| Summary
of Empowerment TherapyEmpowerment
Therapy (ET) is a brief therapy, which has elements of
Cognitive-behavioural, Narrative, Solution-focused, Gestalt,
and Adlerian therapies. However, ET is not just an integrated
or eclectic approach. The Empowerment model contains new
elements that appear to be effective in accelerating the
process of change.
Like
CBT, ET acknowledges that our thought processes create
responses in the form of emotions and subsequent behaviours.
However, ET aims to deal with not just the irrational,
negative or self-defeating thoughts but to get to the
core question which is: Where did the client's negative
thought processes come from in the first instance?
ET
proposes that the answer to this question leads to considering
the client's self-evaluations, how early influences
lead to negative and/or unstable self-evaluations, and
how these in turn lead to a cognitive style characterised
by an increased probability of interpreting events as
beyond the client's control. The issue of perceived
lack of personal control is seen as a central issue
in the development of anxiety, depression and problematic
substance use (Chorpita and Barlow, 1998).
In
ET, clients come to understand the processes, which
led them to `internalise' negative self-evaluations
and then learn to reclaim their own power by reversing
that process.
ET
makes use of therapeutic strategies, which are consistent
with research into the processes of change. Heatherton
and Nichols (1994) studied those who had successfully
changed some major aspect of their life and those who
had been unsuccessful. The most distinct differences
between the groups were that the changers had invariably
re-appraised their goals in life and increased their
self-knowledge and understanding. In similar research,
Miller and De Baca (1994) found that those who maintained
positive changes were those who reported that their
identities were transformed, that their temperament,
values and goals were changed for the better, and that
their lives had taken on new meaning.
In
summary, ET is a brief, structured and collaborative
therapeutic model which focuses on both the client's
structural issues (that is, the impact of early influences)
and process issues (that is, the manner in which the
client currently processes and interprets events and
responds emotionally and behaviourally), and helps the
client move towards a new empowered sense of self.
Bill
Saunders, writing in `Clinical Psychologist' (1997),
expressed the hope for a therapeutic model for treating
addictive behaviour, which incorporated the best of
CBT but also went `beyond' CBT. He posed the question,
`Would CBT be even more effective if it embraced
those aspects that the psychotherapists tell us really
matter?' I think ET goes a long way towards being
the intervention model which Bill argued for so cogently
in that paper.
Key
Features
ET
rests on these basic assumptions/ principles:
1. That
the therapeutic process should be recognised as an
opportunity for growth and the establishment of a
new sense of self. Hanging on to self-limiting labels
such as `alcoholic', `addict' etc is not encouraged.
2. That
rather than labelling excessive alcohol or other drug
use as `dysfunctional', `disordered' or `pathological'
it is far more productive to ask, `What is the function
of this behaviour from my client's perspective?'
3. That
the client's increasing sense of control is not just
in the outcome of therapy but in the process, that
is, a genuinely collaborative framework, in which
exploration of structural and process issues is a
joint procedure. Also, the therapist does not dictate
the goals of therapy, but assists the client in the
formulation of his/her own goals.
4. That
the therapeutic process is brief, focused and easily
comprehensible.
5. That
the emphasis is on well-being, not the illness paradigm
or `disease' model. The emphasis is on helping clients
recognise their own strengths and resources, which
they have often not felt able to identify or access.
Martin Seligman, in his presidential address to the
1998 American Psychological Association convention
said: We need practitioners to recognise that much
of the best work they do is amplifying the strengths
rather than repairing their patients' weaknesses.
6. That
an effective therapy has to incorporate what the research
tells us about the process of change. This is not
just the work of Prochaska and Di Clemente with which
many workers in this area are familiar but also the
work of Heatherton and Nicholls, Miller and De Baca,
and Baumeister on focal events, the crystallisation
of discontent, and establishing a new identity.
Background
Four
years ago I worked with those forms of therapy such
as cognitive-behavioural and solution-focused therapy
which concentrate on the present and future with little
or no emphasis on the past. However, I found that on
those occasions when I did assist a client with exploration
of past traumas and problems and their relevance for
the present, it provided a firm base of understanding
for the client. Most clients are seeking solutions but
they also want to know how they got the problem in the
first place.
I
was drawn to explore and read extensively around Narrative
therapy, and I found the concept of externalising the
problem in Narrative therapy very useful. However, at
one point I read a case study in Narrative therapy where
the practitioner had assisted the client to externalise
`alcohol' as the problem. I realised from working with
my clients that `alcohol', or their drug of choice,
was not the `problem'─what needed to be externalised
were the influences that had led them to internalise
negative self-evaluations.
One
part of ET involves mapping those negative influences
followed by an externalising ritual which clients invariably
find a very powerful and moving exercise. I think this
point acts as a focal event in the therapeutic process.
Just as a focal event, prior to counselling, often leads
our clients to move from the Pre-Contemplation to the
Contemplation Stage, I think the externalisation ritual
in ET constitutes a focal event that powerfully marks
the client's movement from Contemplation to Action.
Pelham
and Swann (1989) mention that self-esteem has relatively
independent cognitive and affective components. I think
a problem with cognitive therapies is they tend to deal
with just the cognitive side─whereas ET addresses
both the cognitive and affective components.
Core
Skills
The
most important skill is to stay `on the client's path'
and work in a genuinely collaborative manner. It's also
important to be able to positively reframe experiences
whenever clients are inclined to drop back into focusing
on negatives and discounting the positives. Therapists
should be able to keep reflecting to the client their
belief that the client can make the changes she/he desires,
and to help clients see that positive changes, however
small, are the result of the client's personal agency.
Length
of Treatment
ET
is a structured sequence of six phases. The therapist
may need to spend longer than one session with a particular
phase depending on the client's needs and level of progress.
However, when the therapist has practised each of the
phases and is comfortable with the process, I find many
now take one session only for each phase. In my own
work I rarely need to see clients beyond six sessions.
The
six phases are:
1. Hearing
the client's story, clarifying the therapeutic goals
in the areas of thoughts, feelings, substance use
and other behaviour, and scaling baseline levels of
goal achievement, self-efficacy, and motivation.
2. Focusing
on the client's strengths, the bases for self-evaluations
and exploring a bi-dimensional perspective on self-esteem.
3. Mapping
developmental influences, and the personal ritual
of externalisation.
4. Contrasting
behaviour, thoughts and feelings associated with the
`automatic pilot' and `me-in-control' lifestyles.
5. Drafting
a new life-plan, including intrinsic aspirations which
Deci and Ryan (1995) call the `basis for true self-esteem'.
6. Contrasting
the Desired Self and Undesired Self-scaling progress
towards goals, and bringing the process to closure
(if the client identifies an appropriate level of
progress through his/her personal agency).
Cost
Effectiveness
The
therapy deals with core issues in an effective and efficient
manner. To have enduring, positive changes after six
sessions is a highly cost-effective intervention.
For
Government-funded centres on tight budgets, ET would
be a very useful intervention because it gets to the
core issues of meaning, purpose, values, aspirations
and identity, as well as addressing process issues,
in six sessions. It allows the therapist to work collaboratively
with the client in a focused manner and remain respectful
of the client's pace throughout.
Differences
From Other Therapies
Some
therapies take the position that understanding the impact
of the past is not necessary for change to occur. However,
in their book `Changing for Good' (1997) Prochaska,
Norcross and Di Clemente write, `Contemplators are not
ready to prepare for action until they achieve a greater
understanding of their behaviour . . . Techniques
without awareness behind them don't have a chance to
make any real impact on our inner selves, and so have
little lasting effect.'
However,
ET does not involve a long-term psycho-dynamic process─the
aim is not explicitly to make the unconscious conscious
as in psycho-dynamic therapies─although this does
happen in ET. I find many of my clients have plenty
of conscious material, which has not been resolved.
ET
incorporates the following elements that make it different
from other therapies:
·
A
bi-dimensional conception of self-esteem which clients
find has considerable explanatory power
·
Developmental Influences mapping─a focused
exploration of developmental influences
·
The
`fundamental error of childhood' which allows the
client to understand that attributional errors common
in childhood have effectively meant that they are
living out someone else's agenda
·
And
the Decision Diary, a quick and simple method of contrasting
interpretations of events and their emotional and
behavioural consequences, simpler than the usual CBT
texts on disputing irrational beliefs.
Advantages
One
of the main advantages of ET is that the therapist can
concentrate entirely on listening to the client and
not have to concentrate on what to say next. The process
is structured but can be used as flexibly as the therapist's
skills and experience allow.
Suitable
Client Groups
ET
may not be suitable for those with intellectual disability,
or those who have alcohol-related brain damage to a
degree which seriously impairs cognitive functioning.
Insufficient work has been done with psychotic clients
to make any pronouncements at this stage about its potential
utility with this group.
On
the other hand, ET is particularly useful for dealing
with not just substance use issues but other co-morbid
issues, especially anxiety and depression, since perceived
lack of personal control has been identified in the
literature as a central issue in these disorders. ET
is specifically intended to enhance the degree of control
that vulnerable individuals exercise over their lives.
Evaluation
Evaluation
of ET is ongoing, but the model has been used and evaluated
with two groups of Vietnam Veterans in a project funded
by the Department of Veterans Affairs. With these groups,
ET was used for individual work in a 4-day intensive
program, together with group work that focused on skills
development, especially anger management and assertive
communication. The outcomes for both groups were very
positive. For example, the following data comes from
the follow-up of one of the groups, six months after
the program.
The
mean score on Diener et al's (1985) Satisfaction with
Life Scale increased from 10.2 to 22.2. Using the Beck
inventories, the mean Depression score dropped from
a pre-program mean of 27.4 to 12.8 at the six-month
follow-up, and the mean Anxiety score decreased from
27.4 to 8.8. The Veterans' level of attainment of their
own goals (on a scale from 0 to 10) increased from 3.1
at the outset of the program to 6.9 at the six-month
follow-up.
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