When asked to design a course on advanced counseling and psychotherapy for Wilmington College's new Certificate of Advanced Study in mental health counseling, I felt both excited and overwhelmed by the range of choices. Mental health counselors charged with developing new courses and those who want to create and offer workshops in this field face a similar task.

The first step is knowing your course or workshop audience, and what their needs are. I have been a program assistant and part-time counselor educator in the CACREP-approved M.S. in Community Counseling (MSCC) program at Wilmington College since 2004, and I believed I had a pretty good feel for our students. Through my active participation in the newly resurrected Delaware Mental Health Counselors Association and Delaware Counseling Association, I was becoming familiar with the wants and needs of professional counselors in the region as well.

Still, designing such a course felt daunting. What would we cover? Advanced theory? Specific techniques? I wanted to avoid turning the course into "CBT 202" or some other modality-oriented technicians' workshop. There are already a plethora of these kinds of training opportunities, from beginner-level to advanced, available to counselors.

There was also the question of distinguishing (if that is possible) between "advanced counseling" and "advanced psychotherapy." The reputed difference between the two activities is a debate that has raged for decades; I decided early on that it would not be productive to engage in this debate. It seemed clear to me that both rely on the same theoretical and practical foundations. Years ago, when strict psychoanalytic treatment was the only "true" form of therapy, psychotherapy meant digging "deep" into the personality or psyche, whereas counseling was humanistic, problem-focused, and more present-centered.

In an age when cognitive therapies predominate in almost all counseling and psychology programs, and when even psychodynamically-oriented clinical psychologists recognize the importance of an integrative, here-and-now ego-psychological approach to therapy, this debate seems all but ended.

Determining What to Teach

When in doubt, I usually turn to research, and in this matter the research seemed clear: Focus on the relationship, and then the relationship, and finally, the relationship. The future belongs to those counselors who focus on establishing strong therapeutic alliances and then proceed with an integrative, prescriptive approach.

Interestingly, I found a relative scarcity of texts that venture significantly beyond restating the classic Rogers-Carkhuff-Truax mantras on empathic listening, understanding, and unconditional positive regard. I found myself being directed along two related but different paths.

Ironically, one of those paths led me away from traditional counseling sources to the work of Paul Wachtel, a psychodynamically-informed psychologist who is well-known in the psychotherapy integration movement. His 1993 book, Therapeutic Communication: Knowing What to Say When seemed a perfect match for this class. It is rich in theory, but more importantly packed with detailed examples and commentary on how to communicate effectively and with deep empathy. In explaining why one particular way of wording a comment is superior to another, or why timing really matters, Wachtel harkens back to earlier works on microcounseling skills, but in a much more psychologically complex framework.

Wachtel's concept of "cyclical psychodynamics" (an ego-psychological revision of Freud's "repetition compulsion") dovetailed nicely into my second path. To be deeply empathic, counselors need to be deeply understanding. To deepen students' understanding of client dynamics, I resurrected two oft-forgotten but highly useful (and entertaining) concepts from transactional analysis (TA): thinking "like a Martian," and the "life script." I started this course with a brief review of basic TA theory, focusing especially on game theory and how scripts are formed and (re)enacted.

To illustrate thinking "like a Martian," I asked the class to read Horace Miner's classic work of cultural anthropology, "Body Ritual Among the Nacirema," an illuminating but hilarious exposition of American bathroom culture and mores in the 1950s. Students also watched-and discussed from the "Martian" point of view-several films with fairytale-like structures (for example, Magnolia and The Neverending Story).

Finally, to underscore this integrative psychotherapy approach, students were also required to read Escape from Babel: Toward a Unifying Language for Psychotherapy Practice by Scott Miller, Barry Duncan, and Mark Hubble. To assist with future self-supervision, I strongly recommended reading Doing Better: Improving Clinical Skills and Professional Competence by Jeffrey Kottler and W. Paul Jones.

Reaching Professionals Who Are Students

To better accommodate working professionals, Wilmington College has long relied on weekend modular courses. I taught this course during the summer over three weekends (Friday night and all day Saturday) spaced three or four weeks apart. The format lends itself excellently to the use of films, role plays, and video critiques that are interspersed with lecture.

On the second Friday night, the class witnessed a role-play involving a student in the role of a client with a real problem and the instructor (me) as the therapist. A written case history circulated to the class prior to the role-play set the stage for this role-play being a third or fourth session rather than an initial intake (necessary to illustrate Wachtel's communication principles). The role-play was videotaped and we spent approximately half of Saturday's class scrutinizing the session in great detail.

We discussed the interchanges one at a time, concentrating on the rationale for what I did or said, the subtle nuances, and possible alternative interventions. I encouraged student speculations about counter-transference when my own material was injected into the session, which in turn led to a long discussion of how to use self-awareness as a self-supervision tool. When a therapist is aware of his or her own issues and triggers, counter-transference reactions can be valuable clues to discerning underlying dynamics, including the beginnings of "therapy games." The time seemed to fly.

In between the second and third weekends, students conducted their own videotaped sessions and were required to write a thorough critique based on what we covered in class to date. During the third weekend, we reviewed a selection of these student projects, and went to the last phase of this class: a discussion of the stages of change model (Prochaska & DiClemente, 1984) along with how therapists might enhance a client's motivation to initiate new behaviors ("experiments") in and outside of the counseling hour to facilitate change.

We also considered the well-worn but radical notion that "resistance" does not really exist, but is instead a combination of counter-transference and bad timing on the part of the therapist. "Resistance" is a term that is applied to explain a therapist's inability to get what he or she wants in a session, or a client. (For a quick list of strategies for advanced counselors, see page 12.)

To make the course appeal to both students and professionals, it was offered for either regular graduate school credit or as an audit for CE credits. Since the college is an NBCC-approved provider of continuing education, professionals who attended the entire class earned 30 CEs, enough to satisfy 75 percent of many states' license-renewal requirements in one fell swoop.

Here are some strategies for the advanced mental health counselor:

• Learn to think in "Martian." Eric Berne, the inventor of transactional analysis, believed that we could unlock most of the mysteries of human psychodynamics if we learned to observe people like wizened ethnographers (or Martians who visited Earth). Reading Berne's 1964 classic, Games People Play and his last book, What Do You Say After You Say Hello? are excellent introductions to what Wachtel later referred to as "cyclical psychodynamics," the tendency people have to engage in repetitive patterns of behavior.
  
• Rather than focus on the suffering caused by cyclical psychodynamics, counselors should look carefully at what the client is attempting to accomplish, and confirm the validity of these goals while gently inquiring about alternative means for achieving them.
  
• In the end, it is always the relationship. New techniques and modalities are exciting to learn and practice, but the relationship is always the bottom line. Without a solid therapeutic relationship, everything crumbles. Most confrontations and all "lectures" to clients are the result of countertransference and are unproductive.
  
• Providing a corrective emotional experience in therapy is more important than insight.
  
• Timing is (almost) everything. The goal of confrontation and interpretation is not to generate anxiety, but to provide clients with the opportunity to face, experience and master their anxiety.
  
• To achieve anything, we must engage our clients, and to engage them we need to have their attention and involve their imagination.
  
• Avoid accusatory interpretations; work on interpretations that imply permission. Example: Rather than "I think you're silent because you're trying to hide a lot of anger," say "I have the sense that you're angry but feel you're not supposed to be." The latter statement carries a much clearer implication that it is all right to be angry.
  
• Phrases like "at least" or "even more" can help clients see their self-destructive behaviors in a more balanced light. For example: "Having affairs with unavailable men at least allows you to practice being intimate without the risk of actually losing your sense of independence,"
  
• Rather than confront the negative, respond to the positive aspects of a client's defense. For example, (to a client who does not take credit for her improved work performance), rather than saying "You say that as though you had nothing to do with it," say "You did something to get that response, I wonder what it was?"
  
• Do not give "homework assignments," but rather invite clients to conduct an experiment. There are no "failed" experiments; whatever the results, we gain additional information. If a client does not follow through on an experiment, it is probably because the therapist's timing was off (as opposed to "resistance").
  
• Become familiar with the "stages of change," and consider only those interventions that are appropriate to a particular stage. Do not attempt action-oriented interventions when a client is in the Contemplation stage; behavioral interventions are most appropriate in the Action stage.
  
• "Resistance" is a term used primarily to place the responsibility for breaks in empathy (or interventions that are poorly timed) on clients. Studying motivational interviewing and Ericksonian hypnotherapy strategies can help therapists learn to "roll with resistance."