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Theories and Phases of Treatment Flashcards
Learn the Theories and Beginning, Middle, and End Phases of Treatment
INITIAL INTERVENTIONS
START WHERE THE CLIENT IS
How should the therapist proceed, what should the therapist do next, what should the therapist do first
If there is a quote or client makes a statement – look for the answer that responds to the quote
Safety first (if there is any hint of suicide, DV, HI, child abuse, regardless of theoretical orientation, address that first
Rule out things you wouldn’t do, then put them in order of what you would do first
INITIAL PHASE IS ABOUT BUILDING RAPPORT, TRUST, AND EXPLORING THE NATURE OF THE PROBLEM
Informed consent
Limits confidentiality
Treatment process – depending on orientation
Client motivation
What are reasons for coming (self-motivated vs. court mandate, referred by a spouse, ultimatum)
REFERRALS
If someone comes in complaining of depression AND medical condition (ex: insomnia) refer to MD or psychiatrist to rule out medical conditions
May also refer to holistic practitioner
Referrals that are relevant to what is happening to client are good initial interventions
Substance use problems should be referred right away
PSYCHOEDUCATION
Good initial intervention
Parents and /or kids
TEST
Pay attention to that first action word
If it’s an initial intervention stage, these are the things you do:
• explore
• identify
• support
• do not confront (this is actions phase)
• do not interpret (this is actions phase)
MIDDLE PHASE
ACTION PHASE OF TREATMENT Help client to change Confronting Challenging Teaching Practicing Modeling Match middle phase interventions with presenting problem Imagine being with your client and say “with this case I would do XYZ to address blah, blah, blah issues” More structure REFORMULATE THE GOALS IF NEEDED Due to no progress: • client not responding • address with client • talk about reformulating goals • initial goals may have been too broad or not the real issue REFER OUT For test, maybe you should refer out: • after consultation • after addressing with client • after working on goals CONFRONT For test, rule confronting out for initial phase, but this is a good option for middle phase You can confront just by calling attention to a client’s behaviors – bring the issue up Doesn’t have to be aggressive
TERMINATION
CAUSES AND SIGNS
Don’t want to see client if no longer benefitting from treatment
No longer having symptoms (symptom free)
Met goals (don’t necessarily have to be related to symptoms)
Maxed out their sessions (if referred by EAP, could advocate or ask for client to pay)
No progress
Already changing goals, changing approach, addressed with client, after consultation
Possibly refer out
But don’t abandon
Provide referrals – low fee clinics
If they clearly still need services, look for answers that make sure you provide adequate resources
Therapist leaves unexpectedly/premature termination:
• provide client with adequate referrals, appropriate for the clients
• process that experience with the client, a lot of clients haven’t had healthy relational terminations
SPACE TERMINATION OUT
Over the span of at least a month
SUMMARIZE
Work we’ve done
Reflect
Review client’s strengths
Review skills they developed in therapy
Practice skills in advance
They are welcome to come back to therapy
CRISIS ISSUES WHEN TERMINATING
Put termination on hold
This does not mean fearfulness or anxiety
Just normalize and address fears
TERMINATION AND THEORIES
Different theories have different goals and treatment models
CBT may be more comfortable with termination than psychodynamic
COGNITIVE BEHAVIORAL THERAPY - Beginning
(COGNITIVE BEHAVIORAL THERAPIES)
• Establish safe and supportive therapeutic relationship
• Complete a functional analysis to assess and define the problem and negative thought patterns
• Explore client’s situation (other areas, not just complaint)
• Educate and explain CBT
• Set collaborative goals
• Where are they having problems in their life: all areas, romance, friendships, family life, etc.; maybe they are strong in one area but not the other – transfer the skills to the other situation
COGNITIVE BEHAVIORAL THERAPY - Middle
(COGNITIVE BEHAVIORAL THERAPIES) • Identify negative thought patterns • Uncover negative schemas • Assign homework to self-monitor thoughts and moods and behaviors • Label cognitive distortions • Reframe thoughts • Learn and practice new skills and behaviors • Teaching coping skills
COGNITIVE BEHAVIORAL THERAPY - End
(COGNITIVE BEHAVIORAL THERAPIES)• Review gains
• Identify skills learned
• Rehearse for new situations
• Anticipate future struggles
• A Cognitive-Behavioral therapist who assessed that a client was ready to terminate would not be reframing symptoms
BEHAVIORAL THERAPY
(COGNITIVE BEHAVIORAL THERAPIES)
In behavioral theory removing a negative stimulus (i.e., “negative reinforcement” where the negative reinforcer is the “requirement” of homework) is one way to increase the rate or presence of a desired behavior (i.e., doing the homework)
Positive reinforcements would be used by a purely Behavioral Therapist
Social or familial “learning” usually connotes Behavioral Therapy
Develop a list of behavioral goals with the family; help the parents set up a rewards chart to reinforce small, positive changes; help the parents develop better communication skills
Diversion techniques are a behavioral intervention
Graded tasks and assignments are a behavioral intervention
Scheduled activities are a behavioral intervention
Systematic desensitization is typically done by a behavioral therapist
• RATIONAL EMOTIVE BEHAVIOR THERAPY Beginning
(COGNITIVE BEHAVIORAL THERAPIES)
• Provide psychoeducation about REBT
• Identify underlying irrational thought patterns and beliefs and the resulting feelings and behaviors
• RATIONAL EMOTIVE BEHAVIOR THERAPY Middle
(COGNITIVE BEHAVIORAL THERAPIES)
• Once these underlying feelings have been identified, the next step is to challenge these mistaken beliefs
• In order to do this, the therapist must dispute these beliefs using very direct and even confrontational methods
• Ellis suggested that rather than simply being warm and supportive, the therapist needs to be blunt, honest, and logical in order to push people toward changing their thoughts and behaviors
• Clients are also encouraged to change unwanted behaviors using such things as meditation, journaling, and guided imagery
• RATIONAL EMOTIVE BEHAVIOR THERAPY End
(COGNITIVE BEHAVIORAL THERAPIES)
• Review progress made and apply learned skills to anticipated future struggles
• DIALECTIC BEHAVIORAL THERAPY Beginning
(COGNITIVE BEHAVIORAL THERAPIES)
• The client to move from being out of control to achieving behavioral control
• Mindfulness and distress tolerance skills are taught
• DIALECTIC BEHAVIORAL THERAPY Middle
(COGNITIVE BEHAVIORAL THERAPIES)
• Fuller emotional experiencing
• Support the client to learn to live
• Define life goals, build self-respect, and find peace and happiness
• They have stress tolerance at this point
• DIALECTIC BEHAVIORAL THERAPY End
(COGNITIVE BEHAVIORAL THERAPIES)
• Finding a deeper meaning through a spiritual existence
• Sometimes important to a client and sometimes not
• REALITY THERAPY Beginning
(COGNITIVE BEHAVIORAL THERAPIES)
• Create a therapeutic environment – both supportive and challenging
• Ask clients what they want from therapy
• Discuss direction of their lives
• Define the wants of the client
• REALITY THERAPY Middle
(COGNITIVE BEHAVIORAL THERAPIES)
• Explore choices client is making in current relationships
• Identify other possible choices
• Encourage client to focus on what they can control
• Formulate action plan for change
• REALITY THERAPY End
(COGNITIVE BEHAVIORAL THERAPIES)
• Review what client learned
• Plan for maintenance of new behavior
• CLIENT/PERSON-CENTERED THERAPY Beginning
(HUMANISTIC/EXISTENTIAL THERAPIES)
o NO PHASES OF TREATMENT
The therapist has no agenda
For test, be careful, there are no stages with client centered therapy; pick answers that focus on self-acceptance; doesn’t matter if its early middle or late phases
• CLIENT/PERSON-CENTERED THERAPY Middle
(HUMANISTIC/EXISTENTIAL THERAPIES)
o NO PHASES OF TREATMENT
The therapist has no agenda
For test, be careful, there are no stages with client centered therapy; pick answers that focus on self-acceptance; doesn’t matter if its early middle or late phases
• CLIENT/PERSON-CENTERED THERAPY End
(HUMANISTIC/EXISTENTIAL THERAPIES)
o NO PHASES OF TREATMENT
The therapist has no agenda
For test, be careful, there are no stages with client centered therapy; pick answers that focus on self-acceptance; doesn’t matter if its early middle or late phases
• GESTALT THERAPY Beginning
(HUMANISTIC/EXISTENTIAL THERAPIES)
o NO PHASES
No map of what to do – attention to here and now
• GESTALT THERAPY Middle
(HUMANISTIC/EXISTENTIAL THERAPIES)
o NO PHASES
No map of what to do – attention to here and now
• GESTALT THERAPY End
(HUMANISTIC/EXISTENTIAL THERAPIES)
o NO PHASES
No map of what to do – attention to here and now
• EXISTENTIAL THERAPY Beginning
o (HUMANISTIC/EXISTENTIAL THERAPIES)
NO DISTINCT PHASES OF TREATMENT
• EXISTENTIAL THERAPY Middle
o (HUMANISTIC/EXISTENTIAL THERAPIES)
NO DISTINCT PHASES OF TREATMENT
• EXISTENTIAL THERAPY End
o (HUMANISTIC/EXISTENTIAL THERAPIES)
NO DISTINCT PHASES OF
• EXPERIENTIAL/SYMBOLIC THERAPY Beginning
(HUMANISTIC/EXISTENTIAL THERAPIES) Beginning • Engage family as authentic person • Battle for structure • Encourage all members to attend • Family wins battle of initiative • Gather information about boundaries, coalitions, roles and level of conflict
• EXPERIENTIAL/SYMBOLIC THERAPY Middle
(HUMANISTIC/EXISTENTIAL THERAPIES) Middle • Develop sense of cohesion • Create alternative interactions, even in sessions (if you say a dismissive parent, identify that another person has a different perspective) • Highlight inappropriate boundaries • Role play situations • Use play and “craziness”
• EXPERIENTIAL/SYMBOLIC THERAPY End
(HUMANISTIC/EXISTENTIAL THERAPIES)
End
• Highlight accomplishments and reflect on growth
• Identify possible block to future growth
• Role play future scenarios
• Each member expresses feelings about their experience of therapy
• NARRATIVE THERAPY Beginning
(POST MODERN THERAPIES)
• Client is invited to tell their Problem-Saturated Stories – the reason client is seeking therapy
• NARRATIVE THERAPY Early/Middle
(POST MODERN THERAPIES) • The problem is externalized • Mapping the influence/effects of the problem • Identify/explore unique outcomes • Re-author story • Enlist a witness
• NARRATIVE THERAPY End
(POST MODERN THERAPIES)
• Document and support new story
• Write letter to self and others
• SOLUTION-FOCUSED THERAPY Beginning
(POST MODERN THERAPIES) • Join with client competencies • Envision preferred future • Begin to identify client’s strengths • Use solution-oriented language • Come up with achievable goals • For test, always answer with solutions • Ask the Miracle Question
• SOLUTION-FOCUSED THERAPY Middle
(POST MODERN THERAPIES)
• Identify strengths, resources and traits client already has used to deal with problem
• Utilize solution-talk
• Identify exceptions to problems
• Utilize scaling questions to reflect on the nature of change the client has experienced
• Feedback to clients that include compliments and tasks
• Catch and highlight small changes
• Compliments/Cheerleading
• SOLUTION-FOCUSED THERAPY End
(POST MODERN THERAPIES)
• Assist client to identify things they can do to continue the changes they have made
• Identify hurdles or perceived barriers that could get in the way of the changes they made
• Help anticipate bumps in the road
• PSYCHODYNAMIC THERAPIES
(PSYCHODYNAMIC THERAPIES)
o MAIN IDEAS
Psychodynamic Theory focuses on insight connected to client past experiences and early childhood relationships
The interplay of client and therapist is important (transference and countertransference)
Psychodynamic approach is broad
Have the belief that people have unconscious motivations, drives, and processes and this impacts how they function
Look at unconscious process constructed by early childhood experiences, specifically with caregivers
When looking form this approach, you support client gaining insight to how they function in the world as it relates to early childhood experiences
Not just intellectual understanding but also the feelings and memories associated with self-understanding
Reliving past experiences with early caregivers
Staying with and exploring different situation form the past to what’s going on in current life (feeling neglected/not listened to)
The therapeutic relationship is the tool for healing
Countertransference and transference are important
Different emotional reactions to each client and vice versa
Focuses on interpretation (make meaning and make sense out of symbolism of language or play)
• OBJECT RELATIONS Beginning
(PSYCHODYNAMIC THERAPIES)
• Establish a holding environment
• Build rapport and therapeutic alliance through listening, exploration of client’s experience, empathy, and maintaining neutrality
• Create a safe environment
• Make clear boundaries (time; functional boundaries)
• Neutrality = still wanting to have a little distance between client (not much self-disclosure) ask them what it’s like to be in a relationship that’s a little lopsided
• OBJECT RELATIONS Middle
(PSYCHODYNAMIC THERAPIES)
• Promote insight and growth through interpretation
• Confront resistance and primitive defense mechanisms
• Focus on transference/countertransference dynamic
• Identify and process projective identification
• Different levels of interpretation:
o what’s going on with how they feel about others; imagine what client may have felt (ex: “my boss made me upset,” so, therapist puts words to what client may have experienced, for example, “dismissed”)
o Another level of interpretation would be to link to past experiences (ex: early child hood experience)
o Interpretation regarding therapist/client relationship (if client feels rejected by therapist); this is the most intense, so don’t do until there is a well-established relationship with client
• Confront (does not mean confrontation, it means more so bring the clients awareness up)
• OBJECT RELATIONS End
(PSYCHODYNAMIC THERAPIES)
• Work through termination and abandonment issues
• Consolidate interpretations
• Review insights gained in therapy
• A lot of times people haven’t experienced proper terminations of relationships
• SELF-PSYCHOLOGY Early
(PSYCHODYNAMIC THERAPIES)
• Establish a therapeutic holding environment
• Demonstrate that the therapist is able to provide containment
• If a client gets highly emotional, therapist can be a warm presence
• Therapist won’t get flooded or anxious
• Can tell therapist something and therapist can HOLD IT, calmly
• Provide “experience-near” empathy (stay with where client is – “sounds like you’re really struggling with …”)
• Don’t challenge right away
• Explore client’s problem and history (early childhood and relationships)
• SELF-PSYCHOLOGY Middle
(PSYCHODYNAMIC THERAPIES)
• Repair disruptions of the self-object transference (repair problems between therapist/client)
• Addressing enactments
• Empathizing with losses and blows to self
• Mourning loss of self-objects (loss of job, relationships, rejection, loss of not having a good mother, acceptance of loss and a sadness that’s allowed to happen, be able to cry for their young self)
• Mourning ambitions and fantasies (a lot of times these ambitions came into being as a defense, okay to mourn)
• Identify alternative self-objects (people they can talk to and be accepted by)
• SELF-PSYCHOLOGY End
(PSYCHODYNAMIC THERAPIES)
• Reflect on treatment process
• Acknowledge and process issues related to termination
• Put words to what experience is like to end that relationship
• Intense feelings can come up around termination
• DEPTH PSYCHOLOGY Beginning
(PSYCHODYNAMIC THERAPIES)
• Invitation and exploration of material the client brings to therapy, including relational situations, dreams, experience, imaginings, fantasies etc.
• DEPTH PSYCHOLOGY Middle
(PSYCHODYNAMIC THERAPIES)
• Placing client experience into a mythopoetic lens, looking at images, myth, story, imagination and archetypal patterns within the conscious and unconscious happenings of the client’s life
• Looking for meaning by orienting one’s experience into the greater human story
• DEPTH PSYCHOLOGY End
(PSYCHODYNAMIC THERAPIES)
• Integration of unconscious material often marked by acceptance of taboo subjects and previously discarded aspects of the personality (dark material)
• Acknowledgement of self-awareness and inner wisdom
• Acceptance of negative personal characteristics
• Adlerian Therapy Beginning:
(Psychodynamic Therapies)
• Establishing the Relationship: Adlerian therapists seek to make person-to-person contact with clients rather than starting with “the problem.” Therapists start by helping clients become aware of their assets and strengths. Completes assessment using early recollections, questionnaires, and family constellations exploration. Summary is shared with client. Focus is on dynamics that may have influenced the sense of self, inferiority and the world.
• Focus on personal goals
• Adlerian Therapy Middle:
(Psychodynamic Therapies)
• Encourage self-understanding and insight through interpretation. Clients are positively encouraged to overcome their feelings of insecurity through therapist’s optimism. Collaboratively explore ways in which client can feel more deeply connected in his social context. Support client to turn dysfunctional styles of life into more functional, socially beneficial ones.
• Encourage client to overcome feelings of insecurity
• Look at dysfunctional styles of life
Maybe explore changing goals (money to better dad)
• Adlerian Therapy End:
(Psychodynamic Therapies)
• Putting insights into practice. Encouraging clients to take risks with new behaviors to act as if they are the people they want to be.
• Get to a point of having a life interest of contributing socially as opposed to inferiority
• Attachment-based Therapy
(Psychodynamic Therapies)
• Attunement is the key intervention in the early stage and consists of forging of a personal relationship between the therapist and the patient. The therapist provides a secure base by reliably demonstrating empathy and care. Collaboratively identifying client’s “attachment style,” that is, problematic behavioral and emotional patterns, formed in early childhood as attempts to maintain attachment to primary caregivers.
• Attachment-based Therapy
(Psychodynamic Therapies)
• Disruptions are explored in the middle phase. Disruptions include those in the early life of the client as well as those in current relationships, including the relationship with the therapist. Support client’s ability regulate and express emotions in relationally difficult situations, teaching clients to have a reflective stance toward themselves.
• Attachment-based Therapy
(Psychodynamic Therapies)
• Repair occurs during the late middle phase and the end of treatment. Repair stage of the therapy aims to alter the patient’s current reactions to the events that cause them emotional distress by sharing their own interpretations of the event. By sharing their own subjective interpretation, the therapist helps create a new reality of the painful events for the patient in order to get rid of unwanted emotions and reactions.
• View different possibilities
• Give them different reposes to situations
o TEST: attachment is specifically focused on how they attach in their relationships, how they regulate their own emotional process, understanding how the client came to understand how relationships work
• General Systems Theory
(Systems Theories)
o Systems Approach
believes problems are a part of entire system and interactions between all the parts of the system (child misbehaving is misbehaving because it is supported by relationships in the system)
problem is everyone’s issue (the way the family is handling the stressors)
look at whole dynamic at play (family unit)
o Note: What it means to be a systems therapist
o Look at person and problem as imbedded in family system
o That person’s symptoms serve a function in relation to the family
o Can’t look at individual in isolation (born in to family with rules, expectations, strengths, weaknesses)
o TEST: answer that take into account the person’s relations with their family (scenario with an individual, but asks how you would work with the family)
o Looking at an individual in the context of that person’s family
Instead of looking at a single problem, look at how they relate to their system; how the family views the symptoms, and how the symptoms make sense in that family.
Possibly invite family into session
Interested in transgenerational rules and meanings
o Help person change their context and how they relate to the broader system
Increasing boundaries with parents
Become connect with other family members they haven’t had relationships with
o Using the system as an assessment of what the problem is and using the system as a solution to what the problem is
o Solutions based on who the people relate to their systems
o Homeostasis: a family finds a way of functioning that is predictable
How a family functions and finds its rhythm
Identified patient holds the family’s problems
When changes are made in the identified patient, the family will be disrupted until it finds a new functioning homeostasis
o Can also use and seek help through broader relationships (supports outside of the immediate family)
o Theory of Change:
Change occurs by helping the system view the family as the problem rather than an individual as the problem.
The family system becomes the focal point of therapeutic interventions.
o Role of the Therapist:
The therapist helps the family explore:
• Belief systems and family values.
• Rules and roles that are present in the family.
• The family hierarchy.
• Expectations
• Defense mechanisms and their purpose.
o Main Concepts:
Homeostasis: Systems tend to resist change and thus deal with issues by keeping things the same rather than dealing with problems.
• Maintained through negative feedback and input loops.
Negative Feedback: Behavioral reactions that correct a deviation of the system and return it to the previous state of homeostasis.
Positive Feedback: In an effort to maintain homeostasis, the system participates in new behaviors, which then creates and reinforces negative communication patterns and exacerbate the problem.
Calibration: The normal operational system of the family.
Wholeness: The whole system is combined of individuals.
• Each individual can have an effect on one another causing change to the whole system.
Equifinality: The same results can be accomplished by different family systems.
• Example: A man experienced the death of his mother when he was a young child, whereas a woman experienced the divorce of her parents when she was an infant. As adults, both of these individuals experienced Major Depression despite having different early experiences.
Equipotentiality: On the other hand, the same experience in a family system can end up with various results later in life.
• Example: Two siblings go through the same experience of being verbally abused when they were young. Later in life one sibling struggles with being in relationships whereas the other sibling struggles with Depression. Therefore, despite the same experience early on, different results occurred.
First Order Change: Change that happens within the family system but has no effect on the system, leaving it unchanged.
Second Order Change: Changes that do impact the family system and how it functions.
Non-Summativity: The family system is treated as a whole and not just each individual family member.
o Treatment Goals:
Move the system towards an equilibrium.
Assist clients in identifying conflicts that are currently affecting them.
Assist the family in exploring and recognizing defense mechanisms that help them deal with dysfunctional family behaviors or patterns.
o Interventions:
No Fault: Individuals are not blamed within the family system for existing problems.
• There is no “identified patient.”
Reframing: Conflict within the family is not accredited to a specific individual, rather the family system is the problem and thus the prime focus.
• Bowen Family Therapy Beginning
(Systems Theories)
• Create a family diagram of multigenerational emotional connections; assess individuals’ levels of differentiation and triangulation; identify dysfunctional patterns that have been passed along through the generations
• Bowen Family Therapy Early/Middle
(Systems Theories)
• Teach and model differentiation through communication skill building; detriangulation; encourage reunification from cutoff family member; teach the family how to take responsibility for their feelings and thoughts
• Teach people difference between thoughts and feelings and the difference between their own feelings and the feelings of others
• Show that the system is perpetuating the problem (parents did it to them)
• Bowen Family Therapy End
(Systems Theories)
• Review new skills and knowledge gained in therapy
• Strategic Family Therapy Beginning
(Systems Theories)
• Define the problem; determine how the client understands the problem; assess family’s destructive patterns of relating and communicating the continued problem; clearly state goals – what behaviors need to change and what would be the signs of change
• Cleary state the goals and what problem to eliminate
• Strategic Family Therapy Middle
(Systems Theories)
• Review attempted solutions; assign ordeals; prescribe the problem; relabel behavior; instruct client to respond to the problem in a new way
• Strategic Family Therapy End
(Systems Theories)
• Plan for maintenance of new behavior; plan for future challenges; emphasize positive changes made.
• Structural Family Therapy Beginning
(Systems Theories)
• Join with family;
• both accommodate to and challenge rules of family system;
• assessment/mapping of hierarchy, alignments, and boundaries;
• reframing of problem to include whole system
• Help family identify how they are creating the system ex: “well, dad doesn’t listen to mom, so how will kids listen”
• Structural Family Therapy Middle
(Systems Theories)
• Highlight and modify interactions; utilize enactments of issues to challenge participants and unbalance system
• Structural Family Therapy End
(Systems Theories)
• Review progress made; reinforce structural change; provide tools for future
• Satir/Communications Therapy Beginning
(Systems Theories)
• Establish rapport, a sense of equality and hope. Assess communication patterns, stances, and concerns. Identify treatment focus and goals.
• Family life chronology
• Satir/Communications Therapy Middle
(Systems Theories)
• Increase the family’s congruent communication. Support and strengthen each individual’s sense of uniqueness and self-esteem.
• Satir/Communications Therapy End
(Systems Theories)
• Help family practice, implement, and integrate changes and increase awareness of larger familial patterns
• COGNITIVE BEHAVIORAL THERAPY (COGNITIVE BEHAVIORAL THERAPIES)
o EVIDENCED BASED PRACTICE
Easy to study
Structured
Collaborative
Devise strategies to eliminate symptoms, thereby leading to change
o CLEAR TREATMENT PLAN
Start with functional analysis of thinking and behaviors
Thoughts and beliefs about the world contribute to behaviors and feelings
When people become clear on problematic thinking patterns, interventions help to alter automatic thoughts
For test, look for question addressing thinking patterns and beliefs
o THEORY OF CHANGE
Change occurs by learning to modify dysfunctional thought patterns and how people think about themselves and the world and the future
Once a patient understands the relationship between thoughts, feelings, and behaviors, s/he can modify or change the patterns of thinking to cope with stressors in a more positive manner and have more flexibility and options about their behavior and experiences
o ROLE OF THERAPIST
The therapist is a collaborative teacher who uses structured learning experiences that teach patients to monitor and write down their negative thoughts and mental images
The goal is to recognize how those ideas affect their mood, behavior, and physical condition
Teaching how to change thinking
Teach people how to prioritize treatment goals
Therapists also teach important coping skills, such as problem solving and scheduling pleasurable experiences
Work with client to determine where to start
The therapist creates structured sessions and provides homework for clients to continue to work on problems in-between visits
Focus on skill building
CBT is very structured
HW is big
o TREATMENT GOALS
Number one goal is to relieve symptoms
Patients learn to recognize negative patterns of thought, evaluate their validity, and replace them with healthier ways of thinking
Patients’ symptoms or problems are relieved
Patients develops positive coping skills and strategies for future problems too
A common Cog-B goal is exploring a client’s cognitive triad
Extinction is a goal
o MAIN CONCEPTS
Negative Cognitive Triad
• 1. View of self (“I’m not worth anything.”)
• 2. View of the world (“Everybody hates me.”)
• 3. View of prospects for the future (“There are no hopes for my future.”)
• These are the sources of people’s problems
• It is likely that a person’s cognitive triad is slanted towards current or recent situations, and they could benefit from reframing their views and highlighting their strengths and ability to recover from these situations
• Teach the client about CBT and negative triad
Automatic Thoughts
• Thoughts about oneself or others that individuals are often not aware of and thus are not assessed for accuracy or relevancy
• We don’t really have an awareness of these thoughts (ex: no one is gunna like me here)
• CBT teaches people about these thoughts and how to identify, explore, and alter them
Maladaptive Automatic Thoughts
• These are automatic thoughts that are typically centered on negative themes or distorted reflections that are accepted as true
• People just accept these as true
Schemas
• A network of rules or templates for information processing that are shaped by developmental influences and other life experiences
• These are how automatic thoughts are generated – they stem from the schema
• These rules dictate how individuals think about and interpret the world and play a role in regulating self-worth and coping skills
• Changing schemas is a major target of CBT
Overgeneralization
• Single negative event is seen as a never-ending pattern of defeat
• One mistake leads to “I never do anything right” (one bad test = never gunna be good at school)
Arbitrary Inference
• Cognitive distortion that leads to drawing conclusions without evidence or facts to support those conclusions (if I try to join conversation and people stop talking, we think they stopped cuz they don’t like us, but it was really a private conversation that only a few people should hear)
Selective Abstraction
• Attending to detail while ignoring total context
• Taking detail out of context and missing the totality of the situation (an actor makes a small mistake in a play, but thinks the whole play was bad)
Personalization
• Seeing yourself as a cause of negative external event (a neighbor doesn’t say high, and you think they don’t like you for some reason or because you because you did something)
Polarized Thinking
• Thinking in extremes, viewing things as black or white (all good or all bad/splitting)
Assumptions/Expectations
• Cognitive-behavioral therapist would focus on assumptions and expectations (i.e., explicit statements about any subject) that people have about anything to determine any larger biases (i.e., “distortions”) they use to interpret themselves and the world
o INTERVENTIONS
Social Skills Training
Aversive Conditioning
• The intention of aversive conditioning (pairing an unpleasant stimulus with a habituated response) is to eliminate the anxiety response by making it even more uncomfortable than it already is
Educational Approach
• Collaborative
• Teaching about how thoughts impact behaviors and feelings and how to address them:
o journaling
o thought stopping
o logs
Socratic Questioning
• Questioning allows the therapist to stimulate the client’s self-awareness, focus in on the problem definition, expose the client’s belief system, and challenge irrational beliefs while revealing the client’s cognitive processes
• Questions that dive below the surface of a person’s thinking (ex: what lead you to believe this; is there evidence)
• Are there alternate ways of thinking about the situations
• Thought process that the person used to reach their conclusion
Reframing
• Thinking differently by “reframing” negative or untrue assumptions and thoughts into ones that promote adaptive behavior and lessen anxiety and depression
Cognitive Restructuring
• Teaches client to identify irrational, distorted, or maladaptive beliefs, question the evidence for the belief, and generate alternative responses
• Doesn’t happen in one session:
o help people identify thoughts and beliefs
o then question evidence
o then find alternate responses
• Step by step approach
Homework
• To assist with cognitive restructuring, clients are often assigned homework
• Typical CBT homework assignments may include activities in behavioral activation, monitoring automatic thoughts, reviewing the previous therapy session, and preparing for the next therapy session
Self-Monitoring
• Also called diary work, self-monitoring is used to record the amount and degree of thoughts and behaviors
• This provides the client and therapist information regarding the degree of a client’s negative affirmations
• Thought record
Behavioral Experiments
• The experiment process includes experiencing, observing, reflecting, and planning
• These steps are conducted through thought testing, discovery, activity, and/or observation
• Ways people can try something new to observe and reflect
• Assign different things for people to do
Systematic Desensitization
• Pairs relaxation with exposure to something stressful
• Clients are taught to relax in anxiety producing situations
• Big in CBT and good for PTSD
• Teach how to relax, then expose
• Real life exposure or imagery
Anxiety Management Training
• Teaches skills for specific situations using imagery
• The client practices relaxation until anxiety is reduced then continues with imagery
Assertiveness Training
• Teaches client to specify desires and needs using minimally effective responses to assert their position (what’s the least they need to do in order to convey needs and wants)
• Used with unassertive or overly aggressive clients.
• “I” statements
• Involves role playing
Behavioral Activation
• Increases activity for depressed or passive clients by using activity scheduling and incentives
• Assigning activity (may or may not use incentive)
• Brisk walks can sometimes be more effective than meds
• Incentives mean get something for doing something
Communication Skills Training
• Used in couples’ therapy to help couples talk about feelings and problems
• About helping people manage conflict
• When in stressful situation, we rely on primitive behaviors
• “I” statements
• Assertive training
• Teach how to listen without interrupting or advice
• Don’t jump in with problem solving
• How to identify when getting overly aroused and upset (flooded)
• When flooding happens to just one person, the other person may not notice it
Downward Arrow
• Used to uncover underlying assumptions
• “If this is true, what does it mean about you and your life”
• Keeps moving down to get to the underlying view of the world/yourself
Exposure
• Client faces fear stimuli without resorting to escape or avoidance maneuvers
• Can be done in real life or with imagery
• Kids = coping cat (exposure therapy through imagery)
Finding Alternatives
• Clients review all possible options and alternatives for either interpreting a situation or resolving a problem (what are other options that could be happening)
Labeling Distortions
• Teaches client to recognize and label particular distortions in thinking that can lead to problems with interpretations of events
• Provide psychoeducation about overgeneralization and the various negative patterns of thinking
Mastery/Pleasure Ratings
• Clients use activity chart and rates mastery or pleasure that they derive from activity
• Person’s skill level at a task; degree to which they enjoy the task
• Ex: when they do an activity, they didn’t want to do, but end up liking it, this creates connections between what they imagined it would be like and what it is like
Opposite Action
• Client is encouraged to engage in behavior that is counterintuitive or opposite to what she or he may feel at time (e.g. when feeling very angry, say something kind or decent)
Problem-Solving Training
• Step by step approach
• Teaches a step approach of orienting to the problem, problem definition, generation of alternatives, decision making and solution implementation and verification of results
• Solution may not always work (try something, but check in and verify if the “solution” is working; reflect)
• Ongoing process
• Reflect on outcomes
Relaxation Training
• Teaches client to relax muscles to condition a relaxation response to counter tension
• Uses imagery, music, and other stimuli to assist in acquiring response
• Before exposure stuff, see if coping skills are good
Successive Approximation
• Client and therapist collaborate in developing a plan for the client to engage in steps that approximate a goal, to allow the client to have success at each step along the way to the goal
• Experience success along the way
• Purpose is to experience successes along the journey (ex: engage in relaxation techniques 1st and this would be the goal at first)
Three-Column Technique
• Client collects record of automatic thoughts and lists the situation in which the thought occurred, the automatic thought, and the associated feelings
• Initial HW assignment
Thought Record
• Expands on the three-column technique, with columns to record alternative responses to the automatic thought and behavioral or emotional outcomes of changing the thought (ex: they didn’t talk to me because she is feeling sick, I know can relax)
Diversion Technique
• An intervention, not a goal
• You would suggest that a person who is anxious do something else with that energy, like take a walk or get some exercise
Building An Alliance
• In the Cognitive-Behavioral framework, consists of creating a problem list and educating the clients about the approach
• RATIONAL EMOTIVE BEHAVIOR THERAPY (COGNITIVE BEHAVIORAL THERAPIES)
o THEORY OF CHANGE
Precursor to CBT
Change occurs through changing irrational beliefs to rational beliefs, which improves clients’ emotional and behavioral functioning
About beliefs people have
o ROLE OF THE THERAPIST
Instructor
Confrontational (this is different from CBT, where they try to build tools)
Direct
o TREATMENT GOALS
Help clients alter illogical beliefs and thinking patters in order to overcome psychological problems and mental distress
o KEY CONCEPTS
A.B.C.
• A – Activating Event:
o something happens in the environment around you
• B – Beliefs:
o you hold a belief about the event or situation
• C – Consequence:
o you have an emotional response to your belief
Common Irrational Beliefs
• Feeling excessively upset over other people’s mistakes or misconduct (other people need to be perfect, and if not, you get upset)
• Believing that you must be 100 percent competent and successful in everything to be valued and worthwhile
• Believing that you will be happier if you avoid life’s difficulties or challenges (anytime there is a challenge, they are negatively affected)
• Feeling that you have no control over your own happiness
• That your contentment and joy are dependent upon external forces
Self-Acceptance
• I have both good and bad points
• I can have flaws
• Despite my good and bad points, I am no worthier or less worthy than any other person
Other-Acceptance
• Sometimes other people will not treat me fairly
• There is no law that other people must treat me fairly all the time
• People who don’t treat me fairly are no worthier or less worthy than any other person
Life-Acceptance
• Life does not always work out the way that you want
• There is no rule that life has to go the way that you want
• Although life will not always be pleasant, it is never awful or completely unbearable
• DIALECTIC BEHAVIORAL THERAPY (COGNITIVE BEHAVIORAL THERAPIES)
o THEORY OF CHANGE
Change happens through mindfulness, skills to manage distress tolerance and emotional regulations, and improving inter-personal problem-solving skills
Emphasis on accepting uncomfortable thoughts instead of struggling with them
This stems from CBT and mindfulness
o ROLE OF THE THERAPIST
Ally
Validate and offer alternatives (combo of validating anger as well as how to deal with it)
o TREATMENT GOALS
The goal is for clients to improve their emotional and cognitive regulation
o KEY CONCEPTS & INTERVENTIONS
Mindfulness
• This is what separates from CBT
• The practice of being fully aware and present in this one moment
• Acceptance of the feelings
Distress Tolerance
• How to tolerate pain in difficult situations, not change it
Interpersonal Effectiveness
• How to ask for what you want and say no while maintaining self-respect and relationships with others
Emotion Regulation
• How to change emotions that you want to change
• Looking at experiences that people have in situations
• What happens when they learn how to accept those emotions
Homework
• Clients are assigned skill building tasks between sessions
• Incorporates individual, group work, and contacting therapist in between session
• REALITY THERAPY (COGNITIVE BEHAVIORAL THERAPIES)
o THEORY OF CHANGE
Change occurs through identifying and meeting needs as well as developing satisfying interpersonal relationships
o ROLE OF THE THERAPIST
The main function of the therapist is to create a nurturing relationship with the client
Supportive, non-judgmental, patient coach
o TREATMENT GOALS
Client learns more effective ways of meeting his or her needs
Clients learn to engage in self-evaluation
Clients gain a sense of inner control of their lives
Clients learn to change what they do as a key to changing how they feel and getting what they want
o KEY CONCEPTS
Based on Choice Theory, which asserts that each of us is a self-determining being who can choose future behaviors and hold ourselves consciously responsible for how we are acting, thinking, feeling, and for our physiological states
Client has a choice
Everyone has four needs (love/belonging, power/achievement, freedom, and fun/relaxation)
Every choice is based on seeking one of these needs
Sometimes needs compete with one another
When people get out of balance, they feel only one need is important, so they’ll put more energy in that one need, further exacerbating the problem
Some people may have only been working on one “need”
Psychoeducation may help them identify what they can work on
People are always trying to meet one of their needs
People are in control of what they are currently doing and have the power to make different choices
Client’s act irresponsibly when one or more of their basic needs aren’t being met
o INTERVENTIONS
Focus on the areas where clients have choices
For test, focus on choices, not past, focus on present
Focus on present choices, avoid discussions of problems in past or symptoms
Challenge client to examine and evaluate their own behavior
Explore client wants, needs, and perceptions
Doing and directing – focus on what client is currently doing and thinking
Discuss feelings only when related to client’s behaviors/choices
Teach self-evaluation (does present behavior have a reasonable chance of getting you what you want)
Formulate action plan for change – focus on positive, attainable action steps
Review results of plan and adjust accordingly
Use humor
• CLIENT/PERSON-CENTERED THERAPY (HUMANISTIC/EXISTENTIAL THERAPIES)
o EMPHASIZES UNDERSTANDING HUMAN EXPERIENCE AND THE CLIENT
Do not emphasize the symptoms
You emphasize what the person is experiencing; their point of view
From Carl Rogers
The therapist is a unique individual
Authentic connection between client and therapist
Unconditional positive regard for the whole person
Non-judgmental
People are always growing and surviving
Make room for peoples’ experiences
Establishing rapport
Make room for identifying judgments they have about themselves
Address past guilt and shame
Accept self and things they feel bad about
o HUMANISTIC THEORY
Focus on acceptance and growth
People constantly grow and try to be happier and better
Acceptance is important, because people disown aspect of self as unacceptable and their past shames are un-processed
The therapist is a unique individual
Try creating a nurturing and authentic environment promoting acceptance for who they are (make room for parts they don’t like about themselves)
Viewing people as inherently good and avoids diagnosing people, avoids what ideal person should be
o THEORY OF CHANGE
Change occurs by creating conditions for the client to grow through the therapeutic relationship with the presence of three essential components: congruence/genuineness, unconditional positive regard, and empathy
o ROLE OF THE
Therapist is nondirective.
A facilitator (helper) who sets the stage and believes the client is able to do what is necessary for growth and change, self-actualization
Client determines goals of therapy and even how many sessions they want to come to
o TREATMENT GOALS
Self-acceptance
Congruence between client’s idealized and actual selves (live more authentically)
Increased self-understanding
Decreased levels of defensiveness, insecurity, and guilt
More positive relationships and increased comfort with others
Increased ability to experience and express feelings in the here and now (improved awareness)
o KEY CONCEPTS
Congruence
• Therapist’s genuineness with client, shares his/her feelings honestly, does not hide behind professional façade or therapy models — therapist is transparent with feelings, thoughts, and beliefs (this is also modeling for the client)
Unconditional Positive Regard
• Complete acceptance of the client, a nonjudgmental respect of client and his/her feelings allows clients to feel less anxious about their perceived weaknesses and taking risks
• This helps lower defenses
Empathy
• Therapist accurately senses the feelings and personal meanings the client is experiencing and can communicate this understanding to the client
Self-Actualization
• Innate tendency of all human beings to reach their fullest potential
Locus of Control
• Through the therapeutic relationship, client can take control of their lives rather than follow the direction of others who were previously in control
• More awareness of the choices they have
• Unconditional empathy = client experiences their experiences in a new way
Non-Directive Therapy
• Clients lead the discussion
• GESTALT THERAPY (HUMANISTIC/EXISTENTIAL THERAPIES)
o FOCUS ON HERE AND NOW
Genuine encounter
The therapist is a unique individual
With each client we are going to fit a little differently
Bring your own person in the room
There are themes:
• work in here and now
• stay with emotion
• full body awareness (“what are you feeling right now”)
Gestalt also pays attention to how things are unfolding and the energy of the therapy
• Tone of voice, body language
o THEORY OF CHANGE
Change occurs through increased awareness of here-and-now experience in a dialogic relationship
Both existential and humanistic
o ROLE OF THE THERAPIST
The therapist is an authentic, present other
Non-directive and non-judgmental (people are free to make their own choices)
No right way to be in the world
Increase the client’s awareness in the present moment
o TREATMENT GOALS
The goal is for clients to become aware of what they are doing, how they are doing it, and how they can change themselves, and at the same time, learn to accept and value themselves
Idea of self-acceptance
o KEY CONCEPTS
Phenomenological Method
• Exploring experience by description and abstaining from interpretation (ex: see them cry or look sad, you say “I see you tearing up, what are you experiencing;” just a description, no interpretation)
• Interpretation my limit what the client could possibly say
Dialogical Relationship
• The therapist’s presence allows for the client to become fully present
• The therapist is not the expert of the client’s feelings
• Importance in therapist being open to client’s experience and not being an expert on the experience
Experiential
• Through experiments, the therapist supports the client’s direct experience of something new, instead of merely talking about the possibility of something new (“I wonder what that would be like for you if you said that a little bit louder and sterner”)
• Just opportunity for client to experience something new
• Even client’s reaction to suggesting is important
Here-and-Now Focus
• The past is discussed in terms of how the past affects the present
• Focus on how they feel as they are describing the past
o INTERVENTIONS
Empty Chair Technique
• For the test, the may put this as a wrong answer on a different therapy
• Used to explore patients’ relationships with themselves or others in their lives
• A form of role-playing, the client addresses an empty chair as if another person was in it in order to act out two or more sides of a discussion
• If you “bring the person into the room” it can be very therapeutic to express those feelings to the “person”
• Belief that if we bring relational difficulty into the room, person can be in the here and now and get closure (finish business)
• Talk to a part of themselves (hole in heart) or directly to themselves
Experiments
• Encourages the client to experience a feeling rather than just talk about it
• Stand up, raise voice
Body Techniques
• Bring patients’ awareness to their body functioning or help them to be aware of how they can use their bodies to support excitement, awareness
• Focuses on the process, what is happening, and the content, what is being talked about
• What’s going on in the body (ex: what does sadness feel like)
• EXISTENTIAL THERAPY (HUMANISTIC/EXISTENTIAL THERAPIES)
o FOCUS ON RESPONSIBILITY AND FREEDOM
Able to respond (responsibility)
The therapist is a unique individual
The meaning people have in their life
How they choose to think and act
People have freedom to choose how they will react to situations
People’s problems come from not exercising choice
Everyone is responsible for their life’s meaning and the choices they make
You drive the car of their life
o THEORY OF CHANGE
Change occurs through finding philosophical meaning in the face of anxiety by choosing to think and act authentically and responsibly
The core question addressed in existential therapy is “How do I exist in the face of uncertainty, conflict, or death”
Emphasizes personal choice about how they want to live life
o ROLE OF THE THERAPIST
Provide an encounter with a “real” other
Presence of the therapist is essential
Help the client focus on personal responsibility for making decisions
o TREATMENT GOALS
Client discovers his own life meaning (purpose)
Client confronts anxiety inherent in living (anxiety is a part of human condition, not about getting rid of it, but handle it, making choices, responsibility for choices)
Client experiences agency and responsibility in the construction of their life
o KEY CONCEPTS
All persons have the capacity for self-awareness
As free beings, everyone must accept the responsibility that comes with freedom (with freedom is anxiety)
Each person has a unique identity that can only by known through relationships with others
Each person must continually recreate himself; the meaning of life and of existence is never fixed, rather, it constantly changes
Anxiety is part of the human condition
Death is a basic human condition that gives significance to life
o INTERVENTIONS
Focus on moment-to-moment process, not on the explicit content
Holding refers to a process of holding up the problem experience so it may be seen, remembered, and re-experienced by the client, in the presence of the empathetic person
The goal is not to take away pain, but to be with them in that pain
Empathic availability is a committed presence to the “other” and openness to the pain and potentials of the other even when such openness is difficult and unpleasant
Telling, talking about, and naming emotional pain places the emotional experience and pain into the world of mutual encounter, where the relationship between client and practitioner can be used to process the situation under circumstances of increased support
Mastering the emotional pain is a process of reflection and behavioral experimentation that helps a client discover unique healing activities that are useful in processing and defusing the problem situation
Honoring the pain refers to the process of celebrating the meaning potentials and opportunities in the problem situation that the client actualizes and makes real (relate to the pain in a different way); view as something you have endured; there is a significance in the pain; it shaped who you are
• EXPERIENTIAL/SYMBOLIC THERAPY (HUMANISTIC/EXISTENTIAL THERAPIES)
o THEORY OF CHANGE
Change happens through the existential encounter – the authentic meeting of the therapist and the client in the present moment and by expanding the client’s range of experience
Generally used with families
o ROLE OF THE THERAPIST
Authentically being with client
Playful, creative
o TREATMENT GOALS
The goal is for growth and increased flexibility
People have fixed ways of being, so this therapy looks to expand behaviors
o KEY CONCEPTS & INTERVENTIONS
Battle for Structure
• Therapist establishes the rules and working atmosphere of treatment
• Includes the need for entire family to be in therapy
• For the test, if answer says, “include whole family” pick that one
Battle for Initiative
• Motivation for change must come from family
• Includes having family state agenda for each session, waiting silently for family to take initiative, allowing family to determine how change is going to happen (don’t work harder than family)
• Wait until they speak
Trial of Labor
• Understanding the roles, boundaries, beliefs, history and levels of conflict within the family (clear understanding of family dynamic)
Activating Constructive Anxiety
• Reframing anxiety as efforts toward competence and anxiety directed towards something positive (fear of failing to accomplish what one is capable of)
Play, Humor and “Craziness”
• Tapping irrational side
• Finding solutions in creative interactions (clinically appropriate laughing and joking)
• NARRATIVE THERAPY (POST MODERN THERAPIES)
o MAIN IDEA
Focuses on deconstructing common beliefs and examining those beliefs and values in an individual’s life
People construct reality and it comes from cultural beliefs (ex: what is success, is it money, being well rounded, helping)
Looks at peoples’ thoughts and behaviors in the context of their culture
Make a link between culture and how they got those ideas of how things should be and how they shouldn’t be
It changes over time and with cultural shifts
Postmodern is exploring the words people use
Also look at the story that the client has about self:
• mapping the problem (ex: understanding how anxiety is impacting life)
• separate the person from the problem
• the person isn’t there problem
• client has a say over their experience
o THEORY OF CHANGE
Change occurs by separating patient from problem and creating a new narrative or story, which emphasizes the client’s competencies and strengths (person has story about self, work with exploring that story and then create a new story, brings out competencies and strengths)
o THERAPIST’S ROLE
Collaborator
Investigator
Co-author
Views individuals as the experts on their own lives (considers ALL cultural and other minority class influences)
o TREATMENT GOALS
Deconstruct problem-saturated stories in order to create more helpful stories
Have more direction in life
Re-authoring the story — having a new story emerge
o INTERVENTIONS
Externalizing the Problem
• Separating the person from the problem story (ex: “what is anxiety trying to tell you to do”)
• Separate a person from their depression
• What does depression do when it comes around; in what context is depression most likely to take over; depression is not part of the person; what happens when depression takes over
• Externalize symptoms
Social Constructivism
• Where the messages are coming from
• Focus is on the present and past — the current problem and the history of the problem
• Special attention is given to social issues, such as culture, gender, race, disability, social class
Deconstructive Questions
• Questions that clarify meaning and help people unpack their stories
• They encourage clients to situate their narratives in broader contexts (what does it mean to be ….)
• Explore the language people use and clarify the meaning (ex: if someone says they are an underachiever, you go deeper; “tell me what you mean by underachiever”)
Mapping the Influence
• Process of eliciting from the client a detailed description of the problem’s effect and influence on client’s life and relationships (“What is the impact of these symptoms on your life; how does it make you feel as a mother; how do his tantrums affect your life”)
• How problem impacts the identity of the person
Identifying Unique Outcomes
• Times in the client’s life during which the client was able to resist the effects of the problem
• Was there ever a time when you felt strong/not depressed/not anxious
• Can also be a fantasy, what would it look like if they did
• If a person can’t identify any, use fantasies
Enlisting A Witness
• Inviting someone who has a sense of who the client is to support & witness the re-authoring process
• Sharing of their experience
Writing A Letter
• Client writing a letter to self and others to reinforce a new story
• SOLUTION-FOCUSED THERAPY (POST MODERN THERAPIES)
o SHORT TERM
Solution focused tends to be shot term therapy
Does not evaluate the root cause of the problem
Create solutions to problems
Collaboratively design a situation with expectations for change; create a situation that client would want to have happen
For test, would not use the word problem
o THEORY OF CHANGE
Change occurs through accessing client’s strengths and resources
Emphasizes finding solutions to a problem, not on discovering the cause or origins of the problem
No exploration of past issues
Focus on present and future
o THERAPIST’S ROLE
Therapist is a consultant, coach
Lots of encouragement
o TREATMENT GOALS
Client implements small and large changes to achieve their preferred future
Client builds on current strengths and resources
Client defines problem/goal
o INTERVENTIONS
Exception Questioning
• The therapist asks the client to think of a time in his life when the problem did not exist and what the client did differently during this time
• The goal here is to focus on what has worked in the past to provide the client with a positive perspective (ex: “Tell me about the times when you don’t get angry”)
Miracle Questioning
• The therapist asks the client to envision how the future will be when the problem no longer exists and what life looks like then (ex: “Imagine that tomorrow morning you wake up and a miracle has happened. What would be different that will tell you a miracle has happened, and your problem has been solved”)
Scaling Questions
• The therapist asks the client to think of a scale ranging from the worst things could be to the best; the client then rates his current position on the scale and is asked to identify how he could move up or down the scale
• The client is also encouraged to identify what point on the scale would be good enough or where his “perfect future” is (ex: “You said that things are between a 4 and a 5. What would need to happen so that things were between a 5 and 6?”)
Presupposing Change
• Rather than focusing on the problem that brought the client in, the therapist can ask the client questions to focus on the positive changes that have been occurring (ex: “What’s is different or better since the last time we met?”)
Coping Questions
• If a client has trouble identifying positive change, coping questions are asked by the therapist in order to illustrate resources that the client already has. This can include validating the client’s difficulties while also showing that she is still able to get up in the morning, go to school, etc. This highlights the client’s strengths without undermining her view of reality. These questions are supportive while also challenging the client and shifting the focus away from problem-focused narratives. Example: “How do you keep going each day even when it feels like there is no hope?”
Affirmations/Compliments
• Regularly acknowledge, progress, strengths and resources (Example: Tell the client, “I am impressed you are sitting in that chair again after what you just went through”)
• OBJECT RELATIONS (PSYCHODYNAMIC THERAPIES)
o OBJECT RELATIONS
Biological drive theory = drive to get needs met
Looks at relationships in lives developed/shaped through external relationships
Object is good or bad
In therapy, the therapist becomes the object
Projection = defense mechanism where somebody is putting their feelings on to another person
Projective identification = therapist takes on identification of that client’s feelings (if therapist feels frustrated, it is the client’s frustration that the client is projecting onto the therapist, so now therapist starts to feel the client’s feelings - if client mad, therapist will become mad)
o THEORY OF CHANGE
Change occurs through both reparative experiences within the treatment relationship (therapist becomes new object) and from new insight into, and modification of, entrenched object relations pathology (new and different experiences with the therapist; gaining insight into past relationships with parental objects)
Be curious about a person’s early child hood experiences
Be curious about how client felt belittled by the therapist
How the person’s views of self and others were formed and how they are shaping interactions today
O ROLE OF THE THERAPIST
Emphasis on transference and countertransference
Neutral
Therapist as a new and good object
o TREATMENT GOALS
Providing reparative experiences and building new internal structures (the person would have views of themselves that will allow them to rely on self-soothing talk in stressful situations)
Gaining insight to how past relationships impact client’s functioning (“this reaction feels bigger than current situation;” question link to past)
Improving relationships with self and others (how feelings connected to past)
Sometimes people have a way of relating to others in a way that is not satisfying, but they continue to engage in the same manner, because they learned it from somewhere
o KEY CONCEPTS
Objects
• Refers to persons in the external world
• Individuals seek objects (others) from birth
• We are inherently object seeking
Internalization
• Early infant-caretaker interactions lead to the person internalizing basic attitudes toward self and other, characteristic relational patterns, and a repertoire of defenses and internal capacities (babies and toddlers internalize and start to make sense of the world and themselves; the world is hostel, or it is safe)
Self/Object-Representations
• The Internalization Process = infants forming images of themselves and others, and once formed, they are fundamental internal structures that affect the ways in which individuals view themselves and others
• If a child experiences that they are too much for parents, they learn that they must pretend to be happy all the time; if mother is warm, the child starts to take in the idea that the world is safe and accepting and vice versa
Ego
• The structure responsible for dealing with the world, for instituting defense mechanisms, for internalizing external objects, and for integrating and synthesizing self/object-representations
• Creates defense mechanisms; some can be primitive, and others can be complex
Splitting
• When two contradictory states, such as love and hate, are compartmentalized and not integrated
• Related to ego
• Somebody is either all good or all bad; can switch fast
• Hard time maintaining relationships cuz people usually will disappoint us
• Therapist wants to work on bringing these two sides together
Projection
• Involves projecting undesirable feelings or emotions onto someone else, rather than admitting to or dealing with the unwanted feelings
Projective Identification
• Refers to a psychological process in which a person will project a thought or belief that they have onto a second person, then the second person is changed by the projection and begins to behave as though he or she is in fact characterized by those thoughts or beliefs that have been projected
• Only used with Object Relations; maybe a test answer
• Therapist or other person takes on the feelings of the client/crazy person
• This is the manipulation of the client/crazy person
Introjection
• Where the subject replicates in themselves, behaviors, attributes, or other fragments of the surrounding world, especially of other people (ex: child grew up in angry home, they become angry and violent; angry = I’m supposed to lash out)
• SELF-PSYCHOLOGY (PSYCHODYNAMIC THERAPIES)
o SELF-PSYCHOLOGY
Emotional Attunement = someone who lacked mirroring ends up disregulated (compensate for that loss)
In therapy, use empathetic attunement for healing
o THEORY OF CHANGE
Change occurs through empathetic attunement and strengthening the self-structures through optimal responsiveness
Real focus on understanding the client and client experience
o ROLE OF THE THERAPIST
Emphasis on empathetic understanding and optimal responsiveness
Reparenting
Allows transferences of self-object experience
Be conscious of repairing any disruption between client and therapist (part of healing process)
o TREATMENT GOALS
Developing self-cohesion and self-esteem
Want person to have more accurate view of self
Improve self-esteem
Get more accurate view of self
Locating better self-objects
o KEY CONCEPTS
Self-Objects
• Early self-objects are those empathetic or attuned caretakers who perform vital functions for the infant that it cannot carry out itself
• If someone doesn’t have an empathetic and available self-object, child has to deal with this rejection in a negative way
Self-Object Needs
• Mirroring
• Idealization of others
• Twin/alter ego
Mirroring
• Approving and confirming responses
• Mirroring = approval and confirmation response
• Example, did the child have parent available when they took first steps, were they met with approval or was no one in the room
Optimal Frustration
• When a self-object is needed, but not accessible, this will create a potential problem for the self if its long term (neglect or abuse), referred to as a “frustration”
• Note: constant mirroring is not good, cuz then they will think world must always be there for them
Mirroring Transference
• The patient seeks acceptance and confirmation of the self from therapist
• They come to therapy wanting to get some kind of confirmation and acceptance
Twinship Transference
• The patient experiences the therapist as someone like himself
• There is a comfort and safety in this
• Looking for someone to look up to
• It’s a validation
Idealizing Transference
• The patient looks up to and admires the therapist
• Stems from child wanting to idealize parents
Adversarial Transference
• The need for a supportive relationship that the patient can oppose, in order to grow
• Person that has been taught that they just have to go along
• A therapist can be a person that cares for them, but they can also push back
Experience-Near Empathy
• When therapist steps into client’s shoes and imagines what it is like to be the client (thoughts feelings, body sensations)
• Like mirroring to the extreme
• Showing client that you really understand feeling and experience
• Work with client to really understand what they were experiencing
• Therapist works with client to clarify understanding, but different than interpretation
• This is more of an empathetic attunement
• Test:
o self-psychology question, look for empathy answer
• DEPTH PSYCHOLOGY (PSYCHODYNAMIC THERAPIES)
o DEPTH PSYCHOLOGY
Based in Jungian approach
Soul psychology
People have a soul and you are treating that soul
o THEORY OF CHANGE
Change occurs through exploring and integrating material from both unconscious and conscious levels of understanding
Unconscious processes include dreams, images, symptoms, intuitions and other non-volitional experiences (things that happen unconsciously)
The soul is speaking out through the symptoms
Soul is a big word in depth psychology
o ROLE OF THE THERAPIST
Client and therapist form a critical alliance, which invites client into exploration of connections and meanings that are below the surface of conscious awareness and engages the transpersonal, mysterious space between therapist and client
Fellow journey men
o TREATMENT GOALS
Increase self-awareness and inner wisdom
Integration of repressed experiences and shadow material (darker side of somebody; selfishness, greed; capacity for a darker side)
The goal is often referred to as individuation (a process that fosters self-awareness through inner and outer exploration of the unconscious and conscious, the individual and the wider community), by which one discovers a more potent sense of meaning and purpose in life
o KEY CONCEPTS
Depth
• Refers to a way of seeing that which lives underneath the cultural, historical, spiritual, psychological manifestations of human experience
• Recognizes the “collective unconscious” which is passed down through generations and is shared by all people (ideas, meanings, and symbols)
• Could be described as a universal library of human knowledge often represented by “archetypes” or basic patterns of human behavior and situations that seem to be common amongst all people (e.g. the hero, the mother, the father, the orphan, the explorer etc.); archetypes come into play at different stages and points of life
Active Imagination
• Is an intervention used to amplify, interpret and integrate the unconscious and includes working with dreams and the creative self via imagination, images etc.
• Active imagination relies on a client’s undirected observation of their imagination or dreams, allowing the images or dreams to speak for themselves as much as possible without overbearing influence from the conscious mind
Psyche and Soul
• Widely used terms in Depth Psychology
• Soul is the dimension of the person that makes meaning possible, turns events into experiences and deepens the human experience
• Depth Psychology attunes itself to the way psyche reveals itself
Mythology
• Personal symptoms, conflicts, and stuckness contain a mythic or transpersonal/archetypal core that when interpreted can reintroduce the client to the meaning of his struggles (e.g., the pain of leaving home can be reimagined as the ageless adventure of the wanderer setting out into the unknown)
• Difficult choices can be made easier if related to a story
• Adlerian Therapy (Psychodynamic Therapies)
o ADLER
People have a need to be socially responsible
Give back to others
Like positive psychology (ex: tell people with depression to do nice things for other people)
Interested in early family constellation:
• memories of childhood situations
• nature of relationships between family members
• understand past family dynamic
• past is informing how the client is currently functioning in life
• people are often behaving out of a feeling of inferiority
• identify situation when inferiority was at play in decisions and behavior
o THEORY OF CHANGE
Change occurs by increasing client’s self-awareness and challenging and modifying his or her fundamental premises, life goals, and basic concepts.
People behaviors are goal oriented, and motivated by inferiority
o Therapist’s Role
Accepting, encouraging, respectful, optimistic
Co-thinker
Relationship is collaborative and built on trust
o Treatment Goals
Challenge the client’s basic premises and life goals (what is the underlying motivation of what they are doing every day, what’s the purpose)
Develop socially useful goals and increase social interests (work to help clients to become more socially engaged, caring for others, taking care of the world)
Increase the client’s sense of belonging (all of children’s behaviors are aimed at belonging; problematic behavior is linked to belonging)
o Primary Concepts & Interventions
Inferiority:
• Inferiority feelings are always present as a motivating force in behavior. Adler proposed that inferiority feelings are the source of all human striving. Individual growth results from compensation, from our attempts to overcome our real or imagined inferiorities.
Early Recollection:
• Used as an assessment tool, these are stories of events that a person says occurred before the age of 10. These are specific incidents that include what the client thought and felt at the time.
• Get a sense for how the client makes sense of their world
Family constellation:
• Exploration of the family atmosphere and relational dynamics that prevailed in the family when the person was a young child. (relationships and perceptions of family nature of those relationships and have the client talk about them)
Lifestyle Assessment:
• Identifying, though a questionnaire and or clinical interview consisting of early recollections, the goals and motivations of the client
• Where did your goals come from, how does it impact you, was it handed down from someone else and does it work for you
o Social Context:
Widened the view that problems were not simply intrapsychic and incorporated the notion that the social context of the person’s lifestyle contributed as well.
How does your community shape you?
o Social Interest:
Therapeutic goal was to develop social interest where client had genuine feelings of empathy for others instead of a need to conquer their feelings of inferiority.
Enhances feelings of belonging and connectedness
Dream Interpretation:
• Adler’s considered dreams as an open pathway to true thoughts, emotions and actions. According to his view, dreams enable us to clearly see our aggressive impulses and desires. Adler considered dreams as a way of compensating for the shortcomings in life. Dreams offer a kind of satisfaction that may be more socially acceptable.
• Understand impulses and desires
Summary:
• Therapist shares the results of the assessments as a narrative summary that is discussed with client.
• Conclusions that the therapist has drawn from therapy
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.
• Explore missing experiences.
Guided Imagery:
• 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.
• Validate their feelings about that those experiences
Encouragement:
• Helping the client to “build courage” by becoming aware of their strengths, feeling connected to others, and having a sense of hope.
• Therapist and client connect
• Attachment-based Therapy (Psychodynamic Therapies)
o Attachment Theory
looking at early impact and attention to the child, thus impacting adulthood
originated and developmental model (not a lot of interventions assigned to this theory, however, a lot of therapies now incorporating attachment theory, ex: EFT)
important thing is how client relates to therapist
Adult Attachment Interview:
• three words to describe your mom, dad, whoever, then ask for supporting memory to support the words
• pay attention more to the client’s delivery
• assess if they get aroused, disorganized, flat affect, or if they have a balanced view) most don’t have balanced view)
TEST: may ask about attachment theory as an assessment tool, pay attention to more process issues of therapy
o How we are parented affects how we interact with others in the future
o Theory of Change
Change occurs through exploration of past and current relational attachments and trauma in the environment of a healing, secure and reliable relationship.
Relationship between client/therapist is heling (reliable, empathetic) all feelings are welcome
In home where parents are highly emotional and enmeshed, kids become easily overwhelmed as adults
Bad = parents are absent or enmeshed and overwhelmed
The kid’s emotional needs are not being met (how to not be shamed or not get in trouble)
Also, attention to what is going on in current relationships
o Role of the Therapist
Provide a sufficiently secure base to enable a person to explore emotional experiences of the past and the present
Create a secure, accepting, caring, non-judgmental, and reliable environment where the patient can feel comfortable sharing their most traumatic experiences and exploring the nature of the client’s attachment pattern
o Treatment Goals
Raise awareness of client’s problematic behavioral and emotional patterns, formed in early childhood as attempts to maintain attachment to primary caregivers (what the client learned to expect from others)
Repair the capacity to regulate affects
Resolve any emotional or social disruptions within the patient’s life
Improve quality of attachment with others
o Key Concepts
Attachment behavior system: the process in which infants and caregivers have an organized pattern of signals and responses that leads to a development of a protecting trusting relationship. The emotional bond that develops between adult romantic partners is partly a function of the same motivational system–the attachment behavioral system.
Secure Attachment: the person has easy access to wide range of feelings and memories, positive and negative. Has a balanced view of parents and has worked through hurt and anger from the past. Has developed a strong sense of self and empathy for others. (very rare)
Preoccupied/Anxious Attachment: The person is still embroiled with anger and hurt at parents. They sometimes value intimacy to such an extent that they become overly dependent on the attachment figure both past and present. They often recall role reversal in childhood and have hard time seeing their own responsibility in relationships. They dread abandonment. Poor ability to regulate their own emotions.
Dismissive/Avoidant Attachment: The person dismisses the importance of love and connection – and the value of emotions in general. Often idealizes parents, but actual memories don’t corroborate. They dislike looking inward and often have a shallow, if any, self-reflection. They often are very independent, dismissive of their own emotionality and have difficulty tolerating the heightened emotions of others.
Fearful/Avoidant Attachment: The person usually has a history of trauma and or loss. Similar to Dismissive/Avoidant they dismiss the importance of love and connection but usually out of fear or a belief that they are unworthy of love. They have a difficulty trusting others and may feel uncomfortable with emotional closeness.
• Bowen Family Therapy (Systems Theories)
o BOWEN
multigenerational transmission of problems
people have different roles in family
different levels of differentiation
these are passed from gen to gen
would have the unit draw out a family tree with different characteristics of the family
triangulation
• ex: an affair (when there is tension, rope in a third party to alleviate tension between two people)
o THEORY OF CHANGE
Change occurs by individual understanding multigenerational dynamics and increasing differentiation.
This is the only therapy that is concerned with the past 3 generations of family (people’s issues are transmitted through the family)
• Person
• Parents
• Grand parents
• Great grand parents
o THERAPIST’S ROLE
Coach/educator
Supervisor
Investigator (investigate the dynamics)
Neutral: don’t take sides or speak for another member of the unit
Bowenian therapist acts as a neutral coach to help a couple learn about their relationship
o TREATMENT GOALS
Reduce anxiety and emotional turmoil in family system
• Not just worry, but tension in family when family is having a problem
• Heightened arousal that doesn’t have a direction or support
• Takes over
Self-differentiation within the context of family
Decrease emotional fusion (allowed to have different reactions)
Improve communication skills (“I” Statements, owning my own emotional experience)
Decrease recurrence of dysfunctional patterns (educate people so they don’t keep doing it)
Reduce emotional reactivity
• Give people the skills to tell difference between thoughts and emotions
• Bowenian emphasizes dampening emotional reactivity
Facilitate detriangulation
o KEY CONCEPTS
TRIANGLES
• A triangle is a three-person relationship system. It is considered the building block or “molecule” of larger emotional systems because a triangle is the smallest stable relationship system.
• Anxiety in a 2-person system may lead to adding a third person to reduce anxiety, AND it doesn’t have to be a person, it could be work, drugs, etc.
o Parent may start talking shit about the other parent to the child
o triangles = a loss of differentiation
• Bowenian therapist would ask each about the impact of triangles on communication and closeness in a family
• TEST: Bowen = multigenerational mapping/genograms or triangulation
DIFFERENTIATION OF SELF
• 2 aspects (intrapsychic and interpersonal differentiation)
o INTRAPSYCHIC DIFFERENTIATION
their own differentiation (separating feelings from thought) Can you differentiate between what’s a thought and what’s a feeling?
Can a person have an emotional response and still hold on to a logical thought? Can they have an emotional response and keep it separate from who they are as an individual? Do they lose all functioning to think through an appropriate response? Can you feel feelings, but logically analyze the situation and maintain calmness?
TEST: psychoeducation
o INTERPERSONAL DIFFERENTIATION
how separated does a person feel from their family (can they be a person in their own right)
If spouse starts to get agitated, does the other get agitated
• Families and other social groups tremendously affect how people think, feel, and act, but individuals vary in their susceptibility to a “group think” and groups vary in the amount of pressure they exert for conformity. These differences between individuals and between groups reflect differences in people’s levels of differentiation of self.
• Look far back in system to see how things are passed down
• differentiation of self is achieved with the help of de-triangulating and decreasing fusion
Nuclear Family Emotional System:
• Individual are interdependent on the other family members’ processes. There are emotional forces happening in the family that happen in recurrent patterns. What are the emotions pulsating through the family?
o If dad comes home from work mad, mom gets mad, then kids get mad.
• The concept of the nuclear family emotional system describes four basic relationship patterns that govern where problems develop in a family. People’s attitudes and beliefs about relationships play a role in the patterns, but the forces primarily driving them are part of the emotional system.
Family Projection Process:
• The family projection process describes the primary way parents transmit their emotional problems to a child. The projection process can impair the functioning of one or more children and increase their vulnerability to clinical symptoms.
o How is it passed/transmitted down from generations to generation?
o Ex: how is conflict handled in family (open or closed and hidden)
o This is one benefit to doing multigenerational mapping
Multigenerational Transmission Process:
• The concept of the multigenerational transmission process describes how small differences in the levels of differentiation between parents and their offspring lead over many generations to marked differences in differentiation among the members of a multigenerational family.
• Have everyone discuss how they learned their styles of being in the family
Emotional Cutoff:
• The concept of emotional cutoff describes people managing their unresolved emotional issues with parents, siblings, and other family members by reducing or totally cutting off emotional contact with them.
o Maybe have a repair with that other person as an intervention, because client has gained tools to manage that relationship.
Genogram:
• Extensive study of family’s history. Acts both as an assessment and treatment tool
• TEST: called family map, genogram, diagram (not like “mapping the problem” in narrative therapy) in structural therapy you do genograms away from the family
• information-gathering tool that connects present issues with family-of-origin issues
Pseudo-Self
• pseudo-self describes an individual who follows the beliefs and values of others, so a Bowenian therapist would evaluate whether the children in the family have developed pseudo-selves
Undifferentiated Family Ego Mass
• refers to intense interdependence between family members, which results from triangles within a family system
• by helping the couple deal with one another in a differentiated manner, Bowenians believe the whole family will begin to act in a more differentiated way
Marital Dyad
• parents withstand the anxiety that occurs in stressful situations without resorting to bickering, withdrawal, or other avoidance mechanisms
o Interventions
Reduce emotional reactivity by having family members talk directly to the therapist one at a time, to decrease anxiety and tension in the room first, therapist needs to present a very non-anxious presence. Be present and a secure base. Separate yourself from their emotional experience. Bowenian therapist focuses on the parents more than the children in a family
• Reframing:
o Reframe the presenting problem as a multigenerational problem that is caused by factors beyond the individual
o Problem is part of a bigger picture
o Makes making choice and changes easier
• Genogram:
o Create a multigenerational map of family emotional system
• De-triangulation:
o Therapist becomes part of a “healthy triangle” where the therapist teaches the couple to manage their own anxiety, distance, and closeness in healthy ways
o Don’t take sides
o Support each individual
o Support communication to each other
o Teach “I” statements to own their own emotional experience
• Opening Cut-off Relationships:
o Encouraging and supporting clients to reengage with estranged family members
o
• Interacts with Family:
o Interrupts arguments – open conflict is prohibited as it raises anxiety
o wants lower levels of anxiety
• Models:
o Demonstrates new ways to interact and communicate
“I” statement, role playing (talking to sister), modeling communications
• Increasing Differentiation:
o By forming supportive relationship with family members to explore the origins and effects of their family’s beliefs and behaviors
• Teaching “I” Statements:
o Increases differentiation
• Bibliotherapy:
o Assigning reading material
o Educator
• Psychoeducation
o educate the couple/family about the impact of stress on their relationship
• Role Play Differentiation
o practice more differentiated behavior
o by helping the couple deal with one another in a differentiated manner, Bowenians believe the whole family will begin to act in a more differentiated way
o role play is used by all Family systems therapists to help them understand each other’s’ perspectives
• Teaching Communication Skills
o an essential alternative intervention for Bowenian therapists
• Journaling
o an alternative intervention that a Bowenian therapist favors in helping a couple improve their communication without encouraging them to react to one another
• Enhancing Cognitive Process
o Bowenian therapist would focus on enhancing a client’s cognitive processes, not on identifying feelings
• ASSERTIVENESS TRAINING
o Bowenian therapists will model and teach assertiveness skills
• EMPTY CHAIR WORK
o Bowenian therapist might use empty chair work to help clients practice more differentiated behavior with their families-of-origin
• Strategic Family Therapy (Systems Theories)
o Strategic
therapist interested in focusing on a specific problem
not concerned with multigenerational or triangulation
focus on each individual problem and help people address problem differently, thus helping the family system when change occurs
extremely directive (“boss”)
assign an ordeal (every time you want to do “x”, do “Y” first, then do “x”)
prescribing the problem (plan on fighting after…)
short term (focus on one problem)
utilize restraining and positioning strategies
o Theory of Change
Change occurs through action-oriented directives and paradoxical interventions.
• Therapist is very directive
• Target specific problems
• One theory where therapist TELLS you what to do.
o Role of the Therapist
Therapist delivers directives that facilitate change, particularly strategies around patterns of communication.
Focuses on solving problem/eliminating symptoms
Designs a specific approach for each person’s presenting problem
o Treatment Goals
Solve the presenting problems
Change dysfunctional patterns of interaction
o Interventions
Paradoxical Directives:
• Maneuvers that are in apparent contradiction to the goals of therapy, yet are actually designed to achieve them; paradoxical interventions help avoid confrontation with therapist’s instructions; undermines resistance by keeping client in charge
Positioning:
• Therapist takes a more exaggerated and extreme view of the problem and the family is obligated to rebel. That leads to them seeing the ways in which they have competency.
• “WOW, YOUR SITUATION IS SOOOOO HOPELESS!!!”
• Idea is that the family rebels
• Taps into own hopefulness
Homework:
• Assignments or directives that take place outside of therapy is essential to the therapy having a successful outcome. The underlying goal of the homework is to try to change the way the family dynamics function around the presenting problem that was identified in session.
• Again, help the person to relate to their problem in a different way, for ex, not saying you shouldn’t worry, just worry during specific times
• Don’t fight with problem
Prescribing the Symptom:
• A strategy in which the therapist encourages or instructs the client to engage in or practice the symptom.
• No longer powerless to the problem
Restraining:
• The therapist will discourage change or changing too quickly in an effort to elicit the desire to change from the client.
• Idea of not power struggling with the problem
Ordeals:
• Particular type of symptom prescription in which clients are encouraged to carry out harmless but unpleasant tasks whenever symptoms occur; example: having to get up and clean the basement every time the client cannot sleep.
• Again, changing persons relationship with the problem
• Giving them more power
• Structural Family Therapy (Systems Theories)
o Structural
created by Menusian
longer treatment
look at whole system and construction of family and how they relate
hierarchy (who is in charge)
who’s aligned to and against who
how closed or open they are
is there enmeshment
too much sharing (mom crying to daughter about issues with husband)
join with the family (mimesis) take on language and cultural values
frame things as part of a system
enactments (seeing how family deals with issues in session)
frame it how the system is supporting the problem, not attribute the problem to one specific family member
observe how people are sitting in room
instruct people to change where they are sitting
will incorporate diagram (genogram, family map, family constellation of relationships)
• should not do this diagram with family
o Theory of Change
Change occurs through restructuring the family’s organization.
Focused on the organization of the family system
• Problem because other things are going on
• Look at bigger picture of family functioning
o Therapist’s Role
Therapist is active and involved.
The therapist helps the family understand how family structure (relationships and hierarchies) can be changed, the impact of rituals and rules, and how new patterns of interaction can be integrated into the family
Become part of the family
Mirror their mannerisms (mimic them)
Understand the culture of the family first, then make change
Help family understand how the family structure is contributing to the problem
o Treatment Goals
Restructure family system to allow for symptom relief and constructive problem solving (how do families move through life stages, sometimes get stuck in transition)
Change dysfunctional transactional patterns and create new ways of relating
• What are they currently doing that is keeping the problem going?
• Try out new behaviors
Help create flexible boundaries
A healthy functioning family =
• Clear generational hierarchy
• Parental coalition
• Spouses have a clear subsystem
• Clear boundaries between individuals and subsystems
o Primary Concepts:
Family map:
• Map out symbolic representation of the difference relationships of the family members (not done with the family, cuz your joining the family culture, mapping with them would make you an outsider)
• Helps with diagnostic formulation and treatment goals
Alliances:
• Subgroups based on gender (mom and daughter), generation, developmental tasks
Coalitions:
• Alignments where 2 or more family members join together to form a bond against another family member
Power Hierarchy:
• Leadership and direction must be provided by the adults, typically parents. Sometimes when parents are intimidated or insecure, the power is upside down and it leads to chaos
Subsystems:
• Families organize themselves by generation, relationship, and necessity. Examples: marital subsystem – spouses; parental subsystem: parents; executive subsystem: people who run the family; sibling subsystem – kids.
Disengaged Boundaries:
• Where family members are isolated from each other. Can lead to AOD use and is a result of rigid boundaries
Enmeshed Boundaries:
• Family members are overly dependent and too closely involved and reactive to other family members. Can lead to incest.
o Interventions
Joining:
• Therapist’s first task; involves blending in with the family, adapting the family’s affect, style, and language
Tracking:
• The therapist pays close attention to family members and how they relate to one another during an enactment or spontaneous behavioral sequence, noticing boundaries, coalitions, roles, rules, etc.
Mimesis:
• The therapist tracks the family’s style of communication and uses it.
Unbalancing:
• Supporting someone who is in a one-down position, thus changing hierarchical position.
o Therapist actually takes the weaker person’s side
Reframe:
• Putting the presenting problem in a perspective that is both different from what the family brings and more workable.
o Moving from the ID patient to how the system is the problem
Enactment:
• The actualization of transactional patterns under the control of the therapist. It allows the therapist to observe how family members mutually regulate their behaviors, and to determine the place of the problem behavior within the sequence of transactions.
o See problem unfold in the session
o Therapist can track and highlight what is going on
o Try again, but this time I don’t want you to give up
o Main intervention in middle phase of treatment
o Allows for boundary making
Boundary Making:
• Special case of enactment, in which the therapist defines areas of interaction that he rules open to certain members but closed to others. Example: a son is asked to leave his chair (in between his parents) and go to another chair on the opposite side of the room, so that he is not “caught in the middle”
• Satir/Communications Therapy (Systems Theories)
o Theory of Change
Change happens through self-awareness and improved communication. A humanistic approach.
o Role of the Therapist
Active Facilitator
Resource Detective
• Looking for the different strengths and untapped resources of family
• People are trying to grow and interact
• Looking for resources that have been flying under the radar due to family functioning
Therapist is genuine and warm (congruence, match what they say)
Honest and direct
• Trust worthy
o Treatment Goals
The goal is for clients to increase congruent communication, improved self-esteem/confidence and personal growth
• Communicate what you feel see and think to others when you are with them (may say things are great, but it looks like your sad)
• Help people internal and external match
• Improve self-esteem, everyone has a uniqueness and eventually respected, and they respect others’ differences
• Growth: respect for differences
o Key Concepts & Interventions
Incongruent Communication:
• Discrepancies between verbal and nonverbal cues.
Styles of Communication:
• The rules that govern family interaction function as a method of ensuring the maintenance and preservation of the family’s current functioning level. Dysfunctional styles are:
o Placater:
Apologizing, never disagreeing, trying to please everyone
o Blamer:
Attacking others, fault finder, dictator, boss
o Computer:
Super reasonable, intellectual, distant, always correct
o Distracter:
Seeking approval by acting out, irrelevant
Modeling Communication:
• Use “I” messages; express thoughts and feelings directly; avoid statements about what others are thinking or feeling; be honest.
• Supports people to express thoughts and feelings
• Avoid trying to know what others are thinking
Family Life Chronology:
• Gathering history as far back as possible. Include: ideology, values, rules, disruptions, moves, and major events. What the family has been through and how did those events impact the family. How past events and unresolved issues are carried out presently
Family Sculpting:
• Put people into a spatial metaphor – a physical representation of family members characterizations
o Exaggerate and cartoonize the different roles (distractor, Placater, etc.)
Take Responsibility:
• Encouraging clients to take responsibility for how they felt, what they experienced, what meaning they made, what feelings they had about their feelings.
o Own what they are feeling and meaning
o Telling a sarcastic family member, “wow, you have a wicked sense of humor.” Acknowledging the issue that is problematic, but trying to build off of it to identify those family resources
Metaphors and Storytelling:
• Used to help clients understand their roles (Cinderella)
Transforming Rules:
• Looking at past family rules
• Assisting clients to create more functional, less rigid guidelines
• Challenging family of origin rules
• Find more functional guidelinesexistentialcggdf
