Contracting for Therapy

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Notes on Advanced Methods in the Practice of Counseling and Psychotherapy©
Demetrios Peratsakis, LPC, ACS
October 28, 20015; revised July 28, 2018
The Goal of the Therapy Process
“There's no coming to consciousness without pain.” - Carl G. Jung
As social beings our understanding of the world as well as our definition and imaginings of self are
inextricably tied to others. This necessarily imparts a systemic, relational component to our beliefs that
shapes our goals and imbues each of our actions with social meaning. Every individual strives for
competence and recognition, for social acceptance and social belongingness (Adler); this imperative is, at
its core, the root of personal growth and social innovation. The more meaningful and purposeful our
relations, the better we adapt to change and navigate the complexities of conflict and power with others.
In a fundamentally true and primary way, this is the essence of emotional wellbeing.
Overall Goals of Treatment
The job of the therapist is to create a remedial process by which adjustment to change can occur.
It entails problem solving and conflict-resolution and often requires that trauma and its corresponding
anger, guilt and shame be reconciled. To a great extent it relies on coaxing and cajoling change in the
client’s long-standing assumptions and beliefs about their problem or situation. To do so, therapy must
provide a safe, yet challenging practice of new ways of thinking and behaving, with treatment becoming a
series of deliberately structured opportunities for change. When done skillfully, the purpose and power of
the symptom is reformed and the reality of its meaning irrevocably changed.
Challenging the Belief System and the World-view
Most clinicians adhere to a constructivist perspective -whereby the individual is viewed as responding to
their own interpretation of events. Since belief drives interpretation, it is important to immediately begin
to challenge the client’s perspective on the nature of their problems and the possible solutions they seek to
their remedy. In its simplest form one adopts a posture of accepting the Presenting Problem (Symptom),
while exploring the scope of its influence and purpose. We broaden narrow interpretations and narrow
broader ones; we examine the influence or “functional value” of the symptom and how, irrespective of
cause, it serves as a focal point around which behavior is organized and social interactions are patterned.
In time, this will evolve to a preferred mechanism for expressing emotion, organizing roles, formulating
rules, and defining shared purpose in intimate relationships. By the very nature of these functions all
symptoms acquire purpose, meaning and power, each of which must be reconciled.
Why is the client seeking treatment at this time? Why not a month or two ago, or next month or the month
after? What is the exact nature of the problem and why this particular problem, in this particular
individual or family? When did it begin; what was happening at the time and who was involved and how?
What happens when it reoccurs; who does what and in what sequence? Does it happen all the time or is it
selective with regard to circumstance, time, people or place? We must also obtain clarity as to the
motivation for treatment and the work that must occur in order to obtain the desired change. How is
success to be understood or measured and in what terms? Who needs to participate to actualize that end
and under what terms or conditions?

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This interrogative method forms the basis of the clinician’s work and is particularly critical to setting the
direction, terms and conditions of treatment called “contracting”. Often mistaken as a one-time or cursory
process, contracting is, in fact, the most sophisticated portion of treatment. As a continuous process of
refining and reaffirming goal expectations, treatment does not begin once the problem has been
sufficiently clarified; it is the very act of clarification that represents this higher form of therapy.
 The history of the Presenting Problem informs you of the difficulties experienced by the client(s) in
adapting or adjusting to change, both normative developmental processes such as marriage or leaving
home, and traumatic events that by their nature demand compensatory action to one’s sense of
security, safety and interpersonal worth.
 By tracking the sequence of interactions that surrounds the Presenting Problem–who does what and
when, we are informed as to the pattern of behaviors that maintain the symptom and ultimately define
its purpose (dysfunctional transactional process). Disrupting these, which can be done with varying
degrees of intensity, will necessarily alter the experience of the symptom by presenting a direct
challenge to its rigidity and inevitability:
1) Create a new symptom (ie. “I am also concerned about ___; when did you first start noticing it?”)
2) Move to a more manageable symptom (one that is behavioral and can be scaled; ie. chores vs attitude).
Broaden narrow problems; narrow broad problems
3) I.P. another family member (create a new symptom-bearer or sub-group; ie. “the kids” or “the boys”).
Shared or distributed “blame” blurs the focus and reduces distress on the IP
4) I.P. a relationship (ie. “the relationship makes her depressed”). Relationships are more “fixable”
5) Push for recoil through paradoxical intention, a risky gambit that requires a greater skill level
6) “Spitting in the Client’s Soup” –make the covert intent overt and devalue its “nobility”
7) Add, remove or reverse the order of the steps (ie. having the symptom come first);
8) Remove or add a new member to the loop
9) Inflate/deflate the intensity of the symptom or pattern
10) Change the frequency or rate of the symptom or pattern
11) Change the duration of the symptom or pattern
12) Change the time (hour/time of day/week/month/year) of the symptom or pattern
13) Change the location (in the world or body) of the symptom/pattern
14) Change some quality of the symptom or pattern
15) Perform the symptom without the pattern; short-circuiting
16) Perform the pattern without the symptom
17) Change the sequence of the elements in the pattern
18) Interrupt or otherwise prevent the pattern from occurring
19) Add (at least) one new element to the pattern
20) Break up any previously whole elements into smaller elements
21) Link the symptoms or pattern to another pattern or goal
22) Reframe or re-label the meaning of the symptom
23) Point to disparities and create cognitive dissonance
Note: 1-4, Minuchin/Fishman; 5-6, 22, 23, Adler; 7-21, O’Hanlon.
Pattern or element may represent a concrete behavior, emotion, or family member
 While labels and diagnoses can be useful short-hand descriptors they represent the beliefs and
impressions of others and can readily cloud one’s initial impressions. They mask the relational
component of the problem and stem from a reductionist perspective that views the individual as the
locus of blame. Moreover, labels describe symptoms as conditions that befall an individual which
belies their dynamic nature as instruments of purpose and intent.

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 The symptom must have a relational component. An effective plan of treatment should consider who
else participates in the problem, whether real or imagined, living or dead.
 Contract goals must have concrete, behavioral components that are measurable and that can be clearly
delineated for evaluating progress and risk.
 Validate the person who has the power to return the member(s) to treatment.
 In the same manner, acknowledge the power of the Presenting Problem. By reaffirming its
importance, especially after each bout of exploring alternative explanations, the purpose for seeking
treatment is upheld while doubt as to its significance is introduced. This see-saw action unbalances
the rigidity with which the symptom is regarded and helps to introduce new constructs and belief
possibilities (cognitive dissonance).
 It is important to continuously gauge the motivation for change. As clients discover the degree or
work required in achieving their goals their ambition may wane or they may gain a more realistic
appreciation of the amount of effort required to accomplish them; do-able doesn’t mean it’s worth
doing. Therapy is as much a process of education as it is of cure.
 Regardless of how unwanted, symptoms serve a purpose, developing greater functionality over time.
Their removal or change may threaten the individual and the system and result in
◦ a worsening of the existing symptom or problem (rebound);
◦ the creation of a new symptom, symptom-bearer or problem (deflection);
◦ the development of physical or psychiatric illness (conversion); or
◦ the abandonment of treatment (escape)
 Contrary to the notion that “the worse that can happen is that change won’t occur”, treatment failure
has serious consequences and may be used by the client to justify
◦ their worthlessness, hopelessness, inadequacy or inability to change (shame)
◦ the severity of the symptom as justification for not changing or avoiding responsibility
◦ the inadequacy or incompetence of the therapist to accomplish change (resentment)
◦ disinterest in seeking further treatment at a later time
Assessment Areas
The investigatory process, what exactly to assess and how to contextualize that within a coherent
framework, is largely driven by one’s theoretical perspective. Unfortunately, given the absence of
standardization across scores of clinical approaches we evidence great uncertainty among clinicians as to
the principles that underlie their eclectic styles.
“Therapy allows for the continuous possibility of a genuine, human-to-human encounter. As the
counselor develops greater “therapeutic relational competence” (Watchel, 2008), their power as an agent
for change matures and grows. In this manner, both therapist and client grow through authentic encounter
with each other (Connell et al.,1999; Napiers & Whitaker, 1978).
In general terms the orientation herein is predicated on the following premises:
 Psychological problems originate from unresolved interpersonal conflict or trauma. They lead to
depression (despondency) or anxiety (fear) and result in damage to one’s sense of self-worth.
 We interpret, then feel and act accordingly. As social beings our relationships are the milieu within
which we must continually adapt to one another (mutual causality) and re-create our opinions and
beliefs about ourselves, others and the world that surrounds us.
 The goal of therapy is adjustment (adaptation) to major life events; it may include the need to heal
trauma, reconcile conflict or remedy injustice. Life-cycle change is normative and continuous.

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 The therapy session is a primary venue for experimentation and the practice of new ways of
thinking, feeling and behaving, as well as a medium through which to experience intimacy and
acceptance.
 Supervision is a transformational process that includes the Supervisor, Counselor and Client. Where
practicable, direct observation of both client counseling and supervisor guidance is preferred.
Areas to explore
1. The Presenting Problem (PP)
 History of the Presenting Problem (PP) informs you as to its purpose and meaning
 Nodal events leading (correlating) to the onset of the PP and of seeking therapy (Why now?)
 Pattern of Interaction (sequence of behavior surrounding the PP) informs you as to who maintains
the presenting problem and how
 What is the observable, characteristic pattern(s) of interaction surrounding the PP or Identified
Patient (IP); who is involved and how?
2. Developmental Tasks: general adjustment and adaptation to major life changes (Family Life
Cycle; Tasks of Life); general strengths, abilities and resiliency of each member.
3. Power, Conflict and Power-struggles: how is power shared/displayed (overtly and covertly) and
conflict reconciled. Who is entrenched with whom in existing conflict and power-struggles: a)
Alliances and Coalitions that are supportive; b) Collusions and Triangulations that are corrosive
4. Intimacy: how and with whom is intimacy expressed? Do active partnerships express mutual respect
and love? If partnership is absent, what barriers exist to active searching?
5. Trauma and Injury to Self Worth: the effects of unresolved trauma are cumulative. The most
debasing trauma is betrayal, including expulsions, abuse, rejection, affairs, abandonment and incest.
6. Therapeutic Alliance Client’s attitude and responsiveness to the therapist and the treatment process.
How the client(s) attempts to influence or control the therapist depicts their interactive style and
often communicates or serves as a metaphor for how they need others to see them; what their terms
are for a relationship
I find the following beliefs about therapy helpful
 Behaviors, emotions and symptoms are purposive (Adler)
o Action is not random but goal-directed and consistent with one’s beliefs and world-view. This is
not simply a matter of the outcome of a sequence of behaviors or actions, but of all sequences.
- "Toward what purpose was the behavior expressed?"
- "Toward what goal was the behavior aiming?"
- "What is the 'use' or function of the behavior?”
- “What is the outcome that occurs, when the behavior is expressed?”
o The primary goal of all human behavior is social belonging, a continuous striving to be part of the
communal whole while maintaining significance and a unique sense of self. We each hold beliefs
and imaginings about ourselves and how best to function with others
o We interpret all action against these beliefs, re-affirming the world and our place in it
o Our own behavior shapes the thoughts and feelings of others who behave in a manner that
reaffirms our own beliefs about the world and how to be in it (worldview re-affirmation)
 Nothing impedes therapy more than the therapist’s own fears. The best clinicians are willing to
immerse themselves in the pain, rage, or insanity of another; to freely step into the abject terror of
another’s pain knowing that for at least those few moments the client is no longer alone.

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 Psychotherapy is the exceedingly deliberate art of manipulating experience. The difference between
counseling and psychotherapy is the degree to which the therapist is willing to accept personal
responsibility for change; to fully embrace that the outcome of therapy is the clinician’s
responsibility and that clients do not fail in therapy -but are failed by therapy.
 Clients come for therapy not because they desire change, but because they failed to accommodate to
change; every client is a forced referral. It is critical to be mindful that if clients could do it outside
of the therapy session, they would have little need to discuss it in therapy. The therapist must make
session a safe haven in which to practice new ways of thinking, feeling and interacting
 Symptoms are purposive; they organize and control others. They are highly effective power-plays
 Whenever possible, pull clients into your own energy, optimism and sense of hope. Self-disclose is
“an absolutely essential ingredient in psychotherapy – no client profits without revelation” (Yalom)
 Don’t push and the client won’t improve, push too hard and the client will leave. Push, apologize,
then push some more
 Expect to “kill” your first fifty clients (Robert Sherman/Harold Mosak)
 Never parent children -unless you’re planning to adopt them; get parent(s) (grandparents) to do so
and observe effectiveness. If ineffectual, zero in on what how and why they abdicate their authority.
Often the child’s problem will deflect from another (ie parental depression) or draw an important,
but distant, member in such as the father. Children make ideal “lightning rods”
 Therapy is failure prone, so never let a client tie your hands; never ask permission unless you are
willing to accept a “No!” Never accept secrets. Never let a client beat you in a power-play. Never
move forward until all your conditions have been met (therein, lies the therapist’s true power)
 The Ideal is unreal. Change in any part, will induce change in the whole
 Sit within arm’s reach of the client
 Make the covert, overt; this exposes the intent of the behavior and the purpose of the symptom
 Betrayal demands revenge. “Punishment” is critical to healing, for the victim and the committer
 Trauma requires work on Guilt, Anger and Shame (GASh) and its damage to Self-Worth
 Never work harder in therapy than your client does. And then, never do more than is necessary
 Believe what one does and does not do. Match behavior with belief and both with intent
 How therapy ends is more important than how it begins
 Some clients are therapist-slayers; they prove their superiority by vexing the therapist and thwarting
treatment. They find “nobility” and righteousness in the struggle and vindication in their failure
 Suicide and depression are extremely powerful (passive-aggressive) forms of revenge
 Never interrupt when work is being done; always interrupt when work is not being done
 The client’s behavior is intended to distract themselves from feeling or experiencing their own pain;
challenge the distracting behaviors and the pain will eventually emerge
 When all else fails
 prescribe the symptom
 invite a consultant or co-therapist into session
 add or subtract a member to session
 convert the client to a therapist
 pronounce the client cured

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Confrontation
A natural component of assessment is a continuous analysis of the client(s) response to the therapist’s line
of inquiry, prodding, musings, “squeezing” and other forms of confrontation:
“Effective confrontation promotes insight and awareness, reduces resistance, increases congruence
between the client’s goals and their behaviors, promotes open communication, and leads to positive
changes in people’s emotions, thoughts and actions” MacCluskie (2010). Linda Finley (Finlay, L.
Relational Integrative Psychotherapy: Process and Theory in Practice, Chichester, Sussex: Wiley, 2015)
listed several key principles to effective challenging:
1) It helps to believe in the value of challenge: it plays a vital role in moving a client towards new ways
of thinking, feeling and behaving. And, while we might find challenging hard to do, authentic, honest
straight, well-meaning comments may actually be less damaging than empathic confluence or
‘pussyfooting’ around.
2) Challenging should be done relationally. In the early stages of therapy, simply attuning to the client
in a non-judgmental way may be all the challenge that is needed. Later, once the relationship is in
place, and trust has been established, more muscular/provocative challenges might be appropriate.
3) Challenges issued need to be in the clients’ interest and not simply be a self-serving product of our
own frustration, impatience or irritation. Sometimes this is easier said than done, particularly if
we’re caught up in powerful counter-transferences and projective identifications. So we need to be
reflexive about our urge to challenge towards finding more constructive modes which can be
received in non-defensive ways.
4) Empathy and compassion need to be to the fore when challenging such that our clients will hopefully
be able to understand that our challenges arise out of caring concern. In other words, the challenge
occurs in the wider context of the therapy. When giving such challenges, it can be useful to use the
‘on the other hand...’ type of intervention. For example, “I can feel something of how hard it is for
you to talk about that. On the other hand, I think it would be helpful to put it into words.” Or, “I’m
hearing you say you’re calm. On the other hand, I see your foot tapping and I’m wondering if your
body is saying something different(?)”.
5) Aim for a proportionate, optimal level of challenge. Too much challenge when the person isn’t ready
to receive it, can be shaming, overwhelming and destructive, and is likely to just cement defensive
resistance. Insufficient challenge means we end up in confluence, colluding with cosy stagnation.
6) Asking permission to challenge or to give feedback can pave the way. “I’d like to offer you a
challenge. Are you up for it?” Then the client is enlisted as an ‘ally’ and the challenge is dialogical
rather than a one-way exercise of power.
7) It can help to encourage self-challenge towards enabling the client to be more self-aware and take
responsibility for choices. For example: “As you’re sharing these different stories of dating with
me, I’m seeing a bit of pattern where it seems you tend to end up feeling used and betrayed. Is this
a familiar pattern? Would you be willing to think about your own role in this?”
8) Often it is more productive to challenge unused strengths rather than weaknesses. To give an
example, it might be more constructive to acknowledge the client’s capacity to care for others if not
themselves, rather than calling them an unhealthy ‘rescuer’.
9) Challenge may often best issued with shared gentle humor – of course, this needs to evolve mutually
(laughing with, not at) and be sensitively done.
10) We, too, need to stay open to being challenged (e.g. by clients or by our supervisor) if we are to
grow and develop as therapists. At the very least it can provide a useful way of modeling the
behavior for clients.

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Symptom Origination
Understanding how and why symptoms originate is crucial to unbalancing their power and redirecting
their purpose. As previously cited, symptoms are enduring patterns of behavior, structures or syndromes
that organize social interaction, mediate stress and provide adaptive response to normative and para-
normative change. Over time, they become hardened patterns of interaction around which relationships
organize and roles and rules of behavior become defined. These acquire history as they organize social
behavior including how love, hate, need and want are communicated and shared. As joint cognitions, the
communal reality created acquires shared history and is subject to the processes of intersubjectivity, joint
problem solving, and distributed cognition.
I find it helpful to categorize symptoms as originating form one of three possible sources: 1) a
psychological problem that develops in response to an inherited or acquired biomedical condition; 2) safe-
guarding behavior developed as adjustment to damage suffered through trauma; or 3) as a passive
aggressive response to a power-struggle and means of controlling others. This latter cause results from
pervasive distress due to chronic conflict and is often mixed with trauma resulting from acts of
misbehavior and betrayal used as punishment or as acts of revenge.
1) Rule-Out Biomedical Conditions
Psychological problems that develop in response to biomedical conditions should not be confused
with a true medical condition that expresses symptoms associated with psychological causes, such as
depression associated with hypothyroidism, panic attacks caused by a pheochromocytoma (a tumor
that secretes epinephrine) or anxiety and increased irritability resulting from a brain tumor. In
instances where a developmental or biomedical condition has acquired psychological purpose and
meaning, the psychosocial component should be considered only after a differential diagnosis has
been completed and medical testing helped to ascertain the limits on ability and function (see ‘rule
out” below). While self-esteem and social identity may be common adjustment challenges to
individuals with these conditions (especially when acquired later in life) the therapist is largely
concerned when infirmaries are utilized to justify inaction, to control others, or as an excuse or
rationale for one’s conduct and for avoiding responsibility to change.
As a matter of course the therapist must rule-out all disorders associated with injury or irregularities
of the body and brain due to medical, hormonal, neurological/neurochemical, structural, congenital or
brain injury conditions:
a) Congenital Brain Damage (CBD): genetic (pre-birth) or birth trauma (at–birth); b)
b) Traumatic Brain Injury (TBI): head/skull injury to brain (accidents, sports injuries, falls, physical
violence); and
c) Acquired Brain Injury (ABI)/Neurological and Medical Illnesses: ie. stroke, tumors, aneurysms,
thyroid disease, cancer, vitamin D deficiency, poisoning/exposure to toxic substances, infection,
strangulation/choking, effects of drugs or alcohol.
While standardized medical and psychological testing may prove necessary, a simple, cursory
examination should be part of the counselor’s routine:
 Review of any historic file or anecdotal evidence of progressive decline in cognitive performance
from a previous level, namely complex attention, executive function, learning and memory,
language, perceptual-motor, or social cognition, as documented by self-report; the expressed
concern of a knowledgeable clinician, informant or observer and supported by 1) standardized
neuropsychological testing or 2) medical examination (ie. blood test, cat scan, MRI, MRSI, MEG
or diffuse tensor imaging). A Mental Status Exam (MSE) or similar guide for detecting cognitive
impairment:
 https://www.alz.org/documents_custom/141209-CognitiveAssessmentToo-kit-final.pdf

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Look for symptoms, which make medical illness more likely.
- a change in headache pattern
- visual disturbances, either double vision or partial visual loss
- speech deficits, either dysarthrias (problems with the mechanical production of speech sounds)
or aphasias (difficulty with word comprehension or word usage).
- abnormal autonomic signs (blood pressure, pulse, temperature)
- disorientation and/or memory impairment
- fluctuating or impaired level of consciousness
- abnormal body movements
- frequent urination, increased thirst (possible symptoms of diabetes)
- significant weight change, gain or loss
 Review of the Selectivity of the Impairment: Is performance relatively consistent across similar
tasks or activities or does it appear to vary depending on interest, surroundings or participants?
 Review of Attitude toward Impairment by Caregivers: Does the behavior elicit compassion or
anger? Are caregivers frustrated or unsure if the IP “Can Not” or “Will Not” function properly?
 Review of the Reply to the “Miracle Question”: “If I waived magic a wand and it got rid of this
symptom forever, what would be different?”; variation: “…what negative consequences would
arise?” The original purpose to this question –first employed by Adler and M. Erikson, was for
differential diagnosis: to determine the possible etiology of a condition (psychogenic vs
psychogenic). If the symptom was back pain and the reply to the question was –as an example,
“the pain would no longer keep me up nights” as opposed to “I’d finally finish school and get
married” then our guess would lean toward a medical or somatic concern.
2) Conflict
Clearly, most psychological injuries occur as a result of conflict, a natural and routine consequence of
social interaction. Conflict is a continuous by-product of our attempt to influence outcome. The
ensuing power-struggles are remedied by an array of common problem-solving strategies:
◦ Collaboration/Alliance (win/win)
◦ Compromise (I bend/you bend)
◦ Accommodation (I lose/you win)
◦ Competition (I win/you lose)
◦ Avoidance (no win/no lose)
◦ Triangulation (win/win/lose)
Unresolved, conflict leads to power-struggles that intensify and lead to chronic tension and duress;
this is characterized by either 1) persistent detouring to an Identified Patient (“scape-goating”) or 2) a
continuous need to hurt, overpower, or sabotage the efforts of another. The effort to break the impasse
or stalemate may result in extreme misbehavior including 1) Treachery and Betrayal (theft,
disloyalty, sabotage, incest, abandonment, infidelity); 2) Revenge (punishment, suicide, crime,
depression, addiction, eating disorders, failure or acts of inadequacy) or 3) Violence (warfare,
bullying, threats, rage, domestic violence, abuse).
 Conflict is always about power; it occurs around issues of money, work, sex, children, chores,
and “in-laws”
 Power determines style of communication and how love, caring, anger, and other emotions are
expressed and understood
 Power determines style of decision-making and problem-solving
 Power defines level of trust for meeting or not meeting needs

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 Power establishes rules for interdependence, independence and for distance and closeness
between members (attachment/mutual accommodation; affection/expressing and experiencing
love)
 Power defines roles and rules around family roles and positions; these are usually reciprocal,
interactive patterns of behavior found primarily in the Family of Origin (Intergenerational). These
tasks/rules are taken or assigned to individual within the family unit and are expected to be
maintained. These qualities (tasks/rules) are relatively enduring (permanent) and acquire “moral
character” and “status” which results in one’s placement in the family's power hierarchy.
Severe conflict will result in power-plays, often resulting in a misuse of power or acts of revenge to
punish or break the stalemate
1. Combat: fighting, bickering, forcing, hurting, bullying, shaming, withholding, stealing, et al.
often triangulating outside parties, for added power, such as friends, family, counseling, the
police, the courts, threats of separation or divorce, seeking legal counsel
2. Sabotage: undermining the partner, their sources of support, their resources or their attempts to
remedy the situation, kids, work, etc.
3. Inadequacy/Failure: One partner becomes dysfunctional, ill, fails or becomes the Identified
Patient (I.P.) to frustrate their partner
4. Isolating/Cutting-off: escape to solo activities, such as hobbies or individual interests; solo acts of
defiance and selfishness
5. Triangulating Others: patterns of adding power through the inclusion of a third-party, such as
friend, family member or child(ren)
6. Betrayal: violence, rape, incest, extra-marital affairs or sexual relationships
 Caution on Violence: fear of being together or separate; extreme swings between fear of
abandonment and fear of engulfment (equated with loss of identity)
Bowen expanded on the family systems’ perspective that symptoms were regulating, adaptive
responses to stress: “When anxiety increases and remains chronic for a certain period, the organism
develops tension, either within itself or in the relationship system, and the tension results in symptoms
or dysfunction or sickness. The tension may result in physiological symptoms or physical illness, in
emotional dysfunction, in social illness characterized by impulsiveness or withdrawal, or by social
misbehavior.” Family Therapy in Clinical Practice, p. 361, 1975.
He identified four (4) outcomes for their expression, each associated with a form of severe conflict:
 Open Discord
o Relationships that are stable but unsatisfying; stale-mates are more covert
o Relationships that are inherently unstable; conflict is open, cyclic and often violent
 Impairment in a Child. Although this may express in different forms, children are active agents
and may target their discouragement in one of 4 basic goals of misbehavior (Adler)
o Attention Seeking
o Power
o Revenge
o Failure or Displays of Inadequacy
 Impairment in One of the Adults
o Failure, depression or illness
o Social misbehavior such as criminal conduct, problem gambling or addiction
 Emotional cut-off, including expulsion, rejection, escape, disassociation and fugue

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3) Trauma
While much has been written on trauma, a better understanding of its cause(s) and the outcome of its
injury is always beneficial. In its broadest term, trauma is a disruption to one’s sense of security and
safety –one’s ability to protect oneself or others from harm. It is also a valuation of self, protection by
others, and the ability to recuperate and to heal. When found wanting, the individual will experience
feelings of guilt and shame, a devaluation in the estimation of their personal and social worth. If the
individual has been victimized, betrayed or blamed for inadequacy or failure they will also experience
anger and possibly resentment or rage. It is for this reason that guilt and shame are so closely
associated with anger. They form a corrosive triad that undermines one’s self-esteem and detracts
from one’s willingness to trust and be vulnerable with others, key requirements of intimacy and love.
Often, the anger is not readily apparent and may be suppressed in the form of anxiety, depression, or
physical illness. It may also express in more passive-aggressive ways such as failure and inadequacy
or under the pretext of self-blame or exaggerated remorse. In this regard, self-blame can be somewhat
insidious, deflecting the critique of others while conveying a sense of righteous indignation. For
some, there may be great “nobility” in the apparent struggle for repentance and forgiveness; “good
intentions”, however, often mask an unwillingness to change. This theme is common to chronic
syndromes such as domestic violence, depression and addiction.
To simplify matters I categorize Trauma according to one of three sources, depending on the injury to
interpersonal dynamics and area of needed treatment: 1) Tragedy, 2) Loss, or 3) Betrayal.
1) Tragedy (often sudden, often impersonal events such as crime victimization, accidents and
natural and man-made disasters)
Process Tragedy results in a sense of great vulnerability, fear and need for safety; one becomes
preoccupied with avoidance.
o Feeling/Tone: increased sense of Vulnerability
o Distinguishing Feature: Fear/Safety Needs
o Preoccupation: Avoidance
o Injury: Trust
2) Loss, including
o loss of a loved one through death or absence due to prolonged hospitalization, incarceration, excessive
work, military service, addiction, divorce, cut-off or expulsion;
o ambiguous loss (no closure) such as POW, run-away, kidnapping, or infertility;
o loss of a valued possession, heirlooms or important material goods;
o loss of a familiar way of being, body part, function or ability;
o loss of prestige, job, status or lifestyle;
o loss of a goal or sorrow over a missed opportunity; and
o regret or guilt over an action taken or failed to in order to harm another/breach of trust
Process:
Loss results in a sense of pervasive emptiness and a sense of grief; there is a great preoccupation
with filling the void, of replacement, of filling the hollowness one experiences.
o Feeling/Tone: increased sense of Emptiness
o Distinguishing Feature: Grief
o Preoccupation: Replacement
o Injury: Trust; Intimacy
2) Betrayal (breach of trust, the most insidious form of harm, the basis of intimacy and love;
Process
Betrayal of an intimate relationship is extremely devastating, resulting in overwhelming feelings
of anger and rage and a desire for revenge. Power-plays occur where the overt expression of rage
has been thwarted.
o Feeling/Tone: increased sense of Power-playing; Power Struggle

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o Distinguishing Feature: Anger; Rage
o Preoccupation: Revenge
o Injury: Trust; Intimacy; Worth
Intervention: Directives and Tactics
Assessment requires a continuous evaluation of the client(s) reactions to the therapist’s interventions.
These should be given as a matter of course and are best understood as distinct instructions or directives
to work given as a prescription, homework, exercise, ordeal or other form of assignment. They can be
very calculated -often manipulative, tasks assigned to provide practice in new ways of thinking and
behaving. The client’s performance provides an opportunity for reassessment and, in turn, redirection.
 Ordering a task or directive:
◦ Simple introductions that communicate the experimental nature of the task work best. This
denotes that the experience is exploratory and time-limited. Examples include: “Let’s try
something…”; “Some people find this helpful…”; “Let’s do an experiment…”; “I’m going to
have you do something that may be uncomfortable… ”
◦ Typically, it is beneficial to advise the client that the task may be difficult or even prone to
failure. This increases the likelihood of success through lower expectations or recoil.
◦ Once a directive is given, it is important to expect the work to be done. While some apprehension
is natural, outright refusal must be immediately addressed before moving forward. Irrespective of
the rationale, the apprehension should be confronted and the power-play, if present, disengaged
and redirected.
◦ Once assigned, the therapist's job is to redirect any straying or delay back to the task, itself. This
can build tension within the therapist who may feel an urgency to rescue the client from their
discomfort. If the client is unable to complete the task, the therapist should explore a) what would
happen had the task actually been completed, and b) “what was happening inside you as you
fought to complete this task?”.
Session Overview: The following highlights family session work but the mechanics of individual
psychotherapy are the same:
1. Join the client(s) (decision-making/executive subsystem) as a coach or mentor, build an alliance
with each member and accommodate to the family’s temperature and style:
1. Determine the source of power and who can mobilize the IP or family to action
2. Immediately challenge assumptions about the Identified Patient (and Presenting Problem)
3. Examine the Presenting Problem and what interactional pattern supports it; examine the
purpose of the symptom to the family
4. Continually check reactions and comfort with tasks, directives and challenges to the
symptom or presenting problem
5. Continually reaffirm family’s power: take one-down and re-frame progress as family’s
love and commitment to each other
6. Create intimacy through use of self and personal history, family bragging, praise,
celebrations and story-telling
7. Continually validate privilege of working with family, their acceptance and their
permission to share pain, secrets and shames
2. Build the executive subsystem: work with the adult(s)/couple as parents and address power-plays,
old betrayals and trust issues, personal dysfunctions with relational components, family-of-origin

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problems, in-law/friend interferences; help members practice expressions of mutual support and
tenderness
3. Get parents to parent. Failure to do so is the result of power-plays or conflict avoidance between
adults or abdication of power by a single-parent who needs individual counseling (ie depression),
4. Make kids age appropriate: throw kids out of spousal alliances; match authority, responsibilities
and benefits by age; promote (or demote) older teens and young adults with “parental”
responsibilities. Due to circumstances it may be wholly appropriate to “promote” young adults
5. Get parents to address individuation issues with teens and young adults by recognizing their
authority and power and supporting their desire and need to eventually leave home
6. Challenge power inequities:
1. Dis-engage and redirect power-plays toward common purpose, task or problem
2. Ensure that functions are clarified, roles are assigned and that authority (power) matches
responsibility
3. Bridge disengaged members and cut-offs and create breathing room and independence
for enmeshed members; interrupt/block inappropriate communications and direct proper
exchanges
7. Address hurt and betrayal and trauma and trust issues as major barriers to effective governance
and growth (Guilt, Anger and Shame = GASh)
8. Examine ghosts: confront family myths, cut-offs, or other legacy issues that interfere or serve as
road-blocks to effective problem-solving or growth. Do this verbally, through imagery, and
through sculpting, empty-chair or other projective techniques
9. Force enactment: encourage in-session practice of new behavior patterns and new forms of
expression; assign related homework, continually reaffirming that behavior rehearsal is critical to
solidify new ways of being.
10. Have fun and get the individual or family to laugh!
Reluctance to Change: Power-plays in Therapy
By the nature of the therapeutic alliance, power-struggles between the client(s) and therapist are a natural
and routine process of the relationship. They exist as a by-product of 1) the client’s ambivalence to the
change process, namely I want to change and I want to remain the same; and 2) the power-struggle
inherent to the process and purpose of therapy itself, namely “I want your help, and I defy you do change
me”. This should not be viewed in a disparaging way. We all desire change, but prefer it on our terms,
without much effort, and without the need to abandon ‘the familiar way of being’ that accompanies the
status-quo; most of us would prefer other people in our life or circumstances change, instead. Similarly,
there is natural reluctance to seeking help or being told what to do. We tend to see the need for seeking
help as a devaluation of our own capabilities and self-worth. For the most part, much of this settles out as
mutual trust develops and greater intimacy unfolds. In time, clients grow more courageous in exposing
their vulnerability and experimenting with change.
Needless to say, most clinicians find outright defiance as a significant cause of aggravation. I find it more
instructive to regard so-called “resistance” as nothing more than fearfulness resulting in a power-struggle
with the therapist. This may express itself in various ways:
“Client Expressions of Power in the Therapeutic Alliance -by Ofer Zur, Ph.D.
 Not talking: Some clients may choose to stay completely silent during therapy or an evaluation
session. For some clients, keeping silent is a way to maintain control and power over the situation.
Adolescents, young adults, inmates, those who were detained in psych. wards, and certain clients with

13. 13
character disorders have been reported to be selectively mute or use the 'silent treatment' against their
therapists, especially if they were coerced or were mandated to enter therapy against their will.
 Not following advice or suggestions: Some clients may maintain autonomy and control by not
following the therapists' ideas, suggestions or homework.
 Non-disclosure [Selective disclosure] or not answering questions: An obvious way for clients to
maintain control over what the therapists know about them is by disclosing very strategically and
discriminately. By limiting their self-disclosure, clients limit therapists' knowledge-base power. Non-
disclosure is more overt and is apparent as when clients do not answer therapists' questions and
inquiries or can be more passive and covert when clients do not disclose important or relevant
information.
 Taking notes or recording sessions: Some clients take notes during therapy or insist on recording
sessions as a way to gain more power or, at least, match therapists' power.
 Coming late or leaving sessions early: One of the many ways that clients may control the beginning
or end of sessions is by either coming late to sessions or leaving early. While leaving early is more
likely to be a more overt way to gain power over the time and length of session, arriving at
appointments late is a more passive way of such time control.
 Non-payment: One of the more common ways for clients to assert control over their therapy and
their therapists is by deliberately withholding agreed upon payments or fees. Like non-disclosure and
timing, clients may choose to withhold payment more passively by making up excuses or more
overtly by stating their intention of withholding payments.
 Stalking: Clients who successfully stalk their therapists are likely to gain a lot of information about
the therapists, which may translate to a power position. Therapists who are stalked are often
frightened for their own safety and the safety of their family or pets. Therapists are often hesitant to
report criminal stalking to the authorities because they either are (needlessly) concerned with
confidentiality issues or are afraid to aggravate their clients. This is especially true with psychopathic,
violent, and Borderline Personality Disordered clients. Stalking clients are often intimidating and
therefore often command significant power in the relationships with their therapists. Cyber-stalking,
which was discussed above, can be performed without a therapist's knowledge and can also yield vast
amounts of personal information about the therapist, which can give the client significant knowledge
power.
 Change seating or other office arrangements: Some clients, in a 'power move', sit in places that
were not assigned by the therapists or even sit in the therapists' chair themselves. Similarly, a client
may turn the clock in the office so it faces him or her and faces away from the therapist. Another
client may move his/her chair closer or further from the therapist or turn it in away from the therapist.
In a fit of rage, some hostile, psychopathic, and Borderline Personality Disordered clients were
reported to reorganize the office furniture.
 Provocative or threatening clothing: Clients may gain power by dressing in certain ways that may
be sexually or otherwise provocative, seductive, or intimidating. Sexually revealing clothing or
garments that bear gang insignias or symbols like swastikas may be intimidating and so are certain
violent, sexist, or racist tattoos. Depending on the gender, ethnicity, age, culture, race, or class of the
therapists and the clients, clients can dress in ways that can give them power.
 Use of language: Violent, vulgar, or threatening language can definitely affect the power
relationships between therapists and clients. Therapists may be intimidated, frightened or simply
distressed by the use of certain expressions and intonations by certain clients. Borderline clients have
been reported to throw tantrums or fits and use language that intimidates and threatens their
therapists.

14. 14
 Rage: Rage-filled clients can be highly intimidating to therapists who may feel frightened and
powerless in the face of raging patients. This is especially true in a private practice setting when
therapists are isolated and often are not trained to deal with clients who are extremely hostile or
violent. Gutheil has written about Borderline rage:
Borderline rage is an affect that appears to threaten or intimidate even experienced clinicians to the
point that they feel or act as though they were literally coerced -moved through fear- by the patient's
demands; they dare not deny the patient's wishes. Such pressure may deter therapists from setting
limits and holding firm to boundaries for fear of the patient's volcanic response to being thwarted or
confronted. . . Patients with borderline personality disorder who are dysfunctional in many areas of
life may still preserve intact powerful interpersonal manipulative skills. They may still be capable of
getting even experienced professionals to do what they should know better than to do or -all too
commonly- what they do know better than to do. (Gutheil, 1989, p. 598)
 Dominating the conversation: Another way that clients may gain the 'upper hand' is by dominating
the conversation, talking excessively and incessantly, or simply taking all the airtime.
 Inappropriate touch: The professional literature has described several situations where clients
surprised their therapists with a kiss on the cheek or lips, sexual embrace, or even reached out and
touched the therapists' genitals. Needless to say, any of these actions, when they catch the therapists
by surprise or unprepared, can cause a power shift in the relationships.
 Inappropriate gifts: Clients may give very expensive gifts (i.e., season tickets, a car) or symbolically
inappropriate gifts (e.g., sex toys, a dozen roses, weapons) in a power move over their therapists.
 Offering incentives: Clients may offer their therapists a promising business contact, lucrative
business deals, investment tips or promise to give them referrals as a way to level the playing field or
even to gain the upper hand.
 Acting seductively: Clients can act seductively in many ways. It can be the content of their dreams,
description of their private behavior and, of course, the way they talk, move, or dress. Clients can
gain significant power if they get the sense that their therapist is attracted to them and their
seductiveness is effective.”
The following are more common to couple and family therapy and pose a greater challenge to on-
boarding the therapy process itself. Again, while this may cause consternation in the clinician it is better
to view them as power-struggles originating from fear, providing a possible opportunity to be therapeutic
and to impact the contracting process:
1. Sets appointment, cancels/no-shows; sets appointment, cancels/no-shows
 Declare them not ready! Inform them that they are not ready and advise them to try later.
If they persist, ascribe an overt message to any next cancellation: “I am not convinced its a good
time, but I’m willing to set another appointment so long as we agree that if, for whatever reason,
you are unable to keep it we agree that it means that this is NOT a good time”.
 Pronounce them cured! Congratulate them on what they are doing; advise them to continue
2. Key member/partner sets appointment, other key member or partner refuses to attend
It is common for one member to be more motivated to attend treatment. Reasons include:
 beliefs about the value of treatment or cultural morays about seeking help;
 desire to refuse or punish the partner or family spokesperson;
 fear of being attacked at session;
 viewing the therapist as the another’s/partner’s choice or advocate;
 concern that things could worsen;
 the invitation to attend was poorly given; and
 appropriate concerns and barriers such as child-care, loss of work, etc.

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Hidden Agenda At times, the initiator has a hidden agenda and desires to attend treatment on their
own. Typically, it is about leaving the partner and wishing to utilize the treatment process as a way to
collude with the therapist or sway the treatment outcome.
To Begin or Not? The therapist must decide whether to begin without key individuals and whether
doing so will encourage the absence; in particular, this is a dilemma in couple therapy:
 an “empty chair” could be brought in as a proxy for the absent member
 the agenda could be highly restricted to work that does NOT include the missing member
 absence should be given an overt meaning, a statement, possibly of intent: “her absence means
she’s unsure about this”
Treatment should begin with strategies for inviting the partner or key member to attend. If/when the
missing member or partner attends the therapist should explore concerns about bias and establish a
new starting point
3. One sets appointment, then sabotages another’s participation
 garner support from the therapist in advance
 prepare to escape the relationship
 dump some major information about the relationship held secret from the partner or family
4. Both attend, one sees a problem, one does not
The temptation for the therapist may be to take sides, especially with the “yes, there is a problem”
perspective. This is a Trap!
Both must be fully invested either in agreeing to a common issue or that the issue pushed by one
partner has sufficient concern or angst to the partner to make investing in its resolution of value.
 let them struggle (Do NOT take sides!)
 have partner worsen their problem
5. Both attend, both agree that one partner is the problem or “Identified Patient” (IP)
This is an acceptable starting point. The couple sees and agrees that one is the cause of all their ills or
it may be a bona fide individual crisis, such as the partner having recently suffered a great loss. The
therapist begins with the Presenting Problem and begins to point to relational elements, thereby
broadening the issue to the dyad. If a crisis, the partner’s support is invaluable to the process of
healing; if a chronic concern, then the therapist can begin to explore the burden and frustrations
(anger/resentment) the partner holds for the Identified patient (IP). This is an acceptable starting
point, whether Crisis or Chronic
 Crisis: get partner’s support
 Chronic; get partner’s support, then point to relational burdens and resentments
6. Both attend, agenda moves to Individual Counseling (I/C) or child focus (F/C)
 It’s possible the therapist moved too fast.
 Has the Therapist moved too fast?
 Has a bona fide crisis occurred?
7. Both attend, one begins to No-show (leaving therapist with partner/spouse)
 Hidden Agenda?
 Has the Therapist alienated the partner?
 Has the attendee sabotaged the partner’s attendance?
8. Both attend, one drops a “bomb” (ie. sexual affair, drug abuse, major illness)
a) Consider it a Marital Crisis can the couple continue?
b) Consider a “structured separation”
9. Both attend, one discloses their desire to separate or divorce
a) Consider it a Marital Crisis  can the couple continue?
b) Consider a “structured separation”

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c) Therapist can help work toward separation and divorce
d) Therapist should be prepared to continue with abandoned partner
10. Both attend, one or both unclear on commitment (separate or remaining together)
a) Not uncommon (couple should be told so)
b) Explore how to decide: work toward one extreme or the other
11. Both attend, one or both continually triangulate the therapist
a) Point out and examine purpose
b) Sit further from couple, take turns, add co-therapist (examine issue in clinical supervision)
12. Shot-gunning/Carpet-bombing: Both attend, the agenda and goal of therapy continually
changes or vacillates
a) Keeps the therapy off-balance (means of controlling)
b) Explore couple’s difficulty prioritizing/committing to one item or goal
Ultimately, the best method of reconciling a power-struggle by the client is to closely examine its purpose
and assume a 1-down position. By its nature, the therapist obtains power from possessing a skill inherent
in the “helper” role; this can only be given freely by the therapist who thereby retains power over their
own participation. One cannot control what others do, but can control whether they elect to participate
and move forward at every given moment. To reconcile the power play pose the obvious dilemma and
allow the client to choose the course of outcome:
“I’m getting mixed messages and I’m now confused as to how to proceed. On the one-hand you seem
to be very clear that you want to achieve this goal and are asking for my help, but on the other-hand
you then negate my ability to help by not doping (X,Y and Z) . What should I do? How should I
proceed?”.
This approach recognizes the ambivalence of change while also validating the client’s sense of control.
Simultaneously, it reaffirms the therapist’s power by stating their inability (or refusal) to proceed without
a “green light”.
Goal Conceptualization and Contracting
The agreement to work must contain more than a mutual interest in achieving some goal or an outcome. It
must provide a clear and compelling reason for exerting the kind of energy and commitment to change
that successful treatment requires. Given that, the greatest danger lies in moving forward prior to a full
appraisal of the 1) the motivation for change, 2) how achievable is the goal and at what cost, and 3)
determining the possible hazards of change and its unintended consequences.
1. Pre-Contact Preparation
a) Basics: meeting space, transportation, forms & releases, Supervisor, etc.
b) Appointment setting: connecting, referral purpose, participants, etc.
2. Contracting (start of therapy; very sophisticate component)
a) Joining
b) Assessing and Challenging the Identified Problem or Person
c) Setting initial goal with time-frame, membership, expected outcomes, etc.
3. Mid-pointing
a) Re-assessing progress; evaluating the partnership
b) Re-calibrating toward termination
4. Termination
a) Reaching closure
b) Post-therapy supports, predictions and re-connection possibilities

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 Is this a crisis with practical implications that must be attended to first? What about safety and
security for children and vulnerable members? Times needed to meet, child care and other practical
arrangements? How often, for how long and for how many sessions?
 If this was NOT the problem, what or who would be? What does the problem seem to mask? What
might be the purpose of the symptom? What is at risk if things were to change?
 Who needs to participate and under what circumstances? What can be done if that person is not
available or refuses to attend? What will the alliances and collusions look like and what problem
does that pose for the clinician?
 How do we measure success and what are the bench-marks along the way? How would use of
consultants, session limits and co-therapy intensify therapy and maximize clinical gain?
 How will power struggles be understood by the therapist?
 Does the client need to control others in order to feel more worthwhile or superior?
 Is the client angry or upset with the therapist?
 Is the client second-guessing the utility or effectiveness of treatment?
 Has the therapist behaved in a manner that is suspect or that has damaged the trust?
 Does the therapist misuse their power and belittle, shame, or induce guilt in the client, especially
by moralizing, lecturing or assuming a haughty or “parental” attitude?
 Is the client frightened, contending with mistrust from prior emotional trauma and psychological
injury? Testing the client’s tolerance for more invasive techniques is important and is dependent on trust
 Is the client worried or freighted about the potential consequences of change? Growth in treatment
is isomorphic; the therapist must be open to personal growth and risk-taking as well. There is no inaction to
treatment; one is either actively discouraging or passively encouraging; treatment is either therapeutic or
counter-therapeutic.
 How will power struggles be disengaging and redirected by the therapist?
 Stop the process and ask directly about the issue. “I think I may have stepped on your toes a bit, are we
going to be okay?……..”
 Take a 1-down: “I’m not sure where we are; how should we proceed?”; “I’m a bit lost, where should we go
from here?”
 Point to the ambivalence: “I’m getting some mixed messages; should we move forward or not; is this worth
trying to change?”
 Seek permission to power-play: “My role is to push you in ways that will be uncomfortable. That may be
more than you bargained for but otherwise we may waste a lot of time and not get as much done. Would
you rather I annoy you or waste your time?”
The therapeutic alliance is more than the unconditional foundation of therapy; it is the single most reliable
instrument of change. Through trust, acceptance and the use of self, the therapist provides the client(s)
with a safe opportunity to experiment with new ways of thinking and feeling; a new way of being. This is
the value of intimacy and the absolute importance of trust; it is an agreement to share in each other’s
foibles and to entrust one’s own vulnerability to another. When this occurs the meaning and purpose of
our actions is altered and some measures of forgiveness and redemption arise.
“Love is the only way to grasp another human being in the innermost core of his personality. No one can
become fully aware of the very essence of another human being unless he loves him. By his love he is
enabled to see the essential traits and features in the beloved person; and even more, he sees that which is
potential in him, which is not yet actualized but yet ought to be actualized. Furthermore, by his love, the
loving person enables the beloved person to actualize these potentialities. By making him aware of what
he can be and of what he should become, he makes these potentialities come true.” ― Viktor E. Frankl,
Man's Search for Meaning.