Adler's contributions to mental health included several levels of intervention. While the art of psychotherapy was his primary work, he also had a major impact on the field of education in efforts to prevent psychological disorders (Adler 1957). Adler started by training parents, but realized that in order to reach the majority of children he needed to switch his focus to teachers. In Vienna he spent a great deal of time lecturing to teachers and demonstrating how to understand and influence children. In addition, he was asked to establish child guidance clinics attached to the schools throughout Vienna. He saw prevention through education as the first level of intervention and as a great investment in the future. Continuing in these efforts, many of Adler's followers simplified some of the ideas for use by teachers and parents (Dreikurs and Soltz 1964; Dreikurs and Grey 1968), thus furthering Adler's influence.
The next level of intervention is counseling. Adlerian counseling is generally time-limited, supportive therapy that is usually focused on specific problems. It leads to moderate insight, attitude change, and behavioral change. Anthony Bruck, an associate of Adler, developed brief counseling to a fine art, including the use of explanatory graphics and charts (Bruck, 1978). Examples of the focus of counseling include parenting, marital relationships, and career choice and development. These interventions can help individuals cope with developmental milestones, life crises, and change points in their lives. The potential for personality change at a deep level, however, lies in psychotherapy.
The overall goal of Adlerian psychotherapy is helping an individual develop from a partially functioning person into a more fully functioning one. Fully functioning means solving each of the areas of life more cooperatively, more courageously, with a greater sense of contribution and a greater sense of satisfaction. To do this, an individual must identify and work toward becoming her best self. In other words, the overall goal of therapy is to increase the individual's feeling of community. This is very practical. It is not merely a matter of gaining insight, but of using that insight to take concrete steps to improve relationships with family, friends, community, and work. In its largest sense, the goal of therapy is not to improve just the client's life; the therapist is working to improve the quality of life for everyone in the client's circle of contact, as well as improving society through the client.
Thus, the first specific goal of therapy is not necessarily fulfilling the client's expectation. The client may want instant, and somewhat magical, relief of symptoms or to continue what he is doing without feeling so uncomfortable. The therapist has to be sympathetic to this desire, but must clarify and establish, as quickly as possible, the cooperative working relationship that is required for genuine improvement of a difficult situation.
Adler suggested that we must provide a belated parental influence of caring, support, encouragement and stimulation to cooperate. By reawakening courage and creativity in the client, a new, unfamiliar feeling of community may develop as he discovers that he has something valuable to offer. Some people have been cared for in a mistakenly indulgent way and have absorbed it, but they have not learned to feel or express a genuine caring for others. These people, although they need to be cared for in a new encouraging way, also need to be challenged to start caring for others in this new way.
For teaching purposes, Adlerian psychotherapy can be divided into twelve stages, and within each stage, cognitive, affective, and behavioral changes are gradually promoted (Stein, 1990). At the last three stages, the spiritual domain can also be addressed. The stages reflect progressive strategies for awakening a client's underdeveloped feeling of community. What we must remember, however, is that the actual therapy is very spontaneous and creative and cannot be systematized into steps to which we rigidly adhere. Empathy and encouragement, although emphasized at certain points, are present in every stage of effective psychotherapy. A highly abbreviated overview of the twelve stages follows [The stages were suggested by Sophia de vries who studied with Alfred Adler. They were then developed by Henry Stein].
The initial therapeutic goal is to help the client become a more cooperative person, and this starts with learning to cooperate in therapy. When the client's cooperation is lacking, the therapist can diplomatically point to this. If the client attempts to endorse full responsibility for change to the therapist, the therapist can suggest that the rate of progress will depend on the degree of cooperation between them. Therapists may help in the discovery of some new helpful ideas, but the ideas must be applied to improve a situation. Initially, the client may need to express a great deal of distress with little interruption. In response, the therapist offers genuine warmth, empathy, acceptance, and understanding. To understand the uniqueness of each client, the therapist must be able to "stand in the shoes" of the client and "see and feel" what the client is experiencing. If the client is feeling hopeless, the therapist must be able to feel the client's hopelessness without feeling sorry for her, but then step back and provide hope for change. Thus, the therapist must be able to come close enough psychologically to the client in order to empathize, but withdraw neutrally at some point in order to generate hope and discuss possible improvements. An atmosphere of hope, reassurance, and encouragement enables the client to develop feeling that things can be different.
The therapist gathers relevant information: the presenting problem and its history, the client's level of functioning in the three life tasks, information about the family of origin, early memories, and dreams. Religious and cultural influences may also have significance. When appropriate, intelligence, interest, and psychological testing are included.
The information given always contains a degree of distortion, as well as significant omissions. After studying the parallel patterns of childhood and the present and analyzing the rich projective material in early recollections and dreams, the therapist develops preliminary hypotheses about the inferiority feelings, goal, life style, private logic, and antithetical scheme of apperception.
Socratic questioning clarifies the client's core beliefs about self, others, and life. Then the consequences of these beliefs are evaluated and compared with new possibilities. Mistaken ideas and private logic are corrected to align with common sense. The client's ideas must be unraveled to trace how she first adopted them in childhood. A client may have the idea that if his wife doesn't give him what he wants, then she doesn't love him. The therapist might ask a series of questions to illuminate the private logic behind this statement: "Is it your idea that love is only giving you what you want? What if what you want is no good for you? Should your wife give you what is unhealthy for you? Is that really being loving?" These questions will help the client explore the meaning he gives to love and marriage and may come to change his private views of these matters.
Symptoms may serve as excuses for avoiding something that the client is not doing. One way that the therapist can ferret this out is to ask the question: "If you did not have these symptoms, what would you do?" The client's answer is often quite revealing about what she is avoiding.
The therapist cannot give clients courage; they must find it within themselves. The therapist can begin this process by acknowledging the courage in what the client has already done: e.g., coming to therapy. Then therapist and client together can explore small steps that, with a little more courage, the client might take. It is through actually trying new behaviors and realizing that disaster is not an inevitable consequence that the client's courage grows.
Clients may have exaggerated inferiority feelings that they want to eliminate totally, believing that if they realize their goal these painful feelings will disappear. The therapist must first reduce these feelings to a manageable level and then convince the clients that normal inferiority feelings are a blessing that they may "use" as a spur for improvement.
Genuine self-esteem does not come from the approval or praise of others. It comes from the person's own experience of conquering difficulties. Therefore, small progressive action steps, aimed at overcoming previously avoided difficulties, must be taken, one at a time. For many clients, this is equivalent to doing the "felt impossible." During and after these steps, new feelings about efforts and results are acknowledged and discussed.
In attempting to avoid failure, discouraged people often decrease their level and radius of activity. They can become quite passive, wait for others to act, and limit their radius of activity to what is safe or emotionally profitable. Gradually, the level, radius, and quality of a client's activity must increase. A move in the wrong direction is often a necessary first step which can then be corrected after commending the attempt. Without new activity and experimentation there will be little real progress. Some new success must be achieved to prepare for the next stage.
Psychological movements are the thinking, feeling, and behavioral motions that clients make in response to the external tasks facing them. Thus, in addition to listening to what the client says, the therapist must be attuned to what the client actually has done and currently does in relation to life tasks. Movements in therapy are the most visible. Does the client come on time or late; get off the track; talk all the time and leave little opportunity for the therapist to say anything; agree with everything but "forget" to put it into practice between sessions? The therapist's job is to describe these movements precisely and help the client identify the immediate goals or final goal to which they lead.
Depreciation and aggression are tactics clients use to elevate artificially their self esteem and punish others for not living up to their mistaken expectations. Clients are often quite clever in adopting the weapon that will hurt others the most. The therapist must show the client how ineffective or childish the weapons are or that they eventually hurt the client more than they hurt the intended victim.
To dissolve the client's antithetical scheme of apperception, the therapist must dialectically question it. However, the client will probably resist this dialogue because the scheme provides certainty and supports the pursuit of the childlike, egocentric, final goal. Clients' final goals represent visions of what they imagine will help them feel absolutely superior, safe, significant, and secure. When faced with changing these final goals, the alternative often looks like being nobody, worthless, and vulnerable. The client's scheme uses cognitive rigidity to generate very strong feelings. It locks the client into a dichotomized, superior/inferior way of seeing the world, evaluating experiences, and relating to others. Thus, to dissolve the antithetical scheme of apperception, the therapist must help the client see the real and subtly distinguishing qualities of people and experiences rather than dividing impressions into "either-or," rigidly absolute categories.
All behavior is purposive and is aimed at moving toward the final goal. If clients have goals that are on the useless side of life, then their emotions will also serve these goals. Frequently, emotion is used to avoid responsibility for actions. This is reflected in the often-heard claims of the client: "He made me angry; I couldn't help it." Each individual's use of emotions is unique, and the therapist must be sensitive and precise in identifying the underlying purposes of these emotions.
The final goal includes expectations of the roles that others should play. If the final goal is to be adored, then others must play the role of adorers; if the final goal is to dominate, then others must be submissive. The therapist must help the client identify these expectations and their actual impact on relationships. Rather than having such demands of others, clients need to learn how to generate self-demand, determining what they will do to contribute to their own development and to other people and situations.
After unfolding the meaning of the client's movements and their immediate goals, the therapist eventually leads to interpreting the core dynamics of the client's inferiority feeling, final goal, and style of life. Family constellation and experiences, current behavioral patterns, early recollections, and dreams are integrated into a unique, vivid, and consistent portrait.
In revealing the client's goal, diplomacy, good timing, and sensitivity are essential. The client must feel the encouragement of new successes before she will feel open and ready to face a clear picture of the mistaken direction she had previously followed. The therapist helps the client evaluate the goal and discover what is really gained or lost in this pursuit--using logic, humor, metaphors, reduction to absurdity, and what Adler called "spitting in the soup." In this last strategy, the therapist makes the final goal -- e.g., being powerful, intimidating, and demanding respect -- "taste bad," perhaps by comparing it to being a Mafia don. The discussion around the client's final goal reflects a very vigorous form of thinking about the meaning of life and what the client is doing with it and what else he could or should be doing.
Previously, the client relied on the therapist to interpret her movements and their connection to the life style and goal. Now the client interprets situations, sharing his or her insights with the therapist. Many clients are tempted to terminate at this point, feeling that they know enough, even though they have not actually applied their insight and changed their main direction in life.
Some clients cling to strong negative feelings through powerful images and memories from childhood. These feelings may inhibit or poison their contact with people. Others may lack a depth of positive feeling in their work and relationships. They try to do "the right thing" but do not have a feeling of enjoyment or affection in the process. They may have sufficient insight but not have enough positive emotional anticipation to take new action. While it is possible with some clients to promote change through cognitive interpretation, with others an emotional breakthrough is more effective. The therapist can use role-play, guided imagery, or eidetic imagery exercises to dissolve negative imprints from parents and siblings and replace them with new nurturing, encouraging experiences and images. Ongoing groups, or one-day group marathons are preferable for role-playing techniques, utilizing group members for the parental or sibling figures. Longer individual sessions can also be effective.
Insight and newly found courage are mobilized to approach old difficulties and neglected responsibilities. Small, experimental steps are ventured in the main arenas of life. Initially, this is going to be hard for clients because they will not expect a positive feeling as a result of taking steps in a new direction. However, it is possible to start with what the person is willing to attempt and gradually make it more socially useful. A very aggressive person who verbally attacks others might be encouraged to attack his problems vigorously and productively instead.
Generally, all of the behavioral steps that clients are encouraged to take in therapy are directed toward increasing their level of confidence and changing their life style. However, profound change occurs after the client and therapist have together identified and discussed the client's final goal and life style. On the basis of this insight, then, the client can work to change the main direction of movement and approach to the three main tasks of life (community, work, and love).
Most of the client's actions have been egocentric, providing imagined protection or self-enhancement, and neglecting the needs of others. The therapist helps clients learn to let go of themselves and focus on others, on tasks, and the needs of situations.
All of these new positive actions are encouraged and supported. As the client begins overcoming major difficulties that had been previously avoided, courageous efforts, good results, and feelings of pride and satisfaction are affirmed. As a result, the egocentricity gradually dissolves. Emotional coaching may be needed to experience and express the new positive feelings.
The therapist's feeling of community has been demonstrated to the client continuously, since the very first meeting, by accepting him unconditionally as a fellow human being, expressing a deep interest through listening and concern for his distress, and indicating a willingness to help. Perhaps skeptical of the therapist's good will at first, the client has felt and appreciated the genuine caring and encouragement.
The conquering of obstacles has generated courage, pride and a better feeling of self, which now leads to a greater cooperation and feeling of community with the therapist. This feeling should now be extended to connect more with other people, cooperate with them, and contribute significantly to their welfare. As the client's new feeling of community develops, she will become motivated to give her very best to her relationships and her work.
When the client begins to let go of an old goal and life style of self-protection, self-enhancement, and personal superiority over other people, he experiences a temporary feeling of disorientation as a new horizon opens up. Now, after exploring and experimenting, he may adopt a new, conscious life goal that is inspiring and socially useful. He abandons his former direction and pursues the new one because it yields a more positive feeling of self and greater appreciation from others.
Clients constantly observe their therapists and may use them as positive or negative models. How therapists behave is critical, as it may interfere with the therapy process if clients see that their therapists do not embody what they are trying to teach the clients.
Maslow explored the characteristics of many fully functioning people and concluded that what we usually refer to as "normal" or "average" functioning is actually a commonly accepted form of very limited psychological development. He set the standard of psychological health many notches higher than the benchmarks of most of his contemporaries. Adler and Maslow were in agreement on this issue, which was not to set our therapeutic sights merely on the "normal" or "average," but to aspire to the ideal of what people could become. Not many clients may be willing to reach this far -- but some will be interested, and the therapist should be prepared to facilitate this journey.
As clients improve, the therapist can help them see that they can use new, more liberating and inspiring guides for their lives. These alternative guides are what Maslow called meta-motivation or higher values -- e.g., truth, beauty, justice (Maslow 1971). The values that individual clients choose will depend on their unique sensitivities and interests.
The client has learned to love the struggle of overcoming difficulties, now prefers the unfamiliar, and looks forward to the unexpected in life. Feeling equal to others, and eager to develop fully, she expresses a spirit of generosity and wants to share what she has accomplished. Now the client can become a generator of encouragement to other people.
Feeling stronger and functioning better, the client may need a self-selected challenge to stimulate the development of his best self. The very best in a person does not simply flow out, but is a response to a healthy self-demand. It may be stimulated by an unexpected situation or a chosen challenge. The therapist may prompt the search for such a challenge and can help the client evaluate what would be a worthy, meaningful, stimulating, and socially useful challenge -- one that is neither too big nor too small for the client's capabilities. For some clients, it may be the recognition of a "mission" or "calling" in their lives.
The creative freedom inherent in Adlerian practice demands a variety of strategies that suit the uniqueness of each client and capture the spontaneous therapeutic opportunities the client hands to us in each session. Although the twelve stages represent a conceptual center line of treatment, essentially, a unique therapy is created for each client. The specific techniques used at any one time depend on the direction that seems currently accessible. Four main strategies characterize current Classical Adlerian therapeutic technique: assessment, Socratic questioning, guided and eidetic imagery, and role-playing [These strategies are rooted in the original Adlerian treatment style and are enriched by the contributions of Sophia de Vries, Alexander Müller, and Henry Stein].
Assessment. A thorough life style analysis serves as the guide to the therapeutic process; generally this occurs during the first three stages of treatment. A central technique that Adler pioneered to assess life style is the projective use of early memories (Adler 1933). These memories, whether they are "true" or fictional, embody a person's core beliefs and feelings about self and the world. They contain reflections of the person's inferiority feelings, goal, scheme of apperception, level and radius of activity, courage, feeling of community, and style of life.
In addition to these early memories, the therapist uses the following to do the assessment: (1) description of symptoms, the circumstances under which they began, and the client's description of what he would do if not plagued with these symptoms; (2) current and past functioning in the domains of love relationships, family, friendships, and school and work; (3) family of origin constellation and dynamics, and extended family patterns, (4) health problems, medication, alcohol, and drug use, and (5) previous therapy and attitude toward the therapist. While much of this information can be collected in the early therapy sessions, it can also be obtained by asking the client to fill out an Adlerian Client Questionnaire (Stein 1993). This permits the client to answer in detail many important questions and increases the client's level of activity in the therapy process. In addition, it saves some therapeutic time and enables the therapist to obtain a binocular view from both the client's written and verbal descriptions.
Socratic Questioning. The Socratic method of leading an individual to insight through a series of questions lies at the heart of Adlerian practice (Stein 1990; Stein 1991). It embodies the relationship of equals searching for knowledge and insight in a gentle, diplomatic, and respectful style, consistent with Adler's philosophy. In the early stages of psychotherapy, the therapist uses questions to gather relevant information, clarify meaning, and verify feelings. Then, in the middle stages of therapy, more penetrating, leading questions uncover the deeper structures of private logic, hidden feelings, and unconscious goals. The therapist also explores the personal and social implications of the client's thinking, feeling, and acting, in both their short and long term consequences. Throughout, new options are generated dialectically, examined, and evaluated to help the client take steps in a different direction of her own choosing. The results of these new steps are constantly reviewed. In the latter stages of therapy, the Socratic method is used to evaluate the impact of the client's new direction and to contemplate a new philosophy of life. The Socratic style places the responsibility for conclusions and decisions in the lap of the client. The role of the therapist is that of a "co-thinker," not the role of a superior expert. Just as Socrates was the "midwife" attending the birth of new ideas, the Adlerian therapist can serve as "midwife" to the birth of a new way of living for a client.
Guided and Eidetic Imagery. For many clients, cognitive insight and new behavior lead to different feelings. Some clients need additional specific interventions to access, stimulate, or change feelings. Guided and eidetic imagery, used in an Adlerian way, can lead to emotional breakthroughs especially when the client reaches an impasse. Eidetic imagery can be used diagnostically to access vivid symbolic mental pictures of significant people and situations that are often charged with emotion. Guided imagery can be used therapeutically to change the negative imprints of childhood family members that weigh heavily on a client and often ignite chronic feelings of guilt, fear, and resentment. These techniques are typically used in the middle stages of therapy. Alexander Müller recommended the use of imagery when a client knew that a change in behavior was sensible, but still didn't take action (Müller 1937). Some clients need a vivid image of themselves as happier in the future than they presently are, before they journey in a new direction that they know is healthier.
Role-Playing. In the middle stages of therapy, role-playing offers clients opportunities to add missing experiences to their repertoire, and to explore and practice new behavior in the safety of the therapist's office. To provide missing experiences -- e.g., support and encouragement of a parent -- a group setting is recommended. Group members, rather than the therapist, can play the roles of substitute parents or siblings. In this way, a client can engage in healing experiences and those who participate with him can increase their own feeling of community by contributing to the growth of their peers. When learning and practicing new behaviors, the therapist can offer coaching, encouragement, and realistic feedback about probable social consequences. This is somewhat equivalent to the function of children's play as they experiment with roles and situations in preparation for growing up. Clients need to be treated with gentleness and diplomacy, yet offered challenges that strengthen their confidence and courage.
Adlerian psychotherapy is an art, not a science, and must be practiced with the same integrity of any artistic endeavor. Though it is based on theory, philosophy, and principles, its practice must come honestly from the heart. It is not a mere technology that can be practiced "by the numbers," nor is it bag of tricks that can be added successfully to an eclectic pile of value-free tools.
The uniqueness of each client requires constant invention. Similarly, the personality of each therapist makes his or her approach inimitable. However, as Adler himself (Hoffman 1994) and his followers demonstrated, the personality of the therapist must be congruent with the philosophy of the therapy [This comes both from personal knowledge of Sophia de Vries, Anthony Bruck, Alexander Müller, and Kurt Adler and the description of Lydia Sicher's work (Davidson 1991)]. Through a vigorous study analysis, an Adlerian therapist assesses and reduces to a manageable level his own inferiority feelings, identifies and redirects the final goal and style of life, and develops on all levels a strong feeling of community. In addition, the person struggles with the philosophical issues of life and engages with the study analyst in a search for higher values that would be most uniquely suited to that individual.