Theory Supports Practice: Mental Health Therapists Have Assumptions

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Mental health therapists get a lot of good press, and even when they’re portrayed as sociopathic, at least they’re still played by Anthony Hopkins, and that’s not a bad thing. However, very few people understand just what goes into therapist training beyond spending a considerable amount of time and money. While knowing exactly the training for a professional isn’t needed to take advantage of their services, it’s usually a good idea to have an idea of what went into it, as often this helps us identify things to watch out for.

On average, a licensed mental health therapist needs a minimum of a Master’s degree, but that’s only to get a preliminary license. To be fully licensed requires, depending on the state, approximately two more years of work in the profession under the, ideally, watchful eye of an established therapist supervisor. There are state-level tests that must be passed as well, and once all this is completed, the person is fully licensed in the sense that they don’t need to answer to a supervisor when delivering the state-defined services of mental health therapy.

On the surface, all that time would indicate a level of proficiency in understanding concerning the nature of how behavioral change occurs. However, this is not the case, because in the training received by therapists, little differentiation is made between a theory of psychotherapy and the intervention strategies for manifesting change. We are taught skill sets for listening, empathic responding, and being attentive, but, for instance, no attention is paid to just what the "mind" is that we're supposed to be working with, and certainly not in how any such entity relates to behavioral change. For that matter, in much of modern psychotherapy, behavioral change isn’t even the point of therapy anymore, as more people turn to affirmative models that place the locus of change on society rather than the individual. Responsibility has been replaced by social justice.

At the heart of this disconnect between therapeutic practice and how behavioral change occurs is an almost complete lack of appraisal concerning an ideological worldview that touches on the nature of humanity, the tension between the individual and collectivist forces, the nature of mind and its relationship to the body (or even whether the separation is relevant in some contexts), and how any of that relates to the particular psychological Theory the therapist will say they adhere to.

Worldview Guides the Identification of Possible Behavior

Why is it important to understand or at least minimally contemplate Worldview and Theory? The embedded assumptions from the former that reside in the therapist and Theory provide the underlying support for the relational practice of therapy. How a therapist interacts with their clients is determined largely by their views concerning human nature, how behavioral change occurs, and the qualities of the roles taken in the therapeutic relationship.

Further, by better understanding the underlying assumptions brought to the work of therapy, it becomes easier for dialogue to evolve between the therapist and client about the change desired and the means of approaching it. Talking past one another, misunderstandings of content, and " resistance" are often the result of unconscious assumptions about the nature of the world and the process for change. Taking the time to see how one's worldview connects to the practicing theory of therapy will then help identify which strategies for intervention will be most helpful.

Questions to Consider

To help encourage reflection, both by the therapist and the potential patient, what follows is a set of questions to consider. Therapy doesn’t require a degree in philosophy, nor should sessions simply be an intellectualizing affair. Every question or point of inquiry is as much about self-knowledge as it is about determining how or whether there therapeutic relationship will function. Identifying our assumptions can be a first step to figuring out why we do the things we do, given they’re often based on things we think are right, but are not.

Wordview / Paradigm 

Q: what characterizes human nature?

Q: how does behavioral change occur at the personal and social level?

Psycho-therapeutic Theory 

Q: what characterizes the working relationship between client and therapist?

Q: what role does each play in leading to behavioral change?

Intervention Strategies 

Q: how does it relate to the theory supported by the therapist?

Q: in what way does the intervention encourage behavioral change?

To be honest, the above assumes that behavioral change is the central point of therapy. I find that, while analysis and the "deep stuff" can be exhilarating and at times helpful, it is so largely because it helps the person direct their attention and move towards their Value-directed goals. A person comes to therapy because situation x is a significant struggle for them. If life were without stress, there'd be no need to seek help to build new ways of coping and/or moving forward in different ways.

The Process of Change

The first two sections of questions concern Worldview and Theory because what change is possible and how it is judged will be determined by these. A client may come in with a worldview that only allows for change to occur between A and C. The therapist may believe the client has the space to change between A and E. The potentially problematic difference between these two is fueled by views concerning the power and influence of culture, the nature of self, will and ego, and the nature of relationships. Freud, Rogers, Skinner, Systems, and Feminist Theory, to name but a few, all have assumptions providing a structure for how and what type of change will occur.

Intervention strategies come last because they are the means for generating change, which occurs within the context of worldview and theory. There are very few strategies incapable of being cannibalized by different theories. The strength of an intervention to generate change is linked to the level of belief in its ability to promote that change. If an intervention is attempted without knowing how Worldview and Theory provide the foundation for Intervention, confusion can and will be felt by the therapist and client.

Thankfully, knowing every connection between Worldview, Theory, and Intervention is not necessary for the practice of good and helpful therapy. Expanding understanding will accomplish the building of a greater therapeutic relationship to effect a more powerful and easier process of behavioral change. Just as the dynamics shift with each new client, comprehending the process of therapy is constantly evolving. Working with humanity requires that it be this way.

References:

Mindfulness and Acceptance Workbook for Depression

Mahoney, M. J. Constructive Psychotherapy.

Olinick, S. L. (1977). Psychotherapeutic Instrument (Classical Psychoanalysis and Its Applications). New York: Jason Aronson Inc. Publishers.

Truscott, Derek. Becoming an Effective Psychotherapist.

Wachtel, Paul. Relational Theory and the Practice of Psychotherapy.