Therapist Behavior 

 

     The most commonly accepted definition of leadership is the process of influencing the activities of an individual or group in efforts toward goal achievement in a given situation" (Hersey & Blanchard, 1977, p. 84). Clearly, this is also a description of what therapists do. Therefore, ACT presumes that the roles of leader and therapist are comparable and draws heavily from research on leadership behavior. It is important to note that leadership behavior is not role-bound; that is, a client can lead a therapist. It is the boss or therapist who is designated leader, however, and unless there is awareness in a given situation that a role reversal is in effect, confusion and inefficiency may result, both in business and in a clinical hour.

     Studies consistently have found two principal variables affecting leadership behavior; one having to do with leader attitude and the other with leader behavior. The pioneering work by a group at Ohio State University (Stogdill & Coorn, 1957) identified the variables as consideration and initiation structure; Blake and Mouton (1964) called them concern for people and concern for production; Hersey and Blanchard labeled these variables relationship behaviors and task behaviors; and most recently, Blanchard and Johnston ( 1982) have adopted the terms support and direction.

     Direction behaviors. Behaviors directed toward the accomplishment of an identified goal are on the direction continuum of therapist behavior. Answers to the questions, "What?" "When?" "Where?" "In what order?" "By what means?" and "Who does what?" all refer to the direction continuum. What varies is how much structure or directive behavior is provided by the therapist and how much by the client or other sources. A therapist who is high on the direction behavior dimension, for example, would be directive. focused on accomplishing a specific task, initiating of activities with clients, and highly structured. On the other hand, a therapist who is low on the direction behavior dimension would not be directive, not be working toward a specific goal, and would look to the client to provide structure or to give direction to the clinical meeting. It is not difficult to see that in the first instance, a behavioral approach fits beautifully, whereas at the other end of the continuum therapist behaviors similar to the psychoanalytic approach are suggested.

     It would be inaccurate to think, however, that high-direction therapists are interested in overt behavior, whereas low-direction therapists have more to do with cognitions and feelings. It is in fact possible to address thoughts and emotions employing a high-direction style. Rational Emotive Therapy Is a good example of this. The important point is that the determination of the direction level of a given technique depends upon the degree to which the initiation and structuring of activities are controlled by the therapist (high-direction) or the client (low-direction).
 

     Relationshiplsupport behavior. A second, independent continuum along which a therapist's style may be measured is the degree of supportive behavior. The importance of the therapist-client relationship has long been appreciated in psychotherapy. Initially, analytic theorists conceived that importance as being central to the working through of the transference neurosis. Later, client-centered therapists viewed the therapeutic relationship by itself to be necessary and sufficient to produce therapeutic change. With the rise of behaviorism and emphasis on direction-related phenomena, there are currently some conditions in the therapy under which the quality of the therapeutic relationship is decidedly secondary. Setting up and running a token economy program would be one example,

     Therapists high on the support behavior dimension would devote considerable time, thought, and energy to showing concern for the client, demonstrating support, being empathic, and building rapport. Such techniques are designed to help clients feel understood, approved of, cared for. and supported by the therapist. Techniques that do not include facilitating the therapeutic relationship would be classified as low on the support behavior continuum.

     Classifying an approach as high or low in support behavior does not imply that one results in a better therapeutic relationship than the other. In fact, ACT predicts that the best therapeutic relationships are the result of accurately assessing the task readiness of the client and correctly determining the requirements of the presenting problem. Nearly every practicing therapist has been in the puzzling position of using good support skills and receiving no response from certain clients. In certain situations, the use of a high support behavior approach will lead to a poor therapeutic relationship, whereas the choice of a low support style would be more likely to yield a good working alliance. In the arena of relationship behavior, it is ACT's objective to define the parameters for using both high and low support behaviors in a therapeutic context.
 

Types of Therapist Styles

     The two dimensions of therapist behavior, direction and support, can now be combined to produce the four basic therapist behavior quadrants presented in Figure 1. Each of these quadrants depicts a different type of therapist style.



Figure 1.  Types of therapist styles.  TELLING = high task/low relationship; 
TEACHING = high task/high relationship, SUPPORTING = low task/high relationship, DELEGATING = low task/low relationship.


     Each style represents a different mix of the direction and support dimensions. As will be shown in Section 3, specific therapeutic techniques can be assigned to each of these four therapist style categories. It should also be pointed out that techniques relating to a particular theoretical school of thought or targeted toward a particular mode of human functioning (e.g., behavioral, affective, cognitive; cf. Lazarus, 1967) can be assigned to an appropriate quadrant.

   The four quadrants in Figure 1 are designated Q1 through Q4. Hersey and Blanchard (1977) have given the following shorthand designation for the basic leadership styles associated with those quadrants as: Q1 "telling," Q2 "selling," Q3 "supporting," and Q4 "delegating." The different styles (S1 through S4) associated with each of the quadrants are elaborated below.

     S1: high direction/low support. In this style (HD-LS) the therapist assumes the responsibility for deciding what needs to be done, how it needs to be done, and in what order. The client role is to comply, to do what is prescribed. In the practice of emergency room medicine, this situation exists when the patient is essentially passive, with the physician diagnosing the problem and implementing the treatment. Essential to operating from this quadrant is an assessment that indicates that the client is not in a position, from ignorance or from emotional disturbance, to make appropriate life decisions.

     In psychotherapy, when it becomes clear that a client is either unwilling or unable (or both) to direct himself or herself toward goal achievement, most therapists will move toward a more directive stance with that client. If they do not, there is the risk that therapy will grind to halt, because to continue to require autonomous functioning in this kind of situation is to ask the impossible. One does not ask someone in the midst of a psychotic break to decide whether or not to go to the hospital; one does not ask court-ordered clients whether or not they want to continue treatment.

     S2: high direction/high support. In the latest revision of his model Blanchard (1982) labels Q3 (HD-HS) "consults," implying that the leader dialogues with the follower about decisions, but retains the final power of decision. ACT generally prefers to call this quadrant "teach." A teacher is often in the position of dispensing information to persons who do not have it, but who have indicated that they want to have it. This condition is called "willing, but unable." All of us can look back on our school careers and recall the teachers who most inspired us and from whom we learned the most. In all likelihood, they were the ones gave us the information along with a great deal of enthusiasm and encouragement. They were probably the ones who took a personal interest in us and seemed to care that we learned the material. This is the S2 approach. In psychotherapy, it is common knowledge that change'of any kind is difficult. A good example is social skills training. Suppose a client presents as someone who is meek and victimized by other people. Suppose also that this person wishes to alter that situation. In order to maximze the opportunity for change to occur, most therapists would combine the teaching of assertion skills with some form of encouragement and support. They would, in effect, take an S2 stance with that particular client.

     S3 low direction1high support. A therapist's behavior in this style is primarily supportive (LD-HS). The focus is less on what the client is doing and more on how the client is doing. The therapist gives hints, reminders of previously learned concepts, but is more concerned with projecting caring. support, and understanding. An image that comes to mind is that of the football coach who is intensely involved with how players on a field are doing, pacing up and down the sidelines, slapping backs, shouting encouragement, cheering for triumph, and commiserating with failure. Clinical examples of S3 abound, as it is often the most natural and intuitive stance for a therapist to take and frequently the therapist behavior taught in graduate programs. Being with and physically comforting a client who is newly bereaved or allowing the client to share his or her joy are both examples of S3 behavior. In this quadrant, the therapist has moved away from both telling and teaching. In short, responsibility for directive behavior belongs to the client. The therapist facilitates, clarifies. and reflects material presented by the client. Rogerian therapy is the prototype of this high support, low directive behavior position. Accurate assessment would show that clients who respond to this stance are often both willing and either newly able or lacking confidence. Most of the time, this reluctance is due to a failure of courage, and thus, the S3 position of encouragement and support is the one of choice to ensure client progress.

     S4: low direction/low support. By now, it should be obvious that quadrants SI-S4 are in fact an analogue of the therapy process itself and that they move from a therapist position of much control to a therapist position of little control, depending upon the assessed position or needs of the client. Thus, the S4 quadrant (LD-LS) is one in which the therapist functions as an interested observer of the client's progress. The prototype of S4 behavior is classical psychoanalysis in which the client is fully responsbile for content. and the analyst serves as a clarifier-commentator. The presumption of this stance is that the client is both willing and able to direct his or her own process. The S4 position frequently becomes the position of choice in the termination phase of successful therapy of all kinds. As the client achieves objectives and gains confidence in his or her ability to self-direct, it is most appropriate that a therapist relinquish control and move away from a heavily supportive approach.

Relationship of Client Readiness to Therapeutic Style

     The heart of ACT lies in the prediction that the four categories of therapist styles (SI-S4) will be differentially effective as a function of the readiness level of the client. This section will further discuss the concept of client readiness level, as well as speculate about the precise nature of the misalignment between therapist style and client readiness.

     In ACT, readiness is not to be understood as a global personality trait that an individual exhibits in a transsituational manner. Readiness for ACT's purposes is defined as being relative to a cluster of closely related activities or tasks. Suppose, for example, that one considers the stereotype of the dedicated. brilliant scientist who is a social isolate. How much readiness is this Individual exhibiting? It depends entirely on the context in which the scientist is being considered. Work-related readiness could be extremely high, whereas social and interpersonal readiness could be quite low. Exactly the opposite readiness profile would exist for the socially active, interpersonally skilled student who could not manage to attend classes regularly or complete assignments. It is important not to consider a client high on readiness or low on readiness in some total sense. ACT recommends that the concept of readiness be considered only with respect to the objectives targeted for therapy and to the related tasks to be performed.

     Just as therapist styles are divided into four quadrants, so are client readiness levels. The numbers correspond to those of therapist styles, with RI being low readiness, R2 low moderate readiness, R3 high moderate readiness. and R4 high readiness. Recalling that the three aspects of client readiness according to Hersey and Blanchard are willingness, ability. and self-confidence, it becomes simple to understand that these elements in various combinations constitute the four levels of client readiness.

     Clients who are both unwilling and unable, or very insecure about accomplishing the targeted clinical goal, are in the low readiness (R 1) category. Those who are willing, able, and confident enough to make necessary changes are in the high readiness (R4) quadrant. Individuals with mixed or intermediate levels of willingness, ability, and confidence generally can be assigned to the two middle quadrants (R2, R3). It is important to bear in mind that these categories are defined discretely for convenience and clarity. In actual practice, there is fluidity and movement from one quadrant to another with respect to both therapist style and client readiness level.
 

The Concept of Match and Move

     ACT conceptualizes progress in therapy as movement by the client from an unready state to a more ready state in terms of a specifically designated therapeutic task. This maturation process can also be viewed as movement from a passive to a more active stance, or as a gradual shift from a dependent to an independent position. Early in the therapeutic process. clients tend to rely more heavily upon the therapist for direction and support than in the termination phase of treatment.

     It cannot be overemphasized that assessment of a client's readiness level is critical to determining what therapeutic approach will be most beneficial for that client. The optimal approach will (1) meet the client's needs at his or her present readiness level and (2) encourage movement by the client to a higher readiness level. Implicit in ACT is the notion that a miscalculation of client readiness level in either direction will decrease the chances of therapeutic progress and perhaps even undermine the process. With clients at very low readiness levels, for example, a great deal of directive behavior by the therapist is needed in order to generate initial movement in therapy. It is precisely for this reason that highly directive techniques are often successful with severely disturbed or poorly functioning clients. As the client progresses into more mature levels of functioning, the therapist reduces directiveness and takes a supportive, encouraging stance with the client. Once a higher level of readiness is achieved, the therapist may decrease supportive behavior and encouragement until the client is functioning independently, a sign of readiness to terminate treatment.

     The relationship between client readiness level and recommended style is depicted in Figure 2. 



Figure 2.  Determining an appropriate therapist style according to client maturity level.


     One can see the four quadrants depicting the four therapist styles as shown in Figure 1. The client readiness dimension has been added to the bottom of the figure. You should note that extremely low readiness is found at the right-hand side of the figure, whereas high levels of client readiness can be found to the left side. The bell-shaped curve transversing the four therapist styles represents the optimally effective therapist style for clients at the particular readiness level as predicted by ACT theory. This curve is actually the smoothing of a stepwise process of moving back on (decreasing) structure or directive behavior and up on (increasing) supportive behavior through S I and S2. For S3 and S4 the curve is a smoothed stepwise process of decreasing both directive behavior and supportive behavior as the client assumes more and more responsibility for the maintenance of the targeted direction behaviors.

     Therefore, if one wants to determine the most appropriate therapist style for any level of client readiness, one simply locates the client's position on the readiness dimension and constructs a vertical line that intersects the bell-shaped curve. The quadrant in which this vertical line ntersects the curve represents the therapeutic style recommended by the ACT model.

     Using the four shorthand designations (S I "telling," S2 "teaching," S3 "supporting," and S4 "delegating") described earlier in this section, we see the appropriate therapist style for each readiness level in Figure 2. Situational Leadership Theory (Hersey & Blanchard, 1977) not only predicts the optimal leadership style for each readiness level but also suggests the probability of success of the other three leadership styles when applied to that situation. Each style's probable success is a function of its distance from the predicted "best style" along the bell-shaped curve. Styles at a greater distance stand less of a chance of success than styles nearer to the recommended therapist style for that readiness level. Table 1, then, represents an ordering in terms of probability of success of the four therapist styles at each of the four client readiness levels.

     One should note that "supporting" and "teaching" therapist styles (styles that include high support behaviors) are never designated as having a low probability of success. Although they are not always the optimal approaches, they might be considered somewhat "safe" in that they will never be the least preferred approach. Being totally unsure about a client's readiness level, one cannot go far wrong by employing a style that is high in support behavior. In the absence of other information, therapists characteristically engage in moderate amounts of supportive behavior while seeking information on which to formulate an approach to treatment. However, choices of appropriate therapist style that simply avoid gross mismatches of therapist style and client task readiness are far from the precise selection and matching that we hope ACT theory will foster.

     The remaining sections of this article probe the implications of the ACT model presented in this section. Much of the empirical literature, theoretical insight, and practical wisdom developed over the years in the field of psychotherapy will be reinterpreted from the ACT perspective. Finally, we should emphasize that we are not simply proposing yet another theory of psyphotherapy. Instead, ACT represents a systematic, integrative model that encompasses the broad array of existing theories of psychotherapy, and couches them in a metamodel that recommends a systematic, eclectic use of psychotherapeutic methods.

SECTION 3: IN THE BEGINNING ...
ALL WERE RIGHT

     The major proposition developed in this section of the article is that all approaches to psychotherapy are best suited to the client populations from which the approaches were first conceived. Because the originating populations varied on developmental readiness, consistent with ACT theory, the approaches developed vary on the directive and supportive leadership dimensions.

    ACT is primarily concerned with how a therapist behaves and how he or she selects from a range of available therapeutic interventions those (hat best match the task-relevant readinessof theclient. For this reason, as we look at the picture of where various therapeutic approaches fit, particular attention will be paid to the client's readiness and the therapist's behaviors on the directive and supportive dimensions.

     The remainder of this section will describe the four major styles of ACT beginning with S4, which is low on both directive behavior and supportive behavior, and then move through S3, S2, and S1.

S4: Low Directive Behavior/
Low Supportive Behavior

     Beginning in the low directive behavior/low supportive behavior quadrant, we see the classical psychoanalyst in a chair, listening to the free associations of the patient on the couch. The behavior of the analyst is consistent with the S4 conceptual framework. Too much support on the therapist's part will inhibit the critical transference process through which the patient first projects onto the blank screen of the analyst manifestations of unresolved intrapsychic conflicts. The analyst raises questions and calls attention to the cloudy or unfocused parts of the projected picture. In working through the transference, the patient comes to see himself and the world more clearly with Iess distortion from unconscious conflicts.

     The original problem studied and treated by Freud determined the direction of his theroretical contributions. High anxiety psychoneurotic disorders are well suited to S4 psychotherapy. Bright, verbal, and suffering clients are both motivated and competent for nondirective and low supportive treatment. The goal of psychoanalytic treatment is self-awareness and intrapsychic resolution rather than specific behavioral changes. One psychoanalyst, Jacob Arlow (1977), described the task:

Essentially, psychoanalysis continues the rationalist spirit of Greek philosophy in its command to "know thyself." Knowing one's self, however, is understood in quite a different way. It is not to be found in the pursuit of formal, logical analysis of thinking. As far as the individual is concerned, the sources of his neurotic illness and suffering are by their very nature "unknowable." They reside outside the realm of consciousness, having been barred from awareness by virture of their painful, unacceptable quality. By enabling the patient to understand how his neurotic symptoms and behavior represent derivatives of unconscious conflicts, psychoanalysis permits the patient to make rational choices instead of responding automatically (p. 19).
     With self-understanding as the goal and transference as a key therapeutic process, certain limits on the supportive dimension are thus established. What about the directive dimension? Another quote from Arlow (1977) addresses that question.
The technical principle behind the organization of the psychoanalytic situation is to create a set of conditions in which the functioning of the patient's mind and the thoughts and images that emerge into consciousness are as much as possible endogenously determined. The patient's thoughts and associations should come primarily from the stimulus of the persistent dynamic internal pressure of the drives as organized in unconscious fantasies. His thoughts and associations should not represent responses to external manipulation, exhortation. stimulation. or education. This is what is uniquely psychoanalytic in the therapeutic interaction. (p. 19)
     One might imagine the treatment process as the patient and the analyst standing over the La Brea Tar Pits of the patient's unconscious mind. They observed the areas in which the tar is hot and bubbling and look for bones or other artifacts through which the intrapsychic past and present can be better understood. From an analytic perspective, too much directive behavior, information, education, or structure will interfere with the observational work of the naturally occurring phenomena. This noninterference is consistent with Freud's consideration of psychoanalysis as a scientific learning process. At the same time, psychoanalysis was both a form of therapy and a method of scientific investigation.

     Many practitioners who espouse and use psychoanalytic theory do not limit their therapeutic behaviors to the S4 quadrant. One example is psychodrama, in which evocative, directive, active techniques may be employed by an analytically oriented therapist to "turn the heat up" under a suspected repressed conflict. In a sense, much of the work of the psychoanalytic therapists after Freud has been directed toward the goal of accomplishing treatment more efficiently and effectively. In that process they have ventured out of S4 into the more active and/or more supportive styles. A psychiatrist friend of the authors, trained in psychoanalytic therapy, once "confessed" that he had made suggestions to a certain client about what to do. A client, new to the city, was having trouble making friends, did not like bars, and was lonely and unhappy. (The analytic view is that if the client is lonely and unhappy, it reflects an intrapsychic and/or Interpersonal problem.) The psychiatrist, himself active in politics, suggested the client volunteer to work for a political candidate. Having committed the heresy of being so directive, the psychiatrist reported looking uneasily at the picture of Dr. Karl Menninger hanging in his office. The client followed the suggestion, made some friends, started enjoying her life in the new city, and terminated therapy.

     It is not difficult to see that psychoanalysis, with its somewhat distant style of therapist behavior would, in the ACT model, require a highly motivated and capable client, because most of the responsibility in this approach rests with the client. Analysands must be willing and able to commit time (possibly 34 times a week for 2 to 5 years) and money; they are responsible for the content of therapy, and they must be willing and able to introspect. The classical psychoneurotic disorders of anxiety hysteria, obsession-compulsion, and other states characterized by anxiety are the disorders out of which psychoanalytic treatment emerged and the ones for which this particular psychotherapy is best suited. Again, the original population treated determined theoretical development.

     One assurance that analysis will be successful is that analysands apply and are selected for treatment, whereas unsuitable candidates are not accepted. In fact, significant problems occur when S4 methods are applied to clients who are at lower levels of task-relevant readiness. The S4 approach utilized with populations such as psychopathic prisoners, low-functioning schizophrenics, or clients lacking behavioral skills is countra-indicated by the ACT model.

S3: Low Directive Behavior/
High Supportive Behavior

     Moving to the upper left quadrant in our ACT view of psychotherapy, we find as a prototype the client-centered approach of Carl Rogers.  S3 brings the chair out from behind the couch. Further, it replaces the couch with a chair comparable to one in which the therapist sits. The client, never a patient, is face-to-face with a therapist who seeks to create the conditions of acceptance, support, unconditional positive regard, and empathic understanding of that client's internal frame of reference. Rogerian theory assumes the client knows best, and the therapist is present as a friendly helper in the client's own process. When exposed to those aforementioned therapeutic conditions, clients are able to explore, integrate and accept themselves; to become autonomous, self-actualized persons who function effectively. The therapeutic relationship is the necessary and sufficient condition for change.

     All the approaches to therapy, except some in S 1, focus considerable attention on the therapeutic relationship. The variation among them is about how much relationship, and whether relationship alone, is sufficient or insufficient to produce change. The ACT model would predict the S3 style to be a good match and sufficient to produce change with R3 clients, but not with clients of less willingness or ability in the task-relevant domain. Patterson, a client-centered proponent, maintains his theoretical chastity by labeling any focus on direction (versus focus on support) to be education, not therapy.

What about client problems that involve lack of information or knowledge, lack of skills of various kinds? . . . Surely where these are lacking or inadequate the providing of a relationship is not sufficient. Although it might appear to be a resort to specious reasoning. dealing with such problems wou ld appear to be education (or reeducation) or teaching rather than therapy. While it may be difficult to draw a line between therapy and (remedial) teaching there would seem to be some value in doing so. One difference might be that therapy is concerned with persons who arc not lacking in knowledge or skills but who are unable for some reason to use their knowledge or skills. Their problem ... is not one of learning but of performance. Therapy as a relationship is sufficient for enabling them to do those things that they are capable of doing. On the other hand the relationship may not be sufficient where there is a lack or deficit. It is here that the cognitive methods and techniques developed by Meichcnbaum. for example, would be relevant and appropriate. (Patterson, 1980, pp. 661-662)
     Client-centered therapy does not even include a direction dimension! For this reason, the selection of clients appropriate for this intervention style is just as critical as selecting analysands for analysis. One must wonder what a pure client-centered therapist would do with someone who honestly did not know how to do something. We are reminded of a woman who complained that she did not receive adequate treatment when she had sought help in coping with a divorce. The divorce was a real crisis in her life, and she was "failing apart." She felt she needed (and we agree) a therapist who would help her get control of her life. Instead her therapist nodded a lot; said, "Uh huh"; and asked her. "What do you think?" When Rogers attempted to extend his nondirective client-centered techniques to more psychologically disturbed clients (those in the RI and R2 categories), he discovered, among other things, that it was necessary to be much more verbally active in the therapy process. Consequently, he was forced to do a great deal of "empathic guessing." In describing his interaction with a schizophrenic client from a research program applying person-centered therapy to a schizophrenic population, Rogers writes, "Unlike many of the clients in this research the relationship had, almost from the first, seemed to have some meaning to him" (Corsini, 1979, p. 154). Because the first (or only) task of client centered therapy is relationship building, then with the other, less developmentally mature clients, Rogers was forced to do something else or give up when the relationship had no meaning or impact. In fact, it seems that whenever proponents of a particular approach to therapy have ventured outside of the task-relevant readiness range on which the approach was developed, they had to change their behavior in directions predicted by the ACT model. These same proponents, however, usually will interpret such movement as being consistent with their theoretical concepts, rather than labeling it as changing their theories. A person centered therapist using an S3 approach is more likely to interpret increased activity as self-disclosure or genuineness, not directiveness.

     Next to be considered are the therapeutic behaviors of the S2 therapist who is by definition willing to be directive and educative in addition to maintaining the importance of the client-therapist relationship.
 

S2: High Directive Behavior/
High Supportive Behavior

     As we move our attention to the S2-high directive behavior/high supportive behavior style, the range of therapeutic behaviors continues to expand. Two typical approaches reflective of this style, Adlerian and Reality Therapy, involve much more active directive behavior and structuring of the goals and processes of therapy by the therapist. Maintaining the relationship connections of S3, an S2 therapist is willing to be not only more directive but also more judgmental. Harold Mosak (1979), a proponent of AdIarian Therapy, characterizes the therapist's behavior as "authentically himself--a caring, sharing person; who remains free to have feelings, opinions and to express them; revealing of himself as a person; task oriented; operating from a value base which is used in setting goals and evaluating behavior" (pp. 79-80). Both high support and high direction elements are prominent.

     One of the definitions for S2 is"SELL"--selling the client on the need for therapy, the need for change, that other options are possible, or to give up a problematic behavior. The very term could send shivers through Rogerian and classically psychoanalytic therapists. From an S2 perspective, the S4 analyst does "Sell," but it is done indirectly and one must hang around until the patient "buys" analytic formulation of the problem.

     Adlerians are consistent with a willingness to assume an S2 stance, and, where necessary, outline ways of converting the reluctant (Mosak &Shulman, 1963). Progress toward the goals of gaining insight into the "basic mistakes" that have led to a faulty life-style and reorienting toward a life-style of realistic expectations or positive social values can only be accomplished if the client becomes somewhat willing. Hence, there is willingness on the part of the therapist to convert the initially unwilling but "needing" client. Adlerians were among the first to involve the families of a patient in treatment, based on the recognition that the person presented to the therapist as needing treatment--particularly a child--may be carrying the symptoms for someone else in the family or for the family system itself.

     Another label for S2 is "TEACH." The S2 therapist is comfortable teaching willing (but unable) clients alternative ways of viewing and relating to themselves and the world around them. From this perspective, it is consistent to view psychotherapy as "a cooperative educational enterprise ... with the ... subject matter of this course in re-education being the patient himself--his lifestyle and his relationship to the life tasks" (Mosak, 1979, p. 64).

     An Adlerian's willingness to assume a more active, directive role in therapy stems from the willingness of Adler himself, and his proponents, to leave the consulting room and venture into the community and the real world. Encountering a wider range of human behavior, including some persons who would never darken the door of an analyst's office, meant in effect, that Adler was exposed to a wider range of task-relevant readiness in those persons with whom he had contact. From his experience, Adler could not conceive of the therapy process as being limited to a one-to-one, I-thou relationship within narrow confines. He believed in social action (child care centers, public access to treatment), education (parenting skills, school consultation), group, and family therapy. These global notions of therapy were his attempts to make treatment relevant for everyone, not just "the elect." Small wonder that many social workers and others "out there in the trenches" have seen the necessity of S2 behaviors in achieving therapeutic results.

     William Glasser (1965) acknowledges the incorporation of many Adlerian concepts into his Reality Therapy. Because Reality Therapy is of more recent vintage (1950s) and the originating populations are clearly defined, the fit with the ACT model can be seen vividly. The Ventura (California) School for Girls, whose residents are seriously delinquent adolescent girls, was the setting out of which Reality Therapy principles developed. In ACT terms, residents were dominated by R I and R2 levels of task-relevant readiness, and appropriate interventions would thus consist of high-direction, low-relationship, or high-direction, high-relationship therapist behavior. Reality Therapy concepts, such as the importance of identity, positive self-concept, and individual autonomy, are directly related to ACT concepts of task-relevant readiness levels and the therapist styles appropriate to them.

This is the ability to let go and relinquish environmental supports and substitute internal psychological support, the ability of an individual to psychologically stand on his own two feet [1141. This, of course, does not mean not to be involved. not to give, not to love, and so forth. It means for the individual to take responsibility for who he is and what he wants in life and to develop responsible plans to fulfill his needs and his goals. (Glasser & Zunin, 1979, p. 314)
     Like Adlerian therapy, Reality Therapy includes learning and teaching as integral parts of therapy, important in effecting behavioral change. The developmental "match and move" principles of ACT arc evident in Reality Therapy (i.e., match the client where he or she is, such as R I or R2, and move toward R4, which is where a client finds himself or herself having attained identity, responsibility, and commitment).

     An illustration of how certain readiness levels naturally and logically require differential therapist responses might help clarify at this point how a client makes a commitment to follow through on a plan. If the client says, "If you want me to do this, I'II do it for you," a Rogcrian or S3 therapist might respond, "If you want to do it, don't do it for me, do it for yourself." Glasser and Zunin (1979) found in working with R I and R2 clients that 

to ask people to make commitments for themselves is often too much to ask. This ideal might be realized at the end stage (R4) but is unrealistic at the initial stage (R I or R2). Therefore if a patient says to a reality therapist, "I'll do it for you," the reality therapist, in the early and intermediate stage of therapy, will respond favorably and positively. (p. 322)
In effect, the principles of ACT theory seem to have been imbedded in the theory and practice of all effective therapists, whatever their theoretical persuasion. One is reminded of the research of Fiedler (1950, 1951), who discovered that experienced therapists behaved in much more similar ways than their theoretical affiliation or self-report of their behavior would have predicted. We contend that such therapists have in common an intuitive understanding of the ACT model, the adherence to which makes them more like than unlike one another. In working with clients, one tends to do "whatever will work," and good therapists from all persuasions tend to do similar things when confronted with similar client problems.

     We move now to considerations of the remaining quadrant, S1. The most actively directive quadrant, SI has developed largely from need. Earlier therapies that required clients to assume responsibility simply were not successful with clients who could not do so.
 

SI: High Directive Behavior/ 
Low Supportive Behavior

     Two psychotherapeutic approaches associated with high direction and low support as their dominant style are some of the operant behavior therapies developed by B. F. Skinner, among others, and Albert Ellis's Rational-Emotive Therapy. Both have been substantially involved in the seemingly unending dispute over which approach is the best approach. Ellis (1979) refers to less directive and higher support styles as "indulgence therapy" (p. 295), and feels they are much less efficient than the "highly cognitive, active-directive, homcwork-assigning and discipline-oriented therapies like RET" (p. 86).

     SI behaviorists seem to say in effect, "give me control over a relevant array of reinforcers and I can build behavior changes by the clients. We don't even need to like each other." When various kinds of power in therapy are considered in Section 5, it will seem that from an ACT viewpoint, in order for S I to be the dominant style, significant external motivation and reinforcers are necessary. Two examples are "You don't eat until you comb your hair, and I have control over the only food source" and "When you perform this task I want you to do, you will get X as a reward." Whether pellets from a Skinner box, or pieces of candy in toilet training, the use of rewards and sanctions that are external, but relevant to the client, are necessary to move behavior in the desired direction. S I involves the use of primarily direction-oriented therapist behaviors. external rewards and punishments, and low emotional affect from the therapist. Thus, saying, "I'm not angry at you or punishing you by instructing you to make your bed before you will be served breakfast. Making your bed is a part of your responsibilities as a member of this group (family or otherwise). Here's how to make the bed. Step I ... and so forth," is an unemotional straightforward emphasis on direction.

     It is clear why behavioral approaches, be they S like Skinner's, or inclusive of more support as in S2, have been extremely helpful in institutional settings, where the residents or inmates may be both unwilling and unable to take care of themselves. The ACT model would predict that, unless those behaviors are internalized (i.e., the client becomes a willing and able R4), as soon as the controls on the contingencies are removed the new behavior will stop. Prisons or substance abuse programs frequently have revolving doors, because the client is clean or dry while access to a weapon or drug is externally controlled; but as soon as the environmental controls are lifted, the old problematic behavior returns. The implications of employing Sl behavior with clients, suddenly followed by S4 behavior, will be discussed in Section 5.

     A less institutionalized example of S I behavior occurs thousands of times daily in America. Many people weigh too much, so they vow to go on a very strict, structured diet. All the foods for each meal are prescribed-or even prepackaged. The cupboard is emptied. It is even better if they have paid a lot of money for this program to increase the negative reinforcement for not sticking to their avowed goal-to lose 30 pounds. Often, unless people are bolstered by social and self-support, they may go off the diet within a few days or a few pounds. If they stay with the diet for the full loss of weight, unless they have discovered satisfaction in their new habits, dieters may reward themselves for reaching the weight loss goal with a food orgy at some favorite restaurant, thereby beginning the destructive cycle again. Many people have lost and regained thousands of pounds over their adult lives. In the ACT developmental cycle, unless the R I client is moved systematically through the cycle to R4, the environmental structure and social support must be maintained. An analogy can be found in child development, where no reasonable parent would require behavior from a child that was not developmentally age-appropriate. One does not tell a 10-year-old to make family financial decisions or to drive the car to the grocery store.

     Ellis conceptualizes RET as a high direction/ low support theory, and seems to be partially reacting to analytic and humanistic forces and partially reflecting his own personality style. Ellis (1979) employs a fairly rapid-fire, active-directive, persuasive-philosophic methodology in working through a client's faulty cognitions or irrational beliefs. In the end, the client has adopted a rational emotive cognitive set by which to interpret his internal and external world. ACT would predict the presence of considerably supportive behavior from the RET therapist as the adoption of the rational belief system by the client proceeds. Psychoanalytic writers see Ellis in their own terms as mitigating the influence of the superego by giving the client a new superego. These psychodynamically inclined thinkers compare what Ellis does to religious conversion. "Some preach the 10 commandments, Ellis preaches the I I Irrational Beliefs.... The priest says 'Stop masturbating.' Ellis says 'Stop Musturbating' (Arlow, 1977, p. 4).

     It is possible to incorporate Ellis's ideas without adopting his style. The ACT model would contend that (1) Ellis's S1 RET approach would match clients in R1 by bolstering their confidence and providing a specific, structured framework and (2) clients at more mature levels would not remain long with an S1 therapist. No one who can control his or her own behavior enjoys being controlled. S1 therapy is, in fact, best used with persons who have never developed, or have temporarily lost, control over their behavior.

     Howard, G. S., Nance, D. W., & Myers, P. (1986). Adaptive counseling and therapy: An integrative, eclectic model. Counseling Psychologist, 14, 372-377