CAN CLIENTS BE THEIR OWN THERAPISTS?

 A CASE STUDY ILLUSTRATION

This article reports on the use of self-management training (SMT), a therapeutic strategy which capi- talizes on the advantages of brief therapies, while at the same time reducing the danger of leaving too many tasks not fully accomplished. . . . The essence of this approach involves teaching the client how to be his or her own behavior therapist. The client is taught how to assess problems along behavioral dimensions and to develop specific tactics, based on existing treatment techniques, for overcoming problems. As this process oc- curs, the traditional client–therapist relationship is
altered considerably. The client takes on the dual role of client and therapist, while the therapist takes on the role of supervisor.
The case of Susan
Susan, a 28-year-old married woman, entered therapy complaining that she suffered from a deficient memory, low intelligence, and lack of self-confidence. The presumed deficiencies “caused” her to be inhibited in a number of so- cial situations. She was unable to engage in dis- cussions about films, plays, books, or magazine articles “because” she could not remember them well enough. She often felt that she could not understand what was being said in a conversa- tion and that this was due to her low intelligence. She attempted to hide her lack of comprehen- sion by adopting a passive role in these inter- actions and was fearful lest she be discovered by being asked for more of a response. She did not trust her own opinions and, indeed, some- times doubted whether she had any. She felt dependent on others to provide opinions for her to adopt.

Administering a Wechsler Adult Intelligence Scale (WAIS), I found her to have a verbal IQ of about 120, hardly a subnormal score. Her digit span indicated that at least her short-term memory was not deficient. The test confirmed what I had already surmised from talking with her: that there was nothing wrong with her level of intelligence or her memory. After discussing this conclusion, I suggested that we investigate in greater detail what kinds of things she would be able to do if she felt that her memory, intel- ligence, and level of self-confidence were suffi- ciently high. In this way, we were able to agree upon a list of behavioral goals, which included such tasks as stating an opinion, asking for clari- fication, admitting ignorance of certain facts, etc. During therapy sessions, I guided Susan through overt and covert rehearsals of anxiety-arousing situations . . . structured homework assignments which constituted successive approximations of her behavioral goals, and had her keep records of her progress. In addition, we discussed negative statements which she was making to herself and which were not warranted by the available data (e.g., “I’m stupid”). I suggested that whenever she noticed herself making a statement of this sort, she counter it by intentionally saying more appropriate, positive statements to herself (e.g., “I’m not stupid—there is no logical reason to think that I am”).
During the fifth session of therapy, Susan re- ported the successful completion of a presum- ably difficult homework assignment. Not only had she found it easy to accomplish, but, she reported, it had not aroused any anxiety, even on the first trial. . . . It was at this point that the nature of the therapeutic relationship was altered.

During future sessions, Susan rated her progress during the week, determined what the next step should be, and devised her own homework as- signments. My role became that of a supervisor of a student therapist, reinforcing her successes and drawing attention to factors which she might be overlooking.
After the ninth therapy session, direct treat- ment was discontinued. During the following month, I contacted Susan twice by phone. She reported feeling confident in her ability to achieve her goals. In particular, she reported feeling a new sense of control over her life. My own impressions are that she had successfully adopted a behav- ioral problem-solving method of assessment and had become fairly adept at devising strategies for accomplishing her goals.
Follow-up
Five months after termination of treatment, I con- tacted Susan and requested information on her progress. She reported that she talked more than she used to in social situations, was feeling more comfortable doing things on her own (i.e., without her husband), and that, in general, she no longer felt that she was stupid. She summarized by say- ing: “I feel that I’m a whole step or level above where I was.”
I also asked her which, if any, of the techniques we had used in therapy she was continuing to use on her own. . . . Finally, she reported that on at least three separate occasions during the 5-month period following termination of treatment, she had told another person: “I don’t understand that— will you explain it to me?” This was a response which she had previously felt she was not capable of making, as it might expose her “stupidity” to the other person.
Three months after the follow-up interview, I received an unsolicited letter from Susan (I had moved out of state during that time), in which she reminded me that “one of [her] imaginary exer- cises was walking into a folk dancing class and feeling comfortable; well, it finally worked.”




*Source: Kirsch, I. (1978). Teaching clients to be their own therapists: A case study illustration. Psychotherapy: Theory, Research, and Practice, 15, 302–305. (Reprinted by permission.)