166
Intellectualization, 62
Interactive models, 23
Internal boundaries, 206
Internal interpretations, 171
Interpersonal empowerment, 25
Interpersonal (object) relations, 61
Interpersonal therapy and

spirituality, 186–187
Interpretation of Dreams, The, 57
Inter-subjectivity, 92
Intervention. See also Crisis intervention

behavior theory, 155–156
cognitive theory, 181–186
cognitive-behavioral, 192–195
curative factors, 7–8
effectiveness research and evaluation,

11–16
ego psychology, 4–5, 64–65, 66–71
family emotional systems theory,

122–127
motivational interviewing, 260–264
narrative theory, 288
object relations theory, 92, 100
person-centered, 41–42
probably efficacious, 164–165, 195
solution-focused therapy, 238–242
spiritually-guided, 30–31
structural family theory, 215–218
theories and, 4–6
well-established, 164–165, 194–195

Interviewing. See Motivational interviewing
Introjection, 62, 89
IPT. See Interpersonal therapy and

spirituality
Irrational beliefs, 178–179
Isolation (punishment), 160
Isolation of affect, 62

J
Japanese-Americans in World War II,

292–293
Johnson Administration, 204
Joining activities, 291
Journalist case, 244–245
Judgment, 61
Juvenile sex offenders, 295–297

K
Kennedy Administration, 204

L
Language in solution-focused therapy, 236
LGBT families, 208–211
Life Story objective, 296
Listening skills, 185
Logical positivism, 148, 173
Logotherapy, 72

M
Magnification, 178
Manipulation, 157
Manual-based intervention, 197
Manuals

best practices, 12
defined, 14
narrative theory, 300

Marital conflicts/satisfaction. See also
Families

behavior theory, 166
family systems theory, 119, 128–131,

140–141
solution-focused therapy, 249

Masculinity, 93
Mastery, 59, 71–72, 152
Mental illnesses

crisis intervention and, 320–321, 328
family emotional systems theory and,

127
narrative theory and, 291

Mental Research Institute (MRI) brief
therapy model, 234

Mid-range theories, 3
Minimization, 178
Miracle question, 240–241
Misconceptions, 177
Modeling, 148, 149, 151–152
Moderate behaviorism, 148
Monkey nurturing practices, 87
Mood disorders, 248

S U B J E C T I N D E X 387

Mothering, good-enough, 94
Motivational enhancement therapies, 255,

264–267
Motivational interviewing, 255–277

assessment, 260
case illustrations, 268–272
criticisms of, 273–274
effectiveness evidence, 272–273
intervention, 260–264
major concepts, 256–258
nature of problems and change, 259
origins and social context, 256–258
overview, 255–256, 274, 275–277
social justice issues, 268
spirituality in, 267
worker-client relationship, 259–260

Motives, 174
Motor theories, 173, 176–177
Multiculturalism, 24–25, 279. See also

Cultures
Multigenerational perspective, 117
Mutuality, 92
Myths, family, 211

N
Narrative Means to Therapeutic Ends, 282
Narrative Process Coding System, 300
Narrative theory, 278–305

assessment, 287–288
case illustrations, 293–297
criticisms of, 300–301
effectiveness evidence, 297–300
intervention, 288, 325–326
major concepts, 283–285
nature of problems and change,

285–287
origins and social context, 279–282
overview, 278–279, 301–302, 303–305
social justice issues, 292–293
spirituality and, 292
worker/client relationship, 287

Neural plasticity, 87
Non-directive therapy, 36
Normalizing, 215, 288–289, 325
Nuclear family emotional system, 117, 119
Nurturing, effects of early, 87–88

O
Object constancy, 91, 96
Object relations theory, 85–112

assessment, 99

case illustrations, 101–106
contemporary concepts, 89, 96
criticisms of, 108
developmental concepts, 93–96
effectiveness evidence, 78–80, 106–107
intervention, 100
major concepts, 89–93
nature of problems and change, 96–98
origins and social context, 86–89
overview, 85–86, 108, 110–112
social justice issues, 101
spirituality and, 71–72
worker-client relationship, 92–93,

98–99, 100–101
Objects, defined, 85, 90
Obsessive compulsive disorder, 165, 196
Older adults

behavior therapy, 161–164
crisis intervention, 326
family emotional systems theory,

131–139
narrative therapy, 298
solution-focused therapy, 250

Omnipotence, infant, 94
On Becoming a Person, 34
Operant conditioning, 147, 148, 149, 151
Orientation, future vs. past, 63–64
Outcome studies (narrative theory),

297–299
Outpatient settings, 249
Overgeneralization, 178

P
Parallel processes, 173
Parenting. See also Families

attachment theory, 88–89
behavior theory, 158–161
cognitive theory, 189–190
crisis intervention, 328–329
family emotional systems theory, 141
good-enough mothering, 94–95
narrative theory, 297–298
projection, 120
risk and resilience framework and,

22–24
skills development, 151, 158, 161
solution-focused therapy, 246–248,

249–250
structural family theory, 225–226

Part objects, 90

388 S U B J E C T I N D E X

Partializing intervention, 70
Past orientation, 63–64
Perceived control, 26
Perceptions, 281–282
Personal construct theory, 174
Personal declarations, 291
Personal empowerment, 25
Personal narratives, 278, 281, 283–284
Personal values, 19
Personality disorders. See also specific

disorders
dialectical behavior therapy,

194–195
narrative therapy, 295–297
object relations therapy, 97, 106

Personalization, 178
Person-centered theory (PCT), 33–54

actualizing tendency, 37–38
assessment, 40
case illustrations, 44–48
congruence, 39
criticisms of, 50–51
effectiveness evidence, 48–50
intervention, 41–42
major concepts, 37–39
nature of problems and change, 40
origins and social context, 34–37
outline, 54
overview, 33–34, 51–52
self-concept, 38–39
social justice issues, 43–44
spirituality and, 42–43

Person-centered therapy, 37
Person-in-environment perspective, 26
Person-situation reflection, 4, 68,

69, 125
Physical domain, 154
Political empowerment, 26
Positive regard, 39
Positive self-regard, 39
Positivism, 148, 173, 197
Postmodernism, 279, 280–281
Post-traumatic stress disorder, 75–78, 297,

298, 309
Poverty during the 1960s, 204
Power imbalances, 212
Practice. See Direct social work practice
Practice expertise, 15
Practice theories, 3–6. See also Theories
Practicing stage of individuation, 95

Practitioner/client relationship, research
on, 49–50

Pragmatism, 172–173
Preconscious process, 172
Pregnancy crisis case, 324–325
Premed student case illustration, 44–47
Pre-session change questions, 239
Probably efficacious intervention, 12,

164–165, 195
Problem tracking, 216
Problem-focused coping, 311
Problem-solving training, 185–186,

188–189
Process studies (narrative theory), 300
Professional values, 19
Projection, 62, 97, 120
Projective identification, 97, 98
Protective influences, 22–24
Psychoanalytic feminism, 93
Psychoanalytic theory, 57, 58
Psychodynamic theories, 55–56, 115, 116.

See also Ego psychology; Object
relations theory

Psychological Birth of the Human Infant,
The, 95

Psychological coping, 311–312
Psychological empowerment, 26
Psychological stress, 309
Psychosocial development stages, 65–66
Psychosomatic diabetes, 225
Psychotherapy and Personality, 34
PTSD, 75–78, 297, 298, 309
Punishments, 149, 151, 153, 157, 160

Q
Quality of object relations, 106

R
Radical behaviorism, 148
Randomized controlled therapy

(RCT), 79
Rapprochement, 96
Rational life, 113
Rationalization, 62
Reactance, 260, 261–262
Reaction formation, 63
Reason and Emotions in Psychotherapy, 174
Reauthoring, 284, 289–290
Reconstruction, 284, 289–290, 325
Reflecting (deconstructing), 289, 325

S U B J E C T I N D E X 389

Reflection
amplified, 262
developmental, 68, 70–71, 100, 125
double-sided, 262
person-situation, 4, 68, 69, 125
simple, 262

Reflective listening, 185
Reframing, 238–239, 263
Regression, 63
Reinforcements, 149–151, 157, 159
Relabeling, 215
Relational coping, 311
Relational theory, 91–93
Relationship therapy, 36
Relative dependence, 95
Relaxation techniques, 163
Repetition, 215
Representation, 89–90
Repression, 63
Research

effectiveness and evaluation, 11–16
empowerment and, 27–28
person-centered therapy, 48–50

Resilience, 22–24
Resistance, handling, 261–262
Resistance stage, 310
Restructuring, cognitive, 181–183, 189–190
Rigidity, 63
Risk and resilience framework, 22–24
Role reversals, 217
Role transitions, 213
Role-playing, 186, 215, 217, 218
Roles of family members, 206–207
Rules, 206

S
Scaling exercise, 238
Schemas, 174, 175, 177
Schizophrenia, 116, 250
Sculpting, 216
Secure infant attachment style, 88
Seizure disorder case, 318–319
Selective abstraction, 178
Self, differentiation of, 117–118
Self, false, 91
Self-actualization, 36, 37–38
Self-concept, 38–39
Self-efficacy, 260, 263–264
Self-instruction skills development, 184
Self-motivational statements, 261

Self-objects, 90–91
Sensory theory, 173
Separation, 87, 93, 95
Sex offenders, 188, 295–297
Sexual abuse, 98, 328
Sexual assault case, 317–318
SFT. See Solution-focused therapy
Shame, 29
Shaping, 158–159
Shifting focus, 262
Short-term psychodynamic

psychotherapy, 79
Siblings’ birth order, 121
Simple reflection, 262
Situational crises, 310
Sleep problems, 165–166
Social concerns, 29
Social constructivism, 281–282
Social Diagnosis, 57
Social domain, 154
Social institutions, 204
Social justice

behavior theory, 157–158
cognitive theory, 187
as core value, 20
crisis theory, 327
ego psychology, 72–73
family emotional systems theory, 128
motivational interviewing, 268
narrative theory, 292–293
object relations theory, 101
person-centered theory, 43–44
solution-focused therapy, 243
structural family theory, 219

Social learning theory, 146, 171
Social phobia, 165
Social reinforcements, 159
Social skills development, 161, 193
Social support, 184, 312–313
Social Work, 174
Social work origin, 56–58
Social work practice. See Direct social

work practice
Societal emotional processes, 121–122
Societal values, 19
Sociology influence, 203, 204, 233, 309
Socratic questioning, 180, 187
Solution-focused therapy, 233–254

assessment, 238–242
case illustrations, 244–248

390 S U B J E C T I N D E X

Solution-focused therapy, (continued)
criticisms of, 251
effectiveness evidence, 248–250
intervention, 238–242, 323–325
major concepts, 235–236
nature of problems and change,

236–237
origins and social context, 233–235
overview, 233, 251, 252–254
social justice issues, 243
spirituality and, 243
worker/client relationship, 237–238

Somatization, 63
Space manipulation, 216
Spectator questions, 290
Spirituality

behavior theory and, 156–157
in clinical practice, 28–31
cognitive theory and, 186–187
crisis theory and, 326–327
definition, 42
ego psychology and, 71–72
family emotional systems theory

and, 127
interpersonal therapy and, 186–187
in motivational interviewing, 267
narrative theory and, 292
object relations theory and, 71–72
person-centered theory, 42–43
solution-focused therapy and, 243
in structural family theory, 218

Splitting, 90, 96–97
Stimulus regulation, 61
Stimulus-response model, 146
STPP, 79
Strengths-oriented practice, 20–22, 307
Strengths-reinforcing coping questions,

239
Stress, 87–88, 309
Stress management skills, 216
Structural Family Systems Ratings Scale, 218
Structural family theory, 202–232

assessment, 214–215
case illustrations, 219–225
criticisms of, 227–228
effectiveness evidence, 225–227
intervention, 215–218, 321–323
major concepts, 205–212
nature of problems and

change, 212–214

origins and social context, 203–204
overview, 202–203, 228, 230–232
social justice issues, 219
spirituality in, 218
worker/client relationship, 214

Structural functionalism, 204
Structuring intervention, 70
Sublimation, 63
Substance abuse

behavior therapy, 166
family systems therapy, 128–131, 140
motivational interviewing, 256,

268–270, 272–273
narrative therapy, 297
solution-focused therapy, 250
structural family therapy, 226–227

Subsystems, 205, 212
Suicide crisis theory, 308, 315–316,

320–321, 328
Superego, 56
Support group case illustration, 47–48
Supporting system strengths, 215
Surprise task, 241
Sustainment intervention, 68, 69, 100
Symbiosis, 95, 116
Symbolic interactionism, 279
Systematic desensitization, 148, 150,

161–162, 164
Systems theory/thinking. See also Family

emotional systems theory
cognitive theory, 197
narrative theory, 301
overview, 115–116
solution-focused therapy, 234, 235, 236

T
Task-centered Practice, 174
Tasks, 158, 217, 240–242
Theories. See also specific theories

best suited to develop, 15–16
critical thinking and, 10–11
curative factors, 7–8
definition and types, 2–3
effectiveness research, 11–16
field agencies’ use of, 1–2
functions of, 6–7
intervention and, 4–6
person-centered, 33–54
practice, 3–6
selecting, 8–10

S U B J E C T I N D E X 391

Thought process regulation, 61
Threats as stress, 309
Time measures, 218
Time-out, 160
Token economies, 159–160
Traits, 174
Transference, 67–68, 92, 94, 98
Transitional objects, 95
Transtheoretical Stages of Change

model, 257
Traumatic stress, 309
Triage assessment model, 314–315
Triangulation

in alcoholic families, 128–129
career decision problems and,

140
detriangulation, 124–125
emotional fusion, 118–119
opinions on marriage and, 141
overview, 118–119, 207
sibling position and, 121

True self, 91
TSOC model, 257

U
Unconditional positive regard, 38, 41
Unconscious process, 172
Undoing, 63
Uniqueness, 279–280

V
Validation (listening skill), 185
Values, 18–20
Ventilation intervention, 68–69
Verifiability principle, 173

W
Well-established intervention, 164–165,

194–195
Whole objects, 90
Wholeness, 116
Will to meaning, 72
Working alliance, 15, 237

392 S U B J E C T I N D E X

Brief Contents

Contents

Preface

About the Author

Ch 1: Thinking about Theory��

What is a Theory?��

What is a Practice Theory?��

The Functions of Theory��

Curative Factors in All Practice Theories��

Selecting Theories for Practice��

Critical Thinking��

Social Work Research on Theory and Practice Evaluation��

Summary��

Topics for Discussion

Idea for Class Activity

Ch 2: A Social Work Perspective on Theory and Practice��

Defining Direct Social Work Practice��

The Value Base of Social Work Practice��

Strengths-Oriented Practice��

A Risk and Resilience Framework for Practice��

Diversity and Multiculturalism��

Client Empowerment��

Spirituality in Direct Practice��

Summary��

Topics for Discussion

Ideas for Assignments

Ch 3: Person-Centered Theory��

Origins and Social Context��

Major Concepts��

The Nature of Problems and Change��

Assessment and Intervention��

Spirituality and PCT��

Attention to Social Justice Issues��

Case Illustrations��

Evidence of Effectiveness��

Criticisms of the Theory��

Summary��

Topics for Discussion

Ideas for Classroom Activities/Role-Plays

Ch 4: Ego Psychology��

Origins and Social Context��

Major Concepts��

The Nature of Problems and Change��

Assessment and Intervention��

Spirituality and the Psychodynamic Theories��

Attention to Social Justice Issues��

Case Illustrations��

Evidence of Effectiveness��

Criticisms of the Theory��

Summary��

Topics for Discussion

Ideas for Classroom Activities/Role-Plays

Appendix: Ego Psychology Theory Outline

Ch 5: The Relational Theories, with a Focus on Object Relations��

Origins and Social Context��

Major Concepts��

Developmental Concepts��

The Nature of Problems��

The Nature of Change��

Assessment and Intervention��

Attention to Social Justice Issues��

Case Illustrations��

Evidence of Effectiveness��

Criticisms of the Theory��

Summary��

Topics for Discussion

Ideas for Classroom Activities/Role-Plays

Appendix: Object Relations Theory Outline

Ch 6: Family Emotional Systems Theory��

Origins and Social Context��

Major Concepts��

The Nature of Problems and Change��

Assessment and Intervention��

Spirituality and Family Emotional Systems Theory��

Attention to Social Justice Issues��

Case Illustrations��

Evidence of Effectiveness��

Criticisms of the Theory��

Summary��

Topics for Discussion

Ideas for Role-Plays

Appendix: Family Emotional Systems Theory Outline

Ch 7: Behavior Theory��

Origins and Social Context��

Major Concepts��

The Nature of Problems and Change��

Assessment and Intervention��

Spirituality and Behavior Theory��

Attention to Social Justice Issues��

Case Illustrations��

Evidence of Effectiveness��

Criticisms of the Theory��

Summary��

Topics for Discussion

Ideas for Role-Plays

Appendix: Behavior Theory Outline

Ch 8: Cognitive Theory��

Origins and Social Context��

Major Concepts��

The Nature of Problems and Change��

Assessment and Intervention��

Spirituality and Cognitive Theory��

Attention to Social Justice Issues��

Case Illustrations��

Combining Cognitive and Behavioral Interventions��

Evidence of Effectiveness��

Criticisms of the Theory��

Summary��

Topics for Discussion

Ideas for Classroom Activities/Role-Plays

Appendix: Cognitive Theory Outline

Ch 9: Structural Family Theory��

Origins and Social Context��

Major Concepts��

The Nature of Problems and Change��

Assessment and Intervention��

Spirituality in Structural Family Theory��

Attention to Social Justice Issues��

Case Illustrations��

Evidence of Effectiveness��

Criticisms of the Theory��

Summary��

Topics for Discussion

Ideas for Role-Plays

Appendix: Structural Family Theory Outline

Ch 10: Solution-Focused Therapy��

Origins and Social Context��

Major Concepts��

The Nature of Problems and Change��

Assessment and Intervention��

Spirituality and Solution-Focused Intervention��

Attention to Social Justice Issues��

Case Illustrations��

Evidence of Effectiveness��

Criticisms of the Therapy��

Summary��

Topics for Discussion

Ideas for Classroom Activities/Role-Plays

Appendix: Solution-Focused Therapy Outline

Ch 11: Motivational Interviewing and Enhancement Therapy��

Origins, Social Context, and Major Concepts��

The Nature of Problems and Change��

Assessment and Intervention��

Spirituality in Motivational Interviewing and Enhancement��

Attention to Social Justice Issues��

Case Illustrations��

Evidence of Effectiveness��

Criticisms of Motivational Interviewing and Enhancement
Therapy

Summary��

Topics for Discussion

Ideas for Class Role-Plays

Appendix: Motivational Interviewing and Enhancement Outline

Ch 12: Narrative Theory��

Origins and Social Context��

Major Concepts��

The Nature of Problems and Change��

Assessment and Intervention��

Spirituality and Narrative Theory��

Attention to Social Justice Issues��

Case Illustrations��

Evidence of Effectiveness��

Criticisms of the Theory��

Summary��

Topics for Discussion

Ideas for Role-Plays

Appendix: Narrative Theory Outline

Ch 13: Crisis Theory and Intervention��

Origins and Social Context��

Major Concepts��

Assessment and Intervention��

Spirituality and Crisis Theory��

Attention to Social Justice Issues��

Evidence of Effectiveness��

Criticisms of the Theory��

Summary��

Topics for Discussion

Ideas for Role-Plays

Appendix: Crisis Theory Outline

References

Author Index

Subject Index

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