Why Moving Beyond an Individualized Approach is Critical to Effective and Ethical Practice
The Phoenix Prevention Program (PPP) is the clinical therapy component of a continuum of services offered at Phoenix Youth Programs in Halifax, nova Scotia.
Susan was a client who came to the PPP for therapy. She gave us permission to share her story1 to highlight the importance of understanding the context of clients’ lives, to move beyond the tendency in the therapeutic world to locate problems within individuals, and to understand that advocacy is therapy.
Susan was a seventeen year old girl who struggled with anxiety. She had previous counselling that focused on coping skills and changes to her thinking. Following the therapy, Susan experienced an increase in the anxiety and had at least two panic attacks. She was reluctant to re-engage in counselling.
Within the first couple of sessions at the PPP Susan disclosed that her family was living in poverty. She was helping to pay all of the bills and supporting her mother and sister through a full time job. Susan was an impressive young woman, in grade twelve, often working twelve to fourteen hour days while being home-schooled. She explained that her mother had mental health challenges and only a small unreliable income. Her mother had previously applied for welfare but felt she had been treated dismissively and was denied assistance. Susan was feeling guilty about the extent to which she felt burdened and overwhelmed. She was convinced that she had an anxiety disorder and wondered if she needed medication.
Susan spoke about her dream to become a chef and attend culinary school but she felt this dream was out of reach due to poverty.
As therapists, we need to develop contextual competence (Fook, 2003). Considering the context in which a client’s problems exist, and advocating for change, is integral to effective, ethical, responsive, social justice-oriented therapy. in our work at the PPP we pay attention to the complex situations that affect client’s lives.
Acts of advocacy are powerfully therapeutic when advocacy honours the complexity of clients’lives, defines the problem as separate from the client (White & Epston, 1990), and addresses contextual challenges. Advocacy is even more therapeutic if the client experiences the therapist as an ally with power to advocate for needed change to their environments.
Since we know that the quality of the therapeutic alliance is the single most important factor toward a positive outcome in therapy (Horvath & Symonds, 1991), it makes sense to incorporate therapeutic advocacy as a central component. Our experience has shown us that an effective way to strengthen the therapeutic alliance with clients is through asking specific questions about the details of their lives. When a client’s problems are assessed separately from their socio-economic and cultural contexts, important underlying contributors are ignored and the client is left to understand themselves as deficient (Waldegrave, 2005).
In our case example, a strong therapeutic alliance was developed with Susan as she and her therapist unpacked the reality of her life. Once her therapist understood that Susan and her family were living in poverty, the anxiety was discussed against this backdrop and the meaning of it changed. The immediate suffering brought on by the anxiety was not ignored. Susan learned about mindfulness and relaxation techniques. She and her therapist discussed the ways in which the anxiety was affecting her life and how Susan could take back control from its presence. However, Susan’s therapist didn’t see her solely through the lens of an anxiety “disorder.” instead, she viewed Susan as a resourceful, resilient, and remarkable young woman who was living in, and was rightfully anxious about, an untenable situation. She understood that Susan was worried about very real and adult things like how to pay the bills, buy food, and keep the heat on.
In contrast, Susan spoke of experiencing little or no therapeutic alliance when in previous therapy, where she was told that she had a disorder and distorted thinking. She was not asked about the context of her life. no inquiry was made about details of her daily struggles. This decontextualized approach left her feeling that she was deficient and to blame for not functioning or adapting well.
Asking people to adapt to and cope with their environments without addressing the social context runs the risk of perpetuating social injustice (Ratts, 2009). Problems cannot be understood solely by assessing behavior and cognition, and expecting change to come only from within the client. Contextual curiosity and competency is an ethical responsibility that requires therapists to advocate with and for clients. Acknowledging the presence of poverty in Susan’s life and connecting Susan and her family to resources and supports were core components of her therapy. Advocacy was critical to the process; not an “add on” service that would typically be relegated to other helping professionals (Lewis, Ratts, Paladino, & Toporek, 2011).
Susan began to understand the anxiety as a normal response to a very stressful situation when the focus of therapy shifted to addressing the family’s lack of income and deconstructing the shame that Susan felt about it. A respectful working alliance was formed with Susan’s mother, who over the course of several sessions was open to allowing the therapist to support her in re-applying for income assistance. The successful application to welfare alleviated some of the financial burden on Susan that was feeding her anxiety. This made space for her to focus on her educational and career aspirations.
Susan and her therapist discussed her dreams for the future. Together, they applied for scholarships offered by supporters of Phoenix Youth Programs. Susan subsequently graduated from culinary school at the top of her class. She won awards in culinary competitions and is now working in a highly regarded restaurant.
Unpacking, honouring, and collaboratively acting upon the contexts of clients’ lives is an ethical responsibility that is rooted in social justice principles. This approach lends itself to the establishment of a strong therapeutic alliance and can contribute to effective and longterm change. Typically clinicians are afforded little time in their practice to advocate. We argue that it is a critical time-saving measure in the long run (Ungar, 2011). When Susan’s problem with anxiety was discussed as only internal, there was no lasting decrease in the anxiety. When the problem was rightfully situated in Susan’s socio-economic context, steps were taken to address barriers and advocate for change that extended well beyond the therapy room. As a result, Susan experienced a significant decrease in anxiety and an increase in overall feelings of wellness and competency.
As therapists at the PPP, we incorporate advocacy in our clinical practice, firmly believing that it is an ethical, effective, and critical component of all therapy.