Therapeutic Approaches

Clinical social workers must be proficient in a range of therapeutic approaches and know when to apply each one based on the client's diagnosis, presenting concerns, preferences, and cultural context. The ASWB exam tests your understanding of the theoretical foundations, key techniques, and appropriate applications of major therapeutic modalities.

Cognitive Behavioral Therapy (CBT)

CBT is one of the most widely researched and practiced therapeutic approaches. Developed by Aaron Beck, CBT is based on the premise that thoughts, feelings, and behaviors are interconnected, and that changing maladaptive thought patterns leads to changes in emotions and behavior.

Core Concepts:

• Automatic thoughts: Immediate, spontaneous thoughts that arise in response to situations
• Cognitive distortions: Systematic errors in thinking that reinforce negative beliefs
• Core beliefs (schemas): Deep-seated beliefs about self, others, and the world formed through early experiences
• Behavioral experiments: Testing negative predictions through real-world experience

Common Cognitive Distortions:

CBT Techniques: Thought records, cognitive restructuring, behavioral activation, graded exposure, relaxation training, problem-solving training, activity scheduling.

Best For: Depression, anxiety disorders, PTSD, OCD, insomnia, panic disorder, social anxiety.

Dialectical Behavior Therapy (DBT)

DBT was developed by Marsha Linehan specifically for Borderline Personality Disorder and has since been adapted for other conditions. DBT balances change strategies (from CBT) with acceptance strategies (from mindfulness and Zen practices).

Four Skill Modules:

1. Mindfulness: Staying present in the moment without judgment. Core skills include Wise Mind (balancing emotional mind and rational mind), observing, describing, and participating.

2. Distress Tolerance: Surviving crisis situations without making them worse. Skills include TIPP (Temperature, Intense exercise, Paced breathing, Progressive relaxation), distraction, self-soothing, and radical acceptance.

3. Emotion Regulation: Understanding and managing intense emotions. Skills include identifying emotions, checking the facts, opposite action, and reducing vulnerability (PLEASE skills: treating Physical illness, balanced Eating, avoiding mood-Altering substances, balanced Sleep, and Exercise).

4. Interpersonal Effectiveness: Maintaining relationships and self-respect while asking for what you need. Skills include DEAR MAN (Describe, Express, Assert, Reinforce, Mindful, Appear confident, Negotiate), GIVE (Gentle, Interested, Validate, Easy manner), and FAST (Fair, Apologies, Stick to values, Truthful).

DBT Treatment Components: Individual therapy, skills training group, phone coaching, and therapist consultation team.

Psychodynamic Therapy

Psychodynamic therapy is rooted in psychoanalytic theory (Freud) and its modern adaptations. It focuses on unconscious processes, early childhood experiences, and the therapeutic relationship as a vehicle for change.

Key Concepts:

• Unconscious processes: Thoughts, feelings, and motivations outside of awareness that influence behavior
• Defense mechanisms: Unconscious psychological strategies used to protect the ego from anxiety

• Transference: The client projects feelings about significant others onto the therapist
• Countertransference: The therapist's emotional reactions to the client, which must be monitored and managed
• Free association: The client says whatever comes to mind to access unconscious material
• Interpretation: The therapist offers insight into the client's unconscious patterns

Solution-Focused Brief Therapy (SFBT)

SFBT, developed by Steve de Shazer and Insoo Kim Berg, is a strengths-based, goal-oriented approach that focuses on solutions rather than problems. It is typically brief (5-8 sessions).

Key Techniques:

• Miracle question: "If a miracle happened overnight and your problem was solved, what would be different?" Helps clients envision a preferred future.
• Exception-finding: "Tell me about a time when this problem didn't happen or was less severe." Identifies existing solutions the client may not recognize.
• Scaling questions: "On a scale of 1-10, where 10 is your problem fully solved, where are you now?" Measures progress and motivation.
• Compliments: Genuine affirmation of client strengths and efforts.
• Coping questions: "How have you managed to keep going despite these challenges?" Highlights resilience.

Motivational Interviewing (MI)

Motivational Interviewing, developed by William Miller and Stephen Rollnick, is a client-centered approach specifically designed to address ambivalence about behavior change. It is widely used in substance use treatment but applicable to any area where clients are ambivalent.

Spirit of MI (PACE):

• Partnership: Collaborating with the client rather than directing
• Acceptance: Respecting autonomy, affirming strengths, showing empathy
• Compassion: Prioritizing the client's welfare
• Evocation: Drawing out the client's own motivations and resources

Core Skills — OARS:

• Open questions: "What would you like to see change?"
• Affirmations: Recognizing the client's strengths and efforts
• Reflections: Mirroring the client's statements to deepen exploration
• Summaries: Pulling together key points from the conversation

Key MI Concepts:

• Change talk: Client statements favoring change (desire, ability, reasons, need, commitment)
• Sustain talk: Client statements against change
• Ambivalence: Simultaneous motivation for and against change — this is normal, not resistance
• Rolling with resistance: Responding to resistance with reflection rather than confrontation
• Developing discrepancy: Helping clients see the gap between their current behavior and their values/goals

Person-Centered Therapy (Carl Rogers)

Person-centered therapy (also called client-centered therapy), developed by Carl Rogers, is based on the belief that individuals have an innate capacity for growth and self-actualization. The therapist's role is to create the conditions that facilitate this natural growth process.

Three Core Conditions:

1. Unconditional Positive Regard (UPR): Accepting and valuing the client without conditions or judgment. The therapist values the client as a person regardless of their behavior.
2. Empathy: Accurately understanding the client's experience from their frame of reference and communicating this understanding back to the client.
3. Genuineness (Congruence): Being authentic and transparent in the therapeutic relationship. The therapist's inner experience matches their outward expression.

Rogers believed that when these three conditions are present, clients will naturally move toward growth, self-awareness, and positive change. Person-centered therapy is non-directive — the therapist does not prescribe solutions or interpret the client's experience.

EMDR (Eye Movement Desensitization and Reprocessing)

EMDR, developed by Francine Shapiro, is an evidence-based treatment primarily used for PTSD and trauma. It uses bilateral stimulation (typically eye movements, but also tapping or auditory tones) to help the brain process and integrate traumatic memories.

Eight Phases of EMDR:

1. History taking and treatment planning
2. Preparation: Building coping skills and explaining the process
3. Assessment: Identifying the target memory and associated images, beliefs, emotions, and body sensations
4. Desensitization: Processing the memory using bilateral stimulation
5. Installation: Strengthening positive beliefs to replace negative ones
6. Body scan: Checking for residual physical tension
7. Closure: Returning the client to a state of equilibrium
8. Reevaluation: Reviewing progress and identifying remaining targets

Narrative Therapy

Narrative therapy, developed by Michael White and David Epston, views people as the authors of their own life stories. Problems arise when dominant narratives are problem-saturated, and therapy helps clients re-author their stories.

Key Techniques:

• Externalization: Separating the person from the problem ("The anxiety is affecting you" vs. "You are anxious")
• Unique outcomes: Identifying times when the problem did not dominate
• Re-authoring: Developing preferred stories that highlight strengths and agency
• Definitional ceremonies: Inviting witnesses to reflect on the client's preferred story
• Letters and documents: Using therapeutic letters and certificates to reinforce new narratives