Kathryn D. Perez
Counseling and Psychotherapy Theories
Graduate Degree Program in General Psychology
Crescendo Therapeutic Model
Crescendo is a term most commonly used in music notation to mean gradual increase in intensity. Crescendo therapy uses the same premise, but instead of intensity, the gradual increase is in therapist involvement in the therapeutic relationship. Integrating White and Epston’s narrative therapy model (Corey, 2009) with other progressively more therapist involved approaches will accomplish this. The main therapeutic models of crescendo will be the previously mentioned narrative therapy progressively including and integrating Glasser’s reality therapy, Meichenbaum’s cognitive behavioral therapy (CBT) and Ellis’s rational emotive behavioral therapy (REBT) in that order. Each of these models involves the therapist progressively more than the model before. The client will be guided forward through talking, realization, understanding and behavioral changes. A few other facets of additional therapeutic models will be integrated as necessary for a particular client. I appreciate the information that I’ve acquired through texts written by Dr. Gerald Corey (2009) and will integrate the above named dominant models and secondary therapeutic models to build my own using what he has provided.
Basic View of Human Nature
Human nature is very eclectic and diverse. There are likely as many variations of response and behavior as there are sentient beings on Earth. Each accepts what they choose to and rejects that which they cannot accept. Trying to niche all people into a neat little package is impractical, not beneficial, and possibly irresponsible and harmful in psychological therapy.
Even with the vast array of personalities, I have notices some general traits of human nature to be more consistent. Most people tend to remember negative events with more clarity than positive events. I also observe that many try to make sense of events they’ve witnessed or experienced.
Another group of dominant traits of human nature include frustration when failing to change others, tendency to not ask for help, and negative perceptions and stigma involving psychological counseling. In effect, many do not wish to appear out of control or weak.
Key Factors Accounting for Changes in Behavior
Factors that can help a person to change include self-realization, self-empowerment, and a change in personal perception of others, events, and themselves. Most people have encountered an unpleasant person or situation; helping the client to acknowledge that traumatic or stressful events and radical changes occur to most everyone. Helping them to see the fact that they survived the experience may help them to realize that they are capable of overcoming negative stimuli and influences from their past, present, and even future life.
Working with the client to rewrite their own story, realize their own relationship to problems, and understanding the ways he or she can change are all keys to that change. Practicing changes in behavior and thought processes will guide the client toward positive changes in their perceptions and social future. Helping a client to weed the positive out of a negative problem will teach them to do it themselves.
Among the factors helping the client to rewrite their own future through narration, practice, therapeutic advice and empowerment, a strong factor in feminist therapy, the client should try to keep grounded through their own improvement. Sometimes finding one’s own voice can become overwhelming. Advising the client that the key goal is to improve their own place in the world is important. Empowerment should assure equality as well as personal and emotional strength, instead of changing the balance of power. Empowerment in some form is a useful step but should be taken with caution.
Nature of Therapist-Client Relationship
The therapist would have the expectation of guiding the client but only as far as helping the client to see their own way through the darkness until they determine if they need more help. The client will be expected to follow through on any homework or practice any skills discussed in a session. They will also be expected to be truthful about both the events that brought them to therapy and whether they believe they are being helped or not so that the process can move forward at the appropriate pace to help the client.
Mutual trust would help to make the therapist-client relationship a better working model to improve the potential for success in the process. By ensuring that the therapist and the client do their part to maintain integrity during the therapeutic sessions, each can feel confident that secrets will not be shared without cause. There should be a friendly relationship between parties to help ease the stress of opening up, as a client, and telling tales that they may be uncomfortable to discuss.
By allowing a client personal control over therapy, each client has the opportunity to make changes to their behavior while feeling less resistance and apprehension. Narrative and reality therapies provide the client with such an opportunity. Once the beginning sessions have been concluded the client may be ready to go forward on their own, or choose to continue until they can find resolution to their problems or concerns, garnering a more active role by the therapist.
Key Functions of the Therapist and Client
The therapist should indicate that he or she has expectations of the client just as the client has expectations of the therapist. Informing the client that they (the client) will be doing the bulk of the work at the beginning clarifies the expectations up front. The therapist will be responsible in pointing out key items in their story. The expectations for the client will be that they tell their stories honestly, think of positives in their lives, acknowledge personal responsibility, admit that they are the first step in their own change, acknowledge that they will be unlikely able to change other people, that they follow through, and do the homework that will be discussed during sessions. As long as the client and therapist have full knowledge of the expectations of each other there should be little communication issues as therapy moves forward.
The therapist-client relationship should begin from a client-centered approach using narrative guidelines to therapy and gradually integrate therapist-client models of reality and CBT. If these more client or client-therapist models are insufficient then REBT, with a more hands-on approach to therapy by the therapist, would be added to not just guide but rather instruct the client to perform specific behavioral changes in their daily lives, and report back to the therapist their progress in making the new behaviors more dominant and natural. In each step of the process the client should be guided to think about current problems and try to avoid dwelling on the past. The therapist should stress the importance of the client working in a forward direction.
As therapy sessions progress, initially the therapist will be expected to keep a client journal. He should include observations of positive or unusual outcomes during their narratives that the client can build upon to improve their coping skills. The therapist will present this journal to the client after three or four sessions to continue updating as homework. Narrative therapy is intended to help the client to see the holes in their ‘story’ and guide them to fill in any gaps or change any misdirection by offering mild suggestions or asking the client how they thought they could have improved on their behavior (Corey, 2009). If narrative therapy is not proving adequate, the therapist then integrates reality therapy with narrative therapy in attempt to guide the client toward clearer realizations by the client. The client should be able to accept truths and address misperceptions within their own narrative. At this point, the client should also be able to discuss their own choices during the events in discussion and candidly admit whether they felt they could have done things differently, and how. Reality therapy concentrates on choice theory. When using reality therapy with narrative therapy, the client should learn to accept their personal choices along with finding ways to make alternative choices.
The therapist continues to make homework more complex or involved in order to help the client to progress with their therapy. If the client is able to take advantage of acknowledgement of choices they should be asked to write down pros and cons to specific choices that were made and explanations of why they believe that each is a positive or negative choice (Corey, 2009). The full integration of the client in their own improvement may help them to develop a feeling of accomplishment which helps them to see beyond their own perceived limitations so they can reach new heights of confidence and capability.
Key Goals of Therapy
Clients come to therapy because they need help with resolving a conflict within themselves. Expectations and goals of therapy should include helping the client to overcome these conflicts and learn new and more positive methods of dealing with their internal conflicts. Helping the client to find their own voice and improve their behavior and cognitive skills will provide them with a repertoire of behaviors and coping mechanisms they can use instead of relying on long term therapy.
The main goal is to help the client to reintegrate back into the society or culture that they live in without changing that culture. The client should feel comfortable returning to the life they live, but be better equipped with adequate coping and response techniques to deal with some of the more stressful or challenging parts of that life.
Techniques and Procedures
The therapist begins by assuring the client that although he or she has the skills to help guide the client to a positive lifestyle, the client knows themselves best. If the therapist takes too much time attempting to second-guess the client then therapeutic success will be hampered. Theories such as narrative, reality, CBT, and REBT follow the crescendo therapy model’s progress from client control to therapist intervention and instruction.
Narrative and Reality Therapies
After interviews, the therapist begins the consultations with the client by listening. He or she will begin by asking the client what is going on in their life and the client then begins their narrative. The client will be in control of the initial pace of therapy. He or she is encouraged to tell their story. The therapist asks questions only when it is necessary, allowing the client to continue uninterrupted as long as their story is going forward. In the event that a part of the client’s story can be highlighted, the therapist will make a note of the comment to address at the end of the narrative. When the narrative is over, the therapist can refer to the notes taken and point out positive moments that the client showed clarity or self control in the midst of what they are discussing. At this point the therapist can also begin to help the client to shape their own destiny for their autobiographical speech. The client will be expected to truthfully account for their experiences, especially the ones that led them to therapy. Narrative therapy is extremely intense in finding those things that change in the story which improved the outcome (Corey, 2009). Reality therapy is used to find methods of enabling the client to accept their own choices and take responsibility for them (Corey, 2009). Once the choices are accepted then they can be changed.
Integration of CBT
For clients who are not confident after telling their narrative and trying to change their story based on alternative choices and realizations of the truth, CBT is integrated into the process. CBT involves the therapist offering suggestions of how the client can learn from their experiences, keeping things current. Narrative, reality, and CBT models do not deal with past situations and experiences (Corey, 2009). It is more important that the client learn to live today than to dwell on the past, which cannot be changed (Corey, 2009). Living in the now, as Pearls contends in gestalt therapy, will help the client to keep their attention focused on what is happening in their life as they are being counseled (Corey, 2009). The client will be expected to follow through on suggested changes in behavior and to write in their journal what they have discovered from their real life practice of the changes in behavior, and report to the therapist.
Inclusion of REBT
As the sessions progress the client should begin to feel more comfortable with therapy and either improve or request additional guidance and some suggestions from the therapist. At this juncture the therapist should discuss with the client if they feel their perceptions have improved. He or she should explain REBT before integration because of the difference in this approach from the other three. The therapist takes on a very instructor mode of therapy once REBT becomes the dominant model used (Corey, 2009). The therapist should indicate that the client will be given specific tasks to perform in the real world and record in the journal what it is that they accomplished, and how others reacted to the different behavior from the client. The client will be expected to do their part in this concluding model that is integrated into the therapeutic process. The client will be required to dig deep into their own memories and be brutally honest with themselves about their current behavior. Self-acceptance is part of the process (Corey, 2009).
Specific Problems and Demographics Helped Best by Crescendo Model
The demographics that would benefit most from crescendo therapy would be those who are willing and able to take control of their own lives. Veterans, corporate employees, substance abusers, teenagers, and anyone with a short-term need to help coping with a specific event would benefit from the gradual step approach that crescendo model employs. The ability to end the therapeutic process at any time during the crescendo of therapies enables the counselor and the client to both determine where it is best to stop therapy without leaving the process unresolved.
Women and culturally negated groups would learn a great deal about the behaviors of others and would benefit well from crescendo therapy. Each would learn how others perceive them, how they perceive themselves and others, and how they can change their own behaviors without removing that which makes them unique in society.
In certain situations crescendo therapy would work in prison systems to help guide prisoners through their ill conceived choices and work with them to find more positive choices for the time when they are released from incarceration. I think that this demographic is much like military demographics in that they find themselves currently in a situation that they are unable to find relief from, thus learning how to cope and assimilate behaviorally will benefit them.
Individuals who have suffered experiential trauma, those who are in abusive relationships, and people who have encountered specific behaviors or events that they are unable to escape, such as an overbearing employer, would benefit from behavior modification that enables them to begin at the beginning and progressively work through each of the steps until they find a method that works for them when encountering the stressful catalyst. Individuals who suffer from PTSD, assimilation trouble, or other immediate negative environmental influences to their behavior would benefit as well.
Specific Problems and Demographics Helped Least by Crescendo Model
Those who suffer from mental problems that are a result of physiological difficulties, such as low serotonin levels in the brain, or head trauma would be less able to use crescendo model because their behaviors are related to problems that are controlled or managed by medications or surgery.
People who suffer from schizophrenia, bi-polar disorder, autism and ADHD may not find positive results from crescendo therapy, either. Again, because these are better managed pharmacologically, talk and behavioral therapy may not be successful in helping these people with coping. This demographic is not suffering from environmental influences, or a personal perception.
Children may not be able to follow through with the homework so it is probable that crescendo therapy may be initially helpful but would not be as beneficial as the process was increased. In addition, I would not recommend this model for groups or family therapy as it is paced by the individual, and not everyone is going to progress at the same rate.
Ethical Considerations for Crescendo Therapy
Ethically the therapist should ensure that they are able to keep their mind open to the different cultural groups they may encounter through therapy and not try to change them. The goal of therapy is not to mold each client into the therapist’s perception of what is normal. Rather the client should be taught skills that can help them to overcome stress and situations that they may come across in their personal daily life.
When helping a client, using a diagnosis to label them may become a detrimental event in the client’s already tenuous thought processes. Unfortunately in certain circumstances a diagnosis based on the DSM-IV-TR is necessary for the client to receive appropriate dispensation, or compensation, as with military veterans looking for disability. In such situations the diagnosis should be conducted with the utmost care to assure the client that he is capable of being whole again and the requirements of the state, nor a diagnosis, should not change his optimism.
The therapist who wishes to utilize a self-paced and gradual increase in therapist involvement in the therapeutic relationship may find the crescendo therapy model a method that is useful to them. Of course, with any therapeutic model there is room for improvement and this method is no exception. Using gradual integration of narrative, reality, CBT, and REBT models with exceptional additions of other models as the client’s needs require, the therapist should find success with many of their clients. However, therapeutic models are not a one-size-fits-all; certain groups will not benefit from this model because of their specific and unique medical or physiological requirements.
The client will keep a journal. Personally, I will visit book stores and collect a variety of journals and gift a book of their choice to each client. This journal will first be used by the therapist and then the client to keep up with their homework. Although the therapist would not be required to provide journals, I believe that it is more convenient for the client and a gesture of kindness, but also a motivator for the client to keep their obligations in therapy.
Corey, G. (2009). Case approach to counseling and psychotherapy (7th ed.). Belmont, CA: Thomson Brooks/Cole.
Corey, G. (2009). Theory and practice of counseling and psychotherapy (8th ed.). Belmont, CA: Thomson Brooks/Cole.