(p. 1) Introducing Goal Focused Positive Psychotherapy
Welcome to Goal Focused Positive Psychotherapy (GFPP), an exciting, important advancement in the field of psychotherapy. GFPP promotes client strengths, hope, and positive emotions in order to assist clients in accomplishing what they desire in life (i.e., the client’s approach goals). Positive psychology research and theory have developed sufficiently in recent years to form the basis of this comprehensive psychotherapeutic approach with the goal of optimizing well-being while diminishing the effects of psychological distress.
We see GFPP as the fifth force in psychotherapy: an approach that profoundly embraces and enhances a client’s resources for experiencing happiness, in contrast to the more traditional clinical approaches that focus almost exclusively on reducing client pathology. Proclaiming that our approach is the fifth force may seem presumptuous in comparison to the four other forces: psychoanalytic/psychodynamic, behavioral/cognitive-behavioral, humanistic/experiential, and multicultural. We see GFPP as revolutionary in its departure from the previous four paths because GFPP prioritizes well-being, happiness, hope, strengths, and positive emotions, as well as a change process based on positive emotions.
GFPP helps clients understand what they want in life and opens the horizons to involvement in activities that are meaningful to the client via frequent positive emotions. Goals for a lifetime are sought and affirmed throughout therapy, providing an inspirational “best possible self” for the future. As a GFPP therapist, you will communicate that virtuous, meaningful goals lead to happiness AND that accomplishing goals by harnessing positive emotions and personal strengths can contribute to an enjoyable, satisfying life, moving a person incrementally toward lifelong aspirations.
At the same time, the therapist explains to clients that their problems—typically the reasons clients seek therapy—will be addressed using a positive, strength-oriented focus. The rationale is that as clients find better, more enjoyable, and more meaningful lives, the effects from their initial problems diminish and their ability to cope with the inevitable challenges of life expands. Through therapy, positive states such as hope, optimism, gratitude, and self-compassion are generated, (p. 2) allowing clients to move toward more enjoyable and meaningful lives. The burden of the initial problems and their accompanying symptoms are alleviated through a generative method that produces those positive emotions and uplifting experiences associated with enhanced well-being.
A Happy Life
The ultimate outcome goal of GFPP is increased happiness or subjective well-being.1 Philosophers and researchers alike have championed happiness as an ultimate goal for a meaningful life. Aristotle and the Dalai Lama agree that the meaning of life is centered on happiness; that is, living well or flourishing (Garfield, 2011).2 Arguments attributed to Aristotle may best express the rationale: happiness is reasoned to be the highest goal in life because happiness is the final-good. In other words, when reflecting upon what your specific motivation is for a particular action, you may often find that the action is a means to an end. The initial activity is a way to achieve a secondary, greater purpose: the “final-good,” or ultimate purpose, is not typically contained within the initial action. In contrast, Aristotle’s “final-good,” or highest goal, is done only for itself, not in order to accomplish something further. As the final-good, happiness is both the ends and the means.
For example, why do you strive for money? Money is not a final purpose. We usually seek money to accomplish a subsequent, associated goal. Perhaps that associated goal is security, and the next is peace of mind, and so on, until reaching the ultimate goal of happiness, at which point there is no farther to go, for what else could a person wish that would not be contained within the wish for happiness? Happiness can be argued to be the final goal because we do not seek happiness to accomplish another goal.
Another of Aristotle’s arguments for the worth of happiness is based upon self-sufficiency (Garfield, 2011). That is, if you have happiness, then you want for nothing else. For example, wealth or honor can be considered very important. However, even having wealth or honor, you could still long for happiness. Having happiness is so marvelous that you need nothing else. Happiness is sufficient—and necessary— for a good life.
To accept the argument of final good or self-sufficiency, happiness must be defined carefully. Defining happiness has historically been a challenge. For Aristotle, happiness consists of an evaluation of one’s life as a whole, not just the experience of the present moment. The positive psychology literature uses the construct of life-satisfaction to describe the evaluation of life overall. If people believe that their lives are ideal and contain almost no regrets, then they have high life-satisfaction (Diener, 1984). In positive psychology, happiness or subjective well-being is defined as a person experiencing (a) life-satisfaction or a satisfying life overall, (b) frequent positive emotions, and (c) infrequent negative emotions (Diener, 1984). Later, we will more clearly define what contributes to happiness as the outcome goal for GFPP. As a psychological construct, happiness can be defined (p. 3) relatively clearly, while at the individual level, happiness is almost always idiosyncratic. For example, research unequivocally demonstrates that cultivating social relationships contributes to happiness. But the specific types of relationships and the characteristics of the people in those relationships that produce happiness will vary significantly from client to client. The client’s context, worldview, and personal priorities must be honored when considering the constituents of happiness.
Is Happiness Too Selfish?
People’s first reaction to happiness as a life goal is often repulsion: “How selfish! This is just the problem with the world today!” However, as you may guess we, the authors, have changed our initially negative opinion. The next few paragraphs are included to win you over to happiness as a worthy goal if at first reading you are feeling skeptical.
While GFPP has nothing to do with religion, religious beliefs may be viewed as conflicting with the goal of happiness. We offer a brief account of our prior struggles reconciling religion and positive psychology in hope that our journey may provide a perspective that helps readers to integrate their particular religious beliefs and the goals of GFPP. Growing up in a small-town Presbyterian church (the first author) and a Catholic church (the second author), we believed that sacrifice for others was the goal of life. How does happiness fit in this worldview? Our early belief was that one should be suffering in order to live a good life, that experiencing happiness was actually antithetical to living a good life. Our personal understanding of religion was that engaging in meaningful acts that better the lives of others would not make us happy, but virtuous acts would make us good people. Furthermore, many religious beliefs dictate that happiness will not be attained until after death, and upon going to heaven.
Our resolution of the happiness issue came through several discoveries. For us, religion has been about how to be good people. Studying psychology––and especially positive psychology––has been an awakening. By experiencing the effects of practicing positive psychology, we have come to a realization that happiness can be a worthwhile goal. Research reveals that virtuous acts lead to happiness (Buschor, Proyer & Ruch, 2013).
Apart from religion, consider altruism. Altruism is the motivation to help others even at personal loss (Bateson, 2011). Some argue that altruistic behaviors are actually performed for personal gain, while others believe that some acts are certainly self-sacrifice. It is difficult to argue with the common experience that acts of kindness toward others are personally reinforcing, because often the outcome is feeling happy. Research indicates that experiences of increased health and subjective well-being accompany altruistic behavior (Miller, Kahle, & Hastings, 2015): virtuous acts create happiness. (The research supporting virtues will be presented in Chapter 2.)
Therefore, the eternal argument about whether a virtuous action is performed for the sake of another or to make us happy becomes a moot point. Acting (p. 4) altruistically leads to happiness automatically when engaging in a virtuous act. Acting in ways that reflect individual meaning creates happiness whether or not one believes that virtue creates happiness. Being virtuous is a good way to live life!
Consider heaven or reincarnation as the ultimate goal in life. Aristotle’s question of the final-good could be phrased as “Why do you want to go to heaven?” The desire to go to heaven (i.e., the goal of Christianity) is to be happy. The final-good is then to be happy.
Perhaps you, the reader, found happiness an easy goal to accept from the beginning. Great! Sorry to waste your reading time with an unnecessary, persuasively oriented section. Probably every psychotherapy theory has the implicit outcome goal of helping the client experience greater happiness anyway. However, if you are still having difficulty accepting happiness as a worthy life goal, please keep an open mind to being happy and helping others be happy! We have more research evidence that is especially persuasive. In addition, if you are having trouble accepting our philosophical arguments for happiness as a life goal, we will also have some very pragmatic ones in support of happiness as the goal of therapy. To pique your curiosity here, we offer the observation that it is very difficult, if not impossible, for a person to be both happy and unhappy at the same time, and happy people are better equipped to overcome hardships and difficult circumstances than those who are unhappily preoccupied with problems and dissatisfaction. Systems theory informs us that when one component of a system changes, other corresponding components change as well. The conditions of happiness affect one’s state of unhappiness. More reasoning and research will follow in later chapters to offer support for happiness as the goal of therapy. Next, we move to introducing our GFPP therapy model.
Clients and Goals
The issue of goals is central to GFPP and significant in several ways. One very important issue surrounding goals is the way in which goals become confused with problems. As we have already mentioned, the initial motivation for therapy often resides in the desire to decrease or eliminate a problem. Reorienting the client to think differently and more expansively is often difficult. Clients have often lived so long with a problem such as depression or anxiety that all they can think of is to be rid of the negative experiences and conditions. The goal of ceasing to have a problem is an avoidance goal. Avoidance goals emphasize escaping negative outcomes, such as conflict, rejection, or resentment (Gable, 2006). What to replace the negative feelings with often seems unimportant initially to the client. However, the goal of simply avoiding feared experiences leaves clients entangled with their feared experiences and thus continuously troubled by them, no matter how hard they try to reduce their exposure to and awareness of the avoided experiences.
On the other hand, moving toward a goal that is meaningful and virtuous typically increases the client’s happiness. Goals that focus upon a desirable end-state (p. 5) are approach goals (Gable, 2006). The client decides on approach goals with the encouragement and guidance of the therapist. Incredibly, the establishment of approach goals can be the most difficult accomplishment of therapy, and once they are established, the client sometimes needs little or no help in accomplishing them. However, to continue with the explanation of the importance of goals, let us assume that suitable goals have already been established before moving to the next phase of progression toward the goals.
As clients progress toward significant approach goals, problems that brought them to seek therapy often change. Some problems disappear because they are outgrown. For example, the experience of depression that is heavily influenced by loneliness can be outgrown as the client enjoys the benefits of an intimate friendship or partner. Outgrowing a problem happens in the best circumstance. However, some life problems must be faced and accepted because some of life’s problems cannot be outgrown or solved. Everyone experiences sadness and loss in life; such experiences cannot be avoided and should not be denied as important life occurrences. The major way in which GFPP contributes to clients’ ability to face and accept life’s losses and unchangeable difficulties is by increasing clients’ subjective well-being. Coping is enhanced when clients experience confidence that despite life’s difficulties, they can still experience happiness. The realities of life’s losses and suffering do not fundamentally negate life’s meaningfulness and happiness, although they often temporarily make the meaning and happiness feel less accessible or potent. The inevitability of suffering and loss in life heightens the importance of learning the skills to embrace the joy in life, be it meager or bountiful.
A visual representation of a client’s experience may communicate more clearly the influence of increased well-being. Figure 1-1 represents the experience of a client entering psychotherapy. The size of life’s problems is perceived as larger than the client’s experience of well-being. The client experiences an inability to effectively deal with such large problems with the available resources. After successfully increasing well-being, Figure 1-2 represents the client’s perception of the same-sized problem from the perspective of greatly enhanced well-being. The problems that were experienced as initially overwhelming loom less threatening in the new perspective that contrasts problems and well-being. Well-being brings many resources to counter despair. (p. 6)
Psychological Versus Physical Sciences Metaphor
Fundamentally GFPP approaches psychological problems from a different perspective than most previous methods (e.g., psychodynamic therapy, cognitive-behavioral therapy). The difference in perspective can be understood through the metaphors that either explicitly or implicitly guide the logic of psychotherapy. We believe that the physical sciences metaphor,3 the historical framework for understanding psychotherapy, actually constrains and somewhat misdirects most psychotherapy theories. The physical sciences metaphor refers to expecting the general rules of physics to fit psychotherapy.
A fundamental assertion in physics is that every effect has a specific cause. The functioning of a car provides an appropriate application of the physical sciences paradigm. For example, when the engine of a car does not start, the most important step is to identify the source of the problem. Why is the car broken? What is the specific cause or critical part that is failing? Identifying the cause of the car’s malfunction is essential. The mechanic should not change the spark plugs if the car is out of gas! After diagnosing the cause of the problem, a specific intervention is applied that will cause the car to function again. For a car, the specific intervention consists of replacing or fixing a dysfunctional part. The car functions once again just as it did before! Cause-and-effect reasoning—the linchpin of the physical sciences paradigm—works splendidly for machines.
In psychotherapy, too often the corresponding belief prevails that understanding the cause of a problem will reveal its cure. Even when physics does not apply, the physical sciences metaphor is assumed. Perhaps you have heard or experienced the statement, “At least I know what I’m dealing with now.” Presumably, if the cure is not known, the physical sciences metaphor offers reassurance because (p. 7) knowing the problem is the first step toward solving the problem. Or “We need to get at the root of the problem.” Similarly, the statement assumes that the actual cause can be known—and indeed must be known—in order to create an effective solution.
The physical sciences metaphor creates difficulty because a person’s psychological processes do not operate according to the laws of physical sciences. Perhaps the most cogent example is that diagnosing a client does not lead to a specific or unique psychotherapy treatment (Lopez, Edwards, Pedrotti, et al., 2006; Wampold, 2007; Wampold & Imel, 2015).
To further explain the point, we will define mechanization as the opposite of anthropomorphism. Anthropomorphism involves attributing human characteristics to nonhumans. Problems occur when expecting the nonhuman to behave as a human would. For example, “That chair fell over while I was sitting in it, so I kicked it! Now it will behave.” Nonsensical, eh? On the other hand, mechanization can be defined as regarding something mechanical that is not mechanical, like a human’s psychological functioning: “The person does not work adequately; therefore, the person is defective. The person must be fixed.” A central difference is how change typically occurs. Something specific inside a machine is changed to make it function. However, a person’s way of thinking or acting is changed through perception or context, rather than by replacing or adjusting a single “defective” internal component. Both ideas of change occur from outside of the person to influence the person to act, think, or feel differently. However, the person is less likely to feel “pathologized” when what is seen as needing alteration is the perception or the context instead of something internal.
Too often the physical sciences metaphor is forced to fit psychotherapy. For example, the first pillar of physics is cause and effect. If the cause is found, then the effect can be altered. Translated to psychotherapy, this might lead us to search for the singular cause of a person’s problem. For example, the client’s problem could be relationship difficulties, and eventually the therapist may find that the primary parent was often intrusive and sometimes distant. The therapist might conclude that the root problem is that the client as a child could not count on a supportive parent. Attachment theory would support that that problematic parenting style causes the client’s anxiety, insecurity, and poor relational skills. Now the cause of the client’s problem becomes clear. But wait: is insecure attachment the real cause? Perhaps the parents functioned well enough as parents. Could the real cause be the client’s terrible childhood friends? Or could the cause be that there were no good role models for relationships? Or could it also be that the client just went through a terrible divorce? Or is the cause a recent sexual trauma? Which cause is the real cause that needs treatment? If the real cause is not identifiable in the physical sciences model, treatment cannot work.
After identifying a list of probable causes for the client’s problem, the second issue with following a physical sciences metaphor occurs when fixing the problem. How does the treatment change based upon the cause? The ability to be free of a haunting past, and learning how to have good relationships, may not be contingent on the cause of the problem. The interventions that support clients’ (p. 8) growth in dealing with scary, intrusive memories as well as having the confidence in and knowledge about relationships will be what will help them make progress in treatment, regardless of the sources of the problem.
Another significant concern in using the physical sciences metaphor in psychotherapy theory is that the outcome goal of therapy becomes implicitly or explicitly achieving the no-symptom or no-problem level of functioning. Two concerns become obvious with a no-symptom outcome goal. First, psychotherapy outcome goals that aspire to benefits beyond the goal of “no problem” or maintenance of a status quo are more ethical because of beneficence (i.e., what creates the greater good). A central goal of GFPP and positive psychology is based upon moving beyond a symptom/problem focus. GFPP focuses on creating meaningful lifelong goals that are pursued with as much enjoyment as possible. Investigating the meaningful goals and paths for experiencing happiness, fulfillment, and flourishing are our lofty, transformative purpose. Goals such as increasing an individual’s successful experiences in love, vocation, friendship, and forgiveness are typical meaningful goals.
The second concern in focusing upon a goal of attaining a “no problem” outcome for psychotherapy is that the goal is impossible. Life presents us with problems every day! Psychotherapy cannot promise the existence of a life without problems. To promise an existence of being fixed, meaning the individual has no problems, creates false expectations. Promising false expectations is unethical in that it causes maleficence. Depression, anxiety, loss, and loneliness, to name but a few human challenges, are an inevitable part of life. Psychotherapists can never promise to help the client attain a life without anxiety, depression, or loss.
Rather than contorting the physical sciences metaphor in an attempt to understand psychological processes, we propose a simple, elegant shift: use a psychological metaphor to describe psychotherapy. After all of the years of practice and research, surely there could be some fitting metaphors for our field. As you probably guessed, we have a metaphor to suggest!
A Psychological Metaphor
Our psychological metaphor is based on two issues:
• First, the goal of psychotherapy is to facilitate the client’s subjective well-being.
• Second, influence is the closest psychological equivalent of causality.
The research cited throughout this book underscores the central goal of well-being. Research describes the endpoints and the more distal waypoints along the routes to well-being. However, the individual client decides the values that form the realities of life that supply the details of well-being. The second point is installing influence as a psychological replacement for the physical science term of cause and effect or simply causality. The individual client perceives, processes, (p. 9) interprets, and decides as a human, thus making all actions upon the individual mediated rather than direct. That is, the individual thinks and feels. The predictable cause and effect does not occur because a human does not simply react when acted upon. The term influence means that change occurs in psychotherapy because of the client and only indirectly through the therapist. GFPP focuses on the influence of the relationship in therapy and the client’s positive emotions.
The psychological metaphor facilitates increased clarity of direction (goals) and facilitates movement (change) toward thriving based upon the “ingredients” discovered via research, while also being informed by the client’s specific desires and idiosyncrasies.4 By this we are referring to those things that the client wants in each of the categories that contribute to a happy life or subjective well-being. When people experience higher states of subjective well-being, they increase their opportunities for effectively addressing challenges and accomplishing fulfilling lives. Whatever the life issues are—typical developmental issues or traumatic unpredictable occurrences—a higher state of well-being5 allows clients both to live with unresolvable problems more easily and to resolve manageable issues with greater ability.
One way to understand the benefit of achieving higher well-being is the attainment of a position of strength: using all possible capabilities to deal with problems rather than ignoring or avoiding them. An analogous common experience provides an example of how high well-being assists in the change process. Consider how having a good night’s sleep contributes to dealing with or accepting an issue. Sleep does not typically make a problem go away. However, viewing an issue from a rested, fully capable state can make a problem seem less difficult to deal with or to accept. Creativity, confidence, determination, and many other helpful personal strengths are more readily available when we are rested, even though the problem may still be present. Sleep, like a high level of well-being, provides a psychological context for dealing with life more effectively. Cause and effect of problems is not relevant in this more accurate rendering: sleep does not cause the creation of a solution, nor does it cause acceptance of an insoluble problem. Additionally, we bet that you did not say to yourself, “Oh, sleep only works if the problem is about relationships” or “Everyone knows that sleep never works when dealing with job problems.” That is because the diagnosis or cause of the problem becomes unimportant when the remedy is universal. Sleep helps bring forth more psychological resources when compared to being tired. Sleep was not prescribed for a specific problem.
The psychological metaphor we propose borrows heavily from humanistic psychology and positive psychology. Carl Rogers (1951), a founder of the humanistic psychology movement, asserted and researched the value of supportive relationships that facilitated clients’ growth toward their life goals. He theorized that people innately grow toward self-actualization or flourishing when in a supportive environment. In a similar vein, positive psychology research expands our knowledge about supportive environments that facilitates our inclination to grow toward high subjective well-being or thriving. We borrow heavily from the work of Carol Ryff (1989) and Kristen Neff (2012) in this assertion, because their (p. 10) research demonstrates that psychological well-being and self-compassion predict subjective well-being.
More specifically, helping people with the following goals and processes facilitates their subjective well-being. The goals of life include relationships, work, play/hobbies/interests, and meaningful involvement. The attainment of subjective well-being has research supporting universal importance, even though the importance of the components (i.e., life satisfaction, positive affect, and negative affect) in contributing to subjective well-being can differ (Diener, Oishi, & Ryan, 2013). Similarly, a great deal of research supports our selection of general goals fitting into a multicultural context, which is detailed in a subsequent chapter. The individual client specifies how the goal is defined. For example, while you, as the therapist, urge multiple high-quality relationships based upon the theory, whom a relationship is with and what type of a relationship will be determined by the client, not by you or GFPP.
Additionally, how a person accomplishes goals or lives life while moving toward goals matters. How we live our life matters. The processes endorsed by GFPP, which are to be maximized when pursuing life goals, include feeling effective, involved, mindful, autonomously motivated, and engaged. Ideally, the process of achieving goals is also supported by the desire to be virtuous, as well as the experience of frequent positive feelings, enduring hope, and persistent self-compassion. The details of the research supporting these goals and processes will be outlined in the following chapters.
The Process of Change
Growth, change, and learning are ways to describe the process of moving toward goals. When the process of moving toward goals is painful, it is human nature to tend to avoid the goals. A friend put it clearly when I explained our commitment to having big life goals. My friend said, “Oh, you want me to have another reason to beat myself up!” He was correct by inferring that promoting lofty goals without considering the larger context could be anti-therapeutic. Too often motivation for achieving a goal comes from the threat of a negative outcome like shame, embarrassment, or guilt. For example, “I know that one of my big goals in life is to have a loving family. I am such a selfish, thoughtless, inconsiderate, poor excuse of a person for not being in contact with my brother. If I do not call my brother today, then I will feel even worse. I had better call today or it will prove how worthless I am.” Sadly, such self-flagellations work well, but at a cost. Probably I will not enjoy speaking with my brother and my sour, guilty mood might spoil the conversation for him too. The ultimate goal of creating a loving family might be unintentionally undermined.
Lofty goals are facilitated by a client enlisting kind ways to facilitate growth and engage in self-evaluation. In facilitating change, GFPP enlists the client’s positive emotions, strengths, self-compassion, hope, and mindfulness, which can buffer against the pain of change. Additionally, the process of change is viewed as an incremental process to counter the typical client belief in all-or-nothing (p. 11) polarities. While clients do at times make very large changes immediately, GFPP suggests change to the client in small increments that are noticeable and defined by the client.
Growth can be painful or enjoyable. Every person experiences both. Learning to purposefully employ enjoyable methods of change in therapy is highly ethical as well as functional. Subsequent chapters will more clearly present the research and procedures for facilitating change, including the central importance of the Broaden-and-Build Theory (Fredrickson, 2001).
The Case Study of George
This case example provides an illustration of GFPP. The case is a good example of GFPP because it concerns a client, whom we will refer to as “George,” coming to therapy with what others had defined as his problem, and a diagnosis given by a previous clinician who did not possess an acceptable treatment course. The lack of autonomous client motivation is an important issue in this real case that makes the case very difficult, yet especially illuminating of GFPP.
George was a 50-year-old male retired from the military after an extensive combat history that included multiple wounds in battle and several experiences of seeing “my buddies gone” and then “gaining revenge” from the enemy. George reported symptoms corresponding to posttraumatic stress disorder (PTSD) that included nightmares, insomnia, suicidal ideation, and flashbacks. He had arrived at therapy because his partner threatened to leave him if he did not get help for what she described as his problems with anger. George disagreed, denying feeling anger or any other emotions. He stated, “I don’t feel. I just am here skating along feeling nothing one way or another.” George explained his presence in therapy as being a means of appeasing his partner.
In previous referrals to other agencies, George had been unwilling to cooperate with the evidence-supported treatment fitting his diagnosis. Similarly, this time he came into therapy committed to proving to the current therapist and to himself the futility of any therapeutic method that directly addressed the problem or its symptoms as previously defined by others. He was fully committed to thwarting any attempts at problem resolution. In the first session he reported that he had become an expert in frustrating previous therapists who had diagnosed him with PTSD and treated him through the corresponding treatments. His previous treatments at the Veterans Administration (VA) hospital had consisted of exposure-oriented methods to process the trauma and the use of selective serotonin reuptake inhibitors (SSRIs). George bragged that none of the treatments had been effective. He expressed resignation to live his life out as it was at that moment, and predicted that it would be “a short ride from here.” He also reported constant suicidal ideation but denied current plans to act on his suicidal thoughts. However, he proclaimed that if he did decide to commit suicide, he would not let the therapist or anyone else know ahead of time.
(p. 12) As might be imagined, this caused considerable consternation and concern. Consequently, the therapist acted to ensure George would be safe from suicide by––after some wrestling back and forth––convincing George of the need to agree to inform the therapist if he started to move closer to acting on his suicidal thoughts. The therapist reasoned with George that giving fair warning would help to ensure George’s safety, and without some level of assurance from George, the therapist explained that he would not be able to move beyond the issue of suicide to the process of assisting George in creating a better life.
This discussion and its resulting information were carried out through a traditional intake interview. Invoking GFPP’s emphasis on client-centered positive goal formation, the therapist asked George to describe what he would like better than his current situation, what his desired state was, and how it would be possible for him to lead a satisfying life. This was the therapist’s initial attempt to move toward forming approach goals. In response, George demonstrated his desire to maintain control in therapy by stating that a satisfying and desirable life was impossible for him.
George’s one request of the therapist was to judge whether or not he was currently “sane.” He would ask every session for the therapist’s opinion about his sanity. Without answering the question, the therapist would reframe by praising George for wanting to understand what normality was after so many years of living under the abnormal conditions of war. A continuing theme that George communicated to the therapist in a number of ways was that “you need to deal with me and where I am at.” George explained that the therapist should “pay attention to my problems even though you cannot help me with them.” The therapist validated George’s horrific experiences in combat and during an abusive childhood. The therapist demonstrated traditional empathy by depicting these experiences as “internal struggles.” Using positive empathy,6the therapist tentatively suggested the goal of George freeing himself from his past. George was unwilling to describe his combat experiences as “struggles” and was more willing to talk about his childhood living with an abusive mother. George found it easier to accept the empathy the therapist showed for George’s experiences as a child. He viewed his childhood abuse as indicating his “toughness and hard life.” George consistently revealed fantastic stories of danger in the military, near-death experiences, and multiple events of being shot or stabbed while in combat. The horrific stories were perhaps offered as evidence that life could never again be good.
The therapist invariably communicated unconditional acceptance for all that George revealed and celebrated his positive experiences, emotions, and strengths (e.g., being a hard worker; caring deeply about his daughter; demonstrating great resiliency and perseverance; possessing a heroic attitude) that George identified through the process of talking about his life. The therapist used what Harlene Anderson (1995) terms the “not knowing” stance. The “not knowing” stance means accepting the client where he or she is attitudinally and emotionally, not doubting as real or true what the client talks about. By doing this, the therapist is acknowledging that the client’s constructed reality is (p. 13) what is important, not a reconstructed conceptualization based on diagnostic categories and symptoms of the diagnosis. The therapist listened carefully and vigilantly for George’s expression of emotion, both positive and negative. The therapist accentuated positive emotions and events during the session.
Over the course of eight sessions, the therapist uncovered and reported back to George several strengths the therapist had observed through their interactions. These included George’s sense of humor; resilience; good-naturedness (per his descriptions, donations, and other caring and altruistic actions); creative and entertaining storytelling (the therapist highlighted the power of George’s life narratives); the use of metaphors (e.g., “our therapeutic dance,” “the box where the client’s emotions were held”); and George’s penchant for philosophical interpretations of his life (e.g., “life is somewhat a self-fulfilling prophecy;” “life is what you make of it”). Overall, the therapist was successful in communicating to George the therapist’s appreciation for him as a worthwhile person, authentically demonstrating to George both the therapist’s hope and affinity for him as a person with much to contribute to others. The therapist continually accentuated George’s reported acts of kindness toward his daughter, his partner, and countless experiences of helping homeless veterans on the street. Over the course of treatment George softened his stance toward the therapist and therapy.
Overall, multiple strengths, positive experiences, and emotions were identified during therapy. George was able to acknowledge his growing appreciation and positive feelings toward the therapist. His growing engagement and investment in therapy was also noted. George stated that he saw the therapist as “different,” and as an exception to other “shrinks.” The therapist also complimented George in taking pride in being able to relate honestly to others, as exemplified by his relationship to his daughter, his partner, animals, and the therapist. George’s progress was noted in feeling unburdened from the blame he had previously carried concerning his childhood abusive episodes. George’s heroism and selflessness––exemplified by episodes of saving the lives of others during his military tours––was also emphasized. His heroism was generalized to current acts of kindness toward others. A goal was formed for George to find meaning and healing through his acts of kindness toward others.
The therapist did not attempt to focus directly on George’s suffering, although multiple times he expressed his desire that George find a less painful and more healthy way to live his life. Concern for George’s lack of sleep and his hopelessness about the future were expressed. George initially pushed away statements of traditional empathy, but was able to more readily accept statements of positive empathy such as “you would like to see a future for yourself,” and “you would like to move forward instead of feeling stuck due to your past.” When George did show emotions, both negative and positive, the therapist framed them as “opening up the box.” George seemed to appreciate when the therapist identified progress denoted by demonstrations of emotion.
Progressively, George became more invested and engaged in the therapeutic process, as demonstrated by his consistent attendance and his willingness to stay for the whole session, something he had found difficult to do in early (p. 14) sessions. In the first sessions, when George was feeling tense about a topic that had come up marked by the emergence of an emotion, he would leave, using the excuse that he needed a smoke, and not return. The therapist would then call to encourage George to come back for the next session.
Eventually, George was willing to talk about what he wanted to be different in his life. The approach goals that he identified (prompted by the therapist) were as follows: creating more meaningful relationships/supports; engendering a stronger sense of optimism and hope for the future; and deepening his self-awareness and insight about what he was feeling. George eventually was able to expand upon the initial goals that the therapist and he had developed. He desired to deepen his ability to recognize, tap into, and acknowledge his emotional states; and to feel safe in sharing his emotional states with others (e.g., partner; daughter) in more honest and vulnerable ways.
After 15 sessions, George suggested stopping, saying that he had obtained what he needed from the experience. He also told the therapist that he would miss him, indicating caring and appreciation for his therapist, a relational state that initially had seemed a very distant possibility. The outcomes noted and acknowledged by the therapist and George included feeling more hopeful (as indicated by the emergence of immediate and future goals for George’s life with clear pathways and motivation to work to accomplish the goals); sleeping through the night for the first time in over 20 years; and expressing positive feelings toward the therapist and generalizing this change to other important people in his life, such as his daughter and partner. Over the course of therapy, George rather suddenly opened up in revealing both positive and negative emotions that he was experiencing. He seemed to discover the relief that accompanied letting the emotions out of his metaphorical box. Consequently, he expressed relief from the burden that he had been carrying around for so long. Regarding hopefulness, George was able to predict a long life and a vision for his future.
All this was accomplished without directly addressing George’s suicidal ideation, problems with sleep, the trauma from combat, or the apparent and unacknowledged anger he was experiencing.
In the case example, the therapist helped George achieve change through building a therapeutic context based upon client strengths and the creation of positive emotions. Approach goals were formed as a result of the principles and techniques of GFPP described in this book. Therapy was concentrated on the in vivo experiences of validation, authenticity, and consistent concentration on what was right about the client, and how his life could be different. The client’s process during the course of therapy included broadening in which he became less guarded, more open to the therapist’s suggestions, and more able to expand his own cognitive set. The promotion of the client’s autonomous motivation in therapy was an important ingredient in the success of the process. Overall, George was able to move to the realization that future happiness and well-being were possible, because he had experienced brief examples of feeling happy that were highlighted during therapy.
(p. 15) Examples make theories come alive. However, no single example provides enough supportive evidence for a psychotherapy model. This case example provides a taste of how GFPP can be applied. Moving beyond our personal clinical experience, the following section provides our rationale for why we believe GFPP is helpful to clients.
Research Support for GFPP
The Contextual Perspective
Bruce Wampold and his associates have championed the Contextual Model as a psychological meta-model that obviates the grip of the physical sciences model or the medical model on psychotherapy, observing that “the medical model is too seductive and often we succumb to its allure, unaware of our implicit approval of a model that cannot, in the long run, advance our specialty” (Wampold, Ahn & Coleman, 2001, p. 268). The following is a summary of Wampold’s arguments, as well as germane clinical research evidence providing support for the GFPP model.7
Research supports that psychotherapy works (Lambert & Bergin, 1994)! Furthermore, Wampold asserts that any psychotherapy meeting the requirements of the Contextual Model will be effective, but no more effective than any other model of psychotherapy. Fortunately, GFPP meets the criteria for the Contextual Model. The criteria are as follows:
a. Treatments need to appear to the patients to be efficacious, and the rationale needs to be cogent and acceptable;
b. The therapists have to have confidence in the treatment and believe, to some extent, that the treatment is legitimate (e.g., not a sham);
c. The treatment has to be delivered in a manner consistent with the rationale provided and contain actions that induce the patient to participate in therapeutic actions that reasonably address his or her problems; and
d. The treatment has to be delivered in a healing context (Wampold & Imel, 2015, Kindle Locations 2727–2733).
Meta-analysis results support the contention that treatments that include the specifications listed in the Contextual Model are not statistically different from one another in helping clients accomplish their outcome goal (e.g., Wampold et al., 1997).
For our purposes in presenting GFPP, the significance of Wampold’s research supporting the Contextual Model is twofold. First, Wampold provides a strong and eloquent argument supporting our concerns about the physical science model, and he promotes a psychological metaphor for change. In arguing against the physical science model, Wampold asserts that the specific actions of the therapist are not significant (p. 16) if they are not consistent with the beliefs of the client and the therapist. A physical sciences model is based upon cause and effect. That is, specific actions should lead to a specific effect even when the therapist and client believe that the physical science treatment will not work. If a therapist follows an empirically based treatment manual closely, the physical science model predicts a specific outcome. However, evidence supports the importance of both the therapist and client needing to believe the treatment will work for the predicted results to occur (Messer & Wampold, 2002). The idea that belief is the key variable rather than precise actions clearly contrasts a psychological versus a physical sciences metaphor for psychotherapy.
We go one step further than Wampold’s assertion by naming a specific belief about the therapeutic interventions that facilitates success. In GFPP, we view hope as central. The client as well as the therapist must have hope that the therapy will lead to successful outcomes. Without a therapist’s hope for the process—that is, if the therapist does not believe that the therapy plans can be effective—surely the process is doomed to failure. Furthermore, without the benefit of the therapist’s authentic hope, why would the client be hopeful? Hopefulness is persuasive and breeds commitment to a process of therapeutic change. Frank and Frank (1991), in their seminal work Persuasion and Healing, put forward the Contextual Model and support the importance of engendering hope in therapy. In fact, they assert that the central purpose of therapy is client re-moralization (i.e., facilitating the creation of client hope for change).
The second reason for presenting Wampold’s thesis is that Wampold provides a data-driven argument that supports the outcome effectiveness of GFPP. The good news is that psychotherapy helps! The statistical magnitude when comparing psychotherapy to a placebo is very large, and the magnitude when comparing psychotherapy to no treatment is even larger (i.e., the effect sizes are .48 and .82 respectively; Lambert & Bergin, 1994). However, comparing the outcomes of two or more psychotherapies meeting the criteria of the Contextual Model results in no difference or an effect size that dwindles to zero (Wampold et al., 1997). In essence, this means that there is statistically no difference in outcomes between psychotherapy approaches. There are many implications of these rather startling results. Our implication is that GFPP should do as well as any other therapy that fits the criteria of the Contextual Model.
Before you put down the book because you have decided that it really makes no difference what you do as a therapist, WAIT! There is more to the story! Remember the four criteria for the Contextual Model. Several of the criteria make a big difference in outcome success, and they are not as simple as initially thought. The variable that makes the biggest difference in client change according to the extant research is the therapist (Wampold & Imel, 2015). Did you see that coming? So this book will help you become the therapist you want to be!
The two primary results supporting the importance of the therapist in psychotherapy center on the therapist’s ability to create a therapeutic relationship with the client and the therapist’s belief in the treatment (i.e., allegiance). The next section discusses the evidence that the GFPP model is superior at facilitating the therapeutic alliance and specifically the therapeutic relationship!
(p. 17) Summary of the Three-Year Study of GFPP
The effectiveness of the GFPP model as an integrated psychotherapy treatment is based upon a three-year treatment comparison study. The purpose of the research was to examine the therapeutic effectiveness of GFPP compared to empirically supported psychotherapy as performed in a clinic. The three-year effectiveness study examined what the clients thought of the psychotherapy sessions (i.e., the process) and how effective the psychotherapy was (i.e., the outcome). The results of this initial evaluation of GFPP are quite favorable. The hypothesized non-difference between the GFPP and treatment-as-usual clients on the outcome measures was correct: GFPP was not better or worse in reducing client symptoms than previously empirically supported treatments. The outcome results match the decades of research on therapy outcome that find similar outcomes when comparing complete psychotherapy models that are performed by therapists who believe in their psychotherapy model (Wampold & Imel, 2015). The GFPP three-year study substantiates that GFPP performs as well as the empirically supported psychotherapies.
The reason you should use GFPP is because the GFPP clients rated their therapy sessions more positively than the treatment-as-usual clients. The clients reported that they liked the relationship with the therapist, the goals discussed and the topics talked about in the session, and the approach the therapist used in GFPP more than the treatment-as-usual sessions. The heart of our argument for using the GFPP is that clients rate the therapy sessions and the therapist higher. That is, clients like the process of focusing upon their strengths, positive emotions, and goals as described in the GFPP model.
Research indicates that the therapist, not the client, makes a larger difference in whether a client rates the therapeutic alliance as high or low (Baldwin, Wampold & Imel, 2007). Certain therapists consistently receive higher scores from their clients regarding the therapeutic alliance, while other therapists consistently receive lower alliance scores. GFPP facilitates a higher therapeutic alliance. The therapeutic alliance is a central psychotherapy process that consists of developing a relationship bond between the therapist and client, as well as agreeing upon the goals and tasks to be pursued in a therapy session (Hatcher & Barends, 2006; Horvath & Bedi, 2002). Research consistently reveals that a higher therapeutic alliance predicts client success (Del Re, Flückiger, Horvath, Symonds, & Wampold, 2012) and reduced client dropout (Sharf, Primavera, & Diener, 2010). The therapeutic alliance reveals clients who generally benefit less from psychotherapy. For example, clients with lower educational levels tend to benefit less from therapy and also report a lower therapeutic alliance (Sharf, Primavera, & Diener, 2010). Since clients rate GFPP higher in therapeutic alliance than treatment as usual, GFPP should help groups of people who have historically benefitted less from traditional psychotherapy.
The authors attribute the higher therapeutic alliance scores for the GFPP compared to treatment as usual to be a result of the GFPP techniques that promote the therapists’ expression of the characteristics and techniques that the literature (p. 18) describes as facilitative of the alliance. A literature review by Ackerman and Hilsenroth (2003) specified the therapist attributes and techniques that have contributed to strong alliances. The techniques they identified include exploration, reflection, supportive statements, noting past therapy success, accurate interpretation, facilitating expression of affect, actively affirming, understanding, attending to clients’ experiences, and interpreting what the clients want. The therapist’s personal attributes include being flexible, respectful, trustworthy, interested, friendly, warm, and open. The GFPP model structures most of the techniques and characteristics known for facilitating therapeutic alliance into the process of therapy. Although not enumerated by Ackerman and Hilsenroth, GFPP adds techniques that identify strengths, positive emotions, and approach goals that surely enhance the therapeutic alliance. We contend that GFPP elicits the characteristics of the therapist that clients value through the GFPP-promoted therapeutic techniques and attitudes.
In conclusion, the first effectiveness study of GFPP supported the theory’s benefits when compared to treatment as usual. GFPP was as good at producing the client outcome scores as treatment as usual and was better at achieving a higher therapeutic alliance. The three-year GFPP study is presented in detail in Chapter 6. Wampold and Imel’s (2015) meta-analyses remind us that therapies meeting the contextual definition are not different from one another in helping clients change. However, GFPP was superior to treatment as usual in client ratings of the therapeutic alliance. The superiority of GFPP in the formation of the therapeutic alliance makes sense. The therapeutic intention of GFPP therapists is to focus on client strengths, increase in-session as well as out-of-session positive emotions, increase hope, and establish goals toward well-being. When clients experience hope and belief in their own abilities that the GFPP therapist has identified and emphasized, then good session ratings should occur. We believe that future research will reveal that the greater enjoyment of the GFPP sessions will predict increased client attendance and a healthier client self-definition, and even enhance the lives of therapists using GFPP. GFPP therapists have reported that they enjoy life and therapy more after a year of training!
In the first chapter, we have introduced you to GFPP—its philosophy, foundational premises, and initial empirical support. In doing so, we have promoted subjective well-being as the overall goal of therapy by offering a philosophical and pragmatic argument for why well-being is a worthwhile goal of therapy. We have also explained how GFPP differs from traditional psychotherapy by focusing on positive emotions, client strengths, the formation of approach goals, and the instillation of hope as the central foci of therapy. Finally, we have described some of the advantages of GFPP:
• GFPP is ethical by virtue of promoting beneficence while protecting against maleficence;
• GFPP uses a psychological metaphor that is more fitting with psychotherapy than the physical sciences metaphor;
• GFPP is at least as efficacious as traditional therapy;
• GFPP enhances the therapeutic alliance significantly more than traditional therapy;
• GFPP attends to the client and the client’s context at least as much as the client’s problems; and
• GFPP focuses on positive emotions to create change.
We have also presented a case that demonstrates the therapeutic process of GFPP. The process is based in positive psychology as well as humanistic psychology and is grounded in facilitating clients to discover a more virtuous and meaningful life, which in turn equips them to fend off the debilitating effects of life’s inevitable problems. In the next chapter, we go into more detail of the theoretical grounding and research supporting the four hallmarks of GFPP: creating approach goals, identifying strengths, promoting positive emotions, and engendering hope.
1.Happiness, subjective well-being, and well-being will be used interchangeably.
2. In all likelihood Aristotle’s definition of happiness will not be similar to modern definitions. However, no original texts exist of Aristotle’s writings; only second-, third-, or fourth-hand reports exist of what Aristotle originally said, and therefore accounts of his meaning disagree.
3. Sometimes the physical science metaphor is referred to as the medical model of psychotherapy.
4. When writing about client idiosyncrasies, we mean to communicate the client’s strengths, immediate and past life experiences, and immediate and long-term goals. Included in a client’s strengths and past life experiences are culture, education, relationship history, and many other issues that make all of us distinctive individuals.
5. In our writing, we will use happiness, subjective well-being, and well-being interchangeably. Later in the book distinctions will be made between these terms and psychological well-being.
6. Positive empathy is intuiting what the client wants based upon the present content and context. Further definition occurs in subsequent chapters.